Hatem A. Mousa

Postnatal screening for thrombophilia in women with severe pregnancy complications.

Objective To examine the prevalence of maternal thrombophilia in women with severe preeclampsia/eclampsia, placental abruption, fetal growth restriction, and unexplained stillbirth. Methods We studied 102 women who had pregnancy complications and 44 healthy women with uncomplicated pregnancies. All women were tested 10 weeks postpartum for mutations of factor V Leiden, methylenetetrahydrofolate reductase (MTHFR) C677T, and G20210A prothrombin gene; deficiencies of protein C, protein S, and antithrombin III; and the presence of lupus anticoagulant and anticardiolipin antibodies. We aimed to recruit 100 cases and 300 controls to detect a 10% difference in thrombophilia between the groups. However, we were able to recruit only 44 controls. Results Abnormal thrombophilia screen was found in 54 women with pregnancy complications (53%) and in 17 women (39%) with normal pregnancies (odds ratio [OR] 1.8; 95% confidence interval [CI] 0.87, 3.67). Mutations encoding for factor V Leiden, G20210A prothrombin gene, and MTHFR C677T (homozygous) were identified in 18% of women with complications compared with 16% of controls (OR 1.1; 95% CI 0.44, 2.94). Activated protein C resistance, not due to factor V Leiden mutation, was the most common thrombophilic defect, found in 26% of women with pregnancy complications compared with 18% of controls Conclusion In our cohort of women with pregnancy complications, maternal thrombophilia was less common than previously thought, and multiple thrombophilias were not a major additional risk factor

Major postpartum hemorrhage: survey of maternity units in the United Kingdom

Background.  To determine current clinical practice among different maternity units in the United Kingdom for the management of major postpartum hemorrhage.

Thrombin activatable fibrinolysis inhibitor and its fibrinolytic effect in normal pregnancy

We investigated changes in both thrombin activatable fibrinolysis inhibitor (TAFI) antigen levels and its functional effect on in vitro fibrinolysis in normal pregnancy. 152 pregnant women and 31 women in the immediate postpartum period were studied, with pregnancy divided into 6 windows at 4 weekly intervals. As TAFI influences and is in turn influenced by components of the protein C (PC) pathway, its measurements were correlated with levels of soluble thrombomodulin, PC, protein S (PS) and the overall phenotype of activated PC resistance (APCR). Compared with mean TAFI levels at booking gestation (6.6 +/- 1.2 microg/ml), levels peaked at 35-39 weeks gestation (9.6 +/- 2 microg/ml, p = 0.001), followed by a significant drop within 24 hours of delivery (7.2 +/- 1.1 microg/ml). In functional terms, the mean clot lysis time (CLT) (101 +/- 13 min at booking) also peaked at 35-39 weeks gestation (141 +/- 42 min, p = 0.007) and dropped after delivery (99 +/- 33 min), and was significantly correlated with gestational age (r = 0.410, p = 0.001) and could be abrogated in the presence of an inhibitor to TAFI activation. A significant negative correlation was found between TAFI levels and APCR (r = -0.478, p <0.001), APCRV (r = -0.598; p <0.001), PS (r = -0.490, P <0.001) and PC (r = -0.198, p = 0.02). In summary, there is a significant increase in TAFI levels, which translates into increased CLT during pregnancy. Furthermore, changes in TAFI contribute to the increasing APCR of pregnancy.

Evaluating the Intra- and Interobserver Reliability of Three-Dimensional Ultrasound and Power Doppler Angiography (3D-PDA) for Assessment of Placental Volume and Vascularity in the Second Trimester of Pregnancy

Three-dimensional (3-D) power Doppler angiography (3-D-PDA) allows visualisation of Doppler signals within the placenta and their quantification is possible by the generation of vascular indices by the 4-D View software programme. This study aimed to investigate intra- and interobserver reproducibility of 3-D-PDA analysis of stored datasets at varying gestations with the ultimate goal being to develop a tool for predicting placental dysfunction. Women with an uncomplicated, viable singleton pregnancy were scanned at 12, 16 or 20 weeks gestational age groups. 3-D-PDA datasets acquired of the whole placenta were analysed using the VOCAL software processing tool. Each volume was analysed by three observers twice in the A plane. Intra- and interobserver reliability was assessed by intraclass correlation coefficients (ICCs) and Bland Altman plots. At each gestational age group, 20 low risk women were scanned resulting in 60 datasets in total. The ICC demonstrated a high level of measurement reliability at each gestation with intraobserver values >0.90 and interobserver values of >0.6 for the vascular indices. Bland Altman plots also showed high levels of agreement. Systematic bias was seen at 20 weeks in the vascular indices obtained by different observers. This study demonstrates that 3-D-PDA data can be measured reliably by different observers from stored datasets up to 18 weeks gestation. Measurements become less reliable as gestation advances with bias between observers evident at 20 weeks.

