Increased adverse pregnancy outcomes with unreliable last menstruation

Gestational age assessed by optical skin reflection in low-birth-weight newborns: Applications in classification at birth

Introduction

A new medical device was previously developed to estimate gestational age (GA) at birth by processing a machine learning algorithm on the light scatter signal acquired on the newborn's skin. The study aims to validate GA calculated by the new device (test), comparing the result with the best available GA in newborns with low birth weight (LBW).

Methods

We conducted a multicenter, non-randomized, and single-blinded clinical trial in three urban referral centers for perinatal care in Brazil and Mozambique. LBW newborns with a GA over 24 weeks and weighing between 500 and 2,500 g were recruited in the first 24 h of life. All pregnancies had a GA calculated by obstetric ultrasound before 24 weeks or by reliable last menstrual period (LMP). The primary endpoint was the agreement between the GA calculated by the new device (test) and the best available clinical GA, with 95% confidence limits. In addition, we assessed the accuracy of using the test in the classification of preterm and SGA. Prematurity was childbirth before 37 gestational weeks. The growth standard curve was Intergrowth-21st, with the 10th percentile being the limit for classifying SGA.

Results

Among 305 evaluated newborns, 234 (76.7%) were premature, and 139 (45.6%) were SGA. The intraclass correlation coefficient between GA by the test and reference GA was 0.829 (95% CI: 0.785-0.863). However, the new device (test) underestimated the reference GA by an average of 2.8 days (95% limits of agreement: -40.6 to 31.2 days). Its use in classifying preterm or term newborns revealed an accuracy of 78.4% (95% CI: 73.3-81.6), with high sensitivity (96.2%; 95% CI: 92.8-98.2). The accuracy of classifying SGA newborns using GA calculated by the test was 62.3% (95% CI: 56.6-67.8).

Discussion

The new device (test) was able to assess GA at birth in LBW newborns, with a high agreement with the best available GA as a reference. The GA estimated by the device (test), when used to classify newborns on the first day of life, was useful in identifying premature infants but not when applied to identify SGA infants, considering current algohrithm. Nonetheless, the new device (test) has the potential to provide important information in places where the GA is unknown or inaccurate.

Premature or Small for Gestational Age Discrimination: International Multicenter Trial Protocol for Classification of the Low-Birth-Weight Newborn Through the Optical Properties of the Skin

Background

A low birth weight is an independent risk factor for adverse infant outcomes and a predictor of chronic disease in adulthood. In these situations, differentiating between prematurity and small for gestational age (SGA) or simultaneous conditions is essential to ensuring adequate care. Such diagnoses, however, depend on reliable pregnancy dating, which can be challenging in developing countries. A new medical optoelectronic device was developed to estimate gestational age (GA) at birth based on newborn skin reflection.

Objective

This study will aim to evaluate the device’s ability to detect prematurity or SGA, or both conditions simultaneously as well as predict short-term pulmonary complications in a cohort of low-birth-weight newborns.

Methods

This study protocol was designed for a multicenter cohort including referral hospitals in Brazil and Mozambique. Newborns weighing 500-2500 g will be eligible for inclusion with the best GA available, considering the limited resources of low-income countries. Comparator-GA is based on reliable last menstrual period dating or ultrasound assessment before 24 weeks’ gestation. Estimated GA at birth (Test-GA) will be calculated by applying a novel optoelectronic device to the newborn’s skin over the sole. The average difference between Test-GA and Comparator-GA will be analyzed, as will the percentage of newborns who are correctly diagnosed as preterm or SGA. In addition, in a nested case–control study, the accuracy of skin reflection in the prediction of prematurity-related respiratory problems will be evaluated. The estimated required sample size is 298 newborns.

Results

Teams of health professionals were trained, and standard operating procedures were developed following the good practice guidelines for the clinical investigation of medical devices for human participants. The first recruitment started in March 2019 in Brazil. Data collection is planned to end in December 2020, and the results should be available in March 2021.

Conclusions

The results of this clinical study have the potential to validate a new device to easily assess postnatal GA, supporting SGA identification when pregnancy dating is unreliable or unknown.

