Key content
Polyhydramnios is a common obstetric condition, but its management can often be challenging.
Mild polyhydramnios resolves frequently and is not usually associated with adverse perinatal outcomes.
There is a higher prevalence of aneuploidy (10–20%) in severe polyhydramnios.
Unexplained polyhydramnios has been associated with increased rates of perinatal morbidity and mortality.
Learning objectives
To gain an overview of the aetiology and investigations for polyhydramnios in singleton pregnancies.
To understand the implications of mild and unexplained polyhydramnios for both mother and fetus.
To develop an evidence‐based approach for managing this condition and provide a surveillance strategy.
Ethical issues
Can we justify the benefits of early induction in unexplained polyhydramnios in the face of associated risks?
Introduction
Preterm birth remains the major cause of neonatal mortality, in developed countries, despite major improvements in neonatal care. Appropriate antenatal intervention helped in prolonging gestation and reducing mortality and morbidity.
This study was organised to review the cases managed by the trust's Preterm Prevention Clinic (PPC) and audit its performance based on trust and RCOG guideline.
Methodology
The study involved a retrospective case-note analysis of patients registered under the PPC from November 2007 to January 2009.
Results
105 patients were registered during this time period, with mean age=30.16 years (18-41) and mean BMI = 27.86kg/m2.
The commonest reason for referral was previous preterm labour or mid-trimester loss (n=83). Of these, 60 referrals were made after one previous preterm delivery, 19 were after two and 12 after three or more previous preterm losses.
All patients underwent serial transvaginal scan monitoring and infection screening between 16 and 28 weeks. The relevant management options were discussed. 25 patients underwent cervical cerclage, of which 18 received progesterone supplementation. 29 patients had progesterone alone.
66 patients delivered after 37 weeks with mean birth weight of 2511gm. 26 preterm babies were admitted to the neonatal unit and only 5 of these babies died from complications of prematurity.
Through the PPC, we achieved a term delivery rate (>37 weeks) in 74%, 42% and 41% in those patients with previous one, two and three preterm deliveries, respectively.
Conclusion
With counselling and appropriate patient selection for intervention, the PPC has successfully reduced prematurity related morbidity and mortality in our unit.
Desmosterolosis is a rare autosomal recessive disorder of cholesterol biosynthesis resulting in multiple congenital abnormalities and syndromic intellectual disability. It is caused by defects in DHCR24, the gene encoding 3-β-hydroxysterol-24-reductase (24-dehydrocholesterol reductase), which acts in conversion of cholesterol precursor desmosterol, hence resulting in elevated plasma desmosterol levels. To date, desmosterolosis has been reported in 10 patients. Here we report an eleventh patient with desmosterolosis, and the first one to be diagnosed antenatally. Diagnosis was made on whole exome sequencing after amniocentesis due to complex antenatal abnormalities including cerebellar hypoplasia, microgyria, aortic stenosis, and renal tract abnormalities. Sterol quantitation was subsequently done postnatally, which supported the diagnosis. Although the nonspecific features make desmosterolosis difficult to suspect, we demonstrate that disorders of cholesterol synthesis can be considered as a differential diagnosis antenatally.
Background
Twins have a much higher stillbirth rate than singletons with causes of intrauterine death frequently unexplained. In the North of England the stillbirth rate in twins is higher than the national rate.
Aim
To audit antenatal surveillance of twin pregnancy resulting in antepartum stillbirth against regional consensus standards of care.
Methods
A retrospective, case-note analysis of all antepartum stillbirths in twins delivered 2005–2009, identified from the population-based Northern Survey of twin and multiple pregnancy. Antenatal care was reviewed independently by two consultants.
Results
There were 43 antepartum stillbirths in 38 pregnancies. 21 were DCDA, 14 MCDA, one MCMA and in two cases the chorionicity was unknown. Autopsy was performed in 18 (47%) pregnancies. Major causes of stillbirth were acute or chronic antepartum hypoxia (n=25) and twin-to-twin transfusion (TTTS n=14, 9 pregnancies). Case-note review clarified causes of death in 22 cases confirming TTTS in 8 pregnancies affecting 13 twins. 66% pregnancies were delivered within 24 h of diagnosis of death, 53% by Caesarean section. The review of case notes highlighted a number of cases where elements of antenatal care might have been improved with antenatal surveillance in the majority being in line with regional standards.
Conclusion
Sometimes in spite of exemplary antenatal care, stillbirths in twins may not be avoidable. The issues arising from the review will be fed back for discussion at a regional workshop. Regional datasets facilitate discussion of practice between maternity units and enable areas for improvement to be identified.
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