Adverse Perinatal Outcomes In Women Research Articles

Association of change in haemoglobin A1c with adverse perinatal outcomes in women with pregestational diabetes.

To determine whether a net decline in glycosylated haemoglobin (HbA1c ) from early to late pregnancy is associated with lower risk of adverse perinatal outcomes at delivery among women with pregestational diabetes. A retrospective analysis from 2012 to 2016 at a tertiary care centre. The exposure was the net change in HbA1c from early (<20weeks gestation) to late pregnancy (≥20weeks gestation). Primary outcomes were large for gestational age (LGA) and neonatal hypoglycaemia. The association between outcomes per 6mmol/mol (0.5%) absolute decrease in HbA1c was evaluated using modified Poisson regression, and adjusted for age, body mass index, White Class, early HbA1c and haemoglobin and gestational age at HbA1c measurement and delivery. Among 347 women with pregestational diabetes, HbA1c was assessed in early (9weeks [IQR 7,13]) and late pregnancy (31weeks [IQR 29,34]). Mean HbA1c decreased from early (59mmol/mol [7.5%]) to late (47mmol/mol [6.5%]) pregnancy. Each 6mmol/mol (0.5%) absolute decrease in HbA1c was associated with a 12% reduced risk of LGA infant (30%, aRR:0.88; 95% CI:0.81,0.95), and a 7% reduced risk of neonatal hypoglycaemia (35%, aRR:0.93; 95% CI:0.87,0.99). Preterm birth (36%, aRR:0.93; 95% CI:0.89,0.98) and neonatal intensive care unit admission (55%, aRR:0.95; 95% CI:0.91,0.98) decreased with a net decline in HbA1c , but not caesarean delivery, pre-eclampsia, shoulder dystocia and respiratory distress syndrome. Women with pregestational diabetes with a reduction in HbA1c may have fewer infants born LGA or with neonatal hypoglycaemia. Repeated assessment of HbA1c may provide an additional measure of glycaemic control.

Middle cerebral arterial flow redistribution is an indicator for intrauterine fetal compromise in late pregnancy in low-resource settings: A prospective cohort study.

ObjectiveWe aimed to determine the prevalence of abnormal umbilical artery (UA), uterine artery (UtA), middle cerebral artery (MCA) and cerebroplacental ratio (CPR) Doppler, and their relationship with adverse perinatal outcomes in women undergoing routine antenatal care in the third trimester.DesignProspective cohort.SettingKagadi Hospital, Uganda.PopulationNon‐anomalous singleton pregnancies.MethodsWomen underwent an early dating ultrasound and a third‐trimester Doppler scan between 32 and 40 weeks of gestation, from 2018 to 2020. We handled missing data using multiple imputation and analysed the data using descriptive methods and a binary logistic regression model.Main outcome measuresComposite adverse perinatal outcome (CAPO), perinatal death and stillbirth.ResultsWe included 995 women. The mean gestational age at Doppler scan was 36.9 weeks (SD 1.02 weeks) and 88.9% of the women gave birth in a health facility. About 4.4% and 5.6% of the UA pulsatility index (PI) and UtA PI were above the 95th percentile, whereas 16.4% and 10.4% of the MCA PI and CPR were below the fifth percentile, respectively. Low CPR was strongly associated with stillbirth (OR 4.82, 95% CI 1.09–21.30). CPR and MCA PI below the fifth percentile were independently associated with CAPO; the association with MCA PI was stronger in small‐for‐gestational‐age neonates (OR 3.75, 95% CI 1.18–11.88).ConclusionIn late gestation, abnormal UA PI was rare. Fetuses with cerebral blood flow redistribution were at increased risk of stillbirth and perinatal complications. Further studies examining the predictive accuracy and effectiveness of antenatal Doppler ultrasound screening in reducing the risk of perinatal deaths in low‐ and middle‐income countries are warranted.Tweetable abstractBlood flow redistribution to the fetal brain is strongly associated with stillbirths in low‐resource settings.

Influence of BMI on adverse perinatal outcomes in women undergoing ToLAC in preterm delivery

Influence of BMI on adverse perinatal outcomes in women undergoing ToLAC in preterm delivery

Perinatal outcomes of women with hypertensive disorders of pregnancy in Jimma Medical Center, southwest Ethiopia: Retrospective cohort study.

