Rates of intrauterine fetal demise and neonatal morbidity at term: determining optimal timing of delivery

Objective: To examine rates of unexplained intrauterine fetal demise (IUFD) and neonatal morbidity in uncomplicated term pregnancies to identify the optimal gestational age for delivery.

Methods: A retrospective case control study was performed with singleton pregnancies delivered between 37 0/7 weeks and 42 6/7 weeks. Exclusion criteria were “complicated pregnancies”: emergency deliveries, maternal hypertension, diabetes, infection, fetal disease/malformations and placental abnormalities.

Results: Nineteen thousand two hundred and sixty-four maternal/infant pairs were examined. The overall rate of NICU admission was 2.7% and the rate of unexplained IUFD was 2.02 per 1000 births. The lowest rate of IUFD was found at 39 weeks (1.40 per 1000 births). Odds ratios adjusted for maternal smoking, ethnicity, age and mode of delivery showed 2.74 (95% CI 0.35–21.83) risk of IUFD at 42 versus 39 weeks, 2.09 (1.47–2.98) risk of NICU admission at 37 versus 38 weeks, 2.54 (1.62–3.97) risk of respiratory morbidity at 37 versus 38 weeks and 3.38 (1.84–6.18) risk of transient tachypnea of the newborn or respiratory distress syndrome at 37 versus 38 weeks.

Conclusions: Neonatal respiratory morbidity was lowest for deliveries at 38–39 weeks. IUFD was 2.74 times more likely at 42 weeks versus 39 weeks. Our findings support current guidelines advising clinicians when to deliver term pregnancies.     

Contemporary practice patterns in the use of amniocentesis for fetal lung maturity*

Purpose: Fetal lung maturity (FLM) testing has been performed to help direct delivery timing in complex obstetrical conditions. We explored current practice patterns of FLM testing attempting to identify factors affecting its use.

Materials and methods: We distributed a 31-question survey to obstetricians and perinatologists that examined practice characteristics potentially affecting FLM usage. Logistic regression measured associations between these factors and test utilization. Weighted averages were calculated for conditions in which respondents considered FLM testing helpful.

Results: Three hundred four surveys were completed. The response rate for respondents actively practicing obstetrics was 52%. The majority of respondents utilize FLM testing; however, 80% reported a decline in use over the past five years with 64% citing “published guidelines” as the reason. Respondents found FLM testing most applicable for poorly dated pregnancies. After an immature FLM test, 44% of respondents administer antenatal corticosteroids in the late-preterm period. None of the factors surveyed were significantly associated with FLM testing use.

Conclusion: The majority of respondents use FLM testing although significant factors contributing to its use were not identified. We discover a high frequency of antenatal corticosteroid administration beyond 34 weeks gestational age in response to immature FLM indices that may be an area for future study.     

Velamentous cord insertion: is it associated with adverse perinatal outcomes?

Introduction: Velamentous cord insertion (VCI) can be identified on prenatal ultrasound with an incidence of around 1%. We set out to examine the association between VCI and perinatal outcomes.

Methods: This was a retrospective cohort study of 482?812 pregnancies using the California vital statistics birth cohort dataset linked with patient discharge dataset from 2006 during which 2327 (0.48%) were complicated by VCI. Outcomes examined included intrauterine fetal demise (IUFD), small for gestational age (SGA), preterm delivery, manual removal of the placenta and cesarean delivery. Statistical analysis was performed using Chi squared tests and multivariable logistic regression analyses.

Results: Pregnancies with VCI, compared to those without, were associated with an increased risk of IUFD (2.6% versus 0.28%, p?=?0.001), SGA (16.93% versus 10.17%, p?=?0.001), preterm delivery <37 weeks (12.5% versus 9.10%, p?=?0.001), manual removal of placenta (14.47% versus 0.76%, p?=?0.01) and postpartum hemorrhage (6.66% versus 2.88%, p?=?0.001). Adjusting for confounders, the adjusted odds of IUFD were more than nine times in pregnancies with VCI (aOR 9.56; 95% CI 6.76–13.5) than those without.

