Clinical Management Of Pregnancies Research Articles

Health professionals' experiences and views on obstetric ultrasound in Tanzania: A cross-sectional study.

Obstetric ultrasound is considered important for determining gestational age, identifying single or multiple pregnancies, locating the placenta and fetal anomalies and monitoring fetal growth and pregnancy-related complications in order to improve patient management. To explore health professionals' perspectives on different aspects of obstetric ultrasound in Tanzania regarding self-reported skills in performing ultrasound examinations and what could improve access to and utilization of obstetric ultrasound in the clinical setting. Cross-sectional study. Data was collected between November and December 2017 using a questionnaire based on previous qualitative research results from the CROss Country UltraSound Study (CROCUS Study). Seventeen healthcare facilities in 5 urban and semiurban municipalities in the Dar-es-Salaam region were included, with 636 health professionals participating (physicians, n = 307 and midwives/nurses, n = 329). Most health professionals (82% physicians, 81% midwives/nurses) believed that obstetric ultrasound was decisive in the clinical management of pregnancy. Results indicate proficiency gaps across disciplines: 51% of physicians and 48.8% of midwives/nurses reported no or low-level skills in assessing cervical length. Similarly, deficiencies were observed in evaluating the four-chamber view of the fetal heart (physicians: 51%, midwives/nurses: 61%), aorta, pulmonary artery (physicians: 60.5%, midwives/nurses: 65%) and Doppler assessments (umbilical artery: physicians 60.6%, midwives/nurses 56.1%). Compared to midwives/nurses, physicians were significantly more likely to agree or strongly agree that utilization would improve with more ultrasound machines (odds ratio (OR) 2.13; 95% confidence intervals (CI) 1.26-3.61), better quality of ultrasound machines (OR 2.27; 95% CI 1.10-4.69), more training for health professionals currently performing ultrasound (OR 2.11; 95% CI 1.08-4.17) and more physicians trained in ultrasound (OR 2.51; 95% CI 1.30-4.87). Improving the provision of obstetric ultrasound examinations in Tanzania requires more and better-quality ultrasound machines, enhanced training for health professionals and an increased number of physicians trained in ultrasound use. To further increase the accessibility and utilization of obstetric ultrasound in maternity care in Tanzania, it is essential to provide training for midwives in basic obstetric ultrasound techniques.

The Feasibility and Potential Benefits of a Two-Dimensional Amniotic Fluid Index (Afi2) In the Clinical Management of Pregnancy

The Feasibility and Potential Benefits of a Two-Dimensional Amniotic Fluid Index (Afi2) In the Clinical Management of Pregnancy

A Case of Pregnant Uterus Perforation During Laparoscopy

RELEVANCE Pregnant uterus perforation during laparoscopy is a rare complication, accompanied by a higher risk of infection and miscarriage. Clinical management of pregnancy and its outcome have practical interest and need discussion.AIM To provide a clinical case of pregnant uterus perforation during laparoscopy.MATERIAL AND METHODS Patient L., 34 years old, with a tumor of the right ovary and 21–22 weeks of pregnancy. Result The article describes a clinical case of independent childbirth on time after pregnant uterus perforation during laparoscopy with removing a significant volume of amniotic fluid in a 21–22 weeks pregnant woman.CONCLUSION The prolongation of pregnancy and independent childbirth on time after uterus perforation with a gestation period of 21 or 22 weeks is possible in case of timely diagnosis of the complication, careful restoration of uterine integrity and rational management of the postoperative period.

Better Estimation of Spontaneous Preterm Birth Prediction Performance through Improved Gestational Age Dating.

The clinical management of pregnancy and spontaneous preterm birth (sPTB) relies on estimates of gestational age (GA). Our objective was to evaluate the effect of GA dating uncertainty on the observed performance of a validated proteomic biomarker risk predictor, and then to test the generalizability of that effect in a broader range of GA at blood draw. In a secondary analysis of a prospective clinical trial (PAPR; NCT01371019), we compared two GA dating categories: both ultrasound and dating by last menstrual period (LMP) (all subjects) and excluding dating by LMP (excluding LMP). The risk predictor’s performance was observed at the validated risk predictor threshold both in weeks 191/7–206/7 and extended to weeks 180/7–206/7. Strict blinding and independent statistical analyses were employed. The validated biomarker risk predictor showed greater observed sensitivity of 88% at 75% specificity (increases of 17% and 1%) in more reliably dated (excluding-LMP) subjects, relative to all subjects. Excluding dating by LMP significantly improved the sensitivity in weeks 191/7–206/7. In the broader blood draw window, the previously validated risk predictor threshold significantly stratified higher and lower risk of sPTB, and the risk predictor again showed significantly greater observed sensitivity in excluding-LMP subjects. These findings have implications for testing the performance of models aimed at predicting PTB.

