Gerald Marquette

Caesarean Section on Maternal Request: Risks and Benefits in Healthy Nulliparous Women and Their Infants

OBJECTIVE To determine the risks and benefits of an elective Caesarean section (CS) at term in healthy nulliparous women. METHODS We conducted a population-based cohort study of deliveries between 1994 and 2002. Using bivariate and multivariable techniques, we compared maternal and neonatal outcomes in healthy nulliparous women who had undergone elective pre-labour CS (using breech presentation as a surrogate) with those in women who had undergone spontaneous labour with anticipated vaginal delivery (SL) at full term. RESULTS There were 1046 deliveries in the pre-labour CS group and 38 021 in the SL group. Life-threatening maternal morbidity was similar in each group. Life-threatening neonatal morbidity was decreased in the CS group (RR 0.34; 99% CI 0.12 to 0.97). Subgroup analysis of the SL group by mode of delivery demonstrated the increased neonatal risk was associated with operative vaginal delivery and intrapartum CS but not spontaneous vaginal delivery. CONCLUSION An elective pre-labour Caesarean section in a nulliparous woman at full term decreased the risk of life-threatening neonatal morbidity compared with spontaneous labour with anticipated vaginal delivery. However, the 63% of women with spontaneous labour who achieved a spontaneous vaginal delivery would not have benefited from delivery by Caesarean section. Further research is needed to better identify women with an increased likelihood of an operative vaginal or intrapartum Caesarean section, as this may assist maternity caregivers in decision-making about childbirth. Further research is also needed to determine if these findings can be confirmed in a prospective study.

Timing of delivery for pregnancies with congenital diaphragmatic hernia

Please cite this paper as: Hutcheon J, Butler B, Lisonkova S, Marquette G, Mayer C, Skoll A, Joseph K. Timing of delivery for pregnancies with congenital diaphragmatic hernia. BJOG 2010;117:1658–1662.

First-Trimester Imaging of Combined Esophageal and Duodenal Atresia Without a Tracheoesophageal Fistula

To the Editor: A 39-year-old healthy primigravida was referred to our Fetal Diagnostic Service at 12 weeks’ gestation because of a recent sonographic finding of a fetal intra-abdominal malformation. At 12 weeks’ gestation, our images revealed that the biometric measurements were appropriate; the nuchal translucency was normal; and there was a single large cystic structure in the anterior upper abdomen. In Figure 1, the left image shows the large single cyst. The right image, lower in the abdomen, could be misinterpreted as a “double-bubble” sign. No other abnormality was seen. It was thought that these findings were more consistent with a dual obstruction of both the esophagus and the duodenum. After the diagnosis of trisomy 21 on chorionic villous sampling and pregnancy termination, fetal autopsy revealed atresia of both the duodenum and esophagus without a tracheoesophageal fistula. Tsukerman et al1 reported a case of duodenal stenosis and esophageal atresia in the first trimester in a fetus with a normal karyotype. The lesion they described was similar to a doublebubble sign consistent with isolated duodenal atresia during the first trimester.2 With a closed loop, we could postulate that the degree of duodenal and gastric distention is much greater than with isolated duodenal atresia. In our case, we observed a single large cystic lesion in the upper abdomen in the first trimester, in accordance with the observations of Estroff et al3 in the second trimester. It is possible that this arose because this closed loop of bowel had no possibility of drainage from a tracheoesophageal fistula. To our knowledge, this was the first time that this observation was made during the first trimester. In the near future, we will likely rely more on prenatal screening with nuchal translucency late in the first trimester. Sonographic findings similar to ours would be useful for adjusting the risk of aneuploidy. This would allow earlier prenatal diagnosis and possibly pregnancy termination at a gestational age that would be suitable for dilation and evacuation with a lesser degree of maternal morbidity.

P19.01: Previable premature rupture of membranes in dichorionic twin pregnancies: selective reduction or expectant management? A retrospective case series: Poster discussion hub abstracts

diagnosis of two diseases were searched and the diagnostic value was evaluated. Results: Quantile (Q) value of the internal diameter of the aorta (AO Q-score), the ratio of the diameter of the pulmonary artery to the internal diameter of the aorta (PA/AO), and Q value of the ratio of the diameter of the pulmonary artery to the internal diameter of the aorta (PA/AO Q-score) were the key parameters for the differential diagnosis of fetal large VSD and TOF. PA/AO is the primary parameter, which area under the curve (AUC) of PA/AO is 0.951. The mean value of PA/AO in normal fetuses was 1.22, in fetuses with large VSD was 1.21, and in TOF fetuses was 0.49. If we set the threshold of two differential diagnosis of PA/AO to 0.89, then the diagnostic sensitivity can be guaranteed more than 90% in range of false positive rate of 10%. Conclusions: The accuracy of ultrasonic diagnostic parameters of large VSD and TOF is high by medical data statistics and big data analysis. It provides a new way for prenatal diagnosis of large VSD and TOF.

Outcomes of Selective Reduction of DCDA Twins Complicated by PV-PROM Compared with Expectant Management: A Case Series and Review of the Literature

OBJECTIVE To report the outcomes of selective reduction (SR) in dichorionic twins complicated by pre-viable, premature rupture of membranes (PV-PROM). METHODS Retrospective case series. Ultrasound database was searched for cases of dichorionic twin pregnancy with PV-PROM, either managed conservatively or with SR. Chart reviews were done for these cases. Simple descriptive statistics were used where appropriate. RESULTS Twenty-two cases of expectantly managed dichorionic twins complicated by PV-PROM with delivery information were available for analysis. Mean GA at PV-PROM was 20.6 weeks, mean GA of delivery was 27.6 weeks, and the mean latency was 39.6 days. There were five cases of SR following PV-PROM in dichorionic twin pregnancies. Mean GA of PV-PROM was 17.0 weeks. Average time from PV-PROM to procedure was 2.5 weeks. Mean GA of delivery of the surviving fetus was 32.6 weeks (P = 0.20) with mean latency of 108 days (P = 0.06). Twelve additional cases have been published and are summarized along with our five cases. CONCLUSION There was a trend towards an increase in latency interval between cases of PV-PROM managed by SR and expectant management in our institution. When combined with the existing literature data, there may be an improvement in latency.

OC156: Is the estimated fetal weight a good predictor of success for external cephalic version?

women once a week from week 35 + 0 till 39 + 0 and twice a week from week 39 + 1 till spontaneous labour. The length of the cervix from the membranes covering the internal os to the external os was measured. An experienced midwife estimated the Bishop score. In our second study the new classification (UCR) and the cervical length was determined in women with normal pregnancies before starting induction of labour based on the midwives’ examination of the cervix. The Bishop score was noted. Results: The new classification is based on a dynamic ultrasound examination and includes three visible parameters: