Background & Aims: Intrahepatic cholestasis of pregnancy (ICP) is associated with an increased risk of stillbirth. This study aimed to assess the relationship between bile acid concentrations and fetal cardiac dysfunction in patients with ICP who were or were not treated with ursodeoxycholic acid (UDCA). Methods: Bile acid profiles and NT-proBNP, a marker of ventricular dysfunction, were assayed in umbilical venous serum from 15 controls and 76 ICP cases (36 untreated, 40 UDCAtreated). Fetal electrocardiogram traces were obtained from 43 controls and 48 ICP cases (26 untreated, 22 UDCA-treated). PR interval length and heart rate variability (HRV) parameters were measured in 2 behavioral states (quiet and active sleep). Results: In untreated ICP, fetal total serum bile acid (TSBA) concentrations (r = 0.49, p = 0.019), hydrophobicity index (r = 0.20, p = 0.039), glycocholate concentrations (r = 0.56, p = 0.007) and taurocholate concentrations (r = 0.44, p = 0.039) positively correlated with fetal NT-proBNP. Maternal TSBA (r = 0.40, p = 0.026) and alanine aminotransferase (r = 0.40, p = 0.046) also positively correlated with fetal NT-proBNP. There were no significant correlations between maternal or fetal serum bile acid concentrations and fetal HRV parameters or NT-proBNP concentrations in the UDCA-treated cohort. Fetal PR interval length positively correlated with maternal TSBA in untreated (r = 0.46, p = 0.027) and UDCA-treated ICP (r = 0.54, p = 0.026). Measures of HRV in active sleep and quiet sleep were significantly higher in untreated ICP cases than controls. HRV values in UDCA-treated cases did not differ from controls. Conclusions: Elevated fetal and maternal serum bile acid concentrations in untreated ICP are associated with an abnormal fetal cardiac phenotype characterized by increased NT-proBNP concentration, PR interval length and HRV. UDCA treatment partially attenuates this phenotype. Lay summary: The risk of stillbirth in intrahepatic cholestasis of pregnancy (ICP) is linked to the level of bile acids in the mother which are thought to disrupt the baby's heart rhythm. We found that babies of women with untreated ICP have abnormally functioning hearts compared to those without ICP, and the degree of abnormality is closely linked to the level of harmful bile acids in the mother and baby's blood. Babies of women with ICP who received treatment with the drug UDCA do not have the same level of abnormality in their hearts, suggesting that UDCA could be a beneficial treatment in some ICP cases, although further clinical trials are needed to confirm this.

Objective Establish whether the reliable measurement of cardiac time intervals of the fetal ECG can be automated and to address whether this approach could be used to investigate large datasets. Design Retrospective observational study. Setting Teaching hospitals in London UK, Nottingham UK and New York USA. Participants Singleton pregnancies with no known fetal abnormality. Methods Archived fetal ECG's performed using the MonicaAN24 monitor. A single ECG (PQRST) complex was generated from 5000 signal-averaged beats and electrical cardiac time intervals measured in an automated way and manually. Main Outcome measure Validation of a newly developed algorithm to measure the cardiac time intervals of the fetal ECG. Results 188/236 (79.7%) subjects with fECGs of suitable signal:noise ratio were included for analysis comparing manual with automated measurement. PR interval was measured in 173/188 (92%), QRS complex in 170/188 (90%) and QT interval in 123/188 (65.4%). PR interval was 107.6 (12.07) ms [mean(SD)] manual vs 109.11 (14.7) ms algorithm. QRS duration was 54.72(6.35) ms manual vs 58.34(5.73) ms algorithm. QT-interval was 268.93 (21.59) ms manual vs 261.63 (36.16) ms algorithm. QTc was 407.5(32.71) ms manual vs 396.4 (54.78) ms algorithm. The QRS-duration increased with gestational age in both manual and algorithm measurements. Conclusion Accurate measurement of fetal ECG cardiac time intervals can be automated with potential application to interpretation of larger datasets.

Introduction: Heart disease complicating pregnancy is a leading cause of maternal morbidity and mortality in Sri Lanka. Understanding the pattern and outcomes of heart disease complicating pregnancy will help to optimise the care.Objective: Describe maternal and fetal outcomes of heart disease complicating pregnancy in a tertiary care unit from 2013 to 2017.To compare the pattern of heart disease complicating pregnancy over the years from the same unit to assess whether there is a change in the pattern of cases presenting in pregnancy.To study the reasons for termination of pregnancy in patients with cardiac disease during the study period Method: Retrospective analysis of secondary data collected from clinical notes of pregnancies complicated with heart disease.Results: A total of 248 cases with diagnosis of cardiac disease complicating pregnancy were included in the study.15 patients had termination of pregnancy in the first trimester due to severe heart disease. Two hundred thirty three (233) patients continued the pregnancy until the delivery. Out of these 233, heart disease was diagnosed during the index pregnancy in 18.9% (n-44) of the patients. Heart disease was categorised as acquired (47.2%), congenital (28.2%), mitral valve prolapse (15%), cardiac arrhythmias (9.4%). Among acquired heart disease 89% was rheumatic in origin. Mitral valve (89.7%) was the commonest valve affected amongst women with rheumatic carditis (n=98). Cardiac decompensation at delivery occurred in 7.7%. Pulmonary hypertension was present in 22.9% with acquired heart disease and 31.7% with congenital heart disease. Three intra uterine fetal demise and two maternal deaths occurred during this period. Conclusion:Rheumatic heart disease remains the commonest heart disease in pregnant women in Sri Lanka. There is an increase proportion of women with congenital heart disease. A significant number required therapeutic termination which highlights the need for improved pre-pregnancy preparation.

SLCOG Guideline Introduction, background and epidemiologyManagement of second stage of labour frequently necessitates assisted birth, to avoid a potentially hazardous second stage caesarean section. In the United Kingdom 10% to 15% of all women undergo assisted vaginal birth, even though rate is much lower in Sri Lanka 1 . Instrumental delivery when performed correctly by a trained clinician, results in satisfactory feto-maternal outcomes 2 . However, clinician should be aware that serious and rare complications, such as subgaleal and intracranial haemorrhage, skull fractures and spinal cord injury, can occur particularly in the untrained hands as well as with repeated failed attempts 3 . Mastering the art of safe assisted delivery is an essential skill in the modern obstetrician's armament.