Foeto-maternal complications associated with low birth weight: A prospective multicenter study in northern Ghana.

ObjectiveThe study evaluated the socio-demographic characteristics, obstetric variables and foeto-maternal complications associated with low birth weight (LBW) in order to provide better treatment and management options.MethodsThe prospective study conducted from February, 2019 to June, 2020 recruited 312 primigravid pregnant women who reported for antenatal care in three tertiary referral hospitals in northern Ghana. Their socio-demographic, obstetric and adverse foeto-maternal outcome information were obtained with a well-structured questionnaire according to the World Health Organisation (WHO) guidelines. Participants’ blood samples were collected for haematological tests. Odds ratio [OR, 95% confidence interval (CI)] for the association between socio-demographic, obstetric characteristics, foeto-maternal complications and haematological tests in relation to LBW were assessed using logistic regression model.ResultsThis study reported a LBW prevalence of 13.5%. Increasing maternal systolic blood pressure (SBP) and diastolic blood pressure (DBP) at 1st visit, before and after delivery significantly increased the odds of LBW. Preterm delivery (PTD<37 weeks) (COR = 9.92, 95% CI (4.87–2020), p<0.001), preeclampsia (PE) (COR = 5.94, 95% CI (2.96–11.94), p<0.001), blood transfusion (COR = 14.11, 95% CI (2.50–79.65), p = 0.003), caesarian delivery (COR = 3.86, 95% CI (1.96–7.58), p<0.001) and male sex neonates (COR = 2.25, 95%CI (1.14–4.47), P = 0.020) presented with increased odds of LBW. Increasing gestational age at delivery presented with 28% reduced odds of LBW (COR = 0.72, 95% CI (1.12–4.40), P = 0.023). Upon controlling for potential confounders in multivariate logistic regression, only gestational age at delivery (AOR = 0.67, 95% CI (0.47–0.96), P = 0.030) remained significantly associated with reduced odds of LBW.ConclusionThis study found that high blood pressure at 1st visit, before and after delivery results in increased chances of delivering a baby with LBW. Furthermore, PTD<37 weeks, having PE in current pregnancy, and male sex potentiate the risk of LBW. On the other hand, increasing gestational age reduces the risk of LBW. Thus, we recommend that midwives should intensify education to pregnant women on the benefits of regular ANC visits to aid in the early detection of adverse foeto-maternal complications. We also recommend proper clinical management of pregnancies associated with an elevated blood pressure at registration. Also, maternal intrapartum blood pressure measurement could be used to predict LBW in low resourced settings.

Clinical management of pregnancy in women with polycystic ovary syndrome: An expert opinion.

Polycystic ovary syndrome (PCOS) is associated with a higher risk for pregnancy and birth complications according to the specific features associated with PCOS. The features include obesity before and during pregnancy, hyperandrogenism, insulin resistance, infertility, cardiometabolic risk factors, and poor mental health. PCOS is not often recognized as a risk factor for poor pregnancy and birth outcomes in pregnancy care guidelines, while its associated features are. Pregnancy‐related risk profile should ideally be assessed for modifiable risk factors (e.g., lifestyle and weight management) at preconception in women with PCOS. Hyperglycaemia should be screened using a 75‐g oral glucose tolerance test at preconception or within the first 20 weeks of pregnancy if it has not been performed at preconception and should be repeated at 24–28 weeks of pregnancy. In the absence of evidence of benefit for strategies specific to women with PCOS, the international evidence‐based guidelines for the assessment and management of PCOS recommend screening, optimizing, and monitoring risk profile in women with PCOS (at preconception, during and postpregnancy) consistent with the recommendations for the general population. Recommended factors include blood glucose, weight, blood pressure, smoking, alcohol, diet, exercise, sleep and mental health, emotional, and sexual health among women with PCOS. The guidelines recommend Metformin in addition to lifestyle for assisting with weight management and improving cardiometabolic risk factors, particularly in those with overweight or obesity. Letrozole is considered the first‐line pharmacological treatment for anovulatory infertility in PCOS. Individualized approach should be considered in the management of pregnancy in PCOS.

