Fetal Medicine Research Articles

Pharmacometrics in obstetrics and maternal-fetal medicine research: Bridging gaps in maternal and fetal pharmacology.

Pharmacometrics in obstetrics and maternal-fetal medicine research: Bridging gaps in maternal and fetal pharmacology.

The Significance of the Myocardial Performance Index and Fetal Doppler Abnormalities in Growth-Restricted Fetuses: A Systematic Review of the Literature

Introduction: This review aims to investigate the clinical implications of using the myocardial performance index (MPI), obtained through tissue Doppler imaging (TDI) and spectral Doppler, in assessing fetal cardiac function in growth-restricted fetuses. It explores the MPI’s potential in predicting adverse perinatal outcomes and its utility when combined with conventional pulsed-wave Doppler assessments for enhanced fetal well-being evaluations. Material and Methods: A systematic search of PubMed and Google Scholar databases spanning from 2004 to 2023 was conducted to identify pertinent articles on the MPI’s clinical application in managing growth-restricted fetuses. Inclusion criteria followed the Fetal Medicine Barcelona definition of fetal growth restriction (FGR) to mitigate study group heterogeneity. The research sources were PubMed and Google Scholar databases, and the review was conducted without any specific clinical or laboratory setting. Only articles meeting the inclusion criteria for FGR, as per the Fetal Medicine Barcelona definition, were considered. Six studies meeting these criteria were included in the review. The review analyzed the correlation between MPI values and conventional Doppler parameters, investigating the progression of myocardial function impairment and its association with the risk of fetal demise. The primary outcome measures included the relationship between MPI values, fetal well-being, and the potential for prenatal cardiac dysfunction in growth-restricted fetuses. Results: The findings indicate that as conventional Doppler parameters deteriorate, MPI values increase, suggesting progressive myocardial dysfunction. The MPI may cross the 95th percentile before abnormal flow in the ductus venosus and aortic isthmus, highlighting the potential for diastolic dysfunction preceding hypoxia in growth-restricted fetuses. Elevated MPI levels were observed in both growth-restricted and small-for-gestational-age (SGA) fetuses, indicating prenatal cardiac impairment. The strong association between an abnormal MPI and perinatal mortality has been shown for early FGR. Conclusions: MPI alterations appear to precede abnormal Doppler parameters in early- and late- onset FGR, potentially indicating diastolic dysfunction preceding hypoxia. Additionally, the MPI correlates with the risk of fetal demise. However, larger studies are needed to establish its sensitivity and specificity. Furthermore, the significance of prenatal cardiac impairment in some SGA fetuses raises questions about its potential impact on perinatal outcomes and cardiovascular programming.

Validation of Fetal Medicine Foundation charts for fetal growth in twins: nationwide Danish cohort study.

To assess the validity of the Fetal Medicine Foundation (FMF) chorionicity-specific models for fetal growth in twin pregnancy. This was an external validation study of the FMF models using a nationwide Danish cohort of twin pregnancies. The cohort included all dichorionic (DC) and monochorionic diamniotic (MCDA) twin pregnancies with an estimated delivery date between 2008 and 2018, which satisfied the following inclusion criteria: two live fetuses at the first-trimester ultrasound scan (11-14 weeks' gestation); biometric measurements available for the calculation of estimated fetal weight (EFW) using the Hadlock-3 formula; and delivery of two liveborn infants. Validation involved assessing the distributional properties of the models and estimating the mean EFW Z-score deviations. Additionally, the models were applied to pregnancies that delivered preterm and attended non-scheduled visits (complicated pregnancies). Overall, 8542 DC and 1675 MCDA twin pregnancies met the inclusion criteria. In DC twins, 17 084 fetuses were evaluated at a total of 95 346 ultrasound scans, of which 44.5% were performed at scheduled visits in pregnancies carried to 37 + 0 weeks or later. The median number of growth scans per DC twin fetus from 20 + 0 weeks onwards was four. The model showed good agreement with the validation cohort for scheduled visits in DC twins delivered at 37 + 0 weeks or later (mean EFW Z-score, -0.14 ± 1.05). In MCDA twins, 3350 fetuses underwent 31 632 eligible ultrasound scans, of which 59.5% were performed at scheduled visits in pregnancies carried to 36 + 0 weeks or later. The median number of growth scans per MCDA twin fetus from 16 + 0 weeks onwards was 10. The model showed favorable agreement with the validation cohort for scheduled visits in MCDA twins delivered at 36 + 0 weeks or later (mean EFW Z-score, -0.09 ± 1.01). Non-scheduled visits and preterm delivery before 37 + 0 weeks for DC twins and before 36 + 0 weeks for MCDA twins corresponded with smaller weight estimates, which was consistent with the study's definition of complicated pregnancy. The FMF models provide a good fit for EFW measurements in our Danish national cohort of uncomplicated twin pregnancies assessed at routine scans. Therefore, the FMF models establish robust criteria for subsequent investigations and potential clinical applications. Future research should focus on exploring the consequences of clinical implementation, particularly regarding the identification of twins that are small-for-gestational age, as they are especially susceptible to adverse perinatal outcome. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Early detection and management of congenital pulmonary airway malformation in a newborn with stable clinical course

