Cases Of Intrauterine Fetal Demise Research Articles

Epidemiology and placental pathology of intrauterine fetal demise in a tertiary hospital in the Philippines

ObjectivesThe Philippines has at least 25,000 stillbirth or intrauterine fetal demise (IUFD) cases every year. Despite its burden, there is scarce information on IUFD epidemiology in the Philippines. Hence, this study reported the epidemiology and placental pathology of IUFD in a tertiary hospital in the Philippines. Study designThis cross-sectional study analyzed second- and third-trimester IUFD cases at the Philippine General Hospital from 2012 to 2021. We reviewed maternal sociodemographic and clinical characteristics and evaluated placental pathology. All statistical tests were done with GraphPad Prism software version 8.0. ResultsWe recorded 947 (2.28 %) cases of IUFD out of 41,562 obstetric deliveries from 2012 to 2021. Out of 947 IUFD cases, 532 had placental pathology reports. Second-trimester IUFD cases showed higher rates of no antenatal care (42.86 %) compared to third-trimester cases (10.61 %). Hypertensive disorders were more common in third-trimester IUFD. Infarcts (23.34 %), calcifications (4.12 %), and hemorrhages/hematomas (3.00 %) were the most prevalent placental abnormalities. While these abnormalities were more common in third-trimester IUFD, placental and fetal membrane infections like chorioamnionitis were more frequent in second-trimester IUFD. ConclusionThe results highlighted the differences in maternal sociodemographic and clinical characteristics, and placental pathology between second- and third-trimester cases of IUFD. These observations revealed distinct pathological processes and potential etiologies contributing to IUFD in the Philippines.

Folic acid: The key to a healthy pregnancy - A prospective study on fetomaternal outcome.

The objective of the study is to study the fetomaternal outcome associated with folic acid deficiency in pregnancy. This hospital-based observational study was conducted in the Department of Obstetrics and Gynaecology at Base Hospital, Delhi Cantt, and a total of 351 participants were enrolled who were fulfilling the inclusion criteria. The plasma folic acid level of the selected patients was measured in the booking visit by automated chemiluminescence assay. The cutoff levels of folic acid were taken at 8.6 ng/mL. Based on these values, the study population was divided into two groups, one with folic acid values <8.6 ng/mL and the other with values ≥8.6 ng/mL. Plasma Vitamin B12 levels were measured to check for any concurrent deficiencies. Obstetric outcomes included first- and second-trimester miscarriages, development of anemia, gestational hypertension/preeclampsia, gestational diabetes mellitus, hypothyroidism, placental abruption, and intrauterine fetal growth restriction (FGR). Furthermore, the period of gestation at delivery, fetal weights, APGAR scores at 5 min were documented. The study also considered fetal neural tube defects, intrauterine fetal demise for data collection. Collected data were analyzed statistically to find the association of the above-mentioned outcomes with levels of folic acid. The rate of preterm deliveries was significantly higher in the folic acid group with levels <8.6 ng/mL (16.94%). The incidence of small for gestational age/FGR was higher in the folic acid group with levels <8.6 ng/mL (27.11%) compared to the high folic acid group with levels ≥8.6 ng/mL (13.38%). The differences in the incidence of anemia, gestational hypertension, gestational diabetes, and preeclampsia between the two groups were not statistically significant and no cases of intrauterine fetal demise or placental abruption were observed in either group. Moreover, there was no significant difference in the relative risk of low Apgar scores at 5 min between the two groups. The present study suggests that low folic acid levels during pregnancy are associated with a higher risk of adverse pregnancy outcomes such as anemia, miscarriages, preterm delivery, and FGR. Therefore, adherence to nutritional recommendation of folic acid supplementation during pregnancy is essential to prevent these adverse outcomes.

