Antibiotic prophylaxis in prelabor spontaneous rupture of fetal membranes at or beyond 36 weeks of pregnancy

Objective

To assess the effectiveness of prophylactic antibiotics compared with placebo in preventing neonatal and maternal infection-related morbidity associated with prelabor spontaneous rupture of membranes at or beyond 36 weeks of pregnancy.

Methods

In the present randomized controlled trial conducted during 2009–2011, 1640 women with prelabor spontaneous rupture of fetal membranes at or beyond 36 weeks of pregnancy were randomly assigned to receive a single dose of prophylactic intravenous antibiotics or placebo on admission to the labor ward of Ain Shams University, Cairo, Egypt. The participants, caregivers, and investigators were blinded to the group assignment. The primary outcome measure was early-onset neonatal sepsis. An intention-to-treat analysis was performed.

Results

Early-onset neonatal sepsis occurred in 34 (4.1%) and 24 (2.9%) neonates in the antibiotics and placebo groups, respectively (risk ratio 1.42; 95% confidence interval 0.85–2.37). Maternal infection outcomes were not significantly different between the 2 trial arms.

Conclusion

The routine use of prophylactic antibiotics in women with prelabor spontaneous rupture of fetal membranes at or beyond 36 weeks of pregnancy does not reduce the risk of neonatal and maternal infection-related morbidity.Trial registration number: ACTRN12608000501347     

The effect of routine magnesium supplementation on fetal cardiac time intervals: a fetal magnetocardiographic study

Objectives

Magnesium deficiency in pregnancy is frequent, and in consequence magnesium supplementation is widely used. As magnesium crosses the placental barrier and since the fetal kidney does not excrete magnesium as efficiently as the mature kidney, effects on fetal cardiac time intervals are probable, but still unknown.

Study design

Sixty pregnant women were included in an observational study: 31 patients received oral routine magnesium supplementation. In addition to routine fetal echocardiography, fetal magnetocardiography (fMCG) was used to investigate electrophysiological rhythm patterns with high temporal resolution. fMCG tracings were analyzed according to a predefined procedure for fetal cardiac time interval (CTI)-detection. fCTI findings (P-wave, PQ-segment, PR-interval, QRS complex, ST segment, T-wave and QTc interval) were registered.

Results

Significant widening of the QRS-complex (p = 0.004) was demonstrated in fetuses whose mothers received magnesium supplementation (240 mg/day) relative to the control group.

Conclusion

Magnesium exposed fetuses demonstrated a prolonged ventricular arousal, but healthy neonatal outcome was found in all exposed fetuses. Although fMCG is a preclinical method and limited in its availability, the procedure could help to monitor fetuses.     

Dosing interval of 24 hours versus 48 hours between mifepristone and misoprostol administration for mid-trimester termination of pregnancy

Objective

To compare the efficacy of a shorter interval (24 hours) between misoprostol and mifepristone administration with that of the conventional dosing interval (48 hours) for second-trimester termination of pregnancy (TOP).

Methods

This was a prospective randomized, controlled, open-label study of 98 healthy women opting for mid-trimester TOP. The women were randomized to receive 200 mg mifepristone orally, followed 24 hours (Group 1) or 48 hours (Group 2) later by misoprostol (800 μg, then 400 μg every 3 hours). The primary outcome measure was the percentage of successful abortions within 24 hours. Secondary outcome measures were the induction-to-abortion interval (measured from misoprostol administration) and the frequencies of complications and adverse effects.

Results

The rate of successful abortions was similar with the 24-hour and 48-hour dosing intervals (95.8% and 93.6%, respectively; P = 0.38). The mean induction-to-abortion interval was also comparable between the 2 groups (8.6 ± 4.1 hours versus 8.7 ± 3.9 hours; P = 0.37). Nulliparous women and women with a pregnancy duration of 16 weeks or more had a longer induction-to-abortion interval in both groups.

Conclusion

The 24-hour dosing interval between misoprostol and mifepristone administration seems to be as effective as the 48-hour dosing interval for second trimester TOP.Clinical Trial Registry India: CTRI/2011/05/001770.     

