N. Peters

Carbetocin for the Prevention of Postpartum Hemorrhage A Systematic Review

The objective of this review was to evaluate the efficacy and safety of carbetocin in the prevention of postpartum hemorrhage. All trials found during a targeted Medline and Cochrane database search were screened for eligibility. Outcome measures were estimated blood loss, uterine tone, amount and type of lochia, fundal position after delivery (number of centimeters above or below the umbilicus), side-effects, adverse effects, vital signs, levels of hemoglobin/hematocrit before delivery compared with 24 or 48 hours postpartum, the need for additional uterotonic therapy, and/or uterine massage and duration of the third stage of labor. The retrieved studies were difficult to compare because of differences in study design and outcome. We conclude that carbetocin probably is as effective as oxytocin or syntometrine in the prophylactic management of the third stage of labor. Also carbetocin has a similar safety profile to oxytocin, which is now used as a standard prophylactic treatment. However, more research on this subject is needed. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After reading this article, the reader should be able to describe the pharmacological and clinical characteristics of carbetocin, outline active management of the third stage of labor to decrease the risk of postpartum hemorrhage, and compare the results of literature on the use of carbetocin to oxytocin for the prevention of postpartum hemorrhage.

Well being of obstetric patients on minimal blood transfusions (WOMB trial)

BackgroundPrimary postpartum haemorrhage is an obstetrical emergency often causing acute anaemia that may require immediate red blood cell (RBC) transfusion. This anaemia results in symptoms such as fatigue, which may have major impact on the health-related quality of life. RBC transfusion is generally thought to alleviate these undesirable effects although it may cause transfusion reactions. Moreover, the postpartum haemoglobin level seems to influence fatigue only for a short period of time. At present, there are no strict transfusion criteria for this specific indication, resulting in a wide variation in postpartum policy of RBC transfusion in the Netherlands.Methods/DesignThe WOMB trial is a multicentre randomised non-inferiority trial. Women with acute anaemia due to postpartum haemorrhage, 12-24 hours after delivery and not initially treated with RBC transfusion, are eligible for randomisation. Patients with severe physical complaints are excluded. Patients are randomised for either RBC transfusion or expectant management. Health related quality of life (HRQoL) will be assessed at inclusion, at three days and one, three and six weeks postpartum with three validated measures (Multi-dimensional Fatigue Inventory, ShortForm-36, EuroQol-5D). Primary outcome of the study is physical fatigue three days postpartum. Secondary outcome measures are general and mental fatigue scores and generic health related quality of life scores, the number of RBC transfusions, length of hospital stay, complications and health-care costs.The primary analysis will be by intention-to-treat. The various longitudinal scores will be evaluated using Repeated Measurements ANOVA. A costs benefit analysis will also be performed. The power calculation is based on the exclusion of a difference in means of 1.3 points or greater in favour of RBC transfusion arm regarding physical fatigue subscale. With missing data not exceeding 20%, 250 patients per arm have to be randomised (one-sided alpha = 0.025, power = 80%).DiscussionThis study will provide evidence for a guideline regarding RBC transfusion in the postpartum patient suffering from acute anaemia. Equivalence in fatigue score, remaining HRQoL scores and physical complications between both groups is assumed, in which case an expectant management would be preferred to minimise transfusion reactions and costs.Trial registrationClinicalTrials.gov NCT00335023, Nederlands Trial Register NTR335

Electroencephalography During Normotensive and Hypertensive Pregnancy: A Systematic Review

The objective of this review was to evaluate the available medical literature concerning the electroencephalogram (EEG) during hypertensive disorders of pregnancy. All articles found during a MEDLINE and Embase database search on the subject of EEG differences associated with hypertensive disorders in pregnancy were screened for eligibility. In all, 22 articles which describe the EEG during preeclampsia (PE)/eclampsia were retrieved. Abnormal EEG findings were observed in the majority of the preeclamptic/eclamptic patients, consisting of slow waves most frequently localized in the occipital lobe, as well as spike discharges. The EEG abnormalities in PE/eclampsia were reversible in the majority of the cases. We conclude that these described abnormalities may be interpreted as a warning sign of deterioration of brain function in PE/eclampsia. However, some caution regarding this conclusion is advised because most of the retrieved articles were published in the 1950s and 1960s, and were not consistent with current clinical guidelines or medical terminology. Further research is needed to establish the clinical value of implementing EEGs in the assessment of the preeclamptic/eclamptic patient. Target Audience: Obstetricians & Gynecologists, Neurologists, Family Physicians Learning Objectives: After completion of this educational activity, the obstetrician, gynecologist and neurologist should be better able to evaluate whether the EEG is normal for pregnancy; distinguish EEG abnormalities in hypertensive disorders in pregnancy, and assess the value of EEG abnormalities in preeclampsia (PE)/eclampsia for the detection of early signs of ischemia.

