Predictive factors for premature birth and respiratory exacerbation in pregnancies of women with cystic fibrosis

ObjectiveIn this present study, the authors evaluated the predictive factors for adverse maternal-fetal outcomes in pregnancies of women with cystic fibrosis (CF). Patients were followed up by a referral center for adults in southern Brazil.MethodsThis is a retrospective cohort study that used data from electronic medical records regarding pregnancies of women diagnosed with CF.ResultsThe study included 39 pregnancies related to 20 different women. The main adverse outcomes were high prevalence rates of premature birth (38.5%) and maternal respiratory exacerbation (84.6%). Lower body mass index (BMI) values (< 20.8) and younger ages of CF diagnosis increased the risk of premature birth. The presence of methicillin-resistant and absence of methicillin-sensitive Staphylococcus aureus, as well as a younger age of diagnosis, increased the risk of maternal respiratory exacerbation during pregnancy.ConclusionsConception in women with CF is often associated with maternal and fetal complications. Continuous monitoring by a multidisciplinary team should emphasize appropriate nutritional status, investigation of bacterial colonization, and immediate attention to respiratory exacerbations.     

ICMR Task Force National Collaborative Study on Identification of High Risk Families, Mothers and Outcome of their Off-springs with particular reference to the problem of maternal nutrition, low birth weight, perinatal and infant morbidity and mortality in rural and urban slum communities. Summary, conclusions and recommendations.

The objectives was to assess the determinants of and rates of abortion, stillbirth, and infant mortality for a cohort of pregnant women from slums in New Delhi, Calcutta, and Madras, India and rural slums in Hyderabad, Varanasi, and Chandigarh, India in 1981. The relationship of low birthweight (LBW) and high risk pregnancies to social, environmental, nutritional, cultural, and biological factors was of interest. The results showed variation both between and within urban and rural areas. Rural pregnancy outcome showed fewer LBWs and perinatal and neonatal mortality. Perinatal, neonatal, and infant mortality rates were consistent with prior findings. There was a demonstrated need for prenatal care and referral due to the 10-12% with a poor obstetric history and the significant number with anemia, bleeding, hypertension, toxemia, and urinary tract infections during this pregnancy. Many women were malnourished (body weight 40 kg, height 145 cm, and midarm circumference of 22.5 cm. These women can be identified as high risk. Other risk factors identified were women with disadvantageous personal habits: smoking, alcohol use, tobacco chewing, and working. 10-25% of pregnancies were not registered even though the prenatal clinic was accessible and outreach was provided. 20% completed the recommended number of prenatal visits. 75-85% visited at least once and sometimes more often. Screening for high risk must be done at the 1st visit. Women had strong feelings about the preference for a Dai during delivery and for place of delivery. Poor training of health workers was reflected in the lack of adequate sanitation during the birthing process. Neonatal units were lacking and primary care absent. 10-14% of births were preterm of which 50% occurred at 36 weeks. Multiple regression identified risk factors for fetal and neonatal mortality and LBW as maternal age, preterm birth, maternal anemia, previous preterm or LBW, birth interval, and previous fetal and neonatal mortality. Recommendations are for improving sanitation, hygiene, and water supplies, promoting community awareness of the adverse effects of early marriage and close birth spacing, improving the delivery of health care, allocating health resources based on morality rates, using an intersectoral approach for dealing with the complex social and personal habits adversely affecting childbearing and 7 other suggestions. Existing services and their use are inadequate.     

