Routine Pregnancy Care Research Articles

Proposed clinical management of pregnancies after combined screening for pre-eclampsia at 30-34 weeks' gestation.

To estimate the patient-specific risk of pre-eclampsia (PE) at 30-34 weeks' gestation by a combination of maternal characteristics and medical history with multiples of the median (MoM) values of mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), serum placental growth factor (PlGF) and serum soluble fms-like tyrosine kinase-1 (sFlt-1), and stratify women into high-, intermediate- and low-risk management groups. This was a prospective observational study in women attending a third-trimester ultrasound scan at 30-34 weeks as part of routine pregnancy care. Patient-specific risks of delivery with PE at < 4 weeks from assessment and at < 40 weeks' gestation were calculated using the competing-risks model to combine the prior risk from maternal characteristics and medical history with MoM values of MAP, UtA-PI, PlGF and sFlt-1. On the basis of these risks, the population was stratified into high-, intermediate- and low-risk groups. Different risk cut-offs were used to vary the proportion of the population stratified into each risk category and the performance of screening for delivery with PE at < 4 weeks from assessment and delivery with PE from 4 weeks after assessment and up to 40 weeks' gestation was estimated. The study population of 8128 singleton pregnancies included 234 (2.9%) that subsequently developed PE. Using a risk cut-off of 1 in 50 for PE delivering at < 4 weeks and a risk cut-off of 1 in 150 for PE delivering at < 40 weeks' gestation, the proportion of the population stratified into high, intermediate and low risk was about 3%, 26% and 71%, respectively. The high-risk group contained 90% of pregnancies with PE at < 4 weeks and 40% of those with PE at 4 weeks from assessment to 40 weeks' gestation. The intermediate-risk group contained a further 49% of women with PE at 4 weeks from assessment to 40 gestational weeks. In the low-risk group, none of the women developed PE at < 4 weeks and only 0.3% developed PE at 4 weeks to 40 gestational weeks. The study presents risk stratification of PE by the combined test at 30-34 weeks, aiming to identify a high-risk group in need of intensive monitoring from the time of the initial assessment and up to 40 weeks' gestation and an intermediate-risk group in need of monitoring from 4 weeks after the initial assessment and up to 40 weeks' gestation. All pregnancies would need to be reassessed at 40 weeks' gestation. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

The Effect of Relaxation on Mother's Anxiety and Maternal–Fetal Attachment in Primiparous IVF Mothers

ObjectivesInfertility is one of the main stressful events of life and a crisis affecting various dimensions of infertile couples' lives. Relaxation, as a strategy, can be effective in the individuals' resistance to stress and anxiety. Therefore, the present study aimed to assess the effect of relaxation on mother's anxiety and maternal–fetal attachment in primiparous women who used In Vitro Fertilization (IVF) to get pregnant. MethodsIn this clinical trial, 80 primiparous women who had used IVF to get pregnant were randomly divided into a control and an intervention group. The intervention group took part in four 90-min relaxation classes in addition to receiving the routine pregnancy care. Anxiety and maternal–fetal attachment were evaluated before and one month after the intervention. Also, maternal–infantile attachment score was computed after delivery. The statistical analyses were performed using the SPSS statistical software. Chi-square and independent t-test was used to analyze the data. ResultsThe results revealed no significant difference between the two groups regarding the mean scores of anxiety and attachment before the intervention. However, a significant difference was observed in this regard after the intervention (41.4 ± 4.1 vs. 51.0 ± 10.4, P < 0.01). ConclusionThe study results showed that relaxation training was effective in reduction of anxiety and increase of maternal–fetal attachment in the women who had used IVF to get pregnant. Although there are other methods for reducing anxiety, relaxing can be used for IVF women due to its ease of use and its wide acceptance.

Screening for pre-eclampsia using sFlt-1/PlGF ratio cut-off of 38 at 30-37 weeks' gestation.

