Significance of Birthweight for Gestational Age in Identifying Infants at Risk

If the gestational age and birthweight of all infants are routinely assessed on admission to the newborn nursery, the nurse can identify and bring to the physician's attention infants who are at risk because of prematurity or discrepant weight for gestational age. Treatment then can be started earlier and the prognosis of these infants improved. This paper describes a method of categorizing neonates by weight and gestational age, and physical characteristics such as texture of hair, which can be used as indexes for classification. Weight and age characteristics of intrauterine growth retardation and respiratory distress syndrome are discussed.     

小于胎龄儿脑发育的随访观察

目的　探讨小于胎龄儿 (SGA)出生时脑发育受影响的程度和出生后脑发育的情况 ,为有脑发育异常的 SGA进行早期干预提供依据。　方法　运用颅脑超声对 SGA的小脑进行冠状位和矢状位小脑面积、周长、纵横径及大脑半球宽度的测量 ,并与适于胎龄儿 (AGA)进行比较分析。　结果　婴儿出生时小脑面积、周长、横径及纵径与其胎龄和出生体重存在较好的相关关系 ,尤以小脑面积和周长与其胎龄和出生体重相关较好 ;大脑半球宽度也与婴儿出生体重存在较好的相关关系。出生时 SGA的脑发育落后于 AGA,出生后 SGA的脑生长速度与 AGA相似 ,但随访至 12个月时 SGA脑发育仍落后于 AGA ,SGA其他脑的异常发生率也较 AGA高。　结论　 SGA不仅在宫内脑的发育受到影响 ,而且可影响到生后脑和神经系统发育 ,故应加强围产期保健 ,制订早期干预计划 ,做好优生工作。     

Risk of Perinatal Death in Early-Onset Intrauterine Growth Restriction according to Gestational Age and Cardiovascular Doppler Indices: A Multicenter Study

Objective: To assess the value of gestational age and cardiovascular Doppler indices in predicting perinatal mortality in a multicenter cohort of early-onset intrauterine growth-restricted (IUGR) fetuses. Methods: A multicenter prospective cohort study including 157 early-onset (<34 weeks) IUGR cases with abnormal umbilical artery (UA) Doppler was conducted. Cardiovascular assessment included the ductus venosus (DV), the aortic isthmus flow index (IFI), and the myocardial performance index (MPI). Isolated and combined values to predict the risk of perinatal death were evaluated by logistic regression and by decision tree analysis, where the gestational age at delivery, UA, and middle cerebral artery (MCA) were also included as covariates. Results: Perinatal mortality was 17% (27/157). All parameters were significantly associated with perinatal death, with individual odds ratios (OR) of 25.2 for gestational age below 28 weeks, 12.1 for absent/reversed DV atrial flow, 5.3 for MCA pulsatility index <5th centile, 4.6 for UA absent/reversed diastolic end-flow, 1.8 for IFI <5th centile, and 1.6 for MPI >95th centile. Decision tree analysis identified gestational age at birth as the best predictor of death (<26 weeks, 93% mortality; 26-28 weeks, 29% mortality, and >28 weeks, 3% mortality). Between 26 and 28 weeks, DV atrial flow allowed further stratification between high (60%) and low risk (18%) of mortality. Conclusions: Gestational age largely determines the risk of perinatal mortality in early-onset IUGR before 26 weeks and later than 28 weeks of gestation. The DV may improve clinical management by stratifying the probability of death between 26 and 28 weeks of gestation.     

