Fionnuala Mone

Should we recommend universal aspirin for all pregnant women

&NA; Low‐dose aspirin has been demonstrated to reduce the incidence of preeclampsia and fetal growth restriction in at‐risk populations. Its role in low‐risk populations is as yet unknown. Novel preeclampsia screening tests are emerging that can predict the risk of the development of preeclampsia from as early as 11 weeks of gestation. It may be more efficacious, acceptable, and cost‐effective to prescribe low‐dose aspirin to all pregnant women from the first trimester as opposed to performing a screening test in the first instance. There is variation in opinion: the American College of Obstetricians and Gynecologists suggests the use of aspirin only in women who are at risk of preeclampsia, based on patient history; the National Institute for Health and Clinical Excellence, UK, and the US Preventative Services Task Force recommend the use of low‐dose aspirin if there is 1 major or 2 moderate risk factors. This point‐counterpoint discussion shall address (1) controversies regarding the real impact of low‐dose aspirin; (2) controversies in the actual guidelines among the different national societies; (3) controversies regarding emerging preeclampsia screening tests in terms of cost‐effectiveness and efficacy, and (4) points in favor of the provision of universal vs screened‐positive women.

Prenatal detection of structural cardiac defects and presence of associated anomalies: a retrospective observational study of 1262 fetal echocardiograms

The aim of this study is to document the detection of fetal congenital heart defect (CHD) in relation to the following: (1) indication for referral, (2) chromosomal and (3) extracardiac abnormalities.

Predicting why women have elective repeat cesarean deliveries and predictors of successful vaginal birth after cesarean

To compare the characteristics of women who select elective repeat cesarean rather than trial of labor after cesarean (TOLAC) for delivery, and to determine individual predictors for success and failure within a TOLAC group and observe differences in maternal and neonatal morbidity.

Vaginal birth after caesarean section prediction models: a UK comparative observational study.

OBJECTIVE Primarily, to assess the performance of three statistical models in predicting successful vaginal birth in patients attempting a trial of labour after one previous lower segment caesarean section (TOLAC). The statistically most reliable models were subsequently subjected to validation testing in a local antenatal population. STUDY DESIGN A retrospective observational study was performed with study data collected from the Northern Ireland Maternity Service Database (NIMATs). The study population included all women that underwent a TOLAC (n=385) from 2010 to 2012 in a regional UK obstetric unit. Data was collected from the Northern Ireland Maternity Service Database (NIMATs). Area under the curve (AUC) and correlation analysis was performed. RESULTS Of the three prediction models evaluated, AUC calculations for the Smith et al., Grobman et al. and Troyer and Parisi Models were 0.74, 0.72 and 0.65, respectively. Using the Smith et al. model, 52% of women had a low risk of caesarean section (CS) (predicted VBAC >72%) and 20% had a high risk of CS (predicted VBAC <60%), of whom 20% and 63% had delivery by CS. The fit between observed and predicted outcome in this study cohort using the Smith et al. and Grobman et al. models were greatest (Chi-square test, p=0.228 and 0.904), validating both within the population. CONCLUSION The Smith et al. and Grobman et al. models could potentially be utilized within the UK to provide women with an informed choice when deciding on mode of delivery after a previous CS.

Outcome following selective fetoscopic laser ablation for twin to twin transfusion syndrome: an 8 year national collaborative experience

OBJECTIVE With the recognition of the role of fetoscopic laser ablation for twin to twin transfusion syndrome (TTTS), there is a requirement for auditable standards for this technically challenging and specialized treatment. The purpose of this study is to report on the perinatal and medium-term neurodevelopmental outcomes following an 8-year national single center experience in the management of TTTS using the selective fetoscopic laser ablation technique. STUDY DESIGN An audit of all cases of TTTS treated with selective laser ablation by a single national fetal medicine team was performed. Overall perinatal survival and medium-term neurodevelopmental outcomes were reported and correlated with gestational age at diagnosis, placental location, volume of amnio-reduction, Quintero staging and percentage inter-twin growth discordance. Procedure-related complications were recorded. RESULTS The overall fetal survival for the first 105 consecutive cases of TTTS was 61% (128/210 fetuses). Dual survival occurred in 47% (49/105) of cases, and with a single survival rate of 28% (30/105), perinatal survival of least one infant was achieved in 75% (79/105) of cases. No correlation was found between any clinical or sonographic marker and perinatal outcome, although dual survival was noted to be significantly decreased with increasing Quintero stage (p=0.041). Currently, 86% of survivors have been reported to have a normal medium-term neurological outcome. CONCLUSION Fetoscopic laser ablation is the established optimal treatment for severe twin to twin transfusion syndrome (TTTS). We report comparable short and medium-term outcomes following the selective fetoscopic technique comparing results from our national program with internationally published single-center outcomes, supporting the efficacy and safety of this treatment at our center.

An open-label randomized-controlled trial of low dose aspirin with an early screening test for pre-eclampsia and growth restriction (TEST): Trial protocol

OBJECTIVE Pre-eclampsia remains a worldwide cause of maternal and perinatal morbidity and mortality. Low dose aspirin (LDA) can reduce the occurrence of pre-eclampsia in women with identifiable risk factors. Emerging screening tests can determine the maternal risk of developing placental disease, such as pre-eclampsia from the first trimester of pregnancy. The aim of this study is to determine if it is more beneficial in terms of efficacy and acceptability to routinely prescribe LDA to nulliparous low-risk women compared to test indicated LDA on the basis of a positive screening test for placental disease. METHODS We propose a three armed multi-center open-labeled randomized control trial of; (i) routine LDA, (ii) no aspirin, and (iii) LDA on the basis of a positive first trimester pre-eclampsia screening test. LDA (75mg once daily) shall be given from the first trimester until 36-week gestation. The primary outcome measures include; (i) the proportion of eligible women that agree to participate (acceptability), (ii) compliance with study protocol (acceptability and feasibility), (iii) the proportion of women in whom it is possible to obtain first trimester trans-abdominal uterine artery Doppler examination (feasibility) and (iv) the proportion of women with a completed screening test that are issued the screening result within one week of having the test performed (feasibility). CONCLUSION This will be the first clinical trial to determine the efficacy and acceptability in low-risk women of taking routine LDA versus no aspirin versus LDA based on a positive first trimester screening test for the prevention of placental disease.

