High risk pregnancy

Purpose: To evaluate the efficiency of transvaginal ultrasound in the early diagnosis of ovarian cancer. Methods: Screening transvaginal ultrasound has been annually performed during the last 2 years in asymptomatic women without familial history of ovarian cancer. When abnormalities were detected, the procedure was repeated after 4-6 weeks. If the findings disappeared, the study was repeated after 1 year. If the abnormality persisted, study was complemented with tumor markers, computed tomography and laparoscopic surgery. The findings were compared with a control group of women in whom ovarian transvaginal ultrasonography was formally indicated. Results: A total of 26007 transvaginal ultrasound were performed: 8813 (33.8%) belonged to the screening group and 17194 (66.2%) to the control group. In 14 patients of the screening group, a malignant tumor was diagnosed and histologically confirmed. The mean age of these patients was 45 years old (SD 12). Eleven of these tumors were stage I (seven Ia, and four Ic), two stage IIIc and one was a metastatic melanoma in both ovaries. Six lesions were borderline tumors (five serous and one mucinous). In the control group, 27 ovarian cancers were diagnosed in patients with a mean age of 48 years (SD 17). In this group, 11 tumors were in stage I, and six were borderline. Conclusions: Although consensus about the benefits of using transvaginal ultrasound as a screening procedure is not conclusive, our data reveals that tumors detected in patients screened with transvaginal ultrasound are in earlier stages when compared with those diagnosed in the control group. No differences were found in age and number of borderline tumors between both groups. Additional studies are needed to support this preliminary findings.

In previous pilot studies, fetal vein of Galen (GV) blood velocity has been shown to be non-pulsatile in normal pregnancies. A pulsating pattern in high-risk pregnancies has been related to adverse outcome of pregnancy. The aim of this study was to establish reference ranges for fetal cerebral venous blood flow and compare them to the recordings in high-risk pregnancies in terms of predicting adverse perinatal outcome.

The developing fetal upper aerodigestive system provides the structural support for respiratory and ingestive functions necessary to sustain life at birth. This study investigated prenatal development of upper aerodigestive anatomy and the association of emerging functions as predictors of postnatal feeding skills. Biometric measures of oral, lingual, pharyngeal and laryngeal structures were obtained in fetuses 15-38 weeks gestational age using a four-plane sonographic technique. Accompanying ingestive behaviors were tallied across development. The data from 62 healthy controls were compared to seven cases at risk for postnatal feeding and swallowing dysfunction (Type II Arnold Chiari Malformation, trisomy 18, polyhydramnios, intrauterine growth restriction, Brachmann-de Lange Syndrome). Significant (p<0.001) linear regressions occurred in pharyngeal and lingual growth across gestation while ingestive behavior such as suckling emerged in a sequence of basic to complex movement patterns. Jaw and lip movements progressed from simple mouth opening to repetitive open-close movements important for postnatal suckling. Lingual movements increased in complexity from simple forward thrusting and cupping to anterior-posterior motions necessary for successful suckling at term. Laryngeal movements varied from shallow flutter-like movements along the lumen to more complex and complete adduction-abduction patterns. Fetal swallowing primarily occurred in the presence of concomitant oral-facial stimulatory activity. Significant variations (p<0.01) in the form and function of the ingestive system occurred in comparisons of gestational age-matched controls to at-risk cases. We postulate that prenatal developmental indices of emerging aerodigestive skills may guide postnatal decisions for feeding readiness and, ultimately, advance the care of the premature, medically fragile neonate.

Amniotic band syndrome causes a variety of fetal malformations involving the limbs, craniofacial region, and trunk. Six prenatally diagnosed cases of amniotic band syndrome are discussed. The diagnosis was based on sonographic visualization of either amniotic sheets or bands associated with fetal deformation or deformities in nonembryologic distributions known to characterize the amniotic band syndrome. Seven additional cases are considered in which an aberrant sheet of tissue with a free edge was visualized within the amniotic cavity but no restriction of fetal motion or subsequent deformity was demonstrated.

