Volume 40, Issue 6

Aim: We sought to assess the effect of progesterone in increasing or decreasing duration of pregnancy for mothers with twins and triplets. Methods: Women with multiple pregnancy were randomized at 16+0 to 20+6 weeks’ gestation to receive daily doses of either 90 mg progesterone vaginal gel or placebo until 35+6 weeks or delivery. Primary outcome was gestational age (GA) at delivery. Secondary outcomes included preterm birth, infant morbidity and mortality, and adverse events up to 28 days after delivery. A sample size of 40 per group was required to detect a 2-week difference in GA at delivery. Results: Eighty-four women were randomized (42 to progesterone, 42 to placebo). Median GA at delivery was 36+3 and 36+2, respectively (difference, 1 day; 95% confidence interval, 4 to –1 days, P=0.585). There were no clinically or statistically significant differences between groups for risk of delivery before 35 or 37 weeks’ GA, rates of infant morbidity and mortality, treatment compliance, or adverse events. Conclusions: Daily treatment with progesterone gel did not prolong multiple pregnancy compared with placebo. Effective prevention strategies are needed to reduce preterm deliveries among women with multiple gestations.

Objective: The aim of this study was to investigate the association between high-sensitivity C-reactive protein (hs-CRP) serum levels in early pregnancy with the severity of preeclampsia (PE) and birth weight. Study design: A prospective cohort study was conducted in Noor City (in the north of Iran) from February 2008 to March 2009. The maternal serum hs-CRP levels were measured in 778 healthy pregnant women between 14 and 20 weeks of gestation. They were followed up to delivery. The women were divided into three groups according to ACOG criteria: mild and severe PE and normal group. Results: In total, 63 (8.1%) of the subjects developed PE: 30 (3.9%) mild and 33 (4.2%) severe PE. Mean±SD hs-CRP levels in mild (7.2±2.2 mg/L) and severe (9.4±3.9 mg/L) PE were significantly higher than the normal group (2.5±2.7 mg/L). Mean±SD birth weights in severe (3100±590 g) and mild (3150±742 g) PE were significantly lower than uncomplicated pregnancies (3340±590 g). Multiple and linear logistic regression analysis showed that there were significant relationships between hs-CRP levels in mild (odds ratio, 1.66; 95% confidence interval, 1.43–1.93) and severe PE (odds ratio, 2.35, 95% confidence interval, 1.90–2.92) and with birth weight (P<0.001). The receiver operator characteristic curve showed that hs-CRP >4.5 and >5 mg/dL could predict mild and severe PE, respectively. At this level, sensitivity and specificity for mild PE were 100% and 80.7%, and for severe PE were 93.9% and 75.7%, respectively. Conclusion: hs-CRP can be useful in identifying pregnant women at risk for PE and low-birth weight infants.

Objective: Teaching intrapartum care is one of the most challenging tasks in undergraduate medical education. High-fidelity obstetric simulators might support students’ learning experience. The specific educational impact of these simulators compared with traditional methods of model-based obstetric teaching has not yet been determined. Study design: We randomly assigned 46 undergraduate medical students to be taught using either a high-fidelity simulator or a scale wood-and-leather phantom. Their self-assessments were evaluated using a validated questionnaire. We assessed obstetric skills and asked students to solve obstetric paper cases. Main outcome measures: Assessment of fidelity-specific teaching impact on procedural knowledge, motivation, and interest in obstetrics as well as obstetric skills using high- and low-fidelity training models. Results: High-fidelity simulation specifically improved students’ feeling that they understood both the physiology of parturition and the obstetric procedures. Students in the simulation group also felt better prepared for obstetric house jobs and performed better in obstetric skills evaluations. However, the two groups made equivalent obstetric decisions. Conclusion: This study provides first data on the impact of high-fidelity simulation in an undergraduate setting.

