Nishel Mohan Shah

Background/Objectives: Tubal ectopic pregnancy (TEP) remains a significant cause of maternal morbidity and mortality. Early access to pregnancy assessment units now allows for the detection of many TEPs at a stage at which they could potentially resolve spontaneously. The current selection of women for expectant management is guided by human chorionic gonadotrophin (hCG) concentrations, alongside ultrasonographic and clinical features, although reported success rates vary widely in the literature. We evaluated whether progesterone, another biomarker secreted during pregnancy, can predict successful expectant management alone or in combination with hCG. Methods: A narrative review was undertaken using Ovid MEDLINE and Embase, searched from 1 January 1990 to 1 May 2026, with a supplementary grey literature search. Of 1363 records identified, 27 studies were included. Results: Progesterone is associated with pregnancy viability but performs poorly in isolation for distinguishing ectopic from non-ectopic pregnancy. However, in studies of expectant management success, it has been identified as a second-tier variable that may improve prediction of successful expectant management of TEP. Conclusions: Current evidence does not support the use of progesterone as an independent predictor of expectant management success. It may provide additional prognostic information within an hCG-defined stratum, but this requires further validation before implementation in clinical practice.

Background: Preterm birth is the most common cause of death in babies and children aged under five worldwide. Globally, 10% of births are preterm. In the peri-viable period (22–24 weeks), the risk of mortality and, in those that survive, the risk of disability is highest. Between 24 and 28 weeks of gestation, approximately 80% of preterm births are related to infection. Safely delaying birth by just a few days may substantially reduce the risk of mortality and long-term disability. We propose to use a novel point-of-care methodology with a precision-medicine approach to identify those presenting in threatened preterm labour (tPTL) who have infection, the causative organism and its antibiotic resistance profile, allowing us to give targeted antibiotics. Using this approach, we will test the hypothesis that targeted antibiotic treatment increases the latency to birth and may potentially improve neonatal outcome. Methods: The objectives of this randomised controlled non-blinded trial are to assess the acceptability and feasibility of amniocentesis-guided personalised treatment in women with preterm prelabour rupture of membranes (PPROM) or tPTL with intact membranes. Patients with tPTL or PPROM with singleton pregnancies between 23 + 0 and 34 + 0 weeks and none of the exclusion criteria or an indication for immediate delivery will be approached to take part. Following written informed consent, patients will be randomised in a 1:1 ratio to either usual care or personalised care. Those in the personalised care arm will undergo amniocentesis, and the amniotic fluid will be analysed with a point-of-care IL-6 assay, BioFire assessment for microbial DNA, conventional culture and microscopy. Treatment will be determined based on the IL-6 and BioFire results. Participants will be followed up until birth, with maternal and neonatal outcomes recorded. Discussion: Recruitment to the PROMPT study opened to recruitment in April 2024 and is ongoing. It is currently a single-site study, but the addition of other sites is in progress. Trial registration: ClinicalTrials.gov registration number NCT04878978.

Background: Early access to pregnancy assessment units now detects many tubal ectopic pregnancies (TEP) at a stage when they could resolve spontaneously, creating a management dilemma. Methods: We performed a hypothesis-generating exploratory analysis in a retrospective study to assess whether serum progesterone (P4) levels in women with TEP are associated with management outcome. Results: Ninety-one cases of TEP managed in a single centre over three years were analysed. Receiver operating characteristic (ROC) curve analysis was used to explore serum levels of progesterone (P4), first human chorionic gonadotropin (hCG) and peak hCG (alone and in combination) in relation with successful completion of expectant management. Decision-tree analysis using first hCG and P4 was additionally performed to explore clinical sequential risk stratification. 23% (n=21) successfully completed expectant management. P4 concentrations in the expectant management group (median 3 nmol/L, IQR 2.00–8.50) were significantly lower than in those requiring surgical or medical management (median 17 nmol/L, IQR 5.75– 29.25; p=0.0002). Area under the ROC curve (AUC) values for P4, log10 first hCG, log10 peak hCG and P4 with log10 first hCG were 0.766, 0.814, 0.811 and 0.835, respectively, for predicting successful expectant management. However, hCG was not significantly outperformed. Nonetheless, Youden optimised thresholds for hCG and P4 are reported, alongside decision-tree analysis that identified sequential first hCG and P4 thresholds associated with successful expectant management. Conclusion: Lower P4 levels are associated with successful expectant management of TEP but they do not outperform hCG either alone or as an adjunctive marker. Lay summary: Early pregnancy scans now identify many small, symptom-free fallopian tube pregnancies; human chorionic gonadotrophin (hCG) is a pregnancy hormone that can predict if these pregnancies will resolve naturally but it has its limitations. This study looked at 91 women with a fallopian tube pregnancy. It compared another important hormone called progesterone to see if, when used with hCG, its levels are associated with natural resolution. This study found that hCG was the most useful test, and progesterone did not provide any additional benefit.