Fetal macrosomia--a continuing obstetric challenge

BACKGROUND: Macrosomic fetuses represent a continuing challenge in obstetrics. OBJECTIVES: We studied maternal risk factors of fetal macrosomia and maternal and infant outcome in such cases. METHODS: A retrospective cohort study was carried out with a total of 26,961 singleton pregnancies between 1989 and 2001. Records of 886 mothers who gave birth to live born infants weighing > or =4,500 g were compared to those of 26,075 mothers with normal weight (<4,500 g) infants. Multiple regression analysis was used to identify independent reproductive risk factors. Perinatal complications were also assessed. RESULTS: The incidence of fetal macrosomia was 3.4%. Diabetes, previous macrosomic birth, postdatism (>42 weeks of gestation), obesity (BMI > 25 before pregnancy), male infant, gestational diabetes mellitus, and non-smoking were independent risk factors of fetal macrosomia, with adjusted risks of 4.6, 3.1, 3.1, 2.0, 1.9, 1.6, 1.4, respectively. In the macrosomic group, birth and maternal traumas occurred significantly more often than in the control group. However, records of subsequent pregnancies (n = 250) after the study period showed that a previous uncomplicated birth appeared to decrease complication risks. CONCLUSIONS: Most cases of fetal macrosomia occur in low-risk pregnancies and evaluation of maternal risks cannot accurately predict which women will eventually give birth to an overweight newborn. After an uncomplicated birth of a macrosomic infant, vaginal delivery may be a safe option for the infant and mother.     

Complex multigestational anomalies

The increase in multiple gestation pregnancies has resulted in significant health care implications for both mother and child. Our ability to diagnose and intervene on an at-risk multi-gestation pregnancy has dramatically improved. It is important for the pediatric surgeon to be equipped with a basic fund of knowledge concerning these pregnancies. An understanding of amnionicity and chorionicity will equip the practitioner with the ability to identify which pregnancies are at risk for specific complications. This article highlights multi-gestation pregnancies that are monochorionic (single shared placenta) and can be complicated by twin-twin transfusion syndrome (TTTS), twin reversed arterial perfusion (TRAP) sequence, twin anemia polycythemia sequence (TAPS), or selective fetal intrauterine growth restriction (sIUGR). The risk of fetal demise is significant in these pregnancies. Understanding recommended surveillance and warning signs can alert surgeons to developing complications. Specialized fetal care centers possess the ability to intervene on these pregnancies in utero.     

The uterine artery blood flow velocity waveform in pathological pregnancy

Uterine artery blood flow velocity waveforms (FVW) were recorded longitudinally in 41 women with undisturbed pregnancy as well as in 32 women with complicated pregnancy at 4-week intervals from a gestational age of 18 weeks onwards. Of these women, four did not complete the study. In a second group of 76 patients at least one FVW was recorded after admission to the obstetrical department because of complicated pregnancy. The Pulsatility-Index (PI) for normal pregnancy was based on the results of the 41 women with undisturbed pregnancy (Mulders et al. (1988) Early Hum. Dev., 17, 55–70). The complete study group (n = 145) was divided in two groups, based on the value of the last measured uterine artery PI before delivery; in the abnormal PI group (PI ⩾ 1.02 before 32 weeks or PI ⩾, 0.91 after 32 weeks, n = 38) hypertension, fetal distress during pregnancy, premature delivery, small for gestational age babies (SGA) and lower placental weight were all significantly increased. In each of the groups of patients with either SGA, fetal distress during pregnancy, pre-existing hypertension with proteinuria and pregnancy-induced hypertension with or without proteinuria the mean PI was significantly increased as compared to the results in normal pregnancy. Sensitivity and specificity of the last uterine artery PI for the detection of SGA and/or fetal distress during pregnancy were 48.8% and 82.7%, respectively. The longitudinally studied women (n = 73) were divided in two groups, based on uterine artery PI before 32 weeks of gestation; in the abnormal PI group (PI ⩾1.02, n = 12) pregnancy was more complicated by premature delivery and low birth weight. Sensitivity for the early prediction of pathological pregnancies (at least one pathological phenomenon as mentioned above) was 30.4%, whereas specificity was 90.0%.     

