Current use of noninvasive prenatal testing in Europe, Australia and the USA : A graphical presentation

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Postpartum obstetric red cell transfusion practice: A retrospective study in a tertiary obstetric centre

Background Traditional management of anaemia due to postpartum haemorrhage (PPH) has relied upon salvage therapy with red cell transfusion. Recently published guidance recommends a change in approach toward holistic patient blood management. Aims To determine whether postpartum red cell transfusion practices are consistent with best practice and to identify opportunities for improvement. Materials and methods A retrospective audit of postpartum red cell transfusions was conducted at a tertiary level obstetrics unit. Relevant clinical and laboratory data were collected for all cases of postpartum red cell transfusions and PPH. Clinical decision making and appropriateness of transfusions were evaluated. Results Among the 3235 women who delivered in 2013, 110 (3.4%) received a postpartum red cell transfusion. About 101 of the transfusions were associated with primary PPH. Overall PPH complicated 460 (14.2%) deliveries. Antenatal anaemia was identified as a major correctable risk factor for transfusion in women who experienced PPH (odds ratio 6.55, 95% CI: 3.17–13.6). Volume of blood loss and the aetiology of PPH were additional risk factors for transfusion. Transfusion was associated with lower birth weight and increased maternal length of stay. Transfusion triggers were more likely to be appropriate when transfusion took place in the operating theatre, within 12 h of delivery and when prescribed by anaesthetists. Post-transfusion Hb levels were uniformly above target for all women transfused. Conclusions A significant number of red cell transfusions were outside the recommendations of the new guidelines. Maximising red cell mass during pregnancy and improving transfusion practices were identified as opportunities for future improvement

Recurrent Chronic Intervillositis: The Diagnostic Challenge – A Case Report and Review of the Literature

Background: Chronic intervillositis (CI) is a rare placental condition involving diffuse infiltration of intervillous spaces by CD68- or CD45-positive maternal mononuclear inflammatory cells. Because no validated clinical or biochemical markers are specific to CI, the diagnosis is purely histopathological and is made postpartum. Case: This report describes a case of recurrent CI associated with adverse complications in two successive pregnancies. Both pregnancies were complicated by intrauterine growth restriction. Coexistent massive perivillous fibrin deposition was present in the first placenta. This case highlights the importance of CI in explaining and predicting adverse perinatal outcomes. Conclusion: CI is associated with adverse pregnancy outcomes and a high risk of recurrence, and it can coexist with massive perivillous fibrin deposition. Pathologists must ensure that the significance of these diagnoses is adequately conveyed to clinicians, to optimize management of subsequent pregnancie

First trimester ferritin screening for pre-delivery anaemia as a patient blood management strategy

Objectives To determine the optimum approach and timing to screen for iron deficiency in pregnancy. Background There is a lack of consensus on identifying and treating iron deficiency during pregnancy. Patient blood management programs may be refined by evaluating outcomes. Methods Retrospective data collection on women delivering prior to and following implementation of patient blood management interventions. Ferritin, transferrin saturation and haemoglobin levels were evaluated in first and second trimesters as predictors of pre-delivery anaemia. The optimum time to screen was determined. Comparison with results following a quality improvement intervention was undertaken. A separate retrospective study was performed to validate the predictive value of ferritin using data extracted from the laboratory information system. Results Ferritin and transferrin saturation in first trimester detected women who subsequently had anaemia pre-delivery, with ferritin being most discriminatory. Both were superior to haemoglobin concentration. Iron studies in second trimester did not predict pre-delivery anaemia and haemoglobin remained poorly discriminatory. Iron studies lost predictive value when a systematic program ensured treatment of iron depletion during pregnancy. The ability of ferritin to predict pre-delivery anaemia in the first, but not the second, trimester was confirmed on the validation cohort. Conclusion First trimester serum ferritin may identify candidates for iron therapy during pregnancy. This strategy may be preferable to haemoglobin screening alone or universal replacement in centres at low risk of anaemia.Philip Crispin receives support from the Australian Government Research Training Progra

Cold reacting anti-M causing delayed hemolytic disease of the newborn

BACKGROUND: Hemolytic disease of the fetus and newborn (HDFN) is due to passively transferred maternal antibodies directed against fetal red blood cell (RBC) antigens and can lead to severe morbidity and mortality. Anti-M is usually a naturally occurring antibody of low clinical significance, although occasionally severe cases of HDFN are seen. CASE REPORTS: Two M+ sisters are presented, each developing hemolysis during the first 2 weeks of life due to maternal anti-M, resulting in severe anemia and requiring blood transfusion. RBC agglutination was observed in peripheral blood samples of both infants at room temperature with dissociation at 37°C. Maternal anti-M detected by column indirect agglutination technique, was of low titer (1:16) and demonstrated low thermal amplitude, reacting in saline at 4°C but was not detectable in saline at 37°C. CONCLUSIONS: Anti-M of low thermal amplitude may cause hemolytic disease of the newborn with laboratory features resembling cold agglutinin disease

Identifying the barriers faced by obstetricians and registrars in screening or enquiry of intimate partner violence in pregnancy: A systematic review of the primary evidence

Introduction: Intimate partner violence (IPV) disproportionally affects women compared to men. The impact of IPV is amplified during pregnancy. Screening or enquiry in the antenatal outpatient setting regarding IPV has been fraught with bar-riers that prevent recognition and the ability to intervene.Aims: The aim of this systematic review was to determine the barriers that face ob-stetricians/gynaecologists regarding enquiry of IPV in antenatal outpatient settings. The secondary objective was to determine facilitators.Methods: Primary evidence was searched using Ovid MEDLINE, Ovid Maternity and Infant Care, PubMed and Proquest from 1993 to May 2023. The included studies comprised empirical studies published in English language targeting a population of doctors providing antenatal outpatient care. The review was PROSPERO- registered (CRD42020188994). Independent screening and review was performed by two au-thors. The findings were analysed thematically.Results: Nine studies addressing barriers and two studies addressing facilita-tors were included: three focus- group or semi- structured interviews, six sur-veys and two randomised controlled trials. Barriers for providers centred at the system level (time, training), provider level (personal beliefs, cultural bias, experience) and provider- perceived patient level (fear of offending, patient readiness to disclose). Increased experience and the use of validated tools were strong facilitators.Conclusion: Barriers to screening reflect multi- level obstruction to the identifica-tion of women exposed to IPV. Although the antenatal outpatient clinic setting ad-dresses a particular population vulnerable to IPV, the barriers for obstetricians are not unique. The use of validated cueing tools provides an evidence- based method to facilitate enquiry of IPV among antenatal women, assisting in identification by clinicians. Together with education and human resources, such aids build capacity in women and obstetric provider