Benefits and risks of fetal red-cell transfusion after 32 weeks gestation

OBJECTIVE: To compare the outcome after intrauterine transfusion (IUT) between fetuses treated before and those treated after 32 weeks gestation. SETTING: National referral center for intrauterine treatment of red-cell alloimmunization in The Netherlands. Study DESIGN: Retrospective evaluation of an 11 year period, during which 209 fetuses were treated for alloimmune hemolytic disease with 609 red-cell IUTs. We compared fetal and neonatal outcome in three groups: fetuses only treated before 32 weeks gestation (group A, n=46), those treated both before and after 32 weeks (group B, n=117), and those where IUT was started at or after 32 weeks (group C, n=46). RESULTS: Survival rate was 48% in group A, 100% in group B, and 91% in group C. Moreover, fetuses in group A were hydropic significantly more often. Short-term perinatal loss rate after IUT was 3.4% in the 409 procedures performed before 32 weeks and 1.0% in the 200 procedures performed after 32 weeks gestation. CONCLUSION: Perinatal losses were much more common in fetuses only treated before 32 weeks gestation. Two procedure-related perinatal losses in 200 IUT after 32 weeks remain a matter of concern because of the good prospects of alternative extrauterine treatment.     

Management of fetal death after 20 weeks of gestation complicated by placenta previa

Objective.?To determine the frequency and risk factors associated with neonatal chemical hypoglycemia in neonates of mothers with type 2 diabetes and gestational diabetes mellitus (GDM).

Research Design and Methods.?A retrospective cohort study of women with type 2 diabetes or GDM and their singleton neonates. The primary outcome measure was the presence of neonatal chemical hypoglycemia (capillary plasma equivalent glucose <45?mg/dl) within 1?h of birth. Statistical methods included bivariate and multivariate analyses.

Results.?242 mother infant dyads were identified. Sixty-eight (28%) were treated with diet, 110 (46%) with glyburide, and 64 (26%) with insulin. The incidence of neonatal chemical hypoglycemia was 18% (44/242). The incidence was significantly higher in those requiring pharmacotherapy (25% vs. 3%, p?p?=?0.58). The frequency of neonatal chemical hypoglycemia was statistically associated with birth weight, macrosomia and ponderal index (p?Conclusion.?Neonatal chemical hypoglycemia occurs more frequently in infants from women with type 2 diabetes and GDM treated with glyburide or insulin. An increased neonatal ponderal index is a strong predictor of significant neonatal chemical hypoglycemia.     

Intrauterine fetal death

Sadly, the death of a fetus may occur at any stage of a pregnancy, including during the labour process. A pregnancy loss will be devastating for the expectant parents. Obstetricians should be familiar with the management of intrauterine fetal death as prompt and appropriate counselling will aid the couple’s grief process. Understandably, couples wish to know the cause and chances of recurrence; thus, the full investigation of possible aetiological factors using a pragmatic approach will help in the postnatal counselling and management of future pregnancies. This review also explores the legal and ethical aspects of postmortem consent.     

Intrauterine fetal death

Sadly, intrauterine fetal death is a common occurrence and one that all labour ward personnel should be trained to manage. Recent advances have improved the likelihood of identifying a cause. The key to this is a logical and methodical approach to investigation. Postmortem examination remains a critical aspect of investigation and labour ward teams require a clear understanding of the legal aspects of this. Sympathetic and supportive care of parents should respect parental wishes and allow choice wherever possible. However, maternal safety should also be a central aspect of this care.     

Perinatal management and problems of preterm twins less than 32 weeks of gestation in Japan

Between 1983 and 1998 there were 23433 births at Kitasato University Hospital, including 359 births. A retrospective analysis was performed on 320 twin pairs analyzing survivability indexes with respect to fetal age, chorionicity and birth weight discordance. Furthermore, the paper illustrates an analysis of causes of neonatal deaths as well as the rate of various complications of twins delivered before 32 weeks gestation such as twin-twin transfusion syndrome and periventricular leukomalacia.     

Chronic intrauterine bleeding and fetal growth at less than 32 weeks of gestation

Placental hemosiderin deposition representing intrauterine bleeding at least 24-48 h before delivery is detected frequently in prematurity. The objective of this study was to assess incidence and site of histologic evidence of intrauterine bleeding in association with fetal growth in prematurity. Placentas of consecutive nonanomalous singleton liveborns delivered <32 weeks of gestation were studied for the presence of hemosiderin in decidua of the placental basal plate or extraplacental membranes (confirmed by Prussian blue stain). Cases of placenta previa, clinical abruption, or coagulopathy and cases in whom obstetric and neonatal gestational age assessment differed by >2 weeks were excluded. A single reviewer blinded to clinical data except for gestational age at delivery assessed the presence of decidual hemosiderin. Statistical analysis included ANOVA, and Mann-Whitney U test with p<0.05 considered significant. The study included 352 patients delivered for principal indication of premature rupture of membranes (PROM) or preterm labor (PTL) and 78 patients delivered for preeclampsia between 1989 and 1994. Mean birth weight percentiles for neonates delivered following PROM/PTL versus preeclampsia were: no decidual hemosiderin 42+/-25 versus 17.4 +/-25, extraplacental membrane hemosiderin 42+/-25 versus 9.2 +/-10, placental basal plate hemosiderin 42+/-25 versus 17+/-24, and hemosiderin in both sites 27+/-21 versus 6.4+/-10 (p = 0.02). Hemosiderin deposition in both placental basal plate and extraplacental decidua is associated with significantly lower mean birth weight percentiles in PROM/PTL at less than 32 weeks of gestation. We postulate that in these patients placental disruption which accompanies decidual bleeding may explain the relatively impaired fetal growth. In preeclampsia, hemosiderin depositions are not associated with further impaired fetal growth.     

