Trimester Complications Research Articles

Predicting adverse obstetric outcome after early pregnancy events and complications: a review

BACKGROUND The aim was to evaluate the impact of early pregnancy events and complications as predictors of adverse obstetric outcome. METHODS We conducted a literature review on the impact of first trimester complications in previous and index pregnancies using Medline and Cochrane databases covering the period 1980-2008. RESULTS Clinically relevant associations of adverse outcome in the subsequent pregnancy with an odds ratio (OR) > 2.0 after complications in a previous pregnancy are the risk of perinatal death after a single previous miscarriage, the risk of very preterm delivery (VPTD) after two or more miscarriages, the risk of placenta praevia, premature preterm rupture of membranes, VPTD and low birthweight (LBW) after recurrent miscarriage and the risk of VPTD after two or more termination of pregnancy. Clinically relevant associations of adverse obstetric outcome in the ongoing pregnancy with an OR > 2.0 after complications in the index pregnancy are the risk of LBW and very low birthweight (VLBW) after a threatened miscarriage, the risk of pregnancy-induced hypertension, pre-eclampsia, placental abruption, preterm delivery (PTD), small for gestational age and low 5-min Apgar score after detection of an intrauterine haematoma, the risk of VPTD and intrauterine growth restriction after a crown-rump length discrepancy, the risk of VPTD, LBW and VLBW after a vanishing twin phenomenon and the risk of PTD, LBW and low 5-min Apgar score in a pregnancy complicated by severe hyperemesis gravidarum. CONCLUSIONS Data from our literature review indicate, by finding significant associations, that specific early pregnancy events and complications are predictors for subsequent adverse obstetric and perinatal outcome. Though, some of these associations are based on limited or small uncontrolled studies. Larger population-based controlled studies are needed to confirm these findings. Nevertheless, identification of these risks will improve obstetric care.

Enough is enough! Time for a new model of care for women with early pregnancy complications

Australian women with early pregnancy complications, like their English counterparts, should have access to ultrasound-based early pregnancy units (EPUs) nationwide. This modern approach to women with first trimester problems would not only streamline individual care pathways but also reduce the impact that early pregnancy problems have on already overburdened public emergency departments. Dedicated EPUs, with trained gynaecological sonologists experienced in the management of first trimester complications, should become the benchmark standard of care for Australian women in early pregnancy.

Management of Gastroschisis

After completing this article, readers should be able to: 1. Describe various aspects of prenatal management for pregnancies complicated by gastroschisis, including diagnosis and counseling. 2. Know the increased risk of third trimester complications in pregnancies with gastroschisis and the need for close monitoring and vigilance during the perinatal period. 3. Discuss the controversial management strategies regarding timing and mode of delivery in gastroschisis and the resolution of some of the ongoing debates. 4. Delineate the important aspects of neonatal management of gastroschisis, including enumeration of modalities of surgical repair and postoperative complications. 5. Discuss the need for multicenter prospective controlled trials to standardize care of infants who have gastroschisis and improve outcomes. Gastroschisis is a common neonatal congenital anomaly whose global prevalence is increasing. Although survival of affected infants has improved over the past several decades, the relationship among prenatal diagnosis, the resulting perinatal management (including timing and mode of delivery), and timing and type of neonatal surgery remain uncertain. Over the past several years, a number of clinical and animal studies have clarified some aspects of the confusion. ### Diagnosis Gastroschisis is diagnosed prenatally via ultrasonography that documents the ventral abdominal wall defect through which loops of bowel protrude and float freely in the amniotic fluid. The umbilical cord insertion site usually appears normal, but it can be difficult to discern because herniated bowel loops may be pressed against it. Maternal serum alpha-fetoprotein concentrations usually are elevated and may be a marker for fetal gastroschisis, but specific diagnostic biochemical testing (eg, amniotic fluid acetylcholine esterase) is not recommended as a screening tool. Furthermore, genetic amniocentesis generally is not recommended because of the low risk of chromosomal abnormalities. Researchers have tried to identify sonographic predictors of bowel damage, such as fixed dilation of the herniated bowel and thickening of the bowel wall, but none has been …

P01.03: Screening for non chromosomic fetal malformations using first‐trimester followed by second‐trimester detailed ultrasound examination: evaluation of the performance

