D. Stott, P. Pandya, G. Attilakos, J. Lang, J. Wolfenden, R. Yates
Fetal cardiac arrhythmias are relatively common and account for up to 20% of referrals to fetal cardiologists. Arrhythmias may occur because of structural abnormalities of the fetal heart, or because of abnormal functioning of the cardiac conduction system in an otherwise structurally normal heart. Arrhythmias may be diagnosed using ultrasound and M‐mode and Doppler echocardiography. Transplacental therapy for tachyarrhythmias has been one of the success stories of fetal cardiology, and good outcomes can be expected in the absence of hydrops. Congenital heart block is most commonly caused by the transplacental passage of anti‐Ro and anti‐La antibodies and transplacental therapy is less successful in managing this.
{"title":"The diagnosis and management of fetal cardiac arrhythmias","authors":"D. Stott, P. Pandya, G. Attilakos, J. Lang, J. Wolfenden, R. Yates","doi":"10.1111/tog.12803","DOIUrl":"https://doi.org/10.1111/tog.12803","url":null,"abstract":"Fetal cardiac arrhythmias are relatively common and account for up to 20% of referrals to fetal cardiologists. Arrhythmias may occur because of structural abnormalities of the fetal heart, or because of abnormal functioning of the cardiac conduction system in an otherwise structurally normal heart. Arrhythmias may be diagnosed using ultrasound and M‐mode and Doppler echocardiography. Transplacental therapy for tachyarrhythmias has been one of the success stories of fetal cardiology, and good outcomes can be expected in the absence of hydrops. Congenital heart block is most commonly caused by the transplacental passage of anti‐Ro and anti‐La antibodies and transplacental therapy is less successful in managing this.","PeriodicalId":51862,"journal":{"name":"Obstetrician & Gynaecologist","volume":null,"pages":null},"PeriodicalIF":1.4,"publicationDate":"2022-03-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45224760","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Dear Editor, We read with interest the article by Busuulwa et al. addressing the role of antenatal corticosteroids (ACS) in improving neonatal outcomes. We would like to add a few interesting points from the Antenatal Late Preterm Steroids (ALPS) study and recent meta-analysis evidence in support of the authors of the paper in being cautious about the use of ACS to improve neonatal outcomes in the context of late preterm deliveries (34–36 weeks’ gestation). Although late preterm deliveries account for approximately two-thirds of preterm infants, the recommendation for ACS for late pretermgestations has beenminimal,mainly because of the lack of randomised controlled trials (RCTs) and the possibility of long-term neurological impact outweighing short-term benefit. The ALPS study was the principal trial published in the literature and showed short-term respiratory benefits. The hypoglycaemia cutoff used by the ALPS study was very low: <2.2 mmol/L (widely accepted level <2.6–4.0 mmol/L); this suggests that hypoglycaemia incidence may be more than the 24% quoted in the study for the group who received steroids. Of note, hypoglycaemia is an independent predictor of poor neurodevelopmental outcomes in neonates. A recent meta-analysis by Mangesh et al., which included seven RCTs, showed reduced need for respiratory support in the steroid category (relative risk 0.68), while neonatal hypoglycaemia risk was high. Interestingly, the recent paper by Badreldin et al. showed no respiratory benefit of ACS in late preterm deliveries. Another high-risk group is neonates of type 1 and type 2 diabetic pregnant mothers, who have a 48% risk of hypoglycaemia. The National Institute for Health and Care Excellence guideline on diabetes in prenancy recommends delivery between 37 and 38 weeks, with either induction of labour or caesarean section. Steroid administration before delivery is standard practice for caesarean sections before 38 weeks. Steroid administration in this group poses an additional risk of neonatal hypoglycaemia on top of the baseline risk of 48% in neonates of diabetic mothers. For clinicians, there is a clinical dilemma (respiratory benefits versus neonatal hypoglycaemia in caesarean delivery at less than 39 weeks) because neonatal hypoglycaemia is associated with developmental delay, seizures, visual processing problems and cognitive difficulties, as well as hypoxic-ischaemic encephalopathy (HIE) and perinatal arterial ischemic stroke in the territory of the posterior cerebral artery. ACS in late preterm neonates therefore warrants cautious use until more RCTs on long-term outcomes can provide further recommendation.