Objectives: We investigated the relationship between premature rupture of the membranes (PROM) and early mortality among triplets in the United States. Study design: Analysis was conducted on matched and linked triplet sets born to mothers in the United States between 1995 and 1997. The generalized estimating equation framework was used to generate odds ratios after capturing the effects of sibling correlations within triplet clusters. Results: Triplets exposed to PROM were twice as likely to experience stillbirth (OR ¼ 2:17, 95% CI [1.26-3.41]), neonatal death (OR ¼ 2:23, 95% CI [1.70-3.0]) and infant death (OR ¼ 2:21, 95% CI [1.72-2.85]), as compared to those who did not. The population-attributable risk for early mortality due to PROM was 11-12%. Conclusions: Triplets associated with PROM had a significantly higher level of early mortality than those without. Assuming a causal relationship, 11-12% of all early deaths among triplets in the United States are accounted for by PROM. #

Day by day there is a definite increase in the number of woman bearing children in their older age. So, elder maternal age has become an important topic in the world wide. But yet it has not received adequate attention in our country. This study has done with an objective to find out problems associated with pregnancy and perinatal outcome in woman 35 years of age and above. It is a comparative study. This study was done in BSMMU from August 2008 to January 2009. A total 1130 obstetric patient were admitted during this study period. From this admitted patient consecutive 35 patients were selected for this study, whose ages were above 35 years. At the same time 35 patients were selected as a control, whose age was below 35 years. Among 35 elderly patients caesarian section was significantly high both in elderly patients (Group A)88.5% & control group(Group B) 63%, followed by vaginal delivery(11.5% Vs 37%). Pregnancy complications were found significantly high in A group (57%) compared to B group(20%). Most common complications observed in group A were APH 14.2%, preeclampsia 11.4%, malpresentation 11.4%, obstructed labour 8.5% oigohydramnions 5.7%. Post delivery maternal complications were more in A group (40%) compared to B group (23%). Failure of lactation was found more in A group(11%) compared to B group(5.7%), PPH was found 8.5% in A group and 5.8% in B group, wound infection 5.8% in A group and 2.8% in B group, emergency peripartum hysterectomy 5.7% in A group and 2.8% in B group. The rate of alive baby in group A was 86% and group B was 94%, still born rate in Group A and Group B was respectively 8.5% & 2.8% and early neonatal death was respectively 5.7% & 2.8%.

= Objective: To describe parents' reaction to a prenatal tour of the neonatal intensive care unit (NICU) during a high-risk pregnancy and identify advice they have for other parents and health care professionals who participate in a such a tour.

The aim of this study was to compare the pregnancy outcome and delivery complications in women 40 years or older (cases) to that of women 20 to 30 years old (controls). Over a 5-year period, 319 cases had a singleton delivery in our institution. These women were compared with 326 controls. Parity was significantly higher in cases compared with controls (3.2 vs. 1.8). Advanced maternal age, compared with younger age, was associated with significantly higher rates of preterm delivery (16.0 vs. 8.0%), cesarean delivery (CS) (31.3 vs. 13.5%), and the occurrence of one or more antepartum complications (29.5 vs. 16.6%). When the two groups were subdivided according to parity, rates of preterm delivery, CS, preeclampsia, gestational diabetes, chronic hypertension, and labor induction were each significantly higher among older multiparas compared with control multiparas. However, only preterm delivery, CS rates, and uterine fibroids were found to be significantly higher in older nulliparous compared with young nulliparous women. We conclude that multiparous women at least 40 years old have a higher antepartum complication rate including intrauterine fetal death compared with younger women.

In 42 cases of trisomy 13 at 10±14 weeks of gestation, compared with 947 controls, the median multiple of the median (MoM) of maternal serum free b-human chorionic gonadotrophin (b-hCG) and pregnancy associated plasma protein A (PAPP-A) was signi®cantly decreased (0.506 MoM and 0.248 MoM respectively), whilst fetal nuchal translucency was increased (2.872 MoM). In 38% and 71% of cases of trisomy 13 maternal serum free b-hCG and PAPP-A was below the 5th centile of the appropriate normal range for gestation and in 62% of cases the nuchal translucency was above the 95th centile. When combined together in a multivariate algorithm with maternal age, 90% of cases of trisomy 13 could be detected at a 0.5% false positive rate or 84% at a 0.1% false positive rate. We conclude that speci®c trisomy 13 risks should be part of developing risk algorithms combining maternal serum biochemistry and nuchal translucency for use in ®rst trimester screening alongside those for trisomy 21 and trisomy 18.

