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There is an opportunity to determine how best to deploy sexually transmitted infection testing technologies to improve health. Our results suggest that a mixed (hub-and-spoke) approach offered the lowest cost per adverse outcome averted. Supplemental digital content is available in the text., Background Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (NG) are common sexually transmitted infections (STIs) associated with adverse outcomes, yet most countries do not test and conduct syndromic management, which lacks sensitivity and specificity. Innovations allow for expanded STI testing; however, cost is a barrier. Methods Using inputs from a pilot program in Botswana, we developed a model among a hypothetical population of 50,000 pregnant women to compare 1-year costs and outcomes associated with 3 antenatal STI testing strategies: (1) point-of-care, (2) centralized laboratory, and (3) a mixed approach (point of care at high-volume sites, and hubs elsewhere), and syndromic management. Results Syndromic management had the lowest delivery cost but was associated with the most infections at delivery, uninfected women treated, CT/NG-related low-birth-weight infants, disability-adjusted life years, and low birth weight hospitalization costs. Point-of-care CT/NG testing would treat and cure the most infections but had the highest delivery cost. Among the testing scenarios, the mixed scenario had the most favorable cost per woman treated and cured ($534/cure). Compared with syndromic management, the mixed approach resulted in a mean incremental cost-effectiveness ratio of $953 per disability-adjusted life years averted, which is cost-effective under World Health Organization's one-time per-capita gross domestic product willingness-to-pay threshold. Conclusions As countries consider new technologies to strengthen health services, there is an opportunity to determine how to best deploy resources. Compared with point-of-care, centralized laboratory, and syndromic management, the mixed approach offered the lowest cost per infection averted and is cost-effective if policy makers' willingness to pay is informed by the World Health Organization's gross domestic product/capita threshold.

Aims To determine whether women with abnormal gestational diabetes (GDM) screening test results short of frank GDM have increased health-services utilization compared to women with normal results. Methods We conducted a retrospective-cohort study among 29,999 women enrolled in Kaiser Permanente Northwest who completed GDM screening (two-step method: 1-h, 50-g glucose-challenge test (GCT); 3-h, 100-g oral-glucose-tolerance test (OGTT)). Test results were categorized as normal GCT (referent, n = 25,535), normal OGTT (n = 2246), abnormal OGTT but not GDM (n = 1477), and GDM (n = 741). Rate ratios (RRs) were calculated for utilization measures and analyses were age- and BMI-adjusted. Results Compared to women with normal GCT, rates for obstetrical ultrasound, noninvasive and invasive antenatal testing, and ambulatory visits to the obstetrics department were significantly greater among women with abnormal OGTT (RRs 1.2 [95%CI 1.1, 1.4], 1.3 [1.1, 1.4], 1.7 [1.3, 2.3], and 1.1 [1.1, 1.1], respectively) and GDM (RRs 1.8, 1.8, 2.0, and 1.3, respectively). Women with abnormal OGTT results were more likely to visit a dietician than women with normal GCT; RRs ranged from 4.0 [3.3, 4.9] for women with abnormal GCT but normal OGTT to 72.1 [64, 81] for women with GDM. Conclusions Health-services utilization increased with severity of glucose result, even among women without GDM.

Mini-commentary on BJOG-20-1640.R2: Aetiologic testing compared with syndromic management for sexually transmitted infections in Human Immunodeficiency Virus-infected pregnant women in South Africa: a non-randomised prospective cohort study

The primary objective of this study was to ascertain if among women with fetal growth restriction (FGR; estimated fetal weight [EFW] 10th percentile) the frequency of severe FGR (sFGR; EFW3rd percentile for gestational age) differed among various classes of obesity.This was a retrospective cohort study of all pregnancies complicated by FGR from August 2016- March 2019 at a single center, undergoing weekly antenatal surveillance (biophysical profiles and umbilical artery Doppler). Exclusion criteria included multiple gestation, prenatally diagnosed fetal anomalies, and unknown maternal body mass index (BMI) at the time of the ultrasound exam. We defined fetal growth restriction as an estimated fetal weight less than the 10th percentile for gestational age using Hadlock criteria. Severe FGR was defined as the estimated fetal weight below 3rd percentile for gestational age. Maternal BMI was categorized as non-obese (BMI ≤ 29.9), Class I obesity (30.0-34.9), and Class II or III obesity (≥35.0 kg/mOf 974 women that met the inclusion and exclusion criteria, 678 (70%) were not obese, 151 (15%) had class I obesity, and 145 (15%) had class II or III obesity. Obese women were significantly more likely to be multiparous and had a lower mean gestational age at diagnosis of FGR. Hypertensive disorders were more common with increasing BMI, as was type II diabetes mellitus (Among women with FGR, obese women were more likely to have severe FGR and abnormal Dopplers compared to non-obese women. These findings warrant further study into predictors of adverse outcomes among obese women with FGR. Such information could be useful in counseling patients as to the possible course of disease after diagnosis of fetal growth restriction.

