Predictors of poor perinatal outcome following maternal perception of reduced fetal movements--a prospective cohort study.

BACKGROUND: Maternal perception of reduced fetal movement (RFM) is associated with increased risk of stillbirth and fetal growth restriction (FGR). RFM is thought to represent fetal compensation to conserve energy due to insufficient oxygen and nutrient transfer resulting from placental insufficiency. OBJECTIVE: To identify predictors of poor perinatal outcome after maternal perception of reduced fetal movements (RFM). DESIGN: Prospective cohort study. METHODS: 305 women presenting with RFM after 28 weeks of gestation were recruited. Demographic factors and clinical history were recorded and ultrasound performed to assess fetal biometry, liquor volume and umbilical artery Doppler. A maternal serum sample was obtained for measurement of placentally-derived or modified proteins including: alpha fetoprotein (AFP), human chorionic gonadotrophin (hCG), human placental lactogen (hPL), ischaemia-modified albumin (IMA), pregnancy associated plasma protein A (PAPP-A) and progesterone. Factors related to poor perinatal outcome were determined by logistic regression. RESULTS: 22.1% of pregnancies ended in a poor perinatal outcome after RFM. The most common complication was small-for-gestational age infants. Pregnancy outcome after maternal perception of RFM was related to amount of fetal activity while being monitored, abnormal fetal heart rate trace, diastolic blood pressure, estimated fetal weight, liquor volume, serum hCG and hPL. Following multiple logistic regression abnormal fetal heart rate trace (Odds ratio 7.08, 95% Confidence Interval 1.31-38.18), (OR) diastolic blood pressure (OR 1.04 (95% CI 1.01-1.09), estimated fetal weight centile (OR 0.95, 95% CI 0.94-0.97) and log maternal serum hPL (OR 0.13, 95% CI 0.02-0.99) were independently related to pregnancy outcome. hPL was related to placental mass. CONCLUSION: Poor perinatal outcome after maternal perception of RFM is closely related to factors which are connected to placental dysfunction. Novel tests of placental function and associated fetal response may provide improved means to detect fetuses at greatest risk of poor perinatal outcome after RFM.

Haemoptysis in pregnancy caused by a well-differentiated fetal adenocarcinoma: a case report.

INTRODUCTION: Haemoptysis in pregnancy is frequently assumed to be caused by a pulmonary embolism. However, it can also be an indicator of serious pathology. CASE PRESENTATION: We report the case of a 27-year-old Caucasian woman who presented with haemoptysis in pregnancy that was discovered to be caused by a well-differentiated fetal adenocarcinoma of the lung. CONCLUSION: This case demonstrates the importance of establishing an accurate diagnosis when a pregnant woman presents with haemoptysis and that more serious pathology should be considered if the clinical symptoms persist and/or the presumed diagnosis of pulmonary embolism is not confirmed.

Endometrial adenocarcinoma: an analysis of treatment and outcome.

This study aims to review the survival and morbidity in patients treated for endometrial cancer, at a single centre and analyses the effects of co-morbidity on these outcomes. Case notes of all patients referred to the Christie Hospital with endometrial carcinoma from January 1, 1993 to December 31, 1995 (n=499) were reviewed. Twenty patients presented with recurrence and were not included in this analysis. Three hundred and seventy-five patients had previously undergone a total abdominal hysterectomy and bilateral salpingoophorectomy (+/- pelvic lymphadenectomy). Of these, 175 received adjuvant external beam radiotherapy (XRT) only, 49 received XRT and brachytherapy, 30 received brachytherapy alone and 121 patients had no further therapy. One hundred and four patients were referred for primary treatment. Radical radiotherapy was administered to 63 patients who were unfit for surgery, with 10 of these receiving XRT + brachytherapy and 53 receiving brachytherapy alone. Thirteen patients received palliative XRT and 28 supportive care only. The overall 5-year survival for those treated radically was 73.3%. There was no significant survival difference between patients who underwent surgery and adjuvant radiotherapy, in whatever form (p=0.115). Patients who did not undergo surgery did less well as a group, although there was no significant survival difference between those treated with combination therapy or brachytherapy alone (p=0.33). Survival was significantly associated with FIGO stage, tumour grade, age (especially those >75 years) and co-morbidity (ACE-27 score). Late morbidity occurred in 46 patients, with severe toxicity affecting 12 (3.8%). Toxicity was associated with ACE-27 score (p=0.0019), treatment dose and modality, with 50% (n=6) of severe toxicity seen in patients receiving adjuvant XRT + ICT. These data demonstrate that survival in patients with endometrial carcinoma treated radically remains good, with the stage and grade of tumour being significant factors for overall survival. The incidence of severe morbidity related to radiotherapy of any modality was 3.8%. A high co-morbidity (ACE-27) score was significantly associated with poorer survival (p<0.0055) and increased late treatment morbidity (p=0.0019).