The relation between viscero-abdominal disproportion and type of omphalocele closure

OBJECTIVE To investigate the relation between prenatal ultrasound measurements of viscero-abdominal disproportion and the expected type of postnatal surgical closure of an omphalocele. STUDY DESIGN Retrospectively, 24 fetuses diagnosed with an isolated omphalocele in the 2nd trimester of pregnancy were selected (period 2003-2013). An image of the axial plane of the abdomen at the level of the defect was retrieved. The ratio of omphalocele circumference to abdominal circumference (OC/AC), and the ratio of defect diameter to abdominal diameter (DD/DA) were calculated. Prognostic outcome was primary closure. Sensitivity and specificity and the corresponding area under the ROC curve of these ratios were calculated as measurements of prognostic accuracy. RESULTS Primary closure was achieved in 15/24 cases. For the OC/AC-ratio a cut-off value of 0.82 successfully predicted outcome in 23/24 cases with an area under the ROC curve of 0.99. A cut-off value of 0.61 for the DD/DA-ratio successfully predicted type of closure in 20/24 cases with an area under the ROC curve of 0.88. In all cases without eviscerated liver tissue, the defect was primarily closed. CONCLUSION In prenatal isolated omphalocele cases, the OC/AC-ratio is better at predicting postnatal surgical closure than the DD/DA-ratio and can be used as a prognostic tool for expected type of closure in the 2nd trimester of pregnancy.

OP37.03: Primary or delayed omphalocele closure prediction in the second trimester of pregnancy

Objectives: To determine (1) the antenatal detection rate for facial clefts in non-selected population during the routine anomaly scan (2) the accuracy of diagnosis (3) the association of cleft lip/palate (CL/P) with chromosomal and other associated anomalies and (4) the appropriate postnatal referral and feeding outcome. Methods: A retrospective analysis of all cases of CL/P detected at routine anomaly scans (2D – Aloka 5000 & 5500) in a DGH in UK between 2005–9. Data was cross referenced between (1) antenatal ultrasound and patient records, (2) postnatal records from the regional craniofacial unit and (3) records of the breast feeding advisor. We used FASP guideline to look at coronal view of lips with nasal tip. Results: During the study period 16.261 women underwent routine anomaly scans .Of these, 38 cases of CL/P were reported postnatally. Antenatal anomaly scan detected 30 cases (79%), including isolated cleft lip (78%), isolated cleft palate (0%) and combined lip & palate (100%). Seven (18%) cases had chromosomal aberrations, in additional three (8%) cleft was part of a syndrome or sequence. There were 6 terminations, 5 of which had associated major anomalies (including 3 chromosomal), 2 had trisomy 18, 1 had inverted duplication of chr2, 1 had hydrolethalus syndrome and 1 amniotic band syndrome. 16 (41%) cases demonstrated other physical or associated anomalies. BMI > 35 was associated with lower detection rate. FM specialist was found to be more accurate in diagnosing the side and type of defect. 100% of diagnosed cases underwent antenatal cardiac assessment. 100% of diagnosed cases were referred to maxillofacial surgeon for counselling and also to cleft nurse specialist for feeding advice. Breast feeding was successful in 8/9 babies of isolated cleft lip. Only 3 babies with complete cleft palate needed NGT feeding. In the rest, 26 babies fed successfully assisted with special teats. Conclusions: The ability to detect CL/P in a DGH using a 2D USS is comparable to those of referral centres. Detection of facial cleft is important because of its association with chromosomal aberrations and other physical abnormalities. Postnatal feeding support by nurse specialist is very useful in helping cleft babies with feeding.

