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Glycogen storage disease type 1a (GSD 1a) is a metabolic disorder caused by deficiency of an enzyme required for glycogen breakdown, causing hypoglycaemia and lactic acidosis. Metabolic derangements cause disease manifestations affecting the kidneys, liver and platelet function. Physiological changes in pregnancy worsen fasting intolerance and increase reliance on exogenous glucose to avoid lactic acidosis. Fetal macrosomia and declining respiratory function result in high rates of caesarean sections. We report the multidisciplinary team (MDT) management of a 25-year-old woman with GSD 1a in an unplanned pregnancy. Existing percutaneous endoscopic gastrostomy tube feeding, alongside high-calorie drinks and intravenous dextrose during labour, managed the risks of hypoglycaemia and lactic acidosis. Metabolic parameters were regularly monitored and fortnightly growth scans were assessed for macrosomia. Allopurinol was continued throughout the pregnancy to reduce the risk of hyperuricaemia. MDT management optimised maternal and fetal care throughout pregnancy and labour, resulting in a successful vaginal delivery.

Chronic histiocytic intervillositis (CHI) is a rare, but highly recurrent inflammatory placental lesion wherein maternal macrophages infiltrate the intervillous space. Pregnancies with CHI are at high risk of fetal growth restriction, miscarriage or stillbirth. Presently, the diagnosis can only be made after histopathological examination of the placenta. Given its proposed immunological etiology, current treatments include aspirin, heparin, and immunomodulatory agents. However, the rationale for these medications is largely based upon small case series and reports as there is a lack of larger studies investigating treatment efficacy. Therefore, this study sought to determine whether inclusion of immunomodulatory medications was effective at reducing the severity of lesions and improving pregnancy outcomes in subsequent pregnancies. Thirty-three women with a history of CHI in at least one pregnancy (index case) were identified retrospectively through medical records. Twenty-eight participants presented with a first subsequent pregnancy and a further 11 with a second subsequent pregnancy at a specialist clinic for pregnancy after loss. Data on maternal demographics, medical history, medication, pregnancy outcome, and placental pathology was collected and compared between pregnancies. Twenty-seven (69%) subsequent pregnancies were treated with at least one or both of prednisolone and hydroxychloroquine. Inclusion of at least one immunomodulatory agent in treatment regimen resulted in an almost 25% increase in overall livebirth rate (61.5 vs. 86.2%). In women treated with immunomodulatory medication a greater proportion of placentas had reduced severity of lesions compared to those treated without (86.7 vs. 33.3%, respectively). A reduction in CHI severity was associated with a 62.3% improvement in livebirth rate compared to those where severity remained unchanged in relation to the index case. These data provide preliminary evidence that the use of immunomodulatory medication in the management of CHI improves histopathological lesions and the chance of livebirth in subsequent pregnancies. Due to CHI's rarity and ethical and feasibility issues, randomized controlled trials in affected women are challenging to conduct. As a result, collaboration between centers is required in future to increase study sample sizes and elucidate the mechanisms of hydroxychloroquine and prednisolone in reducing pathology.

Preterm deliveries remain the leading cause of neonatal morbidity and mortality. Current therapies target only myometrial contractions and are largely ineffective. As labor involves multiple coordinated events across maternal and fetal tissues, identifying fundamental regulatory pathways of normal term labor is vital to understanding successful parturition and consequently labor pathologies. We aimed to identify transcriptomic signatures of human normal term labor of two tissues: in the fetal-facing choriodecidua and the maternal myometrium. Microarray transcriptomic data from choriodecidua and myometrium following term labor were analyzed for functional hierarchical networks, using Cytoscape 2.8.3. Hierarchically high candidates were analyzed for their regulatory casual relationships using Ingenuity Pathway Analysis. Selected master regulators were then chemically inhibited and effects on downstream targets were assessed using real-time quantitative PCR (RT-qPCR). Unbiased network analysis identified upstream molecular components in choriodecidua including vimentin, TLR4, and TNFSF13B. In the myometrium, candidates included metallothionein 2 (MT2A), TLR2, and RELB. These master regulators had significant differential gene expression during labor, hierarchically high centrality in community cluster networks, interactions amongst the labor gene set, and strong causal relationships with multiple downstream effects. In vitro experiments highlighted MT2A as an effective regulator of labor-associated genes. We have identified unique potential regulators of the term labor transcriptome in uterine tissues using a robust sequence of unbiased mathematical and literature-based in silico analyses. These findings encourage further investigation into the efficacy of predicted master regulators in blocking multiple pathways of labor processes across maternal and fetal tissues, and their potential as therapeutic approaches.