BackgroundHypertensive disorders of pregnancy (HDP) increases adverse perinatal outcomes in women with the disorder. About 16% of all still births and 10% of early neonatal deaths are accounted by HDP. In Ethiopia, HDP complicates about 6% of all pregnancies. Hence, the objective of this study was to determine the risk of adverse perinatal outcomes among women with HDP in Jimma Medical Center, southwest Ethiopia.MethodsA retrospective cohort study was conducted on a total of 777 women who gave birth from June 2017 to March 2020 at Jimma Medical Center, southwest Ethiopia. Women with HDP and normotensive women who gave birth at or after 28 weeks of gestation were enrolled as exposed and unexposed respectively. Simple random sampling technique was used to select study participants. Data were reviewed using structured data collection performa that was prepared after reviewing relevant literatures. Data were entered to Epi-Data then exported to STATA version 13 for analysis. The adverse perinatal outcomes risk were examined using log binomial and modified Poisson regression model with robust standard errors.ResultsIn this study, the overall incidence of adverse perinatal outcome was higher among women with hypertensive disorders of pregnancy (HDP) than normotensive women (64.1% versus 32.8%). After adjusting for confounders, women with HDP were at higher risk of babies with low birth weight (adjusted RR = 2.88 (2.2, 3.75)), preterm birth(aRR = 2.31(1.7, 3.14)), fifth minute low Apgar score (aRR = 2.6(1.53, 4.42)), admission to neonatal intensive care unit (aRR = 1.77(1.32, 2.37), stillbirth (aRR = 2.02(1.11, 3.01)), and perinatal mortality (aRR = 3.88(1.97, 7.66)) than normotensive women.ConclusionWomen with hypertensive disorder of pregnancy were at higher risk of adverse perinatal outcomes than normotensive women who gave birth at Jimma Medical Center, southwest Ethiopia. Therefore, health care providers should strengthen prevention, early diagnosis and prompt management of HDP in order to reduce adverse perinatal outcomes.

1153 Influence of race on adverse perinatal outcomes in women undergoing TOLAC

To examine the association between race and adverse maternal and neonatal outcomes in women who undergo Trial of Labor after Cesarean (TOLAC). This is a retrospective cohort study of singleton non-anomalous pregnancies between 2007 and 2011 using linked vital statistics and discharge data. Chi-square tests were used to compare rates of adverse outcomes for women who underwent TOLAC categorized by race. Multivariable logistic regression was used to control for several factors including race. Race was categorized into six categories of White (Non-Hispanic), Black, Hispanic, Asian, American Native, and Other. The adverse maternal outcomes examined were postpartum hemorrhage (PPH), perineal lacerations, chorioamnionitis, maternal blood transfusion, placental abruption, severe maternal morbidity (SMM), and endomyometritis. The neonatal outcomes examined were infant death, neonatal death (NND), intrauterine fetal death (IUFD), Neonatal Intensive Care Unit (NICU) admission, birth injuries, brachial plexus injury (BPI), hypoxic ischemic encephalopathy (HIE), clavicle fracture, and skull fracture. The cohort consisted of 362,270 pregnancies with a prior CD, 29,628 pregnancies resulted in TOLAC. The cohort of 2,699,312 women consisted of 36,195 TOLAC, 29,638 of which were singleton non-anomalous pregnancies. After controlling for several confounders of interest there was a statistically significant increase in PPH, lacerations, chorioamnionitis, maternal blood transfusions, SMM, endomyometritis, infant death and birth injuries in Asian Women. There was a statistically significant increase in chorioamnionitis and HIE as well as a decrease in lacerations in Black Women. There was a statistically significant increase in chorioamnionitis and endomyometritis in Hispanic women as well as a decrease in infant death (Table 1). Different racial backgrounds increase the risk of maternal and neonatal complications in the settings TOLAC. Practitioners should exercise heightened awareness of the effect of race on these potential adverse outcomes when managing TOLAC.

