Cesarean Delivery For Fetal Distress Research Articles

Balloon catheters versus vaginal prostaglandins for labour induction (CPI Collaborative): an individual participant data meta-analysis of randomised controlled trials

Induction of labour is one of the most common obstetric interventions globally. Balloon catheters and vaginal prostaglandins are widely used to ripen the cervix in labour induction. We aimed to compare the effectiveness and safety profiles of these two induction methods. We did an individual participant data meta-analysis comparing balloon catheters and vaginal prostaglandins for cervical ripening before labour induction. We systematically identified published and unpublished randomised controlled trials that completed data collection between March 19, 2019, and May 1, 2021, by searching the Cochrane Library, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and PubMed. Further trials done before March 19, 2019, were identified through a recent Cochrane review. Data relating to the combined use of the two methods were not included, only data from women with a viable, singleton pregnancy were analysed, and no exclusion was made based on parity or membrane status. We contacted authors of individuals trials and participant-level data were harmonised and recoded according to predefined definitions of variables. Risk of bias was assessed with the ROB2 tool. The primary outcomes were caesarean delivery, indication for caesarean delivery, a composite adverse perinatal outcome, and a composite adverse maternal outcome. We followed the intention-to-treat principle for the main analysis. The primary meta-analysis used two-stage random-effects models and the sensitivity analysis used one-stage mixed models. All models were adjusted for maternal age and parity. This meta-analysis is registered with PROSPERO (CRD42020179924). Individual participant data were available from 12 studies with a total of 5460 participants. Balloon catheters, compared with vaginal prostaglandins, did not lead to a significantly different rate of caesarean delivery (12 trials, 5414 women; crude incidence 27·0%; adjusted OR [aOR] 1·09, 95% CI 0·95-1·24; I2=0%), caesarean delivery for failure to progress (11 trials, 4601 women; aOR 1·20, 95% CI 0·91-1·58; I2=39%), or caesarean delivery for fetal distress (10 trials, 4441 women; aOR 0·86, 95% CI 0·71-1·04; I2=0%). The composite adverse perinatal outcome was lower in women who were allocated to balloon catheters than in those allocated to vaginal prostaglandins (ten trials, 4452 neonates, crude incidence 13·6%; aOR 0·80, 95% CI 0·70-0·92; I2=0%). There was no significant difference in the composite adverse maternal outcome (ten trials, 4326 women, crude incidence 22·7%; aOR 1·02, 95% CI 0·89-1·18; I2=0%). In induction of labour, balloon catheters and vaginal prostaglandins have comparable caesarean delivery rates and maternal safety profiles, but balloon catheters lead to fewer adverse perinatal events. Australian National Health and Medical Research Council and Monash Health Emerging Researcher Fellowship.

Added prognostic value of Doppler ultrasound for adverse perinatal outcomes: A pooled analysis of three cohort studies.

Fetal growth restriction (FGR) is an obstetric complication associated with adverse perinatal outcomes. Doppler ultrasound can improve perinatal outcomes through monitoring at-risk fetuses and helping time delivery. To investigate the prognostic value of different Doppler ultrasound measurements for adverse perinatal outcomes. Individual participant data. We performed a pooled analysis on individual participant data. We compared six prognostic models using multilevel logistic regression, where each subsequent model added a new variable to a base model that included maternal characteristics. Estimated fetal weight (EFW) and four Doppler ultrasound measurements were added in turn: umbilical artery pulsatility index (UA PI), middle cerebral artery pulsatility index (MCA PI), cerebroplacental ratio (CPR), and mean uterine artery pulsatility index (mUtA PI). The primary outcome was a composite adverse perinatal outcome, defined as perinatal mortality, emergency caesarean delivery for fetal distress, or neonatal admission. Discriminative ability was quantified with area under the curve (AUC). Three data sets (N=3284) were included. Overall, the model that included EFW and UA PI improved AUC from 0.650 (95% CI 0.624-0.676) to 0.673 (95% CI 0.646-0.700). Adding more ultrasound measurements did not improve further the discriminative ability. In subgroup analysis, the addition of EFW and UA PI improved AUC in both preterm (AUC from 0.711 to 0.795) and small for gestational age pregnancies (AUC from 0.729 to 0.770), but they did not improve the models in term delivery or normal growth subgroups. Umbilical artery pulsatility index added prognostic value for adverse perinatal outcomes to the already available information, but the combination of other Doppler ultrasound measurements (MCA PI, CPR or UtA PI) did not improve further prognostic performance.

