Lipiodol flush under ultrasound guidance in Australia.

BACKGROUND: Lipiodol tubal flushing is offered to select subfertile women primarily to confirm tubal patency and to increase pregnancy rates. AIMS: To investigate the safety of hystero-salpingo contrast sonography (HyCoSy) using Lipiodol flush (through frequency of adverse events and mean recalled pain score) and secondarily to quantify pregnancy rates. MATERIALS AND METHODS: Retrospective observational Phase 1 study of subfertile women in three centres across Australia between June 2017 and June 2019. Cases were identified from medical records, and women telephoned to assess adverse outcomes, procedure tolerability and confirm pregnancy outcomes within six months from procedure. RESULTS: A total of 325 cases were identified; 14 were excluded due to incomplete or abandoned procedure, 32 were lost to follow-up, leaving 279 for analysis. Fourteen women (5% overall) experienced mild vasovagal reactions, with one case of infection and no reports of anaphylaxis or allergy. There were 141 conceptions reported (51%) within six months after Lipiodol flush, and an ongoing pregnancy in 43% (119) of women. For women with ongoing pregnancies, 55% (78/119) conceived spontaneously, and 45% (63/119) via artificial reproductive technology. Mean recalled pain score was 5.7 (SD 3.2; range 0-10) at a single site. CONCLUSIONS: This Phase 1 study has indicated that Lipiodol flush using HyCoSy may be a safe and efficacious alternative to hysterosalpingography in the workup for infertility. The low adverse effect profile observed in this study coupled with a substantial ongoing pregnancy rate indicates that further investigation of Lipiodol under HyCoSy is warranted.

Regimens of ultrasound surveillance for twin pregnancies for improving outcomes.

BACKGROUND: Increased ultrasound surveillance of twin pregnancies has become accepted practice due to the higher risk of complications. There is no current consensus however as to the method and frequency of ultrasound monitoring that constitutes optimal care. OBJECTIVES: To systematically review the effects of different types and frequency of ultrasound surveillance for women with a twin pregnancy on neonatal, fetal and maternal outcomes. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (all searched 11 August 2017), and reference lists of retrieved studies. SELECTION CRITERIA: Randomised and quasi-randomised trials (including those published in abstract form) comparing the effects of described antenatal ultrasound surveillance regimens in twin pregnancies. Trials using a cluster-randomised design would have been eligible for inclusion in this review but none were identified. Trials using a cross-over design are not eligible for inclusion in this review.Different types and frequencies of ultrasound testing (for fetal surveillance and detection of specific problems) compared with each other and also compared with no testing. For example, an intervention might comprise a specific approach to ultrasound examination with dedicated components to detect twin-specific pathology. Different interventions could also include a specific type of surveillance at different intervals or different combinations at the same intervals.In this review we only found one study looking at fetal growth (biometry) and Doppler ultrasounds at 25, 30 and 35 weeks' gestation versus fetal growth alone. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trials for inclusion and quality, and extracted data. We checked data for accuracy. MAIN RESULTS: We included one trial of 526 women with a twin pregnancy of two viable twins, with no known morphological abnormality, in this review. The trial compared women receiving fetal growth and Doppler ultrasounds at 25, 30 and 35 weeks' gestation to fetal growth alone. We judged the included study to be at low risk of bias however the risk of performance and detection bias were unclear.The primary outcome was the perinatal mortality rate (after randomisation), for which there was no evidence of a clear difference between the fetal growth + Doppler and the fetal growth alone groups (risk ratio (RR) 0.88, 95% confidence interval (CI) 0.32 to 2.41, low-quality evidence) with similar rates in both groups (seven events in the Dopper + fetal growth group and eight in the fetal growth alone group). No clear differences were seen between the two regimens for the other outcomes in this review: stillbirth (RR 0.67, 95% CI 0.11 to 3.99), neonatal death (RR 1.01, 95% CI 0.29 to 3.46, low-quality evidence), gestational age at birth (weeks) (mean difference 0.10, 95% CI -0.39 to 0.59, moderate-quality evidence), infant requiring ventilation (RR 0.86, 95% CI 0.59 to 1.25), admission to special care or intensive care units (RR 0.96, 95% CI 0.88 to 1.05), caesarean section (any) (RR 1.00, 95% CI 0.81 to 1.23, high-quality evidence), elective caesarean section (RR 1.06, 95% CI 0.77 to 1.47), emergency caesarean section (RR 0.93, 95% CI 0.66 to 1.32), induction of labour (RR 1.10, 95% CI 0.80 to 1.50, moderate-quality evidence) or antenatal hospital admission (RR 0.96, 95% CI 0.80 to 1.15, high-quality evidence). The number of preterm births before 28 weeks' gestation was not reported in the included study. For the mortality-related outcomes, event numbers were small.The included study did not report the majority of our maternal and infant secondary outcomes. Infant outcomes not reported included fetal acidosis, Apgar scores less than 7 at five minutes and preterm birth before 37 and 34 weeks' gestation. The maternal outcomes; length of antenatal hospital stay, timely diagnosis of significant complications, rate of preterm, prelabour rupture of membranes and women's level of satisfaction with their care were not reported. The study did not classify twin pregnancies according to their chorionicity. An awareness of the chorionicity may have improved applicability of this data set.We downgraded outcomes assessed using GRADE for imprecision of effect estimates. AUTHORS' CONCLUSIONS: This review is based on one small study which was underpowered for detection of rare outcomes such as perinatal mortality, stillbirth and neonatal death.There is insufficient evidence from randomised controlled trials to inform best practice for fetal ultrasound surveillance regimens when caring for women with a twin pregnancy. More studies are needed to evaluate the effects of currently used ultrasound surveillance regimens in twin pregnancies. Future research could report on the important maternal and infant outcomes as listed in this review.