978 Cerclage versus vaginal progesterone in low risk pregnant women with a short cervix

To compare vaginal progesterone to cerclage in preventing preterm birth and adverse perinatal outcomes in women with a singleton gestation, incidentally found sonographic cervical length of <15 mm, and no history of preterm birth. A retrospective cohort study was conducted on 68 women who delivered at the University of Kansas Health System with a singleton gestation found to have a cervical length <15 mm on transvaginal ultrasound and no history of preterm birth. Women treated with vaginal progesterone (n=29) were compared to women who underwent cerclage placement (n=39). The primary outcome was the difference in average latency period. Secondary outcomes include preterm birth < 37, <34, and <28 weeks, and neonatal morbidities. Of the 268 patients who had a cervical length of <15 mm on transvaginal ultrasound, 68 participants met inclusion criteria and were included in the final analysis. Twenty-nine participants received vaginal progesterone and 39 participants received cervical cerclage. The average cervical length at initiation of therapy was greater in the progesterone cohort (10.5 mm vs 8.0 mm, p<0.01). All other baseline characteristics were similar between groups, including no difference in average gestational age at initiation of therapy (21.6 weeks vs. 21.5 weeks, p=0.87). Average latency after therapy did not differ between groups (100 days vs. 92.7 days p=0.43). The incidence of preterm birth at <37 weeks (41.4% vs. 51.3%), <34 weeks (27.6% vs. 35.9%), and <28 weeks (10.3% vs. 18%), did not differ significantly between groups. Additionally, no difference in neonatal morbidity was detected. At our institution we found no difference between vaginal progesterone and cerclage in the average latency period or risk of preterm birth among women with an incidental short cervix of < 15 mm and no history of preterm birth, despite the significantly shorter initial cervical length in the cerclage group. These findings suggest either vaginal progesterone or cerclage could be used to reduce the risk of preterm birth among this high risk population.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Feto-placental Dopplers are not altered in women with obstructive sleep apnoea symptoms.

Snoring, gasping or choking during sleep are common symptoms of sleep-disordered breathing and are associated with multiple adverse maternal and obstetric outcomes. The mechanisms responsible remain unknown; however, placental dysfunction is suspected. The aim of this study was to investigate feto-placental and fetal cardiac function in women with pregnancies complicated by obstructive sleep apnoea symptoms. This was a prospective observational cohort study at a large tertiary obstetric hospital in Australia. Women were asked to complete a questionnaire relating to the presence and severity of obstructive sleep apnoea symptoms. They also underwent an ultrasound scan where Doppler indices of various feto-placental vessels and fetal cardiac function were measured. Regional cerebral perfusion was also assessed. A total of 255 women were included in the final analysis. Of these, 36.1% (92/255) of women reported no obstructive sleep apnoea symptoms; 63.9% (163/255) reported they experienced some form of obstructive sleep apnoea symptoms that included any frequency of snoring or choking/gasping, while 42.0% (107/255) complained of severe obstructive sleep apnoea symptoms (snoring ≥3 times a week or choking/gasping). There were no significant differences in feto-placental Dopplers or fetal cardiac function parameters in women with obstructive sleep apnoea symptoms. There were also no differences in regional cerebral blood flow between groups, or any correlation with severity of symptoms. Our data challenge the current perspective that adverse perinatal outcomes in women with obstructive sleep apnoea symptoms are related primarily to placental dysfunction and fetal compromise.

Increased rates of adverse perinatal outcomes in women with gestational diabetes and depression

Objective We sought to examine the impact of depression on adverse perinatal outcomes in women with Gestational Diabetes Mellitus (GDM). Methods We performed a retrospective cohort study comparing the rates of perinatal complications among singleton, nonanomalous births to women with GDM and the diagnosis of depression compared to GDM women without depression between 2007 and 2011 in California. Perinatal outcomes were analyzed using chi-square and multivariable logistic regression to compare frequencies of characteristics and outcomes and to determine the strength of association of depression and adverse perinatal outcomes among women with GDM. Statistical comparisons with a p-value of less than .05 and 95% CI that did not cross the null were considered statistically significant. Results Among the cohort of 170,572 women with GDM, 2090 (1.22%) were diagnosed with antenatal depression. Women with GDM and depression had significantly higher rates of preeclampsia (adjusted Odds Ratio [aOR] 1.28, 95% CI 1.11–1.49) and gestational hypertension (aOR 1.23, 95% CI 1.05–1.44). Women with GDM and depression also had higher rates of preterm delivery at <37, and <34 weeks gestational age (aOR 1.33, 95% CI 1.18–1.50 and 1.36, 95% CI 1.15–1.61, respectively). Conclusion Women with GDM and a diagnosis of depression have higher rates of adverse perinatal outcomes than women with GDM alone. Identifying and managing depression among women with GDM has the potential to improve the care and health of this high-risk population.