Eating disorders in pregnancy can have profound effects upon both fetus and mother. Critical periods of fetal development may be altered in the presence of maternal undernutrition, and the psychological impact of pregnancy may be severe for the mother. This essay explores how midwives can best support women with eating disorders throughout the antenatal period.

Proefschrift ter verkrijging van de graad van Doctor aan de Universiteit Leiden, op gezag van de Rector Magnificus Dr. D.D. Breimer, hoogleraar in de faculteit der Wiskunde en Natuurwetenschappen en die der Geneeskunde, volgens besluit van het College voor Promoties te verdedigen op donderdag 23 maart 2006 klokke 16.15 uur door Denise Marta Vera Pelikan geboren te Groningen in 1972 P r o m o t i e c ommissie

Abstract: Triage in hospitals typically aim to categorize and prioritize pregnant women who present for emergent or urgent care before detailed evaluation and management. However, obstetric patients are best served if local emergency services develop protocols whereby they were taken to the most appropriate facility.
Aim of the study: this study aimed to assess the effect of nurse’s application of structure obstetrics triage guideline on pregnant women outcomes.
Design: A prospective quasi-experimental design (pre and post intervention) was utilized.
Setting: at obstetrics department in Prince Hussein Bin Abdullah (Amman, Jordan).
Sample: a convenience sample consists of all nurses (50) working in obstetric department at the time of data collection. Instruments: included a structured interview questionnaire consisting of two parts; “personal characteristics, and knowledge about obstetric Triage” and the performance assessment checklist through Maternal Fetal Triage Index (MFTI) adopted from AWHONN’s, (2016). Results: nurses were gain knowledge and practices for obstetric women triage as well as “Maternal Fetal Triage Index” after intervention than in before intervention with statistical significance difference p<0001 for all knowledge item about triage. In addition nurses after intervention increase their level of outcomes evaluation above the upper confidence level. An increases in nurses’ practicing in relation to improve maternal outcomes after intervention increase their level of outcomes evaluation “above the upper confidence levels”, than before intervention “below the confidence level”.
Conclusion: Nurses application improved in their proficiency after conducting Structured Obstetrics Triage Guideline for pregnant women outcomes on post intervention than on pre intervention. Recommendations: 1- theoretical and practical training of obstetric triage for nurses in hospitals as well as undergraduate curriculum.2-Continous educational training programs about obstetric triage for health team should be provided to increase their knowledge and skills 3-Simple manual guidelines for Triage and MFTI should be available at every obstetric unit to guide nurses to priories newly admitted cases according to severity of obstetric symptoms 4-Establish an emergency simulation scenarios with staff from multiple areas to help everyone involved to be better prepared when an actual emergency occurred. Keywords: Structured Obstetrics Triage, Guideline, pregnant Women Outcomes.

Objective To investigate the predictive value of the combination of first-trimester serum placental protein 13 (PP13), uterine artery Doppler pulsatility index (PI) and pulse wave analysis (augmentation index at a heart rate of 75 beats per min (AIx-75)), and to evaluate concurrent and contingent strategies using this combination for assessing the risk of pre-eclampsia in high-risk women.

While child marriage persists in sub-Saharan Africa (SSA), little is known about its influence on institutional delivery/high-risk births (IDHRB). We analyzed pooled data on young women aged 15-24 (N = 113,588) from the most recent Demographic and Health Surveys of 31 SSA countries to examine the influence of child marriage on IDHRB. Binary logistic regression analysis was done to explore statistically significant relationships. Findings showed that unskilled delivery was significantly higher among women who married before age 15 (67.2%) and at ages 16-17 (48.2%) compared to those who married at age 18+ (30.2%). The prevalence of high-risk birth was higher among women who married before age 15 (97.2%) and at ages 16-17 (80.8%) compared to those who married at 18+ (48.4%). Inferential analysis showed that respondents who married before age 15 and at ages 16-17, respectively, had five-fold and twofold higher odds of experiencing unskilled delivery compared to those who married at age 18 +. Odds of having high-risk births were significantly higher among child-brides compared to those who had first marriage as adults. This study concludes that policies/programs that would successfully delay first marriage among women must be pursued to reduce high-risk births and unskilled delivery in SSA.

