Higher Rate Of Fetal Loss Research Articles

Gestational Malnutrition is Still the Skeleton in the Closet: Where Are the Malnutrition Risk Screening Criteria?

In 2020 there were 3,613,647 live births in the US. Fifty to 90% of those pregnancies were affected by nausea and vomiting of pregnancy (NVP) while the most severe NVP, known as hyperemesis gravidarum (HG) affected 1.5- 3.0% of those gravidas. In 2014 58,436 gravidas were hospitalized with HG. While hospital admissions for HG were down 42%, the number seen in Emergency departments rose by 27.7%. Although HG has been viewed as a positive predictor of a favorable pregnancy outcome, patients who also demonstrate weight loss and electrolyte disturbance may be a distinct entity and at greater risk for growth retardation and fetal anomalies. Poorly managed HG can result in compounded maternal injuries, increased rates of therapeutic abortions and suicide ideation, as well as a high rate of fetal loss. This study focuses on one of the most severe catastrophes originating from HG: Wernicke’s encephalopathy (WE) continues to be an under-recognized and often misunderstood disease in all populations. The acknowledged cause of WE is vitamin B1 or thiamin deficiency, a specific form of malnutrition. Unfortunately, this syndrome is most often recognized at autopsy, especially among non-alcoholics. One manifestation of WE is cognitive dysfunction which may explain the increase in suicidal ideation and/or elected terminations. The current mounting legislation of pregnancy termination limits will complicate the decision to abort for critically ill gravidas and their medical providers. However, antecedent events to WE are extremely poor nutritional intake leading to excessive weight loss and delayed nutritional interventions which can mitigate these situations.

Unmet Needs of Immune Thrombotic Thrombocytopenic Purpura (iTTP)-Specific Pregnancy Counseling, Care and Outcomes in Women with Ittp

Unmet needs of iTTP-specific pregnancy counseling, care and outcomes in women with iTTP INTRODUCTION: Pregnancy is a known trigger for an initial episode or relapse of immune thrombotic thrombocytopenic purpura (iTTP) and outcomes of pregnancy in women with iTTP have historically been suboptimal with high rates of recurrent iTTP, fetal loss, preeclampsia and HELLP syndrome. More recent data suggest that prophylactic immunosuppression to normalize ADAMTS13 levels before conception, and ADAMTS13 monitoring and prophylactic steroids or plasma exchange during pregnancy can improve maternal and fetal outcomes. However, it is not clear whether women with iTTP are routinely counseled regarding these options. We conducted this study to understand the experiences of women with iTTP with reproductive healthcare, how iTTP has impacted their reproductive decisions, and outcomes of pregnancy. METHODS: We developed a web-based (RedCap) survey focused on the reproductive healthcare experiences of women with iTTP with in three major sections: (1) counseling and education around pregnancy that was provided to them, (2) the impact of iTTP on their reproductive decisions, and (3) outcomes of any pregnancies they had experienced. The survey was distributed through social media and email mailing lists of a patient advocacy organization and was kept open for one month (January 2023). Survey data were summarized using counts and percentages. The focus of the analysis was to identify gaps in patient education and care where efforts could be focused on educating clinicians or providing information to patients though patient advocacy groups. RESULTS: Seventy-five females with iTTP responded to the survey. The median age of the respondents was 44 years (range 23 - 65). Sixty-five (74.7%) identified as White, 13 (14.9%) as Black, 6 (6.9%) as Asian and 3 (3.4%) identified as other/prefer not to say. Nearly all (94.6%) were followed by a hematologist or hematologist-oncologist and 82.9% reported being monitored regularly for iTTP. Only 26.7% (20 of 75) reported that their doctor talked to them about measures that may help achieve a successful pregnancy. These included ADAMTS13 monitoring (n=15), plasma exchange treatments (n=10), rituximab (n=10), and aspirin (n=3) (options are not mutually exclusive so total is > 20). Moreover, 30.0% (21 of 70) reported that they were advised by their doctor to not get pregnant due to their iTTP. Some patients (36.0%) avoided pregnancy out of fear of the consequences of iTTP and 28.4% (21 of 74) responded that their iTTP diagnosis has affected their ability to get into a relationship, which impacts their quality of life (Figure 1). Fifty-three patients reported that they had had at least one pregnancy. Of these, 35 had pregnancies before iTTP diagnosis, 10 with the initial presentation of iTTP, and 8 women had a total of 11 pregnancies following the diagnosis of iTTP. Consistent with prior reports, there was a high rate of maternal and fetal complications in pregnancies that occurred in the setting of a first iTTP episode complicating pregnancy, or pregnancies after an iTTP diagnosis (Table 1). iTTP relapse occurred in 27.3% (3 of 11) pregnancies in women with prior iTTP. Fetal loss occurred in 30% of pregnancies with first TTP diagnosis and 9% of pregnancies after iTTP. In both groups, approximately 20% were small for gestational age. Preeclampsia or HELLP syndrome occurred in 50% and 18.2% of pregnancies complicated by initial TTP diagnosis or after iTTP diagnosis, respectively. CONCLUSION: Though pregnancy in women with iTTP is high risk, close monitoring and prophylactic interventions can improve outcomes. While many women with iTTP are counseled regarding the risks of pregnancy, few receive counseling regarding their options to potentially improve pregnancy outcomes. This limits their reproductive choices and impacts their relationships. Educating clinicians and providing information to patients though patient advocacy groups may help address these healthcare gaps.