Introduction: The Royal College of Obstetricians and Gynaecologists, in their document “The future role of the consultant,” recommended that there should be a resident obstetric consultant present in the labour ward for 24 h in large UK hospitals. There is little work that validates this recommendation. The period from midnight to 08:00 h is the most disruptive to work-life balance. Objectives: This retrospective study evaluates obstetric outcomes from midnight until 08:00 h in relation to the consultant being a resident or on-call from home over a 3-year period. Methods: The Hull Royal Infirmary is a obstetric unit delivering more than 5000 babies annually. There are nine consultant obstetricians and three associate specialists who provide cover; nine always go home when on-call and return to the hospital if needed after midnight and three are resident in the hospital for personal reasons. There is a registrar and house officer resident at all times. All birth data are contemporaneously recorded on a database. Results: A total of 5318 deliveries were studied over a 3-year period (resident consultant, n=1226; consultant on-call from home, n=4092). There were significantly fewer forceps deliveries when the consultant was on-call from home (3.3% vs. 5.1%, odds ratio 0.65, 95% confidence interval 0.48–0.88), but there was no difference in any other delivery outcome (caesarean 14.5% vs. 13.9%). There were no differences between the rates of stillbirth (0.4% vs. 0.4%) and babies born with low Apgar scores (1.4% vs. 1.3%) when the consultant was on-call from home. Conclusion: There is an increased incidence of forceps delivery when the consultant is resident, but there is no difference in any other obstetric parameter. The recommendation for consultant presence in the labour ward has not been validated by this study.

Objective: Pre-eclampsia (PE) and intrauterine growth restriction (IUGR) are associated with abnormal placentation. Heme oxygenase (HO) and carbon monoxide (CO) are involved in normal placental development and function and vasomotor control in the placenta. The objective of our study was to measure CO levels, as assessed by carboxyhemoglobin (COHb) levels in the umbilical cord arterial blood of women with PE, normotensive IUGR (<10 th percentile for birth weight), and normotensive pregnancies with appropriate-for-gestational age (AGA) infants. Design and methods: We prospectively analyzed COHb levels in the umbilical arterial blood of women with PE, normotensive IUGR, and normotensive AGA pregnancies. Exclusion criteria included cigarette smoke exposure, hemolytic disorders, a positive direct anti-globulin test, chronic hypertension, fever, and any significant medical illness. COHb levels were measured using the ABL 725 blood gas analyzer. Results: There were 41 women in the normotensive AGA group, 42 in the PE group, and 36 in the normotensive IUGR group. Maternal age, mode of delivery, gravidity, parity, and gender of the infants were similar in the three groups. Gestational age and birth weight were significantly higher in the normotensive AGA group compared with the other two groups. COHb levels were significantly lower in the PE group compared with the normotensive AGA group (0.38±0.06% vs. 0.77±0.11%, P<0.05). COHb levels, although lower in the normotensive IUGR group compared with the normotensive AGA group, did not reach statistical significance. Conclusion: Our data suggests the HO-CO system may have a role in the pathogenesis of PE. We also, for the first time, provide information on umbilical arterial COHb levels in normotensive IUGR pregnancies.

Background: A known side effect of labour epidural analgesia (EDA) is maternal fever. It is unclear whether this has effects on the anti-infectious management of the neonate. Methods: A systematic literature search and a hand search of abstract publications were conducted. Studies reporting sepsis evaluation or antibiotic treatment were further assessed. For meta-analysis, risk ratio (RR) and 95% confidence interval (CI) were calculated using the random effects model. Results: Five relevant articles reporting on 4667 parturients were identified; three were observational studies and two were randomised controlled trials (RCT). The RR for sepsis workup of all studies analysed together was 2.58 (95% CI, 1.06–6.27, P=0.04). The RR for antibiotic treatment of the neonate was 2.76 (95% CI, 1.20–6.31, P=0.02). When considering the RCTs alone, the RRs for sepsis evaluation and antimicrobial treatment were still significantly elevated. Discussion: Our data suggest that EDA-related maternal hyperthermia results in an increased likelihood of sepsis workup and antibiotic treatment of the infant. A crucial question is whether EDA-related maternal hyperthermia is truly infectious. If not, administration of antibiotics would not be justified and may be dangerous.

