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Introduction: Vasa previa (VP), defined as unprotected fetal vessels traversing the membranes over the cervix, is associated with a high perinatal mortality when undiagnosed prenatally. Conversely, prenatal diagnosis with ultrasound and cesarean delivery before the membranes rupture is associated with excellent outcomes. However, controversy exists regarding screening for VP. In the UK, routine screening for VP is not recommended. The objective of this study was to report the incidence of VP and our experience in the detection of VP with a universal screening protocol at the time of the second‐trimester fetal anomaly scan with third‐trimester confirmation in an unselected population of pregnancies. Material and methods: We performed a single‐center historical cohort study of all pregnant women who underwent routine second‐trimester anomaly screening scans at West Middlesex University Hospital, London, UK, between 2012 and 2016. Over 5 years, every patient undergoing routine anomaly screening was evaluated for VP using a systematic protocol during their 20‐week anomaly scan. Suspected cases of VP were rescanned in the third trimester by specialist sonographers with an interest in VP. The primary outcomes were the incidence and detection of VP. Results: During the study period, 24 690 anatomy scans were performed. A total of 64 patients were identified as having potential VP at the second‐trimester anomaly screening scan, of which 19 were confirmed by the specialist sonographer in the third trimester and at delivery. The screen positive rate was 0.26% (95% confidence interval [CI] 0.20%–0.32%). VP at birth was found in 19/24690 births (1:1299 [95% CI: 1:832–1:2030] births). Universal screening for VP using our protocol had a sensitivity of 100% and a specificity of 99.78% (95% CI: 99.72%–99.84%). The false‐positive rate of the second‐trimester screen was 0.18% (95% CI: 0.13–0.24). There were no false positives or false negatives at delivery. Of the 19 patients with confirmed VP, 17 had scheduled cesarean deliveries, and two required emergency deliveries due to antepartum hemorrhage. One baby died, giving a perinatal mortality of 5%. Conclusions: VP complicates approximately 1:1300 pregnancies. Routine screening for VP yielded a 100% detection rate. We suggest the inclusion of structured VP assessment in standard fetal anomaly screening programs. [ABSTRACT FROM AUTHOR]

LEGAL ASPECTS RELATING TO PRENATAL DIAGNOSIS The guidance also clarifies legal aspects in relation to termination of pregnancy for a germline cancer susceptibility gene variant. Prenatal and pre-implantation genetic testing for monogenic disorders for germline cancer susceptibility gene variants: UK joint consensus guidance Although it is anticipated that there would be fewer requests for prenatal diagnosis or PGT-M for moderate penetrance genes and sex-specific variable penetrance genes, sensitive reproductive counselling by an appropriately trained genetic/genomic healthcare professional and case discussion in multidisciplinary forums is recommended. Testing for germline pathogenic variants in cancer susceptibility genes is now commonplace and routine practice, in order to guide management of individuals with cancer and to determine surveillance and risk-reduction options for those at increased genetic risk. [Extracted from the article]

Introduction: Perinatal palliative care services are increasingly available globally, offering a range of clinical and psychological support services to families during pregnancy, in the neonatal period and following the death of a baby with a life‐limiting or life‐threatening condition. Little is understood about the role of children's hospice care and how it contributes to effective perinatal palliative care. Design: The study aims to answer the question "what is the role of children's hospices in the provision of perinatal palliative care and advance care planning in the United Kingdom?" Methods: An electronic survey was sent to all 54 children's hospices in the United Kingdom between May and June 2022. Results: Thirty hospices responded, representing 54% of the sector. All regions of all four counties are represented. Numbers of referrals to hospices for perinatal palliative care have increased significantly over the last 5 years. Hospices provide a range of services for families and babies, usually from the point of diagnosis or recognition of a life‐limiting or life‐threatening condition, underpinned with counseling and emotional support. Hospices worked with a range of professionals and services, most commonly fetal medicine and neonatal services. Advance care plans were an important element of effective perinatal palliative care, strengthening parent–professional and interprofessional relationships. Conclusion: Children's hospice services play an important and growing role in the perinatal care of babies and families following the diagnosis or recognition of a life‐limiting or life‐threatening condition. The family‐centered approach to care, from a broad, biopsychosocial perspective means that hospices make a unique and meaningful contribution to both the clinical and psychological needs of families. Clinical relevance: The family‐centered approach to care, from a broad, biopsychosocial perspective means that hospices make an important contribution to both the clinical needs of babies, and psychological needs of families antenatally, in the neonatal period and after death. [ABSTRACT FROM AUTHOR]

