Felicity Park

Clinical evaluation of a first trimester algorithm predicting the risk of hypertensive disease of pregnancy

The aim of this study is to validate the Fetal Medicine Foundation (FMF) multiple logistic regression algorithm for prediction of risk of pre‐eclampsia in an Australian population. This model, which predicts risk using the population rate of pre‐eclampsia, a variety of demographic factors, mean maternal arterial blood pressure (MAP), uterine artery PI (UtA PI) and pregnancy‐associated plasma protein A (PAPP‐A), has been shown to predict early‐onset pre‐eclampsia (delivery prior to 34 weeks) in 95% of women at a 10% false‐positive rate.

Prediction and prevention of early‐onset pre‐eclampsia: impact of aspirin after first‐trimester screening

To examine the effect of a combination of screening and treatment with low‐dose aspirin on the prevalence of early‐onset pre‐eclampsia (PE).

Transverse occiput position: Using manual Rotation to aid Normal birth and improve delivery OUTcomes (TURN-OUT): A study protocol for a randomised controlled trial.

BackgroundFetal occiput transverse position in the form of deep transverse arrest has long been associated with caesarean section and instrumental vaginal delivery. Occiput transverse position incidentally found in the second stage of labour is also associated with operative delivery in high risk cohorts. There is evidence from cohort studies that prophylactic manual rotation reduces the caesarean section rate. This is a protocol for a double blind, multicentre, randomised, controlled clinical trial to define whether this intervention decreases the operative delivery (caesarean section, forceps or vacuum delivery) rate.Methods/DesignEligible participants will be ≥37 weeks pregnant, with a singleton pregnancy, and a cephalic presentation in the occiput transverse position on transabdominal ultrasound early in the second stage of labour. Based on a background risk of operative delivery of 49%, for a reduction to 35%, an alpha value of 0.05 and a beta value of 0.2, 416 participants will need to be enrolled. Participants will be randomised to either prophylactic manual rotation or a sham procedure. The primary outcome will be operative delivery. Secondary outcomes will be caesarean section, significant maternal mortality and morbidity, and significant perinatal mortality and morbidity.Analysis will be on an intention-to-treat basis. Primary and secondary outcomes will be compared using a chi-squared test. A logistic regression for the primary outcome will be undertaken to account for potential confounders. This study has been approved by the Ethics Review Committee (RPAH Zone) of the Sydney Local Health District, Sydney, Australia, (protocol number: X110410).DiscussionThis trial addresses an important clinical question concerning a commonly used procedure which has the potential to reduce operative delivery and its associated complications. Some issues discussed in the protocol include methods of assessing risk of bias due to inadequate masking of a procedural interventions, variations in intervention efficacy due to operator experience and the recruitment difficulties associated with intrapartum studies.Trial registrationThis trial was registered with the Australian New Zealand Clinical Trials Registry (identifier: ACTRN12613000005752) on 4 January 2013.

Demographic factors that can be used to predict early-onset pre-eclampsia

Abstract Objective: To define the maternal demographic factors that predicts the risk of developing early-onset pre-eclampsia (requiring delivery before 34 weeks’ gestation) in an Australian population. These are compared to risk factors described in a British population to determine whether the Fetal Medicine Foundation (FMF) risk algorithm for predicting early-onset pre-eclampsia needs to be modified for an Australian population. Methods: A secondary analysis of prospective cohorts in Australia and in the United Kingdom was conducted. Demographic details and past medical history were obtained. Odds ratios (ORs) for the development of early-onset pre-eclampsia were calculated for maternal factors in both populations. Forest plots were used to compare the two sets of odds ratios. Results: In the Australian population, pre-existing hypertension (OR 19.89, 95% CI 4.17–94.93) and body mass index >40 kg/m2 (OR 9.04, 95% CI 1.13–72.40) predicted risk of developing early-onset pre-eclampsia. There were no significant differences in the odds ratios for maternal factors in the two populations. Conclusions: This study shows that the ORs used to describe risks associated with maternal characteristics in the FMF algorithm for early-onset pre-eclampsia are consistent with those found in our local population. There does not appear to be any value in changing the weighting of demographic factors included in the FMF algorithm for an Australian population.

TNF-R1 as a first trimester marker for prediction of pre-eclampsia

Abstract Objective: To examine whether the maternal serum concentration of the soluble receptor-1 of tumor necrosis factor-α (TNF-R1) at 11–13 + 6 weeks of gestation is a predictor of development of pre-eclampsia (PE). Methods: This is a nested case–control study in which the concentration of TNF-R1 at 11 + 0 to 13 + 6 weeks was measured in 426 pregnant women in the first trimester. TNF-R1 values were expressed as multiples of the median (MoM) adjusted for maternal factors. The distributions of log TNF-R1 MoM in the control group and hypertensive disorders (early-PE [ePE], late-PE [lPE] and gestational hypertension [GH]) groups were compared. Logistic regression analysis was used to determine whether maternal factors, TNF-R1 or their combination make a significant contribution to the prediction of PE. Screening performance was determined by analysis of receiver–operating characteristics curves. Results: Median concentration of TNF-R1 (ng/ml) was higher in ePE (2.62 ± 0.67), lPE (2.12 ± 0.56) and GH (2.19 ± 0.45) compared to controls (2.04 ± 0.42), p = 0.001. Logistic regression analysis demonstrated that the addition of TNFR-1 to maternal factors did not make a significant contribution to the prediction of PE. Conclusions: The maternal serum TNF-R1 concentration at 11–13 + 6 weeks of gestation was increased in pregnancies which developed hypertensive disorders, however, the addition of TNFR-1 did not improve the detection rate of these conditions compared with maternal factors alone.

29 – Intraabdominal Masses

Intraabdominal masses are rare and often only recognized in the third trimester of pregnancy. There are typically multiple options for diagnosis, but the differential diagnosis can be narrowed by considering the locality and consistency of the lesion. Magnetic resonance imaging may be useful. Some cases will have other concurrent pathology. Karyotyping may be needed.

Epidemic of large babies highlighted by use of INTERGROWTH21st international standard

To compare birth weights in central Sydney to the INTERGROWTH21st international standard to describe current trends in relation to optimal growth and to define areas that may benefit from improved obstetric surveillance and intervention.