Part Of Routine Antenatal Care Research Articles

Assessing supply-side barriers to uptake of intermittent preventive treatment for malaria in pregnancy: a qualitative study and document and record review in two regions of Uganda

BackgroundIntermittent preventive treatment in pregnancy (IPTp) with sulfadoxine–pyrimethamine (SP), provided as part of routine antenatal care (ANC), is one of three malaria-in-pregnancy prevention and control mechanisms recommended by the World Health Organization (WHO). However, despite high ANC attendance and increased efforts to address known obstacles, IPTp uptake figures have remained low. This study aimed to identify and assess barriers that continue to impede IPTp uptake in Uganda, in particular for women who attend ANC. The paper focuses on supply-side barriers, i.e., challenges relating to the health service provider.MethodsIn-depth interviews were conducted in two regions of Uganda in November 2013 and April/May 2014 with four different target audiences: seven district health officials, 15 health workers, 19 women who had attended ANC, and five opinion leaders. In addition, a document and record review was carried out at four health facilities.ResultsGuidelines with regard to IPTp provision in Uganda have been shown to be inconsistent and, at the time of the research, did not reflect the most recent WHO policy recommendation. There is a lack of training and supervision opportunities for health workers, resulting in poor knowledge of IPTp guidelines and uncertainty about the safety and efficacy of SP. ANC is not consistently offered in health facilities, leading to some women being denied services. While strengthening of the supply chain appears to have reduced the occurrence of stock-outs of SP in public facilities, stock-outs reportedly continue to occur in the private sector. There are also sources of data inaccuracy along the data recording and reporting chain, limiting policy makers’ ability to react adequately to trends and challenges.ConclusionsGiven the high ANC attendance rates in Uganda, supply-side barriers are likely to account for many missed opportunities for the provision of IPTp in Uganda. Improvements will require consistent provision of ANC, implementation of current WHO IPTp policy recommendations, supply of SP to the private sector, availability of clear guidelines, as well as improved training and supervision for health workers. Improving facility and district-level recording and reporting will further strengthen the country’s ability to address uptake of IPTp.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-016-1405-4) contains supplementary material, which is available to authorized users.

Screening for Syphilis During Pregnancy in Turkey

OBJECTIVE: To assess the prevalence of syphilis among patients at a tertiary referral center in Turkey and determine the need for antenatal syphilis screening based on the results. STUDY DESIGN: A retrospective cohort study based on patient data obtained from a tertiary referral center in Turkey. Serological syphilis screening using the Venereal Disease Research Laboratory (VDRL) was performed on all pregnant women as a part of routine antenatal care at their first hospital visit during pregnancy. Treponema pallidum hemagglutination assay (TPHA) was used to confirm positive screening results for syphilis. RESULTS: Patients’ mean age was 27.4 years. The incidence of positive syphilis serology was 0.013% (one patient), which was supported by a positive confirmatory test (0.013%).The TPHA-positive pregnant woman diagnosed with syphilis was treated with benzathine penicillin, and she gave birth to normal infants without any signs of congenital syphilis. CONCLUSION: Syphilis prevalence should be determined in each developing country with population-based studies. According to the prevalence of syphilis, each country should determine its own syphilis antenatal screening policies.

Vitamin D supplementation for women during pregnancy.

