Isabelle Dehaene

Thinking ahead--the rising tide of AIDS orphans.

656 For many years the worldwide community has been committed to the fight against HIV/AIDS. Many battles have been fought already. The implementation of prevention of mother-to-child transmission of HIV and increased accessibility of antiretroviral (ARV) treatment in developing countries are the latest milestones in the world’s response to AIDS. In addition to piloting and monitoring prevention and treatment programmes, a significant part of research nowadays focuses on the demographic, geopolitical and economic impact of AIDS, both at present and in the future. Furthermore, mathematical modelling experts have provided insights on how prevention and treatment (or the lack of it) may influence future trends of the HIV epidemic. Perhaps the latest trend in public health research on HIV is an increased focus on assessment of homeand community-based care programmes for people and/or families affected by HIV/AIDS.

How an extended perinatal audit may improve perinatal policy.

Abstract Objective: A perinatal audit has the intention of quality of care improvement based on analysis of perinatal death, with our without analysis of maternal morbidity and/or mortality. Additional analysis of cases of intrapartum asphyxia could provide more insight into ways to improve quality of perinatal care. Methods: Analysis of cases of perinatal death and asphyxia in Jan Yperman Hospital, Ieper, Belgium, in 2012. Results: Three perinatal deaths occurred, none were preventable. Nineteen cases of proven metabolic acidosis have been identified. Three cases are considered possibly preventable, four cases are considered preventable. In three (possibly) preventable cases, foetal monitoring was absent during the active second stage of labour. In two preventable cases, intervention following a significant ST event in the second stage of labour was delayed. In one case intervention was delayed in the first stage of labour, while in another, indicated operative delivery in the second stage was not conducted. Conclusions: Integrating intrapartum asphyxia in the perinatal audit gives an opportunity to identify and eliminate weak points in the perinatal care chain, thereby optimizing quality of care. Lessons learned from our internal audit are the value of foetal monitoring and adequate action on significant ST events during second stage of labour.

Creatine kinase as an indicator for hysterectomy in postpartum endomyometritis due to group A streptococci: a hypothesis illustrated by a case report.

Background: Puerperal group A streptococcus (GAS) infection, once the leading cause of postpartum sepsis, has been increasing again since the 1980s. Streptococcal toxic shock syndrome (STSS) is a serious complication characterized by rapidly spreading GAS infection, shock, and multiple organ failure. Immediate recognition and implementation of therapy is crucial for survival. Making informed decisions regarding surgical debridement, namely hysterectomy, based on clinical indicators is difficult for practitioners. Objectives: This article discusses the potential role of creatine kinase in the decision-making process for treatment of STSS, particularly with regard to hysterectomy. Material and Methods: A case report is presented. The literature was searched using the key words ‘group A streptococcus’, ‘postpartum hysterectomy’, ‘creatine kinase’, ‘endomyometritis’, and ‘streptococcal toxic shock syndrome’ in PubMed and the UptoDate database. Relevant articles published between 1991 and 2011 were evaluated. Conclusion: Decisions regarding hysterectomy in STSS management are difficult. A rise in CK levels in the serum may indicate involvement of the myometrium and may be an important parameter in the difficult decision of hysterectomy when treating STSS.

Maintaining and repeating tocolysis: A reflection on evidence

It is inherent to human logic that both doctors and patients want to suppress uterine contractions when a woman presents in threatened preterm labor. Tocolysis is widely applied in women with threatened preterm labor with a variety of drugs. According to literature, tocolysis is indicated to enable transfer to a tertiary center as well as to ensure the administration of corticosteroids for fetal maturation. There is international discrepancy in the content and the implementation of guidelines on preterm labor. Tocolysis is often maintained or repeated. Nevertheless, the benefit of prolonging pregnancy has not yet been proven, and it is not impossible that prolongation of the pregnancy in a potential hostile environment could harm the fetus. Here we reflect on the use of tocolysis, focusing on maintenance and repeated tocolysis, and compare international guidelines and practices to available evidence. Finally, we propose strategies to improve the evaluation and use of tocolytics, with potential implications for future research.

Can the cerebroplacental ratio (CPR) predict intrapartum fetal compromise? A prospective observational study

Objective: To investigate the potential clinical use of serial fetal CPR measurements during the last month of pregnancy for the prediction of adverse perinatal outcome in unselected low-risk pregnancies. Methods: A multicenter prospective observational cohort study in 315 consecutively recruited low-risk pregnancies. All eligible pregnancies underwent serial sonographic evaluation of fetal weight and Doppler indices at two week intervals, from 36 weeks gestation until delivery. Data were converted into centiles correcting for gestational age. These data were not available for the obstetrical team and hence, could not influence management decisions. Primary outcomes were operative delivery for presumed fetal compromise and a composite neonatal outcome (arterial cord Ph 90th centile). Results: Three hundred fifteen women were recruited in this study. We ecxluded 32 pregnancies because of small for gestational age babies (SGA), leaving 293 women and 583 CPR values for data-analysis. There were 85 (27%) adverse neonatal outcomes and 29 patients (9%) underwent operative delivery for presumed fetal compromise. Both primary and secondary outcomes were not significant different between the different CPR groups. Furthermore, we examined if individual serial CPR measurements could predict adverse outcome and found no linear correlation between repeated measurements of CPR and adverse outcomes. Conclusion: Our study shows that routine serial screening by CPR measurements provides poor prediction for adverse perinatal outcome in uncomplicated pregnancies.

