Routine Antenatal Appointments Research Articles

New diagnosis of myasthenia gravis in the third trimester – A case report

Myasthenia gravis (MG) is an acquired autoimmune disorder of the neuromuscular junction with an annual incidence rate of 2 to 21 per million. A 25-year-old primiparous woman with no significant medical history presented for a routine antenatal appointment at 37weeks of gestation. She reported a two-week history of transient diplopia and a five-month history of fluctuating weakness in her proximal limbs. Pertinent neurological exam findings included right upper limb flaccidity, and bilateral upper and lower limb weakness more pronounced in the upper limbs and in proximal muscle groups. Cranial nerves III, IV and VI showed mild restriction in all directions, with diplopia in horizontal and downwards gaze. Following one week of investigations, including spirometry, magnetic resonance imaging of brain and spine, and needle electromyography, she was diagnosed with MuSK (anti-muscle-specific tyrosine kinase antibodies) associated myasthenia gravis. Potential complications in this context included myasthenic crisis, delivery complications, and transient neonatal myasthenia gravis. She was initially treated with 5days of plasmapheresis and prednisone. She proceeded to have an elective caesarean section for unstable lie at 39weeks of gestation under combined spinal/epidural anaesthesia without complications. The baby boy was born in good health, was monitored over four days and did not display signs of myasthenia gravis. This case outlines the rare occurrence of newly diagnosed myasthenia gravis in pregnancy, the complexities of management, and need for early multidisciplinary care.

Protocol for the INFORMED (Individualised Patient Care and Treatment for Maternal Diabetes) Study: a randomised controlled trial embedded within routine care

IntroductionDiabetes in pregnancy presents a unique physiological challenge to manage glycaemia while maintaining adequate nourishment for the growing fetus. Women with diabetes who become pregnant are at greater risk of...

Development and testing of a reduced carbohydrate intervention for the management of obesity and reduction of gestational diabetes (RECORD): protocol for a feasibility randomised controlled trial

IntroductionPrevious trials of dietary interventions to prevent gestational diabetes mellitus (GDM) have yielded only limited success. Low-carbohydrate diets have shown promise for the treatment of type 2 diabetes, but there...

"It only takes two minutes to ask"-a qualitative study with women on using the FIGO Nutrition Checklist in pregnancy.

ObjectiveTo gain an in‐depth understanding of how the FIGO Nutrition Checklist could work in clinical practice, from the perspective of pregnant women.MethodsThis qualitative study was part of a pilot study of the FIGO Nutrition Checklist in the antenatal department of a tertiary‐level university maternity hospital in Dublin, Ireland. Individual semistructured phone interviews were conducted with pregnant women who had completed the FIGO Nutrition Checklist as part of the pilot. Interviews were transcribed verbatim and analyzed using content analysis after manual coding of transcripts. Themes and subthemes are described.ResultsTen interviews were completed. Subthemes related to the FIGO Nutrition Checklist emerged including ease of use and comprehension. Participants discussed how the tool could add value to their appointment by supporting initiation of nutrition conversations and highlighting nutritional issues. The first trimester was identified as the highest priority for using the FIGO Nutrition Checklist. The convenience of having nutrition addressed as part of standard care, rather than a separate appointment, also emerged.ConclusionWomen in this study had a desire for nutrition and weight to be addressed by clinicians during routine antenatal appointments. The findings support using the FIGO Nutrition Checklist to address this.

Examining the use of the FIGO Nutrition Checklist in routine antenatal practice: multistakeholder feedback to implementation.

ObjectiveTo gain insights from pregnant women and obstetricians on the utility of the FIGO Nutrition Checklist in antenatal practice.MethodsWomen were recruited from the antenatal department of a large tertiary‐level university maternity hospital in Dublin, Ireland, between October and December 2019. Participants completed the FIGO Nutrition Checklist before their routine antenatal appointment. Obstetricians and women were encouraged to discuss the FIGO Nutrition Checklist during the clinical visit. Completed FIGO Nutrition Checklists were collected after appointments. Acceptability was assessed through questionnaires.ResultsThe majority (80.0%) of women answered “No” to at least one diet quality question, indicating a potential nutritional risk. While none of the participating obstetricians routinely discussed nutrition with women, all agreed that using the Checklist encouraged them to address nutrition with pregnant women. Nearly every woman (99.0%) found the Checklist quick to complete; however, all participating obstetricians felt there was not enough time to discuss it in routine practice. Despite this, most obstetricians and pregnant women recommended the FIGO Nutrition Checklist for use.ConclusionThe FIGO Nutrition Checklist is acceptable for use in routine antenatal practice in tertiary care settings. It helped identify potentially at‐risk women during early pregnancy and facilitated conversations related to optimum diet.

