Umber Agarwal

Quantifying the impact of deprivation on preterm births: a retrospective cohort study.

Background Social deprivation is associated with higher rates of preterm birth and subsequent infant mortality. Our objective was to identify risk factors for preterm birth in the UKs largest maternity unit, with a particular focus on social deprivation, and related factors. Methodology/Principal Findings Retrospective cohort study of 39,873 women in Liverpool, UK, from 2002–2008. Singleton pregnancies were stratified into uncomplicated low risk pregnancies and a high risk group complicated by medical problems. Multiple logistic regression, and generalized additive models were used to explore the effect of covariates including area deprivation, smoking status, BMI, parity and ethnicity on the risk of preterm birth (34+0 weeks). In the low risk group, preterm birth rates increased with deprivation, reaching 1.6% (CI95 1.4 to 1.8) in the most deprived quintile; the unadjusted odds ratio comparing an individual in the most deprived quintile, to one in the least deprived quintile was 1.5 (CI95 1.2 to 1.9). Being underweight and smoking were both independently associated with preterm birth in the low risk group, and adjusting for these factors explained the association between deprivation and preterm birth. Preterm birth was five times more likely in the high risk group (RR 4.8 CI95 4.3 to 5.4), and there was no significant relationship with deprivation. Conclusions Deprivation has significant impact on preterm birth rates in low risk women. The relationship between low socio-economic status and preterm births appears to be related to low maternal weight and smoking in more deprived groups.

Vulval lipoma: a rare occurrence

Case report.An extremely rare case of vulval lipoma is being reported for its rarity and brief review discussed.

Diagnostic accuracy of individual antenatal tools for prediction of small‐for‐gestational age at birth

To determine the accuracy of fetal and newborn growth charts for the prediction of small‐for‐gestational age (SGA) at birth (birth weight < 10th centile).

Diagnostic accuracy of individual antenatal tools for the detection of the small for gestational age newborn.

To determine the accuracy of fetal and newborn growth charts for the prediction of small‐for‐gestational age (SGA) at birth (birth weight < 10th centile).

Intrapartum posterior uterine wall rupture in lower segment cesarean section scarred uterus

Intrapartum uterine rupture is a well-documented complication of labor that fortunately is a rare event. The majority of these cases arise in women with scarred uteri secondary to some event such as previous cesarean section myomectomy deep cornual resection metroplasty tubo-cornual anastomosis iatrogenic or traumatic uterine rupture. Vaginal birth after cesarean (VBAC) is now a safe and well-accepted procedure of conduct in women with one previous lower segment cesarean section (LSCS). Uterine rupture in such women commonly involves the anteriorly placed scar. Posterior rupture in women in whom VBAC was attempted has also been reported although only twice in the literature. Here we report a similar case of posterior uterine rupture in a woman in labor with a previous LSCS to add further data to this rare and isolated complication. (excerpt)

Massive Hematocolpos Mimicking as an Ovarian Tumor: Atypical Presentation of Imperforate Hymen

This paper reports on an atypical presentation of imperforate hymen. A case of silent massive hematocolpos in a 11-year-old girl mimicking as a giant ovarian cyst is described. The diagnosis was made after examination under anesthesia. Successful surgery was then performed. We conclude that hematocolpos should always be included in the differential diagnosis of cystic pelvic pathology in perimenarcheal girls even in the absence of clinical symptom of cyclical lower abdominal pain.

The ugly face of septic abortion

A 23-year-old woman, Gravida 3, Para 2 presented following termination of a 10 weeks pregnancy by an unauthorised local practitioner 2 days earlier with complains of severe pain in lower abdomen, recurrent vomiting and inability to pass stools or flatus for 24 h. She was hypothermic, pale and dehydrated with a pulse rate of 100/min and blood pressure of 90/70 mmHg. The respiratory and cardiovascular system examination were normal. The abdomen was distended, tense and tender with guarding and rigidity all over. Shifting dullness was present and bowel sounds were sluggish. On speculum examination, blood clots were seen in the vagina and the cervical os was not visualised. On vaginal palpation the os was open, with tissue fragments felt in the vagina which could not be removed. There was severe lower abdominal tenderness and both fornices appeared full. The exact size of the uterus could not be made out as the patient was very tender. An erect abdominal X-ray revealed the presence of gas under the diaphragm and ultrasound of the abdomen was suggestive of multiple organised fluid pockets with dilated bowel loops. A provisional diagnosis of septic abortion with uterine and gut perforation with peritonitis was made, and the patient was prepared for exploratory laparotomy. At operation fecal peritonitis was present with about 2 l of dirty foul smelling fluid. The uterus was normal in shape and size with multiple loops of ileum seen entering it via a fundal perforation (Fig. 1). The loops could not be extracted even after giving pressure through the vagina. Bowel exploration revealed a terminal gangrenous ileum within 5 cm of the ilieo–caecal junction. A single 1 cm 1 cm perforation was found in the ileum proximal to the gangrenous area. Total abdominal hysterectomy with right hemicolectomy with excision of the gangrenous bowel (Fig. 2) with ileo-transverse anastomosis with peritoneal lavage was done. Two drains were left in the peritoneal cavity—one in the pelvis and the other in Morrison’s pouch. Intraoperatively, she received 6 units of whole blood and 4 units of plasma. On postoperative day 7, her condition deteriorated suddenly, and fecal matter started discharging from the abdominal wound. A repeat laparotomy confirmed an ilieo–colic anastomotic leak. Closure of the colon segment with terminal ileostomy was done. She had a stormy postoperative course complicated by septicaemia and chest infection requiring ventilatory support for 10 days. She was discharged in satisfactory condition on postoperative day 27 and closure of the ileostomy was successfully accomplished 3 months later.