Perinatal outcomes for untreated women with gestational diabetes by IADPSG criteria: a population-based study.

To estimate the risk for adverse perinatal outcomes for women who met the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria but not the two-step criteria for gestational diabetes mellitus (GDM). Population-level cross-sectional study. Ontario, Canada. A total of 90140 women who underwent a 75-g oral glucose tolerance test. Women were divided into those who met the diagnostic thresholds for GDM by two-step criteria and were therefore treated, those who met only the IADPSG criteria for GDM and so were not treated, and those who did not have GDM by either criteria. Hypertensive disorders of pregnancy, preterm delivery, primary caesarean section, large-for-gestational-age, shoulder dystocia and neonatal intensive care unit admission. Women who met the IADPSG criteria had an increased risk for all adverse perinatal outcomes compared with women who did not have GDM. Women with GDM by two-step criteria also had an increased risk of most outcomes. However, their risk for large-for-gestational-age neonates and for shoulder dystocia was actually lower than that of women who met IADPSG criteria. Women who met IADPSG criteria but who were not diagnosed with GDM based on the current two-step diagnostic strategy, and were therefore not treated, had an increased risk for adverse perinatal outcomes compared with women who do not have GDM. The current strategy for diagnosing GDM may be leaving women who are at risk for adverse events without the dietary and pharmacological treatments that could improve their pregnancy outcomes. Women who meet IADPSG criteria for GDM have an increased risk for adverse perinatal outcomes compared with women without GDM.

Serum AMH levels are not associated with adverse perinatal outcomes in women undergoing IVF treatment due to diminished ovarian reserve

Objective: Anti-Mullerian hormone (AMH) is used as a biomarker for the estimation of fertility related parameters such as quality and quantity of oocytes in in vitro fertilization (IVF) procedures. High oocyte quality may also be associated with healthy trophoblastic invasion and lower complication rates during pregnancy. The aim of this study is to evaluate the relationship between AMH values and perinatal complications in infertile women with poor ovarian reserve (POR).&#x0D; Material and Methods: A total of 68 women undergoing IVF treatment were included in the study. Thirty six of them constituted the study group (POR) and 32 pregnant women constituted the control group (Tubal factor). All women in the study were chosen from patients who have undergone to their first IVF cycle. Serum AMH levels were analyzed with an ELISA kit in all patients.&#x0D; Results: AMH level was 5.4 times higher in the control group compared to that of the study group (p&lt;0.05). No significant differences were observed between the groups with regard to preterm birth rate, gestational age at birth, birth weight, 1st and 5th minute Apgar scores, and neonatal intensive care unit admission rates (all, p&gt;0.05).&#x0D; Conclusion: We found that AMH did not predict adverse perinatal outcomes in women with POR.

Ursodeoxycholic acid versus placebo in women with intrahepatic cholestasis of pregnancy (PITCHES): a randomised controlled trial

SummaryBackgroundIntrahepatic cholestasis of pregnancy, characterised by maternal pruritus and increased serum bile acid concentrations, is associated with increased rates of stillbirth, preterm birth, and neonatal unit admission. Ursodeoxycholic acid is widely used as a treatment without an adequate evidence base. We aimed to evaluate whether ursodeoxycholic acid reduces adverse perinatal outcomes in women with intrahepatic cholestasis of pregnancy.MethodsWe did a double-blind, multicentre, randomised placebo-controlled trial at 33 hospital maternity units in England and Wales. We recruited women with intrahepatic cholestasis of pregnancy, who were aged 18 years or older and with a gestational age between 20 weeks and 40 weeks and 6 days, with a singleton or twin pregnancy and no known lethal fetal anomaly. Participants were randomly assigned 1:1 to ursodeoxycholic acid or placebo, given as two oral tablets a day at an equivalent dose of 500 mg twice a day. The dose could be increased or decreased at the clinician's discretion, to a maximum of four tablets and a minimum of one tablet a day. We recommended that treatment should be continued from enrolment until the infant's birth. The primary outcome was a composite of perinatal death (in-utero fetal death after randomisation or known neonatal death up to 7 days after birth), preterm delivery (<37 weeks' gestation), or neonatal unit admission for at least 4 h (from birth until hospital discharge). Each infant was counted once within this composite. All analyses were done according to the intention-to-treat principle. The trial was prospectively registered with the ISRCTN registry, number 91918806.FindingsBetween Dec 23, 2015, and Aug 7, 2018, 605 women were enrolled and randomly allocated to receive ursodeoxycholic acid (n=305) or placebo (n=300). The primary outcome analysis included 304 women and 322 infants in the ursodeoxycholic acid group, and 300 women and 318 infants in the placebo group (consent to use data was withdrawn for 1 woman and 2 infants). The primary composite outcome occurred in 74 (23%) of 322 infants in the ursodeoxycholic acid group and 85 (27%) of 318 infants in the placebo group (adjusted risk ratio 0·85 [95% CI 0·62–1·15]). Two serious adverse events were reported in the ursodeoxycholic acid group and six serious adverse events were reported in the placebo group; no serious adverse events were regarded as being related to treatment.InterpretationTreatment with ursodeoxycholic acid does not reduce adverse perinatal outcomes in women with intrahepatic cholestasis of pregnancy. Therefore, its routine use for this condition should be reconsidered.FundingNational Institute for Health Research Efficacy and Mechanism Evaluation Programme.

