Towards the modern management of ectopic pregnancy: a complete audit cycle of practice in a London teaching hospital.

We carried out a complete audit cycle of the management of ectopic pregnancy at a London teaching hospital over 2 years. Case notes of women presenting to St George's Hospital, London in 1995 with ectopic pregnancy were examined and management was assessed. The targets were low rates of rupture, high rates of sonographic diagnosis of ectopic pregnancy, acceptable rates of tubal conservation and laparoscopic surgery.

Vasa previa: an avoidable obstetric tragedy.

Unlabelled: Vasa previa is a rarely reported condition in which the fetal blood vessels, unsupported by either the umbilical cord or placental tissue, traverse the fetal membranes of the lower segment of the uterus below the presenting part. The condition has a high fetal mortality due to fetal exsanguination resulting from fetal vessels tearing when the membranes rupture. Despite improvements in medical technology, vasa previa often remains unsuspected until this fatal fetal vessel rupture occurs.

A strategy for reducing the mortality rate from vasa previa using transvaginal sonography with color Doppler.

Vasa previa is a cause of sudden unanticipated fetal death, with a fetal mortality of 33-100%. Transvaginal sonography (TVS) and color Doppler may aid in making the diagnosis antenatally, allowing elective Cesarean delivery, thereby avoiding fetal death from exsanguination which would occur if the membranes were allowed to rupture in labor. Whilst it is not feasible to screen all pregnant women for vasa previa, antenatal examination with TVS and color Doppler of women at risk, specifically those with low-lying placentas, bi-lobed, multi-lobed and succenturiate-lobed placentas, multiple pregnancies and pregnancies resulting from in vitro fertilization may lead to antenatal diagnosis of the condition.

A novel approach to the management of pregnancies complicated by uteroplacental insufficiency and previous stillbirth.

To our knowledge, this is the first time that a combination of aspirin and glyceryl trinitrate (GTN) has been used in the prophylaxis of preeclampsia and fetal growth retardation, and their use associated with not only Doppler screening of the uterine arteries but also regular Doppler follow-up of the fetal arterial and venous circulation. Whilst future trials are needed to prove whether screening, prophylaxis and Doppler management are individually beneficial, we propose that this combination of management strategies contributed to a good outcome in the cases described. Furthermore, randomized trials are required to determine the safety and efficacy of prophylactic low-dose aspirin combined with GTN treatment in pregnancies affected by an impaired uteroplacental circulation.