Introduction: Congenital pulmonary airway malformation (CPAM) is a rare developmental lung anomaly characterized by cystic lung lesions, constituting about 25% of congenital pulmonary anomalies. It typically occurs sporadically and is not significantly associated with race, age, or other maternal factors. The prenatal course of CPAM can vary based on factors such as lesion size, mediastinal shift, and associated anomalies. While the overall prognosis is generally favorable in the absence of severe complications like hydrops fetalis, which can adversely affect outcomes, management strategies include corticosteroids, thoracoamniotic shunt (TAS), and, in severe cases, open fetal surgery or the EXIT procedure. Postnatal surgical excision usually offers a curative outcome with an excellent prognosis. Without surgical intervention, there are risks of recurrent infections and, rarely, malignant transformation. Effective prenatal detection significantly impacts clinical decision-making and neonatal outcomes, and the necessity and timing of surgery for asymptomatic infants remain subjects of ongoing debate, underscoring the need for personalized, multidisciplinary care. Case Report: A female infant, delivered at 38 weeks via Cesarean section, was diagnosed with CPAM following routine prenatal ultrasound. Presence of extensive cystic regions in the right lung confirmed the diagnosis and a CPAM volume ratio (CVR) of 0.37 indicated a low risk of severe complications. The pregnancy was largely uneventful, with maternal chronic hypertension managed by Nifedipine and mild intermittent asthma. Postnatal chest radiography corroborated the CPAM diagnosis, while an abdominal ultrasound investigated intrahepatic calcifications. Maternal screening for cytomegalovirus and toxoplasmosis yielded negative results, and postnatally, the infant also tested negative for both infections. The neonate, though asymptomatic and stable, required close monitoring in the neonatal intensive care unit to prevent potential respiratory compromise. Conclusion: Advances in prenatal imaging have greatly improved the early detection and management of CPAM, allowing for targeted neonatal care and strategic planning. This case highlights the importance of a multidisciplinary approach involving obstetricians, maternal-fetal medicine specialists, neonatologists, and pediatric thoracic surgeons in the effective management of CPAM. Early identification and diligent postnatal monitoring are essential for ensuring optimal outcomes and minimizing the risk of complications. The coordinated care and strategic decision-making exemplified in this case underscore the potential for enhanced neonatal health and long-term well-being through comprehensive management of congenital anomalies.

The Role of Collaboration in Prenatal Congenital Heart Disease Diagnosis: A Comparison of Maternal-Fetal Medicine Specialist and Pediatric Cardiologist Performance.

