RSS 1.0Maternity
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A-EQUIP : pilot to practice through partnership powerThis article chronicles the journey of the Coventry and Warwickshire A-EQUIP partnership; from undertaking the pilot phase of the new A-EQUIP model, through to a region-wide implementation. Partnership benefits include a 'critical friend' approach as well as shared learning and a wider appreciation of the challenges and successes touching midwives in maternity service delivery across the local patch. This partnership team is optimistic about the future benefits A-EQUIP will bring to midwives, women and babies in their area.
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‘INVENT’ – a collaborative regional multicentre service evaluation and audit of multiple pregnancies : preliminary results from three centresPoster abstract 2600 from the 2019 World Congress of the Royal College of Obstretriscians and Gynaecologists, RCOG 2019. London, United Kingdom.
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Can CTG (cardiotocography) predict chorioamnionitis and funisitis – a retrospective observational studyObjective To analyse the fetal heart rate patterns and changes in uterine contractions on CTG where the histological examination of the placenta confirmed chorioamnionitis and funisitis. Design The data from the histology of the placenta confirming acute chorioamnionitis and funisitis was collected and correlated with the CTG. Two independent reviewers reviewed the CTG to avoid bias in interpretation. The data was collected from 2014 to 2020. Methods A retrospective analysis of confirmed chorioamnionitis and or funisitis on histological examination of the placentae and associated features on the CTG traces. The preterm CTGs were excluded in this observational study. Results 60 cases were identified were the histological examination of the placenta confirmed chorioamnionitis and funisitis over a period of 6 years. Out of the 57 cases, 27 cases (47.4%) had features of funisitis confirmed on histology. 100% of the CTG traces had an increase in the baseline compared to the gestational age with an average of an increase by 25 bpm and variable decelerations with overshoot were noted in cases where funisitis was confirmed in 25 cases (92.6%). Loss of cycling was noted in 54 CTGs and a sinusoidal pattern was identified in 27 CTGs. 42 women (73.7%) had intrapartum pyrexia and none of the mothers had an increased temperature at the point of fetal tachycardia (persistent increase in baseline heart rate by >10 bpm). 25 out of 57 (43.8%) babies did not have a baseline heart rate increase more than 160 bpm. 43 out of 57 CTGs were found to have a uterine tachysystole or hyperstimulation. Uterine hypertonus was noted in 7 out of 57 cases. Only 15 out of 57 (26.3%) cases had meconium stained amniotic fluid (MSAF). 54 (94.7%) out of 57 women had a caesarean mode of delivery and their babies were admitted to special care baby unit (SCBU) after delivery out of which 15 babies were admitted to with APGAR score of 6 or less. There was one neonatal death at 12 h of age because of sepsis. Conclusion Rising baseline during labour along with loss of cycling with or without features of tachysystole or hyperstimulation in labour should be considered as features of chorioamnionitis. Delivery should be expedited in such cases to avoid adverse perinatal outcomes such as neonatal sepsis, neonatal death and maternal infection. Neonatal sepsis can lead to serious consequences such as cerebral palsy and death.
