Association of maternal body mass index change with risk of large for gestational age among pregnant women with and without gestational diabetes mellitus: a retrospective cohort study

OBJECTIVE

To investigate the associations of body mass index (BMI) change and large for gestational age (LGA) among prepregnancy normal-weight women with and without gestational diabetes mellitus (GDM).

METHODS

The retrospective study including 9515 normal-weight pregnant women (1331 women with GDM and 8184 without GDM) was conducted in Fujian Maternity and Child Health Hospital in 2020. The BMI change was calculated as gestational weight gain in kilograms by maternal height in meters. The binary logistic regression, stratified analyses, restricted cubic spline models and additive interaction analysis were adopted to reveal the relationship between BMI change and LGA.

RESULTS

Pregnant women with GDM had a lower level of BMI change but a higher incidence of LGA compared with those without GDM. After adjustment for covariates variables, we found that the risk of LGA was associated with the highest quartile of BMI change (OR = 1.89, 95%CI:1.27-2.8 for GDM and OR = 1.48,95%CI:1.27-1.75 for non-GDM). There were significant linear relationships of BMI change and LGA with the inflection point of 5.096 and 5.401 kg/m2 in GDM and non-GDM groups. Significant additive interaction was observed between parity and BMI change level concerning LGA. A significant difference in BMI change and gestational weight gain (GWG) for LGA prediction was detected.

CONCLUSION

Higher BMI changes were significantly associated with a higher risk of LGA in pregnant women with or without GDM in a linear dose-response relationship, with the threshold around 5.096 and 5.401 kg/m2, respectively. These suggested that BMI changes may be a useful predictor for the incidence of LGA in singleton pregnant women.

Performance of noninvasive prenatal screening for fetal sex chromosome aneuploidies in a cohort of 116,862 pregnancies

BACKGROUND

Noninvasive prenatal screening (NIPS) has shown good performance in screening common aneuploidies. However, its performance in detecting fetal sex chromosome aneuploidies (SCAs) needs to be evaluated in a large cohort.

RESEARCH DESIGN AND METHODS

In this retrospective observation, a total of 116,862 women underwent NIPS based on DNA nanoball sequencing from 2015 to 2022. SCAs were diagnosed based on karyotyping or chromosomal microarray analysis (CMA). Among them, 2,084 singleton pregnancies received karyotyping and/or CMA. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of NIPS for fetal SCAs were evaluated.

RESULTS

The sensitivity was 97.7% (95%CI, 87.7-99.9), 87.3% (95% CI, 76.5-94.4), 96.1% (95%CI, 86.5-99.5), and 95.7% (95% CI, 78.1-99.9), the PPV was 25.8% (95%CI, 19.2-33.2), 80.9% (95%CI, 69.5-89.4), 79.0% (95%CI, 66.8-88.3), and 53.7% (95%CI, 37.4-69.3) for 45,X, 47,XXY, 47,XXX, and 47,XYY, respectively. The specificity was 94.1% (95%CI, 93.0-95.1) for 45,X, and more than 99.0% for sex chromosome trisomy (SCT). The NPV was over 99.0% for all.

CONCLUSIONS

NIPS screening for fetal SCAs has high sensitivity, specificity and NPV. The PPV of SCAs was moderate, but that of 45,X was lower than that of SCTs. Invasive prenatal diagnosis should be recommended for high-risk patients.

Association of fetal growth restriction and stillbirth in twin compared with singleton pregnancies

OBJECTIVE

Twin pregnancies are at an increased risk of stillbirth compared to singletons. Fetal growth restriction (FGR) is a leading cause of perinatal mortality and morbidity, in both singleton and multiple pregnancies. Whether the contribution of FGR to stillbirth in twin pregnancies differs from that in singletons is yet to be determined. The main aim of this study was to determine the association between FGR and stillbirth in twin compared to singleton pregnancies. The secondary objectives include an assessment of the contribution of FGR to stillbirths, stratified by gestational age at delivery. Furthermore, we aimed to compare the association between FGR and stillbirth in twin pregnancies using the twin-specific versus singleton birthweight charts, stratified by chorionicity.

METHODS

This was a cross-sectional study including pregnancies receiving obstetric care and birth at St George's Hospital, London. The exclusion criteria included triplet and higher order pregnancies, those resulting in miscarriage or livebirths at or prior to 23+6 weeks, or had a termination of pregnancy, or with missing data on the gestational age at birth. FGR and small for gestational age (SGA) were defined as birthweight <5th and <10th centile, respectively. While standard logistic regression was used for singleton pregnancies, the association of FGR and SGA designation with stillbirth in twin pregnancies was investigated with mixed-effects logistic regression models. For twin pregnancies, intercepts were allowed to vary for twin pairs to account for inter-twin dependency. Analyses were stratified by gestational age at delivery and chorionicity.

RESULTS

The study included 95,342 singleton and 3,576 twin pregnancies. There were 494 (0.52%) stillbirths in singleton and 41 (1.15%) stillbirths in twin pregnancies (17 dichorionic and 24 monochorionic). FGR and SGA were significantly associated with stillbirth in singleton pregnancies, across all gestational ages at delivery (before 32 weeks- SGA: OR 2.36; 95% CI 1.78-3.13, p<0.001 and FGR: OR 2.67; 95% CI 2.02- 3.55, p<0.001; between 32-36 weeks- SGA: OR 2.70; 95% CI 1.71-4.31, p<0.001 and FGR: OR 2.82; 95% CI 1.78- 4.47, p<0.001; above 36 weeks- SGA: OR 3.85; 95% CI 2.83 - 5.21, p<0.001 and FGR: OR 4.43; 95% CI 3.16 - 6.12, p<0.001) A greater proportion of fetuses from twin pregnancies were diagnosed as SGA and FGR when singleton compared to the twin-specific chart was used (48.43% vs. 9.12%, and 36.73% vs. 6.23%, respectively). When stratified by gestational age at delivery, both SGA and FGR determined by the twin-specific charts were associated with significantly increased odds of having a stillbirth for those delivered before 32 weeks (SGA: OR 3.87; 95% CI 1.56-9.50, p=0.003 and FGR: OR 5.26; 95% CI 2.11-13.01, p<0.001), those delivered between 32-36 weeks (SGA: OR 6.67; 95% CI 2.11-20.41, p=0.001 and FGR: OR 9.54; 95% CI 3.01-29.40, p<0.001) and those delivered beyond 36 weeks (SGA: OR 12.68 95% CI 2.47-58,15, p=0.001 and FGR: OR 23.84; 95% CI 4.62-110.25, p<0.001), whereas the association of stillbirth with either SGA or FGR was inconsistent when analysed using singleton charts (before 32 weeks- SGA: p=0.014 and FGR: p=0.005; between 32-36 weeks- SGA: p=0.036 and FGR: p=0.008; above 36 weeks- SGA: p=0.080 and FGR: p=0.063). For dichorionic twins delivered before 32 weeks, the odds of an SGA or FGR fetus having a stillbirth was increased when analysed using twin-specific charts. In contrast, monochorionic twins delivered before 32 weeks showed lower and non-significant associations with stillbirth for both SGA and FGR cases using either twin-specific or singleton charts. In dichorionic twin pregnancies delivered between 32-36 weeks, the OR for stillbirth of SGA using twin birthweight chart was 6.70 (95% CI 0.80-56.46, p=0.059), and using singleton chart was 0.92 (95% CI 0.11-7.71, p=0.934) and statistically non-significant. Similarly, the OR for stillbirth of FGR using twin birthweight chart and singleton chart was 9.59 (95% CI 1.14-81.06, p=0.025), and 1.40 (95% CI 0.17-11.76, p=0.735), respectively. On the other hand, in monochorionic twin pregnancies delivered between 32-36 weeks, the OR for stillbirth of SGA and FGR using twin birthweight chart was 9.37 (95% CI 2.20- 37.72, p=0.001), and 13.55 (95% CI 3.12 - 55.94 p < 0.001) respectively.

CONCLUSIONS

Our study demonstrates a significant association between SGA, particularly for FGR, with increased odds of stillbirths in singleton pregnancies across all gestational ages. For twin pregnancies, when twin-specific charts were used, SGA and in particular FGR were associated with a significantly increased risk of stillbirth, across all gestational ages at delivery. This article is protected by copyright. All rights reserved.

Effects of vaginal progesterone and placebo on preterm birth and antenatal outcomes in women with singleton pregnancies and short cervix on ultrasound: a meta-analysis

Background

Vaginal progesterone in preterm birth and adverse outcomes caused by cervical insufficiency remains controversial. To address it, the effect of vaginal progesterone on preterm delivery and perinatal outcome of single pregnancy women with short cervix (less than 25 mm) was systematically evaluated by meta-analysis.

Methods

"Vaginal progesterone," "placebo," "ultrasound," "cervix," "singleton pregnancy," "preterm birth," and "antenatal outcomes" were entered to screen clinical studies PubMed, Embase, and the Chinese Biomedical Literature Database (CBM). The study population consisted of women with singleton pregnancies and a short cervix on ultrasound, and were assigned into the progesterone group (n = 1,368) and the placebo group (n = 1,373). Treatment began after the patient was diagnosed with short cervix until delivery. Neonatal survival rate, Neonatal Intensive Care Unit (NICU) admission rate, respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH), neonatal mortality, and birth weight <1,500 g were analyzed.

Results

A total of 8 articles, totaling 2,741 study subjects, were enrolled. The progesterone group exhibited an obvious reduced rate of preterm birth at <34 weeks (OR = 0.67, 95% CI: 0.53∼0.84; Z = 3.53, P = 0.004), preterm birth at <32 weeks (OR = 0.46, 95% CI: 0.28∼0.77; Z = 2.99, P = 0.003), NICU admission rate (OR = 0.45, 95% CI: 0.30∼0.66; Z = 0.15, P < 0.0001), RDS rate (OR = 0.42, 95% CI: 0.28∼0.63; Z = 4.25, P < 0.0001), IVH incidence rate (OR = 0.40, 95% CI: 0.17∼0.95; Z = 2.08, P = 0.04), neonatal mortality (OR = 0.25, 95% CI: 0.13∼0.46; Z = 4.39, P < 0.0001), and proportion of neonates with birth weight < 1,500 g (OR = 0.45, 95% CI: 0.32∼0.64; Z = 4.50, P < 0.0001).

Conclusion

Vaginal progesterone lowered the incidences of preterm birth and adverse pregnancy outcomes in women with singleton pregnancies and a short cervix.

Longitudinal evaluation of cervical length and shear wave elastography in women with spontaneous preterm birth

OBJECTIVES

To compare longitudinal changes in cervical length (CL) and mean cervical shear wave elastography (CSWE) scores between women with singleton and twin pregnancies who experience spontaneous preterm birth (sPTB) and those who have term births (TB).

METHODS

This was a prospective longitudinal study of 1264 unselected women with singleton (n=1143) and twin (n=121) pregnancy attending a dedicated research clinic for screening of sPTB at 4 timepoints during pregnancy including 11-15+6 (visit 1), 16-20+6 (visit 2), 21-24+6 (visit 3) and 28-32+6 (visit 4) weeks of gestation. At each visit, a transvaginal ultrasound scan was conducted to measure the CL and the CSWE scores from six regions of interest (ROI) (inner, middle, and external parts of anterior and posterior lips) in the cervix. The mean of CSWE scores from the six ROIs were calculated for data analysis. Log10 transformation was applied to make the data Gaussian prior to statistical analysis. A multilevel mixed-effects analysis was performed to compare CL and CSWE longitudinally between sPTB and TB groups.

RESULTS

A total of 57 (4.99%) singleton pregnancies and 33 (27.27%) twin pregnancies were complicated with sPTB. Women with sPTB had shorter CL across gestation when controlling for history of cervical surgery, number of fetuses, gestational age at cervical assessment (GA), and the interaction between GA and sPTB. CL in the sPTB group was significantly lower than that of the TB group at 21-24+6 weeks (p=0.039) and 28-32+6 weeks (p<0.001). Twin pregnancies had significantly longer CL throughout pregnancy, compared to singleton pregnancies (coefficient=0.01864, p<0.001). Furthermore, after adjusting for maternal age, weight, height, body mass index (BMI), and GA, CSWE scores in sPTB group were significantly lower in the sPTB group across gestation, compared to the TB group (1.28265 vs 1.32832; p=0.013). However, in the individual visit analysis, CSWE scores in the sPTB group were significantly lower than that of the TB group only at 11-15+6 weeks (p=0.013). There was no difference in CSWE scores between singleton and twin pregnancies throughout pregnancy (coefficient=-0.00128, p=0.937).

CONCLUSION

Women with sPTB have shorter CL and softer cervix across gestation when compared to those with TB. In the individual visit analysis, the reduction in CL in the sPTB group occurs from late second trimester onwards, while the reduction in cervical stiffness in the sPTB group is observed primarily in the first trimester. Additionally, our study has found that CL is significantly shorter in singleton pregnancies compared to twin pregnancies, while cervical stiffness does not differ between the two types of pregnancy. Our findings indicate that the cervix tends to undergo a softening process prior to shortening in the sPTB cases This article is protected by copyright. All rights reserved.

Major postpartum haemorrhage after frozen embryo transfer: A population-based study

OBJECTIVE

To investigate the effect on major postpartum haemorrhage (PPH) of mode of conception, differentiating between naturally conceived pregnancies, fresh embryo in vitro fertilisation (fresh-IVF) and frozen embryo transfer (frozen-IVF).

DESIGN

Retrospective cohort study.

SETTING

The French Burgundy Perinatal Network database, including all deliveries from 2006 to 2020, was linked to the regional blood centre database.

POPULATION OR SAMPLE

In all, 244 336 women were included, of whom 240 259 (98.3%) were singleton pregnancies.

METHODS

The main analyses were conducted in singleton pregnancies, including 237 608 naturally conceived, 1773 fresh-IVF and 878 frozen-IVF pregnancies. Multivariate logistic regression models adjusted on maternal age, body mass index, smoking, parity, induction of labour, hypertensive disorders, diabetes, placenta praevia and/or accreta, history of caesarean section, mode of delivery, birthweight, birth place and year of delivery, were used.

MAIN OUTCOME MEASURES

Major PPH was defined as PPH requiring blood transfusion and/or emergency surgery and/or interventional radiology.

RESULTS

The prevalence of major PPH was 0.74% (n = 1749) in naturally conceived pregnancies, 1.92% (n = 34) in fresh-IVF pregnancies, and 3.30% (n = 29) in frozen-IVF pregnancies. The risk of major PPH was higher in frozen-IVF pregnancies than in both naturally conceived pregnancies (adjusted odds ratio [aOR] 2.63, 95% CI 1.68-4.10) and fresh-IVF pregnancies (aOR 2.78, 95% CI 1.44-5.35).

CONCLUSIONS

We found that frozen-IVF pregnancies have a higher risk of major PPH and they should be subject to increased vigilance in the delivery room.

Are Cervical Pessaries Effective in Preventing Preterm Birth?

Preterm births are a significant concern, as they can have serious consequences for both infants and mothers. It is crucial to identify risk factors associated with preterm birth and to implement effective interventions, such as progesterone, cervical pessary, and cervical cerclage, to prevent it. This systematic review aims to evaluate the efficacy of cervical pessary in reducing spontaneous preterm delivery. However, cervical pessaries have limited research and conflicting findings when compared to other interventions for preventing preterm labor. Therefore, this review seeks to analyze various studies to evaluate their overall effectiveness and better understand their role in treating this vulnerable population. The literature search was conducted using PubMed between January and September 2023, and the systematic review adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The results of this review highlight the importance of continued research into mitigation strategies for preterm birth. There is some evidence that indicates that using cervical pessaries before 34 weeks can be effective. While some studies have reported positive outcomes when cervical pessaries are combined with other treatments like progesterone, there is no solid statistical evidence to support this claim. Furthermore, additional research is needed to comprehend the impact of singleton pregnancies and long-term outcomes for both mothers and infants.

Physical Examination-Indicated Cerclage in Singleton and Twin Pregnancies and Risk Factors for Predicting Preterm Birth < 28 Weeks

We compare the outcomes of physical examination-indicated cerclage (PEIC) between singleton and twin pregnancies and analyze predictive factors for preterm birth < 28 weeks of gestation. Patients who underwent PEIC at our center were reviewed. We compared perinatal outcomes between singleton and twin pregnancies. The primary outcome was delivery before 28 weeks of gestation. Also, we analyzed perioperative clinical, laboratory, and sonographic findings to determine the risk factors for predicting preterm birth < 28 weeks. The rate of preterm birth < 28 weeks was not significantly different. Also, neonatal outcomes were not different. Also, we compared the outcomes according to GA (gestational age) at delivery before (Group A) or after (Group B) 28 weeks, which is the primary outcome. In perioperative findings, group A was likely to have more advanced cervical dilatation, bulging membranes into the vagina, positive fFN or IGFBP-1, and shorter postoperative CL (cervical length) than group B. Also, positive fFN or IGFBP-1 and postoperative CL < 21.6 mm were independently associated with a higher risk of preterm birth < 28 weeks. These findings provide the effectiveness of PEIC with twin pregnancy as well as singleton pregnancy and helpful predictive methods that might effectively identify women at high risk of preterm birth < 28 weeks following PEIC.

The role of maternal age on adverse pregnancy outcomes among primiparous women with singleton birth: a retrospective cohort study in urban areas of China

BACKGROUND

Both young and advanced maternal age pregnancies have strong associations with adverse pregnancy outcomes; however, there is limited understanding of how these associations present in an urban environment in China. This study aimed to analyze the associations between maternal age and pregnancy outcomes among Chinese urban women.

METHODS

We performed a population-based study consisting of 60,209 singleton pregnancies of primiparous women whose newborns were delivered after 20 weeks' gestation between January 2012 and December 2015 in urban areas of China. Participants were divided into six groups (19 or younger, 20-24, 25-29, 30-34, 35-39, 40 or older). Pregnancy outcomes include gestational diabetes mellitus (GDM), preeclampsia, placental abruption, placenta previa, premature rupture of membrane (PROM), postpartum hemorrhage, preterm birth, low birthweight, small for gestational age (SGA), large for gestational age (LGA), fetal distress, congenital microtia, and fetal death. Logistic regression models were used to assess the role of maternal age on the risk of adverse pregnancy outcomes with women aged 25-29 years as the reference group.

RESULTS

The risks of GDM, preeclampsia, placenta previa, and postpartum hemorrhage were decreased for women at a young maternal age and increased for women with advanced maternal age. Both young and advanced maternal age increased the risk of preterm birth and low birthweight. Young maternal age was also associated with increased risk of SGA (aOR 1.64, 95% CI 1.46-1.83) and fetal death (aOR 2.08, 95% CI 1.35-3.20). Maternal age over 40 years elevated the odds of placental abruption (aOR 3.44, 95% CI 1.47-8.03), LGA (aOR 1.47, 95% CI 1.09-1.98), fetal death (aOR 2.67, 95% CI 1.16-6.14), and congenital microtia (aOR 13.92, 95% CI 3.91-49.57). There were positive linear associations between maternal age and GDM, preeclampsia, placental abruption, placenta previa, PROM, postpartum hemorrhage, preterm birth, LGA and fetal distress (all P for linear trend < .05), and a negative linear association between maternal age and SGA (P for linear trend < .001). The analysis of the associations between maternal age and adverse fetal outcomes showed U-shape for preterm birth, low birth weight, SGA, fetal death and congenital microtia (all P for quadratic trend < .001).

CONCLUSIONS

Advanced maternal age predisposes women to adverse obstetric outcomes. Young maternal age manifests a bidirectional effect on adverse pregnancy outcomes. The findings may contribute to improving women's antenatal care and management.

Birthweight of the subsequent singleton pregnancy following a first twin or singleton pregnancy

INTRODUCTION

Birthweight is an important pregnancy indicator strongly associated with infant, child, and later adult life health. Previous studies have found that second-born babies are, on average, heavier than first-born babies, indicating an independent effect of parity on birthweight. Existing data are mostly based on singleton pregnancies and do not consider higher order pregnancies. We aimed to compare birthweight in singleton pregnancies following a first twin pregnancy relative to a first singleton pregnancy.

MATERIAL AND METHODS

This was a prospective registry-based cohort study using maternally linked offspring with first and subsequent pregnancies registered in the Medical Birth Registry of Norway between 1967 and 2020. We studied offspring birthweights of 778 975 women, of which 4849 had twins and 774 126 had singletons in their first pregnancy. Associations between twin or singleton status of the first pregnancy and birthweight (grams) in subsequent singleton pregnancies were evaluated by linear regression adjusted for maternal age at first delivery, year of first pregnancy, maternal education, and country of birth. We used plots to visualize the distribution of birthweight in the first and subsequent pregnancies.

RESULTS

Mean combined birthweight of first-born twins was more than 1000 g larger than mean birthweight of first-born singletons. When comparing mean birthweight of a subsequent singleton baby following first-born twins with those following first-born singletons, the adjusted difference was just 21 g (95% confidence interval 5-37 g).

CONCLUSIONS

Birthweights of the subsequent singleton baby were similar for women with a first twin or a first singleton pregnancy. Although first twin pregnancies contribute a greater combined total offspring birthweight including more extensive uterine expansion, this does not explain the general parity effect seen in birthweight. The physiological reasons for increased birthweight with parity remain to be established.

Physical examination-indicated cerclage in twin pregnancies compared with singleton pregnancies

OBJECTIVE

The aim of this study was to compare pregnancy outcomes of physical examination-indicated cerclage in twin and singleton pregnancies with bulging membranes.

