Maternal Neonatal Outcomes Research Articles

Poor maternal–neonatal outcomes in pregnant patients with confirmed SARS-Cov-2 infection: analysis of 145 cases

PurposeThe coronavirus 2 (SARS-CoV-2) infection has recently spread causing millions of individuals affected globally. The raising mortality rate highlighted the necessity to identify the most susceptible populations, such as pregnant women and their fetuses, in order to protect them. Few studies have been conducted trying to identify maternal-neonatal outcomes among pregnant patients affected by COVID 19. In this scenario, this study aims to analyse poor maternal–neonatal outcomes in pregnant women affected by SARS-CoV-2 infection. MethodsThis was a double-centre, 5 months retrospective analysis conducted in Italy. The study population consisted of pregnant women with confirmed SARS-CoV-2 infection assessed by Time Quantitative Reverse Transcription PCR (qRT-PCR) nasopharyngeal swabs.Results145 pregnant women affected by confirmed SARS-CoV-2 infection were included. Among them, 116 (80%) were symptomatic and 29 (20%) were asymptomatic. Up to half of the patients (n = 111; 76.5%) had a past history of respiratory disease. The mean gestational age at delivery was 36 weeks ± 5 days, while the mean maternal age was 31.5 ± 5.63. Reactive C protein (CRP) serum levels were higher than the normal range corresponding to a mean value of 56.93 ± 49.57 mg/L. The mean interval between the diagnosis of maternal COVID-19 infection and the delivery was 8.5 days. With regard to the type of delivery, the percentage of patients who delivered vaginally was higher than those who experienced a caesarean section. (74.4% vs 25.6%). The percentage of term birth was higher than preterm one (62% vs 38%). Finally, the percentages of maternal and neonatal death were found to be 5% and 6%, respectively; similarly, the percentage of the infection vertical transmission was 5%. ConclusionCOVID-19 infection in pregnant women seems to negatively affect both maternal and neonatal outcomes. However, it is important to emphasize that most of the cases of maternal death occurred in patients with severe symptoms and highly altered parameters related to SARS-CoV-2 infection. In the future, larger studies are warranted in order to validate these findings.

The effects of vitamin D supplementation on glycemic control and maternal-neonatal outcomes in women with established gestational diabetes mellitus: A systematic review and meta-analysis

Gestational Diabetes Mellitus (GDM) is associated with a well-documented range of adverse pregnancy outcomes. The present meta-analysis was conducted to evaluate the effects of vitamin D supplementation on glycemic control and maternal-neonatal outcomes in women with established GDM. Published literature was retrieved and screened from PubMed, Embase, Web of Science, CNKI (China National Knowledge Infrastructure), Wanfang, and Cochrane Center Register of Controlled Trails up to May 2020. RCTs of vitamin D supplementation on pregnant women with GDM were included. 19 RCTs (1550 participants) were eligible for meta-analyses. Overall, vitamin D supplementation significantly reduced serum fasting plasma glucose (FPG) (MD:-10.20mg/dL, 95%CI:-13.43 to-6.96), insulin concentration (MD:-5.02 μIU/mL, 95%CI:-6.83 to-3.20) and the homeostasis model assessment of insulin resistance (HOMA-IR) (MD:-1.06, 95%CI:-1.40 to-0.72) in women with GDM. In addition, vitamin D supplementation in pregnant women with GDM significantly reduced adverse maternal outcomes including cesarean section (RR: 0.75, 95%CI: 0.63 to 0.89), maternal hospitalization (RR: 0.13, 95%CI: 0.02 to 0.98) and postpartum hemorrhage (RR: 0.47, 95%CI: 0.22 to 1.00). Several adverse neonatal complications including neonatal hyperbilirubinemia (RR: 0.47, 95%CI: 0.33 to 0.67), giant children (RR: 0.58, 95%CI: 0.38 to 0.89), polyhydramnios (RR: 0.42, 95% CI: 0.24 to 0.72), fetal distress (RR: 0.46, 95%CI: 0.24 to 0.90) and premature delivery (RR: 0.43, 95% CI: 0.26 to 0.72) were also significantly reduced. This meta-analysis suggested that supplementation of GDM women with vitamin D may lead to an improvement in glycemic control and reduction of adverse maternal-neonatal outcomes.

