1
|
Wallace AD, Blue NR, Morgan T, Workalemahu T, Silver RM, Quinlan AR. Placental somatic mutation in human stillbirth and live birth: A pilot case-control study of paired placental, fetal, and maternal whole genomes. Placenta 2024; 154:137-144. [PMID: 38972082 PMCID: PMC11368634 DOI: 10.1016/j.placenta.2024.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 06/18/2024] [Accepted: 06/19/2024] [Indexed: 07/09/2024]
Abstract
INTRODUCTION A high frequency of single nucleotide somatic mutations in the placenta has been recently described, but its relationship to placental dysfunction is unknown. METHODS We performed a pilot case-control study using paired fetal, maternal, and placental samples collected from healthy live birth controls (n = 10), live births with fetal growth restriction (FGR) due to placental insufficiency (n = 7), and stillbirths with FGR and placental insufficiency (n = 11). We quantified single nucleotide and structural somatic variants using bulk whole genome sequencing (30-60X coverage) in four biopsies from each placenta. We also assessed their association with clinical and histological evidence of placental dysfunction. RESULTS Seventeen pregnancies had sufficiently high-quality placental, fetal, and maternal DNA for analysis. Each placenta had a median of 473 variants (range 111-870), with 95 % arising in just one biopsy within each placenta. In controls, live births with FGR, and stillbirths, the median variant counts per placenta were 514 (IQR 381-779), 582 (450-735), and 338 (245-441), respectively. After adjusting for depth of sequencing coverage and gestational age at birth, the somatic mutation burden was similar between groups (FGR live births vs. controls, adjusted diff. 59, 95 % CI -218 to +336; stillbirths vs controls, adjusted diff. -34, -351 to +419), and with no association with placental dysfunction (p = 0.7). DISCUSSION We confirmed the high prevalence of somatic mutation in the human placenta and conclude that the placenta is highly clonal. We were not able to identify any relationship between somatic mutation burden and clinical or histologic placental insufficiency.
Collapse
Affiliation(s)
- Amelia D Wallace
- University of Utah Health, Department of Human Genetics, 15 N 2030 E, Eccles Institute of Human Genetics Rm 7160B, Salt Lake City, UT, 84112, USA; Utah Center for Genetic Discovery, 15 N 2030 E, #2100, Salt Lake City, UT, 4112, USA
| | - Nathan R Blue
- University of Utah Health, Department of Obstetrics and Gynecology, 30 N Mario Capecchi Dr, Level 5 South, Salt Lake City, UT, 84132, USA
| | - Terry Morgan
- Oregon Health & Science University, Departments of Pathology and Obstetrics and Gynecology, 3181 SW Sam Jackson Park Rd, L-113, Portland, OR, 97239, USA
| | - Tsegaselassie Workalemahu
- University of Utah Health, Department of Obstetrics and Gynecology, 30 N Mario Capecchi Dr, Level 5 South, Salt Lake City, UT, 84132, USA
| | - Robert M Silver
- University of Utah Health, Department of Obstetrics and Gynecology, 30 N Mario Capecchi Dr, Level 5 South, Salt Lake City, UT, 84132, USA.
| | - Aaron R Quinlan
- University of Utah Health, Department of Human Genetics, 15 N 2030 E, Eccles Institute of Human Genetics Rm 7160B, Salt Lake City, UT, 84112, USA; Utah Center for Genetic Discovery, 15 N 2030 E, #2100, Salt Lake City, UT, 4112, USA.
| |
Collapse
|
2
|
Blok EL, Burger RJ, Bergeijk JEV, Bourgonje AR, Goor HV, Ganzevoort W, Gordijn SJ. Oxidative stress biomarkers for fetal growth restriction in umbilical cord blood: A scoping review. Placenta 2024; 154:88-109. [PMID: 38943922 DOI: 10.1016/j.placenta.2024.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Revised: 06/20/2024] [Accepted: 06/21/2024] [Indexed: 07/01/2024]
Abstract
Fetal growth restriction and underlying placental insufficiency are associated with increased oxidative stress. Current diagnostics fail to identify all growth restricted fetuses and newborns, due to focus on small size. This scoping review aims to summarize the available evidence on usefulness of cord blood oxidative stress biomarkers for identification of growth restricted newborns in need of monitoring and support because of associated health risks. MEDLINE and EMBASE were searched from inception to May 2024. Studies were included if oxidative stress biomarkers were measured in cord blood collected immediately after delivery in newborns suspected to be growth restricted. Biomarkers were categorized based on the origin and/or biological function and their interrelationships. Oxidative stress was determined for each individual biomarker and category. Literature search identified 78 studies on 39 different biomarkers, with a total of 2707 newborns with suspected growth restriction, and 4568 controls. Total oxidant/antioxidant status, catalase, glutathione, ischemia-modified albumin, and nucleated red blood cells were most consistently associated with suspected growth restriction. Reactive oxygen species/reactive nitrogen species, factors in their production, antioxidant enzymes, non-enzymatic antioxidants, and products of oxidative stress were not consistently associated. This review collates the evidence of associations between cord blood oxidative stress biomarkers and growth restriction. Total oxidant/antioxidant status, catalase, glutathione, ischemia-modified albumin, and nucleated red blood cells could potentially be candidates for developing a cord blood diagnostic tool for future clinical use.
Collapse
Affiliation(s)
- Evelien L Blok
- Amsterdam UMC Location University of Amsterdam, Department of Obstetrics and Gynaecology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands.
| | - Renée J Burger
- Amsterdam UMC Location University of Amsterdam, Department of Obstetrics and Gynaecology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands.
| | - Jenny E Van Bergeijk
- University Medical Center Groningen, University of Groningen, Department of Obstetrics and Gynaecology, Hanzeplein 1, Groningen, the Netherlands.
| | - Arno R Bourgonje
- University Medical Center Groningen, University of Groningen, Department of Gastroenterology and Hepatology, Hanzeplein 1, Groningen, the Netherlands.
| | - Harry Van Goor
- University Medical Center Groningen, University of Groningen, Department of Pathology and Medical Biology, Hanzeplein 1, Groningen, the Netherlands.
| | - Wessel Ganzevoort
- Amsterdam UMC Location University of Amsterdam, Department of Obstetrics and Gynaecology, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Reproduction and Development Research Institute, Amsterdam, the Netherlands.
| | - Sanne J Gordijn
- University Medical Center Groningen, University of Groningen, Department of Obstetrics and Gynaecology, Hanzeplein 1, Groningen, the Netherlands.
| |
Collapse
|
3
|
Hugh O, Cowan J, Butler E, Gardosi J. Fetal size vs growth: comparative analysis of 3 models of growth velocity based on third trimester estimated fetal weights for identifying stillbirth risk. Am J Obstet Gynecol 2024; 231:336.e1-336.e11. [PMID: 38151221 DOI: 10.1016/j.ajog.2023.12.029] [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: 10/14/2023] [Revised: 12/20/2023] [Accepted: 12/21/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Fetal growth velocity is being recognized as an important parameter by which to monitor fetal wellbeing, in addition to assessment of fetal size. However, there are different models and standards in use by which velocity is being assessed. OBJECTIVE We wanted to investigate 3 clinically applied methods of assessing growth velocity and their ability to identify stillbirth risk, in addition to that associated with small for gestational age. STUDY DESIGN Retrospective analysis of prospectively recorded routine-care data of pregnancies with 2 or more third trimester scans in New Zealand. Results of the last 2 scans were used for the analysis. The models investigated to define slow growth were (1) 50+ centile drop between measurements, (2) 30+ centile drop, and (3) estimated fetal weight below a projected optimal weight range, based on predefined, scan interval specific cut-offs to define normal growth. Each method's ability to identify stillbirth risk was assessed against that associated with small-for-gestational age at last scan. RESULTS The study cohort consisted of 71,576 pregnancies. The last 2 scans in each pregnancy were performed at an average of 32+1 and 35+6 weeks of gestation. The 3 models defined "slow growth" at the following differing rates: (1) 50-centile drop 0.9%, (2) 30-centile drop 5.1%, and (3) below projected optimal weight range 10.8%. Neither of the centile-based models identified at-risk cases that were not also small for gestational age at last scan. The projected weight range method identified an additional 79% of non-small-for-gestational-age cases as slow growth, and these were associated with a significantly increased stillbirth risk (relative risk, 2.0; 95% CI, 1.2-3.4). CONCLUSION Centile-based methods fail to reflect adequacy of fetal weight gain at the extremes of the distribution. Guidelines endorsing such models might hinder the potential benefits of antenatal assessment of fetal growth velocity. A new, measurement-interval-specific projection model of expected fetal weight gain can identify fetuses that are not small for gestational age, yet at risk of stillbirth because of slow growth. The velocity between scans can be calculated using a freely available growth rate calculator (www.perinatal.org.uk/growthrate).
Collapse
Affiliation(s)
- Oliver Hugh
- Perinatal Institute, Birmingham, United Kingdom
| | - Joyce Cowan
- Auckland University of Technology, Auckland, New Zealand
| | | | | |
Collapse
|
4
|
Desaunay P, Eslier M, Alexandre J, Dreyfus M, Chrétien B, Guénolé F. Antidepressants and fetal death: A systematic review and disproportionality analysis in the WHO safety database (VigiBase Ⓡ). Psychiatry Res 2024; 339:116048. [PMID: 38959577 DOI: 10.1016/j.psychres.2024.116048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 04/03/2024] [Accepted: 06/16/2024] [Indexed: 07/05/2024]
Abstract
Recent research suggests that fetal exposure to antidepressants (ADs) is significantly associated with fetal death, including stillbirth. However, there has been limited investigation into the timing of AD exposure during pregnancy, the specific effect of each drug, and the possibility of indication bias. To address these gaps in knowledge, we conducted a systematic review of literature and disproportionality analyses using the WHO Safety Database (VigiBaseⓇ). The systematic review provided evidence for increased risks of fetal death with exposure to any selective serotonin reuptake inhibitor (SSRI) at any time of pregnancy, stillbirth with exposure to any AD during the first trimester, and stillbirth with exposure to any SSRI during the first trimester. Disproportionality analyses revealed significant associations with citalopram, clomipramine, paroxetine, sertraline, and venlafaxine. Combining both sets of results, we conclude that exposure to ADs, especially during the first trimester of pregnancy, seems to be associated with fetal mortality, and that ADs with highest placental transfer may be particularly involved. Further research should investigate the links between ADs during early pregnancy and fetal mortality.
Collapse
Affiliation(s)
- Pierre Desaunay
- Centre Hospitalier Universitaire de Caen Normandie, service de psychiatrie de l'enfant et de l'adolescent, Avenue de la côte de nacre, 14000, Caen, France
| | - Maxime Eslier
- Polyclinique du Parc, service de gynécologie et d'obstétrique, 20 Avenue du Capitaine Georges Guynemer, 14000, Caen, France; Center for Research on Epidemiology and Statistics Sorbonne Paris Cité, Obstetrical Perinatal and Pediatric Epidemiology Research Team, 10 Avenue de Verdun, 75010, Paris, France
| | - Joachim Alexandre
- Centre Hospitalier Universitaire de Caen Normandie, service de pharmacologie, Avenue de la côte de nacre, 14000, Caen, France
| | - Michel Dreyfus
- Centre Hospitalier Universitaire de Caen Normandie, service de gynécologie-obstétrique et de médecine de la reproduction, Avenue de la côte de nacre, 14000, Caen, France
| | - Basile Chrétien
- Centre Hospitalier Universitaire de Caen Normandie, service de pharmacologie, Avenue de la côte de nacre, 14000, Caen, France
| | - Fabian Guénolé
- Centre Hospitalier Universitaire de Caen Normandie, service de psychiatrie de l'enfant et de l'adolescent, Avenue de la côte de nacre, 14000, Caen, France.
| |
Collapse
|
5
|
Farrell T, Minisha F, Khenyab N, Ali NM, Al Obaidly S, Yaqoub SA, Pallivalappil AR, Al-Dewik N, AlRifai H, Hugh O, Gardosi J. A customised fetal growth and birthweight standard for Qatar: a population-based cohort study. J Perinat Med 2024; 0:jpm-2024-0060. [PMID: 39167534 DOI: 10.1515/jpm-2024-0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 07/28/2024] [Indexed: 08/23/2024]
Abstract
OBJECTIVES Customized birthweight centiles have improved the detection of small for gestational age (SGA) and large for gestational age (LGA) babies compared to existing population standards. This study used perinatal registry data to derive coefficients for developing customized growth charts for Qatar. METHODS The PEARL registry data on women delivering in Qatar (2017-2018) was used to develop a multivariable linear regression model predicting optimal birthweight. Physiological variables included gestational age, maternal height, weight, ethnicity, parity, and sex of the baby. Pathological variables such as hypertension, preexisting and gestational diabetes and smoking were calculated and excluded to derive the optimal weight at term. RESULTS The regression model found a term optimal birthweight of 3,235 g for a Qatari nationality mother with median height (159 cm), booking weight (72 kg), parity (1) and gestation at birth (276 days) at the end of an uncomplicated pregnancy. Constitutional coefficients significantly affecting birthweight were gestational age, height, weight, and parity. The main pathological factors were preexisting diabetes (increase by +175.7 g) and smoking (decrease by -190.9 g). The SGA and LGA rates in the entire cohort after applying the population-specific customized centiles were 11.1 and 12.2 %, respectively (contrasting with the Hadlock standard: SGA-26.3 % and LGA-1.8 %, and Fenton standard: SGA-12.9 % and LGA-4.0 %). CONCLUSIONS Constitutional and pathological variations in fetal growth and birthweight apply in the maternity population in Qatar and have been quantified to allow the generation of customised charts for better identification of pregnancies with abnormal growth. Currently in-use population standards may misdiagnose many SGA and LGA babies.
Collapse
Affiliation(s)
- Thomas Farrell
- Department of Obstetrics and Gynecology, Women's Wellness and Research Centre, 36977 Hamad Medical Corporation , Doha, Qatar
- Department of Research, Women's Wellness and Research Centre, 36977 Hamad Medical Corporation , Doha, Qatar
- College of Medicine, Qatar University, Doha, Qatar
| | - Fathima Minisha
- Department of Obstetrics and Gynecology, Women's Wellness and Research Centre, 36977 Hamad Medical Corporation , Doha, Qatar
| | - Najat Khenyab
- Department of Obstetrics and Gynecology, Women's Wellness and Research Centre, 36977 Hamad Medical Corporation , Doha, Qatar
- Obstetrics and Gynecology, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Najah Mohammed Ali
- Department of Obstetrics and Gynecology, Women's Wellness and Research Centre, 36977 Hamad Medical Corporation , Doha, Qatar
| | - Sawsan Al Obaidly
- Department of Obstetrics and Gynecology, Women's Wellness and Research Centre, 36977 Hamad Medical Corporation , Doha, Qatar
- Obstetrics and Gynecology, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Salwa Abu Yaqoub
- Department of Obstetrics and Gynecology, Women's Wellness and Research Centre, 36977 Hamad Medical Corporation , Doha, Qatar
- Obstetrics and Gynecology, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Abdul Rouf Pallivalappil
- Department of Research, Women's Wellness and Research Centre, 36977 Hamad Medical Corporation , Doha, Qatar
| | - Nader Al-Dewik
- Department of Research, Women's Wellness and Research Centre, 36977 Hamad Medical Corporation , Doha, Qatar
| | - Hilal AlRifai
- Department of Pediatrics and Neonatology, Women's Wellness and Research Centre, 36977 Hamad Medical Corporation , Doha, Qatar
- Women's Wellness and Research Centre, 36977 Hamad Medical Corporation , Doha, Qatar
| | | | | |
Collapse
|
6
|
Atwani R, Saade G, Kawakita T. Impact of the ARRIVE Trial on Stillbirth Rates in Nulliparous Individuals. Am J Perinatol 2024. [PMID: 39137898 DOI: 10.1055/s-0044-1789018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/15/2024]
Abstract
OBJECTIVE We aim to examine the population-level rates of induction, stillbirth, perinatal mortality, and neonatal death before and after the ARRIVE (A Randomized Trial of Induction Versus Expectant Management) trial. STUDY DESIGN This study was a cross-sectional analysis of publicly available U.S. Live Birth data linked with Infant Death and Fetal Death certificate data from National Vital Statistics Online. We limited analyses to nulliparous individuals with singleton pregnancy and cephalic presentation who delivered at 39 weeks or greater. The pre- and post-ARRIVE periods spanned from August 2016 to July 2018, and from January 2019 to December 2020, respectively. Our primary outcome was a stillbirth. Secondary outcomes included induction of labor, perinatal mortality, and neonatal death. Outcomes were compared between the pre- and post-ARRIVE periods. Modified Poisson regression was used to calculate adjusted relative risks (aRRs). RESULTS Of 2,817,071 births, there were 1,454,346 births in the pre-ARRIVE period and 1,362,725 in the post-ARRIVE period; there were 1,196 and 1,062 stillbirths in the pre- and post-ARRIVE periods, respectively. Compared to the pre-ARRIVE period, the post-ARRIVE period was not associated with a significant decrease in the risk of stillbirth at 39 weeks or greater (aRR 0.92 [95% confidence interval {95% CI} 0.85-1.00]) and stillbirth at 40 weeks or greater (aRR 0.92 [95% CI 0.82-1.04]). Compared to the pre-ARRIVE trial period, the post-ARRIVE trial was associated with increased rates of induction of labor at 39 weeks (aRR 1.37 [95% CI 1.37-1.38]) and 40 weeks (aRR 1.24 [95% CI 1.24-1.25]. Similar to stillbirth, there was no significant decrease in the risk of perinatal mortality at 39 weeks or greater or 40 weeks or greater. There was also no statistically significant change in neonatal death rates at 39 weeks or greater or at 40 weeks or greater. CONCLUSION The increase in induction of labor at 39 weeks was not large enough to impact the stillbirth rate at 39 weeks or greater. KEY POINTS · Post-ARRIVE trial, rate of induction of labor increased at 39 and 40 weeks.. · Post-ARRIVE trial, stillbirth and perinatal mortality rates remained unchanged.. · Induction rate rise post-ARRIVE trial did not impact neonatal death rates..
Collapse
Affiliation(s)
- Rula Atwani
- Department of Obstetrics and Gynecology, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia
| | - George Saade
- Department of Obstetrics and Gynecology, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia
| | - Tetsuya Kawakita
- Department of Obstetrics and Gynecology, Macon & Joan Brock Virginia Health Sciences at Old Dominion University, Norfolk, Virginia
| |
Collapse
|
7
|
Ageheim M, Skalkidou A, Bergman E, Iliadis S, Lampa E, Lindström L, Oberg AS. Fetal growth after fresh and frozen embryo transfer and natural conception: A population-based register study. BJOG 2024; 131:1229-1237. [PMID: 38351638 DOI: 10.1111/1471-0528.17786] [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: 07/31/2023] [Revised: 01/07/2024] [Accepted: 01/24/2024] [Indexed: 07/04/2024]
Abstract
OBJECTIVE To investigate fetal growth trajectories and risks of small and large for gestational age (SGA and LGA), and macrosomia in pregnancies after fresh and frozen embryo transfer (ET), and natural conception (NC). DESIGN Longitudinal population-based cohort study. SETTING Swedish national registers. POPULATION A total of 196 008 singleton pregnancies between 2013 and 2017. METHODS Of all singleton pregnancies resulting in live births in the Swedish Pregnancy Register, 10 970 fresh ET, 6520 frozen ET, and 178 518 NC pregnancies with ultrasound data were included. A general least squares model was used to examine the effect of fresh or frozen ET on fetal growth while adjusting for confounders. MAIN OUTCOME MEASURES Fetal growth velocity. SGA, LGA and macrosomia. RESULTS At 120 days, fetal weights were lower in fresh ET pregnancies compared with NC pregnancies. Thereafter fresh ET as well as FET fetuses had higher fetal weights than NC fetuses, with no differences between themselves until the second trimester. From 210 days, FET fetuses were heavier than fresh ET fetuses, whereas fresh ET fetuses had lower fetal weights than NC fetuses from 245 days. After fresh ET, SGA was more frequent, whereas LGA and macrosomia were less frequent, than after FET. CONCLUSIONS This study gives new insights into the differences in fetal growth dynamics between fresh and frozen ET and NC pregnancies. Clinically relevant differences in proportions of SGA, LGA and macrosomia were observed.
