Preventing term stillbirth: benefits and limitations of using fetal growth reference charts Purpose of review This review examines the variation in clinical practice with regards to ultrasound estimation of fetal weight, as well as calculation of fetal weight centiles. Recent findings Placental dysfunction is associated with fetal smallness from intrauterine malnutrition as well as fetal disability and even stillbirth from hypoxemia. Although estimating fetal weight can be done accurately, the issue of which fetal weight centile chart should be used continues to be a contentious topic. The arguments against local fetal growth charts based on national borders and customization for variables known to be associated with disease are substantial. As for other human diseases such as hypertension and diabetes, there is a rationale for the use of an international fetal growth reference standard. Irrespective of the choice of fetal growth reference standard, a significant limitation of small for gestational age (SGA) detection programs to prevent stillbirth is that the majority of stillborn infants at term were not SGA at the time of demise. Summary Placental dysfunction can present with SGA from malnutrition and/or stillbirth from hypoxemia depending on the gestational age of onset. Emerging data show that at term, fetal Doppler arterial redistribution is associated more strongly with perinatal death than fetal size. Properly conducted trials of the role for maternal characteristics, fetal size, placental biomarkers, and Doppler assessing fetal well-being are required urgently.

Obstetric complications in pregnancies with life-limiting malformations Purpose of review The implementation of palliative care at birth has led to a significant rise in the number of couples who choose to continue with pregnancies complicated by life-limiting malformations (LLMs). Prenatal counselling and appropriate antenatal/perinatal management in these cases are poorly studied and may pose significant challenges. The purpose of this review is to outline specific obstetric risks and to suggest management for mothers who choose to continue with pregnancies with the most common LLMs. Recent findings In pregnancies complicated by LLMs where parents opt for expectant management, clinicians should respect parental wishes, whilst openly sharing potential serious maternal medical risks specific for the identified abnormalities. The focus of both antenatal and perinatal care should be maternal wellbeing rather than foetal survival. Follow-up ultrasound examinations and maternal surveillance should be aimed at achieving timely diagnosis and effective management of obstetric complications. A clear perinatal plan, agreed with the couples by a multi-disciplinary team including a foetal medicine specialist, a neonatologist and a geneticist, is crucial to reduce maternal morbidity. Summary This review provides a useful framework for clinicians who face the challenges of counselling and managing cases complicated by LLMs where parents opt for pregnancy continuation.

Revisiting the basis for haemoglobin screening in pregnancy Purpose of review Anaemia affects up to 50% of pregnancies worldwide, and is associated with maternal and neonatal morbidity and mortality. Prevention and management of anaemia remains a priority. Despite this, there is ongoing debate on the optimal approach to identifying anaemia in pregnant women and the best strategies for prevention and management. The objective of this review is to describe the current landscape of haemoglobin testing in pregnancy in low and high-income countries. Recent findings Current definitions of anaemia in pregnancy comprise a laboratory threshold of haemoglobin below which treatment is offered. Haemoglobin measurement is not sensitive in detecting iron deficiency – the most common cause of maternal anaemia. Furthermore, these historical thresholds were derived from heterogeneous populations comprising men and women. Women with anaemia in pregnancy are offered iron therapy, without testing for the underlying cause. This may be appropriate in high-income settings, where iron deficiency is the likely cause, but may not address the complex causes of anaemia in other geographical areas. Summary Current thresholds of haemoglobin defining anaemia in pregnancy are under review. Further research and policy should focus on optimal strategies to identify women at risk of anaemia from all causes.

General anaesthesia during caesarean sections: implications for the mother, foetus, anaesthetist and obstetrician Purpose of review A general anaesthetic is usually given for an emergency caesarean section (Category 1), where there is imminent threat to the mother or foetus. There are many risks in performing a general anaesthetic. The aim of this review is to highlight the effects and risks to the mother and foetus of each step of a general anaesthetic. Recent findings Anaesthetic techniques are changing, and the traditional mantra of using a general anaesthetic for an emergency caesarean sections is being challenged. There are also multiple potential risks of a general anaesthetic that are being better defined. This ranges from awareness during surgery, through to foetal and maternal risks of complications. Summary This review will outline the different stages of a general anaesthetic and highlight the risks. This summary will allow a better understanding of anaesthetic risks. This will allow obstetricians to have a more informed conversation with an anaesthetist as to form of anaesthetic required (general anaesthetic versus spinal or epidural top-up). The review will also allow obstetricians to give more informed consent to mothers and be aware of the postoperative risks.

Performance of ultrasound for the visualization of the placental cord insertion Purpose of review The purpose of this review was to review the literature on the performance of ultrasound for the visualization of the placental cord insertion (PCI) and for the diagnosis of abnormal placental cord insertion (APCI). APCI included both marginal cord insertion (MCI) and velamentous cord insertion (VCI) PCI. Recent findings The overall rate of visualization of the PCI across all trimesters is 90.3% and for those studies routinely using color Doppler, 98.1% (P < 0.0001). Although the visualization was lower with advancing gestational age, it remained high even into the late third trimester. In all studies, where time was reported, the PCI was visualized in most cases in less than 1 min. Ultrasound performed best for the diagnosis of VCI with a sensitivity, specificity and positive predictive value of 100, 99.9 and 85.7%, respectively, with routine use of color Doppler. Summary Ultrasound is an excellent screening test for the evaluation of PCI across all trimesters. The use of color Doppler increases the rate of visualization and should be routinely used. Ultrasound with color Doppler is also an excellent screening test for the diagnosis of VCI. However, the performance of ultrasound is reduced with the inclusion of MCI.