Intra-anal swabbing for GBS in pregnancy did not improve detection rate, but increased the detection of ESBL-producing E.coli.

Group B streptococcus (GBS) is a common rectal bacterial flora which can vertically infect a newborn during delivery. When the bacteria are transmitted from mother to newborn, between 1 and 2% of those newborns will suffer from sepsis or meningitis.[1, 2] Some obstetrical guidelines including USA [1, 2] recommend screening for GBS in the third trimester of pregnancy using vaginal, perianal, or intra-anal cultures and administrating intrapartum antibiotic prophylaxis as required. They concluded that intra-anal swabbing is preferable [1]; however, intra-anal swabbing may sometimes be painful. In the present study, we performed a historical control study comparing the detection rate of GBS with and without intra-anal swabbing during routine antenatal appointments.

Weighing as part of your care: a feasibility study exploring the re-introduction of weight measurements during pregnancy as part of routine antenatal care

BackgroundThe UK does not currently have guidelines on gestational weight gain owing to gaps in the evidence base. Reintroducing routine weighing of women throughout pregnancy would begin to provide the evidence needed to fill this gap. The aim of this research was to re-introduce measurement of weight at each routine antenatal appointment in a small scale study, in order to determine the feasibility and acceptability of implementing the practice on a larger scale.MethodsA feasibility study, incorporating quantitative and qualitative components, was conducted in one antenatal hospital clinic and with one community midwifery team. Thirty-eight pregnant women were recruited at their 20 week anomaly scan appointment and weighed at their appointments throughout the rest of their pregnancy; five participated in a telephone interview at approximately 37 weeks gestation. Data were collected on: numbers consenting to be weighed, reasons for declining to be weighed and number of weight measurements recorded. Qualitative interviews were used to explore acceptability of the practice to pregnant women.ResultsOverall, 79.2% (38 out of 48) of those approached consented to being weighed throughout pregnancy; of the 10 who declined, three cited not wanting to be weighed. In the interviews, women discussed routine weighing as a positive experience, described several benefits of weighing and indicated they would like more information about weight during pregnancy. No major barriers to the integration of a weight measurement into routine antenatal appointments were encountered. Completion of the weight record sheets that were inserted into women’s handheld notes varied between staff: of the 26 sheets recovered from handheld notes, only 3 (11.5%) had no weights recorded, 17 (65.4%) had between one and three weights recorded and six (23.1%) had more than 4 weights recorded.ConclusionsIn this feasibility study, routine weighing was acceptable to pregnant women. No barriers that would inhibit re-introduction of weighing women throughout pregnancy into standard antenatal care were encountered. Implementation of routine weighing during pregnancy on a larger scale should be considered as it may have benefits for women in the short and long-term, particularly with regard to informing appropriate gestational weight gain guidelines in the UK.

Neurodevelopment of HIV-exposed uninfected children in South Africa: outcomes from an observational birth cohort study

