Poster Sessions – UK Annual Preterm Birth virtual conference 2021

Efficacy of cerclage, progesterone and pessary in preventing preterm birth in women with prior excision of the cervix: A systematic review

PO1

Authors

Faye Platt, Angharad Care, Kate Navaratnam, Andrew Sharp

Presenter

Faye Platt

Abstract

Background

Studies have demonstrated an increased risk of preterm birth (PTB) in women with a prior knife cone biopsy (KCB) or large loop excision of the transformation zone (LLETZ). PTB is the leading cause of neonatal morbidity and mortality worldwide. Interventions to prolong pregnancy are indicated following the finding of a mid-trimester cervical length <25mm. Whether cerclage presents superior efficacy over progesterone and the Arabin pessary is a question that remains unanswered.

Method

We searched Pubmed, Scopus and Cinahl databases to identify eligible studies. We included any randomised controlled trials and observational studies comparing either vaginal cerclage, progesterone, intramuscular 17-α hydroxyprogesterone caproate or Arabin pessary to one another or a control group, in pregnant women with prior LLETZ or KCB. Two independent reviewers screened papers for inclusion and assessed risk of bias. Cases of uncertainty were resolved by discussion with a third review author. The GRADE approach was used for quality assessment. All analyses were performed using Revman 5.4.1 and results were presented as forest plots.

Results

We identified 6 eligible retrospective cohort studies for inclusion in this review. All 6 studies reported outcomes for cerclage vs no cerclage. There is no evidence to support the use of history-indicated cerclage to prolong pregnancy in women with prior cervical surgery. There is insufficient evidence to draw conclusions on neonatal outcomes following the siting of a vaginal cerclage. There is no evidence surrounding the use of other interventions to prevent PTB in this cohort.

Conclusion

In women with prior LLETZ or KCB of the cervix, those receiving a vaginal cerclage are at a higher risk of PTB. Results are likely biased due to confounding. Studies comparing interventions to one another are required to determine the comparative efficacy of interventions in preventing PTB in women with prior cervical surgery.

Spatial characterisation of the reproductive tract microbiome in preterm prelabour rupture of fetal membranes (PPROM)

PO2

Authors

T. Beleil, RG. Brown, S. Kundu, YS. Lee, PR. Bennett, DA. MacIntyre.

Presenter

Dr Tanweer Beleil

Abstract

Background

PPROM precedes 30% of spontaneous preterm birth cases. Prior to PPROM, there is a shift from Lactobacillus spp. dominance of vaginal microbiota towards highly diverse compositions. It remains unclear if this pattern is reflected in the upper gestational tissues. In this study, we explore this association through metataxonomic and metagenomic approaches to compare the microbiome of matched vaginal, fetal membranes (FM) and placental samples in women presenting with PPROM.

Method

Matched vaginal swabs taken close to delivery by caesarean section, placenta tissue and FM tissue (distal, midway and adjacent to rupture site) were collected from women presenting with PPROM (n=15). Environmental and reagent controls were also collected and processed. Sequencing of 16S rRNA gene amplicons and shotgun sequencing were performed to profile microbiota community structure.

Results

A total of 7/15 (47%) women with PPROM had highly diverse vaginal microbiota compositions deplete in Lactobacillus species. The remainder (8/15, 53%) were dominated by Lactobacillus species. Despite Gardnerella vaginalis being readily detected in 6/15 (>2% relative abundance) vaginal samples, it was detected in only 3/60 (0.05%) FM and placenta samples. Similarly, vaginal Lactobacillus iners dominance was poorly correlated with FM or placental colonisation. Codetection of Sneathia spp. was observed in 3 matched patient sample sets. Analysis of shotgun sequencing data showed that some vaginal bacterial strains detected prior to rupture were the same as those found in FM and/or placenta following PPROM and delivery.

Conclusion

Our data supports ascending vaginal colonisation as a likely route of infection in some cases of PPROM. However, in other women vaginal microbiota composition is not always reflective of upper gestational tissue composition at delivery suggesting alternative colonisation pathways (e.g., haematogenous spread to the placenta). We are currently undertaking strain-tracking approaches to determine directionality of pathogenic colonisation and validation in a larger cohort. Studies of immune mediators in matched samples will examine whether the presence or absence of specific bacteria in the reproductive tract and gestational tissues influences the local inflammatory environment.

Prediction of preterm birth in twin pregnancies

PO3

Authors

Robyn Chilton, Dr Joanna Gent, Dr Richard Jackson, Dr Kate Navaratnam, Dr Andrew Sharp

Presenter

Robyn Chilton

Abstract

Background

Preterm birth is the most significant cause of morbidity and mortality amongst neonates, with twins making up 15-20% of these births despite accounting for only 2-3% of all live births. We aimed to identify clinical factors associated with preterm birth in twins.

Method

Electronic records were searched for twin pregnancies booked and delivered in Liverpool Women’s Hospital (Jan 2010-Nov 2020). Maternal demographics and pregnancy data were extracted. The primary outcome was preterm birth prior to 34+0 weeks. Univariable and multivariable analysis was performed to assess the impact of each clinical variable on gestational week of delivery. Multivariable analysis was performed on all covariates using a backwards step-wise process based on Akaikes information criterion (AIC).

Results

1584 twin pregnancies were identified, 1193 (75.3%) dichorionic (DC) diamniotic pregnancies, 374 (23.6%) monochorionic (MC) diamniotic and 17 (1.1%) monochorionic monoamniotic. Univariable analysis revealed a history of previous preterm birth and MC pregnancy were associated with earlier gestational age at delivery (-1.43, -1.82 weeks). Parity of 1 and 2+ (+0.78 and +0.88 weeks) and increasing maternal age (+0.03 weeks) were associated with increased gestational age at delivery. Multivariable analysis by chorionicity revealed parity of 1 (+0.94/+0.56 and +1.05/+0.74 weeks) and 2+ (+1.29/+0.87 and +1.24/+1.00 weeks) had a positive effect on both MC and DC. History of a previous preterm birth reduced gestation at delivery for MC and DC (-2.00/-1.33 and -2.36/-1.56 weeks). The negative effect of an increasing BMI (-0.03 weeks) was only significant in MC.

Conclusion

Nulliparity, younger maternal age, previous preterm birth, and monochorionicity all reduce the gestational age at delivery in twin pregnancies. Most significant variables have more impact in DC than MC. We have described a twin cohort at high-risk of preterm birth that may be the basis for preterm prevention studies.

Optimising the triaging of women presenting with threatened preterm labour: an analysis of in-utero transfer requests in Yorkshire and the Humber between January 2018 and December 2020

PO4

Authors

Sumeyya Tontus(1), Professor Dilly Anumba(1), Dr Catherine Harrison(2)

Presenter

Sumeyya Tontus

Abstract

Background

In-utero transfers (IUTs) are an important aspect of improving outcomes for preterm neonates. However, preterm delivery is difficult to predict, with less than 10% of women presenting with threatened preterm labour (TPTL) going on to deliver preterm. IUTs can pose a large burden to the women, who sometimes travel many miles from their booking hospital to be placed in an appropriate unit for their care. Despite this burden, many women to be unnecessarily transferred – 3 previous studies within Yorkshire and the Humber found that only 52%, 35.1% and 32.8% of women delivered within 48 hours of transfer. Testing for cervicovaginal biomarkers, such as fetal fibronectin, is an extremely useful method of identifying women at high risk of delivery, with studies finding an extremely high negative predictive value (NPV) for prediction of delivery within 7 days. However, use of these within the region has previously been found to be low. Our study aimed to explore the use of predictive biomarker testing prior to IUT within Yorkshire and the Humber in a much larger cohort than what has been achieved so far.

Method

This study was a retrospective cohort study, reviewing all IUT requests handled by Embrace (the Yorkshire and Humber neonatal transport service) between January 2018 and December 2020. For each request, gestation, use of antenatal corticosteroids, use of predictive testing, and transfer outcome were analysed.

Results

1,389 requests within the study period were reviewed. Only 24.55% of women underwent predictive testing before an IUT was requested, with 83.87% of these positive and 16.13% negative. Use remained constant over the 3 years – 22.62% in 2018, 22.45% in 2019 and 26.25% in 2020. There was a large variation in usage between hospitals, with the highest use found in Barnsley, an LNU (43.4%) and the lowest use in Hull and Bradford, both NICUs (8.1%). 89.77% of women received antenatal corticosteroids prior to IUT request.

