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BACKGROUND: The benefit of antenatal corticosteroid (ACS) administration for the prevention of neonatal morbidity and mortality has been well described for preterm infants. Some studies have demonstrated a benefit for infants born by elective caesarean section (CS) at late preterm or term gestations. However, the neonatal benefits of ACS are not well described when given to pregnant women with diabetes. AIMS: The aim of this study was to evaluate the neonatal outcomes following ACS administration in women with pre-gestational diabetes mellitus (PGDM) when administered prior to elective CS after 36 weeks gestation. METHODS: This retrospective observational study included all women with PGDM who gave birth by elective CS between 36+0 and 38+6 weeks gestation. Neonatal outcomes for exposed participants were compared to outcomes for non-exposed participants. RESULTS: Of the 306 women identified, 65 (21.2%) were exposed to ACS within seven days prior to birth and 241 (78.8%) were not. Although not statistically significant, ACS-exposed infants born prior to 38+0 weeks were less likely to require respiratory support or neonatal nursery admission compared to those who were not exposed; however, exposed infants born after 37+0 weeks were more likely to require parenteral treatment for neonatal hypoglycaemia. CONCLUSION: This study did not demonstrate any statistically significant beneficial or harmful effects of ACS in neonates of women with PGDM who are born by elective CS. While it is plausible that ACS could reduce neonatal respiratory morbidity in this population, further prospective studies evaluating the benefits and harms are required before recommending this practice.

OBJECTIVE: To evaluate the common and severe maternal morbidities associated with medical termination of pregnancy (MTOP) for fetal anomaly ≥20 weeks' gestation. METHODS: A 10-year retrospective cohort study (January 2010-December 2019) analyzing 407 consecutive singleton pregnancies MTOP for fetal anomaly ≥20 weeks' gestation, at a quaternary maternity centre in Australia (Royal Women's Hospital, Melbourne). RESULTS: The cohort comprised of 191 primiparous and 216 multiparous women, of whom 75 (34.7%) had at least one prior Cesarean; 13 women had a low-lying placenta or placenta praevia. The average gestation was 23 weeks (interquartile range 22-26 weeks). A spontaneous unassisted vaginal delivery was achieved by the majority (n = 403, 99.0%). The most common maternal morbidities were transferred to the theater for manual removal of retained placental tissue (n = 65, 16.0%) and postpartum haemorrhage (PPH) (n = 45, 11.1%). Severe maternal morbidity occurred in six cases (1.3%) and included amniotic fluid embolism, cardiac arrest, major obstetric haemorrhage, uterine rupture and intensive care unit admission. There were no maternal deaths. CONCLUSIONS: The most common complications of MTOP for fetal anomaly ≥20 weeks' gestation were manual removal of placenta and PPH. Severe maternal morbidity affected 1 in 81 women.

Pregnancy following renal transplantation is increasingly common. Overall pregnancy outcomes are favourable; however, specific transplant-related risks do exist. In particular, the risk of caesarean delivery is much higher in renal transplant recipients when compared to the general obstetric population. This is owing to the necessity for preterm delivery in cases of severe and early-onset pre-eclampsia and/or fetal growth restriction. We describe two recent cases of renal transplant injury at caesarean delivery at our institution, a tertiary/quaternary obstetric service, which highlight the potential operative risks associated with abdominal surgery. We propose a standardised approach in the care of transplant recipients undergoing caesarean delivery which is aimed at minimising harm and increasing patient safety.

Objective: To investigate if cerebroplacental ratio (CPR) adds to the predictive value of umbilical artery pulsatility index (UA PI) alone – standard of practice – for adverse perinatal outcome in singleton pregnancies. Design and setting: Meta-analysis based on individual participant data (IPD). Population or sample: Ten centres provided 17 data sets for 21 661 participants, 18 731 of which could be included. Sample sizes per data set ranged from 207 to 9215 individuals. Patient populations varied from uncomplicated to complicated pregnancies. Methods: In a collaborative, pooled analysis, we compared the prognostic value of combining CPR with UA PI, versus UA PI only and CPR only, with a one-stage IPD approach. After multiple imputation of missing values, we used multilevel multivariable logistic regression to develop prediction models. We evaluated the classification performance of all models with receiver operating characteristics analysis. We performed subgroup analyses according to gestational age, birthweight centile and estimated fetal weight centile. Main outcome measures: Composite adverse perinatal outcome, defined as perinatal death, caesarean section for fetal distress or neonatal unit admission. Results: Adverse outcomes occurred in 3423 (18%) participants. The model with UA PI alone resulted in an area under the curve (AUC) of 0.775 (95% CI 0.709–0.828) and with CPR alone in an AUC of 0.778 (95% CI 0.715–0.831). Addition of CPR to the UA PI model resulted in an increase in the AUC of 0.003 points (0.778, 95% CI 0.714–0.831). These results were consistent across all subgroups. Conclusions: Cerebroplacental ratio added no predictive value for adverse perinatal outcome beyond UA PI, when assessing singleton pregnancies, irrespective of gestational age or fetal size. Tweetable abstract: Doppler measurement of cerebroplacental ratio in clinical practice has limited added predictive value to umbilical artery alone.