Discussion: VCI is associated with an increased risk of adverse perinatal outcomes such as IUFD, SGA, preterm delivery <37 weeks, need for manual removal of placenta and post-partum hemorrhage. Routine identification of the placental cord insertion site should be considered. Close surveillance of these pregnancies should be undertaken. Future research should focus on the optimal management including the gestational age for delivery of these pregnancies.     

Impact of a prenatally diagnosed nuchal cord on obstetrical outcome in an unselected population

Objective: Evaluate the outcome of prenatally diagnosed nuchal cord.

Methods: A retrospective study on all cases of prenatally diagnosed nuchal cord. Study end points were gestational age at delivery, intrapartum fetal heart rate (FHR) abnormalities, mode of delivery, intrauterine fetal growth retardation (IUGR), intrauterine fetal demise (IUFD), and the rate of labor induction.

Results: This study included 44 cases; 86% were diagnosed at second trimester scan, confirmed by Color Doppler and 3D ultrasound. Mean gestational age at delivery was 39 weeks.18/44 cases (41%) underwent labor induction mostly as a result of parental anxiety. Primary cesarean rate was 34% (15/44), and 16% (7/44) had intrapartum FHR abnormalities with no impact for induction of labor. Instrumental vaginal delivery was used in 5 cases. IUGR was present in 7% (3/44), and none had IUFD. Nuchal cord was confirmed at birth in all cases. Correct prenatal diagnosis was in only one case of the 5/44 (11%) with multiple loops.

Conclusion: Prenatal diagnosis of nuchal cord is feasible with difficulty in determining multiple loops. Outcome is favorable, but parental anxiety is common and may increase induction rates, without leading to difference in cesarean rates or FHR abnormalities.     

Transcervical Foley’s catheter versus Cook balloon for cervical ripening in stillbirth with a scarred uterus: a randomized controlled trial

Objective: To compare the efficacy and safety of the use of transcervical Foley’s catheter versus Cook cervical ripening balloon in pregnant women with stillbirth, unfavorable cervix and scarred uterus.

Design: Randomized controlled study.

Setting: El Minia University Hospital, El Minia, Egypt.

Patients and methods: Two-hundred pregnant women with stillbirth, unfavorable cervix and scarred uterus were recruited into this study. They were randomized into two groups. In group I (n?=?100), cervical ripening was done using Foley’s catheter. In group II (n?=?100), cervical ripening was done using Cook cervical ripening balloon.

Main outcome measures: Balloon insertion to delivery interval, successful ripening rate, cesarean delivery rate, maternal adverse events and maternal satisfaction.

Results: Time from balloon insertion to expulsion and from balloon insertion to delivery was significantly shorter in Foley’s catheter group. However, the difference between the two groups regarding time from balloon insertion to active labor, time from balloon expulsion to delivery, cervical ripening, cesarean section, instrumental delivery, pain score, need for analgesia, hospital stay and maternal satisfaction was not statistically significant.

Conclusions: Foley’s catheter and Cook cervical ripening balloon are comparable regarding efficacy and safety profile when used to ripen the cervix in pregnant women with stillbirth, unfavorable cervix and scarred uterus. However, Foley’s catheter has a shorter induction to delivery interval and is relatively cheaper device.     

The influence of psychological factors on postpartum weight retention 12 months post-birth

Background

During the first postpartum year 20% of women retain excessive weight from pregnancy (postpartum weight retention; PPWR), which predicts long-term overweight/obesity.

Objective

The aim of this study was to explore the associations between psychological factors (depression, anxiety and stress symptoms and body attitudes) in late gestation and at 12-months postpartum with PPWR one-year post-birth.

Methods

Pregnant women (N = 176) completed questionnaires in early–mid pregnancy (Time 1; mean (SD) = 16.97 (1.35) weeks), late pregnancy (Time 2; mean (SD) = 33.33 (2.05) weeks), and one year postpartum (Time 3; mean (SD) = 53.12 (3.34) weeks). Women provided demographic characteristics, height and pre-pregnancy weight at Time 1. At Times 2 and 3, weight, depressive, anxiety and stress symptoms and body attitudes (salience of weight and shape, attractiveness, feeling fat, and strength and fitness) were assessed in addition to physiological, socio-contextual and lifestyle factors. Gestational weight gain and PPWR were calculated. Hierarchical linear regression models were conducted to explore variance in 12-month PPWR.