Introduction: Consanguineous unions occur when a couple are related outside marriage and is associated with adverse genetic and perinatal outcomes for affected offspring. The objectives of this study were to evaluate: (i) background characteristics, (ii) uptake of prenatal and postnatal investigation and (iii) diagnostic outcomes of UK consanguineous couples presenting with a fetal structural anomaly.Material and Methods: This was a retrospective and partly prospective cohort study comparing consanguineous (n = 62) and non-consanguineous (n = 218) pregnancies with current or previous fetal structural anomalies reviewed in a UK prenatal genetic clinic from 2008 to 2019. Outcomes were compared using odds ratios (OR).Results: Most consanguineous couples were of Pakistani ethnicity (odds ratio [OR] 29, 95% confidence interval [95% CI] 13-62) and required use of an interpreter [OR 9, 95% CI 4-20). In the consanguineous group, the uptake of prenatal invasive testing was lower (OR 0.4, 95% CI 0.2-0.7) and the number declining follow up was greater (OR 10, 95% CI 3-34) than in the non-consanguineous group. This likely explained the lower proportion of consanguineous couples where a final definitive unifying diagnosis to explain the fetal structural anomalies was reached (OR 0.3, 95% CI 0.2-0.6). When a diagnosis was obtained in this group, it was always postnatal and most often using genomic sequencing technologies (OR 6, 95% CI 1-27). The risk of perinatal death was greater (OR 3, 95% CI 1-6) in the consanguineous group, as was the risk of fetal structural anomaly recurrence in a subsequent pregnancy (OR 4, 95% CI 1-13). There was no difference in the uptake of perinatal autopsy or termination of pregnancy between groups.Conclusions: Consanguineous couples are a vulnerable group in the prenatal setting. Although adverse perinatal outcomes in this group are more common secondary to congenital anomalies, despite the evolution of genomic sequencing technologies, due to a lower uptake of prenatal testing it is less likely that a unifying diagnosis is obtained and recurrence can occur. There is a need for proactive genetic counseling and education from the multidisciplinary team, addressing language barriers as well as religious and cultural beliefs in an attempt to optimize reproductive options. [ABSTRACT FROM AUTHOR]

Objective: To develop enhanced prediction models to update the QUiPP App prototype, a tool providing individualized risk of spontaneous preterm birth (sPTB), for use in women with symptoms of threatened preterm labor (TPTL), incorporating risk factors, transvaginal ultrasound assessment of cervical length (CL) and cervicovaginal fluid quantitative fetal fibronectin (qfFN) test results.Methods: Participants were pregnant women between 23 + 0 and 34 + 6 weeks' gestation with symptoms of TPTL, recruited as part of four prospective cohort studies carried out at 16 UK hospitals between October 2010 and October 2017. The training set comprised all women whose outcomes were known in May 2017 (n = 1032). The validation set comprised women whose outcomes were gathered between June 2017 and March 2018 (n = 506). Parametric survival models were developed for three combinations of predictors: risk factors plus qfFN test results alone, risk factors plus CL alone, and risk factors plus both qfFN and CL. The best models were selected using the Akaike and Bayesian information criteria. The estimated probability of sPTB < 30, < 34 or < 37 weeks' gestation and within 1 or 2 weeks of testing was calculated and receiver-operating-characteristics (ROC) curves were created to demonstrate the diagnostic ability of the prediction models.Results: Predictive statistics were similar between the training and the validation sets at most outcome time points and for each combination of predictors. Areas under the ROC curves (AUC) demonstrated that all three algorithms had good accuracy for the prediction of sPTB at < 30, < 34 and < 37 weeks' gestation and within 1 and 2 weeks' post-testing in the validation set, particularly the model combining risk factors plus qfFN alone (AUC: 0.96 at < 30 weeks; 0.85 at < 34 weeks; 0.77 at < 37 weeks; 0.91 at < 1 week from testing; and 0.92 at < 2 weeks from testing).Conclusions: Validation of the new prediction models suggests that the QUiPP App v.2 can reliably calculate risk of sPTB in women with TPTL. Use of the QUiPP App in practice could lead to better targeting of intervention, while providing reassurance and avoiding unnecessary intervention in women at low risk. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

Objectives: Accurate mid-pregnancy prediction of spontaneous preterm birth (sPTB) is essential to ensure appropriate surveillance of high-risk women. Advancing the QUiPP App prototype, QUiPP App v.2 aimed to provide individualized risk of delivery based on cervical length (CL), quantitative fetal fibronectin (qfFN) or both tests combined, taking into account further risk factors, such as multiple pregnancy. Here we report development of the QUiPP App v.2 predictive models for use in asymptomatic high-risk women, and validation using a distinct dataset in order to confirm the accuracy and transportability of the QUiPP App, overall and within specific clinically relevant time frames.Methods: This was a prospective secondary analysis of data of asymptomatic women at high risk of sPTB recruited in 13 UK preterm birth clinics. Women were offered longitudinal qfFN testing every 2-4 weeks and/or transvaginal ultrasound CL measurement between 18 + 0 and 36 + 6 weeks' gestation. A total of 1803 women (3878 visits) were included in the training set and 904 women (1400 visits) in the validation set. Prediction models were created based on the training set for use in three groups: patients with risk factors for sPTB and CL measurement alone, with risk factors for sPTB and qfFN measurement alone, and those with risk factors for sPTB and both CL and qfFN measurements. Survival analysis was used to identify the significant predictors of sPTB, and parametric structures for survival models were compared and the best selected. The estimated overall probability of delivery before six clinically important time points (< 30, < 34 and < 37 weeks' gestation and within 1, 2 and 4 weeks after testing) was calculated for each woman and analyzed as a predictive test for the actual occurrence of each event. This allowed receiver-operating-characteristics curves to be plotted, and areas under the curve (AUC) to be calculated. Calibration was performed to measure the agreement between expected and observed outcomes.Results: All three algorithms demonstrated high accuracy for the prediction of sPTB at < 30, < 34 and < 37 weeks' gestation and within 1, 2 and 4 weeks of testing, with AUCs between 0.75 and 0.90 for the use of qfFN and CL combined, between 0.68 and 0.90 for qfFN alone, and between 0.71 and 0.87 for CL alone. The differences between the three algorithms were not statistically significant. Calibration confirmed no significant differences between expected and observed rates of sPTB within 4 weeks and a slight overestimation of risk with the use of CL measurement between 22 + 0 and 25 + 6 weeks' gestation.Conclusions: The QUiPP App v.2 is a highly accurate prediction tool for sPTB that is based on a unique combination of biomarkers, symptoms and statistical algorithms. It can be used reliably in the context of communicating to patients the risk of sPTB. Whilst further work is required to determine its role in identifying women requiring prophylactic interventions, it is a reliable and convenient screening tool for planning follow-up or hospitalization for high-risk women. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

