Christopher Griffin

Impact of the new IADPSG gestational diabetes diagnostic criteria on pregnancy outcomes in Western Australia.

There is debate as to the most appropriate diagnostic criteria to diagnose gestational diabetes mellitus (GDM). The proposed International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria have recently been endorsed by various bodies, but there remains no national consensus.

New directions in the prediction of pre-eclampsia.

Pre‐eclampsia remains an important worldwide cause of maternal and perinatal morbidity and mortality. Improved prediction of those destined to develop this condition would allow for timely initiation of prophylactic therapy, appropriate antenatal surveillance and better targeted research into preventive interventions. This paper reviews recent research into strategies for the prediction of pre‐eclampsia, including the use of maternal risk factors, mean maternal arterial pressure, ultrasound parameters and biomarkers. The most promising strategies involve multiparametric approaches, which use a variety of individual parameters in combination, as has been established in first‐trimester aneuploidy screening. The paper concludes with a discussion of the issues around the introduction of such testing into clinical practice.

Probiotics in obstetrics and gynaecology

Despite the great advances in modern medicine, our understanding of the most basic function of our complete genetic makeup is extremely poor. Our complete genetic make up is complemented by 100 trillion cells living within or on our body and is called the microbiome. Manipulation of the microbiome is in the embryological stages of investigation but promises great hope in targeting both pregnancy specific and general medical / gynaecological conditions. This review presents an undertanding of the microbiome manipulation with probiotics in womens health in 2015.

Spontaneous Uterine Rupture in a Preterm Pregnancy following Myomectomy

A 44-year-old nulliparous woman was transferred to a tertiary obstetric hospital for investigation of acute onset abdominal pain. She was at gestation of 32 weeks and 2 days with a history of previous laparoscopic fundal myomectomy. An initial bedside ultrasound demonstrated oligohydramnios. Following an episode of increased pain early the following morning, a formal ultrasound diagnosed a uterine rupture with the fetal arm extending through a uterine rent. An uncomplicated classical caesarean section was performed and the neonate was delivered in good condition but with a bruised and oedematous right arm. The neonate was transferred to the Special Care Nursery for neonatal care. The patient had an uncomplicated postoperative course and was discharged home three days following delivery. This is an unusual presentation of uterine rupture following myomectomy where the fetal arm had protruded through the uterine wall.

Patient attitudes towards outpatient cervical ripening prior to induction of labour at an Australian tertiary hospital

Abstract A prospective patient questionnaire was conducted to assess attitudes and opinions towards outpatient cervical ripening in women attending an Australian tertiary hospital’s labour and birth suite for a booked induction of labour. Questionnaires were distributed over a three-month period and information collected included demographic data, pregnancy and obstetric history, attitudes towards cervical ripening and willingness to undergo cervical ripening in the outpatient setting. Responses to 57 completed questionnaires were analysed. Forty-one patients (72%) underwent cervical ripening with Foley Catheter Balloon (FCB) only, eight (14%) with FCB and vaginal prostaglandins (VP), two (3.5%) with VP only and six patients (10.5%) did not require cervical ripening. One-third (33%) of patients stated, both before the commencement of cervical ripening and after delivery, that they would feel happy to undergo outpatient cervical ripening. Patient acceptance of outpatient cervical ripening has potential economic and psychosocial benefits for the healthcare system and patient respectively.

Re: The vaginal microbiome, vaginal anti‐microbial defence mechanisms and the clinical challenge of reducing infection‐related preterm birth

We read with great interest the most engaging and erudite review article by Professor Witkin. The concept of treating vaginal dysbiosis with lactic acid is a most attractive concept to supplant the current over-use of antibiotics for what is essentially a nonlife-threatening maternal condition. However, high concentrations of hydrogen peroxide produced in vitro by lactobacilli are bactericidal to the actual source of the hydrogen peroxide, i.e. the same lactobacilli. This selfregulatory mechanism is designed to keep in check the growth of lactobacilli. Could the exogenous administration of lactic acid potentiate the vicious cycle of lactobacilli deficiency and thus in the longer term prove to be of no benefit to the patient. We would be most interested in Professor Witkin’s thoughts on this matter.&

Risk factors for sleep-disordered breathing in pregnancy

The stimulating paper of Pien et al 1 reported the findings of a prospective cohort study of pregnant women examining risk factors for sleep-disordered breathing (SDB). It was notable that, despite a marked increase in the number of women with obstructive sleep apnoea (OSA) from the first to third trimester (from 10.5% to 26.7%, respectively), there were no significant associations between any SDB variable and development of gestational hypertension or preeclampsia …

The cervix – a philosopher's dream?

If a man is offered a fact that goes against his instincts, he will scrutinise it closely, and unless the evidence is overwhelming, he will refuse to believe it. If on the other hand, he is offered something that affords a reason for acting in accordance with his instincts, he will accept it even on the slightest evidence. The origin of myths is explained in this way. . .. Bertrand Russell 21st century philosopher.

