Appropriate Timing Of Delivery Research Articles

Whether induction of labor ahead in low-risk women improves pregnancy outcomes?: A retrospective cohort, observational study.

The appropriate timing of delivery for pregnancies has always been a concern for medical staff, and the timing of elective labor induction at 41 weeks in low-risk pregnant women has always been controversial. We compared maternal and fetal outcomes between gestational age at 40 0/7 to 40 6/7 and 41 0/7 to 41 6/7 weeks. This retrospective cohort study was conducted at the obstetrics department of Jiangsu Province Hospital from January 1st to December 31st in 2020. Maternal medical records and neonatal delivery data were collected. One-way analysis of variance, Mann-Whitney U test, χ2 test, Fisher exact test and logistig regression analysis were performed. The study included 1569 pregnancies, with 1107 (70.6%) delivered at 40 0/7 to 40 6/7 weeks and 462 (29.4%) delivered at 41 0/7 to 41 6/7 weeks. Intrapartum cesarean section (8% vs 16%, P < .001), meconium-stained amniotic fluid (13% vs 19%, P = .004), episiotomy (41% vs 49%, P = .011), and macrosomia (13% vs 18%, P = .026) were significantly lower at 40 0/7 to 40 6/7 weeks. The premature rupture of membranes rate (22% vs 12%, P < .001), vaginal delivery rate of artificial rupture of membrane induction (83% vs 71%, P = .006) and balloon catheter combined with oxytocin induction (88% vs 79%, P = .049) were significantly higher at 40 0/7 to 40 6/7 weeks. Low-risk women who delivered at 40 0/7 to 40 6/7 weeks showed better outcomes in terms of the mother's and baby's health, such as decreased rates of intrapartum cesarean section, meconium-stained amniotic fluid, episiotomy, and macrosomia, compared with those who delivered at 41 0/7 to 41 6/7 weeks.

“TO ASSESS FETO-MATERNAL CIRCULATION BY DOPPLER STUDY IN WOMEN WITH THIRD TRIMESTER AND ITS CO RELATION WITH FETO-MATERNAL OUTCOMES.”

INTRODUCTION : Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity throughout the world, accounting for 24% of all maternal deaths in India. 1,2 In developed countries, it accounts for 7-10% of perinatal mortality and 20% in developing countries. Early detection of preeclampsia may allow for vigilant antenatal surveillance and timely foetal delivery to avoid serious complications. The aim of the study was to determine and compare the diagnostic performance of Doppler sonography of fetal middle cerebral artery (MCA) and umbilical artery (UA) in prediction of adverse perinatal outcome in suspected intrauterine growth retardation (IUGR) and severe PE. METHODOLOGY: 100 pre-eclampsia patients were taken in study at Sir T. General Hospital, Bhavnagar from January 2021 to July 2022. The various measures of central tendencies and graphical representations were used to analyse the data. RESULTS: Majority of patients were in the age group of 26-30 years. Maximum incidence was seen with primigravida (65%).Out of all patients maximum patients delivered normally (67%). Patients delivered low birth weight babies were around 38%. Umbilical Artery Doppler parameters such as abnormal S/D ratio,Elevated Resistivity index, and elevated Pulsatility Index were found as (78.72%), (80.85%) and (87.23%) in Adverse Outcome event which is statistically signicant compared to Good outcome(p&lt;0.0001). Middle cerebral artery Doppler parameters such as abnormal S/D ratio, Elevated Resistivity index, and elevated Pulsatility Index are found as (25.53%),(76.59%) and (72.34%) in Adverse Outcome event which is statistically signicant compared to Good outcome(p&lt;0.0001). In addition, Cerebro Placental Ratio have found signicantly high abnormality (89.36%) of neonates in adverse group. CONCLUSION: The Doppler technology is helpful in repetitive noninvasive haemodynamic monitoring of pregnancy. In an obstetric patient population with a high prevalence of complications like preeclampsia, the Doppler indices from the fetal circulation can reliably predict adverse perinatal outcomes. Thus the appropriate timing of delivery is to be made before these changes occur. However, the Doppler study of multiple vessels helps predict adverse outcomes , manage high-risk pregnancies complicated by preeclampsia

Preeclampsia and Related Problems.