Aim: This study aimed to investigate ST waveform analysis (STAN) signal quality during the second stage of labor by comparing signal quality in the first and second stages of labor. Methods: Fifty women who delivered vaginally were randomly selected in a large prospective database including all women with STAN monitoring during labor. Quality signal was analyzed during the second stage of labor (Period B) and during the same period of the first stage of labor (Period A), just preceding active pushing. STAN signal quality was evaluated using seven variables. Main outcome was the presence of at least one signal loss >4 min. Results: At least one signal loss >4 min was present for, respectively, 4% (95% confidence interval [CI] 0–9.43) of patients in Period A and 28% (95% CI 15.5–40.5) of patients in Period B (P<0.05). A significant difference was detected for all variables analyzed between the two periods (P<0.05). Conclusion: STAN quality signal deteriorates in the second stage of labor compared to that in the first stage. As guidelines clearly indicate that signal quality influences the decision process, it should be carefully and systematically checked before including STAN analysis in the decision-making.

Aim: The aim of this study was the development of a curriculum for the management of postpartum hemorrhage and an objective assessment of technical skills (OSATS) for uterine compression sutures. Method: Twenty-two residents participated in the study. Evaluations included the global rating scale, task-specific checklist, and pass/fail rating for the OSATS and task-specific checklist for the hemorrhage drill. The reliability and validity of the evaluation tools were calculated. Results: The inter-rater reliability was 0.98 for the hemorrhage drill checklist, 0.77 for the global rating scale, and 0.93 for the uterine suture checklist. Construct validity evaluation revealed senior residents performed superiorly to junior residents on the global rating scale (P=0.006) and on the uterine suture checklist (P=0.04). There was an improvement in performance on the post-test in comparison to the pretest (P=0.001). Conclusion: We present an inexpensive, reliable, and valid curriculum to teach and evaluate the medical and surgical management of postpartum hemorrhage.

Aim: The aim of this study was to evaluate the transplacental transfer of clarithromycin, which was used in the treatment of preterm premature rupture of membranes (PPROM) in human pregnancies, by comparing umbilical cord and maternal serum clarithromycin concentrations. Methods: Singleton pregnant women with PPROM (<34 weeks) were prospectively enrolled between April 2009 and January 2011. The diagnosis of PPROM was made with vaginal pooling, leakage, nitrazine, and Amnisure tests. The women were managed expectantly with bed rest, corticosteroids, and a triple antibiotic combination including ceftriaxone, clindamycin, and clarithromycin. Amniocentesis was offered, and culture for aerobe/anaerobe and mycoplasma was performed. After delivery, blood was drawn from the mother’s antecubital and umbilical cord veins. Clarithromycin concentrations were measured using liquid chromatography-tandem mass spectrometry. The percentage and correlation between cord and maternal serum clarithromycin concentrations were calculated. Logistic regression analysis was performed to investigate the factors related to the cord and maternal serum clarithromycin concentration percentage. Results: A total of 34 cord-maternal serum pairs were included in the final analysis. The mean cord-maternal serum clarithromycin concentration percentage was 7.93±0.9%. There was a good correlation between cord serum and maternal serum clarithromycin concentration ( r =0.795, P<0.001). The cord-maternal serum clarithromycin concentration percentage significantly increased according to advancing gestation (P<0.001). Conclusions: Our data showed that the mean placental transfer of clarithromycin is approximately 8% and dependent on gestational age.

Objective: To assess the sensitivity (Sen) and false positive ratio (FPR) of stepwise sequential screening [1 st step: combined test (CT), 2 nd step: modified genetic sonography (major malformation and nuchal fold, MGS)] as a screening method for Down’s syndrome (DS) in the general population of pregnant women. Methods: Prospective study. During a 5-year study period (July 2005 to June 2010), 17,911 pregnant women were screened for DS using a stepwise sequential screening method (CT+MGS). We evaluated the Sen and FPR (95% CI) of the two chromosomal disorder screening methods for DS: CT and CT+MGS. Results: Seventeen thousand nine hundred and eleven cases were analysed, including 67 with chromosome abnormalities and 45 with DS. The Sen of CT for DS was 80% (95% CI; 68.3–91.7) (36/45) with a FPR of 4.2% (95% CI; 3.9–4.5) (752/17, 866). The Sen of CT+MSG for DS was 93.3 (95% CI; 85.9–99) (42/45) with a FPR of 4.8% (95% CI; 4.5–5.1) (860/17, 866). Conclusions: MGS coupled with CT increases the Sen of DS diagnosis by 13.3% (95% CI; 2.7–25.9), with an increase in FPR of 0.6% (95% CI; 0.5–0.7).