Evaluation of the Intraobserver and Interobserver Reliability of Data Acquisition for Three-Dimensional Power Doppler Angiography of the Whole Placenta at 12 Weeks Gestation

The aim of this study was to investigate the intra- and interobserver reproducibility of three-dimensional (3-D) power Doppler (3-DPD) data acquisition from women at 12 weeks gestation, which were then subsequently measured by a single observer. Women with an uncomplicated, viable singleton pregnancy were scanned between 12 + 0 and 13 + 6 weeks gestations with a Voluson 730 Expert. 3-DPD data were acquired of the whole placenta by two observers: the first observer captured two datasets and the second a single dataset. Each dataset was analysed using VOCAL in the A plane with 9 degree rotation steps. Eighteen low risk women were recruited with a total of 54 datasets analysed. The intraclass correlation coefficient (ICC) was highest for the vascular indices vascularisation index (VI) and vascularisation-flow index (VFI), greater than 0.75. ICC for flow index (FI) showed moderate correlation at 0.47 to 0.65. Bland Altman plots showed the most precise vascular index to be the FI (-15% to 10% for interobserver agreement). There was no bias between datasets. Prospective studies are now required to identify if this analysis tool and method is sensitive enough to recognise patients with early-onset placental dysfunction.

Do practice guidelines guide practice? A prospective audit of induction of labor – three years experience

Background. To examine the effect of implementation of guidelines for induction of labor on the process of care and outcome measures.

Omental pregnancy in a woman taking the progestogen‐only pill

A 25-year-old, gravida 6, para 4, was referred to the Early Pregnancy Assessment Unit with 6 weeks of amenorrhea and ten days history of progressive non-specific abdominal pain. She was taking the progestogen-only pill (POP), norethisterone 0.35 mg/daily (Micronor, Jassen – Cilag, United Kingdom), and there was no history of missed pills over the past six weeks. Her periods were regular but her last period was lighter and lasted three instead of five days. She had had four full term normal vaginal deliveries with no previous history of pelvic inflammatory diseases. She stopped taking the combined oral contraceptive pill at the age of 22 due to migraine headaches and was advised to take the POP. Ten days earlier, she had presented to the Emergency Department with a history of non-specific lower abdominal pain. She was given antibiotics for a presumptive diagnosis of urinary tract infection. Three days prior to admission, she was seen by her General Practitioner for lower abdominal pain and fainting attack. A mild analgesic was prescribed. Pregnancy test was not carried out on the two previous occasions. On examination, she was hemodynamically stable. There was localized tenderness in the left iliac fossa but there were no signs of peritonism. Bimanual pelvic assessment revealed a slightly tender, normal sized uterus with a closed external cervical os. She had cervical excitation with left adnexa tenderness but no adnexal mass was palpable. There was no vaginal bleeding and the pregnancy test was positive. Ultrasound scan (transabdominal and transvaginal) demonstrated a thickened endometrial lining, no intrauterine gestational sac and the right ovary appeared normal. On the left, two complex masses of mixed echogenicity were noted and these measured 73¿61¿28 mm and 47¿42¿38 mm. The left ovary could not be identified. Free fluid was noted in the pelvis. Her serum b human chorionic gonadotrophin (b-hCG) was 21107 IU/L. The findings and investigations were suggestive of an ectopic pregnancy with a complex ovarian cyst. An exploratory laparotomy was carried out through a transverse suprapubic incision. A 7¿5¿2 cm mass consisting of blood clots and tissue fragments was found attached to the omentum and the posterior aspect of the left broad ligament. The left ovary was enlarged by 4¿4¿4 cm corpus luteum cyst. The uterus, right ovary and right tube were normal. The left tube was normal in caliber with no evidence of enlargement or active bleeding. There was 300 ml of blood and blood clots in the Pouch of Douglas. Active bleeding occurred during separ-

Clinical evaluation of the IONA test: a non-invasive prenatal screening test for trisomies 21, 18 and 13.

To evaluate the clinical accuracy of the IONA® test for aneuploidy screening.

Fractional volume of placental vessels in women with diabetes using a novel stereological 3D power Doppler technique

OBJECTIVES In maternal diabetes the placenta is large with abnormal vascular development and increased villous volume. We used a novel stereological 3D power Doppler ultrasound technique to investigate differences in-vivo in the placental fractional volume of power Doppler signal (FrVol-PD) between women with and without diabetes. METHODS We recruited 17 pregnant women with pre-gestational diabetes and 20 controls, all with anterior placentae. Each subject had ultrasound scans (Voluson 730 Expert) every 4 weeks between 12 and 32 weeks gestation. 3D power Doppler data were acquired and the placenta manually outlined using VOCAL (4D View). Power Doppler signal within the resultant volume was counted in a 3D manner adapting the random but systematic techniques used in stereology. RESULTS Subjects were of similar age, BMI and parity. From 16 weeks the mean (SD) placental FrVol-PD was higher in the non-diabetic than in the diabetic group: 16 weeks - 0.125 (0.03) versus 0.108 (0.03), 20 weeks - 0.144 (0.05) versus 0.104 (0.03), 24 weeks - 0.145 (0.05) versus 0.128 (0.03), 28 weeks - 0.159 (0.05) versus 0.133 (0.02) and 32 weeks - 0.154 (0.03) versus 0.123 (0.04). These differences were significant between control and diabetic subjects [F(1,35) = 4.737, p = 0.036] and across gestation [F(3,140) = 8.294, p < 0.001]. CONCLUSION Using a novel stereological-based ultrasound technique we have demonstrated the reliability of this application in the placenta. This technique shows promise for non-invasive assessment of placental function: further studies are required to identify if structural changes in a diabetic placenta are accompanied by altered function, manifest as reduced perfusion demonstrable in-vivo.

Small for gestational age: Case definition & guidelines for data collection, analysis, and presentation of maternal immunisation safety data

2017 Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).