Digital fetal scalp stimulation (dFSS) versus fetal blood sampling (FBS) to assess fetal wellbeing in labour-a multi-centre randomised controlled trial: Fetal Intrapartum Randomised Scalp Stimulation Trial (FIRSST NCT05306756)

BACKGROUND

Cardiotocography (CTG) is a screening test used to detect fetal hypoxia in labour. It has a high false positive rate resulting in many potentially unnecessary caesarean sections. Fetal blood sampling (FBS) is a second-line test of the acid-base status of the fetus. It is used to provide either reassurance that it is safe for labour to continue or objective evidence of compromise so that delivery can be expedited. Digital fetal scalp stimulation (dFSS) to elicit a fetal heart rate acceleration is an alternative less invasive second-line test of fetal wellbeing. This study aims to provide robust evidence on the role of these two second-line tests in assessing fetal wellbeing and potentially preventing operative delivery.

METHODS

A multi-centre parallel group randomised controlled trial (RCT) is planned in four maternity centres in Ireland. The study aims to recruit 2500 nulliparous women with a term (≥37+0 weeks) singleton pregnancy who require a second-line test of fetal wellbeing in labour due to an abnormal CTG. Women will be allocated randomly to dFSS or FBS on a 1:1 ratio. The primary outcome is caesarean section. With 1250 women in each arm, the study will have 90% power to detect a difference of 5-6%, at a two-sided alpha significance level of 5%, assuming a caesarean section rate of at least 20% in the dFSS group.

DISCUSSION

If the proposed study shows evidence that dFSS is a safe, reliable and effective alternative to FBS, this would have ground-breaking implications for labour management worldwide. It could potentially lead to a reduction in invasive procedures and emergency caesarean sections.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05306756. Registered on 31 March 2022. The trial commenced enrolment on 10 May 2022. Ethical committee approval has been granted by the Research Ethics Committee (REC) of each hospital: Dublin/CWIUH REC: 12.06.2019; Cork/UCC REC: 29.11.2019; Galway/NUIG REC: 06.09.2019; Limerick/UL REC: 30.09.2019.

P-427 Pregnancy outcomes following recurrent first-trimester miscarriage: a retrospective cohort study

Study question

What are the subsequent pregnancy outcomes (livebirths, miscarriages or other adverse pregnancy outcomes) in a cohort of women with recurrent miscarriage (RM)?

Summary answer

The overall live birth rate in women with RM was 62% (466/748), falling to 44% in women aged >40 and 54% in women with infertility.

What is known already

RM affects approximately 1% of women of reproductive age. RM is recognized as a prognostic indicator for subsequent pregnancies and adverse pregnancy outcomes including ante-partum hemorrhage, diabetes, preterm birth, small for gestational age and perinatal death. While RM has known associations with advanced maternal age, obesity, diabetes, thyroid dysfunction and endometriosis, approximately 50% of women/couples will be left without an explanation for their pregnancy loss, even after completing investigations.

Study design, size, duration

A retrospective cohort study was undertaken to identify subsequent pregnancy outcomes in women with RM, where RM referral criteria are 3 consecutive first-trimester miscarriages. Women attending the pregnancy loss clinic at a tertiary university hospital in the Republic of Ireland over a 12-year period (2008 - 2020) with a confirmed diagnosis of primary or secondary first-trimester RM were eligible for inclusion. In total, 923 charts were identified for review against the eligibility criteria.

Participants/materials, setting, methods

Women with non-consecutive first trimester miscarriages or ectopic pregnancy were excluded. Epidemiological and clinical information was gathered from paper and electronic medical records. Data were analysed descriptively using SPSS (Version 27).

Main results and the role of chance

Of 748 women identified, 332(44%) had primary RM, 416(56%) had secondary RM. The median age was 36(range 19-47) years with 12% aged under 29 and 64% of women aged ≥35. 142(19%) had a history of infertility with 43(5.7%) attending for ART.

12% of women had anti-nuclear antibodies(89/742), 8% had abnormal thyroid function tests(60/742), 4.7% were heterozygous carriers of the Factor V Leiden gene mutation(35/737), 1.5% had positive anti-cardiolipin antibodies(11/733), 2% were carriers of a Prothrombin gene mutation(7/343) and 1% had elevated HbA1c levels(7/742).

Fetal karyotype was recorded in 141 pregnancies, with 111 abnormal results(78%;111/141). Trisomy(T) 16 was most common(17/111; 15%) followed by T21 and T22(n = 14; 13%). Parental karyotyping of 697 sets of parents identified 28 balanced translocations(4%; 28/697).

Prescribed pharmacological treatments included high dose folic acid(75%; n = 548/728), aspirin(96%; 696/726), progesterone (52%; 389/728), tinzaparin(24%; 175/727), prednisolone(4%; 28/726), metformin(2%; 12/727) and hydroxychloroquine(1%; 7/727).

573 women had a subsequent pregnancy (76.6%); 359(62%; 359/573) had a live birth, 190 had a miscarriage(33%) and 18(3%) had an adverse pregnancy outcome such as ectopic pregnancy, stillbirth or second-trimester miscarriage.

Including successive pregnancies over the study period, the overall live birth rate was 62%(466/748), falling to 44% in women aged >40 and 54% in women with infertility.

Limitations, reasons for caution

This work covers a 12-year period, and while the RM clinic staffing is largely unchanged, some changes in management of RM patients has occurred in this time, reflecting up-to-date evidence and greater public awareness. Furthermore, the adoption of an electronic health chart in 2017 may have affected data availability.

Wider implications of the findings

Our findings confirm RM occurs more frequently in women aged >35. Aneuploidy remains a leading cause of miscarriage. Age is a prognostic indicator for livebirth after RM. These findings will facilitate counselling in this cohort. The substantial rates of prescribed medications and infertility in women with RM merit further exploration.

Trial registration number

N/A

P-393 The care experiences of women and men who have received recurrent miscarriage care in Ireland: a national survey

Study question

What are the care experiences of women and men who have received recurrent miscarriage (RM) care in the Republic of Ireland?

Summary answer

Of the participants, 24% rated a poor experience of RM care (n = 32), while 36% said the care they received was much worse than expected (n = 48).

What is known already

International guidelines suggest that couples who experience RM should be referred for specialist investigations, support and, if possible, treatment. Providing individualised care, respect for women’s opinions, and appropriate clinical information is imperative to those experiencing RM. However, currently, there is no national standard for the management, investigation, or follow-up of those who experience RM in Ireland. Research on patient-centred early pregnancy care concluded that it is essential for healthcare professionals (HCPs) to realise that women undergoing miscarriage experience a significant life event and recommended that future studies explore potential targets for improving RM care and patients’ perspectives.

Study design, size, duration

A cross-sectional study of women and men who have experienced RM was conducted. An anonymous web-based national survey was used to examine the experience of those who have interacted with the maternity services following RM. The survey was distributed online using Qualtrics between September – November 2021. The survey was shared through emails, websites, newsletters, and social media accounts as well as the Pregnancy Loss Research Group and the Miscarriage Association of Ireland among others.

Participants/materials, setting, methods

Women and men over 18 who have experienced two≥ first trimester miscarriages in the last ten years and who have received care for RM in the Republic of Ireland were invited to participate in the survey. The survey was purposefully designed using relevant literature, including questions on key areas such as sociodemographic information, pregnancy and pregnancy loss history, investigation and treatment for RM. Descriptive statistics and subgroup analysis are ongoing using Stata.

