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Our objective was to assess the effect of maternal intravenous immunoglobulin (IVIG) administration for severe red blood cell (RBC) alloimmunisation on fetal outcomes. This is a case-control study. Women with a history of severe early onset alloimmunisation resulting in fetal loss in a previous pregnancy and high anti-D or anti-K antibody titres received IVIG in a subsequent pregnancy. We assessed gestational age at first transfusion and fetal outcomes in the subsequent pregnancy and compared these with the outcomes in the previous pregnancy. The most responsible antibody was anti-D in 17 women and anti-K in two others, whilst seven had more than one antibody. In all, 19 women received IVIG in 22 pregnancies, two of which did not even need an intrauterine transfusion (IUT). For previous early losses despite transfusion, IVIG was associated with a relative increase in fetal haemoglobin between treated and untreated pregnancies of 36.5 g/L (95% confidence interval 19.8-53.2, p = 0.0013) and improved perinatal survival (eight of eight vs. none of six, p = 0.001). For previous losses at20 weeks, it enabled first transfusion deferral in subsequent pregnancies to at least 19.9 weeks (mean 23.2 weeks). Overall, IVIG decreases the severity of haemolytic disease of the fetus and newborn and allows deferral of the first IUT to a safer gestation in severe early-onset RBC alloimmunisation and rarely may even avoid the need for IUT entirely.

ImportanceReducing maternal mortality is a global objective. The maternal mortality ratio (MMR) is low in Hong Kong, China, but there has been no local confidential enquiry into maternal death, and underreporting is likely.ObjectiveTo determine the causes and timing of maternal death in Hong Kong and identify deaths and their causes that were missed by the Hong Kong vital statistics database.Design, Setting, and ParticipantsThis cross-sectional study was conducted among all 8 public maternity hospitals in Hong Kong. Maternal deaths were identified using prespecified search criteria, including a registered delivery episode between 2000 to 2019 and a registered death episode within 365 days after delivery. Cases as reported by the vital statistics were then compared with the deaths found in the hospital-based cohort. Data were analyzed from June to July 2022.Main Outcomes and MeasuresThe outcomes of interest were maternal mortality, defined as death during pregnancy or within 42 days after ending the pregnancy, and late maternal death, defined as death more than 42 days but less than 1 year after end of the pregnancy.ResultsA total of 173 maternal deaths (median [IQR] age at childbirth, 33 [29-36] years) were found, including 74 maternal mortality events (45 direct deaths and 29 indirect deaths) and 99 late maternal deaths. Of 173 maternal deaths, 66 women (38.2%) of individuals had preexisting medical conditions. For maternal mortality, the MMR ranged from 1.63 to 16.78 deaths per 100 000 live births. Suicide was the leading cause of direct death (15 of 45 deaths [33.3%]). Stroke and cancer deaths were the most common causes of indirect death (8 of 29 deaths [27.6%] each). A total of 63 individuals (85.1%) died during the postpartum period. In the theme-based approach analysis, the leading causes of death were suicide (15 of 74 deaths [20.3%]) and hypertensive disorders (10 of 74 deaths [13.5%]). The vital statistics in Hong Kong missed 67 maternal mortality events (90.5%). All suicides and amniotic fluid embolisms, 90.0% of hypertensive disorders, 50.0% of obstetric hemorrhages, and 96.6% of indirect deaths were missed by the vital statistics. The late maternal death ratio ranged from 0 to 16.36 deaths per 100 000 live births. The leading causes of late maternal death were cancer (40 of 99 deaths [40.4%]) and suicide (22 of 99 deaths [22.2%]).Conclusions and RelevanceIn this cross-sectional study of maternal mortality in Hong Kong, suicide and hypertensive disorder were the dominant causes of death. The current vital statistics methods were unable to capture most of the maternal mortality events found in this hospital-based cohort. Adding a pregnancy checkbox to death certificates and setting up a confidential enquiry into maternal death could be possible solutions to reveal the hidden deaths.

