1
|
Martin E, Fisher O, Tone J, Suldsuren N, Kularatna S, Beckmann M, Miller YD. Health-related quality of life and utility of maternity health states amongst post-partum Australians. PLoS One 2024; 19:e0310913. [PMID: 39374261 PMCID: PMC11457989 DOI: 10.1371/journal.pone.0310913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/09/2024] [Indexed: 10/09/2024] Open
Abstract
BACKGROUND This study aimed to measure patient-reported health-related quality of life amongst post-partum women in Queensland, Australia. METHODS Patient-reported health-related quality of life data was prospectively collected from 134 post-partum women using the EQ-5D-5L at weekly intervals during the first six weeks following birth. Data across the five health domains of the EQ-5D-5L was converted to a single health utility value to represent overall health status. Linear mixed modelling and regression analysis were used to examine changes in utility over the first six weeks post-birth and determine associations between utility and clinical and demographic characteristics of post-partum women. FINDINGS Gestation at birth and weeks post-partum were significantly associated with utility values when considered in a multivariate linear mixed model. Mean utility values increased by 0.01 for every week increase in gestation at birth, and utility values were 0.70 at one week post-partum and increased to 0.85 at six weeks post-partum, with the largest increase occurring between one- and two-weeks post-birth. When controlling for variables that were found to predict utility values across the first six weeks post-partum, no single state of health predicted utility values at one-week post-partum. CONCLUSIONS Maternity services can use our data and methods to establish norms for their own service, and researchers and maternity services can partner to conduct cost-effectiveness analysis using our more relevant utility values than what is currently available. Time since birth and gestational age of the woman's baby should be considered when selecting post-partum health state utility values for maternity services cost-effectiveness analyses.
Collapse
Affiliation(s)
- Elizabeth Martin
- Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
- Wesley Research Institute, Brisbane, Queensland, Australia
| | - Olivia Fisher
- Wesley Research Institute, Brisbane, Queensland, Australia
| | - Jessica Tone
- Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
| | - Narmandakh Suldsuren
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Sanjeewa Kularatna
- Australian Centre for Health Services Innovation, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Michael Beckmann
- Mater Research Institute, University of Queensland, Brisbane, Queensland, Australia
| | - Yvette D. Miller
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| |
Collapse
|
2
|
Pinto L, Paulo-de-Sousa C, Ayres-de-Campos D. Impact of a simulator-based training program on the success rate of external cephalic version. Eur J Obstet Gynecol Reprod Biol 2024; 301:60-63. [PMID: 39098222 DOI: 10.1016/j.ejogrb.2024.07.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2024] [Accepted: 07/31/2024] [Indexed: 08/06/2024]
Abstract
OBJECTIVE To compare the success and complication rates of external cephalic version before and after the implementation of a simulator-based training program at a tertiary care university centre with a dedicated external cephalic version team. STUDY DESIGN In this single-center intervention study, the success rate and the complication rates of external cephalic version in the two years before the implementation of a simulation-based training program for all specialists and residents, were compared with the two years following the event. T- student, Mann-Whitney, and Chi-square tests were used. All data were extracted from the hospital's electronic patient records. RESULTS A total of 96 external cephalic versions were performed in the 2 years before the training program, and 74 after the training program. The overall success rates were similar between the two groups: 44.8 % before training and 43.2 % after training (p = 0.824). No major complications occurred, and no emergency cesarean deliveries were performed in either period. CONCLUSION In a tertiary care university training center with a dedicated team in external cephalic version, a structured simulation-based training program did not impact the success rate or the complication rates of the procedure.
Collapse
Affiliation(s)
- Luísa Pinto
- Faculdade de Medicina, Universidade de Lisboa, Portugal.
| | - Catarina Paulo-de-Sousa
- Departamento de Obstetrícia, Ginecologia e Medicina da Reprodução, Centro Hospitalar Universitário Santa Maria, Lisboa, Portugal
| | - Diogo Ayres-de-Campos
- Faculdade de Medicina, Universidade de Lisboa, Portugal; Departamento de Obstetrícia, Ginecologia e Medicina da Reprodução, Centro Hospitalar Universitário Santa Maria, Lisboa, Portugal
| |
Collapse
|
3
|
Pinto L, Fonseca A, Ayres-de-Campos D. Impact of a regional simulation-based training course in the implementation of external cephalic version: Intervention study. Int J Gynaecol Obstet 2024. [PMID: 38972009 DOI: 10.1002/ijgo.15774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 06/19/2024] [Accepted: 06/25/2024] [Indexed: 07/08/2024]
Abstract
OBJECTIVE The aims of this study were to assess whether a regional simulation-based training course in external cephalic version (ECV) would lead to the adoption of this technique in hospitals where it was not previously practiced, and to improve success rates in those already performing it. METHODS This was an intervention study where two specialists in obstetrics and gynecology from 10 Portuguese public maternity hospitals attended a structured simulation-based training in ECV. Hospitals were categorized based on whether ECV was conducted prior to the training program, and on their annual number of deliveries. Main outcomes were the number of ECVs performed in the 2 years before and after the course, and their success rates. RESULTS Implementation of ECV was achieved in four additional hospitals during the 2 years following the course. Among the three hospitals already performing ECV and able to report their data, no significant differences in success rates were observed in the 2 years following the course (45.6% vs. 47.9%, P = 0.797). After a successful ECV, 77.7% of women had a vaginal delivery. CONCLUSION A regional simulation-based training course in ECV led to an increase in the number of hospitals implementing the technique in the subsequent 2 years, but it did not impact the success rates in centers where it was already performed. This study highlights the potential of simulation-based courses in ECV, as well as the need to improve patients´ access to the technique and to centralize ECV services at a regional level.
Collapse
Affiliation(s)
- Luísa Pinto
- Lisbon Medical School, University of Lisbon, Lisbon, Portugal
| | - Andreia Fonseca
- Lisbon Medical School, University of Lisbon, Lisbon, Portugal
- Department of Obstetrics and Gynecology, Hospital Garcia de Orta, Almada, Portugal
| | - Diogo Ayres-de-Campos
- Lisbon Medical School, University of Lisbon, Lisbon, Portugal
- Department of Obstetrics, Gynecology and Reproductive Medicine, Santa Maria University Hospital, Lisbon, Portugal
| |
Collapse
|
4
|
Rivero-Arias O, Png ME, White A, Yang M, Taylor-Phillips S, Hinton L, Boardman F, McNiven A, Fisher J, Thilaganathan B, Oddie S, Slowther AM, Ratushnyak S, Roberts N, Shilton Osborne J, Petrou S. Benefits and harms of antenatal and newborn screening programmes in health economic assessments: the VALENTIA systematic review and qualitative investigation. Health Technol Assess 2024; 28:1-180. [PMID: 38938110 PMCID: PMC11228689 DOI: 10.3310/pytk6591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2024] Open
Abstract
Background Health economic assessments are used to determine whether the resources needed to generate net benefit from an antenatal or newborn screening programme, driven by multiple benefits and harms, are justifiable. It is not known what benefits and harms have been adopted by economic evaluations assessing these programmes and whether they omit benefits and harms considered important to relevant stakeholders. Objectives (1) To identify the benefits and harms adopted by health economic assessments in this area, and to assess how they have been measured and valued; (2) to identify attributes or relevance to stakeholders that ought to be considered in future economic assessments; and (3) to make recommendations about the benefits and harms that should be considered by these studies. Design Mixed methods combining systematic review and qualitative work. Systematic review methods We searched the published and grey literature from January 2000 to January 2021 using all major electronic databases. Economic evaluations of an antenatal or newborn screening programme in one or more Organisation for Economic Co-operation and Development countries were considered eligible. Reporting quality was assessed using the Consolidated Health Economic Evaluation Reporting Standards checklist. We identified benefits and harms using an integrative descriptive analysis and constructed a thematic framework. Qualitative methods We conducted a meta-ethnography of the existing literature on newborn screening experiences, a secondary analysis of existing individual interviews related to antenatal or newborn screening or living with screened-for conditions, and a thematic analysis of primary data collected with stakeholders about their experiences with screening. Results The literature searches identified 52,244 articles and reports, and 336 unique studies were included. Thematic framework resulted in seven themes: (1) diagnosis of screened for condition, (2) life-years and health status adjustments, (3) treatment, (4) long-term costs, (5) overdiagnosis, (6) pregnancy loss and (7) spillover effects on family members. Diagnosis of screened-for condition (115, 47.5%), life-years and health status adjustments (90, 37.2%) and treatment (88, 36.4%) accounted for most of the benefits and harms evaluating antenatal screening. The same themes accounted for most of the benefits and harms included in studies assessing newborn screening. Long-term costs, overdiagnosis and spillover effects tended to be ignored. The wide-reaching family implications of screening were considered important to stakeholders. We observed good overlap between the thematic framework and the qualitative evidence. Limitations Dual data extraction within the systematic literature review was not feasible due to the large number of studies included. It was difficult to recruit healthcare professionals in the stakeholder's interviews. Conclusions There is no consistency in the selection of benefits and harms used in health economic assessments in this area, suggesting that additional methods guidance is needed. Our proposed thematic framework can be used to guide the development of future health economic assessments evaluating antenatal and newborn screening programmes. Study registration This study is registered as PROSPERO CRD42020165236. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR127489) and is published in full in Health Technology Assessment; Vol. 28, No. 25. See the NIHR Funding and Awards website for further award information.
