Lethal fetal abnormalities: how to approach perinatal palliative care?

Objective: Some of the antenatally diagnosed fetal pathologies are unlikely to get compatible with life. Still some women choose to continue with pregnancy. Subsequently, perinatal palliative care (PPC) has become a constructive demarche in such situations. Our study, based on a multicentric survey, reports some cases of fetal pathologies considered as lethal according to perinatal professionals and reveals the decisional process in each case.

Methods: We sent by emails a questionnaire to 434 maternal–fetal medicine specialists and fetal care pediatric specialists at 48 multidisciplinary centers for prenatal diagnosis.

Results: The participation rate was 49.3%. In total, 61 obstetric–gynecologists and 68 neonatologists completed the survey. The results showed that 35.4% of the pregnant women asked for the continuation of pregnancy and 24.7% asked for the termination of pregnancy. More than half of professionals (52.9%) took the initiative of informing women about the options for birth support (including PPC), while 32.7% of obstetric gynecologists did not take this initiative versus 10.2% of neonatologists (p Conclusion: This study demonstrates the absolute need to provide PPC training for professionals and to standardize its practices.     

Ignác Semmelweis and the etiology of fetal and neonatal sepsis.

It is well-known that Ignác Semmelweis discovered the etiology and prophylaxis of puerperal sepsis. However, few historians have focused on his understanding of the pathophysiology of fetal and neonatal sepsis. Based on several key observations, Semmelweis realized that puerperal fever (also known as "childbed fever") could be transmitted to the fetus, especially when the first stage of labor was prolonged and multiple examiners performed vaginal examinations while their fingers were contaminated. This insight was particularly valuable in that it helped him decipher the mystery of puerperal sepsis. This paper presents some of these concepts and supporting evidence.     

Mothers' arms--the past and future locus of neonatal care?

With the advent of neonatal intensive care, medical professionals inserted themselves between the baby and its family. Even for healthy newborn, the mother could only get to her infant with permission from the medical staff and then only for limited periods and in a very restricted manner. Family-centered care restored the family's right to full access to their baby, but as generally practiced(and certainly as NICUs are currently designed) medical professionals still view the infant as a solitary individual who sleeps most of the time in a bed. Future NICU design should recognize that the baby must spend most of its time in its mother's arms to get the full benefit of her sensory environment as experienced throughout our evolution. NICUs must therefore be planned to facilitate this extended proximity as much as possible (ie, not just providing for parents at the bedside with the bed as the locus of care, but transforming the preferred and predominant locus of care from the bed to the parents' arms, with the design changes inherent to that concept). Designing our units to facilitate this interaction will not assure that it will always occur, but it will guarantee that we have not created permanent structural features that interfere with this crucial relationship.     

Sertoli–Leydig cell tumor: A rare ovarian neoplasm. Case report and review of literature

Background.?Sertoli–Leydig cell tumor is a gonadal tumor of the sex cord–stromal type. It is a rare tumor comprising 0.1 to 0.5% of all ovarian tumors. Management of these cases poses a difficult therapeutic challenge.

Case.?A 13-year-old girl presented with acute urinary retention, excessive hair growth and deepening of the voice. A mass the size of a 28-week gravid uterus was arising from the pelvis. Serum testosterone level was raised to 145.2 ng/dl. Computed tomography revealed a heterogeneously hypoechoic, solid cystic mass arising from the left adnexa. Left salpingo-oophorectomy was done. A histopathological diagnosis of Sertoli–Leydig cell tumor (intermediate, Meyers type II) was given.

Conclusion.?Patients with Sertoli–Leydig cell tumors present with signs of defeminization followed by masculinization. Age of the patient, stage of the disease and degree of tumor differentiation based on morphology are the most important factors to consider in the management of the case.     

Diagnosis and cause of death in a neonatal intensive care unit – How important is autopsy?

Objectives.?To characterize mortality in a tertiary referral Neonatal Intensive Care Unit (NICU) in Portugal and evaluate the concordance between ante-mortem and post-mortem diagnoses.