Does serial 3rd trimester ultrasound improve detection of small for gestational age babies: Comparison of screening policies in 2 European maternity units.

OBJECTIVE Methods for the antenatal detection of small for gestational age babies (SGA) differ between countries. The aim of this study was to compare the diagnostic accuracy of routine versus selective small for gestational age babies screening policy using data from two European Maternity Units. STUDY DESIGN This was a retrospective cohort study from Liverpool Womens Hospital, UK, that uses selective third trimester sonography and from the University Hospital Centre Zagreb, Croatia, that uses routine third trimester sonography for SGA detection. Screen positive cases were defined as pregnancies with estimated fetal weight (EFW) <10th centile at the last 3rd trimester scan. True positives had both EFW and birth weight <10th centile. Pregnancy management data and perinatal outcomes were retrieved from hospital electronic data and special care baby unit (SCBU) reports. RESULTS The proportion of small for gestational age babies was higher in Liverpool (7.8%) compared with Zagreb (4%); P<0.001. Sensitivity for detection of SGA babies in Zagreb was 27% (95%CI 15%-44%) and 33% (95%CI 23%-45%) in Liverpool. The specificity was high in both centres (Zagreb 100% (95%CI); Liverpool 98% (95%CI)). The induction of labour for antenatally diagnosed SGA babies was more common in Liverpool (38.5%) than in Zagreb (9.1%). In both centres, all antenatally diagnosed SGA babies admitted to SCBU were preterm babies. Their indications for admission to SCBU were complications related to prematurity. CONCLUSION The effectiveness of selective SGA screening policy is comparable to universal third trimester ultrasound screening. Further prospective evaluations of SGA screening policies are warranted and they should include full cost-effectiveness analysis and assessment of possible harm from increased interventions leading to more preterm births.

Screening and Management of the Small for Gestational Age Fetus in the UK: A Survey of Practice

BACKGROUND Antenatal detection of the small for gestational (SGA) fetus has become an important indicator of quality of antenatal care in the UK. This has been driven by a desire to reduce stillbirth in this at risk group. METHODS We conducted a postal survey of 187 NHS consultant units within the UK to determine what the current practice for the detection and subsequent management of the suspected SGA fetus was following the guidance from the Royal College of Obstetricians and Gynaecologists (RCOG) in 2013. RESULTS The survey was performed in 3 rounds between 2016 and 2017 with a response rate of 65%. 85% of units assessed risk factors for SGA at booking. 81% of units used a customized symphysis fundal height (SFH) chart to screen for SGA with 95% of them using a cut off of <10th centile to refer for ultrasound assessment. When ultrasound is used to detect SGA, 80% of units used estimated fetal weight (EFW), with 89% of these using a cut off of <10th centile to diagnose SGA. Umbilical artery (UA) Doppler monitoring was undertaken in 97% of management and 94% delivered after 37 weeks. Only 24% of units had a dedicated fetal growth clinic, whilst 48% of units were able to offer computerised CTG to monitor the SGA fetus. CONCLUSIONS Overall there is consistency in the screening methods for SGA (customised SFH charts) and identification of suspected SGA (SFH <10th centile, EFW <10th centile, UA monitoring and induction of labour at term). There was a low uptake of computerized CTG to monitor SGA babies and a low number of specialised fetal growth clinics.

P16 Quantifying the risk of deprivation on preterm birth in UK maternity units

Objective To explore risk factors for preterm birth (PTB) between 24+0 and 34+0 gestational weeks in the UKs largest maternity unit, with a particular focus on low risk pregnancies and the effect of socioeconomic status. Design Retrospective cohort study of routinely collected obstetric and neonatal data. Setting 50 486 singleton pregnancies booked at the Liverpool Womens NHS Foundation Trust for all women delivering after 24+0 weeks gestation over a 7-year period from 2002 to to 2008. Main Outcome Measure The primary outcome was preterm birth. Pregnancies were stratified into three groups: low risk; those complicated by medical problems; pregnancies in women with a history of preterm delivery. Multiple logistic regression and generalised additive models were used to explore the effect of covariates including area deprivation, smoking status, BMI, parity and ethnicity. Results The proportion of PTB was significantly different in the three groups: 1.35% (95% CI 1.24 to 1.47, n=38 994) in the low risk group, compared to 6.55% (CI 6.09 to 7.03, n=10 760) in the medical disorder group and 9.2% (CI 7.39 to 11.61, n=732) in the previous preterm group. 64% of the women delivering at LWH were in the most deprived quintile relative to the English population. The unadjusted odds of preterm delivery in the most deprived quintile compared to the least was 1.60 (CI 1.28 to 2.00) in the uncomplicated group. In a multiple regression model, ever having smoked (OR 1.68 CI 1.35 to 2.08), underweight (OR 1.65 CI 1.005 to 2.56) and highest quintile of area deprivation (OR 1.59 CI 1.19 to 2.11) were associated with increased the risk of PTB. Being overweight decreased the risk of PTB (OR 0.76 CI 0.59 to 0.97). In the medical disorders group, age (OR 1.02 CI 1.011 to 1.04), highest quintile of area deprivation (OR 1.46 CI 1.14 to 1.88), underweight (OR 1.68 CI 1.09 to 2.51), ever having smoked (OR 1.19 CI 1.00 to 1.44), nulliparity (OR 1.37 CI 1.13 to 1.66) and black ethnic group (OR 1.61 CI 1.00 to 2.48) were associated with PTB. Conclusions Preterm delivery contributes to inequalities in infant mortality. In a cohort of women with no identifiable risk factors for PTB at booking, deprivation of area of residence is associated with higher risk of PTB, even with adjustment for smoking and underweight, which are also important independent risk factors. Deprivation of area of residence needs to be considered when comparing obstetric outcomes in units around the UK.