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Lemieux A, Khalilipalandi S, Lauzon-Schnittka J, Tousignant A, Perreault L, Rego K, Dubois M, Watelle L, Roy LO, Dallaire F. Meta-analysis of risk factors for congenital heart disease - part 2: maternal medication, reproductive technologies, and familial and fetal factors. Can J Cardiol 2024:S0828-282X(24)00949-8. [PMID: 39288833 DOI: 10.1016/j.cjca.2024.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2024] [Revised: 09/09/2024] [Accepted: 09/11/2024] [Indexed: 09/19/2024] Open
Abstract
BACKGROUND The quantitative effects of congenital heart disease (CHD) risk factors are not fully understood. We conducted a meta-analysis of all CHD risk factors. This report explores maternal medication, assisted reproductive technologies (ART), and familial and fetal factors. METHODS Relevant studies were identified using a search strategy encompassing the concepts of CHD and prenatal risk factors with the following inclusion criteria: (1) peer-reviewed articles, (2) quantifying the effects of CHD risk factors, (3) between 1989 and 2022. Pooled odds ratios (OR) and 95% confidence interval (CI) were calculated using a random effect model. RESULTS 131 articles met the inclusion criteria. Associations were found between CHDs and extracardiac anomalies (OR 3.41, 95% CI 1.72-6.77), increased nuchal translucency (OR 6.87, 95% CI 2.42-19.53), family history of CHD (OR 2.90, 95% CI 2.25-3.75), maternal antidepressants (OR 1.23, 95% CI 1.09-1.38) and antihypertensives (OR 2.07, 95% CI 1.80-2.38). A positive association was observed between severe CHDs and lithium, but with a very wide CI encompassing the null effect. A positive association was observed between severe CHDs and ARTs (OR 1.98, 95% CI 1.30-3.02). The data were insufficient for anomalies of the umbilical cord, anticonvulsants and retinoid medication. CONCLUSION There were strong associations between CHDs and increased nuchal translucency, extracardiac anomalies and family history of CHD. Effect sizes were modest for maternal medication and ART. Data was scarce and sometimes inconclusive for some risk factors commonly cited as being associated with CHD, such as lithium, anomalies of the umbilical cord, anticonvulsants, and retinoid medication.
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Affiliation(s)
- Alyssia Lemieux
- Faculty of medicine and health sciences, Université de Sherbrooke, and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Qc, Canada
| | - Sara Khalilipalandi
- Faculty of medicine and health sciences, Université de Sherbrooke, and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Qc, Canada
| | - Jonathan Lauzon-Schnittka
- Faculty of medicine and health sciences, Université de Sherbrooke, and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Qc, Canada
| | - Angélique Tousignant
- Faculty of medicine and health sciences, Université de Sherbrooke, and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Qc, Canada
| | - Laurence Perreault
- Faculty of medicine and health sciences, Université de Sherbrooke, and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Qc, Canada
| | - Kevin Rego
- Faculty of medicine and health sciences, Université de Sherbrooke, and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Qc, Canada
| | - Mélodie Dubois
- Faculty of medicine and health sciences, Université de Sherbrooke, and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Qc, Canada
| | - Laurence Watelle
- Faculty of medicine and health sciences, Université de Sherbrooke, and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Qc, Canada
| | - Louis-Olivier Roy
- Faculty of medicine and health sciences, Université de Sherbrooke, and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Qc, Canada
| | - Frédéric Dallaire
- Faculty of medicine and health sciences, Université de Sherbrooke, and Centre de Recherche du Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Qc, Canada.
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Saxena M, Hungund B. Single umbilical artery and associated birth defects in perinatal autopsies: prenatal diagnosis and management. J Pathol Transl Med 2024; 58:214-218. [PMID: 38973329 PMCID: PMC11424200 DOI: 10.4132/jptm.2024.07.03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Accepted: 06/12/2024] [Indexed: 07/09/2024] Open
Abstract
BACKGROUND The umbilical cord forms the connection between the fetus and the placenta at the feto-maternal interface and normally comprises two umbilical arteries and one umbilical vein. In some cases, only a single umbilical artery (SUA) is present. This study was conducted to evaluate associations between SUA and other congenital malformations discovered in perinatal autopsies and to ascertain the existence of preferential associations between SUA and certain anomalies. METHODS We evaluated records of all fetuses sent for autopsy to the Department of Pathology during the 10-year period from 2013 through 2022 (n = 1,277). The data were obtained from the hospital's pathology laboratory records. The congenital anomalies were grouped by organ or system for analysis and included cardiovascular, urinary tract, nervous system, gastrointestinal tract, musculoskeletal, and lung anomalies. RESULTS A SUA was present in 8.61% of the autopsies. The gestational age of the affected fetuses ranged between 13 to 40 weeks. An SUA presented as an isolated single anomaly in 44 cases (3.4%). Of the 110 SUA cases, 60% had other congenital anomalies. There was a significant association between birth defects and SUAs (p < .001). Strong associations between SUA and urinary tract, lung, and musculoskeletal anomalies were observed. CONCLUSIONS A SUA is usually seen in association with other congenital malformations rather than as an isolated defect. Therefore, examination for associated anomalies when an SUA is detected either antenatally or postnatally is imperative. The findings of this study should be helpful in counseling expectant mothers and their families in cases of SUA.
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Affiliation(s)
- Manushree Saxena
- Department of Pathology, KAHER'S Jawaharlal Nehru Medical College, Belagavi, India
| | - Bhagyashri Hungund
- Department of Pathology, KAHER'S Jawaharlal Nehru Medical College, Belagavi, India
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Thomas MA, Bedard T, Crawford S, Lowry RB. Prenatal findings in 11 cases with craniofacial microsomia using the Alberta Congenital Anomalies Surveillance System, 1997-2019. Am J Med Genet A 2024; 194:e63594. [PMID: 38553895 DOI: 10.1002/ajmg.a.63594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 02/29/2024] [Accepted: 03/04/2024] [Indexed: 07/05/2024]
Abstract
Craniofacial microsomia (CFM) primarily includes specific head and neck anomalies that co-occur more frequently than expected. The anomalies are usually asymmetric and affect craniofacial features; however, there are frequently additional anomalies of variable severity. Published prenatal findings for CFM are limited. This study contributes 11 cases with CFM and their anomalies identified prenatally. Cases born between January 1, 1997 and December 31, 2019 with CFM were abstracted from the Alberta Congenital Anomalies Surveillance System, which is a population-based program ascertaining congenital anomalies for livebirths, stillbirths, and termination of pregnancies for fetal anomalies. There were 11 cases ascertained with prenatal findings including facial anomalies: one each with left cleft lip, right microtia, and bilateral microphthalmia. Two cases had vertebral anomalies. In addition, anomalies of the kidneys, brain, heart, and radial ray were identified. Six (55%) had a single umbilical artery, five (45%) were small for gestational age, and three (27%) were from a twin pregnancy that were discordant for anomalies. Four (36%) overlapped another proposed recurrent constellations of embryonic malformation condition. This study describes prenatal findings for 11 cases with CFM. Comparable to prior published cases, there were recurring anomalies on prenatal imaging, including anomalies of the brain, eye, heart, kidneys, and radial ray, which may aid in the prenatal diagnosis of CFM.