Late miscarriage and stillbirth in asymptomatic and symptomatic hospitalised pregnant women in Belgium during the first and second waves of COVID-19: a prospective nationwide population-based study

BackgroundStillbirth has been recognized as a possible complication of a SARS-CoV-2 infection during pregnancy, probably due to destructive placental lesions (SARS-CoV-2 placentitis). The aim of this work is to analyse stillbirth and late miscarriage cases in unvaccinated pregnant women infected with SARS-CoV-2 during the first two waves (wild-type period) in Belgium.MethodsStillbirths and late miscarriages in our prospective observational nationwide registry of SARS-CoV-2 infected pregnant women (n = 982) were classified by three authors using a modified WHO-UMC classification system for standardized case causality assessment.ResultsOur cohort included 982 hospitalised pregnant women infected with SARS-CoV-2, with 23 fetal demises (10 late miscarriages from 12 to 22 weeks of gestational age and 13 stillbirths). The stillbirth rate was 9.5‰ for singleton pregnancies and 83.3‰ for multiple pregnancies, which seems higher than for the background population (respectively 5.6‰ and 13.8‰). The agreement between assessors about the causal relationship with SARS-Cov-2 infection was fair (global weighted kappa value of 0.66). Among these demises, 17.4% (4/23) were “certainly” attributable to SARS-CoV-2 infection, 13.0% (3/23) “probably” and 30.4% (7/23) “possibly”. Better agreement in the rating was noticed when pathological examination of the placenta and identification of the virus were available, underlining the importance of a thorough investigation in case of intra-uterine fetal demise.ConclusionsSARS-CoV-2 causality assessment of late miscarriage and stillbirth cases in our Belgian nationwide case series has shown that half of the fetal losses could be attributable to SARS-CoV-2. We must consider in future epidemic emergencies to rigorously investigate cases of intra-uterine fetal demise and to store placental tissue and other material for future analyses.

A study on the placenta in stillbirth: an evaluation of molecular alterations through next generation sequencing

IntroductionPlacental dysfunction is one of the most common causes of Intrauterine Fetal Demise (IUFD). Due to its characteristics, the placenta may be the target of molecular research aimed to investigate potential causes of IUFD. In the literature, there are no studies on human placentas that have investigated possible associations between somatic mutations and the occurrence of IUFD. The aim of this study was to identify the presence of gene mutations in placental tissues in a series of cases of IUFD and to evaluate potential correlations with placental microscopic findings. Materials and methodsThirty-seven samples of formalin-fixed and paraffin-embedded placental tissues were retrospectively selected from pregnancies ending in IUFD between 23rd to 40th week. Six control placentas of physiological pregnancies were included as controls. After sampling, made according to standardized protocol and conventional histopathological examination, placental tissues were subjected to DNA extraction and sequencing by means of Next Generation Sequencing with a 56-gene panel. ResultsThe most frequent mutation observed in 32/37 IUFD cases (86.5%) and absent in any of the 6 control placentas was in c-KIT gene, which is implicated in placental tissue differentiation. However, no significant correlation was found between the presence of individual gene mutations and placental histopatological findings. DiscussionAs the present study found an elevated frequency of c-KIT mutation in IUFD, it further supports the hypothesis that c-KIT is involved in abnormal tissue differentiation leading to altered placental vascularization and function.

Intrauterine Fetal Demise Associated with Vascular Malperfusion and Multiple Uterine Leiomyomata: A Report of Two Cases

Background Uterine leiomyomata have been loosely associated with intrauterine fetal demise (IUFD), largely attributed to fetal growth restriction from cavitary distortion. We present two cases of IUFD in patients with non-distorting leiomyomata and pathologic placental findings of maternal vascular malperfusion (MVM) and fetal vascular malperfusion (FVM). Case Report Case 1 details a 28w3d IUFD associated with large leiomyomata (largest 11.9 × 7.6 × 9.7 cm), post-partum deep vein thrombosis, and severe pre-eclampsia histologic features. Case 2 details a 25w2d IUFD associated with smaller leiomyomata (largest 3.1 × 3.0 × 3.3 cm). Both placentas demonstrated MVM, including parenchymal thrombi and accelerated villous maturity, and FVM, including avascular stem villi. Discussion As the placentas in both cases demonstrated findings consistent with altered placental perfusion, we posit that leiomyomata in these cases may have been associated with both maternal and fetal vascular malperfusion, ultimately contributing to fetal demise.