SummaryBackgroundHIV infection is known to cause developmental delay, but the effects of HIV exposure without infection during pregnancy on child development are unclear. We compared the neurodevelopmental outcomes of HIV-exposed uninfected and HIV-unexposed children during their first 2 years of life.MethodsPregnant women (>18 years of age) at 20–28 weeks' gestation were enrolled into the Drakenstein Child Health cohort study while attending routine antenatal appointments at one of two peri-urban community-based clinics in Paarl, South Africa. Livebirths born to enrolled women during follow-up were included in the birth cohort. Mothers and infants received antenatal and postnatal HIV testing and antiretroviral therapy per local guidelines. Developmental assessments on the Bayley Scales of Infant and Toddler Development, third edition (BSID-III), were done in a subgroup of infants at 6 months of age, and in the full cohort at 24 months of age, with assessors masked to HIV exposure status. Mean raw scores and the proportions of children categorised as having a delay (scores <–2 SDs from the reference mean) on BSID-III were compared between HIV-exposed uninfected and HIV-unexposed children.Findings1225 women were enrolled between March 5, 2012, and March 31, 2015. Of 1143 livebirths, 1065 (93%) children were in follow-up at 6 months and 1000 (87%) at 24 months. Two children were diagnosed with HIV infection between birth and 24-month follow-up and were excluded from the analysis. BSID-III assessments were done in 260 (24%) randomly selected children (61 HIV-exposed uninfected, 199 HIV-unexposed) at 6 months and in 732 (73%) children (168 HIV-exposed uninfected, 564 HIV-unexposed) at 24 months. All HIV-exposed uninfected children were exposed to antiretrovirals (88% to maternal triple antiretroviral therapy). BSID-III outcomes did not significantly differ between HIV-exposed uninfected and HIV-unexposed children at 6 months. At 24 months, HIV-exposed uninfected children scored lower than HIV-unexposed for receptive language (adjusted mean difference −1·03 [95% CI −1·69 to −0·37]) and expressive language (−1·17 [–2·09 to −0·24]), whereas adjusted differences in cognitive (−0·45 [–1·32 to 0·43]), fine motor (0·09 [–0·49 to 0·66]), and gross motor (−0·41 [–1·09 to 0·27]) domain scores between groups were not significant. Correspondingly, the proportions of HIV-exposed uninfected children with developmental delay were higher than those of HIV-unexposed children for receptive language (adjusted odds ratio 1·96 [95% CI 1·09 to 3·52]) and expressive language (2·14 [1·11 to 4·15]).InterpretationUninfected children exposed to maternal HIV infection and antiretroviral therapy have increased odds of receptive and expressive language delays at 2 years of age. Further long-term work is needed to understand developmental outcomes of HIV-exposed uninfected children, especially in regions such as sub-Saharan Africa that have a high prevalence of HIV exposure among children.FundingBill & Melinda Gates Foundation, SA Medical Research Council, Wellcome Trust.

The comorbidity of low back pelvic pain and risk of depression and anxiety in pregnancy in primiparous women

BackgroundApproximately 50% of Australian women experience low back pain in pregnancy, with somewhere between 8 and 36% of women suffering from pregnancy related depression/anxiety. Both low back and pelvic pain and depression and anxiety are associated with poor maternal health outcomes, including increased sick leave, higher rates of functional disability, and increased access to healthcare. It also impacts upon time and mode of delivery with an increase in inductions and elective caesarean sections. For babies of women with depression and anxiety preterm birth, low birth weight and intrauterine growth restriction are all common complications. Given these poor health outcomes, it is important to determine the co-morbidity of low back and pelvic pain and depression/anxiety in pregnancy.MethodsA cross sectional study of a hospital based sample of 96 nulliparous women were assessed at 28 weeks as part of their routine antenatal appointment. Data was collected via interview and clinical records and included the Edinburgh Depression Scale (EDS), the Numerical Rating Scale (NRS) and the Modified Oswestry Low Back Pain Disability Questionnaire (MODQ). Spearman’s correlation co-efficients, prevalence ratios and ANOVA were used to determine comorbidity.Results96 women consented to participation in the study. All study outcomes were moderately correlated. There were three main findings: One, there was a positive correlation between low back and pelvic girdle pain (LBPP) and depression/anxiety was rho = 0.39, p < 0.001, between LBPP and functional disability was rho = 0.51, p < 0.001 and between risk of depression/anxiety and functional disability was rho = 0.54, p < 0.001. Two, a woman with LBPP was 13 times more likely to have increased risk of depression/anxiety, whilst a woman with increased risk of depression/anxiety was 2.2 times more likely to have LBPP and finally three, amongst women who reported LBPP, the level of disability experienced was significantly higher in women who had concurrent increased risk of depression/anxiety (p = 0.003). This occurred even though the severity of pain did not differ between groups (NRS score mean p = 0.38).ConclusionsThis study found a high level of co-occurrence of LBPP, functional disability and depression/anxiety in women in their third trimester of pregnancy. Importantly women who reported higher depression/anxiety symptoms appeared to experience higher levels of functional disability in relation to their LBPP, than women with lower depression/anxiety symptoms and LBPP.