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Affiliation(s)
- Mary Ann Thomas
- Alberta Congenital Anomalies Surveillance System, Alberta Health Services, Calgary, Alberta, Canada
- Department of Pediatrics, University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada
- Department of Medical Genetics, University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tanya Bedard
- Alberta Congenital Anomalies Surveillance System, Alberta Health Services, Calgary, Alberta, Canada
| | - Susan Crawford
- Alberta Perinatal Health Program, Alberta Health Services, Calgary, Alberta, Canada
| | - R Brian Lowry
- Alberta Congenital Anomalies Surveillance System, Alberta Health Services, Calgary, Alberta, Canada
- Department of Pediatrics, University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada
- Department of Medical Genetics, University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Merc MD, Kotnik U, Peterlin B, Lovrecic L. Further exploration of cardiac channelopathy and cardiomyopathy genes in stillbirth. Prenat Diagn 2024; 44:1062-1072. [PMID: 38813989 DOI: 10.1002/pd.6616] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 05/09/2024] [Accepted: 05/20/2024] [Indexed: 05/31/2024]
Abstract
OBJECTIVE To explore genetic variation including whole genome copy number variation and sequence analysis of 98 genes associated with pediatric or adult cardiomyopathies, cardiac channelopathies, and sudden death in an unexplained intrauterine fetal death cohort. METHODS The study population included 55 stillbirth cases that remained unexplained after thorough postmortem examination, excluding maternal, fetal, and placental causes of stillbirth. Molecular karyotyping was performed in 55 cases and the trio exome sequencing approach was applied in 19 cases. RESULTS The analysis revealed six rare variants with predicted effects on protein function in six genes (CASQ2, DSC2, KCNE1, LDB3, MYH6, and SCN5A) previously reported in cases of stillbirth or severe early onset pediatric cardiac related phenotypes. When applying strict American College of Genetics and Genomics classification guidelines, these are still variants of uncertain significance. CONCLUSIONS Several potentially stillbirth-related genetic variants were detected in our cohort, adding to the growing literature on cardiac phenotype gene variation in stillbirth. However, the mechanisms of action, gene-gene interaction, and contribution of the uterine environment are still to be deciphered. In order to advance our knowledge of the genetics of unexplained fetal death, there is an evident need for international collaboration and field standardization.
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Affiliation(s)
- Maja Dolanc Merc
- Division of Gynecology and Obstetrics, Department of Perinatology, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Urška Kotnik
- Clinical Institute for Genomic Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Borut Peterlin
- Clinical Institute for Genomic Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Luca Lovrecic
- Clinical Institute for Genomic Medicine, University Medical Centre Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Jauniaux E, Ebbing C, Oyelese Y, Maymon R, Prefumo F, Bhide A. European association of perinatal medicine (EAPM) position statement: Screening, diagnosis and management of congenital anomalies of the umbilical cord. Eur J Obstet Gynecol Reprod Biol 2024; 298:61-65. [PMID: 38728843 DOI: 10.1016/j.ejogrb.2024.04.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
Congenital anomalies of the umbilical cord are associated with an increased risk of pregnancy and perinatal complications. Some anomalies of the cord have a higher prevalence than other fetal structural anomalies. The most common anomalies are the absence of an umbilical artery and velamentous insertion of the cord (with or without vasa previa). These anomalies, even when not associated with fetal structural defects, increase the risk of adverse perinatal outcome including, fetal growth restriction and stillbirth. In the absence of prenatal diagnosis, vasa previa is associated with the highest perinatal morbidity and mortality of all congenital anomalies of the umbilical cord. Most cases can be detected by ultrasound from the beginning of the second trimester and should be included in the routine mid-pregnancy ultrasound examination. Documentation should include cord insertion site, number of vessels in the cord, and if other pathologies have been detected. Pregnancies at increased risk of velamentous cord insertion should be screened for vasa previa using transvaginal ultrasound and colour Doppler imaging. If a velamentous cord insertion or isolated single umbilical artery is detected, individualised follow-up during pregnancy and tailored obstetric management are indicated.
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Affiliation(s)
- Eric Jauniaux
- EGA Institute for Women's Health, Faculty of Population Health Sciences, University College London (UCL), London, UK.
| | - Cathrine Ebbing
- Department of Obstetrics and Gynecology, Haukeland University Hospital and Department of Clinical Science, University of Bergen, Bergen, Norway, Norway
| | - Yinka Oyelese
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - Rony Maymon
- Department of Obstetrics and Gynecology, The Yitzhak Shamir Medical Center Israel, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Isreal
| | - Federico Prefumo
- Obstetrics and Gynaecology Unit, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | - Amar Bhide
- Fetal Medicine Unit, Department of Obstetrics and Gynecology, St. George's Hospital, UK
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Zhang L, Wu S, Miao X, Li Y, Yuan X, Gao Z. Perforation of Meckel's diverticulum in two neonates with single umbilical artery. WORLD JOURNAL OF PEDIATRIC SURGERY 2024; 7:e000770. [PMID: 38737961 PMCID: PMC11086476 DOI: 10.1136/wjps-2024-000770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/02/2024] [Indexed: 05/14/2024] Open
Affiliation(s)
- Lifeng Zhang
- General Pediatric Surgery, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shannan Wu
- Department of Pediatric Surgery, Yiwu Branch of Children's Hospital, Zhejiang University School of Medicine, Yiwu, China
| | - Xuefeng Miao
- Department of Pediatric Surgery, Yiwu Branch of Children's Hospital, Zhejiang University School of Medicine, Yiwu, China
| | - Yonglin Li
- Department of Pediatric Surgery, Yiwu Branch of Children's Hospital, Zhejiang University School of Medicine, Yiwu, China
| | - Xiaojian Yuan
- Department of Pediatric Surgery, Yiwu Branch of Children's Hospital, Zhejiang University School of Medicine, Yiwu, China
| | - Zhigang Gao
- General Pediatric Surgery, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Yu J, Wu Q, Kong F, Ning Y. Diagnosis of single umbilical artery and risk of foetal congenital malformations by prenatal ultrasound: a retrospective study. BMC Pregnancy Childbirth 2024; 24:193. [PMID: 38475732 DOI: 10.1186/s12884-024-06375-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 02/27/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Single umbilical artery (SUA) is strongly associated with foetal structural abnormalities; however, the exact pattern of this association has not been described. We aimed to investigate the occurrence of malformations in singleton pregnancies with SUA in China and to study the association between the absent side of the umbilical artery and foetal malformations. METHODS This was a retrospective study of singleton pregnancies for which routine first-trimester anatomical screening was performed at 11+ 0-13+ 6 gestational weeks and, if the pregnancy continued, a second-trimester scan was performed at 20+ 0-24+ 0 weeks. Data were extracted from records at the referral centre, the Obstetrics and Gynecology Hospital of Fudan University, between January 2011 and April 2019 (n = 47,894). Using logistic regression, the odds ratios (OR) with 95% confidence intervals (CIs) were calculated for malformations associated with SUA. RESULTS The incidence of SUA in our study was 2.0% (970/47,894). Of all foetuses with SUA, 387 (39.9%) had structural malformations. The malformation type varied, with cardiovascular complications being the most common. A robust association was observed between SUA and oesophageal stenosis or atresia (OR: 25.33), followed by cardiovascular (OR: 9.98-24.02), scoliosis (OR: 18.62), genitourinary (OR: 2.45-15.66), and brain malformations (OR: 4.73-9.12). The absence of the left umbilical artery (n = 445, 45.9%) was consistent with that of the right umbilical artery (n = 431, 44.4%). Furthermore, a significantly higher rate of an absent right than the left umbilical artery (p<0.01) was observed in SUA with foetal abnormalities than in SUA with no malformations. CONCLUSIONS Overall, we observed a higher risk of various specific malformations in foetuses with SUA, and a strong association between SUA and oesophageal stenosis or atresia. The absence of the right umbilical artery was most common in foetuses with SUA and structural malformations. This study provides a reference for ultrasonographers in conducting foetal structural screening for pregnant women with SUA.
