Intended delivery mode and neonatal outcomes in pregnancies with fetal growth restriction

Objective: To compare neonatal outcomes in pregnancies with fetal growth restriction (FGR) by intended delivery mode.Methods: This is a retrospective cohort study of singleton pregnancies with FGR that were delivered ≥34.0 weeks gestation. Neonatal outcomes were compared according to the intended delivery mode, which the attending obstetrician determined. Of note, none of the subjects had a contraindication to labor. Crude and adjusted odds ratios (ORs) and corresponding confidence intervals (CIs) were calculated via logistic regression models to assess the potential association between intended delivery mode and neonatal morbidity defined as a composite outcome (i.e. umbilical artery pH ≤7.1, 5-min Apgar score ≤7, admission to the neonatal intensive care unit, hypoglycemia, intrapartum fetal distress requiring expedited delivery, and perinatal death). A sensitivity analysis excluded intrapartum fetal distress requiring emergency cesarean delivery from the composite outcome since only patients with spontaneous labor or labor induction could meet this criterion. Potential confounders in the adjusted effects models included maternal age, body mass index, hypertensive disorders, diabetes, FGR type (i.e. early or late), and oligohydramnios.Results: Seventy-two (34%) patients had an elective cesarean delivery, 73 (34%) had spontaneous labor and were expected to deliver vaginally, and 67 (32%) underwent labor induction. The composite outcome was observed in 65.3%, 89%, and 88.1% of the groups mentioned above, respectively (p < 0.001). Among patients with spontaneous labor and those scheduled for labor induction, 63% and 47.8% required an emergency cesarean delivery for intrapartum fetal distress. Compared to elective cesarean delivery, spontaneous labor (OR 4.32 [95% CI 1.79, 10.42], p = 0.001; aOR 4.85 [95% CI 1.85, 12.66], p = 0.001), and labor induction (OR 3.92 [95% CI 1.62, 9.49] p = 0.002; aOR 5.29 [95% CI 2.01, 13.87], p = 0.001) had higher odds of adverse neonatal outcomes.Conclusion: In this cohort of FGR, delivering at ≥34 weeks of gestation, pregnancies with spontaneous labor, and those that underwent labor induction had higher odds of neonatal morbidity than elective cesarean delivery.

Is There Still a Place for Forceps Delivery in Modern Obstetrics?

BACKGROUND

Nowadays, we are witnessing a decrease of vaginal instrumental deliveries and continuous increase of caesarean section rate. However, proper identification of possibility of execution, indications for instrumental delivery and their skilful use may improve the broadly understood maternal and neonatal outcomes. The aim of this study is to present prevalence, risk factors, indications and outcomes of forceps deliveries among the patients at Department of Perinatology, Lodz.

MATERIAL AND METHODS

A retrospective study was conducted at the Department of Perinatology, Medical University of Lodz. The study included forceps deliveries carried out between January 2019 and December 2022. Total number of 147 cases were analysed in terms of indications for forceps delivery and maternal and neonatal outcomes such as vaginal - or cervical - laceration, postpartum haemorrhage, perineal tear, newborn injuries, Apgar score, umbilical cord blood gas analysis, NICU admission and cranial ultrasound scans.

RESULTS

The prevalence of forceps delivery was 2.2%. The most common indication for forceps delivery was foetal distress (81.6%). Among mothers, the most frequent complication was vaginal laceration (40.1%). Third-and fourth-degree perineal tears were not noted. Regarding neonatal outcomes, Apgar score ≥ 8 after 1st and 5th minute of life received accordingly 91.2% and 98% of newborns. Only 8.8% experienced severe birth injuries (subperiosteal haematoma, clavicle fracture).

CONCLUSIONS

Although foetal distress is the most common indication for forceps delivery, the vast majority of newborns were born in good condition and did not require admission to NICU. Taking into consideration high efficacy and low risk of neonatal and maternal complications, forceps should remain in modern obstetrics.

Neonatal outcomes and congenital anomalies in pregnancies affected by hypothyroidism

BACKGROUND

Maternal hypothyroidism has been reported to have concerns over neonatal outcomes, not only in the context of neurocognitive development but also in the short term as birth weight and neonatal jaundice.

PATIENTS AND METHODS

We conducted a cross-sectional retrospective study on 638 cases who delivered live births in the Aga Khan University Hospital after ethical approval. Data were collected on hypothyroid pregnant females who were diagnosed before conception or during their antenatal visits during the year 2008-2016. Neonatal outcomes were noted for birth weight, maturity, and neonatal jaundice, neonatal hypothyroidism, neonatal respiratory distress syndrome, sepsis, hypocalcaemia, congenital anomalies, need for intensive care admission, and neonatal death. Subgroup analysis was performed on the timing of diagnosis of maternal hypothyroidism. Data analysis was performed on Statistical Package for the Social Sciences version 20.0.

RESULTS

Neonatal jaundice was the most common neonatal outcome (37.6%) in our cohort of 662 live births. Nearly 15% required intensive care unit admission, however, neonatal death was very rare. The most common clinically significant congenital anomalies were cardiovascular defects, whereas Mongolian spots were the commonest congenital condition to report. There is a statistically significant association between low birth weight (OR 1.86, 95% CI 1.0-3.2, p ≤ 0.05) and congenital anomalies (OR 2.39, 95% CI 1.4-4.0, p ≤ 0.05) with women diagnosed with hypothyroidism before pregnancy.

CONCLUSION

We report the neonatal outcomes and spectrum of congenital anomalies of hypothyroid pregnancies diagnosed before and during conception for the first time from the region of Pakistan.KEY MESSAGEOverall, none of the neonates of hypothyroid pregnancies developed congenital hypothyroidism.Cardiovascular defects in these neonates imply extensive screening and monitoring during pregnancy.Low birth weight and congenital anomalies are associated with the timings of diagnosis of hypothyroidism in pregnancy.

Ursodeoxycholic acid improves pregnancy outcome in patients with intrahepatic cholestasis during pregnancy: A protocol for systematic review and meta-analysis

BACKGROUND

Intrahepatic cholestasis of pregnancy (ICP) is a common complication in the third trimester of pregnancy, which may result in premature delivery, fetal distress, stillbirth, and other adverse pregnancy outcomes. Ursodeoxycholic acid (UDCA) is a first-line treatment for ICP and has been controversial in improving adverse pregnancy outcomes. The purpose of this protocol is to systematically evaluate the effect of UDCA on pregnancy outcomes in patients with intrahepatic cholestasis during pregnancy.

METHODS

To search the databases PubMed, Embase, Web of Science, the Cochrane Library, CNKI, WanFang, VIP, CBMDIsc by computer, then to include randomized controlled clinical studies on UDCA for treatment of intrahepatic cholestasis during pregnancy from the establishment of the database to October 1, 2020. Two researchers independently extract and evaluate the data of the included studies, and meta-analysis is conducted on the included literatures using RevMan5.3 software.

RESULTS

This protocol evaluates the outcome of UDCA in improving ICP by incidence of postpartum hemorrhage in pregnant women preterm birth rates meconium contamination rate in amniotic fluid incidence of fetal distress scale of newborns scoring <7 in 5-min Apgar incidence of neonatal admission to neonatal intensive care unit.

