Peter McParland

Shoulder dystocia — is it predictable?

An unmatched comparative study is described to determine if routine clinical indicators are useful predictors for shoulder dystocia. Parity, maternal weight gain during pregnancy, and a history of a previous large baby and increased operative vaginal delivery rate were more often associated with shoulder dystocia. No other significant associations were found. However, shoulder dystocia can not be predicted accurately antepartum using routinely available clinical factors.

Antenatal screening for human platelet antigen-1a: results of a prospective study at a large maternity hospital in Ireland.

Objective Fetomaternal mismatch for human platelet antigen (HPA)‐1a accounts for approximately 85% of cases of neonatal alloimmune thrombocytopenia. The purpose of the study was to determine the prevalence of the HPA‐1a negative platelet phenotype in a cohort of pregnant women in Ireland, the rate of alloimmunisation to HPA‐1a in HPA‐1 mismatched pregnancies and the associated incidence of neonatal alloimmune thrombocytopenia.

Multiple and massive arteriovenous malformations in pregnancy

Arteriovenous malformations (AVM) are rare in the reproductive years of life. There is a paucity of data regarding AVMs in pregnancy. Pregnancy can influence both the development and the progression of AVMs. The tendency to bleed is unpredictable. Many AVMs undergo spontaneous postpartum regression. We report on a 30-year old primipara with multiple generalised AVMs, both congenital and acquired, and a massive congenital AVM involving her entire right upper limb and shoulder girdle. Magnetic resonance imaging suggested there were AVMs in both the pelvis and the lower abdominal wall. The main management dilemma was mode of delivery. A trial of vaginal delivery was successful after spontaneous onset at term. The patient had a series of significant postpartum haemorrhages, warranting blood transfusion.

Should we recommend universal aspirin for all pregnant women

&NA; Low‐dose aspirin has been demonstrated to reduce the incidence of preeclampsia and fetal growth restriction in at‐risk populations. Its role in low‐risk populations is as yet unknown. Novel preeclampsia screening tests are emerging that can predict the risk of the development of preeclampsia from as early as 11 weeks of gestation. It may be more efficacious, acceptable, and cost‐effective to prescribe low‐dose aspirin to all pregnant women from the first trimester as opposed to performing a screening test in the first instance. There is variation in opinion: the American College of Obstetricians and Gynecologists suggests the use of aspirin only in women who are at risk of preeclampsia, based on patient history; the National Institute for Health and Clinical Excellence, UK, and the US Preventative Services Task Force recommend the use of low‐dose aspirin if there is 1 major or 2 moderate risk factors. This point‐counterpoint discussion shall address (1) controversies regarding the real impact of low‐dose aspirin; (2) controversies in the actual guidelines among the different national societies; (3) controversies regarding emerging preeclampsia screening tests in terms of cost‐effectiveness and efficacy, and (4) points in favor of the provision of universal vs screened‐positive women.

Prediction of outcome in twin pregnancy with first and early second trimester ultrasound

Abstract Objective: To establish if first or second trimester biometry is a useful adjunct in the prediction of adverse perinatal outcome in twin pregnancy. Methods: A consecutive cohort of 1028 twin pregnancies was enrolled for the Evaluation of Sonographic Predictors of Restricted growth in Twins (ESPRiT) study, a prospective study conducted at eight academic centers. Outcome data was recorded for 1001 twin pairs that completed the study. Ultrasound biometry was available for 960 pregnancies. Biometric data obtained between 11 and 22 weeks were evaluated as predictors of a composite of adverse perinatal outcome (mortality, hypoxic ischemic encephalopathy, periventricular leukomalacia, necrotizing enterocolitis, respiratory distress, or sepsis), preterm delivery (PTD) and birthweight discordance greater than 18% (18% BW). Outcomes were adjusted for chorionicity and gestational age using Cox Proportional Hazards regression. Results: Differences in crown-rump length (CRL) were not predictive of adverse perinatal outcome. Between 14 and 22 weeks, a difference in abdominal circumference (AC) of more than 10% was the most useful predictor of adverse outcome, PTD and 18% or more BW discordance in all twins. Overall the strongest correlation was observed for intertwin differences in biometry between 18 and 22 weeks. Conclusion: Biometry in the early second trimester can successfully identify twin pregnancies at increased risk. Intertwin AC difference of greater than 10% between 14 and 22 weeks gestation was the best individual predictor of perinatal risk in all twins. Sonographic biometry in the early second trimester should therefore be utilized to establish perinatal risk, thus allowing prenatal care to be improved.