Collapse
Affiliation(s)
- Mårten Ageheim
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Alkistis Skalkidou
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Eva Bergman
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Stavros Iliadis
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Erik Lampa
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Linda Lindström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Anna Sara Oberg
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
8
|
Raktong W, Sawaddisan R, Peeyananjarassri K, Suwanrath C, Geater A. Predictors and a scoring model for maternal near-miss and maternal death in Southern Thailand: a case-control study. Arch Gynecol Obstet 2024; 310:1055-1062. [PMID: 38713295 DOI: 10.1007/s00404-024-07539-6] [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: 01/31/2024] [Accepted: 04/24/2024] [Indexed: 05/08/2024]
Abstract
PURPOSE To identify predictors and develop a scoring model to predict maternal near-miss (MNM) and maternal mortality. METHODS A case-control study of 1,420 women delivered between 2014 and 2020 was conducted. Cases were women with MNM or maternal death, controls were women who had uneventful deliveries directly after women in the cases group. Antenatal characteristics and complications were reviewed. Multivariate logistic regression and Akaike information criterion were used to identify predictors and develop a risk score for MNM and maternal mortality. RESULTS Predictors for MNM and maternal mortality (aOR and score for predictive model) were advanced age (aOR 1.73, 95% CI 1.25-2.39, 1), obesity (aOR 2.03, 95% CI 1.22-3.39, 1), parity ≥ 3 (aOR 1.75, 95% CI 1.27-2.41, 1), history of uterine curettage (aOR 5.13, 95% CI 2.47-10.66, 3), history of postpartum hemorrhage (PPH) (aOR 13.55, 95% CI 1.40-130.99, 5), anemia (aOR 5.53, 95% CI 3.65-8.38, 3), pregestational diabetes (aOR 5.29, 95% CI 1.27-21.99, 3), heart disease (aOR 13.40, 95%CI 4.42-40.61, 5), multiple pregnancy (aOR 5.57, 95% CI 2.00-15.50, 3), placenta previa and/or placenta-accreta spectrum (aOR 48.19, 95% CI 22.75-102.09, 8), gestational hypertension/preeclampsia without severe features (aOR 5.95, 95% CI 2.64-13.45, 4), and with severe features (aOR 16.64, 95% CI 9.17-30.19, 6), preterm delivery <37 weeks (aOR 1.65, 95%CI 1.06-2.58, 1) and < 34 weeks (aOR 2.71, 95% CI 1.59-4.62, 2). A cut-off score of ≥4 gave the highest chance of correctly classified women into high risk group with 74.4% sensitivity and 90.4% specificity. CONCLUSIONS We identified predictors and proposed a scoring model to predict MNM and maternal mortality with acceptable predictive performance.
Collapse
Affiliation(s)
- Wipawan Raktong
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Rapphon Sawaddisan
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand.
| | - Krantarat Peeyananjarassri
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Chitkasaem Suwanrath
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Alan Geater
- Department of Epidemiology, Faculty of Medicine, Prince of Songkla, University, Songkhla, Thailand
| |
Collapse
|
9
|
Blankstein AR, Sigurdson SM, Frehlich L, Raizman Z, Donovan LE, Lemieux P, Pylypjuk C, Benham JL, Yamamoto JM. Pre-existing Diabetes and Stillbirth or Perinatal Mortality: A Systematic Review and Meta-analysis. Obstet Gynecol 2024:00006250-990000000-01125. [PMID: 39088826 DOI: 10.1097/aog.0000000000005682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 05/23/2024] [Indexed: 08/03/2024]
Abstract
OBJECTIVE Despite the well-recognized association between pre-existing diabetes mellitus and stillbirth or perinatal mortality, there remain knowledge gaps about the strength of association across different populations. The primary objective of this systematic review and meta-analysis was to quantify the association between pre-existing diabetes and stillbirth or perinatal mortality, and secondarily, to identify risk factors predictive of stillbirth or perinatal mortality among those with pre-existing diabetes. DATA SOURCES MEDLINE, EMBASE, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials from inception to April 2022. METHODS OF STUDY SELECTION Cohort studies and randomized controlled trials in English or French that examined the association between pre-existing diabetes and stillbirth or perinatal mortality (as defined by the original authors) or identified risk factors for stillbirth and perinatal mortality in individuals with pre-existing diabetes were included. Data extraction was performed independently and in duplicate with the use of prespecified inclusion and exclusion criteria. Assessment for heterogeneity and risk of bias was performed. Meta-analyses were completed with a random-effects model. TABULATION, INTEGRATION, AND RESULTS From 7,777 citations, 91 studies met the inclusion criteria. Pre-existing diabetes was associated with higher odds of stillbirth (37 studies; pooled odds ratio [OR] 3.74, 95% CI, 3.17-4.41, I2=82.5%) and perinatal mortality (14 studies; pooled OR 3.22, 95% CI, 2.54-4.07, I2=82.7%). Individuals with type 1 diabetes had lower odds of stillbirth (pooled OR 0.81, 95% CI, 0.68-0.95, I2=0%) and perinatal mortality (pooled OR 0.73, 95% CI, 0.61-0.87, I2=0%) compared with those with type 2 diabetes. Prenatal care and prepregnancy diabetes care were significantly associated with lower odds of stillbirth (OR 0.26, 95% CI, 0.11-0.62, I2=87.0%) and perinatal mortality (OR 0.41, 95% CI, 0.29-0.59, I2=0%). CONCLUSION Pre-existing diabetes confers a more than threefold increased odds of both stillbirth and perinatal mortality. Maternal type 2 diabetes was associated with a higher risk of stillbirth and perinatal mortality compared with maternal type 1 diabetes. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42022303112.
Collapse
Affiliation(s)
- Anna R Blankstein
- Department of Medicine, the Department of Obstetrics, Gynecology and Reproductive Sciences, and the Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, the Department of Community Health Sciences, the Department of Medicine, the Department of Obstetrics and Gynecology, the Alberta Children's Hospital Research Institute, the O'Brien Institute for Public Health, and the Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, and the Department of Medicine, Université Laval, Quebec City, Quebec, Canada; and Stanford Lifestyle Medicine, Stanford University, Redwood City, California
| | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Silver RM, Reddy U. Stillbirth: we can do better. Am J Obstet Gynecol 2024; 231:152-165. [PMID: 38789073 DOI: 10.1016/j.ajog.2024.05.042] [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: 12/27/2023] [Revised: 04/23/2024] [Accepted: 05/20/2024] [Indexed: 05/26/2024]
Abstract
Stillbirth is far too common, occurring in millions of pregnancies per year globally. The rate of stillbirth (defined as death of a fetus prior to birth at 20 weeks' gestation or more) in the United States is 5.73 per 1000. This is approximately 1 in 175 pregnancies accounting for about 21,000 stillbirths per year. Although rates are much higher in low-income countries, the stillbirth rate in the United States is much higher than most high resource countries. Moreover, there are substantial disparities in stillbirth, with rates twice as high for non-Hispanic Black and Native Hawaiian or Other Pacific Islanders compared to non-Hispanic Whites. There is considerable opportunity for reduction in stillbirths, even in high resource countries such as the United States. In this article, we review the epidemiology, risk factors, causes, evaluation, medical and emotional management, and prevention of stillbirth. We focus on novel data regarding genetic etiologies, placental assessment, risk stratification, and prevention.
Collapse
Affiliation(s)
- Robert M Silver
- Departments of Obstetrics and Gynecology, Divisions of Maternal Fetal Medicine, University of Utah, Salt Lake City, UT.
| | - Uma Reddy
- Departments of Obstetrics and Gynecology, Divisions of Maternal Fetal Medicine, Columbia University, New York, NY
| |
Collapse
|
11
|
Parker J, Hofstee P, Brennecke S. Prevention of Pregnancy Complications Using a Multimodal Lifestyle, Screening, and Medical Model. J Clin Med 2024; 13:4344. [PMID: 39124610 PMCID: PMC11313446 DOI: 10.3390/jcm13154344] [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: 06/19/2024] [Revised: 07/16/2024] [Accepted: 07/22/2024] [Indexed: 08/12/2024] Open
Abstract
Prevention of pregnancy complications related to the "great obstetrical syndromes" (preeclampsia, fetal growth restriction, spontaneous preterm labor, and stillbirth) is a global research and clinical management priority. These syndromes share many common pathophysiological mechanisms that may contribute to altered placental development and function. The resulting adverse pregnancy outcomes are associated with increased maternal and perinatal morbidity and mortality and increased post-partum risk of cardiometabolic disease. Maternal nutritional and environmental factors are known to play a significant role in altering bidirectional communication between fetal-derived trophoblast cells and maternal decidual cells and contribute to abnormal placentation. As a result, lifestyle-based interventions have increasingly been recommended before, during, and after pregnancy, in order to reduce maternal and perinatal morbidity and mortality and decrease long-term risk. Antenatal screening strategies have been developed following extensive studies in diverse populations. Multivariate preeclampsia screening using a combination of maternal, biophysical, and serum biochemical markers is recommended at 11-14 weeks' gestation and can be performed at the same time as the first-trimester ultrasound and blood tests. Women identified as high-risk can be offered prophylactic low dose aspirin and monitored with angiogenic factor assessment from 22 weeks' gestation, in combination with clinical assessment, serum biochemistry, and ultrasound. Lifestyle factors can be reassessed during counseling related to antenatal screening interventions. The integration of lifestyle interventions, pregnancy screening, and medical management represents a conceptual advance in pregnancy care that has the potential to significantly reduce pregnancy complications and associated later life cardiometabolic adverse outcomes.
Collapse
Affiliation(s)
- Jim Parker
- School of Medicine, University of Wollongong, Wollongong 2522, Australia;
| | - Pierre Hofstee
- School of Medicine, University of Wollongong, Wollongong 2522, Australia;
- Tweed Hospital, Northern New South Wales Local Health District, Tweed Heads 2485, Australia
| | - Shaun Brennecke
- Department of Maternal-Fetal Medicine, Pregnancy Research Centre, The Royal Women’s Hospital, Melbourne 3052, Australia;
- Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne 3052, Australia
| |
Collapse
|
12
|
Wong GP, Hartmann S, Simmons DG, Ellis S, Nonn O, Cannon P, Nguyen TV, Nguyen A, Bartho LA, Tong S, Hannan NJ, Kaitu'u-Lino TJ. Trophoblast Side-Population Markers are Dysregulated in Preeclampsia and Fetal Growth Restriction. Stem Cell Rev Rep 2024:10.1007/s12015-024-10764-w. [PMID: 39028417 DOI: 10.1007/s12015-024-10764-w] [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] [Accepted: 07/10/2024] [Indexed: 07/20/2024]
Abstract
Dysregulated progenitor cell populations may contribute to poor placental development and placental insufficiency pathogenesis. Side-population cells possess progenitor properties. Recent human trophoblast side-population isolation identified enrichment of 8 specific genes (CXCL8, ELL2, GATA6, HK2, HLA-DPB1, INTS6, SERPINE3 and UPP1) (Gamage et al. 2020, Stem Cell Rev Rep). We characterised these trophoblast side-population markers in human placenta and in placental insufficiency disorders: preeclampsia and fetal growth restriction (FGR). Trophoblast side-population markers localised to mononuclear trophoblasts lining the placental villous basement membrane in preterm control, preeclamptic and FGR placental sections (n = 3, panel of 3 markers/serial section). Analysis of single-cell transcriptomics of an organoid human trophoblast stem cell (hTSC) to extravillous trophoblast (EVT) differentiation model (Shannon et al. 2022, Development) identified that all side-population genes were enriched in mononuclear trophoblast and trophoblasts committed to differentiation under hTSC culture conditions. In vitro validation via 96 h time course hTSC differentiation to EVTs or syncytiotrophoblasts (n = 5) demonstrated ELL2 and HK2 increased with differentiation (p < 0.0024, p < 0.0039 respectively). CXCL8 and HLA-DPB1 were downregulated (p < 0.030, p < 0.011 respectively). GATA6 and INTS6 increased with EVT differentiation only, and UPP1 reduced with syncytialisation. SERPINE3 was undetectable. Trophoblast side-population marker mRNA was measured in human placentas (< 34-weeks' gestation; n = 78 preeclampsia, n = 30 FGR, and n = 18 gestation-matched controls). ELL2, HK2 and CXCL8 were elevated in preeclamptic (p = 0.0006, p < 0.0001, p = 0.0335 respectively) and FGR placentas (p = 0.0065, p < 0.0001, p = 0.0001 respectively) versus controls. Placental GATA6 was reduced in pregnancies with preeclampsia and FGR (p = 0.0014, p = 0.0146 respectively). Placental INTS6 was reduced with FGR only (p < 0.0001). This study identified the localisation of a unique trophoblast subset enriched for side-population markers. Aberrant expression of some side-population markers may indicate disruptions to unique trophoblast subtypes in placental insufficiency.
Collapse
Affiliation(s)
- Georgia P Wong
- The Department of Obstetrics, Gynaecology and Newborn Health, Mercy Hospital for Women, University of Melbourne, 163 Studley Road, Heidelberg, Victoria, 3084, Australia.
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia.
| | - Sunhild Hartmann
- The Department of Obstetrics, Gynaecology and Newborn Health, Mercy Hospital for Women, University of Melbourne, 163 Studley Road, Heidelberg, Victoria, 3084, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
- Experimental and Clinical Research Center, a cooperation between the Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association and the Charité - Universitätsmedizin Berlin, Berlin, Germany
- Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- DZHK (German Center for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - David G Simmons
- School of Biomedical Sciences, University of Queensland, Brisbane, Australia
| | - Sarah Ellis
- Olivia Newton-John Cancer Research Institute, Heidelberg, VIC, 3084, Australia
- School of Cancer Medicine, La Trobe University, Melbourne, VIC, 3086, Australia
| | - Olivia Nonn
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
- Experimental and Clinical Research Center, a cooperation between the Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association and the Charité - Universitätsmedizin Berlin, Berlin, Germany
- Max-Delbrück-Center for Molecular Medicine in the Helmholtz Association (MDC), Berlin, Germany
- DZHK (German Center for Cardiovascular Research), partner site Berlin, Berlin, Germany
- Division of Cell Biology, Histology and Embryology, Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
| | - Ping Cannon
- The Department of Obstetrics, Gynaecology and Newborn Health, Mercy Hospital for Women, University of Melbourne, 163 Studley Road, Heidelberg, Victoria, 3084, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Tuong-Vi Nguyen
- The Department of Obstetrics, Gynaecology and Newborn Health, Mercy Hospital for Women, University of Melbourne, 163 Studley Road, Heidelberg, Victoria, 3084, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Anna Nguyen
- The Department of Obstetrics, Gynaecology and Newborn Health, Mercy Hospital for Women, University of Melbourne, 163 Studley Road, Heidelberg, Victoria, 3084, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Lucy A Bartho
- The Department of Obstetrics, Gynaecology and Newborn Health, Mercy Hospital for Women, University of Melbourne, 163 Studley Road, Heidelberg, Victoria, 3084, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Stephen Tong
- The Department of Obstetrics, Gynaecology and Newborn Health, Mercy Hospital for Women, University of Melbourne, 163 Studley Road, Heidelberg, Victoria, 3084, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Natalie J Hannan
- The Department of Obstetrics, Gynaecology and Newborn Health, Mercy Hospital for Women, University of Melbourne, 163 Studley Road, Heidelberg, Victoria, 3084, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Tu'uhevaha J Kaitu'u-Lino
- The Department of Obstetrics, Gynaecology and Newborn Health, Mercy Hospital for Women, University of Melbourne, 163 Studley Road, Heidelberg, Victoria, 3084, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| |
Collapse
|
13
|
Umapathy A, Clark A, Sehgal A, Karanam V, Rajaraman G, Kalionis B, Jones H, James J, Murthi P. Molecular regulators of defective placental and cardiovascular development in fetal growth restriction. Clin Sci (Lond) 2024; 138:761-775. [PMID: 38904187 PMCID: PMC11193155 DOI: 10.1042/cs20220428] [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: 12/29/2023] [Revised: 05/12/2024] [Accepted: 05/22/2024] [Indexed: 06/22/2024]
Abstract
Placental insufficiency is one of the major causes of fetal growth restriction (FGR), a significant pregnancy disorder in which the fetus fails to achieve its full growth potential in utero. As well as the acute consequences of being born too small, affected offspring are at increased risk of cardiovascular disease, diabetes and other chronic diseases in later life. The placenta and heart develop concurrently, therefore placental maldevelopment and function in FGR may have profound effect on the growth and differentiation of many organ systems, including the heart. Hence, understanding the key molecular players that are synergistically linked in the development of the placenta and heart is critical. This review highlights the key growth factors, angiogenic molecules and transcription factors that are common causes of defective placental and cardiovascular development.
Collapse
Affiliation(s)
- Anandita Umapathy
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
| | - Alys Clark
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
- Auckland Bioengineering Institute, Bioengineering Institute, New Zealand
| | - Arvind Sehgal
- Department of Paediatrics, Monash University, Melbourne, VIC, Australia and Monash Newborn, Monash Children’s Hospital, Melbourne, VIC, Australia
| | - Vijaya Karanam
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne and Royal Women’s Hospital, Victoria, Australia
| | - Gayathri Rajaraman
- First year college, Victoria University, St Albans, Victoria 3021, Australia
| | - Bill Kalionis
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne and Royal Women’s Hospital, Victoria, Australia
- Department of Maternal Fetal Medicine, Pregnancy Research Centre, Royal Women’s Hospital, Victoria, Australia
| | - Helen N. Jones
- Department of Physiology and Aging, University of Florida College of Medicine, Gainesville, FL, U.S.A
- Center for Research in Perinatal Outcomes, University of Florida College of Medicine, Gainesville, FL, U.S.A
| | - Jo James
- Department of Obstetrics and Gynaecology, Faculty of Medical and Health Sciences, University of Auckland, New Zealand
- Auckland Bioengineering Institute, Bioengineering Institute, New Zealand
| | - Padma Murthi
- Department of Obstetrics, Gynaecology and Newborn Health, University of Melbourne and Royal Women’s Hospital, Victoria, Australia
- Department of Maternal Fetal Medicine, Pregnancy Research Centre, Royal Women’s Hospital, Victoria, Australia
- Department of Pharmacology, Biomedicine Discovery Institute, Monash University, Clayton, Victoria, Australia
| |
Collapse
|
14
|
Darby JRT, Saini BS, Holman SL, Hammond SJ, Perumal SR, Macgowan CK, Seed M, Morrison JL. Acute-on-chronic: using magnetic resonance imaging to disentangle the haemodynamic responses to acute and chronic fetal hypoxaemia. Front Med (Lausanne) 2024; 11:1340012. [PMID: 38933113 PMCID: PMC11199546 DOI: 10.3389/fmed.2024.1340012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 06/04/2024] [Indexed: 06/28/2024] Open
Abstract
Introduction The fetal haemodynamic response to acute episodes of hypoxaemia are well characterised. However, how these responses change when the hypoxaemia becomes more chronic in nature such as that associated with fetal growth restriction (FGR), is less well understood. Herein, we utilised a combination of clinically relevant MRI techniques to comprehensively characterize and differentiate the haemodynamic responses occurring during acute and chronic periods of fetal hypoxaemia. Methods Prior to conception, carunclectomy surgery was performed on non-pregnant ewes to induce FGR. At 108-110 days (d) gestational age (GA), pregnant ewes bearing control (n = 12) and FGR (n = 9) fetuses underwent fetal catheterisation surgery. At 117-119 days GA, ewes underwent MRI sessions where phase-contrast (PC) and T2 oximetry were used to measure blood flow and oxygenation, respectively, throughout the fetal circulation during a normoxia and then an acute hypoxia state. Results Fetal oxygen delivery (DO2) was lower in FGR fetuses than controls during the normoxia state but cerebral DO2 remained similar between fetal groups. Acute hypoxia reduced both overall fetal and cerebral DO2. FGR increased ductus venosus (DV) and foramen ovale (FO) blood flow during both the normoxia and acute hypoxia states. Pulmonary blood flow (PBF) was lower in FGR fetuses during the normoxia state but similar to controls during the acute hypoxia state when PBF in controls was decreased. Conclusion Despite a prevailing level of chronic hypoxaemia, the FGR fetus upregulates the preferential streaming of oxygen-rich blood via the DV-FO pathway to maintain cerebral DO2. However, this upregulation is unable to maintain cerebral DO2 during further exposure to an acute episode of hypoxaemia. The haemodynamic alterations required at the level of the liver and lung to allow the DV-FO pathway to maintain cerebral DO2, may have lasting consequences on hepatic function and pulmonary vascular regulation after birth.