CONCLUSION

This protocol will provide an evidence-based basis for clinical use of UDCA in the treatment of intrahepatic cholestasis during pregnancy.

ETHICS AND DISSEMINATION

Private information from individuals will not be published. This systematic review also does not involve endangering participant rights. Ethical approval was not required. The results may be published in a peer-reviewed journal or disseminated at relevant conferences.

OSF REGISTRATION NUMBER

DOI 10.17605 / OSF.IO / BE67H.

COVID-19 and pregnancy: a review of current knowledge

BACKGROUND

Since December 2019, coronavirus disease 2019 (COVID-19) has become a major health problem that is spreading all over the world. Several viral infections such as SARS, MERS, and influenza have been associated with adverse pregnancy outcomes. The question arises whether pregnant women are at greater risk of complications related to COVID-19 compared to other people What complications should we expect in the fetuses whose mothers were infected?

AIMS

This review aims to provide a summary of studies on symptoms of COVID-19 and the possible risks of COVID-19 among pregnant women, as well as complications in fetuses and neonates whose mothers were infected with COVID-19.

METHODS

The included data were provided from Web of Science, Cochrane, PubMed, and Scopus which are extracted from the published studies in English until April 2nd, 2020 that contained data on the risk of COVID-19 in pregnancy.

RESULTS

The early symptoms of patients with COVID-19 were fever, cough, dyspnea, myalgia, and fatigue; while production of sputum, headache, hemoptysis, and diarrhea were other symptoms which were less common. There is no evidence of vertical maternal-fetal transmission in pregnant women with COVID-19.

CONCLUSIONS

The clinical findings in pregnant women with COVID-19 are not significantly different compared to other patients, and pregnant women with COVID-19 are not at a higher risk of developing critical pneumonia compared to non-pregnant women. Although, there has been no sign of vertical infection in infants, but maternal infection can cause serious problems such as preterm labour and fetal distress.

Role of Doppler ultrasound at time of diagnosis of late-onset fetal growth restriction in predicting adverse perinatal outcome: prospective cohort study

OBJECTIVE

Pregnancies complicated by late-onset fetal growth restriction (FGR) are at increased risk of short- and long-term morbidities. Despite this, identification of cases at higher risk of adverse perinatal outcome, at the time of FGR diagnosis, is challenging. The aims of this study were to elucidate the strength of association between fetoplacental Doppler indices at the time of diagnosis of late-onset FGR and adverse perinatal outcome, and to determine their predictive accuracy.

METHODS

This was a prospective study of consecutive singleton pregnancies complicated by late-onset FGR. Late-onset FGR was defined as estimated fetal weight (EFW) or abdominal circumference (AC) < 3^rd centile, or EFW or AC < 10^th centile and umbilical artery (UA) pulsatility index (PI) > 95^th centile or cerebroplacental ratio (CPR) < 5^th centile, diagnosed after 32 weeks. EFW, uterine artery PI, UA-PI, fetal middle cerebral artery (MCA) PI, CPR and umbilical vein blood flow normalized for fetal abdominal circumference (UVBF/AC) were recorded at the time of the diagnosis of FGR. Doppler variables were expressed as Z-scores for gestational age. Composite adverse perinatal outcome was defined as the occurrence of at least one of emergency Cesarean section for fetal distress, 5-min Apgar score < 7, umbilical artery pH < 7.10 and neonatal admission to the special care unit. Logistic regression analysis was used to elucidate the strength of association between different ultrasound parameters and composite adverse perinatal outcome, and receiver-operating-characteristics (ROC)-curve analysis was used to determine their predictive accuracy.

RESULTS

In total, 243 consecutive singleton pregnancies complicated by late-onset FGR were included. Composite adverse perinatal outcome occurred in 32.5% (95% CI, 26.7-38.8%) of cases. In pregnancies with composite adverse perinatal outcome, compared with those without, mean uterine artery PI Z-score (2.23 ± 1.34 vs 1.88 ± 0.89, P = 0.02) was higher, while Z-scores of UVBF/AC (-1.93 ± 0.88 vs -0.89 ± 0.94, P ≤ 0.0001), MCA-PI (-1.56 ± 0.93 vs -1.22 ± 0.84, P = 0.004) and CPR (-1.89 ± 1.12 vs -1.44 ± 1.02, P = 0.002) were lower. On multivariable logistic regression analysis, Z-scores of mean uterine artery PI (P = 0.04), CPR (P = 0.002) and UVBF/AC (P = 0.001) were associated independently with composite adverse perinatal outcome. UVBF/AC Z-score had an area under the ROC curve (AUC) of 0.723 (95% CI, 0.64-0.80) for composite adverse perinatal outcome, demonstrating better accuracy than that of mean uterine artery PI Z-score (AUC, 0.593; 95% CI, 0.50-0.69) and CPR Z-score (AUC, 0.615; 95% CI, 0.52-0.71). A multiparametric prediction model including Z-scores of MCA-PI, uterine artery PI and UVBF/AC had an AUC of 0.745 (95% CI, 0.66-0.83) for the prediction of composite adverse perinatal outcome.

CONCLUSION

While CPR and uterine artery PI assessed at the time of diagnosis are associated independently with composite adverse perinatal outcome in pregnancies complicated by late-onset FGR, their diagnostic performance for composite adverse perinatal outcome is low. UVBF/AC showed better accuracy for prediction of composite adverse perinatal outcome, although its usefulness in clinical practice as a standalone predictor of adverse pregnancy outcome requires further research. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Intraperitoneal hemorrhage during pregnancy and parturition: Case reports and literature review

We aim to investigate the diagnosis, treatment, and prognosis of intraperitoneal hemorrhage during pregnancy and parturition.Three cases with intraperitoneal hemorrhage during pregnancy and parturition admitted to our hospital from Jan. 2008 to Jan. 2018 were included in this study. One case showed fetal distress. Abdominal ultrasonography and abdominal CT showed pyoperitoneum in 2 cases. Abdominal puncture was performed in 2 patients, and noncoagulant blood was collected. The indications of emergency caesarean section in 3 cases were intraperitoneal hemorrhage. The etiology included rupture of posterior wall of uterus, rupture of blood vessel on uterine surface, and rupture of inflammatory vessel on uterine surface, respectively. The average volume of intraperitoneal bleeding was 2630 ml, and the average transfusion volume was 1530 ml. Caesarean section, and suture hemostasis were performed in 3 cases. The gestational age of delivery were 40 weeks, 40 weeks, and 25 weeks, respectively. There were 1 stillborn fetus and 2 live infants. All the puerperas were cured and discharged.Intraperitoneal hemorrhage in pregnancy is rare and is easily misdiagnosed. The mortality of pregnant women and perinatal infant is high. Therefore, early diagnosis, and timely operation is important.