Utility of a 7- question online screener for DHA intake

The secondary analyses of two large, recently completed randomized clinical trials of DHA supplementation in pregnancy found that women with a low baseline DHA status benefited from randomization to a higher dose (800 vs 0 and 1000 vs 200 mg/day DHA). To obtain DHA status, it is necessary to obtain a blood sample and conduct an analysis using gas chromatography (GC) or GC-mass spectrometry (GCMS), both barriers to clinics where pregnant women receive advice on nutrition. Participants consuming less than 150 mg/day of DHA at baseline in our recent trial had a lower risk of early preterm birth and preterm birth when assigned to 1000 vs 200 m/day DHA. DHA intake was determined using a 7-question food frequency questionnaire administered by a trained nutritionist. Because the need for trained personnel to administer the questionnaire would be a barrier to implementing this finding in clinical management of pregnancy, the goal of this study was to determine if an online version of the questionnaire could be validly completed without assistance.

ОСОБЕННОСТИ ТЕЧЕНИЯ И СОСТОЯНИЯ ПЛОДОВ ПРИ МНОГОПЛОДНОЙ БЕРЕМЕННОСТИ, ОСЛОЖНЕННОЙ СИНДРОМОМ ФЕТО-ФЕТАЛЬНОЙ ТРАНСФУЗИИ

Problem of multiple pregnancy is one of the most relevant in obstetrics nowadays,being not only a medical, but also a socially significant problem. The problem of pregnancy management is of scientific and practical interest, it is caused by an increase in the number of multiple pregnancies. The current trend towards all cases of multiple pregnancies is explained by the activity of assisted reproductive technologies, the ever-increasing age of women in labor. This article discusses the features of the gestation period in multiple pregnancies, characteristic complications, as well as the features of the condition of the fetus and newborn in this condition. Multiple pregnancy is a model of fetoplacental insufficiency, which is explained by the fact that evolutionarily a woman's body is adapted to bear one fetus. According to research data, the course of multiple pregnancies is more often associated with the presence of various complications than the course of a singleton pregnancy. One of the most serious complications of multiple pregnancy is fetal-fetal transfusion syndrome. The occurrence of this complication requires the use of special tactics of pregnancy management, continuous monitoring of the condition of the mother and fetus, readiness to make emergency correct decisions about prolonging pregnancy or delivery, readiness to provide highly specialized assistance to the fetus and subsequent newborns. Clinical management of pregnancy, treatment and prognosis depend on the extent of development of feto-fetal transfusion syndrome, gestation, on which has developed the syndrome, presence or absence of the mother's genital or extragenital pathology, as well as the fetus. The main methods of treatment of feto-fetal transfusion syndrome are methods of fetal surgery, the most effective of which is the method of fetoscopic coagulation of placental anastomoses.

Clinical management of pregnancies with positive screening results for rare autosomal aneuploidies at a single center.

ObjectiveTo review our experiences on clinical management of pregnancies with positive noninvasive prenatal testing (NIPT) results for rare autosomal aneuploidies (RAAs) at a single center.MethodsWe performed a retrospective study and reviewed data from 18,016 pregnancies undergoing NIPT at a single center in China from March 2017 to February 2020. Depending on the patient’s choice, women with positive screening results for RAAs underwent chromosomal microarray analysis for invasive prenatal diagnosis.ResultsThirty-three positive cases for RAAs were identified, with a positive screening rate of 0.18%. The most common RAA was trisomy 7 (33.3%), while trisomies for other chromosomes were less frequent. Monosomies involving chromosomes 16, 14, and 22 were observed. Twenty-eight cases of RAAs underwent invasive diagnosis. Abnormal pregnancy outcomes were observed in four cases, including true fetal mosaicism (n=1), partial uniparental disomy (n=1), miscarriage (n=1), and structural anomalies on ultrasound (n=1).ConclusionsRAAs at NIPT might be associated with fetal uniparental disomy, mosaic aneuploidy, and poor pregnancy outcomes, but most positive cases have normal pregnancy outcomes. For RAAs, genetic counseling on the potential risks of abnormal NIPT results, as well as on benefits and limitations of invasive prenatal diagnosis, might help guide clinical management.