Collapse
Affiliation(s)
- Jack R. T. Darby
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Brahmdeep S. Saini
- Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Research Institute, Toronto, ON, Canada
| | - Stacey L. Holman
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Sarah J. Hammond
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
| | - Sunthara Rajan Perumal
- Preclinical, Imaging & Research Laboratories, South Australian Health & Medical Research Institute, Adelaide, SA, Australia
| | - Christopher K. Macgowan
- Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Research Institute, Toronto, ON, Canada
| | - Mike Seed
- Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Research Institute, Toronto, ON, Canada
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Janna L. Morrison
- Early Origins of Adult Health Research Group, Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia, Adelaide, SA, Australia
- Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Research Institute, Toronto, ON, Canada
- Department of Physiology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
15
|
Leroy AC, Braund S, Dreyfus M, Diguet A, Mathieu N, Benichou J, Verspyck E. Comparative analysis of quality scores images between second- and third-trimester ultrasound scan. J Gynecol Obstet Hum Reprod 2024; 53:102805. [PMID: 38844086 DOI: 10.1016/j.jogoh.2024.102805] [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: 03/03/2024] [Revised: 05/19/2024] [Accepted: 05/21/2024] [Indexed: 06/20/2024]
Abstract
OBJECTIVES To evaluate whether the quality scores validated for second-trimester ultrasound scan can be used for third-trimester ultrasound scan. METHODS Prospective multicenter ancillary study using data from the RECRET study. Nulliparous women, with no reported history, with second- and third-trimester ultrasound examinations performed by the same ultrasonographer and using the same ultrasound machine were recruited. The global score and the individual score of each ultrasound image were compared between second- and third-trimester ultrasound scan. The sample size was calculated for a non-inferiority (one-sided) paired Student t test. RESULTS 103 women with 1606 anonymized ultrasound images were included. The median term at second- and third-trimester ultrasound scan was 22.2 weeks gestation (22.0-22.7) and 31.6 weeks gestation (30.7-34.7), respectively. The mean global score of ultrasound images was comparable between the second- and the third-trimester ultrasound examination (32.37 ± 2.62 versus 31.80 ± 3.27, p = 0.13). Means scores for each biometric parameters i.e. head circumference, abdominal circumference, and femur diaphysis length were comparable. The scores for the four-chamber view (5.11 ± 0.91 versus 5.36 ± 0.75, p = 0.02) and the spine (4.18 ± 1.17 versus 5.22 ± 1.02, p < 0.001) were significantly lower in the third trimester compared to the second trimester. The score for the kidney image was significantly higher for third trimester images compared to second trimester images (4.73 ± 0.51 versus 4.32 ± 0.67, p < 0.001. CONCLUSIONS Biometrics parameters quality scores images previously validated for the second trimester ultrasound scan can be also used for the third trimester scan. However, anatomical quality scores images performances may vary between the second and the third trimester scan.
Collapse
Affiliation(s)
- A C Leroy
- Department of Obstetrics and Gynecology, Lens Hospital, Lens, France
| | - S Braund
- Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, France
| | - M Dreyfus
- Department of Obstetrics and Gynecology, Caen University Hospital, Caen, France
| | - A Diguet
- Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, France
| | - N Mathieu
- Department of Obstetrics and Gynecology, Maternity Mathilde, Rouen, France
| | - J Benichou
- Department of Biostatistics, Rouen University Hospital, Rouen, France and Inserm U1018, France
| | - E Verspyck
- Department of Obstetrics and Gynecology, Rouen University Hospital, Rouen, France.
| |
Collapse
|
16
|
Sabren S, Hagar T, Khateeb N, Evgeny F, Yara FN, Perlitz Y, Farid N. Placental and serum levels of human α-Klotho in preeclampsia & intra-uterine growth retardation: A potential sensitive biomarker? Pregnancy Hypertens 2024; 36:101115. [PMID: 38608394 DOI: 10.1016/j.preghy.2024.101115] [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: 05/02/2023] [Revised: 01/22/2024] [Accepted: 02/17/2024] [Indexed: 04/14/2024]
Abstract
INTRODUCTION α-Klotho protein has three isoforms: a transmembrane (mKL), a shed- soluble isoform, and a circulating soluble isoform (sKL). mKL is expressed in the kidney and placenta, while sKL is detectable in blood and urine. It is known that α-Klotho levels fluctuate during pregnancy mainly in women with complications such as preeclampsia (PE) and intra-uterine growth restriction (IUGR). METHODS Forty-nine participants were divided into two groups: healthy and complicated pregnancy (PE, IUGR or both). Tissue samples (2 cm3) from the maternal side, Blood and urine samples were collected during pregnancy and postpartum. Samples were subjected to biochemical (WB), histological (H&E and IHC) staining as well as genetic analysis (qPCR). RESULTS Blood αKL levels were preserved in both healthy and complicated pregnancies. Significantly lower blood αKL concentrations were found in PE postpartum (PP) compared to levels during pregnancy, and were significantly lower compared with postpartum of a healthy pregnancy. αKL activity was reduced in complicated pregnancies vs. healthy pregnancies. Placen tal mKL levels (ELISA) and expression (WB) were lowered in complicated pregnancies compared with the healthy pregnancies group. Additionally, we found a significant decline in the expression of mKL mRNA in PE/IUGR placentas compared with the healthy group. DISCUSSION Several studies have focused on the involvement of αKL in normal placentation during pregnancy. Our results suggest lower function of sKL in complicated pregnancy compared with a control, and present differences in placental mKL levels as well as tissue and gene expression between healthy and complicated pregnancy. In light of our results, we conclude that complicated pregnancy is associated with in decline in mKL.
Collapse
Affiliation(s)
- Shehada Sabren
- Diabetes and Metabolism Lab, Tzafon Medical Center, Israel; Azrieli Faculty of Medicine, Safed, Bar Ilan University, Ramat-Gan, Israel
| | - Tadmor Hagar
- Diabetes and Metabolism Lab, Tzafon Medical Center, Israel
| | - Nardeen Khateeb
- Gynecological and Obstetrics Department, Tzafon Medical Center, Israel
| | | | - Francis-Nakhle Yara
- Gynecological and Obstetrics Department, Galilee Medical Center, Nahariya, Israel
| | - Youri Perlitz
- Gynecological and Obstetrics Department, Tzafon Medical Center, Israel
| | - Nakhoul Farid
- Azrieli Faculty of Medicine, Safed, Bar Ilan University, Ramat-Gan, Israel; Cardiovascular Laboratory, Medical Research Institute, The Galilee Medical Center, Nahariya, Israel.
| |
Collapse
|
17
|
Robles Espinoza K, López Uriarte GA, García Castañeda GB, Torres Muñoz I, Lugo Trampe JDJ, Elizondo Riojas G, Barboza Quintana O, Ponce Camacho M, Guzmán López A, Martínez de Villareal L. Multidisciplinary Workup for Stillbirth at a Tertiary-Care Hospital in Northeast Mexico: Findings, Challenges and Perspectives. Matern Child Health J 2024; 28:1072-1079. [PMID: 38184497 DOI: 10.1007/s10995-023-03874-3] [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] [Accepted: 12/17/2023] [Indexed: 01/08/2024]
Abstract
OBJECTIVES Stillbirth is an important health problem, and in Mexico, only half of the stillbirths have an explainable cause. The aim of this study was to implement a multidisciplinary workup to identify the etiology and potential risk factors for stillbirth at the Hospital Universitario "Dr. José Eleuterio González". METHODS This is a prospective, descriptive, observational study that included stillbirths from the Obstetrics Service from October 1st, 2019 to May 25, 2020. Evaluation strategies included a complete maternal medical history, physical examination of the fetus, and a photographic medical record. For every stillbirth either a prenatal ultrasound, a postnatal x-ray, or a fetal autopsy, were needed. Multiplex Ligation Probe Amplification (MLPA) was performed with an umbilical cord sample. RESULTS Thirty-three stillbirths were reported; 21 were included in the analysis. Eleven women (52.3%) had known risk factors for stillbirth, mainly elevated body mass index and diabetes. On physical examination, external birth defects were found in 8 fetuses (38%). X-ray was performed in 14 cases (66%), alterations were detected as a probable etiologic cause just in one. All cases underwent MLPA, which were reported negative. Three cases had criteria for autopsy. Findings were inconclusive to determine etiology. CONCLUSIONS The best tools for evaluation of stillbirth were the elaboration of clinical history, physical examination, and prenatal ultrasound. Diabetes and obesity were the most frequent risk factors found in our population. These factors are preventable by implementing strategies that lead to better prenatal care.
Collapse
Affiliation(s)
- Kiabeth Robles Espinoza
- Department of Genetics, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico.
| | - Graciela Arelí López Uriarte
- Department of Genetics, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico.
| | - Gloria Beatriz García Castañeda
- Department of Genetics, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - Iris Torres Muñoz
- Department of Genetics, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - José de Jesús Lugo Trampe
- Department of Genetics, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - Guillermo Elizondo Riojas
- Department of Radiology and Imaging, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - Oralia Barboza Quintana
- Department of Pathologic Anatomy, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - Marco Ponce Camacho
- Department of Pathologic Anatomy, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - Abel Guzmán López
- Gynecology and Obstetrics Service, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| | - Laura Martínez de Villareal
- Department of Genetics, Universidad Autónoma de Nuevo León, Facultad de Medicina y Hospital Universitario "Dr. José Eleuterio González", Monterrey, Mexico
| |
Collapse
|
18
|
Yusrika MU, Al Fattah AN, Kusuma RA, Widjaja FF, Marizni S, Putri VP. Incidence and first trimester risk factors of stillbirth in Indonesia. J Perinat Med 2024; 52:392-398. [PMID: 38407221 DOI: 10.1515/jpm-2023-0348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 01/28/2024] [Indexed: 02/27/2024]
Abstract
OBJECTIVES To determine the incidence and the risk factors of stillbirth from maternal biophysical, ultrasound, and biochemical markers at 11-13 weeks of gestation in the Indonesian population. METHODS This was a retrospective cohort study of pregnant women for first-trimester preeclampsia screening at 11-13 weeks of gestation in some clinics and hospital in Jakarta. Maternal characteristics and history, mean arterial pressure (MAP) measurement, uterine artery pulsatility index (UtA-PI) ultrasound, maternal ophthalmic peak ratio (Oph-PR) Doppler, and placental growth factor (PlGF) serum were collected during the visit. Stillbirth was classified into placental dysfunction-related when it occurred with preeclampsia or birth weight <10th percentile and non-placental dysfunction-related. Bivariate and multivariate logistic regression analyses were employed to determine the risk factors associated with stillbirth. RESULTS Of 1,643 eligible participants, 13 (0.79 %) stillbirth cases were reported. More than half of the stillbirths (7) were placental dysfunction-related. After adjusted with maternal age, body mass index (BMI), and parity status, chronic hypertension (aOR (adjusted odds ratio)) 24.41, 95 % CI {confidence interval} 5.93-100.43), previous pregnancy with preeclampsia (aOR 15.79, 95 % CI 4.42-56.41), MAP >101.85 (aOR 26.67, 95 % CI 8.26-86.06), UtA-PI >1.90 (aOR 10.68, 95 % CI 2.34-48.58, and PlGF <28.77 pg/mL (aOR 18.60, 95 % CI 5.59-61.92) were associated with stillbirth. CONCLUSIONS The incidence of stillbirth in the population is comparable to studies conducted in developed countries. Most routine variables assessed at the 11-13 weeks combined screening for preeclampsia are associated with the risk of stillbirth.
Collapse
Affiliation(s)
| | - Adly Nanda Al Fattah
- 633485 Indonesian Prenatal Institute , Jakarta, Indonesia
- Kosambi Maternal and Children Center, Jakarta, Indonesia
| | - Raden Aditya Kusuma
- 633485 Indonesian Prenatal Institute , Jakarta, Indonesia
- Harapan Kita National Women and Children Hospital, Jakarta, Indonesia
| | | | - Shinda Marizni
- 633485 Indonesian Prenatal Institute , Jakarta, Indonesia
| | - Vania Permata Putri
- 633485 Indonesian Prenatal Institute , Jakarta, Indonesia
- Kosambi Maternal and Children Center, Jakarta, Indonesia
| |
Collapse
|
19
|
Bowman A, Sullivan T, Makrides M, Flenady V, Shepherd E, Hawke K, Stuart-Butler D, Leane C, Middleton P. Lifestyle and sociodemographic risk factors for stillbirth by region of residence in South Australia: a retrospective cohort study. BMC Pregnancy Childbirth 2024; 24:368. [PMID: 38750442 PMCID: PMC11097586 DOI: 10.1186/s12884-024-06553-5] [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: 03/14/2024] [Accepted: 04/29/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Stillbirth rates remain a global priority and in Australia, progress has been slow. Risk factors of stillbirth are unique in Australia due to large areas of remoteness, and limited resource availability affecting the ability to identify areas of need and prevalence of factors associated with stillbirth. This retrospective cohort study describes lifestyle and sociodemographic factors associated with stillbirth in South Australia (SA), between 1998 and 2016. METHODS All restigered births in SA between 1998 ad 2016 are included. The primary outcome was stillbirth (birth with no signs of life ≥ 20 weeks gestation or ≥ 400 g if gestational age was not reported). Associations between stillbirth and lifestyle and sociodemographic factors were evaluated using multivariable logistic regression and described using adjusted odds ratios (aORs). RESULTS A total of 363,959 births (including 1767 stillbirths) were included. Inadequate antenatal care access (assessed against the Australian Pregnancy Care Guidelines) was associated with the highest odds of stillbirth (aOR 3.93, 95% confidence interval (CI) 3.41-4.52). Other factors with important associations with stillbirth were plant/machine operation (aOR, 1.99; 95% CI, 1.16-2.45), birthing person age ≥ 40 years (aOR, 1.92; 95% CI, 1.50-2.45), partner reported as a pensioner (aOR, 1.83; 95% CI, 1.12-2.99), Asian country of birth (aOR, 1.58; 95% CI, 1.19-2.10) and Aboriginal/Torres Strait Islander status (aOR, 1.50; 95% CI, 1.20-1.88). The odds of stillbirth were increased in regional/remote areas in association with inadequate antenatal care (aOR, 4.64; 95% CI, 2.98-7.23), birthing age 35-40 years (aOR, 1.92; 95% CI, 1.02-3.64), Aboriginal and/or Torres Strait Islander status (aOR, 1.90; 95% CI, 1.12-3.21), paternal occupations: tradesperson (aOR, 1.69; 95% CI, 1.17-6.16) and unemployment (aOR, 4.06; 95% CI, 1.41-11.73). CONCLUSION Factors identified as independently associated with stillbirth odds include factors that could be addressed through timely access to adequate antenatal care and are likely relevant throughout Australia. The identified factors should be the target of stillbirth prevention strategies/efforts. SThe stillbirth rate in Australia is a national concern. Reducing preventable stillbirths remains a global priority.
Collapse
Affiliation(s)
- Anneka Bowman
- Aboriginal Communities and Families Health Research Alliance (ACRA), Adelaide, Australia.
- South Australian Health and Medical Research Institute, North terrace, Adelaide, Australia.
- University of Adelaide, Adelaide, Australia.
- Centre for Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia.
| | - Thomas Sullivan
- South Australian Health and Medical Research Institute, North terrace, Adelaide, Australia
- University of Adelaide, Adelaide, Australia
| | - Maria Makrides
- South Australian Health and Medical Research Institute, North terrace, Adelaide, Australia
- University of Adelaide, Adelaide, Australia
| | - Vicki Flenady
- Centre for Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia
| | - Emily Shepherd
- South Australian Health and Medical Research Institute, North terrace, Adelaide, Australia
- University of Adelaide, Adelaide, Australia
| | - Karen Hawke
- Aboriginal Communities and Families Health Research Alliance (ACRA), Adelaide, Australia
- Flinders University, Adelaide, Australia
| | - Deanna Stuart-Butler
- Centre for Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia
| | - Cathy Leane
- Aboriginal Health Division of the Women's and Children's Health Network, Adelaide, Australia
| | - Philippa Middleton
- Aboriginal Communities and Families Health Research Alliance (ACRA), Adelaide, Australia
- South Australian Health and Medical Research Institute, North terrace, Adelaide, Australia
- University of Adelaide, Adelaide, Australia
- Centre for Research Excellence in Stillbirth, Mater Research Institute, The University of Queensland, Brisbane, Australia
| |
Collapse
|
20
|
Ewington LJ, Hugh O, Butler E, Quenby S, Gardosi J. Accuracy of antenatal ultrasound in predicting large-for-gestational-age babies: population-based cohort study. Am J Obstet Gynecol 2024:S0002-9378(24)00578-7. [PMID: 38723984 DOI: 10.1016/j.ajog.2024.04.052] [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: 02/22/2024] [Revised: 04/30/2024] [Accepted: 04/30/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND Pregnancies with large-for-gestational-age fetuses are at increased risk of adverse maternal and neonatal outcomes. There is uncertainty about how to manage birth in such pregnancies. Current guidelines recommend a discussion with women of the pros and cons of options, including expectant management, induction of labor, and cesarean delivery. For women to make an informed decision about birth, antenatal detection of large for gestational age is essential. OBJECTIVE To investigate the ability of antenatal ultrasound scans to predict large for gestational age at birth. STUDY DESIGN In this retrospective cohort study, we analyzed data from a routinely collected database from the West Midlands, United Kingdom. We included pregnancies that had an antenatal ultrasound-estimated fetal weight between 35+0 and 38+0 weeks gestation for any indication and a subgroup where the reason for the scan was that the fetus was suspected to be big. Large for gestational age was defined as >90th customized GROW percentile for estimated fetal weight as well as neonatal weight. In addition, we tested the performance of an uncustomized standard, with Hadlock fetal weight >90th percentile and neonatal weight >4 kg. We calculated diagnostic characteristics for the whole population and groups with different maternal body mass indexes. RESULTS The study cohort consisted of 26,527 pregnancies, which, on average, had a scan at 36+4 weeks gestation and delivered 20 days later at a median of 39+3 weeks (interquartile range 15). In total, 2241 (8.4%) of neonates were large for gestational age by customized percentiles, of which 1459 (65.1%) had a scan estimated fetal weight >90th percentile, with a false positive rate of 8.6% and a positive predictive value of 41.0%. In the subgroup of 912 (3.4%) pregnancies scanned for a suspected large fetus, 293 (32.1%) babies were large for gestational age at birth, giving a positive predictive value of 50.3%, with a sensitivity of 77.1% and false positive rate of 36.0%. When comparing subgroups from low (<18.5 kg/m2) to high body mass index (>30 kg/m2), sensitivity increased from 55.6% to 67.8%, false positive rate from 5.2% to 11.5%, and positive predictive value from 32.1% to 42.3%. A total of 2585 (9.7%) babies were macrosomic (birthweight >4 kg), and of these, 1058 (40.9%) were large for gestational age (>90th percentile) antenatally by Hadlock's growth standard, with a false positive rate of 4.9% and a positive predictive value 41.0%. Analysis within subgroups showed better performance by customized than uncustomized standards for low body mass index (<18.5; diagnostic odds ratio, 23.0 vs 6.4) and high body mass index (>30; diagnostic odds ratio, 16.2 vs 8.8). CONCLUSION Late third-trimester ultrasound estimation of fetal weight for any indication has a good ability to identify and predict large for gestational age at birth and improves with the use of a customized standard. The detection rate is better when an ultrasound is performed for a suspected large fetus but at the risk of a higher false positive diagnosis. Our results provide information for women and clinicians to aid antenatal decision-making about the birth of a fetus suspected of being large for gestational age.
Collapse
Affiliation(s)
- Lauren J Ewington
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, United Kingdom
| | - Oliver Hugh
- Perinatal Institute, Birmingham, United Kingdom
| | | | - Siobhan Quenby
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, United Kingdom; University Hospitals Coventry and Warwickshire, United Kingdom
| | - Jason Gardosi
- Division of Biomedical Sciences, Warwick Medical School, University of Warwick, United Kingdom; Perinatal Institute, Birmingham, United Kingdom.
| |
Collapse
|
21
|
Moore MD, Mazzoni SE, Wingate MS, Bronstein JM. Severe Maternal Morbidity among Low-Income Patients with Hypertensive Disorders of Pregnancy. Am J Perinatol 2024; 41:e563-e572. [PMID: 35977711 DOI: 10.1055/a-1925-9972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECTIVE Hypertensive disorders of pregnancy (HDP) contribute significantly to the development of severe maternal morbidities (SMM), particularly among low-income women. The purpose of the study was to explore the relationship between maternal characteristics and SMM, and to investigate if differences in SMM exist among patients with HDP diagnosis. STUDY DESIGN This study utilized 2017 Alabama Medicaid administrative claims. SMM diagnoses were captured using the Centers for Disease Control and Prevention's classification by International Classification of Diseases codes. Maternal characteristics and frequencies were compared using Chi-square and Cramer's V statistics. Logistic regression analyses were conducted to examine multivariable relationships between maternal characteristics and SMM among patients with HDP diagnosis. Odds ratios and 95% confidence intervals (CIs) were used to estimate risk. RESULTS A higher proportion of patients experiencing SMM were >34 years old, Black, Medicaid for Low-Income Families eligible, lived in a county with greater Medicaid enrollment, and entered prenatal care (PNC) in the first trimester compared with those without SMM. Almost half of patients (46.2%) with SMM had a HDP diagnosis. After controlling for maternal characteristics, HDP, maternal age, county Medicaid enrollment, and trimester PNC entry were not associated with SMM risk. However, Black patients with HDP were at increased risk for SMM compared with White patients with HDP when other factors were taken into account (adjusted odds ratio [aOR] = 1.37, 95% CI: 1.11-1.69). Patients with HDP and SMM were more likely to have a prenatal hospitalization (aOR = 1.45, 95% CI: 1.20-1.76), emergency visit (aOR = 1.30, 95% CI: 1.07-1.57), and postpartum cardiovascular prescription (aOR = 2.43, 95% CI: 1.95-3.04). CONCLUSION Rates of SMM differed by age, race, Medicaid income eligibility, and county Medicaid enrollment but were highest among patients with clinical comorbidities, especially HDP. However, among patients with HDP, Black patients had an elevated risk of severe morbidity even after controlling for other characteristics. KEY POINTS · Patients with SMM were more likely to have a HDP diagnosis.. · Among those with HDP, Black patients had elevated risk of SMM.. · Differences in care delivery did not explain SMM disparities..