Methods.?Retrospective review of the clinical and pathological records of infants who died in five consecutive years was done. Pathological findings and clinical diagnoses were compared and classified according to general concordance and to modified Goldman classification.

Results.?During the referred period, 1938 patients were admitted to the NICU, with a mortality rate of 5.7% (110 patients). The median of age at death was 10.5 days and the most frequent causes of death were congenital malformations and prematurity with its complications. Autopsy was performed in 53 patients resulting in a 48.2% overall autopsy rate. There was complete agreement between pathological and clinical diagnoses in 18 cases (34%) and additional findings were identified in 22 cases; in 13 cases (24.5%), the diagnosis was revised or established by pathology. Five autopsies revealed information relevant for genetic counseling.

Conclusion.?Despite the high agreement rate between clinical and pathological diagnoses, autopsy frequently added important data, including several cases in which it established the diagnosis or provided information relevant for parental counseling regarding future pregnancies.     

Temporal and quantitative associations of electronic fetal heart rate monitoring patterns and neonatal outcomes†

Objective: The objective of this study is to evaluate the associations of electronic fetal heart rate monitoring (EFM) patterns and adverse neonatal outcomes

Study design: From 2013 to 2016; 12,067 term, singleton deliveries in labor ≥2?h with abnormal EFM defined as absent accelerations, variable, late or prolonged decelerations, tachycardia, bradycardia, or minimal variability were analyzed as any documentation during labor, in first hour and last hour of labor. Outcomes were composite neonatal adverse outcomes, neonatal intensive care unit (NICU) admission, neonatal hypoxia, neonatal hypoglycemia, umbilical artery pH, and base excess. Independent associations were ascertained using regression analysis.

Results: Significant independent associations occurred between any abnormal EFM during the last hour and five adverse neonatal outcomes; between abnormal EFM at any time and one adverse neonatal outcome while there was none with the first hour of labor. In the last hour, accelerations had significant negative associations with three adverse neonatal outcomes, while prolonged decelerations, late decelerations, tachycardia, and bradycardia had significant positive associations with three adverse neonatal outcomes. Throughout labor, increasing accelerations events were significantly negatively correlated with all adverse neonatal outcomes, while increasing frequency of late, variable, and prolonged decelerations were positively associated with five adverse neonatal outcomes. Hierarchical analysis showed that bradycardia/tachycardia contributed only 0.8%, while all EFM periodic changes contributed 1%; the addition of the frequencies of abnormal EFM events contributed 0.6% to the variance in umbilical artery pH and base excess.

Conclusions: Terminal EFM patterns are independently associated with neonatal outcomes. Accelerations are protective of adverse neonatal outcomes. Increasing frequency of EFM patterns overtime contributes to neonatal outcome.     

Intrapancreatic rupture of a splenic artery aneurysm during pregnancy – a rare case report with fetal and maternal survival

Rupture of a splenic artery aneurysm (SAA) during pregnancy is a rare and severe condition. A 35-year-old woman at 34 weeks' gestation came to our observation for acute abdominal pain. After being diagnosed with intra-pancreatic SAA rupture, she was delivered of a live fetus by cesarean section. This is a rare case with both fetal and maternal survival.     

Impact of maternal fasting on fetal well-being parameters and fetal–neonatal outcome: a case–control study

Objective: To assess the impact of maternal fasting on fetal well-being parameters and neonatal outcome.

Methods: Two-hundred ten healthy women with singleton uncomplicated pregnancies at 36–40 weeks’ gestation who had fasted for 12–16 h were defined as the study group with 240 healthy non-fasted pregnant women matched for age, parity and gestational age were defined as the control group. Both groups were subjected to tests of fetal well-being in the form of non-stress test (NST), modified biophysical profile and Doppler indices of the umbilical and middle cerebral arteries (MCA). Women were followed-up till delivery to record the obstetric outcome.

