Adverse Perinatal Outcome In Pregnancies Research Articles

The IRELAnD study—investigating the role of early low-dose aspirin in diabetes mellitus: a double-blinded, placebo-controlled, randomized trial

Although aspirin therapy is being increasingly advocated with the intention of risk modification for a wide range of pregnancy complications, women with prepregnancy diabetes mellitus are commonly excluded from clinical trials. The primary aim of this study was to examine the effect of aspirin therapy on a composite measure of adverse perinatal outcome in pregnancies complicated by pregestational diabetes mellitus. A double-blinded, placebo-controlled randomized trial was conducted at 6 university-affiliated perinatology centers. Women with type 1 diabetes mellitus or type 2 diabetes mellitus of at least 6 months' duration were randomly allocated to 150-mg daily aspirin or placebo from 11 to 14 weeks' gestation until 36 weeks. Established vascular complications of diabetes mellitus, including chronic hypertension or nephropathy, led to exclusion from the trial. The primary outcome was a composite measure of placental dysfunction (preeclampsia, fetal growth restriction, preterm birth <34 weeks' gestation, or perinatal mortality). The planned sample size was 566 participants to achieve a 35% reduction in the primary outcome, assuming 80% statistical power. Secondary end points included maternal and neonatal outcomes and determination of insulin requirements across gestation. Data were centrally managed using ClinInfo and analyzed using SAS 9.4. The 2 treatment groups were compared using t tests or chi-square tests, as required, and longitudinal data were compared using a repeated-measures analysis. From February 2020 to September 2022, 191 patients were deemed eligible, 134 of whom were enrolled (67 randomized to aspirin and 67 to placebo) with a retrospective power of 64%. A total of 101 (80%) women had type 1 diabetes mellitus and 25 (20%) had type 2 diabetes mellitus. Reaching the target sample size was limited by the impact of the COVID-19 pandemic. Baseline characteristics were similar between the aspirin and placebo groups. Treatment compliance was very high and similar between groups (97% for aspirin, 94% for placebo). The risk of the composite measure of placental dysfunction did not differ between groups (25% aspirin vs 21% placebo; P=.796). Women in the aspirin group had significantly lower insulin requirements throughout pregnancy compared with the placebo group. Insulin requirements in the aspirin group increased on average from 0.7 units/kg at baseline to 1.1 units/kg by 36 weeks' gestation (an average 83% within-patient increase), and increased from 0.7 units/kg to 1.3 units/kg (a 181% within-patient increase) in the placebo group, over the same gestational period (P=.002). Serial hemoglobin A1c levels were lower in the aspirin group than in the placebo group, although this trend did not reach statistical significance. In this multicenter, double-blinded, placebo-controlled randomized trial, aspirin did not reduce the risk of adverse perinatal outcome in pregnancies complicated by prepregnancy diabetes mellitus. Compared with the placebo group, aspirin-treated patients required significantly less insulin throughout pregnancy, indicating a beneficial effect of aspirin on glycemic control. Aspirin may exert a plausible placenta-mediated effect on pregestational diabetes mellitus that is not limited to its antithrombotic properties.

Evaluating the Association between Prenatal Care Visits and Adverse Perinatal Outcome in Pregnancies Complicated by Opioid Use Disorder.

This study aimed to evaluate the association between number of prenatal care visits and adverse perinatal outcome among pregnant individuals with opioid use disorder (OUD). This is a retrospective cohort of singleton, nonanomalous pregnancies complicated by OUD that delivered from January 2015 to July 2020 at our academic medical center. Primary outcome was the presence of composite adverse perinatal outcome, defined as one or more of the following: stillbirth, placental abruption, perinatal death, neonatal respiratory distress syndrome, need for morphine treatment, and hyperbilirubinemia. Logistic and linear regression estimated the association between the number of prenatal care visits and the presence of adverse perinatal outcome. A Mann-Whitney U test evaluated the association between number of prenatal care visits and length of hospital stay for the neonate. A total of 185 patients were identified, of which 35 neonates required morphine treatment for neonatal opioid withdrawal syndrome. During pregnancy, most individuals were treated with buprenorphine 107 (57.8%), whereas 64 (34.6%) received methadone, 13 (7.0%) received no treatment, and 1 (0.5%) received naltrexone. The median number of prenatal care visits was 8 (interquartile range: 4-10). With each additional visit per 10 weeks of gestational age, the risk of adverse perinatal outcome decreased by 38% (95% confidence interval [CI]: 0.451-0.854). The need for neonatal intensive care and hyperbilirubinemia also significantly decreased with additional prenatal visits. Neonatal hospital stay decreased by a median of 2 days (95% CI: 1-4) for individuals who received more than the median of eight prenatal care visits. Pregnant individuals with OUD who attend fewer prenatal care visits experience more adverse perinatal outcome. Future research should focus on barriers to prenatal care and interventions to improve access in this high-risk population. · Use of prenatal care affects newborn outcomes.. · More prenatal care shortens neonatal hospital stay.. · Prenatal care reduces certain adverse outcomes..