Study of fetal tracheal fluid velocities using Doppler ultrasound

Objective

To characterize tracheal fluid flow during fetal breathing movements by Doppler ultrasound.

Study design

To use pulsed Doppler to measure flow velocity during inspiration and expiration in a cross-sectional study of 15 normal fetuses and determine the correlation, if any, between flow velocity and gestational age.

Results

Cyclic respiratory profiles – both regular and irregular – were observed. Intratracheal flow velocity was very elevated during inspiration, ranging from 10 to 80 cm/s and from 5 to 20 cm/s during expiration.

Conclusion

This technique enables the noninvasive semiquantitative evaluation of fetal breathing movements. This Doppler application opens the field for future studies to characterize the extent of pulmonary hypoplasia.     

Idiopathic urinary findings and fetal growth restriction in low risk pregnancy

Objective

To determine whether maternal urinary findings in the first trimester of pregnancy are associated with fetal growth restriction.

Study design

The prevalence of urinary findings in singleton pregnancies complicated by fetal growth restriction were compared with a low-risk control group of pregnancies who gave birth to normal weight babies, in the same condition.

Results

There were significant statistical differences in the mean gestational age (p < 0.001), isolated asymptomatic bacteriuria (p < 0.001), hematuria (p = 0.002, OR = 6.6, CI = 1.8–24.2) and proteinuria (p = 0.016, OR = 4.1, CI = 1.2–13.3). There was no recognizable relation between ketonuria and fetal growth restriction.

Conclusion

Our data showed a relation between the increase of adverse pregnancy outcomes, including fetal growth restriction, and hematuria, proteinuria and asymptomatic bacteriuria. Appropriate monitoring of pregnant women using these findings may be helpful in the identification of more complications.     

A multi-country study of the “intrapartum stillbirth and early neonatal death indicator” in hospitals in low-resource settings

Objective

To determine the feasibility of introducing a simple indicator of quality of obstetric and neonatal care and to determine the proportion of potentially avoidable perinatal deaths in hospitals in low-income countries.

Methods

Between September 1, 2011, and February 29, 2012, data were collected from consecutive women who were admitted to the labor ward of 1 of 6 hospitals in 4 low-income countries. Fetal heart tones on admission were monitored, and demographic and birth data were recorded.

Results

Data were obtained for 3555 women and 3593 neonates (including twins). The doptone was used on 97% of women admitted. The overall perinatal mortality rate was 34 deaths per 1000 deliveries. Of the perinatal deaths, 40%–45% occurred in the hospital and were potentially preventable by better hospital care.

Conclusion

The results demonstrated that it is possible to accurately determine fetal viability on admission via a doptone. Implementation of doptone use, coupled with a concise data record, might form the basis of a low-cost and sustainable program to monitor and evaluate efforts to improve quality of care and ultimately might help to reduce the in-hospital component of perinatal mortality in low-income countries.     

Fetal intra-abdominal tumors: assessment of spectrum,accuracy of prenatal diagnosis,perinatal outcome and therapy at a tertiary referral center

Objective

To describe the varieties and ultrasound characteristics of prenatally diagnosed fetal abdominal tumors and to scrutinize the accuracy of prenatal diagnosis as well as the postnatal outcome and therapy of affected pregnancies.

Study design

Retrospective study of 354 fetuses found to have abdominal tumors on prenatal sonogram, identified from 1993 to 2009 at a tertiary referral center for prenatal medicine. The cohort was classified into subgroups according to the sonographic appearance of the fetal tumor and the affected anatomic structure (urinary, gastrointestinal and genital tracts and other locations). Sensitivity, specificity, positive predictive value and false-positive rate of ultrasonography in identifying the system of origin were calculated. Relationships between relevant outcome domains and the different subgroups were assessed using the chi-square test and Fisher's exact test.