Conclusion

Results show that the use of predictive testing in the region is still extremely low, undoubtably contributing to the issue of inappropriate IUTs. The use of predictive testing must increase to minimise the number of women being unnecessarily transferred from their homes, as well as the demand on transport services. Our retrospective data did not include delivery outcomes, and further prospective work has been conducted to include full delivery outcome data.

Predicting Preterm Birth from Cervicovaginal Metabolome of Women at High-risk: A Comparative Study Using Different Machine Learning Algorithms

PO5

Authors

David Tian, Zi-Qiang Lang, Emmanuel Amabebe, Neha Kulkarni and Dilly Anumba

Presenter

David Tian

Abstract

Background

Preterm birth (PTB, delivery before 37 weeks’ gestation) remains a major global health challenge. The currently-employed diagnostic tools including cervical ultrasound and fetal fibronectin measurements have limited effectiveness, particularly in low risk asymptomatic women (LRA). The cervicovaginal (CV) metabolome is altered in women at risk of PTB [1]. It is hypothesized that the CV metabolome can be analyzed by machine learning to effectively predict the risk of PTB in both LRA and symptomatic women. This work applies machine learning to study the potential of metabolome based PTB prediction.

Method

CV fluid metabolites of 297 LRA and symptomatic women (44 preterm and 253 term) from the ECCLIPPx pilot study between 20 and 28 weeks gestation [1, 2] were analyzed by nuclear magnetic resonance spectroscopy (1H-NMR). The dataset consisted of 8 features (metabolites). The distribution of the data was analyzed using histograms and feature significance by hypothesis testing followed by Pearson’s correlation (r). Three classifiers: logistic regression, polynomial kernel SVM and random forest were trained as PTB predictors. The dataset was randomly split into 100 training sets of 66% women and 100 test sets of 34% women using stratified sampling. For each training set, the 3 classifiers were trained and evaluated on the corresponding test set. This process was repeated 100 times, with different training set and test set used at each time.

Results

The histograms showed a non-normal data distribution. None of the 8 metabolites was significant using Mann-Whitney U test and 0.05 significance level with the p-values ranging from 0.094 (alanine) to 0.548 (formate). Glucose had the smallest correlation with every other metabolite (r = -0.015-0.180). The correlation between glucose and acetate/succinate was the smallest (r = -0.015 and 0.028) (Fig. 1). The mean training area under the curve (AUC) and mean testing AUC of each classifier over the 100 times were: logistic regression (training AUC: 1±0, testing AUC: 0.58±0.11 (max AUC: 0.88)); SVM (training AUC: 1±0, testing AUC: 0.51±0.06 (max AUC: 0.62); and random forest (training AUC: 1±0, testing AUC: 0.54±0.08 (max AUC: 0.71).

Conclusion

The predictive capacities of the algorithms for preterm birth in this cohort were modest perhaps due to relatively small dataset. This could be improved with larger datasets. Meanwhile, the results suggest that machine learning has significant potential clinical utility for CV metabolome-based PTB prediction.

References

[1] Stafford et al. Front Physiol. 2017 Aug 23;8:615. doi: 10.3389/fphys.2017.00615.
[2] Anumba et al. Ultrasound Obstet Gynecol. 2020 Aug 15. doi: 10.1002/uog.22180.

Outcomes of transabdominal cerclage following cervical trauma

PO6

Authors

Dr Kate McMurrugh 1,2, Miss Chloe Blatchford 2, Dr Megan Hall 2, Dr Natalie Suff 2, Professor Andrew Shennan 2

Presenter

Kate McMurrugh

Abstract

Background

Transabdominal cerclage is widely accepted in the literature and in clinical practice to be the superior option in the prevention of preterm birth once other options have failed or are deemed impossible to insert. Women with cervical trauma are known to be at high risk group for preterm birth and the efficacy of inserting TAC in these women is unknown. In this study we aim to evaluate outcomes related to different aetiological and risk factors necessitating transabdominal cerclage.

Method

An observational, retrospective cohort study including women to have a TAC placed at St Thomas’ Hospital between November 2014 and October 2020 who have had a subsequent pregnancy (n=81). Women were separated into two groups, those with previous cervical trauma and those without. Cervical trauma was defined as previous cone biopsy, LLETZ, radical trachelectomy or full dilatation Caesarean section (FDCS).

Results

Overall, 66% of women delivered at 37 weeks or above. The median gestational age at delivery in the previous cervical trauma group was 264 days compared to 266 in the non cervical trauma group, p=0.1426 (ns). There were 4 late miscarriages within the study, 2 in each group, giving an overall rate of 6.2%. 2 of these late miscarriages occurred in women who had a previous FDCS (n=8), giving a rate of mid trimester miscarriage in this subgroup of 25%. In subgroup analysis, women with a history of full-dilatation caesarean section were significant more likely to have a mid-trimester loss than women with a TAC for other risk factors for preterm birth (p=0.0397). There were no neonatal deaths in the study. 8 babies required admission to neonatal intensive care unit (NICU) after birth, 7 (87.5%) of whom were born to mothers who had prior cervical trauma.

Conclusion

Overall, this study shows that TAC is an effective method at preventing preterm birth in high risk women, including those with cervical trauma. Women with a TAC can be reassured as to the high success rate and management doesn’t need to differ based on their underlying risk factor for preterm birth. However, it is important to note that women with FDCS have a higher rate of midtrimester miscarriage and this requires further investigation.

Rapid Quality Improvement in a Preterm Birth Clinic during the COVID-19 Pandemic

PO7

Authors

Sara Zarasvand1,2, Erna Bayar1,2, Malko Adan1,2,3, Katherine Mountain1,2, Holly Lewis1,2, Karen Joash1, TG Teoh1, Phillip R. Bennett1,2,3, Sabrina Das1, Lynne Sykes1,2,3 *

Presenter

Katherine Mountain

Abstract

Background

Preterm Birth (PTB) occurs in 8% of births in the UK. At Imperial College Healthcare NHS Trust our PTB prevention clinic manages the care of approximately 1000 women/year. Women referred to the clinic are seen from 12 weeks of pregnancy with subsequent appointments every 2-4 weeks to measure cervical length (CL) using transvaginal ultrasound (TVUS). Women with a history of cervical weakness or short cervix on TVUS are offered a cervical cerclage.

During the COVID-19 outbreak, pregnant women were strongly advised to avoid social mixing and public transport. NHS services had to rapidly adopt remote consultation and re-design clinical pathways in order to reduce transmission, exposure and spread amongst women at high risk of PTB.

Method

We focused on SMART aims and used a driver diagram to visualise our changes. We used series of PDSA (Plan Do Study Act) cycles to evaluate and adapt change ideas through the UK’s national lockdown during the COVID-19 pandemic between March 23rd and May 29th 2020.

Results

We reduced the number of face to face (FTF) appointments by 54%. This was achieved by increasing remote telephone consultations from 0 to 64%, and by reducing the intensity of surveillance. The rate of regional anaesthetic was increased from 53 to 95% for cerclage placement in order to minimise the number of aerosol generating procedures. Patient and staff satisfaction responses to these changes were used to tailor practices. No women tested positive for COVID-19 during the study period.

Conclusion

By using quality improvement (QI) methodology we were able to safely and rapidly implement a new care pathway for women at high risk of PTB which was acceptable to patients and staff, and effective in reducing exposure of COVID-19.

The Impact of the Antenatal Late Preterm Steroids Trial on the administration of Antenatal Corticosteroids: An Interrupted Time Series Analysis

PO8

Authors

Ms Elise O.R. KEARSEY Bsc (Hons),1 Dr Jasper V. BEEN MD, PhD, 2,3 Dr Vivienne SOUTER MD, 4,5 Dr Sarah J. STOCK MD, PhD 1,5

Presenter

Elise Kearsey

Abstract

Background

In 2016 the Antenatal Late Preterm Steroids study was published, demonstrating that antenatal corticosteroid therapy (ACT) given to women at risk of late preterm delivery reduces respiratory morbidity in infants. However, the administration of ACT in late preterm infants remains controversial. Late preterm infants do not suffer from the same rate of morbidity as early preterm infants, and the short-term benefits of ACT are less pronounced. This study aimed to evaluate the association between the publication of the Antenatal Late Preterm Steroids study or the subsequent changes in guidelines and the rates of antenatal corticosteroid therapy administration in late preterm infants in the United States.