Main results and the role of chance

In total, 213 participants completed the survey (some did not experience a consecutive RM or receive care between 2011-2021 (n = 65)). Therefore, 147 participants were eligible (97% female, n = 135). Of the female participants, 79% were aged 35-44 years (n = 106), 95% were white Irish (n = 128) and 84% were married (n = 114). Women were educated, with 38% having postgraduate degrees (n = 53) or a university degree (27%, n = 36). 57% had experienced two consecutive RM (n = 77) and 25% three consecutive RM (n = 34). Of the 135 women, 53% had investigations for RM (n = 71), with 45% having investigations after two RM (n = 32) or 27% after three RM (26). When asked if their HCP did everything to investigate their RM, 49% said no. Of those who had investigations (n = 71), 83% always had confidence and trust in their HCP (n = 59), and 42% felt treated with dignity and respect (n = 30). However, 44% did not have a HCP to talk to about their worries and fears (n = 31). 24% of women rated a poor experience when receiving RM care (n = 32), 36% said the care they received was much worse than expected (n = 48), with 60% of women saying that HCPs in different places did not work well together during their RM care (n = 81).

Limitations, reasons for caution

Despite an open call to recruit women and men, only four men participated. Therefore, further research needs to include strategies to recruit men to provide a complete picture of RM care experiences. There is also the potential for recall bias as some women received care several years ago.

Wider implications of the findings

This study demonstrates that the overall experience for RM care is poor, providing areas for improvements such as communication and better care coordination between HCPs across hospitals/units. These results provide a better understanding of the drivers shaping care experiences to help inform and improve RM care in Ireland.

Trial registration number

not applicable

P-376 Estimating the costs associated with the implementation of a best practice model of care for recurrent miscarriage clinics in Ireland: a cost analysis

Study question

What are the potential costs to the Irish healthcare system of implementing a ‘best practice’ model of care for recurrent miscarriage clinics?

Summary answer

Total cost for RM patients ranges from €1,634.19 to €4,817.87 for a pregnancy outcome and from €1,245.77 to €4,317.87 for women who do not conceive.

What is known already

Recurrent miscarriage (RM) affects 1% -5% of the reproductive age population. It is recognised that the best care for RM is offered in a dedicated recurrent miscarriage clinic (RMC). While RM represents a significant burden to couples, the setup of RMCs involves substantial resource costs. This study reports on the cost impact to the Irish healthcare system of implementing a ‘best practice’ model of care for RMCs. Evidence from cost analysis plays an important role in informing the cost-effectiveness of interventions ensuring that those available resources are used efficiently, as health policymakers plan for future healthcare services.

Study design, size, duration

A micro-costing approach was employed using a range of data sources to identify, measure, and value the resources required to implement the proposed model of care. Data was collected from March – September 2021. The cost analysis was calculated using the following components: 1. The initial set up costs of a best practice RMC, 2. The ongoing implementation costs of delivering a best practice RMC, and 3. The subsequent and related care pathway costs.

Participants/materials, setting, methods

Per patient costs were estimated within a best practice RMC using two scenarios (a typical versus a complex RM case). The cost estimates were extrapolated to estimate the cost impact to the Irish healthcare care system over a 1-year period using population data and published prevalence rates for RM. A sensitivity analysis was performed to control for the uncertainty in each of the parameters.

Main results and the role of chance

The total cost to set up a best practice RMC is €37,321. The yearly on-going delivery cost is €6,212.25. The total cost for a RM patient who has another pregnancy after receiving investigations, treatment and reassurance scans ranges between €1,634.19 (typical) and €4,817.87 (complex). For a RM patient who does not conceive again, costs range from €1,245.77 (typical) to €4,317.87 (complex). Using population estimates, the total budget impact to the health service for women who experience ≥2 losses costs €61,927,630 (typical) /€20,336,229 (complex) for a pregnancy outcome and €22,480,630 (typical)/€7,78,437 (complex) for women who do not conceive. Sensitivity analysis identified RM investigations and treatments costs as the main cost drivers for per-patient costs.

Limitations, reasons for caution

With only six RMCs operating in Ireland, calculating costs savings was not possible. A fixed number of investigations and treatments for patient scenarios were applied. In a real-world setting, investigations and treatments will vary significantly by patient need, risk factors and previous history of loss, directly impacting the costs reported.

Wider implications of the findings

This study proposes a model of care for RMCs in Ireland, providing cost estimates at the patient and healthcare system level. While future studies should consider the cost-effectiveness of this model of care, this analysis provides a valuable first step in providing a breakdown of the resources and costs.

Trial registration number

Not applicable

Experience of women on the Irish National Gestational Trophoblastic Disease Registry

OBJECTIVE

Gestational Trophoblastic Disease (GTD) is a rare pregnancy related disorder and the most curable of all gynaecological malignancies. GTD comprises the premalignant conditions of complete or partial hydatidiform mole known as molar pregnancy and a spectrum of malignant disorders termed gestational trophoblastic neoplasia. Clinical management and treatment in specialist centres is essential to achieve high cure rates and clinical guidelines recommend registration with a GTD centre as a minimum standard of care. National GTD registries are valuable repositories of epidemiological data and facilitate clinical audit, centralised pathology review and human chorionic gonadotropin (hCG) monitoring. This study sought the opinion of women enrolled on the Irish National GTD registry to inform future service development and establish a knowledge base for molar pregnancy in Ireland.

STUDY DESIGN

A cross-sectional survey using an anonymised questionnaire was distributed by post to all women on the GTD registry. The questionnaire was designed by a multidisciplinary team and consisted of twenty-five closed-ended questions and two open-ended questions to facilitate feedback. Data collected in the survey included information on the patient experience of registration, knowledge of molar pregnancy, diagnosis at their local hospital, hCG monitoring and overall satisfaction with the service.

RESULTS

The survey had a successful participation rate of 42.6% (215/504). Forty-nine percent (n = 106) of respondents rated a rapid hCG result as their top priority. Forty percent (n = 84) of women had concerns about future pregnancies but acknowledged that these were largely addressed by the GTD specialist nurses. A quarter of respondents reported that other medical professionals with whom they interacted during follow-up treatment did not understand their condition. Many women commented on the emotional stress of attending their local maternity unit for phlebotomy while dealing with pregnancy loss.

CONCLUSION

This study is unique in being the first survey of women on the Irish National GTD registry. It highlights the specific needs of women with molar pregnancy in terms of psychological support, bereavement counselling and peer support groups. It reveals a knowledge gap in molar pregnancy amongst healthcare professionals which should be considered in future planning of medical and nursing curricula.

Placental growth factor in assessment of women with suspected pre-eclampsia to reduce maternal morbidity: a stepped wedge cluster randomised control trial (PARROT Ireland)

OBJECTIVE

To determine whether the addition of placental growth factor (PlGF) measurement to current clinical assessment of women with suspected pre-eclampsia before 37 weeks' gestation would reduce maternal morbidity without increasing neonatal morbidity.

DESIGN

Stepped wedge cluster randomised control trial from 29 June 2017 to 26 April 2019.

SETTING

National multisite trial in seven maternity hospitals throughout the island of Ireland PARTICIPANTS: Women with a singleton pregnancy between 20⁺⁰ to 36⁺⁶ weeks' gestation, with signs or symptoms suggestive of evolving pre-eclampsia. Of the 5718 women screened, 2583 were eligible and 2313 elected to participate.

INTERVENTION

Participants were assigned randomly to either usual care or to usual care plus the addition of point-of-care PlGF testing based on the randomisation status of their maternity hospital at the time point of enrolment.

MAIN OUTCOMES MEASURES

Co-primary outcomes of composite maternal morbidity and composite neonatal morbidity. Analysis was on an individual participant level using mixed-effects Poisson regression adjusted for time effects (with robust standard errors) by intention-to-treat.

RESULTS

Of the 4000 anticipated recruitment target, 2313 eligible participants (57%) were enrolled, of whom 2219 (96%) were included in the primary analysis. Of these, 1202 (54%) participants were assigned to the usual care group, and 1017 (46%) were assigned the intervention of additional point-of-care PlGF testing. The results demonstrate that the integration of point-of-care PlGF testing resulted in no evidence of a difference in maternal morbidity-457/1202 (38%) of women in the control group versus 330/1017 (32%) of women in the intervention group (adjusted risk ratio (RR) 1.01 (95% CI 0.76 to 1.36), P=0.92)-or in neonatal morbidity-527/1202 (43%) of neonates in the control group versus 484/1017 (47%) in the intervention group (adjusted RR 1.03 (0.89 to 1.21), P=0.67).