Results

Our cohort comprised 222 urinary tract lesions, 37 genital tract lesions, 80 gastrointestinal lesions and 15 tumors of other origins. The mean gestational age at diagnosis was 26 + 0 wks. The prenatally established diagnosis was exactly concordant with postnatal findings in 88.9%. Sensitivity, specificity, positive predictive value and false-positive rate of ultrasonography in identifying the system of origin (urinary, gastrointestinal, genital tracts and other locations) were 98.3%, 97.6%, 92.6% and 2.4%, respectively. The favorable postnatal outcome rate was highest among fetuses with genital tract lesions (95%) and lowest among those with tumors of the urinary tract (62%, p = < 0.001). Twenty per cent of tumors regressed spontaneously, mostly gastrointestinal tumors (36%, p = < 0.001). In 75/354 cases (21%) the parents opted to terminate the pregnancy: intra-uterine fetal demise and neonatal death were each noted in 4%. Prenatal therapy was performed in 24 of 354 cases (7%) and postnatal surgery in 64 cases (18%).

Conclusion

The majority of fetal abdominal anomalies were accurately diagnosed and the vast majority of affected fetuses had a favorable outcome, some tumors even resolved with advancing pregnancy. Pre- and post-natal invasive surgical interventions were mandatory in only a small number of cases.     

Resultados perinatales en 492 presentaciones podálicas: cesárea vs. parto vaginal

Objective

To analyze the perinatal results in our hospital comparing vaginal delivery and cesarean section in breech presentation singleton pregnancies at term.

Material and Methods

All live ante-partum singleton fetuses in breech presentation, at 37 to 41+6 weeks and days who delivered between July 2006 and August 2010 were included in the study. We compared perinatal results between cesarean section and vaginal delivery.

Results

There were no differences in Apgar score at 5 minutes < 7, pH umbilical cord < 7, base deficits and lactate, neonatal intensive care unit admission or perinatal mortality.

Conclusions

With appropriate maternal and fetal conditions and a qualified medical team, a breech vaginal delivery could be propose obtaining good perinatal outcomes.     

Risk factors and perinatal outcomes associated with idiopathic small for gestational age Taiwanese newborns

Objective

To determine risk factors and perinatal outcomes associated with small for gestational age (SGA) neonates among healthy pregnant women.

Methods

A retrospective cohort study was conducted of 49 945 women who gave birth at Chang Gung Memorial Hospital, Taipei, Taiwan, after 24 weeks of pregnancy. Idiopathic SGA newborns (n = 3398) were characterized by a birth weight below the 10th percentile for mean weight corrected for GA and fetal sex.

Results

Risk factors for idiopathic SGA newborns included hypercoiling of the umbilical cord (adjusted odds ratio [aOR], 3.3; 95% confidence interval [CI], 1.6–7.0); prior fetal death (aOR, 2.8; 95% CI, 2.0–3.9); primiparity (aOR, 1.5; 95% CI, 1.4–1.7); adolescent pregnancy (aOR, 1.5; 95% CI, 1.2–2.0), low prepregnancy weight (aOR, 1.6; 95% CI, 1.5–1.8), low prepregnancy body mass index (aOR, 1.1; 95% CI, 1.0–1.3); short stature (aOR, 1.3; 95% CI, 1.1–1.4); and entangled umbilical cord (aOR, 1.1; 95% CI, 1.0–1.3). Idiopathic SGA newborns correlated with increased risk of adverse perinatal outcomes, including fetal death, low Apgar scores, oligohydramnios, placental abruption, and admission to the neonatal intensive care unit.

Conclusion

Some risk factors for idiopathic SGA newborns were modifiable, suggesting potential implications for public health.     

Reference values for strong ion difference—A novel tool for fetal metabolic assessment

Objectives

The aim of this pilot study was to establish reference values for strong ion difference (SID) in umbilical cord blood and investigate the feasibility of evaluating fetal metabolism according to the comprehensive approach to acid–base abnormalities, based on Stewart's physiochemical theory.

Study design

A prospective observational study. Women who underwent an elective cesarean section at term (n = 40) were compared to women who completed a normal spontaneous delivery at term (n = 40). The primary outcome was the establishment of normal values for SID in the umbilical cord vein. We also compared acid–base variables in the umbilical vein between the groups.