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Affiliation(s)
- Junjin Yu
- Department of Obstetrics and Gynecology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Qingqin Wu
- Department of Pharmacy, Dongshan Hospital, Linyi, Shandong, China
| | - Fanbin Kong
- Department of Ultrasound, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.
| | - Yan Ning
- Department of Pathology, Obstetrics and Gynecology Hospital of Fudan University, No. 128, Shenyang Road, Shanghai, 200082, China.
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Pan S, Xu A, Lu X, Chen B, Chen X, Hua Y. Umbilical artery thrombosis risk factors and perinatal outcomes. BMC Pregnancy Childbirth 2024; 24:137. [PMID: 38355469 PMCID: PMC10865511 DOI: 10.1186/s12884-024-06335-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 02/08/2024] [Indexed: 02/16/2024] Open
Abstract
PURPOSE The purpose of this study was to investigate the risk factors for umbilical artery thrombosis (UAT) and the relationship between umbilical artery thrombosis and perinatal outcomes. METHODS This was a retrospective study that enrolled singleton pregnant women who were diagnosed with umbilical artery thrombosis. The control group recruited pregnant woman with three umbilical vessels or those with isolated single umbilical artery (iSUA) who were matched with umbilical artery thrombosis group. The risk factors and perinatal outcomes were compared between the groups. RESULTS Preconception BMI (OR [95%CI]: 1.212 [1.038-1.416]), abnormal umbilical cord insertion (OR [95%CI]: 16.695 [1.333-209.177]) and thrombophilia (OR [95%CI]: 15.840 [1.112-223.699]) were statistically significant risk factors for umbilical artery thrombosis. An elongated prothrombin time (OR [95%CI]: 2.069[1.091-3.924]) was strongly associated with the occurrence of UAT. The risks of cesarean delivery, preterm birth, fetal growth restriction, neonatal asphyxia, and intraamniotic infection were higher in pregnancies with UAT than in pregnancies with three umbilical vessels or isolated single umbilical artery (P<0.05). Additionally, the incidence of thrombophilia was higher in pregnant women with umbilical artery thrombosis than those with isolated single umbilical artery (P = 0.032). Abnormal umbilical cord insertion was also found to be associated with an elevated risk of iSUA (OR [95%CI]: 15.043[1.750-129.334]). CONCLUSIONS Abnormal umbilical cord insertion was the risk factor for both umbilical artery thrombosis and isolated single umbilical artery. The pregnancies with umbilical artery thrombosis had a higher risk of the adverse perinatal outcomes.
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Affiliation(s)
- Shuangjia Pan
- Department of Obstetrics and Gynecology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325027, China
| | - Anjian Xu
- Department of Obstetrics and Gynecology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325027, China
| | - Xinyue Lu
- Department of Obstetrics and Gynecology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325027, China
| | - Baoyi Chen
- Department of Obstetrics and Gynecology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325027, China
| | - Xianjun Chen
- Department of Obstetrics and Gynecology, Taizhou Women and Childrens Hospital of Wenzhou Medical University, Taizhou, 325000, China.
| | - Ying Hua
- Department of Obstetrics and Gynecology, the Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325027, China.
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Heydari MH, Sadeghian A, Khadivi G, Mustafa HJ, Javinani A, Nadjmi N, Khojasteh A. Prevalence, trend, and associated risk factors for cleft lip with/without cleft palate: a national study on live births from 2016 to 2021. BMC Oral Health 2024; 24:36. [PMID: 38185687 PMCID: PMC10771673 DOI: 10.1186/s12903-023-03797-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 12/18/2023] [Indexed: 01/09/2024] Open
Abstract
BACKGROUNDS Cleft lip with or without cleft palate (CL/P) is the most common congenital craniofacial anomaly, including non-syndromic cleft lip with or without cleft palate and cleft palate only. Failure in the fusion of median and lateral nasal processes, the maxillary prominence, and soft tissues around the oral cavity can cause CL/P. Previously, the prevalence has been estimated to be 1 among every 1000 births in 2014 among American neonates and no other reports have been available since. Thus, this study aimed to calculate the prevalence and trend of isolated CL/P among American live births from 2016 to 2021 with its associated risk factors. METHODS AND MATERIALS In this cross-sectional population-based retrospective study, we used live birth data provided by the National Center for Health Statistics (NCHS) from the Center for Disease Control and Prevention (CDC). We calculated the prevalence per 10,000 live births of isolated (non-syndromic) CL/P from 2016 to 2021. To examine risk factors for developing isolated CL/P, we used logistic regression modelling. RESULTS The total prevalence per 10,000 births from 2016 to 2021 was 4.88 (4.79-4.97), for both sexes, and 5.96 (5.82-6.10) for males, and 3.75 (3.64-3.87) for females. The prevalence did not show any consistent linear decreasing or increasing pattern. We found significant association between increased odds of developing isolated CL/P among cases with 20 to 24 year-old mothers (OR = 1.07, 1.01-1.13, p = 0.013), mothers who smoked 11 to 20 cigarettes per day (OR = 1.46, 1.33-1.60, p < 0.001), mothers with extreme obesity (OR = 1.32, 1.21-1.43, p < 0.001), mothers with grade II obesity (OR = 1.32, 1.23-1.42, p < 0.001), mothers with pre-pregnancy hypertension (OR = 1.17, 1.04-1.31, p = 0.009), mothers with pre-pregnancy diabetes mellitus (OR = 1.96, 1.71-2.25, p < 0.001), and mothers who used assisted reproductive technology (OR = 1.40, 1.18-1.66, p < 0.001). CONCLUSIONS Our findings suggest a minuscule increase, albeit insignificant, in the trend of CL/P prevalence from 2016 to 2021. Developing CL/P had greater odds among mothers with pre-pregnancy diabetes, smoking, obesity, and pre-pregnancy hypertension mothers along with mothers who used assisted reproductive technology. Isolated CL/P had the highest prevalence in non-Hispanic Whites, American Indian or Alaskan Native and Native Hawaiian and Other Pacific Islanders.
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Affiliation(s)
- Mohammad-Hossein Heydari
- Department of Oral and Maxillofacial Surgery, Dental Research Center, Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences, Chamran Highway, Velenjak St, Tehran, Iran
- Non-Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Sadeghian
- Department of Oral and Maxillofacial Surgery, Dental Research Center, Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences, Chamran Highway, Velenjak St, Tehran, Iran
| | - Gita Khadivi
- Department of Oral and Maxillofacial Surgery, Dental Research Center, Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences, Chamran Highway, Velenjak St, Tehran, Iran
| | - Hiba J Mustafa
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
- Riley Children's and Indiana University Health Fetal Center, Indianapolis, IN, USA
| | - Ali Javinani
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nasser Nadjmi
- Department of Cranio-Maxillofacial Surgery/University Hospital, Faculty of Medicine & Health Sciences, University of Antwerp, Antwerp, Belgium
| | - Arash Khojasteh
- Department of Oral and Maxillofacial Surgery, Dental Research Center, Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences, Chamran Highway, Velenjak St, Tehran, Iran.
- Dental Research Center, Research Institute of Dental Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
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Solano M AF, García-Perdomo HA. Incidence of congenital heart disease in fetuses diagnosed with single isolated umbilical artery. Systematic review and meta-analysis. Birth Defects Res 2024; 116:e2296. [PMID: 38131119 DOI: 10.1002/bdr2.2296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Revised: 11/20/2023] [Accepted: 12/11/2023] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To estimate the proportion of heart disease in fetuses with a prenatal diagnosis of a single isolated umbilical artery. METHODS We performed a search strategy in MEDLINE (OVID), EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to the present. We assessed the risk of bias and performed a meta-analysis. We completed the subgroup analysis according to the region. RESULTS We found 1384 studies by the search strategy. After carefully reviewing the full-text, 15 studies were included. A total of 2008 fetuses with a single isolated umbilical artery were included, and 177 had cardiac malformations. There was an overall incidence of 9% 95%CI (0.05-0.14) I2 90%. The incidence by country of origin was between 5% and 19%. The most common heart disease reported was a ventricular septal defect. Seven studies were found describing 25 cases. We described other malformations, such as tetralogy of Fallot, coarctation of the aorta, and hypoplastic left ventricle, among others. CONCLUSION The incidence of congenital heart disease in fetuses with a single isolated umbilical artery was high. In addition, half of these correspond to significant heart disease. Based on the above, we suggest that fetuses with a single isolated umbilical artery should have a complete anatomic evaluation emphasizing cardiac evaluation.
