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ObjectivePrepregnancy counselling (PPC) is an important aspect of care for women with chronic liver disease (CLD) and liver transplantation (LT), yet its impact has not been well described. This study aims to assess the experience of women attending a joint obstetric-hepatology PPC clinic in a single-centre unit.Design/methodsA retrospective questionnaire-based study in a tertiary unit within the UK where patients who attended the PPC clinic between March 2016 and July 2021 were invited to participate by filling in a questionnaire. Descriptive data and free-text content were subsequently analysed.Results108 women attended the PPC clinic over a 5-year period. Overall, 58/108 (54%) completed the questionnaire. Principal concerns regarding pregnancy included fears around deterioration in health (66%), maternal death (24%), pregnancy loss (66%), medication effects (60%) and disease transmission (36%). 17/58 (14%) patients felt the presence of multiple doctors was intimidating, however, perceptions improved by the end of the consultation.Overall, 44/58 (76%) respondents felt the clinic helped them reach a decision about pursuing pregnancy. Almost all respondents would recommend the clinic to others. There were no major differences in pregnancy outcomes between those that received PPC and those that did not.ConclusionThe PPC clinic facilitates a personalised approach to care and is well received by patients with CLD/LT. It is difficult to elucidate whether attendance alone impacts on pregnancy outcomes; registry data may be better placed at addressing this important question.

ObjectiveTo assess the association of short-term neonatal outcomes with cross-site working of multiple healthcare professional teams between a level 3 and a level 1 neonatal unit.DesignRetrospective cohort study.SettingA level 1 neonatal unit in London.PatientsAll infants admitted to the neonatal unit, between 2010 and 2021.InterventionsThe clinical service was rearranged in 2014 with the introduction of cross-site working between the level 1 unit and a level 3 unit of neonatal doctors, nurses and allied healthcare professionals.Main outcome measuresAdmission of infants with a temperature less than 36°C, length of stay and time to first consultation by a senior team member.ResultsA total of 4418 infants were admitted during the study period. The percentage of infants delivered at a gestation below 32 weeks was higher in the pre-cross-site period (8.9%) compared with the cross site period (3.6%, pConclusionsCross-site working was associated with lower rates of admission hypothermia, shorter duration of stay and earlier first senior consultation.

Objective To determine maternal, obstetric and neonatal outcomes in a cohort of women with primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC). Design Retrospective cohort study. Setting Ten specialist centres managing pregnant women with liver disease. Population Women with a diagnosis of PBC and PSC and a pregnancy of ≥20 completed weeks of gestation. Methods Retrospective case notes review. Main outcome measures Adverse outcomes were defined as: maternal - development of ascites, variceal bleeding, encephalopathy and jaundice; obstetric events - gestational hypertension, pre-eclampsia and postpartum haemorrhage; and neonatal - stillbirth, preterm delivery and admission to neonatal unit. The relationship of alanine transferase (ALT) and bile acid levels with gestation at delivery was studied. Results The first recorded pregnancies of 34 women with PSC and 27 women with PBC were analysed. There were 60 live births and one intrapartum stillbirth that did not occur in the context of maternal cholestasis. The overall median gestation of delivery was 38 weeks but the rate of preterm birth was 28% (17/61 deliveries), 76% (13/17) of which were spontaneous. Gestation at birth negatively correlated with maternal serum ALT concentration at booking (P = 0.017) and serum bile acid concentration during pregnancy (P = 0.016). There were no other significant correlations and maternal and neonatal outcomes were good. Conclusions Pregnancy in PBC and PSC is well tolerated, but women should be counselled regarding the increased risk of preterm birth. Measurement of maternal ALT and bile acids may help identify women at risk of preterm delivery. Tweetable abstract Pregnancy in women with PBC and PSC is well tolerated; however, rates of preterm birth are high and are related to maternal bile acid levels.

The number of women worldwide undergoing bariatric surgery (BS) is increasing; the majority of them are of reproductive age, and these surgeries have been demonstrated to improve their future fertility. These women have high-risk pregnancies as a result of undergoing such procedures due to the metabolic and anatomical changes caused by their surgery and with the potential for postoperative complications related to the procedure occurring during pregnancy. Clinicians seeing a pregnant woman who has had BS presenting with typical pregnancy-related gastrointestinal symptoms must have a lower threshold to thoroughly investigate to exclude more serious complications. Antenatal care requires an understanding of the type of BS performed and time interval to pregnancy. The care plan should include specialist dietician involvement antenatally, serum monitoring for biochemical deficiencies (ideally prior to pregnancy and then in each trimester), serial fetal growth scans, screening for gestational diabetes, consideration of analgesia, and contraception after delivery.

