Srividhya Sankaran

Aetiology and pathogenesis of IUGR.

Intrauterine growth restriction (IUGR) is a major cause of perinatal mortality and morbidity. A complex and dynamic interaction of maternal, placental and fetal environment is involved in ensuring normal fetal growth. An imbalance or lack of coordination in this complex system may lead to IUGR. Animal studies have given us an insight into some aspects of the basic pathophysiology of IUGR, and recent technologies such as Doppler studies of maternal and fetal vessels have added further information. The aetiologies of IUGR are diverse, involving multiple complex mechanisms, which make understanding of the pathophysiology difficult. However, particular focus is placed on the mechanisms involved in uteroplacental insufficiency as a cause of IUGR, as (1) it is common, (2) outcome can be good if timing of delivery is optimal and (3) it may be amenable to therapy in the future. While the research into the pathophysiology of IUGR continues, there have been interesting discoveries related to the genetic contribution to IUGR and the intrauterine programming of adult-onset diseases attributed to IUGR.

Medical management of fibroids

The ideal medical therapy for fibroids is, arguably, a tablet that is taken by mouth, once a day or, even better, once a week, with minimal, if any, side-effects, that induces fibroid regression and thus a resolution of symptoms rapidly, but without affecting fertility. Such a magic bullet does not yet exist, and there are no indications that one is on the horizon. Driven by the observation that fibroid growth is hormone dependent, current medical treatments mainly involve hormonal manipulations. Gonadotrophin-releasing hormone analogues (GnRHa) have been the most widely used, and while they do cause fibroid regression, they can only be used in the short term, as temporizing measures in the perimenopausal woman, or pre-operatively to reduce fibroid size, influence the type of surgery, restore haemoglobin levels and apparently reduce blood loss at operation. They are notorious for rebound growth of the fibroids upon cessation of therapy, and have major side-effects. GnRH antagonists avoid the initial flare effect seen with GnRHa therapy, but otherwise do not appear to have any additional advantages over GnRHa. Selective oestrogen receptor modulators, such as raloxifene, have been shown to induce fibroid regression effectively in post-, but not pre-, menopausal women; even in the former group, experience with these drugs is limited, and they are associated with significant side-effects. Aromatase inhibitors only appear to be effective in postmenopausal women, have potentially significant long-term side-effects, and experience with their use is also limited. There are suggestions that the levonorgestrel intra-uterine system can cause dramatic reduction in menstrual flow in women with fibroids, but to date there have been no RCTs of its use in these women, in whom rates of expulsion of the device appear to be high. The progesterone antagonists mifepristone and asoprisnil have shown significant promise and warrant further research, as they appear to show efficacy in inducing fibroid regression without major side-effects. However, they and the other hormonal therapies that alter oestrogen and progesterone production or function significantly (danazol, gestrinone) are not compatible with reproduction. Therefore, the quest for the ideal medical therapy for fibroid disease continues, and increasing understanding of fibroid biology is ushering in non-hormonal therapies, although all are confined to laboratory experimentation at present. In the meantime, surgical and radiological approaches remain the mainstay effective therapies.

Diabetes in pregnancy: a review of current evidence.

Purpose of review There is controversy about the best approach to screening and management for gestational diabetes. In the recent Confidential Enquiry in Maternal and Child Health (CEMACH) the outcome of women with diabetes compared with women without diabetes. The results were exceptionally poor, suggesting the need for a new management approach. The aim of this review is to address these findings and our suggested care pathways. Recent findings The CEMACH report showed the congenital malformation rate was four to 10-fold higher, the perinatal mortality rate was four to seven-fold higher, stillbirth was five times more common, and babies were three times more likely to die in the first 3 months of life. Only 39% of women with established diabetes took folic acid and only 37% had some documentation of glycaemic control before pregnancy. Overall, less than a fifth of NHS trusts in the UK had any kind of multidisciplinary preconception services. The results for women with type 2 diabetes were as bad as those for type 1. Caesarean delivery rates were very high (67%). Summary Prepregnancy counselling and multidisciplinary team management is the key in achieving good pregnancy outcomes. There is emerging evidence about the safety and efficacy of oral hypoglycaemics like metformin in pregnancy.

Relationship of intertwin crown-rump length discrepancy to chorionicity, fetal demise and birth-weight discordance.

To study the frequency and clinical significance of crown–rump length (CRL) discrepancy at 11–14 weeks of gestation in twin pregnancies from an unselected population.

Foetal congenital heart disease: obstetric management and time to first cardiac intervention in babies delivered at a tertiary centre.