Vitamin D deficiency or insufficiency is thought to be common among pregnant women. Vitamin D supplementation during pregnancy has been suggested as an intervention to protect against adverse pregnancy outcomes. To examine whether oral supplements with vitamin D alone or in combination with calcium or other vitamins and minerals given to women during pregnancy can safely improve maternal and neonatal outcomes. In this updated review we included 15 trials assessing a total of 2833 women, excluded 27 trials, and 23 trials are still ongoing or unpublished. Nine trials compared the effects of vitamin D alone versus no supplementation or a placebo and six trials compared the effects of vitamin D and calcium with no supplementation. Risk of bias in the majority of trials was unclear and many studies were at high risk of bias for blinding and attrition rates.Vitamin D alone versus no supplementation or a placeboData from seven trials involving 868 women consistently show that women who received vitamin D supplements alone, particularly on a daily basis, had higher 25-hydroxyvitamin D than those receiving no intervention or placebo, but this response was highly heterogeneous. Also, data from two trials involving 219 women suggest that women who received vitamin D supplements may have a lower risk of pre-eclampsia than those receiving no intervention or placebo (8.9% versus 15.5%; risk ratio (RR) 0.52; 95% CI 0.25 to 1.05, low quality). Data from two trials involving 219 women suggest a similar risk of gestational diabetes among those taking vitamin D supplements or no intervention/placebo (RR 0.43; 95% CI 0.05, 3.45, very low quality). There were no clear differences in adverse effects, with only one reported case of nephritic syndrome in the control group in one study (RR 0.17; 95% CI 0.01 to 4.06; one trial, 135 women, low quality). Given the scarcity of data for this outcome, no firm conclusions can be drawn. No other adverse effects were reported in any of the other studies.With respect to infant outcomes, data from three trials involving 477 women suggest that vitamin D supplementation during pregnancy reduces the risk preterm birth compared to no intervention or placebo (8.9% versus 15.5%; RR 0.36; 95% CI 0.14 to 0.93, moderate quality). Data from three trials involving 493 women also suggest that women who receive vitamin D supplements during pregnancy less frequently had a baby with a birthweight below 2500 g than those receiving no intervention or placebo (RR 0.40; 95% CI 0.24 to 0.67, moderate quality).In terms of other outcomes, there were no clear differences in caesarean section (RR 0.95; 95% CI 0.69 to 1.31; two trials; 312 women); stillbirths (RR 0.35 95% CI 0.06, 1.99; three trials, 540 women); or neonatal deaths (RR 0.27; 95% CI 0.04, 1.67; two trials, 282 women). There was some indication that vitamin D supplementation increases infant length (mean difference (MD) 0.70, 95% CI -0.02 to 1.43; four trials, 638 infants) and head circumference at birth (MD 0.43, 95% CI 0.03 to 0.83; four trials, 638 women).Vitamin D and calcium versus no supplementation or a placeboWomen who received vitamin D with calcium had a lower risk of pre-eclampsia than those not receiving any intervention (RR 0.51; 95% CI 0.32 to 0.80; three trials; 1114 women, moderate quality), but also an increased risk of preterm birth (RR 1.57; 95% CI 1.02 to 2.43, three studies, 798 women, moderate quality). Maternal vitamin D concentration at term, gestational diabetes, adverse effects and low birthweight were not reported in any trial or reported only by one study. New studies have provided more evidence on the effects of supplementing pregnant women with vitamin D alone or with calcium on pregnancy outcomes. Supplementing pregnant women with vitamin D in a single or continued dose increases serum 25-hydroxyvitamin D at term and may reduce the risk of pre-eclampsia, low birthweight and preterm birth. However, when vitamin D and calcium are combined, the risk of preterm birth is increased. The clinical significance of the increased serum 25-hydroxyvitamin D concentrations is still unclear. In light of this, these results need to be interpreted with caution. Data on adverse effects were lacking in all studies.The evidence on whether vitamin D supplementation should be given as a part of routine antenatal care to all women to improve maternal and infant outcomes remains unclear. While there is some indication that vitamin D supplementation could reduce the risk of pre-eclampsia and increase length and head circumference at birth, further rigorous randomized trials are required to confirm these effects.

Vitamin D supplementation for women during pregnancy.

Vitamin D supplementation for women during pregnancy.

P-B20 Evaluation of the feasibility of incorporating HPV DNA- based cervical cancer screening into routine antenatal care in Nigeria

