Venous thromboembolism (VTE) remains a leading cause of maternal morbidity and mortality in the developed world. Low molecular weight heparins (LMWH) are routinely used to provide therapeutic anticoagulation during pregnancy for women with VTE, with measurement of plasma anti-FXa activity used to guide dosing in certain patient groups. There is limited evidence to support the use of anti-FXa monitoring in pregnant patients. This study seeks to ascertain whether anti-FXa monitoring of pregnant patients with VTE influences patient outcomes. We performed a single-centre case series including two consecutive groups of pregnant patients treated with LMWH for VTE sustained in the index pregnancy with and without monitoring of anti-FXa levels. 35,394 patients delivered during the study period in a large urban stand-alone maternity hospital, with 26 cases of VTE eligible for inclusion. There was no significant difference between the two groups in any clinical outcome; including maternal blood loss at delivery, recurrent thromboembolic events or rates of planned delivery. These data provide clinical evidence to support current international guideline recommendations that measurement of plasma anti-FXa activity in the majority of patients receiving therapeutic-intensity antenatal LMWH is not warranted.
The perinatal mortality rate in twins improved during the study. The rate of cesarean delivery increased by 1.7% for each year of the study, culminating in a cesarean delivery rate of 62% in 2012. TTTS made a decreasing contribution to the mortality rate in twins during the study.
Objective
To compare mode of delivery in fetuses with known congenital heart disease (CHD) versus the background rate in non-anomalous fetuses.
Methods
We examined all cases of prenatally-diagnosed CHD over the 5-year study period, 2007–2011. Data were extracted from computerised patient records. Control data for non-anomalous fetuses were obtained from published hospital records for 2007. Categorical data were analysed using Fisher’s exact test (5% level significant).
Results
We identified 242 cases of prenatally-diagnosed CHD over the study period. We excluded 25 lethal karyotypes, 7 miscarriages and 1 termination. Of the remaining 209 cases, complete labour records were available for 158 women. There were 146 live births (92%) and 12 antepartum stillbirths at ≥24 weeks (8%). Of the live-born infants with CHD, the perinatal mortality rate was 41 per 1,000. Extra-cardiac defects and non-lethal karyotypic abnormalities were present in 22% (n = 34) and 11% (n = 18) of the cohort respectively. Overall, 23% (34/146) underwent elective caesarean section (CS). The remaining 112 women had a trial of labour, with a 13% (n = 15) intrapartum CS rate. The rate of intrapartum CS for nulliparous women with known CHD was 18% (8/45), which was not different to the rate in nulliparous controls in 2007 (13%; 432/3324; p = 0.27). The equivalent rate in multiparous women was 10% (7/67) in CHD versus 2.4% (80/3392) in controls without previous CS (p = 0.0013).
Conclusions
The rate of intrapartum CS in fetuses with known CHD is not different to the background rate in nulliparous women but is increased in multips.
AbstractsBackground Currently, maternal Rh-D antibody levels are primarily used to triage which alloimmunized women warrant enhanced surveillance with middle cerebral artery Doppler. Traditionally, maternal Rh-D antibody levels ≤15 IU/ml have indicated, at worst, mild anaemia and provided reassurance. This threshold has not been widely studied. Methods A prospective cohort study of all intrauterine fetal transfusions (IUT) for Rh-D alloimmunization performed at our tertiary fetal medicine unit from 1996-2011. Fetal haemoglobin (Hb) levels at the time of IUT were adjusted for gestational age (multiples of median [MoM]) and correlated with the maternal serum Rh-D antibody level taken on the day of IUT, or ≤2 weeks prior to the transfusion. Results 260 IUTs were performed, of which 195 were for Rh-D alloimmunzation in 82 pregnancies. No significant correlation was demonstrated between fetal Hb and serum antibody levels ( Spearman r = 0.08; p = 0.35). Rates of mild (0.65-0.84 MoM), moderate (0.55-0.64 MoM) and severe (<0.55 MoM) fetal anaemia were 32%, 22% and 31% respectively. The sensitivity, specificity, PPV and NPV of a maternal antibody threshold of >15 IU/ml for detecting any fetal anaemia (<0.84 MoM) were 88%, 14%, 85% and 18%. The equivalent results for a threshold of >15 IU/ml detecting moderatesevere anaemia (<0.65 MoM) were 88%, 12%, 52% and 47%. Using a lower antibody threshold of >8 IU/ml, the sensitivity, specificity, PPV and NPV of maternal serum antibody levels detecting any fetal anaemia were 96%, 5%, 85% and 17% respectively. Conclusion The widely used Rh-D threshold of >15 IU/ml may miss a substantial proportion of cases of fetal anaemia.
Prenatal Detection of Structural carDiac DefectS anD PreSence of aSSociateD anomalieS: a ProSPective StuDy of 1,244 fetal echocarDiogramS
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