Insights from outside BJOG

It has become axiomatic that maternal awareness of fetal movements is part of modern antenatal care. After 28 weeks’ gestation, women are asked to be aware of kicks and movements and if a reduction in fetal activity is noted, to record movements over specific periods known as fetal movement charting or ‘kick counting’. Charting is also used to monitor high-risk pregnancies, where there is a history of untoward outcomes such as stillbirth, complications with hypertensive disorders, antepartum haemorrhage or suspected growth restriction. These actions presuppose that reduced fetal movements accompany or precede a deterioration in fetal wellbeing and, in its most severe form, herald a stillbirth. This received wisdom is supported by a retrospective study comparing fetal movement reduction in pregnancies resulting in stillbirth with those with healthy outcomes (Heazell et al. BMJ Open 2018;8:e020031). But the perception of decreased fetal activity needs to be confirmed, reported to care-givers, investigated and, if found to be ‘suspicious’ (usually using cardiotocographic monitoring), acted upon if fetal jeopardy is to be avoided. Prospective evidence is lacking for stillbirth prevention. To test a hypothesis of stillbirth avoidance, a randomised trial was carried out in the UK and Ireland incorporating 33 hospitals, with data collected from more than 400 000 pregnancies (Norman et al. Lancet 2018;392:1629–38). Each hospital had a control period, a wash-out interval and an intervention phase, allowing each unit to be its own control with protocols in place to manage episodes of reduced fetal movement. The outcome was the incidence of stillbirths, measured at 4.40 per 1000 births during the control period and 4.06 per 1000 births during the intervention period (OR 0.90, 95% CI 0.75–1.07), a non-significant difference (Figure 1). The authors conclude that the benefits of a policy that promotes awareness of reduced fetal movements to prevent stillbirths remain unproven. However, an editorial takes a more stringent view of the findings, arguing that the trial's conclusion should be that it is harmful to encourage awareness of fetal movements (Walker and Thornton Lancet 2018;392:1601–2). They base their arguments on the following: Further, they say that these results are in keeping with the only previous large trial and recommend that obstetricians discourage campaigns that promote fetal movement awareness prior to 37 weeks’ gestation. They question decreased fetal movements as an automatic indication for inducing labour. The results of similar ongoing trials are awaited with interest. My personal belief has always been that fetal movement charting provides a useful indication of fetal wellbeing and is an adjunct to diligent antenatal care. However, decreased fetal movement periods are normal and if a woman is instructed to be ‘on the alert’ for a change in movements, these normal cycles of decreased activity may cause anxiety and over-reaction. The article reported here makes me question my outlook and perhaps I have ‘seen what I wanted to see’. My sense is that this new evidence is correct and a harms/benefit calculation may well find fetal movement awareness to be harmful rather than helpful. Maternal age at first delivery is increasing and has now reached 26.5 years in the USA and 29.5 years in Europe. Adolescent and very young pregnancies are decreasing, but are there any disadvantages in terms of obstetric outcomes to this shift? There are other factors that influence obstetric outcomes more than age, specifically pre-existing hypertension, diabetes, smoking, previous miscarriage, infertility, social disadvantage, rurality and obesity (Schummers et al. Epidemiology 2018;29: 379–87). Generally, the risks of advancing maternal age increase gradually until mid-to-late 30s, then accelerate so that there are no obstetric advantages in delaying reproduction, with the most prominent complications being hypertension, multiple pregnancies, congenital anomalies as well as maternal co-morbidities such as gestational diabetes. The following have J-shaped relationships with maternal age: stillbirths, neonatal mortality and infant mortality. The authors offer their data to assist professionals counselling couples who wish to know the statistical risk of a first pregnancy at advancing age but for data on all pregnancies and maternal age, readers can consult Sheen et al. (Am J Obstet Gynecol 2018;219:390.e1–390.e15). Acupuncture has been employed for the relief of symptoms during the menopause transition but empirical evidence of its effectiveness is limited. A trial from China has been published where electroacupuncture applied at traditional acupoints was compared with sham electroacupuncture at non-acupoints for more than 300 women with mild-to-moderate menopausal symptoms (Liu et al. Am J Obstet Gynecol 2018;219:373. e1-373.e10). The pre-trial standard for a clinically significant reduction in symptoms was set at five points on the Menopause Rating Scale. After 24 treatments over 2 months, the between-group difference was 1.8 points (6.3 versus 4.5), leading the authors to conclude that electroacupuncture did not appear to relieve menopausal symptoms. My thoughts are that this is the placebo effect (in which I sincerely believe) and I am convinced that it is the mechanism whereby acupuncture (and sham acupuncture) improved the patients’ symptoms. The effect was achieved in the trial reported here by carrying out an elaborate intervention in women who wished to have their symptoms relieved. Each woman had time, energy, money and most importantly attention invested in her to achieve a result. That a positive outcome occurred in both arms of the study is unsurprising. Acupuncture has mystique and it pays well but it has no anatomical or physiological basis. It has no evidence published in reputable journals showing that it works better than a placebo. In my view, a series of sessions with a counsellor would be more beneficial and more honest if hormone therapy does not suit a patient. Sexual problems occur when a person has substantial difficulty in controlling their sexual feelings, urges and behaviours. When this causes clinically significant levels of distress or impairment of normal function, a diagnosis of compulsive sexual behaviour disorder is applicable, colloquially referred to as sexual addiction. Its prevalence