{"title":"Re: The role of antenatal corticosteroids in improving neonatal outcomes","authors":"P. Pathiraja, J. Rafi","doi":"10.1111/tog.12796","DOIUrl":"https://doi.org/10.1111/tog.12796","url":null,"abstract":"Dear Editor, We read with interest the article by Busuulwa et al. addressing the role of antenatal corticosteroids (ACS) in improving neonatal outcomes. We would like to add a few interesting points from the Antenatal Late Preterm Steroids (ALPS) study and recent meta-analysis evidence in support of the authors of the paper in being cautious about the use of ACS to improve neonatal outcomes in the context of late preterm deliveries (34–36 weeks’ gestation). Although late preterm deliveries account for approximately two-thirds of preterm infants, the recommendation for ACS for late pretermgestations has beenminimal,mainly because of the lack of randomised controlled trials (RCTs) and the possibility of long-term neurological impact outweighing short-term benefit. The ALPS study was the principal trial published in the literature and showed short-term respiratory benefits. The hypoglycaemia cutoff used by the ALPS study was very low: <2.2 mmol/L (widely accepted level <2.6–4.0 mmol/L); this suggests that hypoglycaemia incidence may be more than the 24% quoted in the study for the group who received steroids. Of note, hypoglycaemia is an independent predictor of poor neurodevelopmental outcomes in neonates. A recent meta-analysis by Mangesh et al., which included seven RCTs, showed reduced need for respiratory support in the steroid category (relative risk 0.68), while neonatal hypoglycaemia risk was high. Interestingly, the recent paper by Badreldin et al. showed no respiratory benefit of ACS in late preterm deliveries. Another high-risk group is neonates of type 1 and type 2 diabetic pregnant mothers, who have a 48% risk of hypoglycaemia. The National Institute for Health and Care Excellence guideline on diabetes in prenancy recommends delivery between 37 and 38 weeks, with either induction of labour or caesarean section. Steroid administration before delivery is standard practice for caesarean sections before 38 weeks. Steroid administration in this group poses an additional risk of neonatal hypoglycaemia on top of the baseline risk of 48% in neonates of diabetic mothers. For clinicians, there is a clinical dilemma (respiratory benefits versus neonatal hypoglycaemia in caesarean delivery at less than 39 weeks) because neonatal hypoglycaemia is associated with developmental delay, seizures, visual processing problems and cognitive difficulties, as well as hypoxic-ischaemic encephalopathy (HIE) and perinatal arterial ischemic stroke in the territory of the posterior cerebral artery. ACS in late preterm neonates therefore warrants cautious use until more RCTs on long-term outcomes can provide further recommendation.","PeriodicalId":51862,"journal":{"name":"Obstetrician & Gynaecologist","volume":null,"pages":null},"PeriodicalIF":1.4,"publicationDate":"2022-02-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47435169","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
V. Asfour, A. Jakes, Jess McMicking, Wei Zian Szetho, A. Sayasneh, Y. Diab, L. Mascarenhas, J. Rymer
Bilateral salpingo‐oophorectomy is indicated for patients with suspected or confirmed gynaecological malignancy. Risk reduction surgery is indicated in patients with a significant family history or a genetic predisposition to developing breast or ovarian cancer. Bilateral salpingectomy with ovarian conservation reduces the risk of ovarian cancer, whilst preserving ovarian function. Oophorectomy prior to the menopause is associated with increased all‐cause mortality and significant menopause related morbidity. Conservative measures such as weight loss, family planning and lifestyle advice could reduce the overall lifetime risk of ovarian cancer.
{"title":"Oophorectomy or ovarian conservation at the time of hysterectomy for benign disease","authors":"V. Asfour, A. Jakes, Jess McMicking, Wei Zian Szetho, A. Sayasneh, Y. Diab, L. Mascarenhas, J. Rymer","doi":"10.1111/tog.12799","DOIUrl":"https://doi.org/10.1111/tog.12799","url":null,"abstract":"Bilateral salpingo‐oophorectomy is indicated for patients with suspected or confirmed gynaecological malignancy. Risk reduction surgery is indicated in patients with a significant family history or a genetic predisposition to developing breast or ovarian cancer. Bilateral salpingectomy with ovarian conservation reduces the risk of ovarian cancer, whilst preserving ovarian function. Oophorectomy prior to the menopause is associated with increased all‐cause mortality and significant menopause related morbidity. Conservative measures such as weight loss, family planning and lifestyle advice could reduce the overall lifetime risk of ovarian cancer.","PeriodicalId":51862,"journal":{"name":"Obstetrician & Gynaecologist","volume":null,"pages":null},"PeriodicalIF":1.4,"publicationDate":"2022-02-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48551255","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
As survival of babies born following high‐risk pregnancies continues to increase globally, understanding the long‐term impacts of suboptimal intrauterine environments on future health becomes increasingly important. The intrauterine environment is a key influence on later metabolic health, particularly the tendency to later‐life obesity and dyslipidaemia. Recent evidence shows that female reproductive function is also highly sensitive to the influence of the early life environment. Various suboptimal intrauterine environments are linked to adverse reproductive and metabolic outcomes, including maternal obesity, low‐protein diets and chronic fetal hypoxia.