Background: Adverse pregnancy outcomes can be prevented through the early detection and treatment of anaemia, HIV and syphilis during the antenatal period. Rates of testing for anaemia, HIV and syphilis among women attending antenatal services in Indonesia are low, despite its mandate in national guidelines and international policy.Methods: Midwife-held antenatal care records for 2015 from 8 villages in 2 sub-districts within Cianjur district were reviewed, alongside the available sub-district Puskesmas (Community Health Centre) maternity and laboratory records. We conducted four focus group discussions with kaders (community health workers) (n = 16) and midwives (n = 9), and 13 semi-structured interviews with laboratory and counselling, public sector maternity and HIV management and relevant non-governmental organisation staff. Participants were recruited from village, sub-district, district and national level as relevant to role.Results: We were unable to find a single recorded result of antenatal testing for HIV, syphilis or anaemia in the village (566 women) or Puskesmas records (2816 women) for 2015. Laboratory records did not specifically identify antenatal women. Participants described conducting and reporting testing in a largely ad hoc manner; relying on referral to health facilities based on clinical suspicion or separate non-maternity voluntary counselling and testing programs. Participants recognized significant systematic challenges with key differences between the more acceptable (and reportedly more often implemented) haemoglobin testing and the less acceptable (and barely implemented) HIV and syphilis testing. However, a clear need for leadership and accountability emerged as an important factor for prioritizing antenatal testing and addressing these testing gaps.Conclusions: Practical solutions such as revised registers, availability of point-of-care tests and capacity building of field staff will therefore need to be accompanied by both funding and political will to coordinate, prioritize and be accountable for testing in pregnancy.

Gestational diabetes mellitus (GDM) is carbohydrate intolerance resulting in hyperglycemia with onset during pregnancy. The article aims to provide clinicians with a working framework to minimize maternal and neonatal morbidity. Landmark historical and recent data are reviewed and presented to provide clinicians with a quick, easy reference for recognition and management of GDM. Data presented tie in insights with underlying pathophysiologic processes leading to GDM. Screening and diagnostic thresholds are discussed along with management upon diagnosis. Good clinical practice regarding screening, diagnosis, and management of GDM effectively reduces risk and improves outcomes of women and fetuses in affected pregnancies.

Antenatal Results and Choices supports parents through antenatal testing and its consequences

BACKGROUND: Alloimmunisation due to irregular erythrocyte antibodies is a recognised cause of hemolytic disease of the fetus and newborn (HDFN). Prior knowledge of red cell alloimmunisation in pregnant females guides the obstetrician to monitor the foetus for HDFN and if required for appropriated intervention. As limited data are available on prevalence of red cell alloimmunisation in pregnant females in India, the current study was carried out to know the prevalence of red cell alloimmunisation in pregnant females coming at our laboratory. METHODS: Screening for irregular erythrocyte antibodies was performed in 1960 pregnant females after obtaining informed consent between June 2015 and June 2016. MatrixTM screening and identification reagent red cells from Tulip Diagnostics (P) Ltd were used, and column agglutination technique was employed as a method for the test. RESULTS: Twenty antibodies (all of single specificity) were detected in 1960 samples giving a prevalence rate of alloimmunisation of 1.02%. Out of the 20 antibodies, 18 were identified to be anti-D, 1 was anti-c and 1 antibody was anti-H. The results obtained were then compared with those reported in the literature. CONCLUSION: Red cell alloimmunisation is not uncommonly observed in pregnant females; the information gained can help the obstetrician to identify high-risk cases to timely start antenatal and post-natal treatment. Obstetricians should request screening for irregular red cell antibody desirably in all pregnant females; however, if limiting factors are there, it should be done at least in select group of pregnant females having bad obstetric history.

Chronic hypertension affects up to 5% of pregnancies. Women can be stratified into low-risk or high-risk chronic hypertension based on baseline laboratory and diagnostic work-up, comorbid conditions, and outcomes in prior pregnancies. Pregnancies complicated by chronic hypertension are at risk for increased adverse maternal and neonatal outcomes including superimposed preeclampsia, fetal growth restriction, placental abruption, and perinatal death. Mainstays of management include blood pressure control, close monitoring for development of superimposed preeclampsia, serial ultrasound assessment of fetal growth, and antenatal testing after 32 weeks.

