Background: Nutrition in the first 1000 days between pregnancy and 24 months of life is critical for child health, and exclusive breastfeeding is promoted as the infant's best source of nutrition in the first 6 months. Caffeine is a central nervous system stimulant occurring naturally in some foods and used to treat primary apnoea in premature babies. However high caffeine intake can be harmful, and caffeine is transmitted into breastmilk. Aim: To systematically review the evidence on the effects of maternal caffeine consumption during breastfeeding on the breastfed child. Method: A systematic search was conducted to October 2017 in MEDLINE, EMBASE, Web of Science, CINAHL, and Cochrane Library. The British Library catalogue, which covers doctoral theses, was searched and PRISMA guidelines followed. Two reviewers screened for experimental, cohort, or case-control studies and performed independent quality assessment using the Newcastle-Ottawa scale. The main reviewer performed data extraction, checked by the second reviewer. Results: Two cohort, two crossover studies, and one N-of-1 trial were included for narrative synthesis. One crossover and two cohort studies of small sample sizes directly investigated maternal caffeine consumption. No significant effects on 24-hour heart rate, 24-hour sleep time, or frequent night waking of the breastfed child were found. One study found a decreased rate of full breastfeeding at 6 months postpartum. Two studies indirectly investigated caffeine exposure. Maternal chocolate and coffee consumption was associated with increased infant colic, and severe to moderate exacerbation of infant atopic dermatitis. However, whether caffeine was the causal ingredient is questionable. The insufficient and inconsistent evidence available had quality issues impeding conclusions on the effects of maternal caffeine consumption on the breastfed child. Conclusion: Evidence for recommendations on caffeine intake for breastfeeding women is scant, of limited quality and inconclusive. Birth cohort studies investigating the potential positive and negative effects of various levels of maternal caffeine consumption on the breastfed child and breastfeeding mother could improve the knowledge base and allow evidence-based advice for breastfeeding mothers. Systematic review registration number: CRD42017078790.

Over the last 5 years there has been a plethora of studies looking at the complications and feasibility of performing myomectomy at the time of caesarean section (Li et al. Acta Obstet Gynecol Scand 2009;88:183–6; Akkurt et al. J Matern-Fetal Neonatal Med 2017;30:1855–60). Few if any of these studies have come from the UK or the USA, and while the commandment ‘thou should never touch a fibroid at a caesarean section’ seems to have originated in the developed world, the rules are being questioned elsewhere, with results that universally show, despite the expected increase in operating time, no significant increase in morbidity besides an increase need for blood transfusion and, most importantly, no excess of hysterectomy being required.

Objective 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.

Paper discussing classification of uterine anomalies.

Perinatal 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.

Hyponatremia during peripartum period is a recognized but underreported complication. Hyponatremia has significant adverse effects on mother as well as infant. Hyponatremia can be dilutional or nondilutional. Dilutional or hypervolemic hyponatremia is more common during the labor and postpartum period. The blood sodium concentration during pregnancy is lower, 130–140 mmol/L, which is being considered normal compared to 135–145 mmol/L in nonpregnant women. Thus, when the blood sodium level is below 130 mmol/L, we should consider it as hyponatremia of pregnancy. Oxytocin can play a major role to cause dilutional hyponatremia if large volumes of hypotonic fluids are consumed or infused intravenously simultaneously. Hyponatremia during labor is such a complex problem that it can be the result of several factors. In hyponatremia, there is progressive dysfunction of the neurological system, which in association with cerebral edema results in various symptoms. Symptoms may vary from headache, nausea, vomiting, lethargy, muscle cramps, and disorientation, progressing to seizures, coma, respiratory arrest, and death. A proper clinical history and various blood tests including serum sodium are important to diagnose the severity of hyponatremia. Women in labor should be advised to drink water only up to their thirst impulse; excessive fluid intake should be avoided. The treatment depends on cause, severity, and duration of hyponatremia, as well as clinical status of patient, and associated comorbidities. Once acute water intoxication and hyponatremia have been diagnosed, it is necessary to correct the hyponatremia by water restriction and to watch sodium concentration in the blood. Severe hyponatremia (sodium <125 mmol/L + symptoms) is a medical emergency. The primary idea of treatment should be to improve symptoms instead to normalize the blood sodium level. Keywords: Fluid balance, Fluid restriction, Hyponatremia, Labor, Oxytocin, Peripartum.

Objective: The aim of this research was to explore mothers' lived experience of early bonding with their twins.Background: Research has suggested that the process of bonding with twins may differ from that of bonding with singletons. However, there is limited research exploring this experience from the mother's perspective.Method: An IPA study involved six participants in semi-structured interviews.Results: Two superordinate themes emerged; 'Twin guilt and shame' and 'I missed out … they miss out'. Results suggested the experience of bonding with two infants simultaneously generated guilt for the mothers, who at points felt that they and their infants had missed out and had had to adapt.Conclusion: The experience of bonding with twins can be complex and take longer than anticipated, with mothers reporting the experience as being different from their expectations. Having a greater understanding and information about the complexities of bonding with twins would be beneficial for both mothers and professionals working with them.

Background: An increasing number of catheter ablations are performed for symptomatic tachyarrhythmias and commonly involve the left atrium, increasing the risk of catheter interaction with the mitral valve (MV) complex. Mitral valve trauma at the time of atrial fibrillation (AF) ablations remains a rare yet emergent situation that requires prompt diagnosis and management to prevent the long-term sequelae of heart failure secondary to MV dysfunction. Case summary: We present a case of a 69-year-old female with symptomatic paroxysmal AF and atrial flutter who underwent a combined ablation procedure. During the pulmonary vein isolation procedure, the mapping catheter became entangled within the MV apparatus but was freed. She presented to our hospital 2 weeks later with dyspnoea, lethargy, and a cough. Clinical examination revealed a pansystolic murmur and right moderate pleural effusion. Transthoracic echocardiogram (TTE) demonstrated a flail posterior MV leaflet with severe eccentric mitral regurgitation (MR). She underwent urgent valve repair at the regional cardiothoracic centre. Upon review 2 months later, she was symptom free with surveillance TTE demonstrating a preserved left ventricular systolic function with a trace of MR. Discussion: Mitral valve injury secondary to catheter entrapment at the time of left-sided ablations is a rare yet serious complication and can present as an emergent situation requiring prompt recognition and early surgical management to salvage valve and cardiac function.

A mini commentary on R Sobel et al., pp. 412–420 in the same issue. See https://doi.org/10.1111/1471-0528.16972.

This article discusses the nutritional needs of moderate and late preterm infants (born between 32+0weeks and 36+6weeks' gestation) and makes recommendations for best practice both while these infants are in hospital and when they are discharged into the community. These recommendations were derived following a roundtable meeting of a group comprising two neonatologists, three paediatric dietitians, a health visitor/paediatric nurse and a midwife practitioner. The meeting and medical writing assistance was sponsored by Nutricia. None of the participants accepted honoraria for their contributions to the discussion.