Objective To evaluate mortality and long term neurodevelopmental outcomes of the second twins born to mothers who attempted vaginal delivery. Study design Two hundred and twenty-seven eligible cases of second twin born to mothers who attempted vaginal delivery were identified retrospectively in a ten-year period. Information on adverse long term outcomes (a composite of mortality and neurodevelopmental disorders) were retrieved from their electronic medical record, and the risk factors were determined. Results The median follow-up duration was 8 years (range 4-13 years). Adverse composite long term outcomes were observed in 6.6% (15/227). Gestation at delivery 30 min (P = 0.000) were significantly associated with adverse long term outcomes of the second twin on multivariate analysis. Second twins in the combined vaginal- caesarean birth group had no significant increase in adverse outcomes compared to those in the vaginal-vaginal birth group. Conclusion Adverse long term outcomes were uncommon among second twins born to mothers who attempted vaginal delivery. Adverse outcomes were associated with prematurity and inter-twin delivery interval of more than 30 min, but not with actual mode of delivery.

Objective: To assess the association between body mass index (BMI) and adverse pregnancy outcomes.Materials and methods: A multicentre retrospective cohort study was conducted in three hospitals in Hong Kong including 67,248 women with singleton pregnancy at 11–13 weeks between 2010 and 2016. The relationship between maternal BMI and (1) miscarriage or stillbirth, (2) development of preeclampsia (PE), (3) gestational hypertension (GH), (4) development of gestational diabetes mellitus (GDM), (5) spontaneous preterm delivery (sPTD)

Objective To examine preferences for follow-up testing in women screened with high or intermediate risk for Down syndrome in the first or second trimester. Design Prospective cohort study. Setting Three public hospitals in Hong Kong, China. Sample Women with pregnancies termed as high risk (≥1:250; HR) or intermediate risk (1:251–1200; IR) for Down syndrome. Methods Women with pregnancies screened as HR were offered the choices of: (1) an invasive test plus chromosomal microarray (CMA) to obtain more detailed fetal genetic information; (2) non-invasive cell-free prenatal DNA screening (NIPT) to detect trisomies 13, 18 and 21, and to avoid procedure-related miscarriage; and (3) to decline any further testing. Women received standardised counselling informing them that the reporting times were identical, the procedure miscarriage risk was 0.1–0.2% and that there was no charge for screening. Women with IR pregnancies (1:251–1200) were offered NIPT as a secondary screening test. Main outcome measures Uptake rate for NIPT. Results Three hundred and forty-seven women had pregnancies deemed as HR; 344 (99.1%) women opted for follow-up testing, 216 (62.2%) of whom chose NIPT. Five hundred and seven of 614 women (82.6%) with IR risk chose NIPT. Seven (21%) of 34 women with nuchal translucency ≥3.5 mm opted for NIPT. Conclusion In a setting where reporting times are similar and there is no cost difference between options, approximately 60% of women with pregnancies classed as HR would opt for NIPT, offering simple but limited aneuploidy assessment, over a diagnostic procedure with comprehensive and more detailed assessment. Tweetable abstract 60% of pregnant Chinese women prefer NIPT over CMA when screened as high risk for Down syndrome.