Collapse
Affiliation(s)
- Oliver Rivero-Arias
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - May Ee Png
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ashley White
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Miaoqing Yang
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | | | - Lisa Hinton
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- THIS Institute, University of Cambridge, Cambridge, UK
| | | | - Abigail McNiven
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | | | - Sam Oddie
- Bradford Institute for Health Research, Bradford Children's Research, Bradford, UK
| | | | - Svetlana Ratushnyak
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - Jenny Shilton Osborne
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Stavros Petrou
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| |
Collapse
|
5
|
Khalil A, Sotiriadis A, D'Antonio F, Da Silva Costa F, Odibo A, Prefumo F, Papageorghiou AT, Salomon LJ. ISUOG Practice Guidelines: performance of third-trimester obstetric ultrasound scan. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:131-147. [PMID: 38166001 DOI: 10.1002/uog.27538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 11/03/2023] [Indexed: 01/04/2024]
Affiliation(s)
- A Khalil
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK
| | - A Sotiriadis
- Second Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Faculty of Medicine, Thessaloniki, Greece
| | - F D'Antonio
- Centre for Fetal Care and High-Risk Pregnancy, University of Chieti, Chieti, Italy
| | - F Da Silva Costa
- Maternal Fetal Medicine Unit, Gold Coast University Hospital, and School of Medicine and Dentistry, Griffith University, Gold Coast, QLD, Australia
| | - A Odibo
- Obstetrics and Gynecology Department, Washington University School of Medicine in St. Louis, St. Louis, MO, USA
| | - F Prefumo
- Obstetrics and Gynecology Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - A T Papageorghiou
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, UK; Nuffield Department for Women's and Reproductive Health, University of Oxford, Oxford, UK
| | - L J Salomon
- URP FETUS 7328 and LUMIERE platform, Maternité, Obstétrique, Médecine, Chirurgie et Imagerie Foetales, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris (AP-HP), Université de Paris, Paris, France
| |
Collapse
|
6
|
Kingdom J, Ashwal E, Lausman A, Liauw J, Soliman N, Figueiro-Filho E, Nash C, Bujold E, Melamed N. Directive clinique n o 442 : Retard de croissance intra-utérin : Dépistage, diagnostic et prise en charge en contexte de grossesse monofœtale. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102155. [PMID: 37730301 DOI: 10.1016/j.jogc.2023.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
OBJECTIF Le retard de croissance intra-utérin est une complication obstétricale fréquente qui touche jusqu'à 10 % des grossesses dans la population générale et qui est le plus souvent due à une pathologie placentaire sous-jacente. L'objectif de la présente directive clinique est de fournir des déclarations sommaires et des recommandations pour appuyer un protocole clinique de dépistage, diagnostic et prise en charge du retard de croissance intra-utérin pour les grossesses à risque ou atteintes. POPULATION CIBLE Toutes les patientes enceintes menant une grossesse monofœtale. BéNéFICES, RISQUES ET COûTS: La mise en application des recommandations de la présente directive devrait améliorer la compétence des cliniciens quant à la détection du retard de croissance intra-utérin et à la réalisation des interventions indiquées. DONNéES PROBANTES: La littérature publiée a été colligée par des recherches effectuées jusqu'en septembre 2022 dans les bases de données PubMed, Medline, CINAHL et Cochrane Library en utilisant un vocabulaire contrôlé au moyen de termes MeSH pertinents (fetal growth retardation and small for gestational age) et de mots-clés (fetal growth, restriction, growth retardation, IUGR, FGR, low birth weight, small for gestational age, Doppler, placenta, pathology). Seuls les résultats de revues systématiques, d'essais cliniques randomisés ou comparatifs et d'études observationnelles ont été retenus. La littérature grise a été obtenue par des recherches menées dans des sites Web d'organismes s'intéressant à l'évaluation des technologies dans le domaine de la santé et d'organismes connexes, dans des collections de directives cliniques, des registres d'essais cliniques et des sites Web de sociétés de spécialité médicale nationales et internationales. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations Assessment, Development and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Obstétriciens, médecins de famille, infirmières, sages-femmes, spécialistes en médecine fœto-maternelle, radiologistes et autres professionnels de la santé qui prodiguent des soins aux patientes enceintes. RéSUMé POUR TWITTER: Mise à jour de la directive sur le dépistage, le diagnostic et la prise en charge du retard de croissance intra-utérin pour les grossesses à risque ou atteintes. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS: Prédiction du retard de croissance intra-utérin Prévention du retard de croissance intra-utérin Détection du retard de croissance intra-utérin Examens en cas de retard de croissance intra-utérin soupçonné Prise en charge du retard de croissance intra-utérin précoce Prise en charge du retard de croissance intra-utérin tardif Prise en charge du post-partum et consultations préconception.
Collapse
|
7
|
Kingdom J, Ashwal E, Lausman A, Liauw J, Soliman N, Figueiro-Filho E, Nash C, Bujold E, Melamed N. Guideline No. 442: Fetal Growth Restriction: Screening, Diagnosis, and Management in Singleton Pregnancies. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2023; 45:102154. [PMID: 37730302 DOI: 10.1016/j.jogc.2023.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2023]
Abstract
OBJECTIVE Fetal growth restriction is a common obstetrical complication that affects up to 10% of pregnancies in the general population and is most commonly due to underlying placental diseases. The purpose of this guideline is to provide summary statements and recommendations to support a clinical framework for effective screening, diagnosis, and management of pregnancies that are either at risk of or affected by fetal growth restriction. TARGET POPULATION All pregnant patients with a singleton pregnancy. BENEFITS, HARMS, AND COSTS Implementation of the recommendations in this guideline should increase clinician competency to detect fetal growth restriction and provide appropriate interventions. EVIDENCE Published literature in English was retrieved through searches of PubMed or MEDLINE, CINAHL, and The Cochrane Library through to September 2022 using appropriate controlled vocabulary via MeSH terms (fetal growth retardation and small for gestational age) and key words (fetal growth, restriction, growth retardation, IUGR, FGR, low birth weight, small for gestational age, Doppler, placenta, pathology). Results were restricted to systematic reviews, randomized controlled trials/controlled clinical trials, and observational studies. Grey literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Table A1 for definitions and Table A2 for interpretations of strong and conditional [weak] recommendations). INTENDED AUDIENCE Obstetricians, family physicians, nurses, midwives, maternal-fetal medicine specialists, radiologists, and other health care providers who care for pregnant patients. TWEETABLE ABSTRACT Updated guidelines on screening, diagnosis, and management of pregnancies at risk of or affected by FGR. SUMMARY STATEMENTS RECOMMENDATIONS: Prediction of FGR Prevention of FGR Detection of FGR Investigations in Pregnancies with Suspected Fetal Growth Restriction Management of Early-Onset Fetal Growth Restriction Management of Late-Onset FGR Postpartum management and preconception counselling.
Collapse
|
8
|
Hedditch A, Laudat M, Ellaway P, Impey L. Do specific maternal sensations experienced in late pregnancy correlate to a breech presenting baby? Evaluation of a simple maternal questionnaire. Birth 2023; 50:565-570. [PMID: 36149235 DOI: 10.1111/birt.12680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 09/07/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To investigate the effectiveness of a structured questionnaire completed at 36 weeks gestation in predicting breech presentation. DESIGN Questionnaire-based study. SETTING Tertiary NHS Foundation Trust. PARTICIPANTS Women attending for a universally offered 36-week fetal growth scan. INTERVENTION Completion of a previously designed maternal questionnaire detailing sensation of fetal movements during the past week, immediately before a routine growth scan. RESULTS Between September 01, 2018 and September 30, 2019, 2341 questionnaires were handed out and 2053 were returned. Analysis was performed in 1938 (94.4%) completed questionnaires. Recorded presentation was breech in 109 (5.6%), transverse/oblique in 15 (0.8%), and cephalic in 1814 (93.6%). Women "thinking their baby was breech" had a high positive likelihood ratio, at 11.8 (95% CI 7.4-19.1), but poor sensitivity (27.3%). "Feeling kicks low down or near the bladder" was sensitive for non-cephalic presentation (76.3%) but with poor specificity (48.9%). The questions "kicks low" ("no") (P = 0.013, aOR 2.18 [1.18-4.04]) and 'thinks cephalic ("no")' (P = 0.001, aOR 0.12 (0.04-0.43) were independent risk factors for a non-cephalic presentation. CONCLUSIONS The questions posed in this questionnaire could aid the detection of breech presentation, but do not perform better than published data on palpation. Missing a breech presentation near term through palpation alone is well reported. Combining the concept of palpation to exclude breech presentation and these questions may help focus a clinician and improve both palpation skills and breech detection. As a minimum, a woman who believes her baby is breech should be taken seriously.
Collapse
Affiliation(s)
- Anita Hedditch
- Fetal Medicine Unit, John Radcliffe Hospital Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Monique Laudat
- Milton Keynes University Hospital NHS Foundation Trust, Milton Keynes, UK
| | - Pauline Ellaway
- Fetal Medicine Unit, John Radcliffe Hospital Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Lawrence Impey
- Fetal Medicine Unit, John Radcliffe Hospital Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| |
Collapse
|
9
|
Knights S, Prasad S, Kalafat E, Dadali A, Sizer P, Harlow F, Khalil A. Impact of point-of-care ultrasound and routine third trimester ultrasound on undiagnosed breech presentation and perinatal outcomes: An observational multicentre cohort study. PLoS Med 2023; 20:e1004192. [PMID: 37023211 PMCID: PMC10079042 DOI: 10.1371/journal.pmed.1004192] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 02/07/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Accurate knowledge of fetal presentation at term is vital for optimal antenatal and intrapartum care. The primary objective was to compare the impact of routine third trimester ultrasound or point-of-care ultrasound (POCUS) with standard antenatal care, on the incidence of overall and proportion of all term breech presentations that were undiagnosed at term, and on the related adverse perinatal outcomes. METHODS AND FINDINGS This was a retrospective multicentre cohort study where we included data from St. George's (SGH) and Norfolk and Norwich University Hospitals (NNUH). Pregnancies were grouped according to whether they received routine third trimester scan (SGH) or POCUS (NNUH). Women with multiple pregnancy, preterm birth prior to 37 weeks, congenital abnormality, and those undergoing planned cesarean section for breech presentation were excluded. Undiagnosed breech presentation was defined as follows: (a) women presenting in labour or with ruptured membranes at term subsequently discovered to have a breech presentation; and (b) women attending for induction of labour at term found to have a breech presentation before induction. The primary outcome was the proportion of all term breech presentations that were undiagnosed. The secondary outcomes included mode of birth, gestational age at birth, birth weight, incidence of emergency cesarean section, and the following neonatal adverse outcomes: Apgar score <7 at 5 minutes, unexpected neonatal unit (NNU) admission, hypoxic ischemic encephalopathy (HIE), and perinatal mortality (including stillbirths and early neonatal deaths). We employed a Bayesian approach using informative priors from a previous similar study; updating their estimates (prior) with our own data (likelihood). The association of undiagnosed breech presentation at birth with adverse perinatal outcomes was analyzed with Bayesian log-binomial regression models. All analyses were conducted using R for Statistical Software (v.4.2.0). Before and after the implementation of routine third trimester scan or POCUS, there were 16,777 and 7,351 births in SGH and 5,119 and 4,575 in NNUH, respectively. The rate of breech presentation in labour was consistent across all groups (3% to 4%). In the SGH cohort, the percentage of all term breech presentations that were undiagnosed was 14.2% (82/578) before (years 2016 to 2020) and 2.8% (7/251) after (year 2020 to 2021) the implementation of universal screening (p < 0.001). Similarly, in the NNUH cohort, the percentage of all term breech presentations that were undiagnosed was 16.2% (27/167) before (year 2015) and 3.5% (5/142) after (year 2020 to 2021) the implementation of universal POCUS screening (p < 0.001). Bayesian regression analysis with informative priors showed that the rate of undiagnosed breech was 71% lower after the implementation of universal ultrasound (RR, 0.29; 95% CrI 0.20, 0.38) with a posterior probability greater than 99.9%. Among the pregnancies with breech presentation, there was also a very high probability (>99.9%) of reduced rate of low Apgar score (<7) at 5 minutes by 77% (RR, 0.23; 95% CrI 0.14, 0.38). There was moderate to high probability (posterior probability: 89.5% and 85.1%, respectively) of a reduction of HIE (RR, 0.32; 95% CrI 0.0.05, 1.77) and extended perinatal mortality rates (RR, 0.21; 95% CrI 0.01, 3.00). Using informative priors, the proportion of all term breech presentations that were undiagnosed was 69% lower after the initiation of universal POCUS (RR, 0.31; 95% CrI 0.21, 0.45) with a posterior probability greater of 99.9%. There was also a very high probability (99.5%) of a reduced rate of low Apgar score (<7) at 5 minutes by 40% (RR, 0.60; 95% CrI 0.39, 0.88). We do not have reliable data on number of facility-based ultrasound scans via the standard antenatal referral pathway or external cephalic versions (ECVs) performed during the study period. CONCLUSIONS In our study, we observed that both a policy of routine facility-based third trimester ultrasound or POCUS are associated with a reduction in the proportion of term breech presentations that were undiagnosed, with an improvement in neonatal outcomes. The findings from our study support the policy of third trimester ultrasound scan for fetal presentation. Future studies should focus on exploring the cost-effectiveness of POCUS for fetal presentation.