OBJECTIVES The aim of this study was to determine the timing of neonatal cardiac intervention in babies with antenatally diagnosed congenital heart disease and the impact on obstetric management. METHODS A retrospective review of all deliveries between January, 2008 and December, 2009 was conducted in a tertiary centre with foetal and paediatric cardiology, maternal-foetal medicine, and obstetric units. All live births with antenatally detected congenital heart disease were included. Data were collected from foetal, paediatric cardiology, and maternity databases and records. Induction, delivery mode, and timing of the first cardiac intervention in the neonate were studied. RESULTS 205 deliveries were included. Induction and elective Caesarean section rates were 51.2% (105/205) and 14.1% (29/205), respectively. The vaginal delivery rate was 56% (115/205). There was a non-significant trend towards a higher rate of vaginal delivery after spontaneous labour than after induction (75% versus 66%; p = 0.234). The rate of neonatal cardiac intervention during the initial stay was 59.5% (122/205); it was 18.5% (38/205) within 48 hours and 25.8% (53/205) within 72 hours. The median time to first intervention was 4 days (interquartile range 2-8). Babies with hypoplastic left heart syndrome (median 3, interquartile range 2-6), transposition of the great arteries (median 1, interquartile range 0-4.5), and arrhythmia (median 0.5, interquartile range 0-1) had a significantly earlier time to first intervention compared with those with other conditions (p = 0.001). CONCLUSION Vaginal delivery can be achieved in women delivering babies with major congenital heart disease at a tertiary centre. Delivery in or near a tertiary centre is recommended for patients requiring early intervention, of which many can be identified in advance.

Survival of pregnancies with small for gestational age detected before 24 weeks gestation

OBJECTIVE Counselling women where severe growth abnormalities are detected early in the pregnancy is often difficult due to a paucity of outcome data of this specific subset of early onset disease. This study therefore aimed to assess the outcome of pregnancies where an estimated fetal weight less than the third centile were detected prior to 24 weeks gestation. STUDY DESIGN A retrospective study in two London teaching hospitals, over an eight year period was performed, analysing all pregnancies with an ultrasound estimated fetal weight less than the third centile prior to 24 weeks gestation. Outcome data: intrauterine death, neonatal death, survival to discharge, gestation at delivery and birthweight were collected. RESULTS Out of 20 pregnancies included in the analysis, six died in utero, two died in the neonatal period and 12 (60%) survived until discharge. Of the livebirths, 67% delivered preterm and 100% percent of livebirths were delivered by Caesarean Section. CONCLUSION When severe growth abnormalities were detected before 24 weeks, more than half of pregnancies resulted in survival to neonatal discharge. There was an increased incidence of preterm delivery, caesarean section and neonatal unit admission. This information is useful in counselling parents.

The prediction of intra-partum fetal compromise in prolonged pregnancy

Summary This is a prospective study conducted in a dedicated post-dates clinic to investigate the importance of antenatal ultrasound, Doppler and cardiotocographic (CTG) indices in the prediction of adverse intra-partum events in prolonged pregnancy. Operative delivery for abnormal fetal ECG-ST segment analysis and/or an arterial cord pH < 7.15 were regarded as adverse events. There were 462 singleton pregnancies with 87 adverse intra-partum events included in the analysis. Intra-partum adverse events were associated with nulliparity, oligohydramnios and induction of labour. The birth weight of fetuses was significantly less in the group with adverse intra-partum events. Logistic regression analysis showed that only nulliparity, birth weight and oligohydramnios had a significant independent influence on the risk of an adverse intra-partum event. Nulliparity was associated with five-fold increase in risk of an adverse intra-partum event. Oligohydramnios was associated with a three-fold increase in the risk. The risk decreased with increasing birth weight.

Dichorionic triplet pregnancies: risk of miscarriage and severe preterm delivery with fetal reduction versus expectant management. Outcomes of a cohort study and systematic review

In trichorionic pregnancies, fetal reduction from three to two lowers the risk of severe preterm delivery, but provides no advantage in survival. Similar data for dichorionic triamniotic (DCTA) triplets is not readily available.

Screening in the presence of a vanished twin: Nuchal translucency or combined screening test?

We present a case of an initial twin pregnancy with early demise of one twin, at the time of first trimester screening where the addition of biochemical markers helped to detect an aneuploidy in the live fetus. Using the NHS Fetal Anomaly Screening Programme recommendations (NHS FASP, 2010), only nuchal translucency (NT) should have been taken into consideration, which would have given a low risk for the chromosomal abnormalities trisomy 18 and 21. The learning point in this case is that when faced with abnormal biochemistry results in cases with a vanished twin, attention should be paid to the level of the individual biochemical markers.

A descriptive single‐centre experience of the management and outcome of maternal alloantibodies in pregnancy

Haemolytic disease of the fetus and newborn (HDFN) occurs when maternal IgG alloantibodies to fetal red blood cell antigens cross the placenta, causing haemolysis in the fetus and/or neonate. After delivery, the main concern is hyperbilirubinaemia, which can cause neurological damage.