Results

Overall, models explained 26–39% variance in PPWR. Gestational weight gain in late pregnancy and low attractiveness at 12 months postpartum were the only variables associated significantly with 12-month PPWR.

Conclusion

While psychological factors did not appear to be important direct contributors to PPWR at 12 months, the overall contribution of all variables suggests that such factors may be implicated in a small and incremental way. Exploration of the interactions between variables will help unpack potential mechanisms of the development of PPWR at 12 months post-birth.     

Polycystic ovary syndrome and low-grade inflammation with special reference to YKL-40

Objective: To evaluate the plasma level of YKL-40 in a Danish polycystic ovary syndrome (PCOS) population and to investigate whether YKL-40 is associated with CVD risk factors such as waist circumference, body mass index (BMI), insulin resistance (IR), fasting glucose, fasting insulin, blood lipids and CRP.

Design: Cross-sectional study.

Setting: Gynecological clinics at three Danish University Hospitals.

Patients: One hundred seventy-one premenopausal women with PCOS recruited consecutively from April 2010 to February 2012. PCOS was diagnosed according to the Rotterdam criteria.

Main outcome measures: Plasma level of YKL-40 in four phenotypes of PCOS defined by BMI and IR.

Results: No statistically significant difference was observed in the plasma level of YKL-40 across the four BMI/IR-phenotypes. Positive associations were observed between YKL-40 and BMI, total and free testosterone, triglycerides, and CRP. Total and free testosterone were independent predictors of YKL-40.

Conclusion: YKL-40, the marker of low-grade inflammation is not increased in women with PCOS.     

Impact of amniotic fluid “sludge” on the risk of preterm delivery

Objective: To evaluate the impact of amniotic fluid “sludge” (AFS) on the risk of preterm delivery and to describe the effect of antibiotic treatment in that situation.

Methods: Case–control study including singleton pregnancies with or without AFS, between 15–32 weeks of gestation. Factors associated with preterm delivery before 32 weeks, 34 weeks and 37 weeks were evaluated with univariate and multivariate logistic regression. Since all women with AFS in this study were treated with antibiotics, a historical comparison was performed with similar patients with AFS found before 2007 and not treated with antibiotics.

Results: AFS was observed in 90/1220 patients (7.4%). AFS was associated with shorter cervical length, greater body mass index, cervical cerclage and preterm birth before 28 weeks. However, after adjustment, AFS did not remain associated with preterm delivery before 32 or 34 weeks. The historical comparison suggested that azithromycin could significantly reduce the risk of preterm delivery before 34 weeks (odds ratio: 0.2; 95% CI: 0.04–0.92).

Conclusions: AFS, treated with azithromycin, was associated with a higher risk of prematurity, but not independently after adjustment for cervical length and second trimester vaginal bleeding. Further studies need to evaluate the effect of antibiotics in pregnancies with AFS.     

Third trimester perinatal mortality associated with immediate delivery versus expectant management according to birthweight category

Objective: Immediate delivery compared with expectant management in a low risk population stratified by birthweight.

Methods: Retrospective cohort of births, stillbirths and neonatal deaths from 2010 through 2012 compiled by the National Center for Health Statistics. Birthweight categories were created using population derived deciles. Gestational age at birth was adjusted to account for time from death to delivery. The risk of immediate delivery was the neonatal death rate. The risk of expectant management was the sum of the conditional stillbirth risk plus the neonatal death rate for the following week. Relative risks were calculated comparing immediate delivery with expectant management by birthweight category.

Results: There were 4 966 067 births, 6660 stillbirths and 6979 neonatal deaths. The gestational age at which expectant management exceeded risk of immediate delivery was consistently at or after 39 weeks for all except birthweights above the 95th centile, where the relative risk for death with immediate delivery was 1.72 (95% CI: 1.74–1.7) at 36 and 0.83 (95% CI: 0.84–0.81) by 37 weeks.