The relationship between marriage before 16 years and pregnancy outcome throughout the childbearing period was examined. Participants included all married women attending six randomly selected primary health care units in Jeddah with at least one infant and complete medical files. Early teenage marriage was found for 27.2% of women. Most of these were illiterate [57.1%], housewives [92.4%]and grand multiparae [66.7%]. They were at twice the risk of spontaneous abortion, four times the risk of combined fetal death and infant mortality, and twice the risk of losing pregnancies any time during their childbearing years. They remained at high risk of poor pregnancy outcome throughout their reproductive lives. Despite tradition, marriage should be discouraged before 16 years

Health care delivery for pregnant women at high risk is changing in response to the nation's need to contain costs and improve care. Perinatal nurse practitioners can provide specialized care to women at high risk in a wide variety of settings. They provide quality, costeffective care and can improve access to prenatal care for families at risk for untoward pregnancy outcomes.

This case illustrates the importance of blood group antibodies in antenatal serology other than Rh system as a cause of hemolytic disease of newborn (HDN). In India, antenatal antibody screening is done at majority of transfusion centers in only Rh (D) negative mothers. In this multigravida woman with high risk obstetrical history, an antenatal antibody screening by indirect antiglobulin test (IAT) was not performed as she was Rh (D) positive. Postnatal work up for the pathological jaundice in the neonate revealed that red cell alloimmunization had occurred due to anti-Jk b . We conclude that antenatal antibody screening should be done in all pregnant women irrespective of the D antigen status to detect and manage red cell alloimmunization to any other clinically significant blood group antigens.

Background: Considering the fact that a significant proportion of high-risk pregnancies are currently referred to tertiary level hospitals; and that a large proportion of low obstetric risk women still seek care in these hospitals, it is important to explore the factors that influence the childbirth experience in these hospitals, particularly, the concept of humanized birth care. The aim of this study was to explore the organizational and cultural factors, which act as barriers or facilitators in the provision of humanized obstetrical care in a highly specialized, university-affiliated hospital in Quebec province, in Canada.

The main objective of this study was to assess awareness of danger
signs of pregnancy and its associated factors in Mekelle public
hospitals, 2014.
Institutional based cross sectional study was conducted among 422
pregnant mothers. Data was collected using interviewer administered
questionnaire; it was entered and analyzed using SPSS version 16.
The data were presented using texts, graphs and tables.
Out of the total participants of this study 79.6% mothers had
information about danger signs of pregnancy from which 61.9%
mothers had information about vaginal bleeding followed by sudden
gush of fluid before labor which was mentioned by 41.9% of
respondents. Severe unusual abdominal pain was the least known
danger signs as mentioned by 19 % of mothers. The main source of
information for the danger signs was health personnel and
Negligence was the main reason for not having good awareness about
danger signs of pregnancy.
Therefore, health extension workers should strengthen their
awareness creation activities; community mobilization and health
education should be considered with policy makers and other
interested organizations.

Objective: The purpose of this study was to determine the superior technique, if either, of the amniotic fluid index (AFI) vs the single deepest pocket technique in predicting an adverse pregnancy outcome among high-risk patients undergoing antenatal testing. Study design: Patients having modified biophysical profile (nonstress test plus sonographic estimation of amniotic fluid) were randomized to either have AFI or determination of the presence or absence of a 2!1-cm single deepest pocket. Results: Between January of 1997 and December of 2001, 1080 women were randomized with 530 women in the AFI arm, and 558 in the 2!1 pocket arm. The maternal demographics and prenatal complications were similar between groups. Significantly more patients were identified as having oligohydramnios using AFI (17%) compared with using 2!1 pocket (10%) (P = .002). The overall rate of cesarean section for nonreassuring fetal heart rate (FHR) tracing was 3.8% (30 cases, with 16 cases in the AFI-monitored, and 14 cases in the 2!1 pocketemonitored groups, respectively, P = .608). Logistic regression analysis showed no difference between the groups with respect to the ability to identify patients who underwent cesarean section for nonreassuring FHR tracing during labor (P = .999). The umbilical artery pH !7.1 (P = .688) and admission to the newborn intensive care unit were also comparable between groups. Conclusion: During antepartum fetal surveillance, use of single deepest pocket compared with amniotic fluid index is associated with a significantly lower rate of suspected oligohydramnios.