To evaluate a soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF) ratio cut-off of 38 for the prediction of pre-eclampsia (PE) in routine assessment in singleton pregnancies at 30-37 weeks' gestation. This was a prospective observational study in women attending a third-trimester ultrasound scan at 30-37 weeks as part of routine pregnancy care. Serum sFlt-1 and PlGF were measured and their ratio was calculated. We estimated the detection rate (DR), false-positive rate (FPR), positive predictive value (PPV) and negative predictive value (NPV) of sFlt-1/PlGF ratio >38 for the prediction of delivery with PE at < 1, < 4 and ≥ 4 weeks after assessment. The study population of 12 305 singleton pregnancies was examined at a median of 32.4 (range, 30.0-36.9) weeks and included 14 (0.11%), 77 (0.63%) and 227 (1.84%) cases that subsequently delivered with PE at < 1, < 4 or ≥ 4 weeks' after assessment, respectively. The DR, FPR, PPV and NPV of sFlt-1/PlGF ratio > 38 in the prediction of delivery with PE at < 1 week were 78.6%, 4.5%, 1.9% and 99.97%, respectively; the values for delivery with PE at < 4 weeks were 76.6%, 4.1%, 10.4% and 99.85% and for delivery with PE ≥ 4 weeks were 20.7%, 4.3%, 8.3% and 98.47%. In routine screening of singleton pregnancies, the performance of a sFlt-1/PlGF ratio > 38 is modest for the prediction of delivery with PE at < 1 and at < 4 weeks after assessment and poor for the prediction of delivery with PE at ≥ 4 weeks after assessment. A sFlt-1/PlGF ratio > 38 predicted 79% of cases delivering with PE at < 1 week after assessment, at a FPR of 4.5%; consequently, a policy of hospitalizing patients with a ratio > 38 would potentially lead to unnecessary hospitalization in 4.5% of pregnancies and a ratio of ≤ 38 would falsely reassure one fifth of women who will deliver with PE within 1 week of assessment. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Effect of Vocalization of the Holy Quran With and Without Translation on Pregnancy Outcomes: A Randomized Clinical Trial.

BackgroundDuring recent decades, research in Iran in the area of the Quran and medical science has been seriously engaged in. With respect to the tendency toward spirituality and alternative medicine, we tried to find other aspects of the influence of the Quran.ObjectivesThis study aimed to determine the effect of vocalizations of the Holy Quran with and without translation on the consequences of pregnancy (the prevalence of preterm delivery, caesarean delivery, and neonatal anthropometric indices) in women admitted to health care centers in Urmia, Iran.Materials and MethodsThis was a three-armed parallel-group randomized clinical trial in which 168 pregnant women (25-28 weeks) in their first and second pregnancies were divided into three groups of 56 (Holy Quran with translation, Holy Quran without translation, and control group) by randomized blocking. The intervention was implemented once a week for three weeks in the health center, and on other days of the week, the participants listened at home to a CD they were given. The intervention and the control groups all received routine pregnancy care once a week. These mothers were tracked during their labor. Outcomes including gestational age at delivery, delivery type, and neonatal anthropometric indices were recorded based on the mother’s records.ResultsThere was no statistically significant difference between the groups in terms of demographic and obstetric characteristics before the intervention. In comparison with the control group, the probability of preterm delivery was lower in the Holy Quran with translation group (odds ratio: 0.3, CI 95%: 0.1-1.2) and in the Holy Quran without translation group (0.6, 0.2-1.9) as compared to the control group. However, this difference was not statistically significant. Similarly, the probability of caesarean delivery was lower in the Holy Quran with translation group (0.6, 0.3-1.4) and the Holy Quran without translation group (0.5, 0.2-1.2) as compared to the control group. Based on one-way ANOVA, there was no statistically significant difference between the study groups regarding the infants’ anthropometric indices.ConclusionsBased on the results of this study, despite the lower prevalence of preterm labor and caesarean section in the intervention groups as compared to the control group, no statistically significant effect was seen. This was apparently due to the small sample size.

Excess Gestational Weight Gain in Pregnancy and the Role of Lifestyle Intervention.

With increasingly adverse lifestyles, young women in many countries have rapid weight gain and rising obesity. In keeping with this, most pregnant women exceed recommended gestational weight gain (GWG) and then retain weight postpartum. The consequences of excess GWG include maternal risks during pregnancy, neonatal risks and maternal obesity and chronic disease longer term, presenting a significant public health and economic burden worldwide. This article discusses the adverse maternal and infant risks with excess GWG apparent from observational studies, summarizes the existing guidelines for optimal GWG and highlights the need for further research to identify optimal GWG recommendations across the different ethnicities and weight ranges.We also review the evidence for lifestyle interventions in pregnancy to prevent excess GWG and highlighting the work underway to integrate large scale meta-analyses of individual patient data from lifestyle intervention studies to inform clinical practice beyond current observational data. Finally, we address the need to implement lifestyle interventions into routine pregnancy care to improve short and long term maternal health outcomes.