Conclusions: In this low risk cohort, risk at 39 weeks favored immediate delivery, except for birthweight over the 95th centile, where expectant management did not appear to be beneficial after 37 weeks.     

ß-hCG and prediction of therapeutic success in ectopic pregnancies treated with methotrexate,results from a prospective observational study

Objective: To evaluate the diagnostic accuracy of different beta-human chorionic gonadotrophin (ß-hCG) levels measurement, for predicting success of medical treatment in cases diagnosed as tubal ectopic pregnancy (TEP).

Design: Five-year prospective observational study.

Setting: Prenatal Diagnosis Unit, Vall d'Hebron University Hospital – Barcelona.

Patients: TEP cases fulfilling criteria for medical treatment with Methotrexate.

Interventions: ß-hCG levels were measured on d 0, 4 and 7 of treatment. Results were compared by non-parametrical tests. A ROC curve was plotted to define cut-off points. Diagnostic accuracy of the different measurements was evaluated.

Main outcome measure: Failure of treatment defined as need for surgical treatment or persistence of high ß-HCG levels despite treatment.

Results: 126 women were diagnosed as TEP, eligible for medical treatment. There were no differences in parity, age, previous TEP, or adnexal mass size. Success rate was 88%. ß-HCG decreased significantly more, between days 0–7 and 4–7, in the successful cases. LR for success prediction was 6.2 and 7.8 for ß-HCG levels at days 4 and 7 respectively, 4.02 and 2.47 for decrement between days 0–7 (25%) and 4–7 (20%), respectively.

Conclusion: ß-hCG cutoff values have a potential for predicting a successful medical treatment of TEP.     

Type-2 diabetes mellitus: does prenatal care affect outcomes?

Objective: To determine if prenatal care affects adverse perinatal outcomes in pregnant women with Type-2 diabetes mellitus (T2DM).

Study design: This was a retrospective cohort study of pregnant women with pregestational diabetes mellitus pregnancies in the state of California between 1997 and 2006, using vital statistics data linked to birth certificates. Women were stratified by time of presentation to care and we compared those who presented in the first trimester, third trimester, and those who had no prenatal care prior to delivery. Perinatal outcomes looked at included: preeclampsia, macrosomia, preterm delivery, cesarean delivery, and intrauterine fetal demise (IUFD). The two groups were compared with chi-squared testing to determine statistical significance.

Results: In women with pregestational diabetes those who presented at time of delivery had an 11.3% risk of IUFD compared to 0.9% in those who presented in the first trimester. There was also an increased rate of preterm birth in the late presentation cohort (29.4% at time of delivery versus 21.0% in the first trimester). After adjusting for possible confounding variables using logistic regression models, rates of IUFD and preterm delivery were still found to be statistically significant with adjusted odds ratios of 11.37 (95% CI: 6.10–21.16) and 1.55 (95% CI: 1.03–2.32), respectively. There were no differences in rates of macrosomia or preeclampsia between the three cohorts.

Conclusions: Treatment of T2DM throughout pregnancy leads to improved maternal and neonatal outcomes.     

Mode of delivery changes oxidative and antioxidative properties of human milk: a prospective controlled clinical investigation

Objective: To evaluate the influence of delivery mode on oxidative stress in human breast milk.

Methods: Thirty-three women who delivered by vaginal birth and 55 women who underwent cesarean section (CS) were included in this study. Colostral samples were collected on the second day after delivery. Total antioxidative status (TAS), total oxidative status (TOS), oxidative stress index (OSI), malonyldialdehyde (MDA), and glutathione peroxidase (GSH-Px) levels were determined and compared.

Results: Colostrum TAS was significantly higher in women of vaginal birth, than in women with CS (p?<?0.001). Milk TOS and OSI were found to be significantly increased in women with CS under general anesthesia. A marked increase in colostral GSH-Px levels after vaginal delivery was also noticed (p?<?0.001).

Conclusion: This study revealed that vaginal birth is associated with decreased oxidative stress in colostrum than CS, which suggest that mode of delivery plays an important role in the antioxidative production of breast milk.     

Little beneficial effect of maternal vitamin supplement on metabolic disturbances in the offspring from the obese mother mice

Objective: To examine whether vitamin supplement before and during pregnancy alters the detrimental effect of maternal obesity on the offspring.