499: Depression is associated with increased rates of adverse perinatal outcomes in women with gestational diabetes

There is a known relationship of depression and pre-existing diabetes. We sought to determine the rates adverse perinatal outcomes in patients with gestational diabetes (GDM) and depressive disorder in comparison to non-depressed women. A retrospective cohort study comparing the rate of maternal and neonatal outcomes among singleton, non-anomalous births in California to women with or without the diagnosis of depression between 2007 and 2011. Among women with GDM, perinatal outcomes were analyzed using Chi square and multivariate logistic regression to compare frequencies of characteristics and outcomes and to determine the strength of association of depression and adverse perinatal outcomes. Statistical comparisons and a p-value of less than 0.05 was used to indicate statistical significance. Of the 170,572 women with GDM who delivered in California, 2,090 (1.22%) were diagnosed with depression. Depressed women with GDM had significantly increased rates of perinatal adverse outcomes including hypertensive disorders of pregnancy (preeclampsia or gHTN) (Adjusted Odds Ratio [aOR] 1.25, 95% CI 1.09- 1.43), cesarean delivery (aOR 0.99, 95% CI 0.88-1.11), stillbirths (aOR 1.28, 95% CI 0.68-2.42), and preterm delivery at <37, <34, and <32 weeks gestational age (aOR 1.33, 95% CI 1.18-1.50; 1.36, 95% CI 1.15-1.61; 1.22, 95% CI 0.99-1.51 respectively) (Table 1 and Figure 1). Women with GDM and a diagnosis of depression have higher frequencies of perinatal adverse outcomes. Whether early testing and diagnosis of GDM in this population can improve perinatal outcomes is unknown but should be considered a high-risk population for GDM.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Influence of adenomyosis on pregnancy and perinatal outcomes in women with endometriosis.

Several studies have investigated the correlation between endometriosis and adverse pregnancy and perinatal outcomes. However, the role of adenomyosis as a risk factor for adverse perinatal outcome in women with endometriosis has yet to be established. The aim of this study was to explore if fetal and maternal outcomes, in particular the incidence of a small-for-gestational-age (SGA) infant, are different in pregnant women with endometriosis only from in those with the concomitant presence of diffuse or focal adenomyosis. This was a retrospective analysis of data collected prospectively during a 3-year period. We included 206 pregnant women with endometriosis: 148 (71.8%) with endometriosis only, 38 (18.4%) with focal adenomyosis and 20 (9.7%) with diffuse adenomyosis. Adenomyosis was diagnosed using ultrasonography and was classified as focal or diffuse. The study included patients who conceived spontaneously or by an assisted reproductive technique. Demographics, ultrasound variables and outcome were compared between women with endometriosis only and those with diffuse and those with focal adenomyosis. Logistic regression analysis was performed to assess the association of variables with SGA at birth in women with diffuse and those with focal adenomyosis. The three groups were similar in demographic characteristics (age, body mass index, mode of conception). Patients with diffuse adenomyosis compared with those with endometriosis only had significantly lower pregnancy-associated plasma protein A (0.61 vs 0.88 multiple of the median, P < 0.001), higher mean uterine artery pulsatility index in the first (2.23 vs 1.67, P < 0.001) and second (1.30 vs 0.94, P < 0.001) trimesters of pregnancy, and higher incidence of SGA (40% vs 10.8%, P < 0.001). No statistically significant differences were found in patients with focal adenomyosis compared with those with endometriosis only. Logistic regression analysis demonstrated that diffuse adenomyosis (odds ratio = 3.744; 95% CI, 1.158-12.099; P = 0.027) was the only independent risk factor for SGA. The presence of diffuse adenomyosis in pregnant women with endometriosis is strongly associated with delivery of a SGA infant. Women with diffuse adenomyosis should be treated as being at high risk of placental dysfunction, and these pregnancies might therefore need closer monitoring. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Large-for-Gestational-Age Neonates in Type 1 Diabetes and Pregnancy: Contribution of Factors Beyond Hyperglycemia.