Objective Pregnancies complicated by maternal preexisting diabetes have a 4-5-fold increased risk of stillbirth, and consequently routine antenatal nonstress testing (NST) was implemented into clinical practice decades ago. Though, international guidelines lack consensus and recommend anything from twice weekly testing from 32 weeks to once weekly testing from 38 weeks. The objective of this study was to examine how routine antenatal NST was used in centers with specific interest and dedication in the care of pregnant women with preexisting diabetes. Study Design An electronic survey concerning the routine use of antenatal NST was sent to members of the European Diabetic Pregnancy Study Group (DPSG) between October 2016 and January 2017, representing in total 55 centers in 26 countries taking care of pregnant women with diabetes. Results Answers from 38 centers (69.1 % (38/55)) in 22 countries were received. Based on real world information from these primarily European centers, anything from avoiding routine antenatal NST to testing twice weekly from early in third trimester in women with preexisting diabetes was reported. NST was commonly used (71.1 % of centers) if insulin treatment was needed. NST was also used among diet treated women with type 2 diabetes in several places. The use varied markedly within and between countries. The most common practice was routine NST once weekly from 32 weeks. Conclusion Among pregnant women with preexisting diabetes, routine antenatal testing practice with NST differs considerably both within and between countries. Studies examining the cost benefit of routine antenatal NST in pregnancies in women with the different types of diabetes are needed.

Infertility is considered a major public health issue, and approximately 1 out of 6 people worldwide suffer from infertility during their reproductive lifespans. Thanks to technological advances, genetic tests are becoming increasingly relevant in reproductive medicine. More genetic tests are required to identify the cause of male and/or female infertility, identify carriers of inherited diseases and plan antenatal testing. Furthermore, genetic tests provide direction toward the most appropriate assisted reproductive techniques. Nevertheless, the use of molecular analysis in this field is still fragmented and cumbersome. The aim of this review is to highlight the conditions in which a genetic evaluation (counselling and testing) plays a role in improving the reproductive outcomes of infertile couples. We conducted a review of the literature, and starting from the observation of specific signs and symptoms, we describe the available molecular tests. To conceive a child, both partners' reproductive systems need to function in a precisely choreographed manner. Hence to treat infertility, it is key to assess both partners. Our results highlight the increasing importance of molecular testing in reproductive medicine.

Background HIV, syphilis, malaria and anaemia are leading preventable causes of adverse pregnancy outcomes in sub-Saharan Africa yet testing coverage for conditions other than HIV is low. Availing point-of-care tests (POCTs) at rural antenatal health facilities (dispensaries) has the potential to improve access and timely treatment. Fundamental to the adoption of and adherence to new diagnostic approaches are healthcare workers’ and pregnant women’s (end-users) buy-in. A qualitative approach was used to capture end-users’ experiences of using POCTs for HIV, syphilis, malaria and anaemia to assess the appropriateness, acceptability and feasibility of integrated testing for ANC. Methods Seven dispensaries were purposively selected to implement integrated point-of-care testing for eight months in western Kenya. Semi-structured interviews were conducted with 18 healthcare workers (14 nurses, one clinical officer, two HIV testing counsellors, and one laboratory technician) who were trained, had experience doing integrated point-of-care testing, and were still working at the facilities 8–12 months after the intervention began. The interviews explored acceptability and relevance of POCTs to ANC, challenges with testing, training and supervision, and healthcare workers’ perspectives of client experiences. Twelve focus group discussions with 118 pregnant women who had attended a first ANC visit at the study facilities during the intervention were conducted to explore their knowledge of HIV, syphilis, malaria, and anaemia, experience of ANC point-of-care testing services, treatments received, relationships with healthcare workers, and experience of talking to partners about HIV and syphilis results. Results Healthcare workers reported that they enjoyed gaining new skills, were enthusiastic about using POCTs, and found them easy to use and appropriate to their practice. Initial concerns that performing additional testing would increase their workload in an already strained environment were resolved with experience and proficiency with the testing procedures. However, despite having the diagnostic tools, general health system challenges such as high client to healthcare worker volume ratio, stock-outs and poor working conditions challenged the delivery of adequate counselling and management of the four conditions. Pregnant women appreciated POCTs, but reported poor healthcare worker attitudes, drug stock-outs, and fear of HIV disclosure to their partners as shortcomings to their ANC experience in general. Conclusion This study provides insights on the acceptability, appropriateness, and feasibility of integrating POCTs into ANC services among end-users. While the innovation was desired and perceived as beneficial, future scale-up efforts would need to address health system weaknesses if integrated testing and subsequent effective management of the four conditions are to be achieved. Electronic supplementary material The online version of this article (10.1186/s12913-018-3844-9) contains supplementary material, which is available to authorized users.