Perinatal Outcome in Term Pregnancy with Isolated Oligohydramnios: Retrospective Observational Study

Introduction: Isolated Oligohydramnios complicates 3 to 5% of pregnancy at term both in terms of fetal outcome and mode of delivery.
 Aims: To study the perinatal outcome in isolated oligohydramnios (Amniotic Fluid Index≤8) and compare the outcome between Borderline (Amniotic Fluid Index=5.1-8 cm) and Severe (<5 cm) oligohydramnios.
 Methods: Retrospective observational study of pregnancy outcome with isolated oligohydramnios (Amniotic Fluid Index≤8 cm) at term was carried out in Gandaki Medical College Teaching Hospital, Pokhara for one year from January 2019 to December 2019. Patients were divided into Borderline Oligohydramnios (Amniotic Fluid Index=5.1 to 8 cm) and Severe Oligohydramnios (Amniotic Fluid Index ≤5 cm). The two groups were compared in terms of fetal outcome like: meconium passage, low birth weight, low APGAR (Appearance, Pulse, Grimace, Activity and Respiration) score at 1 and 5 min, Neonatal Intensive Care Unit (NICU) admission and neonatal death. Similarly mode of delivery was also compared.
 Results: There were total of 100 patients with isolated oligohydramnios. Of which 51(51%) were with Borderline Oligohydramnios and 49(49%) with Severe Oligohydramnios. The incidence of adverse perinatal outcome and caesarean delivery was high in patients with isolated oligohydramnios. When compared with the two groups there was significant difference in terms of meconium passage (11% vs 48.9%), low birth weight (5.8% vs 18%), low APGAR (Appearance, Pulse, Grimace, Activity and Respiration) score at 1 min (1.9% vs 14%), NICU (Neonatal Intensive Care Unit) admission (11% vs 67%) and Caesarean delivery (39% vs 79.5%).
 Conclusion: Isolated oligohydramnios at term has been associated with an increased risk for caesarean delivery for fetal distress and adverse perinatal outcomes. Severe oligohydramnios is a sensitive predictor for the adverse perinatal outcome both in terms of fetal outcome and termination of pregnancy.

556 Resolved but not forgotten: does a diagnosis of resolved placenta previa affect labor and delivery?

Placenta previa (PP) is diagnosed in up to 15% of pregnancies at the anatomy ultrasound (US) and 0.5% persist to term. There is limited data regarding pregnancy outcomes with resolved previa (RPP). We aim to examine patients with RPP to determine if abnormal placentation at any time during pregnancy is associated with adverse events during labor. Anatomy US done at the Mount Sinai West Fetal Evaluation Unit between Mar 2018 - June 2020 were reviewed. Patients with PP were identified, included if PP resolved with placental edge >2cm from os, excluded if PP persisted to term, resolution occurred prior to 20 weeks, prior cesarean delivery or missing outcomes. Time matched controls identified among patients with normal placentation. Demographic data and outcomes collected. Student t-test, Wilcoxon rank-sum test, Chi-square, Fisher exact test, Univariable and multivariable logistic regression were used as appropriate A total of 8,881 US were performed, 560 with PP, 275 identified as RPP, 285 excluded. RPP patients were significantly older with lower pre pregnancy BMI. Patients with RPP were significantly more likely to be a current smoker, have used assisted reproductive technology, have had previous uterine surgeries (Table 1). Patients with RPP were 5.2 times more likely to have a post partum hemorrhage (PPH) (OR 5.2, 95% CI 2.1-12.7; p<0.01) and 3.4 times more likely to require extra uterotonic medications (OR 3.4, 95% CI 1.9-6.2; p<0.01). As the placental edge gets farther away from the os at resolution, the risk of PPH decreases (OR 0.9, 95% CI 0.9-1.0; p=0.03). There is no difference with regards to rates of operative delivery or cesarean delivery for fetal distress (OR 1.2, 95% CI 0.7-1.9; p=0.48), or Cat II/III fetal heart tracing at delivery. Patients with RPP had a higher rate of PPH and use of uterotonic agents. They were also more likely to have similar underlying risk factors of patients with persistent PP. This information might have important clinical implications and could be incorporated into the hemorrhage risk assessment during labor.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Ulcerated Arm Lesion in a 10-day-old Girl