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Affiliation(s)
- Armicson Felipe Solano M
- Gynecology and Obstetrics Universidad Libre, Cali, Colombia
- Maternal Fetal Medicine Unit Versalles Clinic and Farallones Clinic, Cali, Colombia
| | - Herney Andrés García-Perdomo
- Division of Urology/Urooncology, Department of Surgery, School of Medicine, Universidad del Valle, Cali, Colombia
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Murlewska J, Witkowski S, Biały Ł, Respondek-Liberska M, Słodki M, Strzelecka I. Cardiac Adaptation and Preferential Streaming in Fetuses with Multiple Nuchal Cords. Diagnostics (Basel) 2023; 14:77. [PMID: 38201386 PMCID: PMC10802835 DOI: 10.3390/diagnostics14010077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 01/12/2024] Open
Abstract
The echocardiographic monitoring of a fetus with multiple nuchal cords around the fetal neck is important as it may result in cardiac remodeling and preferential streaming, thus affecting the condition of the fetus. The main aim of our study was to assess whether the collision of the umbilical cord around the fetal neck can lead to discrepancies in the size of the pulmonary artery and the aorta in the three-vessel view and to an increase in the size of the heart, which may result from the compression of the carotid arteries caused by the umbilical cord wrapping around the fetal neck. A total number of 854 patients were included in this study and divided into three groups. Group A (control group) included 716 fetuses (84%) without the umbilical cord around the fetal neck. Group B (study group B) included 102 fetuses (12%) with one coil of the umbilical cord around the fetal neck. Group C (study group C) included 32 fetuses (4%) with two coils of the umbilical cord around the fetal neck. The range of the gestational age of the patients considered for this study was 27-40.2 weeks based on the ultrasound biometry and was not statistically different between the analyzed groups A, B and C (p > 0.05). The Pa/Ao index was calculated by dividing the value of the width of the pulmonary artery (in mm) to the width of the aorta (in mm) measured in the ultrasound three-vessel view. We found that fetuses that the fetuses with one and two coils of the umbilical cord around the neck showed significantly higher values of the width of the pulmonary trunk with the unchanged value of the aorta width. Therefore, we also observed significantly higher values of the ratio of the pulmonary trunk to the aorta for the fetuses wrapped with the umbilical cord around the neck compared with the control group without the umbilical cord around the neck (. Moreover, in the fetuses with one and two coils of the umbilical cord around the fetal neck, an increased amount of amniotic fluid was observed, whereas larger dimensions of CTAR in the fetuses with two coils of the umbilical cord around the neck were present (p < 0.05). The wrapping of the fetus with the umbilical cord around the fetal neck may induce the redistribution of blood flow, leading to fetal heart enlargement and disproportion and may be the cause of polyhydramnios.
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Affiliation(s)
- Julia Murlewska
- Department of Prenatal Cardiology, Polish Mother’s Memorial Hospital Research Institute, 93-338 Lodz, Poland
| | - Sławomir Witkowski
- Department of Prenatal Cardiology, Polish Mother’s Memorial Hospital Research Institute, 93-338 Lodz, Poland
| | - Łucja Biały
- Department of Prenatal Cardiology, Polish Mother’s Memorial Hospital Research Institute, 93-338 Lodz, Poland
| | - Maria Respondek-Liberska
- Department of Prenatal Cardiology, Polish Mother’s Memorial Hospital Research Institute, 93-338 Lodz, Poland
- Department of Diagnoses and Prevention of Fetal Malformations of Medical, University of Lodz, 90-136 Lodz, Poland
| | - Maciej Słodki
- Department of Prenatal Cardiology, Polish Mother’s Memorial Hospital Research Institute, 93-338 Lodz, Poland
- Collegium Medicum, Masovian University in Plock, 09-402 Plock, Poland
| | - Iwona Strzelecka
- Department of Prenatal Cardiology, Polish Mother’s Memorial Hospital Research Institute, 93-338 Lodz, Poland
- Department of Diagnoses and Prevention of Fetal Malformations of Medical, University of Lodz, 90-136 Lodz, Poland
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12
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Thomas MA, Bedard T, Crawford S, Grevers X, Lowry RB. Craniofacial Microsomia, Associated Congenital Anomalies, and Risk Factors in 63 Cases from the Alberta Congenital Anomalies Surveillance System. J Pediatr 2023; 261:113528. [PMID: 37268037 DOI: 10.1016/j.jpeds.2023.113528] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 04/26/2023] [Accepted: 05/25/2023] [Indexed: 06/04/2023]
Abstract
OBJECTIVE To report associated congenital anomalies with unexplained craniofacial microsomia (CFM) and the phenotypic overlap with other recurrent constellations of embryonic malformations (RCEM), and to assess prenatal and perinatal risk factors. STUDY DESIGN This is a retrospective cross-sectional study. Cases with CFM, delivered between January 1, 1997, and December 31, 2019, were abstracted from the population-based Alberta Congenital Anomalies Surveillance System. Livebirths, stillbirths, and early fetal losses were reviewed to include all types of pregnancy outcomes along the spectrum of this condition. Prenatal and perinatal risk factors were compared with the Alberta birth population to assess differences between the 2 groups. RESULTS There were 63 cases with CFM, yielding a frequency of 1 per 16 949. There was a high rate of cases (65%) with anomalies outside the craniofacial and vertebral regions. Congenital heart defects were the most common (33.3%). A single umbilical artery was found in 12.7% of cases. The twin/triplet rate of 12.7% was significantly higher than the Alberta rate of 3.3% (P < .0001). There was an overlap with a second RCEM condition in 9.5% of cases. CONCLUSIONS Although CFM is primarily a craniofacial condition, the majority of cases have congenital anomalies affecting other systems requiring additional assessments, including an echocardiogram, renal ultrasound examination, and a complete vertebral radiograph. The high rate of an associated single umbilical artery raises the possibility of a related etiological mechanism. Our findings support the proposed concept of RCEM conditions.
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Affiliation(s)
- Mary Ann Thomas
- Alberta Congenital Anomalies Surveillance System, Alberta Health Services, Calgary, Alberta, Canada; Departments of Pediatrics and Medical Genetics, University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada; Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Tanya Bedard
- Alberta Congenital Anomalies Surveillance System, Alberta Health Services, Calgary, Alberta, Canada
| | - Susan Crawford
- Alberta Perinatal Health Program, Alberta Health Services, Calgary, Alberta, Canada
| | - Xin Grevers
- Alberta Congenital Anomalies Surveillance System, Alberta Health Services, Calgary, Alberta, Canada
| | - R Brian Lowry
- Alberta Congenital Anomalies Surveillance System, Alberta Health Services, Calgary, Alberta, Canada; Departments of Pediatrics and Medical Genetics, University of Calgary and Alberta Children's Hospital, Calgary, Alberta, Canada; Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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13
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Josowitz R, Linn R, Rychik J. The Placenta in Congenital Heart Disease: Form, Function and Outcomes. Neoreviews 2023; 24:e569-e582. [PMID: 37653088 DOI: 10.1542/neo.24-9-e569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
Abstract
The maternal-fetal environment, controlled and modulated by the placenta, plays a critical role in the development and well-being of the fetus, with long-term impact through programming of lifelong health. The fetal cardiovascular system and placenta emerge at the same time embryologically, and thus placental form and function are altered in the presence of congenital heart disease (CHD). In this review, we report on what is known about the placenta from a structural and functional perspective when there is CHD. We describe the various unique pathologic findings as well as the diagnostic imaging tools used to characterize placental function in utero. With growing interest in the placenta, a standardized approach to characterizing placental pathology has emerged. Furthermore, application of ultrasonography techniques and magnetic resonance imaging now allow for insights into placental blood flow and functionality in vivo. An improved understanding of the intriguing relationship between the placenta and the fetal cardiovascular system will provide opportunities to develop novel ways to optimize outcomes. Once better understood, therapeutic modulation of placental function offered during the vulnerable period of fetal plasticity may be one of the most impactful ways to alter the course of CHD and its complications.