Knowledge, attitudes and behaviors related to sexuality and family planning in adolescent women with and without diabetes

BACKGROUND: Sexually active adolescents with diabetes are at high risk for unplanned pregnancies and reproductive complications. OBJECTIVE: Knowledge, attitudes, intentions, and behaviors regarding diabetes and reproductive issues, sexuality, and contraception were examined in teens with diabetes in relation to a non-diabetic group. METHODS: A multisite, case-control, theory-based structured telephone interview was conducted on adolescent women: 80 with diabetes mellitus (DM) and 37 matched controls without diabetes (non-DM). RESULTS: Teens with diabetes appeared to lack an understanding of critical information that could prevent unplanned pregnancies and pregnancy-related complications. Although they scored significantly higher than the non-DM group on diabetes-related information, the DM group had their lowest mean average of 59% for the diabetes and pregnancy score. They did not appear to have greater protective attitudes regarding reproductive health issues than the non-DM group. The DM group felt that they were only moderately susceptible to becoming pregnant and that severe complications would not happen to them. The DM group perceived greater severity to sex-related outcomes (p = 0.001). The DM group did not report safer and more effective family planning behaviors (mean age coitus = 15.7 yr), which for them could be more detrimental. Similar trends were noted between groups regarding contraceptive methods; only a single method (e.g., pill only) rather than a dual method (e.g., pill and condom) was most frequently used. CONCLUSION: Having diabetes did not appear to significantly decrease the risk-taking behavior of the teens. Early and some unsafe sexual practices may increase their risk for an unplanned pregnancy that could result in pregnancy-related complications. Enhancing awareness, knowledge, and attitudes through preconception counseling and reproductive health education may reduce these risks by empowering young women to plan healthy future pregnancies.     

A Comparison of Fetal Echocardiography in University and Health Maintenance Organization Settings

Fetal echocardiographic findings, and decisions to continue or to terminate affected pregnancies, may differ between university (UNIV) and health maintenance organization (HMO) settings. The aim of this study was to review the fetal echocardiographic experience at a combined university/health maintenance organization program over a 4-year period. Imaging and counseling for affected pregnancies were provided by the same, single investigator at both sites. Out of a total of 1382 studies (940 UNIV, 442 HMO), 127 abnormals were identified (94 UNIV, 33 HMO). Among the 127 pregnancies with fetal heart disease, 24 (19%) underwent elective termination, 16% at UNIV and 27% at HMO (p= 0.2). Mean gestational age at the time of diagnosis was 25.2 weeks at UNIV compared with 22.3 weeks at HMO (p= 0.002). At UNIV, only 51% of diagnoses were made before 24 weeks compared with 79% at HMO (p= 0.003). Screening fetal sonograms, performed between 18 and 20 weeks on every pregnancy at HMO but not at UNIV, enabled earlier detection of congenital heart disease (CHD) and allowed more women with severely affected pregnancies the option to terminate. In both settings, indications with the highest yields for CHD included a right-sided stomach, abnormal four-chamber view, sustained bradycardia, abnormal fetal karyotype, fetal omphalocele, and maternal indomethacin. An echogenic reflector was identified in 86 pregnancies (7%) and did not represent a risk factor for CHD. No major differences in CHD were found between UNIV and HMO. In summary, this study found a significantly earlier diagnosis of CHD at HMO than at UNIV. This discrepancy between programs may explain, at least in part, the trend toward a higher frequency of decisions to terminate affected pregnancies at HMO than at UNIV, despite similar fetal findings.     

Cystic fibrosis and pregnancy. Current results of a study (1980-1990)

This study is a recent collection of data on 19 women with cystic fibrosis who became pregnant between 1980 and 1990. The following data have been recorded:--age at diagnosis, progress of disease prior and during pregnancy, and during confinement. Satisfactory clinical score values and the fact that the mean age at diagnosis was 10.5 years indicated a less serious nature of the disease in the group studied. Pregnancy was complicated by pulmonary exacerbations and by poor weight gain in two thirds of cases. No maternal deaths during pregnancy and delivery were recorded. Abortions were induced in two pregnancies. More than one third of newborns were premature. It is noteworthy that of the 22 infants 16 were male. All of the children had negative sweat chloride tests. Eleven women could breast feed successfully. In twelve cases the mother's state of health deteriorated after pregnancy, and did not return to that before gravidity.     

Pregnancy outcomes in mothers of offspring with inherited bone marrow failure syndromes

1 Background

Children with inherited bone marrow failure syndromes (IBMFSs) may be symptomatic in utero, resulting in maternal and fetal problems during the pregnancy. Subsequent pregnancies by their mothers should be considered “high risk”.