{"title":"Impact of the intrauterine environment on future reproductive and metabolic health","authors":"S. Dunkerton, C. Aiken","doi":"10.1111/tog.12797","DOIUrl":"https://doi.org/10.1111/tog.12797","url":null,"abstract":"As survival of babies born following high‐risk pregnancies continues to increase globally, understanding the long‐term impacts of suboptimal intrauterine environments on future health becomes increasingly important. The intrauterine environment is a key influence on later metabolic health, particularly the tendency to later‐life obesity and dyslipidaemia. Recent evidence shows that female reproductive function is also highly sensitive to the influence of the early life environment. Various suboptimal intrauterine environments are linked to adverse reproductive and metabolic outcomes, including maternal obesity, low‐protein diets and chronic fetal hypoxia.","PeriodicalId":51862,"journal":{"name":"Obstetrician & Gynaecologist","volume":null,"pages":null},"PeriodicalIF":1.4,"publicationDate":"2022-02-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44263898","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Even in the modern age, with vastly improved access to training, resources and experience, obstetric and gynaecological haemorrhage still pose a serious challenge to the trainee and senior clinician alike. In the latest MBBRACEUK Report, there were 14 potentially preventable deaths attributed to haemorrhage (abruption, placenta accreta, uterine inversion, atony and trauma) and for our learning, we reflect on various articles pertaining to this subject from past issues of The Obstetrician and Gynaecologist (TOG).
{"title":"Spotlight on… haemorrhage","authors":"H. Sekar, L. Berg, W. Yoong","doi":"10.1111/tog.12782","DOIUrl":"https://doi.org/10.1111/tog.12782","url":null,"abstract":"Even in the modern age, with vastly improved access to training, resources and experience, obstetric and gynaecological haemorrhage still pose a serious challenge to the trainee and senior clinician alike. In the latest MBBRACEUK Report, there were 14 potentially preventable deaths attributed to haemorrhage (abruption, placenta accreta, uterine inversion, atony and trauma) and for our learning, we reflect on various articles pertaining to this subject from past issues of The Obstetrician and Gynaecologist (TOG).","PeriodicalId":51862,"journal":{"name":"Obstetrician & Gynaecologist","volume":null,"pages":null},"PeriodicalIF":1.4,"publicationDate":"2022-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42019272","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
The latest report from the UK and Ireland Confidential Enquiries into Maternal Deaths and morbidity, the eighth in the now annual report format, includes surveillance and Confidential Enquiries covering the period 2017–19. The report also includes reviews into the care of women who died during or after pregnancy in the Republic of Ireland as well as the UK. Following the annual topic-specific format, this report includes topic-specific reviews into the care of women who died from mental health-related causes, venous thromboembolism, homicide and malignancy. The report also includes a Morbidity Confidential Enquiry into the care of women who gave birth aged over 45 years.