小于胎龄儿血糖的系统监测

目的　探讨小于胎龄儿 (small for gestational age infant,SGA儿 )血糖监测的重点对象及持续时间 ,减少血糖异常造成的损伤。　方法　对 37例出生 (2 .6± 2 .4) h (0 .2 5～ 10 .0 h,中位数 2 .0 h)、非 NICU收治、入院时无输液且未开始喂养的 SGA儿进行为时 (133± 115 ) h (16～ 5 2 4h,中位数 93h)的血糖监测。　结果　监测过程中 2 4例 (6 4% )出现血糖异常 ,其中低血糖 19例(5 1% ) ,高血糖 2例 (5 % ) ,高血糖及低血糖均有发生 3例 (8% )。血糖异常最后发生时间的中位数为10 h,其 95 %可信限为 5～ 5 5 h。 3例反复低血糖发生时间超过 2 40 h。逐步回归分析显示分娩方式与早期血糖水平有关 (P=0 .0 13) ,自然分娩者早期血糖水平高 ;出生体重越低 ,血糖异常最后发生时间越晚 (P<0 .0 1)。另外 ,分析结果显示男婴血糖异常最后发生时间较晚 (P=0 .0 8)。监测期间 ,所有SGA儿未出现血糖异常的相应症状 ,13例予以部分或全静脉营养。　结论　 SGA儿为血糖异常 ,特别是低血糖高危人群 ;对非自然分娩出生的 SGA儿 ,尤应注意早期血糖监测 ;对所有 SGA儿 ,尤其是出生体重及其百分位数低者、男婴应行动态血糖监测 ,并持续至出生后 5 5 h     

The Impact of Parity on the Incidence of HELLP Syndrome and Small for Gestational Age Infants in Hypertensive Pregnant Women

Objectives: To determine whether maternal and fetal complications such as HELLP hemolysis, elevated liver enzymes, low platelets) syndrome and the incidence of small for gestational age infants in women with preeclampsia and gestational hypertension differ with both gravidity and parity.Study Design: The charts of 441 hypertensive women, 182 with preeclampsia and 259 with gestational hypertension, presenting for delivery at B.C. Women’s Hospital were retrospectively reviewed. Multiple clinical parameters, including gestational age at presentation the incidence of small for gestational age SGA infants, HELLP syndrome, and the severity of preeclampsia, were compared among three groups of women: (A) primigravid primiparous, (B) multigravid primiparous, and (C) multiparous. Mean values between the groups were compared using analysis of variance with pair-wise comparison using the Tukey test.Results: The incidence of HELLP syndrome among the women with preeclampsia was similar in groups A and B 35% and 50%, respectively), but significantly lower (p < 0.012) in group C (19%). The incidence of small for gestational age infants among the women with preeclampsia was similar for groups A, B, and C (27%, 31% and 19%) respectively). In the gestational hypertensive group the incidence of SGA infants was similar for groups A, B, and C (14%, 11%, and 12% respectively).Conclusions: The preeclamptic primigravid primiparous and multigravid primiparous groups behaved similarly in their clinical expression of hypertensive complications but differed from the multiparous group by having a higher incidence of HELLP syndrome. The incidence of complications in hypertensive pregnant women varied by parity but not by gravidity. The gestational hypertensive groups did not differ in their clinical expression of hypertensive complications.     

Placental Thickness: Its Correlation with Ultrasonographic Gestational Age in Normal and Intrauterine Growth-Retarded Pregnancies in the Late Second and Third Trimester

Objective

The aim was to study the correlation of placental thickness, measured at the level of the umbilical cord insertion, with the ultrasonographic gestational age in normal and IUGR pregnancies in the late second and third trimester.

Materials and Methods

A total of 498 patients were observed for correlation of the placental thickness with ultrasonographic gestational age and their outcomes by dividing them into Group A (outcome fetal weight < 2,500 g, n = 122) and Group B (fetal weight > 2,500 g, n = 376). The mean placental thickness was calculated at the umbilical cord insertion in both groups along with ultrasonographic fetal age and estimated fetal weight. The mean values of placental thickness along with respective standard deviation were calculated from the 24th to 39th week of gestational age.

