Association between high-risk pregnancy and mode of delivery in Kalibaru

Introduction: High-risk & severe-risk pregnancies are characterized by increased risks of complications for both the mother and the fetus, which can result from several factors such as maternal age, medical situations, lifestyle habits, and previous pregnancies. These complications are a major concern, mostly in developing countries like Bangladesh, where maternal and infant mortality rates remain high. Maternal complications associated with high-risk and severe-risk pregnancies may include maternal death, severe bleeding, sepsis, and hypertensive disorders, while fetal complications may include preterm delivery, fetal growth restriction, and stillbirth. The objective of this study was to investigate the perinatal outcomes of high-risk and severe-risk pregnancies. Methods: This prospective purposive study was carried out on the admitted patients in the Department of Obstetrics and Gynaecology, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka from July 2007 to December 2007. Total hundreds of risk groups pregnant women (N=100) were enrolled in the study among them eighty-five (n=85) scoring 3-6 included as high risk pregnancy and fifteen (n=15) scoring 7 or more included as severe-risk pregnancy. All relevant data were recorded for each individual study subject on predesigned data collection sheet. All collected data were compiled and analyzed by computer-based statistical software (Instat). Chi-square tests were performed to compare the prevalence of study variables where, p < 0.05 considered the level of significance with 95%CI. Ethical clearance of this study was obtained from the Institutional Review Board (IRB) of BSMMU, Dhaka, Bangladesh. Results: In the high-risk group (n=85), around one-fourth of the patients (22,25.9%) and in a severe- risk group (n=15), one patient (1,6.7%) underwent vaginal delivery, Caesarean section was done in sixty-three patients (63,74.1%) in high-risk pregnant women and fourteen patients (14,93.3%) in severe-risk pregnant women respectively. The distribution of risk group and mode of delivery is statistically highly significant (P <0.001). Out of sixty-three patients (n1=63), nineteen (19, 30.2%) were required to be delivered by caesarean section for fetal distress and fifteen (15, 30.16%) were malpresentation. Out of forty-one patients (n2=14), the most common indications were a history of previous caesarean section with multiple risk factors in eight patients (8, 57.1%). Birth asphyxia was present in nine neonates (9, 13.6%) in a high-risk group (n = 65) and a severe- risk group (n2=14), and birth asphyxia was present in five neonates (5, 35.7%). Based on the outcome, in high-risk pregnancy (n=85), four neonates (4, 4.5%) died and in severe-risk pregnancy (n=15), one (1, 6.3%) died. Conclusion: The study found various obstetric complications and outcomes associated with high-risk and severe-risk pregnancies. The results indicated a significantly higher proportion of caesarean sections performed in severe-risk pregnancies compared to high-risk pregnancies. Moreover, the overall outcome was favorable, with only five neonatal deaths reported among the one hundred maternal risk groups.

Cesarean delivery on maternal request is one of the important public health issues in China. Our study aimed to apply the theory of planned behaviour to comprehensively determine the factors regarding pregnant women's preference for cesarean section and to provide references for establishing measures to reduce cesarean delivery on maternal request. This cross-sectional analysis was conducted in four women's and children's hospitals in China from May to June 2018. Eligible women arriving for routine antenatal visits at these hospitals were recruited to answer a structured questionnaire. A total of 1853 pregnant women consented to participate in the investigation, with a response rate of 88.75%. Finally, 1677 pregnant women (984 nulliparae and 693 multiparae) were involved in the analysis. Descriptive statistics and logistic regression analyses were used. Of the study participants, 20.39% preferred cesarean section. For both nulliparae and multiparae, those who had lower scores of attitudes towards vaginal delivery, lower scores of childbirth self-efficacy and higher scores of subjective norms were more likely to prefer cesarean section. Pregnant women's birth preferences were significantly associated with their attitudes towards the delivery mode, childbirth self-efficacy and subjective norms, which is consistent with the theory of planned behaviour. Interventions to reduce cesarean delivery on maternal request can be developed based on the theory of planned behaviour.

How should preterm singleton babies in breech presentation be delivered?