Collapse
Affiliation(s)
- Matthew D Moore
- Department of Health Policy and Organization, School of Public Health, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Sara E Mazzoni
- Department of Obstetrics and Gynecology, School of Medicine, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Martha S Wingate
- Department of Health Policy and Organization, School of Public Health, The University of Alabama at Birmingham, Birmingham, Alabama
| | - Janet M Bronstein
- Department of Health Policy and Organization, School of Public Health, The University of Alabama at Birmingham, Birmingham, Alabama
| |
Collapse
|
22
|
Yeshitila YG, Gold L, Riggs E, Abimanyi-Ochom J, Sweet L, Le HND. Trends and disparities in perinatal health outcomes among women from refugee backgrounds in Victoria, Australia: A population-based study. Midwifery 2024; 132:103980. [PMID: 38547597 DOI: 10.1016/j.midw.2024.103980] [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: 11/05/2023] [Revised: 03/03/2024] [Accepted: 03/18/2024] [Indexed: 04/28/2024]
Abstract
BACKGROUND Women from refugee backgrounds generally experience poorer pregnancy-related outcomes compared to host populations. AIM To examine the trend and disparities in adverse perinatal outcomes among women of refugee background using population-based data from 2003 to 2017. METHODS A population-based cross-sectional study of 754,270 singleton births in Victoria compared mothers of refugee backgrounds with Australian-born mothers. Inferential statistics, including Pearson chi-square and binary logistic regression, were conducted. Multiple logistic regression was conducted to explore the relationship between adverse perinatal outcomes and the women's refugee status. FINDINGS Women of refugee background had higher odds of adverse neonatal and maternal outcomes, including stillbirth, neonatal death, low APGAR score, small for gestational age, postpartum haemorrhage, abnormal labour, perineal tear, and maternal admission to intensive care compared to Australian-born women. However, they had lower odds of neonatal admission to intensive care, pre-eclampsia, and maternal postnatal depression. The trend analysis showed limited signs of gaps closing over time in adverse perinatal outcomes. DISCUSSION AND CONCLUSION Refugee background was associated with unfavourable perinatal outcomes, highlighting the negative influence of refugee status on perinatal health. This evidences the need to address the unique healthcare requirements of this vulnerable population to enhance the well-being of mothers and newborns. Implementing targeted interventions and policies is crucial to meet the healthcare requirements of women of refugee backgrounds. Collaborative efforts between healthcare organisations, government agencies and non-governmental organisations are essential in establishing comprehensive support systems to assist refugee women throughout their perinatal journey.
Collapse
Affiliation(s)
- Yordanos Gizachew Yeshitila
- Institute for Health Transformation, Deakin Health Economics, School of Health and Social Development, Faculty of Health, Deakin University, 1Gheringhap Street, Geelong, Victoria 3220, Australia; School of Nursing, College of Medicine and Health Science, Arba Minch University, Arba Minch, Ethiopia; Intergenerational Health, Murdoch Children's Research Institute, Parkville, Victoria, Australia.
| | - Lisa Gold
- Institute for Health Transformation, Deakin Health Economics, School of Health and Social Development, Faculty of Health, Deakin University, 1Gheringhap Street, Geelong, Victoria 3220, Australia
| | - Elisha Riggs
- Intergenerational Health, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Department of General Practice, The University of Melbourne, Victoria, Melbourne, Australia
| | - Julie Abimanyi-Ochom
- Institute for Health Transformation, Deakin Health Economics, School of Health and Social Development, Faculty of Health, Deakin University, 1Gheringhap Street, Geelong, Victoria 3220, Australia
| | - Linda Sweet
- School of Nursing and Midwifery, Deakin University, Victoria, Australia; Centre for Quality and Patient Safety Research, Western Health Partnership, Institute for Health Transformation, Victoria, Australia
| | - Ha N D Le
- Institute for Health Transformation, Deakin Health Economics, School of Health and Social Development, Faculty of Health, Deakin University, 1Gheringhap Street, Geelong, Victoria 3220, Australia
| |
Collapse
|
23
|
Caradeux J, Martínez-Portilla RJ, Martínez-Egea J, Ávila F, Figueras F. Routine third-trimester ultrasound assessment for intrauterine growth restriction. Am J Obstet Gynecol MFM 2024; 6:101294. [PMID: 38281581 DOI: 10.1016/j.ajogmf.2024.101294] [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: 09/29/2023] [Revised: 01/02/2024] [Accepted: 01/03/2024] [Indexed: 01/30/2024]
Abstract
Intrauterine growth restriction significantly impacts perinatal outcomes. Undetected IUGR escalates the risk of adverse outcomes. Serial symphysis-fundal height measurement, a recommended strategy, is insufficient in detecting abnormal fetal growth. Routine third-trimester ultrasounds significantly improve detection rates compared with this approach, but direct high-quality evidence supporting enhanced perinatal outcomes from routine scanning is lacking. In assessing fetal growth, abdominal circumference alone performs comparably to estimated fetal weight. Hadlock formulas demonstrate accurate fetal weight estimation across diverse gestational ages and settings. When choosing growth charts, prescriptive standards (encompassing healthy pregnancies) should be prioritized over descriptive ones. Customized fetal standards may enhance antenatal IUGR detection, but conclusive high-quality evidence is elusive. Emerging observational data suggest that longitudinal fetal growth assessment could predict adverse outcomes better. However, direct randomized trial evidence supporting this remains insufficient.
Collapse
Affiliation(s)
- Javier Caradeux
- Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Clínica Santa María, Santiago, Chile (Drs Caradeux and Ávila)
| | - Raigam J Martínez-Portilla
- Clinical Research Branch, Evidence-Based Medicine Department, National Institute of Perinatology, Mexico City, Mexico (Dr Martínez-Portilla)
| | - Judit Martínez-Egea
- BCNatal Fetal Medicine Research Center, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Instituto Clínic de Ginecología, Obstetricia i Neonatología, Universitat de Barcelona, Barcelona, Spain (Drs Martínez-Egea and Figueras)
| | - Francisco Ávila
- Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Clínica Santa María, Santiago, Chile (Drs Caradeux and Ávila)
| | - Francesc Figueras
- BCNatal Fetal Medicine Research Center, Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), Instituto Clínic de Ginecología, Obstetricia i Neonatología, Universitat de Barcelona, Barcelona, Spain (Drs Martínez-Egea and Figueras).
| |
Collapse
|
24
|
Palmrich P, Kalafat E, Pateisky P, Schirwani-Hartl N, Haberl C, Herrmann C, Khalil A, Binder J. Prognostic value of angiogenic markers in pregnancy with fetal growth restriction. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:619-626. [PMID: 37774098 DOI: 10.1002/uog.27509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 09/01/2023] [Accepted: 09/20/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE Pregnancies with fetal growth restriction (FGR) are at increased risk for pre-eclampsia. Angiogenic markers including soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) are altered in pregnancies complicated by FGR, but their utility for predicting pre-eclampsia in growth-restricted pregnancies is uncertain. This study aimed to evaluate the prognostic value of angiogenic markers for predicting the development of pre-eclampsia in pregnancies with FGR and suspected pre-eclampsia. METHODS This was a retrospective study of singleton pregnancies with FGR, defined according to Delphi consensus criteria, which underwent sampling of sFlt-1 and PlGF for suspicion of pre-eclampsia at the Medical University of Vienna, Vienna, Austria, between 2013 and 2020. Women with an established diagnosis of pre-eclampsia at sampling were excluded. Cox regression analysis and logistic regression analysis were performed to evaluate the association of angiogenic markers with the development of pre-eclampsia at various timepoints. RESULTS In this cohort of 93 women, pre-eclampsia was diagnosed in 14 (15.1%) women within 1 week after sampling, 21 (22.6%) within 2 weeks after sampling and 38 (40.9%) at any time after assessment. The sFlt-1/PlGF ratio consistently showed a stronger association with the development of pre-eclampsia compared to sFlt-1 or PlGF alone (pre-eclampsia within 1 week: area under the receiver-operating-characteristics curve, 0.87 vs 0.82 vs 0.72). Models including the sFlt-1/PlGF ratio were associated more strongly with pre-eclampsia hazard compared to models including sFlt-1 or PlGF alone (concordance index, 0.790 vs 0.759 vs 0.755). The risk classification capability of the sFlt-1/PlGF ratio decreased after the 2-week timepoint. The established cut-off value for the sFlt-1/PlGF ratio of < 38 was effective for ruling out pre-eclampsia within 2 weeks, with a negative predictive value of 0.933 and sensitivity of 0.952. CONCLUSIONS Use of the sFlt-1/PlGF ratio is preferrable to the use of PlGF alone for the prediction of pre-eclampsia in pregnancies with FGR. Established cut-offs for ruling out the development of pre-eclampsia in the short term seem to be effective in these patients. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- P Palmrich
- Department of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - E Kalafat
- Department of Obstetrics and Gynecology, School of Medicine, Koc University, Istanbul, Turkey
| | - P Pateisky
- Department of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - N Schirwani-Hartl
- Department of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - C Haberl
- Department of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - C Herrmann
- Department of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - J Binder
- Department of Obstetrics and Feto-Maternal Medicine, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
25
|
Boo YY, Bora AK, Chhabra S, Choudhury SS, Deka G, Kakoty S, Kumar P, Mahanta P, Minz B, Rani A, Rao S, Roy I, Solomi V C, Verma A, Zahir F, Deka R, Kurinczuk JJ, Nair M. Maternal and fetal factors associated with stillbirth in singleton pregnancies in 13 hospitals across six states in India: A prospective cohort study. Int J Gynaecol Obstet 2024; 165:462-473. [PMID: 38234106 DOI: 10.1002/ijgo.15367] [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: 10/06/2023] [Revised: 12/25/2023] [Accepted: 12/28/2023] [Indexed: 01/19/2024]
Abstract
OBJECTIVE This study aimed to investigate the incidence of and risk factors for stillbirth in an Indian population. METHODS We conducted a secondary data analysis of a hospital-based cohort from the Maternal and Perinatal Health Research collaboration, India (MaatHRI), including pregnant women who gave birth between October 2018-September 2023. Data from 9823 singleton pregnancies recruited from 13 hospitals across six Indian states were included. Univariable and multivariable Poisson regression analysis were performed to examine the relationship between stillbirth and potential risk factors. Model prediction was assessed using the area under the receiver-operating characteristic (AUROC) curve. RESULTS There were 216 stillbirths (48 antepartum and 168 intrapartum) in the study population, representing an overall stillbirth rate of 22.0 per 1000 total births (95% confidence interval [CI]: 19.2-25.1). Modifiable risk factors for stillbirth were: receiving less than four antenatal check-ups (adjusted relative risk [aRR]: 1.75, 95% CI: 1.25-2.47), not taking any iron and folic acid supplementation during pregnancy (aRR: 7.23, 95% CI: 2.12-45.33) and having severe anemia in the third trimester (aRR: 3.37, 95% CI: 1.97-6.11). Having pregnancy/fetal complications such as hypertensive disorders of pregnancy (aRR: 1.59, 95% CI: 1.03-2.36), preterm birth (aRR: 4.41, 95% CI: 3.21-6.08) and birth weight below the 10th percentile for gestational age (aRR: 1.35, 95% CI: 1.02-1.79) were also associated with an increased risk of stillbirth. Identified risk factors explained 78.2% (95% CI: 75.0%-81.4%) of the risk of stillbirth in the population. CONCLUSION Addressing potentially modifiable antenatal factors could reduce the risk of stillbirths in India.
Collapse
Affiliation(s)
- Yebeen Ysabelle Boo
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Amrit K Bora
- Sonapur District Hospital, Guwahati, Assam, India
| | - Shakuntala Chhabra
- Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India
| | | | - Gitanjali Deka
- Tezpur Medical College and Hospital, Tezpur, Assam, India
| | - Swapna Kakoty
- Fakhruddin Ali Ahmed Medical College and Hospital, Barpeta, Assam, India
| | - Pramod Kumar
- Mahatma Gandhi Institute of Medical Sciences, Sevagram, Maharashtra, India
| | | | - Bina Minz
- Sewa Bhawan Hospital Society, Basna, Chhattisgarh, India
| | - Anjali Rani
- Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
| | - Sereesha Rao
- Silchar Medical College and Hospital, Silchar, Assam, India
| | - Indrani Roy
- Nazareth Hospital, Shillong, Meghalaya, India
| | - Carolin Solomi V
- Makunda Christian Leprosy and General Hospital, Karimganj, Assam, India
| | - Ashok Verma
- Dr Rajendra Prasad Government Medical College, Kangra, Himachal Pradesh, India
| | - Farzana Zahir
- Assam Medical College (AMC), Dibrugarh, Assam, India
| | - Rupanjali Deka
- Srimanta Sankaradeva University of Health Sciences, Guwahati, Assam, India
| | - Jennifer J Kurinczuk
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Manisha Nair
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| |
Collapse
|
26
|
Mathewlynn S, Kitmiridou D, Impey L, Ioannou C. The impact of late pregnancy dating on the detection of fetal growth restriction at term. Acta Obstet Gynecol Scand 2024; 103:938-945. [PMID: 38240293 PMCID: PMC11019509 DOI: 10.1111/aogs.14769] [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: 11/12/2023] [Revised: 12/11/2023] [Accepted: 12/19/2023] [Indexed: 04/17/2024]
Abstract
INTRODUCTION The inaccuracy of late pregnancy dating is often discussed, and the impact on diagnosis of fetal growth restriction is a concern. However, the magnitude and direction of this effect has not previously been demonstrated. In this study, we aimed to investigate the effect of late pregnancy dating by head circumference on the detection of late onset growth restriction, compared to first trimester crown-rump length dating. MATERIAL AND METHODS This was a cohort study of 14 013 pregnancies receiving obstetric care at a tertiary center over a three-year period. Universal scans were performed at 12 weeks, including crown-rump length; at 20 weeks including fetal biometry; and at 36 weeks, where biometry, umbilical artery doppler and cerebroplacental ratio were used to determine the incidence of fetal growth restriction according to the Delphi consensus. For the entire cohort, the gestational age was first calculated using T1 dating; and was then recalculated using head circumference at 20 weeks (T2 dating); and at 36 weeks (T3 dating). The incidence of fetal growth restriction following T2 and T3 dating was compared to T1 dating using four-by-four sensitivity tables. RESULTS When the cohort was redated from T1 to T2, the median gestation at delivery changed from 40 + 0 to 40 + 2 weeks (p < 0.001). When the cohort was redated from T1 to T3, the median gestation at delivery changed from 40 + 0 to 40 + 3 weeks (p < 0.001). T2 dating resulted in fetal growth restriction sensitivity of 80.2% with positive predictive value of 78.8% compared to T1 dating. T3 dating resulted in sensitivity of 8.6% and positive predictive value of 27.7%, respectively. The sensitivity of abnormal CPR remained high despite T2 and T3 redating; 98.0% and 89.4%, respectively. CONCLUSIONS Although dating at 11-14 weeks is recommended, late pregnancy dating is sometimes inevitable, and this can prolong the estimated due date by an average of two to three days. One in five pregnancies which would be classified as growth restricted if the pregnancy was dated in the first trimester, will be reclassified as nongrowth restricted following dating at 20 weeks, whereas nine out of 10 pregnancies will be reclassified as non-growth restricted with 36-week dating.
Collapse
Affiliation(s)
- Sam Mathewlynn
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe HospitalOxfordUK
- Nuffield Department of Women's Reproductive Health, John Radcliffe HospitalOxford UniversityOxfordUK
| | - Despoina Kitmiridou
- Oxford University Hospitals NHS Foundation Trust, John Radcliffe HospitalOxfordUK
| | - Lawrence Impey
- Nuffield Department of Women's Reproductive Health, John Radcliffe HospitalOxford UniversityOxfordUK
- Department of Fetal Medicine, John Radcliffe HospitalOxford University Hospitals NHS TrustOxfordUK
| | - Christos Ioannou
- Nuffield Department of Women's Reproductive Health, John Radcliffe HospitalOxford UniversityOxfordUK
- Department of Fetal Medicine, John Radcliffe HospitalOxford University Hospitals NHS TrustOxfordUK
| |
Collapse
|
27
|
Bridges AG, Allshouse AA, Canfield DR, Grover BW, Son SL, Einerson BD, Silver RM, Haas DM, Grobman WA, Simhan HN, Day RC, Blue NR. Association of Prostaglandin Use for Cervical Ripening with Mode of Delivery in Small for Gestational Age versus Non-Small for Gestational Age Neonates. Am J Perinatol 2024; 41:e456-e464. [PMID: 35863371 DOI: 10.1055/a-1906-8919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Prostaglandins (PGs) use for cervical ripening with small for gestational age (SGA) fetuses is controversial since it remains uncertain if use increases the chance of cesarean delivery (CD). We aimed to assess the association between PG use for cervical ripening and mode of delivery between SGA and appropriate for gestational age (AGA) neonates. STUDY DESIGN Secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be (nuMoM2b), a prospective observational cohort study of 10,038 nulliparas. We included women undergoing induction with nonanomalous fetuses in the cephalic presentation. Women with >2 cm cervical dilation or prior uterine scar were excluded. We assessed the association of PG use with CD among women with SGA and AGA neonates. SGA was defined as birth weight <10th percentile for gestational age and sex. Multivariable logistic regression was used to adjust for potential confounders and test for interaction. Secondary outcomes included adverse neonatal outcomes, indication for CD, maternal hemorrhage, and chorioamnionitis. RESULTS Among 2,353 women eligible, PGs were used in 54.8%, SGA occurred in 15.1%, and 35.0% had CD. The association between PG use and CD differed significantly (interaction p = 0.018) for SGA versus AGA neonates; CD occurred more often in SGA neonates exposed to PGs than not (35 vs. 22%, p = 0.009). PG use was not associated with CD among AGA neonates (36 vs. 36%, p = 0.8). This effect remained significant when adjusting for body mass index, race/ethnicity, and cervical dilation. Among SGA neonates, CD for "nonreassuring fetal status" was similar between PG groups. Among SGA neonates, PG use was not associated with adverse neonatal outcomes or postpartum hemorrhage but had a higher rate of chorioamnionitis (7.0 vs. 2.1%, p = 0.048). CONCLUSION PG use was associated with a higher rate of CD in SGA but not AGA neonates; however, further studies are needed before PG use is discouraged with SGA neonates. KEY POINTS · PGs are commonly used for cervical ripening.. · PG use was associated with increased risk of cesarean delivery in SGA neonates.. · PG use was not associated with adverse neonatal outcomes..