Urgent Cesarean Delivery Following a Spontaneous Coronary Artery Dissection

BACKGROUND Spontaneous coronary artery dissection is the most common etiology of pregnancy-associated myocardial infarction. It is characterized by high rates of maternal morbidity and mortality and may cause fetal complications and death as well. CASE REPORT A 44-year-old female (G2P1) suffered from pregnancy-related spontaneous coronary artery dissection with dissection of distal left anterior descending coronary artery. The patient was hemodynamically stable and did not required revascularization, but signs of fetal distress were detected and thus an urgent cesarean delivery was performed. This emergency procedure was undertaken in the catheterization laboratory (Cath-Lab) right after coronary angiography, thanks to a multidisciplinary team. Health conditions of the newborn were good. The patient instead suffered from a recurrence of spontaneous coronary artery dissection 6 days later, complicated by left ventricular apical thrombus and epistenocardial pericarditis. The dissection self-healed in 1 month. CONCLUSIONS Careful evaluation of pregnancy-related spontaneous coronary artery dissection is needed to assess and manage both maternal and fetal complications. Under specific circumstances, a cesarean delivery may be required and be even performed in the Cath-Lab after coronary catheterization.

What may cause fetus loss from acute pancreatitis in pregnancy: Analysis of 54 cases

Acute pancreatitis in pregnancy (APIP) poses a serious threat to the mother and her fetus, and might lead to fetal loss including miscarriage and stillbirth in certain patients. We sought to identify possible factors that affect fetal distress and evaluated outcomes of patients with APIP.We retrospectively reviewed clinical records of 54 pregnant women with APIP, who were treated at 2 tertiary clinical centers over a 6-year period. Clinical characteristics including etiology and severity of APIP, fetal monitoring data, and maternofetal outcomes were analyzed.Etiology of APIP included acute biliary pancreatitis (ABP, n = 14), hyperlipidemic pancreatitis (HLP, n = 22), and other etiologies (n = 18). Severity was classified as mild acute pancreatitis (MAP, n = 23), moderately severe acute pancreatitis (MSAP, n = 24), and severe acute pancreatitis (SAP, n = 7). The incidence of preterm delivery, fetal distress, and fetal loss increased with the progression of severity of APIP (P < .05). The severity of HLP was significantly higher than that of ABP and APIP of other etiology (P < .01). HLP was more likely to lead to fetal distress than other APs (P < .01). Only 12 (22.2%) patients had fetal monitoring including non-stress test (NST); 1 case of SAP (14.3%) and 15 cases of MSAP (62.5%) were not transferred to intensive care unit for intensive monitoring.The incidence of fetal distress and fetal loss increased with worsening of APIP severity. HLP tends to result in worse fetal outcomes. The deficiencies of fetal state monitoring, lack of assessment, and management of pregnant women might increase the fetal loss in APIP.

Fetal outcomes and associated factors of adverse outcomes of pregnancy in southern Chinese women with systemic lupus erythematosus

This study aims to investigate the fetal outcomes and associated factors of adverse pregnancy outcomes (APOs) in pregnant women with systemic lupus erythematosus (SLE). Clinical data from 251 SLE patients with 263 pregnancies from 2001 to 2015 were analyzed retrospectively. APOs occurred in 70.0% of pregnancies, in which pregnancy loss occurred in 28.5%; preterm delivery occurred in 21.3%; intrauterine growth retardation occurred in 12.2%; and fetal distress occurred in 8.0%. Over time, the rate of APOs decreased from 82.8% during 2001~2005 to 59.6% during 2011~2015. In multivariate analysis, predictors of APOs included positive antiphospholipid antibodies (OR 8.4, 95% CI 1.7~40.8, P = 0.008), lower complement (OR 3.6, 95% CI 1.3~9.9, P = 0.01), hypoalbuminemia (OR 3.2, 95% CI 1.2~8.3, P = 0.02), and hypertension (OR 14.6, 95% CI 1.5~141.6, P = 0.02). The use of antimalarial medications was associated with lower risk for APOs (OR 0.3, 95% CI 0.1~0.7, P = 0.01). In total, 109 patients underwent fetal umbilical artery Doppler in the third trimester. The The adjusted systole/diastole (S/D) ratio, pulsatility index (PI) and resistance index (RI) of SLE patients with APOs were higher than that of patients without APOs (2.9±0.9 vs. 2.4±0.5, P = 0.001). Lupus pregnancy was still at high risk of APOs in terms of pregnancy loss and preterm delivery. Umbilical artery Doppler was a good monitor method for APOs in the third trimester.

Idiopathic spontaneous hemoperitoneum during pregnancy

Spontaneous hemoperitoneum is defined as bleeding within the peritoneal cavity of non-traumatic and non-iatrogenic etiology. It is a rare and life-threatening condition during pregnancy. Spontaneous hemoperitoneum is considered idiopathic when the source of bleeding is not detected during the exploratory laparotomy. The authors report two cases of spontaneous hemoperitoneum during pregnancy with sudden onset of abdominal pain during the third trimester of their pregnancy. Cesarean section was performed for fetal distress. In both cases, hemoperitoneum with a large quantity of blood was found, but the source of bleeding could not be identified during surgical exploration.

Biophysical and biochemical markers at 30-34 weeks' gestation in the prediction of adverse perinatal outcome

OBJECTIVE

To investigate the potential value of biophysical and biochemical markers at 30-34 weeks' gestation in the prediction of adverse perinatal outcome.

METHODS

This was a screening study in 8268 singleton pregnancies at 30-34 weeks' gestation. Estimated fetal weight (EFW), uterine artery (UtA) pulsatility index (PI), umbilical artery (UA) PI, fetal middle cerebral artery (MCA) PI, mean arterial pressure (MAP), serum placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) were measured. The detection rate (DR) and false-positive rate (FPR) of screening by each biomarker were estimated for stillbirth, pre-eclampsia, delivery of small-for-gestational-age (SGA) neonate, Cesarean section for fetal distress before or during labor, umbilical arterial cord blood pH ≤7.0 or umbilical venous cord blood pH ≤7.1, 5-min Apgar score < 7 and admission to the neonatal unit (NNU).

RESULTS

Multivariable regression analysis demonstrated that significant prediction of PE was provided by PlGF, sFlt-1, MAP and MCA-PI, with a DR of 98% for PE delivering < 37 weeks' gestation and 56% for those delivering ≥ 37 weeks, at a 10% FPR. Prediction of SGA was provided by EFW, PlGF, sFlt-1, UtA-PI, UA-PI and MCA-PI, with a DR of 88% for SGA delivering < 37 and 51% for those delivering ≥ 37 weeks' gestation, at a 10% FPR. Prediction of stillbirth was provided by EFW, UtA-PI and MCA-PI, with DR of 30% at 10% FPR. Prediction of Cesarean section for fetal distress before labor was provided by EFW, sFlt-1, UtA-PI and UA-PI, with a DR of 90% at a 10% FPR. Prediction of fetal distress in labor was provided by EFW and sFlt-1, with a DR of 16% at a 10% FPR. There were no significant differences from the normal outcome group in any of the biomarkers for low cord blood pH, low Apgar score or NNU admission for cases other than those with PE and/or SGA.

CONCLUSION

At 30-34 weeks' gestation, biomarkers of impaired placentation and fetal hypoxemia provide good prediction of PE, SGA and fetal distress before labor, but poor or no prediction of stillbirth and adverse events in labor or after birth.