OBJECTIVE: We report the outcome of pregnancies treated with intravenous immunoglobulin (IVIG) for severe red blood cell alloimmunization, evaluating whether IVIG defers the development of severe fetal anaemia and its consequences. BACKGROUND: Although fetal anemia can be treated very successfully with intrauterine transfusion (IUT), procedures before 20 weeks' gestation can be very challenging technically and may be hemodynamically stressful to an extremely premature and already compromised fetus. The procedure-related fetal loss rate is approximately 5.6% for IUTs performed < 20 weeks' gestation, compared to 1.6% overall. IVIG may prevent hemolysis and could therefore be a noninvasive alternative for early transfusions. STUDY DESIGN: We included consecutive pregnancies over a nineteen year period in the Fetal Medicine Unit, Mount Sinai Hospital, University of Toronto, Canada, of alloimmunized women with a history of severe early onset haemolytic disease who received IVIG until intrauterine transfusion could safely be performed. Previous untreated pregnancies were used as controls. IVIG therapy was commenced between 11 and 14 weeks' gestation. Our usual protocol was IVIG 2 g/kg per week every 3 weeks, until the first IUT could be performed. Each 2g/kg dose was administered over 2 days, 1g/kg per day, to reduce the chance of severe headaches. In three pregnancies, IVIG 1g/kg was given weekly. We compared the clinical outcomes (gestation at first IUT, fetal Hb at first FBS, gestation at delivery, perinatal survival) between previous pregnancies without IVIG and the subsequent pregnancy treated with IVIG. In comparing fetal Hb's between two pregnancies, a linear relationship between fetal Hb and gestation was used to correct for variable gestations. The fetal Hb was converted to a standardized fetal Hb value (multiples of the standard deviation [SD]). Statistical analysis was performed on 'Statistical Package for Social Science Version 16.0' (SPSS Inc, Chicago, Illinois). RESULTS: Seventeen women referred to our unit for a previous pregnancy loss secondary to severe RBC alloimmunization received IVIG treatment in 20 subsequent pregnancies; all eventually requiring intrauterine transfusion. For previous early losses despite transfusion, immunoglobulin was associated with a relative increase in fetal hemoglobin between treated and untreated pregnancies of 32.6 g/L (95%CI 15.2-50.0, P=0.003) and improved perinatal survival (8/8 vs 0/6, P=0.001). For previous losses CONCLUSION: Our results show that, among severely sensitized cases with previous early fetal loss despite IUT, use of IVIG in subsequent pregnancies is associated with a significantly higher fetal Hb before first IUT, deferral of first IUT, delivery at a later gestation and increased perinatal survival. The timing of the first FBS/IUT was delayed by 3 weeks in pregnancies treated with IVIG compared to a previous untreated pregnancy. Figure 1 Figure 1. Disclosures No relevant conflicts of interest to declare.

Acupuncture is commonly used in various aspect of Western medicine in recent years including in-vitro fertilization (IVF) treatment. Although there are many clinical trials of acupuncture in IVF and the Cochrane meta-analysis did not find benefit of adjuvant acupuncture for IVF, there is no report on the pregnancy outcomes of women who had received acupuncture during their IVF treatment.To compare the pregnancy outcomes of women randomized to receive real versus placebo acupuncture during their IVF treatment.A retrospective chart review was performed on the 212 women with on-going pregnancies after receiving real or placebo acupuncture by sterile disposable stainless steel needles or Streitberger's placebo needles to the acupoints before and after the embryo transfer on the day of fresh or frozen-thawed embryo transfer. The pregnancy outcomes were obtained from the Hospital Authority Clinical Management System for deliveries in the public sector or from a self-returned questionnaire if those in the private sector.No significant differences were found between the demographics of the two groups including their age, gravida, parity and the duration of subfertility. Maternal adverse outcomes including gestational diabetes and hypertensive disorder were comparable for the real acupuncture group (35.3% and 4.4% respectively) and the placebo acupuncture group (39.7% and 5.5% respectively). None of the patients had placenta accreta. The preterm delivery (37 weeks gestation) rate in the real acupuncture group (23/86, 26.7%) was similar to that in the placebo acupuncture group (25/97, 25.8%). No statistical significant difference was found in the mode of delivery. There were no significant differences between the two groups for Apgar scores and birthweight.Acupuncture during IVF treatment does not influence pregnancy outcomes.