Background\ud Post-partum haemorrhage is the leading cause of maternal death worldwide. Early administration of tranexamic acid reduces deaths due to bleeding in trauma patients. We aimed to assess the effects of early administration of tranexamic acid on death, hysterectomy, and other relevant outcomes in women with post-partum haemorrhage.\ud \ud Methods\ud In this randomised, double-blind, placebo-controlled trial, we recruited women aged 16 years and older with a clinical diagnosis of post-partum haemorrhage after a vaginal birth or caesarean section from 193 hospitals in 21 countries. We randomly assigned women to receive either 1 g intravenous tranexamic acid or matching placebo in addition to usual care. If bleeding continued after 30 min, or stopped and restarted within 24 h of the first dose, a second dose of 1 g of tranexamic acid or placebo could be given. Patients were assigned by selection of a numbered treatment pack from a box containing eight numbered packs that were identical apart from the pack number. Participants, care givers, and those assessing outcomes were masked to allocation. We originally planned to enrol 15 000 women with a composite primary endpoint of death from all-causes or hysterectomy within 42 days of giving birth. However, during the trial it became apparent that the decision to conduct a hysterectomy was often made at the same time as randomisation. Although tranexamic acid could influence the risk of death in these cases, it could not affect the risk of hysterectomy. We therefore increased the sample size from 15 000 to 20 000 women in order to estimate the effect of tranexamic acid on the risk of death from post-partum haemorrhage. All analyses were done on an intention-to-treat basis. This trial is registered with ISRCTN76912190 (Dec 8, 2008); ClinicalTrials.gov, number NCT00872469; and PACTR201007000192283.\ud \ud Findings\ud Between March, 2010, and April, 2016, 20 060 women were enrolled and randomly assigned to receive tranexamic acid (n=10 051) or placebo (n=10 009), of whom 10 036 and 9985, respectively, were included in the analysis. Death due to bleeding was significantly reduced in women given tranexamic acid (155 [1·5%] of 10 036 patients vs 191 [1·9%] of 9985 in the placebo group, risk ratio [RR] 0·81, 95% CI 0·65–1·00; p=0·045), especially in women given treatment within 3 h of giving birth (89 [1·2%] in the tranexamic acid group vs 127 [1·7%] in the placebo group, RR 0·69, 95% CI 0·52–0·91; p=0·008). All other causes of death did not differ significantly by group. Hysterectomy was not reduced with tranexamic acid (358 [3·6%] patients in the tranexamic acid group vs 351 [3·5%] in the placebo group, RR 1·02, 95% CI 0·88–1·07; p=0·84). The composite primary endpoint of death from all causes or hysterectomy was not reduced with tranexamic acid (534 [5·3%] deaths or hysterectomies in the tranexamic acid group vs 546 [5·5%] in the placebo group, RR 0·97, 95% CI 0·87-1·09; p=0·65). Adverse events (including thromboembolic events) did not differ significantly in the tranexamic acid versus placebo group.\ud \ud Interpretation\ud Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset.\ud \ud Funding\ud London School of Hygiene & Tropical Medicine, Pfizer, UK Department of Health, Wellcome Trust, and Bill & Melinda Gates Foundation.

There is a paucity of strong evidence associated with adverse pregnancy outcomes and thrombophilia in pregnancy. These problems include both early (recurrent miscarriage) and late placental vascular-mediated problems (fetal loss, pre-eclampsia, placental abruption and intra-uterine growth restriction). Due to poor quality case-control and cohort study designs, there is often an increase in the relative risk of these complications associated with thrombophilia, particularly recurrent early pregnancy loss, late fetal loss and pre-eclampsia, but the absolute risk remains very small. It appears that low-molecular weight heparin has other benefits on the placental vascular system besides its anticoagulant properties. Its use is in the context of antiphospholipid syndrome and recurrent pregnancy loss and also in women with implantation failure to improve live birth rates. There is currently no role for low-molecular weight heparin to prevent late placental-mediated complications in patients with inherited thrombophilia and this may be due to small patient numbers in the studies involved in summarising the evidence. There is potential for low-molecular weight heparin to improve pregnancy outcomes in women with prior severe vascular complications of pregnancy such as early-onset intra-uterine growth restriction and pre-eclampsia but further high quality randomised controlled trials are required to answer this question.