Methods: Obese C57BL/6 female mice were randomly divided into four groups and fed with the control, vitamin D, folic acid or multivitamin supplement diet before and during pregnancy. Physiologic and biochemical variables were obtained.

Results: No significant differences were observed in glucose and lipid variables among offspring from each maternal obese group.

Conclusions: Overall, vitamin D, folic acid or multivitamin supplement cannot ameliorate the detrimental effect of maternal obesity on the metabolic disturbances in the offspring.     

Perinatal risk factors and mode of delivery associated with mortality in very low birth weight infants

Objective: To investigate the association of perinatal risk factors including delivery mode with mortality in very low birthweight (VLBW) in a tertiary hospital setting.

Methods: Medical records of 241 live-born VLBW infants (≤1500?g) were retrospectively reviewed. Details of maternal, obstetrical, perinatal risk factors and their associations with infant mortality were evaluated.

Results: The overall infant mortality rate was 23.2%. Mortality was significantly higher for infants born at ≤27 gestational weeks and with a birthweight of ≤750?g (p?=?0.000 and p?=?0.000, respectively), showing a steep decrease thereafter. On ROC analysis, a cut off of 26.5 weeks was determined for mortality with a sensitivity of 57.1% and a specificity of 90.3% (area under the curve?=?0.792, 95% CI: 0.719–0.866). On multivariate regression analysis, gestational week at birth, birthweight, antenatal steroid treatment and pathologic Doppler ultrasound findings were found as independent risk factors for mortality.

Conclusions: Gestational week at birth, birthweight and antenatal steroid treatment remain the most important perinatal risk factors for infant mortality in VLBW infants. Mode of delivery does not seem to be associated with mortality when adjusted for other perinatal risk factors.     

The effect of cerclage in twin gestations with short cervix: a Bayesian evaluation

Objective: Bayesian inference allows the revision of prior clinical estimates of treatment effectiveness based on current data. We apply it to a published dataset evaluating the effect of cerclage upon preterm delivery in twin gestations with a short cervix.

Study design: Prior probability distributions for delivery <35 weeks gestation for the control group and the treatment (cerclage) group were constructed under assumptions ranging from treatment having no effect (prior A) to halving early deliveries (prior C). Likelihood functions were calculated based on a published meta-analysis. Posterior probability densities were derived from which risk ratios for early delivery were computed, with 95% credible intervals and the probability of cerclage benefit.

Results: Median posterior risk ratios (95% credible intervals) for delivery <35 weeks with cerclage are 1.51 (1.02–2.33) for prior A and 1.11 (0.72–1.77) for prior C. The probability of cerclage benefit ranged from 2.1% for prior A to 31.4% for prior C. By comparison, the conventional risk ratio (95% confidence interval) for early delivery, based on the data alone, is 2.08 (1.18–3.69).

Conclusions: As might be anticipated, those with low expectation of cerclage benefit remain more convinced of the ineffectiveness (or harm) of the procedure than those with higher expectations.     

The role of narrative medicine in pregnancy after liver transplantation

Narrative medicine allows professionals from all fields of medical sciences to understand the patient’s total experience of illness, and meet his/her needs in an empathetic environment. Narrative medicine helps spread holistic knowledge of a multitude of complex clinical conditions, including transplantation.

Objective: To underline the role of narrative medicine in women who become pregnant after a liver transplant by using their narrations of this very special experience.

Methods: We describe our study with narration and listening to the stories of three women expecting their first child after a liver transplant, by analysing the structure and role of narration in the context of relationships between patients and caregivers. The narrations were transcribed verbatim with the main plot analysed in order to address all the aspects of this rare clinical condition and the transition to parenthood.

Results: The women narrated this experience in three phases: transplantation, pregnancy and delivery, and post-partum. They described all phases of pregnancy as stressful but satisfying, whereas the fact of becoming a mother was perceived as a victory both as a woman and as a transplant patient.

Conclusions: Our results suggest that narrative medicine represents a significant professional tool for caring for transplant patients during pregnancy.     