Norwegian obstetricians’ experiences of the use of ultrasound in pregnancy management. A qualitative study

ObjectiveTo explore obstetricians’ experiences and views of the use of obstetric ultrasound in clinical management of pregnancy. MethodsA qualitative interview study was undertaken in 2015 with obstetricians (N = 20) in Norway as part of the CROss Country Ultrasound Study (CROCUS). ResultsThree categories developed during analyses. ‘Differing opinions about ultrasound and prenatal diagnosis policies’ revealed divergent views in relation to Norwegian policies for ultrasound screening and prenatal diagnosis. Down syndrome screening was portrayed as a delicate and frequently debated issue, with increasing ethical challenges due to developments in prenatal diagnosis. ‘Ultrasound’s influence on the view of the fetus’ illuminated how ultrasound influenced obstetricians’ views of the fetus as a ‘patient’ and a ‘person’. They also saw ultrasound as strongly influencing expectant parents’ views of the fetus, and described how ultrasound was sometimes used as a means of comforting women when complications occurred. ‘The complexity of information and counselling’ revealed how obstetricians balanced the medical and social aspects of the ultrasound examination, and the difficulties of ‘delivering bad news’ and counselling in situations of uncertain findings. ConclusionThis study highlights obstetricians’ experiences and views of ultrasound and prenatal diagnosis in Norwegian maternity care and the challenges associated with the provision of these services, including counselling dilemmas and perceived differences in expectations between caregivers and expectant parents. There was notable diversity among these obstetricians in relation to their support of, and adherence to Norwegian regulations about the use of ultrasound, which indicates that the care pregnant women receive may vary accordingly.

Increasing possibilities – Increasing dilemmas: A qualitative study of Swedish midwives' experiences of ultrasound use in pregnancy

Objectiveto explore Swedish midwives’ experiences and views of the use of obstetric ultrasound in clinical management of pregnancy, and in situations where maternal and fetal health interests conflict. Designan exploratory qualitative study based on focus group discussions (FGDs) was undertaken in 2013 as part of the CROss Country Ultrasound Study (CROCUS). Data were analysed using qualitative content analysis. Setting and participantsmidwives (N=25) were recruited from four public hospitals located in the northern and central parts of Sweden. Findingsthe analysis resulted in three categories. The first ‘Acknowledging ultrasound as optimising care but also as creating worry and ethical dilemmas’ reflects midwives’ experiences of two different aspects of ultrasound use, one being recognition of ultrasound as an important tool to optimise care and pregnancy outcomes, the other being the dilemmas that arise for maternity care in situations of uncertain or unwanted findings. The second category ‘Dealing with insufficient informed consent processes and differing expectations of ultrasound’ describes routine ultrasound as an unquestioned norm that means its full purpose and use is not always well communicated to, or understood by, expectant parents, resulting in differing expectations of ultrasound outcomes between caregivers and expectant parents. Midwives also experienced expectant parents as having great trust in ultrasound, with perceptions of ‘all clear’ scan as a ‘guarantee’ for a healthy baby. The third category ‘Balancing maternal and fetal health interests in a context of medico-technical development’ included experiences of the fetus being given greater importance in maternity care as diagnostic and fetal treatment possibilities increase; that new methods are often introduced without appropriate ethical discussion; and also that ethical challenges will increase in line with increasing demand for ‘quality assurance’ in pregnancy. Key conclusions and implications for practicemidwives described ultrasound as a vital tool in pregnancy surveillance and management, facilitating conditions to be optimised for the woman and her baby during pregnancy, birth and the postpartum period. However, the increasing possibility of obtaining detailed information about the fetus was also experienced as increasing ethical dilemmas in maternity care. This study indicates that there is a need to improve informed consent processes regarding the use of ultrasound for prenatal screening and diagnostic purposes. The ambivalence midwives expressed in relation to management of ultrasound findings furthermore indicates a need for ongoing training for maternity care professionals to increase confidence in counselling women and to promote consistency in management. Finally, it is important to monitor any increasing focus on the fetus by care providers for potential impacts on women’s autonomy to make their own decisions about pregnancy and birth.

