Lin Lin Su

Antenatal education and postnatal support strategies for improving rates of exclusive breast feeding: randomised controlled trial

Objective To investigate whether antenatal breast feeding education alone or postnatal lactation support alone improves rates of exclusive breast feeding compared with routine hospital care. Design Randomised controlled trial. Setting A tertiary hospital in Singapore. Participants 450 women with uncomplicated pregnancies. Main outcome measures Primary outcomes were rates of exclusive breast feeding at discharge from hospital and two weeks, six weeks, three months, and six months after delivery. Secondary outcomes were rates of any breast feeding. Results Compared with women who received routine care, women in the postnatal support group were more likely to breastfeed exclusively at two weeks (relative risk 1.82, 95% confidence interval 1.14 to 2.90), six weeks (1.85, 1.11 to 3.09), three months (1.87, 1.03 to 3.41), and six months (2.12, 1.03 to 4.37) postnatally. Women receiving antenatal education were more likely to breast feed exclusively at six weeks (1.73, 1.04 to 2.90), three months (1.92, 1.07 to 3.48), and six months (2.16, 1.05 to 4.43) postnatally. The numbers needed to treat to achieve one woman exclusively breast feeding at six months were 11 (6 to 80) for postnatal support and 10 (6 to 60) for antenatal education. Women who received postnatal support were more likely to exclusively or predominantly breast feed two weeks after delivery compared with women who received antenatal education (1.53, 1.01 to 2.31). The rate of any breastfeeding six weeks after delivery was also higher in the postnatal support group compared with women who received routine care (1.16, 1.02 to 1.31). Conclusions Antenatal breast feeding education and postnatal lactation support, as single interventions based in hospital both significantly improve rates of exclusive breast feeding up to six months after delivery. Postnatal support was marginally more effective than antenatal education. Trial registration Clinical Trials NCT00270920.

Current strategies for the prevention of postpartum haemorrhage in the third stage of labour.

Purpose of review Despite evidence that active management of the third stage of labour reduces the incidence of postpartum haemorrhage, expectant management is still widely practised. Factors accounting for this situation include the desire for a more natural experience of childbirth, the philosophy that active management is unnecessary in low-risk women, and avoidance of the adverse effects of conventional uterotonic agents. This review will evaluate the various strategies currently used for the prevention of primary postpartum haemorrhage. Recent findings Since publication of the first systematic review comparing active with expectant management in 1988, active management of the third stage using oxytocics has become increasingly adopted. Recent surveys, however, show that there are still wide variations in practice around the world. Recent interest has focused on the use of misoprostol for the prevention of postpartum haemorrhage. Carbetocin, an oxytocin receptor agonist, shows promise but has not been evaluated for use after vaginal births. Summary Active management of the third stage of labour is superior to expectant management in terms of blood loss, postpartum haemorrhage and other serious complications, but is associated with unpleasant side effects and hypertension when ergometrine is included. Intramuscular oxytocin results in fewer side effects. Oral and rectal misoprostol has been extensively assessed and found to be less effective than conventional oxytocics with more side effects. Until alternative regimes of misoprostol are studied in large controlled trials, misoprostol is not recommended for routine use in the third stage of labour. Of the remaining uterotonic agents evaluated, intramuscular carbetocin appears the most promising.

Monoamniotic twins: diagnosis and management

Monoamniotic twins, although uncommon, are associated with high antenatal and perinatal morbidity and mortality. The associated complications include cord entanglement, congenital anomalies, twin–twin transfusion syndrome, intrauterine growth retardation and preterm delivery. A thorough literature search using Medline and OVID was performed to look at the current diagnostic criteria for monoamniotic twins and the subsequent management. Specific criteria are employed during ultrasonography for making the diagnosis. Different opinions in the literature exist regarding the proper antepartum monitoring of monoamniotic twins, the optimal timing and the mode of delivery. Generally, it is agreed that there should be regular antepartum fetal heart trace monitoring and serial sonograms with umbilical artery Doppler flow study. Most studies advocate delivery at 32 weeks to reduce the risk of intrauterine deaths related to cord entanglement. Cesarean section is the preferred mode of delivery even though cases of successful vaginal delivery have been reported.

Lipidomic analysis of human placental Syncytiotrophoblast microvesicles in adverse pregnancy outcomes

PROBLEM Syncytiotrophoblast microvesicles (STBM) are shed from placenta into the maternal circulation. STBM circulate in increased amounts in adverse pregnancies, e.g., preeclampsia and recurrent miscarriages (RM). Recently dysregulation of lipid metabolites has been proposed to be associated with their pathogenesis. Lipid composition of STBM in healthy and adverse pregnancies remains unknown. OBJECTIVE To determine lipid composition of STBM and whether STBM lipid composition differs in pathologic and normal pregnancies. STUDY DESIGN Patients with Preeclampsia (n = 6) or history of RM (n = 9) (>2 consecutive losses <20 weeks) and gestational age-matched normal pregnant controls (same number as cases) were recruited. STBM were prepared from placental explant culture supernatant. Lipid profiling of STBM was performed by mass spectrometry in combination with liquid chromatography. We quantified ∼200 lipids in STBM including (i) glycerophospholipids (phosphatidylcholine, PC; phosphatidylethanolamine, PE; phosphatidylinositol, PI; phosphatidylglycerol, PG; phosphatidylserine, PS; phosphatidic acid, PA); (ii) sphingolipids (sphingomyelin, SM; ceramide, Cer; Glucosylceramide, GluCer; ganglioside mannoside 3, GM3); (iii) free cholesterol and cholesteryl esters, CE. RESULTS The major lipid classes in STBM were SM, Chol, PS, PC and PI, along with PA and GM3 enrichments. SM/PC ratio showed a unique reversal (3:1) compared to that normally found in human cells or plasma. Level of total PS was significantly upregulated (p < 0.005) in preeclampsia patients, while PI (p < 0.0005), PA (p < 0.005), and GM3 (p < 0.05) were significantly downregulated. Similar trends were obtained in RM. CONCLUSIONS Differential lipid expression of STBM in preeclampsia or RM includes those that are implicated in immune response, coagulation, oxidative stress, and apoptosis.