Introduction: Persistent high-risk HPV infection is a necessary cause of cervical cancer. HPV DNA testing is now the primary WHO recommended approach to cervical cancer screening. Cervical cancer screening uptake remains abysmally low in Nigeria and in other low and middle income countries (LMIC). Antenatal care-based HPV DNA testing is a largely unexplored strategy to increase uptake of cervical cancer screening in LMIC. Up to 70% of women in Africa attend ANC at least once during their pregnancy and many attend at least twice. We evaluated the acceptability of HPV DNA testing as part of routine antenatal care among pregnant women and healthcare workers in Nigeria. Methodology: We conducted focus group discussions (FGD) among pregnant women and Key Informant Interviews among healthcare providers at a hospital facility in Abuja, Nigeria. A total of 24 muslim and christian pregnant women were invited for the focus groups and each group comprised of 6–10 participants. Obstetric/Gynaecologists (O&G) and ANC nurses were interviewed. We used content analysis method for data analysis. Coding sheets were developed to summarize findings. Results: Our study showed fair level of knowledge and awareness of cervical cancer and cervical cancer screening among the pregnant women, however, practice was poor, as none of the women had ever been screened for cervical cancer. Lack of awareness about cervical cancer screening, costs, and fear of screening outcome were commonly cited as barriers to uptake. The nurses interviewed expressed reservations about the willingness of pregnant women to participate in screening but there was a high level of willingness among the pregnant women to be screened during the ANC period. Their religion and parity played no role in determining the acceptance of HPV DNA testing in ANC. The O&G specialists expressed full support for integrating HPV DNA testing into routine ANC services. Conclusions: Our results show the need to explore more innovative public health interventions to reduce cervical cancer burden in LMIC.

Effectiveness of regular weighing, weight target setting and feedback by community midwives within routine antenatal care in preventing excessive gestational weight gain: randomised controlled trial.

BackgroundMany pregnant women gain excess weight during pregnancy which increases the health risks to the mother and her baby. Interventions to prevent excess weight gain need to be given to the whole population to prevent excess weight gain. The aim of this study was to assess the effectiveness of a simple and brief intervention embedded withinroutine antenatal care to prevent excessive gestation weight gain.MethodsSix hundred and ten pregnant women (between 10-14 weeks gestation), aged ≥18 years with a body mass index (BMI) ≥18.5 kg/m2, planned to receive community midwife led care or shared care at the time of recruitment are eligible to take part in the study. Women will be recruited from four maternity centres in England. Community midwives complete a short training module before delivering the intervention. In the intervention, midwives weigh women, set maximum weight limits for weight gain at each antenatal appointment and ask women to monitor their weight at home. Themaximum weight limit is adjusted by the midwife at each antenatal appointment if women have exceeded their maximum weight gain limit set at their previous appointment. The intervention will be compared with usual antenatal care. The primary outcome is the proportion of women per group who exceed the Institute of Medicine guidelines for gestational weight gain at 38 weeks of pregnancy according to their early pregnancy BMI category.DiscussionThe proposed trial will test a brief intervention comprising regular weighing, target setting and monitoring ofweight during pregnancy that can be delivered at scale as part of routine antenatal care. Using the professional expertise of community midwives, but without specialist training in weight management, the intervention will incur minimal additionalhealthcare costs, and if effective at reducing excess weight gain, is likely to be very cost effective. Trial registrationCurrent controlled trials ISRCTN67427351. Date assigned 29/10/2014.

Controversial ultrasound findings in mid trimester pregnancy. Evidence based approach.

Mid trimester fetal anatomy scan is a fundamental part of routine antenatal care. Some U/S soft markers or controversial U/S signs are seen during the scan and create some confusion regarding their relation to fetal chromosomal abnormalities. Example of these signs: echogenic focus in the heart, echogenic bowel, renal pyelectasis, ventriculomegaly, polydactely, club foot, choroid plexus cyst, single umbilical artery. We are presenting an evidence based approach from the literature for management of these controversial U/S signs.

Feasibility and acceptability of regular weighing, setting weight gain limits and providing feedback by community midwives to prevent excess weight gain during pregnancy: randomised controlled trial and qualitative study