Evaluation of the relation between cerebroplacental ratio, umbilical-cerebral ratio, and cerebro-placental-uterine ratio with the occurrence of adverse perinatal outcomes in pregnancies complicated by fetal growth restriction

Introduction: Fetal growth restriction (FGR) is a major obstetric complication associated with an increased risk of adverse perinatal outcomes. Objectives: This study aimed to evaluate the relationship between Doppler parameters, including the cerebroplacental ratio (CPR), umbilicocerebral ratio (UCR), and cerebro-placental-uterine ratio (CPUR), with adverse perinatal outcomes in singleton pregnancies complicated by FGR. Patients and Methods: This was a prospective study of 100 women with a singleton pregnancy 28 and 36.8 weeks of gestation was complicated by FGR and mild abnormalities. Feto-maternal Doppler examinations were conducted by the CPR, UCR, and CPUR parameters. Adverse outcomes were defined as Apgar score &lt;7 at 5 minutes, preterm birth &lt;37-week, neonatal intensive care unit (NICU) admission, fetal distress, and emergency cesarean section. These outcome parameters were checked with the results of the last ultrasound which performed 1-2 weeks before delivery. Results: Mean umbilical artery pulsatility index (UA-PI) (1.18±0.31 versus 1.04±0.21, P=0.010) and mean uterine arteries (UtAs)-PI (1.18±0.45 versus 0.96±0.36, P=0.20) were significantly higher in pregnancies that experienced adverse perinatal outcomes than those that did not experience them. Mean CPUR (1.82±1.03 versus 2.25±0.83, P=0.039) was significantly lower in pregnancies that experienced adverse perinatal outcomes versus those that did not. In binary multivariate logistic regression analysis, CPR, UCR, and CPUR parameters were evaluated with adverse perinatal outcomes. Only CPUR had a significant relationship with adverse perinatal outcomes. CPUR had a substantial relationship with Apgar score &lt;7 at 5 minutes (OR: 0.13; 95% CI: 0.02-0.63; P=0.012). Conclusion: CPUR is a new Doppler ratio associated with adverse perinatal outcomes in FGR pregnancies with minimal abnormalities.

Risk of adverse perinatal outcomes in pregnancies with “small” fetuses not meeting Delphi consensus criteria for fetal growth restriction

Previous research endeavors examining the association between clinical characteristics, sonographic indices, and the risk of adverse perinatal outcomes in pregnancies complicated by fetal growth restriction have been hampered by a lack of agreement regarding its definition. In 2016, a consensus definition was reached by an international panel of experts via the Delphi procedure, but as it currently stands, this has not been endorsed by all professional organizations. This study aimed to assess whether an independent association exists between estimated fetal weight and/or abdominal circumference of <10th percentile and adverse perinatal outcomes when consensus criteria for growth restriction are not met. Data were derived from a passive prospective cohort of singleton nonanomalous pregnancies at a single academic tertiary care institution (2010-2022) that fell into 3 groups: (1) consecutive fetuses that met the Delphi criteria for fetal growth restriction, (2) small-for-gestational-age fetuses that failed to meet the consensus criteria, and (3) fetuses with birthweights of 20th to 80th percentile randomly selected as an appropriately grown (appropriate-for-gestational-age) comparator group. This nested case-control study used 1:1 propensity score matching to adjust for confounders among the 3 groups: fetal growth restriction cases, small-for-gestational-age cases, and controls. Our primary outcome was a composite: perinatal demise, 5-minute Apgar score of <7, cord pH of ≤7.10, or base excess of ≥12. Pregnancy characteristics with a P value of <.2 on univariate analyses were considered for incorporation into a multivariable model along with fetal growth restriction and small-for-gestational-age to evaluate which outcomes were independently predictive of adverse perinatal outcomes. Overall, 2866 pregnancies met the inclusion criteria. After propensity score matching, there were 2186 matched pairs, including 511 (23%), 1093 (50%), and 582 (27%) patients in the small-for-gestational-age, appropriate-for-gestational-age, and fetal growth restriction groups, respectively. Moreover, 210 pregnancies (10%) were complicated by adverse perinatal outcomes. None of the pregnancies with small-for-gestational-age OR appropriate-for-gestational-age fetuses resulted in perinatal demise. Twenty-three of 511 patients (5%) in the small-for-gestational-age group had adverse outcomes based on 5-minute Apgar scores and/or cord gas results compared with 77 of 1093 patients (7%) in the appropriate-for-gestational-age group (odds ratio, 0.62; 95% confidence interval, 0.39-1.00). Furthermore, 110 of 582 patients (19%) with fetal growth restriction that met the consensus criteria had adverse outcomes (odds ratio, 3.08; 95% confidence interval, 2.25-4.20), including 34 patients with perinatal demise or death before discharge. Factors independently associated with increased odds of adverse outcomes included chronic hypertension, hypertensive disorders of pregnancy, and early-onset fetal growth restriction. Small-for-gestational age was not associated with the primary outcome after adjustment for 6 other factors included in a model predicting adverse perinatal outcomes. The bias-corrected bootstrapped area under the receiver operating characteristic curve for the model was 0.72 (95% confidence interval, 0.66-0.74). The bias-corrected bootstrapped area under the receiver operating characteristic curve for a 7-factor model predicting adverse perinatal outcomes was 0.72 (95% confidence interval, 0.66-0.74). This study found no evidence that fetuses with an estimated fetal weight and/or abdominal circumference of 3rd to 9th percentile that fail to meet the consensus criteria for fetal growth restriction (based on Doppler waveforms and/or growth velocity of ≥32 weeks) are at increased risk of adverse outcomes. Although the growth of these fetuses should be monitored closely to rule out evolving growth restriction, most cases are healthy constitutionally small fetuses. The management of these fetuses in the same manner as those with suspected pathologic growth restriction may result in unnecessary antenatal testing and increase the risk of iatrogenic complications resulting from preterm or early term delivery of small fetuses that are at relatively low risk of adverse perinatal outcomes.