Introduction: Doppler ultrasound velocimetry of uteroplacental umbilical and fetal vessels has become established method of antenatal monitoring.Cerebroplacental ratio has been studied to predict neonatal outcomes.Aim of the work: Our aim was to assess role of cerebro-placental ratio in prediction of perinatal outcome in high-risk pregnancies with intrauterine growth restriction.Patients and Methods: In this study was held in Ain Shams university maternity hospital which included 60 high risk pregnant women divided in to two groups: Group I: study group: 30 high risk pregnant women with IUGR, Group IIcontrol group: 30 high risk pregnant women without IUGR. Results:The current study showed that among patients with IUGR and low CPR, 17 (56.7%)had CS for fetal distress, 12 (40.0%)had neonate with low APGAR, 13 (43.3%)had neonatal meconium aspiration, 6 (20.0%) had neonatal Hypoxic ischemic Encephalopathy, 15 (50.0%) had neonate need NICU admission, 3 (10.0%)had neonatal death, 1 (3.3%) had neonatal still birth.The current study showed that among patients without IUGR and low CPR, 8 (26.7%) had CS for fetal distress, 5 (16.7%) had neonate with low APGAR, 4 (13.3%) had neonatal meconium aspiration, 1 (3.3%) had neonatal Hypoxic ischemic Encephalopathy, 5 (16.7%) had neonate need NICU admission, 1 (3.3%) had neonatal death, 0 (0.0%) had neonatal still birth.Conclusion: Cerebro -placental ratio has high predictive value of perinatal outcome in high risk pregnancy with intrauterine growth restriction.

Background: To analyze the impact of a multidisciplinary collaborative diagnosis and treatment (MDT) management in obstetric outpatient departments on the outcome of high-risk pregnancies, and to summarize the experience and to improve the diagnosis and treatment ability of for critically ill obstetric patients. Method: Two hundred sixty-six pregnant and lying-in women with multidisciplinary treatment were selected for retrospective analysis. According to the criteria, 176 high-risk pregnant women were included, including 83 cases of outpatient MDT and 93 cases of inpatient MDT. The classification of pregnancy diseases and pregnancy risk was carried out. The source of high-risk pregnant women, the distribution and number of collaborative clinics, the classification of major diseases, the classification of pregnancy risk, the mode of delivery, the condition of labor, and pregnancy outcome were all analyzed to determine the impact of participating in MDT timing on adverse pregnancy outcomes through logistic regression analysis. Result: (1) The top 3 diseases in high risk pregnant women undergoing MDT were pregnancy with cardiac disease 42.6% (75/176), pregnancy with hypertension 14.2% (25/176), and pregnancy with immune system disease 11.9% (21/176). Among pregnant women with cardiac disease, 38 (50.7%) were mainly congenital cardiac disease. (2) The number of high-risk pregnant women with MDT in the hospital was more than that in the outpatient department (p < 0.05), and the number of departments involved in MDT in the hospital was more than that in the outpatient department (p < 0.05). The proportion of pregnant women with pregnancy risk grade of I–III in outpatient MDT cardiac disease was higher than that in inpatient MDT (p < 0.05), while the pregnant women with pregnancy risk grade of IV–V were all inpatient MDT cardiac disease with the majority being in late pregnancy (12/16). (3) The high-risk pregnant women who received MDT in the late pregnancy had a red risk level, which was higher than that then in early and middle pregnancy (p < 0.05). There was a higher rate of premature delivery, multiple organ damage, intensive care unit (ICU) monitoring, cesarean section, and neonatal asphyxia in high-risk pregnant women with later MDT gestational age (p < 0.05). The late timing of participating in MDT was a risk factor for ultimately developing adverse pregnancy outcomes (p < 0.05). Conclusions: Outpatient MDT management can effectively improve the pregnancy outcome of high-risk pregnant women, early outpatient MDT mode management should be actively promoted, and a comprehensive and professional MDT team should be utilized to reduce adverse pregnancy outcomes.