BackgroundRegular weighing in pregnant women is not currently recommended in many countries but has been suggested to prevent excessive gestational weight gain. This study aimed to establish the feasibility and acceptability of incorporating regular weighing, setting maximum weight gain targets and feedback by community midwives.MethodsLow risk pregnant women cared for by eight community midwives were randomised to usual care or usual care plus the intervention at 10–14 weeks of pregnancy. The intervention involved community midwives weighing and plotting weight on a weight gain chart, setting weight gain limit targets, giving brief feedback at each antenatal appointment and encouraging women to weigh themselves weekly between antenatal appointments. Women and midwives were interviewed about their views of the intervention. The focus of the study was on process evaluation.ResultsCommunity midwives referred 123 women and 115 were scheduled for their dating scan within the study period. Of these, 84/115 were approached at their dating scan and 76/84 (90.5 %) randomised. Data showed a modest difference favouring the intervention group in the percentage of women gaining excessive gestational weight (23.5 % versus 29.4 %). The intervention group consistently reported smaller increases in depression and anxiety scores throughout pregnancy compared with usual care. Most women commented the intervention was useful in encouraging them to think about their weight and believed it should be part of routine antenatal care. Community midwives felt the intervention could be implemented within routine care without adding substantially to consultation length, thus not perceived as adding substantially to their workload.ConclusionsThe intervention was feasible and acceptable to pregnant women and community midwives and was readily implemented in routine care.Trial registrationISRCTN81605162

More needs to be done to prevent Group B strep infection in the UK

Group B streptococcus (GBS) is the most common cause of sepsis and meningitis in infants under the age of 3 months with a 10% mortality and significant morbidity for many survivors. In the UK, over 40 babies die each year of GBS-related sepsis. Early-onset infection can be prevented in the majority of cases by giving women known to be colonised with GBS intravenous antibiotics during labour, but this requires a screening process which is not currently recommended in the UK. In many countries, including the USA, Canada and much of Europe, screening for GBS colonisation is part of routine antenatal care. This article aims to review the issues surrounding antenatal screening for GBS and argues that we could be doing much more in the UK to prevent this potentially devastating infection in newborn babies.

Vitamin D Efficiency in Pregnancy: An Updated Viewpoint in Indian Scenario

A decade ago identified as bone-building mineral improving calcium absorption, today new re-search opens potentials of Vitamin D in spectrum of diseases from diabetes, hypertension to cancer including special population like pregnancy & lactation. As calcium demands increase during pregnancy, Vitamin D status becomes crucial for optimal maternal & fetal outcomes. Adverse health outcomes such as preeclampsia, low birth weight, neonatal hypocalcemia, bone fragility & increased incidence of autoimmune diseases have been linked to low Vitamin D levels during pregnancy & infancy. Vitamin D deficiency is common during pregnancy & lactation despite widespread use of prenatal vitamins, because these are inadequate to maintain normal Vitamin D levels. The current IOM (US) as well as ICMR (India) recommendations for Vitamin D supplementation is not sufficient to maintain the optimal levels of serum 25(OH) D above 30 ng/ml required during pregnancy. It may therefore be judicious to include screening of all pregnant women for Vitamin D levels as a part of routine antenatal care and supplementation should be considered if deficiency persists. Till date interventional trials in special population suggest that administration of Vitamin D during pregnancy & lactation is safe & beneficial for optimal maternal & fetal outcomes. When Vitamin D deficiency is identified during pregnancy, most experts agree that up to 2000 IU/day of Vitamin D is safe. This review elaborates Vitamin D deficiency in Indian scenario and the need for Vitamin D supplementation, expounds and exercises the facts for implementation of Vitamin D supplementation to be advised when planning for pregnancy, current recommendations and implications of Vitamin D deficiency during pregnancy and lactation.

Missed opportunities: a qualitative exploration of the experiences of smoking cessation interventions among socially disadvantaged pregnant women.

Pregnant women who smoke are rarely consulted in the design and evaluation of the interventions that target them. In Australia, women will typically be counselled for smoking cessation as a part of routine antenatal care. However this approach achieves only modest rates of cessation. This study aimed to privilege the perspectives of women from low socioeconomic backgrounds who are most likely to smoke during pregnancy and who are less likely to quit spontaneously. Guided by feminist principles, in-depth interviews were undertaken with a purposive sample of six pregnant women, who resided in lower socioeconomic status areas in South Australia. Their experiences and views of being part of a smoking cessation intervention in metropolitan Adelaide were explored. Transcriptions were thematically analysed using an inductive approach and an open coding framework. An over-arching theme of 'missed opportunities' and four inter-related sub-themes encapsulated the predominantly negative experiences of the intervention for the women. The women's interest in quitting was hindered by a didactic communication style employed by maternity care professionals. The participants' information and support needs were reported as being superficially managed by maternity care professionals or Quitline workers who provided care in routine ways. These findings indicate that smoking cessation interventions and associated Quitline support needs to become more personalised and sensitive to the needs of women who face barriers posed by complex socio-economic disadvantage. These findings have important policy and practice implications for Australian public maternity care settings where smoking cessation interventions are embedded.

