Good Obstetric Outcome Research Articles

#2095 Genetic kidney disease in pregnancy – experience of tertiary referral hospital

Abstract Background and Aims Genetic kidney diseases (GKD) are rarely seen in pregnancy and some diagnosis will only be made during gestation, due to a high proportion of chronic kidney diseases (CKD) of unknown etiology and recent advances in genetic testing. Genetic counseling and, when possible, preimplantation genetic testing (PGT) should be offered pre-pregnancy to this specific CKD population. Method Retrospective analysis of maternal, obstetric and perinatal outcomes of pregnant women with GKD surveilled at Hospital Santa Maria, at the nephro-obstetric clinic from 2011 to 2023. Results We evaluated 34 pregnancies in 28 women, mean maternal age 30±6 years-old [21-37], 89% Caucasian. Molecular genetic testing was performed pre-pregnancy, during and post-pregnancy in 12/19, 2/19 and 5/19 patients, respectively. At baseline, mean serum creatinine (SCr) and proteinuria (Pr) was 1.0±0.9 mg/dL and 222±516 mg/g, with CKD stage 1/2/3/4/5 in 27/2/2/1/2 gestations and chronic hypertension (HTN) in 11/34 pregnancies. Only 1/28 patients performed PGT, while 1/28 patient declined it. De novo or increased Pr occurred in 10/34 gestations and de novo or worsening HTN in 5/34 gestations. Deterioration of renal function occurred in one patient (CKD3) without recovery and one patient (CKD5) induced dialysis 4 months post-pregnancy. Nephrotic Pr developed in 4/34 gestations. One patient (FSGS APOL1) was treated with tacrolimus and low dose steroids. The patient with TSC re-started sirolimus on week 22 to treat severe fetal ventricular rhabdomyoma. Miscarriage occurred in 2 pregnancies. The C section rate was 21,8%. There were 7 preterm deliveries of which 3 before 32 weeks of pregnancy, mainly due to severe preeclampsia. Mean gestational age at delivery was 37,6 ± 4 weeks (26-41), mean birth weight 2756 ± 831 g (560-3835). Eight newborns were admitted to neonatal ICU due prematurity, fetal TSC, and feeding difficulties. Pulmonary hemorrhage and sepsis caused the death of 2 newborns. We found 1 maternal death, due to rupture of a cerebral aneurism 1 month postpartum (PKD patient). Conclusion Our cohort was very heterogenous regarding CKD etiologies, but generally with good kidney function, which allowed overall good obstetric outcomes. Still, maternal, obstetric and fetal complications, namely HTN, Pr, PE and prematurity had an increased incidence compared to pregnancy in healthy patients. This particular population should be approached by an experienced multidisciplinary team in CKD pregnancy care to optimize outcome.

The Pattern and Significance of Delivery Outcome in Anaemia-Induced Changes of the Placenta

Abstract Background: Anemia is a clinical sign of the most prevalent nutritional deficiency in pregnant women worldwide. Histopathological study of the placenta provides valuable information on changes due to anemia in pregnancy. Aim: The present study was undertaken to evaluate the significance of macroscopic and histopathological changes in the placenta due to deficiency anemia in pregnancy consequently affecting the delivery outcome. Material and methods: An observational, prospective, cross-sectional study was conducted for one year. All the obstetric patients having hemoglobin (Hb) less than 11gm/dl were included in the study. After applying the exclusion criteria, 57 cases were included in the study. After delivery, the placenta was collected, fixed in formalin, weight measured, dimensions noted and volume was calculated. Gross features were noted and representative tissue was taken for histopathological study. Results: Term pregnancy was found commonly in mild anaemia (17 cases, 30%), preterm delivery in moderate anemia (14 cases, 25%), and Intrauterine fetal death (IUFD) /abortion in severe anemia (2 cases, 3%). The frequency of the presence of increased placental weight, decreased vascularity, increased fibrosis, and endarteritis are obliterans was found significantly higher in higher grades of anemia than in mild anemia. The same gross and histopathological features were significantly associated with poor obstetric outcomes (IUFD/abortion, preterm delivery) than good obstetric outcomes (term pregnancy). Conclusion: Studies of the placenta have a significant role in understanding the pathophysiology of anemia in pregnancy.

High-Order Parity Improves the Perinatal Outcome of Twin Deliveries.

Twin gestations are associated with an increased risk of obstetric and perinatal complications. We studied the association between parity and the rate of maternal and neonatal complications in twins deliveries. We performed a retrospective analysis of a cohort of twin gestations delivered between 2012 and 2018. Inclusion criteria consisted of twin gestation with two nonanomalous live fetuses at ≥24 weeks' gestation and no contraindications to vaginal delivery. Women were divided into three groups based on parity: primiparas, multiparas (parity of 1-4), and grand multiparas (parity ≥5). Demographic data were collected from electronic patient records and included maternal age, parity, gestational age at delivery, need for induction of labor, and neonatal birth weight. The primary outcome was mode of delivery. Secondary outcomes were maternal and fetal complications. The study population included 555 twin gestations. One hundred and three were primiparas, 312 were multiparas, and 140 were grand multiparas. Sixty-seven (65%) primiparas delivered the first twin vaginally, as did 294 (94%) multiparas and 133 (95%) grand multiparas (p <0.05). Thirteen (2.3%) women required delivery of the second twin by cesarean section. Among those who delivered both twins vaginally, there was no significant difference in the average time interval between the delivery of the first and the second twins between the groups. The need for transfusion of blood products was higher in the primiparous group compared with the other two groups (11.6 vs. 2.5 and 2.8%, p < 0.05). The rate of adverse maternal composite outcomes was higher among primiparous women compared with multiparous and grand multiparous (12.6, 3.2, and 2.8%, respectively, p < 0.05). The gestational age at delivery was earlier in the primiparous group compared with the other two groups, and the rate of preterm labor at <34 weeks' gestation was higher among the primiparas. The rate of second twin's 5-minute Apgar's score <7 and the composite adverse neonatal outcome among the primiparous group were significantly higher than the multiparous and grand multiparous groups. Our study demonstrates that there is an association between high-parity and good obstetric outcomes in twin pregnancies; high parity seems to serve as a protective, rather than a risk factor for adverse maternal and neonatal outcomes. · There is an association between high-parity and good obstetric outcome in twin pregnancies.. · High parity serves as a protective factor for adverse maternal outcomes in twin deliveries.. · High parity serves as a protective factor for adverse neonatal outcomes in twin deliveries..

A retrospective cohort study of pregnancy outcomes during the pandemic period of the SARS‐CoV‐2 omicron variant: A single center's experience

SynopsisOur retrospective review revealed that antenatal infection with the Omicron variant is associated with minimal symptoms in vaccinated patients, minimal medical intervention, and good obstetric outcomes.

Ultrasound correlation of transcerebellar diameter with last menstrual period for gestational age in second and third trimester of pregnancy

Background: Foetal biometry is useful modality in assessment of gestational age (GA) for good obstetric outcome. Objectives: To compare ultrasonographic measurement of transverse cerebellar diameter (TCD) with other previously established foetal ultrasound biometric parameters. Methods: An analytical cross-sectional study was conducted from August 2020 to February 2021 in Department of Radiology at Kathmandu Medical College after ethical clearance. Convenience sampling technique was utilised to include all pregnant women in second and third trimester with known last menstrual period (LMP). Written informed consent was taken from those willing to participate. Congenital malformations, multiple pregnancies, irregular menstrual cycle, and maternal illness were excluded. Data were entered and analysed by using SPSS v.22. Descriptive statistics like mean, standard deviation, and percent were used. Inferential statistics (t- test and Pearson correlation) was also used to see the correlation between different variables. Results: Among 100 participants who participated in the study, 63 (63%) were primigravida with singleton pregnancy without any congenital anomalies. The mean foetal heart rate was 144.9 ± 13.6. The mean GA based on LMP, TCD, and other parameters were 30.86 ± 7.76 weeks, 31.07 ± 8.45 weeks, and 29.75 ± 6.61 weeks respectively. In 15-28 weeks, all parameters had nearly equal r-values. Among all, TCD revealed highest correlation (0.888). In 29-40 weeks, there was considerable difference in r-values. The second most accurate correlation was seen with head circumference (r = 0.874). Conclusion: TCD being stable parameter not affected by foetal growth status maybe preferred over other parameters in estimating foetal gestational age.

Very Early Onset Severe Preeclampsia and Eclampsia Syndrome with Posterior Reversible Encephalopathy Syndrome- A Catastrophe

Early onset severe preeclampsia and eclampsia is a direct cause in the deadly triad of maternal mortality along with haemorrhage and sepsis with high perinatal mortality. Antiphospholipid Syndrome (APS) with Recurrent Pregnancy Loss (RPL) may also result in early onset severe preeclampsia, eclampsia and its catastrophic complications. Present report is a rarest case of a 33-year- old, unbooked G6A5 at 21+4 weeks gestation with eclampsia, HELLP (Haemolysis, Elevated liver Enzymes, Low Platelet count) syndrome, Posterior Reversible Encephalopathy Syndrome (PRES), Intrauterine foetal demise (IUFD) with RPL due to APS with Hepatitis B positive status. Patient was managed by a multidisciplinary team of Obstetricians, Intensivists, Cardiologists and Neurologists. Eclampsia was managed with magnesium sulphate (Pritchard’s regime), intravenous labetalol and delivery of stillborn male foetus weighing 645 gm achieved within 24 hours of eclamptic seizure. Lupus anticoagulant and beta-2 glycoprotein IgM (Immnoglobulin M) antibodies were positive in high titres confirming APS. Postdelivery patient had persistent headache with blurring of vision. A diagnosis of PRES was confirmed on Magnetic Resonance Imaging (MRI) brain. Patient was put on Levetiracetam and low molecular weight heparin and was discharged in satisfactory condition on seventh postpartum day with an advice to follow- up at two weeks, six weeks and 12 weeks. Early onset preeclampsia is encountered in Obstetrics but very early onset severe preeclampsia (&lt;24 weeks of gestation) and eclampsia with HELLP syndrome, PRES in a patient of RPL due to APS is rarest. Early diagnosis of APS and early onset preeclampsia with timely referral to tertiary care and multidisciplinary management can save women from severe dreaded complications with a good obstetric outcome in future.

Obstetric and perinatal outcomes in the first wave of COVID-19 infected pregnant women

Objective: The COVID-19 pandemic continues to be a rapidly evolving situation with limited data on its impact on pregnancy. The study was conducted to evaluate the maternal and perinatal outcomes of pregnant women in the first wave of COVID-19 infection Materials and Methods: Clinical records were retrospectively reviewed for 129 pregnant women with laboratory confirmed COVID-19 infection admitted in the Department of Obstetrics and Gynecology, Regional Institute of Medical Sciences, Imphal (Manipur, India) from 27th July to 27th November 2020. The maternal and perinatal outcomes were collected and analyzed. Evidence of perinatal transmission of the virus was assessed with SARS-Cov-2 Reverse transcriptase polymerase chain reaction testing done on oropharyngeal swab of neonate taken 24 to 48 hours after delivery.Results: Of the 129 cases, 119 (92.24%) were asymptomatic and two (1.55%) had severe symptoms with one necessitating intensive care unit (ICU) admission and ventilatory support, subsequently causing maternal death. There were three cases (2.33%) of abortion, two ectopic pregnancies (1.55%) and ten preterm deliveries (8.54%). Two cases of neonatal asphyxia were observed, both requiring admission with one resulting in neonatal death. Furthermore, two out of 83 neonates were tested positive for COVID-19 on oropharyngeal swab. Conclusion: Majority of the COVID-19 positive pregnant women were asymptomatic in the first wave and associated with good obstetric and perinatal outcome, however, severe case was associated with increased risk of ICU admission and mechanical ventilation ultimately leading to maternal death. Probable chances of vertical transmission of COVID-19 infection could not be ruled out at present.

P–746 Obstetric outcomes of singleton birth after hysteroscopic division of septate uterus

Abstract Study question The aim of this study is to determine the obstetric outcomes in patients with a singleton birth after hysteroscopic division of septate uterus. Summary answer The data suggest excellent obstetric outcomes for singleton gestation after hysteroscopic division of a septate uterus reaching either the internal or the external cervical os. What is known already Septate uterus is a rare Müllerian anomaly with major impact on reproductive outcomes, particularly with a septum over 10mm. Controversy still exists over the need for surgical correction of the septum due to conflicting data on outcomes, particularly in women with histories of good obstetric outcomes and incidental septum findings. Placental location in relation to the septum may account for such conflicting reports. Most data on reproductive outcomes after hysteroscopic surgical correction combine both septate and subseptate uteri. There is limited published data on obstetric outcomes after hysteroscopic surgical correction of septate uteri, especially septate uteri reaching the external os. Study design, size, duration This retrospective cohort study included 107 patients with infertility and/or recurrent pregnancy loss (RPL) who received treatment between 2002 –2019. The study group included 24 patients with a singleton birth after hysteroscopic correction of septate uterus (Class Va; ASRM classification) that was diagnosed on trans-vaginal 3D ultrasound. The control group included 83 patients with a singleton birth who had normal endometrial cavity on hysteroscopy during the same period of time, before starting treatment. Participants/materials, setting, methods This study was conducted at an infertility clinic affiliated with a teaching hospital. In the study group the septum reached the internal or the external cervical os in 14 and 10 patients respectively. After hysteroscopic correction, all patients were offered various infertility treatments depending on the underlying etiology. The inclusion criterion in this study was to have a singleton birth after hysteroscopy. Demographic and clinical data and obstetric outcomes were compared between the two groups. Main results and the role of chance There was no significant difference in mean age, infertility duration, infertility type and incidence of male infertility or ovulatory disorders between the two groups. There was a significantly higher BMI (0.048), and a higher incidence of history of miscarriage (P = 0.002) and history of RPL (P = 0.017) in the study group. There was significant lower incidence of tubal factors infertility (P = 0.005) and endometriosis (P = 0.03) in the study group, therefore there was higher incidence of spontaneous conception (70.8% vs 19.3%; P = 0.000) and lower incidence of conception with IVF-ET (20.8% vs 66.3%; P = 0.000) in the study group compared to the control group respectively. There was significantly higher incidence of prophylactic cervical cerclage (17.4% vs 0%; P = 0.000), and delivery by CS (69.6% vs 41.2%; P = 0.019) and lower incidence of vaginal delivery (30.4% vs 58.8%; P = 0.019), in the study group compared to the control group. There was no significant difference in gestational age in weeks (38.3 + 1.8 vs 38.6 + 2.0), newborn birth weight in grams (3173.9 + 630.0 vs 3202.1 + 555.6), incidence of premature birth (12.5% vs 12.2%), or other obstetric complications (25% vs 17.6%) between the study and the control groups respectively. For premature births, mean gestational age was 34.3 + 0.47 and 34.6 + 1.2 weeks in the study and control groups respectively. Limitations, reasons for caution A retrospective study has its own inherent bias. Furthermore, the small sample size is explained by the fact that a septate uterus is a rare anomaly leading to difficulties finding cases and organizing a prospective study to achieve a larger sample size. A multicenter prospective study is needed. Wider implications of the findings: Regardless of whether the septum reached the internal or external os, there were excellent obstetric outcomes in singleton gestations after hysteroscopic correction of septate uteri. There was no increased risk with septate uteri involving the cervix. Hysteroscopic surgical correction should be the treatment of choice for patients with septate uteri. Trial registration number Not applicable

P-746 Obstetric outcomes of singleton birth after hysteroscopic division of septate uterus

Abstract Study question The aim of this study is to determine the obstetric outcomes in patients with a singleton birth after hysteroscopic division of septate uterus. Summary answer The data suggest excellent obstetric outcomes for singleton gestation after hysteroscopic division of a septate uterus reaching either the internal or the external cervical os. What is known already Septate uterus is a rare Müllerian anomaly with major impact on reproductive outcomes, particularly with a septum over 10mm. Controversy still exists over the need for surgical correction of the septum due to conflicting data on outcomes, particularly in women with histories of good obstetric outcomes and incidental septum findings. Placental location in relation to the septum may account for such conflicting reports. Most data on reproductive outcomes after hysteroscopic surgical correction combine both septate and subseptate uteri. There is limited published data on obstetric outcomes after hysteroscopic surgical correction of septate uteri, especially septate uteri reaching the external os. Study design, size, duration This retrospective cohort study included 107 patients with infertility and/or recurrent pregnancy loss (RPL) who received treatment between 2002 -2019. The study group included 24 patients with a singleton birth after hysteroscopic correction of septate uterus (Class Va; ASRM classification) that was diagnosed on trans-vaginal 3D ultrasound. The control group included 83 patients with a singleton birth who had normal endometrial cavity on hysteroscopy during the same period of time, before starting treatment. Participants/materials, setting, methods This study was conducted at an infertility clinic affiliated with a teaching hospital. In the study group the septum reached the internal or the external cervical os in 14 and 10 patients respectively. After hysteroscopic correction, all patients were offered various infertility treatments depending on the underlying etiology. The inclusion criterion in this study was to have a singleton birth after hysteroscopy. Demographic and clinical data and obstetric outcomes were compared between the two groups. Main results and the role of chance There was no significant difference in mean age, infertility duration, infertility type and incidence of male infertility or ovulatory disorders between the two groups. There was a significantly higher BMI (0.048), and a higher incidence of history of miscarriage (P=0.002) and history of RPL (P=0.017) in the study group. There was significant lower incidence of tubal factors infertility (P=0.005) and endometriosis (P=0.03) in the study group, therefore there was higher incidence of spontaneous conception (70.8% vs 19.3%; P=0.000) and lower incidence of conception with IVF-ET (20.8% vs 66.3%; P=0.000) in the study group compared to the control group respectively. There was significantly higher incidence of prophylactic cervical cerclage (17.4% vs 0%; P=0.000), and delivery by CS (69.6% vs 41.2%; P=0.019) and lower incidence of vaginal delivery (30.4% vs 58.8%; P=0.019), in the study group compared to the control group. There was no significant difference in gestational age in weeks (38.3 + 1.8 vs 38.6 + 2.0), newborn birth weight in grams (3173.9 + 630.0 vs 3202.1 + 555.6), incidence of premature birth (12.5% vs 12.2%), or other obstetric complications (25% vs 17.6%) between the study and the control groups respectively. For premature births, mean gestational age was 34.3 + 0.47 and 34.6 + 1.2 weeks in the study and control groups respectively. Limitations, reasons for caution A retrospective study has its own inherent bias. Furthermore, the small sample size is explained by the fact that a septate uterus is a rare anomaly leading to difficulties finding cases and organizing a prospective study to achieve a larger sample size. A multicenter prospective study is needed. Wider implications of the findings Regardless of whether the septum reached the internal or external os, there were excellent obstetric outcomes in singleton gestations after hysteroscopic correction of septate uteri. There was no increased risk with septate uteri involving the cervix. Hysteroscopic surgical correction should be the treatment of choice for patients with septate uteri. Trial registration number Not Applicable

Obstetric Outcomes of Women Who Sustained Traumatic Spinal Injury during Pregnancy: A Systematic Review.

Literature regarding pregnant women who sustained traumatic spinal injury during pregnancy is limited. Existing papers are mainly case reports, and this indicates a need for more high-quality research evidence in this area. Therefore, this study was designed to systematically review available literature that reported demographic information, clinical characteristics, and obstetric outcomes of women who sustained spinal injury during pregnancy. Studies published from the earliest record to January 2019, which reported traumatic spinal injury during pregnancy, were included. Studies that have reported pregnancy in patients with pre-existing spinal injury, review articles, commentaries, letter to editors, conference papers, and studies published in languages other than English were excluded. Sixteen studies reporting on 26 women were included. Their mean age was 26.7±5.5 years. Motor vehicle accidents were the main cause of spinal injury (n=15, 58%). Of the cases, four women sustained spinal injury during the 1st trimester of pregnancy, of which one had a spontaneous abortion, one delivered a baby with arthrogryposis multiplex congenital disorder, and the third one delivered a premature baby who died shortly after the delivery. Fifteen women sustained injury during their 2nd trimester, of which 14 delivered normal babies, while six sustained spinal injury during the 3rd trimester. Of these women, five delivered normal babies at term. Outcomes of pregnancy appear significantly affected if a spinal injury occurs during the 1st trimester of pregnancy; however, injuries sustained during the 2nd and 3rd trimesters can have good obstetric outcomes.

Cluster Analysis of the Combined Association of Sleep and Physical Activity with Healthy Behavior and Psychological Health in Pregnant Women.

The purposes of the study were to (1) identify clusters based on patterns of sleep quality and duration and physical activity levels of healthy Korean pregnant women, and (2) subsequently investigate the association of identified clusters with pre-pregnancy healthy behaviors, depressive symptoms, and pregnancy stress. Two hundred eighty-four pregnant women participated in the study while attending a prenatal education program provided by a tertiary hospital in Seoul, Korea. The survey questionnaire consisted of the Pittsburg Sleep Quality Index, the International Physical Activity Questionnaire, and the Center for Epidemiologic Studies Depression scale. We used the Latent GOLD to identify distinct clusters and the chi-square test and ANOVA to compare clusters. We identified three clusters: ‘good sleeper’ (63.4%), ‘poor sleeper’ (24.6%), and ‘low activity’ (12.0%). Women in the good-sleeper cluster were more likely to have higher education and income levels and reported more healthy behaviors before pregnancy. Poor-sleeper and low-activity clusters were more likely to report higher scores in depressive symptoms and pregnancy stress (p < 0.001 and p = 0.005, respectively). Tailored intervention for pregnant women who are physically inactive or sleep poorly may promote their psychological well-being as well as bringing good obstetric outcomes.

Management of a patient in the state of total occlusion of aorta due to Takayasu arteritis in preconceptional and pregnancy period

Abstract Objectives Total aortic occlusion is a severe complication of Takayasu arteritis (TAK). Pregnancy follow-up in the state of total aortic occlusion due to TAK has not been reported before. Case presentation A 35 year-old nulliparous woman with total aortic occlusion in the distal aorta due to TAK, admitted with pregnancy desire. She had developed a collateral vessel system which has maintained the lower body circulation. She was informed about the potential risks after an evaluation and she admitted to our clinic at the seventh week of pregnancy, and acetylsalicylic acid was prescribed. At 20th gestational week anomaly screening was in normal limits although the uterine artery Doppler had lower S/D, PI and RI values. She was followed-up regularly in every two weeks. Vascular examination was performed by using an ankle brachial index (ABI) by duplex ultrasound. At 20th gestational week ankle brachial index score was 0.8–0.9 which indicates mild disease. Around 28th gestational week her claudication got worse again and ABI was in moderate level (0.5–0.8) and low molecular weight heparin was started. Until 37th gestational week her disease was stable, ABI was above 0.5, her blood pressure was in normal limits, no vascular complication occurred and the baby’s growth percentile was at 25th centile. At 37th gestational week a 2,640 g baby was delivered. Patient was discharged without any complications at third post-operative day. Conclusions Complicated TAK patients may have good obstetric outcomes with a multidisciplinary approach in experienced tertiary centers.

Multi-stakeholder Perspectives on the Maternal, Provider, Institutional, Community, and Policy Drivers of Disrespectful Maternity Care in South-East Nigeria.

PurposeUnderstanding the contextualized perspectives of stakeholders involved in maternal health care is critical to promoting respectful maternity care. This study explored maternal, provider, institutional, community, and policy level drivers of disrespectful maternity care in Southeast Nigeria. This study also identified multi-stakeholder perspectives on solutions to implementing respectful maternity care in health facilities.Materials and MethodsThis was a mixed-methods cross-sectional study conducted in two urban cities of Ebonyi State, South-eastern Nigeria. Data were collected using semi-structured questionnaires, focus group discussions, and key informant interviews with mothers, providers, senior facility obstetric decision-makers, ministry of health policymaker, and community members. Quantitative data and qualitative data were analysed using SPSS version 20 and manual thematic analysis, respectively.ResultsMaternal level drivers were poor antenatal clinic attendance, uncooperative clients, non-provision of birthing materials, and low awareness of rights. Provider factors included work overload/stress, training gaps, desire for good obstetric outcome, under-remuneration and under-appreciation. Institutional drivers were poor work environments including poorly designed wards for privacy, stressful hospital protocols, and non-provision of work equipment. Community-level drivers were poor female autonomy, empowerment, and normalization of disrespect and abuse during childbirth. The absence of targeted policies and the high cost of maternal health services were identified as policy-related drivers.ConclusionA variety of multi-level drivers of disrespectful maternity care were identified. A diverse and inclusive multi-stakeholder approach should underline efforts to mitigate disrespectful maternity care and promote respectful, equitable, and quality maternal health care.

Labor outcomes with epidural analgesia: an observational before-and-after cohort study comparing continuous infusion versus programmed intermittent bolus plus patient-controlled analgesia.

Scientific evidence shows that programmed intermittent epidural bolus (PIEB) for labor analgesia achieves good obstetric outcomes. After implementing our institutional standard for epidural analgesia, we compared PIEB + patient-controlled epidural analgesia (PCEA) versus continuous epidural infusion (CEI). In an observational cohort study, we compared CEI with 0.2% ropivacaine + 100-μg fentanyl initial bolus versus PIEB+PCEA with 0.1% ropivacaine + 2 μg mL-1 fentanyl in primiparous women. The primary outcome was mode of delivery. Secondary outcomes were duration of the second stage of labor and total ropivacaine and fentanyl doses. Other outcomes, in the PIEB+PCEA group only, were motor block, use of PCEA and rescue bolus, maternal mobility and maternal satisfaction. Univariate statistical analysis was performed using the χ2 Test, analysis of variance or nonparametric Kruskal-Wallis Test. Multivariate analysis was performed using multiple logistic regression analysis. The study included 221 patients (CEI 116; PIEB+PCEA 105). Multiple logistic regression showed that the PIEB+PCEA group had significantly fewer caesarean sections (CEI [14%] vs. PIEB+PCEA [5%], P=0.015) and instrumental deliveries, after correcting for confounders (OR=0.49; 95% CI: 0.27-0.89). The second stage of labor did not significantly differ between groups. Total ropivacaine dose was significantly lower with PIEB+PCEA. There was no relationship between mild motor block and increased use of PCEA in the PIEB+PCEA group. Mode of delivery and duration of the second stage of labor were not influenced by motor block either. Maternal satisfaction was high. PIEB+PCEA offers obstetric and analgesic advantages over CEI in daily clinical practice.

Oncological and Reproductive Outcomes of Fertility-sparing Surgery in Women with Early-stage Epithelial Ovarian Carcinoma: A Multicenter Retrospective Study.

With delayed childbearing in women, preservation of fertility is an important issue for reproductive-age patients with epithelial ovarian carcinoma (EOC). Fertility-sparing surgery (FSS) can be considered in patients with early-stage disease in order to preserve fertility and improve quality of life. In order to evaluate oncological safety, attitudes toward childbearing and reproductive outcomes in women with EOC who underwent FSS, this multicenter retrospective study was conducted. Between January 2005 and December 2014, total of 87 young women with FIGO stage I EOC were included, with their clinicopathologic parameters in relation to disease-free survival (DFS) and overall survival (OS) assessed. Attitudes toward childbearing, ovarian function and fertility were studied in women undergoing FSS (n=36). As a result, in contrast to radical surgery, FSS did not affect prognosis by Kaplan-Meier curves (log-rank test; DFS: P=0.484; OS: P=0.125). However, two of the three recurrence cases and both death cases were in FSS group stage IC. All women undergoing FSS resumed regular menstrual periods after chemotherapy. Only 16 (44.44%) had tried to conceive, and 17 pregnancies occurred in 15 (93.75%) women. Among 20 women who did not attempt conception, the most common reason was not being married (70%), followed by already having children (15%). In summary, FSS is considered safe in young women with stage IA EOC. Regular menstruation and good obstetric outcomes can be achieved. This study also provides some insight into the attitudes and social factors regarding fertility in EOC patients.

Myasthaenia gravis in pregnancy, delivery and newborn.

Myasthaenia gravis (MG) is the most common disease of the neuromuscular junction; clinical presentation of the disease includes a variety of symptoms, the most frequent beign the only ocular muscles involvement, to the generalized myasthenic crisis with diaphragmatic impairment and respiratory insufficiency. It is most common in women between 20 ad 40 years. We performed a comprehensive search of relevant studies from January1990 to Dicember 2019 to ensure all possible studies were captured. A systematic search of Pubmed databases was conducted. Pregnancy has an unpredictable and variable effect on the clinical course of MG; however, a stable disease before is likely not to relapse during pregnancy. exacerbations can still occur more often during the first trimester and the post partum period. The transplacental passage of antibodies results in a neonatal transient disease, whereas the major concern is related to foetal malformations such as fetal arthrogryposis and polyhydramnios. The overall neonatal outcome described in literature is variable, perinatal mortality in women with MG is generally the same as non affected patients, although in one study the risk of premature rupture of the membranes was higher. Treatment of MG in pregnangncy includes pyridostigmine and corticosteroids, although the latter have been associated with higher risk of cleft palate, premature rupture of the membranes and preterm delivery. These drugs appear also to be safe in breastfeeding. In MG patients spontaneous vaginal delivery should be encouraged, for surgery could cause acute worsening of myasthenic symptoms; also an accurate anesthesiological evaluation must be performed prior to both general and local anesthesia due to increased risk of complications. Most of the myasthenic women could have uneventful pregnancy with good obstetrical outcomes, both for mother and neonate. However, a careful planning of pregnancy and multidisciplinary team approach, composed by neurologists, obstetricians, neonatologists and anesthesiologists, is required to manage these pregnancies.

Determination of Gestational Age by Tibial Length using Ultrasound in A Nigerian Tertiary Hospital

BACKGROUND: Determining fetal gestational age accurately is important to good obstetric care and outcome. Methods like measurement of symphysio-fundal height have been used but not accurate. With the advent of ultrasound, various fetal biometric parameters e.g. BPD, FKL, and fetal limbs are now being used. AIMS AND OBJECTIVES: The aim of this study is to ultrasonographically evaluate the usefulness of fetal tibial lengths as an alternate to femur lengths in predicting gestational age from the second to third trimesters. MATERIAL AND METHODS: A total of 500 pregnant Nigerian women between the GA of 13 to 41 week had ultrasound scan evaluation done at the fetal assessment unit of a Teaching Hospital. Fetal biometric parameters BPD, FL, and TL were measured and recorded against the calculated gestational age from the last menstrual periods. RESULTS: There was a strong relationship between TL and EGA with a significant positive linear correlation (r= 0.915 P&lt;0.05). For FL, r= 0.900 and for BPD r=0.906, all related to GA. The study has also shown a good correlation between TL and the other measured variables. For TL and FL, r=0.889 while TL and BPD r=0.867, making TL a substitute limb for limb measurement and as a pointer to a skeletal anomaly or delayed bone growth or dwarfs. The mean TL ranged from 13.47 mm at 13 week to 74.64 mm at 41 weeks of gestation. CONCLUSION: This study has been able to justify the tibia as an important substitute for femur in the prediction of GA especially where the femur is susceptible to errors.

The Indication for Cervical Cerclage and Pregnancy Outcome in a Teritiary Hospital in South-South Nigeria: A Five Year Review

Background: Cervical incompetence is a major cause of second trimester miscarriage. Recurrent pregnancy loss in the second trimester is associated with significant distress. However, there should be a justifiable indication before a cerclage is inserted. There is no documentation of the indication of cervical cerclage and pregnancy outcome in Yenagoa, southsouth Nigeria. Objectives: This paper focuses on documenting the indication and obstetric outcome following cervical cerclage insertion at the Federal Medical Center Yenagoa, Bayelsa State. Methodology: A 5 year retrospective study was carried out in women who had cervical cerclage for cervical incompetence in the Federal Medical Centre, Yenagoa. The study was conducted from the 1 st of January 2014 to 31st of December 2018. All the case files of patients who had cervical cerclage were retrieved and reviewed. Results: A total of 41 patients had cervical cerclage. The commonest indication for cervical cerclage insertion was history indicated cerclage 59.4%. This was followed by ultrasound indicated cerclage 28.1% and rescue cerclage accounting for 12.5%. All patients employed McDonald’s method of cervical cerclage. The position of the knot wasin 12 0’ clock position in 53.1% of the patients and in the 6 0’clock position for 46.9% of the patients. The success rate following insertion of cerclage was 79.3%. The mode of deliveries was vaginal in 90.6% of the patients and 9.4% had caesarean section. Conclusion: There may be concern about the diagnosis of cervical incompetence. However, findings from this study clearly showed that the application of cervical cerclage is associated with good obstetric outcome.

The outcome of induced labor after oxytocin infusion discontinuation in the active phase

Objective The objective was to determine whether discontinuation of oxytocin infusion after established active phase of induced labor gives good obstetric outcome without any adverse maternal and neonatal effect. Background Oxytocin is one of the most widely drugs used in induction of labor. Continuous infusion of oxytocin after establishment of the active phase of labor may lead to uterine atony and postpartum hemorrhage. Therefore, we should stop oxytocin infusion once the active phase has started. Patients and methods A total of 90 pregnant women who required labor induction and fulfilled the criteria of the study population were enlisted in this prospective controlled randomized clinical trial and then were assigned to either group A or B. In group A cases, infusion of oxytocin was started in incremental doses until 5 cm of cervical dilatation and to be maintained at that level throughout the labor, whereas in group B cases, infusion of oxytocin was started incrementally but discontinued when cervical dilatation reached 5 cm. Results This study showed that there was a statistically significant difference between group A and group B regarding the first stage of labor, uterine hyperstimulation, maximal and total doses of oxytocin, neonatal outcome, and incidence of postpartum hemorrhage. There was statistically insignificant difference between group A and group B regarding age, BMI, mean gestational age, parity, indications for induction of labor, detection of meconium upon rupture of membranes, and mode of delivery. Conclusion There is no need to continue oxytocin infusion after the establishment of active phase of labor.

Salmon Bias and Preterm Birth Among Western Immigrants in China.

Introduction Immigrants from Western industrialized countries are rarely found in immigrant studies. Our primary objective was to calculate the rate of cesarean delivery, 5-min Apgar score <7, and preterm birth among Chinese and Western women. Our secondary objective was to examine whether there are significant differences in terms of risk factors between Western immigrants who chose to deliver in their country of citizenship compared to those who chose to deliver in China. Methods Single-center retrospective cohort study in Shanghai, China. Multivariate logistic regression models used delivery outcome, and place of delivery (China vs. country of citizenship) as outcome variables. Results Preterm birth occurred at a rate of 3.82% among Chinese citizens, 4.12% among Chinese-born Western citizens, and 6.54% among non-Chinese-born Western citizens. After adjustment, preterm birth <37weeks was more frequent among non-Chinese-born Western citizens compared with Chinese citizens, with an odds ratio of 1.82 (Confidence Interval 1.20-2.78), p = 0.005. Variables statistically associated with giving birth in China were maternal age ≥35years and being Chinese-born Western, as well as the absence of medical or obstetrical conditions. Discussion Western immigrants have overall good obstetrical outcomes in China, and this could be partly explained by selective immigration, but also by the Salmon bias, as women with risk factors tend to return to their country of citizenship for the delivery. However, the preterm birth rate was higher among Western women than in their Chinese counterparts, and further research is needed.