Changing trends of cesarean section births by the Robson Ten Group Classification in a tertiary teaching hospital

Objective. To analyse changing trends of cesarean section (CS) birth rates over an 11 year period (2000–2010) using the Robson Ten Group Classification System (RTGCS) to identify the main contributors to the rising CS birth rates at a tertiary teaching hospital in Singapore. Design. Retrospective study. Setting. National University Hospital, Singapore. Population. All women who delivered between 1 January 2000 and 31 December 2010 (hospital maternity database). Methods. The RTGCS was used to classify these women according to parity, past obstetric history, singleton or multiple pregnancy, fetal presentation, gestational age and mode of onset of labor/delivery. Main outcome measures. The RTGCS results. Results. From 2000 to 2010 the CS rate increased from 19.9 to 29.6 per 100 births. Multiparous women with a previous cesarean birth (Group 5) were the greatest contributor to the CS rate, followed by nulliparous women with singleton cephalic full‐term pregnancy in spontaneous labor (Group 1). These two groups contributed to 75% of the rise in the CS rate from 2000 to 2010. Conclusions. The increase in CS rate is attributed largely to the rising CS rate in Group 5, followed by Group 1. We propose that future efforts to reduce overall CS rate should be focused on increasing vaginal birth after cesarean and reduce CS rates in nulliparous women with singleton cephalic full‐term pregnancy (Groups 1 and 2), which in turn will reduce the number of pregnant women with a previous CS.

Proteomic analysis of human placental syncytiotrophoblast microvesicles in preeclampsia

BackgroundPlacental syncytiotrophoblast microvesicles (STBM) are shed into the maternal circulation during normal pregnancy. STBM circulate in significantly increased amounts in preeclampsia (PE) and are considered to be among contributors to the exaggerated proinflammatory, procoagulant state of PE. However, protein composition of STBM in normal pregnancy and PE remains unknown. We therefore sought to determine the protein components of STBM and whether STBM protein expressions differ in preeclamptic and normal pregnancies.Patients with PE (n = 3) and normal pregnant controls (n = 6) were recruited. STBM were prepared from placental explant culture supernatant. STBM proteins were analyzed by a combination of 1D Gel-LC-MS/MS. Protein expressions levels were quantified using spectral counts and validated by immunohistochemistry.ResultsOver 400 proteins were identified in the STBM samples. Among these, 25 proteins were found to be differentially expressed in preeclampsia compared to healthy pregnant controls, including integrins, annexins and histones.ConclusionSTBM proteins include those that are implicated in immune response, coagulation, oxidative stress, apoptosis as well as lipid metabolism pathways. Differential protein expressions of STBM suggest their pathophysiological relevance in PE.

Misoprostol: a quarter century of use, abuse, and creative misuse.

Misoprostol is a prostaglandin E1 analog originally intended for use to prevent NSAID-induced gastric ulcers. However, because of its cervical ripening and uterotonic property, misoprostol has become one of the most useful drugs in obstetrics and gynecology. Misoprostol has proven to be a very convenient and flexible drug because of its formulation as a tablet that is stable and that can be administered orally, rectally, vaginally and by the sublingual route. Beginning with its abuse for illegal abortion in the late 1980s, misoprostol has quickly become established as one of the most effective drugs for terminating pregnancies in the first and second trimesters, as well as for inducing labor in the third trimester. Its use for routine prevention of postpartum hemorrhage has not been so successful, partly as the high doses required for this indication often result in troublesome side effects. Despite the large body of medical evidence about its efficacy and relative safety, the use of misoprostol in pregnant women remained off-label until the spring of 2002. Target Audience Obstetricians & Gynecologists, Family Physicians Learning Objectives After completion of this article, the reader should be able to outline the pharmacologic properties of the misoprostol, to list the adverse effects of misoprostol, and to summarize the off-label uses of misoprostol.

Carbetocin versus syntometrine for the third stage of labour following vaginal delivery-a double-blind randomised controlled trial

Objective  Prevention of postpartum haemorrhage is essential in the pursuit of improved health care for women. However, limited literature is available for comparing the use of oxytocin agonist carbetocin with syntometrine in women undergoing vaginal deliveries. We aimed to compare intramuscular carbetocin with intramuscular syntometrine for the routine prevention of postpartum haemorrhage in women who deliver vaginally.

Sonographic diagnosis and successful medical management of an intramural ectopic pregnancy

We report a case of posterior wall intramural pregnancy in a 36‐year‐old primigravida at 6 weeks gestation. Sonographic examination showed a viable intramural pregnancy distorting the contour of the uterus. The pregnancy was terminated by intrafetal injection of potassium chloride followed by intra‐amniotic methotrexate injection.

Noninvasive prenatal exclusion of haemoglobin Bart's using foetal DNA from maternal plasma†

Prenatal diagnosis of alpha‐thalassaemia requires invasive testing associated with a risk of miscarriage. Cell‐free foetal DNA in maternal plasma presents an alternative source of foetal genetic material for noninvasive prenatal diagnosis. We aimed to exclude HbBarts noninvasively by detection of unaffected paternal alleles in maternal plasma using quantitative fluorescence PCR (QF‐PCR).