This study compared the accuracy of prenatal congenital heart disease (CHD) diagnosed by maternal-fetal medicine specialists (MFMs) and pediatric cardiologists (PCs), using postnatal cardiac findings as the reference standard. This retrospective analysis at Siriraj Hospital, Bangkok, Thailand, involved 125 pregnancies with fetal CHD diagnosed by MFMs and evaluated by PCs later. Prenatal CHD diagnoses by either MFM or PC were compared with postnatal diagnoses obtained through echocardiography, cardiac surgery/catheterization, or autopsy. Diagnostic accuracy was classified as (A) correct diagnosis, (B) minor differences not impacting clinical management or outcomes, or (C) major differences affecting prognosis or treatment. Cardiac sonography by MFM achieved diagnostic accuracies of 73.6% (A), 16% (B), and 10.4% (C), while fetal echocardiography by PC resulted in accuracies of 72% (A), 20% (B), and 8% (C). No statistically significant differences were found between MFM and PC in each category (P = .375-.832). The MFMs' accuracy was highest for tetralogy of Fallot (94.4%; 95% CI, 72.7-99.9%) and lowest for right atrial isomerism (71.4%; 95% CI, 29-96.3%) and pulmonary atresia with ventricular septal defect (57.1%; 95% CI, 18.4-90.1%). MFMs and PCs demonstrated high and comparable accuracy in prenatal CHD diagnosis. Although PCs tended to outperform MFMs in cases where misdiagnosis could significantly impact neonatal care and outcomes, MFMs can effectively perform primary screening for fetal CHD in all pregnancies. Collaboration with PCs remains essential when fetal CHD is suspected, particularly in complex cases.

Unexplored topics in intrahepatic cholestasis of pregnancy: A review and bibliometric analysis.

To conduct a comprehensive bibliometric analysis of research published on intrahepatic cholestasis of pregnancy (ICP) and explore the related frontiers and critical issues concerning it, we searched the Web of Science Core Collection for ICP-related publications from the beginning of 2001 until August of 2023. CiteSpace and VOSviewer were utilized to evaluate the contribution and co-occurrence relationships of various countries and regions, institutes and so on to identify new frontiers and currently exciting topics. Our bibliometric analysis scrutinized 933 articles from 59 countries/regions. China has generated the largest number of publications (31.6% of the total), whereas Germany ranked first when it came to citations per publication. The Imperial College London ranked first with respect to publication output on ICP and betweenness centrality. The Journal of Maternal-Fetal & Neonatal Medicine was the journal with the highest plurality of papers. Authors such as Williamson, Beuers, Ulrich, and Shao were the most influential. Pregnancy, ursodeoxycholic acid, and ICP were principally noted in publications. Cluster analysis of the references that correlated with the 933 publications showed that they clustered into mortality, ABCB11, BSEP, MRP2, bile acid, and intrahepatic cholestasis. ICP is associated with adverse clinical outcomes for both the mother and fetus. This study provides a critical analysis of the current status and future research trends regarding ICP. It can serve as a useful reference, allowing researchers to conduct in-depth investigations into this promising field.

Design and Pilot Implementation of an ECHO Module to Facilitate Treatment of Hepatitis C Virus Infection During Pregnancy

Abstract Background Pregnant patients are largely excluded from Hepatitis C virus (HCV) research and treatment. Studies show that pregnant patients want to discuss treatment while providers feel they lack the knowledge and training for these discussions. To bridge this gap, we designed an ECHO module about management of HCV in pregnancy and infancy. Methods Content experts from pediatric infectious diseases, hepatology, maternal-fetal medicine, bioethics and members of ECHO-Chicago discussed: prior data, potential topics, target audience and scheduling of sessions. We held 8 one-hour sessions with 20-30 minutes of didactics and 30-40 minutes of solicited case discussion. Participants included those who participated in prior ECHO training and prenatal providers in local and regional practices. A 7-point Likert scale pre- and post-training survey was administered to assess metrics of self-efficacy for management of HCV in pregnancy and childhood. Results The sessions were conducted from May to June 2023 on the following topics: HCV screening; HCV pathophysiology/clinical presentations; staging fibrosis in HCV; HCV Treatment in non-pregnant patients; harm reduction; clinical considerations of HCV in pregnancy; shared decision-making for HCV treatment in pregnancy; and HCV screening in infants & treatment for children. Fourteen participants completed pre- and post-surveys. In the pre-survey, participants had low ratings of self-efficacy (average 3.0). In the post-survey (Table 1), participants reported dramatic increases in all areas (average 5.2, increase of 2.2) with the largest in the following areas: “Ability to discuss and manage timing of hepatitis C treatment in a pregnant person”, average 5.1, increase of 3; “Ability to identify suitable pregnant candidates for treatment for Hepatitis C”, average 5.2, increase of 2.7. For context, a 1-point increase in self-efficacy is considered meaningful. All respondents reported increased ability to address HCV in a preconception, pregnant, postpartum, or neonatal population. Conclusion As pivotal studies of pan-genotypic antivirals indicate efficacy and safety during pregnancy, this ECHO module could be distributed to support providers who are discussing therapy initiation. Table 1: Average Change in Self-Efficacy between Pre- & Post-Series Surveys