The Effect of the Educational Program on Iranian Fathers’ Involvement in Infant care: A Randomized Clinical Trial Study

Introduction With the increase in women's employment and change in attitudes towards father's role in family, father involvement in infant care can indirectly influence the physical health and well being of infant and mother. Materials and Methods This randomized clinical trial study was performed on 150 qualified pregnant women and husbands. During the 35-37 weeks of pregnancy, fathers in fathers' training group and couples in couples' training group, participated in two training sessions of healthy infant caring. Fathers in control group received no training and mothers in all three groups received the routine pregnancy training and care. At the end of 4 and 8 weeks after birth, the involvement rate of fathers in infant care questioners were completed by mothers in all three groups. The data were analyzed using Analysis of variance (ANOVA) and SPSS software version 16. Results The total amount of involvement was calculated 55.77 for the fourth week and 62.64 for the eighth week. The average of total involvement rate and three dimensions of direct father-child interaction, accessibility and responsibility and providing financial resources in two training groups comparing with that the control group, indicated a significant difference (P�0.05). Conclusion Training the fathers regarding the infant care led to an increase in the fathers' involvement dimensions in infant care. Thus, paternal training of this educational program should be considered in pregnancy care programs.

Financial Incentives for Smoking Cessation in Pregnancy

Each year, 25,000 spontaneous miscarriages are associated with smoking during pregnancy. While there are many medical approaches to smoking cessation, they have not proven to be the particularly effective. A recent Cochrane systematic review suggests that financial incentives may be effective in helping pregnant smokers quit. The current study explored the efficacy and cost-effectiveness of financial incentives added to routine specialist pregnancy NHS “Stop Smoking Services” that provide assistance to pregnant women to quit smoking. The design of this study used a phase II therapeutic randomized controlled trial in a single center that covered a wide geographical location. Women eligible for the study were smokers who had a carbon monoxide measurement of 7 ppm, were 16 years or younger, at less than 24 weeks’ gestation, and resident in NHS Greater Glasgow and Clyde. All eligible women were allocated to a control group (306) or incentives (306). The routine specialist pregnancy care consisted of a face-to-face appointment followed by 4 weekly phone support calls and free nicotine replacement therapy for 10 weeks, with a confirmation of smoking status at 4 and 12 weeks of agreed quit date. Control groups were offered routine support; an intervention group received a £50 voucher for attending all appointments and to set a quit date. The incentive group was also offered £400 shopping vouchers if they engaged with stop smoking services or quit. Those who remained abstinent, confirmed by a carbon monoxide breath test (<10 ppm), in the intervention group were also given additional £50 vouchers at 2 weeks and £100 vouchers at 12 weeks. A final £200 voucher was given to the incentive group when confirmed smoking abstinence at quit date. In the primary outcome assessment, there was a significant difference between the 2 groups. More women had stopped smoking in the incentives group (22.5% vs 8.6 %; P < 0.001), and relative risk of not smoking at the end of pregnancy was 2.63 (95% confidence interval, 1.73–4.01). Secondary outcome assessment revealed a higher rate of continued abstinence 4 weeks after quit date in the incentives group. This study suggests that financial incentives can aid women to quit smoking during pregnancy and are more effective than other approaches currently recommended. The cost of this incentive is also below the current UK National Health Service threshold and is a cost-effective option in the short term. Smoking during pregnancy may prevent both maternal and neonatal complications, and financial incentives should be considered as a more effective method to avoid these conditions than the current incentives provided.