METHODS

All women with bulging membranes in the second trimester of pregnancy who were admitted to La Fe University and Polytechnic Hospital from January 2009 to January 2022 were included. A total of 128 participants were enrolled, 102 singleton pregnancies and 26 twin pregnancies. All patients underwent an amniocentesis to rule out intra-amniotic inflammation (IL-6 < 2.6 ng/mL). Cerclage was placed in the absence of intra-amniotic inflammation.

RESULTS

Compared with singleton gestations, twin pregnancies displayed a significantly higher prevalence of nulliparity and assisted reproductive techniques. The incidence of intra-amniotic inflammation/infection was similar in both groups (68.62% in singleton vs. 65.38% in twin pregnancies). The average gestational age of delivery without cerclage in singleton gestations was 23.83 weeks (95% CI 22.82-24.84) and in twin pregnancies, it was 23.69 weeks (95% CI 21.8-25.57). The average gestational age at delivery among patients with cerclage was 37.27 weeks (95% CI 35.35-39.19) in singleton gestations and 36 weeks (95% CI 33.51-38.63) in twin pregnancies, with no significant differences. Time from diagnosis to delivery in patients with IL-6 < 2.6 ng/mL was 79.88 days, and in those with IL > 2.6 ng/mL was 10.87 days. Gestational age at delivery was significantly higher in both singleton and twin pregnancies with cerclage, compared with those without cerclage (log-rank p < .001).

CONCLUSIONS

Singleton and twin pregnancies with bulging membranes behave similarly when cerclage is placed in the absence of intraamniotic inflammation/infection.

Uterine Artery Doppler Indices as Predictor of Adverse Fetal Outcome in Hypertensive Disorders of Pregnancy: An Observational Study

Background Hypertensive disorders of pregnancy (HDP) pose significant risks to maternal and fetal health. The utility of Doppler indices in predicting adverse fetal outcomes in HDP patients remains an area of active research. This observational study aimed to assess the correlation between abnormal uterine artery Doppler indices and adverse fetal outcomes in HDP patients. Methods Over a two-year period, we enrolled 138 pregnant women with HDP beyond 28 weeks of gestation and singleton pregnancies. Detailed clinical assessments, laboratory investigations, and Doppler studies of the uterine artery were conducted. The Doppler indices that were assessed included the systolic/diastolic (S/D) ratio, resistance index (RI), and pulsatility index (PI). Adverse fetal outcomes were classified based on appearance, pulse, grimace, activity, and respiration (APGAR) scores, birth weight, NICU admissions, and perinatal deaths. Statistical analyses were performed to evaluate the predictive value of Doppler indices. Results Abnormal uterine artery Doppler indices, specifically an elevated S/D ratio and the presence of a diastolic notch showed a positive correlation with adverse fetal outcomes. However, Doppler indices such as PI and RI did not demonstrate a significant correlation with adverse fetal outcomes in HDP patients. These findings suggest that the S/D ratio and the presence of a diastolic notch in uterine artery Doppler studies hold potential as predictive markers for adverse fetal outcomes in HDP patients. Conclusion Uterine artery Doppler indices, specifically the S/D ratio and the presence of a diastolic notch, appear to be valuable predictors for adverse fetal outcomes in patients with hypertensive disorders of pregnancy. These findings underscore the importance of regular monitoring of uterine artery Doppler flow in the management of HDP to identify pregnancies at higher risk for adverse fetal outcomes.

Delivery Progress, Labor Interventions and Perinatal Outcome in Spontaneous Vaginal Delivery of Singleton Pregnancies between Nulliparous and Primiparous Women with One Previous Elective Cesarean Section: A Retrospective Comparative Study

Trial of labor after cesarean (TOLAC) is an alternative to repeated cesarean for women with singleton pregnancy and one previous transverse lower segment cesarean section (LSCS), resulting in most cases being a successful vaginal birth after cesarean section (VBAC). The primary objective of this study was to examine if the progress and the duration of the active first stage and the second stage of labor in nulliparous women with singleton pregnancy, spontaneous start of labor and vaginal birth differ from primiparous women succeeding VBAC after one previous elective LSCS in a country with a low cesarean section and high VBAC rate. Secondary objectives were to compare labor interventions and maternal-neonatal outcomes between the two groups.

METHODS

This is a retrospective comparative study. Data were collected in a four-year period at the departments of Obstetrics and Gynecology at Kristianstad and Ystad hospitals in Sweden. Out of 14,925 deliveries, 106 primipara women with one previous elective LSCS and a spontaneous labor onset in the subsequent singleton pregnancy were identified. Of these women, 94 (88.7%) delivered vaginally and were included in the study (VBAC group). The comparison group included 212 randomly selected nulliparous women that had a normal singleton pregnancy, spontaneous labor onset and delivered vaginally.

RESULTS

The rate of cervical dilation during the active first stage of labor as well as the duration of the second stage did not differ between the two groups. When adjusting for cervical dilation at admission, there was no significant difference between the two groups regarding the duration of the active phase of the first stage of labor. No significant differences were found in maternal-neonatal outcomes between the two groups except for higher birth weight in the VBAC group. The use of epidural analgesia was associated with slower dilation rhythm over the duration of the active phase and second stage of labor, need for labor augmentation, postpartum bleeding and need for transfusion at higher rates, irrespective of parity when epidural was used.

CONCLUSIONS

Our study provides evidence that in women with one previous elective LSCS undergoing TOLAC in the subsequent pregnancy resulting in vaginal birth, the progress and duration of labor are not different from those in nulliparous women when labor is spontaneous and the it is a singleton pregnancy. The use of epidural was associated with prolonged labor, need for labor augmentation and higher postpartum bleeding, irrespective of parity. This information may be useful in patient counseling and labor management in TOLAC.

Perinatal Outcomes of Pregnancy in Women with Scarred Uteri

Objective

Uterine scarring is risky for the pregnancy and is closely associated with adverse pregnancy outcomes. Here, we investigated risk factors and associated perinatal outcomes in singleton pregnant women with uterine scars.

Methods

This retrospective cohort study was conducted on singleton pregnant women who delivered at the West China Second University Hospital between January 1, 2021, and December 31, 2021.

Results

The control group included 13,433 cases without uterine scars. The study group involved 2397 cases with one previous cesarean delivery (PCD), 163 cases with two PCDs, 12 cases with three PCDs, and 184 cases with non-cesarean uterine scars. The study group had a significantly higher incidence of placenta previa (6.4%), placenta percreta (5.3%), preterm delivery (10.3%), postpartum hemorrhage (3.4%), uterine rupture (9.4%), hysterectomy (0.18%), and bladder injury (0.4%) when compared with the control group (P <0.05). The scarred uterus cases with 1, 2, or 3 PCDs had significantly different complications, with the higher PCD frequency correlating with increased rates of placenta previa, placenta percreta, postpartum hemorrhage, uterine rupture, and uterine resection. Moreover, the hospitalization time, cesarean operation time, and intrapartum bleeding in the current pregnancy significantly increased with increasing PCD frequency (P <0.05). Analysis of the association between the duration of the interval between PCD and re-pregnancy and pregnancy complication revealed that the incidence of pernicious placenta previa was statistically higher in cases with intervals of <2 years or ≥5 years (4.7%) than in cases with 2 years ≤ interval time <5 years (2.5%) (P <0.05).

Conclusion

Pregnancies with uterine scars may experience higher rates of adverse perinatal outcomes. This calls for increased observation during pregnancy and delivery to reduce maternal and fetal complications.

Evaluation of Vitamin D Status and the Analysis of Risk Factors of Vitamin D Deficiency in Twin Pregnancies

OBJECTIVE

Optimization of maternal vitamin D (VD) status has beneficial effects on pregnancies, but little is known about it of twin pregnancies (TP). Our aim was to promote the current understanding of VD status and its associated factors in TP.

METHODS

We performed liquid chromatography-tandem mass spectrometry to quantify 25-hydroxyvitamin D [25(OH)D] and used the enzyme-linked immunosorbent assay method to detect vitamin D binding protein (VDBP) in 218 singleton pregnancies (SP) and 236 TP.

RESULTS

Levels of 25(OH)D and VDBP were higher in TP than SP. The 25(OH)D, free 25(OH)D, C-3 epimer of 25-hydroxyvitamin D [epi-25(OH)D], and VDBP all increased with gestational progress. Age, body 
mass index, and hemoglobin level were associated with VD deficiency (VDD). Analysis of covariance demonstrated that the 25(OH)D and VDBP of TP and SP still showed differences after adjusting for the above associated factors.

CONCLUSION

Differences in VD status were found in SP and TP, suggesting that the assessment of VD status in TP should be treated with caution. High VDD prevalence is observed among pregnant Chinese women, and it is recommended to promote evaluation for VDD.

Investigating the predictive role of uterocervical angle in predicting preterm labor in singleton pregnancies: a meta-analysis

OBJECTIVES

In this meta-analysis, we aimedto demonstrate the relationship between uterocervical angle and preterm labor in singleton pregnancies more clearly and reliablywith this meta-analysis.

MATERIAL AND METODS

In this study, we use keywords such as "uterocervical angle," "cervical angle," "angle," "cervix," "cervical," "preterm," and "preterm labour." We searched various databases, including PubMed, MEDLINE, ClinicalKey, Scopus, ScienceDirect, Web of Science, and Google Scholar. The search encompassed the period from January 1, 2010, to December 27, 2020. As a result of the literature review, a total of 585 articles were identified. After the screening and selection process, six studies met the inclusion criteria and were included in the analysis. These six studies were deemed relevant and provided valuable information on the research topic.

RESULTS

When the Egger test (p = 0.020) and Begg test (p = 0.188) were performed, no significant publication bias was found in the studies examined. These statistical tests assess publication bias, and the resulting p-values indicate a low probability of bias in the included studies. Cochran's Q test revealed the presence of heterogeneity among the included studies. Heterogeneity indicates variability in the results beyond what would be expected by chance alone. This finding suggests that the studies may differ in methodologies, populations, or other factors, which could impact the overall results and require further investigation. There was a significant difference between the patient and control groups (p < 0.001). This result provides strong evidence to support the importance of the difference between the two groups compared.

CONCLUSIONS

Based on the findings of this study, a wider uterocervical angle appeared to be significantly associated with an increased risk of preterm delivery in overall effect. It concluded that a wide uterocervical angle may be a potential risk factor for preterm delivery. Moreover, the study revealed a significant association between wider uterocervical angles and an elevated risk of preterm labour in singleton pregnancies. In this study, the definition of preterm birth accepts as birth before 37 weeks of gestation. These results highlight the potential significance of evaluating the uterocervical angle as a meaningful predictor for identifying the propensity of preterm labour in singleton pregnancies.

Postoperative cervical length to predict success of repeat cerclage in singleton pregnancies with prolapsed membranes after prior cerclage

Background

This study aimed to evaluate the outcome of repeat cerclage (RC) in singleton pregnancies with prolapsed membranes following a prior cerclage and analyze predictive factors for delivery at ≥26 weeks of gestation following RC.