Power Doppler rendering of fetal bilateral accessory renal arteries in virtual reality.

The renal arteries normally arise from the abdominal aorta proximal to the bifurcation. Known anatomic variations in renal arteries, for example accessory renal arteries, are present in 20–30% of the general population and show different places of origin and various courses1. Accessory renal arteries are embryonic mesonephric arteries that failed to degenerate2. Accessory renal arteries may be parallel to the main renal arteries, this being the most common anatomic variation2. Other known variations include a divergent, convergent or crossed trajectory of the renal arteries on the same side1. We observed, in a fetus at 26 weeks’ gestation, two normal kidneys with bilateral accessory renal arteries. Three-dimensional (3D) power Doppler datasets were obtained using a GE Voluson E8 system (GE Medical Systems, Zipf, Austria). These datasets were analyzed in 4D view and by use of a virtual reality system to render images in the Barco I-space3. The Barco I-space is a CAVE-like virtual reality system, which, by use of the V-scope volume rendering application, creates a hologram from a 3D dataset. The hologram, projected onto the walls and floor of a dark room, is analyzed wearing 3D glasses and using a special joystick. By making use of the third dimension, ‘depth perception’, virtual reality enabled us to visualize the fetal vascular anatomy in more detail. The different kinds of voxels (3D pixels), i.e. power Doppler and gray-scale voxels, can easily be separated, allowing visualization of Doppler images of the fetal vasculature with and without the internal organs. The fetal vascular system, including the bilateral accessory renal arteries, is shown in Figure 1 as seen in 4D view and in Figure 2a as a hologram as seen in the Barco I-Space; Figure 2b is a schematic representation of Figure 2a. Visualization of three-dimensional images on a two-dimensional (2D) screen has technical limitations. In contrast to assessment in 4D view, the virtual reality

P01.14: Bilateral accessory renal arteries: a prenatal observation

an almost linear way with gestational age, whereas little variability is observed for PI and RI in the renal arteries. The Vmax in the renal veins increases with gestational age, whereas little variation in PI is observed. These data are consistent with those in literature. Conclusions: Reference curves for renal Dopplers flow measurements in normal pregnancies are provided. These will serve as potential predictors for renal function in fetuses with renal and urinary tract pathology.

OP37.04: Multidisciplinary prediction on likelihood of primary closure for an omphalocele

Objectives: To compare predictive performance of obstetric physicians (OP) vs. pediatric physicians (PP), judging standardized high quality US images of omphalocele in terms of the likelihood of primary surgical closure. To establish the key information guiding that judgment. Methods: Cases with an omphalocele, isolated or with minor anomalies, with ≥1 complete investigation between 12–23 weeks of gestation (n = 21) were drawn from our US database. Additional prenatal characteristics and postnatal outcome data were collected. We devised a standardized presentation of each case on a form, providing: images, image related data (defect O; 2 ratios: cele circumference/abdominal circumference and defect O/abdominal O), and prenatal data. Respondents were required to state the likelihood of primary closure in terms of quantitative probability (6 range categories: 0–20%, 20–40%, 40–60% and 80–100%) An ‘unable to predict’ category was included. Respondents were: 10 OP vs. 9 PP. All respondents were blinded towards the patient and unaware of postnatal outcome. Results: The 19 physicians provided 399 answers for 21 cases (complete). In retrospect primary closure was observed in 13/21, and predicted correctly (majority of respondents predicted 60% or more answer) in 5/13 cases. In the remaining 8/21 cases of non closure, in 1/8 the majority predicted failure (20% or less answer). From a predictive point of view, in 92% of the >60% responses, this prediction was correct. However, in only 60% of the <20% predictions, primary closure actually failed. Prediction failure did not differ according to specialty, yet individuals showed pessimism/optimism differences. Individual accuracy ranged from 2/21 to 13/21. The cele content was the primary information tag according to 17/19 respondents, while only 4/19 mentioned the diameter and 8/19 the ratios. Conclusions: Antenatal judgment on primary closure of an omphalocele by OP and PP shows no inter-professional differences. However, these experts were too pessimistic as 40% predicted non closures actually closed. This may affect counseling results.