Randomized controlled trial of elevation of the fetal head with a fetal pillow during cesarean delivery at full cervical dilatation.

OBJECTIVE: To evaluate whether use of the Fetal Pillow (Safe Obstetric Systems, Shenfield, UK) affects maternal and fetal morbidity in cesarean delivery at full cervical dilatation. METHODS: A randomized controlled trial was conducted at two teaching hospitals in West Bengal, India, between April 1, 2013, and March 31, 2014. Women undergoing cesarean delivery at full dilatation were enrolled and randomly assigned with computer-generated random numbers (block size 10) to undergo delivery with or without the Fetal Pillow. Group assignment was not masked. The primary outcome was the incidence of major uterine wound extensions (grade 2-3). RESULTS: Overall, 120 women were assigned to each group. Major uterine wound extensions occurred in 6 (5.0%) women in the Fetal Pillow group and 39 (32.5%) in the control group (relative risk 0.23, 95% confidence interval 0.11-0.48). CONCLUSION: Use of the Fetal Pillow in second-stage cesarean delivery significantly reduces the risk of a major extension of the uterine incision. CTRI registration number: CTRI/2015/03/005651.

Diagnostic accuracy of maternal serum macrophage inhibitory cytokine-1 and pregnancy-associated plasma protein-A at 6-10 weeks of gestation to predict miscarriage.

OBJECTIVE: To determine whether serum macrophage inhibitory cytokine-1, pregnancy-associated plasma protein-A (PAPP-A), anandamide, or ß-human chorionic gonadotropin (hCG) measured in an asymptomatic population in the middle of the first trimester with a viable fetus predicts subsequent miscarriage. METHODS: We undertook a prospective cohort study at Mercy Hospital for Women between 2004 and 2008. Participants (N=782) were recruited from prenatal clinics, where samples were taken from asymptomatic women at 6 0/7 to 10 6/7 weeks of gestation. We collected samples from only those women for whom we were able to obtain ultrasound evidence of a singleton with fetal cardiac activity. Serum macrophage inhibitory cytokine-1, PAPP-A, anandamide, and ß-hCG concentrations were assayed. RESULTS: Twenty-one (2.7%) miscarried and 761 did not. Among those who miscarried, macrophage inhibitory cytokine-1 and PAPP-A were significantly decreased at 63% (multiples of the median (MOM) 0.63, 25th-75th percentiles 0.33-0.88) and 23% (MOM 0.23, 25th-75th percentiles 0.12-0.48) of levels seen among those with ongoing pregnancies (P<.001 for both comparisons). In contrast, neither serum ß-hCG (MOM 0.99, 25th-75th percentiles 0.46-1.86) nor anandamide (MOM 1.07, 25th-75th percentiles 0.87-1.19) was elevated or decreased among those who miscarried compared with those with ongoing pregnancies. At a fixed 10% false-positive rate (90% specificity), a test combining macrophage inhibitory cytokine-1 and PAPP-A yielded 63% sensitivity and a 6.6 positive likelihood ratio in predicting miscarriage. CONCLUSION: Low serum levels of macrophage inhibitory cytokine-1 and PAPP-A measured from asymptomatic women at 6-10 weeks of gestation with viable pregnancies can predict subsequent miscarriage. These analytes are likely to have an important biological role in early pregnancy and are likely to be useful clinical biomarkers for miscarriage and other early pregnancy complications. LEVEL OF EVIDENCE: II.

The predictive value of antral follicle count remains unchanged across the menstrual cycle.

OBJECTIVE: To explore whether the predictive value of antral follicle count (AFC) changes when measured at different times during the menstrual cycle. Antimüllerian hormone (AMH) and AFC are considered to be equally predictive of poor ovarian response; however, AMH is considered to have an advantage over AFC, because AMH concentrations can be measured at any time during the menstrual cycle. DESIGN: Retrospective cohort study. SETTING: Private IVF clinic. PATIENT(S): A total of 3,117 patients with a transvaginal ultrasound within 3 months before their first IVF cycle. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Receiver operating curves (ROCs) were constructed for AFC as a screening test for poor ovarian response (fewer than four eggs collected). The areas under the curve (AUCs) were compared for ROCs from patients at different phases of the cycle. RESULT(S): When all patients except those with polycystic ovaries were included, the AUC was 0.79. Further subgroup ROC analyses revealed that the AUCs did not differ significantly when AFC was measured at different phases of the menstrual cycle. CONCLUSION(S): AFC can be measured regardless of the phase of the menstrual cycle without apparent effect on its predictive value for poor ovarian response.

Miscarriage risk for asymptomatic women after a normal first-trimester prenatal visit.