This case report describes a baby who was diagnosed antenatally with a significant left-sided congenital cystic adenomatoid malformation. Following diagnosis of a fluid-filled, macrocystic structure on the left side of the chest, the mother was referred at 27 weeks’ gestation to her regional fetal medicine unit for assessment and ongoing management. Fetal MRI demonstrated a cyst measuring 6.7 mm × 4.3 mm, associated with mediastinal shift and affecting cardiac contractility. Scalp …

Objectives: To investigate prognosis of the fetus with isolated gastroschisis and bowel dilatation from a systematic review of the literature. We aimed to compare the incidence of (a) intrauterine death, (b) death within 4 weeks of delivery, (c) bowel resection, (d) length of time to oral feeds and (e) time as inpatient in fetuses with gastroschisis with and without evidence of bowel dilatation. Methods: Literature was identified by searching two bibliographical databases between 1980 and 2007. Studies were assessed for quality and stratified according to the definition of bowel dilatation. The data extracted were inspected for clinical and methodological heterogeneity. Results: The search strategy yielded 1335 potentially relevant citations. Full manuscripts were retrieved for 92 citations. 10 studies (273 patients) were finally included in the systematic review. No difference was found between groups for death within 4 weeks of delivery (OR = 0.62 (95% CI 0.11 to 3.32); heterogeneity p = 0.39) or bowel resection (OR = 3.35 (95% CI 0.82 to 13.74); heterogeneity p = 0.39). There were insufficient data to compare the risk of intrauterine death and length of time to oral feeds. The mean inpatient stay was not significantly different between groups (OR = 16.63 (95% CI 0.98 to 32.28); heterogeneity p = 0.23). Conclusion: Current available evidence suggests that fetuses with isolated gastroschisis and bowel dilatation are not at increased risk of adverse perinatal outcome compared to those without bowel dilatation. However, there is a paucity of studies, and a randomised controlled trial is urgently needed.

Adverse pregnancy outcomes, such as pregnancy loss and pre-eclampsia, are associated with thrombotic mechanisms and thrombophilia. Antithrombotic interventions, particularly low-molecular-weight heparin, have been investigated in women identified by previous pregnancy outcome; however, the results have been inconsistent. This may reflect heterogeneity of both the study groups and the disease processes resulting in inadequate stratification to guide antithrombotic interventions. Furthermore, the variation in gestation at initiation of low-molecular-weight heparin treatment might be important. Despite limited evidence of efficacy, low-molecular-weight heparin is often used in an attempt to prevent these complications, owing to the lack of other effective treatments and its perceived safety in pregnancy. Research is required to better understand the disease processes, identify possible biomarkers and thereby more homogeneous groups for targeted treatment.

Normal pregnancy is associated with the presence of circulating placental microvesicles (MVs). Increased MV shedding and altered immune activation are seen in patients with preeclampsia, suggesting that placental MVs may play a role in the pathophysiology of this disease. Therefore, the aim of this study was to investigate the activation of peripheral blood mononuclear cells (PBMCs) by MVs shed by first-trimester, normal term, and preeclamptic term placenta. First-trimester and preeclamptic term, but not normal term, placental-derived MVs activated PBMCs, as evidenced by elevated IL1B. Significant changes were also seen with several other cytokines and chemokines, and in general when compared to normal term MVs, preeclamptic MVs induced a greater pro-inflammatory response in PBMCs. Pretreatment of PBMCs with first-trimester or normal term placental MVs resulted in a dampened IL1B response to a subsequent lipopolysaccharide (LPS) challenge. In contrast, treatment of PBMCs with preeclamptic term placental MVs exacerbated the LPS response. This was also the case for several other cytokines and chemokines. These studies suggest that placental MVs can modulate basal peripheral immune cell activation and responsiveness to LPS during normal pregnancy, and that in preeclampsia this effect is exacerbated.