1. Brittany Lehrer, MD* 2. Kyle Pronko, MD*,† 3. Alina G. Burek, MD*,† 1. *Medical College of Wisconsin, Milwaukee, WI 2. †Children’s Wisconsin, Milwaukee, WI 1. Address correspondence to Brittany Lehrer, MD, Children’s Corporate Center, Suite 730, 999 N 92nd St, Milwaukee, WI 53226. E-mail: blehrer{at}mcw.edu A 10-day-old girl presents with a progressive right upper extremity skin lesion. She was born large for gestational age at term via cesarean delivery for fetal distress. Pregnancy was complicated by diet-controlled gestational diabetes and a maternal history of genital herpes. The mother received prophylactic valacyclovir and no active herpes lesions developed during pregnancy. Immediately after birth, the infant was noted to have a 2-cm, tender, well-circumscribed area of erythema and induration over the right antecubital fossa. The extremity also had decreased movement, diminished radial pulse, and weak grasp reflex. Otherwise, she was well-appearing and her examination was normal. Radiographs of the forearm and clavicle were negative for fracture. She was diagnosed with hematoma and possible brachial plexus injury and discharged from the nursery on postnatal day 3 with the arm immobilized in a sling and acetaminophen as needed for pain. Since discharge from the nursery, the lesion has spread, ulcerated, and started draining malodorous white discharge, so the patient returns for evaluation on postnatal day 10. On physical examination, she has a poorly demarcated, erythematous, tender, indurated, circumferential plaque that extends from the mid-upper arm through the antecubital fossa to the mid-forearm. The center of the lesion is violaceous and ulcerated with white discharge (Fig 1). The affected extremity has decreased spontaneous movement, weak radial pulse, nearly absent grasp reflex, and she has pain with passive manipulation of the affected elbow. Her vital signs and the remainder of her physical examination are normal. Complete blood cell count with differential, procalcitonin, and c-reactive protein are within normal limits for age. Blood culture and herpes simplex virus polymerase chain reaction …

UMBILICAL ARTERY DOPPLER VERSUS NON-STRESS TEST IN HIGH RISK PREGNANCIES

Background: Maternal monitoring of fetal movement is a mean of screening fetal status. The rationale is based on the assumption that early recognition of decreased fetal movement (DFM) makes it possible for the clinician to intervene at a stage when the fetus is still compensated, and thus prevent progression to fetal or neonatal injury or death. Objective: To evaluate the role of non-stress test and umbilical artery Doppler measurements as an antenatal screening test for assessment of fetal well-being in high risk pregnancies affected by decreased fetal movements. Patients and methods: The current study enrolled 200 patients complaining of decreased fetal movements came for ante natal care in ante natal care clinic of Al Azhar Assiut University Hospital. Enrolled women were randomly allocated in two equal groups, the study continued for 1 year (from January 2019 – December 2019). Results: This study shows that the use of umbilical artery Doppler ultrasound assessment as an antenatal screening test was associated with a reduction in the incidence of cesarean delivery for fetal distress, more successful induction of labor, less admissions to NICU and better APGAR score in high risk pregnant population complaining of decreased fetal movement compared to non-stress test. Conclusion: Umbilical artery Doppler ultrasound assessment of the fetus in conjunction with a policy of directed intervention resulted in a decrease in the rate of cesarean delivery for fetal distress in a high-risk pregnancy, when compared with the NST.

UMBILICAL ARTERY DOPPLER VERSUS NON-STRESS TEST IN HIGH RISK PREGNANCIES

Background: Maternal monitoring of fetal movement is a mean of screening fetal status. The rationale is based on the assumption that early recognition of decreased fetal movement (DFM) makes it possible for the clinician to intervene at a stage when the fetus is still compensated, and thus prevent progression to fetal or neonatal injury or death. Objective: To evaluate the role of non-stress test and umbilical artery Doppler measurements as an antenatal screening test for assessment of fetal well-being in high risk pregnancies affected by decreased fetal movements. Patients and methods: The current study enrolled 200 patients complaining of decreased fetal movements came for ante natal care in ante natal care clinic of Al Azhar Assiut University Hospital. Enrolled women were randomly allocated in two equal groups, the study continued for 1 year (from January 2019 – December 2019). Results: This study shows that the use of umbilical artery Doppler ultrasound assessment as an antenatal screening test was associated with a reduction in the incidence of cesarean delivery for fetal distress, more successful induction of labor, less admissions to NICU and better APGAR score in high risk pregnant population complaining of decreased fetal movement compared to non-stress test. Conclusion: Umbilical artery Doppler ultrasound assessment of the fetus in conjunction with a policy of directed intervention resulted in a decrease in the rate of cesarean delivery for fetal distress in a high-risk pregnancy, when compared with the NST.

