Improving health outcomes for pregnant women with metabolic risk factors

PhDThe epidemic of maternal obesity is increasing worldwide. Simple, effective and acceptable interventions are needed to combat obesity and improve pregnancy outcomes in women with metabolic risk factors such as dyslipidaemia and obesity. Dietary and lifestyle interventions reduce gestational weight gain, however, their effect on maternal and fetal outcomes is not clearly known. I conducted a large pragmatic randomised trial to evaluate the effectiveness of a Mediterranean-based dietary intervention to reduce the risk of adverse maternal and fetal outcomes in pregnant women with metabolic risk factors (The ESTEEM trial). The intervention significantly reduced gestational diabetes and gestational weight gain by an average of 1.2 Kg with some protective effect on fetal outcomes. I analysed the methodological challenges encountered in the trial and discussed applied solutions. I conducted a systematic review on the commonly used dietary assessment tools in trials involving pregnant women to assess their characteristics, validity, and applicability. Self-reporting dietary tools were the most commonly used to assess dietary intake in pregnancy such as food frequency questionnaires. Only 8% of studies validated the chosen tools and applied a defined adherence criterion. I applied the findings of this review to develop and validate a custom designed food frequency questionnaire, and a short 12 items questionnaire, to assess the participants’ adherence in the ESTEEM study. I assessed the dietary intake in a randomised cohort from the ESTEEM study and compared the questionnaires’ accuracy to 24 hour dietary recalls as the reference method. Both the FFQ and the short questionnaire performed well for assessing the adherence to and the intake of key foods in the Mediterranean diet. I systematically reviewed available online information sources on the risks and management of obesity in pregnancy in the English language. I assessed 53 websites for their information credibility, accuracy, readability, content and technological quality. Overall I found that non-governmental funded websites that are obesity-spBart’s charity for the ESTEEM study (grant number 732/2029)

Spotlight on… training

Training in obstetrics and gynaecology has evolved significantly over the past two decades, offering thrilling opportunities to progress women’s health and, at the same time, presenting various challenges to both trainees and trainers. In this Spotlight, we highlight the changes in training reflected in past issues of The Obstetrician and Gynaecologist (TOG) from 2001 until now, initially with the implementation of the Modernising Medical Careers (MMC) training scheme, moving on to the introduction of new subspecialty training and finally the focus on team learning and non‐technical skills. We now recognise the importance of human factors, self‐reflection, and learning from Serious Incidents Requiring Investigation (SIRI) as an integral part of the development of an obstetrician and gynaecologist. We explore the issues of alternative training opportunities allowing doctors to pursue the Certificate of Eligibility for Specialist Registration (CESR) accreditation as an alternative to Certificate of Completion of Training (CCT). In this Spotlight, we also confront the high attrition (Br J Hosp Med 2017;78(6):334–8) and undermining rates reported by trainees, as well as the increasing physician burnout in our speciality

Time’s up on empty zero-tolerance slogans : a national survey concerning sexual harassment

Purpose: The purpose of this paper was to examine the employers’ role in the prevention of sexual harassment within the healthcare workforce. We surveyed all the UK medical schools to inquire about their policies, procedures, complaint numbers and outcomes under the freedom of information law Design/methodology/approach: We submitted freedom of information requests to all 36 medical schools in the UK seeking information on all submitted sexual harassment complaints between January 2008 and January 2018. This included each school disciplinary policies in general and those concerning sexual harassment in specific, the number of formal complaints, and the final outcome of all investigations. Findings: We received interpretable responses from 30/36 contacted medical schools (83%). All 30 schools confirmed having generic code of conduct policies (100%), however, only 12/36 schools (40%) had specific policies and procedures to deal with sexual harassment concerning staff, students or both. None offered any formal training to dealing with sexual harassment. Only three schools confirmed having >5 sexual harassment complaints (3/30, 10%), thirteen had <5 complaints (13/30, 43%) and eleven had no complaints at all (11/30, 37%). Research limitations/implications: Policies, structures and processes alone are not sufficient for addressing sexual harassment. Knowing the policies and procedures alone will not prevent misconduct, keeping to the rules and regulations will. Medical Schools should rise to the challenge through concrete boundaries-related educational interventions, not empty slogans of zero tolerance. Originality/value: This paper highlights the employers’ obligation to engage staff in training to ensure compliance with specific rules and regulations for preventing sexual harassment in the healthcare workplace