Background: The COVID-19 pandemic caused major disruption to medical education, including rapid shifts to remote teaching, reduced clinical exposure, and open-book examinations (OBE). This study explored medical students' retrospective perceptions of these changes and their impact on learning, wellbeing, and preparedness for clinical practice.Methods: A cross-sectional online survey was distributed between October 2022 to March 2023 to approximately 400 Imperial College London medical students who had been in years 1-3 during the 2020/2021 lockdown period. Quantitative data were analysed descriptively, and free-text responses were examined using inductive thematic analysis.Results: Of 138 submitted responses, 57 complete responses were analysed. Four themes were identified: engagement with learning, missed in-person teaching, wellbeing, and study approach. Digital fatigue was reported by 84% of respondents, and 44% were unable to attend some in-person teaching. Among first-year students, 70% reported isolation and difficulty forming friendships. OBEs altered study behaviour: 56% reported revising less, 67% relied on external resources, and no students reported avoiding external resources entirely during examinations.Conclusion: Pandemic-related disruption affected students' engagement, wellbeing, study strategies, and perceived preparedness. Although digital teaching and OBE offered flexibility, students described reduced interaction, missed practical learning, and concerns about knowledge retention. Future curricula should preserve the benefits of digital delivery while ensuring structured interaction, clinical exposure, and assessment preparation.

Objective: To explore the perceptions of Ugandan Master Trainers (MTs) and UK-based stakeholders on the wider impact, benefits, and sustainability of the Royal College of Obstetricians and Gynaecologists' Excellence in Obstetric Skills (EOS) and Resilience in Obstetric Skills (ROS) courses. Design: Descriptive, cross-sectional qualitative study using semi-structured interviews. Setting: Five health facilities in Masaka District, Uganda, and UK-based institutional settings. Population or Sample: Seven participants (five Ugandan MTs and two UK-based stakeholders) identified through purposive sampling. Methods: Semi-structured interviews were conducted via Zoom, transcribed, anonymised, and analysed using inductive thematic analysis. Main Outcome Measures: Participants' perceptions of the courses' impact on clinical practice, professional development, patient care, challenges encountered, and sustainability of the training model. Results: Four overarching themes were identified: expected outcomes (improved clinical knowledge, appropriate escalation, knowledge sharing), unexpected outcomes (career development, improved patient communication, enhanced physical environments), challenges (variable skills uptake, short course duration, funding constraints, staff attrition), and sustainability considerations. Participants reported enhanced confidence in managing obstetric emergencies, with anecdotal reductions in maternal mortality in participating facilities. Key barriers included lack of formal accreditation, inconsistent funding, and understaffing. Conclusions: The EOS/ROS courses improved clinical knowledge, professional development, and patient care in Uganda. Sustainable impact requires formal government accreditation, dedicated funding, and integration into continuing professional development programmes.

The transplacental transfer of maternal immunoglobulin G from the mother to the foetus is central for providing immunity in early life, resulting in full-term newborns having IgG repertoires and levels similar to those of their mothers. The neonatal Fc receptor is recognised as the primary transporter of IgGs across the placental epithelium. Understanding the mechanisms of transplacental antibody transfer and factors that affect them is essential in optimising maternal vaccination strategies, ultimately protecting infants from various environmental pathogens. This review first outlines the biological mechanisms governing transplacental IgG transfer, followed by a discussion of how this process may be disrupted by physiological and pathological conditions during pregnancy, including preterm birth, hypergammaglobulinemia, maternal pathogenic IgG, maternal infections, hyperglycaemia, and exposure to biological therapies. We also summarise currently available models used to study transplacental IgG transfer, highlighting existing knowledge gaps and future directions for research in this field.

Mesenchymal stem cells (MSCs) derived from the placenta, fetal membranes, or umbilical cord may be used to study the pathophysiology of gestational diabetes mellitus (GDM). The phenotype of MSCs may reflect fetal programming in response to the maternal milieu of a GDM pregnancy. Altered fetal programming is linked to high rates of obesity and type 2 diabetes mellitus (T2DM) in the offspring of mothers with GDM. This review discusses recent findings characterizing the phenotype of GDM-exposed MSCs (GDM-MSCs) which enhance our understanding of the mechanisms of fetal programming. It also considers how MSCs may be used as markers of long-term offspring health to test the benefit of putative interventions and highlights the need for further translational studies to clearly link the MSC phenotype to clinical parameters and interventions.