Maternal Risk Factors and Their Effect on Outcome and Procedure-Related Complications in Cordocentesis: A Multicenter Retrospective Study.

Cordocentesis is used in clinical situations in which lower-risk diagnostic procedures do not deliver the desired results. The aim of this study was to evaluate the risk for procedure-related complications and fetal loss in correlation to maternal risk factors. This is a multicenter retrospective study investigating the complications, risk factors and perinatal outcome of diagnostic cordocentesis between 1998 and 2019 in three different centers. A total of 1806 cordocenteses were performed and procedure-related complications (IUFD within 48 h, contractions, bradycardia, unsuccessful puncture, chorioamniotic separation) were noted in 1.6% of cases. Fetuses with chromosomal aberrations, intrauterine growth restriction and hydropic fetuses had a significantly higher rate of fetal loss compared to other indications. Fetal blood sampling (FBS) performed before 17+0 weeks of gestation was associated with a higher risk of procedure-related complications. Maternal BMI ≥ 40 increased the risk for fetal loss, whereas maternal age, number of previous miscarriages, number of previous abortions, history of vaginal bleeding or nicotine abuse did not affect the risk for complications or overall fetal loss rate. In the hands of experienced operators, FBS is a safe way to further fetal diagnostics, and the risk of complications is low.

Pregnancy in Complement-Mediated Thrombotic Microangiopathy: Maternal and Neonatal Outcomes

Pregnancy, delivery, and neonatal outcomes in women with complement-mediated thrombotic microangiopathy (cTMA) have not been well described. A better understanding of these outcomes is necessary to provide women with competent pregnancy counseling. Cohort study. Women with a history of cTMA and pregnancies enrolled into the Vienna thrombotic microangiopathy cohort. New onset or relapses of cTMA. Pregnancy, delivery, and neonatal outcomes of pregnancies in women (a) before cTMA manifestation, (b) complicated by pregnancy-associated cTMA (P-cTMA), and (c) after first manifestation of cTMA or P-cTMA. Mixed models were used to adjust the comparison of pregnancy, delivery, and neonatal outcomes between conditions (before, with, and after cTMA) for repeated pregnancies using the mother's ID as random factor. In addition, the fixed factors, mother's age and neonate's sex, were used for adjustment. For (sex-adjusted and age-adjusted) centile outcomes, only the mother's age was used. Adjusted odds ratios were derived from a generalized linear mixed model with live birth as the outcome. Least squares means and pairwise differences between them were derived from the linear mixed models for the remaining outcomes. 28 women reported 74 pregnancies. Despite higher rates of fetal loss before the diagnosis of P-cTMA and preterm births with P-cTMA, most of the women were able to conceive successfully. Neonatal development in all 3 conditions of pregnancies was excellent. Pregnancy and neonatal outcomes were better in women with a pregnancy after the diagnosis of cTMA. Although our data set comprises a considerable number of 74 pregnancies, the effective sample size is lower because only 28 mothers with multiple pregnancies were observed. The statistical power for detecting clinically relevant effects was probably low. A recall bias for miscarriages cannot be ruled out. Prepregnancy counseling of women with a history of cTMA can be supportive of their desire to become pregnant.

Determinants of short birth interval among child-bearing age women in the Gedeb Hasasa district of the West Arsi zone, Ethiopia.