Rates of pregnancy in women with cirrhosis are increasing. Risk of hepatic decompensation during pregnancy, therefore, merits tailored obstetric and hepatology care. Prognostic markers that determine pregnancy outcomes are lacking. Medical records of women who attended hepatology clinic at King’s College Hospital with chronic liver disease (CLD) who became pregnant from 1983 to 2017 were reviewed. Information on demographics, clinical history, serology, and outcome of pregnancy was collected. In all, 165 pregnancies occurred in 100 women with CLD including 80 pregnancies in 48 women with cirrhosis. Median age of conception in cirrhotic and non-cirrhotic women were 26 years (16–44) and 28 years (16–51) respectively (p = 0.015). Whilst women with cirrhosis had similar live birth rate to non-cirrhotic women (75 vs. 85% p = 0.119), they were significantly less likely to proceed beyond 37 weeks gestation (45 vs. 58% p = 0.033). Women who received preconception counseling were more likely to have stable liver disease at conception (100 vs 86% p = 0.02). Compared with preconception MELD (model for end stage liver disease), preconception Albumin-Bilirubin score (ALBI) more accurately predicted live birth with an area under the receiver-operator curve (AUROC) of 0.741 (p

In liver transplant (LT) recipients, the cause of graft dysfunction in pregnancy is often difficult to ascertain. Moreover, a liver biopsy in late pregnancy is often avoided as a consequence of patient and physician factors. Management of graft dysfunction can be difficult in this setting. We report a 30-year-old female LT recipient who developed acutely deranged liver biochemistry during the third trimester of her first pregnancy. At 29 weeks gestation, her liver function test (LFT) became abnormal; AST peaked at 978 IU/L (normal range 10-50), GGT 25 IU/L (normal range 1-55), bilirubin 1.5 mg/dL (normal range 0.3-1) and serum bile acids 52 µmol/L (normal range

Pregnancy after liver transplantation (LT) is increasingly common and is a frequent scenario that transplant physicians, obstetricians, and midwives encounter. This review summarizes the key issues surrounding preconception, pregnancy-related outcomes, immunosuppression, and breastfeeding in female LT recipients. Prepregnancy counseling in these patients should include recommendations to delay conception for at least 1-2 years after LT and discussions about effective methods of contraception. Female LT recipients are generally recommended to continue immunosuppression during pregnancy to prevent allograft rejection; however, individual regimens may need to be altered. Although pregnancy outcomes are overall favorable, there is an increased risk of maternal and fetal complications. Pregnancy in this cohort remains high risk and should be managed vigilantly in a multidisciplinary setting. We aim to review the available evidence from national registries, population-based studies, and case series and to provide recommendations for attending clinicians.

Reports of pregnancy in liver transplantation (LT) patients have largely favorable outcomes. Concerns remain with regards to maternal and graft risk, optimal immunosuppression (IS), and fetal outcomes. We review all post-LT pregnancies at our center with regard to the outcomes and safety for the patient, graft, and fetus. A total of 117 conceptions occurred in 79 patients. Median age at conception was 29 years. Maternal complications included graft loss (2%), acute cellular rejection (ACR; 15%), pre-eclampsia/eclampsia (15%), gestational diabetes (7%), and bacterial sepsis (5%). ACR was significantly more common in those women who conceived within 12 months of LT (P = 0.001). The live birth rate was 73%. Prematurity occurred in 26 (31%) neonates, and 24 (29%) neonates were of low or very low birth weight. IS choice (cyclosporine versus tacrolimus) had no significant effect on pregnancy outcomes and complications. No congenital abnormalities occurred, and only 1 child born at 24 weeks had delayed developmental milestones. In conclusion, pregnancy following LT has a favorable outcome in the majority, but severe maternal risks remain. Patients should be counseled with regard to the above information so informed decisions can be made, and pregnancy must be considered high risk with regular monitoring by transplant clinicians and specialist obstetricians.

Liver transplantation (LT) is a successful treatment for both acute liver failure and end-stage liver disease. The number of women of reproductive age undergoing LT is increasing. Pregnancy outcomes are favorable, but there is still a lack of prognostic markers. We aimed to identify factors predictive of adverse pregnancy outcomes in LT recipients. An analysis of all pregnancies occurring in LT recipients from 1989 to 2016 at King's College Hospital was performed. Clinical data of 162 conceptions in 93 women were reviewed. Descriptive and regression analyses were done to examine associations between laboratory markers and hepatological scores with pregnancy outcomes of live birth and preterm birth. Median age at LT was 23 years (range, 1-41 years), with a median age at conception of 30 years (range, 18-47 years). The live birth rate was 75% (n = 121). Of live births, 35% (n = 39/110 available) were delivered preterm. Preconception creatinine levels were higher in patients who had a preterm birth (85 versus 74 μmol/L; P = 0.008), with a preconception estimated glomerular filtration rate (eGFR)