Preterm delivery is the leading cause of perinatal mortality and morbidity. Current tocolytics target myometrial contractions, a late step in the labor cascade. Identifying earlier events in parturition may lead to more effective therapeutic strategies. We hypothesized that inflammatory events in decidua (the maternal-fetal interface), characterized by leucocyte infiltration, are an early event during term and preterm labor (PTL). Leucocyte abundance in decidua of human pregnancies was quantified following term labor and PTL (idiopathic and infection associated), in conjunction with investigation of temporal inflammatory events in rat uterus during the perilabor period and in PTL induced by mifepristone. In human decidua, macrophage numbers were 4-fold higher in term labor (P < 0.01) and 2.5-fold higher in non-infection-associated PTL (P < 0.05) than in term nonlaboring samples. Neutrophil abundance was unchanged with labor but elevated in PTL with infection (5- to 53-fold increase; P < 0.01). T and NK cells were more abundant in idiopathic PTL than TL (P < 0.05). In rat, decidual macrophage infiltration increased 4.5-fold 12 h prior to labor and remained elevated during labor and early postpartum (P < 0.01). Decidual infiltration preceded that of the myometrium and was 4-fold higher (P < 0.01). In rat PTL, decidual macrophage numbers were also elevated (P < 0.01) and exceeded those of the myometrium (P < 0.05). These studies show for the first time that leucocytes infiltrate decidua during labor at term and preterm, supporting a role for leucocyte-derived inflammatory mediators in decidual activation. In the rat, this occurred prior to labor, suggesting it is an early event during parturition and thus a potential target for intervention.

This case describes a woman who presented with raised α-fetoprotein (AFP) on second trimester screening, and developed early onset fetal growth restriction (FGR) and severe pre-eclampsia (PET) before 24 weeks' gestation requiring magnesium sulphate and intravenous antihypertensives. Ultrasonography revealed a structurally normal fetus with estimated weight

Introduction Prematurity remains a leading cause of neonatal morbidity and mortality. A better understanding of what triggers spontaneous preterm labour (PTL) may allow the development of novel therapies to arrest the process. Labour is associated with inflammatory processes, but little is known about the nature or timing of these events. We hypothesized that macrophage infiltration of uterine tissues is an early event in the labour process. Method Rat models were used to examine the timing of inflammatory events. Multiple sections of pregnant uteri on day (d) 21, 22 (am and pm), 23 (term labour) and d1 and 4 postpartum were collected. Uteri were also collected from two models of PTL induced by mifepristone (d16 and 19). Macrophages were identified in fixed uterine sections by immunohistochemistry and quantified by image analysis. Results Macrophage numbers were significantly increased in both decidua and myometrium during labour (p Conclusions These studies confirm that decidual inflammatory events precede labour, and occur prior to myometrial macrophage infiltration, supporting a role for the decidua in triggering labour. Intervening in the labour process at an early stage, for example blocking decidual inflammation, may allow the development of a more successful treatment to prevent PTL.

Background Antenatal thrombocytopenia occurs in 5% of pregnancies and is predominantly due to gestational thrombocytopenia (GTP), or more rarely is immunologically-mediated (ITP). The risk of significant neonatal thrombocytopenia ( 9 /L) has been suggested as 5–10% in women with ITP, although risk of bleeding is low. The aim of this study was to report pregnancy outcomes of women with thrombocytopenia in a large UK tertiary referral centre. Methods Pregnant women with platelet counts ≤ 120 × 10 9 /L were identified retrospectively from the laboratory records between December 2011 and December 2012. Pregnancy and neonatal records were examined and data collected. Results Laboratory records identified 215 women with a platelet count ≤ 120 × 10 9 /L during pregnancy. 118/215 (55%) were excluded due to pre-eclampsia, sepsis or post-partum haemorrhage. 100 infants were born to 97 women, 25 (26%) delivered by Caesarean section. 17 had presumed GTP, 30 ITP, with 50 being of unknown cause antenatally. 10/98 (10.2%) had a blood loss greater than 1000mls, comparable to the hospital population (9.2%). Neonatal platelet counts were available 69/101(68%) babies. 19/69 (27.5%) had thrombocytopenia 9 /L, with 3 (4.3%) 9 /L. There was one report of a small non-significant intraventricular haemorrhage (platelets 12 × 10 9 /L). Maternal platelet count did not correlate with either blood loss or neonatal platelet count. Conclusions Whilst neonatal thrombocytopenia was relatively common (27.5%), clinically significant neonatal thrombocytopenia was rare which is reassuring for women. Low maternal platelets did not increase the risk of postpartum haemorrhage.

