Joanna Girling

Obstetric cholestasis, outcome with active management: a series of 70 cases

Objective To determine the nature and outcome of obstetric cholestasis in a United Kingdom population.

Quantitative Fetal Fibronectin to Predict Preterm Birth in Asymptomatic Women at High Risk

OBJECTIVE: To evaluate the diagnostic accuracy of cervicovaginal fluid quantitative fetal fibronectin, measured by a bedside analyzer, to predict spontaneous preterm birth before 34 weeks of gestation. METHODS: We conducted a prospective masked observational cohort study of cervicovaginal fluid quantitative fetal fibronectin concentration in asymptomatic women at high risk of spontaneous preterm birth (n=1,448; 22–27 6/7 weeks of gestation) measured using a rapid bedside analyzer. The routine qualitative result (positive–negative) was made available to clinicians at the time of testing, but the quantitative result remained blinded until after delivery. RESULTS: Spontaneous preterm birth (less than 34 weeks of gestation) increased from 2.7%, 11.0%, 14.9%, 33.9%, and 47.6% with increasing concentration of fetal fibronectin (less than 10, 10–49, 50–199, 200–499, and 500 ng/mL or greater, respectively). A threshold of 200 ng/mL had a positive predictive value of 37.7 (95% confidence interval [CI] 26.9–49.4) with specificity 96% (95% CI 95.3–97.3). Women with a fetal fibronectin concentration of less than 10 ng/mL had a very low risk of spontaneous preterm birth at less than 34 weeks of gestation (2.7%), no higher than the background spontaneous preterm birth rate of the general hospital population (3.3%). The quantitative fetal fibronectin test predicted birth at less than 34 weeks of gestation with an area under the curve (AUC) of 0.78 (95% CI 0.73–0.84) compared with the qualitative test AUC 0.68 (95% CI 0.63–0.73). Quantitative fetal fibronectin discriminated risk of spontaneous preterm birth at less than 34 weeks of gestation among women with a short cervix (less than 25 mm); 9.5% delivered prematurely less than 10 ng/mL compared with 55.1% greater than 200 ng/mL (P<.001). DISCUSSION: Alternative risk thresholds (less than 10 ng/mL and greater than 200 ng/mL) improve accuracy when using quantitative fetal fibronectin measurements to define risk of spontaneous preterm birth. This is particularly relevant for asymptomatic women with a short cervix. LEVEL OF EVIDENCE: II

Factors influencing postnatal liver function tests

Objective To investigate liver function tests (LFTs) changes in the puerperium and the influence of specific obstetric events on these changes.

Hypothyroidism in pregnancy: pre‐pregnancy thyroid status influences gestational thyroxine requirements

There is considerable uncertainty about the management of hypothyroidism in pregnancy. Our aim was to establish the pattern of thyroxine dose adjustment needed and to determine the clinical reasons for these changes and the contributory factors. Of 89 pregnancies, thyroxine dose was unchanged in 50, increased (by a mean of 38 micrograms) in 34, and decreased in 5. Twenty‐three percent of women who were tested in the first trimester needed an immediate increase in thyroxine. One‐quarter (26%) of the women who needed a gestational increase in thyroxine dose had had a recent pre‐pregnancy increase in thyroxine requirement (compared with 0% in women on static dose in pregnancy, P < 0.001). Furthermore, they did not require a decrease in thyroxine dose postpartum, suggesting a long‐term need for more thyroxine rather than a transient gestational effect. None of the women who had stable doses of thyroxine during pregnancy had required recent pre‐pregnancy changes in dose or needed postnatal changes. Inadequate pre‐pregnancy control of thyroid function is associated with a need to increase thyroxine dosage during pregnancy.

Re-evaluation of plasma creatinine concentration in normal pregnancy

Renal function improves during pregnancy, a well-known clinical manifestation of this being a fall in plasma creatinine concentration. However, there are no secure data upon which to determine the extent to which creatinine concentration changes during pregnancy. A well-defined reference range is important for the correct interpretation of results, but to date one has not been published. This study uses a large cohort of women experiencing normal pregnancy, modern laboratory technique and robust statistical analysis to construct a cross-sectional reference interval. This study shows that the upper limit of normal for creatinine in pregnancy is higher than previously suggested, although still much lower than outside pregnancy. Values for the upper limit of normal can be taken as 85 mumol/l, 80 mumol/l and 90 mumol/l in the first, second and third trimesters of pregnancy respectively. This information is important for the clinical assessment of a result from a pregnant woman, particularly in conditions such as pre-eclampsia where abnormalities of renal function may occur.

A novel cause for abnormal liver function tests in pregnancy and the puerperium: non-alcoholic fatty liver disease

Please cite this paper as: Page L, Girling J. A novel cause for abnormal liver function tests in pregnancy and the puerperium: non‐alcoholic fatty liver disease. BJOG 2011;118:1532–1535.

Quantitative Fetal Fibronectin at 18 Weeks of Gestation to Predict Preterm Birth in Asymptomatic High-Risk Women.