An Early Pregnancy HbA1c ≥5.9% (41 mmol/mol) Is Optimal for Detecting Diabetes and Identifies Women at Increased Risk of Adverse Pregnancy Outcomes

Unrecognized diabetes in parturients can cause poor obstetric outcomes. Several professional associations recommend screening for diabetes in pregnancy at the first antenatal visit, although the most appropriate test and threshold remain unclear. Measurement of hemoglobin A1c (HbA1c) can be added to the routine early pregnancy tests, with a level of 6.5% or greater (48 mmol/mol) recommended as the diagnostic cutoff for diabetes. However, the optimal threshold in pregnancy is likely lower. This prospective cohort study was performed to determine the optimal early pregnancy HbA1c threshold to detect diabetes and whether this threshold identifies women at increased risk of adverse pregnancy outcomes. The association of the HbA1c levels was compared with diagnoses of preexisting diabetes or gestational diabetes mellitus (GDM) as measured by the standard oral glucose tolerance test (OGTT) performed at less than 20 weeks’ gestation. Diabetes was defined as fasting ≥126 mg/dL (7.0 mmol/L) or 2 hours ≥200 mg/dL (11.1 mmol/L) and GDM as fasting ≥92 mg/dL (5.1 mmol/L), 1 hour ≥180 mg/dL (10.0 mmol/L), or 2 hours ≥153 mg/dL (8.5 mmol/L). Women were referred for management of GDM only when fasting levels were ≥99 mg/dL (5.5 mmol/L) or 2 hours ≥162 mg/dL (9.0 mmol/L). HbA1c testing was performed for 16,122 women at a median of 47 days’ (interquartile range, 38–62 days’) gestation. The mean ± SD HbA1c level was 5.3% ± 0.3% (34 ± 3.3 mmol/mol); 33 (0.2%) women had HbA1c of 6.5% or greater (48 mmol/mol). The OGTTs were performed at less than 20 weeks in 974 of 4201 women at a median of 99 days (interquartile range, 84–113 days). Fifteen women met the OGTT criteria for diabetes, with a median HbA1c of 6.5% (48 mmol/mol; range, 5.9%–8.9%; 41–74 mmol/mol). The OGTT criteria for GDM were met by 170 women at less than 20 weeks, with a median HbA1c of 5.8% (40 mmol/mol; range, 4.8%–7.3%; 29–56 mmol/mol). The optimal HbA1c screening threshold for detecting diabetes was 5.9% or greater (41 mmol/mol) and was met by 2.9% of the total cohort. Sensitivity was 100% (95% confidence interval [CI], 91.8%–100%), specificity 97.4% (95% CI, 95.5%–99.2%), positive predictive value 18.8% (95% CI 15.7%–22.4%), and negative predictive value 100% (95% CI, 100%–100%). For early GDM, this HbA1c threshold was highly specific at 98.4% (95% CI, 97.0–99.9), but less sensitive at 18.8% (95% CI, 6.6%–31.1%). In total, 128 women (74.0%) with early HbA1c of 5.9% or greater who had an OGTT met GDM criteria at some point in the pregnancy; 18 (10.4%) of these women met diabetes criteria. Seventy-three of 78 patients had a postnatal OGTT; 34 (46.6%) were abnormal, 10 (13.7%) had diabetes, 24 (32.9%) had impaired glucose tolerance, and 8 (11.0%) had impaired fasting glucose (100–109 mg/dL; 5.6–6.0 mmol/L). Of the 29 women with HbA1c of 6.5% or greater at less than 20 weeks, 25 (86.2%) had a postnatal OGTT, 20 (80%) had diabetes, and 5 (20%) had impaired glucose tolerance. Compared with women with HbA1c of less than 5.9%, those with HbA1c of 5.9% or greater had more than 2-fold increased relative risk (RR) of preeclampsia, shoulder dystocia, and major congenital anomaly; more than a 3-fold increased RR of perinatal death; and more than a 1.5-fold increased RR of delivery at less than 37 weeks. Four perinatal deaths occurred for women with HbA1c of 5.9% to 6.4% who received routine pregnancy care. Hemoglobin A1c of 5.9% or greater identified all women with diabetes in those who had an OGTT at less than 20 weeks’ gestation. A threshold of 6.5% or greater would have missed almost 50% of these parturients and is thus too high for screening purposes. Future studies are needed to confirm these results and to assess the impact of early detection and treatment on maternal and fetal outcomes and the cost-effectiveness of HbA1c compared with OGTT.

Routine Use of an Antenatal Infection Screen-and-Treat Program to Prevent Preterm Birth: Long-Term Experience at a Tertiary Referral Center.