Even though syphilis can be prevented effectively and treated inexpensively, it has remained a global public health problem. Untreated congenital syphilis results in neonatal death, stillbirth, preterm birth, or congenital deformities. Many developing countries have recently instituted syphilis prevention programs in antenatal care, but there has not been a systematic study of the effects of such programs. This paper is the first to study antenatal testing laws initiated in the U.S. in 1938-1947 which mandated physicians and other persons permitted by law to attend to a pregnant woman to test her for syphilis. We use the variation in the timing of state antenatal testing laws to estimate the laws' effect on neonatal mortality rates and deaths due to preterm birth. Using 1931-1947 Vital Statistics data, we find that these laws decreased neonatal mortality rates of nonwhites by 3.15 per 1000 live births (a 8.6% reduction) while having no discernible impact on whites. The laws contributed to an 18% narrowing of the white-nonwhite neonatal mortality gap by 1947. Using 1950 U.S. Census data, we find that mandatory antenatal testing led to a 7% increase in the cohort size of nonwhite poor, which is consistent with the neonatal mortality results. We find universal antenatal testing to be very cost-effective, with an estimated $7600 cost (in 2013 dollars) per life-year saved.

The MERIDIAN study examined whether in-utero MRI (iuMRI) improves the accuracy of diagnosis of foetal brain abnormalities, when used as an adjunct to ultrasound anomaly scanning. A diagnostic iuMRI differs from routine ultrasound screening because of its infrequent use and scanning procedure. Nested within this trial, this sociological study explored the acceptability of iuMRI as a technology and its contribution to parental decision-making. Our sociological interpretation of the role of iuMR images in prenatal diagnosis draws on narrative interviews with women (and some partners) who underwent MRI imaging at three different centres. Overall, participants found iuMRI helpful in decision-making because it either confirmed or disconfirmed previous results, or provided additional information. Expectant couples experienced the iuMR imaging process as informative, but also as having emotive and practical value. Our paper extends the existing sociological literature on antenatal testing and visualising the foetus, by using iuMR diagnostic imaging to further explore the concept of the unborn entity. Our data suggest that alongside the iuMR images, the 'parental gaze' and accompanying commentary are used by parents to construct and transform foetal and parental identities despite ongoing uncertainties about, and shifting social contexts to their pregnancy.

Fetal anomaly screening at 18-21 weeks now routinely includes cleft lip. If detected, the manner in which the diagnosis is communicated can considerably influence prospective parents' decision-making in regard to further testing and termination of pregnancy (TOP). Given the known psychological impact of an antenatal diagnosis of cleft lip on prospective parents, this study aimed to explore the decision-making process from the parents' perspective, in order to evaluate how well current practice is meeting guidelines. Data from 217 parents of children born with cleft lip (with or without cleft palate) were collected using a mixed-methods online survey. Respondents reported feeling upset, offended and/or anxious following the diagnosis, due to unsatisfactory information and a perceived lack of empathy from health professionals. Some respondents had felt under pressure to make a decision quickly, with a minority having regretted undergoing amniocentesis, and/or experiencing significant distress at having come close to TOP unnecessarily. A number of suggestions are made as to how the discussion between parents and health professionals could be improved, to ensure that the information and support needs of families affected by cleft lip are fully addressed.

Twin pregnancies are at increased relative risk of many obstetric complications compared to singletons, including aneuploidy. Antenatal testing for aneuploidy in twin pregnancies, both invasive and noninvasive, has additional complexities compared to singleton pregnancies, in both dizygotic and monozygotic twinning. Although the accuracy of cell-free DNA-based noninvasive prenatal testing (cfDNA NIPT) in twin pregnancies for aneuploidy and fetal Rhesus D status appears comparable to singleton pregnancies, substantially fewer overall tests (and papers published) have been performed in twin pregnancies. Trisomy 18 and trisomy 13, in particular, have not been adequately investigated. Thus, when couples are being counseled for cfDNA NIPT they must be informed that there are insufficient data to definitively demonstrate its accuracy in standard clinical practice at present. Although research in this field is rapidly advancing, certain biological scenarios will mean that cfDNA NIPT will never be 100% accurate, as with current screening and invasive testing.

This chapter provides a quick primer of all aspects of prenatal care for diabetic pregnancies including frequency of blood glucose monitoring, antenatal testing, routine laboratory evaluation, and the timing of delivery.

Antepartum fetal surveillance aims to decrease perinatal morbidity and mortality; however, unnecessary iatrogenic preterm delivery should be avoided as well. Antenatal testing may include contraction stress tests, nonstress tests, biophysical profiles, and modified biophysical profiles. Decreased fetal movement by maternal report is appealing as an inexpensive, simple screening method, but evidence is mixed regarding its utility [1].

Objective: This study aims to compare outcomes of antenatal testing in women who received testing between 40 weeks and 40+6 weeks versus those who received testing at ≥41 weeks. Materials and methods: This retrospective study included women without maternal comorbidities, who were referred for outpatient antenatal testing for gestational age ≥40 weeks. We compared women who received antenatal testing between 40 and 40+6 weeks (Group 1), to those who were only tested at ≥41 weeks (Group 2). Results: A total of 827 Group 1 and 244 Group 2 pregnancies were evaluated. One-hundred and eighty-nine (18%) were sent to labor and delivery (L&D) for further evaluation. There were no significant differences between groups in terms of being sent or admitted to labor and delivery, the reason for which women were sent, induction of labor, mode of delivery, neonatal length of stay, or admission to intensive care. Conclusion: Pregnancies tested at 40 weeks were identified as abnormal and sent to L&D at the same rate as those tested at 41 weeks. Therefore, it may be reasonable to initiate fetal surveillance at the estimated date of delivery.