Placental Insufficiency in Fetuses That Slow in Growth but Are Born Appropriate for Gestational Age: A Prospective Longitudinal Study

OBJECTIVES

To determine whether fetuses that slow in growth but are then born appropriate for gestational age (AGA, birthweight >10th centile) demonstrate ultrasound and clinical evidence of placental insufficiency.

METHODS

Prospective longitudinal study of 48 pregnancies reaching term and a birthweight >10th centile. We estimated fetal weight by ultrasound at 28 and 36 weeks, and recorded birthweight to determine the relative change in customised weight across two timepoints: 28-36 weeks and 28 weeks-birth. The relative change in weight centiles were correlated with fetoplacental Doppler findings performed at 36 weeks. We also examined whether a decline in growth trajectory in fetuses born AGA was associated with operative deliveries performed for suspected intrapartum compromise.

RESULTS

The middle cerebral artery pulsatility index (MCA-PI) showed a linear association with fetal growth trajectory. Lower MCA-PI readings (reflecting greater diversion of blood supply to the brain) were significantly associated with a decline in fetal growth, both between 28-36 weeks (p = 0.02), and 28 weeks-birth (p = 0.0002). The MCA-PI at 36 weeks was significantly higher among those with a relative weight centile fall <20%, compared to those with a moderate centile fall of 20-30% (mean MCA-PI 1.94 vs 1.61; p<0.05), or severe centile fall of >30% (mean MCA-PI 1.94 vs 1.56; p<0.01). Of 43 who labored, operative delivery for suspected intrapartum fetal compromise was required in 12 cases; 9/18 (50%) cases where growth slowed, and 3/25 (12%) where growth trajectory was maintained (p = 0.01).

CONCLUSIONS

Slowing in growth across the third trimester among fetuses subsequently born AGA was associated with ultrasound and clinical features of placental insufficiency. Such fetuses may represent an under-recognised cohort at increased risk of stillbirth.

Cervical condition and fetal cerebral Doppler as determinants of adverse perinatal outcome after labor induction for late-onset small-for-gestational-age fetuses

OBJECTIVE

To estimate the combined value of fetal cerebral Doppler examination and Bishop score for predicting perinatal outcome after labor induction for small-for-gestational-age (SGA) fetuses in the presence of normal umbilical artery Doppler recordings.

METHODS

We conducted a cohort study in two tertiary centers, including 164 women with normal umbilical artery Doppler recordings who underwent induction of labor because of an estimated fetal weight < 10(th) percentile. The fetal middle cerebral artery pulsatility index and cerebroplacental ratio (CPR) were obtained in all cases within 24 h before induction. Cervical condition was assessed at admission using the Bishop score. A predictive model for perinatal outcomes was constructed using a decision-tree analysis algorithm.

RESULTS

Both a very unfavorable cervix, defined as a Bishop score < 2, (odds ratio (OR), 3.18; 95% CI, 1.28-7.86) and an abnormal CPR (OR, 2.54; 95% CI, 1.18-5.61) were associated with an increased likelihood of emergency Cesarean section for fetal distress, but only the latter was significantly associated with the need for neonatal admission (OR, 2.43; 95% CI, 1.28-4.59). In the decision-tree analysis, both criteria significantly predicted the likelihood of Cesarean section for fetal distress.

CONCLUSION

Combined use of the Bishop score and CPR improves the ability to predict overall Cesarean section (for any indication), emergency Cesarean section for fetal distress, and neonatal admission after labor induction for late-onset SGA in the presence of normal umbilical artery Doppler recordings.

Self-reported sleep in late pregnancy in relation to birth size and fetal distress: the E Moe, Māmā prospective cohort study

OBJECTIVES

To explore associations between features of sleep during pregnancy and adverse outcomes for the infant.

SETTING

E Moe, Māmā is a cohort study in Aotearoa/New Zealand that investigates self-reported sleep and maternal health in late pregnancy and the postpartum period.

PARTICIPANTS

Women (N=633; 194 Māori) reported detailed information on their sleep duration, quality, disturbances, disorders (snoring, breathing pauses, twitching legs, restless legs) and daytime sleepiness between 35 and 37 weeks gestation.

OUTCOME MEASURES

Birthweight and fetal distress during labour were extracted from medical records. Associations between each sleep variable and small or large for gestational age (SGA/LGA) using customised birthweight centile or fetal distress were estimated using multinomial/logistic regression, controlling for potential confounders. Secondary analyses considered differences in associations between Māori and non-Māori women.

RESULTS

There was some indication that breathing pauses (a measure of sleep apnoea) were associated with both SGA (OR 2.8, 95% CI 0.9 to 9.0, p=0.08) and LGA (OR 2.0, 95% CI 0.7 to 5.7, p=0.20), with the association for LGA being stronger when only pregnancy-onset breathing pauses were considered (OR 3.5, 95% CI 1.3 to 9.6, p=0.01). There was also some evidence that pregnancy-onset leg twitching (OR 3.3, 95% CI 1.1 to 10.0, p=0.03) and frequent sleep disturbance due to feeling too hot or too cold (OR 1.7, 95% CI 0.9 to 3.6, p=0.13) were associated with higher risk of fetal distress. Other sleep measures, including snoring, were not associated with SGA, LGA or fetal distress. Many of the associations we observed were considerably stronger in Māori compared with non-Māori women.

CONCLUSIONS

We did not find evidence of previously reported associations between snoring and SGA. Our findings tentatively suggest that self-reported breathing pauses and leg twitching in late pregnancy are associated with infant outcomes, and highlight ethnic inequalities.

[Obstetric dermatoses]

The specific dermatoses of pregnancy are rare and consist of pemphigoid gestationis (PG), intrahepatic cholestasis of pregnancy (ICP), polymorphic eruption of pregnancy and atopic eruption of pregnancy. The dermatoses are characterized by pruritus, and they are important to recognize since PG and ICP increase the risk of prematurity, fetal distress and stillbirth. Diagnosis is based on medical history, morphology, blood sample and biopsy. The dermatoses are treated with respectively ursodeoxycholic acid (in case of ICP) and steroids. Breast-feeding is recommended and induction of labour is not normally indicated.

Umbilical cord prolapse in primary midwifery care in the Netherlands; a case series. Part 2

We aimed to gain insight into eight cases of umbilical cord prolapse (UCP) reported by primary care midwives in the Netherlands. Diagnosis-to-delivery interval (DDI) and risk factors were identified. Six cases occurred at home. Risk factors were found in four cases, but only two (unengaged fetal head) were known to the midwife prior to birth. One infant died of severe birth asphyxia; the other infants recovered and were discharged in good condition. The DDI varied from 13 to 72 minutes (median 41 minutes). The shortest DDI was found in the two cases of UCP occurring in hospital and birthing centre. In the six cases of UCP at home, DDI ranged from 31-72 minutes. The DDI is increased when UCP occurs at home, but no association with a less favourable perinatal outcome was found. Continuing multidisciplinary training is encouraged and guidelines should be developed and implemented.