Despite significant reductions in serious adverse perinatal outcomes for women with type 1 diabetes in pregnancy, the opposite effect has been observed for fetal overgrowth and associated complications, such as neonatal hypoglycemia, shoulder dystocia, and admission to the neonatal intensive care unit. In addition, infants born large for gestational age (LGA) have an increased lifetime risk of obesity, diabetes, and chronic disease. Although exposure to hyperglycemia plays an important role, women who seemingly achieve adequate glycemic control in pregnancy continue to experience a greater risk of excess fetal growth, leading to LGA neonates and macrosomia. We review potential contributors to excess fetal growth in pregnancies complicated by type 1 diabetes. In addition to hyperglycemia, we explore the role of glycemic variability, prepregnancy overweight and obesity, gestational weight gain, and maternal lipid levels. Greater understanding of the stimuli that drive excess fetal growth could lead to targeted management strategies in pregnant women with type 1 diabetes, potentially reducing the incidence of LGA neonates and the inherent risk of acute and long-term complications.

Vaginal progesterone is as effective as cervical cerclage to prevent preterm birth in women with a singleton gestation, previous spontaneous preterm birth, and a short cervix: updated indirect comparison meta-analysis

An indirect comparison meta-analysis published in 2013 reported that both vaginal progesterone and cerclage are equally efficacious for preventing preterm birth and adverse perinatal outcomes in women with a singleton gestation, previous spontaneous preterm birth, and a sonographic short cervix. The efficacy of vaginal progesterone has been challenged after publication of the OPPTIMUM study. However, this has been resolved by an individual patient-data meta-analysis (Am J Obstet Gynecol. 2018;218:161-180). To compare the efficacy of vaginal progesterone and cerclage in preventing preterm birth and adverse perinatal outcomes in women with a singleton gestation, previous spontaneous preterm birth, and a midtrimester sonographic short cervix. MEDLINE, EMBASE, LILACS, and CINAHL (from their inception to March 2018); Cochrane databases, bibliographies, and conference proceedings. Randomized controlled trials comparing vaginal progesterone to placebo/no treatment or cerclage to no cerclage in women with a singleton gestation, previous spontaneous preterm birth, and a sonographic cervical length <25 mm. Updated systematic review and adjusted indirect comparison meta-analysis of vaginal progesterone vs cerclage using placebo/no cerclage as the common comparator. The primary outcomes were preterm birth <35 weeks of gestation and perinatal mortality. Pooled relative risks (RRs) with 95% confidence intervals were calculated. Five trials comparing vaginal progesterone vs placebo (265 women) and 5 comparing cerclage vs no cerclage (504 women) were included. Vaginal progesterone, compared to placebo, significantly reduced the risk of preterm birth <35 and <32 weeks of gestation, composite perinatal morbidity/mortality, neonatal sepsis, composite neonatal morbidity, and admission to the neonatal intensive care unit (RRs from 0.29 to 0.68). Cerclage, compared to no cerclage, significantly decreased the risk of preterm birth <37, <35, <32, and <28 weeks of gestation, composite perinatal morbidity/mortality, and birthweight <1500 g (RRs from 0.64 to 0.70). Adjusted indirect comparison meta-analyses did not show statistically significant differences between vaginal progesterone and cerclage in the reduction of preterm birth or adverse perinatal outcomes. Vaginal progesterone and cerclage are equally effective for preventing preterm birth and improving perinatal outcomes in women with a singleton gestation, previous spontaneouspreterm birth, and a midtrimester sonographic short cervix. The choice of treatment will depend on adverse events and cost-effectiveness of interventions and patient/physician's preferences.