Results

The apparent SID in the umbilical vein was 34.61 ± 3.92 mequiv./L after normal delivery and 35.98 ± 2.56 mequiv./L after elective cesarean section (the effective SID is 37.43 ± 1.93 and 38.29 ± 2.38 mequiv./L, respectively). The pH values were similar in both groups, but the pCO₂ was significantly higher and the plasma principal weak acids (albumin and phosphate) were significantly lower after cesarean sections.

Conclusions

SID enables a comprehensive approach to acid–base abnormalities in the neonate, making it a potential additional tool for evaluating fetal acid–base status.     

The effectiveness of antepartum surveillance in reducing the risk of stillbirth in patients with advanced maternal age

Objective

To estimate the effectiveness of antepartum surveillance and delivery at 41 weeks in reducing the risk of stillbirth in advanced maternal age (AMA) patients.

Study design

Retrospective cohort study of all patients managed in one maternal–fetal medicine practice from June 2005 to May 2012. We included all singleton pregnancies delivered at ≥20 weeks of gestation. All AMA patients (age ≥35 years at their estimated delivery date) underwent weekly biophysical profile testing beginning at 36 weeks, as well as planned delivery at 41 weeks, or sooner if indicated. We compared the rate of fetal death at ≥20 weeks and fetal death at ≥36 weeks in AMA vs. non-AMA patients. Fetal deaths due to lethal and chromosomal abnormalities were excluded.

Results

4469 patients met the inclusion criteria: 1541 (34.5%) were AMA and 2928 (65.5%) were non-AMA. Using our AMA protocol for surveillance and timing of delivery, the incidence of stillbirth was similar to the non-AMA population (stillbirth ≥20 weeks: 3.9 per 1000 vs. 3.4 per 1000, p = 0.799; stillbirth ≥36 weeks: 1.4 per 1000 vs. 1.1 per 1000, p = 0.773). When looking at women age <35, age 35–39, and age ≥40, the incidence of stillbirth ≥20 weeks and ≥36 weeks did not increase across the three groups. Our findings were similar when we excluded all patients with other indications for antepartum surveillance.

Conclusions

In AMA patients, antepartum surveillance and delivery at 41 weeks appears to reduce the risk of stillbirth to that of the non-AMA population. Routine antepartum surveillance should be considered in all AMA patients.     

Assessment of the female fetal DNA concentration in the plasma of the pregnant women as preeclampsia indicator—Preliminary report

Objectives

This research was designed to analyze the presence of fetal female DNA, expressed in copy number, in the plasma of the pregnant woman with preeclampsia-complicated pregnancy.

Study design

Twenty-four pregnant women with female fetuses identified by means of ultrasound scanning were enrolled in this pilot study. The study group consisted of 12 pregnant women with symptoms of preeclampsia, with 12 healthy women, matched for gestational age, as controls.

Results

Mean DNA number of genomic equivalents per reaction in the group was 201 geq/PCR (from 44.9 to 375) and increased over time after onset of PE, which was the reason for pregnancy termination. In the group of women with preeclampsia, a notably higher DNA copy number in comparison to the control group was noted (p = 0.0003 U Mann–Whitney test).

Conclusions

The pilot study presented in this work confirms that also in the case of preeclampsia-complicated pregnancy with female fetuses it is possible to implement the method of fetal DNA quantification. Use of the presented methods confirms that in severe preeclampsia-complicated pregnancies an increase of the number of DNA genomic equivalents per reaction in comparison to the control group is observed. Due to the small study group further research on the described issue is vital, but this study proves that it is also feasible among women carrying female fetuses.     

A cohort study of Plasmodium falciparum malaria in pregnancy and associations with uteroplacental blood flow and fetal anthropometrics in Kenya

Objective

To use ultrasound to explore the impact of malaria in pregnancy on fetal growth and newborn outcomes among a cohort of women enrolled in an intermittent presumptive treatment in pregnancy (IPTp) with sulfadoxine/pyrimethamine (SP) program in coastal Kenya.

Methods

Enrolled women were tested for malaria at first prenatal care visit, and physical and ultrasound examinations were performed. In total, 477 women who had term, live births had malaria tested at delivery and their birth outcomes assessed, and were included in the study.