Collapse
Affiliation(s)
- Samantha Knights
- Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom
| | - Smriti Prasad
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Erkan Kalafat
- Department of Statistics, Middle East Technical University, Faculty of Arts and Sciences, Ankara, Turkey
- Department of Obstetrics and Gynaecology, Koc University, School of Medicine, Istanbul, Turkey
| | - Anahita Dadali
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Pam Sizer
- Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom
| | - Francoise Harlow
- Department of Obstetrics and Gynaecology, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, United Kingdom
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, United Kingdom
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom
- Fetal Medicine Unit, Liverpool Women's Hospital, Liverpool, United Kingdom
| |
Collapse
|
10
|
Chen AX, Hunt RW, Palmer KR, Bull CF, Callander EJ. The impact of assisted reproductive technology and ovulation induction on breech presentation: A whole of population‐based cohort study. Aust N Z J Obstet Gynaecol 2023. [DOI: 10.1111/ajo.13663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 02/15/2023] [Indexed: 03/29/2023]
|
11
|
Institutionalization of limited obstetric ultrasound leading to increased antenatal, skilled delivery, and postnatal service utilization in three regions of Ethiopia: A pre-post study. PLoS One 2023; 18:e0281626. [PMID: 36791077 PMCID: PMC10045583 DOI: 10.1371/journal.pone.0281626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 01/29/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND A minimum of one ultrasound scan is recommended for all pregnant women before the 24th week of gestation. In Ethiopia, there is a shortage of skilled manpower to provide these services. Currently, trained mid-level providers are providing the services at the primary healthcare level. The aims of this study were to compare antenatal care 1 (ANC1), antenatal care 4 (ANC4), skilled birth attendance (SBA), and postnatal care (PNC) service utilization before and after institutionalizing Vscan limited obstetric ultrasounds at semi-urban health centers in Ethiopia. METHODS A pre and post intervention observational study was conducted to investigate maternal and neonatal health service utilization rates before and after institutionalizing Vscan limited obstetric ultrasound services, between July 2016 and June 2020. The data were extracted from 1st August- 31st December 2020. RESULTS The observed monthly increase on the mean rank of first ANC visits after the introduction of Vscan limited obstetric ultrasound services showed a statistically significant difference at KW-ANOVA H (3) = 17.09, P = 0.001. The mean rank of fourth ANC utilization showed a statistically significant difference at KW- ANOVA H (3) = 16.24, P = 0.001. The observed mean rank in skilled birth attendance (SBA) showed a statistically significant positive difference using KW-ANOVA H (3) = 23.6, P<0.001. The mean rank of increased utilization in postnatal care showed a statistically significant difference using KW-ANOVA H (3) = 17.79, P<0.001. CONCLUSION The introduction of limited obstetric ultrasound services by trained mid-level providers at the primary healthcare level was found to have improved the utilization of ANC, SBA, and postnatal care (PNC) services. It is recommended that the institutionalization of limited obstetric ultrasound services be scaled up and a further comparative study between facilities with and without ultrasound services be conducted to confirm causality and assess effects on maternal and perinatal outcomes.
Collapse
|
12
|
Azimirad A. What to do when it is breech? A state-of-the-art review on management of breech presentation. World J Obstet Gynecol 2023; 12:1-10. [DOI: 10.5317/wjog.v12.i1.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/15/2022] [Accepted: 12/14/2022] [Indexed: 01/20/2023] Open
Abstract
Any non-cephalic presentation in a fetus is regarded as malpresentation. The most common malpresentation, breech, contributes to 3%-5% of term pregnancies and is a leading indication for cesarean delivery. Identification of risk factors and a proper physical examination are beneficial; however, ultrasound is the gold standard for the diagnosis of malpresentations. External cephalic version (ECV) refers to a procedure aimed to convert a non-cephalic presenting fetus to cephalic presentation. This procedure is performed manually through the mother’s abdomen by a trained health care provider, to reduce the likelihood of a cesarean section. Studies have reported a version success rate of above 50% by ECV. The main objective of this review is to present a broad perspective on fetal malpresentation, ECV, and delivery of a breech fetus. The focus is to elaborate all clinical scenarios of breech and to provide an evidence-based clinical approach for them. After discussing breech prevalence, risk factors, diagnosis, and management, an updated review of ECV is presented. Moreover, ECV indications/contraindications, alternatives, clinical techniques on how to perform ECV and breech vaginal delivery, and obstetrical considerations for the delivery of malpresentations are thoroughly discussed.
Collapse
Affiliation(s)
- Afshin Azimirad
- Department of Obstetrics and Gynecology, Tufts Medical Center, Boston, MA 02111, United States
- Diabetes Clinical Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, United States
| |
Collapse
|
13
|
Self A, Chen Q, Desiraju BK, Dhariwal S, Gleed AD, Mishra D, Thiruvengadam R, Chandramohan V, Craik R, Wilden E, Khurana A, Bhatnagar S, Papageorghiou AT, Noble JA. Developing Clinical Artificial Intelligence for Obstetric Ultrasound to Improve Access in Underserved Regions: Protocol for a Computer-Assisted Low-Cost Point-of-Care UltraSound (CALOPUS) Study. JMIR Res Protoc 2022; 11:e37374. [PMID: 36048518 PMCID: PMC9478819 DOI: 10.2196/37374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 06/12/2022] [Accepted: 06/21/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The World Health Organization recommends a package of pregnancy care that includes obstetric ultrasound scans. There are significant barriers to universal access to antenatal ultrasound, particularly because of the cost and need for maintenance of ultrasound equipment and a lack of trained personnel. As low-cost, handheld ultrasound devices have become widely available, the current roadblock is the global shortage of health care providers trained in obstetric scanning. OBJECTIVE The aim of this study is to improve pregnancy and risk assessment for women in underserved regions. Therefore, we are undertaking the Computer-Assisted Low-Cost Point-of-Care UltraSound (CALOPUS) project, bringing together experts in machine learning and clinical obstetric ultrasound. METHODS In this prospective study conducted in two clinical centers (United Kingdom and India), participating pregnant women were scanned and full-length ultrasounds were performed. Each woman underwent 2 consecutive ultrasound scans. The first was a series of simple, standardized ultrasound sweeps (the CALOPUS protocol), immediately followed by a routine, full clinical ultrasound examination that served as the comparator. We describe the development of a simple-to-use clinical protocol designed for nonexpert users to assess fetal viability, detect the presence of multiple pregnancies, evaluate placental location, assess amniotic fluid volume, determine fetal presentation, and perform basic fetal biometry. The CALOPUS protocol was designed using the smallest number of steps to minimize redundant information, while maximizing diagnostic information. Here, we describe how ultrasound videos and annotations are captured for machine learning. RESULTS Over 5571 scans have been acquired, from which 1,541,751 label annotations have been performed. An adapted protocol, including a low pelvic brim sweep and a well-filled maternal bladder, improved visualization of the cervix from 28% to 91% and classification of placental location from 82% to 94%. Excellent levels of intra- and interannotator agreement are achievable following training and standardization. CONCLUSIONS The CALOPUS study is a unique study that uses obstetric ultrasound videos and annotations from pregnancies dated from 11 weeks and followed up until birth using novel ultrasound and annotation protocols. The data from this study are being used to develop and test several different machine learning algorithms to address key clinical diagnostic questions pertaining to obstetric risk management. We also highlight some of the challenges and potential solutions to interdisciplinary multinational imaging collaboration. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR1-10.2196/37374.
Collapse
Affiliation(s)
- Alice Self
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Qingchao Chen
- Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
| | | | - Sumeet Dhariwal
- Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
| | - Alexander D Gleed
- Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
| | - Divyanshu Mishra
- Translational Health Science and Technology Institute, Faridabad, India
| | | | | | - Rachel Craik
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Elizabeth Wilden
- Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
| | | | | | - Aris T Papageorghiou
- Nuffield Department of Women's and Reproductive Health, University of Oxford, Oxford, United Kingdom
- Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, United Kingdom
| | - J Alison Noble
- Institute of Biomedical Engineering, University of Oxford, Oxford, United Kingdom
| |
Collapse
|
14
|
Abawollo HS, Tsegaye ZT, Desta BF, Beshir IA, Mengesha BT, Guteta AA, Heyi AF, Mamo TT, Gebremedhin ZK, Damte HD, Zelealem M, Argaw MD. Contribution of portable obstetric ultrasound service innovation in averting maternal and neonatal morbidities and mortalities at semi-urban health centers of Ethiopia: a retrospective facility-based study. BMC Pregnancy Childbirth 2022; 22:368. [PMID: 35484533 PMCID: PMC9052561 DOI: 10.1186/s12884-022-04703-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 04/20/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The maternal and neonatal mortalities in Ethiopia are high. To achieve the Sustainable Development Goals, innovations in ultrasound scanning and surveillance activities have been implemented at health centers for over 2 years. This study aims to estimate the contribution of obstetric ultrasound services on averted maternal and neonatal morbidities and mortalities in Ethiopia. METHODS A retrospective facility-based cross-sectional study design was conducted in 25 selected health centers. Data were extracted from prenatal ultrasound registers. SPSS version 25 was used for analysis. To claim statistically significant relationship among sartorial variables, a chi-square test was analyzed and P < 0.05 was the cut-off point. RESULTS Over the 2 years, 12,975 pregnant women were scanned and 52.8% of them were residing in rural areas. Abnormal ultrasound was reported in 12.7% and 98.4% of them were referred for confirmation of diagnosis and treatment. The ultrasound service has contributed to the prevention of 1,970 maternal and 19.05 neonatal morbidities and mortalities per 100,000 and 1,000 live births respectively. The averted morbidities and mortalities showed a statistically significant difference among women residing in rural and semi-urban areas, X,2 df (10) = 24.07, P = 0. 007 and X,2 df (5) = 20.87. P = 0.00, 1 respectively. CONCLUSION After availing the appropriate ultrasound machines with essential supplies and capacitating mid-level providers, significant number of high-risk pregnant women were identified on time and managed or referred to health facilities with safe delivery services. Therefore, scaling-up limited obstetric ultrasound services in similar setups will contribute to achieving the Sustainable Development Goals by 2030. It is recommended to enhance community awareness for improved utilization of ultrasound services by pregnant women before the 24th week of gestational age.