OBJECTIVE: To assess the effect of maternal sildenafil therapy on fetal growth in pregnancies with early-onset fetal growth restriction. DESIGN: A randomised placebo-controlled trial. SETTING: Thirteen maternal-fetal medicine units across New Zealand and Australia. POPULATION: Women with singleton pregnancies affected by fetal growth restriction at 22+0 to 29+6 weeks. METHODS: Women were randomised to oral administration of 25 mg sildenafil citrate or visually matching placebo three times daily until 32+0 weeks, birth or fetal death (whichever occurred first). MAIN OUTCOME MEASURES: The primary outcome was the proportion of pregnancies with an increase in fetal growth velocity. Secondary outcomes included live birth, survival to hospital discharge free of major neonatal morbidity and pre-eclampsia. RESULTS: Sildenafil did not affect the proportion of pregnancies with an increase in fetal growth velocity; 32/61 (52.5%) sildenafil-treated, 39/57 (68.4%) placebo-treated [adjusted odds ratio (OR) 0.49, 95% CI 0.23-1.05] and had no effect on abdominal circumference Z-scores (P = 0.61). Sildenafil use was associated with a lower mean uterine artery pulsatility index after 48 hours of treatment (1.56 versus 1.81; P = 0.02). The live birth rate was 56/63 (88.9%) for sildenafil-treated and 47/59 (79.7%) for placebo-treated (adjusted OR 2.50, 95% CI 0.80-7.79); survival to hospital discharge free of major neonatal morbidity was 42/63 (66.7%) for sildenafil-treated and 33/59 (55.9%) for placebo-treated (adjusted OR 1.93, 95% CI 0.84-4.45); and new-onset pre-eclampsia was 9/51 (17.7%) for sildenafil-treated and 14/55 (25.5%) for placebo-treated (OR 0.67, 95% CI 0.26-1.75). CONCLUSIONS: Maternal sildenafil use had no effect on fetal growth velocity. Prospectively planned meta-analyses will determine whether sildenafil exerts other effects on maternal and fetal/neonatal wellbeing. TWEETABLE ABSTRACT: Maternal sildenafil use has no beneficial effect on growth in early-onset FGR, b

Key content Thrombophilias, whether inherited or acquired, have been linked to adverse pregnancy outcomes, such as pre‐eclampsia, placental abruption, fetal growth restriction, stillbirth, thrombosis and recurrent pregnancy loss in many but not all case–control studies. Prospective cohort studies have confirmed that the majority of women who carry inherited thrombophilias do not experience adverse pregnancy outcomes. Thrombophilia testing is expensive and the positive yield of such investigations, in particular with respect to informing management in a subsequent pregnancy, is low. This review critically evaluates the benefit of thrombophilia testing in the obstetric setting and provides guidance with respect to care of women in a subsequent pregnancy following an adverse outcome. Learning objectives To understand the relationship between the various thrombophilias and pregnancy complications. To appreciate the appropriate role of screening for and treating thrombophilias in the context of such pregnancy complications. Ethical issues Should thrombophilia testing following adverse pregnancy outcome be informed by specific factors in the clinical history? Can placental histopathology help guide selection of women requiring further assessment? Thrombophilias may be associated with thromboembolic complications in later life – is it therefore ethical to withhold testing in women with a history of adverse pregnancy outcomes?

peer-reviewed, Objective To evaluate the correlation between Umbilical Artery (UA) Doppler and its feasibility across categories of maternal BMI in the presence of foetal growth restriction (FGR). Methods 1074 Singleton pregnancies with suspected FGR on ultrasound examination between 24+0 and 36+0 weeks' gestation were reviewed. Evaluation of the UA Doppler was performed at 1‐2 weekly intervals. Abnormal UA Doppler findings and delivery outcomes were compared between the different maternal BMI categories. Results Increased UA pulsatility index (PI > 95th centile) was reported in 81% of obese category 2 patients (BMI <35 ‐ 39.9 kg/m2) compared to a 46% incidence in the remaining categories, normal (BMI <24.9 kg/m2), overweight (BMI <25 ‐ 29.9 kg/) and obese class 1 (BMI <35 ‐ 39.9 kg/m2) (p = 0.001). In absent or reversed end diastolic flow (AEDF/REDF) we found an increasing incidence across the BMI categories (4%‐25%) (p<0.0001). Higher maternal BMI was associated with Lower birthweights and higher C‐section rates. Increasing maternal BMI did not affect successful assessment of UA Doppler. Conclusion There is a positive correlation between increasing maternal BMI and abnormal UA Doppler findings in FGR. Maternal BMI may be considered as an additional risk factor when evaluating UA Doppler for placental insufficiency.