Characteristics and Maternal Neonatal Outcomes Analysis of Referral Cases at Lakipadada Regional Public Hospital, Tana Toraja on Period March-August 2019

Background: Referral system is often noticed as an obstacle for getting health services because it requires more time, higher cost, health services that are not appropriate with competence, patients are accumulated in several health care facilities that can reduce satisfaction of the patient. The implementation of tiered referral system also experiences obstacles that related to geographical factors, distance, transportation and limitations of health services, therefore it is necessary to have an assessment how the characteristics and outcomes of obstetric referral cases in an area. Objective: To identify the charactheristics of obstetric referral cases and maternal – neonatal outcomes from referral cases at Lakipadada Regional Public Hospital on period March – August 2019. Methods: : This study was a retrospective analysis study using descriptive methods of medical record data in obstetric patients at Lakipadada Regional Public Hospital, Tana Toraja on period March - August 2019. Results: The total number of obstetric referral cases is 218 cases, which 154 cases were referred from inside Tana Toraja itself (the most referrals were from private clinics), 64 cases were referred from outside Tana Toraja (the most referrals were from Enrekang District) with the most referral indication was Prolonged Latent Phase. Vaginal delivery was performed in 86 total of cases, caesarean section was 117 total of cases. Conclusion: In the referral cases, there was still a delay in referring patients which on period March-August 2019, there were 2 maternal death, 2 infant deaths and 5 IUFD.

Gestational diabetes: A link between OGTT, maternal-fetal outcomes and maternal glucose tolerance after childbirth

Background and aimThe relationship among distribution of pathological values at the Oral Glucose Tolerance Test (OGTT), metabolic risk factors and pregnancy outcomes in women with Gestational Diabetes (GDM), has not been clearly identified. We retrospectively compared metabolic and therapeutic parameters, maternal–fetal outcomes and post-partum OGTTs, with respect to the number and distribution of altered values of diagnostic OGTT in pregnancy. Secondly, we assessed whether insulin therapy predictive factors were identifiable. Methods and resultsThis analysis included 602 pregnant women with GDM, followed in Diabetes and Pregnancy Unit of Perugia Hospital from diagnosis to childbirth. All women were diagnosed diabetic upon 75g OGTT, according IADPSG criteria. Women were divided into 3 groups, respect to distribution of diagnostic blood glucose (BG) values at OGTT: Group 1: only fasting BG (OGTT0h); Group 2: 1 and/or 2h (OGTT1-2h); Group 3: both fasting and 1 h and/or 2h (OGTT0+1–2h) BG.Pregnant women with fasting hyperglycemia at OGTT (Groups 1 and 3) had similar metabolic characteristics (weight, prevalence of obesity, gestational weight gain, HbA1c), a greater need for insulin therapy, and a higher risk of impaired glucose tolerance persistence after childbirth, as compared to Group 2. No significant differences were observed in terms of maternal and neonatal outcomes (p > 0.05), except for a greater prevalence of caesarean sections in Group 3. ConclusionThe metabolic characteristics of GDM women are mirrored by OGTT values at diagnosis, but are not associated with adverse pregnancy outcomes. Intensive management and a tailored treatment of GDM improve maternal-neonatal outcomes, regardless of diagnostic values distribution and pre-gestational metabolic characteristics.

Antenatal Care Health Education Intervened by Social Networking on Mobile Phone Compared with Usual Care to Improve Maternal and Neonatal Outcomes: Randomized Controlled Trial