Objective: To study fetal acid-base status and its implications under different modes of anaesthesia for caesarean sections. Methods: A prospective cohort study was conducted of 196 consecutive women with singleton non-anomalous fetuses who underwent either elective or emergency caesarean section after 36 completed weeks. Immediately after the baby was delivered, blood was drawn from the umbilical vein and one of the umbilical arteries and sent in ice for acid-base analysis. Maternal demographics, pre-existing medical conditions and antenatal complications were retrieved from antenatal records. Apgar scores and admissions to neonatal intensive care units (NICUs) were noted. Results: Six women were excluded from analysis because the umbilical venous blood was either not collected or clotted. Another two were excluded because of placental abruption. The number of subjects that received spinal, epidural and general anaesthesia were 134, 36 and 18, respectively. Apgar scores were higher in spinal anaesthesia and epidural anaesthesia group (P<0.01). General anaesthesia was associated with a higher incidence of fetal acidaemia, both in the umbilical artery and vein. Spinal anaesthesia was associated with the highest pH in umbilical venous blood. Base excess in umbilical venous samples was highest in the spinal anaesthesia group (P=0.006), although pH values were similar for the three groups. There was no difference in admissions to NICU. Conclusions: This study provided evidence of the advantages of spinal anaesthesia over epidural and general anaesthesia. Our findings are in contrast with recent evidence in the literature.

Objective: To describe the development of the integrative capacity of the fetal autonomic nervous system (ANS) according to gestational age and emerging behavioral states, assuming that developing integrative ANS functions are reflected in increasing autocorrelation of fetal heart rate and fetal heart rate variability markers. Methods: Magnetocardiograms of 114 healthy fetuses (21–40 weeks of gestation) were recorded. Level of fetal activity (quiet/active sleep) was estimated according to characteristic heart rate patterns. Autocorrelation functions of (i) fetal heart rate and (ii) time patterns of SDNN (standard deviation of normal-to-normal intervals) and RMSSD (root mean square of successive differences in normal-to-normal intervals) were calculated and autocorrelation was determined over different time scales. Age and activity related changes were examined using linear regression and non-parametric tests. Results: During pregnancy, autocorrelation increased in fetal heart rate signals and time patterns of SDNN and RMSSD. Short-time correlation (0–20 s) changed between 21 and 31 gestational weeks. Long-time correlation (75–300 s) accelerated later in pregnancy and did not increase in quiet heart rate patterns. Strong state-dependent changes were found with time patterns of SDNN. Conclusions: Emerging integrative ANS functions are reflected in increasing autocorrelation of fetal heart rate fluctuations over increasing time scales. The period from 21 to 31 gestational weeks seems to be critical to ANS development. Increasing long-time correlation is specific to active sleep states.

Breast pumps have been used since antiquity, and their form has changed with the available material. The ancient Greeks used the ceramic guttus type, both to empty the breast and feed the infant. The Romans invented glass milk-extractors, sucked by the mother herself to elevate retracted nipples. Devices in the form of a smoking pipe were in widespread use when corsets had caused an epidemic of flat nipples in the 17 th century. In the 19 th century, vessels to be sucked both by mother and infant were developed to facilitate breastfeeding for preterm infants. When from 1870 the role of pathogenic bacteria became known, easy and thorough cleaning became an important feature of breast pumps. The 20 th century sexualized the female breast to such a degree that its nourishing function was threatened. Electric pumps, developed at the beginning of the 20 th century for hospital use, found a large private market when breast feeding in public was no longer tolerated. Today, breast pumps are mainly used to enable breastfeeding mothers to return to work.

Fetuses and breastfed children depend on the maternal docosahexaenoic acid (DHA) supply, which might have long-lasting consequences. We studied the growth of 6-year-old children whose mothers received supplemental DHA from midpregnancy to 3 months after delivery. One hundred and forty-four pregnant women had been randomized to receive one of three vitamin-mineral supplements, one supplying an additional 200 mg/day DHA. Of the original sample, 120 children were measured at age 6 years with standardized methods. As one objective of the follow-up was to investigate the DHA influence on normal growth, the DHA group was compared with the pooled controls after exclusion of five premature infants. The weight, length, body mass index (BMI), head circumference, and skin-fold thickness at 6 years were similar in the 41 children of the DHA group and the 74 controls. Longitudinally, the BMI z-scores of the DHA group increased up at a later age than that of the controls. We found a highly significant negative correlation between height at 6 years and the increase in red blood cell DHA concentration of mothers from 22 to 37 weeks of pregnancy. We conclude that DHA supplements during midpregnancy corrected a low maternal DHA status (which correlated with children’s height) and was favorable in regard to the BMI development up to 6 years.