To what extent are midwives adapting antenatal information for pregnant women with intellectual disabilities? A survey of NHS trusts in England

ObjectivesTo identify the existing antenatal information provision practices for pregnant women with intellectual disabilities in England. To identify how practices between and within local supervising authorities differed, and if midwives were adapting standard antenatal information for pregnant women with intellectual disabilities, including examples of accessible information being used. Study designCross-sectional survey. MethodsAll contact supervisors of midwives from acute trusts with maternity services were accessed via the local supervisor of midwives officers' databases and sent a questionnaire. Quantitative data were collated. Associations between trust size, geographical location, antenatal provision and National Institute for Health and Care Excellence guidelines alongside National policy were examined using Fischer's exact test of association. ResultsContact supervisors of midwives returned a questionnaire on behalf of their trust (74, 53%). The majority worked in maternity units with more than 4000 births a year (50, 66%). Few trusts had a specialist or lead midwife in post for pregnant women with intellectual disabilities (17, 22.9%) but over half (39, 52.7%) reported that their trust had a specialist learning disability nurse in post. Only 28.3% reported availability of post registration training and even fewer (8, 10.8%) had access to written protocols. Less than half reported extra time being offered at the booking (29, 39.1%) or routine antenatal appointments (30, 40.5%). Less than a quarter (17, 22.9%) reported that their trust had routine antenatal written information available in accessible formats. ConclusionReasonable adjustments to standard antenatal information for pregnant women with intellectual disabilities were not common practice. Most trusts did not have local guidelines in place or offer midwives post registration education to help support them in this requirement.

Male child preference: Is it a risk factor for antenatal depression among Iranian women?

Background Male child preference is a phenomenon in decline in Asian women. However, it continues to exert hidden pressure on childbearing women in developing countries to dispose them to depression during pregnancy. Aims This study assessed the prevalence of antenatal depression and hypothesised that maternal perception of a family's male child preference was an independent risk factor for depression. Methods This was a cross-sectional study of 780 pregnant women who attended routine antenatal appointments and were assessed using the Iranian version of the Edinburgh Postnatal Depression Scale (EPDS). The questionnaire investigated sociodemographic characteristics and some possible risk factors, including maternal perception of male child preference in the family. Analysis was done using c2 tests to assess the relationship between variables. Findings The prevalence of antenatal depression was 20.1%. Maternal perception of male child preference was common and was associated with antenatal depression. Husbands and their families were found to prefer to have a male child. Conclusions Consideration of the male child preference as an independent risk factor is important for health care providers to prevent depression.

Ethno-Specific Risk Factors for Adverse Pregnancy Outcomes: Findings from the Born in Bradford Cohort Study.

Objectives Preterm birth (PTB) and small for gestational age (SGA) are major causes of perinatal mortality and morbidity. Previous studies indicated a range of risk factors associated with these poor outcomes, including maternal psychosocial and economic wellbeing. This paper will explore a range of psycho-social and economic factors in an ethnically diverse population. Methods The UK’s Born in Bradford cohort study recruited pregnant women attending a routine antenatal appointment at 26–28 weeks’ gestation at the Bradford Royal Infirmary (2007–2010). This analysis includes 9680 women with singleton live births who completed the baseline questionnaire. Data regarding maternal socio-demographic and mental health were recorded. Outcome data were collected prospectively, and analysed using multivariate regression models. The primary outcomes measured were: PTB (<37 weeks’ gestation) and SGA (<10th customised centile). Results After adjustment for socio-demographic and medical factors, financial strain was associated with a 45 % increase in PTB (OR 1.45: 95 % CI 1.06–1.98). Contrary to expectation, maternal distress in Pakistani women was negatively associated with SGA (OR 0.65: CI 0.48–0.88). Obesity in White British women was protective for PTB (OR 0.67: CI 0.45–0.98). Previously recognized risk factors, such as smoking in pregnancy and hypertension, were confirmed. Conclusions This study confirms known risk factors for PTB and SGA, along with a new variable of interest, financial strain. It also reveals a difference in the risk factors between ethnicities. In order to develop appropriate targeted preventative strategies to improve perinatal outcome in disadvantaged groups, a greater understanding of ethno-specific risk factors is required.

The acceptability of case-finding questions to identify perinatal depression

Background: Guidance from the National Institute for Health and Care Excellence advocates the use of two case-finding questions about depressed mood and loss of interest in activities to identify perinatal depression. However, there are no studies of their acceptability when administered in the antenatal and postnatal period. Methods: The study was an intra-mixed methods cohort study set in an antenatal clinic in an inner-city hospital in the North of England. Pregnant women attending a routine antenatal appointment at approximately 26 weeks' gestation completed a self-report survey at a routine hospital antenatal appointment and a postal survey between 5 and 13 weeks postnatal. Survey responses and free-text commentaries of women's views were analysed using descriptive statistics and qualitative content analysis. Results: Ninety-three percent of participants felt it was desirable to ask about perinatal mental wellbeing, and 97% felt comfortable answering the questions. Free-text comments revealed depressed and non-depressed women found the questions easy, simple and straightforward to answer. Conclusions: Case-finding questions to identify perinatal depression were generally acceptable to depressed and non-depressed pregnant and newly delivered mothers. Health professionals should consider the acceptability and appropriateness of this strategy in order to facilitate identification of perinatal mental health issues in routine maternity care practice.