Untoward obstetric outcome among Smokeless Tobacco (ST - Mishri) users in Western Maharashtra

Background: Use of tobacco and new products is increasing not only among men but also among children, teenagers, women of reproductive age group. Mishri (ST) is one among them. Smoking is an established cause of adverse pregnancy outcome. There are indications that using smokeless tobacco could be as detrimental to fetal health as cigarette smoking. Objective: To compare the outcome of pregnancy among women who were using Mishri during pregnancy and those not using it at Krishna hospital, Karad. Materials and Methods: Pregnant women using Mishri during pregnancy were selected for study from Krishna hospital, Karad and equal numbers of pregnant women not using tobacco were selected as comparison group after matching for age and parity. Observations: The proportion of pregnant women using Mishri during pregnancy was 12%. A significant number of users was found to be anemic (69.8%). Significantly higher number of Mishri users experienced complications like Oligohydramnios, fetal distress, delivery before EDD (91.9%) and birth of Low birth weight babies (81.7%) with short stature and increased Ponderal Index. Conclusion: Special attention should be given to avoid or at least reduce the use of Mishri during pregnancy as a part of routine antenatal care to reduce the adverse perinatal outcome. DOI: http://dx.doi.org/10.3329/bjms.v13i4.15215 Bangladesh Journal of Medical Science Vol.13(4) 2014 p.401-405

Risk of intrauterine growth restriction among HIV-infected pregnant women: a cohort study.

The purpose of this investigation was to study the risk of intrauterine growth restriction in human immunodeficiency virus (HIV)-infected women and to describe the associated risk factors. A cohort study was performed among HIV-infected women who delivered in a single tertiary centre in Barcelona, Spain, from January 2006 to December 2011. Consecutive singleton pregnancies delivered beyond 22 weeks of pregnancy were included. Intrauterine growth restriction (IUGR) was defined as a birth weight below the 10th customised centile for gestational age and IUGR babies were compared to non-IUGR newborns. Intrauterine Doppler findings were described among IUGR foetuses. Baseline characteristics, HIV infection data and perinatal outcome were compared between groups. The results were adjusted for potential confounders. A total of 156 singleton pregnancies were included. IUGR occurred in 23.4 % of cases (38/156). In two-thirds of the cases detected before birth, Doppler abnormalities compatible with placental insufficiency were observed. IUGR pregnancies presented a worse perinatal outcome, mainly due to a higher risk of iatrogenic preterm delivery [adjusted odds ratio 6.9, 95 % confidence interval (CI) 1.4-33.5]. IUGR foetuses also had a higher risk of emergent Caesarean section and neonatal intensive care unit admission. No cases of intrauterine foetal death occurred. A high rate of IUGR was observed among HIV pregnancies, and it was associated with adverse perinatal outcomes, mainly iatrogenic preterm and very preterm birth due to placental insufficiency. Our results support that ultrasound detection and follow-up of IUGR foetuses should be part of routine antenatal care in this high-risk population to improve antenatal management.

The feasibility and acceptability of regular weighing of pregnant women by community midwives to prevent excessive weight gain: RCT.

Pregnancy is a critical period for the development of later obesity. Regular weighing of pregnant women is not currently recommended in the UK. This study aimed to demonstrate the feasibility of regular weighing by community midwives (CMWs) as a potential intervention to prevent excessive gestational weight gain. Low risk healthy/overweight pregnant women cared for by eight CMWs were randomised to usual care or usual care plus the intervention at 10-14 weeks of pregnancy. The intervention involved CMWs weighing and charting weight gain on an IOM weight gain chart, setting a weight target and giving brief feedback at antenatal appointments. The focus of the study was on process evaluation outcomes. Data on other outcomes were also collected including gestational weight gain. We interviewed women and CMWs about their views of the intervention. CMWs referred 123 women, 95 agreed to participate and 76 were randomised. Over 90% of women were weighed at 38 weeks of pregnancy demonstrating high follow up. There was no evidence the intervention caused anxiety. Most women commented they had found the intervention useful in encouraging them to think about their weight and believed it should be part of routine antenatal care. CMW's felt the intervention could be implemented within antenatal care without adding substantially to consultation length. To conclude, pregnant women were keen to participate in the study and the intervention was acceptable to pregnant women and CMWs. An effectiveness trial is now planned.