Predictors of adverse perinatal outcomes in fetal growth restriction using a combination of maternal clinical factors and simple ultrasound parameters.

To identify predictors of adverse perinatal outcomes in pregnancies with fetal growth restriction (FGR) using a combination of maternal clinical factors and simple ultrasound parameters and develop a risk-scoring model for predicting adverse perinatal outcomes. A retrospective study of 370 non-anomalous singleton pregnancies with FGR was conducted. Multivariate logistic regression analysis was used to identify factors associated with adverse perinatal outcomes; P< 0.05 was considered statistically significant. The discriminative ability was measured with the area under the receiver operating characteristic curve (AUC). A weighted score for each predictor was calculated. Adverse perinatal outcomes occurred in 165/370 (44.6%) cases. There were eight predictive factors, including a history of pregnancy-induced hypertension (PIH) (score=1), chronic hypertension (score=3), PIH (score=2), maternal weight gain less than 8kg (score=1), early-onset FGR (score=1), estimated fetal weight less than 5th percentile (score=2), amniotic fluid index less than 5cm (score=3), and abnormal umbilical artery Doppler (score=2), with total scores ranging from 0 to 15. AUC for the eight-item predictive model was 0.799 (95% confidence interval 0.753-0.845). A combination of maternal clinical factors and simple ultrasound parameters showed acceptable predictive performance for adverse perinatal outcomes in FGR.

Predictive index for adverse perinatal outcome in pregnancies complicated by fetal growth restriction.

To develop and validate an index predictive of adverse perinatal outcome (APO) in pregnancies meeting the consensus-based criteria for fetal growth restriction (FGR) endorsed by the International Society of Ultrasound in Obstetrics and Gynecology (ISUOG). This was a retrospective analysis of consecutive singleton non-anomalous gestations meeting the ISUOG-endorsed criteria for FGR at a single tertiary care center from November 2010 to August 2020. The dataset was divided randomly into a development set (two-thirds) and a validation set (one-third). The primary composite APO comprised one or more of: perinatal demise, Grade III-IV intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), seizures, hypoxic ischemic encephalopathy (HIE), necrotizing enterocolitis (NEC), sepsis, bronchopulmonary dysplasia (BPD) and length of stay in the neonatal intensive care unit (NICU) > 7 days. Regression analysis incorporated clinical factors readily available at the time of FGR diagnosis. The sum of β coefficient-based weights yielded an index score, the performance of which was assessed in the validation set. Score cut-offs were selected to identify 'high-risk' and 'low-risk' ranges for which positive (PPV) and negative (NPV) predictive values and positive (LR+) and negative (LR-) likelihood ratios were calculated. Of the 875 consecutive pregnancies that met the criteria for FGR and were included in the study cohort, 405 (46%) were complicated by one or more components of the composite APO, including 54 (6%) perinatal deaths, 22 (3%) neonates with Grade III-IV IVH and/or PVL, nine (1%) with seizures and/or HIE, 91 (10%) with BPD, 57 (7%) with sepsis, 21 (2%) with NEC, and 361 (41%) who remained in the NICU > 7 days. In addition, 270 (31%) pregnancies were delivered by Cesarean section for non-reassuring fetal status, 43 (5%) were admitted to the NICU for < 7 days, 79 (9%) had 5-min Apgar score < 7, 125/631 (20%) had a cord gas pH ≤ 7.1 and 35/631 (6%) had a base excess ≥ 12 mmol/L. The predictive index we developed included seven factors available at the time of FGR diagnosis: hypertensive disorder of pregnancy (HDP) (+8 points), chronic hypertension without HDP (+4 points), gestational age ≤ 32 weeks (+5 points), absent or reversed end-diastolic flow in the umbilical artery (+8 points), prepregnancy body mass index ≥ 35 kg/m2 (+3 points), isolated abdominal circumference < 3rd percentile (-4 points) and non-Hispanic black race (-2 points). The bias-corrected bootstrapped (1000 replicates) area under the receiver-operating-characteristics curve (AUC) of the predictive index for composite APO in the validation group was 0.88 (95% CI, 0.84-0.92), which was similar to that in the development group (AUC, 0.86 (95% CI, 0.82-0.89); P = 0.34). In the total cohort, 40% of pregnancies had a low-risk index score (≤ 2), associated with a NPV of 85% (95% CI, 81-88%) and a LR- of 0.21 (95% CI, 0.16-0.27), and 23% had a high-risk index score (≥ 10), associated with a PPV of 96% (95% CI, 93-98%) and a LR+ of 27.36 (95% CI, 14.33-52.23). Of the remaining pregnancies that had an intermediate-risk score, 50% were complicated by composite APO. An easy-to-use index incorporating seven clinical factors readily available at the time of FGR diagnosis is predictive of APO and may prove useful in counseling and management of pregnancies meeting the ISUOG-endorsed criteria for FGR. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Colour Doppler and Adverse Perinatal Outcomes in Pregnancies with Foetal Growth Restriction: A Prospective Longitudinal Study