Results

A positive correlation was observed between placental thickness and ultrasonographic gestational age in both groups (p value of 0.01), with Pearson’s correlation coefficient (“r”) values of 0.325 in Group A and 0.135 in Group B. Regression analysis yielded linear equations of relationship with placental thickness and gestational age in both groups. The placental thickness was also found to be lower in Group A between 26 and 27 weeks and 30 and 31 weeks, having mean values of 2.48 ± 0.063 cm (p value of 0.042) and 2.76 ± 0.552 (p value of 0.05) in Group A as compared to 3.04 ± 0.25 and 3.13 ± 0.183 cm in Group B.

Conclusions

Placental thickness measured at the level of umbilical cord insertion can be used as an accurate sonographic indicator in assessment of gestational age in singleton pregnancies because of its linear correlation.     

Evaluating the Prevalence of Regret With the Decision to Proceed With a Hysterectomy in Women Younger than Age 35

ObjectiveThis study sought to evaluate prevalence of regret with the decision to undergo a hysterectomy at a young age.MethodsA retrospective cohort study was performed at two centres and included patients who underwent an elective hysterectomy for benign indications under age 35, between January 1, 2008 and December 31, 2015. Eligible patients were contacted and completed a validated decision regret survey and patient health questionnaire.ResultsA total of 189 patients met the study criteria. Of the 95 patients who could be contacted, 71 consented to participate (response rate, 75%). The most common indications for surgery were menorrhagia (35.2%), uterine fibroids (22.5%), endometriosis (19.7%), and pain (15.5%). Overall, 91.5% of patients agreed that having this surgery was the right decision for them, and 90% said that they would make the same choice in the future. A total of 2.8% regretted the choice that they made, and 14% responded that this caused them harm. Over 95% of patients reported that the decision was either mostly patient driven or shared with the physician.ConclusionThis is the first evaluation of regret after hysterectomy specifically examining a younger patient population. The study results suggest that patients who are appropriately counselled do not regret their decision to proceed with hysterectomy.     

Prevalence and Impact of Chronic Endometritis in Patients With Intrauterine Adhesions: A Prospective Cohort Study

Study Objective

To evaluate the prevalence and impact of chronic endometritis (CE) in patients with intrauterine adhesions (IUAs).

A Comparison of the Fetal Femur Length and Biparietal Diameter in Predicting Gestational Age in the Third Trimester

Summary: Using 2 published normograms relating ultrasonic fetal femur length and gestational age, the accuracy of predicting gestational age using fetal femur length was compared to that using the biparietal diameter after 28 weeks' gestation in 50 patients. The results showed that ultrasonic feta! femur length was more accurate than the biparietal diameter in predicting gestational age in the third trimester. Ultrasonic fetal femur length provides an additional parameter in assessing gestational age in late pregnancy.     

Accuracy of Serum Human Chorionic Gonadotrophin for Estimating Gestational Age in the First Trimester of Pregnancy: Population-Based Study

This study determined the accuracy of first-trimester serum human chorionic gonadotrophin (hCG) for estimating gestational age (GA). We included 273 584 singleton live births that had a first-trimester ultrasound and measured serum hCG at 4–12 weeks gestation in Ontario from 2012 to 2018. We estimated hCG accuracy compared to known GA, within a boundary of ± 1 week. Between 4 to 8 weeks gestation, sensitivity of hCG was over 88% and specificity over 51%. However, at 9–12 weeks gestation, sensitivity declined from 72% to 0%, and specificity rose from 86% to 100%. At all GA, the positive predictive value was consistently under 42%, while negative predictive values were over 96%. Within epidemiological studies in which GA is otherwise unknown, first-trimester serum hCG may aid somewhat in estimating GA between 4 to 6 weeks gestation, but much less so thereafter. Thus, there remains an ongoing need for an accurate method for estimating missing GA within large datasets.     