in populations has been speculated upon but not formally evaluated because of the lack of a definition, and it has only recently been added to the International Classification of Diseases. It also requires a perception or judgement that the person's own behaviour is out of control and that screening instruments are available that can reliably assist individuals in reaching a conclusion of distress or impairment. Such instruments measure distress associated with shame or engagement in sex for emotional regulation, as well as gauging psychosocial impairment interpersonally or occupationally. A publication has reported on the occurrence of distress associated with sexual emotions and behaviours in over 2000 people in the USA (Dickenson et al. JAMA Netw Open 2018;1:e184468). The authors had estimated that up to 6% of the population would be categorised as having the disorder and that twice as many men than women would be affected. In the event, they found that 7% of women and 10% of men reported experiencing difficulty controlling their sexual feelings, urges and behaviours, with this causing distress and/or impairment in psychosocial functioning. They hypothesise that they captured data from a wide range of people who had non-clinical problems of sexual control, through to others with clear clinical disorders and therefore found a prevalence higher than they had anticipated. As far as the unexpectedly small difference in gender prevalence is concerned, the researchers suggested that cultural shifts toward increasing permissiveness of female sexual expression and electronic communication are leading to more women finding themselves distressed by their sexual feelings, urges and behaviours. The current view of addiction is that of a brain disease rather than some deficiency in ‘will or moral fibre’. It is a recalibration of the urges or desires registering the reward centre of the brain. There is an escape from conventional modulation of reward substances or actions that are usually monitored by the cognitive areas of reason and consequential considerations. It is a maladaptive form of learning that leads to personal, familial and societal repercussions (Lewis N Engl J Med 2018;379: 1551–60). Addiction can be initiated by substances or behaviours that are processed by the reward centre. The brain adjusts to bypass the normal checks and balances of stimuli reaching the reward centre and these changes in neuronal activity result in an addictive cycle being set up. The brain disease model has changed the perception of addiction and moved reactions from punishment and isolation to acceptance as a disease and appropriate rehabilitation that is not punitive but inclusive. Published by Adolescents 360°, this technical brief focuses on a programme in Tanzania that has been designed to work directly with adolescent girls aged 15–19 years to develop and implement interventions to increase the use of modern contraceptive methods. The briefing states that the programme uses a transdisciplinary approach that integrates public health, adolescent developmental science, cultural anthropology, human-centred design and social marketing, and involves adolescents in all stages of the research, design and implementation process. The technical brief focuses on the Kuwa Mjanja programme as it was implemented in Tanzania (related programmes are underway in Nigeria and Ethiopia) and discusses the strategy and the lessons learned, providing recommendations for future similar implementations of adolescent and youth sexual and reproductive health services. The Kuwa Mjanja programme blueprint revolves around three key steps: understand me, identify with me and serve me. Key aspects of the programme design are discussed including segmentation, mobilisation, Mjanja connect, clinic- and community-based pop-up events, and youth-friendly timing and location of events. Four main lessons learned and recommendations are highlighted: adaptive implementation as a natural partner to human-centred design, mixed-methods monitoring is key to an adaptive footing and risk mitigation in scale-up, the importance of combined public and private sector engagement for youth service delivery, and cost-effectiveness and its role in sustainability. The Population Council-led Evidence to End FGM/C project has recently further developed and expanded its global online database of female genital mutilation/cutting (FGM/C) programmes to ensure comprehensive and accessible access. The database contains detailed information about both ongoing and recently completed research studies undertaken since the year 2000 that address FGM/C around the world. The database can be searched by programme or research study name, country, category of intervention/study or target population. The developers state that they hope that the database will be used by both researchers and organisations for knowledge-sharing purposes. This report, produced by Promundo and the International Center for Research on Women, reports on a study that aimed to explore men's involvement, attitudes, perceptions and experiences of premarital abortion, and the role of men in women's decision-making and experiences regarding terminating a pregnancy. Few studies have explored this topic. The report focuses on India where it is reported that unsafe abortion is the third leading cause of maternal death, accounting for 8% of all maternal deaths annually. The study, conducted in New Delhi, is based on 17 in-depth interviews with men and their partners seeking termination of pregnancy services, six focus group discussions involving both young men and women, and 15 key informant interviews with experts and service providers that were held between February and July 2018. Chapter one focusses on norms and perceptions surrounding premarital sex and abortions, and chapter two discusses experiences and male involvement in premarital abortions. The annexure provides a useful overview of enablers and barriers to male involvement. The report states that the findings show that it is possible for men to be involved in providing support if they are well informed and if the health service provider itself allows men to participate. Five key recommendations are provided along with guidance for potential action and change: capture the missing male voice, leverage men's role as ‘quasi-service providers’ (information seekers and providers), leverage men's agency