Objective: The M6 risk-prediction model was published as part of a two-step protocol using an initial progesterone level of ≤ 2 nmol/L to identify probable failing pregnancies (Step 1) followed by the M6 model (Step 2). The M6 model has been shown to have good triage performance for stratifying women with a pregnancy of unknown location (PUL) as being at low or high risk of harboring an ectopic pregnancy (EP). This study validated the triage performance of the two-step protocol in clinical practice by evaluating the number of protocol-related adverse events and how effectively patients were triaged.Methods: This was a prospective multicenter interventional study of 3272 women with a PUL, carried out between January 2015 and January 2017 in four district general hospitals and four university teaching hospitals in the UK. The final pregnancy outcome was defined as: a failed PUL (FPUL), an intrauterine pregnancy (IUP) or an EP (including persistent PUL (PPUL)). FPUL and IUP were grouped as low-risk and EP/PPUL as high-risk PUL. Serum progesterone and human chorionic gonadotropin (hCG) levels were measured at presentation in all patients. If the initial progesterone level was ≤ 2 nmol/L, patients were discharged and were asked to have a follow-up urine pregnancy test in 2 weeks to confirm a negative result. If the progesterone level was > 2 nmol/L or a measurement had not been taken, hCG level was measured again at 48 h and results were entered into the M6 model. Patients were managed according to the outcome predicted by the protocol. Those classified as 'low risk, probable FPUL' were advised to perform a urine pregnancy test in 2 weeks and those classified as 'low risk, probable IUP' were invited for a scan a week later. When a woman with a PUL was classified as high risk (i.e. risk of EP ≥ 5%) she was reviewed clinically within 48 h. One center used a progesterone cut-off of ≤ 10 nmol/L and its data were analyzed separately. If the recommended management protocol was not adhered to, this was recorded as a protocol deviation and classified as: unscheduled visit for clinician reason, unscheduled visit for patient reason or incorrect timing of blood test or ultrasound scan. The classifications outlined in the UK Good Clinical Practice (GCP) guidelines were used to evaluate the incidence of adverse events. Data were analyzed using descriptive statistics.Results: Of the 3272 women with a PUL, 2625 were included in the final analysis (317 met the exclusion criteria or were lost to follow-up, while 330 were evaluated using a progesterone cut-off of ≤ 10 nmol/L). Initial progesterone results were available for 2392 (91.1%) patients. In Step 1, 407 (15.5%) patients were classified as low risk (progesterone ≤ 2 nmol/L), of whom seven (1.7%) were ultimately diagnosed with an EP. In 279 of the remaining 2218 women with a PUL, the M6 model was not applied owing to protocol deviation or because the outcome was already known (usually on the basis of an ultrasound scan) before a second hCG reading was taken; of these patients, 30 were diagnosed with an EP. In Step 2, 1038 women with a PUL were classified as low risk, of whom eight (0.8%) had a final outcome of EP. Of 901 women classified as high risk at Step 2, 275 (30.5%) had an EP. Therefore, 275/320 (85.9%) EPs were correctly classified as high risk. Overall, 1445/2625 PUL (55.0%) were classified as low risk, of which 15 (1.0%) were EP. None of these cases resulted in a ruptured EP or significant clinical harm. Sixty-two women participating in the study had an adverse event, but no woman had a serious adverse event as defined in the UK GCP guidelines.Conclusions: This study has shown that the two-step protocol incorporating the M6 model effectively triaged the majority of women with a PUL as being at low risk of an EP, minimizing the follow-up required for these patients after just two visits. There were few misclassified EPs and none of these women came to significant clinical harm or suffered a serious adverse clinical event. The two-step protocol incorporating the M6 model is an effective and clinically safe way of rationalizing the management of women with a PUL. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

Heart problems are common in newborn babies, affecting approximately 5-10 in 1000 babies. Some are more serious than others, but most babies born with heart problems do not have other health issues. Of those babies who have a serious heart problem, almost 1 in 4 will have heart surgery in their first year. In the UK, pregnant women are offered a scan at around 20 weeks to try and spot any heart problems. In most cases there is not a clear reason for the problem, but sometimes other issues, such as genetic conditions, are discovered. In recent years the care given to these babies after they are born has improved their chances of surviving. However, it is recognised that babies born with heart problems have a risk of delays in their learning and development. This may be due to their medical condition, or as a result of surgery and complications after birth. In babies with heart problems, there is a need for more research on ultrasound and magnetic resonance imaging (MRI) to understand how the brain develops and why these babies are more likely to have delays in learning and development. This paper discusses the way ultrasound and MRI are used in assessing the baby's brain. Ultrasound is often used to spot any problems, looking at how the baby's brain develops in pregnancy. Advances in ultrasound technologies have made this easier. MRI is well-established and safe in pregnancy, and if problems in the brain have been seen on ultrasound, MRI may be used to look at these problems in more detail. While it is not always clear what unusual MRI findings can mean for the baby in the long term, increased understanding may mean parents can be given more information about possible outcomes for the baby and may help to improve the counselling they are offered before their baby's birth. [ABSTRACT FROM AUTHOR]