A study on perinatal outcome in oligohydramnios

Background: In Normal Pregancies, the volume of amniotic fluid increases to about one litre at 36 weeks maximum level. Amniotic fluid volume rises progressively during gestation until 36 weeks, the mean amniotic fluid volume relatively consistent in the level of 700-800ml. After 40 weeks there is a progressive decline of amniotic fluid volume at a rate of 8% per week, with amniotic fluid volume averaging about 400ml at 42 wks. The clinical picture of reduced amniotic volume is termed oligohydramnios. This present study is undertaken to asses the perinatal outcome in Amniotic fluid index of 5 cm or less (oligohydramnios) in term pregnancies.Objective: To determine the perinatal outcome in term pregnancies with Amniotic fluid index 5cms was carried out in, Government Kilpauk Medical College Hospital during the period of February 20016 to January 2017.Sample Size: About 150 cases in AFI < 5cms (Study Group) And 150 Cases in Control Group (AFI > 5cms).Results: In this study perinatal outcome in AFI 5cm or less compared with control group. About 150 cases were studied in each group. 87% in study group & 93% in control group were in the age group 20 - 30yrs.Conclusion: Oligohydramnios with reactive NST is associated with good prognosis (Good apgar, decreased NICU admission & neonatal death).Oligohydramnios with non reactive NST needs careful monitoring and eventuates in early delivery. It increases the incidence of caesarean delivery for fetal distress, NICU admission, low apgar at 5 mins and Neonatal death.Oligohydramnios associated with IUGR carries a poor perinatal outcome (Increased neonatal death, NICU admission, increased rate of CS for fetal distress, very low birth weight) Hence they need good neonatal care.

Diagnostic utility of maximum vertical pocket versus amniotic fluid index in assessing amniotic fluid volume for the prediction of adverse maternal and fetal outcomes: a systematic review and meta-analysis

Objective To compare the utility of maximum vertical pocket versus amniotic fluid index for predicting adverse perinatal outcomes. Methods Systematic review of randomized clinical studies comparing these two ultrasound techniques and random-effects meta-analysis to quantify a range of perinatal outcomes. Result Six studies with 4278 women were eligible. Use of the maximum vertical pocket reduced the rate of diagnosis of oligohydramnios (pooled relative risk 0.38; 95% confidence interval 0.27, 0.53). Use of the maximum vertical pocket was associated with significantly lower rates of non-reassuring fetal heart tracing, cesarean delivery for fetal distress, and induction of labor for oligohydramnios. There were no differences in the rates of cesarean delivery, presence of meconium, umbilical artery pH <7.1, 5-minute Apgar score <7, or admission to the neonatal intensive care unit. Conclusion The use of maximum vertical pocket is associated with a lower rate of pregnancy intervention without any worsening of adverse pregnancy outcomes.

Obesity, Second Stage Duration, and Labor Outcomes in Nulliparous Women.

This study aimed to estimate second stage duration and its effects on labor outcomes in obese versus nonobese nulliparous women. This was a secondary analysis of a cohort of nulliparous women who presented for labor at term and reached complete cervical dilation. Adjusted relative risks (aRR) were used to estimate the association between obesity and second stage characteristics, composite neonatal morbidity, and composite maternal morbidity. Effect modification of prolonged second stage on the association between obesity and morbidity was assessed by including an interaction term in the regression model. Compared with nonobese, obese women were more likely to have a prolonged second stage (aRR: 1.48, 95% CI: 1.18-1.85 for ≥3 hours; aRR: 1.65, 95% CI: 1.18-2.30 for ≥4 hours). Obesity was associated with a higher rate of second stage cesarean (aRR: 1.78, 95% CI: 1.34-2.34) and cesarean delivery for fetal distress (aRR: 2.67, 95% CI: 1.18-3.58). Obesity was also associated with increased rates of neonatal (aRR: 1.38, 95% CI: 1.05-1.80), but not maternal morbidity (aRR: 1.06, 95% CI: 0.90-1.25). Neonatal morbidity risk was not modified by prolonged second stage. Obesity is associated with increased risk of neonatal morbidity, which is not modified by prolonged second stage of labor.