Collapse
Affiliation(s)
- Alexis G Bridges
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
| | - Amanda A Allshouse
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
| | - Dana R Canfield
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
| | - Bryan W Grover
- University of Utah School of Medicine, Salt Lake City, Utah
| | - Shannon L Son
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
| | - Brett D Einerson
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
| | - David M Haas
- Department of Obstetrics and Gynecology, Indiana University, Indianapolis, Indiana
| | - William A Grobman
- Department of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois
| | - Hyagriv N Simhan
- Department of Obstetrics and Gynecology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert C Day
- Department of Obstetrics and Gynecology, University of California-Irvine, Irvine, California
| | - Nathan R Blue
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah
| |
Collapse
|
28
|
Hammer L, Heazell AEP, Povey A, Myers JE, Thompson JMD, Johnstone ED. Assessment of the association between ambient air pollution and stillbirth in the UK: Results from a secondary analysis of the MiNESS case-control study. BJOG 2024; 131:598-609. [PMID: 37880925 DOI: 10.1111/1471-0528.17696] [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: 03/08/2023] [Revised: 09/27/2023] [Accepted: 10/12/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVE We examined whether the risk of stillbirth was related to ambient air pollution in a UK population. DESIGN Prospective case-control study. SETTING Forty-one maternity units in the UK. POPULATION Women who had a stillbirth ≥28 weeks' gestation (n = 238) and women with an ongoing pregnancy at the time of interview (n = 597). METHODS Secondary analysis of data from the Midlands and North of England Stillbirth case-control study only including participants domiciled within 20 km of fixed air pollution monitoring stations. Pollution exposure was calculated using pollution climate modelling data for NO2 , NOx and PM2.5 . The association between air pollution exposure and stillbirth risk was assessed using multivariable logistic regression adjusting for household income, maternal body mass index (BMI), maternal smoking, Index of Multiple Deprivation quintile and household smoking and parity. MAIN OUTCOME MEASURE Stillbirth. RESULTS There was no association with whole pregnancy ambient air pollution exposure and stillbirth risk, but there was an association with preconceptual NO2 exposure (adjusted odds ratio [aOR] 1.06, 95% CI 1.01-1.08 per microg/m3 ). Risk of stillbirth was associated with maternal smoking (aOR 2.54, 95% CI 1.38-4.71), nulliparity (aOR 2.16, 95% CI 1.55-3.00), maternal BMI (aOR 1.05, 95% CI 1.01-1.08) and placental abnormalities (aOR 4.07, 95% CI 2.57-6.43). CONCLUSIONS Levels of ambient air pollution exposure during pregnancy in the UK, all of were beneath recommended thresholds, are not associated with an increased risk of stillbirth. Periconceptual exposure to NO2 may be associated with increased risk but further work is required to investigate this association.
Collapse
Affiliation(s)
- Lucy Hammer
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester, Manchester, UK
| | - Alexander E P Heazell
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester, Manchester, UK
- Saint Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Science Centre, Manchester, UK
| | - Andrew Povey
- Centre for Occupational and Environmental Health, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Jenny E Myers
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester, Manchester, UK
- Saint Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Science Centre, Manchester, UK
| | - John M D Thompson
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
- Department of Paediatrics: Child Health and Youth Health, University of Auckland, Auckland, New Zealand
| | - Edward D Johnstone
- Maternal and Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester, Manchester, UK
- Saint Mary's Hospital, Manchester University Hospitals NHS Foundation Trust, Manchester Academic Science Centre, Manchester, UK
| |
Collapse
|
29
|
Sagberg K, Eskild A, Sommerfelt S, Halle TK, Hillestad V, Haavaldsen C. Two-dimensional (2D) placental ultrasound measurements - The correlation with placental volume measured by magnetic resonance imaging (MRI). Placenta 2024; 149:7-12. [PMID: 38452718 DOI: 10.1016/j.placenta.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Revised: 02/23/2024] [Accepted: 02/26/2024] [Indexed: 03/09/2024]
Abstract
INTRODUCTION Information about placental size in ongoing pregnancies may aid the identification of pregnancies with increased risk of adverse outcome. Placental volume can be measured using magnetic resonance imaging (MRI). However, this method is not universally available in antenatal care. Ultrasound is the diagnostic tool of choice in pregnancy. Therefore, we studied whether simple two-dimensional (2D) ultrasound placental measurements were correlated with placental volume measured by MRI. METHODS We examined a convenience sample of 104 ongoing pregnancies at gestational week 27, using both ultrasound and MRI. The ultrasound measurements included placental length, width and thickness. Placental volume was measured using MRI. The correlation between each 2D placental ultrasound measurement and placental volume was estimated by applying Pearson's correlation coefficient (r). RESULTS Mean placental length was 17.2 cm (SD 2.1 cm), mean width was 14.7 cm (SD 2.1 cm), and mean thickness was 3.2 cm (SD 0.6 cm). Mean placental volume was 536 cm3 (SD 137 cm3). The 2D ultrasound measurements showed poor correlation with placental volume (placental length; r = 0.27, width; r = 0.37, and thickness r = 0.13). DISCUSSION Simple 2D ultrasound measurements of the placenta were poorly correlated with placental volume and cannot be used as proximate measures of placental volume. Our finding may be explained by the large variation between pregnancies in intrauterine placental shape.
Collapse
Affiliation(s)
- Karianne Sagberg
- Department of Obstetrics and Gynecology, Akershus University Hospital, P.O. Box 1000, N-1478, Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, N-0318, Oslo, Norway.
| | - Anne Eskild
- Department of Obstetrics and Gynecology, Akershus University Hospital, P.O. Box 1000, N-1478, Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, N-0318, Oslo, Norway
| | - Silje Sommerfelt
- Department of Obstetrics and Gynecology, Akershus University Hospital, P.O. Box 1000, N-1478, Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, N-0318, Oslo, Norway
| | - Tuva K Halle
- Department of Obstetrics and Gynecology, Akershus University Hospital, P.O. Box 1000, N-1478, Lørenskog, Norway; Institute of Clinical Medicine, University of Oslo, P.O. Box 1171 Blindern, N-0318, Oslo, Norway
| | - Vigdis Hillestad
- Department of Obstetrics and Gynecology, Akershus University Hospital, P.O. Box 1000, N-1478, Lørenskog, Norway; Department of Diagnostic Imaging, Akershus University Hospital, P.O. Box 1000, N-1478, Lørenskog, Norway
| | - Camilla Haavaldsen
- Department of Obstetrics and Gynecology, Akershus University Hospital, P.O. Box 1000, N-1478, Lørenskog, Norway
| |
Collapse
|
30
|
Song W, Guo Q, Puttabyatappa M, Elangovan VR, Wang J, Li F, Liu F, Bi X, Li H, Fu G, Padmanabhan V, Wu X. FGR-associated placental insufficiency and capillary angiogenesis involves disruptions in human placental miRNAs and mRNAs. Heliyon 2024; 10:e28007. [PMID: 38509973 PMCID: PMC10951647 DOI: 10.1016/j.heliyon.2024.e28007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 02/28/2024] [Accepted: 03/11/2024] [Indexed: 03/22/2024] Open
Abstract
Fetal growth restriction (FGR) is one of the most common pregnancy complications culminating in adverse fetal outcome, including preterm birth, neonatal mortality and stillbirth. Compromised placental development and function, especially disruption in angiogenesis and inadequate nutrient supply are contributing factors. Fetal sex also influences placental function. Knowledge of gene expression changes and epigenetic factors contributing to placental dysfunction in FGR pregnancies will help identify biomarkers and help target interventions. This study tested the hypothesis that FGR pregnancies are associated with disruptions in miRNA - an epigenetic factor and mRNAs involving key mediators of angiogenesis and microvessel development. Changes in expression of key genes/proteins involved in placental dysfunction by RT-PCR and immunohistochemistry and miRNA changes by RNA sequencing were undertaken with term placenta from 12 control and 20 FGR pregnancies. Findings showed changes in expression of genes involved in steroidogenesis, steroid action, IGF family members, inflammatory cytokines and angiogenic factors in FGR pregnancies. In addition, upregulation of MIR451A and downregulation of MIR543 in placentas from FGR group with female newborns and upregulation of MIR520G in placentas from FGR group with male newborns were also noted. MIR451A and MIR543 have been implicated in angiogenesis. Consistent with gene changes, CD34, the microvessel angiogenesis marker, also showed reduced staining only in female FGR group. These findings provide evidence that epigentically regulated gene expression changes in angiogenesis and capillary development influence placental impairment in FGR pregnancies. Our preliminary observations also support for these changes to be driven in a sex-specific manner.
Collapse
Affiliation(s)
- Wenhui Song
- Department of Obstetrics and Gynecology, Hebei Medical University, Shijiazhuang, Hebei, PR China
- The Fourth Hospital of Shijiazhuang affiliated to Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Qing Guo
- Department of Obstetrics and Gynecology, Hebei Medical University, Shijiazhuang, Hebei, PR China
- The Fourth Hospital of Shijiazhuang affiliated to Hebei Medical University, Shijiazhuang, Hebei, PR China
- Department of Obstetrics and Gynecology, Hebei Key Laboratory of Maternal and Fetal Medicine, Shijiazhuang, Hebei, PR China
| | | | | | - Jianping Wang
- The Fourth Hospital of Shijiazhuang affiliated to Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Fang Li
- The Fourth Hospital of Shijiazhuang affiliated to Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Fangfang Liu
- The Fourth Hospital of Shijiazhuang affiliated to Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Xuejie Bi
- The Fourth Hospital of Shijiazhuang affiliated to Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Haiying Li
- The Fourth Hospital of Shijiazhuang affiliated to Hebei Medical University, Shijiazhuang, Hebei, PR China
| | - Guangping Fu
- Hebei Key Laboratory of Forensic Medicine, College for Forensic Medicine, Hebei Medical University, Shijiazhuang, Hebei, PR China
| | | | - XiaoHua Wu
- Department of Obstetrics and Gynecology, Hebei Medical University, Shijiazhuang, Hebei, PR China
- The Fourth Hospital of Shijiazhuang affiliated to Hebei Medical University, Shijiazhuang, Hebei, PR China
| |
Collapse
|
31
|
Nyarko SH, Greenberg LT, Phibbs CS, Buzas JS, Lorch SA, Rogowski J, Saade GR, Passarella M, Boghossian NS. Association between stillbirth and severe maternal morbidity. Am J Obstet Gynecol 2024; 230:364.e1-364.e14. [PMID: 37659745 PMCID: PMC10904670 DOI: 10.1016/j.ajog.2023.08.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 08/17/2023] [Accepted: 08/28/2023] [Indexed: 09/04/2023]
Abstract
BACKGROUND Severe maternal morbidity has been increasing in the past few decades. Few studies have examined the risk of severe maternal morbidity among individuals with stillbirths vs individuals with live-birth deliveries. OBJECTIVE This study aimed to examine the prevalence and risk of severe maternal morbidity among individuals with stillbirths vs individuals with live-birth deliveries during delivery hospitalization as a primary outcome and during the postpartum period as a secondary outcome. STUDY DESIGN This was a retrospective cohort study using birth and fetal death certificate data linked to hospital discharge records from California (2008-2018), Michigan (2008-2020), Missouri (2008-2014), Pennsylvania (2008-2014), and South Carolina (2008-2020). Relative risk regression analysis was used to examine the crude and adjusted relative risks of severe maternal morbidity along with 95% confidence intervals among individuals with stillbirths vs individuals with live-birth deliveries, adjusting for birth year, state of residence, maternal sociodemographic characteristics, and the obstetric comorbidity index. RESULTS Of the 8,694,912 deliveries, 35,012 (0.40%) were stillbirths. Compared with individuals with live-birth deliveries, those with stillbirths were more likely to be non-Hispanic Black (10.8% vs 20.5%); have Medicaid (46.5% vs 52.0%); have pregnancy complications, including preexisting diabetes mellitus (1.1% vs 4.3%), preexisting hypertension (2.3% vs 6.2%), and preeclampsia (4.4% vs 8.4%); have multiple pregnancies (1.6% vs 6.2%); and reside in South Carolina (7.4% vs 11.6%). During delivery hospitalization, the prevalence rates of severe maternal morbidity were 791 cases per 10,000 deliveries for stillbirths and 154 cases per 10,000 deliveries for live-birth deliveries, whereas the prevalence rates for nontransfusion severe maternal morbidity were 502 cases per 10,000 deliveries for stillbirths and 68 cases per 10,000 deliveries for live-birth deliveries. The crude relative risk for severe maternal morbidity was 5.1 (95% confidence interval, 4.9-5.3), whereas the adjusted relative risk was 1.6 (95% confidence interval, 1.5-1.8). For nontransfusion severe maternal morbidity among stillbirths vs live-birth deliveries, the crude relative risk was 7.4 (95% confidence interval, 7.0-7.7), whereas the adjusted relative risk was 2.0 (95% confidence interval, 1.8-2.3). This risk was not only elevated among individuals with stillbirth during the delivery hospitalization but also through 1 year after delivery (severe maternal morbidity adjusted relative risk, 1.3; 95% confidence interval, 1.1-1.4; nontransfusion severe maternal morbidity adjusted relative risk, 1.2; 95% confidence interval, 1.1-1.3). CONCLUSION Stillbirth was found to be an important contributor to severe maternal morbidity.
Collapse
Affiliation(s)
- Samuel H Nyarko
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC
| | | | - Ciaran S Phibbs
- Health Economics Resource Center and Center for Implementation to Innovation, Veterans Affairs Palo Alto Health Care System, Menlo Park, CA; Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatology, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Jeffrey S Buzas
- Department of Mathematics and Statistics, University of Vermont, Burlington, VT
| | - Scott A Lorch
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA; Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania, Philadelphia, PA
| | - Jeannette Rogowski
- Department of Health Policy and Administration, The Pennsylvania State University, State College, PA
| | - George R Saade
- Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - Molly Passarella
- Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Nansi S Boghossian
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC.
| |
Collapse
|
32
|
Galis R, Trif P, Mudura D, Murvai R, Daina LG, Szasz F, Negrini R, Hatos A, Gyarmati BF, Daly MC, Mazela J, Kramer BW. Preterm birth and stillbirth during COVID-19 pandemic in Bihor County/Romania. FRONTIERS IN REPRODUCTIVE HEALTH 2024; 6:1286496. [PMID: 38486846 PMCID: PMC10937441 DOI: 10.3389/frph.2024.1286496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 02/20/2024] [Indexed: 03/17/2024] Open
Abstract
Background International studies have reported conflicting data about the effects of COVID-19 pandemic policy measures on maternal and neonatal health. A major impact was reported on stillbirth and prematurity. The published literature suggests that the economic setting influenced the effects of imposed mitigation measures with a more severe effect in low-income countries. Objectives Our objective is to compare pregnancy outcomes at the only tertiary Maternity Hospital in Bihor County-Romania before and during the COVID-19 pandemic. This study aims to observe and document differences in perinatal outcomes across these periods, without inferring direct causation related to the pandemic or its associated restrictions. Materials and methods We used data from the registries of Public Health Services Bihor to conduct a retrospective cohort analysis of preterm births and stillbirths during the COVID-19 pandemic in Bihor County, Romania. Pregnancy outcomes were compared between the pandemic period (March 2020-February 2022) to the corresponding historical pre-COVID-19 period (March 2018-February 2020). Maternal socio-demographic variables and neonatal characteristics of these periods were also examined. Results The COVID-19 pandemic period was associated with an increase in the stillbirth rate (RR: 1.53, 95% CI, 1.05-2.23). Preterm birth was significantly impacted during this period and showed changes when analyzing gestational age (RR: 0.88, 95% CI, 0.79-0.96) or birth weight (RR: 0.91, 95% CI, 0.82-1.00). The main cause of stillbirth was intrauterine asphyxia due to placental causes (67.6%) or cord pathology (12.6%), the most frequently encountered maternal pathology was cardiovascular (28.3%) or infectious (21.7%). Our study revealed no significant changes in terms of maternal and neonatal characteristics during the two-year pandemic period. Conclusions Lockdown restrictions in Bihor County, Romania were associated with an increase in stillbirths, whilst preterm birth rate decreased. This raises concerns about whether pandemic policy measures may have led to a failure in identifying and offering proper care for pregnant women who were more likely to experience an antepartum loss. Further studies across the globe are needed in order to integrate comparable data that will help develop adequate protocols and policies for protecting maternal and child health during the next pandemic that will follow.
Collapse
Affiliation(s)
- Radu Galis
- Department of Neonatology, Emergency County Hospital Bihor, Oradea, Romania
- Neonatology, Poznan University Medical Sciences, Poznan, Poland
| | - Paula Trif
- Department of Neonatology, Emergency County Hospital Bihor, Oradea, Romania
- Doctoral School of Biomedical Sciences, University of Oradea, Oradea, Romania
| | - Diana Mudura
- Department of Neonatology, Emergency County Hospital Bihor, Oradea, Romania
| | - Romina Murvai
- Doctoral School of Biomedical Sciences, University of Oradea, Oradea, Romania
- Department of Obstetrics and Gynaecology, Emergency County Hospital Bihor, Oradea, Romania
| | - Lucia Georgeta Daina
- Department of Psycho-Neuroscience and Recovery, Faculty of Medicine and Pharmacy, University of Oradea, Oradea, Romania
| | - Florin Szasz
- Department of Obstetrics and Gynaecology, Emergency County Hospital Bihor, Oradea, Romania
- Department of Obstetrics and Gynaecology, Faculty of Medicine and Pharmacy, University of Oradea, Oradea, Romania
| | - Rodica Negrini
- Department of Obstetrics and Gynaecology, Emergency County Hospital Bihor, Oradea, Romania
| | - Adrian Hatos
- Doctoral School of Sociology, Faculty of Social Sciences, University of Oradea, Oradea, Romania
| | - Beáta Fatime Gyarmati
- Doctoral School of Sociology, Faculty of Social Sciences, University of Oradea, Oradea, Romania
| | | | - Jan Mazela
- Neonatology, Poznan University Medical Sciences, Poznan, Poland
| | - Boris W. Kramer
- Neonatology, Poznan University Medical Sciences, Poznan, Poland
| |
Collapse
|
33
|
Rial-Crestelo M, Lubusky M, Parra-Cordero M, Krofta L, Kajdy A, Zohav E, Ferriols-Perez E, Cruz-Martinez R, Kacerovsky M, Scazzocchio E, Roubalova L, Socias P, Hašlík L, Modzelewski J, Ashwal E, Castellá-Cesari J, Cruz-Lemini M, Gratacos E, Figueras F. Term planned delivery based on fetal growth assessment with or without the cerebroplacental ratio in low-risk pregnancies (RATIO37): an international, multicentre, open-label, randomised controlled trial. Lancet 2024; 403:545-553. [PMID: 38219773 DOI: 10.1016/s0140-6736(23)02228-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 09/07/2023] [Accepted: 10/03/2023] [Indexed: 01/16/2024]
Abstract
BACKGROUND The cerebroplacental ratio is associated with perinatal mortality and morbidity, but it is unknown whether routine measurement improves pregnancy outcomes. We aimed to evaluate whether the addition of cerebroplacental ratio measurement to the standard ultrasound growth assessment near term reduces perinatal mortality and severe neonatal morbidity, compared with growth assessment alone. METHODS RATIO37 was a randomised, open-label, multicentre, pragmatic trial, conducted in low-risk pregnant women, recruited from nine hospitals over six countries. The eligibility criteria were designed to be broad; participants were required to be 18 years or older, with an ultrasound-dated confirmed singleton pregnancy in the first trimester, an alive fetus with no congenital malformations at the routine second-trimester ultrasound, an absence of adverse medical or obstetric history, and the capacity to give informed consent. Women were randomly assigned in a 1:1 ratio (block size 100) using a web-based system to either the concealed group or revealed group. In the revealed group, the cerebroplacental ratio value was known by clinicians, and if below the fifth centile, a planned delivery after 37 weeks was recommended. In the concealed group, women and clinicians were blinded to the cerebroplacental ratio value. All participants underwent ultrasound at 36 + 0 to 37 + 6 weeks of gestation with growth assessment and Doppler evaluation. In both groups, planned delivery was recommended when the estimated fetal weight was below the tenth centile. The primary outcome was perinatal mortality from 24 weeks' gestation to infant discharge. The study is registered at ClinicalTrials.gov (NCT02907242) and is now closed. FINDINGS Between July 29, 2016, and Aug 3, 2021, we enrolled 11 214 women, of whom 9492 (84·6%) completed the trial and were eligible for analysis (4774 in the concealed group and 4718 in the revealed group). Perinatal mortality occurred in 13 (0·3%) of 4774 pregnancies in the concealed group and 13 (0·3%) of 4718 in the revealed group (OR 1·45 [95% CI 0·76-2·76]; p=0·262). Overall, severe neonatal morbidity occurred in 35 (0·73%) newborns in the concealed group and 18 (0·38%) in the revealed group (OR 0·58 [95% CI 0·40-0·83]; p=0·003). Severe neurological morbidity occurred in 13 (0·27%) newborns in the concealed group and nine (0·19%) in the revealed group (OR 0·56 [95% CI 0·25-1·24]; p=0·153). Severe non-neurological morbidity occurred in 23 (0·48%) newborns in the concealed group and nine (0·19%) in the revealed group (0·58 [95% CI 0·39-0·87]; p=0·009). Maternal adverse events were not collected. INTERPRETATION Planned delivery at term based on ultrasound fetal growth assessment and cerebroplacental ratio at term was not followed by a reduction of perinatal mortality although significantly reduced severe neonatal morbidity compared with fetal growth assessment alone. FUNDING La Caixa foundation, Cerebra Foundation for the Brain Injured Child, Agència per la Gestió d'Ajuts Universitaris i de Recerca, and Instituto de Salud Carlos III.