Incidence and Duration of Breastfeeding for Term Infants in Canada,United States,Europe, and Australia: A Literature Review

Abstract: Background : Analysis of differences in the incidence and duration of breastfeeding across countries may provide information about practices that encourage breastfeeding. This comparative review examines variation in the incidence and duration of breastfeeding for term infants that has been reported in studies from Canada, the United States, Europe, and Australia. Methods : Searches were conducted in PubMed, MEDLINE (from 1966), CINHAL (from 1982), and the Cochrane Database of Systematic Reviews. Studies were limited to nonexperimental and observational research that addressed term infants (>37 weeks gestational age), performed in developed countries, written in the English language, and published since 1990. Additional studies were located from reference lists of meta‐analyses, systematic reviews, and previous articles. All studies that met study criteria were included in the review, regardless of the quality of methodology. Results : Although studies had methodological limitations that precluded conducting a formal systematic review or meta‐analysis, this comparative review revealed consistent differences among countries. For example, Europe and Australia reported a higher initiation and duration of breastfeeding term infants compared with Canada and the United States. Conclusions : Studies that examined reasons for a higher incidence and duration of breastfeeding term infants consistently document that women who initiate and continue to breastfeed are older, married, better educated, and have higher family incomes than women who do not breastfeed.     

Intrauterine Interventions for the Treatment of Twin Anemia-Polycythemia Sequence: A Systematic Review

BackgroundTwin anemia-polycythemia sequence (TAPS) is a complication of monochorionic, multiple gestation pregnancies in which blood shunting through placental anastomoses results in chronic anemia in one fetus and chronic polycythemia in another. The outcomes of different treatment modalities for TAPS are not well known.ObjectiveTo determine the outcomes of the intrauterine interventions used to treat TAPS.Study DesignA systematic literature search of MEDLINE, EMBASE, and CENTRAL was performed in June 2016. Primary outcomes were mortality, morbidity, and adverse perinatal outcomes. Data were summarized in the form of weighted means, and statistical difference was determined.ResultsTwenty-one articles were identified for inclusion in this review and were composed of 105 cases of TAPS. In the cases presented in the literature, there was no statistically significant difference in mortality, morbidity, or emergent Caesarean section rates between expectant management, intrauterine transfusion (IUT), and laser ablation therapy. Laser ablation therapy and IUT were found to have a significantly lower rate of adverse perinatal outcomes when compared to expectantly managed cases.ConclusionsThe literature looking into the treatment of TAPS is very limited, with no randomized controlled trials and only one includable comparative study. Based on the data in the case report and case study literature, there is no mortality difference between any of the treatment modalities. Expectant management may be associated with an increase in adverse perinatal outcomes when compared to laser therapy and IUT. More comparative studies are needed to assist clinicians in adopting an evidence-based approach to the treatment of TAPS.     

On the Complexity of D Antigen Typing: A Handy Decision Tree in the Age of Molecular Blood Group Diagnostics

RH is the most complex of all 29 blood group systems. New discoveries relating to the RHD gene, and an appreciation of its variant phenotypes such as weak D and partial D, have challenged the way that D status is assigned to both blood donors and blood product recipients. This concise review introduces the current concepts of weak D and partial D and how the identification of these variants has influenced the testing methods for the D antigen. We demonstrate how molecular tests of the RHD gene can and should be used in resolving serological discrepancies, in particular in pregnant women.     