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Affiliation(s)
- Rebecca Josowitz
- Division of Cardiology, Fetal Heart Program, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Rebecca Linn
- Division of Anatomic Pathology, Department of Pathology and Laboratory Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA
| | - Jack Rychik
- Division of Cardiology, Fetal Heart Program, Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Pediatrics, Perelman School of Medicine at University of Pennsylvania, Philadelphia, PA
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14
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Matsuzaki S, Ueda Y, Matsuzaki S, Sakaguchi H, Kakuda M, Lee M, Takemoto Y, Hayashida H, Maeda M, Kakubari R, Hisa T, Mabuchi S, Kamiura S. Relationship between Abnormal Placenta and Obstetric Outcomes: A Meta-Analysis. Biomedicines 2023; 11:1522. [PMID: 37371617 PMCID: PMC10295197 DOI: 10.3390/biomedicines11061522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/21/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023] Open
Abstract
The placenta has several crucial physiological functions that help maintain a normal pregnancy. Although approximately 2-4% of pregnancies are complicated by abnormal placentas, obstetric outcomes remain understudied. This study aimed to determine the outcomes and prevalence of patients with abnormal placentas by conducting a systematic review of 48 studies published between 1974 and 2022. The cumulative prevalence of circumvallate placenta, succenturiate placenta, multilobed placenta, and placenta membranacea were 1.2%, 1.0%, 0.2%, and 0.004%, respectively. Pregnancies with a circumvallate placenta were associated with an increased rate of emergent cesarean delivery, preterm birth (PTB), and placental abruption compared to those without a circumvallate placenta. The succenturiate lobe of the placenta was associated with a higher rate of emergent cesarean delivery, whereas comparative results were observed in terms of PTB, placental abruption, and placenta previa in comparison to those without a succenturiate lobe of the placenta. A comparator study that examined the outcomes of multilobed placentas found that this data is usually unavailable. Patient-level analysis (n = 15) showed high-rates of abortion (40%), placenta accreta spectrum (40%), and a low term delivery rate (13.3%) in women with placenta membranacea. Although the current evidence is insufficient to draw a robust conclusion, abnormal placentas should be recognized as a high-risk factor for adverse outcomes during pregnancy.
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Affiliation(s)
- Shinya Matsuzaki
- Department of Gynecology, Osaka International Cancer Institute, Osaka 541-8567, Japan
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Yutaka Ueda
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Satoko Matsuzaki
- Department of Obstetrics and Gynecology, Osaka General Medical Center, Osaka 558-8558, Japan
| | - Hitomi Sakaguchi
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Mamoru Kakuda
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, Osaka 565-0871, Japan
| | - Misooja Lee
- Department of Forensic Medicine, School of Medicine, Kindai University, Osaka 589-8511, Japan
| | - Yuki Takemoto
- Department of Gynecology, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Harue Hayashida
- Department of Gynecology, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Michihide Maeda
- Department of Gynecology, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Reisa Kakubari
- Department of Gynecology, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Tsuyoshi Hisa
- Department of Gynecology, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Seiji Mabuchi
- Department of Gynecology, Osaka International Cancer Institute, Osaka 541-8567, Japan
| | - Shoji Kamiura
- Department of Gynecology, Osaka International Cancer Institute, Osaka 541-8567, Japan
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15
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Luke B, Brown MB, Wantman E, Schymura MJ, Browne ML, Fisher SC, Forestieri NE, Rao C, Nichols HB, Yazdy MM, Gershman ST, Sacha CR, Williams M, Ethen MK, Canfield MA, Doody KJ, Eisenberg ML, Baker VL, Williams C, Sutcliffe AG, Richard MA, Lupo PJ. The risks of birth defects and childhood cancer with conception by assisted reproductive technology. Hum Reprod 2022; 37:2672-2689. [PMID: 36112004 PMCID: PMC9960485 DOI: 10.1093/humrep/deac196] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/04/2022] [Indexed: 11/15/2022] Open
Abstract
STUDY QUESTION Is there an association between fertility status, method of conception and the risks of birth defects and childhood cancer? SUMMARY ANSWER The risk of childhood cancer had two independent components: (i) method of conception and (ii) presence, type and number of birth defects. WHAT IS KNOWN ALREADY The rarity of the co-occurrence of birth defects, cancer and ART makes studying their association challenging. Prior studies have indicated that infertility and ART are associated with an increased risk of birth defects or cancer but have been limited by small sample size and inadequate statistical power, failure to adjust for or include plurality, differences in definitions and/or methods of ascertainment, lack of information on ART treatment parameters or study periods spanning decades resulting in a substantial historical bias as ART techniques have improved. STUDY DESIGN, SIZE, DURATION This was a population-based cohort study linking ART cycles reported to the Society for Assisted Reproductive Technology Clinic Outcome Reporting System (SART CORS) from 1 January 2004 to 31 December 2017 that resulted in live births in 2004-2018 in Massachusetts and North Carolina and live births in 2004-2017 in Texas and New York. A 10:1 sample of non-ART births were chosen within the same time period as the ART birth. Non-ART siblings were identified through the ART mother's information. Children from non-ART births were classified as being born to women who conceived with ovulation induction or IUI (OI/IUI) when there was an indication of infertility treatment on the birth certificate, and the woman did not link to the SART CORS; all others were classified as being naturally conceived. PARTICIPANTS/MATERIALS, SETTING, METHODS The study population included 165 125 ART children, 31 524 non-ART siblings, 12 451 children born to OI/IUI-treated women and 1 353 440 naturally conceived children. All study children were linked to their respective State birth defect registries to identify major defects diagnosed within the first year of life. We classified children with major defects as either chromosomal (i.e. presence of a chromosomal defect with or without any other major defect) or nonchromosomal (i.e. presence of a major defect but having no chromosomal defect), or all major defects (chromosomal and nonchromosomal), and calculated rates per 1000 children. Logistic regression models were used to generate adjusted odds ratios (AORs) and 95% CIs of the risk of birth defects by conception group (OI/IUI, non-ART sibling and ART by oocyte source and embryo state) with naturally conceived children as the reference, adjusted for paternal and maternal ages; maternal race and ethnicity, education, BMI, parity, diabetes, hypertension; and for plurality, infant sex and State and year of birth. All study children were also linked to their respective State cancer registries. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% CIs of cancer by birth defect status (including presence of a defect, type and number of defects), and conception group. MAIN RESULTS AND THE ROLE OF CHANCE A total of 29 571 singleton children (2.0%) and 3753 twin children (3.5%) had a major birth defect (chromosomal or nonchromosomal). Children conceived with ART from autologous oocytes had increased risks for nonchromosomal defects, including blastogenesis, cardiovascular, gastrointestinal and, for males only, genitourinary defects, with AORs ranging from 1.22 to 1.85; children in the autologous-fresh group also had increased risks for musculoskeletal (AOR 1.28, 95% CI 1.13, 1.45) and orofacial defects (AOR 1.40, 95% CI 1.17, 1.68). Within the donor oocyte group, the children conceived from fresh embryos did not have increased risks in any birth defect category, whereas children conceived from thawed embryos had increased risks for nonchromosomal defects (AOR 1.20, 95% CI 1.03, 1.40) and blastogenesis defects (AOR 1.74, 95% CI 1.14, 2.65). The risk of cancer was increased among ART children in the autologous-fresh group (HR 1.31, 95% CI 1.08, 1.59) and non-ART siblings (1.34, 95% CI 1.02, 1.76). The risk of leukemia was increased among children in the OI/IUI group (HR 2.15, 95% CI 1.04, 4.47) and non-ART siblings (HR 1.63, 95% CI 1.02, 2.61). The risk of central nervous system tumors was increased among ART children in the autologous-fresh group (HR 1.68, 95% CI 1.14, 2.48), donor-fresh group (HR 2.57, 95% CI 1.04, 6.32) and non-ART siblings (HR 1.84, 95% CI 1.12, 3.03). ART children in the autologous-fresh group were also at increased risk for solid tumors (HR 1.39, 95% CI 1.09, 1.77). A total of 127 children had both major birth defects and cancer, of which 53 children (42%) had leukemia. The risk of cancer had two independent components: (i) method of conception (described above) and (ii) presence, type and number of birth defects. The presence of nonchromosomal defects increased the cancer risk, greater for two or more defects versus one defect, for all cancers and each type evaluated. The presence of chromosomal defects was strongly associated with cancer risk (HR 8.70 for all cancers and HR 21.90 for leukemia), further elevated in the presence of both chromosomal and nonchromosomal defects (HR 21.29 for all cancers, HR 64.83 for leukemia and HR 4.71 for embryonal tumors). Among the 83 946 children born from ART in the USA in 2019 compared to their naturally conceived counterparts, these risks translate into an estimated excess of 761 children with major birth defects, 31 children with cancer and 11 children with both major birth defects and cancer. LIMITATIONS, REASONS FOR CAUTION In the SART CORS database, it was not possible to differentiate method of embryo freezing (slow freezing versus vitrification), and data on ICSI were only available in the fresh embryo ART group. In the OI/IUI group, it was not possible to differentiate type of non-ART treatment utilized, and in both the ART and OI/IUI groups, data were unavailable on duration of infertility. Since OI/IUI is underreported on the birth certificate, some OI/IUI children were likely included among the naturally conceived children, which will decrease the difference between all the groups and the naturally conceived children. WIDER IMPLICATIONS OF THE FINDINGS The use of ART is associated with increased risks of major nonchromosomal birth defects. The presence of birth defects is associated with greater risks for cancer, which adds to the baseline risk in the ART group. Although this study does not show causality, these findings indicate that children conceived with ART, non-ART siblings, and all children with birth defects should be monitored more closely for the subsequent development of cancer. STUDY FUNDING/COMPETING INTEREST(S) This project was supported by grant R01 HD084377 from the National Institute of Child Health and Human Development. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Child Health and Human Development, or the National Institutes of Health, nor any of the State Departments of Health which contributed data. M.L.E. reports consultancy for Ro, Hannah, Dadi, Sandstone and Underdog; presidency of SSMR; and SMRU board member. The remaining authors report no conflict of interest. TRIAL REGISTRATION NUMBER N/A.
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Affiliation(s)
- Barbara Luke
- Department of Obstetrics, Gynecology, and Reproductive Biology, College of Human Medicine, Michigan State University, East Lansing, MI, USA
| | - Morton B Brown
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | | | - Maria J Schymura
- New York State Department of Health, New York State Cancer Registry, Albany, NY, USA
- Department of Epidemiology and Biostatistics, School of Public Health, University of Albany, Rensselaer, NY, USA
| | - Marilyn L Browne
- Department of Epidemiology and Biostatistics, School of Public Health, University of Albany, Rensselaer, NY, USA
- New York State Department of Health, Birth Defects Registry, Albany, NY, USA
| | - Sarah C Fisher
- New York State Department of Health, Birth Defects Registry, Albany, NY, USA
| | - Nina E Forestieri
- North Carolina Department of Health and Human Services, Birth Defects Monitoring Program, State Center for Health Statistics, Raleigh, NC, USA
| | - Chandrika Rao
- North Carolina Central Cancer Registry, Raleigh, NC, USA
| | - Hazel B Nichols
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Mahsa M Yazdy
- Massachusetts Department of Public Health, Massachusetts Center for Birth Defects Research and Prevention, Boston, MA, USA
| | - Susan T Gershman
- Massachusetts Department of Public Health, Massachusetts Cancer Registry, Office of Data Management and Outcomes Assessment, Boston, MA, USA
| | - Caitlin R Sacha
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Melanie Williams
- Texas Department of State Health Services, Cancer Epidemiology and Surveillance Branch, Texas Health and Human Services, Austin, TX, USA
| | - Mary K Ethen
- Texas Department of State Health Services, Birth Defects Epidemiology and Surveillance Branch, Austin, TX, USA
| | - Mark A Canfield
- Texas Department of State Health Services, Birth Defects Epidemiology and Surveillance Branch, Austin, TX, USA
| | | | - Michael L Eisenberg
- Division of Male Reproductive Medicine and Surgery, Department of Urology, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Valerie L Baker
- Division of Reproductive Endocrinology and Infertility, Department of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Carrie Williams
- Policy, Practice, and Population Unit, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Alastair G Sutcliffe
- Policy, Practice, and Population Unit, UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Melissa A Richard
- Department of Pediatrics, Section of Hematology-Oncology, Baylor College of Medicine, Houston, TX, USA
| | - Philip J Lupo
- Department of Pediatrics, Section of Hematology-Oncology, Baylor College of Medicine, Houston, TX, USA
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16
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Wójtowicz A, Madetko-Talowska A, Wójtowicz W, Szewczyk K, Huras H, Bik-Multanowski M. Cardiovascular Anomalies among 1005 Fetuses Referred to Invasive Prenatal Testing-A Comprehensive Cohort Study of Associated Chromosomal Aberrations. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10019. [PMID: 36011653 PMCID: PMC9408756 DOI: 10.3390/ijerph191610019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/06/2022] [Accepted: 08/12/2022] [Indexed: 06/15/2023]
Abstract
This retrospective cohort study comprehensively evaluates cardiovascular anomalies (CVAs) and associated extracardiac structural malformations (ECMs) among 1005 fetuses undergoing invasive prenatal testing at a single tertiary Polish center in the context of chromosomal aberrations detected in them by array comparative genomic hybridization (aCGH) and G-band karyotyping. The results of our study show that CVAs are among the most common malformations detected in fetuses undergoing invasive prenatal testing, as they affected 20% of all cases seen in our department. Septal defects predominated among fetuses with numerical aberrations, while conotruncal defects were the most common findings among fetuses with pathogenic copy number variants (CNVs). In 61% of cases, CVAs were associated with ECMs (the diagnosis was confirmed postnatally or in cases of pregnancy termination by means of autopsy). The most common ECMs were anomalies of the face and neck, followed by skeletal defects. In total, pathogenic chromosomal aberrations were found in 47.5% of CVAs cases, including 38.6% with numerical chromosomal aberrations. Pathogenic CNVs accounted for 14.5% of cases with CVAs and normal karyotype. Thus, our study highlights the importance of assessing the anatomy of the fetus, and of the genetic testing (preferably aCGH) that should be offered in all CVA and ECM cases.