Short birth intervals have been linked to higher rates of fetal loss, prenatal mortality, and poorer child survival. Therefore, for countries like Ethiopia that have a population policy intended at reducing fertility, understanding the level and factors influencing birth spacing is crucial in order to apply appropriate intervention. This study aimed to assess the prevalence and determinants of the short birth interval among child-bearing age women in the Gedeb Hasasa district of the West Arsi zone, Ethiopia. A community-based cross-sectional study was conducted from 20 July to 20 August 2018. A multistage sampling method was used. Face-to-face interviews were conducted to gather data. The collected data were entered into Epi Data version 3.1 and later exported to SPSS version 21 for analysis. Logistic regression was used to identify factors associated with the short birth interval. The level of significance was declared at a p-value of <0.05. A total of 714 women participated, with a 98% response rate. The median birth interval length was 32 months. The prevalence of the short birth interval was 50.4%. After adjusting for confounding variables, being a rural resident [AOR = 2.50, 95% CI (1.52, 4.09)], having an illiterate husband [AOR = 4.14, 95% CI (2.15, 8.45)], breastfeeding duration for 7-12 months [AOR = 3.16, 95% CI (1.95, 5.13)] and 13-23 months [AOR = 2.45, 95% CI (1.52, 3.95)], sex of the prior child [AOR = 0.63, 95% CI (0.45, 0.88)], and previous child alive [AOR = 0.20, 95% CI (0.14, 0.96)] were the determinants of short birth interval. One in every two women practiced short birth intervals. The median birth interval duration was 32 months, which is below the minimum standard recommended by the WHO duration for the birth interval, which is 33 months. Short birth intervals were determined independently by residence, husband education, breastfeeding time, previous child's sex, and previous child's survival. Therefore, increasing women's awareness of the ideal birth interval should be done through community health professionals and health developmental armies.

Diabetic Ketoacidosis in Pregnancy: Clinical Risk Factors, Presentation, and Outcomes.

Diabetic ketoacidosis (DKA) in pregnancy is an obstetric emergency with risk of maternofetal death. This work aimed to evaluate DKA events in pregnant women admitted to our inpatient obstetric service, and to examine associated clinical risk factors, presentation, and pregnancy outcomes. A retrospective cohort study was conducted at the Mayo Clinic, Rochester, Minnesota, USA, and included women aged 17 to 45 years who were treated for DKA during pregnancy between January 1, 2004 and December 31, 2021. Main outcome measures included maternal and fetal death along with a broad spectrum of maternal and fetal pregnancy outcomes. A total of 71 DKA events were identified in 58 pregnancies among 51 women, 48 (82.8%) of whom had type 1 diabetes. There were no maternal deaths, but fetal demise occurred in 10 (17.2%) pregnancies (6 miscarriages and 4 stillbirths). Maternal social stressors were frequently present (n = 30, 51.0%), and glycemic control was suboptimal (median first trimester glycated hemoglobin A1c = 9.0%). Preeclampsia was diagnosed in 17 (29.3%) pregnancies. Infants born to women with DKA were large for gestational age (n = 16, 33.3%), suffered from neonatal hypoglycemia (n = 29, 60.4%) and required intensive care unit admission (n = 25, 52.1%). DKA is associated with a high rate of maternofetal morbidity and fetal loss. Prenatal education strategies for women with diabetes mellitus should include a strong focus on DKA prevention, and clinicians and patients should have a high index of suspicion for DKA in all pregnant women who present with symptoms that could be attributed to this condition.

Systemic Lupus Erythematosus Management in Pregnancy.

Systemic lupus erythematosus (SLE) affects reproductive aged women. Issues regarding family planning are an important part of SLE patient care. Women with SLE can flare during pregnancy, in particular those who have active disease at conception or prior history of renal disease. These flares can lead to increased adverse pregnancy outcomes including fetal loss, pre-eclampsia, preterm birth and small for gestational aged infants. In addition, women with antiphospholipid antibodies can have thrombosis during pregnancy or higher rates of fetal loss. Women who have anti-Ro/SSA and anti-La/SSB antibodies need special monitoring as their offspring are at risk for congenital complete heart block and neonatal lupus. Ideally, SLE patients should have their disease under good control on medications compatible with pregnancy prior to conception. All patients with SLE should remain on hydroxychloroquine unless contraindicated. We recommend the addition of 81mg/d of aspirin at the end of the first trimester to reduce the risk of pre-eclampsia. The immunosuppressive azathioprine, tacrolimus and cyclosporine are compatible with pregnancy and lactation, mycophenolate mofetil (MMF)/mycophenolic acid are not. Providers should use glucocorticoids at the lowest possible dose. Methotrexate, leflunomide and cyclophosphamide are contraindicated in pregnancy and lactation. SLE patients on the biologics rituximab, belimumab and abatacept can continue these medications until conception and resume during lactation.