2 Methods

We retrospectively analyzed outcomes of 575 pregnancies in 165 unaffected mothers of offspring with Fanconi anemia (FA), dyskeratosis congenita (DC), Diamond–Blackfan anemia (DBA), and Shwachman–Diamond syndrome (SDS) for events noted during pregnancy, labor, and delivery. We compared outcomes of pregnancies with affected and unaffected offspring within each group of mothers and with the general population.

3 Results

The rates of miscarriage (12–20%), elective abortion (5–10%), and live birth (68–78%) among mothers of all IBMFS groups were similar and comparable with general population rates but recurrent miscarriages (≥2) were significantly more common in mothers of offspring with DBA and SDS. Offspring with FA were more frequently born small for gestational age (SGA) than unaffected babies (39% vs. 4%) and had fetal malformations (46%) with 18% having three or more, often necessitating early delivery and surgery; offspring with DC had higher rates of SGA (39% vs. 8%) and fetal distress (26% vs. 3%); and offspring with DBA had fetal hypoxia (19% vs. 1%) leading to preterm and emergency cesarean deliveries (26% vs. 6%). Offspring with early‐onset severe phenotypes had the most prenatal and peripartum adverse events.

4 Conclusion

We identified the high‐risk nature of pregnancies in mothers with IBMFS‐affected fetuses, suggesting the need for prepregnancy counseling and monitoring of subsequent pregnancies by high‐risk fetal–maternal specialists.     

Substance use in pregnancy: do we care?

Two cohorts of substance-using women were compared retrospectively. From 1969 to 1979 a very high perinatal mortality rate (PMR 9.8%) was found among 92 polydrug-using women (1 twin excluded). Preterm delivery occurred in 25% of all pregnancies and in 30% of the children birth weight was below the 10th percentile. Nineteen women using heroin only had a worse fetal outcome (PMR 32%, preterm delivery in 47%, birth weight < 10th percentile in 42%). These results led to a strict surveillance system. In the period 1980–1989, 240 women (4 twins excluded) delivered after 16 weeks. Total fetal loss decreased to 2.1% and PMR to 0.4%, which was similar to results in controls. However, 22% of the women still delivered before 37 weeks and 27% delivered a child < 10th percentile. Methadone-using women were able to halve their dosage during pregnancy and 16 were detoxified. Multivariate analysis within the substance users of the second cohort showed that the neonatal abstinence syndrome, but not the (registered) amount of opiates used, was related to a lower birth weight. Not coping with prenatal care was related to a shorter pregnancy length. Multivariate analysis, including the controls, showed a significant relation of birth weight (345 g lower) with substance use. Also, head circumference was 0.8 cm smaller. Length of pregnancy however was related to smoking. This study shows that it is difficult to make substance users attend prenatal care, but also that women coping with prenatal care reduce substance intake. Opiate use might be responsible for lower birth weight, although not in a clear dose–response relationship, whereas lifestyle, as represented by not coping with prenatal care and the quantity of cigarette smoking, shortens the length of pregnancy.     

Measles as a cause of fetal defects. A retrospective study of tem measles epidemics in Greenland

In a retrospective study of ten epidemics of measles in virgin-soil populations in Greenland, 368 women were found to be pregnant at the time of their infection with measles. Information on the course of the pregnancies was obtained in 327 of these women and a clinical examination was made of 252 of their children. The risk of fetal death among women infected in the first trimester was found to be high. About half of 20 women infected during their first two months of pregnancy and a fifth of 31 women infected in the third month had abortions. 9% of 64 women infected in the first trimester and going to term had stillbirths. 28 women infected in the first two months of pregnancy had live children, but four of these had congenital malformations, three of extreme rarity and severity, leading to death. The rate of perinatal mortality and prematurity was equal among infants exposed to measles in the first, second and third trimester of fetal life.     