Hypertensive disorders of pregnancy can be classified as chronic hypertension (present before pregnancy), gestational hypertension (onset after 20 weeks of pregnancy), and preeclampsia (onset after 20 weeks of pregnancy, along with proteinuria and other organ dysfunction). Preeclampsia and related disorders are a major cause of maternal and fetal morbidity and mortality. Preeclampsia is believed to result from an angiogenic imbalance in the placenta circulation. Antenatal screening and early diagnosis may help improve outcomes. Severe preeclampsia is characterized by SBP ≥160 mm Hg, or DBP ≥110 mm Hg, thrombocytopenia (platelet count <100 × 109/L), abnormal liver function, serum creatinine >1.1 mg/dL, or a doubling of the serum creatinine concentration in the absence of other renal diseases, disseminated intravascular coagulation, pulmonary edema, new-onset headache, or visual disturbances. Severe preeclampsia or eclampsia (preeclampsia with seizures) needs ICU management and is the main cause of morbidity and mortality. Severe hypertension can also result in life-threatening intracranial hemorrhage. Blood pressure control, seizure prevention, and appropriate timing of delivery are the cornerstones of the management of preeclampsia. Besides intravenous antihypertensive drugs, intravenous magnesium sulfate is the drug of choice to prevent or treat seizures, when preparing for urgent delivery. At present, delivery remains the most effective treatment for preeclampsia, and organ dysfunction rapidly recovers after delivery. Novel therapeutic interventions are under development to reduce complications.How to cite this articleNarkhede AM, Karnad DR. Preeclampsia and Related Problems. Indian J Crit Care Med 2021;25(Suppl 3):S261–S266.

Gestational Hypertension and Preeclampsia: An Overview of National and International Guidelines.

Gestational hypertension and preeclampsia are leading causes of maternal and perinatal morbidity and mortality worldwide. Τhe lack of effective screening and management policies appears to be one of the main reasons. The aim of this study was to review and compare recommendations from published guidelines on these common pregnancy complications. A descriptive review of guidelines from the National Institute for Health and Care Excellence, the Society of Obstetric Medicine of Australia and New Zealand, the International Society of Hypertension, the International Society for the Study of Hypertension in Pregnancy, the European Society of Cardiology, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynaecologists of Canada, the American College of Obstetricians and Gynecologists, the International Society of Ultrasound in Obstetrics and Gynecology, the World Health Organization, and the US Preventive Services Task Force on gestational hypertension and preeclampsia was carried out. There is an overall agreement that, in case of suspected preeclampsia or new-onset hypertension, blood and urine tests should be carried out, including dipstick test for proteinuria, whereas placental growth factor-based testing is only recommended by the National Institute for Health and Care Excellence and the European Society of Cardiology. In addition, there is a consensus on the recommendations for the medical treatment of severe and nonsevere hypertension, the management of preeclampsia, the appropriate timing of delivery, the optimal method of anesthesia and the mode of delivery, the administration of antenatal corticosteroids and the use of magnesium sulfate for the treatment of eclamptic seizures, the prevention of eclampsia in cases of severe preeclampsia, and the neuroprotection of preterm neonates. The reviewed guidelines also state that, based on maternal risk factors, pregnant women identified to be at high risk for preeclampsia should receive low-dose aspirin starting ideally in the first trimester until labor or 36 to 37 weeks of gestation, although the recommended dose varies between 75 and 162 mg/d. Moreover, most guidelines recommend calcium supplementation for the prevention of preeclampsia and discourage the use of other agents. However, controversy exists regarding the definition and the optimal screening method for preeclampsia, the need for treating mild hypertension, the blood pressure treatment targets, and the postnatal blood pressure monitoring. The development and implementation of consistent international protocols will allow clinicians to adopt effective universal screening, as well as preventive and management strategies with the intention of improving maternal and neonatal outcomes.

Timing of delivery and blood pressure cut-off in chronic hypertension during pregnancy: State of art and new proposals.