Results

Peripheral malaria was detected via polymerase chain reaction among 10.9% (n = 87) at first prenatal care visit and 8.8% (n = 36) at delivery. Insecticide-treated bed nets (ITNs) were used by 73.6% (n = 583) and were associated with decreased malaria risk. There was a trend for impaired fetal growth and placental blood flow in malaria-infected women in the second trimester, but not later in pregnancy. Among women with low body mass index (BMI), malaria was associated with reduced birth weight (P = 0.04); anthropometric measures were similar otherwise.

Conclusion

With IPTp-SP and ITNs, malaria in pregnancy was associated with transient differences in utero, and reduced birth weight was restricted to those with low BMI.     

Amniotic fluid S100B protein and erythropoietin in pregnancies at risk for fetal hypoxia

Objective

S100B protein is a biochemical marker for brain injury, and high serum S100B levels have been observed in newborns with birth asphyxia. We hypothesized that the concentration of amniotic fluid erythropoietin, which increases in chronic fetal hypoxia, correlates with amniotic fluid S100B concentration.

Study design

Amniotic fluid samples in 35 pregnancies at high risk for chronic fetal hypoxia were obtained at cesarean section or by amniocentesis done within a median of 2 days before delivery. S100B and erythropoietin concentrations were measured by chemiluminescent immunoassays.

Results

A positive correlation existed between the concentrations of S100B and erythropoietin in the amniotic fluid (r = 0.57, p < 0.0001). Amniotic fluid S100B concentration was higher (70 ng/l; 33–469, n = 17) (median; range) in pregnancies with elevated amniotic fluid erythropoietin (≥50 IU/l) than in pregnancies with normal erythropoietin (34 ng/l; 20–340, n = 18) (p < 0.0001, Mann–Whitney U-test). S100B predicted an elevated amniotic fluid erythropoietin concentration in the study population with the sensitivity of 94% and specificity of 83%.

Conclusion

A strong positive correlation exists between amniotic fluid S100B and erythropoietin concentrations in pregnancies at high risk for chronic fetal hypoxia. This suggests that chronic fetal hypoxia increases the intrauterine release of S100B.     

Lactato en sangre de cordón umbilical y estado metabólico en recién nacidos con sufrimiento fetal intraparto

Objective

To relate lactate concentrations in umbilical cord blood and metabolic status in newborns with intrapartum fetal distress.

Materials and methods

A portion of umbilical cord was obtained from term newborns to measure lactate concentrations in the umbilical artery, and pH and base deficit in the umbilical artery and vein.

Results

Of 200 umbilical cords analyzed, 19 (9.5%) were from newborns with a diagnosis of nonreactive fetal status based on changes in cardiotocography (group A). Newborns without alterations were assigned to group B. Mean values of pH and base deficit of the umbilical artery and vein were significantly higher in group A than in group B (P<.05). Lactate concentrations were 5.37 ± 0.99 nmol/L in group A and 4.21 ± 0.88 nmol/L in group B (P<.05). In group A, a moderate, negative and significant association was found between lactate concentrations and base deficit in the umbilical vein (r = –0,554; P>,05).

Conclusion

Lactate concentrations were higher in newborns with intrapartum fetal distress. These concentrations were correlated with base deficit in the umbilical vein in group A but not in group B.     

4D ultrasound study of fetal facial expressions at 20–24 weeks of gestation

Objective

To assess the frequency of fetal facial expressions at 20–24 weeks of gestation using four-dimensional (4D) ultrasonography and to determine whether there was any correlation between facial expression and gestational age (20–34 weeks).

Methods

The facial expressions of 23 healthy fetuses were examined using 4D ultrasound at 20–24 weeks. Each fetus was recorded continuously for 15 minutes. The frequencies of mouthing, yawning, smiling, tongue expulsion, scowling, sucking, and blinking were assessed and the data combined with those expressions observed at 25–34 weeks of gestation in two previous studies (n = 34) to determine the correlation between gestational age and each of the facial expressions.