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Affiliation(s)
- Anna Wójtowicz
- Department of Obstetrics & Perinatology, Jagiellonian University Medical College, 31-501 Kraków, Poland
| | - Anna Madetko-Talowska
- Department of Medical Genetics, Jagiellonian University Medical College, 30-663 Kraków, Poland
| | - Wojciech Wójtowicz
- Information Technology Systems Department, Faculty of Management and Social Communication, Jagiellonian University, 30-348 Kraków, Poland
| | - Katarzyna Szewczyk
- Department of Medical Genetics, Jagiellonian University Medical College, 30-663 Kraków, Poland
| | - Hubert Huras
- Department of Obstetrics & Perinatology, Jagiellonian University Medical College, 31-501 Kraków, Poland
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Zymperdikas CF, Zymperdikas VF, Mastorakos G, Grimbizis G, Goulis DG. Assisted reproduction technology outcomes in women with infertility and preexisting diabetes mellitus: a systematic review. Hormones (Athens) 2022; 21:23-31. [PMID: 34668169 DOI: 10.1007/s42000-021-00329-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 10/11/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To assess maternal and neonatal outcomes in women with or without preexisting diabetes mellitus (DM) undergoing assisted reproduction technology (ART) treatment. METHODS Prospective or retrospective controlled trials reporting on women with or without preexisting DM undergoing ART treatment were considered eligible. Twelve electronic databases were systematically searched up to December 2020. The risk of bias was assessed by the Cochrane Risk OF Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. Each primary outcome was extracted and pooled as maternal- or neonatal-related. RESULTS Two studies were included in the systematic review, reporting on both maternal- and neonatal-related parameters after ART treatment. Due to the limited data, no meta-analysis was conducted. Preterm birth, placenta previa, and excessive bleeding during pregnancy were observed more often in pregnancies complicated by preexisting DM conceived by ART compared with pregnancies without DM. There was no difference in the risk for placental abruption between the groups. Regarding the neonatal outcomes, large-for-gestational-age (LGA) embryos and neonatal intensive care unit (NICU) admission were more commonly reported for women with preexisting DM. In one study, preexisting DM was marginally associated with infant mortality. CONCLUSIONS Despite the scarce data, preexisting DM in pregnancies conceived by ART is associated with increased risk for maternal and neonatal complications. TRIAL REGISTRATION Registered in PROSPERO (registration number: 143187).
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Affiliation(s)
- Christos F Zymperdikas
- Unit of Reproductive Endocrinology, 1St Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece.
- 424 General Military Hospital of Thessaloniki, Thessaloniki, Greece.
| | - Vasileios F Zymperdikas
- 424 General Military Hospital of Thessaloniki, Thessaloniki, Greece
- Department of Orthodontics, Faculty of Dentistry, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - George Mastorakos
- 2Nd Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Grigorios Grimbizis
- Unit of Reproductive Endocrinology, 1St Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Dimitrios G Goulis
- Unit of Reproductive Endocrinology, 1St Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
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18
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Wu F, Wang Z, Bi Y, Guo Z, Wang Y. Investigation of the risk factors of anorectal malformations. Birth Defects Res 2021; 114:136-144. [PMID: 34967143 DOI: 10.1002/bdr2.1974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/09/2021] [Accepted: 12/07/2021] [Indexed: 11/06/2022]
Abstract
PURPOSE To investigate the factors that influence the occurrence of anorectal malformations (ARMs). METHODS From December 2018 to December 2019, 136 children treated for ARMs at the Children's Hospital of Chongqing Medical University were included in the case group. The control group consisted of children with intussusception or perianal abscesses. A uniform questionnaire was filled by the parents of the enrolled children. RESULTS The birth weight of the cases was significantly lower than that of the controls (p < .01), and children with ARMs were more likely to be complicated with single umbilical artery (SUA) (p < .001). Maternal upper respiratory tract infection (adjusted odds ratio [ORadj ], 2.44; 95% confidence interval [CI], 1.29-4.63) and urogenital infection (ORadj , 2.67; 95% CI 1.11-6.38) during the first trimester of pregnancy, anemia during pregnancy (ORadj , 5.69; 95% CI, 1.01-32.07), and exposure to hazardous substances 6 months before pregnancy and during the first trimester of pregnancy (ORadj , 13.82; 95% CI, 3.86-49.35) are associated with increased risk of ARMs. Folic acid supplements (ORadj , 0.31; 95% CI, 0.14-0.65) and multivitamin (ORadj , 0.34; 95% CI, 0.15-0.79) had a protective effect on ARMs. Paternal drug use (ORadj , 9.17; 95% CI, 2.19-38.49) 6 months before their wives' conception increased the risk of ARMs. CONCLUSION Maternal infection, anemia during pregnancy, and maternal hazardous substances exposure are possible risk factors for ARMs. Folic acid supplements and multivitamin can reduce the occurrence of ARMs. Meanwhile, paternal drug use may also be a risk factor for ARMs.
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Affiliation(s)
- Fang Wu
- Gastrointestinal and Neonatal Surgery Department, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Zhili Wang
- Gastrointestinal and Neonatal Surgery Department, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yang Bi
- Pediatric Research Institute, Chongqing Key Laboratory of Pediatrics, Stem Cell Biology and Therapy Laboratory, Chongqing, China
| | - Zhenhua Guo
- Gastrointestinal and Neonatal Surgery Department, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yi Wang
- Gastrointestinal and Neonatal Surgery Department, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders (Chongqing), China International Science and Technology Cooperation base of Child development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
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White M, Grynspan D, Van Mieghem T, Connor KL. Isolated fetal neural tube defects associate with increased risk of placental pathology: Evidence from the Collaborative Perinatal Project. Placenta 2021; 114:56-67. [PMID: 34479062 DOI: 10.1016/j.placenta.2021.08.052] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Accepted: 08/17/2021] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Neural tube defects (NTDs) are amongst the most common congenital anomalies and are associated with significant postnatal morbidity, but also with a higher incidence of low birthweight and fetal growth restriction. Despite the placenta being a critical determinant of fetal growth, placental development has not been extensively studied in fetuses with NTDs. METHODS We performed a matched case-cohort study using data from the Collaborative Perinatal Project to assess the risk of placental pathology in pregnancies with an isolated fetal NTD (cases; n = 74) compared to those without any congenital anomalies (controls; n = 148). We hypothesised that cases would be at an increased risk of placental pathology compared to controls. Data were analysed using adjusted generalized linear and nominal logistic regression models. Results are presented as adjusted β or adjusted odds ratio (aOR; 95% confidence interval). RESULTS Cases had lower placental weight (β = -22.2 g [-37.8 to -6.6]), surface area (β = -9.6 cm2 [-18.3 to -1.0]) and birth length z-scores (β = -0.4 [-0.7 to -0.001]) compared to controls. Cases were more likely to have a single umbilical artery (vs. two; 6 [8.1%] vs. 1 [0.7%]; aOR = 301 [52.6-1726]), placental hypermaturity (9 [12.2%] vs. 5 [3.4%]; aOR = 6.8 [3.1-14.7]), many (vs. few) Hofbauer cells (9 [12.2%] vs. 7 [4.7%]; aOR = 3.02 [1.2-7.3]), and stromal fibrosis (9 [12.2%] vs. 10 [6.8%]; aOR = 3.0 [1.4-6.3]) in placental terminal villi compared to controls. CONCLUSIONS Fetuses with isolated NTDs may be at increased risk of placental pathology, which could be contributing to poor fetal growth in these pregnancies and subsequent postnatal morbidities.
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Affiliation(s)
- Marina White
- Health Sciences, Carleton University, Ottawa, ON, K1S 5B6, Canada
| | - David Grynspan
- Vernon Jubilee Hospital, Vernon, BC, V1T 5L2, Canada; Department of Pathology and Laboratory Medicine, University of British Columbia, Vancouver, BC, V6T 1Z7, Canada
| | - Tim Van Mieghem
- Department of Obstetrics and Gynaecology, Mount Sinai Hospital, Toronto, ON, M5G 1X5, Canada
| | - Kristin L Connor
- Health Sciences, Carleton University, Ottawa, ON, K1S 5B6, Canada.