Introduction: Foetal Growth Restriction (FGR) accounts for a significant proportion of perinatal morbidity and mortality. The study was done to diagnose the foetuses “at risk”, so that timely intervention could prevent perinatal morbidity and mortality, as FGR foetuses with deranged velocimetry of Uterine Artery (UA), Umbilical Artery (UMA), Middle Cerebral Arteries (MCA) are associated with high perinatal morbidity and mortality. Aim: To evaluate the usefulness of blood flow velocimetry of UA, UMA, and MCA as well as a Cerebroplacental Ratio (CPR) on colour doppler and their prediction of adverse perinatal outcome. Materials and Methods: This was a prospective longitudinal study done in the Department of Obstetrics and Gynaecology, Government Medical College and Rajindra Hospital, Patiala, Punjab, India from October 2021 to March 2022. The study was conducted among 200 antenatal patients, who had a singleton pregnancy, irrespective of age and parity and had FGR foetuses. Blood flow velocities in the UA, UMA, MCA, and CPR were measured. Patients were divided into four groups with 50 patients in each group. Group I included FGR foetuses with normal blood velocities, group II included FGR foetuses with abnormal UA velocimetry, group III included FGR foetuses with abnormal UMA and MCA velocimetry and group IV included FGR foetuses with abnormal CPR. Adverse perinatal outcomes in the form of Respiratory Distress Syndrome (RDS), prematurity, Appearance, Pulse, Grimace, Activity and Respiration (APGAR) &lt;7 at 5 minutes, admission to Neonatal Intensive Care Unit (NICU), and perinatal mortality were assessed in relation to these doppler blood flow patterns. Categorical variables were analysed with the help of Chi-square test and Fisher-exact Test. Continuous variables were analysed with ANOVA when data were normally distributed otherwise Kruskal Wallis H test was used. Results: The mean birth weight was 2432±423, 2209±329, 2100±223 and 1329±403 grams in Groups-I, II, III, and IV (p-value of &lt;0.001.) The mean gestational age was 38.1±2.3, 37.3±3.2, 36±3.6 and 33.1±3.1 weeks in groups I, II, III, and IV (p-value of &lt;0.001). Perinatal morbidity in the form of RDS and prematurity were compared among four groups with 0, 3 (6%), 17 (34%), and 39 (78%) in Groups I, II, III, and IV (p-value of &lt;0.001). APGAR score &lt;7 at 5 minutes was 0, 2 (4%), 9 (18%), and 13 (26%) in groups 1, II, III, and IV (p-value of &lt;0.001). A total of 6 (12%), 16 (32%), 37 (74%) and 46 (92%) C-sections were performed in group I, II, III and IV, respectively, p-value of &lt;0.001. Maternal mortality of 1 (2%) in group III and 2 (4%) was observed in group IV. But no maternal death was there in group I and II. Conclusion: The adverse perinatal outcomes were seen with changes in Pulsatility Index (PI) value of UA, UMA, MCA. But the patients with a deranged CPR ratio had got worse perinatal outcomes than either deranged MCA, PI or UMA PI alone. Hence, doppler ultrasound especially CPR ratio should be an integral component of routine evaluation of FGR pregnancies, as it helps in obstetrical surveillance and management, and thereby improving adverse perinatal outcomes.

Adverse perinatal outcomes in pregnancies affected by severe COVID-19 infection

BackgroundSevere COVID-19 infection in pregnancy has been associated with an increase in adverse perinatal outcomes, though studies differ regarding which outcomes are affected. Increased characterization of obstetric and neonatal outcomes are needed including details on indications for preterm delivery and additional neonatal adverse outcomes.ObjectiveTo determine whether there is a higher rate of adverse perinatal outcomes amongst severe-critical COVID-19 infection compared to non-severe COVID-19 infection diagnosed during pregnancy.Study DesignThis was a retrospective observational cohort study that compared rates of adverse perinatal outcomes amongst singleton pregnancies identified as having a positive laboratory PCR diagnosis of COVID-19 infection with severe-critical COVID-19 infection versus non-severe (asymptomatic, mild or moderate). Primary outcomes included hypertensive disorders of pregnancy, cesarean delivery, fetal growth restriction, preterm birth, and neonatal intensive care unit (NICU) admission. Additional neonatal outcomes analyzed include need for CPR, low birthweight (<2500g), 1 or 5 min Apgar <7, need for supplemental oxygen, need for intubation, interventricular hemorrhage, sepsis, respiratory distress syndrome, bronchopulmonary dysplasia, blood transfusion, necrotizing enterocolitis, hypoxic ischemic encephalopathy, birth trauma or neonatal death. Appropriate bivariate analyses were used to compare groups. Logistic regression was used to examine primary outcomes adjusting for confounders.ResultsA total of 441 participants were identified and confirmed via detailed chart review to be pregnant with a singleton pregnancy while diagnosed with COVID-19. Of these, 44 (10%) met NIH criteria for severe-critical COVID-19 infection. The median gestational age at the time of maternal COVID-19 diagnosis was 36.4 weeks (IQR 29.6 – 38.6). Severe-critical COVID-19 infection had a higher risk of a composite adverse neonatal outcome (36.4% vs 21.4%, p=0.03). There was a high incidence of hypertensive disorders of pregnancy overall (20.6%) but this outcome was not higher in the severe-critical vs non-severe group. There were no maternal deaths. There was a low incidence of neonatal COVID-19 test positivity amongst those tested (1.8%). When adjusting for presence of heart disease and gestational age at COVID-19 diagnosis, severe-critical COVID-19 was strongly associated with fetal growth restriction (aOR 2.73, 1.03 – 7.25) and NICU admission (aOR 3.50, CI 1.56 – 7.87). Preterm delivery was more common but was no longer significant after adjustment (aOR 2.23, CI 0.99 – 5.05).ConclusionSevere-critical COVID-19 infection during pregnancy is associated with higher rates of adverse neonatal outcomes and strongly associated with NICU admission and fetal growth restriction compared to non-severe disease. There is a high rate of hypertensive disorders of pregnancy overall in all those affected by COVID-19, regardless of severity. Pregnant persons should be counseled on these risks to encourage vaccination, and those with infection during pregnancy should be monitored for fetal growth disorders.