Objective: To report on the routine clinical implementation of cell-free DNA (cfDNA) analysis of maternal blood for trisomies 21, 18 and 13, contingent on the results of the first-trimester combined test in twin pregnancy.Methods: Screening for trisomies 21, 18 and 13 was carried out in 959 twin pregnancies by assessment of a combination of maternal age, fetal nuchal translucency thickness, and serum free β-human chorionic gonadotropin and pregnancy-associated plasma protein-A at 11-13 weeks' gestation in two UK NHS hospitals. Women in the high-risk group (risk ≥ 1 in 100) were offered the option of invasive testing, cfDNA testing or no further testing, and those in the intermediate-risk group (risk 1 in 101 to 1 in 2500 in the first phase of the study and 1 in 101 to 1 in 500 in the second phase) were offered cfDNA or no further testing. The trisomic status of the pregnancies was determined by prenatal or postnatal karyotyping or examination of the neonates.Results: In 42 (4.4%) of the 959 pregnancies, there was termination, miscarriage or stillbirth with no known karyotype or there was loss to follow-up. The 917 pregnancies with known trisomic status of both twins included six that were discordant for trisomy 21, four that were discordant for trisomy 18 and 907 with no trisomy 21, 18 or 13. Following combined screening, 47 (5.1%), 203 (22.1%) and 667 (72.7%) of the pregnancies were classified as high risk, intermediate risk and low risk, respectively. The high-risk group included five (83.3%) cases of trisomy 21 and three (75.0%) of trisomy 18. The cfDNA test was carried out in 224 pregnancies and results were provided in 214 (95.5%); this group included six pregnancies with trisomy 21, three with trisomy 18 and 206 with no trisomy 21, 18 or 13. The cfDNA test classified correctly as screen positive all six cases of trisomy 21 and two of the three with trisomy 18, and as screen negative for each of the trisomies all 206 unaffected pregnancies. Contingent screening led to prenatal detection of all cases of trisomy 21 and three of four with trisomy 18.Conclusion: This study has demonstrated the feasibility of introducing cfDNA testing, contingent on the results of the first-trimester combined test for major trisomies, in a routine population of twin pregnancies. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

Abstract: This article reviews the Nuffield Council on Bioethics’ report on Non‐Invasive Prenatal Testing (NIPT); and introduces two general questions provoked by the report – concerning, respectively, the nature and extent of the informational interests that are to be recognised in today's ‘information societies’ and the membership of today's ‘genetic societies’. The article also considers the role and nature of the Nuffield Council. While the Council's report identifies a range of individual and collective interests that are relevant to determining the legitimate uses of NIPT, we argue that it should put these interests into an order of importance; we sketch how this might be done; and we suggest that, failing such a prioritisation of interests, the Council should present its reflections in a way that engages public debate around a number of options rather than making firm recommendations. [ABSTRACT FROM AUTHOR]

Objectives: Cell-free DNA (cfDNA) analysis of maternal blood for detection of trisomies 21, 18 and 13 is superior to other methods of screening but is expensive. One strategy to maximize performance at reduced cost is to offer cfDNA testing contingent on the results of the first-trimester combined test that is used currently. The objectives of this study were to report the feasibility of implementing such screening, to examine the factors affecting patient decisions concerning their options for screening and decisions on the management of affected pregnancies and to report the prenatal diagnosis of fetal trisomies and outcome of affected pregnancies following the introduction of contingent screening.Methods: We examined routine clinical implementation of contingent screening in 11,692 singleton pregnancies in two National Health Service (NHS) hospitals in the UK. Women with a risk ≥ 1 in 100 (high-risk group) were offered options of invasive testing, cfDNA testing or no further testing, and those with a risk between 1 in 101 and 1 in 2500 (intermediate-risk group) were offered cfDNA testing or no further testing. The trisomic status of the pregnancies was determined by prenatal or postnatal karyotyping or by examination of the neonates.Results: In the study population of 11,692 pregnancies, there were 47 cases of trisomy 21 and 28 of trisomies 18 or 13. Screening with the combined test followed by invasive testing for all patients in the high-risk group potentially could have detected 87% of trisomy 21 and 93% of trisomies 18 or 13, at a false-positive rate of 3.4%; the respective values for cfDNA testing in the high- and intermediate-risk groups were 98%, 82% and 0.25%. However, in the high-risk group, 38% of women chose invasive testing and 60% chose cfDNA testing; in the intermediate-risk group 92% opted for cfDNA testing. A prenatal diagnosis was made in 43 (91.5%) pregnancies with trisomy 21 and all pregnancies with trisomies 18 or 13. In many affected pregnancies the parents chose to avoid testing or termination and 32% of pregnancies with trisomy 21 resulted in live births.Conclusions: Screening for fetal trisomies by cfDNA analysis of maternal blood, contingent on the results of the combined test, can be implemented easily in routine clinical practice. In the high-risk group from the combined test, most but not all women chose cfDNA testing rather than invasive testing. Performance of screening for trisomy 21 was superior by the cfDNA test than by the combined test. However, prenatal detection of trisomies and pregnancy outcome depend not only on performance of screening tests but also on parental choice. [ABSTRACT FROM AUTHOR]