A pilot study to determine whether progestogen supplementation using dydrogesterone during the first trimester will reduce the incidence of gestational hypertension in primigravidae

BACKGROUND

Gestational hypertension (GH) remains one of the main causes of high maternal and perinatal morbidity and mortality worldwide with the highest incidence among primigravidae of about 10%-15%. However, it was noted that the incidence of GH in primigravidae who conceived following assisted reproductive technique (ART) or intrauterine insemination (IUI) supplemented with dydrogesterone during the first trimester was low.

AIM

To determine whether dydrogesterone supplementation during the first trimester can reduce the incidence of GH among primigravidae.

METHOD

A prospective cross-sectional comparative study was undertaken in 2010 on 116 primigravidae (study group) who conceived following ART or IUI and supplemented with dydrogesterone up to 16 weeks gestation. They were matched for age and race at 16 weeks gestation with a control patient from the early pregnancy clinic who were primigravidae (n = 116) who conceived spontaneously without dydrogesterone supplementation.

FINDINGS

The incidence of GH in the study group was significantly lower than the control group (1.7% versus 12.9%, p = 0.001). The incidence of fetal distress was also significantly lower in the study group compared to the control group (4.3% versus 18.1%, p = 0.001).

INTERPRETATION

Dydrogesterone supplementation during the first trimester significantly reduced the incidence of GH and fetal distress in primigravidae.

[Exceptional hemoperitoneal third trimester of pregnancy]

We report a case of spontaneous break of the wide ligament revealed by an abdominal pelvic painful syndrome of rough appearance in 36 weeks+2 days with an acute foetal suffering and an important hemoperitoneal to a primigeste of 32 years. The laparotomy explorer allowed to make the diagnosis but the foetal forecast was dramatic. The foetal extraction has to be made as a matter of urgency and at the same time that the vascular haemostasis.

[Congenital heart diseases in pregnant women--a risk factor for fetal distress]

The condition of fetoplacental system in pregnant women with congenital heart diseases was studied by means of ultrasound, dopplerometry, cardiotocography, by determination of estradiol, progesterone and placental lactogen in the blood of pregnant women and in the umbilical cord and by means of pathomorphologic study of the placenta. It is shown that congenital heart diseases complicated by heart failure in pregnant women--a important risk factor for fetal distress bouth in the preclinical stage of placental insufficiency (violation of the utero-placental blood flow, changes of fetoplacental hormones levels) and in conjunction with clinical signs of fetal suffering (distress and growth retardation).

Foetal outcome in patients with meconium stained liquor

OBJECTIVE

To determine the foetal outcome and mode of delivery in patients with meconium stained liquor during labour.

METHODS

The observational study was carried out at the Obstetrics and Gynaecology Unit-II of Liaquat University of Medical Health Sciences from June to November 2007. The patients with gestational age more than 37 weeks who presented with meconium stained liquor and cephalic presentation were included and the foetal outcome and mode of delivery was assessed in all such subjects. The data was collected on pre-designed proforma and analysed using SPSS version 10. Chi square test was applied with 95% confidence interval and p-value < or = 0.05 was considered significant.

RESULTS

A total of 75 patients with meconium stained liquor were identified during the study period. The patients with reactive cardiotocography (CTG) were 50 (66.7%) and with non-reactive CTG, 25 (33.36%). Of the total, 45 (60%) patients were delivered through normal vaginal delivery, while 30 (40%) were delivered by caesarean section. The rate of instrumental delivery was also increased which was 12 (26.7%). Among the neonates exposed to meconium stained liquor, 62 (82.7%) babies were delivered with apgar score > 7. Only 13 (17.3%) babies were delivered with apgar score < 7 in one minute.

CONCLUSION

Meconium stained amniotic fluid is a common occurrence during labour and is associated with increased caesarean section rate and foetal morbidity and mortality.

Perinatal outcome associated with nuchal umbilical cord

INTRODUCTION

Nuchal umbilical cord (NUC) is a possible complication of pregnancy which can be associated with adverse perinatal outcome.

MATERIALS AND METHODS

A retrospective study was done at the County Emergency Hospital Timisoara, Romania, between January 2009 and December 2010 and included cases with NUC at the time of delivery. Outcome variable related to the mothers and newborns were studied.

RESULTS

The incidence of NUC in the studied period was 8%. Most were primiparous. There were no significant statistical differences between vaginal births and cesarean section with one minute Apgar scores higher than 8. Five percent of the studied group presented intrauterine fetal death.

CONCLUSIONS

The presence of NUC implies more attention but are not associated with increased rate of operative vaginal or cesarean delivery. One minute Apgar scores in these cases are comparable. NUC can be a cause of IUFD.

[Case of emergent caesarean delivery in a patient with aplastic anemia complicated with pregnant induced hypertension]

A 32-year-old pregnant woman diagnosed with aplastic anemia was admitted for emergent caesarean delivery of 26th week of the gestation due to PIH (pregnancy-induced hypertension) and NRFS (non-reassuring fetal status). After compensating platelets counts to 5.3x10(4) microl-1, general anesthesia was induced with propofol and rocuronium. Anesthesia was maintained with O2 and sevoflurane until delivery and with modified-NLA after delivery. She was additionally monitored with Vigileo/FloTrac system (Edwards Lifesciences, USA) and TOF-WATCH SX (Nihon Kohden, Tokyo). After 8 minutes of operation her baby was born with the 5-minute Apgar score of 5 and the UA-pH of 7.387. It was only 2 hours and 12 minutes that the baby was born after she was admitted. The baby was tracheally intubated and transferred to NICU. Blood loss during operation was 835 g and two units of RCC was transfused. Circulatory values were kept acceptable and neuromuscular blocking was completely reversed by sugammadex and extubated in the operating room. Bleeding tendency and atonic bleeding were not observed. She survived perioperative period and was to be treated for aplastic anemia. Her baby was discharged neurologically free. We should be ready to respond to anesthetic requirement for urgent cases of aplastic anemia.

Obesity in pregnancy: problems and potential solutions

Recent years have witnessed an increase in the prevalence of maternal obesity during pregnancy in the United States and worldwide. Obese women have increased risks for gestational problems, such as diabetes, hypertension, and pre-eclampsia. Further, gestational obesity can adversely impact fetal growth and result in macrosomia, congenital abnormalities, and even fetal death. Measures must be taken to reduce maternal adiposity, as even a modest weight loss during pregnancy is beneficial for the health of mothers and fetus. Calorie restriction and moderate exercise are proven safe methods of stopping weight gain and/or inducing white-fat loss in these subjects. Additionally, therapeutic drugs that activate the AMP-activated protein kinase signaling pathway may be effective in ameliorating pathological conditions in obese patients. Finally, dietary supplementation with L-arginine or its effective precursor (L-citrulline) may be beneficial for managing overweight or obese gestating women by reducing white-fat accretion. Because of ethical concerns over human studies, animal models (e.g., sheep, pigs, baboons, rats, and mice) are warranted to test novel hypotheses with enormous biological significance and clinical applications.