Prenatal detection of structural cardiac defects and presence of associated anomalies: a retrospective observational study of 1262 fetal echocardiograms

The aim of this study is to document the detection of fetal congenital heart defect (CHD) in relation to the following: (1) indication for referral, (2) chromosomal and (3) extracardiac abnormalities.

Reduced fetal exposure to aspirin using a novel controlled‐release preparation in normotensive and hypertensive pregnancies

Objectives To examine the fetal effects of a novel controlled‐release, low dose aspirin preparation in normal and hypertensive pregnancies.

Natural history of fetal trisomy 13 after prenatal diagnosis

There are currently limited data describing the natural history and outcome for fetal trisomy 13 diagnosed prenatally. The aim of this study was to evaluate the fetal and neonatal outcome for pregnancies with an established prenatal diagnosis of fetal trisomy 13, and a parental decision for continuation of the pregnancy. To this end, the obstetric and neonatal outcome data for such pregnancies, diagnosed at two referral Fetal Medicine Centers, were retrospectively obtained and examined. During the study period, there were 45 cases of trisomy 13 diagnosed at both units, of which 26 (56%) continued with the pregnancy to its natural outcome. There were 12 intrauterine deaths in the cohort resulting in a rate of 46.2% of intrauterine lethality. Conversely, the live birth rate was 53.8%. For infants born alive, neonatal death on day 1 of life occurred in 78.6% of cases. The overall early neonatal mortality rate was 93%. There was one infant death at 6 weeks of age and no survival noted beyond this period. These data provide reliable information for parental counseling pertaining to risk of intrauterine death when trisomy 13 is diagnosed prenatally. These data also indicate that the survival outcome is worse than that previously accepted from studies of postnatal follow up of live born infants with this diagnosis.

Approaches to the management of antenatally diagnosed congenital tumours

Congenital fetal tumours are rare, but current imaging modalities including US and MRI facilitate antenatal diagnosis and investigation, allowing a presumptive diagnosis and management strategy. Although the prevalence of fetal tumours is difficult to ascertain, an incidence of 7.2 per 100,000 live births has previously been reported, with the incidence of neonatal malignancy estimated at 36.5 per million births. Teratomas and neuroblastomas are the most common solid tumours described. Tumours may be very large or associated with severe hydrops leading to significant dystocia with the potential for difficult vaginal or caesarean delivery. Once the diagnosis of a fetal tumour is made, optimal management incorporates a multidisciplinary approach including obstetrician, neonatologist, paediatric surgeon and paediatric oncologist so that counselling is appropriate and a clear management plan is in place for parents.

An open-label randomized-controlled trial of low dose aspirin with an early screening test for pre-eclampsia and growth restriction (TEST): Trial protocol

OBJECTIVE Pre-eclampsia remains a worldwide cause of maternal and perinatal morbidity and mortality. Low dose aspirin (LDA) can reduce the occurrence of pre-eclampsia in women with identifiable risk factors. Emerging screening tests can determine the maternal risk of developing placental disease, such as pre-eclampsia from the first trimester of pregnancy. The aim of this study is to determine if it is more beneficial in terms of efficacy and acceptability to routinely prescribe LDA to nulliparous low-risk women compared to test indicated LDA on the basis of a positive screening test for placental disease. METHODS We propose a three armed multi-center open-labeled randomized control trial of; (i) routine LDA, (ii) no aspirin, and (iii) LDA on the basis of a positive first trimester pre-eclampsia screening test. LDA (75mg once daily) shall be given from the first trimester until 36-week gestation. The primary outcome measures include; (i) the proportion of eligible women that agree to participate (acceptability), (ii) compliance with study protocol (acceptability and feasibility), (iii) the proportion of women in whom it is possible to obtain first trimester trans-abdominal uterine artery Doppler examination (feasibility) and (iv) the proportion of women with a completed screening test that are issued the screening result within one week of having the test performed (feasibility). CONCLUSION This will be the first clinical trial to determine the efficacy and acceptability in low-risk women of taking routine LDA versus no aspirin versus LDA based on a positive first trimester screening test for the prevention of placental disease.