The risk of miscarriage following COVID-19 vaccination: a systematic review and meta-analysis

STUDY QUESTION: What is the risk of miscarriage among pregnant women who received any of the COVID-19 vaccines? SUMMARY ANSWER: There is no evidence that COVID-19 vaccines are associated with an increased risk of miscarriage. WHAT IS KNOWN ALREADY: In response to the COVID-19 pandemic, the mass roll-out of vaccines helped to boost herd immunity and reduced hospital admissions, morbidity and mortality. Still, many were concerned about the safety of vaccinesfor pregnancy, which may have limited their uptake among pregnant women and those planning a pregnancy. STUDY DESIGN, SIZE, DURATION: For this systematic review and meta-analysis, we searched MEDLINE, EMBASE and Cochrane CENTRAL from inception until June 2022 using a combination of keywords and MeSH terms. PARTICIPANTS/MATERIALS, SETTING, METHODS: We included observational and interventional studies that enrolled pregnant women and evaluated any of the available COVID-19 vaccines compared to placebo or no vaccination. We primarily reported on miscarriage in addition to ongoing pregnancy and/or live birth. MAIN RESULTS AND THE ROLE OF CHANCE: We included data from 21 studies (5 randomised trials and 16 observational studies) reporting on 149,685 women. The pooled rate of miscarriage among women who received a COVID-19 vaccine was 9% (n = 147,49/123,185, 95%CI 0.05-0.14). Compared to those who received a placebo or no vaccination, women who received a COVID-19 vaccine did not have a higher risk of miscarriage (RR 1.07, 95%CI 0.89-1.28, I2 35.8%) and had comparable rates for ongoing pregnancy or live birth (RR 1.00, 95%CI 0.97-1.03, I2 10.72%). LIMITATIONS, REASONS FOR CAUTION: Our analysis was limited to observational evidence with varied reporting, high heterogeneity and risk of bias across included studies, which may limit the generalisability and confidence in our findings. WIDER IMPLICATIONS OF THE FINDINGS: COVID-19 vaccines are not associated with an increase in the risk of miscarriage or reduced rates of ongoing pregnancy or live birth among women of reproductive age. The current evidence remains limited and larger population studies are needed to further evaluate the effectiveness and safety of COVID-19 in pregnancy. STUDY FUNDING/COMPETING INTEREST: No direct funding was provided to support this work. MPR is funded by the Medical Research Council Centre for Reproductive Heath Grant No: MR/N022556/1. BHA hold a personal development award from the National Institute of Health Research in the UK. All authors declare no conflict of interest. REGISTRATION NUMBER: CRD42021289098

Accuracy of imaging modalities for adnexal torsion : a systematic review and meta-analysis

Background Adnexal torsion (AT), a serious gynaecological emergency, often presents with non‐specific symptoms leading to delayed diagnosis. Objective To compare the test accuracy of ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) to diagnose AT. Search strategy We searched EMBASE, MEDLINE and Cochrane CENTRAL until December 2019. Selection criteria Studies reporting on the accuracy of any imaging modality (Index Test) in female patients (paediatric and adult) suspected of AT compared with surgical diagnosis and/or standard clinical/radiological follow‐up period until resolution of symptoms (Reference Standard). Data collection and analysis We assessed study quality using QUADAS‐2. We conducted test accuracy meta‐analysis using a univariate model or a hierarchical model. Main results We screened 3836 citations, included 18 studies (1654 women, 665 cases), and included 15 in the meta‐analyses. Ultrasound pooled sensitivity (n = 12, 1187 women) was 0.79 (95% CI 0.63–0.92) and specificity was 0.76 (95% CI 0.54–0.93), with negative and positive likelihood ratios of 0.29 (95% CI 0.13–0.66) and 4.35 (95% CI 2.03–9.32), respectively. Using Doppler with ultrasound (n = 7, 845 women) yielded similar sensitivity (0.80, 95% CI 0.67–0.93) and specificity (0.88, 95% CI 0.72–1.00). For MRI (n = 3, 99 women), the pooled sensitivity was 0.81 (95% CI 0.63–0.91) and specificity was 0.91 (95% CI 0.80–0.96). A meta‐analysis for CT was not possible with two case‐control studies and one cohort study (n = 3, 232 women). Its sensitivity range was 0.74–0.95 and specificity was 0.80–0.90. Conclusions Ultrasound has good performance as a first‐line diagnostic test for suspected AT. Magnetic resonance imaging could offer improved specificity to investigate complex ovarian morphology, but more evidence is needed

