Optic nerve sonography and ophthalmic artery Doppler velocimetry in healthy pregnant women: an Australian cohort study.

PURPOSE: Maternal ocular sonography offers a window into cerebrovascular and intracranial pressure changes in pregnancy. This study aimed to determine the Doppler velocimetric variables of the ophthalmic artery, and the mean diameter of the optic nerve sheath (ONSD), in an Australian cohort of healthy pregnant women. METHODS: A prospective observational cohort study of healthy women with uncomplicated singleton pregnancies in the third trimester was undertaken in a tertiary maternity service. A single prenatal ultrasonographic examination was performed on all participants, with a postnatal examination performed on a subgroup with uncomplicated deliveries. RESULTS: Fifty women were examined at a mean gestation of 35 weeks. The mean ± SD Doppler variables in the ophthalmic artery were peak systolic velocity (PSV) 41.89 ± 13.13 cm/s, second peak velocity 20.63 ± 8.97 cm/s, end diastolic velocity 9.29 ± 5.13 cm/s, pulsatility index 1.97 ± 0.53, resistive index 0.78 ± 0.07, peak ratio (second peak velocity/PSV) 0.49 ± 0.12, while the mean ONSD was 4.34 ± 0.4 mm. None of these variables had a demonstrable relationship with gestation or mean arterial pressure (MAP), nor did the sheath diameter have a relationship with any of the Doppler variables. CONCLUSIONS: The ocular sonographic variables observed in this population are similar to those reported in other cohorts. No clear relationship could be identified in this cohort between ophthalmic artery Doppler variables and the ONSD, and between each of these variables and gestation or MAP.

Outcomes following antenatal identification of hydrops fetalis: a single-centre experience from 2001 to 2012.

OBJECTIVE: To describe the aetiologies and outcomes of pregnancies complicated by hydrops fetalis (HF). STUDY DESIGN: Case series of all pregnancies complicated by HF managed at The Royal Women's Hospital (RWH), Melbourne, Australia, between 2001 and 2012. Multiple pregnancies, and cases where antenatal care was not provided at RWH were excluded. Cases were identified from neonatal and obstetric databases. Data were extracted from maternal and neonatal case files, electronic pathology and radiology reports, and obstetric and neonatal databases. RESULTS: Over 12 years, 131 fetuses with HF with a median (IQR) gestational age (GA) at diagnosis of 24 (20-30) weeks were included in the analysis. There were 65 liveborn infants with a median (IQR) GA at birth of 33 (31-37) weeks and a median (IQR) birthweight Z-score of 1.4 (0.4-2.2). Overall survival from diagnosis was 27% (36/131) increasing to 55% (36/65) if born alive. CONCLUSIONS: The perinatal mortality risk for fetuses and newborn infants with HF is high with important differences dependent on underlying diagnosis and the time at which counselling is provided. Clinicians need to be aware of the outcomes of both fetuses and neonates with this condition.

Non-Invasive Prenatal Testing for Sex Chromosome Aneuploidy in Routine Clinical Practice.

OBJECTIVES: To assess the accuracy of non-invasive prenatal testing (NIPT) for sex chromosome aneuploidy (SCA) in routine clinical practice and to review counselling and sonographic issues arising in SCA cases. METHODS: Three specialist Australian obstetric ultrasound and prenatal diagnosis practices offering NIPT after 10 weeks' gestation participated in this study. NIPT was reported for chromosomes 21, 18, 13, X, and Y. RESULTS: NIPT screening was performed in 5,267 singleton pregnancies. The odds of being affected given a positive screening result (OAPR) was lowest for SCAs, most notably for monosomy X (20%). Fewer women underwent invasive prenatal testing when counselled regarding a high risk for SCA (65.5%) compared with those who had a high risk for another aneuploidy (85%). The positive screening rate of NIPT including SCA was 2.3%, but 1.2% if only the autosomal trisomies were included in the panel. CONCLUSION: The addition of SCA testing to NIPT doubles the positive screening rate. The OAPR for SCAs (most notably for monosomy X) is reduced compared with the autosomal trisomies. Clinicians need a more extensive discussion with women prior to the inclusion of the X and Y chromosomes in the NIPT panel, given the complexity in counselling regarding further management and the additional anxiety that these abnormal results may cause. A benefit of sex chromosome analysis is an improvement in antenatal diagnosis of some disorders of sexual development.

Chorionic villus sampling in the cell-free DNA aneuploidy screening era: careful selection criteria can maximise the clinical utility of screening and invasive testing.