Combined Foley's catheter and misoprostol for pre‐induction cervical ripening

Dear Editor, We read with great interest the recent study on a most contemporaneous series of topics, that is, simultaneous use of cervical ripening (CR) agents and the use of misoprostol as a prostaglandin agent for such activity.1 First, we would like clarity upon the definition of the primary outcome of the pregnancy in relation to the study. In the outcome measures this was defined as; ‘the rate of vaginal delivery’. However, the power calculations were based upon successful induction of labour (IOL), yet no definition for this latter statement was forthcoming. The assumption is that perhaps the rate of vaginal delivery and successful IOL are one and the same. However, the results in Table 2 clearly state failed induction rates of 2.9-7.1% being of no statistical significance. Could this anomaly of definitions and outcomes please be clarified as this potentially has considerable impact upon the design of the study and power calculations. Second, the caesarean section rates within the study are high compared to two other large well-conducted studies.2,3 The PROBAAT I clearly demonstrated a similar vaginal birth rate (assisted or unassisted) of 80% for dinoprostone versus Foley catheter for CR. More recently, PROBAAT II (primarily a safety study for misoprostol) demonstrated a vaginal birth rate of 80+% for oral misoprostol or Foley catheter. The PROBAAT authors eloquently displayed a deep flaw in the Cochrane (WHO recommendation) approach to the outcome measures of either cervical ripening or IOL studies.4 The PROBAAT II group did not use a 24 h vaginal birth rate as a measure of a successful outcome. Instead their outcome was any vaginal birth. Hence the total time to achieve a vaginal birth was high but this produced one of the highest recorded vaginal delivery rates in any adequately powered randomised controlled study for CR/IOL within the history of modern medicine. What do the authors attribute their higher caesarean section rate in comparison to these two aforementioned PROBAAT studies? We felt the design of the study to which this letter is addressed demonstrated a more aggressive approach to formally starting syntocinon and or performing membrane rupture. Therefore could this factor be causative of a lower vaginal birth rate in comparison to PROBAAT II. Perhaps of greatest note for current thinking regarding CR is that the PROBAAT II study unequivocally found that oral misoprostol is as safe as a Foley catheter for CR in the absence of specific exclusion factors. The side-effect profile of using misoprostol in this study was similar to the PROBAAT II study. The safety of using combined modalities for CR is in line with the larger MOMI trial where a median five hour shorter time to delivery was found between combined and individual therapies.5 If by using the combined CR method we do shorten the delivery time in cases where an urgent delivery is indicated (i.e. within 24 h), then the combined methodology of prostaglandin and cervical catheter has a place in our medical armamentarium for cervical ripening.

Re: Does low‐molecular‐weight heparin influence fetal growth or uterine and umbilical arterial Doppler in women with a history of early‐onset uteroplacental insufficiency and an inheritable thrombophilia? Secondary randomised controlled trial results LMWH influencing fetal growth

Sir, We thank both Niels Klarskov and Gunnar Lose for their continued interest in our published systematic review and meta-analyses on the role of preoperative urodynamics in stress urinary incontinence (SUI) surgery. We agree that uroflowmetry is a non-invasive part of urodynamics. Many clinicians use only uroflowmetry in isolation rather than complete urodynamics procedure on several occasions to assess voiding. Hence we did not use the two terms ‘uroflowmetry’ and ‘urodynamics’ synonymously. We hope that we have clarified the use of uroflowmetry as an office test to assess voiding function without the insertion of urethral catheter and filling of the bladder to assess lower urinary tract function. Niels Klarskov and Gunnar Lose seem to use noninvasive urodynamics as an alternative term for uroflowmetry. However, other authors have stated a range of techniques such as drop spectrometry, condom catheter, penile cuff inflation/ deflation, penile compression and release and bladder wall thickness as well as uroflowmetry for non-invasive urodynamics. So the use of a nonspecific term such as non-invasive urodynamics may be completely misleading. With regard to their second comment —‘two of which (689 patients together) investigate the value of uroflowmetry and found no value of uroflowmetry in patients with uncomplicated SUI or predominant SUI’—we would like to point out that we have not stated the above in our manuscript. We share Niels Klarskov and Gunnar Lose’s concern about placing midurethral tapes in patients with voiding dysfunction. One of the RCTs in our systematic review had 11.9% of women with voiding dysfunction in the urodynamics group and all of them had a postvoid residual (PVR) <150 ml, which was their inclusion criteria. However, our systematic review included three RCTs. Based on their findings we have recommended performance of uroflowmetry and PVR scan as a part of office evaluation to exclude voiding dysfunction before contemplating surgery for SUI. So all of this argument about why to perform uroflowmetry and exclude voiding dysfunction if voiding dysfunction does not matter is irrelevant to our systematic review and metaanalysis. The sub-group analyses which the authorsmention in their letter is not a part of our systematic review and hence we cannot comment on its statistical significance.&