Betamethasone Exposure and Neonatal Respiratory Morbidity Among Late Preterm Births by Planned Mode of Delivery and Gestational Age.

To estimate the effect of late preterm antenatal steroids on the risk of respiratory morbidity among subgroups of patients on the basis of the planned mode of delivery and gestational age at presentation. This was a secondary analysis of the ALPS (Antenatal Late Preterm Steroid) Trial, a multicenter trial conducted within the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network of individuals with singleton gestations and without preexisting diabetes who were at high risk for late preterm delivery (34-36 weeks of gestation). We fit binomial regression models to estimate the risk of respiratory morbidity, with and without steroid administration, by gestational age and planned mode of delivery at the time of presentation. We assumed a homogeneous effect of steroids on the log-odds scale, as was reported in the ALPS trial. The primary outcome was neonatal respiratory morbidity, as defined in the ALPS Trial. The analysis included 2,825 patients at risk for late preterm birth. The risk of respiratory morbidity varied significantly by planned mode of delivery (adjusted risk ratio [RR] 1.90, 95% CI, 1.55-2.33 for cesarean delivery vs vaginal delivery) and week of gestation at presentation (adjusted RR 0.56, 95% CI, 0.50-0.63). For those planning cesarean delivery and presenting in the 34th week of gestation, the risk of neonatal respiratory morbidity was 39.4% (95% CI, 30.8-47.9%) without steroids and 32.0% (95% CI, 24.6-39.4%) with steroids. In contrast, for patients presenting in the 36th week and planning vaginal delivery, the risk of neonatal respiratory morbidity was 6.9% (95% CI, 5.2-8.6%) without steroids and 5.6% (95% CI, 4.2-7.0%) with steroids. The absolute risk difference of neonatal respiratory morbidity between those exposed and those unexposed to late preterm antenatal steroids varies considerably by gestational age at presentation and planned mode of delivery. Because only communicating the relative risk reduction of antenatal steroids for respiratory morbidity may lead to an inaccurate perception of benefit, more patient-specific estimates of risk expected with and without treatment may inform shared decision making.

MEDICINA FETAL: O AVANÇO QUE LEVOU À CIRURGIA INTRAUTERINA

Objective: To discuss the evolution of fetal medicine with an emphasis on current aspects of fetal surgical therapy. Methodology: An integrative literature review was carried out, using relevant articles found in the databases: Lilacs, PubMed, Scholar Google and Scielo. Studies whose full text was not available for free were excluded. Bibliographical Review: Fetal surgery has gained ground as a therapeutic possibility for various congenital pathologies. Through it, diagnoses that were previously considered lethal or seriously damaging are now treatable. However, its techniques are still constantly improving, and its indications are specific and reserved. It is up to the care team to carry out the timely diagnosis of anomalies, as well as to identify the conditions capable of fetal correction in order to guarantee the adequate physiological development of the fetus through early surgical intervention. Final Considerations: Fetal surgery was a milestone in the treatment of serious congenital pathologies, by enabling intrauterine antenatal treatment. Its advances make it possible to treat more and more pathologies, with a progressive reduction in risks. However, this is not yet an available treatment option for the vast majority of Brazilian patients, as its implementation is limited to a few specialized professionals from large centers.