Gestational Diabetes Screening: The International Association of the Diabetes and Pregnancy Study Groups Compared With Carpenter-Coustan Screening And: Changing the Diagnostic Criteria for Gestational Diabetes Mellitus?

We would like to reflect on two publications, which we read with great interest. The O’Sullivan work aimed to detect patients who would develop diabetes later in life. The goal of The International Association of the Diabetes and Pregnancy Study Groups (IADPSG) guidelines is to focus on perinatal outcomes. Since these guidelines are only 5 years old, long-term follow-up is awaiting. None of the screening criteria have randomized controlled proven effect on short-term outcomes. To prove superiority of the IADPSG criteria for prevention of negative obstetric and long-term maternal and offspring outcomes, a group of patients not diagnosed with gestational diabetes by the CarpenterCoustan-criteria but diabetic according to the IADPSG criteria should be randomized into treated and nontreated groups. Feldman et al compares groups (Carpenter-Coustan criteria compared with IADPSG criteria) that were both treated, so lack of significant difference in outcomes is not surprising. Ethridge et al considered patients who were diabetic according to IADPSG criteria but not Carpenter-Coustan criteria and found more macrosomia in that particular group. Treating these patients might prevent macrosomia and related adverse events. Cheng et al compared the Carpenter-Coustan criteria with the standard screening criteria at that time. They found more macrosomia with standardscreening criteria, as well as more shoulder dystocia and instrumental deliveries. The Carpenter-Coustan criteria were universally accepted, so why not the IADPSG criteria? If we can prevent negative obstetric outcomes and longterm complications due to unrecognized diabetes in patients and even offspring, why not adapt the IADPSG criteria? Even if they are not immediately cost-effective, they might be in the long-term. The aforementioned research proposal would be the ultimate test, but it would take years for results to come out. With increasing rates of obesity, would receiving information on healthy lifestyle and dietary advice be that bad?

Association between antenatal corticosteroid administration-to-birth interval and outcomes of preterm neonates

We read with interest the article by Melamed et al. The main question of this research is to explore the optimal timing of administration of antenatal corticosteroids from 24 to 34 weeks of gestation to gain optimal neonatal therapeutic effects. The large sample size of this retrospective cohort study could provide new evidence for answering this question. Unfortunately, owing to limitations in the internal and external validity of this observational study, we believe it does not. The main limitation is that the relative difference in outcomes between the four study groups is minimal (21– 24%) and that only 31% of the cohort consists of patients with a gestational age less than 28 weeks. Although the choice of the composite primary endpoint seems clinically justified, it fails to reach clinical significance between treatments in the group of gestational age more than 28 weeks, even in this large retrospective design. For the entire cohort, 64 patients are to be treated correctly with antenatal corticosteroids to prevent one composite outcome in comparison with no antenatal corticosteroids at all, 53 in comparison with antenatal corticosteroids for less than 24 hours, and 111 in comparison with antenatal corticosteroids for longer than 7 days. The latter could suggest that a repeat course of antenatal corticosteroids is less effective in reducing nonrespiratory neonatal complications related to prematurity. In the cohort of participants at less than 28 weeks of gestation (the most vulnerable group), the odds ratio of the composite outcome is 2.48 (95% confidence interval 1.79–3.42). For participants at more than 28 weeks, the odds ratio is 1.77 (95% confidence interval 1.23–2.45). These ratios narrowly pass the zone of potential bias but do not reach the zone of potential interest for cohort studies. For now, the most important finding of the study is that 20% of patients did not get antenatal corticosteroids for any reason and that only 40% got an optimal treatment. We nevertheless think that a better designed study, preferably prospective, could confirm or refute the assumption that the optimal timing of antenatal corticosteroids administration is when delivery is expected to be within 7 days after administration. If confirmed, this hypothesis continues to challenge obstetricians to predict when preterm labor is going to result in preterm birth.

P04.15: The use of the VOCAL‐measured VI for treatment follow‐up of scar pregnancies

given intramuscularly in a dose of 50 mg per square meter of bodysurface area. Clinical observation, ultrasound examination were performed and serum chorionic gonadotropin was measured until the level was less than 15 IU/L. The patient required multiple-dose protocol. Time to resolution was 21 days. Conclusion. Small size of ectopic pregnancy after ART and a chance of its atypical localization may often complicate laparoscopic treatment of this condition and, therefore, emphasize the value of ultrasound diagnosis and medical management option.