to facilitate gender equality within relationships, stimulate/encourage service providers’ interactions with men and the need to engage with a range of stakeholders. The Euro-Peristat network has recently published the latest European Perinatal Health Report, Core indicators of the health and care of pregnant women and babies in Europe in 2015. The report is based on data from 5 million births during the year 2015 that were collected from national statistical systems in the European Union member states and in Iceland, Norway and Switzerland. The report includes data for the ten Euro-Peristat core indicators and, additionally, two of the 20 recommended indicators of maternal and newborn health in 2015. It provides detailed statistics on: the characteristics of childbearing women (including multiple births by number of fetuses, maternal age at delivery, distribution of parity, smoking during pregnancy and distribution of maternal pre-pregnancy body mass index), mode of delivery, mothers’ childbearing-associated mortality, and mortality and morbidity during pregnancy and in the first year of life (including fetal mortality, neonatal mortality, infant mortality, distribution of birth weight and distribution of gestational age). Key findings include that increases in many risk factors for childbearing women since 2010 present a common challenge; European disparities in mode of delivery have widened; poor quality statistics continue to hamper European surveillance of maternal deaths; overall, stillbirth and neonatal mortality rates have declined, but with high heterogeneity; and preterm birth and low birthweight remain stable overall with strong geographical patterns. Individual press releases and report highlight documents have been made available for Belgium, Cyprus, Finland, France, the Netherlands and the UK. Faculty of Sexual and Reproductive Healthcare (FSRH) The following guideline is now available at www.fsrh.org FSRH Clinical Guidance: Combined Hormonal Contraception The Society of Obstetricians and Gynaecologists of Canada (SOGC) The following guidelines are now available at www.jogc.com No. 371-Morcellation During Gynaecologic Surgery: Its Uses, Complications, and Risks of Unsuspected Malignancy No. 370-Management of Squamous Cell Cancer of the Vulva American College of Obstetricians and Gynecologists (ACOG) The following guidelines are now available at www.acog.org Approaches to Limit Intervention During Labor and Birth. Committee Opinion 766. Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period. Committee Opinion 767. US2018339133 (A1) Catheter placement assist device and method of use. This patent application outlines a disposable device to aid the placement of a Foley urinary catheter in female patients. Specifically, the device aims to ensure sterile catheter placement by including a labia separator with wings, with a spout at one end and a posterior shield at the other to prevent contamination. This application claims the benefit of the filing date of US Provisional Patent Application No. 62/339,295, filed 20 May 2016 entitled, ‘Catheter Placement Device and Method of Use’. This application is a continuation application based on PCT Application No. PCT/US17/33553, filed 19 May 2017 entitled, ‘Catheter Placement Device and Method of Use’. Meddings J, Delancey JO, Ashton-Miller JA, Fenner DE, Saint S. 29 November 2018. US2018348134 (A1) Apparatus and methods for endometrial tissue identification. This patent application discusses imaging apparatus and methods to detect endometriosis to aid surgical removal. Specifically, the patent proposes using two-photon luminescence apparatus, which it is stated can be used to recognise endogenous fluorescence of hemosiderin to identify endometrial tissue. This application claims priority to US Provisional Patent Application Serial No. 62/506,910 filed 16 May 2017. Feldman MD, Milner TE, Cabe AG, Estrada AD. 6 December 2018. US2018339143 (A1) Implantable device for intraperitoneal drug delivery. This patent application relates to systems and methods for an implantable drug delivery system for controlled release of drugs in the treatment of ovarian cancer. Specifically, the patent discusses continuous intraperitoneal administration of cisplatin directly into the peritoneal cavity over a 24-hour period. This application is a divisional of US application Ser. No. 14/400,216, filed 10 November 2014, which is a national stage of PCT/US2013/040405, filed 9 May 2013, which claims priority to US Provisional Application No. 61/644,497, filed 9 May 2012. Cima MJ, Ye H, Del Carmen M, Birrer M. 29 November 2018. IL241380 (A) Progesterone receptor modulators for use in the therapy of uterine fibroids. This patent application outlines the use of long-term and repeated administration of selective progesterone receptor modulators, particularly ulipristal acetate or a metabolite thereof, for the treatment of uterine fibroids. Preglem SA. 29 November 2018. A recent lawsuit in the UK, pertaining to incurable hereditary diseases, could bring about major changes in UK law regarding patient confidentiality. The legal case centres upon a father, diagnosed with an incurable hereditary disease, who refused permission for his doctors to inform his family, resulting in his daughter going on to have children that she claims she would not have had if she had known of the inheritable condition and had received a positive genetic test result. It is stated that the outcome of this case may have important implications for the practice of medicine in terms of whether doctors legally have a duty to share genetic test results with families and the implications this has for doctor–patient confidentiality. Source: www.bionews.org.uk The United Nations Human Rights Committee has recently published its General Comment on the Right to Life, the result of 3 years’ work involving member states and non-government organisations. The General Comment includes a set of global human rights standards that include rights regarding maternal mortality, access to abortion, access to contraception, and the provision of evidence-based sexual and reproductive health information. The General Comment also asserts that human rights apply only after birth. Source: www.reproductiverights.org Clinicians keen to keep up-to-date regarding clinical studies may find the following informative.

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