Materials and methods

Patients who underwent RC between 2010 and 2020 at the Hallym University Medical Center were reviewed. Women with singleton pregnancies with prolapsed membranes following prior cerclage were candidates for RC. We analyzed the characteristics, pregnancy outcomes, perioperative clinical and laboratory findings, and postoperative cervical length (CL) to identify the factors for predicting delivery at ≥26 weeks following RC.

Results

Thirty-five women with RC were identified; the median gestational age (GA) at a prior cerclage was 14 weeks, the average GA at RC was 21 + 3 weeks, and the median GA at delivery following RC was 26 + 2 weeks. Patients were divided into two groups based on their delivery status at 26 weeks: 17 women delivered at <26 weeks (range, 18 + 4-25 + 6 weeks) (Group A) and 18 women delivered at ≥26 weeks (range, 26 + 2-40 + 3 weeks) (Group B). The median GA at delivery in group A was 22 + 4 weeks, whereas that in group B was 33 + 4 weeks (p < 0.001). No differences in preoperative clinical and laboratory findings were observed between the two groups. However, the postoperative CL in group A was significantly shorter than that in group B (12 mm vs. 21.5 mm, p < 0.001). The ROC curve of postoperative CL predicting delivery at ≥26 weeks showed an AUC of 0.843; a CL of 20 mm showed a sensitivity of 61.1% and a specificity of 100%.

Conclusion

RC may prolong singleton pregnancies with prolapsed membranes following prior cerclage. A postoperative CL ≥20 mm may predict the success of RC.

The efficacy of emergency cervical cerclage in singleton and twin pregnancies: a systematic review with meta-analysis

OBJECTIVE

An emergency (rescue) cervical cerclage can be offered to pregnant women presenting with dilatation and prolapsed membranes in the second trimester of pregnancy because of cervical insufficiency. This study aimed to investigate the effectiveness of an emergency cerclage in both singleton and twin pregnancies in the prevention of extreme premature birth.

DATA SOURCES

We performed a systematic literature search in PubMed and Embase from inception to June 2022 for transvaginal cervical emergency cerclages.

STUDY ELIGIBILITY CRITERIA

All studies on transvaginal cervical emergency cerclages with at least 5 patients and reporting survival were included.

METHODS

Included studies were assessed for quality and risk of bias with an adjusted Quality In Prognosis Studies tool. Random-effects meta-analyses and meta-regressions were performed for the primary outcome: survival.

RESULTS

Our search yielded 96 studies, incorporating 3239 women, including 14 studies with an expectant management control group, incorporating 746 women. Overall survival after cervical emergency cerclage was 74%, with a fetal survival of 88% and neonatal survival of 90%. Singleton and twin pregnancies showed similar survival, with a pregnancy prolongation of 52 and 37 days and a gestational age at delivery of 30 and 28 weeks, respectively. Meta-regression analyses indicated a significant inverse association between mean gestational age at diagnosis and pregnancy prolongation and no association between dilatation or gestational age at diagnosis and gestational age at delivery. Compared with expectant management, emergency cerclage significantly increased overall survival by 43%, fetal survival by 17% and neonatal survival by 22%, along with a significant pregnancy prolongation of 37 days and reduction in delivery at <28 weeks of gestation of 55%. These effects were more profound in singleton pregnancies than in twin pregnancies.

CONCLUSION

This systematic review indicates that, in pregnancies threatened by extreme premature birth because of cervical insufficiency, emergency cerclage leads to significantly higher survival, accompanied by significant pregnancy prolongation and reduction in delivery at <28 weeks of gestation, compared with expectant management. The mean gestational age at delivery was 30 weeks, independent of dilatation or gestational age at diagnosis. Survival was similar for singleton and twin pregnancies, implying that emergency cerclage should be considered in both.

The role of vaginal progesterone for preterm birth prevention in women with threatened labor and shortened cervix diagnosed after 24 weeks of pregnancy

OBJECTIVE

To determine whether vaginal progesterone treatment for women with a short cervix, diagnosed after 24 weeks of pregnancy, reduces preterm birth rates.

METHODS

A retrospective cohort study that included women with a singleton pregnancy, threatened preterm labor, and a short cervix measured between 24+0 and 33+6 weeks. Women who received vaginal progesterone were compared with women who did not receive progesterone. The primary outcome was spontaneous preterm birth before 37 weeks of pregnancy.

RESULTS

Patients who received vaginal progesterone had a lower rate of preterm delivery at less than 37 weeks of pregnancy (18.2% [22/121] versus 28.9% [73/253]; adjusted hazard ratio 0.50; 95% confidence interval 0.28-0.73, P = 0.001). The diagnosis-to-delivery interval was significantly greater in patients who received progesterone than in those who did not-median time to delivery in weeks: 8.2 (interquartile range [IQR] 6.2-9.8) versus 6.6 (4.8-8.8), (P < 0.001). The frequency of neonatal intensive care unit admission was significantly lower in patients who received progesterone than in those who did not (8.3% [10/121] versus 16.2% [41/253], P = 0.04).

CONCLUSIONS

The administration of vaginal progesterone to patients with an episode of threatened premature labor and a short cervix presenting after 24 weeks of pregnancy was associated with lower rates of premature births.

Incidence of stillbirth: effect of deprivation

OBJECTIVES

To examine the relationship between the English index of multiple deprivation (IMD) and the incidence of stillbirth and assess whether IMD contributes to the prediction of stillbirth provided by the combination of maternal demographic characteristics and elements of medical history.

METHODS

This was a prospective, observational study of 159 125 women with a singleton pregnancy who attended their first routine hospital visit at 11 + 0 to 13 + 6 weeks' gestation in two maternity hospitals in the UK. The inclusion criterion was delivery at ≥ 24 weeks' gestation of a fetus without major abnormality. Participants completed a questionnaire on demographic characteristics and obstetric and medical history. IMD was used as a measure of socioeconomic status, which takes into account income, employment, education, skills and training, health and disability, crime, barriers to housing and services, and living environment. Each neighborhood is ranked according to its level of deprivation relative to that of other areas into one of five equal groups, with Quintile 1 containing the 20% most deprived areas and Quintile 5 containing the 20% least deprived areas. Logistic regression analysis was used to determine whether IMD provided a significant independent contribution to stillbirth after adjustment for known maternal risk factors.

RESULTS

The overall incidence of stillbirth was 0.35% (551/159 125), and this was significantly higher in the most deprived compared with the least deprived group (Quintile 1 vs Quintile 5). The odds ratio (OR) in Quintile 1 was 1.57 (95% CI, 1.16-2.14) for any stillbirth, 1.64 (95% CI, 1.20-2.28) for antenatal stillbirth and 1.89 (95% CI, 1.23-2.98) for placental dysfunction-related stillbirth. In Quintile 1 (vs Quintile 5), there was a higher incidence of factors that contribute to stillbirth, including black race, increased body mass index, smoking, chronic hypertension and previous stillbirth. The OR of black (vs white) race was 2.58 (95% CI, 2.14-3.10) for any stillbirth, 2.62 (95% CI, 2.16-3.17) for antenatal stillbirth and 3.34 (95% CI, 2.59-4.28) for placental dysfunction-related stillbirth. Multivariate analysis showed that IMD did not have a significant contribution to the prediction of stillbirth provided by maternal race and other maternal risk factors. In contrast, in black (vs white) women, the risk of any and antenatal stillbirth was 2.4-fold higher and the risk of placental dysfunction-related stillbirth was 2.9-fold higher after adjustment for other maternal risk factors.

CONCLUSIONS

The incidence of stillbirth, particularly placental dysfunction-related stillbirth, is higher in women living in the most deprived areas in South East England. However, in screening for stillbirth, inclusion of IMD does not improve the prediction provided by race, other maternal characteristics and elements of medical history. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Quantification of cervical stiffness changes in single and twin pregnancies using the E-Cervix technique

BACKGROUND

Cervical length is a commonly used clinical indicator for evaluating preterm birth. However, some studies have shown that cervical length does not change in patients with cervical insufficiency.

OBJECTIVE

This study aimed to use the transvaginal ultrasound E-Cervix to quantitatively evaluate the cervical stiffness in women with singleton and twin pregnancies to provide a reference for the clinical prediction of preterm birth.

STUDY DESIGN

We collected the cervical length, cervical hardness ratio, mean internal os strain, and mean external os strain using transvaginal ultrasonographic E-Cervix assessments in pregnant women undergoing routine examinations in the obstetrics department of our hospital from January 2020 to December 2020. We summarized the range of cervical elasticity parameters at different gestational ages and compared the cervical elasticity parameters between singleton and twin pregnancies and between preterm births and full-term births.

RESULTS

A total of 988 pregnant women were enrolled in this study, and after exclusion, 770 pregnant women were enlisted; the interrater and internal consistency for various elasticity parameters were favorable; and cervical elasticity changes in women at full term showed some particular patterns. The declines in cervical length and hardness ratio were commensurate with gestational age, whereas the internal os strain and external os strain rose with increasing gestational age. The cervical hardness ratio in women with twin pregnancies was lower than in women with singleton pregnancies at the same gestational age, although the internal os strain in women with twin pregnancies was higher than in women with singleton pregnancies at the same gestational age (P<.05). The cervical length of women with twin pregnancies was shorter than that of women with singleton pregnancies at the same gestational age when the gestational age was ≥28 weeks of gestation (all P<.05), and the hardness ratio was linearly correlated with gestational age (r=0.68 and r=0.71). The regression model for the cervical hardness ratio in women with singleton pregnancies was hardness ratio = -0.8764×gestational age+100.99, whereas the regression model for the cervical hardness ratio in women with twin pregnancies was hardness ratio = -1.3037×gestational age+103.03. When we compared cervical elasticity parameters between preterm and full-term births, we noted that the cervical hardness ratio in pregnant women who exhibited preterm births was lower regardless of whether they carried singleton or twin pregnancies (P=.000 and P=.000), although their internal os strain was higher (P=.023 and P=.000). We observed no significant difference when we compared the cervical length and external os strain of pregnant women manifesting preterm births vs women with full-term births (P=.216 and P=.345 vs P=.475 and P=.363).

CONCLUSION

When used for the quantification of cervical hardness, the E-Cervix cervical elasticity changes in pregnant women at full term showed some particular patterns. Cervical length and hardness ratio diminished as gestational age increased, whereas internal os strain and external os strain rose as gestational age increased; moreover, the degree of these changes was greater in women with twin pregnancies than in women with singleton pregnancies. Pregnant women experiencing preterm births exhibited a reduced cervical hardness ratio and augmented internal os strain relative to women experiencing full-term births.