Vaginal infection in early pregnancy is associated with preterm birth. This study evaluates long-term results after integrating an antenatal screen-and-treat program for asymptomatic vaginal infections into routine pregnancy care. We retrospectively analyzed data of all women with singleton high-risk pregnancies delivering at our tertiary referral center between 2005 and 2014. The intervention group included women who presented for a prenatal visit for a planned birth between 10+0 and 16+0 gestational weeks. Women were routinely screened for asymptomatic infections using Gram stain. In cases of bacterial vaginosis, candidiasis or trichomoniasis, women were treated according to our clinical protocol. The control group included women who did not undergo the program. Prenatal care was equal in both groups. Preterm birth served as the primary outcome variable. Of the 20,052 women with singleton pregnancies, 8,490 (42.3%) participated in the antenatal prevention program. The mean gestational age at birth was 38.8±2.6weeks and 37.5±4.3weeks in the intervention and control groups, respectively (p<0.001). The incidence of preterm birth was significantly lower in the intervention group than in the control group (9.7% vs 22.3%; p<0.001). Low-birthweight neonates, stillbirths, and late miscarriages were less frequent in the intervention group (p<0.001). Long-term results support the use of an antenatal infection screen-and-treat program to prevent preterm birth. If integrated into routine pregnancy care at a high-risk obstetrical setting, this simple public health intervention could lead to a significant reduction in preterm birth, low infant birthweight, and adverse pregnancy outcomes.

Screening for Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium should it be integrated into routine pregnancy care in French young pregnant women?

Chlamydia trachomatis, Neisseria gonorrhoeae, and Mycoplasma genitalium screening during pregnancy is not performed routinely in France. We conducted the first prospective study in 1004 women attending for routine antenatal care to determine the prevalence and risk factors for these bacterial infections. The overall prevalence of C. trachomatis, N. gonorrhoeae, and M. genitalium infections was 2.5%, 0%, and 0.8%, respectively. In patients aged 18–24years, the prevalence increased to 7.9% for C. trachomatis and to 2.4% for M. genitalium. C. trachomatis infection was associated with age ≤24years or being single or having more than 5 sexual partners in a lifetime. M. genitalium infection was more frequent in patients aged ≤24years or who had a history of abortion or their first sexual intercourse after 20years of age. The high prevalence of C. trachomatis in pregnant women aged ≤24years, mostly asymptomatic, suggests that systematic screening could be beneficial.

Postpartum weight retention and breastfeeding among obese women from the randomized controlled Lifestyle in Pregnancy (LiP) trial.

To study the effects of lifestyle intervention in pregnancy on weight retention 6months postpartum among obese women from the "Lifestyle in Pregnancy" (LiP) study, and to determine associations between breastfeeding with postpartum maternal weight. Six months postpartum follow up after a randomized controlled intervention trial. Two university hospitals in Denmark. A total of 360 women with pregestational body mass index ≥30kg/m(2) . The intervention involved lifestyle changes (diet and exercise) during pregnancy. The control group received routine pregnancy care. Both groups received standard postnatal care. Gestational weight gain, postpartum weight retention and breastfeeding. Follow up was completed in 238 women of whom 46% in the intervention group and 57% in the control group had retained weight 6months postpartum (p=0.088). Women with gestational weight gain ≤9kg, (recommended by the Institute of Medicine), retained less postpartum weight compared with those who exceeded 9kg (median -0.7 vs. 1.5, p<0.001). Ninety-two percent in both weight gain groups initiated breastfeeding. The number of breastfeeding mothers was higher among women with postpartum weight retention ≤5kg compared with those with weight retention >5kg (94% vs. 85%, p=0.034). We could not detect sustained weight control at 6months postpartum despite a lower gestational weight gain for obese women during pregnancy who received a lifestyle intervention rather than standard care. Women who adhered to gestational weight gain recommendations had significantly lower postpartum weight retention. Breastfeeding for 6months was negatively associated with postpartum weight retention.