Background: Although there is a little evidence of social media, especially short message service or SMS, enhancing maternal-neonatal outcomes, clinical trials with social audio-video networking improving their maternal-neonatal outcomes have not been investigated yet. Objective: To determine whether antenatal-health education through audio-video social network about severe obstetric symptoms can provide earlier management and better maternal-neonatal outcomes. Materials and Methods: Using an open-label randomized controlled trial, the difference of the rate of preterm birth, neonatal respiratory distress syndrome (RDS), stillbirth, and perinatal mortality between the control group of routine antenatal health education and the intervention group with audio-video social networking about severe obstetric symptoms was analyzed. Between April 2015 and July 2018, the investigator randomly assigned 1,160 antenatal women in the control (n=558) and the intervention groups (n=602). Data from 832 participants (control n=400, intervention n=432) were available for analyses. Results: The intervention group had an inconclusively non-significant difference in the rate of preterm birth when compared with the control group (8.1% versus 11%), odds ratio (OR) 0.8 (95% confidence interval (CI) 0.5 to 1.2); p=0.260 with the statistical power of 0.26. However, the rate of neonatal RDS was significantly lower in the intervention group than in the control group with statistical significance (0.9% versus 3.8%), OR 0.3 (95% CI 0.1 to 0.9); p=0.028. There was a significant difference in labor pain duration before admission between the intervention and the control groups (121.7±95.3 versus 139.2±7.0 minutes), coefficient –17.7 (95% CI –31.4 to –4.0); p=0.011. Conclusion: Antenatal health education through audio-video social networking was found to significantly lower the rate of the neonatal RDS, which was the result of a significant shorter labor-pain time. The shorter labor-pain time plays a role in the early management of preterm birth and low birth weight. Keywords: Social networking, Mobile phone, Antenatal care, Health education, Maternal outcome, Neonatal outcome, Preterm birth

Conservative management versus cesarean hysterectomy in patients with placenta increta or percreta

Objective To compare conservative management and cesarean hysterectomy in patients with placenta increta or percreta. Materials and methods In this multicenter retrospective study, we recorded data on 2219 patients with placenta increta or percreta from 20 tertiary care centers in China from 1 January 2011 to 31 December 2015. Propensity score analysis was used to control for baseline characteristics. We divided patients into conservative management (C) and hysterectomy (H) groups. The primary outcome was operative/postoperative maternal morbidity; secondary outcomes were maternal–neonatal outcomes. Results In total, 17.9% (398/2219) of patients had placenta increta and percreta; 82.1% (1821/2219) of the patients were in group C. After propensity score matching, 140 pairs of patients from the two groups underwent one-to-one matching. Group C showed less average blood loss within 24 h of surgery (1518 ± 1275 vs. 4309 ± 2550 ml in group H, p<.001). There were more patients with blood loss >1000 ml in group H than in group C (93.6% [131/140] vs. 61.4% [86/140], p<.001). More patients received blood transfusions in group H than in group C (p=.014). There was no significant difference between the groups in terms of bladder injury, postoperative anemia, fever, and disseminated intravascular coagulation. Neonatal outcomes in the two groups were similar. Conclusion Either conservative management or hysterectomy should be considered after thorough evaluation and detailed discussion of risks and benefits. A balance between bleeding control and fertility can be achieved.

The preparedness of the Italian obstetric surveillance system in the response to the emergency of the SARS-CoV-2 pandemic: methodological aspects of a population-based study

This paper aims to describe the Italian obstetric surveillance system (ItOSS) preparedness as an element for a timely response to the new Coronavirus pandemic. ItOSS is a surveillance network that has been collecting data on maternal mortality and conducting population studies on obstetric near misses since 2013. At the beginning of the pandemic, ItOSS launched a new population-based project to monitor SARS-CoV-2 infection during pregnancy and post-partum and promptly give back information useful to clinicians and decision-makers. All the regions and autonomous provinces, for a total of 289 birth units (PN), joined the study. Data relating to pregnant or post-partum women with a confirmed SARS-CoV-2 infection diagnosis addressing the maternities for outpatient visits or hospitalization were collected. The project methodology entails that each participating maternity reports the cases to ItOSS uploading data through an open-source platform. The on-line form includes sociodemographic and clinical data and maternal-neonatal outcomes. Biological samples to detect possible vertical transmission are also collected voluntarily. A total of 534 incident cases were reported from February 25th to July 10th 2020; 7 regions also collected biological samples for 227 cases; data collection is still ongoing.A preliminary analysis of the first 146 SARS-CoV-2 positive women who gave birth between February 25th to April 22nd shows an incidence rate of the infection equal to 2.1/1,000 in Italy and 6.9/1,000 in the Lombardy Region (Northern Italy). The brief time needed to setting up and operating the project, the national coverage, the adoption of shared tools for data collection, the quality and completeness of the information collected show how the availability of active networks like ItOSS represents a crucial element to hold a high level of preparedness in case of a health emergency.