CONCLUSIONS

This was a pragmatic evaluation of an interventional diagnostic test, conducted nationally across multiple sites. These results do not support the incorporation of PlGF testing into routine clinical investigations for women presenting with suspected preterm pre-eclampsia, but nor do they exclude its potential benefit.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02881073.

Maternity Healthcare Chaplains and Perinatal Post-Mortem Support and Understanding in the United Kingdom and Ireland: An Exploratory Study

Perinatal autopsy rates have declined significantly in recent decades. There is a lack of consensus concerning the potential religious influences for bereaved parents in their decision making process for post-mortem. This online study of British and Irish maternity healthcare chaplains explored their understanding of general and local perinatal post-mortem procedures and their experiences in the support of parents. Participants included Christian, Muslim and non-faith chaplains. No chaplain identified any religious prohibition to perinatal post-mortem. A majority of chaplains reported that they had been asked about post-mortem by parents; only a minority felt adequately prepared. A key recommendation is that following appropriate training chaplains may be well placed to support colleagues and parents during the decision making process.

Medicine, media and the law: The effect on training in obstetrics and gynaecology

The inextricable link between medicine and the legal profession has flourished in the 21st century, with countless newspaper articles and social media content on medical cases visible at every juncture. This is particularly true in the speciality of obstetrics and gynaecology, with one of the highest rates of litigation of all medical specialities. We aimed to evaluate the influence of media and the legal environment on the career of trainees in obstetrics and gynaecology. Under the auspices of the Irish national training body, we distributed a 26-item questionnaire to doctors-in-training (DIT) working in obstetrics and gynaecology in the Republic of Ireland. Descriptive statistics and Chi-squared analyses were performed on the anonymised data. 151 DIT responded to the questionnaire, with a response rate of 86.2 % (sample size = 175). The majority were female (79.9 %, n = 121), Irish (85.5 %, n = 106) and had no children (67.0 %, n = 83). 86.7 % (n = 131) felt that the media did not have a positive impact on patients receiving care, and, further, unfairly represented the speciality (94.1 %; n = 142). Additionally, DIT felt that medico-legal issues had a negative impact on issues such as retention and recruitment. These two areas were implicated in over three quarters of DIT considering leaving the speciality. This study demonstrates that DIT perceive media scrutiny and litigation to have a negative effect on the speciality of obstetrics and gynaecology. Further support integrated into specialist training, is needed to ensure that trainees are adequately equipped to deal with both mainstream and social media as well as interactions they may have with the legal profession as they progress through their career.

A prospective study of placental growth factor in twin pregnancy and development of a dichorionic twin pregnancy specific reference range

OBJECTIVE

To develop a dichorionic twin pregnancy specific reference range for placental growth factor (PlGF), and to compare gestation-specific placental growth factor levels in twin pregnancies later complicated by pre-eclampsia, hypertensive disorder of pregnancy or fetal growth restriction with control pregnancies.

DESIGN

Prospective observational study.

SETTING

Single large tertiary maternity unit in Ireland.

POPULATION OR SAMPLE

Women with a twin pregnancy.

METHODS

Consenting pregnant women, across a variety of gestations, had a single blood sample taken at one time-point only during their pregnancy. The plasma was initially biobanked and PlGF was measured later in batches using the point of care Triage^® PlGF test.

MAIN OUTCOME MEASURES

Development of pre-eclampsia, hypertensive disorder of pregnancy or fetal growth restriction.

RESULTS

Placental growth factor levels in uncomplicated dichorionic twin pregnancies were significantly lower in the women who later developed pre-eclampsia than in the controls at all gestational intervals. In those that later developed any hypertensive disorder of pregnancy, median PlGF was lower only in those recruited before 24 weeks of gestation, whereas in infants with a customised birthweight below the third centile, PlGF was lower only in those sampled after 24 weeks of gestation.

CONCLUSIONS

Placental growth factor levels in twin pregnancy differ significantly between those women with a pregnancy that will later be complicated by pre-eclampsia and those that will not. This difference is present many weeks before clinical signs or symptoms of disease are present. Using cross-sectional values from uncomplicated twin pregnancies, we have developed a dichorionic twin pregnancy specific reference range for PlGF.

TWEETABLE ABSTRACT

Placental growth factor levels in twin pregnancy differ significantly between women that will later develop pre-eclampsia and those that will not.

Fetal medicine specialist experiences of providing a new service of termination of pregnancy for fatal fetal anomaly: a qualitative study

OBJECTIVE

To explore fetal medicine specialists' experiences of caring for parents following a diagnosis of fatal fetal anomaly (FFA) during the implementation of termination of pregnancy (TOP) for FFA for the first time.

DESIGN

Qualitative study.

SETTING

Fetal medicine units in the Republic of Ireland.

POPULATION

Ten fetal medicine specialists from five of the six fetal medicine units.

METHODS

nvivo 12 assisted in the thematic analysis of semi-structured in-depth face-to-face interviews.

MAIN OUTCOME MEASURES

Fetal medicine specialists' experiences of prenatal diagnosis and holistic management of pregnancies complicated by FFA.

RESULTS

Four themes were identified: 'not fatal enough', 'interactions with colleagues', 'supporting pregnant women' and 'internal conflict and emotional challenges'. Fetal medicine specialists feared getting an FFA diagnosis incorrect because of media scrutiny and criminal liability associated with the TOP for FFA legislation. Challenges with the ambiguous and 'restrictive' legislation were identified that 'ostracised' severe anomalies. Teamwork was essential to facilitate opportunities for learning and peer support; however, conflict with colleagues was experienced regarding the diagnosis of FFA, the provision of feticide and palliative care to infants born alive following TOP for FFA. Participants reported challenges implementing TOP for FFA, including the absence of institutional support and 'stretched' resources. Fetal medicine specialists experienced internal conflict and a psychological burden providing TOP for FFA, but did so to 'provide full care for women'.

CONCLUSIONS

Our study identified challenges regarding the suitability of the Irish legislation for TOP for FFA and its rapid introduction into clinical practice. It illustrates the importance of institutional and peer support, as well as the need for supportive management, in the provision of a new service.

TWEETABLE ABSTRACT

The implementation of termination services for fatal fetal anomaly is complex and requires institutional support.

The general populations' understanding of first trimester miscarriage: a cross sectional survey

OBJECTIVES

Miscarriage is a common, yet for many, devastating adverse pregnancy outcome. However, despite this the level of public knowledge on the topic is sub-optimal. We aimed to examine the general public's knowledge of miscarriage as well as their health information seeking behaviours associated with this topic.

STUDY DESIGN

We commissioned a national cross-sectional telephone survey of adults in the Republic of Ireland. 967 members of the general public consented to participate to this anonymised telephone survey. Sampling procedures ensured proportionality as per national standards. We examined respondents' definitions of miscarriage, its incidence and clinical findings, as well as the information seeking behaviours of the general population surrounding miscarriage.

RESULTS

699 (72%) of respondents provided an estimate of miscarriage frequency, with 28% of respondents correctly estimating that miscarriage occurs in 21-30% of pregnancies, with 61% under-estimating the incidence. Men were three times more likely than women to under-estimate (aOR3.5; 95% CI 2.4-4.9), as were those without children (aOR 1.7; 95% CI 1.2-2.6), or those living in urban areas (aOR 1.6; 95%CI 1.0-2.4. One third of respondents (33%) believed that the risk of miscarriage was higher following only one miscarriage. While 83% of respondents knew someone who had experienced a miscarriage, just over one third had discussed the topic of miscarriage with a family member/friend.