Method

Data analysed was publicly available USA birth certificate data from 1st January 2016 to 31st December 2018. An interrupted time series design was used to analyse the association between publication of the APLS study and changes in monthly rates of antenatal corticosteroid administration in late preterm gestation (34 to 36 weeks). Births 28 to 32 weeks’ gestation were used as a control. ACT administration in births 32 to 34 weeks and ACT administration in term births (>37 weeks’ gestation) was analysed.

Results

There was a statistically significant increase in antenatal corticosteroid therapy rates in late preterm births following online publication of the Antenatal Late Preterm Steroids study (adjusted Incidence Rate Ratio: 1.48; 95% CI: 1.36-1.61, P-value = 0.00). A significant increase in antenatal corticosteroid therapy rates was also seen in full-term births following online publication of the Antenatal Late Preterm Steroids study. No significant changes were seen in antenatal corticosteroid rates in gestational age groups 32 to 34 weeks or 28 to 31 weeks.

Conclusion

Online publication of the Antenatal Late Preterm Steroids study was associated with an immediate and sustained increase in the rates of antenatal corticosteroid therapy in late preterm birth across the USA. Demonstrating a swift and successful implementation of the Antenatal Late Preterm Steroids study guidance into clinical practise. However, there is an increase in full-term infants receiving ACT unnecessarily and as the long term consequences of ACT are yet to be elucidated effort should be made to minimise the number of infants unnecessarily exposed to ACT.

The outcomes of patients attending the Preterm Birth Prevention Clinic at Birmingham Women’s Hospital between 2018-2020

PO9

Authors

C Odendaal (presenting author), K McMurrugh, V Hodgetts Morton, C Fox

Presenter

Catherine Odendaal

Abstract

Background

The Preterm birth (PTB) prevention clinic at Birmingham Women’s hospital offers specialist antenatal care to women who are at higher risk of preterm birth. The clinical outcomes of the PTB clinic have been audited for 3 consecutive years, 2018-2020. The aim of this study is to evaluate the effectiveness of the PTB clinic during this time and compare the clinical outcomes from year-to-year. This reflects care before and after the implementation of the Saving Babies’ Lives care bundle 2 in March 2019.

Method

Cross-sectional study using patient records (paper or electronic) and Viewpoint data from 2018, 2019 and 2020. 584 women were included, of whom 95% (552) had complete data available for analysis of outcomes. Data were collected using a proforma and collated into an excel spreadsheet. Data was analysed using Fishers exact test (GraphPad prism software).

Results

The clinic saw an increase in number referred from 2018 to 2020 from 168 to 207 women.
The live birth rate of women attending clinic is between 95.9% and 99.3%.
The overall occurrence of preterm birth was 21.1% (110/522).
433 women had previously been pregnant (excluding terminations). The overall occurrence of preterm birth in these women was 25.4% (110/433) whereas based on indication for referral to clinic this was 42.9% (186/433). This is a statistically significant decrease in PTB rates with attendance to clinic, OR = 0.45 95% CI 0.34 – 0.60, P< 0.0001.
Of the women with a previous preterm birth (43.0%, 186/433), 30.1% (56/186) had recurrence of pre-term birth. This is a 69.9% reduction.
26.5-47.2% of pre-term births occurred after 36 weeks’ gestation.
The highest proportion of term births was in 2019 at 80.4%.

Conclusion

This data indicates that the PTB prevention clinic has been successful in its aim. This highlights the need for such services to continue and as demand grows expand. By re-auditing each year, we have been able to identify how the clinic has developed and performed. Of the pre-term births that occur in clinic, a considerable proportion are occurring after 36 weeks This may reflect the impact of timing of suture removal or cessation of progesterone therapy. With newer acknowledgment of the impact of late preterm/early term birth on child outcomes this is a useful area to understand.

Pregnancy outcomes following bone marrow transplant: findings of clinician survey and update on data linkage and UKOSS survey

PO10

Authors

Dr Katherine Birchenall (1), Prof Anna David (2), Dr Melanie Davies (2), Dr Victoria Grandage (2), Dr Raoul Reulen (3), David Winter (3), Julia Lee (4), Rachel Pearce (4), Prof Michael Hawkins (3), & Dr Melanie Griffin (1)

Presenter

Katherine Birchenall

Abstract

Background

Female childhood cancer survivors have increased risk of preterm birth (PTB), with relatively little known about pregnancy outcomes for women treated with bone marrow transplant (BMT) +/- total body irradiation (TBI), and management is likely variable across the UK. Preconception counselling and early referral to high-risk PTB prevention clinics (PTBPC) may improve outcomes.

Method

As introduced at last years’ conference, we are jointly funded by Action Medical Research/Borne to:
1. Determine the current management offered to women who conceive following BMT +/- TBI via a national survey of clinicians.
2. Determine incidence of adverse pregnancy outcomes, including PTB, for these women via:
a. Dataset linkage between British Childhood Cancer/Teenage and Young Adult Cancer Survivor Study cohorts and the British Society of Blood and Marrow Transplantation registry.
b. Prospective UKOSS survey.
3. Develop national guideline recommendations.
Here we report on our progress.

Results

1. Between 21/10/2020 and 22/10/2021, we received 47 clinician survey responses:
• 49% obstetricians and gynaecologists (O&G); 15% haematologists; 11% oncologists, 8% endocrinologists, 17% other.
• Overall, 43% of respondents reviewed women with previous BMT+/-TBI at least every month, 15% at least annually, 15% less than annually, and 27% never. For O&G, these percentages were 13%, 13%, 26%, and 48%, respectively.
• Of 23 O&G responses, 11 reviewed these women in antenatal clinics, three in preconception clinics, three in late effects clinics, two in reproductive medicine clinics, and one in paediatric and adolescent gynaecology clinics.
• Most discuss the potential implications for future pregnancy when meeting these girls and women pre-pregnancy.
• During early pregnancy, the following risks are discussed: 34% late miscarriage, 44% preterm labour, 31% fetal growth restriction, and 30% risks for health other than cancer.
• Of 30 respondents who meet these women during pregnancy:
o 24 refer to specialist clinics: 21 maternal medicine; 14 PTBPC; and six general antenatal.
o 26 offer extra investigations: 21 maternal echocardiogram; 13 renal and liver function tests; 13 serial fetal growth scans; seven cervical length measurement; and seven midstream urinalysis.
o Ten prescribed Aspirin.
o Six had offered cervical cerclage.
o Four prescribed progesterone.
2. a. Datasets have been linked and analysis commenced.
b. UKOSS survey extended to 31st December 2022, with 25 cases reported so far.

Conclusion

There is clear evidence of good care, with fertility and pregnancy discussed early. However, there is variation in management offered during pregnancy. Given the previous observation that pregnancy outcomes improved when managed in PTBPCs, clearer guidelines are required.

Evaluation of the fetal thymus perfusion: a feasibility study

PO11

Authors

Megan Hall, Jana Hutter, Lisa Story

Presenter

Megan Hall

Abstract

Background

Chorioamnionitis complicates up to 70% of preterm pregnancies and is associated with increased risk of fetal and neonatal mortality as well as long term neonatal morbidity as compared to neonates born preterm without chorioamnionitis. Currently there is no test in clinical practice for in vivo chorioamnionitis therefore the timing of delivery to minimize long term morbidity is a difficult clinical conundrum. The thymus, a gland integral to the fetal immune system has previously been of interest as involution has been been associated with chorioamnionitis in both animal models and histopathological studies. Ultrasound and MRI studies have also shown a reduction in 2D dimensions and thymus volume. However, measurements can be unreliable and subject to significant intra and inter observer variability, and it is not used to inform management decisions. However, advanced MRI techniques such as T2* may give additional information about the thymus, including metabolic state which may precede changes in volume. Here, we describe a feasibility study in the normal fetus demonstrating T2* values of the fetal thymus.