Chance of healthy versus adverse outcome in subsequent pregnancy after previous loss beyond 16 weeks: data from a specialized follow-up clinic

PURPOSE: Women with a previous fetal demise have a 2-20 fold increased risk of another stillbirth in a subsequent pregnancy when compared to those who have had a live birth. Despite this, there is limited research regarding the management and outcomes of subsequent pregnancies. This study was conducted to accurately quantify the chances of a woman having a healthy subsequent pregnancy after a pregnancy loss. METHODS: A retrospective study was conducted at a tertiary-level unit between March 2019 and April 2021. We collected data on all women with a history of previous fetal demise attending a specialized perinatal history clinic and compared the risk of subsequent stillbirth to those with a normal pregnancy outcome. Outcome data included birth outcome, obstetric and medical complications, gestational age and birth weight and mode of delivery. Those who had healthy subsequent pregnancies were compared with those who experienced adverse outcomes. RESULTS: A total of 101 cases were reviewed. Ninety-six women with subsequent pregnancies after a history of fetal demise from 16 weeks were included. Seventy-nine percent of women (n = 76) delivered a baby at term, without complications. Overall, 2.1% had repeat pregnancy losses (n = 2) and 2.1% delivered babies with fetal growth restriction (n = 2). There were no cases of abruption in a subsequent pregnancy. Eighteen neonates were delivered prematurely (18.4%), 15 of these (83.3%) were due to iatrogenic causes and three (16.7%) were spontaneous. In univariable logistic regression analyses, those with adverse outcomes in subsequent pregnancies had greater odds of pre-eclampsia (Odds ratio *(OR) = 3.89, 95% CI = 1.05-14.43, p = .042) and fetal growth restriction (OR = 4.58, 95% CI = 1.41-14.82, p = 0.011) in previous pregnancies compared to those with healthy outcomes. However, in multivariable logistic regression analyses, neither variable had a significant odds ratio (OR = 2.03, 95% CI = 0.44-9.39, p = .366 and OR = 3.42, 95% CI = 0.90 - 13.09, p = .072 for pre-eclampsia and FGR, respectively). CONCLUSION: Four in five women had a healthy subsequent pregnancy. This is a reassuring figure for women when contemplating another pregnancy, particularly if cared for in a specialist clinic

Management of obstetric postpartum hemorrhage: a national service evaluation of current practice in the UK

BACKGROUND: Postpartum hemorrhage (PPH) continues to be one of the major causes of maternal mortality and morbidity in obstetrics. Variations in practice often lead to adverse maternity outcomes following PPH. Our objective was to assess the current practice in managing PPH in the UK. METHODS: We performed a national multicenter prospective service evaluation study over one calendar month and compared the current performance to national standards for managing PPH. We used a standardized data collection tool and collected data on patients’ demographics, incidence of PPH, estimated blood loss (EBL), prophylactic and treatment measures, onset of labor, and mode of delivery. RESULTS: We collected data from 98 obstetric units, including 3663 cases of primary PPH. Fifty percent of cases were minor PPH (EBL 500–1000 mL, n=1900/3613, 52.6%) and the remaining were moderate PPH (EBL >1000 to <2000 mL, n=1424/3613, 39.4%) and severe PPH (EBL >2000 mL, n=289/3613, 8%). The majority of women received active management of the third stage of labor (3504/3613, 97%) most commonly with Syntometrine intramuscular (1479/3613, 40.9%). More than half required one additional uterotonic agent (2364/3613, 65.4%) most commonly with Syntocinon intravenous infusion (1155/2364, 48.8%). There was a poor involvement of consultant obstetricians and anesthetists in managing PPH cases, which was more prevalent when managing major PPH (p=0.0001). CONCLUSION: There are still variations in managing PPH in the UK against national guidelines. More senior doctor involvement and regular service evaluation are needed to improve maternal outcomes following PPH

Management and birth outcomes of pregnant women with Chiari malformations : a 14 years retrospective case series