Results

Mouthing was significantly more frequent than the other six facial expressions at 20–24 weeks (P < 0.05). Yawning was significantly more frequent than smiling, scowling, and blinking (P < 0.05), and sucking was significantly more frequent than smiling, scowling, and blinking (P < 0.05). The frequency of yawning, smiling, tongue expulsion, scowling, and blinking increased with gestational age (P < 0.05). Mouthing movement and sucking frequencies remained constant between 20 and 34 weeks.

Conclusion

Frequencies of complicated facial expressions such as smiling and scowling may increase with advancing gestation owing to the development of the fetal brain and central nervous system.     

The value of serial cervical length measurements for the prediction of threatened preterm labour

Objectives

To assess the predictive performance of cervical length measurement at presentation and 24 h later in women with symptoms of preterm labour.

Study design

Cervical length was measured transvaginally at presentation and 24 hours later in 122 women presenting with threatened preterm labour between 23 and 33 + 6 gestational weeks.

Results

Six women delivered within 1 week of presentation. The sensitivity and specificity of a cervical length <15 mm at admission for delivery within one week was 83.3 and 95.8%, respectively. A reduction of >20% in cervical length 24 h after admission predicted 50% of preterm deliveries within 1 week, with a specificity of 92.7%; in combination with cervical length at presentation it did not improve the prediction. The same was observed for birth before 32 weeks (N = 9) and birth before 35 weeks (N = 15).

Conclusions

Women with threatened preterm labour and a cervical length of <15 mm at presentation are at high risk of delivering preterm. Cervical change in the following 24 hours does not seem to improve the prediction.     

Pronóstico perinatal y materno de las gestaciones gemelares concebidas mediante fecundación in vitro,en relación con las obtenidas espontáneamente

Objective

To determine the outcomes of twin pregnancies resulting from in vitro fertilization (IVF) compared with those resulting from spontaneous conception.

Material and methods

We performed a historical cohort study comparing neonatal outcomes of twin pregnancies resulting from IVF (n = 44) with those resulting from spontaneous conception (n = 109) in the Complejo Hospitalario Universitario de Albacete (Spain) in 2001, 2001 and 2003. The primary variable was perinatal mortality. Secondary variables were fetal morbidity (neonatal abnormalities, Apgar < 7, acidotic arterial pH, admission to the neonatal unit), preterm delivery, maternal complications, and type of delivery.

Results

No differences in perinatal mortality and morbidity were found between spontaneous twin pregnancies and twins resulting from assisted reproductive techniques. The rate of preterm labor was significantly higher in spontaneous twin pregnancies (75.2 versus 52%; p = 0.006). The incidence of gestational diabetes was significantly higher in twin pregnancies resulting from IVF than in spontaneous twin pregnancies (25.5 versus 9.7%;p = 0.01).

Conclusions

Perinatal and maternal outcomes in twin pregnancies resulting from IVF are similar to those of spontaneous twin pregnancies.     

Operator experience reduces the risk of second trimester amniocentesis-related adverse outcomes

Objective

To investigate the impact of operator experience on amniocentesis-related adverse outcomes.

Study design

Retrospective study of mid-trimester amniocenteses performed by the same operator on singleton pregnancies in a single private institution during 1994–2007. Outcomes were hemorrhagic or dark amniotic fluid aspiration, insufficient volume aspiration, repeated puncture and fetal loss. Rates were estimated annually, as well as for every 10% of procedures up to the total number. The association of each outcome with epidemiological aspects was also examined.

Results

In total, 5913 amniocenteses were performed. The overall rate of adverse outcomes was 5.4%. The total adverse outcome rate reduced from 10.2% in the first 10% of cases to 3.0% in the last 10% (P = .001). The rate of hemorrhagic fluid gradually decreased from 4.4% to 1.5% (P = .05) over the same intervals. The fetal loss rate was also reduced from 0.5% during the first half to 0.3% in the second half of the study period (P = NS). Logistic regression analysis indicated no significant correlations between adverse outcomes with any of epidemiological parameters of women undergoing amniocentesis.

Conclusion

Operator experience has a beneficial impact on preventing procedure-related adverse outcomes.