Method

Datasets were collected retrospectively from two ongoing studies (PiP and CARP) where T2 and T2* relaxometry data were available. Low risk pregnancies who subsequently delivered at term without additional risk factors (such as hypertensive disease, diabetes risk factors associated with preterm birth, or intrapartum adverse events such as maternal sepsis) were selected. T2 weighted anatomical imaging and multi-echo imaging for T2* mapping was undertaken on a 1.5T MR scanner. Datasets were post processed following in-house-developed pipelines to perform motion correction, T2* mapping and Deformable Slice to Volume Reconstruction in order to align T2* data with T2 anatomical images. Regions of interest containing the thymus were manually segmented on the resulting images to generate thymus volumes and mean thymus T2* values. Statistical analysis was performed in SPSS using Spearman’s coefficient to assess for correlation between mean T2* values and gestational age.

Results

12 cases were included at varying gestational ages from 27+2 to 36+6 weeks. All cases successfully underwent processing and segmentation described above. All women had normal pregnancy outcomes. Gestational age is positively correlated with an increasing thymus volume (Spearman’s coefficient 0.811, p<0.001). Mean T2* is consistent throughout gestation (Spearman’s coefficient 0.105, p=0.745). Figure demonstrates anatomically aligned images (from left to right) T2*, T2 and the segmented fetal thymus.

Conclusion

This study demonstrates the feasibility of T2* relaxometry of the thymus gland accounting for the effects of motion. We have demonstrated an increasing thymic volume and constant T2* values between 27 and 37 weeks gestation. This is likely to reflect similar metabolic requirements during this period. We hypothesise that metabolic requirements are likely to vary significantly during an infectious process and and the future this may represent a candidate marker to assess for the presence of fetal infection. Further work will be required to extensively map normal ranges throughout the whole of gestation and then compare findings with fetuses that subsequently deliver preterm.

Prospective study evaluating one-stop preterm birth clinic’s impact on preterm birth.

PO12

Authors

Watson, H.A., Kalaskar A, Mehta M.

Presenter

helena watson

Abstract

Background

Recent maternity policy has prioritised the provision of specialist preterm birth clinics across the UK in order to realise its maternity safety ambitions. These specialist services are expected to base women’s individualised management on the evidence for preterm birth prevention, prediction and preparation. However, there is very little evidence for the efficacy of preterm birth clinics themselves.

The impact of a new specialist preterm birth clinic on preterm birth outcomes in this inner-city district general hospital was compared with women with the same risk factors for preterm birth in the same maternity unit in the POPPIE (Pilot study Of midwifery Practice in Preterm birth Including women’s Experiences) trial.

Method

A historically controlled prospective study of women at high-risk for preterm birth (previous preterm birth, previous late miscarriage, uterine anomalies, cervical surgery, short cervix < 25mm in current or previous pregnancy) who visited a specialist one-stop preterm birth clinic in a secondary care inner-London maternity unit between April 1st 2020 and September 30th 2020 were compared with women identified with the same risk factors (but with the addition of current smoking identified at booking) in the POPPIE trial (trial recruitment was completed 30th September 2018). Clinic protocols introduced serial transvaginal ultrasound scanning, quantitiative fetal fibronectin testing and individualised management plans by clinicians with an interest in preterm birth as per SBLCB 2 recommendations. The primary outcome was spontaneous preterm birth prior to 37 weeks’ gestation.

Results

There were 64 women in the intervention (clinic) and 333 in control group (POPPIE trial). Characteristics of intervention and control groups were: previous preterm birth 53.1% (34/64) vs 35.4% (118/333) for, late miscarriage 6.25% (4/64) vs 16.5% (55/333), cervical surgery 39. 0% (25/64) vs 32.4% (108/333), current smoking 15.6% (10/64) vs 29.4% (98/333) and uterine anomalies 7.8% (5/64) vs 2.4% (8/333). Following the one-stop preterm birth clinic intervention, spontaneous preterm births were non-significantly reduced to 7.8%
from 11.8% (5/64 vs 39/331 p = 0.3527). Late miscarriages (<24 weeks) were 1.6% (1/64) vs 9/331 (2.7%). Following introduction of the preterm birth clinic, cerclage rates in this high-risk population increased from 5.7% to 21.9% and progesterone use increased from 15.3% to 31.2%.

Conclusion

Following the introduction of a specialist preterm birth clinic spontaneous preterm birth rates in this high-risk group appeared reduced, relative to background rates. This is likely due to the increased use of cervical cerclage and progesterone, but the continuity of care women received both from the continuity of care midwives (legacy of POPPIE trial) and preterm clinic may have contributed. Few before-and-after studies in secondary care settings have access to such a high-quality control group, as prior to the introduction of the clinic these high-risk women are not usually identified. These findings support the commitment to provide all women at risk of preterm birth with local and specialist maternity care.

The cervix over gestational age

PO13

Authors

Glazewska-Hallin A, Reynolds L, Hutter J, Jacques A, Story L

Presenter

Agnieszka Glazewska-Hallin

Abstract

Background

MRI can uniquely assess the entire cervix and tissue properties in-vivo. Previous studies have explored the cervical layers and their association with spontaneous preterm birth (sPTB) risk. However, no systematic quantitative MRI study has been presented of normal pregnancies. In our study we performed 3D reconstruction of cervices from women delivering at term. Measures taken included cervical length (CL), cervical layer volumes and their signal intensity (SI) compared to psoas muscle and cervical canal. These showed good correlation of CL to birth gestational age (GA) but no correlation of layer volume and SI to birth GA.

Method

71 women were identified with no known PTB risk factors delivering at term from the Placental Imaging Project (PIP) (RECLO/11/1147), performed on a clinical 3T Philips Archieva scanner. Of these, 36 MR reconstructions of sufficient quality were analysed. These T2-weighted Turbo Spin Echo sequences (TSE) were acquired from 15 weeks onwards. A manual mask was created in the sagittal plane and a 3D reconstruction of the cervix created. Two independent blinded observers recorded CL, volume of cervical layers (1-3 layers observed) and their relative signal intensity compared to mean cervical canal and psoas muscle SI using ITK-Snap. An intraclass correlation coefficient (ICC) was calculated using a 2-way mixed effect, absolute-agreement model. We recognised coefficients > 0.75 as having a good indicator of reliability.

Results

The gestational age at MRI ranged from 15 to 36 weeks. The cervical layer SI was increased (hyperintense) in the outer compared to inner stromal layer, suggesting increased hydration in the outer stroma. However, the cervical layer volumes and SI did not correlate with scan GA nor delivery GA. The intraclass correlation coefficient (ICC) was 0.922 for intra-observer reliability and 0.864 for inter-observer reliability indicating MR CL acquisition is similarly reliable to ultrasound. Inter-observer measurements for all cervical volumes (0.375, 0.667) and layer 2 SI (0.627) had low reliability.

Conclusion

Cervical MR studies can describe change in cervical architecture throughout pregnancy. However, there is currently limited cervical MR data for women delivering at term. We conducted a preliminary study to establish normal parameters for future investigation. The strength of our study is its inclusion of a wide range of GA at scan. We aim to increase our cohort size and enhance our experience of cervical segmentation. MRI diffusion imaging can further be used to differentiate cervical layers in different risk cohorts.

Adherence to Element 5 Saving Babies Lives Care Bundle (v2) at a Level 3 neonatal unit

PO14

Authors

Carlotta Modestini, Oyku Caunt, Manju Chandiramani

Presenter

Carlotta Modestini

Abstract

Background

Preterm birth is the most important single determinant of adverse infant outcome with regards to survival and quality of life. The national ambition addressed in Saving Babies Lives Care Bundle (v2) – Element 5 is the reduction of preterm birth from 8% to 6%, and where preterm birth is unavoidable, maternity units should focus on better preparation of babies for their imminent birth. We undertook an audit to determine how we were performing in relation to these targets.

Method

All preterm births over a 10-week period were identified. Clinical data including delivery data and medication records were collected.

Results

30 women were delivered at less than 34 weeks’ gestation over this period. Of these women, 50% had a pre-labour caesarean section. 87% received a complete course of antenatal corticosteroids within 1 week of delivery, 7% received their course more than a week before delivery and 6% received no antenatal corticosteroids. 2 of these women were admitted to ITU on ECMO with COVID-19. Over 90% of these women received magnesium sulphate for neuroprotection in the 24 hours prior to delivery. All of the women gave birth in hospital, the appropriate care setting, with access to a Level 3 neonatal unit.