MEASLES AS A CAUSE OF FETAL DEFECTS A Retrospective Study of Ten Measles Epidemics in Greenland

Abstract. In a retrospective study of ten epidemics of measles in virgin-soil populations in Greenland, 368 women were found to be pregnant at the time of their infection with measles. Information on the course of the pregnancies was obtained in 327 of these women and a clinical examination was made of 252 of their children. The risk of fetal death among women infected in the first trimester was found to be high. About half of 20 women infected during their first two months of pregnancy and a fifth of 31 women infected in the third month had abortions. 9% of 64 women infected in the first trimester and going to term had stillbirths. 28 women infected in the first two months of pregnancy had live children, but four of these had congenital malformations, three of extreme rarity and severity, leading to death. The rate of perinatal mortality and prematurity was equal among infants exposed to measles in the first, second and third trimester of fetal life.     

Ovarian function and in vitro fertilization (IVF) in Turner syndrome

Normal numbers of oocytes and ovarian follicles develop to the ovaries during the first half of the fetal life. The oocytes then start gradually disappearing. Abnormal meiotic division due to the lack of a paring X-chromosome has been suggested as the causative factor. A large proportion, 40-50% of Turner girls have at least some pubertal development, and about 10% may undergo menarche. Ovarian follicles have been found in some 40% of teenagers with Turner syndrome. Serum concentrations of antimullerian hormone (AMH) and follicle stimulation hormone (FSH), karyotype with mosaicism or structural chromosomal abnormalities, and spontaneous onset of pubertal development are positive prognostic signs for the presence of oocytes and ovarian function. Spontaneous pregnancies occur in some 2-10% of Turner women, a higher number than estimated earlier. This is probably due to failed identification of the syndrome among Turner women with ovarian function. Premature ovarian failure (POF) at some age can be expected in most of Turner women. FSH-stimulated oocyte retrieval and IVF can be carried out before predicted POF. Counseling not to postpone childbearing unnecessarily is advisable. Collected oocytes can be cryopreserved using vitrification, and stored until a pregnancy is desired. Large number of primordial oocytes within ovarian follicles can be stored in within superficial biopsied pieces of ovarian cortical tissue, for transplantation back to the ovary later on. Oocyte donation is an effective infertility treatment for Turner women who have undergone POF. Adequate hormonal replacement therapy (HRT) before IVF is necessary. Only one embryo at a time should be transferred particularly to these women in order to avoid pregnancy complications. Pregnancies in Turner syndrome women have high risks. Comprehensive health control including MRI of the aorta is recommended already before a planned pregnancy, and aorta has to be followed up by echography at least twice during the pregnancy to evaluate the risk of aortic dissection. Some 30% of Turner women develop hypertension during pregnancy, but this is also common among all oocyte donation pregnancies.     

Intrauterine growth correlation to postnatal growth — influence of risk factors and complications in pregnancy

In a population of 616 pregnant women with increased risk of intrauterine growth retardation, we examined the relationship of third trimester fetal growth to maternal and pregnancy risk factors, the infants condition at birth, and postnatal growth. Intrauterine growth velocity was calculated from repeated estimations of fetal weight using ultrasound. Postnatal growth up to 3 months was measured in 313 of the infants. Intrauterine growth velocity was directly correlated to birth weight deviation (R = 0.35, P < 0.0001) and inversely correlated to postnatal growth (R = 0.21, P = 0.0001). Heavy smoking throughout pregnancy was the most pronounced factor associated with loss of fetal growth percentiles (P = 0.006), and it was also associated with postnatal catchup (P = 0.01). Infants who needed neonatal care had significantly lower intrauterine growth velocities compared to the rest of the study group; no correlation was found between intrauterine growth velocity and Apgar scores or umbilical pH. It is concluded that growth retardation in the third trimester can be identified by ultrasound fetometry, and is associated with maladaptation at birth and postnatal catchup. However, the correlations were weak suggesting that deviation at birth reflects, only to a limited degree, acceleration or deceleration of growth in the third trimester.     