MEDICINA FETAL: O AVANÇO QUE LEVOU À CIRURGIA INTRAUTERINA

Objective: To discuss the evolution of fetal medicine with an emphasis on current aspects of fetal surgical therapy. Methodology: An integrative literature review was carried out, using relevant articles found in the databases: Lilacs, PubMed, Scholar Google and Scielo. Studies whose full text was not available for free were excluded. Bibliographical Review: Fetal surgery has gained ground as a therapeutic possibility for various congenital pathologies. Through it, diagnoses that were previously considered lethal or seriously damaging are now treatable. However, its techniques are still constantly improving, and its indications are specific and reserved. It is up to the care team to carry out the timely diagnosis of anomalies, as well as to identify the conditions capable of fetal correction in order to guarantee the adequate physiological development of the fetus through early surgical intervention. Final Considerations: Fetal surgery was a milestone in the treatment of serious congenital pathologies, by enabling intrauterine antenatal treatment. Its advances make it possible to treat more and more pathologies, with a progressive reduction in risks. However, this is not yet an available treatment option for the vast majority of Brazilian patients, as its implementation is limited to a few specialized professionals from large centers.

7506 Rare Case of Hyperparathyroidism in Third Trimester Pregnancy Requiring Urgent Parathyroidectomy

Abstract Disclosure: A. Rothstein Costris: None. E. Davydov: None. S. Levy: None. Introduction: Primary hyperparathyroidism (PHPT) during pregnancy has risks to both the mother and her fetus. Complications include maternal pre-eclampsia, miscarriage, hyperemesis gravidarum, nephrolithiasis and pancreatitis. Fetal complications encompass hypocalcemia, tetany, intrauterine growth retardation and fetal demise. Though medical treatment is available, parathyroidectomy is the only definitive treatment. Traditionally, surgery is done in the second trimester of pregnancy. We report a case of a third trimester parathyroidectomy in a 29 yo female with PHPT. Case representation: A 29-year-old G1P0 woman at 28 weeks gestation presented with persistent nausea and vomiting, constipation, joint pain, and increased forgetfulness. She has moved to USA from Saudi Arabia and had not received prenatal care in the USA. She was found to have a PTH of 224 (15-65 pg/mL), Calcium of 13.5 (8.2-10.2 mg/dL), Ionized Calcium of 1.63 (1.00-1.35 mmol/L), and a corrected Calcium of 14.2 (8.7-10.1 mg/dL). Electrolyte abnormalities were also noticed, with a Potassium of 2.8 (3.5-5 mmol/L), Phosphorus of 1.7 (2.5-4.5 mg/dL) and Magnesium of 1.2 (1.8-2.3 mg/dL). Vit. D levels were found to be extremely low <7 (20-40 ng/mL). Due to severe dehydration, persistent nausea, vomiting, and hypercalcemia, the patient received fluid resuscitation and Vit. D supplementation. A neck CT scan identified an 11 x 6 x 14 mm arterially hyperenhancing soft tissue structure at T1-T2, suggesting a probable parathyroid adenoma in the right paratracheal region. Management options included surgery or conservative therapy with fluids and Cinacalcet. A joint decision was made between Maternal Fetal Medicine, ENT and Endocrinology to proceed with parathyroidectomy. Surgical excision revealed an enlarged, hypercellular right inferior parathyroid gland (0.51g). Postoperative laboratory studies at 2 weeks showed normal PTH, Ca, Ionized Ca. Conclusion: It is preferable to conduct surgery for PHPT during the second trimester of pregnancy. However, when PHPT leads to severe symptoms, surgery might be considered in the third trimester. The severity of our patient’s symptoms led to inability to tolerate oral intake, deeming surgery necessary. The multidisciplinary team agreed that surgery in the third trimester would be the best course of treatment as it will result in normocalcemia immediately. Second trimester parathyroidectomy is viewed as safer due to the completion of organogenesis and lower teratogenicity risks. Performance of surgery during the third trimester may lead to an increase in the risk of premature birth. However, untreated hypercalcemia may increase fetal loss and thus third trimester parathyroidectomy can be considered as a treatment option for PHPT in pregnancy. It is also imperative to discuss all options with the patient. In our case, the patient had opted for surgery which was successful. Presentation: 6/3/2024