Background Pregnancy-induced hypertension (PIH) remains a major contributor to maternal and perinatal morbidity and mortality, especially in low- and middle-income countries. Abnormal placentation occurring early in gestation plays a central role in its pathogenesis. Evidence suggests that early initiation of low-dose aspirin may improve placentation and reduce hypertensive complications. Objectives To evaluate the effect of early initiation of low-dose aspirin (≤16 weeks of gestation) on the incidence of PIH and on fetomaternal outcomes in high-risk pregnancies. Methods This prospective comparative observational study was conducted in a tertiary care hospital in India. High-risk pregnant women with singleton pregnancies at or before 16 weeks of gestation were enrolled and divided into an aspirin group (low-dose aspirin initiated ≤16 weeks) and a control group receiving routine antenatal care. Participants were followed until delivery. Maternal outcomes included incidence and severity of PIH and need for antihypertensive therapy. Fetal outcomes included gestational age at delivery, birth weight, fetal growth restriction, preterm birth, and neonatal outcomes. Results The incidence of PIH was significantly lower in the aspirin group compared to controls (18% vs 34%, p=0.01). Severe pre-eclampsia and early-onset hypertension were less frequent among aspirin users. Fetal growth restriction, low birth weight, preterm delivery, and NICU admissions were significantly reduced in the aspirin group. No significant increase in maternal adverse effects or bleeding complications was observed. Conclusion Early initiation of low-dose aspirin effectively reduces PIH and improves fetomaternal outcomes in highrisk pregnancies without compromising safety

Objective: This study aimed to assess the hospital based rate of high-risk obese pregnant women at Qena University Hospital, Assess the antenatal Obstetric and Medical complications associated with Obesity among these women and Provide health education for those obese pregnant women about the dietary requirements. Setting: the inpatient antenatal word OF Obstetrics and Gynecology Departments at Qena University Hospital Duration: from 1 st October 2012 to 20 th April 2013. Patients&Methds: Cross Sectional, study of 350 cases of high-risk pregnant women admitted at the inpatient antenatal word at Qena University Hospital was used. Completing semi- structured interviewing sheet from All high risk pregnant obese women with single fetus who have the BMI ≥ 29. After completing the sheet, giving them brochures about nutrition according to their diagnosis and explaining how to follow. Results. More than half (57.4%) of the sample were classified as obesity class one among high risk pregnant women. Complications of obesity increased among high risk pregnant women such as previous caesarean section rate (38.3%), PROM were (13.4%), pregnancy induced hypertension (11.7 %), other risk factors about (16.3 %). Conclusions: hospital based rate of obesity was one third of the total flow of pregnant women at this hospital was obese with high risk pregnancy more than half of high risk pregnant were classified as obesity class one and the most common obstetrics' complications associated with obesity were previous caesarean section and premature rupture of membrane respectively. Recommendations: Nutrition and exercise counseling should begins from pre-puberty, during pregnancy, continues postpartum and before attempting another pregnancy. Key Word: obesity, antenatal complications

Objective To investigate the husband and wife psychological and behavioral intervention on high-risk pregnant women, pregnancy outcome and negative emotions. Methods in line with the number of high-risk pregnancy diagnostic criteria for pregnant women into the group of order packets were completed by the clinical observation of high-risk pregnant women in the intervention group (A) 31 cases, 32 cases of high-risk pregnant women in the control group (group B), spouses of pregnant women in the intervention group (Group C) 31 spouses of pregnant women in the control group (group D). Pregnant women in group A and group B underwent outpatient conventional high-risk pregnancy management, group A, group C received 16 weeks of husband and wife jointly participate in the key psychological problems, negative emotion coping skills to learn, couples communication skills, learning, family and social support operations, rehabilitation and faith strengthening and other intervention as the core content. Quality delivery of newborns, asphyxia, anxiety and depression in pregnant women and their spouses before and after intervention the overall incidence of anxiety and self-assessment scale(SAS) score, the score of the Self-Rating Depression Scale(SDS), the Family APGAR Index Questionnaire score (observation of high-risk pregnancy APGAR) and other changes. Results The average body weight of newborns: the intervention group A (3.12±0.69) kg, than in group B (2.29±0.78) kg, a statistically significant difference (t=2.3148, P=0.024); asphyxia: group A was 12.9% and 34.4% in group B, the difference was statistically significant (χ2=4.0018, P=0.0455); natural birth rate: 58.1% in group A, group B 25%, a statistically significant difference (χ2=7.1023, P=0.0077); the rate of cesarean section: 29.0% in group A, group B, 59.4%, a statistically significant difference (χ2=5.8713, P=0.0154); anxiety and depression in pregnant women: the total incidence after the intervention group A was 19.4%, 46.9% in Group B, the difference was significant (χ2=5.3664, P=0.0205); maternal spouse anxiety and depression: in the overall incidence of A group of 9.7% after the intervention group B 31.2%, the difference was statistically significant (χ2=4.4745, P=0.0344); APGAR score: after the intervention of high-risk pregnant women in group A (9.42±1.53), Group B (7.71±1.56), group A better than group B, the difference was statistically significant (t=4.3910, P=0.000), intimacy, emotional degree, the growth degree, cooperation degree, adapt to the degree of five factor scores in group A than group B, a statistically significant difference (P<0.05, P<0.01). Conclusion High-risk pregnant women and their spouses have a severe negative emotional reaction, the husband and wife psychological and behavioral intervention on the improvement of high-risk pregnant women, pregnancy outcome and negative emotions have an important role. Key words: husband and wife psychological and behavioral intervention, the negative emotions of the high-risk pregnancy