Current Practice and Attitudes of Australian Obstetricians Toward Population-Based Carrier Screening for Inherited Conditions

An anonymous survey of Australian Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists was conducted with the aim of understanding current practice and attitudes toward population-based carrier screening for inherited conditions in the setting of routine pregnancy care. Of 1,121 Fellows invited to complete the online questionnaire by e-mail, 237 (21%) responded, and of these 156 were practicing obstetricians and completed the whole survey. Of the respondents, 83% expressed support for population-based carrier screening for at least some conditions, with 97% supporting carrier screening for β-thalassaemia, and 83% supporting carrier screening for cystic fibrosis (CF). A small proportion of obstetricians reported offering carrier screening as part of routine pregnancy care (20% for β-thalassaemia, 8% for CF, 5% for fragile X syndrome, and 2% for spinal muscular atrophy). The main practical barriers identified for screening were cost, time constraints, and availability of supporting services. Addressing these issues is crucial for the successful implementation of population-based carrier screening programs in Australia and internationally.

Does exercise training during pregnancy affect gestational age and gestational weight gain?

Some controversies exist over the possibility that exercise during pregnancy might increase the risk of preterm delivery. At the same time excessive gestational weight gain is increasing in prevalence and associated with a number of adverse pregnancy outcomes for both mother and child. This study aimed to determine the possible relationship between regular exercise of pregnancy and gestational weight gain and gestational age at the moment of delivery. This was a case-control survey. By using a continued method, performed on 250 women with one or two gestation were assigned to either a training (n=125) or a comparison (n=125) group. The supervised training was included three days a week, 30–45 min, from 20–26th weeks to 38–39th weeks of pregnancy. Pregnancy outcomes include of gestational weight gain and gestational age was recorded for two groups. Statistical analysis was performed using Students’ t-test, man-Whitney, and chi-squared test where appropriate. According finding of this study, No significant differences were found (p>0.05) between 2 groups for gestational age and exercise. The mean gestational age did not differ between the training (39 weeks ±1 day) and the comparison group (39 weeks, 4 days ±1.23 day). There were meaningful statistical evidences for exercise training and gestational weight gain at the time of delivery.According the findings of the present study, healthy gravid with one or two gestation can safely engage in moderate, supervised exercise programmed until the end of gestation as this would not affect gestational age. Also the program proved effective in reducing gestational weight gain at the time of delivery. Such programs should be considered as part of routine pregnancy care for pregnant women especially obese ones.

Maternal Exercise During Pregnancy and Neonatal Outcomes in Iran

Abstract Exercise during pregnancy is interested for pregnant women, but there is worry about fetal outcomes. The purpose of this study was to assess the effect of a planned aerobic exercise program on neonatal outcomes. This was a case-control study. By using a continued method, performed on pregnant women with singleton gestation were assigned to either a training or a control group. The supervised training included three days a week, with duration of 30-45 minutes, from 20-26th weeks until delivery. Neonatal outcomes include neonatal weight and first and fifth minute's apgar was recorded for two groups. According finding of this study, there were not meaningful statistical evidences for exercise training and first and fifth minute's apgar or neonatal weight in two groups. Therefore, such programs should be considered as part of routine pregnancy care for pregnant women.

Effect of learning attachment behaviors on anxiety and maternal fetal attachment in first pregnant women

Background: Anxiety with different shapes induces some complications in women in their first pregnancy. Reducing anxiety level can promote maternal-fetal health. Aim: to examine the effect of learning the “attachment behaviors” on the anxiety level and “maternal fetal attachment” in first pregnant women referring to Shiraz obstetric clinics in 2010 Methods: In this randomized control trial 84 pregnant women were allocated in two groups randomly. Experimental group received routine pregnancy care in addition to four 90- minutes’ sessions on the attachment behaviors during one month of intervention period. The control group received usual pregnancy services. Anxiety and maternal fetal attachment were measured before and after intervention in two groups. Data were collected using Spielberger's State Anxiety Inventory and maternal fetal attachment scale Cranley. Data were analyzed with SPSS software (v.11.5), using statistical tests including Chi square, pair T test, and T test. P value less than 0.05 considered statistically significant. Results: women in the case group experienced significantly less anxiety and more maternal fetal attachment after learning attachment behaviors (p=0.003, p <0.001). No significant changes were found in the control group. Conclusion: educating the attachment behaviors can increase maternal fetal attachment and reduce women’s anxiety in their first pregnancy. It could be suggested to include teaching this subject in to pregnancy health care services.