Collapse
Affiliation(s)
- Marta Rial-Crestelo
- BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital San Joan de Deu, Barcelona, Spain
| | - Marek Lubusky
- The Fetal Medicine Center, Department of Obstetrics and Gynecology Palacky University Hospital, Olomouc, Czech Republic
| | - Mauro Parra-Cordero
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Chile Hospital, Santiago, Chile
| | - Ladislav Krofta
- Institute for the Care of Mother and Child, the Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Anna Kajdy
- First Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Eyal Zohav
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Obstetrics and Gynecology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Elena Ferriols-Perez
- Obstetrics and Gynecology Consorci Parc de Salut Mar, Hospital del Mar, Barcelona, Spain
| | - Rogelio Cruz-Martinez
- Fetal Medicine Department, Instituto Medicina Fetal México, Children and Women's Specialty Hospital of Querétaro, Querétaro, Mexico
| | - Marian Kacerovsky
- University Hospital Hradec Kralove, Charles University, Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Elena Scazzocchio
- Atencio a la Salut Sexual i Reproductiva (ASSIR) de Barcelona, Primary Care Center, Catalan Institut of Health, Barcelona, Spain
| | - Lucie Roubalova
- The Fetal Medicine Center, Department of Obstetrics and Gynecology Palacky University Hospital, Olomouc, Czech Republic
| | - Pamela Socias
- Maternal Fetal Medicine Unit, Department of Obstetrics and Gynecology, University of Chile Hospital, Santiago, Chile
| | - Lubomir Hašlík
- Institute for the Care of Mother and Child, the Third Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Jan Modzelewski
- First Department of Obstetrics and Gynecology, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Eran Ashwal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Obstetrics and Gynecology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Julia Castellá-Cesari
- Obstetrics and Gynecology Consorci Parc de Salut Mar, Hospital del Mar, Barcelona, Spain
| | - Monica Cruz-Lemini
- Maternal Fetal Medicine Department, Hospital de Especialidades del Niño y la Mujer, Dr Felipe Nuñez Lara, Querétaro, Mexico
| | - Eduard Gratacos
- BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital San Joan de Deu, Barcelona, Spain
| | - Francesc Figueras
- BCNatal-Barcelona Center for Maternal-Fetal and Neonatal Medicine, Hospital Clínic and Hospital San Joan de Deu, Barcelona, Spain.
| |
Collapse
|
34
|
Maroudias G, Vrachnis D, Fotiou A, Loukas N, Mantzou A, Pergialiotis V, Valsamakis G, Machairiotis N, Stavros S, Panagopoulos P, Vakas P, Kanaka-Gantenbein C, Drakakis P, Vrachnis N. Measurement of Calprotectin and PTH in the Amniotic Fluid of Early Second Trimester Pregnancies and Their Impact on Fetuses with Growth Disorders: Are Their Levels Related to Oxidative Stress? J Clin Med 2024; 13:855. [PMID: 38337548 PMCID: PMC10856459 DOI: 10.3390/jcm13030855] [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: 10/27/2023] [Revised: 01/08/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Background: During the early stages of human fetal development, the fetal skeleton system is chiefly made up of cartilage, which is gradually replaced by bone. Fetal bone development is mainly regulated by the parathyroid hormone parathormone (PTH) and PTH-related protein, with specific calprotectin playing a substantial role in cell adhesion and chemotaxis while exhibiting antimicrobial activity during the inflammatory osteogenesis process. The aim of our study was to measure the levels of PTH and calprotectin in early second trimester amniotic fluid and to carry out a comparison between the levels observed among normal full-term pregnancies (control group) and those of the groups of embryos exhibiting impaired or enhanced growth. Methods: For the present prospective study, we collected amniotic fluid samples from pregnancies that underwent amniocentesis at 15 to 22 weeks of gestational age during the period 2021-2023. Subsequently, we followed up on all pregnancies closely until delivery. Having recorded fetal birthweights, we then divided the neonates into three groups: small for gestational age (SGA), appropriate for gestational age (AGA), and large for gestational age (LGA). Results: In total, 64 pregnancies, including 14 SGA, 10 LGA, and 40 AGA fetuses, were included in our study. Both substances were detected in early second trimester amniotic fluid in both groups. Concentrations of calprotectin differed significantly among the three groups (p = 0.033). AGA fetuses had a lower mean value of 4.195 (2.415-6.425) IU/mL, whereas LGA fetuses had a higher mean value of 6.055 (4.887-13.950) IU/mL, while SGA fetuses had a mean value of 5.475 (3.400-9.177) IU/mL. Further analysis revealed that only LGA fetuses had significantly higher calprotectin concentrations compared to AGA fetuses (p = 0.018). PTH concentration was similar between the groups, with LGA fetuses having a mean value of 13.18 (9.51-15.52) IU/mL, while SGA fetuses had a mean value of 14.18 (9.02-16.00) IU/mL, and AGA fetuses had similar concentrations of 13.35 (9.05-15.81) IU/mL. The differences in PTH concentration among the three groups were not statistically significant (p = 0.513). Conclusions: Calprotectin values in the amniotic fluid in the early second trimester were higher in LGA fetuses compared to those in the SGA and AGA categories. LGA fetuses can possibly be in a state of low-grade chronic inflammation due to excessive fat deposition, causing oxidative stress in LGA fetuses and, eventually, the release of calprotectin. Moreover, PTH concentrations in the amniotic fluid of early second trimester pregnancies were not found to be statistically correlated with fetal growth abnormalities in either LGA or SGA fetuses. However, the early time of collection and the small number of patients in our study should be taken into account.
Collapse
Affiliation(s)
- George Maroudias
- Department of Obstetrics and Gynecology, Tzaneio General Hospital, 18536 Athens, Greece
| | - Dionysios Vrachnis
- Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (D.V.); (A.F.)
| | - Alexandros Fotiou
- Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece; (D.V.); (A.F.)
| | - Nikolaos Loukas
- Department of Obstetrics and Gynecology, Tzaneio General Hospital, 18536 Athens, Greece
| | - Aimilia Mantzou
- First Department of Paediatrics, Medical School, National and Kapodistrian University of Athens, Aghia Sophia Children’s Hospital, 11527 Athens, Greece (C.K.-G.)
| | - Vasileiοs Pergialiotis
- First Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, Alexandra Hospital, 11528 Athens, Greece;
| | - George Valsamakis
- Second Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, Aretaieion Hospital, 11528 Athens, Greece; (G.V.)
| | - Nikolaos Machairiotis
- Third Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, Attikon Hospital, Rimini 1, 12462 Athens, Greece (P.P.)
| | - Sofoklis Stavros
- Third Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, Attikon Hospital, Rimini 1, 12462 Athens, Greece (P.P.)
| | - Periklis Panagopoulos
- Third Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, Attikon Hospital, Rimini 1, 12462 Athens, Greece (P.P.)
| | - Panagiotis Vakas
- Second Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, Aretaieion Hospital, 11528 Athens, Greece; (G.V.)
| | - Christina Kanaka-Gantenbein
- First Department of Paediatrics, Medical School, National and Kapodistrian University of Athens, Aghia Sophia Children’s Hospital, 11527 Athens, Greece (C.K.-G.)
| | - Petros Drakakis
- Third Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, Attikon Hospital, Rimini 1, 12462 Athens, Greece (P.P.)
| | - Nikolaos Vrachnis
- Third Department of Obstetrics and Gynecology, Medical School, National and Kapodistrian University of Athens, Attikon Hospital, Rimini 1, 12462 Athens, Greece (P.P.)
- Vascular Biology, Molecular and Clinical Sciences Research Institute, St George’s University of London, London SW17, UK
| |
Collapse
|
35
|
Kumar A, Singh A, Kumari S, Saha SC, Singh T, Saini SS. Role of Cerebroplacental Ratio in Predicting Perinatal Outcome. Cureus 2024; 16:e54816. [PMID: 38405647 PMCID: PMC10893822 DOI: 10.7759/cureus.54816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2024] [Indexed: 02/27/2024] Open
Abstract
Objective Doppler velocimetry provides a sensitive, non-invasive, and safe method of surveillance of fetal hemodynamics and fetomaternal circulation. Cerebroplacental ratio (CPR) is an indicator of placental function and fetal maladaptation to placental insufficiency. Cerebroplacental ratio (CPR) is becoming a significant indicator of unfavorable pregnancy outcomes, which has implications for the assessment of fetal well-being. This study aimed to determine the cut-off value of the cerebroplacental ratio (CPR) in appropriate for gestational age (AGA) fetuses in high-risk mothers to predict adverse perinatal outcomes. We also compared the efficacy of CPR, umbilical artery pulsatility index (UmA PI), and middle cerebral artery pulsatility index (MCA PI) for predicting adverse perinatal outcomes. Design and setting This was a prospective observational study conducted at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. Methods A total of 100 women with singleton high-risk pregnancies were included in this prospective observational study. Obstetric ultrasound was performed at the time of recruitment, and fetal weight and CPR were noted. Based on fetal weight, patients were divided into AGA and fetal growth restriction (FGR) groups; CPR was measured; patients were followed up fortnightly; and outcomes were noted. Main outcome The effectiveness of CPR, UmA PI, and MCA PI for predicting poor perinatal outcomes and identifying the cut-off value of CPR in appropriate for gestational age (AGA) fetuses in high-risk mothers was assessed. Result The values of MCA PI, UmA PI, and CPR were statistically significant between AGA and FGR (p-value =.023, .002 and .0001), respectively. The cut-off value for CPR-detecting adverse outcomes in AGA was 1.49. It has sensitivity, specificity, positive predictive value, and negative predictive value of 67.5%, 68%, 71.69%, and 70.21%, respectively. Conclusion Cerebroplacental ratio (CPR) reflects both circulatory insufficiency of the placenta and adaptive changes of the middle cerebral artery, indicating an important non-invasive surveillance modality.
Collapse
Affiliation(s)
- Abhay Kumar
- Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Anju Singh
- Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Snigdha Kumari
- Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - S C Saha
- Obstetrics and Gynecology, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Tulika Singh
- Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Shiv Sajan Saini
- Pediatric Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| |
Collapse
|
36
|
Rajiv P, Cade T, Dean J, Jones GD, Brennecke SP. Maternal serum soluble fms-like tyrosine kinase-1-to-placental growth factor ratio distinguishes growth-restricted from non-growth-restricted small-for-gestational-age fetuses. AJOG GLOBAL REPORTS 2024; 4:100302. [PMID: 38318268 PMCID: PMC10839529 DOI: 10.1016/j.xagr.2023.100302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Fetal growth restriction secondary to chronic placental insufficiency is a major cause of perinatal morbidity and mortality. A significant proportion of fetuses with fetal growth restriction are small for gestational age, defined as a birthweight of ≤10th percentile. However, not all small-for-gestational-age fetuses are growth restricted. Some are constitutionally small and otherwise healthy. It is important to distinguish between small-for-gestational-age fetuses with and without fetal growth restriction to ensure appropriate interventions in small-for-gestational-age fetuses with fetal growth restriction and to minimize unnecessary interventions in healthy small-for-gestational-age fetuses. The maternal serum ratio of soluble fms-like tyrosine kinase-1 and placental growth factor is an indicator of placental insufficiency in the latter half of pregnancy. As such, the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio may be a clinically useful tool to distinguish between small-for-gestational-age fetuses with and without fetal growth restriction. OBJECTIVE This study aimed to determine whether the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio can distinguish between small-for-gestational-age fetuses with and without fetal growth restriction with a birthweight of ≤10th percentile. STUDY DESIGN A retrospective audit of 233 singleton pregnancies delivering an infant with a birthweight of ≤10th percentile corrected for gestational age with an antenatal maternal serum soluble fms-like tyrosine kinase-1-to-placental growth factor result was performed. Fetal growth restriction was defined as a birthweight of ≤10th percentile with an umbilical artery pulsatility index of >95th percentile, fetal middle cerebral artery pulsatility index of <5th percentile, amniotic fluid index of <6 cm, and/or cerebroplacental ratio of <1st percentile. The soluble fms-like tyrosine kinase-1-to-placental growth factor ratios before delivery between fetuses with and without fetal growth restriction (121 [fetal growth restriction] vs 112 [no fetal growth restriction]) were compared. The Student t test and Fisher exact test were used to compare cases and controls. The Mann-Whitney U test, linear regression analysis, and Spearman correlation coefficient (Rho) were used to examine associations between the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio and fetal outcomes to determine whether the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio served as a prognostic marker of fetal growth restriction severity. RESULTS The mean soluble fms-like tyrosine kinase-1-to-placental growth factor ratio was increased in fetal growth restriction cases compared with non-fetal growth restriction controls (234.3±25.0 vs 67.4±7.7, respectively; P<.0001). When controlling for preeclampsia, which is associated with placental insufficiency, fetal growth restriction cases still demonstrated an independent increase in the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio (effect size, 0.865; 95% confidence interval, 0.509-1.220; P<.001). The soluble fms-like tyrosine kinase-1-to-placental growth factor ratio was negatively correlated with birthweight percentiles in pregnancies delivering an infant with a birthweight of ≤10th percentile (r=-0.3565; P<.0001). This association was maintained for fetuses with fetal growth restriction (r=-0.2309; P<.05), whereas fetuses without fetal growth restriction had no significant correlation between the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio and neonatal birthweight percentiles. CONCLUSION The soluble fms-like tyrosine kinase-1-to-placental growth factor ratio was significantly higher in small-for-gestational-age fetuses with fetal growth restriction than small-for-gestational-age fetuses without fetal growth restriction, independent of preeclampsia. Furthermore, the soluble fms-like tyrosine kinase-1-to-placental growth factor ratio was negatively correlated with fetal growth restriction birthweight percentiles, suggesting that it may be a clinical measure of fetal growth restriction severity. Therefore, the ratio may usefully delineate fetal growth restriction from constitutionally small but otherwise healthy fetuses antenatally, allowing for timely interventions in small-for-gestational-age cases with fetal growth restriction and unnecessary interventions to be minimized in small-for-gestational-age cases without fetal growth restriction.
Collapse
Affiliation(s)
- Prithi Rajiv
- Department of Maternal-Fetal Medicine, Pregnancy Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia (Drs Rajiv, Cade, Dean, Davis Jones, and Brennecke)
| | - Thomas Cade
- Department of Maternal-Fetal Medicine, Pregnancy Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia (Drs Rajiv, Cade, Dean, Davis Jones, and Brennecke)
| | - Jennifer Dean
- Department of Maternal-Fetal Medicine, Pregnancy Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia (Drs Rajiv, Cade, Dean, Davis Jones, and Brennecke)
| | - Gabriel Davis Jones
- Department of Maternal-Fetal Medicine, Pregnancy Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia (Drs Rajiv, Cade, Dean, Davis Jones, and Brennecke)
| | - Shaun P. Brennecke
- Department of Maternal-Fetal Medicine, Pregnancy Research Centre, The Royal Women's Hospital, Parkville, Victoria, Australia (Drs Rajiv, Cade, Dean, Davis Jones, and Brennecke)
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Melbourne, Australia (Dr Brennecke)
| |
Collapse
|
37
|
Klemetti MM, Pettersson ABV, Ahmad Khan A, Ermini L, Porter TR, Litvack ML, Alahari S, Zamudio S, Illsley NP, Röst H, Post M, Caniggia I. Lipid profile of circulating placental extracellular vesicles during pregnancy identifies foetal growth restriction risk. J Extracell Vesicles 2024; 13:e12413. [PMID: 38353485 PMCID: PMC10865917 DOI: 10.1002/jev2.12413] [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: 08/15/2023] [Revised: 12/18/2023] [Accepted: 01/13/2024] [Indexed: 02/16/2024] Open
Abstract
Small-for-gestational age (SGA) neonates exhibit increased perinatal morbidity and mortality, and a greater risk of developing chronic diseases in adulthood. Currently, no effective maternal blood-based screening methods for determining SGA risk are available. We used a high-resolution MS/MSALL shotgun lipidomic approach to explore the lipid profiles of small extracellular vesicles (sEV) released from the placenta into the circulation of pregnant individuals. Samples were acquired from 195 normal and 41 SGA pregnancies. Lipid profiles were determined serially across pregnancy. We identified specific lipid signatures of placental sEVs that define the trajectory of a normal pregnancy and their changes occurring in relation to maternal characteristics (parity and ethnicity) and birthweight centile. We constructed a multivariate model demonstrating that specific lipid features of circulating placental sEVs, particularly during early gestation, are highly predictive of SGA infants. Lipidomic-based biomarker development promises to improve the early detection of pregnancies at risk of developing SGA, an unmet clinical need in obstetrics.
Collapse
Affiliation(s)
- Miira M. Klemetti
- Lunenfeld‐Tanenbaum Research InstituteMount Sinai HospitalTorontoOntarioCanada
- Department of Obstetrics & GynecologyUniversity of TorontoTorontoOntarioCanada
| | - Ante B. V. Pettersson
- Program in Translational Medicine, Peter Gilgan Centre for Research and LearningHospital for Sick ChildrenTorontoOntarioCanada
| | - Aafaque Ahmad Khan
- Donnelly Centre for Cellular and Biomolecular ResearchUniversity of TorontoTorontoCanada
| | - Leonardo Ermini
- Lunenfeld‐Tanenbaum Research InstituteMount Sinai HospitalTorontoOntarioCanada
| | - Tyler R. Porter
- Lunenfeld‐Tanenbaum Research InstituteMount Sinai HospitalTorontoOntarioCanada
| | - Michael L. Litvack
- Program in Translational Medicine, Peter Gilgan Centre for Research and LearningHospital for Sick ChildrenTorontoOntarioCanada
| | - Sruthi Alahari
- Lunenfeld‐Tanenbaum Research InstituteMount Sinai HospitalTorontoOntarioCanada
| | | | | | - Hannes Röst
- Donnelly Centre for Cellular and Biomolecular ResearchUniversity of TorontoTorontoCanada
| | - Martin Post
- Program in Translational Medicine, Peter Gilgan Centre for Research and LearningHospital for Sick ChildrenTorontoOntarioCanada
- Institute of Medical ScienceUniversity of TorontoTorontoOntarioCanada
- Department PhysiologyUniversity of TorontoTorontoOntarioCanada
| | - Isabella Caniggia
- Lunenfeld‐Tanenbaum Research InstituteMount Sinai HospitalTorontoOntarioCanada
- Department of Obstetrics & GynecologyUniversity of TorontoTorontoOntarioCanada
- Institute of Medical ScienceUniversity of TorontoTorontoOntarioCanada
- Department PhysiologyUniversity of TorontoTorontoOntarioCanada
| |
Collapse
|
38
|
Mikkola TS, Ylikorkala O. Pregnancy-associated risk factors for future cardiovascular disease - early prevention strategies warranted. Climacteric 2024; 27:41-46. [PMID: 38174425 DOI: 10.1080/13697137.2023.2287628] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 11/20/2023] [Indexed: 01/05/2024]
Abstract
We summarize convincing evidence that future cardiovascular disease (CVD) risk increases one-fold to four-fold for women with a history of pregnancy complicated by hypertensive disorders, gestational diabetes, fetal growth restriction, placental abruption and preterm birth. A concomitant occurrence of two or more complications in the same pregnancy further potentiates the risk. These women should be informed of their future CVD risks during the postpartum check-up taking place after delivery, and also, if needed, treated, for example, for persisting high blood pressure. In these women with high blood pressure, check-up should take place within 7-10 days, and if severe hypertension, within 72 h. Women without diagnostic signs and symptoms should be examined for the first time 1-2 years postpartum and then at intervals of 2-3 years for a complete CVD risk profile including clinical and laboratory assessments. Women should be informed for future CVD risks and their effective prevention with healthy lifestyle factors. Combined oral contraceptives should be avoided or used with caution. If laboratory or other clinical findings indicate, then vigorous treatments consisting of non-medical and medical (antihypertensives, statins, antidiabetic and anti-obesity therapies) interventions should be initiated early with liberal indications and with ambitious therapeutic goals. Low-dose aspirin and menopausal hormone therapy should be used in selected cases. Active control and treatment policies of these women with pregnancy-related risks will likely result in decreases of CVD occurrence in later life.
