David A. Crosby

Is routine transvaginal cervical length measurement cost-effective in a population where the risk of spontaneous preterm birth is low?

A recent meta‐analysis has suggested that routine measurement of the cervical length should be performed in conjunction with the anomaly scan to identify a group of women at increased risk of preterm delivery. We decided to investigate whether this recommendation is justifiable in a population where the risk of preterm birth is low.

A longitudinal study of unplanned pregnancy in a maternity hospital setting

To review family planning in a cohort of women who delivered a second child within 3 years of their first.

Interpregnancy weight changes and impact on pregnancy outcome in a cohort of women with a macrosomic first delivery: a prospective longitudinal study

Objective To determine the median interpregnancy maternal weight change between first and second pregnancies, and second and third pregnancies and to assess the impact of this weight change on pregnancy outcome in a cohort of women with a macrosomic first delivery. Study design Prospective longitudinal study conducted over three pregnancies from 2007 to 2015. Setting Tertiary referral maternity hospital, Dublin, Ireland. Participants Women were recruited if their first baby weighed >4.0 kg. Methods The pregnancy outcomes in the second and third pregnancies were analysed separately. Data were also analysed for both interpregnancy intervals comparing outcomes for those who gained any weight, or more weight than the median, with those who did not. Main outcome measures Recurrent fetal macrosomia ≥4.0 kg and gestational diabetes mellitus. Results There were 280 women who delivered a third baby between 2011 and 2015. There were no differences in pregnancy outcomes for the second pregnancy in women who gained interpregnancy weight compared with those who did not and those who gained more interpregnancy weight than the median compared with those who did not. There was a statistically significant increase in birth weight ≥4.0 kg (54.0% vs 39.6% p=0.03) in those women who gained any weight between the second and third pregnancies. In those women who gained more interpregnancy weight than the median (1.70 kg) between a second and third pregnancy, there was a significant increase in the rate of gestational diabetes (6.5% vs 1.4%, p=0.03). Conclusions This longitudinal study demonstrates that within this cohort maternal interpregnancy weight change between a second and third pregnancy is associated with an increase in birth weight ≥4.0 kg. Additionally, a gain of more weight than the median (1.70 kg) is associated with a higher rate of gestational diabetes.

Age considerations in the management of recurring miscarriage

Dear Editor, We found that in women ≥ 40 years old with recurrent miscarriage (RM), cytogenetic errors are common and antiphospholipid syndrome (APLS) is uncommon. The incidence of RM is between 1 and 5%, with some heterogeneity among the definitions used [1, 2]. Recent reports suggest that the incidence of RM may have increased over the past decade [3]. Some of this increase may be attributed to improved case recognition, while the sociodemographic shift towards delayed childbearing continues to present clinically in age-related pregnancy losses. Chromosomal errors occur more frequently in the conceptions of older women [2]. Despite this, most RM guidelines adopt a standardised approach to investigation and management for women regardless of age. This non-specific approach exposes RM patients to possible delay and even to potential harm from empiric therapies while inappropriate, expensive investigations are undertaken. We performed a retrospective study of patients attending the RM service in a large tertiary referral centre between 2014 and 2017. Data on demographics, clinical features, investigations, management, and obstetric outcomes were analysed by female age groups: (i) 25 to 34, (ii) 35 to 39, and (iii) ≥ 40 years. Anti-Müllerian hormone (AMH) testing was offered to women ≥ 35 years. One hundred seventy cases of RM were analysed. The mean age of women attending the service was 36.3 years (range 22–43). Approximately one third of patients were aged 25–34 years, one third were aged 35–39 years, and almost one third were women over the age of 40 years. Only 2.4% of cases (n = 4) were found to be due to APLS; none of these cases were in women ≥ 40 years. Where karyotype analyses on products of conception (POC) were available (27.1%, n = 46), chromosomal abnormality was demonstrated in the majority of cases (76.1%, n = 35). In women ≥ 35 years who had AMH testing, the median AMH was 7.5 pmol/L (SD12.7). Outcome data on the RM patients are generally reassuring. Half of all the patients with RMwent on to conceive again and the majority had successful outcomes. 78.8% (n = 67) had live born infants and 21.2% (n = 18) suffered a subsequent miscarriage. Outcome data on subsequent pregnancies was stratified according to female age (Table 1). In women over 40 years (n = 49), 51.0% (n = 25) conceived again. Of these, 72.0% (n = 18) had a live birth and the subsequent miscarriage rate was 28.0% (n = 7). One of the challenges in managing patients with idiopathic RM is in counselling individuals on how best to optimise their chances of one or more live births. The significant psychological impact of RM on patients must be considered in adopting an expectant management approach. In an attempt to individualise advice, we routinely assess ovarian reserve (OR) (AMH and antral follicle count). We counsel those with low OR about the potential implications of diminishing OR on family size [4] and advise them to attend fertility services if not pregnant within 4–6 months of trying to conceive. In those womenwith lowAMH result (< 5 pmol/L, n = 29), 51.7% (n = 15) conceived again. Of these, 80.0% (n = 12) had a live birth and the subsequent miscarriage rate was 20.0% (n = 3). In conclusion, in women ≥ 40 years with RM, APLS is rare. Formal testing for APLS can introduce delay, especially in instances where the test needs to be repeated 12 weeks apart [5]. As cytogenetic evaluation of the POC is much more likely to identify the cause of miscarriage, we suggest that women ≥ 40 years presenting with less than three consecutive miscarriages should be offered this test; it is likely to explain the cause and thereby obviate the need for thrombophilia testing or other approaches which are unlikely to benefit the patient. An AMH level < 5 pmol/L in women ≥ 35 years does not appear to increase the rate of miscarriage in subsequent pregnancy. * David A. Crosby crosbyd@tcd.ie