OBJECTIVE: To estimate the risk of miscarriage among asymptomatic women after a prenatal visit between 6 and 11 weeks of gestation where proof of fetal viability of a singleton was obtained by office ultrasonography at the same visit. METHODS: This was a prospective cohort study performed over 2 years (March 2004-2006) at an antenatal clinic at a large tertiary hospital in Victoria, Australia. Those recruited were 697 asymptomatic women who attended their first antenatal visit between 6 (+2 days) and 11(+6 days) weeks of gestation, where evidence of fetal cardiac activity of a singleton was obtained by office ultrasonography. The main outcome measure was rates of miscarriage, stratified by gestation at presentation. RESULTS: One case was lost to follow-up. The risk of miscarriage among the entire cohort was 11 of 696 (1.6%). The risk fell rapidly with advancing gestation; 9.4% at 6 (completed) weeks of gestation, 4.2% at 7 weeks, 1.5% at 8 weeks, 0.5% at 9 weeks and 0.7% at 10 weeks (chi(2); test for trend P=.001). Most who miscarried received their ultrasound diagnoses many weeks after their visit; five (45%) were diagnosed in the second trimester, and all but one received their ultrasound diagnoses after 10 weeks of gestation. CONCLUSION: For women without symptoms, the risk of miscarriage after attending a first antenatal visit between 6 and 11 weeks is low (1.6% or less), especially if they present at 8 weeks of gestation and beyond. Our data could be used to reassure such women that the probability of progressing to later than 20 weeks of gestation is very good.

Increased day 15-17 serum pro-alphaC inhibin levels specific to successful pregnancy.

In early pregnancy, serum levels of the luteal-derived hormone pro-alphaC inhibin peak by the second week after conception. Whether this early rise is biologically important and a consistent feature of only successful pregnancy is unknown. We undertook a prospective cross-sectional study to determine whether serum pro-alphaC inhibin levels at d 15-17 are predictive of a successful clinical in vitro fertilization pregnancy and compared levels between fresh embryo transfer (ET) and frozen-thawed ET. Median (95% confidence interval) pro-alphaC inhibin levels were 68 (57-76) pg/ml in 204 women who did not become clinically pregnant after ET, significantly lower than in either 90 women who became clinically pregnant after fresh ET and who had 3139 (1684-4220) pg/ml or in 39 women with a successful frozen ET who had 877 (678-1111) pg/ml. Pro-alphaC was highly sensitive and specific in predicting clinical pregnancy success but did not improve on the performance of human chorionic gonadotropin. Pro-alphaC inhibin levels were not correlated with progesterone or human chorionic gonadotropin. Levels were no higher in singleton compared with multiple pregnancies and did not increase across gestation, suggestive of a luteal source. The increase in circulating pro-alphaC inhibin in very early pregnancy is highly specific to clinical pregnancy, suggesting a possible biological role in early gestation.

A randomised trial of photographic reinforcement during postoperative counselling after diagnostic laparoscopy for pelvic pain.

OBJECTIVE: To measure the effect of seeing a photograph of the pelvic findings at laparoscopy. SETTING: Two university teaching hospitals. METHOD: A randomised-controlled trial. SUBJECTS: Two hundred thirty-three women undergoing diagnostic laparoscopy for the investigation of chronic pelvic pain. INTERVENTIONS: At operation a Polaroid print was taken of the pelvis. If this was of satisfactory quality, the patient was randomly allocated to either see, or not see, the print during the postoperative consultation. MAIN OUTCOMES: Pain severity and pain belief scores at 3 and 6 months. ANALYSIS: By intention to treat. RESULTS: Postoperative consultations with photographs did not improve immediate understanding and satisfaction with the consultation. In addition, compared to controls, both patients and doctors did not perceive particular benefit for communication from the photograph. There was a consistent trend to more pain in the photographic reinforcement group and more negative pain beliefs. At 3 months, the average within person differences showed some benefit in visual analogue pain scores, McGill affect scores, 'permanence' and 'self-blame' scores. These benefits were not statistically significant. At 6 months, there was a consistent pattern of benefit from pain severity and pain beliefs, again these benefits were not statistically significant. CONCLUSION: No clear benefits result from showing patients photographs of their pelvis.

Pregnancy outcomes following the diagnosis of interstitial cystitis.

OBJECTIVE: To describe the outcome of pregnancy in patients treated for interstitial cystitis. METHODS: Over a 4-year period, 12 patients with interstitial cystitis who had one course of intravesical dimethyl sulphoxide (DMSO) therapy for interstitial cystitis were studied. Information on the effects of the treatment-to-conception interval, symptom control during pregnancy and immediately post partum, other pregnancy events and pregnancy outcome were collected. RESULTS: The mean age was 32 years (SD = 5.4), and 6 (50%) were nulliparous. Fifty-eight percent of the women presented with combined urinary and pain symptoms, 25% with a pain symptom only and 17% with a urinary symptom only. Eleven women had 1 course (6 doses) of DMSO therapy. Symptom relief was maintained during pregnancy in almost all the women. The mean interval from diagnosis of interstitial cystitis to the first day of the last menstrual cycle preceding all pregnancies beyond 28 weeks was 19.3 months (SD = 14.7). This interval was 6 months or less for 2 pregnancies that were terminated on account of symptoms attributable to interstitial cystitis. Thirteen healthy babies were delivered. CONCLUSION: Pregnancy outcomes appear good following treatment for interstitial cystitis with 1 course of intravesical DMSO.