AIM According to the published work, pregnancy termination rates due to prenatal diagnosis of fetal sex chromosome aneuploidies (SCA) vary widely. Some potentially modifiable and non-modifiable factors have been reported to be associated with parental decision. This study aimed to evaluate the rate of pregnancy termination for fetal SCA and the factors influencing parents' decisions in Hong Kong. METHODS This was a 21-year retrospective cohort study of parents' decisions following prenatal diagnosis of SCA. Univariate and multivariate analyses for the association between demographic factors, prenatal factors, or counseling provided and decision-making were conducted. RESULTS The study included 399 pregnancies with prenatal diagnosis of SCA and the overall termination rate was 55.6% (91.7%, 48.0%, 23.4%, 4.8%, and 22.7% for 45,X, 47,XXY, 47,XXX, 47,XYY, and mosaicism, respectively). Pregnancies with ultrasound abnormalities were associated with higher termination rates than pregnancies with normal ultrasound findings (91.3% vs 28.3%, P < 0.0001). From multivariate regression analysis on 226 pregnancies with normal ultrasound examination, a higher likelihood to terminate was found in pregnancies affected by 45,X and 47,XXY (adjusted odds ratio, 4.72, P < 0.0001). Increased maternal age and history of infertility were associated with lower likelihood to terminate (adjusted odds ratio, 0.9, P = 0.012; and 5.12, P = 0.038, respectively). The pregnancy termination rate declined over time. CONCLUSION A significant correlation was found between the termination of SCA-affected pregnancy and the presence of fetal sonographic abnormalities, type of SCA, maternal age, and presence of infertility.

Subamniotic hemorrhage results from rupture of chorionic vessels near the cord insertion. In the literature, it has never been a major cause for severe intrapartum complications. We report the first case of acute massive subamniotic hemorrhage intrapartum resulting in severe perinatal asphyxia.

In this first Asian study, the decision outcomes (decision conflict, decision regret, and anxiety) of 262 pregnant women offered noninvasive prenatal test (NIPT) for high-risk Down screening results were assessed. Decision conflict was experienced by 3.5% and level of decisional regret low (mean score 15.7, 95%CI 13.2–18.3). All 13 cases of decisional regret were NIPT acceptors. Elevated anxiety was experienced by 55.9% at the time of decision making about NIPT and persistent in 30.3%. Insufficient knowledge about NIPT was associated with elevated anxiety at decision making (p = .011) and with decisional regret (p = .016). Decisional regret was associated with prolonged anxiety (p = .010).

Uniparental disomy (UPD) refers to the genetic phenomenon in which both homologous chromosomes are inherited from the same parent, either maternal or paternal. The UPD phenotype is chromosome speci...

Despite a high colonisation rate of 38% in the female lower genital tract (DiGiulio 2012), Candida seldom causes chorioamnionitis in pregnancy. The candida species (including albicans, glabrata and...

This study supports training in genetic counseling for obstetricians and adoption of a multidisciplinary approach in the counseling process following prenatal diagnosis of sex chromosome aneuploidy.

According to the published work, pregnancy termination rates due to prenatal diagnosis of fetal sex chromosome aneuploidies (SCA) vary widely. Some potentially modifiable and non-modifiable factors have been reported to be associated with parental decision. This study aimed to evaluate the rate of pregnancy termination for fetal SCA and the factors influencing parents' decisions in Hong Kong.This was a 21-year retrospective cohort study of parents' decisions following prenatal diagnosis of SCA. Univariate and multivariate analyses for the association between demographic factors, prenatal factors, or counseling provided and decision-making were conducted.The study included 399 pregnancies with prenatal diagnosis of SCA and the overall termination rate was 55.6% (91.7%, 48.0%, 23.4%, 4.8%, and 22.7% for 45,X, 47,XXY, 47,XXX, 47,XYY, and mosaicism, respectively). Pregnancies with ultrasound abnormalities were associated with higher termination rates than pregnancies with normal ultrasound findings (91.3% vs 28.3%, P0.0001). From multivariate regression analysis on 226 pregnancies with normal ultrasound examination, a higher likelihood to terminate was found in pregnancies affected by 45,X and 47,XXY (adjusted odds ratio, 4.72, P0.0001). Increased maternal age and history of infertility were associated with lower likelihood to terminate (adjusted odds ratio, 0.9, P = 0.012; and 5.12, P = 0.038, respectively). The pregnancy termination rate declined over time.A significant correlation was found between the termination of SCA-affected pregnancy and the presence of fetal sonographic abnormalities, type of SCA, maternal age, and presence of infertility.