Background: Infection with Toxoplasma gondii during pregnancy can lead to severe illness in the fetus. Many T. gondii infections are preventable by simple hygienic measures. Methods: We surveyed pregnant women in the US to determine their knowledge about toxoplasmosis and their practices to prevent infection. Volunteer obstetricians selected to be demographically representative of the American College of Obstetricians and Gynecologists recruited the participants. Results: Of 403 women responding to the survey, 48% indicated that they had heard or seen information about toxoplasmosis; however, only 7% were aware of being tested for the disease. Forty percent of responding women knew that toxoplasmosis is caused by an infection, but 21% thought that a poison causes it. The highest level of knowledge was about cats and T. gondii; 61% responded that the organism is shed in the feces of infected cats and 60% responded that people could acquire toxoplasmosis by changing cat litter. There was a low level of knowledge about other risk factors; only 30% of the women were aware that T. gondii may be found in raw or undercooked meat. Nevertheless, a high percentage of women indicated that they do not eat undercooked meat during pregnancy and that they practice good hygienic measures such as washing their hands after handling raw meat, gardening or changing cat litter. Conclusion: Except for the risk of transmission from cats, knowledge among pregnant women about toxoplasmosis is low. However, toxoplasmosis-preventive practices are generally good, suggesting that providers should continue to offer education about practices that help prevent foodborne diseases in general as well as information about preventing toxoplasmosis specifically.

Women with polycystic ovary syndrome (PCOS) have a myriad of phenotypic and clinical features that may guide therapeutic options for metabolic protection and ovulation induction. The use of metformin may prove beneficial in a subset of the population of women with PCOS. Hyperinsulinemia, as demonstrated by elevated insulin levels on a 2-hour 75-g load glucose tolerance test, is an important parameter in deciding whether or not to initiate metformin therapy to women with PCOS with the hope of preventing or delaying the onset of type 2 diabetes mellitus (DM). Cardiovascular risk factors including markers of subclinical inflammation, and dyslipidemia may also be improved by metformin therapy. For ovulation induction, metformin is not as effective as clomiphene citrate as first-line therapy for women with PCOS. There are no clear data to suggest that metformin reduces pregnancy loss or improves pregnancy outcome in PCOS, and it is currently recommended that metformin be discontinued with the first positive pregnancy test result, unless there are other medical indications (eg, type 2 DM). This review addresses practical management guidelines for the uses of metformin in women with PCOS.

The human brain is very sensitive to environmental changes affecting its growth and development. Environmental changes influence neonatal behavior after birth, enabling continuity between prenatal and postnatal behavior, but postnatal adaptation could be considered as discontinuity. Thus there is the question of environmental discontinuity between intrauterine conditions characterized by existence of microgravity and extrauterine life with gravity as a developmental condition sine qua non. Four-dimensional ultrasound is currently being assessed as a functional prenatal screening test for detection of neurological impairment in utero. The Kurjak Antenatal Neurodevelopmental Test (KANET) combines the assessment of fetal behavior, general movements, and three out of four signs that have been postnatally considered as symptoms of possible neurodevelopmental impairment (neurological thumb, overlapping sutures and small head circumference). Although the KANET has been tested on normal and high-risk pregnancies, the significance of the test for detection and prevention of neurodevelopmental disability is still questionable.

Background Post-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage. Methods In this randomised, double-blind, placebo-controlled trial, we recruited women aged 16 years and older with a clinical diagnosis of post-partum haemorrhage after a vaginal birth or caesarean section from 193 hospitals in 21 countries. We randomly assigned women to receive either 1 g intravenous tranexamic acid or matching placebo in addition to usual care. If bleeding continued after 30 min, or stopped and restarted within 24 h of the first dose, a second dose of 1 g of tranexamic acid or placebo could be given. Patients were assigned by selection of a numbered treatment pack from a box containing eight numbered packs that were identical apart from the pack number. Participants, care givers, and those assessing outcomes were masked to allocation. We originally planned to enrol 15 000 women with a composite primary endpoint of death from all-causes or hysterectomy within 42 days of giving birth. However, during the trial it became apparent that the decision to conduct a hysterectomy was often made at the same time as randomisation. Although tranexamic acid could influence the risk of death in these cases, it could not affect the risk of hysterectomy. We therefore increased the sample size from 15 000 to 20 000 women in order to estimate the effect of tranexamic acid on the risk of death from post-partum haemorrhage. All analyses were done on an intention-to-treat basis. This trial is registered with ISRCTN76912190 (Dec 8, 2008); ClinicalTrials.gov, number NCT00872469; and PACTR201007000192283.