Pregnant women with chronic hypertension are recommended to deliver at 36-396/7 weeks. The American College of Cardiology and American Heart Association in 2017 lowered the blood pressure cut-off for stage I hypertension to 130/80mmHg. We performed a literature review on studies comparing elective induction of labor versus expectant management in pregnant women with chronic hypertension. In addition, we reviewed fetal and maternal outcomes in pregnant women with blood pressure of 120-139/80-89 or 130-139/80-89mmHg. We found two randomized clinical trials and one retrospective observational study comparing elective delivery of pregnant women with chronic hypertension versus expectant management. The randomized trials favored expectant management and the observational study favored induction of labor. We found 15 retrospective cohort studies analyzing maternal and fetal outcomes in pregnant women with blood pressure cut-off lower than 140/90mmHg. There was a consistent finding of increased risk of any hypertensive disorder of pregnancy, gestational diabetes mellitus, and small-for-gestational-age neonate. Randomized clinical trials are needed to assess the appropriate timing of delivery for women with stage I hypertension with a blood pressure cut-off of 130/80mmHg.

Chronic hypertension in pregnancy: synthesis of influential guidelines.

Chronic hypertension in pregnancy accounts for a substantial proportion of maternal morbidity and mortality and is associated with adverse perinatal outcomes, most of which can be mitigated by appropriate surveillance and management protocols. The aim of this study was toreview and compare recommendations of published guidelines on this condition. Thus, a descriptive review of influential guidelines from the National Institute for Healthand Care Excellence, the Society of Obstetric Medicine of Australia and New Zealand, the International Society of Hypertension, the International Society for the Study of Hypertension in Pregnancy, the European Society of Cardiology, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynaecologists of Canada and the American College of Obstetricians and Gynecologists on chronic hypertension in pregnancy was conducted. All guidelines agree on the definition and medical management, the need for more frequent antenatal care and fetal surveillance and the re-evaluation at 6-8weeks postpartum. There is also a consensus that the administration of low-dose aspirin is required to prevent preeclampsia, although the optimal dosage remains controversial. No universal agreement has been spotted regarding optimal treatment blood pressure (BP) targets, need for treating mild-to-moderate hypertension and postnatal BP measurements. Additionally, while the necessity of antenatal corticosteroids and magnesium sulfate for preterm delivery is universally recommended, the appropriate timing of delivery is not clearly outlined. Hence, there is a need to adopt consistent practice protocols to optimally manage these pregnancies; i.e. timely detect and treat any potential complications and subsequently reduce the associated morbidity and mortality.

Neonatal Outcomes in Term Births according to Gestational Weeks

Objective: This study aimed to determine neonatal outcomes and morbidities according to gestational weeks in term births. Methods: This was a retrospective observational study of 626 singleton deliveries from 37 0/7 to 41 6/7 gestational weeks in National Health Insurance Service Ilsan Hospital using electronic medical record data from January 1, 2011 to December 31, 2017 Neonatal outcomes and morbidity in women who attempted vaginal delivery were compared at each gestational week. Results: Early term births (37 0/7 to 38 6/7) accounted for 38.7% of full-term births (242/626). The rate of neonatal intensive care unit (NICU) admission was the lowest at 39 gestational weeks (25.0%) and highest at 41 weeks (30.8%). Compared to 39 gestational weeks, the rate of NICU admission days for more than 5 days and 5-minute Apgar score less than 7 were higher at 37 gestational weeks (26.6% vs. 11.3%, P=0.028 and 7.6% vs. 2.0%, P=0.011, respectively). The intubation rate was lower in 39 weeks than in 37 weeks without statistical significance. The incidence of meconium-stained amniotic fluid increased with gestational weeks from 37 weeks (1.3% at 37 weeks, 30.8% at 41 weeks, P<0.001). Severe neonatal morbidities were very low and not different according to gestational weeks. Conclusion: Among term births, our study showed that the prevalence of neonatal morbidities was highest at 37 gestational weeks and lowest at 39 gestational weeks. However, there was no significant difference in severe morbidities. Further studies are urgently required to determine the appropriate timing of delivery to avoid common neonatal complications.