Prenatal screening tests can help to estimate the possibility of a pregnant woman having a baby with trisomy 21 ( Down syndrome). As these tests are optional, it is essential that women are provided with appropriate verbal and written information to enable them to make an informed choice. In this study, we assessed the content and quality of Down syndrome screening information leaflets used by health professionals to provide information to pregnant women in the UK (26 leaflets) and Thailand (11 leaflets). We collected leaflets from health institutions and the Internet, and compared the topics covered in each one against recommendations for patient information on this topic. We also assessed the quality of each leaflet using the DISCERN Genetics tool. While the quality-rating score of the UK leaflets was significantly higher than the Thai leaflets, none of the leaflets included all the recommended topics; some contained erroneous material. In both countries, the quality of information can be improved to provide accurate information to women and their partners, which is essential to ensure prospective parents can make informed choices during pregnancy. [ABSTRACT FROM AUTHOR]

Background Patient autonomy in antenatal screening is a high priority for policy developers in many countries. Objective This paper presents women's understandings of how health professionals should facilitate informed screening choices with an emphasis on their understandings of autonomy and advice. Design, setting and participants The study was carried out in 2009 in the UK, using a qualitative approach. Ninety-eight participants of African, British White, Caribbean, Chinese and Pakistani origin had semi-structured interviews, which were analysed using framework analysis. Results Four themes were identified during the analysis: 'Meanings of advice in antenatal screening: the advice continuum', 'Recognition of the role of health professionals in decision making', 'Understandings of advice in the context of autonomous decision making' and 'Reasons given for wanting advice'. Women said they valued advice from health professionals to make decisions about antenatal screening, but their understandings of 'advice' ranged from information giving only to direction about screening choices. Conclusion Many women wanted health professionals to support the process of making informed choices by engaging in discussion and did not see advice as incompatible with making autonomous choices. However, some women wanted direction about whether to have a screening test or not, something which policy and guidelines explicitly prohibit. This may cause an ethical dilemma for health professionals who are required to both support women's preference for care and adhere to a policy of non-directiveness. Further clarification is needed on how health professionals should support the process of making informed choices when women ask for clear direction on screening choices. [ABSTRACT FROM AUTHOR]

Key content The results of prenatal fetal chromosomal analysis may inform long term prognosis., Recent advances in chromosome microarray (CMA) are enabling genome-wide evaluation of submicroscopic chromosomal changes., Such technological advances promise increased sensitivity and specificity. They also potentially pose challenges of interpretation and clinical management., Learning objectives To systematically review the current literature and explain the benefit and pitfalls of CMAs and their relevance to the practising obstetrician in the NHS., Comment on the future of CMA and its cost effectiveness., Ethical issues Difficulties of informed consent with genome-wide prenatal testing., Difficulties surround results of unknown significance. [ABSTRACT FROM AUTHOR]

SUMMARY Objective To determine if column agglutination technology ( CAT) for titration of anti-D and anti-c concentrations produces comparable results to those obtained by continuous flow analyser ( CFA). Background Anti-D and anti-c are the two commonest antibodies that contribute to serious haemolytic disease of the foetus and neonate ( HDFN). Current practice in the UK is to monitor these antibodies by CFA quantification, which is considered more reproducible and less subjective than manual titration by tube IAT (indirect antiglobulin test). CAT is widely used in transfusion laboratory practice and provides a more objective endpoint than tube technique. Materials and methods Antenatal samples were (i) quantified using CFA and (ii) titrated using CAT with the reaction strength recorded by a card reader and expressed as a titre score ( TS). Results The TS rose in accordance with levels measured by quantification and was able to distinguish antibody levels above and below the threshold of clinical significance. Conclusion CAT titre scores provided a simple and reproducible method to monitor anti-D and anti-c levels. The method was sensitive to a wide range of antibody levels as determined by quantification. This technique may have the potential to replace CFA quantification by identifying those cases that require closer monitoring for potential HDFN. [ABSTRACT FROM AUTHOR]