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All pregnancy headaches are not pre-eclampsia – intracranial aneurysm in third trimesterObjective Headaches in pregnancy are common and mostly diagnosed as pre-eclampsia. However an intracranial aneurysm can present in a similar way which can lead to a diagnostic dilemma. Here we present such a case where the cause for the headache was diagnosed to be an intracranial aneurysm. Case report A 32 year old para 1 was admitted with severe bilateral periorbital and frontal headache for 3 days at 36 weeks. She also had flashes of light and rainbow colour (mainly blue) vision. She had a past medical history of Charcot-Marie-Tooth disease and Rheumatoid arthritis. On admission she was conscious and oriented, stable with moderate tachycardia. There was no proteinuria or worsening pedal edema. There were no focal neurological signs. The liver and renal function tests were within the normal range. An urgent medical review was sought who organised a CT venogram showed the presence of 11 mm right side intracranial aneurysm arising from the intracavernous/ophthalmic division of right Internal Carotid artery (ICA). There was no evidence of cerebral venous sinus thrombosis. She was transferred to tertiary care centre where she had a caesarean section the following day. She was treated with a flow diverter stenting of the Right ICA para opthalmic aneurysm. Post stenting angiogram demonstrated patency of the Right ICA. She was commenced on aspirin 75 mg daily for 6 months and Clopidogrel 75 mg daily for 12 months. She presented with persistent headache and fleeting right sided visual disturbances 2 months later. MRI demonstrated the flow diverter stent to be patent and the aneurysm to have thrombosed significantly. Discussion Headaches are very common in pregnancy. Apart from pre eclampsia, other causes like Migraine, tension headache, hypertension, Sub Arachnoid Haemorrhage, drug related – nifedipine, medication overuse, Postdural tap, meningitis, CVT (expand), idiopathic intracranial hypertension, stroke and arteriovenous malformation should be excluded. A multidisciplinary approach involving neurosurgeons is necessary in situations such where risks of prematurity has to be discussed. The distribution rate of intracranial aneurysm in 1st, 2nd and 3rd trimester in pregnancy are 6%, 31% and 55% respectively, and in puerperal period is 8%. Patients with > 10 mm size aneurysm should be treated and planned LSCS should be done. Conclusion Cerebral aneurysm is a, particularly when symptomatic, can have a catastrophic effect on the life of a pregnant mother and her baby. Prompt diagnosis and MDT approach will result in reducing the maternal morbidity and mortality.
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Management of euglycemic ketoacidosis in gestational diabetesObjective Incidence of GDM is increasing. The incidence of diabetes is 9%. The risk of diabetic ketoacidosis is foetal distress and adverse neurological outcome. Foetal mortality rates at 27%–35%, hypoxia and recurrent late decelerations. Euglycemic DKA is characterised with relatively low blood sugar levels. Diagnosis is based on biochemical triad blood sugar <11 increased anion gap metabolic acidosis, ketonemia. Incidence is 0.8% and 1.1% of all pregnant DKA. It is commonly seen in type 2 diabetes but recently the incidence of euglycemic DKA is increasingly seen in women with gestational diabetes. it is an obstetric and medical emergency. It is Diagnostic challenge as euglycemia often leading providers to believe ketoacidosis is less severe, frequently go unrecognized leading onto maternal and foetal morbidity and mortality. Case 35 Year old Primigravida with BMI of 38 with Gestational diabetes on insulin and metformin came in spontaneous labour at 3 cm dilatation slight raised BP was kept in for observation. The women had skipped insulin during labour. During process of labour it was noted that she was becoming ketotic with 3 + ketones in urine and blood sugar of 8.9 and blood ketones: 3.6. Multidisciplinary input with medical review euglyacemic Diabetic ketoacidosis was done with ph: 7.53, co2: 1.7 on arterial blood gas. She was transferred to intensive unit. Insulin sliding scale was started and IV fluids was started. There were initial CTG changes which settled down with fluids and insulin. She had emergency LSCS for failure to progress at 5 cm. she recovered well in intensive unit and transferred to ward at 20 h after delivery to high dependency unit. Discussion Prompt recognition is needed as it is associated with foetal demise 35% without appropriate treatment. It is important to counsel women about intensive metabolic control, prenatal care in a combined obstetric and diabetic clinic. obstetric and midwifery staff needs to have High index of suspicion to identify early in the course of illness since the development of DKA can be rapid and can also occur at lower blood glucose levels compared to non-pregnant women. Blood ketone strips help in the differentiation of these euglycemic ketoacidosis and dehydration. Early hospitalisation if there are signs of decompensation. Use of Steroids for foetal lung maturity with caution. Conclusion It is important to increase awareness of euglycemic diabetic ketoacidosis among obstetric staff and women diagnosed with gestational diabetes. Multidisciplinary input is need to ensure good outcome.
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Reflections On Midwifery-Led Research By Research Midwives : A Unique Insight.The research team at South Warwickshire NHS Foundation Trust (SWFT) worked with the University of Central Lancashire (UCLan) on the ASPIRE COVID-19 study. We conducted 55 stakeholder interviews to gain insight into the trust’s response to the pandemic. Working on the project presented many opportunities and challenges for us including qualitative interviewing, using digital technology and engaging representative populations. ASPIRE COVID-19 gave us a unique opportunity to be part of a rare qualitative, midwifery-led research project which we fully embraced. We hope that this is the start of a new era of research which encourages midwife-led projects and qualitative studies.