Conclusion

Our local preterm birth rate is 6.7%, despite our urban socially deprived population and one of the biggest preterm birth prevention services in the country. This is a testament to our screening for preterm birth risk at booking and serial surveillance and intervention during pregnancy. Despite good overall adherence to national targets, ongoing shared local learning will facilitate continued understanding of the reasons this small group of women did not receive timely antenatal corticosteroids and magnesium sulphate in preparation for birth.

Early stage Caesarean sections and subsequent midtrimester loss: a case series

PO15

Authors

Glazewska-Hallin A, Goswami P, Littlewood G, Shennan A

Presenter

Agnieszka Glazewska-Hallin

Abstract

Background

Evidence of spontaneous preterm birth (sPTB) following late stage Caesarean sections (CS) has been published. Conversely, we report three cases of mid-trimester loss (MTL) following early stage CS. One of our patients has subsequently undergone insertion of a transabdominal cerclage (TAC). Prolonged early labour and cervical injury may play an aetiological role and current management involving cervical cerclage may offer limited impact on outcome.

Method

Clinical records were reviewed for these cases retrospectively. All patients had a previous sPTB requiring antenatal cervical surveillance.

Results

Patient 1 , G4P2+2, had an uncomplicated term CS at 3cm dilated following a prolonged first stage. Her subsequent pregnancy resulted in preterm prelabour rupture of membranes (PPROM) and sPTB at 23 weeks and neonatal death. During her next pregnancy, an ultrasound indicated cerclage was inserted alongside 400 mg daily progesterone and she delivered at term

Patient 2 , G6P1+5, delivered within the latent phase by uncomplicated term CS following prolonged syntocinon augmentation for spontaneous rupture of membranes (SROM) and suspected pre-eclampsia. Despite strong uterine contractions requiring epidural anaesthesia there was no cervical dilatation. Subsequently, she experienced three first trimester miscarriages and two MTLs following PPROM despite cervical cerclage. A pre-pregnancy TAC has been inserted.

Patient 3, G5P1+3, delivered by term CS at 4cm dilated following induction of labour with prolonged course of syntocinon. Following this, she experienced 2 MTLs. In the following pregnancy she unfortunately had another MTL despite a cervical cerclage.

Conclusion

These cases illustrate progressive uterine contractions without subsequent or minimal dilatation. We hypothesize this causes the lower segment to thin and the cervix to be drawn up over the presenting part. CS incision may be within or near the cervical os causing inadvertent damage. Confounders like technique, suture material, infection and cervical extensions may also be implicated. Of concern, our three cases were associated with pre-viable pregnancy loss, suggesting significant damage. Our data indicates reduced efficacy of cervical cerclage in this population (Watson, 2017 and Hickland, 2020). Currently, cervical length surveillance and foetal fibronectin testing in high risk women has been crucial in decision making, however this needs verification in women with a CS risk factor (Hezelgrave et al., 2016).

Current trends indicate reluctance in instrumental delivery and rising CS rates. We advise caution as our cases demonstrate a potential new facet of cervical injury compounded by strong uterine activity in the latent phase, predisposing women to future pregnancy complications.

Incidence of fetal loss prior to 24 weeks gestation in monochorionic and dichorionic twin pregnancies

PO16

Authors

Robyn Chilton, Dr Joanna Gent, Dr Kate Navaratnam, Dr Andrew Sharp

Presenter

Robyn Chilton

Abstract

Background

Twins have higher complication rates than their singleton counterparts. Monochorionic twins (MC) are at highest risk of adverse outcomes, largely due to shared vascular connections. We aimed to determine the incidence of loss of one or both twins in MC and dichorionic (DC) twin pregnancies prior to 24 weeks gestation.

Method

Electronic records were searched to identify twin pregnancies booked and delivered at Liverpool Women’s Hospital (Jan 2010-Nov 2020). Chorionicity and clinical data were collected from viewpoint and scanned notes. Higher order multiple pregnancies and MCMA twin pregnancies were excluded. The cohort data was coded and analysed using SPSS software and stratified by chorionicity. Data were further divided into two live twins, loss of one, or loss of both twins <24 weeks gestation.

Results

1584 twin pregnancies were identified, with 1567 remaining after exclusions. There were 76.1% (n=1193) dichorionic (DC) and 23.9% (n=374) monochorionic (MC). Spontaneous loss of at least 1 twin at <24 weeks was higher in MC 4.81% (n=18) than DC 1.93% (n=23) (p=0.002). Loss of one twin <24 weeks was higher in MC twins 3.5% vs 1.3% p=0.005, but loss of both twins was non-significant p=0.141. Relative risk of 1 twin lost and both twins lost was higher in MC twins at 2.76 (CI 1.33, 5.96) and 2.13 (CI 0.76, 5.94). 23.1% of MC and 26.7% of DC where 1 twin was lost <24 weeks went on to lose the remaining twin >24 weeks gestation.

Conclusion

MC twins have an increased risk of fetal loss <24-weeks compared to DC twins. Our data agree with current literature but display a lower relative risk and percentage frequency of <24-week twin loss than previously reported cohorts. This is likely explained by this up-to-date cohort reflecting modern surveillance and protocol driven management of twin pregnancies.

The TRANSFER project: ThReatened preterm birth, Assessment of the Need for in utero tranSFER between 22+0-23+6 weeks’ gestation

PO17

Authors

Dr Melanie Griffin, Consultant Obstetrician1 Dr Adam Smith-Collins, Consultant Neonatologist 1 Dr Victoria Hodgetts Morton, Senior Trainee and Clinical lecturer in Obstetrics 2 Professor Katie Morris, Consultant Obstetrician and Professor in Obstetrics2 Dr Laura Magill, Co-Director, BiCOPS2 On behalf of the Transfer Group

Presenter

melanie griffin

Abstract

Background

We are a group of senior clinicians in obstetrics and neonatology who have developed TRANSFER in response to the important recommendation by the British Association of Perinatal Medicine (BAPM), to follow a risk based approach for decisions about care pathways following delivery for the most extremely preterm infants born between 22+0 and 23+6 weeks’ gestation. In order to ensure that we are able to offer the very highest levels of care to women and their babies we must have a clear and accurate appreciation of the impact this recommendation will have on maternity and neonatal services. Whilst there is national data on the number of infants born between 22+0-23+6 weeks’ gestation, surviving delivery and being admitted to neonatal units, this does not take into account the number of women presenting with threatened preterm birth to obstetric units throughout the UK.

TRANSFER aims to establish the incidence of women presenting with threatened preterm birth to obstetric units in England, Scotland, Wales and Northern Ireland between 22+0-23+6 weeks’ gestation and determine the number requiring transfer to an obstetric unit with co-located neonatal intensive care unit (NICU) (level 3). This data is essential to facilitate adequate service provision and planning for obstetric and neonatal units throughout the UK.

Method

In conjunction with the Birmingham Centre for Observational and Prospective Studies (BICOPS), University of Birmingham we are conducting a multi-centre, prospective service evaluation of current practice across obstetric and neonatal units in the United Kingdom.
We have set up a national network including 84 obstetric and neonatal units across England, Wales, Scotland and Northern Ireland who are enrolling women who present with threatened preterm birth between 22+0-23+6 weeks gestation.
Objectives are:
1) Calculate the incidence of women presenting with threatened preterm birth to obstetric units in England, Wales, Scotland and NI between 22+0-23+6 weeks’ gestation.
2) Determine the number of women who present outside an obstetric unit with a Level 3 NICU.
3) Determine the number of in utero transfers of women presenting between 22+0 -23+6 weeks’ gestation
4) Determine the number of women who deliver between 22+0 -23+6 weeks’ gestation in a unit without a Level 3 NICU.
Outcomes include:
Gestation at presentation in completed weeks and days (including estimated date of delivery)
Presence of a co-located NICU (level 3) unit at presenting site
Measurement of biomarker predicting risk of preterm birth (fetal fibronectin or phosphorylated IGFBP-1 protein (actim ® partus)
Need for transfer to unit with co-located NICU (level 3)
Length of antenatal hospital stay, both in presenting unit and receiving unit
Delivery in receiving unit during the hospital episode transfer occurred in
Gestation at delivery (in completed weeks and days)
Survival to admission to NICU
Pregnancy outcome; miscarriage, live birth, stillbirth

Data is being collected via eCRF’s on a secure REDCAP database

This project commenced 17th May 2021 and enrolment will continue until 31st March 2022.