Haemophilia A and B can cause significant bleeding in affected males. Labour management of a potentially affected male should be cautious due to the potential risk of fetal haemorrhage, with delivery advised in a specialist Haemophilia centre. Historically, first trimester invasive testing has been offered but is now rarely pursued due to improved treatments. Some centres offer late (34+ weeks) gestation amniocentesis to aid delivery planning as an unaffected male can then be managed without specialist intervention. This procedure is associated with an estimated pre-term labour risk of 1% and is potentially subject to technical limitations. We report a single centre experience, over a 2 year period, of late amniocentesis in the management of 10 known haemophilia carrier females with male fetuses by first trimester fetal sexing. 50 mL of amniotic fluid was drawn at 34+ weeks gestation. 6 fetuses were confirmed as affected, 2 unaffected and in 2 cases no result was obtained, relating to quality of sample and the underlying mutation. One carrier whose fetus was unaffected subsequently delivered in her local obstetric unit. Gestation at delivery ranged from 36–41 weeks with a median gestation of 38 weeks. Late amniocentesis yields a result in 80% of cases and can be used to guide delivery management where the haemophilia mutation is known. In our series, no result could be provided in 2 out of 3 cases associated with the severe haemophilia A intron 22 inversion mutation. Each diagnostic episode requires specific counselling regarding potential limitations of the technique.

Introduction Enhanced recovery (ER) after surgery is an integrated care pathway based on the principles of best peri-operative patient care.This study looked at potential benefits of introducing an ER pathway for uncomplicated elective Caesarean section (CS). Method 52 selected women undergoing elective CS between August and November 2013 followed the pathway. Women without co-existing medical conditions were selected if uncomplicated surgery was expected. Women followed a typical ER pathway including a pre-operative drink, early catheter removal (approximately 6 hours), early feeding and mobilisation. Data was collected using a prospective audit proforma and women were telephoned the day following discharge. Results 52 patients underwent the pathway. 32/52 (61.5%) were discharged the day following surgery, with a median length of stay of 31.25 h25 hours (range 25–120 h). 9 discharges (17%) were delayed due to neonatal reasons and 4(7.6%) due to social or domestic factors. In 7 women (13.5%) discharge was delayed due to medical reasons. Phone follow-up in 46 found 13 (28%) reported moderate pain on discharge. 3 (6%) women required re-catheterisation and 2/52 (3.8%) required re-admission (hypertension and mastitis). 95.6% of women were very satisfied or satisfied with the ER pathway. Discussion The ER pathway is acceptable to women and can achieve discharge in the majority of women on the day following surgery, compared with 2011 when average length of stay for all CS was 5 days. Positive patient feedback and good clinical results have lead us to introduce the ER pathway as standard practise for all elective CS.

Introduction Rotational instrumental delivery has previously been associated with adverse neonatal outcomes. Since a 1979 study demonstrated 3.49% neonatal mortality associated with Kielland’s forceps there has been a gradual decline in its use, which also coincided with a rise in Caesarean section rate. The objective of this study was to report neonatal outcomes following rotational instrumental delivery. Methods Data was collected retrospectively from 1110 rotational instrumental deliveries conducted at St Mary’s Hospital, Manchester between April 2009 and February 2012 for neonatal intensive care (NICU) admission, jaundice, cooling, sepsis, injuries, ventilation and mortality. Results Data was available for 1023/1110 (92%) deliveries. Numbers of babies with jaundice, cooling, sepsis, injuries, ventilation or mortality were low and not different between rotational methods. More babies delivered by ventouse needed NICU admission; 30/283, 10.6% compared to 48/692, 6.9% babies delivered using either method of forceps (p = 0.030 chi squared). 3/53 failed instrumental deliveries resulted in neonatal injury (5.6%), compared to 14/637 (1.4%) for successful instrumental delivery (p = 0.056). There was no significant difference between any of the neonatal outcomes in babies delivered by consultants compared to more junior training grades. Conclusion For prolonged second stage of labour secondary to malposition, rotational instrumental delivery is a safe option in terms of neonatal outcomes. Differences in method of delivery were marginal, with ventouse being more likely to result in second instrument use and NICU admission.