Background: Prenatal Diagnosis is a rapidly evolving specialty. It is important to collect and understand the statistics for the service to plan for the future. Objective: To describe the patterns of tertiary referrals to a major centre over a ten-year period. Methods: Data from all patients referred to the Mater Centre for Maternal Fetal Medicine were prospectively collected and entered into a database. The indications for referral were categorised into: high risk (e.g. previous abnormal baby), ultrasound markers (e.g. Choroid plexus cyst), single fetal anomalies (e.g. gastroschisis), complex fetal anomalies (anomalies involving multiple systems), and third trimester complications. Diagnostic procedures performed were recorded, and pregnancy outcomes were sought from the initial site of referral. Results: Over the ten-year period, tertiary referrals to the Centre (patients not delivering in the Hospital) increased from 42 in 1993 to 1082 in 2002 (total 4814). Overall, the proportions of patients are: 38.5% high risk, 22% ultrasound markers, 21.4% single anomalies, 13% complex anomalies, and 5% third trimester complications. When divided into two 5-year periods, the rate of rise is most rapid for high risk (13.5 fold), followed by markers (6.8 fold), complex anomalies (3.7 fold), third trimester complications (3.1 fold), and single anomalies (2.7 fold). Overall, 787 invasive procedures were performed (16.3%). The rate of invasive procedures decreased from 21.4% to 15.6% (p < 0.0001) over the two 5-year periods. The proportion of procedures that were amniocentesis increased from 35% to 67% (p < 0.0001), and for CVS decreased from 46.9% to 30.9% (p < 0.001). 5% of pregnancies were terminated, 3% had a stillbirth, and 2% had neonatal deaths. Conclusions: The tertiary referral pattern for prenatal diagnosis has changed significantly. The pattern of invasive diagnostic procedures has also changed. Future service planning needs to take these patterns into consideration.

Color doppler in the diagnosis of ectopic pregnancy in the emergency department: is there anything beyond a mass and fluid?

Pregnant patients with first trimester complications are a common presentation in many Emergency Departments (EDs). The burden of disproving the existence of an ectopic pregnancy falls on the Emergency Physician (EP). This may be a difficult task depending on the availability of specialty backup and radiologic services. For more than a decade EPs have documented use of bedside ultrasonography for ruling out cases of ectopic pregnancy. Now, with the entry of newer technology into many emergency ultrasound programs, color Doppler is available to an increasing number of EPs. Color Doppler is used as an adjunct to diagnosing ectopic pregnancy by both radiology and gynecology practitioners and can at times provide critical information regarding early pregnancy. Presented are three cases of ectopic pregnancy diagnosed on the basis of abnormal color Doppler findings, and a discussion of the technique.

An audit of the management of ectopic pregnancy

To estimate the local incidence of ectopic pregnancy and to review the management of ectopic pregnancy with reference to those misdiagnosed at presentation. To establish management guidelines to be applied to all possible ectopic pregnancies. A review of all ectopic pregnancies presenting over a 2-year period, and of emergency gynaecological admissions during 4 months. A teaching hospital. The local rate of ectopic pregnancy was similar to that seen in other UK studies. Nineteen (13%) women with ectopic pregnancies were sent home with an incorrect diagnosis. Eight were recalled but eight required emergency admission and one died at home. Undue confidence in ultrasound reports and failure to follow up inconclusive histology results were a feature in cases where patients were not recalled. A set of simple management guidelines has been drawn up. Amongst general gynaecological admissions 1 in 12 of all first trimester complications was an ectopic pregnancy. Amongst apparently true uterine miscarriages 20% of histological examinations were inconclusive and histology and ultrasound examinations failed to confirm a uterine miscarriage in 14% of apparently true missed miscarriages. Ectopic pregnancy is common amongst first trimester complications. Adherence to simple management guidelines would minimize the number of patients requiring emergency admission, though up to 20% of patients with apparently true uterine miscarriages would also require further investigation.

Real‐time ultrasonography as a clinical and management tool to monitor pregnancy in a chimpanzee breeding colony

AbstractAccurate assessment of gestational age, date of parturition, and evaluation of placental abnormalities are essential to monitor obstetrical and fetal complications in captive chimpanzee (Pan troglodytes) breeding colonies. Since ultrasonography is a safe and noninvasive technique for monitoring chimpanzee pregnancies, we have developed a technique to estimate the date of parturition using the fetal biparietal diameter (BPD) of the skull from real‐time ultrasonographic measurements. A formula for determining gestational age was based on analysis of data obtained from 62 pregnancies over an 8‐year period. From this formula an estimated gestational age was calculated and compared with menstrual cycle data from the period near the time of the estimated date of conception (EDC). If the data from the scan and cycle history were in agreement within 7 days, the estimate date of conception was corrected to be 3 days prior to detumescence of the sex cycle phase. Lastly, the estimated date of parturition (EDP) was predicted to be 240 days after the EDC. To evaluate the utility of this prediction, we subsequently examined 13 chimpanzee pregnancies using the above technique and compared it to the actual date of parturition (ADP). Nine of the 13 chimpanzees delivered within 2 weeks of the EDP. In addition to estimating gestational age, ultrasonography may be a useful tool for evaluating fetal growth and placental abnormalities and assessing third trimester complications in chimpanzee pregnancies.

Serial plasma diamine oxidase (DAO) assays in first and second trimester complications of pregnancy

Serial plasma diamine oxidase (DAO) assays in first and second trimester complications of pregnancy