Aim: The aim of this study was to examine whether the risk for respiratory syncytial virus (RSV)-related hospitalisation changes through the first year of life in infants of 32–35 weeks’ gestational age (wGA). Methods: Risk factors from the FLIP-2 study (190 cases/4566 age-matched controls) were included in a Cox regression analysis wherein time slices were taken at 1-month intervals from birth. Results: Half of all RSV hospitalisations occurred in the first 68 days after birth, with 56% occurring within 90 days. The time taken for 50% of hospitalisations to occur was 148 days for those born outside the RSV season and 58 days for those born within the season. By 90 days old, 84% of infants born in the season and 20% of those born outside the season were hospitalised. In both groups, hospitalisations occurred ≥5 months after birth. Male sex, smoking whilst pregnant, month of birth, duration of breastfeeding, number of siblings at school, and number of smokers in household all contributed to the risk of RSV hospitalisation beyond the age of 90 days. Conclusions: The risk of RSV hospitalisation appears to persist to at least 5–6 months old in 32–35 wGA infants, which has implications for the optimal management of disease prevention.

Objective: The objective of this study was to assess whether low placental weight is associated with higher risk of emergency delivery (cesarean section and vacuum-assisted delivery). Methods: This was a retrospective cohort study, including 657 normally developed term pregnancies. A strict methodology was used to provide reliable and reproducible placental weight measurement. Fetal heart rate patterns were analyzed according to the guidelines of the Royal College of Obstetricians and Gynecologists. Linear and logistic multiple regression analyses were used to assess risk factors for emergency delivery. Results: Nulliparity, placental weight <10 th percentile, and delivery after 40 weeks of gestation remain significantly associated with higher risk of emergency delivery for non-reassuring fetal status in the multivariable model [odds ratio (OR) 5.13, 95% confidence interval (CI) 2.85–9.22, P<0.001; OR 2.46, 95% CI 1.49–4.06, P<0.001; OR 2.23, 95% CI 1.26–4.51, P=0.01, respectively]. In the group of women who had an emergency delivery, 17.3% had a placental weight <10 th percentile, which was significantly different to the group of women who delivered normally (9.4%, P≤0.04). If only emergency cesarean sections were analyzed, the percentage of women with placental weight <10 th percentile was 37.5% in the cesarean section group compared to 9.8% in women who delivered normally (P≤0.001). Conclusion: This study suggests that, in clinically normally developed term pregnancies, placental weight <10 th percentile is associated with an increased risk for emergency delivery during labor. These results warrant further prospective studies for potential use in clinical practice.

Aim: The aim of the study was to test the safety and feasibility of a system designed to decrease the uterine contractions of human preterm labor using a weak electrical current. Methods: Patients in preterm labor had an electrode catheter placed in the posterior vaginal fornix and attached to an electrical pacemaker. Contraction intervals were determined during the 60-min study, in which minutes 0–20 was the preintervention control period (C1); 21–40 was the electrical intervention (EI), with a 10-s burst of current administered just before each expected contraction; and 41–60 was the postintervention control (C2). Mean intervals were calculated and compared mixed-model ANOVA. Results: Five patients were studied. No maternal or fetal vital sign irregularities were seen. All the babies had a normal neonatal intensive care unit stay for gestational age. The respective mean contraction intervals for C1, EI, and C2 and their within- and between-subject standard deviations were 4.64 (±0.81, ±2.45), 5.71 (±3.03, ±1.62), and 3.83 (±0.83, ±1.31) min. There was a significant difference between EI and C2 (P=0.0078) and no difference between C1 and C2 or between EI and C1 (P=0.1373). Conclusions: EI appears to be a safe and feasible method for decreasing preterm contractions. To confirm and test effectiveness, longer interventions and additional cases are needed.

No Abstract available.

No Abstract available.