Results: There was no significant difference between the two groups regarding the reactivity of NST, modified biophysical scores, Doppler indices of the umbilical and MCA (resistive index, pulsatility index and systolic/diastolic ratio) and the cerebroplacental ratio (p?>?0.05). There was no significant difference between the two groups regarding the gestational age at delivery, mode of delivery, neonatal weight, 5-min Apgar scores and admission to neonatal intensive care unit (p?>?0.05).

Conclusions: Short-term maternal fasting has no deleterious effect on fetal well-being parameters or neonatal outcome. Pregnant women who desire fasting, should be reassured regarding the health of their babies.     

Trends and characteristics of fetal and neonatal mortality due to congenital anomalies,Colombia 1999–2008

Objective: To describe fetal and neonatal mortality due to congenital anomalies in Colombia.

Methods: We analyzed all fetal and neonatal deaths due to a congenital anomaly registered with the Colombian vital statistics system during 1999–2008.

Results: The registry included 213,293 fetal deaths and 7,216,727 live births. Of the live births, 77,738 (1.08%) resulted in neonatal deaths. Congenital anomalies were responsible for 7321 fetal deaths (3.4% of all fetal deaths) and 15,040 neonatal deaths (19.3% of all neonatal deaths). The fetal mortality rate due to congenital anomalies was 9.9 per 10,000 live births and fetal deaths; the neonatal mortality rate due to congenital anomalies was 20.8 per 10,000 live births. Mortality rates due to congenital anomalies remained relatively stable during the study period. The most frequent fatal congenital anomalies were congenital heart defects (32.0%), central nervous system anomalies (15.8%), and chromosomal anomalies (8.0%). Risk factors for fetal and neonatal death included: male or undetermined sex, living in villages or rural areas, mother’s age >35 years, low and very low birthweight, and <28 weeks gestation at birth.

Conclusions: Congenital anomalies are an important cause of fetal and neonatal deaths in Colombia, but many of the anomalies may be preventable or treatable.     

Thirty years of fetal and neonatal physiologic measurements. Have they made a difference?

In looking at fetal and neonatal measurement technology as covered in this issue and as reported in areas not covered in this issue, we need to ask the question: Has this technology made a difference? Unfortunately, the answer is not clear. There are cases where the answer is a solid "yes" and other cases where "maybe" is the best we can say at the present time. There are also a few examples where even though noble attempts have been made, the answer must be "no." What does this mean in terms of what needs to be done? We certainly need to continue the development of new measurement technology and to carry out this development based on sound physiologic and engineering principles. We need to understand better the physical and biologic basis of the measurements that we make and to perform carefully controlled clinical trials of technology before bringing it to the marketplace. Data presentation and archiving is an important issue that, although it is being addressed today, still has future implications as the amount of data increase. Finally, we must not forget the importance of our ultimate goal of helping families to have healthy, happy offspring.     

Placenta increta; conservative management – a successful outcome. Case report and literature review

Placenta increta, a rare complication of pregnancy, is associated with significant postpartum hemorrhage often requiring emergency hysterectomy. We report a case of conservative management, with a combination of parenteral methotrexate, serial ultrasound and Doppler assessment, followed by interval manual removal of placenta.     

Is preeclampsia associated with fetal malformation? A review and report of original research

Objective: To examine fetal malformations in mother–infant pairs with and without pregnancy-related hypertension.

Methods: This was an observational, population-based study of women delivering a singleton at our hospital. Specific fetal malformations identified in women with gestational hypertension or preeclampsia were compared to those without pregnancy-related hypertension. Women with chronic hypertension, superimposed preeclampsia on chronic hypertension and pregestational diabetes were excluded.