PFM.52 Review of maternal and perinatal outcomes for women with polyhydramnios

AimsTo investigate maternal and perinatal outcomes for women with singleton pregnancies with polyhydramnios in Tayside.MethodsAll women diagnosed with polyhydramnios (AFI ≥ 25 cm/deepest pool ≥ 8 cm) between 01/01/13–31/10/13 were...

Pattern and predictors of maternal care-seeking practices for severe neonatal jaundice in Nigeria: a multi-centre survey.

BackgroundNigeria is frequently associated with disproportionately high rates of severe neonatal jaundice (NNJ) underpinned by widespread Glucose-6-phosphate dehydrogenase (G6PD) deficiency. Timely and appropriate treatment of NNJ is crucial for preventing the associated morbidity and neuro-developmental sequelae. Since mothers are likely to be the first mostly to observe the onset of severe illness in their newborns, we set out to identify the pattern and predictors of maternal care-seeking practices for NNJ in three culturally-distinct settings in Nigeria.MethodsA multi-centre study was conducted among women attending antenatal clinics in Abuja, Lagos and Port Harcourt from October 2011 to April 2012 using a pretested questionnaire. Predictors of awareness of NNJ, accurate recognition of NNJ, use of potentially harmful therapies and preference for future hospital treatment were determined with multivariate logistic regressions.ResultsOf the 488 participants drawn from the three locations, 431 (88.3%) reported awareness of NNJ, predominantly (57.8%) attributable to professional health workers. A total of 309 (63.3%) mothers with prior knowledge of NNJ claimed they could recognise NNJ, but 270 (87.4%) from this group accurately identified the features of NNJ. Multiparous mothers (Adjusted odds ratio, AOR:4.05; 95% CI:1.75-9.36), those with tertiary education (AOR:1.91; CI:1.01-3.61), and those residing in Lagos (AOR:2.96; CI:1.10-7.97) were more likely to have had prior knowledge of NNJ. Similarly, multiparous mothers (AOR:2.38; CI:1.27-4.46) and those with tertiary education (AOR:1.92; CI:1.21-3.05) were more likely to recognise an infant with jaundice accurately. Mothers educated by health workers were 40% less likely to resort to potentially harmful treatment for NNJ (AOR:0.60; CI:0.39-0.92) but more likely to seek hospital treatment in future for an infant suspected with jaundice (AOR:1.88; CI:1.20-2.95).ConclusionsWomen with tertiary education and multiparous mothers who attend routine antenatal clinics are more likely than less educated women, to be associated with appropriate care-seeking practices for infants with NNJ regardless of the socio-cultural setting. Systematic efforts by professional health workers are warranted, as part of routine antenatal care, to engage other groups of mothers especially those likely to indulge in self-use of potentially harmful therapies.

Pregnancy and Vitamin D

Vitamin D insufficiency is common in women across different races of childbearing age. It is being increasingly discovered that vitamin D has many important bodily functions apart from skeletal actions pertaining to Calcium homeostasis. Evidence suggests that the maternal risks due to vitamin D deficiency includes eclampsia, increased risk of gestational diabetes mellitus, glucose intolerance; and fetal risks include risk of rickets, osteoporotic fracture in late adulthood. It may be prudent to include screening of all pregnant women for vitamin D level as a part of routine antenatal care and supplementation be given if found deficient.

