Intramuscular oxytocin versus Syntometrine® versus carbetocin for prevention of primary postpartum haemorrhage after vaginal birth: a randomised double-blinded clinical trial of effectiveness, side effects and quality of life

OBJECTIVE

To compare intramuscular oxytocin, Syntometrine^® and carbetocin for prevention of postpartum haemorrhage after vaginal birth.

DESIGN

Randomised double-blinded clinical trial.

SETTING

Six hospitals in England.

POPULATION

A total of 5929 normotensive women having a singleton vaginal birth.

METHODS

Randomisation when birth was imminent.

MAIN OUTCOME MEASURES

Primary: use of additional uterotonic agents. Secondary: weighed blood loss, transfusion, manual removal of placenta, adverse effects, quality of life.

RESULTS

Participants receiving additional uterotonics: 368 (19.5%) oxytocin, 298 (15.6%) Syntometrine and 364 (19.1%) carbetocin. When pairwise comparisons were made: women receiving carbetocin were significantly more likely to receive additional uterotonics than those receiving Syntometrine (odds ratio [OR] 1.28, 95% CI 1.08-1.51, P = 0.004); the difference between carbetocin and oxytocin was non-significant (P = 0.78); Participants receiving Syntometrine were significantly less likely to receive additional uterotonics than those receiving oxytocin (OR 0.75, 95% CI 0.65-0.91, P = 0.002). Non-inferiority between carbetocin and Syntometrine was not shown. Use of Syntometrine reduced non-drug PPH treatments compared with oxytocin (OR 0.64, 95% CI 0.42-0.97) but not carbetocin (P = 0.64). Rates of PPH and blood transfusion were not different. Syntometrine was associated with an increase in maternal adverse effects and reduced ability of the mother to bond with her baby.

CONCLUSIONS

Non-inferiority of carbetocin to Syntometrine was not shown. Carbetocin is not significantly different to oxytocin for use of additional uterotonics. Use of Syntometrine reduced use of additional uterotonics and need for non-drug PPH treatments compared with oxytocin. Increased maternal adverse effects are a disadvantage of Syntometrine.

TWEETABLE ABSTRACT

IM carbetocin does not reduce additional uterotonic use compared with IM Syntometrine or oxytocin.

Parent engagement in perinatal mortality reviews: an online survey of clinicians from six high-income countries

OBJECTIVE

Parent engagement in perinatal mortality review meetings following stillbirth may benefit parents and improve patient safety. We investigated perinatal mortality review meeting practices, including the extent of parent engagement, based on self-reports from healthcare professionals from maternity care facilities in six high-income countries.

DESIGN

Cross-sectional online survey.

SETTING

Australia, Canada, Ireland, New Zealand, UK and USA.

POPULATION

A total of 1104 healthcare professionals, comprising mainly obstetricians, gynaecologists, midwives and nurses.

METHODS

Data were drawn from responses to a survey covering stillbirth-related topics. Open- and closed-items that focused on 'Data quality on causes of stillbirth' were analysed.

MAIN OUTCOME MEASURES

Healthcare professionals' self-reported practices around perinatal mortality review meetings following stillbirth.

RESULTS

Most clinicians (81.0%) were aware of regular audit meetings to review stillbirth at their maternity facility, although this was true for only 35.5% of US respondents. For the 854 respondents whose facility held regular meetings, less than a third (31.1%) reported some form of parent engagement, and this was usually in the form of one-way post-meeting feedback. Across all six countries, only 17.1% of respondents described an explicit approach where parents provided input, received feedback and were represented at meetings.

CONCLUSIONS

We found no established practice of involving parents in the perinatal mortality review process in six high-income countries. Parent engagement may hold the key to important lessons for stillbirth prevention and care. Further understanding of approaches, barriers and enablers is warranted.

TWEETABLE ABSTRACT

Parent engagement in mortality review after stillbirth is rare, based on data from six countries. We need to understand the barriers.

Chlamydia psittaci: a suspected cause of reproductive loss in three Victorian horses

Chlamydia psittaci was detected by PCR in the lung and equine foetal membranes of two aborted equine foetuses and one weak foal from two different studs in Victoria, Australia. The abortions occurred in September 2019 in two mares sharing a paddock northeast of Melbourne. The weak foal was born in October 2019 in a similar geographical region and died soon after birth despite receiving veterinary care. The detection of C. psittaci DNA in the lung and equine foetal membranes of the aborted or weak foals and the absence of any other factors that are commonly associated with abortion or neonatal death suggest that this pathogen may be the cause of the reproductive loss. The detection of C. psittaci in these cases is consistent with the recent detection of C. psittaci in association with equine abortion in New South Wales. These cases in Victoria show that C. psittaci, and the zoonotic risk it poses, should be considered in association with equine reproductive loss in other areas of Australia.

PARENTS 2 study: consensus report for parental engagement in the perinatal mortality review process

OBJECTIVE

The PARENTS 1 study (Parents' Active Role and ENgagement in The review of their Stillbirth/perinatal death) found that parents would endorse the opportunity to give feedback into the perinatal mortality review (PNMR) process. In subsequent focus groups, healthcare professionals were positive about parental engagement, although they considered that there may be significant challenges. The objective of this study was to develop core principles and recommendations for parental engagement in PNMR in the UK.