Assessing the Views and Needs of People at High Risk of Gestational Diabetes Mellitus for the Development of Mobile Health Apps: Descriptive Qualitative Study

BackgroundEarly prevention of gestational diabetes mellitus (GDM) can reduce the incidence of not only GDM, but also adverse perinatal pregnancy outcomes. Moreover, it is of great significance to prevent or reduce the occurrence of type 2 diabetes. Mobile health (mHealth) apps can help pregnant women effectively prevent GDM by providing risk prediction, lifestyle support, peer support, professional support, and other functions. Before designing mHealth apps, developers must understand the views and needs of pregnant women, and closely combine users’ needs to develop app functions, in order to better improve user experience and increase the usage rate of these apps in the future.ObjectiveThe objective of this study was to understand the views of the high-risk population of gestational diabetes mellitus on the development of mobile health apps and the demand for app functions, so as to provide a basis for the development of gestational diabetes mellitus prevention apps.MethodsFifteen pregnant women with at least one risk factor for gestational diabetes were recruited from July to September 2021, and were interviewed via a semistructured interview using the purpose sampling method. The transcribed data were analyzed by the traditional content analysis method, and themes were extracted.ResultsRespondents wanted to develop user-friendly and fully functional mobile apps for the prevention of gestational diabetes mellitus. Pregnant women's requirements for app function development include: personalized customization, accurate information support, interactive design, practical tool support, visual presentation, convenient professional support, peer support, reasonable reminder function, appropriate maternal and infant auxiliary function, and differentiated incentive function.These function settings can encourage pregnant women to improve or maintain healthy living habits during their use of the appConclusionsThis study discusses the functional requirements of target users for gestational diabetes mellitus prevention apps, which can provide reference for the development of future applications.

Does a Short Interim between two Pregnancies Adversely Influence Maternal outcome – A Study from South Punjab

To investigate the occurrence of adverse perinatal outcome in pregnancies with short inter pregnancy interim. Study Design: A Cross – sectional study. Setting: Obstetrics &amp; Gynaecology Unit 1,Combined Military Hospital Multan. Study Duration: 6 months ,( 25-10-2019 to 24-04-2020) Subjects and Methods: Baseline information like age, obesity, parity and educational status was noted. The patients with short Inter pregnancy interval were recruited for perinatal outcomes. Results: Calculated mean of age of gestation of the patients was 38.45 ± 0.21 wks and 147 (61.3%) were at &gt; 38 wks of gestation. Mean age of patients included, was 28.21 ± 4.37 years. Of the 240 study cases, 158 (65.8 %) were living in countryside and 82 (34.2 %) came from inner-city. Of these 240 study cases, 166 (69.2 %) pregnant females had no primary education even and only 74 (30.8%) ladies were literate. Mean BMI of the subjects was 24.99 ± 2.17 kg/m2 while 33 (13.8 %) pregnant females were found obese . Parity mean found to be 2.11 ± 0.78 and 184 (76.7 %) had parity up to 3. Mean of marriage period was 5.22 ± 3.67 yrs and 124 (51.7%) marriage period upto 4.9 years. Preterm birth was noted in 47 (19.6%), premature rupture of membranes was noted in 95 (39.6%) while postpartum hemorrhage was noted in 31 (12.9%). Conclusion: A brief interim (&lt; 1.8 yrs) between two pregnancies, was found to be associated with more risks of preterm births (PTB), premature rupture of membranes (PROM) and postpartum hemorrhage (PPH). Higher frequencies of PTB, PROM and PPH have been observed in our study. Repeated unplanned pregnancies with brief interim between two pregnancies in under-developed countries particularly, lead to high maternal and neonatal morbidity and mortality. Since lack of optimization of maternal health has untoward consequences, awareness and education of mothers in pre and post natal visits about effective contraception is an important component of safe motherhood. Keywords: Inter pregnancy interim, IPI, perinatal outcomes.

Determinants of Perinatal Outcomes in Dialyzed and Transplanted Women in Australia

IntroductionDrivers of adverse perinatal outcomes in pregnancies of women receiving chronic kidney replacement therapy (KRT) remain poorly understood.MethodsBirths ≥ 20 weeks of gestation in Australian women receiving KRT were analyzed for perinatal outcomes stratified by maternal KRT exposure (dialysis or transplant, analyzed separately), by linking the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA) and perinatal data sets (1991–2013).ResultsOf 2,948,084 babies (1,628,181 mothers), 248 were born to mothers receiving KRT (transplant, n = 211; dialysis, n = 37), with live birth rates ≥ 94%. The perinatal death rate was 162, 62, and 9 per 1000 births in the dialysis, transplant, and non-KRT cohorts, respectively. Babies exposed to KRT had increased odds of prematurity, small-for-gestational age (SGA), poor birth condition, resuscitation, intensive care admission, and longer hospitalization, with the dialysis cohort having worse outcomes. Preterm babies of dialyzed and transplanted mothers (compared with preterm babies with no KRT exposure) experienced 1.6- to 2.7-fold higher odds for all adverse outcomes, except birthweight < 2500 g, which was 11-fold higher for the dialysis cohort. In adjusted analyses, transplanted women with better allograft function (serum creatinine ≤ 120 μmol/l) still had >10-fold higher odds of preterm birth and low birthweight and 1.8- to 4.6-fold increased odds of other adverse outcomes. In transplanted women, mediation analysis revealed that pregnancy-induced hypertension contributed only a modest proportional effect (2.5%–11.2%) on adverse outcomes.ConclusionMaternal dialysis and transplantation conferred excess perinatal morbidity, particularly for preterm babies, and even in women with good preconception allograft function. Pregnancy-induced hypertension is not the predominant determinant of perinatal morbidity. Preconception counseling of women with kidney disease should encompass discussion of perinatal complications.