Acute fatty liver of pregnancy

A 17-year-old-female at 39 weeks gestation, presented with pelvic pain, proteinuria and a decrease in fetal heart rate. Timely caesarean section was performed. The postoperative course was complicated by acute renal failure, acute pancreatitis, acute liver failure, anemia, thrombocytopenia, systemic inflammatory response syndrome (SIRS), prolonged coagulopathy, hyperbilirubinemia, ecclampsia, and psychosis. The clinical features and laboratory abnormalities, in conjunction with the timing of gestational age, led to the diagnosis of acute fatty liver of pregnancy. Prompt diagnosis and supportive care in an intensive care unit provided for a positive outcome.

Maternal hurricane exposure and fetal distress risk

Logistic regression and spatial analytic techniques are used to model fetal distress risk as a function of maternal exposure to Hurricane Andrew. First, monthly time series compare the proportion of infants born distressed in hurricane affected and unaffected areas. Second, resident births are analyzed in Miami-Dade and Broward counties, before, during, and after Hurricane Andrew. Third, resident births are analyzed in all Florida locales with 100,000 or more persons, comparing exposed and unexposed gravid females. Fourth, resident births are analyzed along Hurricane Andrew's path from southern Florida to northeast Mississippi. Results show that fetal distress risk increases significantly with maternal exposure to Hurricane Andrew in second and third trimesters, adjusting for known risk factors. Distress risk also correlates with the destructive path of Hurricane Andrew, with higher incidences of fetal distress found in areas of highest exposure intensity. Hurricane exposed African-American mothers were more likely to birth distressed infants. The policy implications of in utero costs of natural disaster exposure are discussed.

Cervical ripening and induction of labor by prostaglandin E2: a comparison between intracervical gel and vaginal pessary

OBJECTIVE

To compare the effectiveness and safety of two formulations of prostaglandin (PG) E2 (gel and pessary) for induction of labor. Primary outcomes were cervical ripening, initiation/duration of labor, and type of delivery.

STUDY DESIGN

A total of 115 women with singleton gestations were consecutively enrolled and assigned to receive intracervical PGE2 (dinoprostone 0.5 mg) by gel (n = 66) or PGE2 (dinoprostone 10 mg) by intravaginal pessary (n = 49).

RESULTS

Independently from parity, the vaginal pessary induced successful cervical ripening with a slightly higher but not statistically significant occurrence of vaginal delivery with respect to gel induction. The mean time interval from induction to vaginal delivery did not differ between groups, despite being shorter for the pessary group in inducation-delivery intervals > 12 h. No significant differences were found between the groups with respect to patients who required a second course of PGE2 (9% vs. 2%), as well as oxytocin (11% vs. 13%) induction. No significant difference was found in the incidence of uterine hyperstimulation and other adverse reactions in nulliparas, or in fetal and neonatal outcome.

CONCLUSION

Independently from parity, both PGE2 administration routes appeared to be effective in achieving cervical ripening, initiation of labor and optimal type of delivery, and showed the same incidence of side-effects.

Management of hyperthyroidism in pregnancy

Maternal hypertiroidism is a relative rare disorder, which can seriously complicate pregnancy in each of its periods. There are several maternal and fetal complications during pregnancy, delivery and postpartum period. Correct management includes an accurate diagnosis, rigorous individualized treatment and minutious follow-up. We are presenting a retrospective study of 38 pregnant women who delivered in the Obstetric Unit of the University Emergency Bucharest Hospital in the past five years. We established a follow-up protocol in collaboration with endocrinologists. Precocious diagnosis of pregnancy is, in our opinion, mandatory. Accurate diagnosis of hormonal status beginning from the first week of pregnancy is of great importance. Maternal (weight, BP, TSH, thyroid hormones, ECG, etc.) and fetal (ultrasound, non-stress test, Doppler study) evaluation during pregnancy were rigorous performed.

RESULTS

abortion rate was 5%; 15% of pregnant women delivered prematurely; cesarean section rate was 22%; fetal outcome was excellent. Treatment adjustment during pregnancy was frequent, 28% of pregnant women had no hormonal treatment in the last trimester of pregnancy. Maternal complications were rare (poor weight gain, tachycardia). Fetal complications included low birth weight (24%), fetal respiratory distress (10%).

CONCLUSIONS

team work with experienced endocrinologists and understanding of versatility of disease leads to good prognosis of mother and fetus in presence of hypertiroidism.

Suspected amniotic fluid embolism following amniotomy: a case report

Amniotic fluid embolism (AFE), also referred to as anaphylactoid syndrome of pregnancy, is a rare obstetric emergency that may manifest itself at any time during pregnancy. AFE is believed to occur when the constituents of amniotic fluid enter the maternal circulation, leading to varying degrees of multiorgan compromise. AFE was first described in 1926, gaining widespread recognition in 1941. This article describes the pathogenesis of AFE, including theories of its immunological mediation available in the literature. The most current diagnostic and treatment modalities are discussed, including several novel therapies. A case report of a 40-year-old parturient who suffered probable AFE following amniotomy, with the development of cardiopulmonary compromise, neurologic involvement, fetal distress, and coagulopathy, is outlined. The patient survived emergency cesarean delivery and hysterectomy with no residual physiologic deficits.

[Relationship of the occurrence of fetal distress and change of umbilical cord and expression of vasoactive substance in umbilical vein in intrahepatic cholestasis of pregnancy]

OBJECTIVE

To investigate the changes of umbilical cord and the vasoactive substance in umbilical vein in intrahepatic cholestasis of pregnancy.

METHODS

By HE staining method we analyzed the pathologic change of umbilical cord of 25 women with intrahepatic cholestasis of pregnancy (ICP) and fetal distress (ICP fetal distress group), 25 ICP women without fetal distress group (ICP control group) and 27 normal pregnancies (control group). The nitric oxide synthase (NOS) and endothelin-1 (ET-1) were detected in human umbilical vein endothelial cells (HUVEC) by immunohistochemistry method. Umbilical vein total bile acid (TBA) and NOS and ET-1 were measured.

RESULTS

(1) A remarkable high TBA level was found in umbilical vein in ICP, and it was higher in ICP fetal distress group (19.0 +/- 2.3) micromol/L than in ICP control group (9.0 +/- 1.7) micromol/L (P < 0.05); it was higher in ICP control group than the control group (4.4 +/- 1.5) micromol/L (P < 0.05). (2) A significant difference was found in the endotheliocytes of umbilical vein in ICP fetal distress group compared with ICP control group. The ratio of cells with pathological changes in ICP fetal distress group (92%, 23/25) was higher than ICP control group (68%, 17/25; P < 0.05). The occurrence of the pathological changes was associated with TBA. (3) The expression of eNOS in ICP fetal distress group 0.09 +/- 0.06 was lower than in ICP control group 0.21 +/- 0.08 (P < 0.05), and it was lower in ICP control group than in control group 0.47 +/- 0.07 (P < 0.05). In contrast, the expression of ET-1 in ICP fetal distress group 0.49 +/- 0.08 was higher than in ICP control group 0.32 +/- 0.07 (P < 0.05), and it was higher in ICP control group than control group 0.14 +/- 0.06 (P < 0.05). The expression of inducible nitric oxide synthase (iNOS) in ICP fetal distress group 0.20 +/- 0.04 and ICP control group 0.21 +/- 0.05 was lower than in control group 0.26 +/- 0.04 (P < 0.05), but no significant difference was found in ICP fetal distress group and ICP control group (P > 0.05). (4) The expression of eNOS, iNOS and ET-1 was correlated with umbilical vein TBA in ICP (r1 = -0.88, r2 = -0.45, r3 = 0.9; P < 0.01), respectively.