Trial Registration

ReBec: RBR-33rnjf; http://www.ensaiosclinicos.gov.br/rg/RBR-33rnjf/

International Registered Report Identifier (IRRID)

DERR1-10.2196/16477

Quality of Pregnancy Dating and Obstetric Interventions During Labor: Retrospective Database Analysis

BACKGROUND

The correct dating of pregnancy is critical to support timely decisions and provide obstetric care during birth. The early obstetric ultrasound assessment before 14 weeks is considered the best reference to assist in determining gestational age (GA), with an accuracy of ±5 to 7 days. However, this information is limited in many settings worldwide.

OBJECTIVE

The aim of this study is to analyze the association between the obstetric interventions during childbirth and the quality of GA determination, according to the first antenatal ultrasound assessment, which assisted the calculation.

METHODS

This is a hospital-based cohort study using medical record data of 2113 births at a perinatal referral center. The database was separated into groups and subgroups of analyses based on the reference used by obstetricians to obtain GA at birth. Maternal and neonatal characteristics, mode of delivery, oxytocin augmentation, and forceps delivery were compared between groups of pregnancies with GA determination at different reference points: obstetric ultrasound assessment 14 weeks, 20 weeks, and ≥20 weeks or without antenatal ultrasound (suboptimal dating). Ultrasound-based GA information was associated with outcomes between the interest groups using chi-square tests, odds ratios (OR) with 95% CI, or the Mann-Whitney statistical analysis.

RESULTS

The chance of nonspontaneous delivery was higher in pregnancies with 14 weeks ultrasound-based GA (OR 1.64, 95% CI 1.35-1.98) and 20 weeks ultrasound-based GA (OR 1.58, 95% CI 1.31-1.90) when compared to the pregnancies with ≥20 weeks ultrasound-based GA or without any antenatal ultrasound. The use of oxytocin for labor augmentation was higher for 14 weeks and 20 weeks ultrasound-based GA, OR 1.41 (95% CI 1.09-1.82) and OR 1.34 (95% CI 1.04-1.72), respectively, when compared to those suboptimally dated. Moreover, maternal blood transfusion after birth was more frequent in births with suboptimal ultrasound-based GA determination (20/657, 3.04%) than in the other groups (14 weeks ultrasound-based GA: 17/1163, 1.46%, P=.02; 20 weeks ultrasound-based GA: 25/1456, 1.71%, P=.048). Cesarean section rates between the suboptimal dating group (244/657, 37.13%) and the other groups (14 weeks: 475/1163, 40.84%, P=.12; 20 weeks: 584/1456, 40.10%, P=.20) were similar. In addition, forceps delivery rates between the suboptimal dating group (17/657, 2.6%) and the other groups (14 weeks: 42/1163, 3.61%, P=.24; 20 weeks: 46/1456, 3.16%, P=.47) were similar. Neonatal intensive care unit admission was more frequent in newborns with suboptimal dating (103/570, 18.07%) when compared with the other groups (14 weeks: 133/1004, 13.25%, P=.01; 20 weeks: 168/1263, 13.30%, P=.01), excluding stillbirths and major fetal malformations.

CONCLUSIONS

The present analysis highlighted relevant points of health care to improve obstetric assistance, confirming the importance of early access to technologies for pregnancy dating as an essential component of quality antenatal care.

Prematurity detection evaluating interaction between the skin of the newborn and light: protocol for the preemie-test multicentre clinical trial in Brazilian hospitals to validate a new medical device

INTRODUCTION

Recognising prematurity is critical in order to attend to immediate needs in childbirth settings, guiding the extent of medical care provided for newborns. A new medical device has been developed to carry out the preemie-test, an innovative approach to estimate gestational age (GA), based on the photobiological properties of the newborn's skin. First, this study will validate the preemie-test for GA estimation at birth and its accuracy to detect prematurity. Second, the study intends to associate the infant's skin reflectance with lung maturity, as well as evaluate safety, precision and usability of a new medical device to offer a suitable product for health professionals during childbirth and in neonatal care settings.

METHODS AND ANALYSIS

Research protocol for diagnosis, single-group, single-blinding and single-arm multicenter clinical trial with a reference standard. Alive newborns, with 24 weeks or more of pregnancy age, will be enrolled during the first 24 hours of life. Sample size is 787 subjects. The primary outcome is the difference between the GA calculated by the photobiological neonatal skin assessment methodology and the GA calculated by the comparator antenatal ultrasound or reliable last menstrual period (LMP). Immediate complications caused by pulmonary immaturity during the first 72 hours of life will be associated with skin reflectance in a nested case-control study.