Adverse perinatal outcomes in pregnancies complicated with placental abruption accompanied by hypertensive disorders of pregnancy

Adverse perinatal outcomes in pregnancies complicated with placental abruption accompanied by hypertensive disorders of pregnancy

Cerebroplacental doppler ratio and perinatal outcome in late-onset foetal growth restriction

The purpose of this study was to determine whether gestational age-specific levels of the cerebroplacental ratio (CPR) as a third-trimester ultrasound marker has benefits in the prediction of perinatal morbidity and mortality on foetuses with late-onset foetal growth restriction (FGR). A retrospective study of singleton pregnancies diagnosed with late-onset FGR was performed. Of 407 pregnancies meeting our inclusion criteria, 313 had normal (Group 1) and 94 had abnormal CPR (Group 2). Both groups were similar in age, gestational age at diagnosis, body mass index and parity. There was a significant association between the presence of oligohydramnios and abnormal CPR. Mean gestational age at delivery and mean neonatal birth weight were significantly lower in Group 2. Neonatal intensive care unit admission, foetal distress, low 5–minute Apgar score <7, and low cord pH < 7.1 rates were significantly higher in Group 2. There was one neonatal death in both groups. Multivariable regression analysis demonstrated that, in the prediction of APO, there was a significant contribution from neonatal birth weight <10th percentile, CPR <5th percentile and oligohydramniosis. Our findings revealed that CPR value less than 5th centile can be used as a predictor of APO in late-onset FGR. IMPACT STATEMENT What is already known on this subject? Low cerebroplacetal ratio (CPR) is a marker of failure to reach the growth potential regardless of foetal weight. What do the results of this study add? The CPR can be used as an adequate predictor of adverse perinatal outcome in pregnancies with late-onset foetal growth restriction. What are the implications of these findings for clinical practice and/or further research? Routine calculation and report of CPR during basic ultrasound examination may help to identify foetuses with FR with a higher risk of adverse perinatal outcome. Future prospective studies on pregnancies with FGR with oligohydroamnios or normal amniotic fluid volume should focus on determining CPR threshold.

Middle Cerebral Artery–to–Uterine Artery Pulsatility Index Ratio and Cerebroplacental Ratio Independently Predict Adverse Perinatal Outcomes in Pregnancies at Term

This study aimed to investigate potential predictors, including the cerebroplacental ratio and the middle cerebral artery (MCA)–uterine artery pulsatility index (PI) ratio, for adverse perinatal outcomes in pregnancies at term. This was an observational, prospective study of recruited pregnancies at term. The data were extracted from the medical records in hospital. An adverse perinatal outcome was set as the primary observational endpoint. The receiver operating characteristic curve was plotted to investigate the predictive and cutoff values of risk factors for adverse perinatal outcomes. Univariate and multivariate logistic regression analyses evaluated independent risk factors (maternal, neonatal, prenatal ultrasound and Doppler variables) for adverse perinatal outcomes. There were 392 pregnancies at term included in the study, with 19.4% experiencing adverse perinatal outcomes. The MCA–uterine artery PI ratio was a good predictor of adverse perinatal outcomes by receiver operating characteristic curve analysis (area under the curve = 0.886, p < 0.001), and the cerebroplacental ratio (odds ratio, 0.42; 95% confidence interval, 0.20–0.93; p = 0.032) and MCA–uterine artery PI ratio (odds ratio, 0.25; 95% confidence interval, 0.16–0.42; p = 0.032) were two independent risk factors for adverse perinatal outcomes by univariate and multivariate logistic regression analyses. Notably, both MCA–uterine artery PI ratio and cerebroplacental ratio are significant predictors of adverse perinatal outcome in pregnancies at term.

Intrapartal cardiotocographic patterns and hypoxia-related perinatal outcomes in pregnancies complicated by gestational diabetes mellitus

AimsIn previous reports, cardiotocographic (CTG) fetal heart rate (FHR) monitoring has shown only limited benefits in decreasing adverse perinatal outcomes in pregnancies complicated by gestational diabetes mellitus (GDM). The aim of the present study was to evaluate whether an association exists between the recently reported ZigZag pattern (FHR baseline amplitude changes of > 25 bpm with a duration of 2–30 min) and asphyxia-related neonatal outcomes in GDM pregnancies.MethodsIntrapartal CTGs were recorded in a one-year cohort of 5150 singleton childbirths. The following CTG changes were evaluated: ZigZag pattern, saltatory pattern, late decelerations, episodes of tachycardia and bradycardia, reduced variability, and uterine tachysystole. The cohort was divided into three groups: women with GDM, women with normal oral glucose tolerance test (OGTT), and women with no OGTT performed. Umbilical artery (UA) blood gases, Apgar scores, neonatal respiratory distress, and neonatal encephalopathy were used as outcome variables.ResultsGDM was diagnosed in 624 (12.1%), OGTT was normal in 4115 (79.9%), and OGTT was not performed in 411 (8.0%) women. Hypoxia-related ZigZag patterns (OR 1.94, 95% CI 1.64–2.34) and late decelerations (OR 1.65, 95% CI 1.27–2.13) of FHR, as well as a greater risk of fetal asphyxia (UA pH < 7.10 and/or UA BE < -12.0 meq/L and/or Apgar scores < 7 at 5-min) (OR 6.64, 95% CI 1.84–12.03) were observed in those with GDM compared with those without GDM.ConclusionsGDM is associated with intrapartal ZigZag pattern and late decelerations, cord blood acidemia and low 5-min Apgar scores at birth indicating increased occurrence of fetal hypoxia in GDM pregnancies.