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Modelling of psychosocial and lifestyle predictors of peripartum depressive symptoms associated with distinct risk trajectories : a prospective cohort studyPerinatal depression involves interplay between individual chronic and acute disease burdens, biological and psychosocial environmental and behavioural factors. Here we explored the predictive potential of specific psycho-socio-demographic characteristics for antenatal and postpartum depression symptoms and contribution to severity scores on the Edinburgh Postnatal Depression Scale (EPDS) screening tool. We determined depression risk trajectories in 480 women that prospectively completed the EPDS during pregnancy (TP1) and postpartum (TP2). Multinomial logistic and penalised linear regression investigated covariates associated with increased antenatal and postpartum EPDS scores contributing to the average or the difference of paired scores across time points. History of anxiety was identified as the strongest contribution to antenatal EPDS scores followed by the social status, whereas a history of depression, postpartum depression (PPD) and family history of PPD exhibited the strongest association with postpartum EPDS. These covariates were the strongest differentiating factors that increased the spread between antenatal and postpartum EPDS scores. Available covariates appeared better suited to predict EPDS scores antenatally than postpartum. As women move from the antenatal to the postpartum period, socio-demographic and lifestyle risk factors appear to play a smaller role in risk, and a personal and family history of depression and PPD become increasingly important.
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Have caesarean section rates become an obsolete statistic? Time to throw in the towel in the fight to reduce caesarean section rates.A comment piece exploring whether caesarean section rates have become an obsolete statistic.
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Pregnancy and neonatal outcomes of COVID-19: The PAN-COVID studyObjective: To assess perinatal outcomes for pregnancies affected by suspected or confirmed SARS-CoV-2 infection. Methods: Prospective, web-based registry. Pregnant women were invited to participate if they had suspected or confirmed SARS-CoV-2 infection between 1st January 2020 and 31st March 2021 to assess the impact of infection on maternal and perinatal outcomes including miscarriage, stillbirth, fetal growth restriction, pre-term birth and transmission to the infant. Results: Between April 2020 and March 2021, the study recruited 8239 participants who had suspected or confirmed SARs-CoV-2 infection episodes in pregnancy between January 2020 and March 2021. Maternal death affected 14/8197 (0.2%) participants, 176/8187 (2.2%) of participants required ventilatory support. Pre-eclampsia affected 389/8189 (4.8%) participants, eclampsia was reported in 40/ 8024 (0.5%) of all participants. Stillbirth affected 35/8187 (0.4 %) participants. In participants delivering within 2 weeks of delivery 21/2686 (0.8 %) were affected by stillbirth compared with 8/4596 (0.2 %) delivering ≥ 2 weeks after infection (95 % CI 0.3-1.0). SGA affected 744/7696 (9.3 %) of livebirths, FGR affected 360/8175 (4.4 %) of all pregnancies. Pre-term birth occurred in 922/8066 (11.5%), the majority of these were indicated pre-term births, 220/7987 (2.8%) participants experienced spontaneous pre-term births. Early neonatal deaths affected 11/8050 livebirths. Of all neonates, 80/7993 (1.0%) tested positive for SARS-CoV-2. Conclusions: Infection was associated with indicated pre-term birth, most commonly for fetal compromise. The overall proportions of women affected by SGA and FGR were not higher than expected, however there was the proportion affected by stillbirth in participants delivering within 2 weeks of infection was significantly higher than those delivering ≥ 2 weeks after infection. We suggest that clinicians' threshold for delivery should be low if there are concerns with fetal movements or fetal heart rate monitoring in the time around infection. The proportion affected by pre-eclampsia amongst participants was not higher than would be expected, although we report a higher than expected proportion affected by eclampsia. There appears to be no effect on birthweight or congenital malformations in women affected by SARS-CoV-2 infection in pregnancy and neonatal infection is uncommon. This study reflects a population with a range of infection severity for SARS-COV-2 in pregnancy, generalisable to whole obstetric populations.