Collapse
Affiliation(s)
- Hailemariam Segni Abawollo
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia.
| | - Zergu Tafesse Tsegaye
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia
| | - Binyam Fekadu Desta
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia
| | - Ismael Ali Beshir
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia
| | - Birhan Tenaw Mengesha
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia
| | - Asfaw Adugna Guteta
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia
| | - Atrie Fekadu Heyi
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia
| | - Tsega Teferi Mamo
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia
| | - Zenawork Kassa Gebremedhin
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia
| | - Heran Demissie Damte
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia
| | - Meseret Zelealem
- Ministry of Health, Maternal and Child Health Directorate, Addis Ababa, Ethiopia
| | - Mesele Damte Argaw
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute Inc, Addis Ababa, Ethiopia
| |
Collapse
|
15
|
Aderoba AK, Nasir N, Quigley M, Impey L, Rivero-Arias O, Kurinczuk JJ. Late pregnancy ultrasound parameters identifying fetuses at risk of adverse perinatal outcomes: a protocol for a systematic review of systematic reviews. BMJ Open 2022; 12:e058293. [PMID: 35321896 PMCID: PMC8943771 DOI: 10.1136/bmjopen-2021-058293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Stillbirths and neonatal deaths are leading contributors to the global burden of disease and pregnancy ultrasound has the potential to help decrease this burden. In the absence of high-Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence on universal obstetric ultrasound screening at or close to term, many different screening strategies have been proposed. Systematic reviews have rapidly increased over the past decade owing to the diverse nature of ultrasound parameters and the wide range of possible adverse perinatal outcomes. This systematic review will summarise the evidence on key ultrasound parameters in the published literature to help develop an obstetric ultrasound protocol that identifies pregnancies at risk of adverse perinatal outcomes at or close to term. METHODS This study will follow the recent Cochrane guidelines for a systematic review of systematic reviews. A comprehensive literature search will be conducted using Embase (OvidSP), Medline (OvidSP), CDSR, CINAHL (EBSCOhost) and Scopus. Systematic reviews evaluating at least one ultrasound parameter in late pregnancy to detect pregnancies at risk of adverse perinatal outcomes will be included. Two independent reviewers will screen, assess the quality including the risk of bias using the ROBIS tool, and extract data from eligible systematic reviews that meet the study inclusion criteria. Overlapping data will be assessed and managed with decision rules, and study evidence including the GRADE assessment of the certainty of results will be presented as a narrative synthesis as described in the Cochrane guidelines for an overview of reviews. ETHICS AND DISSEMINATION This research uses publicly available published data; thus, an ethics committee review is not required. The findings will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42021266108.
Collapse
Affiliation(s)
- Adeniyi Kolade Aderoba
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
- Centre for Population Health and Interdisciplinary Research, HealthMATE 360, Ondo, Nigeria
| | - Naima Nasir
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Univerity of Oxford, Oxford, UK
| | - Maria Quigley
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Lawrence Impey
- Department of Fetal Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Oliver Rivero-Arias
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Jennifer J Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
| |
Collapse
|
16
|
Argaw MD, Abawollo HS, Tsegaye ZT, Beshir IA, Damte HD, Mengesha BT, Gebremedhin ZK, Heyi AF, Guteta AA, Mamo TT, Anara AA, Emiru ZY, Yadeta FS, Wami AB, Kibret MA, Desta BF. Experiences of midwives on Vscan limited obstetric ultrasound use: a qualitative exploratory study. BMC Pregnancy Childbirth 2022; 22:196. [PMID: 35272631 PMCID: PMC8915526 DOI: 10.1186/s12884-022-04523-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/28/2022] [Indexed: 12/04/2022] Open
Abstract
Background Ethiopia is a low-income country located in the horn of Africa’s sub-Saharan region, with very high incidences of maternal and neonatal mortality. Quality antenatal care improves perinatal health outcomes. The USAID funded Transform: Primary Health Care Activity in collaboration with the Ministry of Health and GE Healthcare introduced Vscan limited obstetric ultrasound services in 120 health centers in Ethiopia. So far, the experiences and opinions of midwives on their use have not been explored and described within the local context. This study therefore aims to explore and describe the experiences and opinions of midwives on Vscan limited obstetric ultrasound services at health centers within Ethiopia. Methods An exploratory and descriptive qualitative study was conducted in Amhara, Oromia, and Southern Nations, Nationalities and Peoples’ (SNNP) regions of Ethiopia. Twenty-four participants were selected through a purposeful sampling technique. In-depth individual interviews with trained midwives with practical hands-on limited obstetric ultrasound service provision experience were conducted. The thematic analysis was conducted manually. Results The qualitative data analysis on the experiences and opinions of midwives revealed three themes, namely: individual perception of self-efficacy, facilitators, and barriers of limited obstetric ultrasound services. The basic ultrasound training, which was unique in its organization and arrangement, prepared and built the self-efficacy of trainees in executing their expected competencies. Support of health systems and health managers in dedicating space, availing essential supplies, and assigning human resources emerged as facilitators of the initiated limited obstetric ultrasound services, whereas high workload on one or two ultrasound trained midwives, interruption of essential supplies like paper towels, gel, and alternative power sources were identified as barriers for limited ultrasound services. Conclusion This study explored the experiences and opinions of midwives who were trained on the provision of limited obstetric ultrasound services and served the community in health centers in rural parts of Ethiopia. The results of this study revealed the positive impacts of the intervention on the perceived self-efficacy, facilitation, and breaking-down of barriers to obstetric ultrasound services. Before scaling-up limited obstetric ultrasound interventions, health managers should ensure and commit to availing essential supplies (e.g., paper towels, ultrasound gel, and large memory hard discs), arranging private rooms, and training other mid-level health professionals. In addition, improving pregnant women’s literacy on the national schedule for ultrasound scanning services is recommended. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-022-04523-3.
Collapse
Affiliation(s)
- Mesele Damte Argaw
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia.
| | - Hailemariam Segni Abawollo
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Zergu Taffesse Tsegaye
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Ismael Ali Beshir
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Heran Demissie Damte
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Birhan Tenaw Mengesha
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Zenawork Kassa Gebremedhin
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Atrie Fekadu Heyi
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Asfaw Adugna Guteta
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Tsega Teferi Mamo
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Amare Assefa Anara
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Zelalem Yilma Emiru
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Feyisa Serbessa Yadeta
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| | - Almaz Bekele Wami
- USAID Transform: Primary Health Care Activity, Pathfinder International, Addis Ababa, Ethiopia
| | - Mengistu Asnake Kibret
- USAID Transform: Primary Health Care Activity, Pathfinder International, Addis Ababa, Ethiopia
| | - Binyam Fekadu Desta
- USAID Transform: Primary Health Care Activity, JSI Research & Training Institute, Inc. in Ethiopia, P.O. Box 1392 code 1110, Addis Ababa, Ethiopia
| |
Collapse
|
17
|
Pinto L, Clode N, Ayres‐de‐Campos D. Use of external cephalic version in Portuguese public hospitals. Int J Gynaecol Obstet 2022; 159:398-403. [DOI: 10.1002/ijgo.14114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/01/2022] [Accepted: 01/12/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Luísa Pinto
- Department of Obstetrics, Gynecology and Reproductive Medicine Santa Maria University Hospital Lisbon Portugal
- Medical School University of Lisbon Portugal
| | - Nuno Clode
- Department of Obstetrics and Gynecology, Hospital CUF Torres Vedras Portugal
| | - Diogo Ayres‐de‐Campos
- Department of Obstetrics, Gynecology and Reproductive Medicine Santa Maria University Hospital Lisbon Portugal
- Medical School University of Lisbon Portugal
| |
Collapse
|
18
|
Guy GP, Leslie K, Diaz Gomez D, Forenc K, Buck E, Bhide A, Thilaganathan B. Effect of routine first-trimester combined screening for pre-eclampsia on small-for-gestational-age birth: secondary interrupted time series analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:55-60. [PMID: 34319638 DOI: 10.1002/uog.23741] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/16/2021] [Accepted: 07/16/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To evaluate the impact of a first-trimester combined screening program for pre-eclampsia, based on the Fetal Medicine Foundation (FMF) algorithm, on the rate of small-for-gestational age (SGA) at birth and adverse pregnancy outcome. METHODS This was a retrospective cohort study of data obtained from a London tertiary hospital between January 2017 and March 2019. The data were derived from a secondary analysis of the cohort evaluated in a clinical-effectiveness study on the implementation of a first-trimester screening program for pre-eclampsia. The cohort included 7720 women screened according to the UK National Institute for Health and Care Excellence (NICE) risk-based approach and 4841 women screened by the FMF multimodal approach, which combines maternal risk factors, blood pressure, pregnancy-associated plasma protein-A and uterine artery Doppler indices. The care package for the FMF-screened group included 150-mg aspirin prophylaxis, ultrasound scans at 28 and 36 weeks' gestation and scheduled delivery at 40 weeks. Outcome measures included the rates of SGA neonates at birth, admission to the neonatal unit, intrauterine demise, neonatal death and hypoxic-ischemic encephalopathy assessed by interrupted time series analysis (ITSA). RESULTS There was no significant difference in the rates of intrauterine demise, neonatal death and hypoxic-ischemic encephalopathy between the FMF-screened and NICE-screened cohorts. ITSA showed a significant reduction in the rate of term SGA birth < 10th percentile at 21 months following implementation of the FMF screening program, with a relative effect reduction of 45.1% (P = 0.004). However, there was no significant relative effect reduction in term SGA birth < 5th or < 3rd percentile. CONCLUSIONS First-trimester combined screening for pre-eclampsia based on the FMF algorithm accompanied by a care package including serial ultrasound scans for growth evaluation and elective birth from 40 weeks' gestation resulted in a significant 45% relative effect reduction in term SGA birth < 10th percentile but did not affect term SGA birth < 5th or < 3rd percentile. Further screening strategies to detect and improve the outcome of cases with SGA birth < 5th percentile need to be considered. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- G P Guy
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - K Leslie
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Department of Obstetrics and Gynaecology, Ashford and St Peter's NHS Foundation Trust, Lyne, Chertsey, UK
| | - D Diaz Gomez
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - K Forenc
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - E Buck
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - A Bhide
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Tommy's National Centre for Maternity Improvement, Royal College of Obstetricians and Gynaecologists, London, UK
| |
Collapse
|
19
|
Hamidzadeh A, Tavakol Z, Maleki M, Kolahdozan S, Khosravi A, Kiani M, Vaismoradi M. Effect of acupressure at the BL67 spot on the spontaneous rotation of fetus with breech presentation: A randomized controlled trial. Explore (NY) 2021; 18:567-572. [PMID: 34764014 DOI: 10.1016/j.explore.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 10/02/2021] [Accepted: 10/16/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Breech is a common fetal presentation in preterm pregnancies. This study aimed to investigate the effect of acupressure at the BL67 point on the spontaneous rotation of fetus with breech presentation. METHODS An unblind, two-armed randomized controlled trial was carried out from September 2017 to April 2020. Research participants were 138 pregnant women at 32 to 35 weeks of gestational age that had fetal breech presentation confirmed by ultrasound. They were randomly assigned into intervention and control groups (n=69 in each group). The intervention group received acupressure at the BL67 point on both feet for 10 minutes daily and for two consecutive weeks. The control group received routine care. Demographic and midwifery data questionnaires were used for data collection. RESULTS The spontaneous rotation of fetus with breech presentation into cephalic was observed in the majority of participants in the intervention group (82.6%) compared to the control group (17.4%) (p<0.001). Statistically significant differences in the fetal presentation at delivery was observed between the groups (84.1% cephalic vs. 18.8% breech, p<0.001). Regarding the type of delivery, cesarean section was reported mostly (85.5%) in the control group compared to the intervention group (21.7%) (p<0.001). However, the first- and fifth-minute Apgar scores of newborns had no statistically significant differences between the groups (p=0.773). CONCLUSION It is suggested to incorporate acupressure at the BL67 point into the care process for pregnant women to help with the reduction of the rate of cesarean section and avoid its related complications.