Background. Infectious diseases are transmissible from mother to unborn child. Appropriate treatment during antenatal care is crucial. Objective. To determine whether routine antenatal tests (syphilis, HIV, Rhesus factor) were performed in women delivering at National District Hospital (NDH), Bloemfontein, South Africa, and whether treatment was initiated for women testing positive for these infections. Methods. This descriptive retrospective study consisted of 2 425 women who delivered between January and December 2016. Antenatal care history was obtained from the delivery register. Results. Nearly all women were tested for syphilis (99.1%), HIV (99.9%) and Rhesus factor (99.9%). A third (33.3%) of the patients who tested positive for syphilis were untreated. Of the 27.0% of patients who tested HIV-positive, 99.7% were recorded to have been on treatment. Just over half (54.3%) of the patients who tested Rhesus-negative received prophylaxis. Conclusion. A record of routine antenatal testing of women delivering at NDH was found. The reaction to positive results could improve.

Background Pakistan is the sixth most populous country in the World. High rates of consanguinity and inter caste marriages have resulted in a substantial burden of inherited metabolic disorders (IMDs). Despite this load, there is a dearth of both medical genetic and clinical metabolic services in Pakistan. There are inadequate numbers of appropriately trained clinicians, ill-equipped laboratories, lack of scientists and technologists equipped with skills to deal with the challenging laboratory investigations involved in IMD and a health care infra-structure unable to support a service. Aim We present the first five year experience of the first established metabolic unit at a tertiary care hospital in Pakistan and present the case for screening of parents, parents’ siblings and antenatal diagnostic testing in subsequent pregnancies in order that families can make informed choices in preventing recurrence. Subjects and methods This retrospective observational study comprising of patients’ chart review was conducted in the Department of Paediatrics, AKUH Karachi in Pakistan for patients who presented to the Clinical Genetics unit from January 2008 to December 2012 seeking diagnosis and treatment for the underlying IMD. Results We evaluated 426 children, of which, 333 (78%) had consanguineous parents. Most patients, 151 (35%). evaluated for IMD were between 1 year and 5 years of age. Developmental delay, seizures, hypotonia, microcephaly, neuroregression, dystonia, ataxia and encephalopathy were the most common reasons for referrals. Only 155 (36%) patients underwent metabolic biochemical testing. Among the investigated group of patients, diagnoses were established for 85 (55%) patients equivalent to only 19.8% of the total. Conclusion Neonatal screening for IMDs and their treatment in the current situation is an unaffordable practical option in Pakistan. Screening parents, siblings and subsequent pregnancies, however, is likely to provide a cost effective and acceptable alternative in reducing the burden and enabling early, effective detection of affected progeny before the stage when neurometabolic changes become irreversible in developing countries like Pakistan with very limited resources.

Objectives Despite limited data, antenatal testing has been initiated in many institutions for women with morbid obesity given their increased risk of stillbirth. Therefore, our objective was to evaluate the obstetrical implications of antenatal testing in the morbidly obese population. Study Design We performed a retrospective cohort study of women undergoing antenatal testing from January 2011 through December 2012 who delivered at our institution. The exposed group was women undergoing antenatal testing with morbid obesity (body mass index [BMI] ≥ 40 kg/m(2)). This group was subdivided into two groups: group 1, which included women undergoing testing for morbid obesity alone, and group 2, which included women undergoing testing for morbid obesity with an additional medical comorbidity. The unexposed group (group 3) comprised nonmorbidly obese women (BMI

Objective: Our primary objective was to determine whether vibroacoustic stimulation (VAS) decreases time to fetal reactivity in the antenatal testing unit (ATU) of a tertiary care center. Methods: We performed a prospective, quality assurance initiative to determine whether VAS could increase the efficiency of our ATU. On pre-specified “VAS days,” VAS was applied for 3 s, if the non-stress test was non-reactive in the first 10 min. Generalized estimating equations models were used to account for within subject correlation due to multiple appointments per patient. Results: VAS use was associated with a 3.76-min reduction in time to reactivity (21.79 vs 25.55, p = 0.011) and a 56% reduction in the need for a biophysical profile (OR: 0.44, 95% CI: 0.21–0.90). Overall, however, we found no significant decrease in time spent on the monitor or in the ATU. Conclusion: Compliance with a strict VAS protocol may improve the efficiency of increasingly busy ATUs.