Results: Between March 2002 and December 2012, a total of 151 997 women delivered, and 10?492 (7%) had preeclampsia, 4282 (3%) had gestational hypertension and 137?223 (90%) were referent normotensive controls. Women with preeclampsia were significantly more likely to deliver infants with malformations when compared to normotensive controls (2.5% versus 1.6%, p?<?0.001), whereas women with gestational hypertension were not (1.9% versus 1.6%, p?=?0.16). The overall risk for fetal malformation associated with preeclampsia remained significant following logistic regression for age, race, parity and maternal body-habitus (adjusted OR 1.5; 95% CI: 1.3–1.7). Only single-organ system malformations – microcephaly and hypospadias – remained associated with preeclampsia (p?<?0.001), and fetal growth restriction was a co-factor for both.

Conclusions: Preeclampsia was associated with increased rates of fetal malformations when compared to normotensive women – specifically microcephaly and hypospadias. These associations appear predominantly as a consequence of impaired fetal growth.     

The impact of chorionicity and the type of twin growth on the early neonatal outcome in twin pregnancies – 20 years of experience from one tertiary perinatal center

ObjectiveTwin pregnancies are associated with higher neonatal mortality and morbidity. Growth discordance and monochorionicity are among the factors that worsen the course of pregnancy. The study aimed to assess neonatal conditions and mortality in relation to growth type and chorionicity.Materials and methodsData from 820 pregnant women with twin pregnancies and their 1640 newborns were analyzed. The Apgar score and umbilical artery blood pH, as well as the rate of complications, were compared between dichorionic diamniotic (DCDA) and monochorionic diamniotic (MCDA) twins with symmetric and discordant growth. The Student's t-test and the Pearson chi-square test were used for comparisons.ResultsThere were 576 (70.2%) DCDA pregnancies, including 421 (73.1%) with symmetric growth and 155 (26.9%) with discordant growth, and 244 (29.8%) MCDA pregnancies, including 110 (45.1%) with symmetric growth and 134 (54.9%) with discordant growth. A significantly greater percentage of twins with discordant growth occurred in women older than 34 years than in those that were younger. An Apgar score of ≤7 was significantly more common among MCDA discordant twins, while an arterial umbilical blood pH of <7.2 was more common among MCDA twins with symmetric growth. Early neonatal deaths (n = 29; 1.8%), respiratory disorders, and a birth weight of <1500 g were significantly more common in MCDA twins than in DCDA twins.ConclusionMCDA twins with growth discordance are burdened with a higher risk of neonatal morbidity and mortality than symmetric DCDA twins. Chorionicity and growth discordancy are important determinants of the outcome of twin pregnancy.     

Anxiety in the perinatal period: antenatal and postnatal influences and women’s experience of care

Objective: To examine the characteristics of women with antenatal or postnatal anxiety and to investigate aspects of their care that may be associated with it. Background: Positive outcomes following childbirth are associated with good physical and mental health during pregnancy and following childbirth. Although a degree of anxiety is normal in pregnancy, for some women it can become a serious problem. Methods: This study used data on 5332 women from a 2010 national maternity survey which asked about antenatal and postnatal health and well-being three months after childbirth. Women self-identified as experiencing anxiety and other problems during pregnancy and the postnatal period. Results: Antenatal anxiety was reported by 14% of women and postnatal anxiety by 5% of women. Antenatal anxiety was associated with younger age, Black and Minority Ethnic status, single parenthood, living in a disadvantaged area, having an unwanted pregnancy and long-term health problems. Of these factors, only long-term mental health problems were associated with anxiety in the postnatal period. In the logistic regression models long-term mental health problems dominated the findings. Significant differences in the perceptions of the care experienced were evident in the responses from women with anxiety both antenatally and postnatally. Conclusions: This study shows that antenatal and postnatal anxiety are influenced by health and social factors. Asking women about their current physical and psychological health and past history during pregnancy and following up on their well-being in the postnatal period is an essential element in planning and providing care to meet their needs.     

Are maternal and fetal parameters related to perinatal mortality in HELLP syndrome?

Purpose  

We designed this retrospective study to evaluate the association between maternal and fetal parameters and perinatal mortality in hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome.