Composite Adverse Perinatal Outcome Research Articles

Perinatal outcome of oligohydramnios in academic hospitals in a low resource setting.

Oligohydramnios has been a topical issue in obstetrics. The prevalence of oligohydramnios ranges from 1 to 5%. Conflicting data exists concerning its effects on adverse perinatal outcome. This study aims to assess perinatal outcomes of oligohydramnios at the Mekelle Public Hospitals from April 1, 2018 - March 31, 2019. This was a cross-sectional study and a total population purposive sampling method was employed to collect data prospectively. During the study period, there were a total of 10,451 deliveries in both hospitals. Oligohydramnios complicated 332 pregnancies (3.2%, 95%CI: 2.9%, 3.5%) across all gestations and 273 pregnancies (2.6%, 95% CI: 2.3%, 2.9%) at term. The composite adverse perinatal outcome rate was 29.7% (95% CI, 24.5, 35.4). Primigravidity and presenting at post-term gestation were associated with adverse perinatal outcome. Nearly 70% of mothers gave birth via Cesarean delivery. Oligohydramnios was found to be associated with a significant increase in adverse newborn and maternal outcomes in the study setting. Although a significant proportion of mothers underwent Cesarean delivery for a perceived increased complications associated with vaginal delivery in this population of patients, Cesarean delivery was found to not improve perinatal outcome. Primigravids and postdated pregnancies must receive increased surveillance to detect oligohydramnios early and to institute appropriate and timely interventions. Indications for Cesarean delivery in patients complicated by oligohydramnios must be carefully examined to balance the benefit on the perinatal outcome on the one hand and to avoid unnecessary major surgery with potential fatal maternal complications on the other.

Cost-effectiveness analysis of induction of labour at 41 weeks and expectant management until 42 weeks in low risk women (INDEX trial).

To assess the cost-effectiveness of elective induction of labour (IOL) at 41 weeks and expectant management (EM) until 42 weeks. Cost-effectiveness analysis from a healthcare perspective alongside a randomised controlled trial (INDEX). 123 primary care midwifery practices and 45 obstetric departments of hospitals in the Netherlands. We studied 1801 low-risk women with late-term pregnancy, randomised to IOL at 41 weeks (N=900) or EM until 42 weeks (N=901). The incremental cost-effectiveness ratio (ICER) was expressed as the ratio of the difference in costs and the difference in main perinatal outcomes. A Cost-Effectiveness Acceptability Curve (CEAC) was constructed to assess whether induction is cost-effective for a range of monetary values as thresholds. We performed subgroup analysis for parity. Direct medical costs, composite adverse perinatal outcome (CAPO) (perinatal mortality, NICU admission, Apgar 5min < 7, plexus brachialis injury and/or meconium aspiration syndrome) and composite severe adverse perinatal outcome (SAPO) (including Apgar 5min < 4 instead of < 7). The average costs were €3858 in the induction group and €3723 in the expectant group (mean difference €135; 95 % CI -235 to 493). The ICERs of IOL compared to EM to prevent one additional CAPO and SAPO was €9436 and €14,994, respectively. The CEAC showed a 80 % chance of IOL being cost-effective with a willingness-to-pay of €22,000 for prevention of one CAPO and €50,000 for one SAPO. Subgroup analysis showed a willingness-to-pay to prevent one CAPO for nulliparous of €47,000 and for multiparous €190,000. To prevent one SAPO the willingness-to-pay is €62,000 for nulliparous and €970,000 for multiparous women. Induction at 41 weeks has an 80 % chance of being cost-effective at a willingness-to-pay of €22,000 for prevention of one CAPO and €50,000 for prevention of one SAPO. Subgroup analysis suggests that induction could be cost-effective for nulliparous women while it is unlikely cost-effective for multiparous women.Cost-effectiveness in other settings will depend on baseline characteristics of the population and health system organisation and funding.

Severe Smallness as Predictor of Adverse Perinatal Outcome in Suspected Late Small-for-Gestational-Age Fetuses: Systematic Review and Meta-analysis

ABSTRACT Various adverse perinatal outcomes, such as neonatal morbidity, fetal death, suboptimal neurodevelopment, and delayed effects as an adolescent and adult, are associated with fetal growth restriction (FGR). Failure to detect this condition prenatally is recognized as a contributor to avoidable perinatal death. This systematic review and meta-analysis assessed the evidence regarding the use of severe smallness (eg, birth weight &lt;3%ile) for prediction of adverse perinatal outcome in fetuses with suspected late-onset small for gestational age (SGA) birth. Study eligibility included third-trimester singleton pregnancies with suspected SGA fetuses, based on an estimated fetal weight (EFW) or abdominal circumference &lt;10th percentile, diagnosed at or after 32 weeks' gestation. Included studies were both retrospective cohort studies and randomized controlled trials and reported on the following outcomes: (1) admission to the neonatal intensive care unit (NICU); (2) neonatal acidosis; (3) cesarean delivery for intrapartum fetal compromise; (4) Apgar score &lt;7 at 5 minutes; (5) perinatal death (including stillbirth and neonatal death within 48 hours after birth); and (6) composite adverse perinatal outcome. The analysis identified a total of 6541 articles via database search, and 1 additional study was identified manually. A final review resulted in the inclusion of 12 cohort studies. The studies included 3639 fetuses with suspected late-onset SGA, of which 1246 had severe SGA &lt;3%ile. Significant associations were found between suspected severe SGA and the composite adverse perinatal outcome, with an odds ratio (OR) of 1.97 (95% confidence interval [CI], 1.33–2.92), NICU admission (OR, 2.87; 95% CI, 1.84–4.47), and perinatal death (OR, 4.26; 95% CI, 1.07–16.93). However, the analysis found limited performance of suspected severe SGA to predict perinatal outcomes, with an area under the curve of 60.9% for the composite adverse perinatal outcome. The meta-analysis results indicate that the performance of severe SGA in the study was poorer than that reported for uterine artery Doppler and cerebroplacental ratio. The current analysis found a positive and negative likelihood ratio of 1.53 and 0.76, respectively, for composite adverse perinatal outcome associated with severe smallness. Despite its association with a higher risk of perinatal complications, suspected severe SGA failed to perform as a standalone parameter for the prediction of adverse perinatal outcome.

The Impact of Labour Induction at 38-39 Weeks Period of Gestation versus Expectant Management in Low Risk Pregnancies

Background: The recommendations for induction of labour have been restricted to postdated pregnancies, though many studies have assessed the safety of elective induction at term. The aim of the current study was to assess the outcomes of elective induction of labour at 38-39 weeks period of gestation among low risk pregnancies. Methodology: This was a hospital based observational study, on 134 subjects assessed for fetal well-being and induced based on Bishop’s score. The labour and perinatal outcomes were compared between pregnant women subjected to elective induction of labour &amp; expectant group. Results: Of the 67 subject in the electively induced group, 28.4% delivered by a caesarean section in comparison to 31.3% of the 67 subjects in the expectant group (p-0.143). The mode of delivery in either of the groups was independent of the method of induction &amp; parity. The mean induction to delivery time, maternal outcomes and duration of hospital stay was similar in the 2 groups. Fetal outcomes analyzed by NICU admissions was similar in the 2 groups (p-0.635), though the admissions were significantly more in the electively induced group who underwent caesarean section (p-0.001). Conclusion: Induction of Labour at 38-39 weeks in low-risk women did not result in increase in caesarean section or composite adverse perinatal outcomes. Our data may help low-risk women and their clinicians make decisions regarding benefits of induction of labour at term in an institutional setting.

Factors associated with adverse obstetric events following induction of labour: a retrospective study in a tertiary hospital in Ghana.

Induction of labour (IOL) remains an indispensable intervention in obstetric practice; however, it may be associated with significant untoward perinatal outcomes. This study determined the major adverse outcomes of IOL and the associated factors at a tertiary hospital in Ghana. Retrospective study involving women with singleton gestations, conducted at the Korle Teaching Hospital in Ghana. Multivariable logistic regression was used to explore the factors associated with adverse outcomes of IOL. A total of 195 women who had IOL were analysed with 161 (82.6%) and 34 (17.4%) undergoing vaginal and caesarean deliveries respectively. The main IOL methods used included Misoprostol (91.3%), Oxytocin (5.1%) and Foley's catheter (3.6%). Composite adverse perinatal outcomes occurred in 46 neonates (23.6%) comprising perinatal deaths (7.2%) and or NICU admission (21.0%). Caesarean delivery following IOL was significantly associated with nulliparity, gestational age <41 weeks, hypertensive disorders in pregnancy and birth weight ≥3.5kg. Gestational age <41 weeks and birth weight <2.5kg were significantly associated with adverse perinatal outcome. Five women (2.6%) had uterine rupture all of which occurred in the misoprostol group. Induction of labour may result in significant perinatal complications which are related to both maternal (nulliparity and hypertension) and fetal (gestational age and birth weight) factors. Strict selection criteria and continuous fetal-maternal monitoring are strongly recommended to improve the birth outcomes of IOL.

Safety of COVID-19 vaccination in pregnant women: A study of the adverse perinatal outcomes.

To compare adverse perinatal outcome among coronavirus disease 2019 (COVID-19)-vaccinated and -unvaccinated pregnant women. Retrospective equivalence cohort study comparing 930 women who received at least one BNT162b2 (Pfizer/BioNTech) COVID-19 vaccine during the second or third trimester of pregnancy and 964 unvaccinated women. The primary outcome was a composite adverse perinatal outcome including at least one of the following: preterm delivery <35 weeks of gestation, intrauterine fetal death >23 weeks of gestation, intrauterine growth restriction defined as birth weight < 10th percentile, 5-min APGAR score ≤ 7, and neonatal care unit admission. The authors found no effect of the COVID-19 vaccine on the rate of the individual adverse perinatal outcomes. At least one adverse perinatal outcome was found in 108 (11.25%) of unvaccinated women versus 82 (8.82%) of vaccinated pregnant women (P= 0.080). The observed proportion difference (unvaccinated minus vaccinated) was 0.024. In the equivalence analysis with a margin of 0.05, the 90% confidence interval (0.01-0.05) was entirely within the equivalence zone (-0.05 to 0.05) with a P value of 0.032. The present study demonstrated an equivalent rate of adverse perinatal outcomes among vaccinated and unvaccinated women, thus supporting vaccine safety during the second and third trimesters of pregnancy. The authors believe this information is useful in counseling pregnant women regarding COVID-19 vaccination during pregnancy.

Usefulness of angiogenic factors in prenatal counseling of late-onset fetal growth-restricted and small-for-gestational-age gestations: a prospective observational study.

To create a predictive model including biomarkers and evaluate its ability to predict adverse perinatal outcomes in late-onset small fetuses, ultimately helping to provide individualized counseling at the time of diagnosis. This was a prospective observational study, including singleton pregnancies with an estimated fetal weight (EFW) below the 10th percentile, at a gestational age between 32 + 0 and 36 + 6weeks of gestation (WG). Variables recorded at diagnosis to predict adverse pregnancy outcomes were: soluble fms-like tyrosine-kinase-1 to placental growth factor ratio (sFlt-1/PlGF), fetal Doppler (umbilical artery and middle cerebral artery), uterine artery pulsatility index (UtAPI), EFW percentile, gestational age, and the presence of maternal risk factors for placental insufficiency. Logistic regression models were developed for the prediction of three co-primary outcomes: composite adverse perinatal outcomes (APO), and the need for elective delivery before 35 or 37 WG. Sixty (52.2%) fetal growth restricted (FGR) and 55 (47.8%) small for gestational age (SGA) were enrolled. Thirteen (11.3%) women needed elective delivery before 35 WG and 27 (23.5%) women before 37 WG. At least one APO occurred in 43 (37.4%) pregnancies. The best marker in univariate analyses was the sFlt-1/PlGF ratio [AUC = 0.932 (95% CI, 0.864-0.999)]. The multivariate model including sFlt-1/PlGF showed a better predictive performance for APO than the multivariate model without sFlt-1/PlGF (P < 0.024). sFlt-1/PlGF is a good predictor of APO at the time of late-onset FGR/SGA diagnosis. Our predictive models may be useful to provide early individualized prenatal counseling in this group of women. Further studies are needed to validate these preliminary findings in a larger cohort.

Role of myocardial performance index (MPI) and cerebro-placental ratio (CPR) in predicting adverse perinatal outcome.

This study aimed to evaluate the association of the Myocardial Performance Index (MPI) and Cerebro-Placental Ratio (CPR) in predicting adverse perinatal outcomes in fetuses who are appropriately-grown (AGA), small-for-gestational-age (SGA) and growth restricted (FGR). Singleton pregnancies were recruited after 24weeks. The patients were recruited after having been classified as AGA (AC/EFW>10thcentile), SGA (AC/EFW-3rd-10thcentile without doppler abnormalities), and FGR (AC/EFW<3rdcentile or 3rd-10thcentile with doppler abnormalities). A total of 103 cases comprising 48 AGA, 11 SGA, and 44 FGRfetuses were recruited. The Pulsatility Index of the Umbilical artery, Middle cerebral artery, Ductus Venosus, and Aortic Isthmus was obtained. MPI and CPR were calculated too. The primary outcome was to evaluate the predictive value of MPI and CPR for the composite adverse perinatal outcome. The mean gestational age of recruitment was 30weeks. The OR for Composite Adverse Perinatal Outcome in FGR groupfor MPI>.47 and CPR<1.67was 3.48 (95% CI: 1.00-12.24, p-value<.05)with sensitivity and specificity of 65% each and 11.08 (95% CI: 2.62-46.83, p-value=.001)with the sensitivity of 82% and specificity of 70%, respectively. When combined together, MPI and CPR yielded an OR of 58.5 (95% CI: 4.58-746.57, p-value=.002) with a sensitivity of 56.5% and specificity of 95% in the FGR group. MPI in conjunction with CPR can be used together to predict adverse perinatal outcomes in FGR.

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.

Elective induction of labour and expectant management in late-term pregnancy: A prospective cohort study alongside the INDEX randomised controlled trial.

ObjectiveTo assess adverse perinatal outcomes and caesarean section of low-risk women receiving elective induction of labour at 41 weeks or expectant management until 42 weeks according to their preferred and actual management strategy.DesignMulticentre prospective cohort study alongside RCT.Setting90 midwifery practices and 12 hospitals in the Netherlands.Population3642 low-risk women with uncomplicated singleton late-term pregnancy.Main outcome measuresComposite adverse outcome (perinatal death, Apgar score 5′ < 7, NICU admission, meconium aspiration syndrome), composite severe adverse perinatal outcome (all above with Apgar score 5′ < 4 instead of < 7) and caesarean section.ResultsFrom 2012–2016, 3642 women out of 6088 eligible women for the INDEX RCT, participated in the cohort study for observational data collection (induction of labour n = 372; expectant management n = 2174; unknown preference/management strategy n = 1096).Adverse perinatal outcome occurred in 1.1 % (4/372) in the induction group versus 1.9 % (42/2174) in the expectant group (adjRR 0.56; 95 %CI: 0.17–1.79), with severe adverse perinatal outcome occurring in 0.3 % (1/372) versus 1.0 % (22/2174), respectively (adjRR 0.39; 95 % CI: 0.05–2.88). There were no stillbirths among all 3642 women; one neonatal death occurred in the unknown preference/management group. Caesarean section rates were 10.5 % (39/372) after induction and 8.9 % (193/2174) after expectant management (adjRR 1.32; 95 % CI: 0.95–1.84).A higher incidence of adverse perinatal outcome was observed in nulliparous compared to multiparous women. Nulliparous 1.8 % (3/170) in the induction group versus 2.6 % (30/1134) in the expectant management group (adjRR 0.58; 95 % CI 0.14–2.41), multiparous 0.5 % (1/201) versus 1.1 % (11/1039) (adjRR 0.54; 95 % CI 0.07–24.19). One maternal death due to amniotic fluid embolism occurred after elective induction at 41 weeks + 6 days.ConclusionIn this cohort study among low-risk women receiving the policy of their preference in late-term pregnancy, a non-significant difference was found between induction of labour at 41 weeks and expectant management until 42 weeks in absolute risks of composite adverse (1.1 % versus 1.9 %) and severe adverse (0.3 % versus 1.0 %) perinatal outcome. The risks in this cohort study were lower than in the trial setting. There were no stillbirths among all 3642 women. Caesarean section rates were comparable.

Clinical utility of aortic isthmus Doppler in the prediction of perinatal outcomes

Doppler studies of uteroplacental-fetal circulation have been proven useful in diagnosing fetal growth restriction, appropriately timing delivery, and improving perinatal morbidity and mortality. There has been an extensive search for the ideal means to identify fetuses between the compensatory and acidemic phase (ie, the "preacidemic phase"), and the aortic isthmus Doppler seems to show promise. This study aimed to investigate: (1) the prevalence of abnormal aortic isthmus Dopplers in a cohort of small-for-gestational-age fetuses and their correlation with other conventional Doppler abnormalities, and (2) the predictive ability of abnormal aortic isthmus Dopplers with regard to short-term adverse neonatal outcomes. Fetuses diagnosed as small-for-gestational-age at ≥24 weeks' gestation were included. Management was as per the standard protocol. Aortic isthmus Doppler was performed within a week of delivery with other conventional Dopplers. The adverse perinatal outcomes studied were: requirement of neonatal resuscitation at birth, Apgar score at 5 minutes <7, cord blood pH <7, presence of bronchopulmonary dysplasia, hypoxic-ischemic encephalopathy, grade III/IV intraventricular hemorrhage, necrotizing enterocolitis, sepsis, neonatal intensive care unit stay longer than 14 days, and stillbirth or neonatal death. Among 121 small-for-gestational-age fetuses, 67 showed Doppler abnormalities in ≥1 vessels. The prevalence of abnormal aortic isthmus Doppler was 14.87%. Analysis was between group 1 with 103 normal aortic isthmus and group 2 with 18 abnormal aortic isthmus fetuses; 41 cases had some form of adverse perinatal outcome, the frequency of which was comparable between the groups. Abnormal aortic isthmus Doppler had a significant correlation with low cerebroplacental ratio, absent or reversed end-diastolic flow in the umbilical artery, and high pulsatility index in the ductus venosus. The positive likelihood ratio for predicting composite adverse perinatal outcome was 10.2 for absent or reversed end-diastolic flow in the umbilical artery, 9.6 for low cerebroplacental ratio, 2.28 for absent or retrograde flow in the aortic isthmus, and 2 for abnormal ductus venosus. Predelivery abnormal aortic isthmus Dopplers performed worse than other conventional Dopplers in predicting abnormal perinatal outcomes.

Elective Induction of Labour at 39 Weeks Compared With Expectant Management in Nulliparous Persons Delivering in a Community Hospital

ObjectiveTo determine the impact of offering elective labour induction at 39 weeks gestation on perinatal and maternal outcomes in nulliparous people with low-risk pregnancies. MethodsThe charts of all pregnant people who delivered at Brockville General Hospital between September 2018 and December 2021 were retrospectively reviewed. Perinatal and maternal outcomes of low-risk nulliparous pregnant people who underwent elective induction at 39 weeks and over were extracted and compared with those of low-risk nulliparous pregnant people who underwent expectant management. Exclusion criteria included multiparous people, high-risk pregnancies, multiple gestations, deliveries at less than 39 weeks gestation, and elective cesarean deliveries. Univariate and multivariate analysis was performed. ResultsA total of 174 patients were included. Of these patients, 56 (32.2%) underwent elective induction of labour between 390 and 396 weeks gestation over the period of June 2020 to December 2021, whereas 118 (67.8%) were expectantly managed from 390 weeks gestation over the period of September 2018 to March 2020. Compared with expectant management, those in the 39+ weeks induction group had a significantly lower risk of cesarean delivery (odds ratio [OR] 0.39; 95% confidence interval [CI] 0.15–0.99), composite adverse maternal outcomes (OR 0.34; 95% CI 0.12–0.97), and composite adverse perinatal outcomes (OR 0.26; 95% CI 0.074–0.92). ConclusionOur results suggest that elective induction of labour at 39 weeks gestation and over in low-risk nulliparous people is associated with lower risks of cesarean delivery, composite adverse maternal outcomes, and composite adverse perinatal outcomes than expectant management.

Vaginal delivery of second twins: factors predictive of failure and adverse perinatal outcomes.

This study was performed to explore factors associated with adverse perinatal outcomes for second twins and to identify predictive factors for successful vaginal delivery of the second twin after vaginal delivery of the first twin. This 10-year retrospective study included 231 cases of twin pregnancies in which vaginal delivery of the second twin was attempted after vaginal delivery of the first twin. The relationships of obstetric characteristics with the composite adverse perinatal outcome of the second twin were analysed. Predictive factors for successful vaginal delivery of the second twin were also explored. Gestational age <32 weeks was the only independent risk factor for the composite adverse perinatal outcome and neonatal intensive care unit admission for the second twin. A longer inter-twin delivery interval was associated with greater risk of caesarean delivery of the second twin, but it did not increase the risk of an adverse perinatal outcome. Non-vertex presentation of the second twin at delivery was independently associated with caesarean delivery (9.0% vs 2.0%, P=0.03). For second twins in breech presentation, caesarean delivery was associated with the presence of less experienced birth attendants. Among second twins born to mothers who had attempted vaginal delivery, adverse perinatal outcomes were mainly related to prematurity. The presence of more experienced birth attendants may contribute to successful vaginal delivery of the second twin, particularly for twins in non-vertex presentation.

Severe smallness as predictor of adverse perinatal outcome in suspected late small-for-gestational-age fetuses: systematic review and meta-analysis.

To investigate the performance of severe smallness in the prediction of adverse perinatal outcome among fetuses with suspected late-onset small-for-gestational age (SGA). A systematic search was performed to identify relevant studies in PubMed, Web of Science and Scopus. Late-onset SGA was defined as estimated fetal weight (EFW) or abdominal circumference (AC) < 10th percentile diagnosed at or after 32 weeks' gestation, while severe SGA was defined as EFW or AC < 3rd percentile or < 2 SD. Random-effects modeling was used to generate hierarchical summary receiver-operating-characteristics (HSROC) curves. The performance of severe SGA (as a presumptive diagnosis) in predicting adverse perinatal outcome among singleton pregnancies with suspected late-onset SGA was expressed as area under the HSROC curve (AUC), sensitivity, specificity and positive/negative likelihood ratios. The association between suspected severe SGA and adverse perinatal outcome was also assessed by random-effects modeling using the Mantel-Haenszel method and presented as odds ratio (OR). The non-exposed group was defined as non-severe SGA (EFW ≥ 3rd centile). Twelve cohort studies were included in this systematic review and meta-analysis. The studies included a total of 3639 fetuses with suspected late-onset SGA, of which 1246 had suspected severe SGA. Significant associations were found between suspected severe SGA and composite adverse perinatal outcome (OR, 1.97 (95% CI, 1.33-2.92)), neonatal intensive care unit admission (OR, 2.87 (95% CI, 1.84-4.47)) and perinatal death (OR, 4.26 (95% CI, 1.07-16.93)). However, summary ROC curves showed limited performance of suspected severe SGA in predicting perinatal outcomes, with AUCs of 60.9%, 66.9%, 53.6%, 57.2%, 54.6% and 64.9% for composite adverse perinatal outcome, neonatal intensive care unit admission, neonatal acidosis, Cesarean section for intrapartum fetal compromise, low Apgar score and perinatal death, respectively. Although suspected severe SGA was associated with a higher risk of perinatal complications, it performed poorly as a standalone parameter in predicting adverse perinatal outcome. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Role of the cerebro-placental-uterine ratio in predicting adverse perinatal outcome in low-risk pregnancies at term