Prediction of small for gestational age neonates: screening by maternal factors, fetal biometry, and biomarkers at 35–37 weeks’ gestation

Small for gestational age (SGA) neonates are at increased risk for perinatal mortality and morbidity; however, the risks can be substantially reduced if the condition is identified prenatally, because in such cases close monitoring and appropriate timing of delivery and prompt neonatal care can be undertaken. The traditional approach of identifying pregnancies with SGA fetuses is maternal abdominal palpation and serial measurements of symphysial-fundal height, but the detection rate of this approach is less than 30%. A higher performance of screening for SGA is achieved by sonographic fetal biometry during the third trimester; screening at 30-34 weeks' gestation identifies about 80% of SGA neonates delivering preterm but only 50% of those delivering at term, at a screen-positive rate of 10%. There is some evidence that routine ultrasound examination at 36 weeks' gestation is more effective than that at 32 weeks in predicting birth of SGA neonates. To investigate the potential value of maternal characteristics and medical history, sonographically estimated fetal weight (EFW) and biomarkers of impaired placentation at 35+0- 36+6 weeks' gestation in the prediction of delivery of SGA neonates. A dataset of 19,209 singleton pregnancies undergoing screening at 35+0-36+6 weeks' gestation was divided into a training set and a validation set. The training dataset was used to develop models from multivariable logistic regression analysis to determine whether the addition of uterine artery pulsatility index (UtA-PI), umbilical artery PI (UA-PI), fetal middle cerebral artery PI (MCA-PI), maternal serum placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFLT) would improve the performance of maternal factors and EFW in the prediction of delivery of SGA neonates. The models were then tested in the validation dataset to assess performance of screening. First, in the training dataset, in the SGA group, compared to those with birthweight in ≥10th percentile, the median multiple of the median (MoM) values of PlGF and MCA-PI were reduced, whereas UtA-PI, UA-PI, and sFLT were increased. Second, multivariable regression analysis demonstrated that in the prediction of SGA in <10th percentile there were significant contributions from maternal factors, EFW Z-score, UtA-PI MoM, MCA-PI MoM, and PlGF MoM. Third, in the validation dataset, prediction of 90% of SGA neonates delivering within 2 weeks of assessment was achieved by a screen-positive rate of 67% (95% confidence interval [CI], 64-70%) in screening by maternal factors, 23% (95% CI, 20-26%) by maternal factors, and EFW and 21% (95% CI, 19-24%) by the addition of biomarkers. Fourth, prediction of 90% of SGA neonates delivering at any stage after assessment was achieved by a screen-positive rate of 66% (95% CI, 65-67%) in screening by maternal factors, 32% (95% CI, 31-33%) by maternal factors and EFW and 30% (95% CI, 29-31%) by the addition of biomarkers. The addition of biomarkers of impaired placentation only marginally improves the predictive performance for delivery of SGA neonates achieved by maternal factors and fetal biometry at 35+0-36+6 weeks' gestation.

Characteristics and pregnancy outcomes of patients with severe pneumonia complicating pregnancy: a retrospective study of 12 cases and a literature review

BackgroundPneumonia during pregnancy has been proven to be associated with increased maternal and fetal morbidity and mortality. The management of severe pneumonia in gravid patients is even more challenging. Thus, we summarized the characteristics and pregnancy outcomes of these patients and explored the probable risk factors and predictive factors for pneumonia during pregnancy and the appropriate timing of delivery in severe pneumonia patients.MethodsA retrospective cohort study was conducted with 12 patients who were diagnosed with severe pneumonia complicating pregnancy at Peking Union Medical College Hospital between January 2010 and June 2017. The clinical features, treatment strategies, and pregnancy outcomes were collected from medical records and telephone calls.ResultsAll 12 patients were in their late second or third trimester. The patients had a higher prevalence of anemia (50%) and preeclampsia (25%) than ordinary pregnant women. Delayed diagnoses were not uncommon. Two mothers died in our series, resulting in a mortality rate of 17%. Two intrauterine deaths were observed. Elective delivery was not performed in any of the four patients in their second trimester. Six of the seven patients who presented after 28 weeks of gestation and had live fetuses underwent emergency deliveries. Preterm births (6/7) and cesarean sections (5/7) were the two leading adverse outcomes in newborns.ConclusionsAnemia, advanced gestational age, and preeclampsia might be associated with the severity of pneumonia. Chest radiographs should be taken as soon as pneumonia is highly suspected to facilitate an early diagnosis. High incidences of adverse fetal outcomes were observed; thus, termination of the pregnancy is recommended for patients in their third trimester when respiratory function deteriorates progressively. However, it might be reasonable to continue pregnancy for those in their first or second trimester.