The clinical application of Doppler ultrasound in obstetrics

Current UK guidance advocates the use of uterine artery Doppler for screening and Doppler of the umbilical artery, middle cerebral artery and ductus venosus for surveillance and timing of delivery of the growth‐restricted fetus. This article examines available evidence concerning the clinical application of Doppler ultrasound in obstetrics, with the aim of guiding clinicians in its application. With increasing acceptance of the concept of ‘inversion of the pyramid of antenatal care’, the use of Doppler in the first trimester is also discussed.

Low‐dose aspirin and calcium supplementation for the prevention of pre‐eclampsia

Pre‐eclampsia is a serious systemic condition, which affects 3–5% of all pregnancies and accounts for a significant number of maternal deaths annually. Administration of anti‐platelet agents to women at risk of pre‐eclampsia leads to a 17% reduction in the risk of developing this condition. Calcium supplementation during pregnancy may also be an effective measure to reduce the incidence of pre‐eclampsia within high‐risk populations.

Fetal Umbilical Artery Doppler Pulsatility Index as a Predictor of Cardiovascular Risk Factors in Children - A Long-Term Follow Up Study

Abstract Objective: To determine if high umbilical artery Doppler (UAD) pulsatility index (PI) is associated with cardio-vascular (CV) risk-factors in children at age 12 years. Methods: We studied 195 children at age 12 years who had had in-utero UAD studies performed at 28 weeks’ gestation. The children were grouped according to whether their umbilical Doppler PI was high (indicating poor feto-placental circulation) or normal. At age 12 years we assessed CV risk factors, including anthropometric measures, blood pressure, pulse wave velocity (a measure of arterial compliance), cardio-respiratory fitness, and homocysteine and cholesterol serum levels. Results: Compared with children with a normal UAD PI (N = 88), the children (N = 107) with high UAD PI had higher resting pulse rate (p = 0.04), higher pulse wave velocity (p = 0.046), higher serum homocysteine levels (p = 0.032) and reduced arterial compliance (7.58 versus 8.50 m/s, p = 0.029) using univariate analysis. These differences were not present when adjusting for cofounders was modeled. Conclusion: High PI on UAD testing in-utero may be associated with increased likelihood of some CV risk factors at age 12-years but confounding variables may be as important. Our study raises possible long-term benefits of in-utero UAD measurements.

Clinical disparity of haemolytic disease of the fetus and newborn in twin pregnancy

Dear Sir, A 32-year-old Caucasian woman, blood group O RhD-negative (cde/cde, rr), gravida 4 para 2, presented to our institution for management of a spontaneously conceived dichorionic twin pregnancy. Her previous pregnancy was affected by Haemolytic Disease of the Fetus and Newborn (HDFN), necessitating induction at 38 weeks gestation for elevated and rising levels of anti-D and the baby required phototherapy after delivery. This current pregnancy was a dichorionic twin pregnancy. Both anti-D and anti-G antibodies were detected through indirect antiglobulin testing in a maternal sample at 13 weeks gestation. Anti-D antibody levels were quantified using the Astoria Pacific International 300 (API 300) continuous flow analyser (CFA) using group O R1R1 (CCDDee) reagent cells (Marsh et al., 1968) and are measured in IU mL−1. The following levels of anti-D were used to guide management; <4 (HDFN unlikely), 4–15 (moderate risk of HDFN), >15 (risk of severe HDFN) (Gooch et al., 2007). Anti-D quantitation levels are provided in Table 1. The patient underwent surveillance for fetal anaemia with middle cerebral artery (MCA) Doppler studies once and subsequently twice weekly from 24 weeks gestation. Owing to increasing MCA Doppler Peak systolic velocity values (PSVs) as shown in Table 1, twin A required three intrauterine transfusions (IUTs) by cordocentesis of packed red blood cells (PRCs) of 100, 60 and 160 mL at 27, 29 and 34 weeks gestation, respectively. Anti-D antibody levels rose dramatically to 330 IU/mL following the first IUT. While twin B had evidence of mild intrauterine fetal anaemia (PSV 1·5 MoMs), this did not persist and an IUT was not required. There was no evidence of hydrops or fetal compromise in either twin throughout the pregnancy. The twins were delivered via caesarean section at 34 weeks and 3 days of gestation for the indication of suspected chorioamnionitis. Twin A was 2·4 kg with Apgar scores of nine at 1 and 5 min. Twin A was blood group O RhD-positive (R2r phenotype) cDE/cde, with a strongly positive direct antiglobulin test (DAT) (4+, IgG), haemoglobin of 16·9 g/dL, reticulocytes 222× 109 L−1 (4·2%) and bilirubin of 132 μmol L−1. On the first day of life this infant received intravenous immunoglobulin, phototherapy and a subsequent double volume exchange transfusion using irradiated whole O RhD-negative blood at 8 hours of life in addition