Experience with direct oral anticoagulants in pregnancy – a systematic review

The experience and use of the new direct oral anti coagulants (DOACs) in pregnancy is limited, but as they offer many practical advantages compared to low molecular weight heparin (LMWH), the pursue of their safety is challenging. Systematic review of studies in which DOACs were used during pregnancy and the puerperal period (PROSPERO registry-CRD42021237688). Searches were performed on MEDLINE, Embase, Scopus, Web of Science, and Cochrane Library databases, until July 2021 and secondary sources using the MeSH terms 'pregnancy', 'pregnancy complications', 'venous thrombosis', 'congenital abnormalities', 'Factor Xa Inhibitors,' and names of specific DOACs. Search was limited to human studies, with English or French as languages of report. Literature search yielded 1,989 results which, after duplicate exclusion, resulted in 672 publications. Studies were then screened using the specified eligibility criteria described and studies that did not meet the criteria were excluded, resulting in 21 full text studies to an in-depth analysis and data extraction. Overall, 339 cases of DOACs usage during pregnancy were reported until now. The data demonstrated 56% live births but a miscarriage rate of 22.2% and an elective termination of pregnancy in 21.8%; fetal abnormalities related to DOACs occurred in 3.6%. Our meta-analysis displayed a higher rate of fetal loss and fetal abnormalities with DOACs use compared to LMWH, notwithstanding similar bleeding complications. The current information available for the 339 cases herein reported does not allow a conclusion that DOACs can be safely used in pregnancy.

A medical predictive system for comparative analysis of fetal parameters

A medical predictive system for comparative analysis of fetal parameters” was motivated by the high rate of fetal loss in Nigeria which mostly occurs as a result of wrong medical predictive system. To solve this problem, software that will identify the fetal parameters that predicts the gestational age was developed. The new model will be a hybrid model. It will combine the Nagele’s Rule and Mittendorf Rule to predict the fetal parameter. The new model will take the average of the two models as the predicted date of delivery. In this new system, it is noteworthy to name some ways of determining gestational age based on Last Menstrual Period (LMP). Therefore the proposed model will be a combination of the two model taking average of the number of days to be added to the LMP. This will be used to determine the Expected Date of Delivery in the new system designed. A platform for solving complication problems due to low and excessive birth weights at delivery by accurately estimating fetal parameters (Fetal Weight, Fetal Age, Conception Date, and Delivery Date) was implemented. This was implemented using externally generated data by combining the independent information about fetal size obtained from the three different approaches (i.e. clinical examination, quantitative assessment of maternal characteristics, ultrasonographic fetal biometry). Expert system methodology and Object Oriented Analysis and Design Methodology (OOADM) were adopted in the design of the predictive system. The new system allows the patients to access their antenatal visit records from any internet access point and the software developed helps physicians to accurately estimate the gestational age of the fetus and hence provide a support tool for estimating Gestation Age and to establish accuracy indicators that will provide tolerances for its later use in growth and health evaluation.

A medical predictive system for comparative analysis of fetal parameters

A medical predictive system for comparative analysis of fetal parameters” was motivated by the high rate of fetal loss in Nigeria which mostly occurs as a result of wrong medical predictive system. To solve this problem, software that will identify the fetal parameters that predicts the gestational age was developed. The new model will be a hybrid model. It will combine the Nagele’s Rule and Mittendorf Rule to predict the fetal parameter. The new model will take the average of the two models as the predicted date of delivery. In this new system, it is noteworthy to name some ways of determining gestational age based on Last Menstrual Period (LMP). Therefore the proposed model will be a combination of the two model taking average of the number of days to be added to the LMP. This will be used to determine the Expected Date of Delivery in the new system designed. A platform for solving complication problems due to low and excessive birth weights at delivery by accurately estimating fetal parameters (Fetal Weight, Fetal Age, Conception Date, and Delivery Date) was implemented. This was implemented using externally generated data by combining the independent information about fetal size obtained from the three different approaches (i.e. clinical examination, quantitative assessment of maternal characteristics, ultrasonographic fetal biometry). Expert system methodology and Object Oriented Analysis and Design Methodology (OOADM) were adopted in the design of the predictive system. The new system allows the patients to access their antenatal visit records from any internet access point and the software developed helps physicians to accurately estimate the gestational age of the fetus and hence provide a support tool for estimating Gestation Age and to establish accuracy indicators that will provide tolerances for its later use in growth and health evaluation.

Pregnancy outcomes in different stages of systemic lupus erythematosus among Chinese women - a retrospective cohort study.

To analyze the outcomes of pregnancies and risk factors in Chinese women with different stages of systemic lupus erythematosus (SLE). A total of 55 conceptions in 52 patients with SLE between Jan 2007 and Jan 2019 were retrospected systematically from a general hospital graded 3A in China. Medical records provided us a good way to retrieve the clinical parameters and lab data of patients. Pregnant women with SLE activity had significant hyperimmunoglobulin, hypocomplement, low platelet counts, high erythrocyte sedimentation rate, C-reactive protein and 24-h urine protein. Hydroxychloroquine had been used to reduce the rates of SLE activity in pregnant women. Logistic regression analysis showed low platelet counts, hypocomplement and 24-h urine protein were significantly correlated with fetal loss. Compared to those in stable stage, the active SLE patients have more risks of hypertensive disorders of pregnancy, thrombocytopenia, lupus nephritis and placental infarction, and have worse fetal outcomes, including the higher rate of fetal loss, preterm and asphyxia neonatorum. Different stages of SLE during pregnancy are closely related to maternal and fetal outcomes. It is imperative to provide SLE women with pregnancy consultation and regular multispecialty care.

Pulmonary Hypertension and Pregnancy

Pregnancy in patients with any type of pulmonary hypertension (PH) is associated with significant morbidity and mortality. That is why pulmonary artery hypertension (PAH) is a contraindication to pregnancy and belongs to class IV maternal cardiovascular risks. Maternal mortality rates for pulmonary (especially arterial) hypertension remain high even in the era of specific therapy, in particular, it reaches 12-30% in patients with PAH, 36% in Eisenmenger syndrome and up to 56% in secondary PH. Perinatal effects in such patients are also unfavorable, with high rates of fetal loss, premature birth and miscarriage.&#x0D; Multidisciplinary team of specialists of the National Amosov Institute of Cardiovascular Surgery and Institute of Pediatrics, Obstetrics and Gynecology named after acad. O. M. Lukianova has been providing medical support to such women for 7 years, using modern recommendations and wide experience. Overall, 39 pregnant and parturient women with PH were admitted to the clinic of the National Amosov Institute of Cardiovascular Surgery in the period from December 2013 to October 2020. Patients with PH were assigned to group II (n=24), and those with PAH (8 women) and acute PH (7 women) were assigned to group I. A total of 20 cardiac surgeries were performed. Patients with acute PH (n=6) underwent operations with cardiopulmonary bypass, those with critical mitral valve stenosis had “closed” off-pump surgery, and also there was one case of ECMO system implantation in patient with dilated cardiomyopathy (CMP). Endovascular operations (n=4) involved occluder implantation to patent ductus arteriosus (PDA), implantation of a cardioverter-defibrillator, cardiac resynchronization therapy with pacemaker (CRT-P) and cava-filter insertion. Early (n=1) and late (n=1) maternal mortality rates were 2.6% each. Perinatal loss (n=5) was 12.8%.&#x0D; The main goal at the preconception stage in patients with PH is to eliminate causative factors, and, if it is impossible (idiopathic, familial PAH, Eisenmenger syndrome, etc.), to avoid pregnancy. Patients who become pregnant should be informed of the high risk of pregnancy and discuss abortion, regardless of the WHO FC or other predictive markers. At prolongation of pregnancy careful clinical monitoring, by pregnancy heart team members is strongly recommended. Multidisciplinary support of pregnant women with PH is the cornerstone of a successful treatment strategy for such patients. The professional association of obstetric risk specialists, cardiologists, interventionists, neonatologists, and cardiac surgeons significantly increases the chances of a PH patient for safe delivery and giving birth to a healthy baby.

Pregnancy rates and perinatal outcomes in women with systemic lupus erythematosus: data from the Korean national health claims database.