Strategies for HIV testing vary across Europe, but widespread unacceptably high rates of late diagnosis among women suggest that current testing strategies are not adequately reaching the female population. The only group within the female population that is given specific consideration in guidelines for HIV testing is women who are pregnant, where opt-out testing is often recommended. This article reviews experience from the UK and other European countries with antenatal testing, and trials of routine HIV testing in a range of other settings. Further recommendations for testing strategies for women are required, but need to consider physician barriers to testing, such as constraints on time and training. It is vital to evaluate the motivations that underlie a woman's decision to accept or refuse testing, as these often differ from those of men. Similarly, the consequences of a positive diagnosis for a woman need to be addressed in pre- and post-test discussions.

Pathogenic COL4A2 variants cause abnormalities in collagen production and can have serious implications for a range of organ systems, most notably the brain. Herein, we describe a large family of first-degree relatives affected by a novel heterozygous variant in COL4A2 (c.3490G.A). A wide disease spectrum is described, from asymptomatic to symptomatic, including 2 children with porencephaly and co-existing juvenile idiopathic polyarthritis. During a subsequent pregnancy, antenatal testing identified a positive fetus. In view of the literature, we review management and genetic counselling dilemmas.

Doppler velocimetry has recently become an informative procedure for the real-time and noninvasive evaluation in fetal hemodynamics. The analysis of flow velocity waveforms in various kinds of vessels has been made for not only clarifying fetal physiology and pathophysiology of various disorders but also for determining the most appropriate intervention from the viewpoint of the integrated management protocol. The unique change in both the arterial and venous flow in normal and compromised fetuses has been demonstrated. Clinical applications of the Doppler technique in monitoring the fetus are reviewed.

The objective was to gain a deeper insight into the lived experiences of parents during antenatal testing for Down syndrome and the subsequent birth of their baby. A phenomenological research inquiry used unstructured interviews and thematic framework analysis. Conversations between parents and midwives about Down syndrome, when they occurred, were brief, functional and had a biomedical problem orientation. Antenatal screening failed to meet parents’ expectations of better preparation for birth. After birth, children’s ‘differentness’ rather than health needs was the main focus of care interventions. The inquiry revealed the ‘invisibility’ of the potential child with Down syndrome. Professionals in maternity care services must be equipped with appropriate knowledge about Down syndrome in order to better support parents. Such preparation must include a balanced view of the future of the child, consistent with the principle of reproductive autonomy. Appropriate support after birth is also essential in helping parents to adapt to their new situation.

This report discusses the case of a fetus with previously normal findings of cardiotocograph that experienced an acute neurologic insult antenatally. The fetus presented with abnormalities of its heart rate tracing and its movement patterns on ultrasound. Following delivery, the infant was diagnosed with hypoxic ischemic encephalopathy by DWI in the first 24 h after birth, despite having a normal postnatal brain ultrasound.

In August 2007, the Eunice Kennedy Shriver National Institute of Child Health and Human Development, the National Institutes of Health Office of Rare Diseases, the American College of Obstetricians and Gynecologists, and the American Academy of Pediatrics cosponsored a 2-day workshop to reassess the body of evidence supporting antepartum assessment of fetal well-being, identify key gaps in the evidence, and formulate recommendations for further research. Participants included experts in obstetrics and fetal physiology, and representatives from relevant stakeholder groups and organizations. This article is a summary of the discussions at the workshop, including synopses of oral presentations on the epidemiology of stillbirth and fetal neurological injury, fetal physiology, techniques for antenatal monitoring, and maternal and fetal indications for monitoring. Finally, a synthesis of recommendations for further research compiled from three breakout workgroups is presented.

Stage 1 of routine antenatal RhD immunoglobulin prophylaxis was recommended in late 2002, for RhD negative women having their first child. This was as a result of a 1999 National Health Medical Research Council [NHMRC] recommendation as best practice to further reduce the incidence of HDN due to anti-D. Revised guidelines were released in 2003 by the National Blood Authority with NHMRC endorsement. It is likely that stage 2 [for all pregnancies in RhD negative women] will be in place by early 2005. The introduction of antenatal prophylaxis has raised a number of issues for pathology laboratories: a) frequency of antenatal testing within this new program b) laboratory protocols where the presence of RhD immunoglobulin is confirmed or suspected c) reporting formats in such circumstances d) inventory and supply issues including product traceability e) testing of maternal and cord samples at delivery in women who have received antenatal prophylaxis The Australian & New Zealand Society of Blood Transfusion released revised antenatal testing guidelines in early 2004 to assist laboratories in dealing with some of these issues. Collaboration with ARCBS, CSL and RANZCOG has also resulted in useful information being made available covering other aspects of this new initiative. The presentation will explore some of the above issues leading to more general discussion during the symposium.