CONCLUSIONS

High level of TBA in ICP is harmful to the umbilical vein endothelium, which is correlated with the raised expression of ET-1, and the decreased expression of eNOS,and iNOS in human umbilical cord endothelium cells. All these changes of umbilical vein may be associated with the occurrence of fetal distress in ICP.

[Cesarean section in a woman with acute blood-stage malaria]

Malaria infection during pregnancy is a serious health problem in most of the world's tropical regions. The disease has also been imported into Western countries, however, as an increasing number of infected women, who may become pregnant, emigrate from areas where malaria is endemic. Infection during pregnancy can have serious repercussions for both mother and fetus. Early diagnosis and multidisciplinary management are essential. We report the case of a woman from Guinea who debuted with severe, acute blood-stage malaria in the 32nd week of pregnancy and was admitted to the recovery care unit.

The association between developmental handicaps and traumatic brain injury during pregnancy: an issue that deserves more systematic evaluation

AIMS

Trauma during pregnancy is commonly viewed as benign for the foetus when the delivery occurs normally. This study revisits that point of view.

METHOD

We included eighteen patients having a neurological handicap with an anamnesis of an accident during pregnancy and a follow-up sufficient to determine a definite outcome.

RESULTS

Pregnancy outcome and observed management. Foetal abnormalities were detected in six cases between the first and the thirteenth day after the trauma. Emergency delivery or rapid birth after signs of foetal distress occurred in five cases. One baby died soon after birth. One-third of cases were not submitted to any investigation. VARIOUS NEUROLOGICAL HANDICAPS WERE RECORDED: Congenital microcephaly (three patients), congenital hydrocephalus (three), Infantile cerebral hemiplegy (six), quadriplegy with severe encephalopathy (four), diplegy (one), clumsiness with cerebellar atrophy (one), Moebius syndrome (one), mental retardation with autistic features (two), learning disability (one) auditory agnosia (one). Cerebral imaging showed macroscopic abnormalities in fourteen patients, evoking various pathogenetic hypotheses.

CONCLUSION

The association between maternal trauma and foetal brain lesions lacks sufficient investigation in many cases. Prospective studies are needed to clarify both medical and legal issues. Guidelines are proposed for obstetrical and paediatric management after significant maternal trauma.

Acute twin-twin transfusion syndrome: a case report

BACKGROUND

Clinically relevant acute twin-twin transfusion syndrome (TTTS) is a rare and poorly defined placental pathology because the definitions of chronic TTTS do not apply. Antepartum cases of acute TTTS are infrequently described in the literature despite the presence of vascular anastomoses in most monochorionic placentas.

CASE

A case of otherwise-unexplained acute fetal distress in a monochorionic twin gestation led to an emnergeincy cesarean section and was found to be due to acute heiodynamiic inbalance secondary to activation of a large placental venovenous anastomosis.

CONCLUSION

Obstetricians should be aware of this potential cause of sudden fetal distress in monochorionic twin gestations.

Spontaneous rupture of the left renal collecting system during pregnancy

Spontaneous rupture of a normal renal collecting system during pregnancy is uncommon and all reported cases have occurred in right kidneys. We report a case of spontaneous rupture of the left renal collecting system during pregnancy. A 33-year-old pregnant woman presented with left loin and lower abdominal pain, and signs of preterm labour, at 32 weeks' gestation. An emergency caesarean section was performed for foetal distress but the left loin pain did not subside after delivery. Ultrasonography and a computed tomogram showed a left perinephric collection and urine extravasation, compatible with rupture of the renal collecting system. A percutaneous nephrostomy was inserted and the symptoms subsided. A summary of the literature discussing management of this clinical situation is provided.

L'anesthésie comme cause de souffrance fœtale?

OBJECTIVE

To describe the effects of anaesthetic techniques and agents on the risk of fetal distress during labour pain relief and anaesthesia for caesarean section.

STUDY DESIGN

Data on obstetric anaesthesia- and analgesia-induced fetal distress were searched in Medline database using MESH terms: fetal distress, anaesthesia, analgesia, labour, caesarean section, and umbilical artery pH. Trials published in English or French language were selected.

RESULTS

Because of their haemodynamic effects, regional anaesthesia and analgesia, especially spinal anaesthesia for Caesarean section, could induce a decrease in umbilical artery pH (UApH). Moreover, intravenous ephedrine, especially when used in large doses can worsen the acidosis. Labour epidural analgesia is associated with a better acid-base balance than systemic analgesia. Experimental studies have demonstrated harmful effects of systemic opioids and hypnotic drugs on UApH and the foetal brain respectively. Clinical implications of these potentially detrimental effects remain to be determined.

CONCLUSION

All obstetric anaesthesia and analgesia techniques are associated with a theoretical risk of fetal distress, but given the fact that regional anaesthesia techniques are also associated with well-demonstrated benefits for the mother and the newborn, the latter remain the preferred choice in obstetric practice.

[Hypertriglyceridemia-induced pancreatitis in pregnancy. A case report]

We report the case of a 31-year-old pregnant patient in the 33rd week of gestation, with no history of dyslipidaemia, admitted for sub-acute epigastric pain. The milky aspect of blood samples was remarkable. Blood analysis showed a moderate increase in pancreatic enzymes but a major hyperlipaemia: triglyceridaemia 113 g/l and total cholesterolaemia 25 g/l. We suspected a hypertriglyceridemia-induced pancreatitis in pregnancy. The diagnosis was confirmed by CT-scan. Abdominal echography showed no abnormalities in biliary duct. After few hours, a caesarean was performed for acute fetal distress. The patient was admitted to the intensive care unit where a decrease of hypertriglyceridemia was already observed. Only one plasmapheresis was performed. Heparin was introduced. Rapid clinical improvement allowed discharge from intensive care at day 3. This case report illustrates lipid decrease with undertaken treatments. We discuss the management of hypertriglyceridemia-induced pancreatitis in pregnancy.

Four true umbilical cord knots

BACKGROUND

True umbilical cord knots are rare, but may be associated with intrapartum fetal distress and perinatal complications.

CASE

This report describes a pregnancy complicated by intrauterine growth restriction and oligohydramnios. The labour was complicated by a non-reassuring fetal heart rate tracing. Four umbilical cord knots were discovered at the time of delivery. The baby's neonatal course was uncomplicated.

CONCLUSION

There is currently no reliable method of detecting umbilical cord knots using ultrasound or colour Doppler flow studies. Cord knots may be responsible for fetal compromise during labour and delivery.

Pregnancy on intensified hemodialysis: fetal surveillance and perinatal outcome

OBJECTIVES

To evaluate the effect of intensive fetal surveillance via Doppler ultrasound and fetal non-stress test on the perinatal outcome of pregnant women undergoing an intensified hemofiltration scheme.