The pregnancy rate in systemic lupus erythematosus (SLE) is not fully understood and comparisons of adverse pregnancy outcomes (APOs) with SLE versus the general population are limited. This study aimed to estimate the pregnancy rate and APOs in Korean SLE compared to those without SLE. Pregnant women were identified using the ICD-10 codes for delivery and abortion in the Korean national health claims database (2013-2015). APOs were classified as fetal loss, intrauterine growth retardation (IUGR), pre-eclampsia/eclampsia, and gestational diabetes. Annual incidence rates (IRs) of pregnancy and APOs were calculated in women with SLE and the general population without SLE and the two groups were compared using age-adjusted incidence rate ratios (IRRs). Age-stratified IRRs were further analyzed. The annual IRs of pregnancy in SLE were 29.54-30.70 per 1000 persons. The IRRs were lower in women with SLE than in the general population: 0.68 (0.61-0.76), 0.66 (0.60-0.74), and 0.74 (0.66-0.82) in each respective year. The IRRs of fetal loss, IUGR, and pre-eclampsia/eclampsia were 1.30 (1.14-1.49), 4.65 (3.55-6.09), and 3.43 (2.70-4.36), respectively. However, the IRR of gestational diabetes in SLE did not significantly differ from that of women without SLE. Among the APOs, fetal loss, IUGR, and pre-eclampsia/eclampsia showed decreasing tendencies as age increased. Pregnancy rates in SLE were approximately 30% lower than those in the general population. Except for gestational diabetes, fetal loss, IUGR, and pre-eclampsia/eclampsia were higher in SLE and showed a decreasing tendency with age. Key Points • This population-based cohort study showed that pregnancy rates in SLE were approximately 30% lower than those in the general population. • SLE had a 1.3-fold higher rate of fetal loss, more than 4-fold higher IUGR rate, and more than 3-fold pre-eclampsia or eclampsia rate compared with the general population. • Adverse pregnancy outcomes in SLE showed a decreasing tendency with age.

Laparoscopic appendectomy is safe and feasible in pregnant women during second trimester: A retrospective study in a top-level Chinese center.

Acute appendicitis (AA) is the most common nonobstetric surgical emergency during pregnancy. According to the current guidelines and meta-analyses, traditional open appendectomy (OA) is still recommended for pregnant patients over laparoscopic appendectomy (LA), which might be associated with higher rates of fetal loss. Previous studies and experiences indicated that LA might be safe in the second trimester of pregnancy. The current study aimed to evaluate the safety and feasibility of LA in pregnant women during the second trimester.At our institution, a retrospective study was conducted with pregnant patients who underwent LA or OA during the second trimester between January 2016 and August 2018.A total of 48 patients were enrolled. Of them, 12 were managed with laparoscopy and 36 with the open approach. We found that the LA group had higher BMIs than the OA group (4.0 ± 4.3 vs 21.5 ± 2.9, P = .031). The financial results showed that the average daily medical costs for patients who underwent LA was higher than those who underwent OA (444 ± 107 US$ vs 340 ± 115 US$, P = .009), while the total cost of hospitalization was comparable between the 2 approaches. The perioperative and obstetric outcomes were comparable between LA and OA. In each group, only 1 patient had fetal loss. No “Yinao” was found in any of the patients in the LA group.In this study, with the proven advantages of the laparoscopic techniques, LA was found to be safe and feasible for pregnant women during the second trimester.

A Decade of Experience with the Ovine Model of Myelomeningocele: Risk Factors for Fetal Loss

Introduction: The ovine model is the gold standard large animal model of myelomeningocele (MMC); however, it has a high rate of fetal loss. We reviewed our experience with the model to determine risk factors for fetal loss. Methods: We performed a retrospective review from 2009 to 2018 to identify operative factors associated with fetal loss (early fetal demise, abortion, or stillbirth). Operative risk factors included gestational age at operation, operative time, reduction of multiple gestations, amount of replaced amniotic fluid, ambient temperature, and method of delivery. Results: MMC defects were created in 232 lambs with an overall survival rate of 43%. Of the 128 fetuses that died, 53 (42%) had demise prior to repair, 61 (48%) aborted, and 14 (11%) were stillborn. Selective reduction of multiple gestations in the same uterine horn was associated with increased fetal demise (OR 3.03 [95% CI 1.29–7.05], p = 0.01). Later gestational age at MMC repair and Cesarean delivery were associated with decreased abortion/stillbirth (OR 0.90 [95% CI 0.83–0.90], p = 0.03, and OR 0.37 [95% CI 0.16–0.31], p = 0.02), respectively. Conclusion: Avoiding selective reduction, repairing MMC later in gestation, and performing Cesarean delivery decreases the rate of fetal loss in the ovine MMC model.

