Bjog-An International Journal of Obstetrics and Gynaecology最新文献

Objective: To identify current practices in the management of selective fetal growth restriction (sFGR) in monochorionic diamniotic (MCDA) twin pregnancies.

Design: Cross-sectional survey.

Setting: International.

Population: Clinicians involved in the management of MCDA twin pregnancies with sFGR.

Methods: A structured, self-administered survey.

Main outcome measures: Clinical practices and attitudes to diagnostic criteria and management strategies.

Results: Overall, 62.8% (113/180) of clinicians completed the survey; of which, 66.4% (75/113) of the respondents reported that they would use an estimated fetal weight (EFW) of <10th centile for the smaller twin and an inter-twin EFW discordance of >25% for the diagnosis of sFGR. For early-onset type I sFGR, 79.8% (75/94) of respondents expressed that expectant management would be their routine practice. On the other hand, for early-onset type II and type III sFGR, 19.3% (17/88) and 35.7% (30/84) of respondents would manage these pregnancies expectantly, whereas 71.6% (63/88) and 57.1% (48/84) would refer these pregnancies to a fetal intervention centre or would offer fetal intervention for type II and type III cases, respectively. Moreover, 39.0% (16/41) of the respondents would consider fetoscopic laser surgery (FLS) for early-onset type I sFGR, whereas 41.5% (17/41) would offer either FLS or selective feticide, and 12.2% (5/41) would exclusively offer selective feticide. For early-onset type II and type III sFGR cases, 25.9% (21/81) and 31.4% (22/70) would exclusively offer FLS, respectively, whereas 33.3% (27/81) and 32.9% (23/70) would exclusively offer selective feticide.

Conclusions: There is significant variation in clinician practices and attitudes towards the management of early-onset sFGR in MCDA twin pregnancies, especially for type II and type III cases, highlighting the need for high-level evidence to guide management.

Objective: To investigate the positive rate of late-onset gestational diabetes mellitus (GDM) by additional fasting blood glucose (FBG) screening at 32-34 gestational weeks (GW) and analyse the perinatal outcomes of late-onset GDM after standard treatment.

Design: An Prospective cohort study.

Setting: Single centre in China.

Population: 1130 singleton pregnancies with negative GDM screening in their first and second trimester.

Methods: Additional FBG testing was performed at 32-34 GW. Pregnancies with FBG ≥5.1 mmol/L were diagnosed as GDM and received standardized treatment. Perinatal outcomes were collected and compared.

Main outcome measures: Diagnosis of late-onset GDM, obstetric and neonatal outcomes.

Results: 6.3% (71/1130) of participants had FBG values ≥5.1 mmol/L and were diagnosed with late-onset GDM. Sixty-five (91.5%) were treated by dietary therapy and 6 (8.5%) by insulin therapy. The perinatal outcomes of full-term delivery were compared. The incidence of macrosomia (22.7% vs. 5.1%, adjusted odds ratio (aOR) 5.51, 95% confidence interval (CI) 1.83-16.61, p = 0.002) and NICU transferring (18.3% vs. 10.1%, aOR 1.94, 95% CI 1.01-3.74, p = 0.046) was significantly higher in late-onset GDM group than that in FBG <5.1 mmol/L group. Elevated FBG was associated with overweight or obesity during pregnancy (54.9% vs. 34.9%, OR 2.27, 95% CI 1.40-3.68, p = 0.001).

Conclusions: 6.3% of singleton pregnancies with normal GDM screening results in the first and second trimester were found to have late-onset GDM by additional FBG screening at 32-34 GW, and their risk of macrosomia during a full-term pregnancy remains significantly higher after standard treatment.

Misoprostol, a synthetic analogue of prostaglandin E1, was approved in 1988, for the prevention and treatment of peptic ulcers associated with the use of nonsteroidal anti-inflammatory drugs. It is hard to believe that a drug initially used by gastroenterologists could become a crucial medication in obstetric practice. Misoprostol's versatility in administration, affordability, efficacy, relative safety and easy storage have contributed to its popularity. In 1987, the first studies on the off-label use of misoprostol for pregnancy termination, medical evacuation of missed abortions and as a cervical-priming agent prior to vacuum aspiration of the uterus started being published. These were followed by studies on its use for mid-trimester termination of pregnancy, management of intra-uterine fetal death, third stage of labour, induction of labour and post-partum haemorrhage.¹ It wasn't until nearly 15 years later that the FDA finally approved a new label addressing the use of misoprostol during pregnancy. This was followed by a number of trials demonstrating that misoprostol is at least as safe and effective as dinoprostone, the previous most popular agent for labour induction.² In this issue of BJOG (pages 1167-1180) Patabendige et al. conducted an individual participants' data meta-analysis of randomised controlled trials comparing the use of vaginal misoprostol and dinoprostone for the induction of labour. They concluded that both methods of labour induction were comparable in terms of effectiveness and perinatal safety as well as mode of delivery including vaginal, instrumental or Caesarean birth performed for failure to progress or fetal distress, supporting the non-inferiority of vaginal misoprostol.