Objectives To investigate whether prenatal screening is effective in the detection of total anomalous pulmonary venous connection (TAPVC) and to identify common prenatal features. Methods This was a retrospective collaborative study involving 19 pediatric cardiac centers in the UK, Ireland and Sweden. Cases with TAPVC born between January 1, 1998 and December 31, 2004, and prenatally diagnosed cases whose estimated dates of delivery were within this time frame, were identified. Cases with functionally univentricular circulation or atrial isomerism were excluded. All available data and stored images were reviewed. Results Four-hundred and twenty-four cases with TAPVC were identified prenatally or postnatally, of whom eight (1.9%) had a prenatal diagnosis of TAPVC. Median gestational age at fetal diagnosis was 26 + 6 (range, 22 + 4 to 32 + 0) weeks. Six further fetuses with TAPVC had an abnormality diagnosed on prenatal ultrasound, but not the TAPVC. This included other congenital heart defects (four cases) and isolated pleural effusion (two cases). Seventeen (4.0%) of the 422 liveborn infants had a first-degree relative with congenital heart disease; and six of 17 had a sibling with TAPVC. Two died in utero. Of the liveborn infants diagnosed prenatally with TAPVC, none required urgent intervention for pulmonary venous obstruction and all were alive and well at a median of 2.3 (range, 1.0-7.0) years after surgical repair. Conclusion Prenatal diagnosis of TAPVC is infrequent using current screening methods. Where there is a family history of TAPVC, specialized fetal echocardiography at 20 and 28 weeks' gestation may be indicated. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Background Evidence suggests that in decision contexts characterized by uncertainty and time constraints (e.g. health-care decisions), fast and frugal decision-making strategies (heuristics) may perform better than complex rules of reasoning. Objective To examine whether it is possible to design deliberation components in decision support interventions using simple models (fast and frugal heuristics). Design The 'Take The Best' heuristic (i.e. selection of a 'most important reason') and 'The Tallying' integration algorithm (i.e. unitary weighing of pros and cons) were used to develop two deliberation components embedded in a Web-based decision support intervention for women facing amniocentesis testing. Ten researchers (recruited from 15), nine health-care providers (recruited from 28) and ten pregnant women (recruited from 14) who had recently been offered amniocentesis testing appraised evolving versions of 'your most important reason' (Take The Best) and 'weighing it up' (Tallying). Results Most researchers found the tools useful in facilitating decision making although emphasized the need for simple instructions and clear layouts. Health-care providers however expressed concerns regarding the usability and clarity of the tools. By contrast, 7 out of 10 pregnant women found the tools useful in weighing up the pros and cons of each option, helpful in structuring and clarifying their thoughts and visualizing their decision efforts. Several pregnant women felt that 'weighing it up' and 'your most important reason' were not appropriate when facing such a difficult and emotional decision. Conclusion Theoretical approaches based on fast and frugal heuristics can be used to develop deliberation tools that provide helpful support to patients facing real-world decisions about amniocentesis. [ABSTRACT FROM AUTHOR]

The aim of this study was to determine how many UK maternity units have implemented National Institute for Clinical Excellence (NICE) guidance for routine antenatal anti-D prophylaxis (RAADP). In May 2002, the NICE recommended a policy of RAADP for RhD-negative pregnant women. The policy has the potential to reduce maternal sensitization and prevent deaths from haemolytic disease of the foetus and newborn, but implementation entails considerable clinical, financial and organizational challenges. A postal survey of all 324 UK maternity units was completed in 2005.Responses were received from 91% of units (294 of 324). RAADP was offered by 220 of 294 (75%) and in England and Wales 19% of those offered a single-dose regime. At 12% of maternity units, routine paternal blood group testing was offered. For 84% of maternity units, staff education was offered at the time of implementation. Written patient information was provided at 97% of maternity units and 147 of 217 (69%) returned a copy. We received 60 different leaflets. Three years after NICE guidance was issued, one in four maternity units did not offer RAADP. Among those that do offer RAADP, practice with regard to anti-D administration, paternal testing, provision of written information and staff education varied. Unit and clinician level research is required to understand why. [ABSTRACT FROM AUTHOR]

Objective To describe the sensitivity of fetal anomaly scanning at detecting transposition of the great arteries (TGA) and to investigate whether prenatal detection improves survival. Design Retrospective review of survival by comparing those who had an antenatal diagnosis with those who did not. Setting Population-based study in Wessex region over 13 years. Population Babies with isolated TGA and an intact ventricular septum. Methods Review of outcomes by comparing those who had an antenatal diagnosis with those who did not. Main outcome measures Mortality rates in each group. Results TGA occurred more commonly in boys than in girls. Using the existing national screening policy, the antenatal detection rate of TGA was only 6.9% over the study period, improving to 25% in the last 4 years. This contrasts with a 40% detection rate when TGA was associated with a ventricular septal defect (VSD). All the babies who had TGA diagnosed antenatally survived through surgery. Of those who were not diagnosed antenatally, two were stillborn, five died before the diagnosis was made and four died after surgery. Although the difference in survival rates between those who were antenatally diagnosed and those who were not is not statistically significant (χ2= 3.9; P = 0.11), some of these deaths could have been prevented if a prenatal diagnosis had been made. Conclusions Improved antenatal diagnosis could lead to a significant reduction in the mortality associated with TGA. The current low detection rate of TGA in the UK could be improved by the inclusion of outflow tract views in routine fetal anomaly scans, and we believe that the extra workload is justified. [ABSTRACT FROM AUTHOR]

This prospective observational study reports on 126 women from 25 UK centres with image-proven antenatal venous thromboembolism (VTE), 62% deep vein thrombosis and 38% pulmonary embolism. Thrombophilia screening was of limited benefit except to identify antithrombin deficiency. Sixteen (13%) patients had previous VTE, all but one was related to previous pregnancy or combined oral contraceptive and 12 received no thromboprophylaxis in the index pregnancy, the other four thus received inadequate low molecular weight heparin (LMWH) doses. Treatment was with dalteparin in 25%, enoxaparin in 47%, tinzaparin in 25% and unfractionated heparin alone in 3%. 66% of patients received once-daily LMWH. Anti-activated factor X (anti-Xa) monitoring was performed at 90% of centres, with a wide range of target values. Thus current management of antenatal VTE, despite widely diverse clinical practice, appeared effective and safe, for there were no recurrent events and postpartum haemorrhage was not increased when compared to known rates. Larger studies are required to confirm this. The need for twice as opposed to once daily LMWH and for anti-Xa monitoring is questioned by this study. The importance of clinical risk assessment and adherence to the Royal College of Obstetricians and Gynaecologists guidelines on antenatal thromboprophylaxis, with adequate LMWH dosing is confirmed. [ABSTRACT FROM AUTHOR]