Clarifying the meaning of vaginal birth

The mediating effect of microbial colonization on the effect of cesarean section delivery

The use of Doppler in obstetrics has spread progressively with the ever advancing technology and better understanding of the pathophysiology of the fetoplacental circulation. Although the time scale over which the Doppler changes develop in impaired placentation can vary, the cascade of events is mostly reproducible. This constitutes the rationale for the use of Doppler ultrasound in high-risk pregnancies as one of the main tools for the assessment of fetal wellbeing and leads to interventions such as increased fetal surveillance, labor induction and administration of corticosteroids in anticipation of preterm birth. Undoubtedly, false-positive findings may lead to unnecessary interventions and iatrogenic prematurity that could contribute to neonatal morbidity and increased maternal anxiety. Doppler ultrasound of the uterine and umbilical arteries has also been proposed as a screening test in low-risk pregnancies in order to identify ‘at-risk’ pregnancies and fetuses that may benefit from preventative strategies such as low-dose aspirin. Again, there is a real risk that any potential benefit may be overshadowed by unnecessary interventions and increased maternal anxiety. Here we summarize the findings from three recently updated Cochrane reviews1-3 that replace older versions4-6. Two focused on the fetoplacental (umbilical) circulation, one in high-risk1 and the other in low-risk2 pregnancies. The third review included trials of uterine artery Doppler in both high- and low-risk groups3. Standard Cochrane methodology was used, the details of which can be found in The Cochrane Library, available online7. The first systematic review1 addressed the comparison of fetal and umbilical Doppler ultrasound versus no Doppler ultrasound in high-risk pregnancies. Eighteen studies were included, involving 10 156 women. Fifty-eight meta-analyses were performed, looking separately at various sub-populations (singleton or multiple pregnancies [both primary and secondary outcomes]; small-for-gestational age, pre-eclampsia and hypertension, diabetes, prolonged pregnancy and previous pregnancy loss [primary outcomes only]). There was a statistically significant reduction in perinatal mortality in the Doppler group compared with the no-Doppler group (risk ratio (RR), 0.71; 95% CI, 0.52–0.98; 16 studies; 10 225 babies, perinatal mortality, 1.2% vs. 1.7%; number needed to treat, 203; 95% CI, 103–4352). The difference in perinatal death remained significant when the analysis focused just on potentially preventable perinatal deaths (excluding cases of termination of pregnancy and lethal chromosomal or other fetal abnormalities) (RR, 0.67; 95% CI, 0.46–0.98; 16 studies; 10 225 babies). The data for stillbirth, neonatal deaths and low Apgar score fitted into the overall picture, showing fewer adverse outcomes in the Doppler group, but without reaching statistical significance. The use of Doppler ultrasound in high-risk pregnancies was associated with a reduction in Cesarean sections (RR, 0.90; 95% CI, 0.84–0.97; 14 studies; 7918 women). When separating the Cesarean sections into elective and emergency, the reduction in the number of procedures appeared to be confined to the latter group. No significant differences were found for spontaneous vaginal births and operative vaginal births between the Doppler and no-Doppler groups. There was, however, a significant average reduction in induction of labor for women with Doppler intervention (RR, 0.89; 95% CI, 0.80–0.99; 10 studies; 5633 women). The subgroup analyses suggested that the benefits may be confined to singleton pregnancies, but these data should be interpreted cautiously, because there was just one study involving twins. As yet, there are no published clinical trials focusing on the possible benefit of adding Doppler studies of the fetal circulation (e.g. ductus venosus, middle cerebral arteries), but at least one large trial is currently ongoing8. The second systematic review2 addressed the comparison of routine