METHODS

Five consecutive pregnancies of women undergoing intensified hemodialysis were analyzed due to the following parameters: maternal background, hemodialysis schedule during pregnancy, blood pressure, occurrence of fetal complications, occurrence of obstetric complications, gestational week at delivery, mode of delivery, and newborn outcome and follow-up.

RESULTS

All pregnancies resulted in a live birth, mean gestational age was 32 weeks. Intrauterine growth restriction occurred in 4 fetuses, pathological umbilical artery flow velocity waveforms in 2. The mean birth weight was 1,764 g (range 1,274-2,465 g). Cesarean section was performed in 3 patients because of fetal distress. None of the patients developed severe complications like pre-eclampsia.

CONCLUSIONS

Although intensified dialysis enables the maintenance of stable uteroplacental and fetal perfusion, intensive fetal monitoring is mandatory to reduce perinatal morbidity and mortality in pregnant women on maintenance dialysis.

[Clinical analysis of hypothyroidism during pregnancy]

OBJECTIVE

To investigate the incidence, treatment and pregnant outcomes of women with hypothyroidism during pregnancy.

METHODS

A retrospective analysis was conducted on the perinatal care, treatment and pregnant outcomes of 31 pregnant women with hypothyroidism from Jan.1995 to May.2006 in our hospital. All subjects were received in the high risk clinic, and the thyroid function was monitored every 1.0 - 1.5 months. The dosage of LT4 was adjusted to maintain the normal level of thyroid function.

RESULTS

The incidence of maternal hypothyroidism during the study period was 1.27 per thousand (31/24 327) [0.19 per thousand (1/5251) - 2.32 per thousand (15/6456)]. The average LT4 dosage in pre-gestation, the first, second, third trimester and postpartum was (33 +/- 35), (51 +/- 36), (68 +/- 42), (76 +/- 42) and (38 +/- 34) microg/d, respectively. Compared with the pre-gestational period, the dosage in the first trimester or postpartum was higher although the difference was not significant (P>0.05). The required dose of LT4 during the second and third trimester was respectively, remarkably increased compared to pre-gestational period (P<0.05). The average increase of the dose of LT4 required during the pregnancies was about 35%. All of 31 women had uneventful pregnancies. No perinatal mortality or congenital hypothyroidism occurred. The incidence of abnormal glucose metabolism was up to 16.1%.

CONCLUSIONS

The incidence of maternal hypothyroidism is increasing yearly. It is of great value in improving the pregnant outcome through adjusting the LT4 dose during pregnancy and close monitoring of maternal and fetal status.

How often is a low 5-min Apgar score in term newborns due to asphyxia?

OBJECTIVE

To evaluate how often low 5-min Apgar scores (AS(5-min)) at term are associated with asphyxia.

STUDY DESIGN

A cohort- and case-control study, including all 183 term infants with AS(5-min) below 7 born at Lund University Hospital during 1993-2002, antepartum deaths excluded. The control group included 183 randomly selected term newborns with AS(5-min) 9-10. Cardiotocography (CTG) traces were assessed blinded to group and outcome. Obstetric and pediatric files were reviewed.

RESULTS

After excluding infants with severe malformations, indications of hypoxia were found at the following rates in cases with AS(5-min) below 4 (N = 30), scores 4-6 (N = 143), and controls (N = 182)-abnormal admission CTG: 38%, 8% and 0.6%; abnormal CTG before birth: 88%, 69% and 18%; obstetrical catastrophe: 28%, 6% and 0.6%; interventions for fetal distress: 83%, 48% and 9%; cord artery pH below 7.15: 69%, 54% and 7%; hypoxic ischemic encephalopathy or hypoxic death: 70%, 14% and none. All differences between each case group and controls were statistically significant (p < 0.0001).

CONCLUSIONS

In the absence of severe malformations, the vast majority of AS(5-min) below 4, and at least half of scores 4-6 could be attributed to birth asphyxia. Signs of hypoxia usually appeared during labor, but were present at admission in 38% of cases with AS(5-min) below 4.

[Impact of infection with Listeria monocytogenes on the pregnancy]

During a ten years period (06.1998a.-06.2007) at the delivery ward of Maychin dom university hospital were admitted 31 627 parturients. Among all of them we indentified and evaluated only 6 pregnant patients with Listeria monocytogenes infection. During the first 8 years of the investigated period there was no even single case of the infection, whilst during the last 2 years the frequency of the Listeria infection among all birth deliveries was 0.10%. The first five of our cases were admitted with clinical symptoms of therapeutically uninfluenced preterm birth and had premature labor. One of the five examined births underwent urgent Caesarean Section because of intrapartial fetal distress, which makes 20% of the operative birth deliveries. All five maternity patients are diagnosed during the postpartum period whilst searching for the microbial reason of the severe infection of the newborns. All of the five newborns experience infection complications. Septic condition of two of the neonates was not possible to be overcome and was followed by an exitus. The observed neonatal mortality among the group is 33.3%. The last observed case of infection was diagnosed by detecting the level of antibodies against Listeria monocytogenes in 11th week of gestation. The enhanced antibodies level was accompany by clinical symptoms. Patient was treated with Penicillin 4 x 2.0 g i.v. for fourteen days Repeated serological results was normal. The pregnancy was followed up till the term.

[The importance of clinically detectable ketonuria in patients with post-term pregnancy]

The aim of this study was to ascertain whether the notable ketonuria in patients with postterm pregnancy can be associated with abnormal fetal assessment tests. The 207 pregnant patients with postterm pregnancy after 41 gestation week have been included in the medical survey after testing their urine: including ketons, glucose, pH, albumen and individual weight. 24 patients in this study have been diagnosed with maternal ketonuria (11.59%). The ketonuria in patients with postterm pregnancy directly correlates to abnormal results of fetal heart rate tests, Nonstress test, amniotic fluid index, placenta grading III. The importance of clinically notable ketonuria in patients with postterm pregnancy is discussed.

[What does fetal renal echogenicity mean in intrauterine growth retardation?]

AIMS

The object of this study was to investigate the fetal renal and middle cerebral arterial blood flows in patients with normal and hyperechogenic kidneys during the fetal period.

MATERIAL AND METHODS

Study group consisted of 82 pregnancies with intrauterine growth retardation. Group included pregnant women from the third trimester. Hyperechogenic medullae were detected in 17 out of 82 pregnancies with intrauterine growth retardation.

RESULTS

Fetal renal hyperechogenicity appears to be an indicator of fetal arterial circulatory depression, correlated with pathological changes in the pulsatility index for the fetal renal arteries. The fetal renal arterial blood flow pulsatility index was significantly lower in hyperechogenic cases, while in the middle cerebral artery flow was in the normal range. This may also be an indication of subsequent intrauterine and neonatal complications, such as cesarean section because of fetal distress (47%), treatment in a neonatal intensive care unit (71%) or increased perinatal mortality (12%) in our cases.

CONCLUSIONS

Detailed ultrasound of renal parenchyma and Doppler examination of renal and middle cerebral arteries appear to be an useful method in the prenatal diagnosis of reduced renal perfusion and of intrauterine hypoxia so as to detect possible pathological fetal conditions in utero.