The aim of this study was to determine the compliance rates for women being offered routine antenatal anti-D prophylaxis in two obstetric units in the UK. Haemolytic disease of the newborn (HDN) is a potentially serious condition that can result in substantial morbidity and sometimes death. Current guidelines recommend that 500 IU anti-D immunoglobulin G (IgG) should be offered to all non-sensitized RhD-negative women at 28 and 34 weeks’ gestation in order to prevent the risk of RhD sensitization in pregnancy. Implementing guidance, however, remains a challenge. We conducted a retrospective audit of 207 RhD-negative, non-sensitized pregnant women attending obstetric units during 2004 to assess compliance with national guidance on the provision of antenatal anti-D prophylaxis. Informed consent for routine antenatal anti-D prophylaxis was documented for 185 of these women. In total, 86·5% of women received the two doses of anti-D IgG. The majority of women received their first and second doses within 1 week of 28 and 34 weeks’ gestation (87·0 and 86·0%, respectively). Accurate records of prophylactic anti-D IgG were maintained and updated. This audit demonstrates that the level of patient compliance with the two-dose regimen was high. [ABSTRACT FROM AUTHOR]

Objectives To determine the level of patient knowledge regarding the 20-week screening ultrasound examination, which is performed on over 95% of women in our unit, and to ascertain whether the use of targeted education could improve patient knowledge and expectations, to determine from where patients obtained information on the scan and to ascertain whether patients felt they had chosen to undergo the scan. Methods An anonymous questionnaire was issued to all patients attending for their 20-week scan over a 3-week period in July 2002 (n = 220). There were nine questions, focusing on maternal choice, information and knowledge. As a result of the information obtained, we undertook a program of education for hospital and community medical and midwifery staff. A printed information sheet given to the patients at the time of booking their 20-week scan was introduced. We then issued the questionnaire for another 3-week period in July 2003 (n = 171). Results As a result of our education program, there was a significant increase in the number of women answering various knowledge-based questions correctly about the 20-week scan, in those using the written information provided as a source of information (P < 0.0001), and in those who felt they had been involved in the decision to have the scan (P = 0.003). Conclusions Patients need to be better informed about the 20-week scan, and choose whether or not to have it. Health professionals are pivotal in this process. While written information helps to reinforce the information given, alone it has only a small effect. [ABSTRACT FROM AUTHOR]

Objective To ascertain, by means of a questionnaire, women's preferences for four different approaches to prenatal screening for Down syndrome. Methods Women attending antenatal clinics at six UK maternity units were asked to put in order of preference four different approaches to screening for Down syndrome all of which had the same false positive rate of 5%. The options were: (1) first-trimester testing, 90% detection of Down syndrome with results available in 1 h at one-stop clinics for the assessment of risk (OSCAR); (2)first-trimester testing, 90% detection and results available within 2–3 days (combined screening); (3) first-trimester testing plus second-trimester testing, 93% detection and results available within 2–3 days of second test (integrated testing); (4)second-trimester testing, 75% detection and results available within 2–3 days. Results Over 1100 women attending antenatal clinics at six maternity units across the UK returned the questionnaire. A total of 75% of women selected a first-trimester test (option 1 or option 2) as their first choice with 68.2% expressing a preference for the OSCAR approach and a further 6.8% for combined screening. Twenty-four percent of women opted for integrated testing as their first choice with only 1% expressing a preference for second-trimester screening. Conclusions A first-trimester test is preferred by the majority of women over a test with marginally higher detection rate that delivers results later in pregnancy. Timing and rapid reporting of results appear to influence women's choice of test. [ABSTRACT FROM AUTHOR]

This prospective, cohort study reports early child protection and surveillance process markers for children born to self-proclaimed drug-using mothers. A strong association is reported between maternal drug use and child abuse in North American studies. There are no systematic data describing this association for the UK population. Given the heterogeneous nature of drug cultures and associated behaviour it is difficult to generalize from US data to the UK population. The study group consisted of all women referred to a hospital-based antenatal clinic for pregnant drug users. Infants of non-drug users were matched for social class and gestational age. At 18 months the Bristol and surrounding area child protection registers and child health surveillance records were searched. Infants were coded as to whether they were the subject of an enquiry, case conference, registration, registration with subsequent deregistration, or taken into care. There were 68 infants of drug users and 127 infants of non-drug users. Most (81%) of drug users were heroin and/or methadone users; half were using/had used intravenously. Child health surveillance uptake for both groups is lower than that reported for the Avon population as a whole during the study period, consistent with the relatively deprived populations represented. There is no statistically significant difference between the drug users and non-drug users. The overall risk of child protection proceedings was higher in children of drug users than in children of non-drug users. However, closer inspection of the data shows most of the excess risk is explained by the small group taken into care and the much larger group for whom the concerns were relatively shortlived as shown by their subsequent deregistration during the study period. Maternal drug use does not necessarily lead to unacceptable standards of parenting. More UK-based research is needed to inform the risk assessment process for child protection. [ABSTRACT FROM AUTHOR]