Collapse
Affiliation(s)
- Azam Hamidzadeh
- Student Research Committee, School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran.
| | - Zeinab Tavakol
- Community-Oriented Nursing Midwifery Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran.
| | - Maryam Maleki
- Pediatric and Neonatal Intensive Care Nursing Education Department, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Iran.
| | - Sakineh Kolahdozan
- Sexual Health and Fertility Research Center, Shahroud University of Medical Sciences, Shahroud, Iran.
| | - Ahmad Khosravi
- Center for Health related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran.
| | - Mahdieh Kiani
- School of Nursing and Midwifery, Shahroud University of Medical Sciences, Shahroud, Iran.
| | | |
Collapse
|
20
|
Stephens K, Moraitis A, Smith GCS. Routine Third Trimester Sonogram: Friend or Foe. Obstet Gynecol Clin North Am 2021; 48:359-369. [PMID: 33972071 DOI: 10.1016/j.ogc.2021.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Several risk factors for adverse pregnancy outcomes can be identified by a routine third trimester ultrasound scan. However, there is also potential for harm, anxiety, and additional health care costs through unnecessary intervention due to false positive results. The evidence base informing the balance of risks and benefits of universal screening is inadequate to fully inform decision making. However, data on the diagnostic effectiveness of universal ultrasound suggest that better methods are required to result in net benefit, with the exception of screening for presentation near term, where a clinical and economic case can be made for its implementation.
Collapse
Affiliation(s)
- Katie Stephens
- Department of Obstetrics and Gynaecology, University of Cambridge, Box 223, The Rosie Hospital, Robinson Way, Cambridge CB2 0SW, United Kingdom
| | - Alexandros Moraitis
- Department of Obstetrics and Gynaecology, University of Cambridge, Box 223, The Rosie Hospital, Robinson Way, Cambridge CB2 0SW, United Kingdom
| | - Gordon C S Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, Box 223, The Rosie Hospital, Robinson Way, Cambridge CB2 0SW, United Kingdom.
| |
Collapse
|
21
|
Wilson ECF, Wastlund D, Moraitis AA, Smith GCS. Late Pregnancy Ultrasound to Screen for and Manage Potential Birth Complications in Nulliparous Women: A Cost-Effectiveness and Value of Information Analysis. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:513-521. [PMID: 33840429 DOI: 10.1016/j.jval.2020.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 11/03/2020] [Accepted: 11/03/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Fetal growth restriction is a major risk factor for stillbirth. A routine late-pregnancy ultrasound scan could help detect this, allowing intervention to reduce the risk of stillbirth. Such a scan could also detect fetal presentation and predict macrosomia. A trial powered to detect stillbirth differences would be extremely large and expensive. OBJECTIVES It is therefore critical to know whether this would be a good investment of public research funds. The aim of this study is to estimate the cost-effectiveness of various late-pregnancy screening and management strategies based on current information and predict the return on investment from further research. METHODS Synthesis of current evidence structured into a decision model reporting expected costs, quality-adjusted life-years, and net benefit over 20 years and value-of-information analysis reporting predicted return on investment from future clinical trials. RESULTS Given a willingness to pay of £20 000 per quality-adjusted life-year gained, the most cost-effective strategy is a routine presentation-only scan for all women. Universal ultrasound screening for fetal size is unlikely to be cost-effective. Research exploring the cost implications of induction of labor has the greatest predicted return on investment. A randomized, controlled trial with an endpoint of stillbirth is extremely unlikely to be a value for money investment. CONCLUSION Given current value-for-money thresholds in the United Kingdom, the most cost-effective strategy is to offer all pregnant women a presentation-only scan in late pregnancy. A randomized, controlled trial of screening and intervention to reduce the risk of stillbirth following universal ultrasound to detect macrosomia or fetal growth restriction is unlikely to represent a value for money investment.
Collapse
Affiliation(s)
- Edward C F Wilson
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK; The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.
| | - David Wastlund
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK; Parexel Access Consulting, Parexel International, Stockholm, Sweden
| | - Alexandros A Moraitis
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| | - Gordon C S Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, NIHR Cambridge Biomedical Research Centre, Cambridge, UK
| |
Collapse
|
22
|
Smith GC, Moraitis AA, Wastlund D, Thornton JG, Papageorghiou A, Sanders J, Heazell AE, Robson SC, Sovio U, Brocklehurst P, Wilson EC. Universal late pregnancy ultrasound screening to predict adverse outcomes in nulliparous women: a systematic review and cost-effectiveness analysis. Health Technol Assess 2021; 25:1-190. [PMID: 33656977 PMCID: PMC7958245 DOI: 10.3310/hta25150] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Currently, pregnant women are screened using ultrasound to perform gestational aging, typically at around 12 weeks' gestation, and around the middle of pregnancy. Ultrasound scans thereafter are performed for clinical indications only. OBJECTIVES We sought to assess the case for offering universal late pregnancy ultrasound to all nulliparous women in the UK. The main questions addressed were the diagnostic effectiveness of universal late pregnancy ultrasound to predict adverse outcomes and the cost-effectiveness of either implementing universal ultrasound or conducting further research in this area. DESIGN We performed diagnostic test accuracy reviews of five ultrasonic measurements in late pregnancy. We conducted cost-effectiveness and value-of-information analyses of screening for fetal presentation, screening for small for gestational age fetuses and screening for large for gestational age fetuses. Finally, we conducted a survey and a focus group to determine the willingness of women to participate in a future randomised controlled trial. DATA SOURCES We searched MEDLINE, EMBASE and the Cochrane Library from inception to June 2019. REVIEW METHODS The protocol for the review was designed a priori and registered. Eligible studies were identified using keywords, with no restrictions for language or location. The risk of bias in studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool. Health economic modelling employed a decision tree analysed via Monte Carlo simulation. Health outcomes were from the fetal perspective and presented as quality-adjusted life-years. Costs were from the perspective of the public sector, defined as NHS England, and the costs of special educational needs. All costs and quality-adjusted life-years were discounted by 3.5% per annum and the reference case time horizon was 20 years. RESULTS Umbilical artery Doppler flow velocimetry, cerebroplacental ratio, severe oligohydramnios and borderline oligohydramnios were all either non-predictive or weakly predictive of the risk of neonatal morbidity (summary positive likelihood ratios between 1 and 2) and were all weakly predictive of the risk of delivering a small for gestational age infant (summary positive likelihood ratios between 2 and 4). Suspicion of fetal macrosomia is strongly predictive of the risk of delivering a large infant, but it is only weakly, albeit statistically significantly, predictive of the risk of shoulder dystocia. Very few studies blinded the result of the ultrasound scan and most studies were rated as being at a high risk of bias as a result of treatment paradox, ascertainment bias or iatrogenic harm. Health economic analysis indicated that universal ultrasound for fetal presentation only may be both clinically and economically justified on the basis of existing evidence. Universal ultrasound including fetal biometry was of borderline cost-effectiveness and was sensitive to assumptions. Value-of-information analysis indicated that the parameter that had the largest impact on decision uncertainty was the net difference in cost between an induced delivery and expectant management. LIMITATIONS The primary literature on the diagnostic effectiveness of ultrasound in late pregnancy is weak. Value-of-information analysis may have underestimated the uncertainty in the literature as it was focused on the internal validity of parameters, which is quantified, whereas the greatest uncertainty may be in the external validity to the research question, which is unquantified. CONCLUSIONS Universal screening for presentation at term may be justified on the basis of current knowledge. The current literature does not support universal ultrasonic screening for fetal growth disorders. FUTURE WORK We describe proof-of-principle randomised controlled trials that could better inform the case for screening using ultrasound in late pregnancy. STUDY REGISTRATION This study is registered as PROSPERO CRD42017064093. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 15. See the NIHR Journals Library website for further project information.
Collapse
Affiliation(s)
- Gordon Cs Smith
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Alexandros A Moraitis
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - David Wastlund
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Jim G Thornton
- Division of Child Health, Obstetrics and Gynaecology, School of Medicine, University of Nottingham, Nottingham, UK
| | - Aris Papageorghiou
- Nuffield Department of Obstetrics and Gynaecology, University of Oxford, Oxford, UK
| | - Julia Sanders
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Alexander Ep Heazell
- Faculty of Biology, Medicine and Health, School of Medical Sciences, University of Manchester, Manchester, UK
| | - Stephen C Robson
- Reproductive and Vascular Biology Group, The Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Ulla Sovio
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, University of Birmingham, Birmingham, UK
| | - Edward Cf Wilson
- The Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
- Health Economics Group, Norwich Medical School, University of East Anglia, Norwich, UK
| |
Collapse
|
23
|
Salim I, Staines-Urias E, Mathewlynn S, Drukker L, Vatish M, Impey L. The impact of a routine late third trimester growth scan on the incidence, diagnosis, and management of breech presentation in Oxfordshire, UK: A cohort study. PLoS Med 2021; 18:e1003503. [PMID: 33449926 PMCID: PMC7810318 DOI: 10.1371/journal.pmed.1003503] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Accepted: 12/16/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Breech presentation at term contributes significantly to cesarean section (CS) rates worldwide. External cephalic version (ECV) is a safe procedure that reduces term breech presentation and associated CS. A principal barrier to ECV is failure to diagnose breech presentation. Failure to diagnose breech presentation also leads to emergency CS or unplanned vaginal breech birth. Recent evidence suggests that undiagnosed breech might be eliminated using a third trimester scan. Our aim was to evaluate the impact of introducing a routine 36-week scan on the incidence of breech presentation and of undiagnosed breech presentation. METHODS AND FINDINGS We carried out a population-based cohort study of pregnant women in a single unit covering Oxfordshire, United Kingdom. All women delivering between 37+0 and 42+6 weeks gestational age, with a singleton, nonanomalous fetus over a 4-year period (01 October 2014 to 30 September 2018) were included. The mean maternal age was 31 years, mean BMI 26, 44% were nulliparous, and 21% were of non-white ethnicity. Comparisons between the 2 years before and after introduction of routine 36-week scan were made for 2 primary outcomes of (1) the incidence of breech presentation and (2) undiagnosed breech presentation. Secondary outcomes related to ECV, mode of birth, and perinatal outcomes. Relative risks (RRs) with 95% confidence intervals (CIs) are reported. A total of 27,825 pregnancies were analysed (14,444 before and 13,381 after). A scan after 35+0 weeks was performed in 5,578 (38.6%) before, and 13,251 (99.0%) after (p < 0.001). The incidence of breech presentation at birth did not change significantly (2.6% and 2.7%) (RR 1.02; 95% CI 0.89, 1.18; p = 0.76). The rate of undiagnosed breech before labour reduced, from 22.3% to 4.7% (RR 0.21; 95% CI 0.12, 0.36; p < 0.001). Vaginal breech birth rates fell from 10.3% to 5.3% (RR 0.51; 95% CI 0.30, 0.87; p = 0.01); nonsignificant increases in elective CS rates and decreases in emergency CS rates for breech babies were seen. Neonatal outcomes were not significantly altered. Study limitations include insufficient numbers to detect serious adverse outcomes, that we cannot exclude secular changes over time which may have influenced our results, and that these findings are most applicable where a comprehensive ECV service exists. CONCLUSIONS In this study, a universal 36-week scan policy was associated with a reduction in the incidence but not elimination of undiagnosed term breech presentation. There was no reduction in the incidence of breech presentation at birth, despite a comprehensive ECV service.