Hemoglobin A1c in Pregestational Diabetic Gravidas and the Risk of Congenital Heart Disease in the Fetus

This study aimed to determine whether poor glycemic control in early pregnancy is associated with an increased risk of congenital heart disease (CHD) for infants of women with preexisting diabetes. A retrospective review examined two tertiary care centers of diabetic pregnancies that recorded early hemoglobin A1c (HbA1c) values (<20 weeks). The incidence of prenatally diagnosed CHD was calculated and stratified by HbA1c level. Poor glycemic control was defined as an HbA1c level of 8.5 % or higher. Fetal echocardiography was used to identify fetuses that resulted in infants with suspected CHD. Neonatal echocardiograms and pathology reports were reviewed for confirmation of the diagnosis. Of 535 patients, 30 (5.6 %) delivered an infant with confirmed CHD. Among the patients with poor glycemic control, 8.3 % (n = 17) delivered an infant with CHD, whereas 3.9 % (n = 13) of those with an HbA1c level lower than 8.5 % delivered an infant with CHD (p = 0.03). Poor glycemic control in early pregnancy is associated with an increased risk of CHD in offspring. The incidence of CHD in patients with adequate glycemic control still is sufficiently high to justify routine fetal echocardiography for all gravidas with preexisting diabetes regardless of HbA1c level.     

Paediatric and ophthalmologic observations in offspring of alcohol abusing mothers

The offspring of nine women who had abused alcohol and drugs during pregnancy were studied. Of the 30 children, 10 had fetal alcohol syndrome (FAS) or fetal alcohol effects (FAE). Ophthalmological impairments associated with FAS—impaired vision, optic nerve hypoplasia, cataract, increased tortuosity of retinal vessels—were common. The severity of teratogenic lesions varied among the children and was often related to the level of abuse during pregnancy. Most women were unable to take care of their children during periods of substance abuse. All children with FAS/FAE had learning difficulties. Four mothers abstained from alcohol or drugs during some of their pregnancies and gave birth to children without birth defects.     

Seasonal variations in coitus and other risk factors,and the outcome of pregnancy

Data were analyzed from 36, 068 U.S. pregnancies to determine whether any of the more frequent maternal risk factors are associated with seasonal variations in perinatal mortality rates. These mortality rates decreased below the yearly mean in January and rose sharply above the mean during the spring. The perinatal mortality rate in May/June was 30% above the rate in January/February (P<0.001). This and other seasonal variations in perinatal mortality rates closely followed changes in maternal coital activity. The proportion of women having coitus was 26% greater in May/June than in January/February (P<0.001). Seasonal variations in the frequencies of maternal hypertension, acetonuria and low pregnancy weight gain did not correlate with changes in perinatal mortality rates.     

First trimester ultrasound screening for fetal aneuploidy and middle cerebral artery Doppler assessment for fetal alloimmunization

PURPOSE OF REVIEW: Traditional methods of fetal evaluation require invasive procedures (e.g. amniocentesis) with an inherent, albeit low, risk of complications and pregnancy loss. As medical knowledge and ultrasound technology have advanced, noninvasive modes of fetal evaluation have become increasingly used. Two disorders in which this has been most applied are fetal aneuploidy and alloimmunization to red blood cell antigens. RECENT FINDINGS: First-trimester screening protocols for fetal aneuploidy combine ultrasound measurement of the fetal nuchal translucency with the measurement of two maternal serum hormones, free beta-human chorionic gonadotropin and pregnancy-associated plasma protein-A. This combination detects approximately 85% of women pregnant with fetuses with trisomy 21. An increase in the velocity of fetal middle cerebral artery blood flow occurs in the setting of moderate to severe fetal anemia and can be measured with Doppler ultrasound. Middle cerebral artery evaluation is equally sensitive in the prediction of anemia as amniocentesis for bilirubin breakdown products and has less associated risk. It has an additional benefit because it can also be applied to causes of anemia other than hemolysis. SUMMARY: Noninvasive methods of fetal assessment are becoming increasingly commonplace. There has been a dramatic decrease in the use of prenatal diagnostic services as screening strategies have become available. Doppler assessment of the velocity of blood flow through the fetal middle cerebral artery will allow for more judicious application of invasive procedures to pregnancies at significant risk for anemia.