INTRODUCTION The replacement of 24-h urine collection by protein-creatinine ratio (PCR) for the diagnosis of preeclampsia has been recently recommended. However, the literature is conflicting and there are concerns about the impact of demographic characteristics on the performance of PCR. MATERIAL AND METHODS This was an implementation audit of the introduction of PCR in a London Tertiary obstetric unit. The performance of PCR in the prediction of proteinuria ≥300 mg/day was assessed in 476 women with suspected preeclampsia who completed a 24-h urine collection and an untimed urine sample for PCR calculation. Multivariate logistic regression was used to assess the independent predictors of significant proteinuria. RESULTS In a pregnant population, ethnicity and PCR are the main predictors of ≥300 mg proteinuria in a 24-h urine collection. A PCR cut-off of 30 mg/mmol would have incorrectly classified as non-proteinuric, 41.4% and 22.9% of black and non-black women, respectively. Sensitivity of 100% is achieved at cut-offs of 8.67 and 20.56 mg/mmol for black and non-black women, respectively. Applying these levels as a screening tool to inform the need to perform a 24-h urine collection in 1000 women, would lead to a financial saving of €2911 in non-black women and to an additional cost of €3269 in black women. CONCLUSIONS Our data suggest that a move from screening for proteinuria with a 24-h urine collection to screening with urine PCR is not appropriate for black populations. However, the move may lead to cost-saving if used in the white population with a PCR cut-off of 20.5.

Objective To evaluate whether eponymous maneuvers and mnemonics taught for the management of shoulder dystocia, vaginal breech delivery, and uterine inversion were remembered and understood in practice. Methods A questionnaire was distributed to obstetricians and midwives collecting information about the HELPERR and PALE SISTER mnemonics. Three extended matching questions evaluated participants’ knowledge of the correct maneuvers, with their matching eponyms, used in the management of shoulder dystocia, vaginal breech delivery, and uterine inversion. Results Of the 112 participants, 90% were familiar with the HELPERR mnemonic, with 79% using it in their practice. Of those who used it, only 32% could correctly decipher it ( P = 0.032). PALE SISTER was mostly unfamiliar. The percentages of correct maneuvers used for managing shoulder dystocia, breech delivery, and uterine inversion were 84.6%, 58.3%, and 28.6%, respectively. However, the eponyms were correctly matched to their maneuvers in only 33.3%, 14.3%, and 0% of cases, respectively ( P Conclusion The meanings of the mnemonics for obstetric emergencies were frequently recalled incorrectly. This, together with the poor correlation between knowledge of maneuvers and their eponyms, limits their usefulness and indicates that teaching should focus on learning without relying on mnemonics and eponyms.

This chapter outlines miscellaneous topics in obstetrics, including emergency cerclage, trauma in pregnancy, transfer and transport of pregnant women, pharmacotherapeutics in obstetrics (analgesics, morphine, antiemetics, antibiotics, anticoagulants, antihypertensives, anticonvulsives, corticosteroids, tocolytics, induction agents, and uterine stimulants), and obstetric collapse.

Throughout the affluent world, Caesarean section rates continue to rise. Increasingly, doctors will be faced with a request for Caesarean section without medical indication. A knowledge of the factual evidence of the risks and benefits and an understanding of the possible ethical issues raised by such requests is essential to maintain good practice.

Failure to visualise the fetal nasal bones at 11-14 weeks of gestation is associated with a significant increase in the risk for trisomy 21. However, it is not known whether the ethnic origin of the mother has any effect on the fetal profile and the prevalence of this marker.Prospective study.London Teaching Hospital.Four thousand and four hundred and ninety-two consecutive fetuses undergoing routine first trimester ultrasound scanning at 11-14 weeks of gestation in a multiethnic population.Examination of the nasal bones was attempted in the fetuses.Rate of visualisation of the fetal nasal bones.Five hundred fetuses were excluded from the analysis because of chromosomal abnormalities or a technically unsatisfactory examination. In the remaining 3992 fetuses, the maternal ethnic origin was African in 13.0%, Asian in 15.3% and Caucasian in 66.0%. Compared with Caucasians, the failure to visualise the fetal nasal bones was significantly higher in women of African (P= 0.0001) but not Asian origin (P= 0.24). A multivariable logistic regression model showed that having a mother of African origin is still significantly associated with an increased likelihood of absent fetal nasal bones compared with Caucasians (odds ratio 2.33), even after correcting for maternal age, parity and crown-rump length.There is a significant difference in the rate of visualisation of the fetal nasal bones in the first trimester in mothers of different ethnic origin. This suggest that corrections for maternal ethnicity will be required to ensure equity of fetal nasal bone screening in multiracial populations. Whether corrections are required for the father's ethnic origin remains to be determined.