Collapse
Affiliation(s)
- T S Mikkola
- Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| | - O Ylikorkala
- Department of Obstetrics and Gynecology, Helsinki University Hospital, Helsinki University, Helsinki, Finland
| |
Collapse
|
39
|
Mustafa HJ, Javinani A, Muralidharan V, Khalil A. Diagnostic performance of 32 vs 36 weeks ultrasound in predicting late-onset fetal growth restriction and small-for-gestational-age neonates: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2024; 6:101246. [PMID: 38072237 DOI: 10.1016/j.ajogmf.2023.101246] [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: 05/27/2023] [Revised: 11/21/2023] [Accepted: 11/30/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVE Fetal growth restriction is an independent risk factor for fetal death and adverse neonatal outcomes. The main aim of this study was to investigate the diagnostic performance of 32 vs 36 weeks ultrasound of fetal biometry in detecting late-onset fetal growth restriction and predicting small-for-gestational-age neonates. DATA SOURCES A systematic search was performed to identify relevant studies published until June 2022, using the databases PubMed, Web of Science, and Scopus. STUDY ELIGIBILITY CRITERIA Cohort studies in low-risk or unselected singleton pregnancies with screening ultrasound performed at ≥32 weeks of gestation were used. METHODS The estimated fetal weight and abdominal circumference were assessed as index tests for the prediction of small for gestational age (birthweight of <10th percentile) and detecting fetal growth restriction (estimated fetal weight of <10th percentile and/or abdominal circumference of <10th percentile). The quality of the included studies was independently assessed by 2 reviewers using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. For the meta-analysis, hierarchical summary area under the receiver operating characteristic curves were constructed, and quantitative data synthesis was performed using random-effects models. RESULTS The analysis included 25 studies encompassing 73,981 low-risk pregnancies undergoing third-trimester ultrasound assessment for growth, of which 5380 neonates (7.3%) were small for gestational age at birth. The pooled sensitivities for estimated fetal weight of <10th percentile and abdominal circumference of <10th percentile in predicting small for gestational age were 36% (95% confidence interval, 27%-46%) and 37% (95% confidence interval, 19%-60%), respectively, at 32 weeks ultrasound and 48% (95% confidence interval, 41%-56%) and 50% (95% confidence interval, 25%-74%), respectively, at 36 weeks ultrasound. The pooled specificities for estimated fetal weight of <10th percentile and abdominal circumference of <10th percentile in detecting small for gestational age were 93% (95% confidence interval, 91%-95%) and 95% (95% confidence interval, 85%-98%), respectively, at 32 weeks ultrasound and 93% (95% confidence interval, 91%-95%) and 97% (95% confidence interval, 85%-98%), respectively, at 36 weeks ultrasound. The observed diagnostic odds ratios for an estimated fetal weight of <10th percentile and an abdominal circumference of <10th percentile in detecting small for gestational age were 8.8 (95% confidence interval, 5.4-14.4) and 11.6 (95% confidence interval, 6.2-21.6), respectively, at 32 weeks ultrasound and 13.3 (95% confidence interval, 10.4-16.9) and 36.0 (95% confidence interval, 4.9-260.0), respectively, at 36 weeks ultrasound. The pooled sensitivity, specificity, and diagnostic odds ratio in predicting fetal growth restriction were 71% (95% confidence interval, 52%-85%), 90% (95% confidence interval, 79%-95%), and 25.8 (95% confidence interval, 14.5-45.8), respectively, at 32 weeks ultrasound and 48% (95% confidence interval, 41%-55%), 94% (95% confidence interval, 93%-96%), and 16.9 (95% confidence interval, 10.8-26.6), respectively, at 36 weeks ultrasound. Abdominal circumference of <10th percentile seemed to have comparable sensitivity to estimated fetal weight of <10th percentile in predicting small-for-gestational-age neonates. CONCLUSION An ultrasound assessment of the fetal biometry at 36 weeks of gestation seemed to have better predictive accuracy for small-for-gestational-age neonates than an ultrasound assessment at 32 weeks of gestation. However, an opposite trend was noted when the outcome was fetal growth restriction. Fetal abdominal circumference had a similar predictive accuracy to that of estimated fetal weight in detecting small-for-gestational-age neonates.
Collapse
Affiliation(s)
- Hiba J Mustafa
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Indiana University School of Medicine, Indianapolis, IN (Dr Mustafa); Riley Children and Indiana University Health Fetal Center, Indianapolis, IN (Dr Mustafa).
| | - Ali Javinani
- Maternal Fetal Care Center, Boston Children's Hospital, Harvard Medical School, Boston, MA (Dr Javinani)
| | | | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, St George's University of London, London, United Kingdom (Dr Khalil); Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, United Kingdom (Dr Khalil)
| |
Collapse
|
40
|
Lundén M, Hulthén Varli I, Kopp Kallner H, Åmark H. Incidence of stillbirth among women with different risk profiles in Stockholm 2001-2020: a repeated cross-sectional study. Acta Obstet Gynecol Scand 2024; 103:59-67. [PMID: 37855671 PMCID: PMC10755135 DOI: 10.1111/aogs.14695] [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: 06/09/2023] [Revised: 08/07/2023] [Accepted: 10/04/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION The incidence of stillbirth in Sweden has started to decline. However, some comparable high-income countries in Europe have an even lower incidence, indicating a potential for further reduction. The aim of our study was to investigate how the incidence of stillbirth for singleton pregnancies has changed over the past two decades in the Stockholm Region in different groups of women to detect the groups at highest risk. MATERIAL AND METHODS This was a repeated cross-sectional study with data from the Stockholm Stillbirth Database and the Pregnancy Register including all cases of stillbirth in Stockholm in singleton pregnancies between 2001 and 2020, in total 1804 stillbirths. The time period was divided into four equal groups and the incidence of stillbirth was compared between the groups. RESULTS The overall incidence of stillbirth in the Stockholm Region has decreased from 3.8/1000 births in 2001-2005 to 2.9/1000 births in 2016-2020 (P-value <0.001). In most of the groups studied, the incidence decreased, but among women originating from sub-Saharan Africa the incidence significantly rose from 7.9/1000 births in 2001-2005 to 10.1/1000 births in 2016-2020 (P-value 0.025). In this group, stillbirth occurred prematurely to a higher extent and the women were more likely to be multiparous. CONCLUSIONS The incidence of stillbirth in the Stockholm Region has declined. However, among women originating from sub-Saharan Africa the incidence was significantly higher compared with women originating from other regions and it is still rising. More research is needed to understand why this group is at higher risk and how to monitor their pregnancies to decrease this risk.
Collapse
Affiliation(s)
- Minna Lundén
- Department of Clinical Sciences, Danderyd HospitalKarolinska InstituteStockholmSweden
- Department of Obstetrics and GynecologyDanderyd HospitalStockholmSweden
| | - Ingela Hulthén Varli
- Department of Women's and Children's HealthKarolinska InstituteStockholmSweden
- Department of Obstetrics and GynecologyKarolinska University HospitalStockholmSweden
| | - Helena Kopp Kallner
- Department of Clinical Sciences, Danderyd HospitalKarolinska InstituteStockholmSweden
- Department of Obstetrics and GynecologyDanderyd HospitalStockholmSweden
| | - Hanna Åmark
- Department of Clinical Sciences, Danderyd HospitalKarolinska InstituteStockholmSweden
- Department of Clinical Science and Education, Unit of Obstetrics and Gynecology, SödersjukhusetKarolinska InstituteStockholmSweden
- Department of Obstetrics and GynecologySödersjukhusetStockholmSweden
| |
Collapse
|
41
|
Hertting E, Herling L, Lindqvist PG, Wiberg‐Itzel E. Importance of antenatal identification of small for gestational age fetuses on perinatal and childhood outcomes: A register-based cohort study. Acta Obstet Gynecol Scand 2024; 103:42-50. [PMID: 37875267 PMCID: PMC10755121 DOI: 10.1111/aogs.14697] [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: 05/26/2023] [Revised: 09/28/2023] [Accepted: 09/29/2023] [Indexed: 10/26/2023]
Abstract
INTRODUCTION Fetal growth restriction (FGR) is associated with increased risk for stillbirth, perinatal morbidity, cerebral palsy, neurodevelopmental disorders and cardiovascular disease later in life. Identifying small-for-gestational-age (SGA) fetuses is crucial for the diagnosis of FGR. The aim of this study was to investigate the association between antenatal identification of SGA fetuses and severe adverse perinatal and childhood outcome. MATERIAL AND METHODS A register-based cohort study of all newborns delivered in Stockholm in 2014 and 2017. INCLUSION CRITERIA singleton pregnancies without chromosomal aberrations or structural abnormalities, with a gestational age at delivery between 22+0 and 43+0 (n = 48 843). Data from childbirth records were linked to data from nationwide Swedish registers. Pregnancy including offspring data were reviewed. Adverse outcomes for non-identified and identified SGA newborns were compared using logistic regression models. Primary outcome was a composite outcome called severe adverse outcome, defined as at least one of the following: stillbirth, severe newborn distress (Apgar score <4 at 5 min, pH <7 or resuscitation activities >10 min), severe neonatal outcome (hypoxic ischemic encephalopathy 2-3, necrotizing enterocolitis, neonatal seizures, intraventricular hemorrhage grade 3-4, bronchopulmonary disease or death at <1 year), severe childhood outcome (cognitive impairment or motor impairment or cerebral palsy or hearing impairment or visual impairment or death at 1-3 years old). Secondary outcomes were stillbirth, severe newborn distress, severe neonatal outcome, severe childhood outcome. RESULTS No association was found between antenatal identification of SGA fetuses and severe adverse outcome using the complete composite outcome (adjusted odds ratio [aOR] 1.19, 95% confidence interval [CI] 0.93-1.53). In subgroup analyses, non-identified SGA fetuses had an almost fivefold increased risk for stillbirth (aOR 4.79, 95% CI 2.63-8.72) and an increased risk for severe newborn distress (aOR 1.36, 95% CI 1.02-1.82), but a decreased risk for severe childhood outcome (aOR 0.63, 95% CI 0.40-0.99). No association was found between antenatal identification of SGA and severe neonatal outcome. CONCLUSIONS Non-identified SGA fetuses have an increased risk for stillbirth and severe newborn distress. Conversely, identified SGA fetuses have an increased risk for severe childhood outcome.
Collapse
Affiliation(s)
- Emma Hertting
- Department of Clinical Science and EducationKarolinska Institutet, SödersjukhusetStockholmSweden
- Department of Obstetrics and GynecologySödersjukhusetStockholmSweden
| | - Lotta Herling
- Center for Fetal MedicineKarolinska University HospitalStockholmSweden
- Department of Clinical ScienceIntervention and Technology, Karolinska InstitutetStockholmSweden
| | - Pelle G. Lindqvist
- Department of Clinical Science and EducationKarolinska Institutet, SödersjukhusetStockholmSweden
- Department of Obstetrics and GynecologySödersjukhusetStockholmSweden
| | - Eva Wiberg‐Itzel
- Department of Clinical Science and EducationKarolinska Institutet, SödersjukhusetStockholmSweden
- Department of Obstetrics and GynecologySödersjukhusetStockholmSweden
| |
Collapse
|
42
|
Hao J, Yang L, Wang Y, Lan Y, Xu X, Wang Z, Li Z, Ma L, Li J, Zhang S, Sun Y. Mobile Prenatal Education and Its Impact on Reducing Adverse Pregnancy Outcomes: Retrospective Real-World Study. JMIR Mhealth Uhealth 2023; 11:e46910. [PMID: 38117555 PMCID: PMC10765290 DOI: 10.2196/46910] [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: 03/02/2023] [Revised: 11/03/2023] [Accepted: 11/29/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Pregnancy is a pivotal phase in a woman's life, demanding special attention to ensure maternal and fetal health. Prenatal education plays a vital role in promoting healthy pregnancies and reducing adverse outcomes for pregnant women. Mobile prenatal education programs have gained traction due to their accessibility and timeliness, especially in light of finite health care resources and the constraints imposed by the COVID-19 pandemic. OBJECTIVE This study aims to develop and evaluate the effectiveness of a mobile-based prenatal education program in improving pregnancy outcomes. METHODS We developed a mobile-based prenatal education curriculum in collaboration with a multidisciplinary maternal care team from Peking Union Medical College Hospital (PUMCH) in Beijing, China. Data were retrospectively collected from 1941 pregnant women who had registered for the PUMCH mobile prenatal education program and subsequently delivered at PUMCH between May 2021 and August 2022. The study compared pregnancy outcomes between the completing group, which were pregnant women who had completed at least 1 course, and the noncompleting group. We also analyzed differences among course topics within the completing group and assessed course topic popularity among pregnant women. RESULTS The PUMCH mobile prenatal education curriculum consists of 436 courses across 9 topics. Out of the participants, a total of 1521 did not complete any courses, while 420 completed at least 1 course. Compared with the noncompleting group, pregnant women who completed courses exhibited a significant reduction in the risk of gestational diabetes mellitus, induced abortion, postpartum infection, fetal intrauterine distress, and neonatal malformation. Among those in the completing group, a total of 86% (361/420) started course completion during the first and second trimesters. Furthermore, completing courses related to topics of pregnancy psychology and pregnancy nutrition was associated with reduced risks of premature rupture of membranes and small for gestational age infants, respectively. Pregnancy psychology and postpartum recovery were the preferred topics among pregnant women. CONCLUSIONS The study demonstrates the potential of mobile-based prenatal education programs in improving pregnancy outcomes and supporting health care providers in delivering effective prenatal education. The rise of mobile prenatal education presents an opportunity to improve maternal and child health outcomes. Further research and broader implementation of such programs are warranted to continually improve maternal and child health.
Collapse
Affiliation(s)
- Jie Hao
- Institute of Medical Information & Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lin Yang
- Institute of Medical Information & Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yaxin Wang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Beijing, China
| | - Yushan Lan
- Institute of Medical Information & Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaowei Xu
- Institute of Medical Information & Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ziyang Wang
- Institute of Medical Information & Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zanmei Li
- Institute of Medical Information & Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Liangkun Ma
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Beijing, China
| | - Jiao Li
- Institute of Medical Information & Library, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Suhan Zhang
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Beijing, China
| | - Yin Sun
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Beijing, China
| |
Collapse
|
43
|
Crawford K, Hong J, Kumar S. Mediation analysis quantifying the magnitude of stillbirth risk attributable to small for gestational age infants. Am J Obstet Gynecol MFM 2023; 5:101187. [PMID: 37832646 DOI: 10.1016/j.ajogmf.2023.101187] [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: 09/26/2023] [Revised: 10/06/2023] [Accepted: 10/07/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND Many risk factors for stillbirth are linked to placental dysfunction, which leads to suboptimal intrauterine growth and small for gestational age infants. Such infants also have an increased risk for stillbirth. OBJECTIVE This study aimed to investigate the effect of known causal risk factors for stillbirth, and to identify those that have a large proportion of their risk mediated through small for gestational age birth. STUDY DESIGN This retrospective cohort study used data from all births in the state of Queensland, Australia between 2000 and 2018. The total effects of exposures on the odds of stillbirth were determined using multivariable, clustered logistic regression models. Mediation analysis was performed using a counterfactual approach to determine the indirect effect and percentage of effect mediated through small for gestational age. For risk factors significantly mediated through small for gestational age, the relative risks of stillbirth were compared between small for gestational age and appropriate for gestational age infants. We also investigated the proportion of risk mediated via small for gestational age for late stillbirths (≥28 weeks). RESULTS The initial data set consisted of 1,105,612 births. After exclusions, the final study cohort constituted 925,053 births. Small for gestational age births occurred in 9.9% (91,859/925,053) of the study cohort. Stillbirths occurred in 0.5% of all births (4234/925,053) and 1.5% of small for gestational age births (1414/91,859). Births at ≥28 weeks occurred in 99.4% (919,650/925,053) of the study cohort and in 98.9% (90,804/91,859) of all small for gestational age births. Of the ≥28-week births, stillbirths occurred in 0.2% (2156/919,650) of all births and 0.8% (677/90,804) of the small for gestational age births. Overall, increased odds of stillbirth were significantly mediated through small for gestational age for age <20 years, low socioeconomic status, Indigenous ethnicity, birth in sub-Saharan and North Africa or the Middle East, smoking, nulliparity, multiple pregnancy, assisted conception, previous stillbirth, preeclampsia, and renal disease. Preeclampsia had the largest proportion mediated through small for gestational age (66.7%), followed by nulliparity (61.6%), smoking (29.4%), North-African or Middle Eastern ethnicity (27.6%), multiple pregnancy (26.3%), low socioeconomic status (25.8%), and Indigenous status (18.7%). Sensitivity analysis showed that for late stillbirths, the portions mediated through small for gestational age remained very similar for many of the risk factors. CONCLUSION Although small for gestational age is an important mediator between many pregnancy risk factors and stillbirth, mitigating the risk of small for gestational age is likely to be of value only when it is a major contributor in the pathway to fetal demise.
Collapse
Affiliation(s)
- Kylie Crawford
- Mater Research Institute, University of Queensland, Brisbane, Australia (Drs Crawford, Hong, and Kumar); University of Queensland Mayne Medical School, University of Queensland, Brisbane, Australia (Drs Crawford, Hong, and Kumar); School of Public Health, University of Queensland, Brisbane, Australia (Dr Crawford)
| | - Jesrine Hong
- Mater Research Institute, University of Queensland, Brisbane, Australia (Drs Crawford, Hong, and Kumar); University of Queensland Mayne Medical School, University of Queensland, Brisbane, Australia (Drs Crawford, Hong, and Kumar); Department of Obstetrics and Gynaecology, Faculty of Medicine, Universiti Malaya, Kuala Lumpur, Malaysia (Dr Hong)
| | - Sailesh Kumar
- Mater Research Institute, University of Queensland, Brisbane, Australia (Drs Crawford, Hong, and Kumar); University of Queensland Mayne Medical School, University of Queensland, Brisbane, Australia (Drs Crawford, Hong, and Kumar); National Health and Medical Research Council, Centre of Research Excellence in Stillbirth, Mater Research Institute, University of Queensland, Brisbane, Australia (Dr Kumar).
| |
Collapse
|
44
|
Osborne B, Mitra S, Karol D, Azzi P, Ou K, Alibhai KM, Murphy MSQ, El-Chaâr D. Etiology of stillbirth in a tertiary care center: a retrospective cohort study assessing ultrasound, laboratory, and pathology investigations. J Matern Fetal Neonatal Med 2023; 36:2277131. [PMID: 37926910 DOI: 10.1080/14767058.2023.2277131] [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: 08/03/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Canadian stillbirth data are limited, and a significant proportion of pregnancies resulting in stillbirth have no attributable cause. The objective of this study was to characterize stillbirth case investigations and management at a tertiary care hospital in Ontario, Canada. METHODS This was a retrospective chart review study of all cases of singleton stillbirth at The Ottawa Hospital between 1 January 2012 and 31 December 2017. Terminations and multiples stillbirths were excluded. Chart reviews were conducted to extract maternal sociodemographic, obstetrical, and fetal characteristics, including results from antenatal ultrasounds, autopsy, placenta pathology, and laboratory investigations. RESULTS A total of 155 eligible cases of stillbirth were identified, resulting in a 6-year stillbirth rate of 4.2 per 1000 total births. The median maternal age was 31.0 years (IQR: 29.0, 35.0) and the median gestational age at delivery was 28 weeks (IQR: 24, 35). A total of 9 (5.8%) pregnant individuals had a history of previous stillbirth. Of the 155 stillbirths, 35% underwent the full suite of post-loss laboratory, placental, and fetal autopsy investigations. 63.2% of cases had post-loss laboratory investigations completed. 76% and 71% of cases had fetal autopsy and placenta pathology evaluations completed, respectively. Antenatal characteristics associated with stillbirth included fetal anomalies/genetic markers (27.1%), umbilical cord and placental anomalies (24.5%), fetal growth abnormalities (27.7%), cervical/uterine abnormalities (11.6%), and amniotic fluid abnormalities (25.1%). The most common autopsy findings included evidence of infection (22.7%), fetal anomalies (12.6%), and fetal hypoxia (10%). The most common placental pathology findings included features of placental insufficiency (21.8%), retroplacental abnormalities (16.3%), and umbilical cord accident/infarct (15.4%). CONCLUSIONS Our findings demonstrate that as many as two-thirds of singleton stillbirth cases at our center did not receive the post-perinatal loss investigations recommended by clinical practice guidelines. More thorough collection of post-stillbirth data at all levels (institutional, provincial, national) is warranted to improve our understanding of stillbirth epidemiology, etiology, and management in Canada.