Maternal Renal Dysfunction in Late Pregnancy in Twin and Singleton Pregnancies: Retrospective Study

This study aimed to evaluate the differences in the impact on maternal renal function between singleton and twin pregnancies in the second half of pregnancy. It retrospectively enrolled 1711 pregnant women consisting of 1547 singleton pregnancies and 164 twin pregnancies from Japanese Red Cross Aichi Medical Center Nagoya Daiichi Hospital from January 2019 to June 2021. Patients underwent renal function tests (serum blood urea nitrogen, creatinine, and estimated glomerular filtration rate (eGFR)) at least one month before delivery. The main outcome measure was maternal renal dysfunction, defined as a serum creatinine level above 0.8 mg/dL. The serum creatinine level was significantly higher and the eGFR was significantly lower in twin than in singleton pregnancies (p < 0.001). In addition, the rate of renal dysfunction was significantly higher in twin than in singleton pregnancies (7.9% vs. 2.6%; p < 0.01). Multivariate analysis revealed that twin pregnancy (odds ratio (OR) 3.38), nulliparity (OR 2.31), and preeclampsia (OR 3.64) were significant risk factors for maternal renal dysfunction. Maternal renal dysfunction was observed in 13 twin pregnancies, all of which recovered to within normal limits during the early months of the postpartum period. Twin pregnancy is a significant risk factor for maternal renal dysfunction; renal function should be carefully monitored in twin pregnancies.

The association between induction of labour in nulliparous women at term and subsequent spontaneous preterm birth: a retrospective cohort study

OBJECTIVES

To evaluate the rate of subsequent spontaneous preterm birth in patients with previous induction of labour at term compared to women with previous spontaneous labour at term.

METHODS

This was a retrospective cohort study of all women with consecutive births at the Royal Brisbane and Women's Hospital between 2014 and 2018. All nulliparous women with a singleton pregnancy and induction of labour at term or in spontaneous labour at term in the index pregnancy were included. Data was extracted from electronic medical records. The outcome of spontaneous preterm birth in the subsequent pregnancy was compared between patients with previous term induction of labour and in previous term spontaneous labour.

RESULTS

A total of 907 patients with consecutive births met the inclusion criteria; of which 269 (29.7%) had a term induction of labour and 638 (70.3%) had a term spontaneous labour in the index pregnancy. The overall subsequent spontaneous preterm birth rate was 2.3%. Nulliparous women who underwent term induction of labour were less likely to have a subsequent preterm birth compared to nulliparous women in term spontaneous labour (0.74 vs. 2.98%; odds ratio [OR], 0.25; 95% confidence interval, 0.06-1.07; p=0.0496) in the index pregnancy. This however was not significant once adjusted for confounders (adjusted OR, 0.29; p=0.10). Spontaneous preterm birth was associated with a previous spontaneous labour compared to induction of labour between 37 to 37⁺⁶ and 38 to 38⁺⁶ weeks (adjusted OR 0.18 and 0.21; p=0.02 and 0.004 respectively).

CONCLUSIONS

Term induction of labour does not increase the risk of subsequent spontaneous preterm birth compared to spontaneous labour at term in nulliparous women. Further research is needed to validate these findings in a larger cohort of women and to evaluate the effect of elective IOL among low-risk nulliparous women.

First-Trimester Triglyceride-Glucose Index and Risk of Pregnancy-Related Complications: A Prospective Birth Cohort Study in Southeast China

PURPOSE

To evaluate the relationships of the triglyceride-glucose (TyG) index with pregnancy-related complications (PRCs) and to clarify the predictability of the TyG index for PRCs.

PATIENTS AND METHODS

Totally of 11,387 women with a singleton pregnancy were prospectively followed until after delivery. Maternal fasting lipids and glucose concentration were measured in the first trimester (11 weeks gestation on average). The TyG index was calculated as ln [triglyceride (mg/dL) × fasting plasma glucose (mg/dL)/2]. We used generalized linear models to calculate the relative risks and 95% confidence intervals. Receiver-operating characteristic curve analysis was employed to assess the ability of the TyG index to predict the risks of PRCs.

RESULTS

Smooth spline reveals that the probability of gestational diabetes mellitus (GDM) is intensified with the increasing TyG index. Multivariate logistic regression adjusted for risk factors demonstrates a 1-unit and a 1-SD increment in the TyG index raises the risk of GDM by 3.63 and 1.57 times, respectively. Identically, the risk of GDM maximizes in the TyG quintile 5 (OR: 3.14; 95% CI: 2.55~3.85) relative to the lowest TyG index group. However, no association between TyG index and the risk of other PRCs was observed after full adjustment. The area under receiver operating characteristic curves is 0.647 (95% CI: 0.632-0.66) for GDM, and the optimal predictive cut-off is 8.55, with a specificity of 0.679 and sensitivity of 0.535.

CONCLUSION

The first-trimester TyG index is significantly associated with the risk of incident GDM, while the relationships between the TyG index and other PRCs need further exploration.

Outcome dependent growth curves for singleton pregnancies based on birth weight of babies for Polish population

OBJECTIVES

To create outcome dependent fetal growth curves and birth weight standards that can be analyzed for use in clinic specifically for Western European populations.

MATERIAL AND METHODS

We conducted a retrospective study on fetal growth and birth weight trends from live birth singleton pregnancies between 2005 and 2018 at one of the largest tertiary gynecologic-obstetric hospitals in Poland. The inclusion criteria were at least 22 weeks of gestation at birth regardless of delivery mode (vaginal or C-section), no congenital anomalies diagnosed before and after delivery and an Apgar score of at least 7 in the first minute. The final sample had a total of 39,413 cases (18,562 girls and 20,851 boys). We presented 7 (for all fetuses in the 5th, 10th, 25th, 50th, 75th, 90th and 95th percentiles) and 6 (for boys and girls each at 10th, 50th and 90th percentiles) fetal growth curves between 25 and 40 weeks of gestation. Birth weight trends were obtained and analyzed from all babies in the 5th, 10th, 25th, 50th, 75th and 95th percentiles born between 22 to 42 weeks of gestation with also separate trends for boys and girls.

RESULTS

The largest differences in fetal growth curves were observed in the 10th and 50th percentiles between 22 and 34 weeks of gestation. A decreasing fetal weight gain pattern was observed between 27 and 30 weeks and after 38 weeks of gestation, the decrease was more drastic in female. A significant increase from 2009 to 2017 was observed in the weight of 50th percentile babies born at or after 35 weeks. We found significant discrepancies between our results and the most used European fetal growth curves particularly in the 10th and 90th percentile weights at 30 weeks.

CONCLUSIONS

Separate scales for boys and girls were implied and given the overall difference form commonly used references. We believe there is significant value in using these unique patterns found in fetal growth curves and birth weights of ethnically homogenous population (such as Poland) at everyday clinical practice for more opportunities of safe obstetric care and higher chances of delivering a healthy child.

Comparison of maternal third trimester hemodynamics between singleton pregnancy and twin pregnancy

OBJECTIVES

The impedance cardiography (ICG) technique measures the variation of impedance in the thorax due to the physical contractile activity of the heart. Twin pregnancy is characterized by greater maternal hemodynamic changes than a singleton pregnancy.

METHODS

In a study on 121 pregnant women in the last trimester we performed ICG, evaluating the following hemodynamic parameters: stroke volume, heart rate, cardiac output, ventricular ejection time, left ventricular ejection time, thoracic impedance, and systemic vascular resistance.

RESULTS

The study included singleton and twin pregnancies. Heart rate values in women with single fetus was lower than in those carrying twins (85 vs. 100 beats/min, p=0.021) as were the stroke volume values (64 vs. 83 mL, p=0.010) and the cardiac output (p<0.0001). Systemic vascular resistance decreased in twin pregnancies compared to singleton pregnancy (p=0.023).

CONCLUSIONS

ICG studies are rare, and the validation of their results is an ongoing process. However, the ICG technique is applicable in the third trimester of pregnancy and can yield important information regarding the hemodynamic profile of singleton and twin pregnancies, revealing maternal heart changes specific to twin pregnancies.

Risk Factors Associated with Preterm Delivery in Singleton Pregnancy in a Tertiary Care Hospital in South India: A Case Control Study

Background

Preterm delivery is a major obstetric complication and a leading cause of neonatal mortality and morbidity. It is also associated with significant costs in terms of psychological and financial hardship, to the families.

Objective

The primary objective of this study was to determine the risk factors associated with all preterm deliveries in singleton pregnancy in a tertiary care hospital and the secondary objective was to determine the fetal outcomes among women with preterm delivery.

Materials and Methods

A case control study was conducted between January 2019 and June 2019 in the Department of Obstetrics and Gynecology of a tertiary care center in Central Kerala, India. Women who delivered before 37 completed weeks of gestation were taken as cases and those who delivered at or after 37 weeks were considered as controls in a 1:1 ratio, approximately. Data regarding 191 cases and 200 controls were taken from delivery room records of the years 2016 to 2018 with the help of a predesigned checklist. Univariate and multivariate analysis were done to determine the magnitude of association between the exposure factors and preterm delivery.

Results

The mean age of study participants among the cases was 29.3 ± 5.1 years and controls was 28.1 ± 4.4. Pregnancy induced hypertension (aOR = 14.60; 95% CI 4.8, 44.1; p<0.001), abnormal amniotic fluid volume (aOR = 10.68; 95% CI 3.46, 32.98; p<0.001), premature rupture of membranes (PROM) (aOR = 10.27; 95% CI 4.82, 21.86; p<0.001), previous history of preterm delivery (aOR = 4.12; 95% CI 1.22, 13.85; p<0.002), history of urinary tract infection (UTI) during pregnancy (aOR = 3.67; 95% CI 1.39, 9.68; p<0.002), systemic diseases (aOR = 2.78; 95% CI 1.28, 6.39; p<0.001), anaemia (aOR = 2.54; 95% CI 1.28, 5.03; p<0.004) were found to be the independent risk factors for preterm delivery. On analyzing the fetal outcomes, the average birth weight of preterm babies was 2 ± 0.6 kg compared to 3.1kg among term babies.

Conclusion

Early detection and adequate treatment of various conditions like anaemia, pregnancy induced hypertension, UTI and systemic illness can help in reduction of the prevalence of preterm delivery.

Maternal lipid levels in preeclampsia: singleton vs. twin pregnancies

OBJECTIVE

To compare the maternal lipid levels in preeclampsia (PE) patients between singleton and twin pregnancies.

METHODS

In this retrospective study, pregnant women with PE were divided into singleton group (n = 702) and twin group (n = 198). Serum lipids which include total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C) were measured and the TC/HDL-C ratio, TG/HDL-C ratio, and LDL-C/HDL-C ratio were calculated and compared between the two groups. Covariance analysis was used to correct the potential factors affecting serum lipid levels such as maternal age, pre-pregnancy body mass index, gestational weight gain, etc.