Re: Predicting delivery of a small-for-gestational-age infant and adverse perinatal outcome in women with suspected pre-eclampsia. M. Griffin, P. T. Seed, S. Duckworth, R. North, J. Myers, L. Mackillop, N. Simpson, J. Waugh, D. Anumba, L. C. Kenny, C. W. G. Redman, A. H. Shennan and L. C. Chappell. Ultrasound Obstet Gynecol 2018; 51: 387-395.

Linked Comment: Ultrasound Obstet Gynecol 2018; 51: 387–395

Predicting delivery of a small-for-gestational-age infant and adverse perinatal outcome in women with suspected pre-eclampsia.

ABSTRACTObjectiveTo evaluate the test performance of 47 biomarkers and ultrasound parameters for the prediction of delivery of a small‐for‐gestational‐age (SGA) infant and adverse perinatal outcome in women presenting with suspected pre‐eclampsia.MethodsThis was a prospective, multicenter observational study in which 47 biomarkers and ultrasound parameters were measured in 397 women with a singleton pregnancy presenting with suspected preterm pre‐eclampsia between 20 + 0 and 36 + 6 weeks' gestation, with the objective of evaluating them as predictors of subsequent delivery of a SGA infant and adverse perinatal outcome. Women with confirmed pre‐eclampsia at enrollment were excluded. Factor analysis and stepwise logistic regression were performed in two prespecified groups stratified according to gestational age at enrollment. The primary outcome was delivery of a SGA infant with a birth weight < 3rd customized centile (SGA‐3), and secondary outcomes were a SGA infant with a birth weight < 10th customized centile and adverse perinatal outcome.ResultsIn 274 women presenting at 20 + 0 to 34 + 6 weeks' gestation, 96 (35%) delivered a SGA‐3 infant. For prediction of SGA‐3, low maternal placental growth factor (PlGF) concentration had a sensitivity of 93% (95% CI, 84–98%) and negative predictive value (NPV) of 90% (95% CI, 76–97%) compared with a sensitivity of 71% (95% CI, 58–82%) and a NPV of 79% (95% CI, 68–87%) for ultrasound parameters (estimated fetal weight or abdominal circumference < 10th centile). No individual biomarker evaluated had a better performance than did PlGF, and marker combinations made only small improvements to the test performance. Similar results were found in 123 women presenting between 35 + 0 and 36 + 6 weeks' gestation.ConclusionIn women presenting with suspected preterm pre‐eclampsia, measurement of PlGF offers a useful adjunct for identifying those at high risk of delivering a SGA infant, allowing appropriate surveillance and timely intervention. © 2017 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Prognostic accuracy of cerebroplacental ratio and middle cerebral artery Doppler for adverse perinatal outcome: systematic review and meta-analysis.

ABSTRACTObjectiveDoppler ultrasonographic assessment of the cerebroplacental ratio (CPR) and middle cerebral artery (MCA) is widely used as an adjunct to umbilical artery (UA) Doppler to identify fetuses at risk of adverse perinatal outcome. However, reported estimates of its accuracy vary considerably. The aim of this study was to review systematically the prognostic accuracies of CPR and MCA Doppler in predicting adverse perinatal outcome, and to compare these with UA Doppler, in order to identify whether CPR and MCA Doppler evaluation are of added value to UA Doppler.MethodsPubMed, EMBASE, the Cochrane Library and ClinicalTrials.gov were searched, from inception to June 2016, for studies on the prognostic accuracy of UA Doppler compared with CPR and/or MCA Doppler in the prediction of adverse perinatal outcome in women with a singleton pregnancy of any risk profile. Risk of bias and concerns about applicability were assessed using the QUADAS‐2 (Quality Assessment of Diagnostic Accuracy Studies‐2) tool. Meta‐analysis was performed for multiple adverse perinatal outcomes. Using hierarchal summary receiver–operating characteristics meta‐regression models, the prognostic accuracy of CPR vs MCA Doppler was compared indirectly, and CPR and MCA Doppler vs UA Doppler compared directly.ResultsThe search identified 4693 articles, of which 128 studies (involving 47 748 women) were included. Risk of bias or suboptimal reporting was detected in 120/128 studies (94%) and substantial heterogeneity was found, which limited subgroup analyses for fetal growth and gestational age. A large variation was observed in reported sensitivities and specificities, and in thresholds used. CPR outperformed UA Doppler in the prediction of composite adverse outcome (as defined in the included studies) (P < 0.001) and emergency delivery for fetal distress (P = 0.003), but was comparable to UA Doppler for the other outcomes. MCA Doppler performed significantly worse than did UA Doppler in the prediction of low Apgar score (P = 0.017) and emergency delivery for fetal distress (P = 0.034). CPR outperformed MCA Doppler in the prediction of composite adverse outcome (P < 0.001) and emergency delivery for fetal distress (P = 0.013).ConclusionCalculating the CPR with MCA Doppler can add value to UA Doppler assessment in the prediction of adverse perinatal outcome in women with a singleton pregnancy. However, it is unclear to which subgroup of pregnant women this applies. The effectiveness of the CPR in guiding clinical management needs to be evaluated in clinical trials. © 2017 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

