Antenatal diagnosis of midgut volvulus with successful immediate post-natal management

Fetal volvulus of the midgut occurs when the bowel twists around the axis of the superior mesenteric artery. It is usually diagnosed postnatally but with improving ultrasonography, there have been increasing number of cases reporting antenatal diagnosis that had allowed planning of obstetric intervention and prompt surgery in the postnatal period. We present a case of dichorionic diamniotic twin pregnancy wherein Twin A had multiple anomalies, which included an Ivemark heterotaxy syndrome with a double outlet right ventricle. This twin developed dilated bowel loops at 33 weeks of gestation. The pregnancy continued to have regular antenatal surveillance and was managed by a multidisciplinary team. At 36 weeks of gestation, these bowel loops were found to have absence of peristalsis compared to previous ultrasounds. An emergency caesarean section was performed, which was uncomplicated and Twin A weighing 2760g was born with Apgars of 61 and 85. The diagnosis of volvulus in Twin A was confirmed during its emergency laparotomy along with a Type IV jejunal atresia and was successfully treated surgically with resection and administration of tissue plasminogen activator (TPA). This is the first description of a case treated with TPA after fetal diagnosis. Keywords: Volvulus, Antenatal diagnosis, Tissue plasminogen activator, Congenital anomalie

Complexity of gastroschisis predicts outcome: epidemiology and experience in an Australian tertiary centre

Abstract Background Gastroschisis is a congenital anomaly of the fetal abdominal wall, usually to the right side of umbilical insertion. It is often detected by routine antenatal ultrasound. Significant maternal and pediatric resources are utilised in the care of women and infants with gastroschisis. Increasing rates of gastroschisis worldwide have led institutions to review local data and investigate outcomes. A collaborative project was developed to review local epidemiology and investigate antenatal and neonatal factors influencing hospital length of stay (LOS) and total parental nutrition (TPN) in infants born with gastroschisis. Methods We performed a five-year review of infants born with gastroschisis (2011–2015) at a major Australian centre. Complex gastroschisis was defined as involvement of stenosis, atresia, ischemia, volvulus or perforation and closed or vanishing gastroschisis. We extracted data from files and databases at the two participating hospitals, a major maternal fetal medicine centre and the affiliated children’s hospital. Results There were 56 infants antenatally diagnosed with gastroschisis with no terminations, one stillbirth (2%) and one infant with ‘vanishing’ gastroschisis. The mean maternal age was 23.9 years (range, 15–39 years). The mean gestation at delivery was 36 weeks (range, 25–39+ 3 weeks). Of the 55 neonates who received surgical management, 62% had primary closure. The median LOS was 33 (IQR, 23–45) days and the median duration of TPN was 26 (IQR, 17–36) days. Longer days on TPN (median 35 vs 16 days, P = 0.03) was associated with antenatal finding of multiple dilated bowel loops. Postnatal diagnosis of complex gastroschisis was made in 16% of cases and was associated with both longer LOS (median 89 vs 30 days, P = 0.003) and days on TPN (median 46 vs 21 days, P = 0.009). Conclusion Complex gastroschisis was associated with greater days on TPN and LOS. We found no late-gestation stillbirths and a low overall rate of 1.8%, suggesting the risk for stillbirth associated with gastroschisis is lower than previously documented. This information may assist counselling families. Improved data collection worldwide may reveal causative factors and enable antenatal outcome predictors

Exploring the COVID-19 pandemic experience of maternity clinicians in a high migrant population and low COVID-19 prevalence country: a qualitative study

BACKGROUND: Australia experienced a low prevalence of COVID-19 in 2020 compared to many other countries. However, maternity care has been impacted with hospital policy driven changes in practice. Little qualitative research has investigated maternity clinicians' perception of the impact of COVID-19 in a high-migrant population. AIM: To investigate maternity clinicians' perceptions of patient experience, service delivery and personal experience in a high-migrant population. METHODS: We conducted semi-structured in-depth interviews with 14 maternity care clinicians in Sydney, New South Wales, Australia. Interviews were conducted from November to December 2020. A reflexive thematic approach was used for data analysis. FINDINGS: A key theme in the data was 'COVID-19 related travel restrictions result in loss of valued family support for migrant families'. However, partners were often 'stepping-up' into the role of missing overseas relatives. The main theme in clinical care was a shift in healthcare delivery away from optimising patient care to a focus on preservation and safety of health staff. DISCUSSION: Clinicians were of the view migrant women were deeply affected by the loss of traditional support. However, the benefit may be the potential for greater gender equity and bonding opportunities for partners. Conflict with professional beneficence principles and values may result in bending rules when a disconnect exists between relaxed community health orders and restrictive hospital protocols during different phases of a pandemic. CONCLUSION: This research adds to the literature that migrant women require individualised culturally safe care because of the ongoing impact of loss of support during the COVID-19 pandemic