RESULTS

The levels of TC, TG, LDL-C, and TC/HDL-C ratio, TG/HDL-C ratio, LDL-C/HDL-C ratio in twin PE were significantly higher than those in singleton PE group, and there was no significant difference in the level of HDL-C between the two groups. In late-onset PE patients, the lipid levels of TC, TG, LDL-C, and TC/HDL-C ratio, TG/HDL-C ratio, LDL-C/HDL-C ratio in twin PE group were significantly higher than those in singleton PE group, with no significant difference in the level of HDL-C. However, in early-onset PE patients, there were no significant differences in the lipid levels between the two groups.

CONCLUSIONS

There were more obvious lipid disturbances such as higher levels of TC, TG, LDL-C, and TC/HDL-C ratio, TG/HDL-C ratio, LDL-C/HDL-C ratio in twin PE group than singleton PE group. The differences of lipid levels appeared mainly in late-onset PE group, while the lipid levels in twin PE group were similar to those in singleton PE group during pregnancy in early-onset PE group.

Association Between Pre-Pregnancy Body Mass Index and Maternal and Neonatal Outcomes of Singleton Pregnancies After Assisted Reproductive Technology

OBJECTIVE

To study the association between pre-pregnancy body mass index (BMI) and adverse maternal and neonatal outcomes of singleton pregnancies after assisted reproductive technology (ART).

METHODS

This hospital-based retrospective cohort study of women with live singleton births through ART in China from January 2015 to August 2020 included 3043 Chinese women. According to the latest BMI classification standard of Asian women, the women included in this study were classified as underweight (BMI <18.5 kg/m²), normal (BMI 18.5 to <23 kg/m²), overweight (BMI 23 to <27.5 kg/m²), and obese (BMI ≥27.5 kg/m²). We compared the risk of adverse outcomes of different pre-pregnancy BMI values of women with singleton pregnancies conceived through ART. We used Logistic regression analysis to estimate the associations between pre-pregnancy BMI and adverse perinatal and neonatal outcomes.

RESULTS

Our findings showed that women who were overweight or obese before pregnancy through ART are more likely to have a cesarean section, gestational diabetes mellitus, gestational hypertension, and preeclampsia, regardless of whether confounding factors are adjusted. Moreover, pre-pregnancy obesity was more associated with a higher risk of these adverse outcomes than pre-pregnancy overweight. In addition, neonates from women who had obesity before pregnancy through ART were more likely to have macrosomia; adjusted odds ratios and 95% confidence intervals were 3.004 (1.693-5.330).

CONCLUSIONS

Our research showed that women who had pre-pregnancy overweight or obesity with singleton pregnancies through ART were more likely to have a cesarean section, gestational diabetes mellitus, gestational hypertension, and preeclampsia. Moreover, neonates from women who had obesity before pregnancy were more likely to have macrosomia.

The Impact of Down-Regulation on Obstetrics and Perinatal Outcomes in Singleton Pregnancies After In Vitro Fertilization

BACKGROUND

down-regulation has been widely used in IVF treatment; however, it lacks reports on the impact of down-regulation on obstetrics and perinatal outcomes. The purpose of this study was to compare the obstetrics and perinatal outcomes among different down-regulation conditions.

METHODS

this is a retrospective cohort study on 3578 patients achieving cumulative singleton clinical pregnancy after their first oocytes retrieval cycle. Patients were grouped according to the serum estradiol after down-regulation (E2D) into three groups: <30, 30-55, >55 pg/ml. The obstetrics and perinatal outcomes, and live-birth rate per clinical pregnancy were main outcome measures. In the subgroup analysis, patients were further divided according to the mode of transfer. ANOVA, chi-square test, multivariate logistic regression, and multivariate general linear model were performed for statistical analysis.

RESULTS

the patients with E2D <30, 30-55, >55 pg/ml had similar live-birth rates. The patients with E2D <30 pg/ml had a lower risk of hypertension disorders than those with E2D 30-55 pg/ml. No difference was found in the risks of placenta previa, placenta abruption, premature rupture of membrane, hemorrhage, gestational diabetes mellitus, or intrauterine growth restriction. The newborns in the group with E2D <30 pg/ml had a lower risk of PICU admission than those in the group with E2D >55 pg/ml. There was no difference in the risks of congenital anomalies or mortality among the three groups. No differences were found in the gestational week, percentages of preterm birth and very preterm birth, birth weight, percentages of low birth weight and very low birth weight, delivery mode, or sex of newborn. Subgroup analysis showed that E2D 30-55 pg/ml was associated with a higher risk of low birth weight in patients with one fresh transfer + frozen transfer(s).

CONCLUSION

Down-regulation has no effect on the live-birth rate per clinical pregnancy. Patients with E2D <30 pg/ml may have advantages regarding lower risks of both maternal hypertension and newborn PICU admission. E2D 30-55 pg/ml may be associated with low birth weight in patients with relatively low quality embryos.

Risk of gestational diabetes mellitus in women achieving singleton pregnancy spontaneously or after ART: a systematic review and meta-analysis

BACKGROUND

Women who achieve pregnancy by ART show an increased risk of obstetric and perinatal complications compared with those with spontaneous conception (SC).

OBJECTIVE AND RATIONALE

The purpose of this systematic review and meta-analysis was to synthesize the best available evidence regarding the association between ART and gestational diabetes mellitus (GDM) in women with singleton pregnancies. The research question asked was whether the risk of GDM is higher in women achieving singleton pregnancy by ART compared with those achieving singleton pregnancy spontaneously.

SEARCH METHODS

A literature search, in MEDLINE, Scopus and Cochrane databases, covering the period 1978–2019, was performed aiming to identify studies comparing the risk of GDM in singleton pregnancies after ART versus after SC. Both matched and unmatched studies were considered eligible. Meta-analysis of weighted data was performed using the random effects model. Results were reported as risk ratio (RR) with 95% CI. Heterogeneity was quantified with the I² index.

OUTCOMES

The study reports on 63 760 women who achieved a singleton pregnancy after ART (GDM was present in 4776) and 1 870 734 women who achieved a singleton pregnancy spontaneously (GDM in 158 526). Women with singleton pregnancy achieved by ART showed a higher risk of GDM compared with those with singleton pregnancy achieved spontaneously (RR 1.53, 95% CI 1.39–1.69; I² 78.6%, n = 37, 1 893 599 women). The direction or the magnitude of the effect observed did not change in subgroup analysis based on whether the study was matched (n = 17) or unmatched (n = 20) (matched: RR 1.42, 95% CI 1.17–1.72; I² 61.5%—unmatched: RR 1.58, 95% CI 1.40–1.78; I² 84.1%) or whether it was prospective (n = 12) or retrospective (n = 25) (prospective studies: RR 1.52, 95% CI 1.27–1.83, I² 62.2%—retrospective studies: RR 1.53, 95% CI 1.36–1.72, I² 82.5%). Regarding the method of fertilization, a higher risk of GDM after ART versus SC was observed after IVF (n = 7), but not after ICSI (n = 6), (IVF: RR 1.95, 95% CI 1.56–2.44, I² 43.1%—ICSI: RR 1.42, 95% CI 0.94–2.15, I² 73.5%). Moreover, regarding the type of embryo transfer (ET), a higher risk of GDM after ART versus SC was observed after fresh (n = 14) but not after frozen (n = 3) ET (fresh ET: RR 1.38, 95% CI 1.03–1.85, I² 75.4%—frozen ET: RR 0.46, 95% CI 0.10–2.19; I² 73.1%). A higher risk of GDM was observed after ART regardless of whether the eligible studies included patients with polycystic ovary syndrome (RR 1.49, 95% CI 1.33–1.66, I² 75.0%) or not (RR 4.12, 95% CI 2.63–6.45, I² 0%), or whether this information was unclear (RR 1.46, 95% CI 1.22–1.75, I² 77.7%).

WIDER IMPLICATIONS

The present systematic review and meta-analysis, by analysing 1 893 599 women, showed a higher risk of GDM in women achieving singleton pregnancy by ART compared with those achieving singleton pregnancy spontaneously. This finding highlights the importance of early detection of GDM in women treated by ART that could lead to timely and effective interventions, prior to ART as well as during early pregnancy.

To Evaluate Choroidal and Retinal Thicknesses in Singleton versus Twin Pregnancies using Optical Coherence Tomography

PURPOSE:

The purpose of the study was to evaluate the choroidal and retinal thicknesses in singleton versus twin pregnancies.

MATERIALS AND METHODS:

This study included 20 single and 20 twin pregnant women in their 3^rd trimester with 20 age-matched healthy nonpregnant women as a control group. All participants underwent a detailed ocular examination. Cirrus enhanced depth imaging-optical coherence tomography was used for choroidal thickness (CT) with frame enhancement software. The study was divided into three groups: Group 1 – singleton pregnancy, Group 2 – twin pregnancy, and Group 3 – healthy nonpregnant controls. CT was measured from nasal, subfoveal, and temporal fields.

RESULTS:

Regarding CT, the twin pregnancy group had the thickest choroid followed by the singleton pregnancy group and control group. There was a statistically significant difference between Group 2 and Group 3 in terms of nasal, subfoveal, and temporal CTs (P = 0.002, P = 0.001, and P = 0.003, respectively). There was a statistically significant difference between Group 1 and Group 3 regarding just subfoveal CT (P = 0.028). Regarding retinal thickness, there was a statistically significant difference between Group 1 and Group 3 regarding the mean macular volume and ganglion cell-inner plexiform layer thicknesses (P < 0.05). Furthermore, regarding mean retinal nerve fiber layer thickness, there was a statistically significant difference between Group 1 and Group 2 and between Group 2 and Group 3 (P = 0.004, P = 0.003, respectively).

CONCLUSION:

Our study is the first one which evaluates choroidal and retinal thicknesses in twin pregnancies. We found that there was an increase in CT in the 3^rd trimester of pregnancies and it was prominent in twin pregnancies.

Prediction of time of delivery using cervical length measurement in women with threatened preterm labor

OBJECTIVE

To evaluate the use of transvaginal (TV) sonographic cervical length (CL) measurement alone in predicting time of delivery in women who present in threatened preterm labor.

METHODS

A retrospective cohort study at Royal Brisbane and Women's Hospital of all women who presented between 22 weeks and 0 days and 35 weeks and six-day gestation in threatened preterm labor and were admitted for ongoing management including a TV sonographic CL measure. The accuracy of CL for predicting time of delivery was compared between women with a short cervix (CL  < 25 mm) and those with a normal cervix (CL ≥25 mm). The predictive accuracy of CL for spontaneous preterm delivery was analyzed with different outcome-specific thresholds.

RESULTS

One hundred and forty-six women with threatened preterm labor met the inclusion criteria; of which 74 (50.7%) had a short cervix and 72 (49.3%) had a normal cervix. The group with short cervix were more likely to deliver prematurely before 37-week gestation, as well as a shorter time interval between initial presentation and delivery and delivery within 14 days from presentation (p = .0002, p = .0001, and p = .0001, respectively). Similarly, with respect to the area under the receiver operator characteristic curves, CL measurement was found to be significant for time of delivery before or after 37 weeks (p < .0001), preterm delivery before 34 (p =  .0003) and 31 (p <  .0001) weeks; and preterm delivery within 14 days from presentation (p < .0001). Cervical length measurement has a high negative predictive value ranging from 94.9 to 97.1% depending on the different CL threshold used.