Ethical considerations when offering noninvasive prenatal testing

Technology in the prenatal setting is advancing at an exceptional rate, and these advancements will likely result in major changes to current pregnancy screening and testing paradigms. In Australia, prenatal testing is increasingly becoming a routine part of antenatal care and pregnant women are offered an assortment of screening and diagnostic tests, which give them information about their fetus, and can identify potential anomalies before it is born. In Victoria (Australia), each year approximately 4% of babies will be born with a birth defect or fetal abnormality many of which are diagnosed in uterus. Greater than 97% of women in Victoria have at least one or more ultrasounds during pregnancy and greater than 80% of pregnant women take up screening for Down syndrome, with the majority having First Trimester Combined Screening (FTCS). FTCS combines maternal serum analytes — pregnancy associated plasma protein-A (PAAP-A) and beta human chorionic gonadotrophin (free β-hCG) — with results from the nuchal translucency ultrasound to give a risk figure for Down syndrome and Trisomy 18. Approximately 5% of women will receive a false positive result from FTCS, meaning they screen positive for Down syndrome or Trisomy 18 and do not have an affected pregnancy. Women who are considered to be “increased risk” either because of a screening result or ultrasound finding are offered invasive diagnostic testing whereby a fetal sample is obtained via chorionic villus sampling (CVS) or amniocentesis and sent for conventional or molecular karyotyping (microarray). These tests carry a miscarriage risk of up to 1% above the background rate of miscarriage. There has been increasing demand for a safe and reliable alternative to invasive diagnostic testing and very recently, noninvasive prenatal testing (NIPT) has become commercially available to women in America (2012), Australia and many other countries, including Brazil (2013). NIPT is an advanced screening test, which relies on the fact that small fragments of cell-free fetal DNA and RNA circulate in maternal serum. In the first and second trimesters of pregnancy, approximately 6–10% of total cell free DNA (cfDNA) circulating in maternal serum is thought to be fetal in origin; this fetal fraction rises to 10–20% in the third trimester. Using massively parallel sequencing technology, scientists can sequence cfDNA fragments in maternal plasma and detect specific chromosome aneuploidies such as trisomies 21, 13 and 18, much earlier in pregnancy than has previously been possible,

OC22.06: Discordant anomalies in monochorionic twins

Methods: Retrospective cohort of 453 twin pregnancies in two tertiary centers over an 11-year period. All women had serial ultrasound assessment of CL from 11–13+6 weeks through to 14–15+6, 16–17+6, 18–19+6 and 20–21+6 weeks as part of routine antenatal care. A total of 720 serial CL measurements were recorded. Monochorionic twin pregnancies complicated with twin to twin transfusion syndrome and monoamniotic pregnancies were excluded. We estimated the association between cervical length at each of the five study periods and preterm delivery before 28, 32 and 34 weeks’ respectively. Results: The cumulative incidence of preterm delivery was 6.8%, 13.2% and 26.1% before 28, 32 and 34 weeks’ respectively. A CL below 50 mm at 11–13+6 weeks was associated with preterm delivery before 28 weeks (RR = 1.63, 95% CI = 1.21–2.18, P 45 mm for delivery before 28 (LR− 0.33) and 34 weeks (LR− 0.29) respectively. CL 50 mm at this gestation reflects a low likelihood of preterm delivery.

Author's Reply

Authors' Reply: We thank the authors for bringing up this important association and for presenting relevant studies. Our review1. does not suggest that the association between preeclampsia and future cardiovascular risk is a result of shared risk factors alone. Indeed, we discuss the evidence that preeclamptic pregnancies can result in vascular changes that could modify a woman's risk for future cardiovascular disease (CVD). Certainly, hypovitaminosis D may be associated both with preeclampsia and subsequent risk for CVD. However, we agree with a recent meta-analysis concluding that the role of vitamin D supplementation in pregnancy, as a part of routine antenatal care, is yet to be determined as “the number of high quality trials and outcomes reported is too limited to draw conclusions on its usefulness and safety.”2. Similarly, further trials are required to evaluate whether hypovitaminosis D may be one of the mechanisms underlying the association between preeclampsia and future CVD. This underscores the need for prospective, randomized, and likely multicenter trials that will be adequately powered to study the benefits of vitamin D supplementation during pregnancy, with respect to both immediate and long-term outcomes. Until then, the decision to pursue with intervention should remain a matter of carefully weighing the benefits of vitamin D supplementation for each individual pregnant woman.3.