Perinatal outcomes after intrauterine growth restriction and umbilical artery Doppler pulsatility index of less than the fifth percentile

Objective: To analyze perinatal morbidity and stillbirth after intrauterine growth restriction (IUGR) with an umbilical artery Doppler pulsatility index (UA PI) less than the fifth centile.Study design: This retrospective cohort study included nonanomalous singleton, IUGR pregnancies receiving UA PI testing at a tertiary-care prenatal diagnostic center. Women with persistently elevated UA PI, absent or reversed end-diastolic flow on UA PI, or who had only one UA PI result were excluded. Low UA PI was defined as having ≥1 UA PI <5%. Women with low UA PI were matched by gestational age at IUGR diagnosis in a random 1 case: 4 control computer-generated algorithm to those with normal UA PI (≤95% and ≥5%). The primary outcome was composite neonatal morbidity and mortality (stillbirth, mechanical ventilation, sepsis, intraventricular hemorrhage, and necrotizing enterocolitis). Secondary outcomes included 5-minute Apgar, umbilical artery pH, delivery type, and interval from IUGR diagnosis to delivery. We compared outcomes after low UA PI to those after normal UA PI with multivariable logistic regression, adjusting for gestational age at delivery, betamethasone use, infant gender, and maternal factors.Results: Of the 1893 IUGR pregnancies, 25 (1.3%) had low UA PI <5% and were randomly matched via computer algorithm to 100 controls. There were no stillbirths in either group; the odds of composite neonatal morbidity was similar among IUGR pregnancies with UA PI <5% versus normal (adjusted odds ratio 0.89 (95% confidence interval 0.27–2.75)). There was no difference in 5-minute Apgars, umbilical artery pH, rate of cesarean delivery for fetal distress, or interval from IUGR diagnosis to delivery between the two groups.Conclusion: Among IUGR pregnancies, UA PI <5% is uncommon and not associated with improved neonatal outcomes compared to normal UA PI. These findings suggest low UA PI can continue to be managed as normal UA PI.

Perinatal outcomes after intrauterine growth restriction and intermittently elevated umbilical artery Doppler

Intermittently elevated umbilical artery pulsatility index has been identified among pregnancies with intrauterine growth restriction but has unclear clinical significance. The purpose of this study was to analyze perinatal morbidity and stillbirth after intrauterine growth restriction with an intermittently elevated umbilical artery pulsatility index. This retrospective cohort study included nonanomalous singleton, intrauterine growth-restricted pregnancies that received umbilical artery pulsatility index testing at a tertiary-care prenatal diagnostic center from 2010-2016. Women with persistently elevated umbilical artery pulsatility index, absent or reversed end-diastolic blood flow on umbilical artery pulsatility index, or only 1 umbilical artery pulsatility index result were excluded. Intermittently elevated umbilical artery pulsatility index was defined as ≥1 elevated umbilical artery pulsatility index (>95%) and ≥1 normal umbilical artery pulsatility index (≤95%). Women with an intermittently elevated umbilical artery pulsatility index were matched 1:3 by gestational age at intrauterine growth restriction diagnosis to those with a normal umbilical artery pulsatility index. The primary outcome was composite neonatal morbidity and deaths (stillbirth, mechanical ventilation, sepsis, intraventricular hemorrhage, and necrotizing enterocolitis). Secondary outcomes included 5-minute Apgar score, umbilical artery pH, delivery type, and interval from intrauterine growth restriction diagnosis to delivery. We compared outcomes after intermittently elevated umbilical artery pulsatility index with those after normal umbilical artery pulsatility index with multivariable logistic regression, adjusting for gestational age at delivery, betamethasone use, and maternal factors. Of 1893 women, 143 (7.6%) had an intermittently elevated umbilical artery pulsatility index and were matched to 429 control subjects. Among the 143 women with an intermittently elevated umbilical artery pulsatility index, 78 (54.5%), 52 (36.4%), and 13 (0.9%) women had elevated umbilical artery pulsatility index for 1-24%, 25-49%, and 50-74% of recorded Doppler measurements, respectively. None of the women had an elevated umbilical artery pulsatility index for 75-99% of recorded umbilical artery pulsatility index measurements. The last recorded umbilical artery pulsatility index was elevated for 37 women with an intermittently elevated umbilical artery pulsatility index (25.9%). Overall, the odds of composite neonatal morbidity was similar among intrauterine growth-restricted pregnancies with an intermittently elevated vs a normal umbilical artery pulsatility index (adjusted odds ratio, 1.05; 95% confidence interval, 0.59-1.87); there were no stillbirths. There was no difference in 5-minute Apgar scores, umbilical artery pH, rate of cesarean delivery for fetal distress, or interval from intrauterine growth restriction diagnosis to delivery between the 2 groups. Similarly, sensitivity analyses that stratified the population of intermittently elevated umbilical artery pulsatility index by the proportion of elevated umbilical artery pulsatility index to overall umbilical artery pulsatility index measurements and by whether the last umbilical artery pulsatility index recorded was normal or elevated showed no difference in neonatal morbidity or obstetric outcomes between the comparator groups. Among intrauterine growth-restricted pregnancies, an intermittently elevated umbilical artery pulsatility index is neither uncommon nor associated with an increased risk of neonatal morbidity, stillbirth, or cesarean delivery. These findings suggest intrauterine growth-restricted pregnancies with intermittently elevated umbilical artery pulsatility index could be managed clinically as are those with normal umbilical artery pulsatility index.