Collapse
Affiliation(s)
- Ibtisam Salim
- Nuffield Department of Women’s Reproductive Health, John Radcliffe Hospital, Oxford University, Oxford, United Kingdom
- Oxford Fetal Medicine Unit, John Radcliffe Hospital, Headley Way, Oxford, United Kingdom
- * E-mail:
| | - Eleonora Staines-Urias
- Nuffield Department of Women’s Reproductive Health, John Radcliffe Hospital, Oxford University, Oxford, United Kingdom
| | - Sam Mathewlynn
- Oxford Fetal Medicine Unit, John Radcliffe Hospital, Headley Way, Oxford, United Kingdom
| | - Lior Drukker
- Nuffield Department of Women’s Reproductive Health, John Radcliffe Hospital, Oxford University, Oxford, United Kingdom
| | - Manu Vatish
- Nuffield Department of Women’s Reproductive Health, John Radcliffe Hospital, Oxford University, Oxford, United Kingdom
| | - Lawrence Impey
- Oxford Fetal Medicine Unit, John Radcliffe Hospital, Headley Way, Oxford, United Kingdom
| |
Collapse
|
24
|
Kennedy LM, Tong S, Robinson AJ, Hiscock RJ, Hui L, Dane KM, Middleton AL, Walker SP, MacDonald TM. Reduced growth velocity from the mid-trimester is associated with placental insufficiency in fetuses born at a normal birthweight. BMC Med 2020; 18:395. [PMID: 33357243 PMCID: PMC7758928 DOI: 10.1186/s12916-020-01869-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 11/24/2020] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Fetal growth restriction (FGR) due to placental insufficiency is a major risk factor for stillbirth. While small-for-gestational-age (SGA; weight < 10th centile) is a commonly used proxy for FGR, detection of FGR among appropriate-for-gestational-age (AGA; weight ≥ 10th centile) fetuses remains an unmet need in clinical care. We aimed to determine whether reduced antenatal growth velocity from the time of routine mid-trimester ultrasound is associated with antenatal, intrapartum and postnatal indicators of placental insufficiency among term AGA infants. METHODS Three hundred and five women had biometry measurements recorded from their routine mid-trimester (20-week) ultrasound, at 28 and 36 weeks' gestation, and delivered an AGA infant. Mid-trimester, 28- and 36-week estimated fetal weight (EFW) and abdominal circumference (AC) centiles were calculated. The EFW and AC growth velocities between 20 and 28 weeks, and 20-36 weeks, were examined as predictors of four clinical indicators of placental insufficiency: (i) low 36-week cerebroplacental ratio (CPR; CPR < 5th centile reflects cerebral redistribution-a fetal adaptation to hypoxia), (ii) neonatal acidosis (umbilical artery pH < 7.15) after the hypoxic challenge of labour, (iii) low neonatal body fat percentage (BF%) reflecting reduced nutritional reserve and (iv) placental weight < 10th centile. RESULTS Declining 20-36-week fetal growth velocity was associated with all indicators of placental insufficiency. Each one centile reduction in EFW between 20 and 36 weeks increased the odds of cerebral redistribution by 2.5% (odds ratio (OR) = 1.025, P = 0.001), the odds of neonatal acidosis by 2.7% (OR = 1.027, P = 0.002) and the odds of a < 10th centile placenta by 3.0% (OR = 1.030, P < 0.0001). Each one centile reduction in AC between 20 and 36 weeks increased the odds of neonatal acidosis by 3.1% (OR = 1.031, P = 0.0005), the odds of low neonatal BF% by 2.8% (OR = 1.028, P = 0.04) and the odds of placenta < 10th centile by 2.1% (OR = 1.021, P = 0.0004). Falls in EFW or AC of > 30 centiles between 20 and 36 weeks were associated with two-threefold increased relative risks of these indicators of placental insufficiency, while low 20-28-week growth velocities were not. CONCLUSIONS Reduced growth velocity between 20 and 36 weeks among AGA fetuses is associated with antenatal, intrapartum and postnatal indicators of placental insufficiency. These fetuses potentially represent an important, under-recognised cohort at increased risk of stillbirth. Encouragingly, this novel fetal assessment would require only one additional ultrasound to current routine care, and adds to the potential benefits of routine 36-week ultrasound.
Collapse
Affiliation(s)
- Lucy M Kennedy
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Stephen Tong
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Alice J Robinson
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Richard J Hiscock
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia
| | - Lisa Hui
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Kirsten M Dane
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Anna L Middleton
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Susan P Walker
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia.,Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia
| | - Teresa M MacDonald
- Department of Obstetrics and Gynaecology, University of Melbourne, Mercy Hospital for Women, 163 Studley Road, Heidelberg, VIC, 3084, Australia. .,Mercy Perinatal, Mercy Hospital for Women, Melbourne, VIC, Australia.
| |
Collapse
|
25
|
Drukker L, Cavallaro A, Salim I, Ioannou C, Impey L, Papageorghiou AT. How often do we incidentally find a fetal abnormality at the routine third-trimester growth scan? A population-based study. Am J Obstet Gynecol 2020; 223:919.e1-919.e13. [PMID: 32504567 DOI: 10.1016/j.ajog.2020.05.052] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/08/2020] [Accepted: 05/28/2020] [Indexed: 12/26/2022]
Abstract
BACKGROUND Third-trimester scans are increasingly used to try to prevent adverse outcomes associated with abnormalities of fetal growth. Unexpected fetal malformations detected at third-trimester growth scans are rarely reported. OBJECTIVE To determine the incidence and type of fetal malformations detected in women attending a routine third-trimester growth scan. STUDY DESIGN This was a population-based study of all women with singleton pregnancy attending antenatal care over a 2-year period in Oxfordshire, UK. Women who had a viable singleton pregnancy at dating scan were included. Women had standard obstetrical care including the offer of a routine dating scan and combined screening for trisomies; a routine anomaly scan at 18 to 22 weeks; and a routine third-trimester growth scan at 36 weeks. The third-trimester scan comprises assessment of fetal presentation, amniotic fluid, biometry, umbilical and middle cerebral artery Dopplers, but no formal anatomic assessment is undertaken. Scans are performed by certified sonographers or clinical fellows (n=54), and any suspected abnormalities are evaluated by a team of fetal medicine specialists. We assessed the frequency and type of incidental congenital malformations identified for the first time at this third-trimester scan. All babies were followed-up after birth for a minimum of 6 months. RESULTS There were 15,244 women attending routine antenatal care. Anomalies were detected in 474 (3.1%) fetuses as follows: 103 (21.7%) were detected before the anomaly scan, 174 (36.7%) at the anomaly scan, 11 (2.3%) after the anomaly scan and before the third-trimester scan, 43 (9.1%) at the third-trimester scan and 143 (30.2%) after birth. The 43 abnormalities were found in a total of 13,023 women who had a 36 weeks scan, suggesting that in 1 out of 303 (95% confidence interval, 233-432) women attending such a scan, a new malformation was detected. Anomalies detected at the routine third-trimester scan were of the urinary tract (n=30), central nervous system (5), simple ovarian cysts (4), chromosomal (1), splenic cyst (1), skeletal dysplasia (1), and cutaneous lymphangioma (1). Most urinary tract anomalies were renal pelvic dilatation, which showed spontaneous resolution in 57% of the cases. CONCLUSION When undertaking a program of routine third-trimester growth scans in women who have had previous screening scans, an unexpected congenital malformation is detected in approximately 1 in 300 women.
Collapse
|
26
|
Relph S, Delaney L, Melaugh A, Vieira MC, Sandall J, Khalil A, Pasupathy D, Healey A. Costing the impact of interventions during pregnancy in the UK: a systematic review of economic evaluations. BMJ Open 2020; 10:e040022. [PMID: 33127635 PMCID: PMC7604861 DOI: 10.1136/bmjopen-2020-040022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The aim of this review was to summarise the current evidence on the costing of resource use within UK maternity care, in order to facilitate the estimation of incremental resource and cost impacts potentially attributable to maternity care interventions. METHODS A systematic review of economic evaluations was conducted by searching Medline, the Health Management Information Consortium, the National Health Service (NHS) Economic Evaluations Database, CINAHL and National Institute for Health and Care Excellence (NICE) guidelines for economic evaluations within UK maternity care, published between January 2010 and August 2019 in the English language. Unit costs for healthcare activities provided to women within the antenatal, intrapartum and postnatal period were inflated to 2018-2019 prices. Assessment of study quality was performed using the Quality of Health Economic Analyses checklist. RESULTS Of 5084 titles or full texts screened, 37 papers were included in the final review (27 primary research articles, 7 review articles and 3 economic evaluations from NICE guidelines). Of the 27 primary research articles, 21 were scored as high quality, 3 as medium quality and 3 were low quality. Variation was noted in cost estimates for healthcare activities throughout the maternity care pathway: for midwife-led outpatient appointment, the range was £27.34-£146.25 (mean £81.78), emergency caesarean section, range was £1056.44-£4982.21 (mean £3508.93) and postnatal admission, range was £103.00-£870.10 per day (mean £469.55). CONCLUSIONS Wide variation exists in costs applied to maternity healthcare activities, resulting in challenges in attributing cost to maternity activities. The level of variation in cost calculations is likely to reflect the uncertainty within the system and must be dealt with by conducting sensitivity analyses. Nationally agreed prices for granular unit costs are needed to standardise cost-effectiveness evaluations of new interventions within maternity care, to be used either for research purposes or decisions regarding national intervention uptake. PROSPERO REGISTRATION NUMBER CRD42019145309.