8673 Exploring A Case Study On Navigating Complexities In Endocrine Health And Reproductive Challenges

Abstract Disclosure: S.Y. Rizvi: None. E. Villanueva: None. Introduction: Polycystic ovary syndrome (PCOS) is a common endocrine disorder affecting many reproductive-age women, characterized by irregular menstrual cycles, hirsutism, and challenges with fertility. In this case study, we delve into the medical history of a 24-year-old female presenting with PCOS-related symptoms, hirsutism, and infertility, unraveling the multifaceted aspects of her healthcare journey. Case Description: This patient's diagnostic path began when she received an initial diagnosis of PCOS in her home country due to irregular menstrual periods and clinical signs of hirsutism. Her treatment included metformin, but it was interrupted when she relocated to the United States. Upon her arrival in the U.S., her medical course took an unexpected turn as further evaluations revealed elevated salivary cortisol (++), and a 24-hour urine free cortisol recorded 94.2 mcg (normal 4-50 mcg), indicating hypercortisolism. DHEAS: 730 mcg/dl (normal 18-390 mcg/dl), 17-hydroxyprogesterone: 508 (pre-midluteal: 431), free testosterone: 13 pg/ml (normal 0.1-6.4 pg/ml), with normal CBC, TSH, prolactin, and TPO. CT scan showed large 4.8 cm left adrenal mass. These findings indicated adrenal Cushing's syndrome, leading to referral to a tertiary care hospital's endocrine surgeon. Two months post-adrenalectomy, successful removal of the adrenal mass left the patient with relative adrenal insufficiency. Hydrocortisone replacement therapy was initiated, addressing Cushing's syndrome and revealing a potential factor contributing to infertility. Postoperatively, the patient entered the first trimester unexpectedly, complicating her case. Ensuring proper hydrocortisone levels became crucial for her well-being and the fetus, prompting a collaborative approach with obstetricians and maternal-fetal medicine specialists for optimal pregnancy care. Despite ongoing PCOS effects, including hirsutism, treatment options were limited by pregnancy constraints, deferring Aldactone due to its contraindication during pregnancy. Continuous monitoring included hormonal assessments, metabolic panels, and thyroid tests, aiming to balance adrenal insufficiency, PCOS symptoms, and a healthy pregnancy. Conclusion: This case emphasizes challenges in differentiating PCOS from adrenal Cushing's due to overlapping symptoms. Despite classic symptoms, the initial PCOS misdiagnosis highlights the need for vigilance and comprehensive diagnostics. Complex cases underscore the importance of individualized management and interdisciplinary collaboration. Positive outcomes in complex endocrine disorders and pregnancy are attainable through accurate diagnoses and tailored treatments. The case underscores the critical importance of meticulous evaluation for successful outcomes in challenging medical scenarios. Presentation: 6/3/2024

Dépistage et prévention de la prééclampsie par l’algorithme de la Fetal Medicine Foundation : une étude avant-après

ObjectiveIn order to identify women at high risk of pre-eclampsia and offer them aspirin prophylactic treatment, the Fetal Medicine Foundation (FMF) recommends a first-trimester screening test. The commonly used threshold for aspirin administration is a risk >1/100, which implies treating an important number of patients. We aimed to assess the use of this strategy with a more restrictive threshold: risk >1/70 and evaluate the impact of this strategy on the prevalence of pre-eclampsia with premature delivery in nulliparous women. MethodsA before-and-after cohort study conducted from 01/09/2014 to 01/12/2018, including nulliparous women undergoing first-trimester ultrasound at the University Hospital of Toulouse. Between 09/2014 and 09/2016 (“before cohort”), women did not undergo pre-eclampsia screening. Between 01/2017 and 12/2018 (“after cohort”), women underwent targeted pre-eclampsia screening using the FMF algorithm, and those with a risk >1/70 received 100mg aspirin. The primary outcome was pre-eclampsia with premature delivery. A univariate and then a multivariate analysis were performed to take into account potential confounding factors. ResultsAmong the 1030 women of the before cohort, 17 women (1.7%) experienced pre-eclampsia with premature delivery, compared to 8 women (1.3%) among the 629 of the after cohort, with no significant difference between the two groups (Adjusted Odd Ratio (95%CI)=0.73 [0.31–1.74]). In the after cohort, 18 women (2.9%) had a risk greater than 1/70 and therefore received aspirin. According to the FMF screening test, 89 women (14.1%) had a risk>1/100, which is the usual threshold for prescribing aspirin for prophylaxis. This means that 71 women had a risk greater than 1/100 but less than 1/70 and therefore did not receive aspirin in this study, even though they would have received aspirin at the usual threshold. ConclusionsThe screening and prevention strategy for pre-eclampsia using restrictive thresholds did not decrease the rate of preeclampsia with premature delivery.