{"title":"MBRRACE‐UK update: Key messages from the UK and Ireland Confidential Enquiries into Maternal Death and Morbidity 2021","authors":"M. Knight","doi":"10.1111/tog.12786","DOIUrl":"https://doi.org/10.1111/tog.12786","url":null,"abstract":"The latest report from the UK and Ireland Confidential Enquiries into Maternal Deaths and morbidity, the eighth in the now annual report format, includes surveillance and Confidential Enquiries covering the period 2017–19. The report also includes reviews into the care of women who died during or after pregnancy in the Republic of Ireland as well as the UK. Following the annual topic-specific format, this report includes topic-specific reviews into the care of women who died from mental health-related causes, venous thromboembolism, homicide and malignancy. The report also includes a Morbidity Confidential Enquiry into the care of women who gave birth aged over 45 years.","PeriodicalId":51862,"journal":{"name":"Obstetrician & Gynaecologist","volume":null,"pages":null},"PeriodicalIF":1.4,"publicationDate":"2022-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41741234","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
It is important to focus on preconception care in the well woman because prevention is better than treatment, and interventions commenced in pregnancy may have limited benefit. A lower socioeconomic status is associated with poorer maternal and neonatal outcomes, including gestational diabetes mellitus (GDM), preterm birth (PTB), pre‐eclampsia (PET), and small‐for‐gestational‐age babies. Poor nutrition contributes to epigenetic dysregulation, which can alter gene expression and effect phenotypic change. A healthy diet during pregnancy, high in grains and vegetables, may help to reduce the risk of obesity, GDM, cardiovascular disease, hypertension, PET, and maternal anaemia; the benefits to the fetus include the prevention of low birthweight, macrosomia, PTB and stillbirth. The minimum amount of aerobic activity recommended during the preconception and pregnancy period is either 150 minutes of moderate intensity activity per week, or 30 minutes of activity per day, or 75 minutes of intense activity per week. Alcohol is a teratogen that can cause fetal growth restriction and facial malformations, learning and behavioural challenges and impairment to the central nervous system. Smoking in pregnancy can lead to impaired fetal growth and adverse effects on the immune system.
{"title":"Preconception health in the well woman","authors":"Charlotte Brooks, P. Supramaniam, M. Mittal","doi":"10.1111/tog.12790","DOIUrl":"https://doi.org/10.1111/tog.12790","url":null,"abstract":"It is important to focus on preconception care in the well woman because prevention is better than treatment, and interventions commenced in pregnancy may have limited benefit. A lower socioeconomic status is associated with poorer maternal and neonatal outcomes, including gestational diabetes mellitus (GDM), preterm birth (PTB), pre‐eclampsia (PET), and small‐for‐gestational‐age babies. Poor nutrition contributes to epigenetic dysregulation, which can alter gene expression and effect phenotypic change. A healthy diet during pregnancy, high in grains and vegetables, may help to reduce the risk of obesity, GDM, cardiovascular disease, hypertension, PET, and maternal anaemia; the benefits to the fetus include the prevention of low birthweight, macrosomia, PTB and stillbirth. The minimum amount of aerobic activity recommended during the preconception and pregnancy period is either 150 minutes of moderate intensity activity per week, or 30 minutes of activity per day, or 75 minutes of intense activity per week. Alcohol is a teratogen that can cause fetal growth restriction and facial malformations, learning and behavioural challenges and impairment to the central nervous system. Smoking in pregnancy can lead to impaired fetal growth and adverse effects on the immune system.","PeriodicalId":51862,"journal":{"name":"Obstetrician & Gynaecologist","volume":null,"pages":null},"PeriodicalIF":1.4,"publicationDate":"2022-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47437010","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Despite attention on obesity in pregnancy, within the UK and globally, many women enter pregnancy underweight. There remains a paucity of evidence‐based guidance on the optimal care of these women. Maternal underweight is associated with low birthweight and preterm birth, both spontaneous and iatrogenic, but appropriate gestational weight gain may mitigate low body mass index (BMI). Although being underweight may be protective against several antenatal and intrapartum complications, low BMI can be related to underlying organic disease and/or eating disorders, or there may be modifiable lifestyle factors that should be addressed in pregnancy. BMI at booking should assist as a screening tool. Body image, genetic, socioeconomic and cultural factors may affect BMI, making underweight women a heterogeneous group requiring individualised assessment.
{"title":"Pregnancy in underweight women: implications, management and outcomes","authors":"R. Burnie, Edward Golob, Sonji Clarke","doi":"10.1111/tog.12792","DOIUrl":"https://doi.org/10.1111/tog.12792","url":null,"abstract":"Despite attention on obesity in pregnancy, within the UK and globally, many women enter pregnancy underweight. There remains a paucity of evidence‐based guidance on the optimal care of these women. Maternal underweight is associated with low birthweight and preterm birth, both spontaneous and iatrogenic, but appropriate gestational weight gain may mitigate low body mass index (BMI). Although being underweight may be protective against several antenatal and intrapartum complications, low BMI can be related to underlying organic disease and/or eating disorders, or there may be modifiable lifestyle factors that should be addressed in pregnancy. BMI at booking should assist as a screening tool. Body image, genetic, socioeconomic and cultural factors may affect BMI, making underweight women a heterogeneous group requiring individualised assessment.","PeriodicalId":51862,"journal":{"name":"Obstetrician & Gynaecologist","volume":null,"pages":null},"PeriodicalIF":1.4,"publicationDate":"2022-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41570708","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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