[In Press] The BLIiNG study : breastfeeding length and intensity in gestational diabetes and metabolic effects in a subsequent pregnancy : a cohort study

Background: Gestational diabetes mellitus is associated with higher risk for developing type 2 diabetes. Breastfeeding is protective against the development of type 2 diabetes after gestational diabetes. There are no data regarding the effect of breastfeeding on the development of recurrent gestational diabetes. Objective: Investigate the relationship of previous breastfeeding duration and intensity with the recurrence of gestational diabetes, and second pregnancy glucose tolerance test results. Methods: We conducted a questionnaire-based pilot cohort study, enrolling 210 women during a subsequent second pregnancy, after a gestational diabetes-affected first pregnancy. Models for length and intensity of breastfeeding as predictors of the oral glucose tolerance test and for diagnosis of gestational diabetes in second pregnancy were fitted and then adjusted for possible confounders. Results: Recurrent gestational diabetes rate in the study cohort was 70% (n=146). In a fully adjusted model high intensity breastfeeding was associated with a lower 2-hour glucose level on the oral glucose tolerance test (by .66 mmol/L, 95% CI [0.15-1.17]; p=0.01) and breastfeeding greater than six months with a lower 1-hour glucose on the oral glucose tolerance test (by .67 mmol/L, 95% CI [0.16-1.19]; p=0.01), compared to women who breastfed less intensively or for a shorter duration respectively. There was an 18% reduction in the risk of gestational diabetes if a woman breastfed for more than six months (RR 0.82, 95% CI [0.69–0.98]; p=0.03). The association was attenuated in the fully adjusted model (RR 0.89, 95% CI [0.78–1.02]; p=0.09). Conclusions and implications for practice: We found the risk of recurrent gestational diabetes was reduced by both increased duration and intensity of breastfeeding. Antenatal lactation education should be embedded into care pathways for women diagnosed with gestational diabetes

A perinatal review of singleton stillbirths in an Australian metropolitan tertiary centre.

It is estimated that everyday 7000 women worldwide have their pregnancy end with a stillbirth, however, research and data collection on stillbirth remains underfunded. This stillbirth case series audit investigates an apparent rise in stillbirths at a Sydney tertiary referral hospital in Australia. A retrospective case series of singleton stillbirths from 2005-2010 was conducted at Westmead Hospital. Stillbirth was defined as per the Perinatal Society of Australia and New Zealand classification as a death of a baby before or during birth, from the 20th week of pregnancy onwards, or a birth weight of 400 grams or more if gestational age is unknown. A total of 215 singleton stillbirths were identified in a cohort of 28 109, a rate of 7.6 per 1000 singleton births. There was a significant increase in annual stillbirth rate at our institution; the rate exceeded both Australian national and state singleton stillbirth rates. After pregnancy terminations over 20 weeks were excluded from the data, there was no statistical change in the stillbirth rate over time. Congenital anomalies (27%) and unexplained antepartum death (15%) remained as major causes; fetal growth restriction (17%) was also identified as an increasingly important cause, particularly in preterm gestations. Termination of pregnancy after 20 weeks was found to be the cause of rising stillbirth rate at our institution. Local and national data collection on stillbirth should be standardised and should include differentiation of termination of pregnancy as a separate entity so as to accurately assess stillbirth to target appropriate research and resource allocation

Percentage of consanguinity in Westmead stillbirth population from 2005–2010.

<p>Percentage of consanguinity in Westmead stillbirth population from 2005–2010.</p

Demographics and clinical characteristics of women with stillbirths.

<p>Demographics and clinical characteristics of women with stillbirths.</p

Cause of stillbirth using PSANZ perinatal death classification- comparison of Westmead Hospital singleton data and national data.

<p>Cause of stillbirth using PSANZ perinatal death classification- comparison of Westmead Hospital singleton data and national data.</p