Factors associated with delivery at or after 28 weeks gestation in women with bulging fetal membranes before 26 weeks gestation

Objective: To elucidate the factors that contribute to prolonged pregnancy and promote neonate survival in women with bulging fetal membranes.

Methods: A database was reviewed to identify women with singleton pregnancies who underwent amniocentesis on admission to determine amniotic fluid neutrophil elastase levels before 26?+?0 weeks gestation between July 2001 and January 2015. Following delivery, the placentas of these patients were examined for histologic chorioamnionitis.

Results: Ninety-seven women delivered before 28 weeks gestation, and 117 women delivered at or after 28 weeks gestation. Rescue cerclage performed via the McDonald procedure (adjusted odds ratio [aOR]: 3.78; 95% confidence interval [CI]: 1.35–11.80) was associated with a higher likelihood of reaching at least 28 weeks gestation before delivery, whereas protruding membranes (aOR: 0.38; 95% CI: 0.18–0.78), elevated amniotic neutrophil elastase levels (≥0.15?μg/ml) (aOR, 0.41; 95% CI: 0.20–0.82) and elevated peripheral C-reactive protein levels (≥0.4?mg/dl) (aOR: 0.34; 95% CI: 0.180.65) were associated with a significantly reduced likelihood of reaching this gestational age before delivery. Among women who underwent rescue cerclage, amniorrhexis was associated with a negative prognosis (aOR: 0.18; 95% CI: 0.05–0.51).

Conclusions: Intra-amniotic inflammation, protrusion of fetal membranes and amniorrhexis are factors that may prevent pregnancy prolongation. Rescue cerclage improves pregnancy outcomes.     

Intrauterine fetal death in twin pregnancy

A case of twin pregnancy with intrauterine death of one foetus during the 19th week of pregnancy has been described and the obstetric approach is reported. Pregnancy was actively continued with the following procedure: 1. Tocolysis, 2. Anti-infective prophylaxis; 3. Monitoring of coagulation on factor; 4. Weekly echotomography. In the 39th week the baby was delivered by caesarean section. The baby was discharged in good health on the 5th day after delivery.     

Multicystic encephalomalacia after first-trimester intrauterine fetal death in monochorionic twins

Multicystic encephalomalacia occurs in approximately 20% of surviving cotwins after second- and third-trimester intrauterine fetal death of one twin in monochorionic pregnancies. We report a case of multicystic encephalomalacia after the demise of a cotwin in the first trimester diagnosed by magnetic resonance imaging and confirmed pathologically.     

Preterm preeclampsia: 32 to 37 weeks gestation

Objective: To evaluate neonatal outcomes in late preterm infants delivered due to preeclampsia. Methods: A retrospective cohort of 3580 infants delivered at 32 0/7 to 36 6/7 weeks gestation was examined. Neonatal outcomes of infants delivered due to preeclampsia were compared with outcomes of infants delivered prematurely due to other etiologies. Multivariate logistic regression was used to analyze the association between preeclampsia and the neonatal outcomes. Results: Infants of women with preeclampsia were more likely to be SGA (26.8% vs. 8.4%). They were also more likely to be admitted to the ICN (54.3% versus 39.0%); however, they were less likely to suffer a neonatal death (2.2% vs. 3.4%). Infants born to women with preeclampsia had similar rates of RDS (19.8% vs. 14.2%). Discussion: Neonatal outcomes in late preterm infants born to preeclamptic mothers are significantly different from outcomes in late preterm neonates delivered due to other indications.     

Prognosis in cervical insufficiency at less than 32 weeks of gestation

OBJECTIVE: To identify prenatal events associated with adverse outcome in babies at less than 32 weeks of gestation in cases of cervical insufficiency and preterm labor (PTL)/premature rupture of the membranes (PROM). STUDY DESIGN: A case-control study was performed using a logistic regression model at 17 tertiary hospitals in Japan. Adverse outcome was defined as neonatal death or abnormal cerebral ultrasound scans (intraventricular hemorrhage [IVH] and periventricular leukomalacia [PVL]) prior to discharge from hospital. RESULTS: Data were analyzed for 307 cases (74 for cervical insufficiency and 233 for PTL/PROM). Neonatal death and IVH/PVL were noted in 25 and 29 cases, respectively. A significant association of cervical insufficiency (odds ratio (OR) 1.32, 95% confidence interval (CI) 1.02-1.68), gestational age at delivery (<26 weeks) (OR 4.64, 95% CI 1.73-12.44), and Apgar score <7 at 5 min (OR 3.3, 95% CI 1.42-7.64) with combined neonatal death or IVH and PVL was found in a logistic regression model that controlled for in utero transportation, gestational age on admission, clinical chorioamnionitis, and histopathologic chorioamnionitis. CONCLUSION: Cervical insufficiency is a significant factor related to the occurrence of adverse outcome.