METHODS

A two-round Delphi technique was followed to reach consensus on core principles for parental engagement in the PNMR process; Round 1 included a national consensus workshop and Round 2 an online questionnaire. The consensus meeting was attended by a national panel of stakeholders (clinical and academic experts, parent advocates, managers and commissioners) in stillbirth and neonatal and bereavement care. To develop recommendations for parental engagement, participants discussed four key areas comprising: communication with parents, including receiving feedback; the format of the PNMR meeting; the parental engagement pathway; and challenging aspects of engaging with parents in reviews. Content analysis was conducted to generate recommendations from the meeting for a subsequent anonymous web-based survey. Attendees of the consensus workshop and members of the PARENTS 2 Project Advisory Board were asked to rank recommendations using a 9-point Likert scale from 1 (not important) to 9 (critically important). It had been agreed a priori, in compliance with established Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria, that 'consensus' would be achieved if over 70% of participants scored the principle as 'critical' (score of 7-9) and fewer than 15% scored the principle as 'not important' (score of 1-3). Principles for which consensus was achieved were included in the core recommendations.

RESULTS

Of the 29 invited stakeholders, 22 participated in the consensus meeting and 25 (86% response rate) in the subsequent online questionnaire in June 2017. Consensus was agreed on 12 core principles. Of the 25 participants, 96% agreed that a face-to-face explanation of the PNMR process was of critical importance, 72% considered that parents should be offered the opportunity to nominate a suitable advocate, 92% believed that responses to parents' comments should be formally documented, 96% indicated that it was vital for action plans to be translated into lessons learnt and that this process should be monitored, and 100% of stakeholders voted that a plain-English summary should be produced for the parents following the meeting. There was good agreement on a further seven principles.

CONCLUSIONS

Key national stakeholders were unanimously supportive of parental engagement in the PNMR process and agreed on core principles to make this process feasible, meaningful and robust. A 6-month pilot of parental engagement in the PNMR process (PARENTS 2 study) in two UK units took place after the consensus on core principles. In collaboration with the National Perinatal Epidemiology Unit, the findings will inform the national standardized PNMR tool. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Barriers to the utilization of genetic testing and genetic counseling in patients with suspected hereditary breast and ovarian cancers

A heritable condition is the identified cause of cancer in 5% to 10% of women with breast cancer and in 25% of women with ovarian cancer. It is critical to identify patients at risk for inherited genetic mutations to implement risk-reducing screening and interventions; however, reports in the medical literature indicate that an alarming number of patients with inherited genetic mutations do not receive recommended genetic counseling, testing, or interventions. In order to improve outcomes for these high-risk patients, barriers to genetic testing and counseling must be identified. We analyzed approximately 200 patients seen at our institution with breast or ovarian cancer who met criteria of the National Comprehensive Cancer Network for genetic counseling and testing. Of these patients, almost 70% had appropriate genetic testing and counseling. Review of the remaining 30% revealed that the largest obstacle to receiving genetic testing and/or counseling was lack of referral from the treating oncologist. Of the patients diagnosed with a pathogenic heritable mutation, most underwent appropriate risk-reducing procedures and surveillance. Thus, the initial referral to genetic counseling is the most significant barrier for at-risk patients at our institution and likely in this population at large. Additional study is needed to identify ways to improve appropriate use of genetic testing and counseling.

Usability of virtual-reality simulation training in obstetric ultrasonography: a prospective cohort study

OBJECTIVE

To assess the usability of virtual-reality (VR) simulation for obstetric ultrasound trainees.

METHODS

Twenty-six participants were recruited: 18 obstetric ultrasound trainees (with little formal ultrasonography training) and eight certified experts. All performed five sequential VR-simulated crown-rump length (CRL) scans in a single session and three repetitions of biparietal diameter (BPD), occipitofrontal diameter (OFD) and femur length (FL) measurements. Outcome measures included mean percentage deviation from target for all measurements. Time taken to perform each type of scan was recorded.

RESULTS

The mean percentage difference for the first scan was significantly greater for the trainee group than for the expert group for BPD (P = 0.035), OFD (P = 0.010) and FL (P = 0.008) and for time taken for the first CRL (P < 0.001) and fetal biometry (including BPD, OFD and FL measurements) scan (P < 0.001), demonstrating that trainees were initially significantly less accurate and less efficient. Over subsequent scans, the trainees became more accurate for all measurements with a significant improvement shown for OFD and FL (P < 0.05). The time taken for trainees to complete CRL and fetal biometry scans decreased significantly (all P < 0.05) with repetition, to near-expert efficiency.

CONCLUSIONS

All participants were able to use the simulator and produce clinically meaningful biometry results. With repetition, beginners quickly approached near-expert levels of accuracy and speed. These data demonstrate that obstetricians with minimal experience can improve their ultrasonographic skills with short-phase VR-simulation training. The speed of improvement suggests that VR simulation might be useful as a warm-up exercise before clinical training sessions in order to reduce their impact on clinical service.