Pregnancy and lupus nephritis in developing countries: A systematic review

Systemic lupus erythematosus (SLE) and lupus nephritis (LN) have a significant impact on the course of pregnancy, as well as on maternal and fetal outcomes. LN in pregnancy can increase the maternal risks of SLE flare, acute kidney injury, preeclampsia, and even death. It also affects fetal outcomes by the increased risk of intrauterine growth retardation, premature delivery, and fetal loss. Successful pregnancy outcomes have been well documented in the developed world, but less is known about patients in developing nations. We searched PubMed and Google scholar for all articles published from 1999 to 2016 in developing countries. Twelve of 13 studies were included excluding only one. All studies were independently reviewed. Most of the studies reported a significant association between high flare rates of LN and higher rates of disease flare. Higher rates of active disease at conception were associated with lower live birth rates. Similarly, high flare rates of LN were associated with higher rates of fetal loss. With regard to geographic trends, Indian studies reported lower overall live birth rates and higher rates of active disease at conception. Interestingly, lower rates of preeclampsia were also noted in Indian studies. Higher rates of flare were observed in other Asian studies, but not the Indian studies. Although LN and active SLE at conception are associated with poor fetal outcomes, better outcomes are possible with proper management, even in low-resource settings. More research is necessary to fully understand the relationships between active disease at conception or LN and flare rates, live birth rates, and fetal loss rates in developing countries.

Viral Hemorrhagic Fevers in Pregnant Women and the Vaccine Landscape: Comparisons Between Yellow Fever, Ebola, and Lassa Fever

As research efforts have advanced to understand the pathophysiology of viral hemorrhagic fevers (VHF) and other epidemic viral infections and develop medical countermeasures such as vaccines, pregnant women have remained an underexamined subgroup. To better understand the implications of future outbreaks of VHF for pregnant women amidst an evolving vaccine landscape, we examine three pathogens—yellow fever, Ebola, and Lassa fever—each with different levels of evidence and understanding of disease in pregnancy and at varying stages of vaccine development. There are very limited data available on yellow fever disease in pregnancy and the current live-attenuated 17D yellow fever vaccine is recommended for pregnant women at high risk of exposure. Evidence on Ebola virus disease in pregnancy shows very high case fatality rates (CFRs) among pregnant women and their infants, with mixed evidence on whether mortality is higher in pregnant women than non-pregnant adults. The replication-competent rVSV-ZEBOV vaccine is currently being offered to at-risk pregnant women in the Democratic Republic of the Congo after a revision to an earlier protocol that excluded them. For Lassa fever, there is evidence that CFR is higher in pregnant individuals than non-pregnant adults, especially later in gestation, with high rates of fetal or perinatal loss associated with infection. There are currently no Lassa fever vaccine candidates that have been tested in humans. More evidence is needed to fully understand the implications of infection in pregnancy, but the existing data underscore the serious maternal and fetal health risks associated with each viral infection. It will also be critical to generate evidence on the safety profile of vaccine candidates as they advance through the pipeline to ensure timely and appropriate access for pregnant women at risk of infection. It is important that pregnant women be considered in the design and clinical trial phases of future vaccines.

Silencing of retrotransposon-derived imprinted gene RTL1 is the main cause for postimplantational failures in mammalian cloning

Substantial rates of fetal loss plague all in vitro procedures involving embryo manipulations, including human-assisted reproduction, and are especially problematic for mammalian cloning where over 90% of reconstructed nuclear transfer embryos are typically lost during pregnancy. However, the epigenetic mechanism of these pregnancy failures has not been well described. Here we performed methylome and transcriptome analyses of pig induced pluripotent stem cells and associated cloned embryos, and revealed that aberrant silencing of imprinted genes, in particular the retrotransposon-derived RTL1 gene, is the principal epigenetic cause of pregnancy failure. Remarkably, restoration of RTL1 expression in pig induced pluripotent stem cells rescued fetal loss. Furthermore, in other mammals, including humans, low RTL1 levels appear to be the main epigenetic cause of pregnancy failure.