Approximately, 30% of women in the UK and US deliver by Caesarean section^{3, 4} and at least 5% of these deliveries are performed in the second stage of labour. Full dilatation caesarean sections can be associated with significant maternal and neonatal complications, mainly due to extension of the uterine incision, resulting in haemorrhage, and birth injuries related to ‘impacted fetal head’; both of which are classified as obstetric emergencies. There is no consensus on the definition of ‘impacted head’ and consequently data on its incidence and guidance on the most effective and safest method of management, are lacking. Several management strategies including tocolysis, vaginal disimpaction (‘push’ method), breech extraction, Patwardhan method and use of the Fetal Pillow® have been employed. In 2022, a UKOSS prospective survey showed that the ‘push’ technique was the most commonly used technique to facilitate the delivery of the deeply engaged head, followed by the Fetal Pillow®.⁵ The Fetal Pillow® was first introduced in 2014 and initial small studies suggested a reduction in maternal and fetal complications. However, subsequent studies faile

Objective: To utilise combined diffusion-relaxation MRI techniques to interrogate antenatal changes in the placenta prior to extreme preterm birth among both women with PPROM and membranes intact, and compare this to a control group who subsequently delivered at term.

Design: Observational study.

Setting: Tertiary Obstetric Unit, London, UK.

Population: Cases: pregnant women who subsequently spontaneously delivered a singleton pregnancy prior to 32 weeks' gestation without any other obstetric complications.

Controls: pregnant women who delivered an uncomplicated pregnancy at term.

Methods: All women consented to an MRI examination. A combined diffusion-relaxation MRI of the placenta was undertaken and analysed using fractional anisotropy, a combined T2*-apparent diffusion coefficient model and a combined T2*-intravoxel incoherent motion model, in order to provide a detailed placental phenotype associated with preterm birth. Subgroup analyses based on whether women in the case group had PPROM or intact membranes at time of scan, and on latency to delivery were performed.

Main outcome measures: Fractional anisotropy, apparent diffusion coefficients and T2* placental values, from two models including a combined T2*-IVIM model separating fast- and slow-flowing (perfusing and diffusing) compartments.

Results: This study included 23 women who delivered preterm and 52 women who delivered at term. Placental T2* was lower in the T2*-apparent diffusion coefficient model (p < 0.001) and in the fast- and slow-flowing compartments (p = 0.001 and p < 0.001) of the T2*-IVIM model. This reached a higher level of significance in the preterm prelabour rupture of the membranes group than in the membranes intact group. There was a reduced perfusion fraction among the cases with impending delivery.

Conclusions: Placental diffusion-relaxation reveals significant changes in the placenta prior to preterm birth with greater effect noted in cases of preterm prelabour rupture of the membranes. Application of this technique may allow clinically valuable interrogation of histopathological changes before preterm birth. In turn, this could facilitate more accurate antenatal prediction of preterm chorioamnionitis and so aid decisions around the safest time of delivery. Furthermore, this technique provides a research tool to improve understanding of the pathological mechanisms associated with preterm birth in vivo.

Objective: To investigate the association between postpartum haemorrhage (PPH) and subsequent cardiovascular disease.

Design: Population-based retrospective cohort study, using record linkage between Aberdeen Maternity and Neonatal Databank (AMND) and Scottish healthcare data sets.

Setting: Grampian region, Scotland.

Population: A cohort of 70 904 women who gave birth after 24 weeks of gestation in the period 1986-2016.

Methods: We used extended Cox regression models to investigate the association between having had one or more occurrences of PPH in any (first or subsequent) births (exposure) and subsequent cardiovascular disease, adjusted for sociodemographic, medical, and pregnancy and birth-related factors.

Main outcome measures: Cardiovascular disease identified from the prescription of selected cardiovascular medications, hospital discharge records or death from cardiovascular disease.

Results: In our cohort of 70 904 women (with 124 795 birth records), 25 177 women (36%) had at least one PPH. Compared with not having a PPH, having at least one PPH was associated with an increased risk of developing cardiovascular disease, as defined above, in the first year after birth (adjusted hazard ratio, aHR 1.96; 95% confidence interval, 95% CI 1.51-2.53; p < 0.001). The association was attenuated over time, but strong evidence of increased risk remained at 2-5 years (aHR 1.19, 95% CI 1.11-1.30, P < 0.001) and at 6-15 years after giving birth (aHR 1.17, 95% CI 1.05-1.30, p = 0.005).

Conclusions: Compared with women who have never had a PPH, women who have had at least one episode of PPH are twice as likely to develop cardiovascular disease in the first year after birth, and some increased risk persists for up to 15 years.