P20.02: Prediction of adverse perinatal outcomes using fetal biometric parameters in women with gestational diabetes mellitus: a Korean multicentre study

The purpose of this study was to evaluate the predictive performance of fetal biometric parameters measured around the time of gestational diabetes mellitus (GDM) screening and within 2 weeks before delivery in predicting adverse perinatal outcomes in women with GDM. This was a retrospective cohort study of 603 women with singleton pregnancies with GDM in 4 tertiary care hospitals from 2006 to 2013. We obtained clinical information and fetal biometric parameters such as biparietal diameter (BPD dia), abdominal circumference (AC dia), abdominal diameter (AD dia, AC/π), femur length (FL dia), and estimated fetal weight (EFW dia) measured around the time of GDM diagnosis (dia) and done before delivery (del) and interval changes of these values from medical records. Using these, predictive performance was assessed in predicting perinatal outcomes such as large for gestational age (LGA), macrosomia, shoulder dystocia, NICU admission, respiratory distress syndrome (RDS), neonatal hypoglycemia, low apgar score, Caesarean delivery due to cephalopelvic disproportion (CPD) and postpartum overt diabetes. AC del, AD del, EFW del, (AD minus BPD) del, and (AC minus HC) del were statistically different between groups with and without LGA, macrosomia, NICU admission, RDS, Caesarean delivery due to CPD (P < 0.05). Changes in EFW per week (EFW / weeks) also showed a statistically significant result in LGA and macrosomia. EFW/weeks (area under the curve (AUC) = 0.804 in LGA, 0.836 in macrosomia) was associated with an increased risk of LGA and macrosomia and AC or AD del and EFW del also did. No parameters were significant in predicting neonatal hypoglycemia, low apgar score and postpartum overt diabetes. Fetal biometric parameters and those interval changes may be useful for predicting some adverse perinatal outcomes in women with GDM.

Adjuvant administration of 17-α-hydroxy-progesterone caproate in women with three or more second trimester pregnancy losses undergoing cervical cerclage is no more effective than cerclage alone.

To investigate the role of adjuvant 17-α-hydroxy-progesterone caproate (17OHP-C) in reducing the risk of preterm delivery <34 weeks and adverse perinatal outcomes in women with ≥3 second trimester pregnancy losses attributed to cervical insufficiency undergoing prophylactic cerclage. Retrospective cohort study of women with prophylactic cerclage placed between 2006 and 2014 divided into a cohort of (i) those receiving adjuvant 17OHP-C (n=43), and (ii) controls with cerclage alone (n=59). Demographic characteristics were comparable in both groups. There was no significant difference in gestational age at delivery between the cerclage-17OHP-C group (33.4±5.6 weeks) and the cerclage-alone group (34.4±4.6 weeks); P=0.33. We noted a non-significant increase for deliveries <34 weeks in the cerclage-17OHP-C group (44.2%) compared to controls (28.8%) which remained non-significant after adjusting for confounders; P=0.46. There was no statistically significant difference in the rate of delivery <37, 32, 28 and 24 weeks. Adverse neonatal outcomes were comparable in both groups (cerclage-17OHP-C 48.8% vs. cerclage-alone 39%); P=0.43. Intramuscular 17OHP-C in combination with prophylactic cerclage in women with cervical insufficiency and ≥3 second trimester pregnancy losses had no synergistic effect in reducing the rate of recurrent preterm birth or improving perinatal outcomes.