OBJECTIVES: To quantify the impact of cell-free DNA (cfDNA) screening on chorionic villus sampling (CVS) test indications and outcomes in a tertiary maternity service. METHODS: Retrospective cohort study of all CVS procedures performed for any indication on singleton pregnancies at The Royal Women's Hospital, Melbourne, and at Women's Ultrasound Melbourne, Australia, between August 2008 and February 2015. Karyotypes were classified according to pathogenicity and detectability by standard cfDNA screening panels. RESULTS: A total of 2051 CVS procedures, 25 373 twelve-week scans and 2394 cfDNA tests were performed. The CVS rate per 12-week scan fell from 9.8 to 3.9% following introduction of cfDNA screening. The yield of pathogenic chromosomal anomalies per CVS increased from 12.9 to 25.2%, with 70% of pathogenic results now comprising T21, up from 52%. Sixteen (5.3%) of the pathogenic chromosomal abnormalities identified on CVS would not have been predicted by current cfDNA tests. CONCLUSIONS: There is an evolving tension between improved screening performance for common aneuploidies offered by cfDNA testing, and the increasing diagnostic utility of molecular karyotyping. However, the risk of not identifying pathogenic chromosomal abnormalities is low if cfDNA screening is offered in the absence of a structural fetal anomaly, increased nuchal translucency or relevant family history. © 2017 John Wiley & Sons, Ltd.

The effect of iodine supplementation in pregnancy on early childhood neurodevelopment and clinical outcomes: results of an aborted randomised placebo-controlled trial.

BACKGROUND: Concern that mild iodine deficiency in pregnancy may adversely affect neurodevelopment of offspring has led to recommendations for iodine supplementation in the absence of evidence from randomised controlled trials. The primary objective of the study was to investigate the effect of iodine supplementation during pregnancy on childhood neurodevelopment. Secondary outcomes included pregnancy outcomes, maternal thyroid function and general health. METHODS: Women with a singleton pregnancy of fewer than 20 weeks were randomly assigned to iodine (150 µg/d) or placebo from trial entry to birth. Childhood neurodevelopment was assessed at 18 months by using Bayley Scales of Infant and Toddler Development (Bayley-III). Iodine status and thyroid function were assessed at baseline and at 36 weeks' gestation. Pregnancy outcomes were collected from medical records. RESULTS: The trial was stopped after 59 women were randomly assigned following withdrawal of support by the funding body. There were no differences in childhood neurodevelopmental scores between the iodine treated and placebo groups. The mean cognitive, language and motor scores on the Bayley-III (iodine versus placebo, respectively) were 99.4 ± 12.2 versus 101.7 ± 8.2 (mean difference (MD) -2.3, 95 % confidence interval (CI) -7.8, 3.2; P = 0.42), 97.2 ± 12.2 versus 97.9 ± 11.5 (MD -0.7, 95 % CI -7.0, 5.6; P = 0.83) and 93.9 ± 10.8 versus 92.4 ± 9.7 (MD 1.4, 95 % CI -4.0, 6.9; P = 0.61), respectively. No differences were identified between groups in any secondary outcomes. CONCLUSIONS: Iodine supplementation in pregnancy did not result in better childhood neurodevelopment in this small trial. Adequately powered randomised controlled trials are needed to provide conclusive evidence regarding the effect of iodine supplementation in pregnancy. TRIALS REGISTRATION: The trial was registered with the Australian New Zealand Clinical Trials Registry at http://www.anzctr.org.au . The registration number of this trial is ACTRN12610000411044 . The trial was registered on 21 May 2010.

Antenatal immunoglobulin for fetal red blood cell alloimmunization.

BACKGROUND: Red blood cell alloimmunization in pregnancy can lead to fetal anaemia with potentially disastrous consequences. Traditional management involves the use of intrauterine transfusion, which is associated with significant procedure-related risks. An alternative treatment that has been trialled is the use of immunoglobulin administered intravenously to the mother. OBJECTIVES: The objective of this review was to assess the efficacy and safety of the use of intravenous immunoglobulin antenatally to women with severe fetal red blood cell alloimmunization. SEARCH METHODS: We searched the Cochrane Pregnancy and Childbirth Group trials register (19 December 2012), and reference lists of articles. SELECTION CRITERIA: Randomized trials assessing the antenatal use of intravenous immunoglobulin administered at any dose, frequency or duration with a control group (using any other, or no treatment) in the management of fetal red blood cell alloimmunization. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the available evidence. MAIN RESULTS: There are no included studies. AUTHORS' CONCLUSIONS: No information is available from randomized trials to indicate whether the antenatal use of intravenous immunoglobulin is effective in the management of fetal red blood cell alloimmunization. Several case series suggest a beneficial role in delaying the onset of fetal anaemia requiring invasive intrauterine transfusion.

Contemporary clinical management of the cerebral complications of preeclampsia.

The neurological complications of preeclampsia and eclampsia are responsible for a major proportion of the morbidity and mortality arising from these conditions, for women and their infants alike. This paper outlines the evidence base for contemporary management principles pertaining to the neurological sequelae of preeclampsia, primarily from the maternal perspective, but with consideration of fetal and neonatal aspects as well. It concludes with a discussion regarding future directions in the management of this potentially lethal condition.