fetal and umbilical Doppler ultrasound versus no-Doppler ultrasound in low-risk pregnancies. Twenty publications were identified, of which five studies (14 185 women) were included. There was no statistically significant reduction identified in the risk of perinatal death when Doppler ultrasound was used (average RR across studies, 0.85; 95% CI, 0.47–1.54; four studies; 11 190 women). Just one study assessed serious neonatal morbidity and showed no significant difference (RR, 0.99; 95% CI, 0.06–15.75; one study; 2016 women). There were no significant differences identified for any of the secondary outcomes, including stillbirth, neonatal death, Apgar scores < 7 at 5 min, Cesarean section, operative vaginal birth, spontaneous vaginal birth, induction of labor, neonatal resuscitation and preterm birth. The third systematic review3 addressed the issue of whether the use of uteroplacental Doppler ultrasound (uterine arteries and placental vessels) improves important perinatal outcomes in low- and high-risk pregnancies. Only two relevant trials were included, both assessing low-risk women in the second trimester, with low-dose aspirin administered in the presence of abnormal uterine artery findings. The studies involved a combined total of 4993 women and were of good quality, but the review remained underpowered to detect clinically important differences in serious maternal and neonatal morbidity/mortality. There was no significant difference identified in the pooled estimate of the intervention effect for the primary outcomes (‘any perinatal death after randomization’ and ‘hypertensive disorders’) or for the range of secondary outcomes. As yet, there are no published randomized studies assessing Doppler ultrasound of uterine arteries in the first trimester or in high-risk pregnancies. Updated systematic reviews1-3 using more stringent methodology and quality assessment confirmed previous results4, 5. Use of umbilical artery Doppler in singleton high-risk pregnancies showed a reduction in perinatal death without an increase in obstetric intervention. Nevertheless, the optimum frequency of Doppler assessments and the best timing of delivery in the presence of abnormal Doppler findings remain elusive. The role of umbilical Doppler assessment in other high-risk groups such as post-term, diabetic and dichorionc twin pregnancies remain debatable. On the other hand, there is, at present, no good-quality evidence to support routine umbilical artery Doppler ultrasound, or a combination of umbilical and uterine artery Doppler ultrasound in low-risk or unselected populations2. Similarly, there is insufficient evidence to support a screening package that comprises ‘routine’ uterine artery Doppler followed by low-dose aspirin given to women who have abnormal Doppler findings (i.e. screen-positive women)3. The main difficulty for three of these reviews is the lack of power to test the hypotheses related to rare events such as severe perinatal and/or maternal morbidity. Clearly, setting up large and well-designed, multicenter clinical trials is a difficult task. Data from some observational studies suggest that the assessment of other fetal vessels, such as the ductus venosus, could be more useful for clinical decision-making. Similarly, increasing numbers of observational studies are reporting possible benefits of first-trimester uterine artery Doppler as a potential predictor of pregnancy complications, particularly when combined with maternal biochemistry. Again, rigorous, large clinical trials are needed to show the benefits of this test when managing pregnancy. It is important to explore new avenues for preventative strategies in obstetric care, and Doppler ultrasound will remain the focus of interest for years to come. However, we should not forget that any intervention may bring not just benefit but also harm. Making sure that all future prospective studies collect data not only on effectiveness, but also on safety, cost and women's views would be both a significant contribution to the quality of evidence and of great help to the women and clinicians who have to rely on them.