We sought to compare two approaches to antenatal testing for their impact on the workforce. This is a prospective observational study of women who presented for antenatal testing. All women were given a survey upon presentation. As per hospital protocol, nonstress testing (NST) was performed semiweekly and biophysical profile (BPP) was performed weekly. The choice of testing was determined by the attending physician. χ2- and Student's t-tests were performed where appropriate. A P-value of

Background: Across Australia there are substantial disparities in uptake of antenatal testing for fetal anomalies, with very low uptake observed among Aboriginal women. The reasons behind these disparities are unclear, although poorer access to testing has been reported in some communities. We interviewed health care practitioners to explore the perceived barriers to providing fetal anomaly screening to Aboriginal women. Methods: In 2009 and 2010, in-depth interviews were undertaken with 59 practitioners in five urban and remote sites across the Northern Territory (NT) of Australia. Data were analyzed thematically. Maximum variation sampling, independent review of findings by multiple analysts, and participant feedback were undertaken to strengthen the validity of findings. Results: Participants included midwives (47%), Aboriginal health practitioners (AHP) (32%), general practitioners (12%), and obstetricians (9%); almost all (95%) were female. Participants consistently reported difficulties counseling women. Explaining the concept of "risk" (of abnormalities and the screening test result) was identified as particularly challenging, because of a perceived lack of an equivalent concept in Aboriginal languages. While AHPs could assist with overcoming language barriers, they are underutilized. Participants also identified impediments to organizing testing including difficulties establishing gestational age, late presentation for care, and a lack of standardized information and training. Discussion: The availability of fetal anomaly testing is challenged by communication difficulties, including a focus on culturally specific biomedical concepts, and organizational barriers to arranging testing. Developing educational activities that address the technical aspects of screening and communication skills will assist in improving access. These activities must include AHPs.

Platelet function disorders are a rare cause of bleeding in hematological practice. The inherited variety includes defects in platelet adhesion, aggregation, secretion and platelet procoagulant activities. The clinical presentation is usually mild with mainly mucocutaneous bleeds. Milder phenotypes may pass off unrecognized in childhood and present later in life. Testing includes a coagulation screen, which may show a prolonged bleeding time, followed by platelet aggregation tests with agonists. Flow cytometry for platelet surface markers, membrane glycoprotein analysis and facilities for identification of the genetic defect are usually available in research laboratories. Recent advances have opened vistas for antenatal testing. Bone marrow transplantation is the only curative therapeutic option available.

Most obstetricians adapt some form of strategy for antenatal fetal testing in pregnancies complicated by gestational diabetes mellitus (GDM). There are, however, wide differences of opinion among providers as to the preferred protocol for such testing. The optimal method of fetal surveillance, the gestational age at which to start testing, the frequency of testing, and even whether all patients with GDM require antenatal testing are all controversial, unresolved issues. Indeed, in the absence of prospective, randomized clinical trials, it is impossible to determine whether antenatal fetal testing is beneficial in uncomplicated GDM. Moreover, it appears that even with the use of well-defined antenatal testing protocols, it is unavoidable that some women with GDM will experience an unexplained third trimester stillbirth. Pending the availability of solid data based on prospective trials, it is prudent to incorporate antenatal fetal testing in the management scheme of women with gestational diabetes.

Mass vaccination with the measles-mumps-rubella (MMR) vaccine for children aged 12-15 months was introduced in 1988; schoolgirl vaccination was discontinued in 1996 and replaced by a second dose of MMR for preschool children and post-partum vaccination of susceptible women identified through antenatal testing. In the UK, declining uptake rates due to concerns about the MMR vaccine, and increasing numbers of cases in some European countries where rubella surveillance and preconceptional vaccination are inadequate, coupled with poor uptake rates, has started to show in the number of rubella-susceptible patients presenting at antenatal clinics (ANCs). In this study, samples were collected in serum separator tubes at the West Middlesex University Hospital (WMUH) ANC and sent to the laboratory. Rubella status was determined using a third-generation rubella IgG enzyme immunoassay. Any negative results were retested and confirmed using an alternative method. The concentrations were expressed as iu/mL (World Health Organization [WHO] standard). Over a five-year period, the number of rubella-susceptible patients increased from 4.1% to 6.8% of the total number of specimens tested. The current population susceptibility levels seem to be influenced by a number of factors: the target population, age at vaccination and the level of coverage, and exposure to wild virus.