OBJECTIVE: To compare quantitative fetal fibronectin measurement from 18 to 21 weeks of gestation to measurement at 22–27 weeks of gestation for the prediction of spontaneous preterm birth. METHODS: In a prospective cohort study, we studied the accuracy of cervicovaginal fluid quantitative fetal fibronectin concentrations measured between 18 0/7 weeks of gestation and 21 6/7 weeks of gestation in high-risk asymptomatic women to predict spontaneous preterm birth before 34 weeks of gestation. Predefined fibronectin thresholds were 10 or greater, 50 or greater, and 200 ng/mL or greater. Diagnostic accuracy of the early test (n=898) was compared with the standard test performed between 22 0/7 and 27 6/7 weeks of gestation (n=691) in the same cohort. Subgroup analysis was performed according to cervical length measurement. RESULTS: Of 898 women, 8.7% delivered spontaneously before 34 weeks of gestation. Only 3.8% of the women with concentrations less than 10 ng/mL (65% of test results) delivered before 34 weeks of gestation. A concentration threshold of 10 ng/mL measured at 18 and 22 weeks of gestation had comparably high sensitivity (early 0.71, 95% confidence interval 0.60–0.81; standard 0.76, 0.63–0.87) and negative predictive value (early 0.96, 0.94–0.98; standard 0.97, 0.95–0.99) for delivery before 34 weeks of gestation. Specificity was also comparable (early 0.69, 0.65–0.72; standard 0.70, 0.66–0.74). A threshold of 200 ng/mL had high specificity (early 0.96, 0.94–0.98; standard 0.96, 0.94–0.97) with lower sensitivity (early 0.26, 0.17–0.37; standard 0.35, 0.22–0.49). Consideration of cervical length strengthened prediction. CONCLUSION: Quantitative cervicovaginal fetal fibronectin measured from 18 to 21 weeks of gestation has similar predictive value as measurement at 22–27 weeks of gestation for prediction of spontaneous preterm birth. Low fibronectin concentrations are associated with spontaneous preterm birthrates approaching population background levels.

Intravenous anti-D immunoglobulin in the treatment of resistant immune thrombocytopenic purpura in pregnancy

A 35‐week pregnant 38‐year‐old woman presented with isolated thrombocytopenia (platelet count 4 × 109/l). Investigations confirmed immune thrombocytopenic purpura, and she received treatment with prednisolone and intravenous immunoglobulins with no increment in the platelet count. At 37 and 38 weeks of the pregnancy, she received two doses of WinRho (anti‐D immunoglobulin) at 50 μg/kg. Five days later, with a platelet count of 46 × 109/l, she had an uncomplicated normal vaginal delivery. WinRho is a useful adjunct to other first‐line treatment modalities for immune thrombocytopenia in pregnancy.

Assessment of a Full Dilatation Cesarean Delivery Simulator

OBJECTIVE: To assess a full dilatation cesarean delivery simulator and to establish expert consensus on the most effective techniques for safe delivery. METHODS: Three delivery scenarios with increasing degrees of difficulty were tested. Face and content validity were assessed using visual analog scale (VAS) scores on how realistic the simulator was and how useful it would be for training, respectively. Construct validity was assessed by comparing success at delivery and time taken between senior doctors and junior doctors. Expert opinion was sought through a questionnaire. RESULTS: The training scenarios were undertaken by 30 doctors working in the specialty of obstetrics and gynecology. The number of participants able to deliver and the perceived difficulty they experienced correlated with the difficulty level of the three scenarios (success: scenario 1, 100% [n=30]; scenario 2, 90% [n=27]; and scenario 3, 62% [n=16] P<.05; mean VAS: scenario 1, 29/100; scenario 2, 42/100; and scenario 3, 88/100; P<.001). Average time to delivery for each scenario was 45 seconds, 43 seconds, and 109 seconds, respectively (P<.001). Overall, 87% found the simulator to be realistic (median VAS 58/100, interquartile range 40–74) and 93% thought it would be useful as a training device (median VAS 80/100, interquartile range 55–97). Questionnaires were received from 47 consultants with an average of 18 years of experience. High uterine incision and assistance to push the fetal head up transvaginally were the only two techniques reported by more than half of the respondents. CONCLUSION: This full dilatation cesarean delivery simulator has been validated as a training device; we believe it should be used to develop a consensus for accepted techniques. LEVEL OF EVIDENCE: III

Thyroid disease in pregnancy

•  Trimester‐specific reference ranges should be used to interpret thyroid function during pregnancy. •  The fetus requires maternal thyroxine in the first trimester. •  Optimal management of hypothyroidism should be achieved prior to conception; pregnant women may need to alter their dose of thyroxine in early pregnancy. •  Treatment for hyperthyroidism can often be reduced in the third trimester, to minimise the risk of fetal hyperthyroidism, and then restored postnatally. •  Human chorionic gonadotrophin‐driven hyperthyroidism in hyperemesis gravidarum usually resolves by 20 weeks and does not require antithyroid medication, although thyrotoxicosis must be excluded.