CONCLUSIONS

The general populations' knowledge of miscarriage, its incidence and associated factors is concerning, as are their health information seeking behaviours. Improving the level of knowledge of the general public could be achieved by adopting the topic into existing public health and education strategies. This will allow those experiencing miscarriage to frame their experience and expectations.

Maternal transmission of SARS-COV-2 to the neonate, and possible routes for such transmission: a systematic review and critical analysis

Background

Early reports of COVID‐19 in pregnancy described management by caesarean, strict isolation of the neonate and formula feeding. Is this practice justified?

Objective

To estimate the risk of the neonate becoming infected with SARS‐CoV‐2 by mode of delivery, type of infant feeding and mother‐infant interaction.

Search strategy

Two biomedical databases were searched between September 2019 and June 2020.

Selection criteria

Case reports or case series of pregnant women with confirmed COVID‐19, where neonatal outcomes were reported.

Data collection and analysis

Data were extracted on mode of delivery, infant infection status, infant feeding and mother–infant interaction. For reported infant infection, a critical analysis was performed to evaluate the likelihood of vertical transmission.

Main results

Forty nine studies included information on mode of delivery and infant infection status for 655 women and 666 neonates. In all, 28/666 (4%) tested positive postnatally. Of babies born vaginally, 8/292 (2.7%) tested positivecompared with 20/374 (5.3%) born by Caesarean. Information on feeding and baby separation were often missing, but of reported breastfed babies 7/148 (4.7%) tested positive compared with 3/56 (5.3%) for reported formula fed ones. Of babies reported as nursed with their mother 4/107 (3.7%) tested positive, compared with 6/46 (13%) for those who were reported as isolated.

Conclusions

Neonatal COVID‐19 infection is uncommon, rarely symptomatic, and the rate of infection is no greater when the baby is born vaginally, breastfed or remains with the mother.

Tweetable abstract

Risk of neonatal infection with COVID‐19 by delivery route, infant feeding and mother‐baby interaction.

Risk of neonatal infection with COVID‐19 by delivery route, infant feeding and mother‐baby interaction.

This article includes Author Insights, a video abstract available at https://vimeo.com/rcog/authorinsights16362

Maternity care providers' involvement in research

OBJECTIVE

Despite the widely acknowledged importance of research for improving patient care and outcomes, research in pregnant women is lacking. Many challenges innate to conducting research in pregnant women may discourage maternity care providers from engaging in research. Thus, the current study assessed maternity care providers' involvement in research, their perception of the relevance of research, as well as facilitators and barriers to participating in research.

STUDY DESIGN

A total sample of 145 maternity care providers were recruited from a large tertiary-referral university-based teaching maternity hospital. Maternity care providers included, midwives, nurses, sonographers, consultant obstetricians, and non-consultant hospital doctors. Participants completed a cross-sectional survey between May and October 2018.

RESULTS

The present study found that overall, 49.7% of maternity care providers who participated reported never taking part in conducting research. Medical staff were more likely to report being given the opportunity and to have ever conducted research compared to midwives (p < 0.05). Participants agreed that research is important to maintain the quality of care provided to women (Mean = 4.86/5 in agreeance). However, medical staff were more likely to report understanding research methodology and feeling competent to undertake research compared to midwives (Mean = 3.85 v 3.28, p = 0.002; Mean = 3.56 v 2.60, p < 0.05).

CONCLUSION

The findings suggest future strategies aimed at increased opportunities and additional research training will likely support maternity care providers', specifically midwives, involvement in conducting effective research studies in pregnancy. Such actions hold the potential to contribute research evidence lacking in pregnant women necessary to provide appropriate maternity care.

Irish Inquiry Reports Relating to Perinatal Deaths and Pregnancy Loss Services

Aims External inquiries are carried out following specific adverse events in healthcare, many in maternity care; to identify issues and make recommendations to improve standards of care. Methods Ten publically-available national inquiry reports published between 2005-2018 relating to pregnancy loss services, were reviewed by 2 clinicians, separately, examining the content and recommendations from each report. Results A total of 258 recommendations were made in 9 reports (90%). Five inquiries (50%) clearly stated that affected families were involved and four (40%) involved affected clinical staff. In 9 reports (90%) recommendations included: increase workforce staffing and/or training, strengthen clinical governance, enhance adverse incident management and comprehensive data collection e.g. maternity outcomes. Only two inquiry reports (20%) stated that feedback was sought from key stakeholders prior to publication. Conclusion A collaborative and standardised inquiry process involving and supporting all persons affected as well as key stakeholders would ensure that all relevant issues are identified, recommendations are implemented and essential lessons are learned.

Recurrent hepatocellular carcinoma in pregnancy: A case report and literature review

The incidence of hepatocellular carcinoma in pregnancy is rare, and we present the first reported case of a pregnancy complicated by pre-existing advanced hepatocellular carcinoma. We describe the case of a 39-year-old woman in her second pregnancy, with a diagnosis of hepatocellular carcinoma. This was discovered in 2013 incidentally following hepato-splenectomy and pancreatectomy for a presumed hepatic adenoma in the context of multiple arterio-venous malformations. Recurrent hepatocellular carcinoma, in conjunction with co-existing pulmonary hypertension was successfully managed in a multi-disciplinary setting, resulting in a spontaneous vaginal delivery of a live female infant with maternal and neonatal survival six months following delivery.

Intrapartum fetal deaths and unexpected neonatal deaths in the Republic of Ireland: 2011 - 2014; a descriptive study

BACKGROUND

Intrapartum fetal death, the death of a fetus during labour, is a tragic outcome of pregnancy. The intrapartum death rate of a country is reflective of the care received by mothers and babies in labour and it is through analysing these cases that good aspects of care, as well as areas for improvement can be identified. Investigating unexpected neonatal deaths that may be associated with an intrapartum event is also helpful to fully appraise intrapartum care. This is a descriptive study of intrapartum fetal deaths and unexpected neonatal deaths in Ireland from 2011 to 2014.

METHODS

Anonymised data pertaining to all intrapartum fetal deaths and unexpected neonatal deaths for the study time period was obtained from the national perinatal epidemiology centre. All statistical analyses were conducted using Statistical package for the Social Sciences (SPSS).

RESULTS

There were 81 intrapartum fetal deaths from 2011 to 2014, and 36 unexpected neonatal deaths from 2012 to 2014. The overall intrapartum death rate was 0.29 per 1000 births and the corrected intrapartum fetal death rate was 0.16 per 1000 births. The overall unexpected neonatal death rate was 0.17 per 1000 live births. Major Congenital Malformation accounted for 36/81 intrapartum deaths, chorioamnionitis for 18/81, and placental abruption accounted for eight babies' deaths. Intrapartum asphyxia accounted for eight of the intrapartum deaths. With respect to the neonatal deaths over half (21/36, 58.3%) of the babies died as a result of hypoxic ischaemic encephalopathy. Information is also reported on both maternal and individual baby demographics.

CONCLUSIONS

This is the first detailed descriptive analysis of intrapartum deaths and unexpected intrapartum event related neonatal deaths in Ireland. The corrected intrapartum fetal death rate was 0.16 per 1000 births. Despite our results being based on the best available national data on intrapartum deaths and unexpected neonatal deaths, we were unable to identify if any of these deaths could have been prevented. A more formal confidential inquiry based system is necessary to fully appraise these cases.