Factors Associated with Maternal and Perinatal Complications of Preeclampsia at the Central Hospital of Yaound&amp;#233;: A Cross-Sectional Analytical Study

Introduction: Pre-eclampsia (PE) is a public health problem especially in developing countries due to its incidence and severity. It is responsible for high maternal and perinatal morbidity and mortality. Accordingly, the objective of this work was to study the factors associated with the occurrence of maternal and perinatal complications of preeclampsia. Method: This was an analytical cross-sectional study with prospective and retrospective data collection including all patients, pregnant or postpartum, admitted for pre-eclampsia to the maternity ward of the Yaoundé Central Hospital. It took place over a period of seven (07) months. The data collected was analyzed using CS Pro 7.4, SPSS 20.0 and Microsoft Office Excel 2010 software. We compared the group with complications to the group without complications. We calculated the odds ratio to look for associations between variables and their 95% confidence intervals. The threshold for statistical significance was set at p Results: We recruited 214 cases of preeclampsia in our series. There were maternal complications in 44.4% of cases, dominated by eclampsia (31.8%). We recorded 07 maternal deaths, representing a maternal lethality of 3.3%. We had at least one perinatal complication in 105 cases (49.1%). The predominant perinatal complication was prematurity. We recorded 32 cases of intrauterine fetal demise and 13 cases of early neonatal death, giving a perinatal lethality of 21%. After logistic regression, the factors associated with maternal complications were residing in a rural area (OR = 2.217 [1.054 - 3.09]; p - 36.162]; p - 4.029]). Conclusion: Complications of preeclampsia are very common in our setting. Several identified factors are associated with the occurrence of these complications. We suggest building the capacity of providers of PNC and sensitization of women on the use of PNC services.

Intrauterine fetal death: Five years’ experience in a secondary care hospital.

Objectives: The objectives of this study were to estimate the prevalence, preoperative, and operative risk factors associated with the higher risk of SSI in gynecologic cancer patients undergoing surgery in a tertiary care facility in a developing country. Study Design: Retrospective Study. Setting: Obstetrics and Gynecology Department, Agha Khan Hospital for Women Garden Karachi, Pakistan. Period: Jan 2012 to Dec 2016. Material &amp; Methods: Retrospective review of medical records of patients over a period of five years from Jan 2012 to Dec 2016 was done. Results: The study consisted of 56 cases of intrauterine fetal demise out of 4813 number of deliveries which occurred during the study duration. Overall estimated rate of intrauterine fetal demise was 11.6 %( 56/4813). Approximately 33.9% of cases did not have a clear cause of fetal death identified and hence were un-explained. In 56 cases, 28.6% had some form of congenital abnormality identified on ultrasound, 7.1% (n=4) had anemia, 23.2% (n=13) IUGR, 5.4% (n=3) placental abruption and 1.8% (n=1) of gestational diabetes and around 83.9% (n=47) had normal vaginal delivery and 8 were delivered by LSCS and only 1 patient had instrumental delivery. Fetal characteristics identified 50% (n=28) were males and 50% (n=28) were females. 4 fetuses were born with tight cord around their neck 58.1% were macerated stillbirths (n=25) while 32.6% were fresh stillbirth. Conclusion: Antepartum intrauterine fetal death or stillbirths in the third trimester, affect the entire family. We conclude from our study that quality antenatal care with health education and timely interventions can reduce the number of intrauterine fetal deaths thus reducing the psychological sequelae.