Oral Misoprostol for Induction of Labour in Term PROM: A Systematic Review

ObjectiveTo assess the efficacy of oral misoprostol for induction of labour (IOL) in the context of term pre-labour rupture of membranes (TPROM), and to assess pregnancy outcomes following the administration of oral misoprostol.Data SourcesA systematic literature search was performed using Ovid Medline, Embase, PubMed, and the Cochrane Database of Systematic Reviews.Study SelectionEligible studies were quasi-experimental trials or randomized controlled trials involving the use of oral misoprostol in singleton cephalic term pregnancies with confirmed rupture of membranes and no spontaneous labour at the time of membranes rupture, in mothers with no contraindications to vaginal delivery. Studies were excluded if they utilized vaginal misoprostol, excluded primigravid participants, or if the full text of the article was not accessible in English.Data ExtractionData were extracted by two reviewers using a standardized data extraction form. Study quality was assessed using the modified Jadad score.Data SynthesisTwelve randomized controlled trials that included 1489 singleton pregnancies were included. Doses of oral misoprostol ranged from 20 to 200 μg. The incidence of vaginal birth ranged from 73.0%–95.0% in the oral misoprostol group compared with 52.4%–94% in the control group. Hyperstimulation was infrequent, ranging from 0% to 13.8% in the oral misoprostol group compared with 0%–24% in the control group. Two trials, involving a total of 144 women that compared 50 μg of oral misoprostol every 4 hours versus expectant management followed by PGE₂ gel showed a higher incidence of vaginal birth with misoprostol (pooled risk ratio 1.33, 95% confidence interval 1.10–1.61).ConclusionOral misoprostol appears to be a safe and effective for IOL in TPROM. However, the varying administration, dose, and frequency reported in the literature highlights the need to develop a standardized protocol for use in Canadian obstetrical practice.     

High-Flow Nasal Cannulae for Respiratory Support of Preterm Infants: A Review of the Evidence

Background: High-flow nasal cannulae (HFNC) are gaining in popularity as a form of non-invasive respiratory support for preterm infants in neonatal intensive care units around the world. They are proposed as an alternative to nasal continuous positive airway pressure (NCPAP) in a variety of clinical situations, including post-extubation support, primary therapy from birth and 'weaning' from NCPAP. Objectives: To present and discuss the available evidence for the use of HFNC in the preterm population. Methods: An internet-based literature search for relevant, original research articles (both randomised studies and not) on the use of HFNC in preterm infants was undertaken. Results: A total of 19 studies were included in the review. Distending pressure generated by HFNC in preterm infants increases with increasing flow rate and decreasing infant size and varies according to the amount of leak around the prongs. HFNC may be as effective as NCPAP at improving respiratory parameters such as tidal volume and work of breathing in preterm infants, but probably only at flow rates >2 litres/min. The efficacy and safety of HFNC in preterm infants remain to be determined. Conclusions: There is growing evidence of the feasibility of HFNC as an alternative to other forms of non-invasive ventilation in preterm infants. However, there remains uncertainty about the efficacy and safety of HFNC in this population. Until the results of larger randomised trials are known, widespread use of HFNC to treat preterm infants cannot be recommended.     

A Canadian,Multicentre Study Comparing the Efficacy of a Levonorgestrel-releasing Intrauterine System to an Oral Contraceptive in Women With Idiopathic Menorrhagia

ObjectivesTo evaluate the efficacy of a levonorgestrel-releasing intrauterine system (LNG-IUS) compared with a combined oral contraceptive containing 1 mg norethindrone acetate and 20 μg ethinyl estradiol (OC1/20) in reducing menstrual blood loss (MBL) in women with idiopathic menorrhagia.MethodsA prospective, randomized, open-label study was conducted in nine centres in Canada. Healthy women over 30 years of age suffering from idiopathic menorrhagia were treated either with LNG-IUS (n = 20) or with OC1/20 (n = 19) over 12 months. The primary endpoint was the change in MBL from baseline to 12 months. Secondary endpoints included treatment success (defined as a MBL score < 100 after 12 months), hemoglobin levels, and the menorrhagia severity score.ResultsIn both treatment groups, MBL decreased significantly from baseline to 12 months (P < 0.001). For the primary endpoint, the MBL score decreased significantly more in the LNG-IUS group (median from 228 to 13, mean percent change–83%) compared to the OC1/20 group (median from 290 to 72; mean percent change–68%) (P = 0.002) after 12 months.In the LNG-IUS group, 80% of subjects had treatment success compared with 36.8 % in the OC1/20 group (P < 0.009).Both treatments increased hemoglobin concentrations significantly between baseline and 12 months. The menorrhagia severity score was consistently lower in the LNG-IUS group at all study time points and was significantly lower (P = 0.045) at six months. Both treatments were well tolerated.ConclusionBoth the LNG-IUS and the combined oral contraceptive effectively decreased menstrual blood loss in women with idiopathic menorrhagia. The overall clinical benefit was more pronounced with LNG-IUS than with OC1/20.     