Oocyte Donation Pregnancies- Non-Disclosure of Oocyte Recipient Status to Obstetric Care Providers and Perinatal Outcomes

Background: Oocyte donation pregnancies- non-disclosure of oocyte recipient (OR) status to obstetric care providers and perinatal outcomes.Many studies report a higher rate of pregnancy-induced hypertension (PIH) and severe pre-eclampsia (PET) in OR pregnancies. The objective is to determine the rates of non-disclosure of OR pregnancy to obstetric care providers and also the rates of perinatal complications. Method: This was a retrospective review of all oocyte recipient (OR) pregnancies, who subsequently delivered at Cork University Maternity Hospital, between 2007- 2012 inclusive. Obstetric case notes were reviewed to investigate perinatal outcomes and whether OR status had been documented (unambiguously, in code or not at all). Results: Less than one-third (30.2%; n=32/106) had unambiguous documentation, one-third (33%; n=35/106) had no documentation and the remainder (36.8%; n=39/106) had a code familiar only to their obstetrician. There was a high rate of gestational hypertensive disorders (28.3%; n= 30), most frequently occurring with multiple gestation. Discussion: There was a low rate of clear documentation of OR status. Gestational hypertensive disorders occurred with increased frequency.

Maternity Ultrasound in the Republic of Ireland 2016; A Review

Antenatal ultrasound, comprising of a dating ultrasound in the late first trimester followed by a fetal anomaly scan, is a recognised and necessary component of good antenatal care. We conducted a telephone survey of all 19 obstetric units to ascertain the status of maternity ultrasound provision in Ireland. Fetal anomaly ultrasound is offered universally to all women in 7/19 (37%) units, selectively to some women in 7/19 (37%) units and not offered at all in the remaining 5/19 (26%) units. Overall ? 41,700 (64%) women receive a fetal anomaly ultrasound nationally. Universal first trimester ultrasound, performed in a dedicated ultrasound department by a suitably qualified sonographer, is offered to 47% of women nationally. This study highlights the lack of development in Irish maternity ultrasound services over the last decade. Substantial investment by health care policy makers is urgently needed.

Experience of miscarriage: an interpretative phenomenological analysis

OBJECTIVE

The objective of the study was to explore the experiences of those who have experienced miscarriage, focusing on men's and women's accounts of miscarriage.

DESIGN

This was a qualitative study using a phenomenological framework. Following in-depth semistructured interviews, analysis was undertaken in order to identify superordinate themes relating to their experience of miscarriage.

SETTING

A large tertiary-level maternity hospital in Ireland.

PARTICIPANTS

A purposive sample of 16 participants, comprising 10 women and 6 men, was recruited.

RESULTS

6 superordinate themes in relation to the participant's experience of miscarriage were identified: (1) acknowledgement of miscarriage as a valid loss; (2) misperceptions of miscarriage; (3) the hospital environment, management of miscarriage; (4) support and coping; (5) reproductive history; and (6) implications for future pregnancies.

CONCLUSIONS

One of the key findings illustrates a need for increased awareness in relation to miscarriage. The study also indicates that the experience of miscarriage has a considerable impact on men and women. This study highlights that a thorough investigation of the underlying causes of miscarriage and continuity of care in subsequent pregnancies are priorities for those who experience miscarriage. Consideration should be given to the manner in which women who have not experienced recurrent miscarriage but have other potential risk factors for miscarriage could be followed up in clinical practice.

Healthcare professionals' response to intrapartum death: a cross-sectional study

BACKGROUND

Exposure to adverse perinatal events can impact on the way healthcare professionals (HCPs) provide patient care. The aim of this study was to document the experiences of HCPs following exposure to intrapartum death (IPD), to identify opinions surrounding education and suitable support strategies, and to ascertain if involvement with an IPD had any impact on clinical practice.

METHODS

A questionnaire study, with open and closed questions, was developed and set in a tertiary maternity hospital. Consultant obstetricians, trainee obstetricians and midwives were invited to participate. Respondents were questioned about the impact that an intrapartum death had on them, the support they received in the immediate aftermath and their opinions regarding ongoing education and training in the areas of intrapartum death and self-care.

RESULTS

Eighty percent of HCPs in our study had a direct involvement with an IPD. Most (82%) HCPs received no training in dealing with IPD while 94% had no education on self-care strategies. Despite it being desired by most (80%), debriefing was offered to just 11% of HCPs who were involved in an IPD. Three main qualitative themes emerged from the data; the personal impact of IPDs on HCPs, implications for professional practice and future patient care, and the importance on non-judgemental support.

CONCLUSION

Maternity hospitals need to improve their support structures for HCPs following an IPD. It is hoped that this study will inform future educational practice and identify potential support strategies.

Perinatal determinants of D-dimer levels in a cross-sectional study of low risk pregnant women

BACKGROUND

To examine perinatal determinants of the antenatal levels of D-dimers.

METHODS

Cross-sectional study of 760 low risk pregnant women recruited into five gestational groups. Variables examined in antenatal groups included maternal age, body mass index, parity, smoking, family history venous thromboembolism (VTE) and previous use of the oral contraceptive pill (OCP). Onset of labour and mode of delivery were also examined in the post-natal group.

RESULTS

D-dimer levels in group 4 (38-40 + 6) were significantly lower in the women with a history of taking the OCP when compared to those that had not taken it in the past (P = 0.027). In the day 2 post-natal group, the median level of D-dimer was significantly higher in primparous when compared to multiparous women (P = 0.015). The median D-dimer levels were significantly lower in the elective Caesarean section group in comparison to spontaneous onset (P = 0.003) and induction of labour (P = 0.016). When the mode of delivery was examined, the median D-dimer levels were significantly lower in those that had an elective Caesarean section when compared to normal vaginal delivery (P = 0.008) and instrumental vaginal delivery (P = 0.007). Women post elective Caesarean section had a significantly lower D-dimer than those after emergency Caesarean section (P = 0.008).

DISCUSSION

There are some significant differences in D-dimer levels when certain perinatal determinants are examined. This work is potentially beneficial to the future diagnosis of VTE in pregnancy as it supports previously published recommended D-dimer levels for the diagnosis of VTE in pregnancy.

Previous pregnancy loss has an adverse impact on distress and behaviour in subsequent pregnancy

OBJECTIVE

To investigate whether women with previous miscarriages or terminations have higher levels of anxiety, depression, stress, and altered behaviours in a subsequent pregnancy.

DESIGN

A retrospective analysis of 5575 women recruited into the Screening for Pregnancy Endpoints (SCOPE) study, a prospective cohort study.

SETTING

Auckland, New Zealand, Adelaide, Australia, Cork, Ireland, and Manchester, Leeds, and London, UK.

POPULATION

Healthy nulliparous women with singleton pregnancies.

METHODS

Outcomes were recorded at 15 and 20 weeks of gestation.

MAIN OUTCOME MEASURES

Short-form State-Trait Anxiety Inventory (STAI) score, Perceived Stress Scale score, Edinburgh Postnatal Depression Scale score, and pregnancy-related behaviour measured using behavioural responses to pregnancy score.

RESULTS

Of the 5465 women included in the final analysis, 559 (10%) had one and 94 (2%) had two previous miscarriages, and 415 (8%) had one and 66 (1%) had two previous terminations of pregnancy. Women with one previous miscarriage had increased anxiety (adjusted mean difference 1.85; 95% confidence interval, 95% CI 0.61-3.09), perceived stress (adjusted mean difference 0.76; 95% CI 0.48-1.03), depression (adjusted odds ratio, aOR 1.26; 95% CI 1.08-1.45), and limiting/resting behaviour in pregnancy (adjusted mean difference 0.80; 95% CI 0.62-0.97). In women with two miscarriages, depression was more common (aOR 1.65; 95% CI 1.01-2.70) and they had higher scores for limiting/resting behaviour in pregnancy (adjusted mean difference 1.70; 95% CI 0.90-2.53) at 15 weeks of gestation. Women with one previous termination displayed elevated perceived stress (adjusted mean difference 0.65; 95% CI 0.08-1.23) and depression (aOR 1.25; 95% 1.08-1.45) at 15 weeks of gestation. Women with two previous terminations displayed increased perceived stress (adjusted mean difference 1.43; 95% CI 0.00-2.87) and depression (aOR 1.67; 95% 1.28-2.18).