First trimester fasting plasma glucose screen in advanced maternal age women: a cost-effectiveness analysis

Background The prevalence of preexisting type 2 diabetes mellitus (T2DM) in the United States is on the rise. Women of advanced maternal age (AMA, ≥35 years) are more likely to have preexisting T2DM in pregnancy because glucose intolerance increases with age. Diabetes in pregnancy is associated with significant maternal and neonatal morbidity and mortality, and earlier treatment initiation improves pregnancy outcomes. However, maternal age is not currently recognized as an independent risk factor that warrants diabetes screening prior to the traditional screen at 24–28 weeks gestation. Objective To evaluate the cost-effectiveness of screening all AMA women with a first trimester fasting plasma glucose (FPG) test for earlier diagnosis and management of preexisting T2DM. Study design A decision-analytic model was created to compare pregnancy outcomes in AMA women who undergo a first trimester FPG test vs third trimester oral glucose tolerance test alone. Probabilities were obtained from the literature. Outcomes examined included preeclampsia, preterm delivery, macrosomia, shoulder dystocia, brachial plexus injury (BPI), intrauterine fetal demise (IUFD), cerebral palsy, and neonatal death. The cost, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio of the first trimester screening strategy were examined as well. Sensitivity analyses and a Monte Carlo simulation were performed to test the model’s robustness. Results In AMA women, screening for preexisting T2DM in the first trimester with an FPG test resulted in fewer cases of preeclampsia, preterm delivery, BPI, IUFD, cerebral palsy, and neonatal death compared to performing a third trimester oral glucose tolerance test alone, and is cost-effective. Monte Carlo analysis incorporating the distribution of all probabilities showed that first trimester FPG screening remained cost-effective as long as the incremental cost of initiating diabetes treatment in the first trimester was less than $150,000 and the cost of the FPG screen was less than $2700. Conclusion Compared to third trimester oral glucose tolerance test alone, performing a first trimester FPG screen in AMA women is cost-saving and more effective.

Repeat screening for syphilis in pregnancy as an alternative screening strategy in the UK: a cost-effectiveness analysis

ObjectivesTo assess the cost-effectiveness of universal repeat screening for syphilis in late pregnancy, compared with the current strategy of single screening in early pregnancy with repeat screening offered only to...

Low mortality in fetal supraventricular tachycardia: Outcomes in a 30-year single-institution experience.

To describe a single institutional experience managing fetuses with supraventricular tachycardia (SVT) and to identify associations between patient characteristics and fetal and postnatal outcomes. Sustained fetal SVT is associated with significant morbidity and mortality if untreated, yet the optimal management strategy remains unclear. Retrospective cohort study including fetuses diagnosed with sustained SVT (>50% of the diagnostic echocardiogram) between 1985 and 2018. Fetuses with congenital heart disease were excluded. Sustained SVT was diagnosed in 65 fetuses at a median gestational age of 30 weeks (range, 14-37). Atrioventricular re-entrant tachycardia and atrial flutter were the most common diagnoses, seen in 41 and 16 cases, respectively. Moderate/severe ventricular dysfunction was present in 20 fetuses, and hydrops fetalis was present in 13. Of the 57 fetuses initiated on transplacental drug therapy, 47 received digoxin first-line, yet 39 of 57 (68%) required advanced therapy with sotalol, flecainide, or amiodarone. Rate or rhythm control was achieved in 47 of 57 treated fetuses. There were no cases of intrauterine fetal demise. Later gestational age at fetal diagnosis (odds ratio [OR], 1.1, 95% confidence interval [CI], 1.01-1.2, P = .02) and moderate/severe fetal ventricular dysfunction (OR, 6.1, 95% CI, 1.7-21.6, P = .005) were associated with postnatal SVT. Two postnatal deaths occurred. Fetuses with structurally normal hearts and sustained SVT can be effectively managed with transplacental drug therapy with minimal risk of intrauterine fetal demise. Treatment requires multiple antiarrhythmic agents in over half of cases. Later gestational age at fetal diagnosis and the presence of depressed fetal ventricular function, but not hydrops, predict postnatal arrhythmia burden.