Provider Guidance for the Prevention of Respiratory Syncytial Virus in Infants: Maternal Vaccination Versus Infant Monoclonal Antibody Treatment.

In 2023, the Food and Drug Administration approved 2 new products to reduce the risk of lower respiratory infections caused by respiratory syncytial virus (RSV) in infants: Beyfortus (nirsevimab; AstraZeneca/Sanofi), a single-dose monoclonal antibody for infant administration, and Abrysvo (bivalent RSVpreF vaccine; Pfizer), a single-dose maternal vaccination. We aimed to synthesize data from the literature and the leading professional organizations to provide guidance on RSV and strategies to reduce the risk of infant infection. This information will assist prenatal care clinicians in counseling their patients regarding the choice between maternal vaccination and the infant monoclonal antibody. A descriptive review of the guidelines from the Centers for Disease Control and Prevention, American College of Obstetrics and Gynecology (ACOG), American Academy of Pediatrics, Society for Maternal-Fetal Medicine, and the American Academy of Family Physicians. All 5 organizations recommend that RSV vaccination should be offered to all pregnant people during the RSV season (September-January in the continental United States). Infants younger than 8 months entering into their first RSV season born to those who did not receive maternal vaccination or received vaccination less than 14 days prior to birth should be offered monoclonal antibody administration. RSV vaccination and monoclonal antibodies have the potential to significantly reduce the burden of lower respiratory tract infections due to RSV in infants. Future studies should further evaluate the durability of protection and other strategies to further protect the infant, including cocooning and the role of breast milk in immunity.

Answer from CIANE to article: European Association of Perinatal Medicine (EAPM), European Board and College of Obstetricians and Gynaecologists (EBCOG), European Midwives Association (EMA). Joint position statement: Substandard and disrespectful care in labour – Because words matter. Published: February 29, 2024

Answer from CIANE to article: European Association of Perinatal Medicine (EAPM), European Board and College of Obstetricians and Gynaecologists (EBCOG), European Midwives Association (EMA). Joint position statement: Substandard and disrespectful care in labour – Because words matter. Published: February 29, 2024

Addressing Hypertensive Disorders of Pregnancy through a Combined Renal-Maternal Fetal Medicine Clinic

Addressing Hypertensive Disorders of Pregnancy through a Combined Renal-Maternal Fetal Medicine Clinic

Partnering with the woman who declines recommended maternity care: Development of a statewide guideline in Queensland, Australia.

Choice, a fundamental pillar of woman-centred maternity care, depends in part on the right to decline recommended care. While professional guidance for midwives and obstetricians emphasises informed consent and respect for women's autonomy, there is little guidance available to clinicians or women about how to navigate maternity care in the context of refusal. To describe the process and outcomes of co-designing resources to support partnership between the woman who declines recommended maternity care and the clinicians and health services who provide her care. Following a participatory co-design process involving consumer representatives, obstetricians, midwives, maternal fetal medicine specialists, neonatologists, health service executives, and legal and ethics experts, implementation of the resources was trialled in seven Queensland Health services using Improvement Science's Plan-Do-Study-Act cycles. Resources for Partnering with the woman who declines recommended maternity care have now been implemented statewide, in Queensland, including a guideline, two consumer information brochures (available in 11 languages), clinical form, flowcharts, consumer video, clinician education, and culturally capable First Nations resources. Central to these resources is an innovative shared clinical form, that is accessible online, may be initiated and carried by the woman, and where she can document her perspective as part of the clinical notes. Queensland is the first Australian jurisdiction, and perhaps internationally, to formally establish this kind of guidance in clinical practice. Such guidance is identified as an enabler of choice in the national Australian strategy Woman-centred care: Strategic directions for Australian maternity services.

The IAPM New York 2024 declaration on professional responsibility and abortion.