Objective: To review the efficacy of antenatal group interventions aimed at reducing postnatal depression (PND) in ‘at risk’ women. Method: Medline, Psyclit, HEALTHSTAR, EMBASE, Cochrane library, UK National Research Register and CINHAL searches were performed from 1960 to December 2001 focussing on randomized controlled trials (RCTs). Results: As statistical synthesis of the studies was not feasible, a qualitative review is provided. All five studies reviewed suffer from substantial limitations including small numbers; unrealistic effect sizes; large attrition rates; lack of a systematic approach in identifying those ‘at risk’ and thus clinically heterogenous samples. Three of the studies used unvalidated interventions that were educational or supportive in approach. While one such study reported a benefit of intervention, the largest study using a structured intervention, reported no effect. A very small study using interpersonal therapy, was promising but needs replication with an adequate sample size. Conclusion: There is currently little evidence from RCTs to support the implementation of antenatal group interventions to reduce PND in ‘at risk’ women. Further studies addressing the significant methodological limitations are recommended before concluding that antenatal targeted interventions have no place in maternity care. [ABSTRACT FROM AUTHOR]

Abstract Objective To estimate resource use and costs associated with routine obstetric ultrasound and follow-up tests from both the British National Health Service and women's perspectives. Methods Women attending Liverpool Women's Hospital (UK) in 1998 and 1999 were involved in the study. Bottom-up and top-down costings of National Health Service resources using questionnaires and diaries to record staff time associated with procedures were performed. Questionnaires were used to assess women's costs of attending for antenatal ultrasound scans. Results Routine antenatal ultrasound scans at Liverpool Women's Hospital cost the National Health Service between £14 and £16 per scan. More detailed secondary scans and other follow-up procedures cost substantially more. Costs to women, their families and their employers were estimated at between £9 and £15 per scan, depending on assumptions about the opportunity costs of time when not in paid employment and costs to employers of women who were in paid employment. Conclusions Accurate estimates of costs to the National Health Service associated with routine antenatal ultrasound scanning are substantially lower than that cited in much of the literature. Costs to women are very similar to National Health Service costs. Economic evaluations should attempt to include costs to users of the service, particularly when the burden of cost is likely to shift. [ABSTRACT FROM AUTHOR]

ABSTRACTObjectiveTo audit women’s receipt of information during routine antenatal ultrasound investigations; and to investigate women’s perceptions of, and attitudes towards, routine screening. DesignAnalysis of the records of 384 women from in and around Nottingham, UK, who maintained a diary throughout the course of their pregnancies. ResultsThe mean number of ultrasound scans received by each women during her pregnancy was 2.6, with more than 96% of women receiving at least one scan. Women initially scanned earlier received more scans in total. Women appeared aware of the specific reasons for each scan being undertaken, and only a minority were dissatisfied by the information they had received. The preponderance of information received during the scans related to results and arrangements for subsequent visits, with only 10% of women reporting receiving information about the procedure itself. Most women reported positive feelings towards scanning, and few gave indications that they would prefer changes in the conduct of the procedure. ConclusionsThe great majority of the women in our study were satisfied with their experiences of routine ultrasound scanning, accepting the procedure uncritically. [ABSTRACT FROM AUTHOR]

Focuses on the British Committee for Standards in Haematology guidance on antenatal diagnosis of hemoglobinopathies. Criticisms on the guideline; Incidence of α[sup 0]-thalassaemia; Basis for the guidance.

Objective To develop a measure of informed choice. Conceptualization and measurement The measure is based on the following definition of an informed choice: one that is based on relevant knowledge, consistent with the decision-maker’s values and behaviourally implemented. The measure comprises an eight-item scale of knowledge, a four-item scale assessing attitudes towards undergoing the screening test and a record of test uptake. Participants Sixty-six women awaiting their first antenatal clinic appointments. Measure development In women offered a screening test in pregnancy, the internal reliability of both the knowledge and the attitude scales was acceptable (alpha coefficients 0.82 and 0.83, respectively). Of the 42 women completing both scales, 18 were classified as having made an informed choice, and 24 were classified as having made an uninformed choice. Conclusion The results of this preliminary study provide some evidence to support the feasibility of conceptualizing and measuring informed choices regarding screening using a brief measure assessing knowledge and attitudes. The validity and utility of this approach awaits further studies, involving larger numbers of participants, offered different screening tests. [ABSTRACT FROM AUTHOR]

The article reviews several websites including www.iofbonehealth.org from International Osteoporosis Foundation, www.arc-uk.org from Antenatal Results and Choices, a national charity in Great Britain, and http://fetalanomaly.screening.nhs.uk from National Health Service Fetal Anomaly Screening Programme.

Comments on the progress towards realistic expectations of patients, health professionals and policy-makers concerning prenatal testing in Great Britain. Problems of expectant mothers associated with the detection of fetal anomalies; Knowledge of health care providers of prenatal screening tests; Development of interactive decision-making aids.

An abstract of the research paper "Unintended consequences of UK guidance for anomaly screening and invasive testing," by M. Alberry and colleagues is presented.

The article informs about a study based on the assessment of the incidence of antenatal stroke in Great Britain and identification of risk factors associated with stroke during pregnancy. It mentions that information of the clinical features, survival and prognosis of antenatal strokes was used in the study. It adds that findings of the study reveal that the incidence of a stroke during pregnancy is low.