Clinical profile of pregnancy loss and placental histopathology at a University Hospital

Aims: To review the clinical features of abortion and intrauterine fetal demise with histopathological findings in their placenta&#x0D; Methods: A retrospective study conducted at Kathmandu University Dhulikhel Hospital from 2008 to 2018.&#x0D; Results: A total of 431 placentas were examined over one decade. One third of them (33.2%) had abortion. Mean age of the patients with abortion was 24.72±5.5 years and that of intrauterine fetal demise (IUFD) was 25.36±5.4 years (p=0.2288). Two thirds of patients with abortion presented with vaginal bleeding and/or lower abdominal pain; 73% of IUFD presented with decreased fetal movement. Gross anomaly was the most common comorbid condition in abortion group while pre/post term, antepartum hemorrhage and PIH were the commoner conditions in IUFD group. In this study, 17.4% abortion cases and 18.3% IUFD cases were with histopathologically proven infection.&#x0D; Conclusions: Placental examination helps in revealing unseen pathologies in cases of poor obstetric outcomes in the form of abortion or fetal demise. The service provider should collect and provide required clinical information before studying the placenta to establish a hidden diagnosis.

20: Induction of labor versus expectant management at 39 weeks: a cost-effectiveness analysis

A recent study found that induction of labor at 39 weeks for low-risk women was not associated with an increased risk of adverse neonatal outcomes. We sought to examine the cost-effectiveness and outcomes associated with induction of labor at 39 weeks versus expectant management. A cost-effectiveness model using TreeAge software was designed to compare outcomes in women who were induced at 39 weeks versus expectantly managed. We used a theoretical cohort of 1.6 million women, the approximate number of nulliparous term births in the US annually that are considered low risk. Outcomes included mode of delivery, preeclampsia, macrosomia, intrauterine fetal demise, permanent brachial plexus injury, cerebral palsy, and neonatal death, in addition to cost and quality-adjusted life years (QALY) for both the woman and neonate. Probabilities were derived from the literature, and a cost-effectiveness threshold was set at $100,000/QALY. In our theoretical cohort of 1.6 million women, induction of labor resulted in 49,449 fewer cesarean deliveries and 79,152 fewer cases of preeclampsia. Additionally, we found that induction of labor resulted in 795 fewer cases of intrauterine fetal demise and 49 fewer neonatal deaths, despite 50 more cases of brachial plexus injury and 54 cases of moderate cerebral palsy (Table 1). Induction of labor resulted in increased costs, but increased QALYs with an incremental cost-effectiveness ratio of $97,501 per QALY. Univariate sensitivity analysis demonstrated that induction of labor was cost-effective until the cost of induction exceeded $2000 (Figure 1). In our theoretical cohort, induction of labor in nulliparous term women at 39 weeks of gestation resulted in improved outcomes, but increased costs. The cost-effectiveness ratio was marginally cost effective, but would lead to an additional $2.26 billion of health care costs. Whether individual clinicians and healthcare systems offer routine induction of labor at 39 weeks will need to depend on local capacity and patient preferences.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Placenta in intrauterine fetal demise (IUFD): a comprehensive study from a tertiary care hospital

Background: Intrauterine fetal demise (IUFD) is an unpredictable and challenging obstetric complication. Its etiology is multifactorial with more than 60% attributed to the placental cause. The present study was done with a primary objective of understanding the placental lesions underlying IUFD.Methods: In this retrospective observational study, IUFD cases (>22 weeks) between January 2012 and September 2015 were collected from pathology database. The clinical details with ultrasound findings were collected from mother’s charts. The lesions were classified into (A) maternal vascular malperfusion (MVM) including retroplacental hematomas, (B) fetal vascular malperfusion (FVM), (C) inflammatory lesions, and (D) idiopathic. The contributor to fetal death was classified as direct, major, minor, unlikely, or unknown. Placental findings of fetal hypoxia were recorded.Results: The study included 100 cases of IUFD. The mean maternal age was 26 years (18–36 years). Primipara were 46. There were 65 early preterm (PT) (<34 weeks), 20 late PT (34 weeks to <37 weeks) and 15 term (>37 weeks) IUFD. The mean gestation age was 30 weeks. The ratio of male:female fetuses was 1:1.7. Relevant obstetric complications included preeclampsia (n = 39), intrauterine growth restriction (IUGR) (n = 7), pre-gestational diabetes (n = 7), bad obstetric history (n = 6), oligohydramnios (n = 5). The mean placental weight was 256 g. Maternal vascular malperfusion had the highest incidence (30%), followed by combined maternal and FVM (10%). Exclusive inflammatory lesions and FVM were seen in 12 and 6%, respectively. No cause was identified in 18%. Direct contributor to IUFD was identified in 51 cases and major, minor, unlikely contribution in 21, 11 and nine cases, respectively. In nine cases, it was unknown. Lesions indicating fetal hypoxia were noted in 35 cases. In both early and late PT, MVM featured more commonly (23 and 5%). In term placentas, the most common cause was idiopathic.Conclusions: Lesions of MVM were the most common cause of IUFD and served as a direct contributor to fetal demise.

Types II and III congenital pulmonary airway malformation with hydrops treated in utero with percutaneous sclerotherapy.

To present outcomes of fetuses with congenital pulmonary airway malformation (CPAM) treated with sclerotherapy. Retrospective study of 8 patients with a prenatal diagnosis of CPAM type II or III with secondary hydrops treated with percutaneous sclerotherapy using 5% ethanolamine oleate (EO). All patients underwent ultrasonic measurement of the CPAM volume ratio. Results are expressed as median (range). Gestational age at initial sclerotherapy was 22.0weeks (19.6-31.4); 3 patients underwent 2 procedures. Intrauterine fetal demise (IUFD) occurred in 4 cases; 2 died on postoperative day #1 (one from inadvertent intravascular EO injection); 2 died >6weeks after the procedure. Preoperative CPAM volume ratio was 3.6 (1.6-7.8) in survivors and 2.7 (1.7-4.7) in those with IUFD. The volume of EO at the initial sclerotherapy procedure was 3mL (2-5) in survivors and 7mL (6-10) in IUFD cases. The gestational age at delivery of the 4 survivors was 38.4weeks (37.4-39.3); all underwent postnatal resection. The efficacy of percutaneous sclerotherapy for CPAM types II and III remains in question. Further studies are needed to determine the optimal dose of sclerotherapy agent and the safety and efficacy of this procedure.

Cost Effectiveness of Inpatient vs Outpatient Fetal Monitoring in Monochorionic-Monoamniotic Twin Gestations [30R

INTRODUCTION: To determine the cost-effectiveness of inpatient, continuous fetal monitoring versus outpatient management of monochorionic-monoamniotic (MCMA) twin gestations. METHODS: A decision-analytic model was created comparing continuous fetal monitoring versus outpatient daily nonstress test (NST) in a theoretical cohort of 250 MCMA pregnancies. The two arms were broken down based on gestational age beginning at 26 weeks gestation. All probabilities, utilities, and costs were derived from the literature. The primary outcome was the incremental cost per quality-adjusted life year (QALY). Rates of intrauterine fetal demise (IUFD), neonatal death, and cerebral palsy were also investigated. The cost-effectiveness threshold was set at $100,000 per QALY. Univariate and multivariate analyses were used to investigate model robustness. RESULTS: Inpatient continuous fetal monitoring results in improved neonatal outcomes and decreased cost. Compared to outpatient management, inpatient management would lead to 43 fewer cases of single IUFD, 7 fewer cases of double IUFD, 34 fewer neonatal deaths and 5 fewer neonates with cerebral palsy. Inpatient management improved effectiveness by 4.500 QALYs and saved $6.6 million (primary strategy improved outcomes). Inpatient management remained the dominant strategy as our estimated cost of per week was doubled to $8,325/week, and remained cost-effective up to five-times our estimated cost. CONCLUSION: Inpatient management is a cost-effective strategy for antenatal management of MCMA twin gestations that can reduce perinatal morbidity and mortality. Hospitalization of 5 patients would prevent an IUFD and 8 patients would prevent one neonatal death.