Prior studies have suggested that obstetrical (OB) ultrasound in low-and middle-income countries has aided in detection of high-risk conditions, which in turn could improve OB management. We are participating in a cluster-randomized clinical trial of OB ultrasound, which is designed to assess the effect of basic OB ultrasound on maternal mortality, fetal mortality, neonatal mortality, and maternal near-miss in 5 low-income countries. We designed a 2-week course in basic OB ultrasound, followed by 12 weeks of oversight, to train health care professionals with no prior ultrasound experience to perform basic OB ultrasound to screen for high-risk pregnancies. All patients with high-risk pregnancies identified by the trainees were referred to higher-level health facilities where fully trained sonographers confirmed the diagnoses before any actions were taken. Although there have been several published studies on basic OB ultrasound training courses for health care workers in low-and middle-income countries, quality control reporting has been limited. The purpose of this study is to report on quality control results of these trainees. Health care workers trained in similar courses could have an adjunctive role in ultrasound screening for high-risk OB conditions where access to care is limited. After completion of the ultrasound course, 41 trainees in 5 countries performed 3801 ultrasound examinations during a 12-week pilot period. Each examination was reviewed by ultrasound trainers for errors in scanning parameters and errors in diagnosis, using predetermined criteria. Of the 32,480 images comprising the 3801 examinations, 94.8% were rated as satisfactory by the reviewers. There was 99.4% concordance between trainee and reviewer ultrasound diagnosis. The results suggest that trained health care workers could play a role in ultrasound screening for high-risk OB conditions.

To evaluate risk factors for adverse outcomes in spontaneous vs. assisted conception twin pregnancies. Design: Historical cohort study. Setting: Four academic tertiary medical centers. Patient(s): Women with twin pregnancies, including 2,143 spontaneous and 424 assisted conception; 2,492 nonreduced and 75 reduced. Intervention(s): None (observational). Main Outcome Measure(s): Preeclampsia, preterm premature rupture of membranes, birth Ͻ32 weeks and Ͻ30 weeks, low birth weight, very low birth weight, and slowed midgestation fetal growth (Ͻ10th percentile between 20 and 28 weeks). Result(s): Among nonreduced pregnancies, assisted conception was not significantly associated with any adverse outcomes; among nulliparas, the risk for preeclampsia was increased regardless of method of conception; among spontaneous conceptions, the risks for preterm premature rupture of membranes, low birth weight, very low birth weight, and slowed midgestation fetal growth were increased. Among all pregnancies, fetal reduction increased risks for birth Ͻ32 weeks and Ͻ30 weeks, low birth weight, very low birth weight, and slowed midgestation fetal growth. Among nulliparas with assisted conceptions, fetal reduction increased the risks for birth Ͻ30 weeks, very low birth weight, and slowed midgestation fetal growth.

The use of technology is not benign. As with any health care intervention, there are associated risks and benefits. The practitioner needs to constantly consider the benefits of the technology versus the naturalistic birth experience. The use of technology should optimize birth outcomes while maintaining a balance that provides for the best possible human birth experience. Technology, however, does have merit in the birth setting, regardless of location, but its use should be evaluated on an individual, as needed, basis. The most common technological advances currently available for assessment and maternal/fetal care during birth include electronic fetal monitoring, ultrasonography, blood pressure screening, maternal/fetal pulse oximetry, and infusion pumps. All obstetrical care providers must be familiar with the forms of technology currently available and be aware of emerging technologies for use during the birthing process.

This article describes the individual sonographic markers used in the Genetic Sonogram Scoring Index. The importance of the clustering of markers forms the basis of the scoring index, such that individual markers are assigned point values based on their sensitivity and specificity in the detection of Down syndrome. The points acquired by each fetus are tabulated into a final "score." The performance of the scoring index in the detection of aneuploidy is presented. The clinical application of the scoring index for the detection of chromosomally abnormal fetuses in patients both at highand low-risk for aneuploidy is discussed.

Postpartum hemorrhage due to uterine atony is the primary direct cause of maternal mortality globally. Management strategies in developed countries involve crystalloid fluid replacement, blood transfusions, and surgery. These definitive therapies are often not accessible in developing countries. Long transports from home or primary health care facilities, a dearth of skilled providers, and lack of intravenous fluids and/or a safe blood supply often create long delays in instituting appropriate treatment. We review the evidence for active management of third-stage labor and for the use of specific uterotonics. New strategies to prevent and manage postpartum hemorrhage in developing countries, such as community-based use of misoprostol, oxytocin in the Uniject delivery system, the non-inflatable antishock garment to stabilize and resuscitate hypovolemic shock, and the balloon condom catheter to treat intractable uterine bleeding are reviewed. New directions for clinical and operations research are suggested.