Managing fetal growth restriction: surveillance tests and their interpretation.

The main challenges in pregnancies affected by fetal growth restriction consist in identifying signs of disease progression and determining the appropriate timing of delivery. The risk of continuing the pregnancy must be balanced with the risk of prematurity, which depends on gestational age. To allow appropriate monitoring of the growth-restricted fetus, several surveillance tests are available. These include ultrasound Doppler velocimetry of feto-placental vessels, cardiotocography, and amniotic fluid evaluation. It is well known that the combination of tests performs better than each test alone to predict fetal deterioration. The interpretation of test results depends on the gestational age and on the nature of the growth disorder (early- vs. late-onset disease). Appropriate knowledge on the surveillance tests interpretation and the frequency at which they need to be performed is crucial in managing fetal growth restriction, in order to produce better outcome and prevent stillbirth, and at the same time to avoid unnecessary interventions.

Chorioamnionitis Occurring in Women With Preterm Rupture of the Fetal Membranes Is Associated With a Dynamic Increase in mRNAs Coding Cytokines in the Maternal Circulation.

Preterm prelabor rupture of the fetal membranes (PPROM) is a significant contributor to the morbidity and mortality of preterm birth, particularly in the setting of chorioamnionitis. No sensitive or specific diagnostic or predictive test currently exists for the accurate diagnosis of chorioamnionitis. Our aim was to measure messenger RNA (mRNA) coding cytokines in the maternal blood and examine whether they were increased in association with chorioamnionitis at delivery. We performed a prospective cohort study of women recruited with PPROM at a mean gestational age of 28.9 weeks at risk of developing chorioamnionitis. Blood was sampled from participants, and the expression of mRNA coding for proinflammatory genes was measured in women with and without chorioamnionitis at the time of delivery as well as gestation-matched healthy controls. Expression was measured using quantitative polymerase chain reaction (PCR) and also digital PCR. Interleukin 1β (IL1B) mRNA expression in maternal blood was elevated in women with chorioamnionitis compared to gestation-matched controls. Importantly, among women admitted with PPROM, digital PCR confirmed a significant increase in IL1B expression in maternal blood in women with chorioamnionitis compared to women without chorioamnionitis. Polymerase chain reaction array revealed that CD14, nuclear factor of κ light polypeptide gene enhancer in B-cells 1 (NFKB1), and tumor necrosis factor receptor super family-interacting serine-threonine kinase 1 mRNA were significantly increased in women with chorioamnionitis compared to controls. Digital PCR confirmed that NFKB1 mRNA was significantly increased in patients with chorioamnionitis compared to controls and that CD14 levels increased over time in patients with PPROM having chorioamnionitis. Measuring circulating proinflammatory mRNA in women with PPROM may distinguish those with chorioamnionitis from those without, in turn providing better targeted therapies and appropriate timing of delivery.

Committee Opinion No. 623: Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum period.

Acute-onset, severe systolic hypertension; severe diastolic hypertension; or both can occur in pregnant women or women in the postpartum period. Introducing standardized, evidence-based clinical guidelines for the management of patients with preeclampsia and eclampsia has been demonstrated to reduce the incidence of adverse maternal outcomes. Individuals and institutions should have mechanisms in place to initiate the prompt administration of medication when a patient presents with a hypertensive emergency. Once the hypertensive emergency is treated, a complete and detailed evaluation of maternal and fetal well-being is needed with consideration of, among many issues, the need for subsequent pharmacotherapy and the appropriate timing of delivery.