Association between human brucellosis and adverse pregnancy outcome: a cross-sectional population-based study.

To investigate the association between the incidence of human brucellosis (HB) and adverse pregnancy outcomes (APOs), a population-based, cross-sectional aggregate data study was conducted in Israel between 2010 and 2014. HB-endemic localities were matched by ethnicity, population size and socioeconomic status to localities with a low incidence of HB. We compared APO rates in high-incidence vs low-incidence localities. The primary outcome was intrauterine fetal demise (IUFD). Secondary outcomes were premature birth (less than 37weeks), early or threatened labour and poor fetal growth. APOs are expressed as events per 1,000 live or dead births. Eleven high-incidence localities, all Arab villages or cities, were matched to 11 low-incidence localities. Localities were well-matched with regard to the matching criteria, fertility indices, health insurance access and education, but were imbalanced geographically. All defined APOs occurred significantly more frequently in the high-incidence localities. The associations translated to an absolute increase of 3.6 cases of IUFD (95% CI 1.6-5.3), 11.7 preterm births (4.8-18.3), 6.6 cases of early or threatened labour (2.2-10.9) and 7 cases of poor fetal growth (3-10.8), per 10,000 live or dead births. Owing to a geographic imbalance between high- and low-incidence localities, we conducted an analysis restricted to Southern localities of Arab Bedouins showing a significant association between yearly HB incidence and IUFD incidence, odds ratio 1.05 (1.03-1.06). HB incidence is epidemiologically linked to serious pregnancy complications. Early detection of infection through active surveillance during pregnancy followed by appropriate treatment should be evaluated as additional public heath strategy in endemic settings.

Radiofrequency ablation for selective reduction in complex monochorionic multiple pregnancies: A case series

ObjectiveTo determine the safety and efficacy of radiofrequency ablation (RFA) for selective fetal reduction in complex monochorionic multiple pregnancies. Materials and methodsFrom July 2011 to January 2015, data on all cases treated with RFA were collected prospectively in our hospital. Indications, procedure details, cause of fetal demise and pregnancy outcomes were analyzed. Sonography and magnetic resonance imaging were performed to detect fetal brain damage. Information regarding development after birth was collected according to the Gesell Development Schedule®. ResultsThere were 22 cases of twins (6 presenting with twin-twin transfusion syndrome, 10 with malformations, 4 with selective intrauterine growth restriction, and 2 with twin reversed arterial perfusion sequence); and 11 cases of triplets (9 dichorionictriamniotic, 2 monochorionictriamniotic). All surgeries were completed with one puncture. No maternal complications presented during RFA procedure, and the PPROM rate before 32 w was 9% (3/33). There were 3 cases of intrauterine fetal demise and 4 twin cases where pregnancy was terminated. The fetal survival rate was 77% (17/22) in twins, 91% (20/22) in triplets. Total fetal survival rate was 84% (37/44). The neurodevelopmental follow-up investigations showed no abnormalities in any of the survivors. ConclusionRFA for selective fetal reduction in complex monochorionic multiple pregnancies is effective, minimally invasive, and safe.

Distribution and potential significance of intravillous and intrafibrinous particulate microcalcification

Radiologic studies indicate that placental calcifications seen at 28–32 weeks' gestation are associated with adverse fetal outcome. One type of placental calcification is typically located at the basement membrane of chorionic villi. It has a fine particulate appearance and can only be seen microscopically. We have designated these calcifications as Intravillous and Intrafibrinous Particulate MicroCalcification (IPMC). In this study we examined the distribution and potential significance of IPMC. Placentas from 14 groups of fetal and maternal outcomes are examined histologically for IPMC. These groups were preterm birth, post term birth, intrauterine fetal demise, fetuses with non-reassuring heart rates, intrauterine growth restriction, fetal anomalies, mothers with gestational hypertension, gestational diabetes, placental abruption, pre-eclampsia and placentas of normal spontaneous vaginal births and placentas with chorioamnionitis, chronic villitis and infarcts. We observed fine dust-like particulates deposited in continuous and discrete patches. The particulates were predominantly located in the basement membranes of fibrotic chorionic villi and in perivillous fibrin. Compared to placentas without adverse outcomes, a higher incidence of IPMC was seen in intrauterine fetal demise cases and in cases with infarcts which suggests that hypoxia played a role in the etiology of IPMC.