Transferring responsibility and accountability in maternity care: clinicians defining their boundaries of practice in relation to clinical handover.

OBJECTIVE: This exploratory study reports on maternity clinicians' perceptions of transfer of their responsibility and accountability for patients in relation to clinical handover with particular focus transfers of care in birth suite. DESIGN: A qualitative study of semistructured interviews and focus groups of maternity clinicians was undertaken in 2007. De-indentified data were transcribed and coded using the constant comparative method. Multiple themes emerged but only those related to responsibility and accountability are reported in this paper. SETTING: One tertiary Australian maternity hospital. PARTICIPANTS: Maternity care midwives, nurses (neonatal, mental health, bed managers) and doctors (obstetric, neontatology, anaesthetics, internal medicine, psychiatry). PRIMARY OUTCOME MEASURES: Primary outcome measures were the perceptions of clinicians of maternity clinical handover. RESULTS: The majority of participants did not automatically connect maternity handover with the transfer of responsibility and accountability. Once introduced to this concept, they agreed that it was one of the roles of clinical handover. They spoke of complete transfer, shared and ongoing responsibility and accountability. When clinicians had direct involvement or extensive clinical knowledge of the patient, blurring of transition of responsibility and accountability sometimes occurred. A lack of 'ownership' of a patient and their problems were seen to result in confusion about who was to address the clinical issues of the patient. Personal choice of ongoing responsibility and accountability past the handover communication were described. This enabled the off-going person to rectify an inadequate handover or assist in an emergency when duty clinicians were unavailable. CONCLUSIONS: There is a clear lack of consensus about the transition of responsibility and accountability-this should be explicit at the handover. It is important that on each shift and new workplace environment clinicians agree upon primary role definitions, responsibilities and accountabilities for patients. To provide system resilience, secondary responsibilities may be allocated as required.

Patients' perceptions of safety and quality of maternity clinical handover.

BACKGROUND: Maternity clinical handover serves to address the gaps in knowledge existing when transitions between individuals or groups of clinicians occur throughout the antenatal, intra-partum and postnatal period. There are limited published studies on maternity handover and a paucity of information about patients' perceptions of the same. This paper reports postnatal patients' perceptions of how maternity handover contributes to the quality and safety of maternity care. METHODS: This paper reports on a mixed-methods study consisting of qualitative interviews and quantitative medical record analysis. Thirty English-speaking postnatal patients who gave birth at an Australian tertiary maternity hospital participated in a semi-structured interview prior to discharge from hospital. Interview data were coded thematically using the constant comparative method and managed via NVivo software; this data set was supplemented by medical record data analysed using STATA. RESULTS: Almost half of the women were aware of a handover process. Clinician awareness of patient information was seen as evidence that handover had taken place and was seen as representing positive aspects of teamwork, care and communication by participants, all important factors in the perception of quality health care. Collaborative cross-checking, including the use of cognitive artefacts such as hand held antenatal records and patient-authored birth plans, and the involvement of patients and their support people in handover were behaviours described by participants to be protective mechanisms that enhanced quality and safety of care. These human factors also facilitated team situational awareness (TSA), shared decision making and patient motivation in labour. CONCLUSIONS: This study illustrates that many patients are aware of handover processes. For some patients, evidence of handover, through clinician awareness of information, represented positive aspects of teamwork, care and communication. Cross-checking and cognitive artefacts were observed to support handover. Patient-authored birth plans were described by some to enhance the quality and safety of the handover by providing a 'voice' to the patient in this process. This was a novel and potentially important perspective. Future research involving patients and their support people in supporting and evaluating handover should be considered.

Management of undifferentiated embryonal sarcoma of the liver in pregnancy.

BACKGROUND: Undifferentiated embryonal sarcoma of the liver is a rare mesenchymal neoplasm with a poor prognosis. Most cases occur in children, with few cases reported in adults. Our patient was a woman whose pregnancy was complicated by the recurrence of metastatic undifferentiated embryonal sarcoma of the liver. CASE: In the medical literature only two other women have been described with metastatic undifferentiated embryonal sarcoma of the liver in pregnancy. This is the first reported case of undifferentiated embryonal sarcoma of the liver recurring in and requiring treatment during pregnancy. Radio frequency ablation was used to try to control sites of hepatic disease recurrence during the pregnancy. The patient gave birth to a healthy son before requiring further palliative chemotherapy. CONCLUSION: This case highlights the fact that cancer not infrequently complicates pregnancy and can require treatment, in this case with radio frequency ablation. The case also illustrates a range of complex issues that arise when a patient with cancer has a pregnancy: the doctor's recommendations, the patient's right to choose, the well-being of the infant, and the unpredictable behavior of cancer.