Middle cerebral artery Doppler pulsatility index as a predictor of intrapartum meconium release in prolonged pregnancies.

The aim of this study was to asses the correlation of middle cerebral artery pulsatility index (MCA-PI) and perinatal outcomes in prolonged pregnancies. This was a prospective study of all consecutive pregnant women beyond 41 weeks' gestation attending for obstetric surveillance during a two years period. We evaluated the predictive value of MCA-PI lower than the 5th percentile (<p5) and the occurrence of: cesarean delivery for fetal distress, 5-min Apgar score <7, arterial cord pH < 7.15, presence of thick meconium at delivery, need for admission to the neonatal intensive care and/or neonatal death. Three hundred and one pregnancies met the inclusion criteria and were managed expectantly. Of them, 31 (10.3%) fetuses had an MCA-PI < p5, which showed a significant relationship with the presence of thick meconium at birth (p < 0.001), but was not related to any of the other perinatal outcomes. In prolonged pregnancies, the finding of MCA-PI < p5 is related to meconium emission at the time of delivery, but is not associated with an increased risk of adverse perinatal outcome.

246: Are intermittently elevated UA Doppler Pulsatility Indices associated with increased risk of neonatal morbidity in pregnancies with intrauterine growth restriction?

Intrauterine growth restriction (IUGR) with persistently elevated umbilical artery Doppler Pulsatility Index (UA PI) (>95%) is associated with an increased risk of perinatal morbidity compared to IUGR with normal UA PI (≤95%). Clinically, intermittently elevated UA PI is observed, but the clinical significance is unknown. We aimed to estimate the risk of neonatal morbidity with intermittently elevated UA PI. This retrospective cohort study included all non-anomalous singleton, IUGR pregnancies receiving UA PI testing at a tertiary care prenatal diagnostic center from 01/2010-09/2016. Intrauterine growth restriction was defined as an estimated fetal weight ≤ 10% for gestational age. Women with consistently elevated UA PI or absent or reversed flow were excluded. Intermittently elevated UA PI was defined as having ≥1 UA PI >95% and ≥1 UA PI ≤95%. Women with intermittently elevated UA PI were matched 1:3 by gestational age at IUGR diagnosis to those with consistently normal UA PI. The primary outcome was a composite neonatal morbidity including ventilation, phototherapy, intraventricular hemorrhage, and necrotizing enterocolitis. Secondary outcomes included individual components of the composite, 5-minute APGAR score, umbilical cord artery pH, type of delivery, and interval from diagnosis of IUGR to delivery. 1893 women were included; of these, 143 (7.6%) had intermittently elevated UA PI and were matched to 452 controls. The risk of composite neonatal morbidity was not significantly different among IUGR pregnancies with intermittently elevated versus normal UA PI. Similarly, the individual components of the composite neonatal morbidity were not significantly different between the two groups. Intermittently elevated UA PI was not associated with differences in 5-minute APGAR scores, umbilical artery pH, rates of cesarean delivery (CD) or CD for fetal distress, or interval from diagnosis of IUGR to delivery. Intermittently elevated UA PI is not uncommon among IUGR pregnancies but is not associated with an increased risk of neonatal morbidity or CD. These data suggest intermittently elevated UA PI should be managed clinically as normal UA PI.