The birth rate for women over the age of 40 continues to increase with a rate of 11 births per 1,000 women in 2011.1 Advanced maternal age (AMA) has been associated with an increased riskof stillbirth2–5 even after controlling for risk factors such as hypertension, diabetes, and multiple gestation.2,3 While Fretts et al found an increase in the stillbirth rate among women older than 35 years of age, this rate was significantly higher in women over the age of 40.3 A 2.4-fold increased rate of stillbirth among women 40 years old or greater was noted when compared with women less than 40 years old.3 While the risk of stillbirth increases after 38 weeks for all age groups, Reddy et al noted that it was most remarkable in women over the age of 40, with a hazard of death of 2.5 per 1,000 for ongoing pregnancies in this age category.2 Given the known association of AMA and stillbirth, with a greater risk noted after the age of 40, antenatal testing guidelines have been implemented at many institutions based on maternal age greater than 40 years old. It is plausible that antenatal testing may lead to a higher rate of medical intervention including a higher rate of induction of labor and cesarean delivery. While a higher induction and cesarean delivery rate may be acceptable when the intervention is thought to prevent stillbirths, it is important to understand the implications that antenatal testing has in the AMA population to better counsel our patients. The objective of this study was to evaluate the rate of cesarean delivery and induction of labor among women of AMA who had antenatal testing for AMA compared with those who delivered before the implementation of antenatal testing for AMA. Our hypothesis was that women who undergo antenatal testing for AMA have higher cesarean delivery and induction rates.

Objective: Evaluation and management of patients with multiple maternal antibody isoimmunization is unclear. The presence of ≥ 1 maternal antibody may suggest a worse scenario. The objective of this study was 2-fold: first, to determine whether the presence of multiple antibodies predicts a more severe course than single antibodies and second, to determine the utility of the Queenan curves/protocol in evaluating multiple-antibody isoimmunization. Study Design: Amniotic fluid ΔOD 450 measurements were obtained from the antenatal testing logbook and confirmed by chart review. Cases were categorized by antibody type and clinical outcomes obtained by chart review. Results: Twenty-four pregnancies with isoimmunization and multiple maternal antibodies were identified; of these, 17 had 2 antibodies (anti-D and -C in 13; anti-D and -E in 1; anti-D and -Jka in 1; anti-c and -E in 1; and anti-c and -Jka in 1), and 7 had > 2 antibodies (anti-D, -C, and -E in 4; anti-D, -C, and -N in 1; anti-c, -E, and -FYA in 1; and anti-E, -K, -Fya, -S, and -C in 1). Eleven patients (46%) required at least 1 intrauterine fetal transfusion (mean initial fetal hematocrit, 15%; range, 4.9%-24%). In those not transfused, no ΔOD 450 measurements occurred in the Queenan "fetal death risk" zone. Poorest outcomes (multiple transfusions/hydrops/fetal demise) were in patients with anti-D and anti-C, with or without anti-E. The absence of anti-D was associated with no need for fetal transfusions. The overall transfusion rate was significantly higher compared with a group of 57 isoimmunization patients with only anti-D (46% vs 25%, P ≤.05). Conclusions: The presence of anti-D appears to be the most significant factor guiding the course of isoimmunization with multiple antibodies. The presence of another antibody with anti-D appears to significantly increase the need for intrauterine fetal transfusions. The Queenan protocol can successfully treat patients with multiple maternal red blood cell antibodies. (Am J Obstet Gynecol 2001;185:481-4.)

About 5% of babies are born postterm (that is, delivered after 42 completed weeks of gestation). Postterm infants experience more morbidity and mortality than term infants, prompting routine (and expensive) antenatal testing and active management of postterm pregnancies. This article reviews the epi

Premature births are related to devastating long-term physical complications for newborn infants. To decrease these infant complications and the ensuing extreme financial expenses, Lovelace Health Systems in Albuquerque, New Mexico, developed and implemented a comprehensive Prematurity Prevention Program for all high-risk obstetric patients. The major program components have included program coordination, nutrition counseling, social services, and antenatal testing. The objective of this study was to compare corresponding neonatal outcomes from the 12 months prior to the beginning of the program to each of the first three working years of the program to determine whether outcome improvements were achieved and maintained. Total preterm delivery rates were significantly reduced in 1995–1996 (year 3) in comparison with 1992–1993 (year prior to the program's initiation). During 1993—1994 (year 1) and 1995–1996 (year 3), preterm delivery rates caused by preterm labor only were also significantly decreased. For...

In this study, we assess practice changes made in response to the threat of tort liability in the field of obstetrics, which has one of the highest levels of premiums, claim frequency, and mean dollar value of paid claims. There is much "conventional wisdom" about effects of tort liability risk on obstetrical practice based on obstetricians' perceptions of changes that have occurred. Our data comes from the Survey of Obstetrical Care in 1992, a survey of 963 women who had given birth in 1987 in 31 counties in Florida conducted for purposes of this study and related studies of medical malpractice and birth outcomes. Our results suggest that some antenatal testing is responsive to variation in the threat of being used. But for most measures included in our study, half of the antenatal testing variables, the decision to perform a cesarean section, and various dimensions of maternal satisfaction with care, our empirical analysis failed to reveal that obstetricians practice more "defensively" in areas with relatively high suit rates. (This abstract was borrowed from another version of this item.)

The diagnosis and treatment of the fetus that is small for gestational age (SGA) generally includes those fetuses that have been found to have an estimated fetal weight