Influence of storage time on vitrified human cleavage-stage embryos froze in open system

Background: During in vitro fertilization, rapid growth of vitrification and liquid nitrogen storage of embryos have been well characterized. However, the effect of storage time on vitrified cleavage-stage embryos in an open system is poorly understood.

Aims: To investigate the influence of storage time on the survival and pregnancy outcomes of vitrified human cleavage-stage embryos froze and stored in an open system.

Methods: A retrospective study of 786 vitrified-warmed cycles of 735 patients was performed from January 2013 to October 2013. The cycles were divided into five groups according to storage time: 1–3 months, 4–6 months, 7–12 months, 13–24 and 25–60 months. The clinical outcomes of cycles with different storage time were analyzed.

Results: There were no significant differences of the survival rate, clinical pregnancy outcomes, birth rate, gestational weeks and singleton birthweights at various storage times.

Conclusion: For vitrified embryos froze and stored in an open system, the storage time would not influence the survival rate and pregnancy outcomes by storage time up to 5 years.     

Abdominal delivery in the intact amniotic sac in twin pregnancy

Objective: There has been an increasing trend for Caesarean deliveries in twin pregnancies over the last decades; preferred mode of delivery is still unclear. The article presents the mode of twin delivery within intact amniotic sac.

Methods: The intrapartum courses in 70 matched twin pairs extracted by Caesarean section were analysed. Neonates were distributed to two groups – main (delivered “en caul”) and control (delivered by conventional Caesarean section) groups, and subdivided according to gestational age at the time of delivery: 28–30 weeks, 31–33 weeks and 34–37 weeks. Neonates delivered first and second were matched by pairs.

Results: The duration of Caesarean section was higher in the main group (delivered “en caul”). Apgar score at 5-th min depend on the gestational age at birth and was higher in main group. Mechanical ventilation term and length of hospital stay were lower in main group. Postnatal neurological examination showed lower incidence of brain damage in the main group. During the first year of life, neonates extracted within intact amniotic sac showed lower morbidity rate. This was correct also for pairs of neonates matched by delivery order.

Conclusions: Presented method improves neonates’ Apgar score, reduces the need for resuscitation and influence of intrapartum negative factors. The length of hospital stay and hospitalisation rate for the first year of life were also lower in neonates delivered “en caul", providing an economical benefit.     

Maternal venous hemodynamics assessment for prediction of preeclampsia should be longitudinal

Objective: To address the question whether maternal venous abnormalities exist at the onset of, or develop during the course of pregnancy.

Methods: We present five case reports of patients with early onset preeclampsia (EPE), late onset preeclampsia (LPE), gestational hypertension (GH), essential hypertension (EH) and an uncomplicated pregnancy (UP). Maternal renal and hepatic vein Doppler waves and maternal venous pulse transit times (VPTT) were assessed in early pregnancy and again shortly before delivery.

Results: In all cases, maternal VPTT were normal in early pregnancy and changed to abnormal values in EPE and LPE, which was not true for UP and GH or EH.

Conclusion: These observations support the view that venous hemodynamic dysfunction of preeclampsia (PE) develops during the course of pregnancy. Therefore, assessment of an individual's venous function for prediction of PE should be serial and longitudinal.     

Selective uterine fundal pressure maneuver during the second stage of the first twin delivery at near term

Objective: We examined the perinatal outcomes of twin deliveries following selective uterine fundal pressure maneuver (UFPM) during the second stage of the first twin delivery.

Methods: At our institute, if non-reassuring fetal heart rate and/or maternal exhaustion were observed during the second stage of the first twin, selective UFPM was performed following making sure of the position of the first twin’s buttocks by ultrasonography. We reviewed the obstetric records of all cases of trial of vaginal delivery of twins between 2002 and 2012.

Results: A total of 64 cases were evaluated for the statistical analyses. Of these, selective UFPM for the first twin was performed in 15 cases (24%). Although the cases requiring selective UFPM for the first twin was associated with an increased postpartum hemorrhage, there were no significant differences in neonatal outcomes between the two groups.

Conclusion: There was no evidence that the selective UFPM is unsafe for both mother and two babies during the second stage of the first twin delivery.