Collapse
Affiliation(s)
- Brenden Osborne
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Medicine, University of Galway, Galway, Ireland
| | - Sohini Mitra
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Canada
| | - Dalia Karol
- Department of Obstetrics and Gynecology, University of Toronto, Toronto, Canada
| | - Pierre Azzi
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Faculty of Science, University of Ottawa, Ottawa, Canada
| | - Kelsie Ou
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Kameela M Alibhai
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Faculty of Medicine, University of Ottawa, Ottawa, Canada
| | - Malia S Q Murphy
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Darine El-Chaâr
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
- Department of Obstetrics, Gynecology and Newborn Care, The Ottawa Hospital, Ottawa, Canada
- Department of Obstetrics and Gynecology, University of Ottawa, Ottawa, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| |
Collapse
|
45
|
Tokoro S, Koshida S, Tsuji S, Katsura D, Ono T, Murakami T, Takahashi K. Insufficient antenatal identification of fetal growth restriction leading to intrauterine fetal death: a regional population-based study in Japan. J Matern Fetal Neonatal Med 2023; 36:2167075. [PMID: 36646445 DOI: 10.1080/14767058.2023.2167075] [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: 01/18/2023]
Abstract
OBJECTIVE Fetal growth restriction (FGR) is associated with perinatal adverse outcomes including intrauterine fetal death. Antenatally unidentified FGR has a higher risk of intrauterine fetal death than that identified antenatally. We, therefore, investigated the antenatal identification of FGR among intrauterine fetal deaths, and assessed the perinatal factors associated with the identification of FGR. METHODS This retrospective and population-based study reviewed all stillbirths in Shiga Prefecture, Japan, from 2007 to 2016 with exclusion criteria of multiple births, births at unidentified gestational weeks or < 22 gestational weeks, and lethal disorders. We analyzed cases of FGR, using the Japanese clinical definition: Z-score of estimated fetal weight for gestational age <-1.5 standard deviations (SD). RESULTS We identified 94 stillbirths with FGR among 429 stillbirths. Thirty-seven cases were antenatally identified during pregnancy management (39%). Dividing cases by a Z-score of -2.5 SD, 51 cases were classified as ≤-2.5 SD. Twenty-eight of the 51 cases (55%) with a Z-score <-2.5 SD were antenatally identified as having FGR, whereas 9 of the 43 cases (21%) with a Z-score ≥-2.5 SD were antenatally identified as having FGR (p = .002). Among cases with a Z-Score <-2.5 SD, 16 of 21 (76%) beyond 28 weeks' gestation and 12 of 30 (40%) before 28weeks' gestation were antenatally identified as having FGR (p = .023). CONCLUSION Fetal growth restriction leading to intrauterine fetal death in Japan was antenatally identified in less than half of cases. Antenatal identification of FGR was associated with the severity of growth restriction.
Collapse
Affiliation(s)
- Shinsuke Tokoro
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu-city, Japan
| | - Shigeki Koshida
- Perinatal Center, Shiga University of Medical Science, Otsu-city, Japan
| | - Shunichiro Tsuji
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu-city, Japan
| | - Daisuke Katsura
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu-city, Japan
| | - Tetsuo Ono
- Department of Obstetrics and Gynecology, Omihachiman Community Medical Center, Omihachiman-city, Japan
| | - Takashi Murakami
- Department of Obstetrics and Gynecology, Shiga University of Medical Science, Otsu-city, Japan
| | - Kentaro Takahashi
- Perinatal Center, Shiga University of Medical Science, Otsu-city, Japan
| |
Collapse
|
46
|
Alda MG, Holberton J, MacDonald TM, Charlton JK. Small for gestational age at preterm birth identifies adverse neonatal outcomes more reliably than antenatal suspicion of fetal growth restriction. J Matern Fetal Neonatal Med 2023; 36:2279017. [PMID: 37981759 DOI: 10.1080/14767058.2023.2279017] [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: 06/05/2023] [Accepted: 10/30/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Fetal growth restriction (FGR) is an important reason for premature delivery and a leading cause of perinatal morbidity and mortality. We aimed to evaluate whether classification as small for gestational age (SGA; <10th centile) at birth or antenatal suspicion of FGR was more strongly associated with neonatal morbidity and mortality in preterm infants. METHODS A retrospective audit of infants born between 24 + 0 and 32 + 6 weeks of gestation from 2012-2019 and admitted to the Neonatal Unit at Mercy Hospital for Women (MHW). Infants were categorized according to whether FGR was listed as an antenatal complication in the medical records and whether they were SGA (<10th centile on Fenton chart) or appropriate for gestational age (AGA) at birth, and comparisons for neonatal outcomes were made. RESULTS 371/2126 preterm infants (17.5%) had antenatal suspicion of FGR, and 166 (7.8%) were SGA at birth. No differences in any neonatal outcomes were found between infants with or without suspected FGR, except decreased intraventricular hemorrhage (IVH) in the FGR group. SGA classification was associated with increased rates of all morbidities other than IVH, including bronchopulmonary dysplasia, retinopathy of prematurity, and necrotizing enterocolitis, compared with the AGA group. Death was significantly higher in the SGA group (7.2%) compared with the AGA group (3.5%). CONCLUSION SGA by Fenton chart more reliably identified neonates at risk of adverse neonatal outcomes than antenatal suspicion of FGR, suggesting it is a reasonable clinical proxy. This most likely reflects the much lower tenth centile weight cutoffs on the Fenton charts compared to in-utero charts used antenatally to diagnose FGR based on ultrasound estimated fetal weight. SGA classification by Fenton approximately equates to <3rd centile on in-utero charts at our institution, therefore identifying the most severe FGR cases.
Collapse
Affiliation(s)
- Maria G Alda
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Department of Paediatrics, Mercy Hospital for Women, Melbourne, Australia
| | - James Holberton
- Department of Paediatrics, Mercy Hospital for Women, Melbourne, Australia
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
| | - Teresa M MacDonald
- Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Australia
- Mercy Perinatal, Mercy Hospital for Women, Melbourne, Australia
| | - Julia K Charlton
- Department of Paediatrics, University of Melbourne, Melbourne, Australia
- Division of Neonatology, BC Women's Hospital, Vancouver, Canada
- Department of Pediatrics, University of British Columbia, Vancouver, Canada
| |
Collapse
|
47
|
Jani D, Clark A, Couper S, Thompson JMD, David AL, Melbourne A, Mirjalili A, Lydon AM, Stone PR. The effect of maternal position on placental blood flow and fetoplacental oxygenation in late gestation fetal growth restriction: a magnetic resonance imaging study. J Physiol 2023; 601:5391-5411. [PMID: 37467072 DOI: 10.1113/jp284269] [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: 01/01/2023] [Accepted: 07/03/2023] [Indexed: 07/21/2023] Open
Abstract
Fetal growth restriction (FGR) and maternal supine going-to-sleep position are both risk factors for late stillbirth. This study aimed to use magnetic resonance imaging (MRI) to quantify the effect of maternal supine position on maternal-placental and fetoplacental blood flow, placental oxygen transfer and fetal oxygenation in FGR and healthy pregnancies. Twelve women with FGR and 27 women with healthy pregnancies at 34-38 weeks' gestation underwent MRI in both left lateral and supine positions. Phase-contrast MRI and a functional MRI technique (DECIDE) were used to measure blood flow in the maternal internal iliac arteries (IIAs) and umbilical vein (UV), placental oxygen transfer (placental flux), fetal oxygen saturation (FO2 ), and fetal oxygen delivery (delivery flux). The presence of FGR, compared to healthy pregnancies, was associated with a 7.8% lower FO2 (P = 0.02), reduced placental flux, and reduced delivery flux. Maternal supine positioning caused a 3.8% reduction in FO2 (P = 0.001), and significant reductions in total IIA flow, placental flux, UV flow and delivery flux compared to maternal left lateral position. The effect of maternal supine position on fetal oxygen delivery was independent of FGR pregnancy, meaning that supine positioning has an additive effect of reducing fetal oxygenation further in women with FGR, compared to women with appropriately grown for age pregnancies. Meanwhile, the effect of maternal supine positioning on placental oxygen transfer was not independent of the effect of FGR. Therefore, growth-restricted fetuses, which are chronically hypoxaemic, experience a relatively greater decline in oxygen transfer when mothers lie supine in late gestation compared to appropriately growing fetuses. KEY POINTS: Fetal growth restriction (FGR) is the most common risk factor associated with stillbirth, and early recognition and timely delivery is vital to reduce this risk. Maternal supine going-to-sleep position is found to increase the risk of late stillbirth but when combined with having a FGR pregnancy, maternal supine position leads to 15 times greater odds of stillbirth compared to supine sleeping with appropriately grown for age (AGA) pregnancies. Using MRI, this study quantifies the chronic hypoxaemia experienced by growth-restricted fetuses due to 13.5% lower placental oxygen transfer and 26% lower fetal oxygen delivery compared to AGA fetuses. With maternal supine positioning, there is a 23% reduction in maternal-placental blood flow and a further 14% reduction in fetal oxygen delivery for both FGR and AGA pregnancies, but this effect is proportionally greater for growth-restricted fetuses. This knowledge emphasises the importance of avoiding supine positioning in late pregnancy, particularly for vulnerable FGR pregnancies.
Collapse
Affiliation(s)
- Devanshi Jani
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - Alys Clark
- Auckland Bioengineering Institute, University of Auckland, Auckland, New Zealand
| | - Sophie Couper
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| | - John M D Thompson
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
- Department of Paediatrics and Child Health, University of Auckland, Auckland, New Zealand
| | - Anna L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College Huntley Street, London, UK
| | - Andrew Melbourne
- School of Biomedical Engineering and Imaging, Kings College London, London, UK
| | - Ali Mirjalili
- Department of Anatomy and Medical Imaging, University of Auckland, Auckland, New Zealand
| | - Anna-Maria Lydon
- Centre for Advanced MRI, University of Auckland, Auckland, New Zealand
| | - Peter R Stone
- Department of Obstetrics and Gynaecology, University of Auckland, Auckland, New Zealand
| |
Collapse
|
48
|
Gardosi J, Hugh O. Outcome-based comparative analysis of five fetal growth velocity models to define slow growth. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:805-812. [PMID: 37191400 DOI: 10.1002/uog.26248] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/28/2023] [Accepted: 05/02/2023] [Indexed: 05/17/2023]
Abstract
OBJECTIVE Fetal growth surveillance includes assessment of size as well as rate of growth, and various definitions for slow growth have been adopted into clinical use. The aim of this study was to evaluate the effectiveness of different models to identify stillbirth risk, in addition to risk represented by the fetus being small-for-gestational age (SGA). METHODS This was a retrospective analysis of a routinely collected and anonymized dataset of pregnancies that had two or more third-trimester ultrasound measurements of estimated fetal weight (EFW). SGA was defined as EFW < 10th customized centile, and slow growth was defined according to five published models in clinical use: (1) a fixed velocity limit of 20 g per day (FVL20 ); (2) a fixed > 50 centile drop, regardless of scan-measurement interval (FCD50 ); (3) a fixed > 30 centile drop, regardless of scan interval (FCD30 ); (4) growth trajectory slower than the third customized growth-centile limit (GCL3 ); and (5) EFW at second scan below the projected optimal weight range (POWR), based on partial receiver-operating-characteristics-curve-derived cut-offs specific to the scan interval. RESULTS The study cohort consisted of 164 718 pregnancies with 480 592 third-trimester ultrasound scans (mean ± SD, 2.9 ± 0.9). The last two scans in each pregnancy were performed at an average gestational age of 33 + 5 and 37 + 1 weeks. At the last scan, 12 858 (7.8%) EFWs were SGA, and of these, 9359 were also SGA at birth (positive predictive value, 72.8%). The rate at which slow growth was defined varied considerably (FVL20 , 12.7%; FCD50 , 0.7%; FCD30 , 4.6%; GCL3 , 19.8%; POWR, 10.1%), and there was varying overlap between cases identified as having slow growth and those identified as SGA at the last scan. Only the POWR method identified additional non-SGA pregnancies with slow growth (11 237/16 671 (67.4%)) that had significant stillbirth risk (relative risk, 1.58 (95% CI, 1.04-2.39)). These non-SGA cases resulting in stillbirth had a median EFW centile of 52.6 at the last scan and a median weight centile of 27.3 at birth. Subgroup analysis identified methodological problems with the fixed-velocity model because it assumes linear growth throughout gestation, and with the centile-based methods because the non-parametric distribution of centiles at the extremes does not reflect actual difference in weight gain. CONCLUSION Comparative analysis of five clinically used methods to define slow fetal growth has shown that only the measurement-interval-specific POWR model can identify non-SGA fetuses with slow growth that are at increased risk of stillbirth. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
| | - O Hugh
- Perinatal Institute, Birmingham, UK
| |
Collapse
|
49
|
Leon-Martinez D, Lundsberg LS, Culhane J, Zhang J, Son M, Reddy UM. Fetal growth restriction and small for gestational age as predictors of neonatal morbidity: which growth nomogram to use? Am J Obstet Gynecol 2023; 229:678.e1-678.e16. [PMID: 37348779 DOI: 10.1016/j.ajog.2023.06.035] [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: 12/15/2022] [Revised: 06/15/2023] [Accepted: 06/15/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Fetal growth nomograms were developed to screen for fetal growth restriction and guide clinical care to improve perinatal outcomes; however, existing literature remains inconclusive regarding which nomogram is the gold standard. OBJECTIVE This study aimed to compare the ability of 4 commonly used nomograms (Hadlock, International Fetal and Newborn Growth Consortium for the 21st Century, Eunice Kennedy Shriver National Institute of Child Health and Human Development-unified standard, and World Health Organization fetal growth charts) and 1 institution-specific reference to predict small for gestational age and poor neonatal outcomes. STUDY DESIGN This was a retrospective cohort study of all nonanomalous singleton pregnancies undergoing ultrasound at ≥20 weeks of gestation between 2013 and 2020 and delivering at a single academic center. Using random selection methods, the study sample was restricted to 1 pregnancy per patient and 1 ultrasound per pregnancy completed at ≥22 weeks of gestation. Fetal biometry data were used to calculate estimated fetal weight and percentiles according to the aforementioned 5 nomograms. Maternal and neonatal data were extracted from electronic medical records. Logistic regression was used to estimate the association between estimated fetal weight of <10th and <3rd percentiles compared with estimated fetal weight of 10th to 90th percentile as the reference group for small for gestational age and the neonatal composite outcomes (perinatal mortality, hypoxic-ischemic encephalopathy or seizures, respiratory morbidity, intraventricular hemorrhage, necrotizing enterocolitis, hyperbilirubinemia or hypoglycemia requiring neonatal intensive care unit admission, and retinopathy of prematurity). Receiver operating characteristic curve contrast estimation (primary analysis) and test characteristics were calculated for all nomograms and the prediction of small for gestational age and the neonatal composite outcomes. We restricted the sample to ultrasounds performed within 28 days of delivery; moreover, similar analyses were completed to assess the prediction of small for gestational age and neonatal composite outcomes. RESULTS Among 10,045 participants, the proportion of fetuses classified as <10th percentile varied across nomograms from 4.9% to 9.7%. Fetuses with an estimated fetal weight of <10th percentile had an increased risk of small for gestational age (odds ratio, 9.9 [95% confidence interval, 8.5-11.5] to 12.8 [95% confidence interval, 10.9-15.0]). In addition, the estimated fetal weight of <10th and <3rd percentile was associated with increased risk of the neonatal composite outcome (odds ratio, 2.4 [95% confidence interval, 2.0-2.8] to 3.5 [95% confidence interval, 2.9-4.3] and 5.7 [95% confidence interval, 4.5-7.2] to 8.8 [95% confidence interval, 6.6-11.8], respectively). The prediction of small for gestational age with an estimated fetal weight of <10th percentile had a positive likelihood ratio of 6.3 to 8.5 and an area under the curve of 0.62 to 0.67. Similarly, the prediction of the neonatal composite outcome with an estimated fetal weight of <10th percentile had a positive likelihood ratio of 2.1 to 3.1 and an area under the curve of 0.55 to 0.57. When analyses were restricted to ultrasound within 4 weeks of delivery, among fetuses with an estimated fetal weight of <10th percentile, the risk of small for gestational age increased across all nomograms (odds ratio, 16.7 [95% confidence interval, 12.6-22.3] to 25.1 [95% confidence interval, 17.0-37.0]), and prediction improved (positive likelihood ratio, 8.3-15.0; area under the curve, 0.69-0.75). Similarly, the risk of neonatal composite outcome increased (odds ratio, 3.2 [95% confidence interval, 2.4-4.2] to 5.2 [95% confidence interval, 3.8-7.2]), and prediction marginally improved (positive likelihood ratio, 2.4-4.1; area under the curve, 0.60-0.62). Importantly, the risk of both being small for gestational age and having the neonatal composite outcome further increased (odds ratio, 21.4 [95% confidence interval, 13.6-33.6] to 28.7 (95% confidence interval, 18.6-44.3]), and the prediction of concurrent small for gestational age and neonatal composite outcome greatly improved (positive likelihood ratio, 6.0-10.0; area under the curve, 0.80-0.83). CONCLUSION In this large cohort, Hadlock, recent fetal growth nomograms, and a local population-derived fetal growth reference performed comparably in the prediction of small for gestational age and neonatal composite outcomes.
Collapse
Affiliation(s)
- Daisy Leon-Martinez
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT.
| | - Lisbet S Lundsberg
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT
| | - Jennifer Culhane
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT
| | - Jun Zhang
- International Peace Maternal and Child Health Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Moeun Son
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT
| | - Uma M Reddy
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, CT
| |
Collapse
|
50
|
Valenzuela I, Regin Y, Gie A, Basurto D, Emam D, Scuglia M, Zapletalova K, Greyling M, Deprest J, van der Merwe J. Long-term pulmonary and neurodevelopmental impairment in a fetal growth restriction rabbit model. Sci Rep 2023; 13:20966. [PMID: 38017239 PMCID: PMC10684490 DOI: 10.1038/s41598-023-48174-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 11/23/2023] [Indexed: 11/30/2023] Open
Abstract
Fetal growth restriction (FGR) remains one of the main obstetrical problems worldwide, with consequences beyond perinatal life. Animal models with developmental and structural similarities to the human are essential to understand FGR long-term consequences and design novel therapeutic strategies aimed at preventing or ameliorating them. Herein, we described the long-term consequences of FGR in pulmonary function, structure, and gene expression, and characterized neurodevelopmental sequelae up to preadolescence in a rabbit model. FGR was induced at gestational day 25 by surgically reducing placental blood supply in one uterine horn, leaving the contralateral horn as internal control. Neonatal rabbits born near term were assigned to foster care in mixed groups until postnatal day (PND) 21. At that time, one group underwent pulmonary biomechanical testing followed by lung morphometry and gene expression analysis. A second group underwent longitudinal neurobehavioral assessment until PND 60 followed by brain harvesting for multiregional oligodendrocyte and microglia quantification. FGR was associated with impaired pulmonary function and lung development at PND 21. FGR rabbits had higher respiratory resistance and altered parenchymal biomechanical properties in the lungs. FGR lungs presented thicker alveolar septal walls and reduced alveolar space. Furthermore, the airway smooth muscle content was increased, and the tunica media of the intra-acinar pulmonary arteries was thicker. In addition, FGR was associated with anxiety-like behavior, impaired memory and attention, and lower oligodendrocyte proportion in the frontal cortex and white matter. In conclusion, we documented and characterized the detrimental pulmonary function and structural changes after FGR, independent of prematurity, and beyond the neonatal period for the first time in the rabbit model, and describe the oligodendrocyte alteration in pre-adolescent rabbit brains. This characterization will allow researchers to develop and test therapies to treat FGR and prevent its sequelae.
Collapse
Affiliation(s)
- Ignacio Valenzuela
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Herestraat 49, Box 805, B-3000, Leuven, Belgium.
| | - Yannick Regin
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Herestraat 49, Box 805, B-3000, Leuven, Belgium
| | - Andre Gie
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Herestraat 49, Box 805, B-3000, Leuven, Belgium
- Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
| | - David Basurto
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Herestraat 49, Box 805, B-3000, Leuven, Belgium
| | - Doaa Emam
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Herestraat 49, Box 805, B-3000, Leuven, Belgium
- Department of Obstetrics and Gynaecology, University Hospitals Tanta, Tanta, Egypt
| | - Marianna Scuglia
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Herestraat 49, Box 805, B-3000, Leuven, Belgium
- Developmental Biology and Cancer Research and Teaching Department, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Katerina Zapletalova
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Herestraat 49, Box 805, B-3000, Leuven, Belgium
- Third Faculty of Medicine, Institute for the Care of Mother and Child, Charles University, Prague, Czech Republic
| | - Marnel Greyling
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Herestraat 49, Box 805, B-3000, Leuven, Belgium
| | - Jan Deprest
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Herestraat 49, Box 805, B-3000, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Woman and Child, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Johannes van der Merwe
- Department of Development and Regeneration, Cluster Woman and Child, Group Biomedical Sciences, KU Leuven, Herestraat 49, Box 805, B-3000, Leuven, Belgium
- Department of Obstetrics and Gynecology, Division Woman and Child, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| |
Collapse
|