PurposeThe cerebroplacental ratio (CPR) is associated with adverse perinatal outcome (APO) in low-risk pregnancies near term. A Doppler parameter, which also includes information from the uterine vessels could potentially improve detection of subclinical placental dysfunction. The aim of this study is to investigate the performance of cerebro-placental-uterine ratio (CPUR) related to APO prediction in low-risk term pregnancies in > 40 + 0 weeks.MethodsThis is a retrospective cohort study. All low-risk pregnancies in which feto-maternal Doppler was examined from 40 + 0 weeks and an appropriate for gestational age fetus was present were included. ROC (receiver operating characteristic curves) analyses were performed to assess the predictive value of CPUR. The presence of at least one of the following outcome parameters was defined as composite APO (CAPO): operative delivery (OD) due to intrapartum fetal compromise (IFC), admission to the neonatal intensive care unit, umbilical cord arterial pH ≤ 7.15, 5 min APGAR ≤ 7.ResultsA total of n = 114 cases were included. Mean gestational age at examination and delivery were 40 + 3 weeks and 40 + 6 weeks, respectively. Overall, CAPO occurred in 38 of 114 cases (33.3%). ROC analyses showed a significant association of CPUR (AUC = 0.67, p = 0.004) and CPR (AUC = 0.68, p = 0.002) with CAPO. Additionally, CPUR (AUC = 0.64, p = 0.040) showed a predictive value for OD due to IFC.ConclusionThe CPUR in > 40 + 0 weeks showed a predictive value for CAPO and OD due to IFC in low-risk pregnancies. However, the extent to which CPUR can be used to optimize delivery management warrants further investigations in prospective interventional studies.

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.

Late-term fetuses with reduced umbilical vein blood flow volume: An under-recognized population at increased risk of growth restriction

ObjectivesTo investigate the umbilical vein and uterine arteries blood flow volume (UV-Q, UtA-Q) in late-term pregnancies. Study designThis was a prospective observational cohort study of singleton pregnancies ≥40 + 0 weeks in which UV-Q and UtA-Q, both absolute and normalized for estimated fetal weight (EFW) values, were evaluated in relation to AC drop of ≥20 percentiles from 20 weeks to term, Doppler signs of fetal cerebral blood flow redistribution and composite adverse perinatal outcome. The presence of neonatal hypoglycaemia and the need of formula milk supplementation were also examined. ResultsThe study population comprised 200 women. Fetuses with AC drop (n = 34) had a significantly lower UV-Q and UV-Q/EFW than fetuses without AC drop (n = 166): median UV-Q 184 ml/min (IQR 143–225) vs 233 ml/min (IQR 181–277), p = 0.0006; median UV-Q/EFW 55 ml/min/kg (IQR 42–66) vs 63 ml/min/kg (IQR 48–74), p = 0.03. Fetuses with cerebral blood flow redistribution (n = 48) had a significantly lower UV-Q and UV-Q/EFW than those without (n = 134): median UV-Q 210 ml/min (IQR 155–263) vs 236 ml/min (IQR 184–278), p = 0.04; median UV-Q/EFV 58 ml/min/kg (IQR 45–70) vs 65 ml/min/kg (IQR 50–76), p = 0.04. There was a significant moderate correlation between middle cerebral artery pulsatility index (MCA-PI) and UV-Q and UV-Q/EFW (Spearman Rho −0.20 and −0.20; p = 0.008 and p = 0.006). ConclusionsThe umbilical vein blood flow volume might have a potential role to identify fetuses with stunted growth in late-term pregnancies.

Impact of suspected late-onset fetal growth restriction on obstetrical interventions and perinatal outcomes at term; a retrospective cohort study

ObjectivesFirst, assess accuracy of late third trimester universal fetal growth screening in high risk nulliparous women with a singleton in vertex presentation at term. Second, assess instrumental delivery rates and perinatal outcomes in this population. Study designSingle centre retrospective cohort study in a teaching hospital, The Netherlands. ResultsIn a cohort of 1902 pregnancies, growth ultrasound after 33 weeks was moderately accurate in detecting children with a birthweight below the 10th centile with a sensitivity of 46.2% and a false positive rate of 4.7%. Induction of labour followed an antenatal suspicion of FGR more often than in the group with normal expected fetal weight (73.4% vs 52.6% OR 2.49 (1.88–3.3)) as could be expected from application of guidelines. The caesarean section rates was lowest in the group with suspected FGR compared to the group with expected normal fetal weight (15.2% vs 22.1% OR 0.63 (0.45–0.9)). There were no differences between both groups in rates of composite severe adverse perinatal outcome (0.7% vs 0.8% OR 0.87 (0.2–3.93)). ConclusionsThe detection of growth restriction using universal screening in term high risk nulliparous women with a singleton in vertex position is moderate. Despite this, caesarean section rates were not increased and perinatal outcomes were similar when compared to that found in the randomized controlled trial on which the recommendation for induction of labour for suspected term FGR is based. This supports universal late third trimester fetal growth screening in pregnancies under consultant-led care in the two tiers Dutch obstetrical system.