Comparison between Cerebroplacental Ratio and Umbilicocerebral Ratio in Predicting Adverse Perinatal Outcome in Pregnancies Complicated by Late Fetal Growth Restriction: A Multicenter, Retrospective Study

Introduction: The role of cerebroplacental ratio (CPR) or umbilicocerebral ratio (UCR) to predict adverse intrapartum and perinatal outcomes in pregnancies complicated by late fetal growth restriction (FGR) remains controversial. Methods: This was a multicenter, retrospective cohort study involving 5 referral centers in Italy and Spain, including singleton pregnancies complicated by late FGR, as defined by Delphi consensus criteria, with a scan 1 week prior to delivery. The primary objective was to compare the diagnostic accuracy of the CPR and UCR for the prediction of a composite adverse outcome, defined as the presence of either an adverse intrapartum outcome (need for operative delivery/cesarean section for suspected fetal distress) or an adverse perinatal outcome (intrauterine death, Apgar score <7 at 5 min, arterial pH <7.1, base excess of >−11 mEq/mL, or neonatal intensive care unit admission). Results: Median CPR absolute values (1.11 vs. 1.22, p = 0.018) and centiles (3 vs. 4, p = 0.028) were lower in pregnancies with a composite adverse outcome than in those without it. Median UCR absolute values (0.89 vs. 0.82, p = 0.018) and centiles (97 vs. 96, p = 0.028) were higher. However, the area under the curve, 95% confidence interval for predicting the composite adverse outcome showed a poor predictive value: 0.580 (0.512–0.646) for the raw absolute values of CPR and UCR, and 0.575 (0.507–0.642) for CPR and UCR centiles adjusted for gestational age. The use of dichotomized values (CPR <1, UCR >1 or CPR <5th centile, UCR >95th centile) did not improve the diagnostic accuracy. Conclusion: The CPR and UCR measured in the week prior delivery are of low predictive value to assess adverse intrapartum and perinatal outcomes in pregnancies with late FGR.

Value of second-trimester uterine artery pulsatility index in pregnancies with systemic lupus erythematosus and/or antiphospholipid syndrome

Objective To assess the value of the second trimester mean pulsatility index of the uterine arteries (MPI-UtA) to predict adverse perinatal outcome (APO) in women with systemic lupus erythematosus (SLE) and/or antiphospholipid syndrome (APS). Methods Pregnancies with either an SLE diagnosis or with primary APS controlled at our Hospital during a 10 years period were included. MPI-UtA was performed between 19–23 weeks' gestation. The MPI-UtA was defined as abnormal when it was >95th centile. APO was defined as the presence of: preeclampsia (PE), small for gestational age (SGA) newborn, preterm delivery, placental abruption and fetal or neonatal death. Results There were 39 ongoing pregnancies, 16 of them with SLE and 23 with primary APS. Nine patients had no previous pregnancy (23%). Globally, 35 live births were recorded, being the mean gestational age at delivery 38.1 ± 2.1 weeks and the mean birth weight 2835 ± 492 g. Abnormal MPI-UtA was found in 6 (15%) pregnancies, all of them (100%) had an APO: there were 4 fetal deaths and 2 further severe PE with live newborn. Normal MPI-UtA was shown in the remaining 33 (84.6%); of them, 6 (18%) had an APO: one late PE with a premature newborn, another one severe preterm baby and 4 SGA term newborns. No cases of perinatal death occurred in this group. Therefore, accuracy of MPI-UtA evaluation for APO was: sensitivity 50%, specificity 100%, PPV 100% and NPV 82%, respectively (p < .001). Conclusion Abnormal second-trimester uterine artery Doppler evaluation is highly predictive for adverse perinatal outcome in pregnancies affected by SLE or APS.

Foetal cardiac function in third trimester pregnancies with reduced fetal movements