Results

As of 7th October:
We have 82 sites registered across the UK with 62 having full project approval.
95 patients have been enrolled to the project.
We have outcome data for 39 women, with 11 requiring transfer to an obstetric unit with a co-located level 3 NICU unit.

Conclusion

Through this project, we have established the largest Women’s Health, UK wide audit network to date. We aim to complete the current project by end May 2022, which will provide essential data to guide best practice and service provision for the care of this vunerable group of pregnancies.
Whilst we have established a large network with excellent UK wide geographical coverage, we are still encouraging sites to join our network. We will present project data upto the end of October 2021 at this important meeting.
Beyond this work, we hope to be able to utilise this network for future audit and research projects.

A retrospective service evaluation of pregnancy management and outcomes in women attending the North Bristol Trust Preterm Prevention Clinic

PO18

Authors

Oscar Oglina (Medical Student), Dr Simon Grant, Dr Sherif Abdel-Fattah & Dr Kate Birchenall

Presenter

Oscar Oglina

Abstract

Background

The aim of this service evaluation was to assess pregnancy outcomes for women referred to and attending the North Bristol NHS Trust (NBT) Preterm Birth Prevention Clinic (PTBPC). Pregnancies were analysed according to reason for referral, gestational age at birth, number of preterm births, and whether progesterone and cervical cerclage (CC) were offered.

Method

Women who had been referred to the PTBPC between 31st March 2020 and 31st December 2020 were identified using Lorenzo software. The following data regarding management of these pregnancies for each of these women was obtained from Viewpoint and from hospital notes available via the NBT Electronic Document Management System (EDMS): maternal age, smoking status, number of appointments per woman, gestation and cervical length measurement at each appointment, whether progesterone was offered/prescribed, whether CC was offered/performed, gestational age (GA) at birth, and mode of labour and birth. These data were analysed according to reason for referral.

Results

Between 31st March and 31st December 2020, 323 appointments were scheduled for 107 women. The four most common indications for referral were: previous preterm birth (PPTB) (33 women), previous large loop excision of transformation zone (LLETZ) >10 cm (PLLETZ) (29 women), previous caesarean section at full dilatation (PCSFD) (23 women) and previous second trimester miscarriage (PSTM) (11 women). A further 11 women were referred for uterine anomaly or previous stillbirth.

Across the top four indications for referral, the median GA at birth were: PPTB 38+4 (range 31+2 – 40+3); PLLETZ 39+0 (range 32+2 – 41+2); PCSFD 39+2 (range 37+4 – 41+2); and PSTM 38+0 (35+4 – 40+5). Preterm birth (<37 weeks’) rates were 15% (5/33) for women referred with PPTB, 7% (2/29) for women referred with PLLETZ, 13% (3/23) for women referred with PCSFD, and 0% for women referred with PSTM. Eighteen percent (6/33) of those women with PPTB were prescribed progesterone, compared with none for the other three categories of referral indication; and 12% (4/33) women with PPTB, 7% (2/29) women with PLLETZ, 4% (1/23) women with PCSFD, and 0% of women with PSTM had a CC inserted. Reassuringly, all the women with CC in the PLLETZ and STM groups, and all but one woman in the PPTB group, birthed at term; with one woman who received both progesterone and CC in the PPTB group birthing preterm.

Conclusion

The results of this service evaluation indicate that women are being appropriately referred to and managed in the PTBPC at NBT, with most women birthing at term.

Impact of second stage caesarean on preterm births in subsequent pregnancy: Study of 1000 cases over 10 years

PO19

Authors

Datta, Tamal1; Ramesh, Jayanth2; Viswanatha, Radhika1; Shehata, Hassan1; Ganapathy, Ramesh1

Presenter

Yuti Khare

Abstract

Background

Caesarean in the second stage of labour is performed in around 1.5-2% of deliveries. The hypothesis is that damage to the cervix secondary to surgery and/or pressure damage from the fetal head during labour predisposes women to a risk of preterm birth in subsequent pregnancies. This study evaluated gestational and demographic factors associated with the primary second stage caesarean, which had not been done in previous studies.

Method

This cohort study included only singleton births over a decade period and analysed all second stage caesareans that had a subsequent birth in our hospitals. Analysis included maternal demographics and risk factors in primary caesarean and studied outcomes in subsequent births including gestation at birth.

Results

During the study period, the hospitals had 50924 live singleton births. There were 984 (1.93%) births by caesarean in the second stage of labour. In this cohort, 300 women had subsequent births in our hospitals. We noted an 11%(n=33) rate of preterm births in subsequent pregnancies. However, when we excluded the women (n=9) who had a preterm caesarean at the first surgery, the incidence was similar to background rates of preterm births (7.72%). The cohort analysis also did not suggest an impact of age or ethnicity.

Conclusion

Preterm birth in subsequent pregnancies is increased in women who had a second stage caesarean in their previous birth, however this effect is not seen if the primary caesarean was performed before 36+6 weeks of gestation. Larger cohort studies are needed to confirm these findings. At present the evidence does not suggest second stage caesarean should be considered a risk factor for preterm birth in subsequent pregnancies.

The role of neutrophils in female reproductive biology and implications for women’s health

PO20

Authors

Patricia Hunter 1*, Natalie Suff 2 and Nigel Klein 1

Presenter

Patricia Hunter

Abstract

Background

Neutrophils are the most abundant leukocyte in the human body. Men have higher average neutrophil and lymphocyte counts in blood but premenopausal women have a larger neutrophil compartment (neutrophils as a fraction of total leukocytes) and this compartment further expands during pregnancy (1). The human body makes one billion neutrophils per day per kilogram of body weight (2). A small subset of circulating neutrophils return to the bone marrow or take up extended residence in organs such as the spleen, liver and lungs (3). The fate of the majority is unknown. We propose to demonstrate that the mucosal surfaces of the mouth and cervix, as entry points to the body, are populated with neutrophils that have exited the circulation and egressed irreversibly into the mucus.

Method

Two hundred cervical cytobrushes and 10 saliva samples obtained with informed consent and were prepared and analysed using flow cytometry. Fluorescence-labelled antibodies against CD235a and CD45 were used to identify red blood cells (contaminant) and white blood cells, respectively. Neutrophils were identified using antibodies against CD11b, CD11c, CD13, CD15, CD16, CD64 and CD66b. Macrophages were identified using antibodies that against HLA-DR, CD4, CD11b, CD11c, CD13, CD14, CD33, CD64, CD68, CD103, CD163 and CX3CR1. T cells were identified using anti-CD3 and anti-CD4. B cells were identified using anti-CD19, anti-CD20 and anti-CD21. Eleven mouse vaginal lavages at different stages of estrus were prepared and analysed using flow cytometry. White blood cells were identified using anti-CD45. Neutrophils were identified by their expression of Ly6G (Gr1) using both the 1A8 clone and the RB6 clone as well as CD11b. Macrophages were idenfied using F4/80. T cells were idenfied using CD3 and B cells using CD19. Ten micrograms of the 1A8 clone was injected into the tail vein of 3 mice in estus to see if labelled cells could be recovered in the lavages. Epithelial cells were identified in all samples as the cells that absorbed all fluorescence wavelengths.

Results

Neutrophils were the most abundant leukocyte in oral, cervical and vaginal lavage samples comprising greater than 90% of total leukocyte populations. Macrophages were the second most abundant leukocyte population in the human samples. T cells comprised a small minority population (<0.1%) in <10% of the cohort. Only neutrophils were recovered from mouse vaginal lavages and these were only apparent in the metaestrus phase (figure 1). The 1A8 antibody injected into the tail vein successfully bound and labelled the majority of neutrophils recovered from the lavage.