To evaluate whether high-resolution comparative genomic hybridization (HR-CGH) and subtelomeric and syndrome-specific multiplex ligation-dependent probe amplification (MLPA) would detect minor chromosomal aberrations in fetuses with increased nuchal translucency thickness (NT) and normal karyotype on conventional karyotyping. Chorionic villus samples from 100 fetuses with NT &gt; or = 99(th) percentile and normal G-banding analysis and MLPA for detection of aneuploidies for chromosomes 13, 18, 21, X and Y were included. Examinations were supplemented by HR-CGH and MLPA for syndromes and subtelomeric regions. Pregnancy outcome was followed up. Among 80 liveborn children who were followed up, three (4%) had syndromes involving mental retardation, including a case of Sotos syndrome caused by a de novo mutation. 15% of fetuses were lost during pregnancy due to abnormalities and termination. The rate of adverse outcome overall was 18%. HR-CGH and MLPA did not detect any chromosomal aberr...

We report two foetal complications after amnioinfusion with dye injection for evaluation of severe oligohydramnios in pregnancy. In the ®rst case, an underskin colouring was to disappear within a few days. In the second case, an irreversible skin after-effect with muscular atrophy and lesion of the underskin tissues developed progressively, although the trained practitioner did not notice any particular resistance during the injection of the dye and the ultrasonographer did not point out that the foetus had been stuck by the needle.

Objecti¨e: To assess the value of femur length shortening for prenatal detection of Down syndrome in a Thai population. Method: A prospective study was performed by experienced perinatologists on 3137 women undergoing second-trimester amniocentesis, between 16 and 24 weeks of gestation, for the indications of advanced maternal age and past history of chromosomal abnormality. Biparietal diameter and femur length measurements were obtained before the procedures. Regression equations relating biparietal diameter to femur length were used to calculate observed femur lengthrexpected femur length ratio in the chromosomally normal and Down syndrome fetuses. Sensitivity, specificity, false-positive rate and likelihood ratio of a positive test result at various observed femur lengthrexpected femur length ratios for detection of Down syndrome were calculated. A receiver᎐operator characteristic curve was used to determine threshold screening ratio. Results: There were 3084 chromosomally Ž . normal pregnancies, 26 fetuses with Down syndrome 1:118 , and 27 other chromosomal abnormalities. The Ž . relationship between femur length and biparietal diameter BPD was: expected femur length sy7.631q 0.814 2 . BPD, R s 0.78, P-0.001 . Femur length in Down syndrome fetuses was significantly shorter than in normal fetuses Ž . P-0.001 . A ratio of 0.91 for observed femur lengthrexpected femur length yielded a sensitivity of 42.3%, Ž specificity of 86.2%, false positive rate of 13.8% and likelihood ratio of a positive test result of 3.07 95% CI . 1.94᎐4.84 for detection of Down syndrome. Conclusions: In this study, femur length shortening in the second trimester appears to be a useful screening parameter for fetal Down syndrome in a Thai population. ᮊ

Background: Manual vacuum aspiration is not widely used for the evacuation of retained products of conception in western Europe despite its well-proven success and safety record. Nor is there much information about its use under intravenous (systemic) analgesia or patientcontrolled anaesthesia in modern settings. Aim: To evaluate the use of manual vacuum aspiration for the evacuation of retained products of conception under systemic analgesia or patient-controlled anaesthesia in the management of first trimester miscarriages. Methods: Fifty-eight women with a diagnosis of first trimester miscarriage (42 missed and 16 incomplete miscarriages) were treated with manual vacuum aspiration under systemic analgesia or patient-controlled anaesthesia. Success rates and patient satisfaction and acceptability were recorded. Results: Of the 58 women recruited, 42 underwent the procedure under systemic analgesia and 15 under patient-controlled sedation while 1 woman opted for general anaesthesia. Successful evacuation was achieved in all cases. Both analgesic methods were associated with high levels of patient satisfaction and acceptability. Conclusions: Manual vacuum aspiration is an option in the management of all first trimester pregnancy losses. Comparisons with other treatment options are indicated. #

