Susan Sellers

The management and outcomes of placenta accreta, increta, and percreta in the UK: a population-based descriptive study

To describe the management and outcomes of placenta accreta, increta, and percreta in the UK.

Incidence and risk factors for placenta accreta/increta/percreta in the UK: a national case-control study.

Background Placenta accreta/increta/percreta is associated with major pregnancy complications and is thought to be becoming more common. The aims of this study were to estimate the incidence of placenta accreta/increta/percreta in the UK and to investigate and quantify the associated risk factors. Methods A national case-control study using the UK Obstetric Surveillance System was undertaken, including 134 women diagnosed with placenta accreta/increta/percreta between May 2010 and April 2011 and 256 control women. Results The estimated incidence of placenta accreta/increta/percreta was 1.7 per 10,000 maternities overall; 577 per 10,000 in women with both a previous caesarean delivery and placenta praevia. Women who had a previous caesarean delivery (adjusted odds ratio (aOR) 14.41, 95%CI 5.63–36.85), other previous uterine surgery (aOR 3.40, 95%CI 1.30–8.91), an IVF pregnancy (aOR 32.13, 95%CI 2.03–509.23) and placenta praevia diagnosed antepartum (aOR 65.02, 95%CI 16.58–254.96) had raised odds of having placenta accreta/increta/percreta. There was also a raised odds of placenta accreta/increta/percreta associated with older maternal age in women without a previous caesarean delivery (aOR 1.30, 95%CI 1.13–1.50 for every one year increase in age). Conclusions Women with both a prior caesarean delivery and placenta praevia have a high incidence of placenta accreta/increta/percreta. There is a need to maintain a high index of suspicion of abnormal placental invasion in such women and preparations for delivery should be made accordingly.

Severe Maternal Sepsis in the UK, 2011–2012: A National Case-Control Study

Marion Knight and colleagues conducted a national prospective case-control study in the UK from June 2011 through May 2012 to estimate the incidence, describe the causative organisms and sources of infection, and identify the risk factors for severe maternal sepsis. Please see later in the article for the Editors Summary

Is oxytocin involved in parturition

Peripheral plasma levels of oxytocin were determined in women during pregnancy and labour. There was a significant increase in maternal plasma oxytocin with advancing gestation but no significant change in levels at any stage of labour. Oxytocin concentrations in umbilical cord plasma were measured after spontaneous vaginal delivery and at elective caesarean section. A significant arteriovenous difference, with higher arterial levels, was found in both groups and the values after labour were significantly higher than at elective caesarean section. These findings suggest that the fetus is able to produce oxytocin which may play a role in human parturition.

A comparison of plasma prostaglandin levels in term and preterm labour

Peripheral plasma levels of 13,14‐dihydro‐15‐keto‐prostaglandin F (PGFM) were determined in women during pregnancy and in term and preterm labour. The PGFM concentrations at term were not significantly different from the levels between 26 and 34 weeks gestation. In both term and preterm labour there was a rise in PGFM levels with increasing cervical dilatation although the mean values tended to be lower during preterm labour. These findings may provide an explanation for the effectiveness of prostaglandin synthetase inhibitors in suppressing myometrial activity in preterm labour.

Fetal cerebral Doppler in the recognition of fetal compromise

Objective To establish reference ranges for the human fetal middle cerebral artery pulsatility index (MCA PI) for the local obstetric population, and to compare computerised antenatal fetal heart rate (FHR) analysis with the MCA PI as indicators of fetal compromise.

Factors associated with maternal death from direct pregnancy complications: a UK national case–control study