Physicians' experiences and views on the role of obstetric ultrasound in rural and urban Rwanda: a qualitative study.

To explore Rwandan physicians' experiences and views on the role of obstetric ultrasound in clinical management of pregnancy, and in situations where maternal and fetal health interests conflict. Physicians (n=19) in public and private health facilities in urban and rural Rwanda were interviewed in 2015 as part of the CROss-Country Ultrasound Study (CROCUS). Data were analysed qualitatively. Ultrasound was described as an important tool in maternity care. Availability and quality of equipment varied across sites, and considerable disparities in obstetric ultrasound utilisation between rural and urban areas were described. The physicians wanted more ultrasound training and saw the potential for midwives to perform basic scans. Information about fetal sex and well-being was described as women's main expectations of ultrasound. Although women's right to autonomy in pregnancy was supported in principle by participating physicians, fetal rights were sometimes seen as needing physician 'protection'. There appears to be increasing use and demand for obstetric ultrasound in Rwanda, particularly in urban areas. It seems important to monitor this development closely to secure wise and fair allocation of scarce obstetric expertise and resources and to prevent overuse or misuse of ultrasound. Raising awareness about the benefits of all aspects of antenatal care, including ultrasound may be an important step to improve pregnant women's uptake of services. Increased opportunities for formal ultrasound training, including the training of midwives to perform basic scans, seem warranted. Moreover, in parallel with the transition to more medico-technical maternity care, a dialogue about maternal rights to autonomy in pregnancy and childbirth is imperative.

Society of Fetal Medicine Practice Guidelines for the Second Trimester Anomalies Scan

AbstractUltrasound is now an established tool in the clinical management of pregnancy. Consequent to its major role in clinical decision-making and its remarkable operator dependence, it is necessary to have guidelines for minimum standards of performance of this modality in each area of obstetric ultrasound. The Society of Fetal Medicine guidelines have been developed for use by all the practitioners performing antenatal ultrasound scans. They are intended to provide the entire medical community with standards for the performance of quality ultrasound examinations. Practitioners are encouraged to go beyond these standards in relevant clinical situations. Each guideline in this document has undergone extensive discussion followed by a consensus. In a rapidly evolving technological and research environment, it is imperative to constantly re-evaluate and update these guidelines. Practitioners are advised to be aware of these updates and incorporate these into their daily practice.

Follow-up of Pregnant Women With Autoimmune Hepatitis

To assess maternal and fetal outcomes and clinical management of pregnancy in patients with autoimmune hepatitis (AIH). There is a paucity of information about maternal and fetal outcomes, and AIH activity during pregnancy and in the postpartum period. There is no consensus about the administration of azathioprine during pregnancy and breastfeeding. Retrospective analysis of 54 pregnancies (3 still in progress) in 39 AIH patients. The median age at conception was 24 years, and 68.4% of women had liver cirrhosis. Before conception and in early pregnancy, azathioprine and prednisone were administered in 48.1%, but treatment regimen was usually changed further to 20 mg/d prednisone; and 20.4% were off treatment. There were 36 livebirths, and fetal loss rates were 29.4% (13 miscarriages, 1 stillbirth, and 1 ectopic pregnancy). Preterm birth rate was 11.8%. In 2 cases, there was acute fetal distress; and in 2 others congenital malformations (3.9%). The rate of serious maternal complication was 7.8%, with no deaths. There were no flares in 41.2% pregnancies, but aminotransferase elevations occurred in 54.9%, 31.4% of which were true AIH relapses, only registered in the postpartum period. Despite the high fetal miscarriage rate, pregnancy in AIH was safe. Patients needed careful monitoring, especially in the postpartum period because of relapses. There was no evidence of a cause and effect relationship among azathioprine administration and premature births and congenital abnormalities, but more studies are necessary. Higher doses of prednisone may be an alternative option for those who prefer azathioprine withdrawal during pregnancy.