To assess whether angle of progression (AOP) and head-perineum distance (HPD) measured by intrapartum transperineal ultrasound (ITU) correlate with clinical fetal head station (station); and whether AOP versus HPD varies during uterine contraction and relaxation. In a subset of primiparous women, whether these ITU parameters correlate with time to normal spontaneous delivery (TD).We evaluated prospectively 100 primiparous and multiparous women at term in active labor. Transabdominal and transperineal ultrasound (sagittal and transverse plane) were used to measure fetal head position and ITU parameters, respectively. Digitally palpated station and cervical dilatation were also noted. The results were compared using regression and correlation coefficients.Station was moderately correlated with AOP (r = 0.579) and HPD (r = -0.497). AOP was highly correlated with HPD during uterine contraction (r = -0.703) and relaxation (r = -0.647). In the subgroup of primiparous women, natural log of TD has the highest correlation with HPD and AOP during uterine contraction (r = 0.742), making prediction of TD similar to that of using cervical dilatation.ITU parameters were moderately correlated with station. There was constant high correlation between AOP and HPD. Prediction of TD in primiparous women using ITU parameters was similar to that of using cervical dilatation.

There are only a few series treating ≥10 cases of accreta conservatively, all from university teaching hospitals, with reported success rate of 60-85%. We reported the first series of accreta managed by planned uterine conservation in the setting of non-university district general hospital.Women with placenta previa overlying previous cesarean scar who desired uterine conservation were included. For cases with accreta confirmed during cesarean delivery, placenta was purposefully left behind, followed immediately by uterine artery embolization. Cases were followed in our special postnatal clinic. Charts were reviewed to retrieve clinical details.Among 15 cases of placenta previa overlying cesarean scar opting for conservative management, 12 (80%) were confirmed to be accreta intra-operatively. They had 20-100% of the adherent placentae retained (median 90%) and their uterus preserved. Postpartum, abnormal vaginal bleeding and/or infection led to unscheduled readmission in 67% (8/12), all managed conservatively. Sonographic resolution of placenta took 2-13 months (median 6.6), and was later than menstrual return in 11 cases.Successful planned conservative management of placenta accreta is feasible in the setting of district general hospital with facilities for interventional radiology.

Objective To report secondary or additional findings arising from introduction of non-invasive prenatal testing (NIPT) for aneuploidy by whole genome sequencing as a clinical service. Methods Five cases with secondary findings were reviewed.

We found that foetal alpha thalassaemia major remained a possibility despite normal haemoglobin level, normal mean corpuscular volume (MCV) and normal mean cellular haemoglobin (MCH) results for bo...

A low level of PAPP-A predicts adverse fetal outcomes. As Chinese pregnant women have a higher level of PAPP-A, the predictive performance of PAPP-A and its optimal cutoff value might be different. This study aims to establish a PAPP-A cutoff value in the Chinese population that identifies adverse fetal outcomes. We retrospectively analysed 4936 spontaneous singleton pregnancies of Chinese women who underwent first-trimester combined Down's screening in our unit from March 2010 to January 2014 and had delivery information available. A composite adverse fetal outcome encompassed intrauterine fetal loss (including miscarriages and stillbirths), and live births either before 32 weeks or weighing less than -2 standard deviation (SD) for gestation. The area under the curve of the receiver-operator characteristic curve for prediction of the composite adverse outcome using PAPP-A was 0.626 (95% CI =0.612-0.640, p