ETHICS AND DISSEMINATION

Each local independent ethics review board approved the trial protocol. The authors intend to share the minimal anonymised dataset necessary to replicate study findings.

TRIAL REGISTRATION NUMBER

RBR-3f5bm5.

The effect of pre-pregnancy hair dye exposure on infant birth weight: a nested case-control study

Background

Limited evidences were reported about the risk of pre-pregnancy hair dye use or irregular menstruation with abnormal birth weight during pregnancy, and their joint effects were also unknown. The aim of our study was to explore whether the pre-pregnancy exposure of hair dye and irregular menstruation were associated with the risk of abnormal birth weight.

Methods

We conducted a nested case-control study from a prospective cohort of 6203 pregnant women. Low birth weight study included 315 mother-infant pairs (105 LBW cases and 210 matched controls), and macrosomia study included 381 mother-infant pairs (127 macrosomia cases and 254 matched controls). Meanwhile, lifestyle information including hair dying custom and menstrual history were collected by face-to-face questionnaires and birth outcomes were extracted from the medical records. The logistic regressions models were used to analyze the join effect of irregular menstruation and hair dye use.

Results

Pre-pregnancy hair dye use was associated with increased risk of LBW (adjusted OR = 1.71, 95% CI: 1.01–2.92, P = 0.048). Irregular menstruation had high risk of LBW (adjusted OR = 2.79, 95% CI: 1.53–5.09, P = 0.001) and macrosomia (adjusted OR = 1.93, 95% CI: 1.09–3.44, P = 0.023). Additionally, in the LBW study, women who used hair dye with pre-pregnancy BMI < 18.5 kg/m² had higher OR than those with only one risk factor (3.07 vs 2.53, P_trend = 0.015), and women with both hair dye use and irregular menstruation also had higher risk than those with only one factor (4.53 vs 2.07, P_trend = 0.05). Moreover, in macrosomia study, women with irregular menstruation and pre-pregnancy BMI ≥ 24 kg/m² had higher risk than those with one factor (13.31 vs 2.09, P_trend = 0.001).

Conclusion

Our study showed that either pre-pregnancy hair dye use or irregular menstruation was associated with abnormal birth weight, especially, their joint effects could furthermore increase the risk of low birth weight infants when these two factors existed simultaneously.

Hypertensive disease in pregnancy in Botswana: Prevalence and impact on perinatal outcomes

OBJECTIVES

Perinatal morbidity in sub-Saharan Africa has been attributed to infection, obstetric emergencies, and preterm birth, but less is known about hypertension in pregnancy. Our objective was to characterize the prevalence of hypertension in pregnancy and the impact of hypertension on perinatal outcomes in sub-Saharan Africa.

STUDY DESIGN

We performed surveillance of obstetric records at eight of the largest public hospitals in Botswana. Women were included in this analysis if they were HIV-uninfected and had singleton gestations and at least one prenatal blood pressure measurement.

MAIN OUTCOME MEASURES

We measured stillbirth, preterm birth, small for gestational age, and neonatal death in women with and without hypertension in pregnancy.

RESULTS

We included 14,170 pregnancies. Hypertension occurred in 3156 (22.2%) women, with 602 (19.1%) defined as severe. Severe hypertension increased risk of stillbirth (RR 4.4; 95% CI 3.2-6.2), preterm birth (RR 2.5; 95% CI 2.2-2.8), small for gestational age (RR 2.7; 95% CI 2.3-3.1) and neonatal death (RR 5.1; 95% CI 2.9-5.6). Non-severe hypertension increased risk of stillbirth (RR 2.0; 95% CI 1.5-2.7), preterm birth (RR 1.2; 95% CI 1.1-1.3), and small for gestational age (RR 1.6; 95% CI 1.4-1.8). Perinatal outcomes were worse in women with hypertension who had spontaneous preterm birth compared to those who underwent iatrogenic preterm delivery.

CONCLUSIONS

Hypertension in pregnancy is common in Botswana and leads to a large number of adverse outcomes. Improved management of hypertension in pregnancy may improve perinatal morbidity and mortality.

Time at treatment of severe retinopathy of prematurity in China: recommendations for guidelines in more mature infants

PURPOSE

To investigate the postmenstrual (PMA) age at treatment of severe retinopathy of prematurity (i.e. Type 1 prethreshold or threshold) in infants in a tertiary referral center in China.