Objective The management of Chiari malformations in pregnancy is challenging due to the perceived risk of adverse maternal neurological outcomes and raising intracranial pressure during labour. Our aim was to evaluate the management and health outcomes of pregnant women cared for at a regional referral center and highlight elements of best practice. Study Design A retrospective case series of all pregnant women diagnosed with Chiari malformation over fourteen years (January 2004- June 2018) at the Birmingham Women’s Hospital – UK. Results Twenty-one women (23 pregnancies) with Chiari malformation were included, four had syringomyelia (4/21,19%) and six had previously undergone craniovertebral decompression (6/21, 29%). The median age was 34-years (range 20-41), the median gravidity was two (range 1-8), the median parity was one (range 0-6), and the median extent of tonsillar herniation was 11 mm (range 9-18). The majority of women received their preferred mode of delivery (15 normal vaginal deliveries (15/23, 65.2%) and 6 elective Caesarean sections (6/23, 26.1%)) with two pregnancies ending with an emergency caesarean section for obstetric complications (2/23, 8.7%). Five Caesarean section were performed under general anaesthetic, two under spinal (2/23, 8.7%) and one under epidural anaesthesia (1/23, 4.3%) with no neurological sequelae. There were no adverse neurological outcomes at discharge postnatally. Conclusions Offering normal vaginal delivery with effective analgesia, for women with Chiari malformation, appears to be safe. Pregnancy care should be provided by a multi-disciplinary team with experience in managing Chiari malformation

Comparison of perinatal outcomes for all modes of second stage delivery in obstetric theatres : a retrospective observational study

Objective To compare rates of vaginal delivery and adverse outcomes of instrumental delivery trials in obstetric theatre compared to primary emergency full dilatation Caesarean section Design Retrospective cohort study Setting University teaching hospital Population Women with singleton, non-anomalous, pregnancy undergoing instrumental delivery trial in obstetric theatre Methods Data was collected from consecutive cases during 2014 until 2018 using clinical records. Multivariate regression analysis was used comparing groups per first delivery attempt. Main Outcome Measures Primary outcome was completion of vaginal delivery between all methods of instrumental delivery. Secondary outcome was a composite of immediate perinatal adverse outcomes for instrumental delivery modes and primary full dilatation Caesarean section. Results From 971 deliveries analysed: ventouse delivery was significantly less likely to achieve vaginal delivery compared to Keilland’s forceps delivery (OR 0.42, 95%CI 0.22-0.79). Once confounding factors were adjusted for, adverse outcome rates were less frequent in the Keilland’s forceps group compared with primary full dilatation Caesarean section (OR 0.37, 95% CI: 0.16-0.81), however the receiver operating characteristic curve produced from this model demonstrated low predictive value (AUC 0.64). Conclusions Attempting instrumental delivery in delivery suite theatre, as an alternative to primary emergency full dilatation Caesarean section, is both reasonable and safe. Ventouse delivery in this situation may be associated with a higher chance of failure than other modes of instrumental delivery, thus making appropriate choice of delivery method of paramount importance according to each clinical situation. Funding None Keywords Caesarean section, Keilland’s forceps, ventouse, trial of instrumental deliver

Metabolic inflexibility in women with polycystic ovary syndrome : a systematic review

Polycystic ovary syndrome (PCOS) is a risk factor for dysglycemia, insulin resistance, and type 2 Diabetes Mellitus (T2DM). Inefficient energy oxidation, metabolic inflexibility, is a marker of blunted metabolism. We conducted a systematic review on metabolic inflexibility in women with PCOS. We searched MEDLINE, EMBASE and Cochrane central (inception-October 2018) for studies evaluating metabolic inflexibility and reporting on changes in Respiratory Quotient (ΔRQ). We extracted data and assessed quality using The Newcastle–Ottawa Scale. We included five prospective cohort studies (461 women). Three compared PCOS women to unaffected subjects, one to women with obesity or T2DM, and one to adolescent girls; all had medium quality. Three studies showed higher metabolic inflexibility in women with PCOS (ΔRQ range 0.05–0.098) compared to unaffected subjects. Women with PCOS had similar metabolic inflexibility compared to those with T2DM (ΔRQ 0.05 ± 0.03 vs 0.06 ± 0.04, p = .98) and obesity (p = .06). Inflexibility was higher in hyperandrogenemic women with PCOS (ΔRQ 0.091 ± 0.060 vs 0.120 ± 0.010, p = .014). ΔRQ was lower in PCOS women with insulin resistance vs those with normal insulin sensitivity (0.04 ± 0.02 vs. 0.07 ± 0.04, p = .007). In conclusion, women with polycystic ovary syndrome appear to have higher metabolic inflexibility associated with hyperandrogenemia and insulin resistance