Background Around 20% of labours are induced with the current recommended method being prostaglandin for cervical priming. The 2 commonly used preparations are a prostaglandin gel administered 6 hourly, or a prostaglandin pessary, administered over 24 hours. Following a change in protocol from gel to pessary, we aimed to look at the effect on admission to delivery time (ADT). Methods The notes of 395 women who had labour induced within a large tertiary unit in the North West between August 2009 and May 2012 were studied, excluding those induced for prelabour ruptured membranes. Data was collected retrospectively using a standard proforma. Results 93 women received prostaglandin gel and 302 received the pessary (28 also needed gel). The median ADT for women induced using gel was significantly shorter at 26.37 hours ( interquartile range 15.87–42.96) than with the pessary at 31.83 hours (20.73–46.54 hours p = 0.002 non-parametric testing). There was no difference in parity or oxytocin use between the 2 groups. Outcomes between the 2 groups were the same, with no difference in post-partum haemorrhage rate or vaginal delivery (p > 0.05). Conclusions The prostaglandin pessary was associated with a longer ADT, which is perhaps unsurprising given its longer duration of use prior to assessment for amniotomy. This is probably because the predicted increase in labour commencing in the pessary group without further oxytocin did not occur, reflected in no difference in oxytocin use between the 2 groups. This has implications for bed occupancy, patient flows and NHS costs.

Background Unsuccessful instrumental delivery (ID) is typically associated with increased risks of adverse outcomes. We aimed to investigate the fetal and maternal consequences of failed instrumental deliveries in our unit. Methods Data was collected prospectively as part of ongoing audit of all IDs performed in our unit between October 2008 and March 2012. Results Complete records were available for 2664 IDs. Delivery was unsuccessful in 75 (2.8%). There was 1 maternal bladder injury and 1 hysterectomy. Unsuccessful ID was associated with increased blood loss (EBL), increased decision to delivery interval (DDI) and lower fetal Ph (p Sequential instruments were used in 189 (7%), and were successful in 182/189 cases (96%). Compared with successful use, unsuccessful sequential instruments were associated with higher blood loss, increased DDI and lower fetal Ph (p£0.06, Mann Whitney-U). Two fetal injuries occurred where sequential instruments failed compared to 3 injuries out of 68 unsuccessful deliveries where only 1 instrument was used (p = 0.07 fishers exact test). Conclusions ID was associated with a low risk of failure, but failure was associated with worse outcomes. Although sequential instrument use was associated with the poorest outcomes, outcomes were better if vaginal delivery was achieved in this situation. This highlights the need for careful and competent use of instruments in the presence of experienced operators.

Background Induction of labour (IOL) is conducted in 20% of all UK deliveries. IOL is associated with medicalisation of a natural life event potentially resulting in medical intervention, therefore it is important to ensure that these risks outweigh the benefits of waiting for spontaneous labour. This study aimed to quantify these risks in specific groups. Methods A retrospective audit in a large tertiary centre was undertaken to establish complication rates in women undergoing IOL. Results A total of 552 women undergoing IOL were studied, of whom 35 (7%) had undergone previous LSCS. Previous LSCS was associated with a reduced vaginal delivery rate of 60.5% compared with 79% and an increased estimated blood loss of 450mls (interquartile range 300-600mls) compared to 350mls (IQR 200-500mls, p Conclusions Although induction of labour in association with a previous LSCS is associated with increased risks, the majority achieved a vaginal delivery. In particular, this study has suggested that primparous women induced for post maturity and women with a previous LSCS demonstrate the highest complication rates for lower vaginal delivery rates.

Introduction Infants born with fetal alcohol spectrum disorder (FASD) are the result of high alcohol exposure during pregnancy and have a range of neurological and physical heath problems, including fetal growth restriction. We hypothesised that alcohol exposure in the first trimester, the period critical for normal placental development and organogenesis, negatively affects placental cell turnover and transport of key nutrients for fetal growth and development. Methods First trimester placental explants (n=7) and BeWo choriocarcinoma cells (n=6) treated with ethanol (0–40 mM) were assessed for apoptosis (M30) and proliferation (Ki67) using immunocytochemistry. Nutrient transport via the system A and system β amino acid transporters was quantified by uptake of radiolabelled methylamino-isobutyric acid ( 14 C-MeAIB) and taurine ( 3 H-taurine). Results In first trimester explants, cytotrophoblast proliferation decreased by 40% at 20 mM alcohol (p Conclusion Alcohol may adversely affect placental development by reducing cytotrophoblast proliferation and fetal development by reducing uptake of taurine. Taurine is an amino acid believed to be important for neurological development. Alcohol exposure may therefore contribute to the pathogenesis of FASD via two mechanisms, placental development and transport of nutrients important for organogenesis.