CONCLUSIONS

This study highlights the psychological implications of miscarriage and termination of pregnancy.

Gestation-specific D-dimer reference ranges: a cross-sectional study

OBJECTIVE

To establish a gestation-specific reference range for D-dimer in healthy pregnant women with a singleton pregnancy using the Auto-Dimer assay.

DESIGN

Cross-sectional study

SETTING

Cork University Maternity Hospital, Ireland.

POPULATION

Healthy pregnant women attending for routine antenatal care.

METHODS

Simultaneous-quantile regression was performed to construct a median, 5th percentile, and 95th percentile, model of normal pregnancy D-dimer concentration versus gestational week, ranging from week 6 to 42. Additionally, pair-wise Mann-Whitney U-tests were performed to compare distributions of D-dimer concentrations for each of the four discrete gestational sampling windows with the distribution of D-dimer concentrations 48 hours postpartum.

MAIN OUTCOME MEASURES

D-dimer concentrations (ng/ml) during normal gestation (approximately week 6 to week 42).

RESULTS

Seven hundred and sixty healthy pregnant women were investigated between gestational age week 5 and 48 hours postpartum. There was a clear steady increase in median D-dimer concentrations over the complete gestational period. Additionally, the 95th centile estimates for all gestational time-points were above the accepted non-pregnancy normal cut-off concentration (224 ng/ml). The results of the Mann-Whitney U-tests suggested that the long-term postnatal return to normal D-dimer concentrations begins in the immediate postpartum period.

CONCLUSIONS

We found that there is a continuous increase in D-dimer concentrations across all gestations. This research is potentially beneficial to future diagnosis of venous thromboembolism (VTE) in pregnancy using the new recommended 95th centile potential cut-offs. Possible further investigation involves an observational study comparing D-dimer concentrations in women with proven DVT with those that don't, generating likelihood ratios.

The impact of stillbirth on consultant obstetrician gynaecologists: a qualitative study

OBJECTIVE

To explore the personal and professional impact of stillbirth on consultant obstetrician gynaecologists.

DESIGN

Semi-structured in-depth qualitative interviews.

SETTING

A tertiary university maternity hospital in Ireland with a birth rate of c. 9000 per annum and a stillbirth rate of 4.6/1000.

SAMPLE

Purposive sample of eight consultant obstetrician gynaecologists (50% of consultant obstetrician gynaecologists in the hospital).

METHODS

Semi-structured in-depth interviews analysed by Interpretative Phenomenological Analysis. (IPA) IPA is a methodology for exploring human experience and its meaning for the individual.

MAIN OUTCOME MEASURES

The lived experiences, personal feelings and professional impact of stillbirth on consultant obstetrician gynaecologists.

RESULTS

Stillbirth was identified as amongst the most difficult experiences for consultants. Two superordinate themes emerged: the human response to stillbirth and the weight of responsibility. The human response to stillbirth was characterised by the personal impact of stillbirth for consultants and, in turn, how that shapes the care they provide. The weight of professional responsibility was characterised by the sense of professional burden and the possibility of a medico-legal challenge-mostly for those who are primarily gynaecologists resulting in the question 'what have I missed?'.

CONCLUSIONS

Despite the impact of stillbirth, no consultant has received formal training in perinatal bereavement care. This study highlights a gap in training and the significant impact of stillbirth on obstetricians, professionally and personally. The provision of support, ongoing education, bereavement training and self-care is recommended. Medico-legal concerns following stillbirth potentially impact on care, warranting further research.

Conjoined twins: experience in an Irish tertiary centre

Conjoined twins are rare, with a reported incidence of 0.19 per 10,000 pregnancies in Europe. We discuss four spontaneous conjoined twin pregnancies presenting to a tertiary referral centre from 2005 to 2011, diagnosed on antenatal dating ultrasound. The cases were monitored closely throughout pregnancy by a multidisciplinary team, with serial surveillance, including ultrasound, fetal echocardiography, magnetic resonance imaging, amniocentesis and further referral to cardiology and paediatric surgery specialists, where indicated. Three female sets were determined antenatally to be not surgically separable; these infants were managed palliatively following a live birth. The male set of conjoined twins was accepted for surgical separation at Great Ormond Street Hospital, London, which was successfully performed electively at 4 months. Of interest, all four parents reside within 20 km of each other, representing a possible cluster of cases. The incidence of conjoined twins in our local population is approximately 0.63 per 10,000 over an 8-year period from 2005 to 2012. This case series highlights a cluster of conjoined twins, managed to viability and delivered in a tertiary referral centre.

Maternal serum cholesterol levels are elevated from the 1st trimester of pregnancy: a cross-sectional study

Cholesterol is monitored in the non-pregnant adult population, where normal values are established. Although reported to be elevated in pregnancy, cholesterol is neither routinely measured nor treated. We aimed to investigate cholesterol levels throughout pregnancy and to establish reference values for cholesterol in healthy pregnant women. This was a cross-sectional analysis of serum cholesterol in healthy women with an uncomplicated singleton pregnancy. Pregnant women attending for antenatal care were recruited and cholesterol levels assayed at 12, 20, 28 and 36 weeks' gestation and on day 1-3 postpartum. A total of 222 women were recruited. The majority (95%) were white Irish, with a median age of 31 years (range 16-46). Median BMI was 25.9 kg/m2 (range 18-40) and 16% were smokers. Cholesterol levels were elevated in all trimesters of pregnancy, with median values from 1st trimester raised outside the non-pregnant adult range. High-density lipoprotein (HDL) levels ranged from 0.9 to 3.7 mmol/l and low-density lipoprotein (LDL) levels ranged from 1.3 to 6.1 mmol/l. Fasting, smoking and obesity did not have any significant effects on results. Total and LDL-cholesterol levels were raised throughout pregnancy. Levels were above non-pregnant adult ranges as early as the 1st trimester. The implications of this on fetus and mother are undetermined and deserve further investigation.

Prevalence of subclinical and undiagnosed overt hypothyroidism in a pregnancy loss clinic

Recent studies have associated pregnancy loss with subclinical hypothyroidism, defined as elevated thyroid-stimulating-hormone level, with normal free thyroxine. In overt hypothyroidism, the free thyroxine is low. Subclinical and overt hypothyroidism occurs in 0.25-2.5% and 0.2-0.3% of pregnancies respectively. We examined the prevalence of subclinical and undiagnosed overt hypothyroidism in women with recurrent miscarriage, late miscarriage and stillbirth attending the Pregnancy Loss Clinic. Data was collected from the Pregnancy Loss Clinic records. Women with sporadic miscarriages, autoimmune disorders, thrombophilias and known hypothyroidism were excluded. Two-hundred-and-sixty-two women were included. Median maternal age was 35 years (range 18-47). Subclinical and undiagnosed overt hypothyroidism was found in 11.45% of women. Twenty-two women (8.39%) had subclinical hypothyroidism, eight (3.05%) had undiagnosed overt hypothyroidism. Results were compared to women with ongoing pregnancies. A proportion of women attending the clinic had subclinical or undiagnosed overt hypothyroidism, raising the suspicion of causation in unexplained pregnancy loss.