The objective of our study was to investigate the possible relationship between poor perinatal outcome and foetal cardiac functions in pregnant women with reduced foetal movements (RFM). This cross-sectional study included 126 pregnant women with normal foetal movements (Group 1, Controls) and 42 pregnant women over 32 weeks gestation with RFM (Group 2). Group 2 was further divided into two subgroups according to their perinatal outcome: normal perinatal outcome (Group 2a) and poor perinatal outcome (Group 2b). Cardiotocography, the E/A ratio in both atrioventricular valves, myocardial performance index (MPI) and foetal tricuspid annular plane systolic excursion (f-TAPSE) were evaluated. Foetuses with poor perinatal outcome had a higher MPI (p = .003), higher tricuspid and mitral E/A (p < .001), and lower f-TAPSE values (p < .001). In regression analysis, f-TAPSE was the only parameter (p = .04) independently associated with poor perinatal outcome. İn conclusion, examining f-TAPSE may predict adverse perinatal outcome in pregnancies with RFM. IMPACT STATEMENT What is already known on this subject? Reduced foetal movement (RFM) is associated with adverse pregnancy outcome. Cardiotocography, amniotic fluid assessment, estimated birthweight, foetal Doppler and formal foetal movement count (kick chart) are generally used in the clinical assessment of pregnancies with reduced foetal movements. These tests, we currently use to assess foetal wellbeing in women with reduced foetal movements, have limited sensitivity in predicting foetal compromise. What do the results of this study add? Foetal cardiac Doppler may potentially be used as an important adjunct to the conventional management of women with a perception of reduced foetal movements. What are the implications of these findings for clinical practice and/or further research? Foetal echocardiographic evaluation, such as f-TAPSE, may influence clinical practice by enabling improved risk stratification for poor perinatal outcome, thus allowing more timely definitive intervention. This could help to decrease the rate of stillbirth related to reduced foetal movements. The few established echocardiographically derived parameters, which can asses global right ventricle function, are not always easy to obtain, however, f-TAPSE is easily obtainable using ultrasound and it appears to be a clinically useful echocardiographic measurement of right ventricular function.

305 A predictive index for severe adverse perinatal outcomes in pregnancies complicated by fetal growth restriction

Lack of significance of several covariates in a model we recently validated indicated model reconstruction may improve its performance. Our aim was to redevelop the model and then use it to develop an index predictive of severe adverse perinatal outcomes in pregnancies complicated by fetal growth restriction (FGR). Data was derived from a cohort of singleton non-anomalous gestations meeting Delphi procedure-based consensus criteria [Gordijn S et al. Ultrasound Obstet Gynecol 2016;48(3):333-9] for FGR between 2010-2020 at a single tertiary-care institution. The cohort was retrospectively analyzed according to the occurrence of composite adverse perinatal outcome: perinatal demise, 5-minute Apgar < 7, cord pH ≤ 7.1, or cord base excess ≥ 12. Regression analysis incorporated clinical factors widely available at the time of growth restriction diagnosis. The sum of beta coefficient-based weights yielded a severe adverse perinatal outcome index score. Of the 907 pregnancies that met criteria for FGR, 226 (25%) were complicated by severe adverse perinatal outcomes. 278 (31%) were delivered by cesarean for non-reassuring fetal status and 410 (45%) neonates were admitted to the NICU. The derived index included nine clinical factors: maternal age ≥ 30, body mass index ≥ 40, nulliparity, male fetus, gestational age ≤ 28 weeks, hypertensive disorder of pregnancy both with and without chronic hypertension, umbilical artery absent or reversed end diastolic flow, and gestational diabetes. The index’s bootstrapped bias-corrected AUC was 0.78 (95% CI 0.74-0.81). Index sum cut-points were selected to identify “high risk” (≥ 10) and “low risk” (≤ 4) ranges that have positive and negative predictive values of 73% (95% CI 63-81%) and 88% (95% CI 86-90%), respectively. An index incorporating nine clinical factors widely available at time of growth restriction diagnosis was predictive of severe adverse perinatal outcomes. If validated, the index may prove useful in counseling and management of pregnancies meeting consensus-based criteria for fetal growth restriction.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

304 Predicting severe adverse perinatal outcomes in pregnancies complicated by fetal growth restriction: a validation study

Validate a model predictive of severe adverse perinatal outcomes in pregnancies complicated by fetal growth restriction using clinical factors widely available at time of diagnosis. We assessed the performance of a 7-item model previously developed from 336 pregnancies (2013-2019) meeting Delphi procedure-based consensus criteria [Gordijn SJ et al. Ultrasound Obstet Gynecol 2016;48(3):333-9] for fetal growth restriction (FGR). The model assesses risk of composite severe adverse perinatal outcome: perinatal demise, 5-minute Apgar < 7, cord pH ≤ 7.1, or cord base excess > 12. It includes factors available at diagnosis: hypertensive disorder of pregnancy (HDP), gestational age ≤ 30 weeks, isolated abdominal circumference < 3rd centile, absent/reversed end diastolic flow (A/REDF), chronic hypertension, maternal height > 160 cm, and pre-gravid weight 68.5 kg. To validate the model, we retrospectively analyzed data from non-anomalous, singleton gestations (2010-2020) not included in model development. Severe adverse perinatal outcomes complicated 22% (127) of 585 pregnancies. In addition, there were 257 (45%) NICU admissions and 169 (29%) cesareans for non-reassuring fetal status. Women with the composite outcome were more likely to have a higher body mass index, hypertensive disorders, and abnormal umbilical artery flow. Model performance in the validation cohort [bias-corrected bootstrapped AUC of 0.76 (95% CI 0.69-0.79)], was similar to the development cohort [AUC of 0.81 (95% CI 0.73-0.84)]; however only HDP, A/REDF, and gestational age ≤ 30 weeks were significant. Performance was better for early-onset [n = 316, AUC 0.76 (95% CI 0.71-0.82)] compared to late-onset (n = 269) growth restriction [AUC 0.69 (95% CI 0.55-0.66)]. Performance of a model predictive of severe adverse perinatal outcome in a larger validation cohort was relatively strong. However, lack of significance of four covariates indicates model redevelopment may improve performance and, in doing so, its utility in counseling and management of pregnancies complicated by growth restriction.View Large Image Figure ViewerDownload Hi-res image Download (PPT)