Conclusion

The mucosal surfaces of the mouth and the vagina are populated with neutrophils that have left the circulation and egressed into the mucus. These observations may contribute to explaining the high rate of neutrophil turnover in mammals and increased production in females. Disorders in neutrophil homeostasis and trafficking may increase susceptibility to HIV, HSV and HPV infection, vaginal dysbiosis and in pregancy, ascending infection leading to preterm labour and membrane rupture (4).
Whilst mice do not have haematological menstruation, millions of neutrophils egress into the uterus and then exit through the vagina during the meta-phase of the estrus cycle. Their role in the mammalian reproductive cycle likely relates to their recently described function in tissue repair and remodelling. Similarly, the critical function of neutrophils in placentation and possible role in preparing the uterus and cervix for delivery of the baby and return of these organs back to a pre-pregnancy state should be considered in light of an expanded repertoire of roles within “resolution immunology”.
1. Chen, Y., Zhang, Y., Zhao, G., Chen, C., Yang, P., Ye, S., & Tan, X. (2016). Difference in Leukocyte Composition between Women before and after Menopausal Age, and Distinct Sexual Dimorphism. PloS one, 11(9), e0162953 https://doi.org/10.1371/journal.pone.0162953
2. ATHENS, J. W., HAAB, O. P., RAAB, S. O., MAUER, A. M., ASHENBRUCKER, H., CARTWRIGHT, G. E., & WINTROBE, M. M. (1961). Leukokinetic studies. IV. The total blood, circulating and marginal granulocyte pools and the granulocyte turnover rate in normal subjects. The Journal of clinical investigation, 40(6), 989–995. https://doi.org/10.1172/JCI104338
3. Ley, K., Hoffman, H. M., Kubes, P., Cassatella, M. A., Zychlinsky, A., Hedrick, C. C., & Catz, S. D. (2018). Neutrophils: New insights and open questions. Science immunology, 3(30), eaat4579. https://doi.org/10.1126/sciimmunol.aat4579
4. Hunter, P. J., Sheikh, S., David, A. L., Peebles, D. M., & Klein, N. (2016). Cervical leukocytes and spontaneous preterm birth. Journal of reproductive immunology, 113, 42–49. https://doi.org/10.1016/j.jri.2015.11.002

Overview of cervical cerclage in a Regional Referral hospital, Oman.

PO21

Authors

REHAM AHMED 1, FATEN ANWAR 2, HANSA DHAR 3

Presenter

REHAM AHMED

Abstract

Background

Cervical cerclage is a treatment for cervical weakness and is placed in elective or emergency setting. It provides a degree of structural support to a weak cervix. The objective of the study is to review risk factors, the outcome, and success and failure rates of the procedure. Finally, to assess if indicated or not and to optimize our practice of elective cerclage.

Method

A two-year retrospective observational review of all pregnant women with cervical cerclage, between January 2016 and December 2017, at Nizwa Hospital, Oman was conducted. The study included 212 women. Amongst patients treated with cerclage selected high risk group included; multiple gestation, cases with IVF conception, diagnosed mullerian anomaly, history of prolonged infertility, previous preterm birth or second trimester miscarriage and maternal wishes with previous early pregnancy losses , where in 75(35%)women they had no living issue.

Results

Total number of cerclage done 212(1.56%), elective 210(99.5%) & emergency (rescue) 2 (0.94%). Cerclages done for multiple gestation 6(2.8%), 4(66.6%) of them had preterm birth at 31-33wks despite cerclage implying that the procedure was truly indicated in them .Out of 16 cases of infertility (7.5%), 7(43.7%) delivered prematurely and 8(50%) term delivery, 4of them ended by induction of labor at 38-41weeks for postdate and gestational diabetes. In 19(8.9%) of IVF conceptions, 11(58%) term delivery, 7 had elective caesarean delivery at 37-40 wks, mostly for maternal request and 4(21%) delivered prematurely. A 13(6.13%) elective cerclages in women with uterine anomaly, 4(30.7%) delivered 3-4 weeks after removal suggesting it is not needed, and 5(38.4%) delivered preterm. For group of patients with previous preterm birth or second trimester miscarriage 150 cases, 38(25.3%) delivered 3-4 weeks later either spontaneously or got labor induced for post maturity indicating no cervical weakness. Women who desired for cerclage which was not medically indicated, accounted 9(4.2%), 7(77.7%) delivered by 37-40wks, majority by elective C. section. Out of 2 cases of emergency cerclage, one preterm birth and other ended as fetal demise at 16 wks.

Conclusion

Management and diagnosis of a short cervix is an obstetric dilemma .In our study 52 patients (24.5%) had preterm birth despite cerclage and 49 patients (23.1%) delivered 3-4weeks after cerclage removal suggesting that there is insufficient evidence to recommend this procedure to avoid pregnancy loss .Specific measures like serial transvaginal ultrasonographic examination of the cervix , use of progesterone and senior involvement can save majority of women from unnecessary cerclages .

National Pregnancy in Diabetes Audit: 2017-2020 Internal Review at North Lincolnshire and Goole NHS Foundation Trust, looking contributing factors in the cases of pre-term deliveries and large for gestational age babies in Type 1 and 2 Diabetics

PO22

Authors

Rebecca Braithwaite, Mr Ian Stuart, Miss S Howden

Presenter

Rebecca Braithwaite

Abstract

Background

Following the published results of the National Diabetes in Pregnancy audit an internal review was conducted at North Lincolnshire and Goole NHS Foundation Trust (NLAG) to review the care of diabetic women, exploring areas of practice identified as outlying compared to the national data in relation to pre-term deliveries in both type 1 and type 2 diabetics and large for gestational age babies in Type 2 diabetics.

Method

29 Type 1 and 18 Type 2 Diabetics were identified between 2017-2020, and the case notes were reviewed against a pre-set proforma to identify key risk factors influencing the timing and Mode of delivery of birth including booking HbA1c, BMI, HbA1c in pregnancy

Results

29 Type 1 diabetic patients booked between 2017-2020, 13% of patients booked with a HbA1c < 48.
In type 2 diabetic patients, 27% of patients booked with HbA1c < 48, with 11% of pregnancies complicated by HbA1c > 86.
Of the 47 diabetic patients who booked, the percentage of patients meeting the NICE guidelines of HbA1c < 48 was 19%. 55% of type 1 diabetics had large for gestational age babies, and 33% of type 2 diabetics had LGA babies (compared to 42.9% for 2017-2018). Type 2 diabetics patients had 15% risk of IUGR, with no SGA babies identified in type 1 diabetics In type 1 diabetes 62% of pregnancies were delivered between 35-36+6 weeks pregnant, 13% of pregnancies were delivered at > 37 weeks.
Type 2 diabetics were delivered between 37-38+6 weeks (66%).

Conclusion

Pre-term delivery, particularly in Type 1 diabetics was consistent with the NPID report of 63.6%, and indicated that NLAG was an outlier in the number of pre-term deliveries. In respect to Type 2 diabetes, most cases were delivered >37.
The common theme in pre-gestational care is poor optimisation of diabetic control pre-pregnancy, this appears to be the key to reducing pre-term deliveries in diabetic patients due to pregnancy associated complications necessitating early intervention. The use of embedded prompts in primary care diabetic review tools emphasising effective contraception, pre-conception counselling. Annual review and discussion with all women of child bearing age of the short, medium and long term impacts of poor diabetic control in pregnancy. The importance of the use of continuous glucose monitoring to optimise control, extending this to all diabetic women, particularly those who book with HbA1c > 48.

Antenatal optimisation of the preterm infant, University Hospital Lewisham

PO23

Authors

O. Akinro, H. Waston, A. Kalaskar, M. Mehta

Presenter

Omotayo Akinro

Abstract

Background

Preterm birth (PTB), defined as delivery at less than 37+0 week’s gestation, is a common complication of pregnancy, comprising around 8% of births in England and Wales. It is the most important single determinant of adverse infant outcome with regards to survival and quality of life. Babies born preterm have high rates of early, late, and post-neonatal mortality and morbidity. PTB is estimated to cost health services in England and Wales £3.4bn per year. Aim was to reduce the number of preterm births and optimising care when preterm delivery cannot be prevented.

Method

We did a retrospective audit of preterm deliveries at University Hospital Lewisham to assess antenatal optimization of preterm infants.
We collected the data of all preterm births between March 2020 till February 2021 and analysed the data to see if it met the standards set by saving babies lives bundle 2. We identified cases using the Badgernet and was able to collect information required for analysis. Analysis was done using Microsoft Excel.

Results

Our data revealed, 106 mothers 86 received Steroids. Amongst the 86 mothers that received steroids, 80 received steroids less than 7days before delivery, while 6 had steroids more than 7 days before delivery. Concerning Magnesium Sulphate(MgS04), 30 out of the total number of preterm babies were less than 30 weeks which was the criteria for recieving MgSO4. We discovered 26 babies out of 30 preterm babies received MgSO4 .The four that did not receive was due to delivery occurring less than 4 hours from presentation. Most of the babies less than 27 weeks delivered in an appropriate setting and the three that did not was due to delivery occuring less than four hours from presentation.