Conditions Associated with Intrauterine Fetal Demise (IUFD) in Pregnant Women at King Abdulaziz University (KAUH). A Five-Year Experience

Background: Intrauterine fetal demise is the death of the fetus after twenty week of gestation but before the onset of labor. In more than 50% of cases, the etiology of antepartum fetal death is not known or cannot be determined. Several factors attributed to the risk of IUFD. This study aimed to determine the incidence of IUFD, as well as associated conditions. Method: This retrospective study enrolled all pregnant women who attending at KAUH between 2011 and 2015. Results: During the last five years 248 verified IUFD cases were reported, the mean age was 30.59. Saudi nationality represented by 27 %. PET was represented 17.7% and congenital malformation was represented by 7.3% as risk factors. Regarding the mode of delivery SVD was 58.9% followed by CS 28.6. Conclusion: Stillbirth is an unfavorable event, there are several factors (maternal, fetal & placenta) associated with IUFD. Providing good level of antenatal care helped in reducing IUFD incidence.

Complexity analysis of fetal heart rate preceding intrauterine demise

BackgroundVisual non-stress test interpretation lacks the optimal specificity and observer-agreement of an ideal screening tool for intrauterine fetal demise (IUFD) syndrome prevention. Computational methods based on traditional heart rate variability have also been of limited value. Complexity analysis probes properties of the dynamics of physiologic signals that are otherwise not accessible and, therefore, might be useful in this context. ObjectiveTo explore the association between fetal heart rate (FHR) complexity analysis and subsequent IUFD. Our specific hypothesis is that the complexity of the fetal heart rate dynamics is lower in the IUFD group compared with controls. Study designThis case-control study utilized cases of IUFD at a single tertiary-care center among singleton pregnancies with at least 10min of continuous electronic FHR monitoring on at least 2 weekly occasions in the 3 weeks immediately prior to fetal demise. Controls delivered a live singleton beyond 35 weeks’ gestation and were matched to cases by gestational age, testing indication, and maternal age in a 3:1 ratio. FHR data was analyzed using the multiscale entropy (MSE) method to derive their complexity index. In addition, pNNx, a measure of short-term heart rate variability, which in adults is ascribable primarily to cardiac vagal tone modulation, was also computed. Results211 IUFDs occurred during the 9-year period of review, but only 6 met inclusion criteria. The median gestational age at the time of IUFD was 35.5 weeks. Three controls were matched to each case for a total of 24 subjects, and 87 FHR tracings were included for analysis. The median gestational age at the first fetal heart rate tracing was similar between groups (median [1st–3rd quartiles] weeks: IUFD cases: 34.7 (34.4–36.2); controls: 35.3 (34.4–36.1); p=.94). The median complexity of the cases’ tracings was significantly less than the controls’ (12.44 [8.9–16.77] vs. 17.82 [15.21–22.17]; p<.0001). Furthermore, the cases’ median complexity decreased as gestation advanced whereas the controls’ median complexity increased over time. However, this difference was not statistically significant [−0.83 (−2.03 to 0.47) vs. 0.14 (−1.25 to 0.94); p=.62]. The degree of short-term variability of FHR tracings, as measured by the pNN metric, was significantly lower (p<.005) for the controls (1.1 [0.8–1.3]) than the IUFD cases (1.3 [1.1–1.6]). ConclusionsFHR complexity analysis using multiscale entropy analysis may add value to other measures in detecting and monitoring pregnancies at the highest risk for IUFD. The decrease in complexity and short-term variability seen in the IUFD cases may reflect perturbations in neuroautonomic control due to multiple maternal-fetal factors.