CONCLUSIONS

Cervical length measurement at the time of presentation was significantly associated with the risk of preterm delivery in women presenting with threatened preterm labor and a short cervix. Cervical length measurement was also helpful in predicting time of delivery within 14 days from presentation. The negative predictive value and predictive accuracy of CL as a single measure were of significance.

Lifesaving dose increment of cabergoline in life-threatening spontaneous ovarian hyperstimulation syndrome resistant to all interventions

OBJECTIVE

Spontaneous ovarian hyperstimulation syndrome (SOHSS) is an extremely rare complication that deserves a multidisciplinary approach together with a thorough investigation for the correct diagnosis of the underlying pathology. The aim of this study was to present a case of severe SOHSS resistant to all interventions and to discuss the available interventions to overcome such a rare and serious clinical situation.

CASE REPORT

We report a case of severe, life-threatening spontaneous OHSS with a normal nine weeks singleton pregnancy in a 25-year-old nulliparous woman, which resulted with pregnancy termination and continuation of disease progression until the dose of cabergoline was increased to 1.5 mg/day.

CONCLUSION

This case report emphasizes that patients with life-threatening SOHSS resistant to all medical and surgical interventions may benefit from higher doses of cabergoline. Although spontaneous OHSS is extremely rare, it is potentially a life-threatening clinical entity in its severe form and needs time management and detailed examination of the underlying causes.

Single embryo transfer improve the perinatal outcome in singleton pregnancy

Background and objectives: Most of previous studies are comparing the perinatal outcome on singleton babies. There has been no study evaluating the possible effect of singleton embryo transfer on the perinatal outcomes in initial singleton pregnancy resulting from fresh embryo transfer. The purpose of our study is to access the effect of embryo transfer number on obstetric and perinatal risks in order to examine the role of single embryo transfer on perinatal outcomes on initial singleton pregnancy.Materials and methods: This study is a retrospective cohort study and analyzed 6439 fresh embryo transfer women. 1647 initial singleton pregnancy patients were divided into one of the following three groups according to the embryo transfer number: group A (n = 94): single embryo transfer (SET); group B (n = 1321): double embryo transfer (DET); group C (n = 262): triple embryo transfer (TET). The miscarriage rate and the ectopic pregnancy rate was compared between group A and group B, group C. 1273 live birth patients were divided into three groups too. The obstetrics outcomes and perinatal outcomes between group A and group B, group C.Results: There were 94 singleton pregnancy patients in unselective single embryo transfer. Comparing with double embryo transfer, the early miscarriage rate was higher, but late miscarriage rate, ectopic rate, and live birth rate were comparable between two groups. The obstetrics outcomes were comparable between single embryo transfer and other two groups. Although there was no significant difference between group A and other two groups, preterm birth rate, extremely preterm birth rate, low-birth weight rate and very low-birth weight rate increased with the increase of embryo transfer number. The mean delivery weight was highest in singleton babies in single embryo transfer group. It is higher in group A comparing with group B (3440.4 versus 3320.7 g) and comparing with group C (3440.4 versus 3277.4 g).Conclusions: Single embryo transfer was associated with a better perinatal outcome such as preterm birth and low-birth weight in a singleton pregnancy. The mean birth weight was significantly higher in single embryo transfer group too. Single embryo transfer is a reasonable option to reach the goal of in vitro-fertilization - a healthy singleton neonate.

Ultrasound study of fetal movements in singleton and twin pregnancies at 12-19 weeks

Objective To evaluate fetal behavioral differences between singleton and twin fetuses before 20 weeks of gestation using four-dimensional (4D) ultrasound. Methods 4D ultrasound was used to examine fetal movements in 58 singleton and 48 twin normal fetuses at 12-19 weeks. The frequencies of eight fetal movements were assessed through 15-min recordings. The fetuses were divided into two gestational age groups (12-13 and 14-19 weeks) to evaluate the changes with advancing gestation in twin versus singleton fetuses. Results Arm and general movements were the most frequent movements in singleton fetuses, whereas only general movement was significantly more frequent than the other seven fetal movements in twin fetuses at 12-13 weeks. At 14-19 weeks, frequencies of arm and leg movements were significantly higher than those of the other six movements in singleton fetuses, while only arm movement was significantly more frequent than the other fetal movements in twin fetuses. Comparisons of fetal movements between singleton and twin fetuses revealed that only arm movement showed a significant difference at 12-13 weeks, while the frequencies of all movements in singleton fetuses were significantly higher than those in twin fetuses at 14-19 weeks. Conclusion Our results suggest that the limitation of available space and crowding of twin fetuses with advancing gestation may have a marked impact on twin fetal movements compared with singleton fetuses, even in the first half of pregnancy. Further studies are needed to assess whether decreased fetal movements in twin pregnancy can affect fetal and neonatal development and maturation before and after birth.

Cervical cerclage for singleton pregnant patients on vaginal progesterone with progressive cervical shortening

BACKGROUND

Premature cervical ripening plays a significant role in spontaneous preterm birth. Vaginal progesterone is the recommended treatment in singleton pregnancy with incidental short cervix. There is lack of evidence on whether it is beneficial to reinforce the cervix with cerclage when the cervical length becomes progressively shortened <10 mm while on vaginal progesterone.

OBJECTIVE

Our aims are to determine whether cerclage with vaginal progesterone will: (1) reduce the overall spontaneous preterm birth rate, (2) prolong pregnancy latency, and (3) improve neonatal outcomes compared to vaginal progesterone alone.

STUDY DESIGN

This was a retrospective cohort study at the University of Illinois at Chicago of all women with singleton pregnancy on vaginal progesterone for incidental short cervix, cervical length <20 mm. Only those with progressive cervical length shortening <10 mm who delivered at the University of Illinois at Chicago from January 2013 through December 2016 were included. The decision to perform cerclage was based on individual physician preference. Demographic data; information on serial cervical length status; medical, obstetric, and social history; cerclage vs no cerclage; and neonatal outcomes were compared.

RESULTS

A total of 310 women with incidental short cervix on vaginal progesterone were identified, and of these, 75 had progressive shortening cervical length <10 mm and met inclusion criteria. Among the women with extremely shortened cervical length <10 mm, 36 women (48%) had cervical cerclage plus vaginal progesterone, and 39 women (52%) continued on vaginal progesterone alone. The baseline characteristics, mean cervical length (5.06 vs 5.52 mm), and mean gestational age at diagnosis of extreme short cervix (21.5 vs 21.3 weeks) were similar between women who received cerclage vs those who did not, respectively. The mean gestational age at delivery was significantly greater for those with cerclage (34 weeks and 3 days vs 27 weeks and 2 days; P < .001). The rate of spontaneous preterm birth at <37, 35, 32, 28, and 24 weeks were significantly lower in the cerclage group: 44.1% vs 84.2%, 38.2% vs 81.6%, 23.5% vs 78.9%, 14.7% vs 63.2%, and 11.8% vs 39.5%, respectively. The rate of spontaneous preterm birth <37 weeks remained significant after controlling for confounders (relative risk, 0.11; 95% confidence interval, 0.03-0.41; P < .001). The average pregnancy latency was 14 weeks in the cerclage combined with vaginal progesterone group compared to vaginal progesterone alone group. Neonatal intensive care unit admission and development of respiratory distress syndrome were significantly lower in the cerclage group compared to vaginal progesterone alone group: 13 (36.1%) vs 23 (65.7%) (relative risk, 0.55; 95% confidence interval, 0.34-0.90; P = .018) and 8 (22.2%) vs 17 (43.6%) (relative risk, 0.59; 95% confidence interval, 0.29-0.90; P = .027), respectively. Neonates of women with cerclage were also significantly less likely to develop necrotizing enterocolitis or experience neonatal death.

CONCLUSION

Our study showed that cerclage plus vaginal progesterone in women with extremely shortened cervix significantly decreased overall spontaneous preterm birth rates, prolonged pregnancy latency by 2-fold, and decreased the overall neonatal morbidity and mortality.

Cervical pessary to reduce preterm birth <34 weeks of gestation after an episode of preterm labor and a short cervix: a randomized controlled trial

BACKGROUND

To date, no intervention has proved effective in reducing the spontaneous preterm birth rate in singleton pregnancies following an episode of threatened preterm labor and short cervix remaining.

OBJECTIVE

This study was designed to ascertain whether cervical pessaries could be useful in preventing spontaneous preterm birth in women with singleton pregnancies and a short cervix after a threatened preterm labor episode.

STUDY DESIGN

This open randomized controlled trial was conducted in 357 pregnant women (between 24⁰-33⁶ weeks) who had not delivered 48 hours after a threatened preterm labor episode and had a short cervix remaining (≤25 mm at 24⁰-29⁶ weeks; ≤15 mm at 30⁰-33⁶ weeks). Patients were randomly assigned to cervical pessary (179) or routine management (178). The primary outcome was the spontaneous preterm birth rate <34 weeks. Spontaneous preterm birth <28 and 37 weeks and neonatal morbidity and mortality were also evaluated in an intention-to-treat analysis.

RESULTS

No significant differences between the pessary and routine management groups were observed in the spontaneous preterm birth rate <34 weeks (19/177 [10.7%] in the pessary group vs 24/175 [13.7%] in the control group; relative risk, 0.78; 95% confidence interval, 0.45-1.38). Spontaneous preterm birth <37 weeks occurred less frequently in the pessary group (26/175 [14.7%] vs 44/175 [25.1%]; relative risk, 0.58; 95% confidence interval, 0.38-0.90; P = .01). Preterm premature rupture of membranes rate was significantly lower in pessary carriers (4/177 [2.3%] vs 14/175 [8.0%]; relative risk, 0.28; 95% confidence interval, 0.09-0.84; P = .01). The pessary group less frequently required readmission for new threatened preterm labor episodes (8/177 [4.5%] vs 35/175 [20.0%]; relative risk, 0.23; 95% confidence interval, 0.11-0.47; P < .0001). No serious adverse maternal events occurred; neonatal morbidity and mortality were similar in both groups.

CONCLUSION

Pessary use did not significantly lower the spontaneous preterm birth rate <34 weeks in women with a short cervix remaining after a threatened preterm labor episode but did significantly reduce the spontaneous preterm birth rate <37 weeks, threatened preterm labor recurrence, and the preterm premature rupture of membranes rate.

Are singleton pregnancies after assisted reproduction technology (ART) associated with a higher risk of placental anomalies compared with non-ART singleton pregnancies? A systematic review and meta-analysis

BACKGROUND

Placental anomalies (placenta praevia, placental abruption, morbidly adherent placenta and cord insertion anomalies) are associated with maternal and fetal morbidity and mortality. It has been suggested these might be more prevalent in pregnancies after assisted reproduction technology (ART).