Study of the Significance of Fetal Doppler Flow Velocimetry in the Perinatal Outcome of Growth-restricted Fetuses

ABSTRACTPurposeTo evaluate clinically suspected cases of intrauterine growth restriction (IUGR) for Doppler study of uterine artery, umbilical artery, and fetal middle cerebral artery. To compare the various indices of the three vessels in predicting perinatal outcome. To evaluate the positive predictive value among these parameters. To compare the Doppler findings with fetal outcome.Materials and methodsOne hundred and two singleton pregnancies complicated by IUGR and severe preeclampsia or both were prospectively examined with Doppler ultrasound of the umbilical artery, middle cerebral artery, and umbilical vein which were compared with 104 uncomplicated pregnancies that formed the control group.Observation and ResultsOne hundred and two singleton pregnancies included in the study population had at least one major or minor adverse outcome. Major adverse outcome criteria included perinatal deaths — including intrauterine and early neonatal deaths, etc. Minor outcomes included cesarean delivery for fetal distress, APGAR score below 7 at 5 minutes, and admission to neonatal intensive care unit for treatment.ConclusionLow diastolic and high indices characterize the pregnancies with abnormal outcomes. The uterine artery had a better sensitivity and specificity as compared with the umbilical arteries and diastolic notch had the highest sensitivity and specificity. Doppler also provides a noninvasive method of assessing the fetal and maternal circulation during pregnancy.How to cite this articleKumar V, Sharma G, Khan S, Singhania A, Singhania S. Study of the Significance of Fetal Doppler Flow Velocimetry in the Perinatal Outcome of Growth-restricted Fetuses. Int J Infertil Fetal Med 2017;8(2):83-88.

Obstetric practice patterns in pregnancies complicated by fetal trisomy 13 or 18

Purpose: Describe practice patterns among obstetrician/gynecologists (OB/GYNs) when caring for women with pregnancy complicated by fetal trisomy 13 (T13) or 18 (T18) and compare these between maternal–fetal medicine (MFM) and non-MFM providers. Materials and methods: We conducted an electronic survey using the American College of Obstetricians and Gynecologists database. Using simple statistics, we describe demographics and practice patterns among respondents and compare those of MFM practitioners with non-MFM providers. Results: The survey was sent to 300 individuals, 161 individuals verified email receipt, and 105 had complete response and were included. The median age was 58 (IQR 53,62). Sixty percent were female, 69% were private practice, and 38% were MFM. All providers were more likely to offer than to recommend antenatal and intrapartum interventions. MFMs were more likely to offer growth ultrasounds and neonatal hospice consults (53% vs. 29%, p = .02; 88% vs. 60%, p < .01). During labor, MFMs were more likely offer no fetal heart rate monitoring, (90% vs. 52%, p < .01), 60% of all providers offer breech vaginal delivery; 32% offer cesarean delivery for fetal distress. Conclusion: Many providers offer antepartum and intrapartum interventions for pregnancies complicated by T13/18. We recommend that providers elicit each woman’s goals for pregnancies complicated by T13/18 and tailor management options to meet these goals.

Oligohydramnios in complicated and uncomplicated pregnancy: a systematic review and meta-analysis.

To evaluate adverse pregnancy outcomes in singleton pregnancies diagnosed with oligohydramnios through a systematic review and meta-analysis of controlled trials. We searched electronic databases via OVID, EBSCO, Web of Science, Google Scholar and others from 1980 to 2015. Prospective and retrospective studies with a control group were included. Two authors independently reviewed the abstracts from the literature search. Inclusion criteria were: studies in English, singleton pregnancy, normal fetal anatomy, intact membranes and oligohydramnios determined by the amniotic fluid index (AFI) technique. We stratified the meta-analysis into two groups according to risk: high risk including studies of oligohydramnios with comorbid conditions (e.g. hypertension) and low risk including studies of isolated oligohydramnios. Fifteen trials met the inclusion criteria. Nine were high-risk and six were low-risk studies, including 8067 and 27 526 women, respectively. Compared with women with normal AFI, those with isolated oligohydramnios had significantly higher rates of an infant with meconium aspiration syndrome (relative risk (RR), 2.83; 95% CI, 1.38-5.77), Cesarean delivery for fetal distress (RR, 2.16; 95% CI, 1.64-2.85) and admission to the neonatal intensive care unit (NICU) (RR, 1.71; 95% CI, 1.20-2.42). Patients with oligohydramnios and comorbidities were more likely to have an infant with low birth weight (RR, 2.35; 95% CI, 1.27-4.34). However, rates of 5-min Apgar score < 7 (RR, 1.85; 95% CI, 0.69-4.96), NICU admission (RR, 2.09; 95% CI, 0.80-5.45), meconium-stained amniotic fluid (RR, 1.32; 95% CI, 0.62-2.81) and Cesarean delivery for fetal distress (RR, 1.65; 95% CI, 0.81-3.36) were similar to those for women with normal AFI. Stillbirth rates were too low to analyze in the meta-analysis. This review helps to delineate which adverse outcomes are increased with oligohydramnios in low-risk pregnancy (NICU admission, Cesarean delivery for fetal distress and meconium aspiration syndrome), but does not provide enough data to determine the optimal timing of delivery in such cases. Oligohydramnios in complicated pregnancy is associated with an increased risk of delivery of an infant with low birth weight, but this may be confounded by the comorbid condition. Therefore, in high-risk pregnancy, management should be dictated by the comorbid condition and not the presence of oligohydramnios. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Does ST analysis of fetal ECG reduce cesarean section rate for fetal distress?