Kate Glennon1, Clare Tower2, Joanna Gillham3, Jenny Myers21St Mary's Hospital, Manchester University, Manchester, UK; 2Maternal and Fetal Health Research Centre, St Mary's Hospital, Manchester, UK; 3St Mary's Hospital, Manchester, UKPurpose: To audit the process of informed consent for cesarean section (CS) and instrumental delivery (ID) in a tertiary referral center in the UK.Design: The Royal College of Obstetricians and Gynaecologists (RCOG) guidelines on consent1 were used as audit standards. A retrospective questionnaire was used to assess patients’ recall and views of the consent process. In total, 116 consent forms were audited (CS = 83, instrumental delivery = 33).Findings: The consent forms complied with the auditable standards on consent for CS, in relation to documentation of the major risks of surgery. The majority of CS consent forms did not meet the standards in terms of documentation of the risk of laceration to baby or the possibility of hysterectomy. However, most women were questioned on consent between contractions, in accordance with the RCOG guidance on consent (50% CS deliveries and 68% instrumental deliveries). The patients who consented for elective CS, were more likely than emergency CS patients to be able to recall the risks explained.Action: The findings of this audit indicate that the introduction of a standardized consent proforma would provide a structured approach to preoperative counselling and documentation.Keywords: informed consent, cesarean section, instrumental delivery, patient recall, documentation

Introduction Repeated failed transfers of good quality embryos indicate impaired implantation. Failed implantation is also associated with pregnancy complications such as fetal growth restriction (FGR). The aim of this study was to investigate the hypothesis that women achieving pregnancy after two or more failed embryo transfers (ETs) of good quality embryos have increased incidence FGR compared to those conceiving after the first ET. Materials and Methods The authors conducted a retrospective case-note review of women undergoing in vitro fertilization (IVF) or intracytoplasmic sperm injection ( ICSI) at the St Mary9s Hospital, Manchester, between January 2000 and June 2008. FGR was defined as an individualised birth weight centile ≤5. Statistical comparisons were made with Fishers exact test, using p Results Case notes for 364 eligible patients were identified: 125 conceived after two or more failed embryo transfers (study group) and 239 after the first embryo transfer (control group). The demographic characteristics of the two groups were similar (p>0.05). After the exclusion of multiple pregnancies, X/125 babies in the study group were found to have FGR, compared to Y/239 in the study group (p=0.047, 95% CI 0.05 to 0.99). Conclusions Women conceiving a singleton pregnancy on a third attempt at IVF or ICSI may be at increased risk of developing subsequent FGR, although this did not reach statistical significance by our own rigorous definition. This may imply a common underlying pathology for failed implantation and FGR and suggests these women may benefit from increased fetal surveillance.

Background One in five pregnant women in the United Kingdom undergo induction of labour (IOL), occupying a significant number of maternity beds. Concerns over delays in IOL processes prompted evaluation and modification of this service in our unit. Our objective was to reduce admission to delivery times (ADT), increase vaginal delivery rates and assess secondary outcomes including postpartum haemorrhage (PPH) rates following IOL. Methods 262 admissions for IOL were reviewed in three cycles over 15 months. Following cycle 1, midwives were trained to conduct IOL and an IOL proforma introduced. After cycle 2, a dedicated four-bed IOL bay was introduced. IOL was conducted with prostaglandin gel, followed by artificial rupture of membranes and oxytocin. Statistical significance was tested using one-way analysis of variance (Kruskal–Wallis) for ADT and χ 2 test for vaginal delivery and PPH rates. Results See table. Conclusion The training of midwives to conduct IOL and provision of a dedicated IOL bay have resulted in a significant fall in median ADT from 37.72 to 28.07 h, but no significant change in vaginal delivery or PPH rates. These changes may result in improved efficiencies to the NHS but further work is required to investigate patient satisfaction and to reduce residual delays in the IOL process at our unit.