Human chorionic gonadotropin isoforms and their epitopes: diagnostic utility in pregnancy and cancer

Clinical management of pregnancy, pregnancy-related disorders and trophoblastic tumors is dependent on immunoassay measurements of the complex analyte human chorionic gonadotropin (hCG). Differences in hCG results using different methods affect clinical interpretation with potentially adverse consequences for patient care. Objectives/method: To provide an overview of factors contributing to method-related differences in hCG measurements and how to overcome these drawbacks. Six recently established highly purified and molar unit calibrated World Health Organization Reference Reagents for important hCG variants provide means for in-depth characterization of diagnostic immunoassays for hCG. For different clinical applications in pregnancy and cancer, appropriate epitopes and specificities of pairs of monoclonal antibodies against hCG in immunoassays have been clearly defined. This led to the conclusion that in routine clinical situations assays are preferred that measure all relevant hCG variants. The adoption of new nomenclature unambiguously describing what is being measured and the anticipated introduction of a new highly pure international standard for hCG represent significant progress towards improved analytical reliability and comparability of diagnostic hCG results.

Fetal MRI: what is the future?

Fetal MRI: what is the future?

THE ETHICS OF FETOCIDE

The purpose of this article is to provide an ethical framework for fetocide in the practice of obstetrics. Ethically responsible clinical management of pregnancy and its complications requires ethical justification: the giving of reasons that derive from an ethical framework and that together support a conclusion about what ought or ought not to be done in the care of pregnant patients. An ethical framework provides an account of the concepts that are relevant to clinical practice and identifies the clinical implications of these concepts. In this chapter we will present an ethical framework for fetocide based on the ethical concepts of moral status and of the fetus as a patient and identify the clinical implications of this concept for fetocide both before and after fetal viability.

Clinical management of pregnancy in cats

Average gestation length in domestic cats is 65.6 days, with a range of 52–74 days. Average reported litter size is 4.0 kittens per litter; litter size is not correlated with number of matings in a given estrus. Superfecundation is common in domestic cats; superfetation never has been definitively proven to occur. Eclampsia may occur during pregnancy in queens, with non-specific clinical signs. Ectopic pregnancy and uterine torsion have been reported. Pregnancy loss may be due to infectious causes, including bacteria, viruses or protozoa, or non-infectious causes, such as hypoluteoidism and chromosome errors.

Screening for chronic placental insufficiency by Doppler flow velocimetry of the umbilical artery in patients with symphysis–fundus height determined gestational age

Umbilical artery Doppler flow velocimetry is essential in the clinical management of pregnancies where intrauterine growth restriction (IUGR) is suspected w1,2x. In developing countries 40% or more women are uncertain of the date of their last menstrual period (LMP) w3x. In addition, 28% or more women often visit the antenatal clinic for the first time at a gestational age (GA) beyond 24 weeks when ultrasound determination of GA is inaccurate. Symphysis–fundus (SF) measurement is often used to measure fundal height and GA is determined by plotting this value on the 50th centile of a growth curve w4x. For these reasons it is important to determine how the SF determination of the GA will change the interpretation of the resistance index (RI). The study population was comprised of patients with suspected IUGR whose GAs had been confirmed by ultrasound prior to 24 weeks. A single observer determined the SF height and the RI of the umbilical artery with a Vasoflow Duplex continuous wave Doppler machine.

Confined placental mosaicism and genomic imprinting

The concept of confined placental mosaicism and its relationship to genomic imprinting and uniparental disomy is explained in this chapter. Clinically significant imprinting syndromes, such as Prader–Willi syndrome, Angelman syndrome, Beckwith–Wiedemann syndrome, Silver–Russell syndrome and transient neonatal diabetes mellitus, potentially associated with confined placental mosaicism are described and referenced. Non-Mendelian inheritance of recessive mutations in uniparental disomy is illustrated. Both skewed X chromosome inactivation and isolated gonadal mosaicism are outlined as newly recognized consequences of post-zygotic chromosomal mutation and confined placental mosaicism. Clinical management of pregnancies with confined placental mosaicism is proposed as well as future research directions in the field of confined placental mosaicism and its consequences.