Total pregnancy loss after chorionic villus sampling and amniocentesis: a cohort study.

To identify maternal-, operator- and procedure-related variables that affect procedure-related pregnancy loss after transcervical (TC) and transabdominal (TA) chorionic villus sampling (CVS) and amniocentesis and to estimate the rates of spontaneous and procedure-related loss in comparable subgroups of women. This was a retrospective cohort study conducted at the University Medical Center Groningen and the Academic Medical Center, The Netherlands. Databases of both centers were searched to identify singleton pregnancies that had undergone a combined test and/or anomaly scan at around 20 weeks' gestation, or an invasive procedure (CVS and/or amniocentesis) between January 2001 and December 2011. Maternal characteristics, obstetric history, technical aspects of the invasive procedure, ultrasound examinations and fetal and neonatal outcomes were available for 29 201 cases. Women were categorized, according to the type of examination they had received, into the following five groups: first-trimester combined test (and 20-week anomaly scan); 20-week anomaly scan only; CVS; amniocentesis; amniocentesis after unsuccessful CVS. Rates of fetal loss were compared between groups. Variables significantly associated with a higher rate of fetal loss were, for CVS, repeat attempts during the procedure, use of TC cannula instead of biopsy forceps, gestational age at procedure ≥ 13 weeks and a pregnancy after assisted reproductive techniques, and, for amniocentesis, if indication was fetal anomaly or family history of anomalies and repeat attempts during the procedure. In women aged ≥ 36 years who did not undergo an invasive procedure, spontaneous fetal loss rate (FLR) after first-trimester combined test was 1.40%, whereas after CVS, FLR was 2.76% and 2.43% for a TC and TA approach, respectively. The additional risk of fetal loss with TC-CVS was therefore 1.36% (1 : 74), which varied according to the instrument used (0.27% for forceps and 3.12% for cannula), and with TA-CVS was 1.03% (1 : 97). In women aged ≥ 36 years who underwent a 20-week anomaly scan only, spontaneous FLR was 0.63%. In women who underwent amniocentesis solely because of advanced maternal age, FLR was 1.11%. The additional risk of fetal loss with amniocentesis was 0.48% (1 : 208). The total rate of procedure-related fetal loss after TA- and TC-CVS and amniocentesis appears lower than the risks on which women are currently counseled. There was a trend for a decrease in risk when the level of experience of the operator increased. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Prenatal supplementation with Corn Soya Blend Plus reduces the risk of maternal anemia in late gestation and lowers the rate of preterm birth but does not significantly improve maternal weight gain and birth anthropometric measurements in rural Cambodian women: a randomized trial

Corn Soya Blend (CSB) Plus is a fortified dietary supplement used to help Cambodian women meet their nutritional requirements in pregnancy, although little is known about its ability to improve pregnancy outcomes. This study assessed the effect of prenatal CSB Plus supplementation on birth weight and secondary outcomes of low birth weight (<2500 g), small for gestational age, birth length and head circumference, preterm birth (<37 wk), maternal weight gain, and anemia at 24-28 wk, 30-32 wk, and 36-38 wk of gestation among rural Cambodian women. A cluster-randomized trial was conducted in 75 villages in Kampong Chhnang Province, in which 547 women received CSB Plus (treatment) during the first trimester until delivery or continued their normal diet (control) based on their village residence. All women received routine daily iron folic acid tablets and were treated with additional iron folic acid if they were anemic (hemoglobin <11 g/dL). Cluster-adjusted linear mixed-effect and logistic regression models were used to examine group differences. There was no significant difference in birth weight between the CSB Plus and control group (46 g; 95% CI: -31, 123 g; P = 0.24). Significant reductions were observed in preterm birth (OR = 0.33; 95% CI: 0.12, 0.89) and anemia at 36-38 wk (OR = 0.51; 95% CI: 0.34, 0.77). There were no significant differences in low birth weight, small for gestational age, birth length, head circumference, or maternal weight gain. A higher rate of fetal loss was observed in the treatment group (10.2% compared with 3.7%; P < 0.01). In Cambodian women, CSB Plus consumed during pregnancy did not significantly increase maternal weight gain or improve birth size but did reduce maternal anemia in late gestation and preterm birth in comparison with women consuming a normal diet. The unexpectedly higher rate of fetal loss in the treatment group is concerning and warrants further investigation. This trial was registered at clinicaltrials.gov as NCT01413776.