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The Term Newborn: Postnatal Screening and Testing. Clin Perinatol 2021; 48:555-572. [PMID: 34353580 DOI: 10.1016/j.clp.2021.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Prenatal genetic screening, including evaluation for inherited genetic disorders, aneuploidy risk assessment, and sonographic assessment, combined with a thorough newborn examination and standard newborn screening, including blood, hearing, and congenital heart disease screening, can reveal conditions requiring further evaluation after delivery. Abnormal prenatal or newborn screening results should prompt additional diagnostic testing guided by maternal fetal medicine, perinatal genetics, or pediatric specialists.
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Mark M, Teletin M, Wendling O, Vonesch JL, Féret B, Hérault Y, Ghyselinck NB. Pathogenesis of Anorectal Malformations in Retinoic Acid Receptor Knockout Mice Studied by HREM. Biomedicines 2021; 9:742. [PMID: 34203310 PMCID: PMC8301324 DOI: 10.3390/biomedicines9070742] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 06/22/2021] [Accepted: 06/23/2021] [Indexed: 12/12/2022] Open
Abstract
Anorectal malformations (ARMs) are relatively common congenital abnormalities, but their pathogenesis is poorly understood. Previous gene knockout studies indicated that the signalling pathway mediated by the retinoic acid receptors (RAR) is instrumental to the formation of the anorectal canal and of various urogenital structures. Here, we show that simultaneous ablation of the three RARs in the mouse embryo results in a spectrum of malformations of the pelvic organs in which anorectal and urinary bladder ageneses are consistently associated. We found that these ageneses could be accounted for by defects in the processes of growth and migration of the cloaca, the embryonic structure from which the anorectal canal and urinary bladder originate. We further show that these defects are preceded by a failure of the lateral shift of the umbilical arteries and propose vascular abnormalities as a possible cause of ARM. Through the comparisons of these phenotypes with those of other mutant mice and of human patients, we would like to suggest that morphological data may provide a solid base to test molecular as well as clinical hypotheses.
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Affiliation(s)
- Manuel Mark
- CNRS, INSERM, Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), Université de Strasbourg, 1 rue Laurent Fries, 67404 Illkirch Graffenstaden, France; (M.T.); (O.W.); (J.-L.V.); (B.F.); (Y.H.); (N.B.G.)
- Service de Biologie de la Reproduction, Hôpitaux Universitaires de Strasbourg (HUS), 67300 Schiltigheim, France
- CNRS, INSERM, CELPHEDIA, PHENOMIN-Institut Clinique de la Souris (ICS), Université de Strasbourg, 1 rue Laurent Fries, 67404 Illkirch Graffenstaden, France
| | - Marius Teletin
- CNRS, INSERM, Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), Université de Strasbourg, 1 rue Laurent Fries, 67404 Illkirch Graffenstaden, France; (M.T.); (O.W.); (J.-L.V.); (B.F.); (Y.H.); (N.B.G.)
- Service de Biologie de la Reproduction, Hôpitaux Universitaires de Strasbourg (HUS), 67300 Schiltigheim, France
| | - Olivia Wendling
- CNRS, INSERM, Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), Université de Strasbourg, 1 rue Laurent Fries, 67404 Illkirch Graffenstaden, France; (M.T.); (O.W.); (J.-L.V.); (B.F.); (Y.H.); (N.B.G.)
- CNRS, INSERM, CELPHEDIA, PHENOMIN-Institut Clinique de la Souris (ICS), Université de Strasbourg, 1 rue Laurent Fries, 67404 Illkirch Graffenstaden, France
| | - Jean-Luc Vonesch
- CNRS, INSERM, Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), Université de Strasbourg, 1 rue Laurent Fries, 67404 Illkirch Graffenstaden, France; (M.T.); (O.W.); (J.-L.V.); (B.F.); (Y.H.); (N.B.G.)
| | - Betty Féret
- CNRS, INSERM, Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), Université de Strasbourg, 1 rue Laurent Fries, 67404 Illkirch Graffenstaden, France; (M.T.); (O.W.); (J.-L.V.); (B.F.); (Y.H.); (N.B.G.)
| | - Yann Hérault
- CNRS, INSERM, Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), Université de Strasbourg, 1 rue Laurent Fries, 67404 Illkirch Graffenstaden, France; (M.T.); (O.W.); (J.-L.V.); (B.F.); (Y.H.); (N.B.G.)
- CNRS, INSERM, CELPHEDIA, PHENOMIN-Institut Clinique de la Souris (ICS), Université de Strasbourg, 1 rue Laurent Fries, 67404 Illkirch Graffenstaden, France
| | - Norbert B. Ghyselinck
- CNRS, INSERM, Institut de Génétique et de Biologie Moléculaire et Cellulaire (IGBMC), Université de Strasbourg, 1 rue Laurent Fries, 67404 Illkirch Graffenstaden, France; (M.T.); (O.W.); (J.-L.V.); (B.F.); (Y.H.); (N.B.G.)
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Ebbing C, Kessler J, Moster D, Rasmussen S. Isolated single umbilical artery and the risk of adverse perinatal outcome and third stage of labor complications: A population-based study. Acta Obstet Gynecol Scand 2019; 99:374-380. [PMID: 31603530 DOI: 10.1111/aogs.13747] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 09/26/2019] [Accepted: 10/07/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Isolated single umbilical artery (iSUA) refers to single umbilical artery cords with no other fetal malformations. The association of iSUA to adverse outcome of pregnancy has not been consistently reported, and whether iSUA carries increased risk of third stage of labor complications has not been studied. We aimed to investigate the risk of adverse perinatal outcome, third stage of labor complications, and associated placental and cord characteristics in pregnancies with iSUA. A further aim was to assess the risk of recurrence of iSUA and anomalous cord or placenta characteristics in Norway. MATERIAL AND METHODS This was a population-based study of all singleton pregnancies with gestational age >16 weeks at birth using data from the Medical Birth Registry of Norway from 1999 to 2014 (n = 918 933). Odds ratios (OR) with 95% confidence intervals were calculated for adverse perinatal outcome (preterm birth, perinatal and intrauterine death, low Apgar score, transferral to neonatal intensive care ward, placental and cord characteristics [placental weight, cord length and knots, anomalous cord insertion, placental abruption and previa]), and third stage of labor complications (postpartum hemorrhage and the need for manual placental removal or curettage) in pregnancies with iSUA, and recurrence of iSUA using generalized estimating equations and logistic regression. RESULTS Pregnancies with iSUA carried increased risk of adverse perinatal outcome (OR 5.06, 95% confidence interval [CI] 4.26-6.02) and perinatal and intrauterine death (OR 5.62, 95% CI 4.69-6.73), and a 73% and 55% increased risk of preterm birth and small-for-gestational-age neonate, respectively. The presence of iSUA also carried increased risk of a small placenta, placenta previa and abruption, anomalous cord insertion, long cord, cord knot and third stage of labor complications. Women with iSUA, long cord or anomalous cord insertion in one pregnancy carried increased risk of iSUA in the subsequent pregnancy. CONCLUSIONS The presence of ISUA was associated with a more than five times increased risk of intrauterine and perinatal death and with placental and cord complications. The high associated risk of adverse outcome justifies follow up with assessment of fetal wellbeing in the third trimester, intrapartum surveillance and preparedness for third stage of labor complications.
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Affiliation(s)
- Cathrine Ebbing
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
| | - Jörg Kessler
- Department of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway
| | - Dag Moster
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway.,Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Svein Rasmussen
- Department of Clinical Science, University of Bergen, Bergen, Norway
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