Collapse
Affiliation(s)
- Sophie Relph
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, London, UK
| | - Louisa Delaney
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, London, UK
| | - Alexandra Melaugh
- Health Improvement: Alcohol, Drugs, Tobacco and Justice Division, Public Health England, London, UK
| | - Matias C Vieira
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, London, UK
- Department of Obstetrics and Gynaecology, School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul, Porto Alegre, Brazil
| | - Jane Sandall
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, London, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
- Molecular & Clinical Sciences Research Institute, St George's, University of London, Cranmer Terrace, London, UK
| | - Dharmintra Pasupathy
- Department of Women and Children's Health, King's College London, St Thomas' Hospital, London, UK
- Discipline of Obstetrics, Gynaecology & Neonatology, Westmead Clinical School, Faculty of Medicineand Health, University of Sydney, Sydney, New South Wales, Australia
| | - Andy Healey
- Health Service and Population Research, King's College London, De Crespigny Park, London, UK
| |
Collapse
|
27
|
Drukker L, Bradburn E, Rodriguez GB, Roberts NW, Impey L, Papageorghiou AT. How often do we identify fetal abnormalities during routine third-trimester ultrasound? A systematic review and meta-analysis. BJOG 2020; 128:259-269. [PMID: 32790134 DOI: 10.1111/1471-0528.16468] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Routine third-trimester ultrasound is frequently offered to pregnant women to identify fetuses with abnormal growth. Infrequently, a congenital anomaly is incidentally detected. OBJECTIVE To establish the prevalence and type of fetal anomalies detected during routine third-trimester scans using a systematic review and meta-analysis. SEARCH STRATEGY Electronic databases (MEDLINE, Embase and the Cochrane library) from inception until August 2019. SELECTION CRITERIA Population-based studies (randomised control trials, prospective and retrospective cohorts) reporting abnormalities detected at the routine third-trimester ultrasound performed in unselected populations with prior screening. Case reports, case series, case-control studies and reviews without original data were excluded. DATA COLLECTION AND ANALYSIS Prevalence and type of anomalies detected in the third trimester. We calculated pooled prevalence as the number of anomalies per 1000 scans with 95% confidence intervals. Publication bias was assessed. MAIN RESULTS The literature search identified 9594 citations: 13 studies were eligible representing 141 717 women; 643 were diagnosed with an unexpected abnormality. The pooled prevalence of a new abnormality diagnosed was 3.68 per 1000 women scanned (95% CI 2.72-4.78). The largest groups of abnormalities were urogenital (55%), central nervous system abnormalities (18%) and cardiac abnormalities (14%). CONCLUSION Combining data from 13 studies and over 140 000 women, we show that during routine third-trimester ultrasound, an incidental fetal anomaly will be found in about 1 in 300 scanned women. This information should be taken into account when taking consent from women for third-trimester ultrasound and when designing and assessing cost of third-trimester ultrasound screening programmes. TWEETABLE ABSTRACT One in 300 women attending a third-trimester scan will have a finding of a fetal abnormality.
Collapse
Affiliation(s)
- L Drukker
- Nuffield Department of Women's & Reproductive Health, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Fetal Medicine Unit, Department of Maternal and Fetal Medicine, Women's Center, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - E Bradburn
- Nuffield Department of Women's & Reproductive Health, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - G B Rodriguez
- Nuffield Department of Women's & Reproductive Health, John Radcliffe Hospital, University of Oxford, Oxford, UK.,Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | - N W Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
| | - L Impey
- Fetal Medicine Unit, Department of Maternal and Fetal Medicine, Women's Center, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A T Papageorghiou
- Nuffield Department of Women's & Reproductive Health, John Radcliffe Hospital, University of Oxford, Oxford, UK
| |
Collapse
|
28
|
Smith G. A critical review of the Cochrane meta-analysis of routine late-pregnancy ultrasound. BJOG 2020; 128:207-213. [PMID: 32598533 DOI: 10.1111/1471-0528.16386] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/19/2020] [Indexed: 11/29/2022]
Abstract
A Cochrane review of universal late-pregnancy ultrasound has been highly influential in guiding UK practice, concluding that it does not improve outcome. However, the meta-analysis combines trials that used diverse definitions of screen positive, were designed in the absence of high-quality data on diagnostic effectiveness and did not couple screening to an effective intervention. Moreover, even if the trials had combined a highly effective screening test with a highly effective intervention, the sample size was 15% of that required to study perinatal death. It is not known whether universal late-pregnancy ultrasound confers benefit on the mother or baby. TWEETABLE ABSTRACT: Despite >50 years of research, we do not know whether universal late-pregnancy ultrasound confers benefit on the mother or baby.
Collapse
Affiliation(s)
- Gcs Smith
- Department of Obstetrics and Gynaecology, NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| |
Collapse
|
29
|
Carbillon L, Benbara A, Tigaizin A, Murtada R, Fermaut M, Belmaghni F, Bricou A, Boujenah J. Revisiting the management of term breech presentation: a proposal for overcoming some of the controversies. BMC Pregnancy Childbirth 2020; 20:263. [PMID: 32359354 PMCID: PMC7196223 DOI: 10.1186/s12884-020-2831-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 02/20/2020] [Indexed: 11/29/2022] Open
Abstract
Background The debate surrounding the management of term breech presentation has excessively focused on the mode of delivery. Indeed, a steady decline in the rate of vaginal breech delivery has been observed over the last three decades, and the soundness of the vaginal route was seriously challenged at the beginning of the 2000s. However, associations between adverse perinatal outcomes and antenatal risk factors have been observed in foetuses that remain in the breech presentation in late gestation, confirming older data and raising the question of the role of these antenatal risk factors in adverse perinatal outcomes. Thus, aspects beyond the mode of delivery must be considered regarding the awareness and adequate management of such situations in term breech pregnancies. Main body In the context of the most recent meta-analysis and with the publication of large-scale epidemiologic studies from medical birth registries in countries that have not abruptly altered their criteria for individual decision-making regarding the breech delivery mode, the currently available data provide essential clues to understanding the underlying maternal-foetal conditions beyond the delivery mode that play a role in perinatal outcomes, such as foetal growth restriction and gestational diabetes mellitus. In view of such data, an accurate evaluation of these underlying conditions is necessary in cases of persistent term breech presentation. Timely breech detection, estimated foetal weight/growth curves and foetal/maternal well-being should be considered along with these possible antenatal risk factors; a thorough analysis of foetal presentation and an evaluation of the possible benefit of external cephalic version and pelvic adequacy in each specific situation of persistent breech presentation should be performed. Conclusion The adequate management of term breech pregnancies requires screening and the efficient identification of breech presentation at 36 weeks of gestation, followed by thorough evaluations of foetal weight, growth and mobility, while obstetric history, antenatal gestational disorders and pelvis size/conformation are considered. The management plan, including external cephalic version and follow-up based on the maternal/foetal condition and potentially associated disorders, should be organized on a case-by-case basis by a skilled team after the woman is informed and helped to make a reasoned decision regarding delivery route.
Collapse
Affiliation(s)
- Lionel Carbillon
- Department of Obstetrics and Gynecology, Sorbonne Paris Nord University, Assistance Publique - Hopitaux de Paris, Avenue du 14 juillet, Hôpital Jean Verdier, 93140, Bondy Cedex, France. .,Department of Obstetrics and Gynecology, Assistance Publique - Hôpitaux de Paris, Hôpital Jean Verdier, Bondy, France.
| | - Amelie Benbara
- Department of Obstetrics and Gynecology, Assistance Publique - Hôpitaux de Paris, Hôpital Jean Verdier, Bondy, France
| | - Ahmed Tigaizin
- Department of Obstetrics and Gynecology, Assistance Publique - Hôpitaux de Paris, Hôpital Jean Verdier, Bondy, France
| | - Rouba Murtada
- Department of Obstetrics and Gynecology, Assistance Publique - Hôpitaux de Paris, Hôpital Jean Verdier, Bondy, France
| | - Marion Fermaut
- Department of Obstetrics and Gynecology, Assistance Publique - Hôpitaux de Paris, Hôpital Jean Verdier, Bondy, France
| | - Fatma Belmaghni
- Department of Obstetrics and Gynecology, Assistance Publique - Hôpitaux de Paris, Hôpital Jean Verdier, Bondy, France
| | - Alexandre Bricou
- Department of Obstetrics and Gynecology, Assistance Publique - Hôpitaux de Paris, Hôpital Jean Verdier, Bondy, France
| | - Jeremy Boujenah
- Department of Obstetrics and Gynecology, Assistance Publique - Hôpitaux de Paris, Hôpital Jean Verdier, Bondy, France
| |
Collapse
|
30
|
De Castro H, Ciobanu A, Formuso C, Akolekar R, Nicolaides KH. Value of routine ultrasound examination at 35-37 weeks' gestation in diagnosis of non-cephalic presentation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:248-256. [PMID: 31671470 DOI: 10.1002/uog.21902] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/09/2019] [Accepted: 10/17/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE Undiagnosed non-cephalic presentation in labor carries increased risks for both the mother and baby. Routine pregnancy care based on maternal abdominal palpation fails to detect the majority of cases of non-cephalic presentation. The aim of this study was to report the incidence of non-cephalic presentation at a routine scan at 35 + 0 to 36 + 6 weeks' gestation and the subsequent management of such pregnancies. METHODS This was a retrospective analysis of prospectively collected data in 45 847 singleton pregnancies that had undergone routine ultrasound examination at 35 + 0 to 36 + 6 weeks' gestation. Patients with breech or transverse/oblique presentation were divided into two groups; first, those who would have elective Cesarean section for fetal or maternal indications other than the abnormal presentation, and, second, those who would potentially require external cephalic version (ECV). The latter group was reassessed after 1-2 weeks and, if there was persistence of abnormal presentation, the parents were offered the option of ECV or elective Cesarean section at 38-40 weeks' gestation. Multivariable logistic regression analysis was carried out to determine which of the factors from maternal and pregnancy characteristics provided a significant contribution in the prediction of, first, non-cephalic presentation at the 35 + 0 to 36 + 6-week scan, second, successful ECV from non-cephalic to cephalic presentation, and, third, spontaneous rotation from non-cephalic to cephalic presentation that persisted until delivery. RESULTS First, at 35 + 0 to 36 + 6 weeks, the fetal presentation was cephalic in 43 416 (94.7%) pregnancies, breech in 1987 (4.3%) and transverse or oblique in 444 (1.0%). Second, multivariable analysis demonstrated that the risk of non-cephalic presentation increased with increasing maternal age and weight, decreasing height and earlier gestational age at scan, was higher in the presence of placenta previa, oligohydramnios or polyhydramnios and in nulliparous than parous women, and was lower in women of South Asian or mixed racial origin than in white women. Third, 22% of cases of non-cephalic presentation were not eligible for ECV