Background: An earlier matched cohort study in the United Kingdom found a significantly higher perinatal mortality rate for births booked under an independent midwife compared with births in National Health Service units (1.7% [25 ⁄ 1,508] vs 0.6% [45 ⁄ 7,366]). This study examined independent midwives' management and decision making in the 15 instances of perinatal death that occurred at term. Methods: Thematic analysis of independent midwives' case notes was performed in instances of perinatal mortality. Semi-structured interviews were conducted with the midwives concerned. Results: Home birth was attempted in 13 of the 15 cases. Significant (often multiple) antenatal risk factors were identified in 13 cases, including twin pregnancy, planned vaginal births after cesarean section, breech presentations, and maternal illness. Several women had declined some or all routine antenatal screening. Three deaths occurred before labor onset. Postmortem results were known in only four cases; many causes of death remained unexplained. Professional consensus was that seven deaths were unpreventable; elective cesarean section may have changed the outcome in eight cases. However, the pregnant women had declined this option; some were reported to be avoiding National Health Service care because of previous bad experiences. Transfer to hospital care, when it occurred, was often problematic. Care management was judged to be clinically acceptable within the parameters set by the mothers' choices. Conclusions: Information about clinical processes (and outcomes) is essential if informed decisions are to be made. The women in this review had reportedly accepted the potential consequences of their high-risk situations. If reality is to match rhetoric about ''patient'' autonomy, such decision making in high-risk situations must be accepted. (BIRTH 37:4 December 2010)

To study the outcome of pregnancy in chromosomally normal fetuses with increased nuchal translucency thickness (NT), with respect to fetal loss, structural defects and genetic syndromes with developmental delay, and to provide information that would be helpful for parental counseling on the residual risk of adverse outcome when ultrasound findings are normal.

Objectives Fetuses with trisomy 21 typically present with subtle facial abnormalities, including a hypoplastic nasal bone. The aim of this study was to provide a reference range for the length of the fetal nasal bone and to test its value in second-trimester ultrasound screening for trisomy 21.

Fetal RHD status; Non-invasive prenatal diagnosis; Cell-free fetal DNA Summary RhD blood group incompatibility between a pregnant woman and her fetus can result in maternal alloimmunization and consequent haemolytic disease of the newborn (HDN) in subsequent pregnancies. The D-negative blood group is found in 15% of whites, 3e5% of black Africans, and is rare in Asians. Recent technological advances in non-invasive prenatal determination of the fetal RHD status using cell-free fetal DNA (cffDNA) have opened new avenues for the management of D-negative pregnant women. In this review applications for the high risk women, as well as potential for routine screening will be discussed. The use of non-invasive prenatal diagnosis and the management of other blood incompatibilities will also be discussed. ª

RESUMO OBJETIVO. Descrever a frequência de anomalias cromossômicas em fetos com translucência nucal (TN) aumentada, e a frequência de malformações estruturais, a evolução e o resultado da gestação nos fetos com TN aumentada e cariótipo anormal. MÉTODOS. Estudo retrospectivo envolvendo 246 casos com medida da TN acima do percentil 95º para a idade gestacional, com cariótipo fetal conhecido ou avaliação clínica das crianças no período pós-natal. Os casos foram acompanhados no setor de Medicina Fetal do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. RESULTADOS. O resultado do cariótipo fetal esteve alterado em 14,2% dos casos. O acompanhamento dessas gestações revelou anormalidade estruturais em 80,8% dos fetos, sendo as anormalidades cardíacas as mais comuns (61,5%). Resultados gestacionais adversos, como abortamento, óbitos intraútero e neonatal ocorreram em 76,5% dos fetos. CONCLUSÃO. Translucência nucal aumentada, entre 11 -13 semanas e 6 dias, é importante marcador de anomalias cromossômicas fetais e malformações estruturais fetais, principalmente cardíacas. Diante deste achado, há aumento do risco de abortamento, óbito intrauterino e neonatal para estas gestações. UNITERMOS: Medição de translucência nucal. Ultrassonografia. Gravidez. Anomalias cromossômicas. Cardiopatias congênitas.

OBJECTIVE: Test the hypothesis that a placental function profile can reassure most high-risk women with normal test results yet accurately can identify a subset of women who are destined for major complications that will be attributable to placental disease.