201-POS

Objectives Disorders associated with marked liver dysfunction in late pregnancy include pre-eclampsia, HELLP syndrome, obstetric cholestasis, and acute fatty liver of pregnancy. Accurate diagnosis and appropriate timing of delivery are required in these conditions to minimize risk of maternal and fetal morbidity/mortality. We report a case series of women with significant and persistent liver dysfunction (>3-fold rise = ALT >90 IU/L) in the third trimester, where a definitive diagnosis remained obscure using accepted diagnostic tools for these and other liver conditions. Methods A retrospective audit of 341 consecutive patients referred to the Obstetric Medicine service at a single center over a 30-month period were reviewed for the prevalence of abnormal liver function tests (LFTs). Of the 56 patients ascertained, 39 were excluded with a definitive diagnosis. Of the remaining 15 patients, 10 had severe derangement with ALT elevation >90 IU/L. Results Gestation at diagnosis ranged from 26+5 to 37+1 weeks, and rationale for requesting LFTs was uniformly concern over maternal or fetal well-being. Serum bile acids and bilirubin remained in the normal range for all patients, and 1 patient received ursodeoxycholic acid empirically. Four patients had co-existing gestational hypertension, and 8 underwent planned delivery. Outcomes were reassuring; 1 neonate developed respiratory distress requiring nursery admission (delivery Conclusions This small series outlines a group of previously undescribed patients who showed a slowly-progressive clinical course with generally good neonatal and maternal outcomes. A high rate of planned delivery was contributed to by concern over persistent abnormal LFTs, and/or the development of gestational hypertension. Disclosures C. Brumby: None. I. Idel: None. R. Still: None. L. Skeat: None. L.P. McMahon: None.

Fetal Growth Restriction (FGR)—Fetal Evaluation and Antepartum Intervention

Fetal growth restriction (FGR) is a pathological condition that refers to a fetus that fails to reach his/her genetically predetermined growth potential. By epigenetic effects, substrate and energy deprivation in utero modify fetal metabolism with possible life-long impacts. Management of FGR still represents one of the main challenges for the obstetricians, both for the complexities of management of severe early FGR and for the diagnostic difficulties in late and term FGR. Late onset and term FGR define an intrauterine trajectory of growth that falls below its potential late in gestation, after 34 and 37 weeks of gestation, respectively. Ultrasound biometry examination is crucial for an accurate diagnosis of FGR. Pregnancies at risk of FGR should be considered for longitudinal ultrasound monitoring beyond the routine ultrasound screening at 20 weeks of gestation. Functional assessment of placental and fetal circulation by Doppler velocimetry and blood flow volume, together with computerized assessment of fetal heart rate variability, are key examinations in early and late FGR to assess severity of the disease and monitor fetal wellbeing. Appropriate timing of delivery in early FGR might change the outcome, and appropriate monitoring in late and term FGR might avoid unnecessary interventions.

Predictive value of clinical chorioamnionitis in extremely premature infants

Clinical chorioamnionitis and histological chorioamnionitis are important risk factors for neonatal complications and neurodevelopmental impairment in premature infants. It is unclear, however, whether a diagnosis of clinical chorioamnionitis is sufficient to establish a diagnosis of histological chorioamnionitis. The aim of this study was to evaluate the predictive value of clinical chorioamnionitis in the diagnosis of histological chorioamnionitis in extremely premature infants. This study was a secondary analysis of data from the Neonatal Research Network in Japan, a population-based cohort study aimed at identifying the clinical characteristics and morbidity of very low-birthweight infants. Data for extremely premature infants <28 weeks' gestational age from 2003 to 2007, were used. Subset analysis investigated positive predictive value by gestational age. Of the 2470 infants analyzed, 786 were diagnosed with clinical chorioamnionitis and 1129 with histological chorioamnionitis. The positive predictive value of clinical chorioamnionitis for histological chorioamnionitis was 86.6% (681/786; 95% confidence interval [CI]: 84.4-88.6%), sensitivity was 60.3% (681/1129; 95%CI: 58.8-61.7%), and specificity was 92.2% (1236/1341; 95%CI: 90.9-93.3%). In subset analysis, the positive predictive value was particularly high at 23 weeks of gestation (89.1%; 115/129), with sensitivity of 65.3% (115/176) and specificity of 89.6% (120/134). The finding that clinical chorioamnionitis is a useful predictor of histological chorioamnionitis provides important insights into the relationship between these two diagnoses, and has important implications in determining the appropriate timing of delivery of extremely premature infants.