PRINCIPAL FINDINGS

76.6% (359/469) of infants were treated for threshold disease. 67.5% (317/469) of infants had a birth weight (BW) of 1250 g or above and almost 30% (126) had a gestational age (GA) of 32 weeks or above. There was little difference in the characteristics of infants treated for Type 1 prethreshold or threshold ROP. After controlling for GA, PMA age at treatment was highest in infants with BW ≥2000 g (mean PMA 40.3±4.4 weeks, p<0.001); after controlling for BW, higher GA was associated with higher PMA at treatment (mean PMA 41.5 weeks for gestational age >34 weeks, p<0.001). For every three weeks increase in GA there was a two-week increase in PMA at treatment (R2 = 0.20, p<0.001). The time at treatment of Type 1 prethreshold disease was similar to that for threshold disease i.e. chronological age 5.6∓7.4 weeks, or PMA 34.1∓40.2 weeks but the lower end of the 95% confidence interval for chronological age for Type 1 prethreshold disease among infants with BW ≥2000 g was 3.7 weeks (i.e. before the recommended interval of 4∓6 weeks after birth).

SIGNIFICANCE

The Chinese guidelines regarding timing of the first examination are appropriate for infants with BW <2000 g, but more mature infants should be examined a little earlier, at 3 weeks after birth, in order to detect Type 1 prethreshold disease which has a better prognosis than threshold.

Components and timing of prenatal care

The primary objective for prenatal care has not changed in the past 100 years: to have the pregnancy end with a healthy baby and mother. By identifying risk factors for pregnancy complications or other maternal health concerns that need to be addressed, the provider hopes to optimize pregnancy outcome. By using a series of screening and diagnostic tests, as well as serially trending certain components of the physical examination, the provider monitors the ongoing "health" of the pregnancy. As the ability to screen and intervene has improved over the last century, the issues to be assessed have expanded to include not only medical aspects of care but also barriers to access, psychologic considerations, and patient education about general health, pregnancy, and childbirth.

A comparison of recalled date of last menstrual period with prospectively recorded dates

BACKGROUND

Women are often asked to recall the first day of their last menstrual period (LMP date) in a clinic setting (i.e., pregnancy dating, x-rays). There are no data supporting the validity of these reports.

METHODS

Using data from a group of 385 women ages 35-49 from a larger cohort study in the Washington, DC, area, we constructed menstrual segments from a prospective daily menstrual record. We then compared the first day of a menstrual segment to a woman's recalled LMP date at a subsequent study-related clinic appointment to assess the accuracy of recall.

RESULTS

More than half of the women (56%) accurately recalled their LMP date; 74% were within 1 day, and 81% were within 2 days. Women tended to underreport (25%) the length of time since their last menstrual period rather than overreport the length of time (19%). Recall accuracy did not vary significantly with education or by whether the woman usually recorded her menstrual cycle when not in the study. As one might expect, women with a shorter recall duration tended to report more accurately.

DISCUSSION

Women appear to recall their LMP dates fairly accurately, but inaccurate recall was not random. When length of recall was 3 weeks or longer, women tended to overestimate the time since LMP. This suggests that gestational age calculated from LMP date will tend to be overestimated. Most women can recall the date of their LMP reasonably well regardless of their education and whether they usually record their LMP dates.

Birthweight by gestational age in preterm babies according to a Gaussian mixture model

OBJECTIVE

To provide a statistically sound criterion for identifying implausibly large birthweights for gestational age.

DESIGN

Review of ISTAT 1990-1994 national newborn records.

SETTING

Italy

POPULATION

Forty-two thousand and twenty-nine single first and second liveborn preterm babies.

METHODS

Two-component Gaussian mixture models are used to describe the birthweight distributions stratified by gestational age. Implausibly large babies are identified through model-based probabilistic clustering.

MAIN OUTCOME MEASURES

Gestational age misclassification and weight-for-gestational age centile curves

RESULTS

Gestational age appears under-estimated by about six weeks in 12.3% of the cases. Large babies are equally present in males and females, but are more frequent in second-borns than in first-borns, even when parity-specific models are fitted.

CONCLUSIONS

The approach allows for a quantification of the gestational age under-estimate error and for data correction through model-based clustering. Correct birthweight distributions and growth curves are also provided.