Video Hysteroscopy in the Diagnosis of Molar Pregnancy in two Challenging Situations: Complete Mole with Normal hCG and Partial Mole with Early Gestational Age

Study ObjectiveTo present the first hysteroscopic findings of 2 cases of complete hydatidiform mole (CHM) and partial hydatidiform mole (PHM) within the context of the patients’ clinical histories.DesignPresentation of 2 hysteroscopic videos with narration of the intrauterine findings of molar pregnancy (MP) from Rio de Janeiro Gestational Trophoblastic Disease Reference Center.SettingMP is characterized by abnormal fertilization that generates 2 clinical syndromes: CHM and PHM [1].InterventionsIn the first case, the patient was aged 50 years, and hysteroscopy was indicated to assess abnormal uterine bleeding in the presence of normal serum human chorionic gonadotropin (hCG) and transvaginal ultrassonography showing an endometrial cavity with heterogeneous content. Hysteroscopy found translucent hydropic structures diagnosed as CHM. The negative hCG value was due to the hook effect (hCG after dilution: 2 240 000 IU/L). In the second case, an 18-year-old patient underwent hysteroscopy to assess the endometrial cavity with retained abortion at 7 weeks in which, during conservative management, the hCG level increased over 4 weeks from 25 000 IU/L to 58 000 IU/L. Hysteroscopy visualized the embryo with its umbilical cord and hydatidiform vesicles diagnosed as PHM.ConclusionMP can be an incidental finding during hysteroscopy for abnormal uterine bleeding or retained abortion 2, 3, 4. Knowing its morphology during hysteroscopy is helpful for the correct management of this uncommon clinical situation. Hysteroscopy as an adjunct diagnostic tool (not as first-line treatment for MP) can be of significant benefit in challenging clinical scenarios. Further studies should assess the possible risk of spreading molar cells into the peritoneal cavity owing to hysteroscopic fluid.     

The Role of the Mirena Intrauterine Device in the Management of Endometrial Polyps: A Pilot Study

Study ObjectiveTo study the hypothesis that the levonorgestrel intrauterine device (LNG-IUD) can have a role in the treatment of endometrial polyps confirmed at outpatient hysteroscopy in premenopausal women.DesignCanadian Task Force classification level II1 (a controlled trial that is not randomised).SettingOutpatient hysteroscopy.PatientsPremenopausal women who had a polyp diagnosed at outpatient hysteroscopy.InterventionsPremenopausal women who had a polyp diagnosed at outpatient hysteroscopy and had a LNG-IUD inserted were booked for general anesthesia hysteroscopy and polypectomy through the standard booking process. A contemporaneous control was taken sequentially from the outpatient hysteroscopy database to match the case.Measurements and Main ResultsThe presence of a polyp at hysteroscopy under general anesthesia. A total of 39 patients were included in the study, with 19 in the intervention group and 20 in the control group. The mean age was 43.6 (standard deviation = 5.6) and 43.2 (standard deviation = 8.1) years in the 2 groups, respectively. No difference was found in the time interval between the 2 procedures in the intervention and control groups (mean = 92 vs 84 days, p = .73). However, the proportion of polyps present at the second procedure was significantly higher in the control group (80% vs 37%; relative risk = 2.17; 95% confidence interval, 1.16–4.07; p = .0062).ConclusionOur case-control study found that the LNG-IUD can have a role in the treatment of polyps for women who have heavy menstrual bleeding. This is the first study to show regression of endometrial polyps after treatment with LNG-IUD by direct visualisation at hysteroscopy.