Julie A. Quinlivan

Repeated Prenatal Corticosteroids Delay Myelination in the Ovine Central Nervous System

Maternal administration of corticosteroids is used to promote lung maturation in human infants considered at risk of preterm delivery [1]. Randomised trials of a single course of corticosteroid treatment have indicated no adverse long-term neurological or cognitive sequelae [2-5]. However, the current trend in many obstetric centres is to use repeated courses in cases where preterm birth has not eventuated, but the risk persists 7 days beyond administration of the original course [6-7]. This practice has not yet been subject to randomised trials of outcome. We have examined the effect of repeated injections of corticosteroids on the development of the optic nerve in prenatal fetal sheep and report a significant delay in the myelination of optic axons. Our results, together with those from other animal studies [8], show that repeated courses of corticosteroids may be detrimental to central nervous system (CNS) development. Clinical practice should balance the known beneficial effects on lung maturation of a single course of corticosteroid against the potential damage to the CNS of repeated courses.

Chorioamnionitis and cerebral palsy: A meta-analysis

OBJECTIVE: To examine the relationships between clinical or histological chorioamnionitis and cerebral palsy using a meta-analysis approach. DATA SOURCES: A systematic review of the literature appeared in PubMed between 2000 and 2009 was conducted using the search terms “cerebral palsy” and “infection,” with broad-scope variations in terminology of “white matter damage,” “periventricular leukomalacia,” “cystic periventricular leukomalacia,” “chorioamnionitis,” “intrauterine infection,” “intraventricular hemorrhage,” “funisitis,” “fetal inflammatory response,” “early neonatal sepsis,” “neurological impairment,” “virus,” “bacteria,” “fungi,” and “protozoa,” with variations of suffixes (eg, “viral,” “bacterial,” “fungal,” “protozoan,” etc), and “urinary tract infection,” “bacterial vaginosis,” “bacteriuria,” and “cytokines.” The related key words “gestational age,” “small for gestational age,” “preterm,” and “low birth weight” also were added to the search terms. Only studies published in English were included. METHODS: Three hundred eight articles were retrieved and systematically reviewed independently by two authors. Application of four inclusion criteria led to 15 studies being considered for data abstraction. An exposure was considered relevant if it met the established criteria for clinical or histological chorioamnionitis. The outcome was a diagnosis of cerebral palsy in accordance with established criteria. RESULTS: The data were abstracted onto standard forms, correlated according to eight characteristics, and tabulated. Twelve of the 15 studies contained information on the association between clinical chorioamnionitis and cerebral palsy, and eight studies included information on the association between histological chorioamnionitis and cerebral palsy. The results indicated that there were significant associations between clinical chorioamnionitis or histological chorioamnionitis and cerebral palsy, for clinical chorioamnionitis (&khgr;12=13.91; P<.001) with a pooled odds ratio of 2.42 (95% confidence interval 1.52–3.84), and for histological chorioamnionitis (&khgr;12=6.86; P=.009) with a pooled odds ratio of 1.83 (95% confidence interval, 1.17–2.89). The data suggested increased risks of 140% and 80% for neonates exposed to clinical chorioamnionitis or histological chorioamnionitis, respectively. CONCLUSION: The significant association of clinical or histological chorioamnionitis with cerebral palsy suggested that clinical strategies to prevent or reduce chorioamnionitis would lead to a reduction in cerebral palsy. The culture techniques currently used to diagnose the presence of pathogenic microorganisms during pregnancy need to improve, both in their methodology and in the length of time they require.