Objective: Each pregravidic, gestational or intrapartum complication may, per se, have a different impact on the operative delivery rate, regardless of which fetal monitoring system was adopted. We wanted to verify if CTG plus ST interval analysis (STAN) of fetal ECG might be able to reduce the number of operative delivery for fetal distress in high-risk pregnancies compared to low-risk women monitored with CTG alone.Materials and methods: In this cohort study, we evaluated 100 high-risk pregnancies consecutively with STAN® S31 (Neoventa Medical, Gotenburg, Sweden) and 160 low-risk pregnancies consecutively with continuous CTG (Hewlett Packard, 50 IP, Palo Alto, CA).Results: We found that STAN monitoring, although associated with a higher total operativity rate, both vaginal (11% versus 3.12%, p = 0.015) and cesarean (17% versus 4.37%, p = 0.001), reduced the cesarean section rate performed for fetal distress (29.41% versus 85.71%, p = 0.023) compared with low-risk CTG monitoring group.Conclusion: CTG plus ST interval analysis of fetal ECG reduced the risk of operative cesarean delivery for fetal distress in high-risk gestations.

Placental and fetal hemodynamics in prolonged pregnancies.

We hypothesized that Doppler measurements of the placental and fetal central and peripheral hemodynamics would predict adverse outcomes in prolonged uncomplicated singleton pregnancies. A total of 160 participants were recruited to this study. Doppler measurements of placental and fetal hemodynamics as well as cardiotocography (CTG) were assessed prior to induction of labor at >41+ weeks. CTG during delivery, umbilical artery (UA) pH and base excess at birth and neonatal data were evaluated. In 16% of cases the outcome was unfavorable, defined as UA pH <7.10, 5-min Apgar score <7, cesarean delivery for fetal distress and/or need for admission to neonatal intensive care. There were no differences in the pulsatility indices of the uterine and umbilical arteries, middle cerebral artery, descending aorta, ductus venosus and inferior vena cava between the groups with favorable and unfavorable outcome. In addition, the ventricular inflow patterns, outflow velocities of the great arteries, cardiac outputs and myocardial performance indices were similar between the groups. Doppler parameters of the placental and fetal central and peripheral hemodynamics do not differ prior to the induction of labor in prolonged pregnancies with favorable and unfavorable outcomes. This suggests that their value is limited and that other clinical tools are needed for intermittent fetal surveillance in prolonged pregnancies. © 2016 John Wiley & Sons, Ltd.

Spontaneous rupture of renal angiomyolipoma in the third trimester

Angiomyolipoma (AML) is an uncommon benign tumor with the following three histologic features: adipocytes, smooth-muscle cells, and blood vessels with thickened walls [1]. It is more prevalent inwomen than inmen, suggesting that female hormones play a role in its growth. Most renal AMLs are asymptomatic and are found incidentally during imaging examination. Occasionally, however, patients have severe symptoms. The risk of spontaneous rupture during pregnancy is higher than that seen in nonpregnant women, and this complication can be catastrophic [2]. In addition, AML poses a difficult diagnostic and therapeutic challenge during pregnancy. We herein report a rare case of spontaneous renal AML rupture during pregnancy. We would like to remind obstetricians that this neoplasm should be considered when patients present with sudden-onset abdominal and back pain with hypotension or shock. A 31-year-old primiparous woman presented to our hospital at 37 weeks' gestationwith sudden-onset right upper abdominal pain radiating to her back; there were no other symptoms. The entire lower abdomen was tender, but the pain was more severe on the right side. The fetal heart rate was 50e70 beats/min, prompting emergency cesarean delivery for fetal distress. The 1and 5-minute Apgar scores were 8 and 10, respectively. During surgery, a long, narrow hematoma was noted at the mesentery and in the retroperitoneum. The patient's general condition was good, and her preoperative hemoglobin (Hb) level was 11.0 g/dL, but we opted for a nonexhaustive exploration of the retroperitoneal space due to the risk of rupture associated with handling this hematoma. The cesarean was completed, and computed tomography (CT) was suggested to the patient, but she declined. Her postoperative clinical