Sir, We refer to the article ‘Factors associated with maternal death from direct pregnancy complications: aUKnational casecontrol study’ published in BJOG. This study highlights the significant contribution of medical co-morbidities to deaths arising from obstetric causes (direct deaths). Surprisingly, no mention is made of preconception care and its possible value. The importance of preconception care has been stated and re-iterated in the two most recent confidential enquiries into maternal deaths and we are concerned that there appears to be a lack of implementation of this key aspect of women’s health. Of the six risk factors associated with maternal death from direct pregnancy complications identified in the study, we believe preconception counselling could have affected at least four of these— inadequate use of antenatal care, substance misuse, medical co-morbididties and previous pregnancy problems. Did any of these women receive advice before becoming pregnant? In a recent survey of 100 pregnant and newly delivered women in our unit, 26 had received some form of preconception advice from a health care professional. More concerning was that only one-third of women with medical disorders received advice before getting pregnant. Women were asked what would help to raise awareness and they suggested social media, advertising with posters, and introduction of such awareness as part of secondary school education. As a result we have developed a local initiative (babySAFER) to raise awareness of smoking, alcohol, folic acid, exercise and eating, and rubella vaccination. The information presented as a smart card also refers to the importance of existing medical conditions and medications. This has been widely circulated, for example in pharmacies and GP surgeries, and is under evaluation. Although limited evidence exists in the form of randomised controlled trials to confirm the impact of preconception awareness on maternal and child health, it seems obvious that all women should be encouraged to seek advice before they conceive. Messages from previous maternal mortality reports do not seem to have been taken up by health services. We feel a collective approach from health care professionals involved in the care of women of reproductive age is essential to promote preconception awareness. There is unlikely to be a change in the profile of maternal mortalities before this happens.&

Raised prostaglandin levels in the third stage of labor

Serial measurements of maternal peripheral plasma concentrations of 13,14-dihydro-15-keto-prostaglandin F (PGFM) and oxytocin were made during the three stages of labor and in the immediate puerperium. PGFM levels increased a labor progressed, and reached maximal levels before placental separation had occurred. The mean value in the second stage of labor was significantly higher than that in the first stage (p less than 0.01); similarly, the value 5 minutes after delivery, before expulsion of the placenta, was significantly greater than that in the second stage of labor (p less than 0.01). There was no significant difference between the mean PGFM concentration at placental separation and the level 5 minutes after delivery or in the second stage of labor. Two hours after delivery of the placenta, PGFM levels were not significantly different from values observed in the first stage of labor. Peripheral plasma concentrations of oxytocin did not change significantly at any stage of labor or 2 hours post partum. These results suggest that prostaglandins have a role in the third stage of labor, and this finding may have important clinical implications.

Current trends in the management of heart disease in pregnancy

BACKGROUNDnThe management of heart disease in pregnancy is highly specialized. Guidelines are based on observational studies. This paper describes our experience of these patients, including adverse cardiac events, adherence to guidelines, and areas of suboptimal management.nnnMETHODSnPatients referred to the service between 01/05/1999 and 30/06/2005 were identified using clinic lists and keyword searches in databases. A list of 40 management standards was created from European Society of Cardiology and the Confidential Enquiry into Maternal and Child Health guidelines. Adherence to these was recorded and adverse cardiac events noted.nnnRESULTSnThere were 177 pregnancies in 155 women with a mean age of 28+/-6 years. Service referrals increased linearly throughout the study period. Of 131 cardiac pregnancies 101 had congenital heart disease (77.1%). Pulmonary oedema, deteriorating functional class, sustained arrhythmia or cardiac intervention occurred in 13 pregnancies (10.2%), though not always in high risk cases. Management guidelines were largely followed, though areas of suboptimal management included lack of pre-conception advice and inadequate post-partum follow-up. Controversial areas include the use of beta-blockade in coarctation of the aorta and the use of elective Caesarean section in high risk patients.nnnCONCLUSIONSnCardiac pregnancies are increasing, mainly due to the rise in patients with congenital heart disease. Some patients will experience adverse cardiac events, including low risk patients. Pre-conception advice and post-partum follow-up should be improved. In the absence of prospective studies, management is likely to be driven by observational studies.

THE RELATION BETWEEN THE RELEASE OF PROSTAGLANDINS AT AMNIOTOMY AND THE SUBSEQUENT ONSET OF LABOUR

Maternal peripheral plasma levels of 13,14‐dihydro‐15‐keto‐prostaglandin F (PGFM) were measured in 16 women following amniotomy performed for the induction of labour at term. After 5½ hours, seven patients were in established labour (Group I) but the remaining nine patients required an intravenous infusion of oxytocin (Group II). An initial rapid rise in PGFM concentrations within five minutes of amniotomy occurred in all women and, therefore, the onset of labour does not appear to be a direct consequence of this initial increase. In Group I there was a significant increase in PGFM concentrations between five and 30 minutes after amniotomy and from 30 minutes to the time at which the last sample was collected; these later rises were associated with the onset and progress of labour in these women. These increases in PGFM concentrations did not occur in patients in Group II. The reason for this difference in response to amniotomy is as yet unclear.