The International Academy of Perinatal Medicine (IAPM) firmly supports abortion as a fundamental reproductive right, as declared at their annual meeting on June 28, 2024, in New York City. This stance, grounded in professional responsibility, respects both autonomy and beneficence-based obligations to pregnant patients and fetal patients. TheIAPM asserts that access to safe, legal abortion services is essential for gender equality, public health, and social justice. Their declaration aligns with international human rights standards, advocating for abortion legalization up tofetal viability and beyond in cases of maternal health risks or severe fetal anomalies. This comprehensive approach underscores the critical role of healthcare professionals inproviding compassionate reproductive healthcare, aiming to reduce maternal mortality and improve public health outcomes globally.

Predicting the Difficult Neonatal Airway in Fetuses WithMicrognathia, Oropharyngeal or Neck Mass Lesions: Two-Center Experience With Fetal MRI.

Neonatal airway compromise requiring intubation, due to micrognathia or a mass lesion obstructing the fetal airway, remains difficult but important to predict prenatally. We aimed to validate MR predictors of difficult neonatal airway (DNA) in a multicentre retrospective cohort of fetuses with micrognathia and oropharyngeal/neck masses. The radiology databases of two large Australian maternal-fetal medicine centers were searched for subjects meeting inclusion criteria: Pregnancies of > 18weeks' gestation evaluated with prenatal ultrasound and MRI between 2007 and 2022 where either fetal micrognathia or a fetal cervical, oral or oropharyngeal mass was identified on prenatal ultrasound and MRI, and details of delivery/postnatal course were available including: nature of delivery, need for the fetal airway to be secured at delivery, degree of difficulty in airway securement, survival > 24h postnatally. Imaging predictors of a difficult neonatal airway (DNA) were assessed blinded to these neonatal outcomes. Twenty-six fetuses met the inclusion criteria. Oropharyngeal and neck mass location with polyhydramnios was 100% sensitive and 82% specific for DNA. JI<5th centile with polyhydramnios was 83% sensitive and 70% specific. JI<5th centile with polyhydramnios was associated with DNA in 80% of cases delivered by ex utero intrapartum (EXIT) delivery and none with non-EXIT delivery mode. A cervical or oropharyngeal mass with polyhydramnios predicted a difficult neonatal airway. Polyhydramnios with jaw index < 5th centile was less sensitive and less specific for a difficult neonatal airway.

What Is Culture Made of? An Exploratory Study of Ethical Cultures and Provider Perspectives on the Care of Periviable Neonates

Objective Studies examining intercenter variation in neonatal intensive care unit practices at the limits of fetal viability have hypothesized that institutional “culture” can be one of many factors that impact patient care. This study aimed to describe institutional culture at a single, large academic center with regard to the antenatal consultation, resuscitation, and postnatal management of periviable neonates. Study Design Members of six clinical groups—attending and fellow maternal–fetal medicine physicians, attending and fellow neonatal–perinatal medicine physicians, neonatal nurses, advanced practiced neonatal nurses, pediatric hospitalist physicians, and neonatal respiratory therapists—were invited to complete qualitative, semi-structured interviews. All audio recordings were transcribed. Dedoose software was used to complete team-based coding and thematic analysis. Results Twenty-two interviews were completed. Thematic analysis revealed three central themes described by participants as contributory to institutional culture: Perception, referring to factors based on individual attitudes and insights, Statements of Information, referring to factors anchored in more objective concepts such as outcomes data and institutional policy, and Dynamic Factors, referring to the relatively fluid factors of institutional culture that interact with both Perception and Statements of Information. Participants were more likely to mention factors in the Perception category (n = 430) compared with factors in the Information category (n = 225), and although the latter were described as critical components of antenatal counseling and perinatal management, the philosophy of our unit appeared to be more heavily rooted in institutional memory and individual belief systems. Conclusion Our data demonstrate a personal undertone to institutional culture at the limits of viability, with an emphasis on individual attitudes and subjective interpretations of fact rather than empirical data. As the landscape of neonatology continues to change, understanding those factors that contribute to culture remains a necessary step toward deconstructing institutional belief systems and optimizing clinical care. Key Points