USE OF CORTICOSTEROIDS BY AUSTRALIAN OBSTETRICIANS: A SURVEY OF CLINICAL PRACTICE

Summary: All Fellows, Members and trainees of the Royal Australian College of Obstetricians and Gynaecologists resident in Australia (n = 1,281) received a questionnaire relating to their practice of prescribing antenatal corticosteroids. 833 (65%) responded. The key findings were that 97% of Australian obstetricians prescribe antenatal corticosteroids in the classical setting of uncomplicated early preterm labour and 85% prescribe repeated courses in those cases in which the risk of preterm birth persists or recurs; 50% of obstetricians prescribe this agent weekly in cases with persisting risk of preterm birth. Some of the prescribing practices were found to be related to the number of years since obtaining specialist qualification. In view of the widespread clinical use of repeated doses of corticosteroids revealed in this present survey, it is clear that further research is warranted to determine the possible benefits and hazards of repeated exposures of the developing fetus to this therapy.

A randomised trial of a four-step multidisciplinary approach to the antenatal care of obese pregnant women.

Background:  Obesity is common in pregnancy and results in morbidity to mother and newborn.

Patient Preference the Leading Indication for Elective Caesarean Section in Public Patients‐Results of a 2‐year Prospective Audit in a Teaching Hospital

In response to a Western Australian Ministerial enquiry into the levels of intervention in childbirth, a 2‐year prospective audit was undertaken of the indication and timing of all public Caesarean section deliveries at King Edward Memorial hospital. During the study period, a total of 9,138 deliveries were performed at the hospital, of which 1,624 were by Caesarean section, an overall rate of 17.8%. Of these, 633 (39%) were elective and 911 (61%) were nonelective. The most common primary indication for elective Caesarean section was maternal choice, largely due to a refusal of the patient to consent to a trial of scar following a single previous Caesarean section or a refusal to attempt a trial of vaginal breech delivery. The most common indications for nonelective Caesarean section birth were an intrapartum diagnosis of suspected fetal distress or failure to progress in labour. Strategies to reduce the incidence of Caesarean section birth need to focus on the pathways involved with maternal decision‐making in the birth process, and on improving the diagnosis of intrapartum fetal compromise.

Are pregnant Australian women well informed about prenatal genetic screening? A systematic investigation using the Multidimensional Measure of Informed Choice

Background:  Ethical practice requires that decisions to participate in medical care be well informed. Investigations into prenatal genetic screening for Down syndrome have assessed womens knowledge but have not examined whether being well informed about the potential consequences of screening, such as subsequent diagnostic testing, diagnosis and termination, is associated with psychological distress for women.

Fish-oil supplementation in pregnancy does not reduce the risk of gestational diabetes or preeclampsia

BACKGROUND There is uncertainty regarding the efficacy of increasing n-3 long-chain PUFA (LCPUFA) intake during pregnancy in reducing the risk of gestational diabetes mellitus (GDM) and preeclampsia. OBJECTIVES The objective was to determine whether n-3 LCPUFA supplementation in pregnancy reduces the incidence of GDM or preeclampsia. A secondary objective was to assess the effect of n-3 LCPUFA supplementation on perinatal complications. DESIGN This was a double-blind, multicenter randomized control trial-the DHA to Optimize Mother Infant Outcome (DOMInO) trial. Pregnant women (n = 2399) of <21 wk gestation were randomly assigned to receive DHA-enriched fish oil (800 mg/d) or vegetable oil capsules without DHA from trial entry to birth. The presence of GDM or preeclampsia was assessed through a blinded audit of medical records. Birth outcomes and prenatal complications were also assessed. RESULTS The overall incidences of GDM and preeclampsia were 8% and 5%, respectively, based on clinical diagnosis. The RR of GDM was 0.97 (95% CI: 0.74, 1.27) and of preeclampsia was 0.87 (95% CI: 0.60, 1.25), and they did not differ significantly between the groups. Birth weight, length, and head circumference z scores also did not differ between the groups. There were 12 perinatal deaths and 5 neonatal convulsions in the control group compared with 3 perinatal deaths and no neonatal convulsions in the DHA group (P = 0.03 in both cases). CONCLUSION DHA supplementation of 800 mg/d in the second half of pregnancy does not reduce the risk of GDM or preeclampsia. Whether supplementation reduces the risk of perinatal death and neonatal convulsions requires further investigation. The DOMInO trial was registered with the Australian New Zealand Clinical Trials Registry as TRN12605000569606.