Better life expectancy in women with BRCA2 compared with BRCA1 mutations is attributable to lower frequency and later onset of ovarian cancer.

PURPOSE: No formal assessment of life expectancy in women with BRCA1 and BRCA2 mutations in these genes has been reported previously. We have evaluated life expectancy using actuarial analysis and assessed the effect of breast and ovarian cancers on premature death in >1,000 BRCA1/2 carriers. METHODS: Families with pathogenic mutations in BRCA1 and BRCA2 have been ascertained in a 10-million population region of United Kingdom since 1996. Mutation carriers and their first-degree relatives were used in an analysis of breast and ovarian cancer incidence and mortality as well as to derive and compare an actuarial assessment of life expectancy. RESULTS: Six hundred twelve BRCA1 and 482 BRCA2 female mutation carriers were identified from 482 families. Life expectancy was significantly reduced for BRCA1 carriers compared with BRCA2 (P = 0.0002). This effect was attributable to an increased death rate from ovarian cancer (P = 0.04). Kaplan-Meier analysis revealed a better long-term survival from early-stage ovarian cancer in BRCA2 carriers but no significant differences in deaths from breast cancer or from women presenting with late-stage ovarian cancer. There was no other major contributing cause to death other than breast/ovarian cancer in BRCA1/2 female carriers. CONCLUSION: Interventions to reduce ovarian cancer incidence are likely to have a greater effect on life expectancy in BRCA1 compared with BRCA2 carriers.

Chronic pain and obstetric management of a patient with tuberous sclerosis.

Chronic nonmalignant pain is very disabling and carries a heavy financial strain on the individual and society as a whole. This case describes a woman with tuberous sclerosis, in her fourth pregnancy. Approximately 18 months prior to pregnancy, intractable left loin pain, thought to be secondary to hemorrhage within a tuberous lesion in the left kidney, had led to the siteing of an intrathecal morphine pump. The risks of system failure (dislodgement, dislocation), escalating dosage, infection, use in labor, and neonatal opioid withdrawal are all explored and discussed. While data are limited, with increasing use of intrathecal opioids for nonmalignant pain, such patients may be seen more regularly in obstetric clinics. With a multidisciplinary team approach, risks can be minimized and outcome for mother and baby optimized.

Egg donation--the donor's view: an aid to future recruitment.

The major stumbling block for egg donation lies in the recruitment of sufficient suitable donors. This study ascertained the views of egg donors in the UK by analysing 113 completed questionnaires that asked questions about demographics, stimulus to donate, support network available, ethics, the 'process' of donation and payment. Ideas for future recruitment were also sought. The mean age of donors was 31.7 years, and most donors were donating for the first time. Ninety-one per cent of donors were Caucasian and 93% had children of their own. Ninety-six (85%) donors felt fully supported in their decision to become an egg donor and 60 (53%) discussed their donation with their GP. Information regarding egg donation came from many sources. The main motivation to donate was a desire to help childless couples. Many respondents had themselves suffered, or knew of couples with, infertility. Eighty-three (73.5%) respondents felt that expenses alone should be paid to egg donors, and many expressed concerns that large financial incentives may attract the 'wrong women' to donate. Forty-nine (43%) respondents found the procedure painful or stressful in some way, although 95% had no regrets concerning their donation, and 72% would donate again. A common reason for donors not wishing to donate again was age restriction. Respondents were asked their opinion with regard to recruitment and the enthusiasm they expressed needs to be harnessed if the current shortcomings in available donors are to be overcome. Specific recommendations to achieve this are made.