First cesarean birth and subsequent fertility

Considering the escalating prevalence of high-risk pregnancies encountered in clinical settings, the imperative to safeguard the well-being and survival of both high-risk pregnant women and their babies represents a hotspot of clinical research. This study investigated the clinical effects of an innovative care model for high-risk pregnancies, specifically a combination of staged nursing and nutritional interventions, on maternal nutritional status. Initially, 96 pregnant women were assigned randomly into two groups: a control group receiving routine care and a research group benefiting from the combined approach of staged nursing and nutritional interventions. Comparative analysis revealed that the research group experienced a significant reduction in labor duration and a decrease in the incidence of adverse pregnancy outcomes, thereby highlighting the efficacy of this combined approach in enhancing the safety of childbirth for high-risk pregnancies. Additionally, the research group exhibited more significant improvements in nutritional status than the control group, further endorsing the combined approach as a more effective and reliable safeguard for the health of high-risk pregnant women. Therefore, the implementation of staged nursing in conjunction with nutritional interventions is advocated for use during childbirth in high-risk pregnancies.

A biophysical profile (BPP) includes ultrasound monitoring of fetal movements, fetal tone and fetal breathing, ultrasound assessment of liquor volume with or without assessment of the fetal heart rate. The BPP is performed in an effort to identify babies that may be at risk of poor pregnancy outcome, so that additional assessments of wellbeing may be performed, or labour may be induced or a caesarean section performed to expedite birth. To assess the effects of the BPP when compared with conventional monitoring (CTG only or MBPP) on pregnancy outcome in high-risk pregnancies. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (October 2007), CENTRAL (The Cochrane Library 2006, Issue 4), MEDLINE (1966 to November 2006), EMBASE (1974 to November 2006) and CINAHL (1980 to November 2006). Randomised and quasi-randomised controlled trials involving a comparison of fetal BPP with other forms of antepartum fetal assessment in women with high-risk pregnancies. Two authors independently assessed eligibility, quality and extracted data. We included five trials, involving 2974 women. Most trials were not of high quality. Although the overall incidence of adverse outcomes was low, available evidence from randomised controlled trials does not support the use of BPP as a test of fetal wellbeing in high-risk pregnancies. We found no significant differences between the groups in perinatal deaths (relative risk (RR) 1.33, 95% confidence interval (CI) 0.60 to 2.98) or in Apgar score less than seven at five minutes (RR 1.27, 95% CI 0.85 to 1.92). Combined data from the two high-quality trials suggest an increased risk of caesarean section in the BPP group RR 1.60, 95% CI 1.05 to 2.44, n = 280, interaction test P = 0.03. However, the number of participating women was relatively small (n = 280). Therefore, additional evidence is required in order to be definitive regarding the efficacy of this test in high-risk pregnancies. Furthermore, the impact of the BPP on other interventions, length of hospitalisation, serious short-term and long-term neonatal morbidity and parental satisfaction requires further evaluation. At present, there is insufficient evidence from randomised trials to support the use of BPP as a test of fetal wellbeing in high-risk pregnancies.

Aim of the workTo evaluate the role of the new placental score (PLS) by combining the Doppler umbilical artery score (blood flow classes, BFC) and the uterine artery score (UAS) to predict the pregnancy outcome in high risk pregnancy. Patients and methodsForty pregnant ladies with high risk pregnancy were included in the study. The UAS and the BFC were combined to form a placental score (PLS) as an expression of general placental vascular resistance PLS=BFC+UAS, with figures in the range 0–7. Serial examinations were performed for each patient, in the 3d trimester. The results of last examination were related to the three perinatal outcome variables; premature birth, small for gestational age (SGA), and delivery by cesarean section (CS). ResultsThe relation between placental score and pregnancy outcome revealed – score (0) in 62.5% of patients, which was significant for CS (52%) followed by SGA+CS (28%) – score (I) in 20% of patients, was significant for CS (50%) and SGA (37.5%) – score (II) in 12.5% of patients, was mainly significant for preterm delivery+SGA (80%) – score (III) in 5% of patients, was highly significant for CS+preterm delivery (100%). ConclusionThe new PLS showed a better relationship to adverse perinatal outcome than the BFC and the UAS. The PLS can simplify evaluation of uteroplacental and fetoplacental Doppler velocimetry.