Antenatal detection of abnormal liver function tests - a marker for poor perinatal outcome

The purpose of this study was to examine (a) the incidence of liver disease diagnosed in our antenatal population, (b) the diagnostic value of initial symptoms and liver function tests (LFTs), (c) the adequacy of investigation and management of the liver disorder and (d) the obstetric and neonatal outcome in this group of patients. Women with abnormal LFTs that delivered at our hospital over a 2-year period were identified from computerised hospital records and data was obtained from chart review. Forty-six out of a total of 13 181 (0.35%) women had liver disease diagnosed in pregnancy: Diagnoses included intrahepatic cholestasis of pregnancy (13), pre-eclampsia and the HELLP syndrome (eight), acute fatty liver of pregnancy (three), hyperemesis gravidarum (one), hepatitis C (13), B (four) and hepatitis A (one), cholelithiasis (two) and hepatitis of unknown aetiology (one). Symptoms at presentation were more predictive of the final diagnosis than the initial LFT profile. Investigation of the liver disorder was incomplete in 50% of cases. One mother required intensive care for 6 weeks postpartum and three others had significant postpartum haemorrhage. There was one neonatal death and 24 neonates were admitted to the special care baby unit. Eighteen women attended for their postnatal check up at 6 weeks. Eight of these women were referred to a hepatologist. Detection of liver disease in pregnancy identifies a group at risk of poor neonatal and maternal outcome. Structured guidelines should be implemented in obstetric units to facilitate appropriate investigation, treatment and referral patterns for these women.

Timing of birth related to obstetric practice and neonatal outcome

Several studies have reported time of birth is associated with differences in obstetric practice. We investigated the relationship between timing of birth and obstetric and neonatal outcomes, to help plan working patterns under European Working Time Directive (EWTD) legislation. This was a retrospective observational study undertaken in a tertiary-level university teaching hospital. Data were derived from the labour ward register of births for all women who delivered after 24weeks gestation in 2004. Births during on-call hours refer to those that occurred at weekends and after 1630 and before 0830 on weekdays. The majority of infants, 67.3%, were born in on-call hours. Infants were more likely to be delivered by ventouse(p<0.0001), but there was no difference in caesarean section(CS) rates. 83.0% of operative deliveries performed for failure to advance in the second stage of labour took place in on-call hours, as did 77.5% of emergency CS for fetal distress. 38.9% of infants born during on-call hours on weekdays followed induced labours, compared to 24.7% of births at weekends and 17.7% of births in non on-call hours(p<0.001), while 80.0% of deliveries by emergency CS after induction occurred during on-call hours. The majority of perinatal deaths occurred among infants born during on-call hours, even when excluding congenital malformations, and most infants with low Apgar scores were born during on-call hours. Complicated deliveries were more likely to occur in on-call hours. This study confirms previous reports that time of birth impacts on neonatal outcome. Increased demands on staff working out-of-hours have implications for healthcare, staffing and implementation of new working hours under EWTD legislation.

Stage I twin-twin transfusion syndrome: rates of progression and regression in relation to outcome

OBJECTIVES

Twin-twin transfusion syndrome (TTTS) results in high rates of perinatal mortality and neurological morbidity. Fetoscopic laser ablation of placental anastomoses is now established as the treatment of choice for advanced disease. However, there remains controversy about its use in early-stage TTTS, in which laser-related fetal losses need to be balanced against relatively favorable outcomes with more conservative approaches. We investigated rates of progression and regression in Stage I TTTS and determined factors influencing the course of the disease.

METHODS

We undertook a retrospective observational study of all TTTS cases referred to our tertiary referral fetal medicine service from 2000 to 2006. In patients presenting with Stage I TTTS, the following variables were evaluated for their ability to predict the course and progression of the disease: gestational age (GA) at presentation, amniotic fluid index, recipient and donor deepest vertical pool, presence of artery-artery anastomoses, small-sized bladder compared to normal donor bladder and fetal size discordance. Study end-points were disease regression or progression, and neonatal survival at 28 days.

RESULTS

Among 132 consecutive cases of TTTS, 46 women presented with Stage I disease. In the majority (69.6%), disease remained stable (28.3%) or regressed (41.3%). Of cases that progressed, 79% did so within 2 weeks and 93% progressed to at least Stage III. No factor was significantly linked with progression or regression, although there was a trend towards the absence of an artery-artery anastomosis (P = 0.10) and the presence of a small rather than normal donor bladder (P = 0.10) influencing progression, and later GA at presentation (P = 0.07) influencing regression. At least one infant survived in 83% of cases and there was double survival in 59%. Perinatal outcome was significantly better in cases that regressed (the rates of at least one survivor and double survival being 89% and 89%, respectively) or remained Stage I (77% and 61%, respectively), compared with those cases that progressed (79% and 14%, respectively). Treatment with amnioreduction at first presentation did not influence progression or regression.

CONCLUSIONS

This study demonstrates that a high percentage of Stage I TTTS cases regress or remain early stage. Identification of factors predicting progression would facilitate the selection of patients for definitive therapy, while avoiding treatment-related morbidities in mild or transient disease.

Elevated placental expression of the imprinted PHLDA2 gene is associated with low birth weight

The identification of genes that regulate fetal growth will help establish the reasons for intrauterine growth restriction. Most autosomal genes are expressed biallelically, but some are imprinted, expressed only from one parental allele. Imprinted genes are associated with fetal growth and development. The growth of the fetus in utero relies on effective nutrient transfer from the mother to the fetus via the placenta. Some current research on the genetic control of fetal growth has focused on genes that display imprinted expression in utero. The expression levels of four imprinted genes, the paternally expressed insulin growth factor 2 (IGF2), the mesoderm-specific transcript isoform 1 (MEST); the maternally expressed pleckstrin homology-like domain, family A, member 2 (PHLDA2); and the polymorphically imprinted insulin-like growth factor 2 (IGF2R) gene are all known to have roles in fetal growth and were studied in the placentae of 200 white European, normal term babies. The quantitative expression analysis with real-time PCR showed the maternally expressing PHLDA2 but not the paternally expressing IGF2 and MEST, nor the polymorphic maternally expressing IGF2R placental levels to have a statistically significant effect on birth weight. PHLDA2 expression levels are negatively correlated with size at birth. These data implicate PHLDA2 as an imprinted gene important in fetal growth and also as a potential marker of fetal growth.

Retrospective characterization of Newcastle Disease Virus Antrim '73 in relation to other epidemics, past and present

In November 1973 Newcastle disease suddenly appeared in Northern Ireland, where the viscerotropic disease had not been seen in 3 1/2 years and the two Irelands had been regarded as largely disease free for 30 years. It was successfully controlled with only 36 confirmed affected layer flocks, plus 10 more slaughtered as 'dangerous contacts'. Contemporary investigations failed to reveal the source of the Irish epidemic. Using archival virus samples from most of the affected flocks, RT PCR was conducted with primers selected for all six NDV genes. Phylogenetic analyses of three genes, HN, M and F, confirmed vaccine as the cause of one of the outbreaks. The other six samples were identical and closely related to previous outbreaks in the United States and western Europe initiated by infected imported Latin American parrots. The probable cause of the epidemic followed from the importation from The Netherlands of bulk feed grains contaminated with infected pigeon faeces.

Fetal cells in maternal blood: state of the art for non-invasive prenatal diagnosis

In Singapore, 1 in 5 pregnancies occur in mothers > 35 years old and genetic diseases, such as thalassaemia, are common. Current methods for the diagnosis of aneuploidy and monogenic disorders require invasive testing by amniocentesis, chorion villus biopsy or fetal blood sampling. These tests carry a procedure-related risk of miscarriage that is unacceptable to many couples. Development of non-invasive methods for obtaining intact fetal cells would allow accurate prenatal diagnosis for aneuploidy and single gene disorders, without the attendant risks associated with invasive testing, and would increase the uptake of prenatal diagnosis by women at risk. Isolation of fetal erythroblasts from maternal blood should allow accurate non-invasive prenatal diagnosis of both aneuploidies and monogenic disorders. Expression of gamma-globin in maternal erythroblasts and the inability to locate fetal erythroblasts reliably in all pregnancies have prevented its clinical application. In the absence of a highly specific fetal cell marker, enrichment, identification and diagnosis--the 3 components of non-invasive prenatal diagnosis--have clearly defined objectives. Since fetal cells are rare in maternal blood, the sole purpose of enrichment is yield--to recover as many fetal cells as possible--even if purity is compromised at this stage. In contrast, the primary goal of identification is specificity; absolute certainty of fetal origin is required at this stage if the ultimate objective of diagnosis, accuracy, is to be achieved. This review summarises the current state of the art of non-invasive prenatal diagnosis using fetal erythroblasts enriched from maternal blood.