Routine testing of fetal Rhesus D status in Rhesus D negative women using cell‐free fetal DNA: an investigation into the preferences and information needs of women

ObjectiveThe goal of this study is to investigate women's preferences and information needs for routine implementation of fetal Rhesus D (RhD) typing using cell-free fetal DNA.MethodsA questionnaire was developed following focus groups and interviews with both health professionals and RhD negative (RhD−) women offered fetal RhD genotyping within a research study and distributed to RhD− women attending routine antenatal appointments in four National Health Service hospitals. Current knowledge of blood types, anti-D administration, fetal RhD genotyping and future practices were explored.ResultsA total of 19 respondents participated in interviews and focus groups, and 270 respondents completed the questionnaires. Questionnaire respondents overwhelmingly felt that the test should be offered to all RhD− women (92.1%), and 75.9% said that they would accept this test. Most were happy to have the test even if it involved extra blood tests (89.3%) or appointments (79%). The knowledge of blood groups was poor. Although 90.7% knew that the baby could have a different blood group from themselves, only 34% knew that blood groups are inherited from both parents. More than 40% were not aware that anti-D would not be required if their baby was RhD−.ConclusionsWomen would welcome the introduction of routine fetal RhD genotyping. Information leaflets and training of midwives will be essential for implementation to ensure good understanding regarding testing. © 2013 The Authors. Prenatal Diagnosis published by John Wiley & Sons Ltd.

Life events and difficulties and their association with antenatal distress in White and South Asian women in the UK

Symptoms of distress during pregnancy are common and often go unnoticed. There is a well-established relation between life events and depression. The current study aims to explore the association between life events and difficulties, and symptoms of emotional and somatic distress during pregnancy in White and South Asian women in the UK. 100 pregnant women attending routine antenatal appointments were interviewed using the Life Events and Difficulties Schedule (LEDS). We investigated the frequency and type of events experienced in the year prior to conception and during pregnancy, as predictors for somatic and emotional distress, measured using the GHQ-28. Non-severe stressors accounted for over 90 % of those reported, half of which (43-53 %) were health and reproduction-related. Somatic symptoms were associated with the number of non-severe events, and number of children and emotional symptoms were associated with non-marked difficulties. There was little evidence of an association between severe events and distress. Ethnicity had little effect on any associations although South Asian women were at slightly higher odds of experiencing emotional symptoms, which appear to be buffered by social support. In routine antenatal care it is important to assess both emotional and somatic symptoms. Health professionals need to be sensitive to the health, social, cultural and environmental circumstances of women during pregnancy and ensure appropriate support is in place, particularly for multi-parous women. Regression models explained a small but significant amount of the variance in distress symptoms. Further work is necessary to explore other contributory factors and also the mechanisms through which stressors have their effect.

Antenatal depression and male gender preference in Asian women in the UK

Objective to identify the prevalence of antenatal depression among Asian women living in the UK in one antenatal clinic, and to investigate the possible association with a desire for a male child and other risk factors. Design cross-sectional questionnaire-based study. Setting general antenatal clinic in a hospital in Birmingham. Participants 300 Asian women, irrespective of place of birth. Methods consecutive Asian women attending routine antenatal appointments during the study period self-completed a questionnaire. The first part investigated socio-demographic, cultural and other possible risk factors, including gender preference. The second part comprised the Edinburgh Postnatal Depression Scale (EPDS). Measurements EPDS score greater than or equal to 12 indicating probable depression. Findings the prevalence of depression was 30.7% (92/300, 95% confidence interval 25.4–35.9%). Maternal male gender preference was not common and was not associated with antenatal depression. Family male gender preference, unplanned pregnancy, a history of depression and feeling anxious in pregnancy were independently associated with an increased likelihood of depression, whilst support from family and friends, being satisfied with pregnancy and being multiparous were associated with a reduced likelihood of depression. Conclusion rates of antenatal depression were very high in Asian women with some associated risk factors. However, male gender preference was not associated with antenatal depression. Implications for practice given the high prevalence, screening Asian women for depression may be indicated to allow treatment.