Ultrasound prediction of adverse perinatal outcome at diagnosis of late-onset fetal growth restriction.

ABSTRACTObjectiveTo evaluate the relationship between Doppler and biometric ultrasound parameters measured at diagnosis and perinatal adverse outcome in a cohort of late‐onset growth‐restricted (FGR) fetuses.MethodsThis was a multicenter retrospective study of data obtained between 2014 and 2019 including non‐anomalous singleton pregnancies complicated by late‐onset FGR (≥ 32 weeks), which was defined either as abdominal circumference (AC) or estimated fetal weight (EFW) < 10th percentile for gestational age or as reduction of the longitudinal growth of AC by over 50 percentiles compared to ultrasound scan performed between 18 and 32 weeks of gestation. We evaluated the association between sonographic findings at diagnosis of FGR and composite adverse perinatal outcome (CAPO), defined as stillbirth or at least two of the following: obstetric intervention due to intrapartum fetal distress, neonatal acidemia, birth weight < 3rd percentile and transfer to the neonatal intensive care unit (NICU).ResultsOverall, 468 cases with complete biometric and umbilical, fetal middle cerebral and uterine artery (UtA) Doppler data were included, of which 53 (11.3%) had CAPO. On logistic regression analysis, only EFW percentile was associated independently with CAPO (P = 0.01) and NICU admission (P < 0.01), while the mean UtA pulsatility index (PI) multiples of the median (MoM) > 95th percentile at diagnosis was associated independently with obstetric intervention due to intrapartum fetal distress (P = 0.01). The model including baseline pregnancy characteristics and the EFW percentile was associated with an area under the receiver‐operating‐characteristics curve of 0.889 (95% CI, 0.813–0.966) for CAPO (P < 0.001). A cut‐off value for EFW corresponding to the 3.95th percentile was found to discriminate between cases with and those without CAPO, yielding a sensitivity of 58.5% (95% CI, 44.1–71.9%), specificity of 69.6% (95% CI, 65.0–74.0%), positive predictive value of 19.8% (95% CI, 13.8–26.8%) and negative predictive value of 92.9% (95% CI, 89.5–95.5%).ConclusionsRetrospective data from a large cohort of late‐onset FGR fetuses showed that EFW at diagnosis is the only sonographic parameter associated independently with the occurrence of CAPO, while mean UtA‐PI MoM > 95th percentile at diagnosis is associated independently with intrapartum distress leading to obstetric intervention. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Prenatal imaging for the diagnosis of congenital Zika syndrome

Abstract Introduction: We aim to synthesize the best available evidence on the accuracy of prenatal imaging for the diagnosis of congenital Zika syndrome due to maternal Zika virus (ZIKV) infection. Specifically, we explored the factors that may influence diagnosis accuracy, such as geographic area, endemicity of ZIKA, operator, gestational age, and type of reference standard used. Methods and analysis Study selection criteria: All types of observational studies were included, that examined pregnant women with ZIKV infection (positive real time polymerase chain reaction or immunoglobulin M (IgM) serological tests and plaque neutralization reduction test). The index tests included prenatal imaging studies (ultrasound and/or magnetic resonance imaging). The reference standard was defined as follows: 1) perinatal death, including stillbirth and neonatal death within the first 48 h of birth, 2) neonatal intensive care unit admission, and 3) composite adverse perinatal outcomes. Case reports will be excluded if they only included fewer than five case. Sources of information: PubMed, Scopus, ISI Web of Science, and Google Scholar will be search from inception to March 2021. Two researchers will independently screen study titles and abstracts for eligibility, followed by full-text assessment. Data extraction will include population, settings, timing, and use of the index test and reference standard used. We will assess the methodological quality of the included studies and a meta-analysis will be performed to estimate summary statistics. Bivariate and hierarchical summary receiver operating characteristic modeling will be used to evaluate the diagnostic performance. The quality of evidence will be assessed by the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) metholody. Sources: This systematic review is funded by Secretaria Nacional de Ciencia y Tecnología-Panama. Ethics and dissemination: Ethical approval will not be necessary. Results will be published in a peer review scientific journal. Systematic review registration number in Prospero: CRD42020162914