Antenatal dietary interventions in obese pregnant women to restrict gestational weight gain to Institute of Medicine recommendations: a meta-analysis.

OBJECTIVE: To estimate whether antenatal dietary interventions restrict maternal weight gain in obese pregnant women without compromising newborn birth weight. DATA SOURCES: PubMed and Cochrane Controlled Trials Register were searched using free-text search terms: pregnancy, obesity, overweight, dietary intervention, lifestyle, and randomis(z)ed controlled trial through March 2011 in a similar search strategy to that used in a previous systematic review. METHODS OF STUDY SELECTION: We included randomized controlled trials in which antenatal dietary intervention was provided to pregnant women who were overweight or obese at booking. We extracted 263 abstracts or reports, from which 39 full-text articles were reviewed. TABULATION, INTEGRATION, AND RESULTS: Four randomized controlled trials were identified involving 537 women. The results suggested that there was a significant pool treatment effect (z=11.58, P<.001), because antenatal dietary intervention programs were effective in reducing the total gestational weight gain by 6.5 kg. Despite this, antenatal dietary interventions did not alter newborn birth weight (z=0.18, P=.859). CONCLUSION: Antenatal dietary interventions in obese pregnant women can reduce maternal weight gain in pregnancy without an effect on newborn birth weight.

Adolescent Pregnancy: Psychopathology Missed

Objectives: Few data exist that explore the level of psychosocial problems and drug abuse in an Australian, adolescent, antenatal population. We set out to audit these data from a population of pregnant Western Australian adolescents. We also set out to examine whether social issues and the use of non-prescription drugs are routinely addressed in general public antenatal clinics. Methods: One hundred and sixty patients were involved in the prospective cohort study. In the assessed group, 100 consecutive patients from the King Edward Memorial Hospital Adolescent Antenatal Clinic were interviewed during the antenatal period to determine if any major psychosocial issues or a history of non-prescription drug abuse was present. The control group consisted of 60 adolescent patients who delivered in general antenatal clinics at three Perth metropolitan hospitals. Results: Sixty percent of the assessed group were identified as having a major psychosocial problem that interfered with their ability to carry out acts of daily living. Consumption of cigarettes, alcohol, marijuana, heroin and solvents were higher than that reported for the general Australian adolescent population. Of note, in the control group, many patients did not have a social, psychological, or drug use history taken by their caregivers. Conclusion: Failure to identify psychosocial problems and drug abuse during the antenatal period will result in missed opportunities for positive intervention. These problems are common in this population and interventions are required to offer these women alternative foundations upon which to base their mothercraft skills.

Bacterial aetiological agents of intra-amniotic infections and preterm birth in pregnant women

Infection-related preterm birth is a leading cause of infant mortality and morbidity; knowledge of bacterial populations invading the amniotic cavity and the routes of invasion is required to make progress in the prevention of preterm birth. Significant advances have been made in understanding bacterial communities in the vagina, but much less studied are intra-uterine bacterial populations during pregnancy. A systematic review of data published on the intra-uterine microbiome was performed; molecular information and summaries of species found in healthy individuals and in women with diagnosed infections served to construct a database and to analyse results to date. Thirteen studies fulfilled the reviews inclusion criteria. The data of various investigations were collated, organized, and re-analyzed to achieve a more comprehensive understanding of microbial populations in the intra-amniotic space. The most common intra-amniotic bacterial taxa were species that can colonies the vagina in health and disease; there were others associated with the habitats of the mouth, gastrointestinal tract, and respiratory tract. The results suggest a central role for the ascending route of infections during pregnancy, and point to a possible secondary contribution via haematogenous invasion of the intra-amniotic space. The complete census of the intra-uterine microbiome awaits completion.