because of planned Cesarean section for indications other than the malpresentation. Fourth, of those eligible for ECV, only 48.5% (646/1332) agreed to the procedure, which was successful in 39.0% (252/646) of cases. Fifth, the chance of successful ECV increased with increasing maternal age and was lower in nulliparous than parous women. Sixth, in 33.9% (738/2179) of pregnancies with non-cephalic presentation in which successful ECV was not carried out, there was subsequent spontaneous rotation to cephalic presentation. Seventh, the chance of spontaneous rotation from non-cephalic to cephalic presentation increased with increasing interval between the scan and delivery, decreased with increasing birth-weight percentile, was higher in women of black than those of white racial origin, if presentation was transverse or oblique rather than breech and if there was polyhydramnios, and was lower in nulliparous than parous women and in the presence of placenta previa. Eighth, in 109 (0.3%) cephalic presentations, there was subsequent rotation to non-cephalic presentation and, in 41% of these, the diagnosis was made during labor. Ninth, of the total 2431 cases of non-cephalic presentation at the time of the scan, presentation at birth was cephalic in 985 (40.5%); in 738 (74.9%) this was due to spontaneous rotation and in 247 (25.1%) this was due to successful ECV. Tenth, prediction of non-cephalic presentation at the 35 + 0 to 36 + 6-week scan and successful ECV from maternal and pregnancy factors was poor, but prediction of spontaneous rotation from non-cephalic to cephalic presentation that persisted until delivery was moderately good and this could be incorporated in the counseling of women prior to ECV. CONCLUSIONS The problem of unexpected non-cephalic presentation in labor can, to a great extent, be overcome by a routine ultrasound examination at 35 + 0 to 36 + 6 weeks' gestation. The incidence of non-cephalic presentation at the 35 + 0 to 36 + 6-week scan was about 5%, but, in about 40% of these cases, the presentation at birth was cephalic, mainly due to subsequent spontaneous rotation and, to a lesser extent, as a consequence of successful ECV. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
Collapse
Affiliation(s)
- H De Castro
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - A Ciobanu
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - C Formuso
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - R Akolekar
- Fetal Medicine Unit, Medway Maritime Hospital, Gillingham, UK
- Institute of Medical Sciences, Canterbury Christ Church University, Chatham, UK
| | - K H Nicolaides
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| |
Collapse
|
31
|
Dochez V, Esbelin J, Misbert E, Arthuis C, Drouard A, Badon V, Fenet O, Thubert T, Winer N. Effectiveness of nitrous oxide in external cephalic version on success rate: A randomized controlled trial. Acta Obstet Gynecol Scand 2019; 99:391-398. [PMID: 31630398 DOI: 10.1111/aogs.13753] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2019] [Revised: 10/10/2019] [Accepted: 10/15/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Approximately 4% of singleton pregnancies at term are in breech presentation. External cephalic version (ECV) can reduce the risks of noncephalic birth and cesarean delivery, but this maneuver can be painful. Our aim was to analyze the effect of administering inhaled nitrous oxide for analgesia on the ECV success rate. MATERIAL AND METHODS This prospective, randomized, single-blind, controlled trial included women with singleton pregnancies in breech presentation at term who were referred for ECV in a tertiary care center. Women were assigned according to a balanced (1:1) restricted randomization design to inhale either nitrous oxide (N2 O) in a 50:50 mix with oxygen or medical air during the procedure. The main outcomes reported are the ECV success rate, degree of pain, adverse event rate, and women's satisfaction. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01948115. RESULTS The study included 150 women (nitrous oxide group: n = 74; medical air: n = 76). Inhaled nitrous oxide was not associated with a higher ECV success rate than medical air (24.3 vs 19.7%, P = 0.51). Among parous women (n = 34 in each group), the ECV success rate appeared higher in the nitrous oxide group, respectively 47.1% (n = 16) vs 23.5% (n = 8) (P = 0.042). Neither the median pain level nor adverse event rates differed significantly in women with inhaled nitrous oxide compared with medical air. CONCLUSIONS Use of an equimolar mixture of oxygen and nitrous oxide during ECV appears safe. Although it does not seem to change the overall success rate, it may increase success in parous women.
Collapse
Affiliation(s)
- Vincent Dochez
- Department of Gynecology and Obstetrics, University Hospital of Nantes, Nantes, France.,Clinical Investigation Center (CIC), University Hospital of Nantes, Nantes, France
| | - Julie Esbelin
- Department of Gynecology and Obstetrics, University Hospital of Nantes, Nantes, France
| | - Emilie Misbert
- Department of Gynecology and Obstetrics, University Hospital of Nantes, Nantes, France.,Clinical Investigation Center (CIC), University Hospital of Nantes, Nantes, France
| | - Chloé Arthuis
- Department of Gynecology and Obstetrics, University Hospital of Nantes, Nantes, France.,Clinical Investigation Center (CIC), University Hospital of Nantes, Nantes, France
| | - Anne Drouard
- Clinical Investigation Center (CIC), University Hospital of Nantes, Nantes, France
| | - Virginie Badon
- Clinical Investigation Center (CIC), University Hospital of Nantes, Nantes, France
| | - Olivier Fenet
- Biometrics and Biostatistics Platform, University Hospital of Nantes, Nantes, France
| | - Thibault Thubert
- Department of Gynecology and Obstetrics, University Hospital of Nantes, Nantes, France.,Clinical Investigation Center (CIC), University Hospital of Nantes, Nantes, France
| | - Norbert Winer
- Department of Gynecology and Obstetrics, University Hospital of Nantes, Nantes, France.,Clinical Investigation Center (CIC), University Hospital of Nantes, Nantes, France
| |
Collapse
|
32
|
Mattuizzi A. [Breech Presentation: CNGOF Guidelines for Clinical Practice - Epidemiology, Risk Factors and Complications]. ACTA ACUST UNITED AC 2019; 48:70-80. [PMID: 31682966 DOI: 10.1016/j.gofs.2019.10.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To study the frequency, the risk factors and the mode of delivery of breech presentation. To analyze the perinatal morbidity and mortality associated with breech presentation in comparison to cephalic presentation from all mode of delivery. METHODS MedLine and Cochrane Library databases search in French and English and review of the main foreign guidelines between 1980 and 2019. RESULTS Three modes of breech presentation exist according to fetal lower limbs position: frank in 2/3 of cases, complete in 1/3 of cases or, more rarely, incomplete (LE3). About 5% of women gave birth in breech presentation in France (LE3). As the frequency of breech presentation decreases with increasing gestational age, this incidence is lower after 37 WG and represents only 3% of term deliveries (LE3). Congenital uterine malformation (LE3) and fibroma (LE3), prematurity (LE3), oligoamnios (LE3), some fetal congenital malformations (LE3) and low birthweight for gestational age (LE3) are the main risk factors with breech presentation. In France, one-third of women with a term fetus in breech presentation attempt a vaginal delivery (LE3), which is successful in 70% of cases (LE3). Neonatal outcome is not associated with type of breech presentation (frank or complete) in case of vaginal delivery attempt after 37 WG (LE3). Overall, perinatal morbidity and mortality after 37 WG of breech presentation appear to be greater than in cephalic presentation from all mode of delivery (LE3). The risk of traumatic injury in breech delivery is estimated under 1% (LE3). The most common injuries are collarbone fractures, hematomas or contusions, and brachial plexus injury (LE3). Breech presentation is associated with an increased risk of hip dysplasia (LE3) and cesarean delivery does not seem to be a protective factor (LE3). Breech presentation does not appear to be associated with an increased risk of cerebral palsy compared to cephalic presentation after exclusion of fetuses with congenital malformations (LE3). CONCLUSION Worldwide, mode of delivery of breech presentation has undergone profound changes since the publication of the TBT (Term Breech Trial). There are intrinsic factors associated with breech presentation, which should not be overlooked when interpreting the increased perinatal morbidity and mortality observed in case of breech presentation.
Collapse
Affiliation(s)
- A Mattuizzi
- Service de gynécologie-obstétrique et de médecine fœtale, centre Aliénor d'Aquitaine, CHU de Bordeaux, place Amélie-Raba-Léon, 33000 Bordeaux, France.
| |
Collapse
|
33
|
Bjellmo S, Hjelle S, Krebs L, Magnussen E, Vik T. Adherence to guidelines and suboptimal practice in term breech delivery with perinatal death- a population-based case-control study in Norway. BMC Pregnancy Childbirth 2019; 19:330. [PMID: 31500581 PMCID: PMC6734432 DOI: 10.1186/s12884-019-2464-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 08/20/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND In a recent population-based study we reported excess risk of neonatal mortality associated with vaginal breech delivery. In this case-control study we examine whether deviations from Norwegian guidelines are more common in breech deliveries resulting in intrapartum or neonatal deaths than in breech deliveries where the offspring survives, and if these deaths are potentially avoidable. MATERIAL AND METHODS Case-control study completed as a perinatal audit including term breech deliveries of singleton without congenital anomalies in Norway from 1999 to 2015. Deliveries where the child died intrapartum or in the neonatal period were case deliveries. For each case, two control deliveries who survived were identified. All the included deliveries were reviewed by four obstetricians independently assessing if the deaths in the case group might have been avoided and if the management of the deviations from Norwegian guidelines were more common in case than in control deliveries. RESULTS Thirty-one case and 62 control deliveries were identified by the Medical Birth Registry of Norway. After exclusion of non-eligible deliveries, 22 case and 31 control deliveries were studied. Three case and two control deliveries were unplanned home deliveries, while all in-hospital deliveries were in line with national guidelines. Antenatal care and/or management of in-hospital deliveries was assessed as suboptimal in seven (37%) case and two (7%) control deliveries (p = 0.020). Three case deliveries were completed as planned caesarean delivery and 12 (75%) of the remaining 16 deaths were considered potentially avoidable had planned caesarean delivery been done. In seven of these 16 deliveries, death was associated with cord prolapse or difficult delivery of the head. CONCLUSION All in-hospital breech deliveries were in line with Norwegian guidelines. Seven of twelve potentially avoidable deaths were associated with birth complications related to breech presentation. However, suboptimal care was more common in case than control deliveries. Further improvement of intrapartum care may be obtained through continuous rigorous training and feedback from repeated perinatal audits.
Collapse
Affiliation(s)
- Solveig Bjellmo
- Department of Obstetrics and Gynecology, More and Romsdal Hospital Trust, Postbox 1600, 6026, Aalesund, Norway.
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | - Sissel Hjelle
- Department of Obstetrics and Gynecology, More and Romsdal Hospital Trust, Postbox 1600, 6026, Aalesund, Norway
| | - Lone Krebs
- Department of Gynecology and Obstetrics, University of Copenhagen Holbaek Hospital, Holbaek, Denmark
| | - Elisabeth Magnussen
- Department of Obstetrics and Gynecology, St Olav's University Hospital, Trondheim, Norway
| | - Torstein Vik
- Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| |
Collapse
|
34
|
Dixon AK. The imaging revolution. Postgrad Med J 2019; 95:409-413. [DOI: 10.1136/postgradmedj-2019-136561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 06/22/2019] [Indexed: 11/04/2022]
|