150: When is the optimal time to deliver dichorionic diamniotic twins?

Determining the appropriate timing of delivery of a twin gestation involves balancing the risk of complications such as intrauterine fetal demise (IUFD) which are known to increase with advancing gestational age against the potential morbidity of late preterm and early term birth. We sought to use decision analysis to estimate the optimal gestational age for elective delivery of uncomplicated dichorionic, diamniotic twin gestations.

Neonatal management of the growth-restricted infant

Close collaboration between obstetricians and neonatologists is essential for proper care of the growth-restricted fetus. A joint decision on the appropriate timing of delivery is made, based on the risk of fetal compromise compared with that of neonatal morbidity. A neonatal resuscitative team should be available at delivery. Gestational assessment, anthropological measurements and physical examination are necessary to confirm the diagnosis of intra-uterine growth retardation and establish the symmetric, asymmetric, combined or dysmorphic classification. Neonatal management requires special attention to a number of significant morbidities that growth-restricted infants are more prone to develop compared with normally grown infants, including asphyxia, meconium aspiration syndrome, respiratory distress syndrome, massive pulmonary haemorrhage, chronic lung disease, hypothermia, hypoglycaemia, hypocalcaemia, polycythaemia–hyperviscosity, intraventricular haemorrhage, sepsis, necrotizing enterocolitis, coagulation abnormalities, and congenital anatomical and genetic abnormalities. Intra-uterine growth retardation is associated with a higher stillbirth rate and infant mortality rate in preterm, term and post-term infants.

Etiology of intestinal damage in gastroschisis, II. Timing and reversibility of histological changes, mucosal function, and contractility

Previous work in the fetal lamb examined the relative effects of amniotic fluid and bowel constriction in the etiology of bowel damage in gastroschisis. The present study used the same model to assess the timing and reversibility of these changes during gestation. Gastroschisis was created at 80 days' gestation, and a tape was placed around the bowel to cause gradual constriction with growth. Lambs were killed at 100 days, 120 days, and term. Bowel damage was assessed using histology, mucosal enzyme activity, and in vitro motility. In an additional “repaired” group, the constrictor was removed at 120 days, a silastic pouch placed over the bowel, and bowel damage assessed at term. Normal fetuses at each gestational age were used as controls. A fibrous peel was observed at all gestational ages. Mucosal villous atrophy and mesenteric venous and lymphatic dilation were mild at 100 and 120 days, but severe at term. These changes were present but mild in repaired animals at term. Mucosal enzyme activity decreased gradually with gestational age; inhibition of maltase activity was maximal at term, and was significantly reversed by repair, whereas inhibition of aminooligopeptidase activity was maximal at 120 days, and was not affected by repair. Protein/DNA, DNA/weight, and protein/weight ratios showed that repaired mucosal cells were significantly more proliferative, smaller, and less mature than control or gastroschisis cells. In vitro motility studies demonstrated a mild decrease in contractility at 100 and 120 days, and a large decrease at term. This deleterious effect at the end of gestation was only partially reversed by repair in utero. We conclude that: (1) amniotic fluid causes early peel formation; (2) severe obstruction, and the greatest loss of contractility and mucosal function occur late in gestation; and (3) these changes are only partially and variably reversible. This study has important clinical implications in determining the appropriate timing of delivery for fetuses with gastroschisis.

Aetiology of non-immune hydrops: the value of echocardiography.

Forty-eight pregnancies, five of them multiple, were referred for fetal cardiac assessment following the detection of non-immune hydrops fetalis; there were 52 hydropic fetuses in total. A cardiovascular aetiology was found in 21 of these 52 (40%); structural heart disease was present in 13, tachyarrhythmia in the remaining eight. The accurate delineation of these causes was possible using fetal echocardiography, and enabled rational management to be instituted. This included termination of pregnancy, pharmacological control of arrhythmias and appropriate timing of delivery.

Management of gestational diabetes.

The diagnostic subtleties in gestational diabetes are often elusive and the patient remains at risk throughout pregnancy. A careful screening program, use of the glucose tolerance test, and appropriate timing of delivery can significantly reduce the associated high fetal mortality.