Promoting male involvement to improve PMTCT uptake and reduce antenatal HIV infection: a cluster randomized controlled trial protocol.

BackgroundDespite the availability of a dual therapy treatment protocol and infant feeding guidelines designed to prevent mother to child transmission (PMTCT) of HIV, of the over 1 million babies born in South Africa each year, only 70% of those born to HIV positive mothers receive dual therapy. Similar to other resource-poor nations facing the integration of PMTCT into routine pregnancy and infant care, efforts in South Africa to scale up PMTCT and reduce transmission to < 5% have fallen far short of the United Nation's goal of 50% reductions in paediatric HIV by 80% coverage of mothers.Methods/DesignThis study proposes to evaluate the impact of combining two evidence-based interventions: a couple's risk reduction intervention with an evidence based medication adherence intervention to enhance male participation in combination with improving medication and PMTCT adherence in antenatal clinics to increase PMTCT overall reach and effectiveness. The study will use a group-randomized design, recruiting 240 couples from 12 clinics. Clinics will be randomly assigned to experimental and control conditions and effectiveness of the combined intervention to enhance PMTCT as well as reduce antenatal seroconversion by both individuals and clinics will be examined.DiscussionShared intervention elements may decrease sexual risk and enhance PMTCT uptake, e.g., increased male participation, enhanced communication, HIV counselling and testing, adherence, serostatus disclosure, suggest that a combined sexual risk reduction and adherence intervention plus PMTCT can increase male participation, increase couples' communication and encourage adherence to the PMTCT process. The findings will impact public health and will enable the health ministry to formulate policy related to male involvement in PMTCT, which will result in PMTCT.Trial registrationPACTR201109000318329

Exercise Training in Pregnancy for obese women (ETIP): study protocol for a randomised controlled trial

BackgroundBoth maternal pre-pregnancy obesity and excessive gestational weight gain are increasing in prevalence and associated with a number of adverse pregnancy outcomes for both mother and child. Observational studies regarding physical activity in pregnancy have found reduced weight gain in active mothers, as well as reduced risk of adverse pregnancy outcomes. There is however a lack of high quality, randomized controlled trials on the effects of regular exercise training in pregnancy, especially those with a pre-pregnancy body mass index (BMI) at or above 30 kg/m2.MethodsWe are conducting a randomised, controlled trial in Norway with two parallel arms; one intervention group and one control group. We will enroll 150 previously sedentary, pregnant women with a pre-pregnancy BMI at or above 30 kg/m2. The intervention group will meet for organized exercise training three times per week, starting in gestation week 14 (range 12-16). The control group will get standard antenatal care. The main outcome measure will be weight gain from baseline to delivery. Among the secondary outcome measures are changes in exercise capacity, endothelial function, physical activity level, body composition, serum markers of cardiovascular risk, incontinence, lumbopelvic pain and cardiac function from baseline to gestation week 37 (range 36-38). Offspring outcome measures include anthropometric variables at birth, Apgar score, as well as serum markers of inflammation and metabolism in cord blood.DiscussionThe results of this trial will provide knowledge about effects of regular exercise training in previously sedentary, obese pregnant women. If the program proves effective in reducing gestational weight gain and adverse pregnancy outcomes, such programs should be considered as part of routine pregnancy care for obese women.Trial RegistrationClinicalTrials.gov: NCT01243554

Costs and consequences of treatment for mild gestational diabetes mellitus - evaluation from the ACHOIS randomised trial.