Autosomal recessive omodysplasia: early prenatal diagnosis and a possible clue to the gene location.

Autosomal recessive omodysplasia (ARO), a rare congenital skeletal dysplasia, is characterized by micromelia and craniofacial anomalies. Upper and lower limbs are affected in contrast to the dominant form in which the lower limbs are normal. Radiographic features include shortening and distal tapering of the humerus and femur, proximal radioulnar diastasis, and anterolateral radial head dislocation. We present a recurrence of ARO in a family, detected on prenatal ultrasound at 13 weeks of gestation. Chromosome analysis of the products of conception and the affected sibling showed a paternally-inherited paracentric inversion of 15q13 to q21.3. Due to similarities in the clinical phenotype between diastrophic dysplasia and this condition, testing for DTDST mutation was performed with no mutation detected.

Cervical surveillance as an alternative to elective cervical cerclage for pregnancy management of suspected cervical incompetence.

OBJECTIVE: The aim of the present study was to compare the outcome of pregnancies among patients with suspected cervical incompetence treated either by elective cervical cerclage or an alternative management program involving cervical surveillance. DESIGN, SETTING AND METHODS: A prospective cohort study was performed in two groups of patients at risk of cervical incompetence with singleton gestations attending the Royal Women's Hospital, Melbourne, Australia, from 1996 to 2000. The first group was managed by their obstetric carers with an elective cerclage, while the second group was managed conservatively as part of a cervical surveillance program offered to patients attending the Department of Perinatal Medicine for pregnancy care. This program consists of weekly visits from 16 weeks' gestation and involves alternating transvaginal ultrasound assessment of cervical morphometry with cervico-vaginal bacteriology and fetal fibronectin swabs. Empiric insertion of a cerclage is undertaken when there is evidence of significant cervical shortening (cervical canal <2.5 cm in length at

Differences in learning objectives during the labour ward clinical attachment between medical students and their midwifery preceptors.

OBJECTIVES: Midwives have been actively involved in the clinical teaching of medical students for many years. However, this role has received little attention and limited research has been conducted into either its efficacy or the development of strategies to maximise the potential of such teaching opportunities. We examined medical student and midwifery preceptor attitudes towards students' learning objectives during the labour ward placement. METHODS: A descriptive cross-sectional survey of midwifery preceptors and medical students was undertaken. The setting was an Australian teaching and tertiary referral hospital. The questionnaire contained questions about strategies to improve medical student involvement on the labour ward and opinions towards core competencies of the student curriculum. RESULTS: Of 94 questionnaires issued to midwifery preceptors, 63 were returned (response rate 67%). Of 130 questionnaires issued to medical students, 93 were returned (response rate 72%). Major differences in the expectations of students and midwifery preceptors were identified. Only 17% of midwives felt medical students should be involved in helping mothers with breastfeeding, and some no longer saw a role for students in delivering babies or performing well baby checks. These differences in opinions led to student dissatisfaction with their obstetric learning experience. CONCLUSION: Educators need to ensure that students and midwifery preceptors identify common learning objectives. Failure to address these differences may lead to poor interdisciplinary relationships.

Medical and midwifery students: how do they view their respective roles on the labour ward?

BACKGROUND: It has been suggested that much of the medical and midwifery student curricula on normal pregnancy and birth could be taught as a co-operative effort between obstetric and midwifery staff. One important element of a successful combined teaching strategy would involve a determination of the extent to which the students themselves identify common learning objectives. AIM: The aim of the present study was to survey medical and midwifery students about how they perceived their respective learning roles on the delivery suite. METHODS: A descriptive cross-sectional survey study was undertaken. The study venue was an Australian teaching and tertiary referral hospital in obstetrics and gynaecology Survey participants were medical students who had just completed a 10 week clinical attachment in obstetrics and gynaecology during the 5th year of a six year undergraduate medical curriculum and midwifery students undertaking a one year full-time (or two year part-time) postgraduate diploma in midwifery. RESULTS: Of 130 and 52 questionnaires distributed to medical and midwifery students, response rates of 72% and 52% were achieved respectively The key finding was that students reported a lesser role for their professional colleagues than they identified for themselves. Some medical students lacked an understanding of the role of midwives as 8%, 10%, and 23% did not feel that student midwives should observe or perform a normal birth or neonatal assessment respectively. Of equal concern, 7%, 22%, 26% and 85% of student midwives did not identify a role for medical students to observe or perform a normal birth, neonatal assessment or provide advice on breastfeeding respectively. SUMMARY: Medical and midwifery students are placed in a competitive framework and some students may not understand the complementary role of their future colleagues. Interdisciplinary teaching may facilitate co-operation between the professions and improve working relationships.