Identification of fetal mesenchymal stem cells in maternal blood: implications for non-invasive prenatal diagnosis

Strategies for genetic prenatal diagnosis on fetal cells in the maternal circulation have been limited by lack of a cell type present only in fetal blood. However, the recent identification of mesenchymal stem cells (MSC) in first trimester fetal blood offers the prospect of targeting MSC for non-invasive prenatal diagnosis. We developed protocols for fetal MSC enrichment from maternal blood and determined sensitivity and specificity in mixing experiments of male fetal MSC added to female blood, in dilutions from 1 in 10(5) to 10(8). We then used the optimal protocol to isolate fetal MSC from maternal blood in the first trimester, using blood taken after surgical termination of pregnancy as a model of increased feto-maternal haemorrhage. In model mixtures, we could amplify one male fetal MSC in 2.5 x 10(7) adult female nucleated cells, yielding a 100% pure population of fetal cells, but not one fetal MSC in 10(8) nucleated cells. Fetal MSC were identified in one of 20 post-termination maternal blood samples and confirmed as fetal MSC by XY fluorescence in-situ hybridization (FISH), immunophenotyping and osteogenic and adipogenic differentiation. We report the isolation of fetal MSC from maternal blood; however, their rarity in post-termination blood suggests they are unlikely to have a role in non-invasive prenatal diagnosis. Failure to locate these cells routinely may be attributed to their low frequency in maternal blood, to sensitivity limitations of enrichment technology, and/or to their engraftment in maternal tissues soon after transplacental passage. We speculate that gender microchimerism in post-reproductive maternal tissues might result from feto-maternal trafficking of MSC in early pregnancy.

Is fetal abdominal subcutaneous fat comparable with established indices of growth restriction?

The purpose of this study was to determine if measurement of the abdominal subcutaneous fat antenatally using ultrasound is comparable to other established indices of fetal growth restriction (FGR). One hundred women with singleton pregnancies had an ultrasound scan within 1 week of delivery at term. Ultrasound measurements included abdominal circumference (AC), liquor assessment by amniotic fluid index (AFI) and abdominal subcutaneous fat thickness (FAB). After delivery,infants were weighed and skinfold thickness at triceps and subscapular sites measured. Ponderal index was also calculated. Infants with an abdominal subcutaneous fat measurement antenatally of 5 mm or less (n = 41) were more likely than those with a fat measurement of more than 5 mm (n = 59) to have an AFI < 8 cm (P < 0.001) and to have an AC < 10th centile (P < 0.001). Decreased antenatal fat thickness was associated postnatally with a lower mean ponderal index (24.2 kg/m3 vs. 25.5 kg/m3, P < 0.02) and a decreased skinfold thickness (4.84 vs. 5.55 mm, P < 0.003 and 3.88 vs. 4.37, P < 0.03 for triceps and subscapular, respectively). This study shows that fetal abdominal subcutaneous fat measurement correlates with established predictors of fetal nutrition such as liquor volume, abdominal circumference, ponderal index, triceps and subscapular skinfold thickness.

Remarkable preservation of biomolecules in ancient radish seeds

Desiccated seeds from a 6th century AD storage vessel recovered from Qasr Ibrîm, Egypt, were examined for the presence of lipids and nucleic acids. A remarkable degree of lipid preservation was discovered, the fatty acid and sterol profiles being very similar to those of modern radish seeds. The only significant differences were hydrolysis of triacylglycerols and depletion of the polyunsaturated fatty acids (C18:2 and C18:3). The delta 13 C values of the principal fatty acids were in the range -25.4 to -29.2/1000, which is congruent with modern radish (C3 seeds) taking account of isotopic shifts caused by recent changes in atmospheric CO2. Deoxyribonucleosides and nucleic acid bases were detected by direct chemical analysis, and polymerase chain reactions gave products with sequences comparable to those from modern radish. The degree of lipid preservation, which was much greater than that reported for other archaeological remains, suggests that the microenvironment within desiccated seeds retards biomolecular decay. The results illustrate the utility of combined lipid-nucleic acid analysis in chemotaxonomic and genotypic studies of archaeobotanical remains.

Typing of Listeria monocytogenes by random amplified polymorphic DNA (RAPD) analysis

The aim of the study was to determine the effectiveness of random amplified polymorphic DNA analysis in typing Listeria monocytogenes from human infections. Twenty-five L. monocytogenes serogroup 1/2 and 70 serogroup 4 including 14 serovar 4b(x) were typed by RAPD-PCR analysis. Six primers were used to type each L. monocytogenes isolate and the DNA amplification performed with supertaq DNA polymerase in a Hybaid Thermal Reactor. Each bacterial strain was analysed separately with all primers and the profiles were judged by eye and designated to a group by comparison to other strains. Bands were classified as major or minor. Based on analysis of major band patterns, the 25 serogroup 1/2 isolates gave rise to 12 different groups. The groups only contained serovar 1/2a or 1/2b with a single exception. Using minor bands all isolates could be distinguished. All the serogroup 4 isolates gave the same major band patterns. The 14 serovar 4b(x) isolates which were epidemiologically related gave identical profiles with the exception of one isolate. Of the remaining strains, 41 produced individual patterns on minor band analysis. RAPD analysis with multiple primers is low cost, discriminatory and is most ideally suited to testing small (< 50) numbers of strains. We have shown that serogroup 1/2 L. monocytogenes strains are a more diverse group than serovar 4b strains and RAPD-PCR will provide a technique of considerable value in typing L. monocytogenes in the future.

Functional expression of soluble forms of human CD38 in Escherichia coli and Pichia pastoris

Cyclic adenosine diphosphate (ADP)-ribose (cADPR), a metabolite of nicotinamide adenine dinucleotide (NAD+), mobilizes calcium from intracellular stores in many cells. The synthesis of cADPR from NAD+ and its subsequent hydrolysis to ADPR is catalyzed by an ADP-ribosyl cyclase and a cADPR hydrolase, respectively. The ADP-ribosyl cyclase cloned from the ovotestis of the marine invertebrate Aplysia californica has amino acid sequence homology to the human lymphocyte surface antigen CD38. CD38 has been shown to catalyze both the formation and the hydrolysis of cADPR. In this study, we produced soluble, enzymatically active CD38 using recombinant expression techniques in bacteria and yeast. We engineered a gene coding for a soluble form of CD38 by excision of the region of the gene coding for the N-terminal amino acids representing the putative membrane spanning sequence and short putative intracellular sequence. For expression in bacteria (Escherichia coli), this construct was cloned into the pFlag-1 plasmid which allows induced, periplasmic expression and relatively simple purification of the soluble CD38. For expression in yeast (Pichia pastoris) the CD38 sequence was further modified to eliminate four putative N-linked glycosylation sites and the resulting construct was expressed as a secreted protein. Both systems produce soluble enzymes of approximately 30 kDa and both recombinant enzymes display similar cyclase and hydrolase activities.

DNA in wheat seeds from European archaeological sites

We have used hybridization analysis to detect ancient DNA in wheat seeds collected from three archaeological sites in Europe and the Middle East. One of these samples, carbonized T. spelta dated to the first millennium BC, has yielded PCR products after amplification with primers directed at the leader regions of the HMW (high molecular weight) glutenin alleles. Sequences obtained from these products suggest that the DNA present in the Danebury seeds is chemically damaged, as expected for ancient DNA, and also indicate that it should be possible to study the genetic variability of archaeological wheat by ancient DNA analysis. Finally, we describe a PCR-based system that enables tetraploid and hexaploid wheats to be distinguished.