Antepartum and intrapartum risk factors for neonatal hypoxic–ischemic encephalopathy: a systematic review with meta-analysis Purpose of review To review literature about risk factors of neonatal hypoxic–ischemic encephalopathy (HIE). Recent findings Search in PubMed, MEDLINE, Embase, Clinicaltrials.gov and reference lists from 1999 to 2018. Inclusion criteria: study population composed of neonates who manifested HIE within 28 days from delivery, data reported as proportional rate. Studies were excluded if they included preterm pregnancies, postnatal conditions leading to HIE and/or fetal malformations, focused on a single risk factor, were not in English language. PRISMA guidelines were followed. Interstudies heterogeneity was assessed and a random/fixed models were generated as appropriate. Comparison between neonates with HIE vs. controls was performed by calculating odds ratio–95% confidence interval (OR–95% CI). Differences were significant if 95% CI did not encompass 1. Twelve articles were included. Fetuses with growth restriction (OR: 2.87; 95% CI: 1.77–4.67), nonreassuring cardiotocography (OR: 6.38; 95% CI: 2.56–15.93), emergency cesarean section (OR: 3.69; 95% CI: 2.75–4.96), meconium (OR: 3.76; 95% CI: 2.58–5.46) and chorioamnionitis (OR: 3.46: 95% CI: 2.07–5.79) were at higher risk of developing HIE. Nulliparity, gestational diabetes, hypertension, oligohydramnios, polyhydramnios, male sex, induction of labor, labor augmentation, premature rupture of membrane, and vacuum delivery were not significantly different. Summary Neonatal HIE has multifactorial origin and its cause is often undetermined and not preventable. PROSPERO (Registration number: CRD42018106563).

Junctional zone endometrium alterations in gynecological and obstetrical disorders and impact on diagnosis, prognosis and treatment Purpose of review To investigate the JZE alterations in gynecological and obstetrical disorders and impact on diagnosis, prognosis and treatment. Recent findings JZE was found to be significantly extended in patients with endometriosis, leading to the conclusion that endometriosis is a primary disease of the uterus, much like adenomyosis. Statistical correlation was then demonstrated between the severity of endometriosis and the depth of the adenomyosis infiltrates, hence the thickening of the JZE. Stem cells, predominantly found in the JZE were also found in histological sections of leiomyoma, suggested to be the origin of leiomyoma. This reservoir of JZE stem cells is influenced by different stressors leading to their differentiation into leiomyoma, endometriosis, adenomyosis or endometrial cancer, according to the stressor. The variability in presentation was hypothesized to be connected to genetic and epigenetic factors. JZE was also suggested to act as a barrier, stopping endometrial carcinoma cells invasion and metastasis. In addition, JZE plays a major role in conception, pregnancy and postpartum. Summary JZE is an important anatomical landmark of the uterus contributing to normal uterine function under the influence of ovarian hormones. Alterations of the JZE thickness and contractility can be used as pathognomonic clinical markers in infertility and chronic pelvic pain, for subendometrial and myometrial disorders, for example, adenomyosis and fibroids. Prospective randomized control trials will clarify the diagnostic steps, imaging modalities to follow and probably triage the patients between medical and surgical treatments.

The efficacy of using acupuncture in managing polycystic ovarian syndrome Purpose of review Polycystic ovarian syndrome (PCOS) is a common reproductive disorder, which significantly impairs the fertility of 3–10% of women at reproductive age. It is getting very popular for women with PCOS to seek alternative therapies to treat PCOS, for example, acupuncture. This review examines the currently available evidence from the randomized controlled trial to guide future recommendation on using acupuncture to assist the treatment of PCOS. Recent findings PCOS is manifested by oligo-amenorrhoea, infertility, and hirsutism. The standard treatment of PCOS includes oral pharmacological agents, lifestyle changes, and surgical modalities. Pharmacologically based therapies are only effective in 60% of the patients, which are also associated with different side-effects. As such, acupuncture offered an alternative option. Acupuncture can affect β-endorphin production, which may, in turn, affect gonadotropin-releasing hormone secretion and affecting ovulation and menstrual cycle. Therefore, it is postulated that acupuncture may induce ovulation and restore menstrual cycle via increasing β-endorphin production. Summary Although modern medical science has discovered the action mechanisms underlying how acupuncture may manage the symptoms of PCOS, majority of the trials are small in sample size and lack of consistency in the choice of acupoints. Larger scale trials are needed to provide standardized protocols.

Editorial: Developments in family planning and abortion care: dangerous liaisons? Not No abstract available