Conclusion

The audit helped us to realise that the goals set by Saving Babies Lives Care Bundle 2 were not in quantifiable targets, so was difficult assess if our targets reflected appropriate care. It was recommended that we set our local targets to help us to assess in future audits if we were in line with recommendations and if our care had been optimized.

A service evaluation of the Rainbow Clinic in Cardiff and Vale, caring for women in pregnancy after loss

PO24

Authors

Ursula Gannon, fourth year medical student Cardiff University

Presenter

Ursula Gannon

Abstract

Background

The Cardiff Rainbow Clinic provides consultant-led care for women who’ve lost a baby during pregnancy or shortly after birth from 2017. It’s the only Rainbow Clinic in Wales, based on the Rainbow Clinic in Tommy’s Research Centre at Saint Mary’s Hospital Manchester. The clinic looks after women who’ve had a loss >16 weeks. Around 15 babies die shortly before or after birth in the UK every day. Previous stillbirth is a risk factor for stillbirth and increased obstetric complications. Pregnancy after loss is devastating psychologically for women and families. The clinic provides continuity of care, dealing with psychosocial challenges of pregnancy after loss and increased obstetric complications. The project aims to evaluate the clinic from November 2019 – March 2021 to identify any issues regarding the service and solutions.

Method

119 patients included in data analysis using Microsoft Excel. Data collected using handwritten clinic notes, Euroking E3 maternity database and Welsh Clinical Portal. Women were divided into 3 groups: women who delivered (group A), women with ongoing care (group B) and women only seen for a postnatal debrief (group C).

Results

Ethnic minorities are overrepresented (30%). Most common reason for loss was unexplained second trimester (17%). Overall, 27% (n=32) had an unexplained loss (second and third trimester). 75% who received a postnatal debrief (PND) had a letter. For 79% (n=84) this was the next pregnancy after loss. Most women delivered between 37-37+6 weeks (30%). Most common mode of delivery was spontaneous vertex (44%). Only 24% delivered preterm. 98% were livebirths, with 1 early neonatal death and 1 stillbirth.

Conclusion

This evaluation shows how consultant led care is beneficial in reducing perinatal death recurrence. It reflects how stillbirth rates are higher in ethnic minorities and shows that these women are high-risk obstetrically with higher rates of preterm birth and induction. Areas for improvement include ensuring 100% of PND patients have a letter regarding their previous loss and that data is inputted correctly and completely in real time. Further evaluation of the psychosocial impacts would also be valuable. The Rainbow model of care could be very successful across other UK centres and could be an alternative model of care for women with a second trimester loss rather than a preterm birth clinic.

Service Evaluation/Audit of the Pre-Term Birth Clinic at University Hospitals Dorset (UHD) NHS Foundation Trust

PO25

Authors

Eleanor Waltham. Emma Andre , Louise Melson and Latha Vinayakarao

Presenter

Eleanor Waltham

Abstract

Background

Background: Reducing the rate of preterm birth is a key element of the Saving Babies’ Lives Care Bundle Version 2 (SBLCBv2) in reducing stillbirth. Since 2017 the UHD preterm birth rate has been between 6.3 – 7%, which is already below the national average (8%), however, it remains imperative that as a trust we continue to strive towards further reduction and achievement of the 6% target by 2025.

Method

In March 2018 UHD (previously Poole NHS Foundation Trust) implemented a preterm birth clinic (PTB clinic) to provide preterm health surveillance for patients identified as high risk for having a preterm birth. Women undergo routine cervical assessment, cervical surveillance and interventional treatments if required. Current interventional treatments include cervical cerclage +/- progesterone, Arabin pessary( Only on research ) +/- progesterone and progesterone pessary only.

Retrospective review of 50 sets of maternity notes for patients seen in PTB clinic between January – June 2020. Sample size reduced to 47 as 3 patients were offered appointments but did not attend.

Results

The PTB rate for UHD during 2020 was 6.3% from any cause. 100% of patients with a cervical length of <25mm before 24 weeks were offered interventional treatments. Average gestation at first appointment was 18+3/40. 85% of patients who attended PTB clinic continued in pregnancy until ≥37/40. All three interventional treatments were found to be effective in prolonging pregnancy until ≥37/40. There were 18 patients within the treatment group. Of these patients 4 delivered <37/40, with 3 of these due to reasons unrelated to preterm birth. There were 29 patients within the non-treatment group with 3 patients delivering <37/40 with all of them being within the moderate to late preterm birth category.

Conclusion

PTB clinic is effective in preventing extremely preterm birth (<32/40), with majority of preterm births occurring within the moderate to late preterm birth category (32-36+6 weeks gestation).

PERFORMANCE OF PRETERM PREVENTION CLINIC –ARE WE CONTINUING TO MAKE A DIFFERENCE?

PO26

Authors

Rashid T a, Gupta S b, Malarselvi M c, Patni S d

Presenter

TAYYABA RASHID

Abstract

Background

Preterm delivery because of its impact on neonatal mortality and morbidity with consequent healthcare costs remains the foremost problem in modern obstetrics. Appropriate antenatal intervention can prolong gestation and improve neonatal outcomes. Our trust has a well-established Preterm Prevention Clinic (PPC) since 2007 that manages women identified as high risk for preterm birth (PTB) in index pregnancy.
The aim of this study was to review the interventions and outcomes of all patients registered with the clinic from 1st Jan 2017 to 31st Dec 2020 by determining the proportion of patients who were able to reach a gestation beyond 34 weeks.

Method

Retrospective case-note analysis of PPC patients from 1st Jan 2017 to 31st Dec 2020 was performed. Referral criteria included on-going singleton pregnancy with
(1) Previous spontaneous mid trimester miscarriage (MTM)/ PTB or PPROM between 14-34 weeks of a singleton pregnancy
(2) Previous cervical cerclage or surgery.
Information regarding demographics, scan-findings, intervention, gestation at delivery and neonatal outcomes was collected.

Results

451 pregnancies were referred to PPC during study period. 18 patients were excluded because of inappropriate referral or missing data leaving 433 patients for analysis. The patients were divided into 4 groups.
Group I – Past history of cervical surgery, or incidental finding of shortened cervix without MTM or PTB
Group II – Previous one MTM or PTB
Group III – Previous two MTMs or PTBs
Group IV – Previous more than two MTMs or PTBs
Results shown in tables as well as separate file.
P value -0.0372-Significant difference between the groups.
9.95 % of babies required admission to the neonatal unit.
0.8 % of babies died and all of them were between 24 to 26 weeks. A delivery rate (≥34 weeks) was achieved in 95.9%, 90.2%, 80% and 73.3% in Group I, II, III and IV respectively

Conclusion

With counselling ,appropriate patient selection and timely interventions , PPC has significantly reduced prematurity related morbidity and mortality in patients at high risk of preterm birth. We propose establishing such dedicated clinics across UK to tackle the problem of prematurity.

Why it must be so difficult to find the depth of the LLETZ?

PO27

Authors

F A Vecsei

Presenter

F Attila Vecsei M.D.

Abstract

Background

The importance of previous cervical surgery as one of the risk factors of spontaneous preterm labour and delivery is now widely recognised.
In 2019 the “Reducing Preterm Birth Guidance for Commissioners and Providers” document was published by the UK Preterm Clinical Network. This became the foundation of element 5 of the Saving Babies Lives Care Bundle (V2).
One of the intermediate risk factors has been identified as history of significant cervical excisional event i.e. LLETZ where >10mm depth removed, or >1 LLETZ procedure carried out or cone biopsy (knife or laser, typically carried out under general anaesthetic).

All those who run or support preterm birth prevention and surveillance clinics know how difficult it is to risk-assess patients in a timely manner, especially if it is about the type and number of procedures and the depth or volume of the removed tissue.

Method

Not relevant considering the nature of my presentation.

Results

Not relevant considering the nature of my presentation.

Conclusion

In my presentation I will explore the difficulties around identifying this particular patient group and raise awareness of the lack of easily accessible patient records and histology results.
I am proposing to call a new working party to life within the Preterm Clinical Network to tackle this problem by assessing clinical practice throughout the UK, liaising with clinicians and stakeholders and so enable timely assessment of patients at risk.