OBJECTIVES

To determine whether ART singleton pregnancies are associated with an increased risk of placental anomalies compared with non-ART singleton pregnancies.

SEARCH STRATEGY

MEDLINE, EMBASE, CENTRAL, Web of Science and Scopus (January 2018).

SELECTION CRITERIA

Cohort studies reporting placental anomalies in ART and non-ART singleton pregnancies.

DATA COLLECTION AND ANALYSIS

We report pooled odds ratios (OR) for the comparisons: (1) ART versus SC (spontaneously conceived), (2) ART versus non-ART (unspecified), (3) FET-ART (frozen-embryo transfer) versus SC, (4) ART versus non-ART (subfertile patients). Study quality was assessed using a modified Newcastle -Ottawa scale.

MAIN RESULTS

33 low/moderate quality studies evaluated 124 215 ART and 6 054 729 non-ART singleton pregnancies. Risk of placenta praevia, placental abruption and morbidly adherent placenta was higher in ART than SC pregnancies: odds ratio (OR) (OR 3.76, 95% CI 3.09-4.59); (OR 1.87, 95% CI 1.70-2.06) and (OR 2.27, 95% CI 1.79-2.87) respectively. Risk of placenta praevia and placental abruption was higher in ART than in non-ART (subfertile patients): (OR 2.51, 95% CI 2.12-2.98) and (OR 1.61, 95% CI 1.33-1.95) respectively. Results were similar when comparing ART with unspecified non-ART pregnancies. Risk of placenta praevia was higher, but not significantly so, in FET-ART than in SC pregnancies (OR 2.42, 95% CI 0.63-9.30).

CONCLUSIONS

Singleton ART pregnancies are associated with an increased risk of placental anomalies compared with non-ART singleton pregnancies.

TWEETABLE ABSTRACT

A review of over 6 million singleton pregnancies finds increased risk of placental anomalies after ART.

Prevalences and pregnancy outcome of vanishing twin pregnancies achieved by in vitro fertilization versus natural conception

OBJECTIVE

To evaluate whether vanishing twin (VT) pregnancies achieved by in vitro fertilization and intracytoplasmic sperm injection (IVF-ICSI) had a more adverse perinatal outcome than those after natural conception.

DESIGN

Longitudinal, retrospective cohort study.

SETTING

Tertiary university hospital.

PATIENT(S)

Three hundred and six (78 after IVF-ICSI and 228 after natural conception) VT pregnancies over a 22-year period, with VT cases matched to primarily singleton controls.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Obstetric and neonatal outcome data.

RESULT(S)

The incidence of VT was statistically significantly higher after natural conception (18.2% of twins) than after IVF-ICSI (12.6% of twins). The odds of VT in pregnancies complicated with pregestational or gestational diabetes were disproportionally higher in IVF-ICSI cases than in spontaneously conceived VT pregnancies (adjusted odds ratio [AOR]: 0.80 vs. 3.10 and 1.00 vs. 1.07, respectively). Previous induced abortion (AOR 1.34) or second-trimester fetal loss (AOR 3.3) increased the risk of VT pregnancies after spontaneous conception. Gestational diabetes mellitus in both the previous (AOR 5.41) and the present (AOR 2.3) pregnancy as well as chronic maternal diseases (AOR 3.5) and placentation anomalies all represented independent risk factors for VT after IVF-ICSI.

CONCLUSION(S)

Vanishing twin pregnancies had a lower prevalence and a worse perinatal outcome after IVF-ICSI as compared with those of their spontaneously conceived counterparts.

Gestational diabetes mellitus in women with multiple pregnancies: is the metabolic abnormality milder?

OBJECTIVE

We aimed to compare maternal characteristics and dysglycemia after delivery in women with gestational diabetes mellitus (GDM) according to pregnancy being multiple (MP) or singleton (SP). The hypothesis was that women with GDM and MP would have a milder glycemic abnormality before and after pregnancy than those with SP.

METHODS

We performed a cohort study of 2908 women giving birth between 1986 and 2009. Logistic regression was performed to discriminate between MP and SP after anamnestic pre-pregnancy characteristics. Kaplan-Meier and Cox regression analyses were performed to assess if MP was independently associated with both impaired fasting glucose (IFG)/impaired glucose tolerance (IGT) and diabetes after delivery.

RESULTS

Family history of diabetes was the only independent anamnestic pre-pregnancy characteristic discriminating MP versus SP, OR 2.04 (95% CI 1.12, 3.70, p 0.019). The median time to progress to IFG/IGT was 7.52 years in SP (95% CI 6.92, 8.13) and 7.41 in MP (95% CI 3.84, 10.98), ns and the progression to DM did not differ. In addition, MP was not associated to IFG/IGT or to DM in the Cox regression analysis.

CONCLUSIONS

In this cohort of women with GDM, those with MP did not demonstrate a lesser degree of dysglycemia after controlling for other pregnancy characteristics and pregnancy-independent factors.

Combined first-trimester screening in northern Finland: experiences of the first ten years

OBJECTIVE

To evaluate the efficacy of first trimester combined screening for Down’s syndrome in Northern Finland during the first 10 years of practice.

METHODS

During 1 January 2002 to 31 December 2011, 47,896 women participated voluntarily in combined screening during first trimester. The risk cutoff was 1:250. The study period was divided into two time periods; 2002–2006 and 2007–2011.

RESULTS

During the first half of the study period, the detection rate (DR) was 77.3% with a 4.9% false-positive rate (FPR). During the latter half, the DR was 77.1% with a 2.8% FPR.

CONCLUSIONS

An important issue is the number of invasive procedures needed to detect one case of Down’s syndrome. The screening performance improved markedly in the latter five years period since the FPR lowered from 4.9% to 2.8% and the number of invasive procedures needed to detect one case of Down’s syndrome lowered from 15 to 11.

Extremely large nuchal translucency measurement predicts adverse pregnancy outcome

A prospective study was conducted to determine the outcome of pregnancies with 1st trimester nuchal translucency measurement of ≥ 6.5 mm. The risk of fetal abnormalities increases with enlarging nuchal translucency, being around 45% with a measurement of ≥ 6.5 mm. A total of 27,144 women with singleton pregnancies participated in the combined Down syndrome screening within the public healthcare system in Northern Finland. The study period was 1 May 2002 to 31 May 2009. The nuchal translucency measurement was ≥ 6.5 mm in 16 cases (0.06%). Pregnancy outcome was normal in one case (6.3%). The risk of abnormality was higher in our study than reported in the literature. According to our study, immediate diagnostic tests should be offered after an nuchal translucency measurement of ≥ 6.5 mm. We should also consider analysis of fetal micro-deletions associated with certain syndromes.

Birth experience of women conceiving with assisted reproduction: a prospective multicenter study

OBJECTIVE

To determine how infertility and subsequent assisted reproductive treatment (ART) affect a woman's childbirth experience.

DESIGN

Prospective multicenter case-control study.

SETTING

We recruited women pregnant with a singleton fetus after either ART (n = 324) or spontaneous conception (n = 304) from five infertility clinics and one university maternity clinic in Finland.

METHODS

We studied their childbirth experience with the Delivery Satisfaction Scale. We compared how psychosocial and obstetric factors affected satisfaction and dissatisfaction with childbirth between and within the ART and the control group. Logistic regression was then used to analyse the most important contributors to the experienced dissatisfaction.

RESULTS

Dissatisfaction with childbirth was as common in the ART group (11%) as in the control (10%) group. In the ART group, the women's education level, cesarean section (CS) and their partner's absence from the delivery were associated with dissatisfaction. In the control group, significant factors for dissatisfaction were nulliparity, severe pregnancy-related anxiety, emergency CS, recalled intense pain and the partner's absence from the delivery. According to adjusted logistic regression analysis of the whole sample, the independent risk factors were elective CS [odds ratio (OR) 5.7; 95% confidence interval (CI) 2.2-14.1] and emergency CS (OR 2.9; 95% CI 1.3-6.5), recalled intense pain (OR 6.8; 95% CI 3.3-16.2) and the partner's absence from the delivery (OR 2.7; 95% CI 1.1-7.3).

CONCLUSION

ART is not a risk factor for dissatisfaction with childbirth by itself. However, the contributors to an unsatisfactory childbirth differ partly between women conceiving with ART and those conceiving spontaneously.

Predicting risk of spontaneous preterm delivery in women with a singleton pregnancy

BACKGROUND

Prediction of a woman's risk of a spontaneous preterm delivery (PTD) is a core challenge and an unresolved problem in today's obstetric practice. The objective of this study was to develop prediction models for spontaneous PTD (<37 weeks).

METHODS

A population-based register study of women born in Sweden with spontaneous onset of delivery was designed using Swedish Medical Birth Register data for 1992-2008. Predictive variables were identified by multiple logistic regression analysis, and outputs were used to calculate adjusted likelihood ratios in primiparous (n = 199 272) and multiparous (n = 249 580) singleton pregnant women. The predictive ability of each model was validated in a separate test sample for primiparous (n = 190 936) and multiparous (n = 239 203) women, respectively.

RESULTS

For multiparous women, the area under the ROC curve (AUC) of 0.74 [95% confidence interval (CI) 0.73, 0.74] indicated a satisfying performance of the model, while for primiparous women, it was rather poor {AUC: 0.58 [95% CI 0.57, 0.58]}. For both primiparous and multiparous women, the prediction models were quite good for pregnancies with comparatively low risk for spontaneous PTD, whereas more limited to predict pregnancies with ≥30% risk of spontaneous PTD.

CONCLUSIONS

Spontaneous PTD is difficult to predict in multiparous women and nearly impossible in primiparous, by using this statistical method in a large and unselected sample. However, adding clinical data (like cervical length) may in the future further improve its predictive performance.

Are singleton assisted reproductive technology pregnancies at risk of prematurity?

PURPOSE

Our purpose was to determine the risk of premature delivery among singleton pregnancies derived from assisted reproduction technology (ART).

METHODS

Ninety-five singleton ART pregnancies and 190 matched spontaneous pregnancies were assessed for preterm delivery rates, pregnancy complications, and cesarean section rates in a retrospective study at an academic medical center.

RESULTS

Among the ART singleton deliveries group (n = 95), 19 (20%) were preterm, which was statistically significantly higher than the 4% (8 of 190) found in the control group. Among the pregnancies achieved by intracytoplasmic sperm injection (ICSI) in the severe male-factor infertility subgroup (n = 22), only one preterm delivery occurred (4.5%).

CONCLUSIONS

Singleton ART pregnancies are at an increased risk of preterm delivery compared to singleton pregnancies after spontaneous conception. The higher rate may be attributed to various infertility cofactors, such as uterine malformations, previous operative procedures that involved cervical dilatation, and a history of pelvic infection. This is supported by the finding that ICSI-derived pregnancies in couples with strict male-factor infertility are not at an increased risk of preterm delivery.