To find out whether intrapartum translabial ultrasound examination is painless by comparing pain score of ultrasound-based versus digital vaginal examination of foetal head station.In 94 women carrying uncomplicated-term singleton pregnancies, labour progress was assessed by translabial ultrasound, followed immediately by conventional digital vaginal examination. Pain scores (0-10) using visual analogue pain scale were obtained for both examinations. Forty-eight and forty-six sets of data were obtained in first and second stage of labour, respectively. The difference in pain scores between digital vaginal examination and translabial ultrasound was analysed.The median pain score for translabial ultrasound was 0 (range 0-8), while that for vaginal examination was 4.5 (range 0-10), p 0.05. There was no significant difference in pain scores between first and second stages of labour for translabial ultrasound (p = 0.123) and for vaginal examination (p = 0.680). The pain score for vaginal examination was higher than that of translabial ultrasound in 81.9%, similar in 13.8% and lower in 4.3% of cases. There was no statistically significant difference in pain scores obtained for digital vaginal examination by clinicians with different experience (p = 0.941).Intrapartum translabial ultrasound is generally better tolerated than digital vaginal examination for assessment of labour progress, making it an acceptable adjunctive assessment tool during labour.

OBJECTIVE: To study pregnant women's preference among various screening options for Down syndrome (DS) in routine clinical setting, and its potential association with women's demographic characteristics. METHODS: Women aged 35 years and older carrying singleton pregnancy were offered a variety of screening tests for DS before 14 weeks of gestation. Their preference was confirmed by the test they actually underwent. The association between women's choice of test and a number of demographic characteristics was studied using multinomial regression. RESULTS: Among 1967 eligible women, 619 opted for first-trimester screening test (FTS), 924 for partial integrated test (PIT), and 424 for full integrated test (FIT). Nulliparous women and working mothers were more likely to choose FTS and FIT. Women with history of subfertility were more likely to choose FIT. Women with family history of chromosomal abnormalities were more likely to choose FTS. The choice of screening test could be predicted for 49.9% of women using four demographic characteristics. CONCLUSIONS: Among older women of predominantly Chinese ethnicity, integrated test is a favorite alternative to FTS. Their choice of DS screening test can be predicted by their obstetric and socioeconomic characteristics. Many women show willingness to pay for a test with a lower false-positive rate.

To explore whether the outcomes of second-trimester pregnancy termination for fetal abnormalities are affected by fetal diagnoses.This was a retrospective review of cases undergoing second-trimester pregnancy termination for the fetal diagnoses of hemoglobin Barts, trisomy 21, and trisomy 18 during the period from 1999 to 2006. The affected pregnancies were terminated by vaginal misoprostol. The outcome measures were: (1) abortion within 24 hours after misoprostol commencement, (2) histology-confirmed incomplete abortion, and (3) experience of significant side effects during termination (temperature over 39 degrees C or need for metoclopramide for vomiting).One hundred and twenty cases were available for analysis. After adjusting for maternal age, parity, history of cesarean delivery, body mass index, gestation, and fetal hydrops, pregnancy termination for trisomy 21 was associated with a higher risk of incomplete abortion than trisomy 18 and hemoglobin Barts (odds ratio 5.25, 95% confidence interval 1.24-22.19, p = 0.024). The chance of abortion within 24 hours and experience of significant side effects were not found to be associated with fetal diagnosis.Pregnancy termination for trisomy 21 is associated with a higher risk of incomplete abortion. Fetal diagnosis affects the outcome of pregnancy termination.

Prenatal diagnosis of Apert syndrome has been limited by the difficulty in assessing cranial sutures with 2-dimensional (2D) sonographic scans, and the diagnosis is often made during the third trimester. We present a case in which we used the transparent maximum mode with a 3-dimensional (3D) sonographic scan to assess cranial sutures. Premature closure of the coronal suture can be shown in both 2D and 3D scans, whereas the widely opened metopic suture is best shown with the 3D scan. The presence of craniosynostosis, cardiac abnormalities, and syndactyly enables a targeted molecular test to confirm the diagnosis prenatally during the second trimester.