Noninvasive prenatal testing.

BACKGROUND: Noninvasive prenatal testing (NIPT) has marked a revolution in aneuploidy screening because it allows a simple maternal blood test to detect Down syndrome in a fetus with a very high level of accuracy (at least 99.5% with a false-positive rate of 0.2%). OBJECTIVE: To describe the new tests that have become available and their place in antenatal screening to help GPs and their patients make informed decisions about their use. DISCUSSION: Results are available from 12 weeks gestation, giving a high level of reassurance for Down syndrome early in pregnancy. There are concerns, however, that the test is being offered without proper counselling and that women may not have a 12-week ultrasound to exclude significant structural abnormalities, therefore decreasing the early detection of severe abnormalities. In addition, the test is expensive and therefore prohibitive for many women and their families.

Soluble Flt-1 as a diagnostic marker of pre-eclampsia.

BACKGROUND: Serum levels of soluble fms-like tyrosine kinase (sFlt-1) increase in pre-eclampsia (PE). AIMS: To determine whether concentrations of serum sFlt-1 can differentiate PE or superimposed PE (SPE) from gestational hypertension (GH) or chronic hypertension (CH). METHODS: Blood was collected from pregnant women being investigated for hypertension (blood pressure of > 140 and/or 90 mmHg). Normotensive (NP) and pre-eclamptic (PE-C) control ranges were measured. RESULTS: Patients with evolving hypertension in pregnancy eventually fell into four groups: GH (n = 14), PE (n = 7), CH (n = 9) and SPE (n = 9). Patients who later developed pre-eclampsia had a higher sFlt-1 (PE: 2.61 ng/mL and SPE: 2.77 ng/mL, respectively) than GH (P < 0.001) or CH (1.05 ng/mL, P = 0.11). Women with established PE at recruitment (PE-C; (n = 18) (3.13 ng/mL; interquartile range (IQR): 2.14-4.17 ng/mL) had a median sFlt-1 higher than NP (n = 18) (0.47 ng/mL; IQR: 0.11-0.89) (P < 0.0008). Patients with GH compared to NP had a slight increase (1.33 ng/mL, P < 0.003). Using a sFlt-1 cut-off of > or = 1.9 ng/mL yielded a sensitivity of 94% (95% confidence interval (CI) 73-100%) and specificity of 78% (95% CI 64-82%). CONCLUSIONS: sFlt-1 was elevated in women with PE compared to NP. The sFlt-1 also differentiated women destined to develop PE among those who presented with a diagnostic rise in maternal blood pressure. The sFlt-1 test is a useful diagnostic test for PE.

Review of the confusion in current and historical terminology and definitions for disturbances of menstrual bleeding.

OBJECTIVE: There has been increasing recent recognition of the worldwide confusion in the terminology and definitions for abnormalities of menstrual and uterine bleeding. The present review was undertaken to objectively explore some of the origins and current uses of terms for symptoms, signs, and causes of abnormal uterine bleeding and to demonstrate the international lack of uniformity. DESIGN: A detailed, but not systematic, search of the huge current and historical literature across the range of menstrual terminology, definitions, and some causes, with an emphasis on "menorrhagia" and "dysfunctional uterine bleeding." SETTING: An international collaboration to study ways of reaching worldwide agreement on descriptive terms and definitions for abnormal bleeding. RESULT(S): A large number of synonyms and overlapping terms for heavy menstrual bleeding have been identified, as well as smaller numbers of terms for other symptoms and causes of abnormal uterine bleeding. The origins and meanings of several of these terms have been explored in detail and wide variations in meaning demonstrated. CONCLUSION(S): There is great confusion in the way these terminologies are used and there is an urgent need for international agreement on consistent use of terms and definitions for symptoms, signs, and causes of abnormal uterine bleeding.