BackgroundRecommended best practice is that economic evaluation of health care interventions should be integral with randomised clinical trials. We performed a cost-consequence analysis of treating women with mild gestational diabetes mellitus by dietary advice, blood glucose monitoring and insulin therapy as needed compared with routine pregnancy care, using patient-level data from a multi-centre randomised clinical trial.MethodsWomen with a singleton pregnancy who had mild gestational diabetes diagnosed by an oral glucose-tolerance test between 24 and 34 weeks' gestation and their infants were included. Clinical outcomes and outpatient costs derived from all women and infants in the trial. Inpatient costs derived from women and infants attending the hospital contributing the largest number of enrolments (26.1%), and charges to women and their families derived from a subsample of participants from that hospital (in 2002 Australian dollars). Occasions of service and health outcomes were adjusted for maternal age, ethnicity and parity. Analysis of variance was used with bootstrapping to confirm results. Primary clinical outcomes were serious perinatal complications; admission to neonatal nursery; jaundice requiring phototherapy; induction of labour and caesarean delivery. Economic outcome measures were outpatient and inpatient costs, and charges to women and their families.ResultsFor every 100 women with a singleton pregnancy and positive oral glucose tolerance test who were offered treatment for mild gestational diabetes mellitus in addition to routine obstetric care, $53,985 additional direct costs were incurred at the obstetric hospital, $6,521 additional charges were incurred by women and their families, 9.7 additional women experienced induction of labour, and 8.6 more babies were admitted to a neonatal nursery. However, 2.2 fewer babies experienced serious perinatal complication and 1.0 fewer babies experienced perinatal death. The incremental cost per additional serious perinatal complication prevented was $27,503, per perinatal death prevented was $60,506 and per discounted life-year gained was $2,988.ConclusionIt is likely that the general public in high-income countries such as Australia would find reductions in perinatal mortality and in serious perinatal complications sufficient to justify additional health service and personal monetary charges. Over the whole lifespan, the incremental cost per extra life-year gained is highly favourable.Trial RegistrationAustralian Clinical Trials Registry ACTRN12606000294550

Mild gestational diabetes in pregnancy and the adipoinsular axis in babies born to mothers in the ACHOIS randomised controlled trial

BackgroundMild gestational diabetes is a common complication of pregnancy, affecting up to 9% of pregnant women. Treatment of mild GDM is known to reduce adverse perinatal outcomes such as macrosomia and associated birth injuries, such as shoulder dystocia, bone fractures and nerve palsies. This study aimed to compare the plasma glucose concentrations and serum insulin, leptin and adiponectin in cord blood of babies of women (a) without gestational diabetes mellitus (GDM), (b) with mild GDM under routine care, or (c) mild GDM with treatment.Methods95 women with mild GDM on oral glucose tolerance testing (OGTT) at one tertiary level maternity hospital who had been recruited to the ACHOIS trial at one of the collaborating hospitals and randomised to either Treatment (n = 46) or Routine Care (n = 49) and Control women with a normal OGTT (n = 133) were included in the study. Women with mild GDM (treatment or routine care group) and OGTT normal women received routine pregnancy care. In addition, women with treated mild GDM received dietary advice, blood glucose monitoring and insulin if necessary.The primary outcome measures were cord blood concentrations of glucose, insulin, adiponectin and leptin.ResultsCord plasma glucose was higher in women receiving routine care compared with control, but was normalized by treatment for mild GDM (p = 0.01). Cord serum insulin and insulin to glucose ratio were similar between the three groups. Leptin concentration in cord serum was lower in GDM treated women compared with routine care (p = 0.02) and not different to control (p = 0.11). Adiponectin was lower in both mild GDM groups compared with control (Treatment p = 0.02 and Routine Care p = 0.07), while the adiponectin to leptin ratio was lower for women receiving routine care compared with treatment (p = 0.08) and control (p = 0.05).ConclusionTreatment of women with mild GDM using diet, blood glucose monitoring and insulin if necessary, influences the altered fetal adipoinsular axis characteristic of mild GDM in pregnancy.

Prenatal Diagnosis in Postwar Vietnam: Power, Subjectivity, and Citizenship

Across the world, routine pregnancy care is expanding to include ultrasound imaging and other prenatal diagnostic technologies. Yet, despite their global proliferation, hardly any anthropological research has examined how such technologies are employed outside Euro‐America. In this article, I investigate how pregnant women in Vietnam's capital, Hanoi, handle the hard choices that ultrasonographies confront them with when a fetal anomaly is detected and a decision must be made to either maintain or terminate the pregnancy. Whereas research conducted in North America, in consonance with the emphasis on individualism in advanced liberal societies, frames prenatal diagnosis in terms of individual “moral pioneering,” I show how Vietnamese women turn the choices they have to make into issues of collectivity, kinship, social belonging, and shared responsibility. The general argument advanced is that a comprehensive understanding of individual reproductive actions and intentions necessarily involves close consideration of local configurations of power, subjectivity, and citizenship.