Evaluation of a Nurse-Led Program for Rural Pregnant Women With Opioid Use Disorder to Improve Maternal–Neonatal Outcomes

ObjectivesTo generate effect sizes of preliminary program outcomes and identify areas for program improvement related to a nurse-led, community-based screening, referral, and advocacy program for women with perinatal opioid use disorder (OUD): the Engaging Mothers for Positive Outcomes with Early Referrals (EMPOWER) program. DesignWe extracted outcomes retrospectively from medical records for the first 19 mother–newborn dyads who participated in the program (postintervention group). We compared these outcomes with those of 19 randomly selected mother–newborn dyads in which mothers had perinatal OUD and received care before the program launch (preintervention group). Setting/Local ProblemA maternity care practice and community hospital in a rural Massachusetts county with high rates of perinatal OUD. PatientsWomen with perinatal OUD and their neonates. Intervention/MeasurementsAs part of the EMPOWER program, women with perinatal OUD developed individualized pregnancy plans; were referred to community resources in the prenatal period; and received education about neonatal abstinence syndrome, nonpharmacologic newborn care, and breastfeeding. We compared the pre- and postintervention groups for maternal and neonatal outcomes and prenatal community referrals and generated effect sizes using Cohen’s d and Cramer’s phi (Φ). ResultsRates of breastfeeding initiation (Φ = 0.289) and continuation (Φ = 0.318), mean neonatal birth weight (d = 0.675), and length of hospital stay (d = 0.541) were greater in the postintervention group with medium effect sizes. Diagnosis of neonatal abstinence syndrome and admission to the NICU were also greater in the postintervention group, with small effect sizes (Φ = 0.246 and Φ = –0.144, respectively.) Significantly more women in the postintervention group received prenatal referrals for peer/family support services. We identified areas for program improvement as prenatal education on smoking and postpartum contraceptive use. ConclusionPreliminary findings suggest that the EMPOWER program may contribute to improved outcomes for mothers and newborns affected by OUD; however, further data collection after instituting program improvements is needed.

348. Severe maternal morbidity and pathological puerperium: The impact of hypertensive syndromes

Recognizing severe maternal morbidity (MMG) allows the adoption of effective measures, with emphasis on the contribution of hypertensive syndromes (HS). To analyze the characteristics and maternal-neonatal outcomes of the hypertensive syndrome selected as severe maternal morbidity and/or pathological puerperium. Cross-sectional study (November/2017-March/2018), location: Complexo Hospitalar dos Estivadores/Instituto Social Hospital Alemão Oswaldo Cruz-Santos/Brazil. 70 women with at least one of Santos criteria derived from the definition of MMG of the World Health Organization (2009), Waterstone et al. (2001), Mantel et al. (1998), seeking to homogenize/facilitate this definition according to clinical/laboratory/management and/or recognized as pathological puerperium: ⩾ three days of hospitalization. Variables analyzed: diagnosis of hypertension (NHBPEP/2000), age, parity, blood pressure, gestational age and way of delivery, adequate prenatal care (⩾06 appointments), maternal complications and immediate perinatal outcomes. We identified that 53 (75.7%) patients had HS. Average age: 28 years. Previous pregnancies: 35 (66%). Adequate prenatal care: 49 (92.4%). Cesarean section in 73.6%. Signs of severity in 62.3%, HELLP syndrome (28.3%) and eclampsia (3.8%), used magnesium sulfate (69.8%) and admission to an adult ICU (7.5%). Neonatal: 5’ Apgar score of 8–10 (96.2%), prematurity (20.8%) and neonatal ICU admission (24.5%). A high HS rate was observed among women with MMG and with prolonged hospitalization with their risks/costs. The numerically adequate number of prenatal consultations questions the quality of the care (not evaluated). There is a need to reflect on strategies that enhance vaginal delivery and reproductive planning. The frequency of complications demonstrated the severity of the clinical expression and the expressive neonatal impact: prematurity and need for ICU neonatal admission, although the Apgar score frequently above 07, reinforces the need for recognition of SH regarding its frequency and extension of postpartum complication.

The radiological myometrial appearance after cesarean section: is it associated with postpartum complications and subsequent delivery outcome?

To evaluate whether the characteristics of the radiological uterine myometrial discontinuity (RMD) is associated with maternal-neonatal outcomes and post-cesarean section (CS) complications. A secondary aim was to describe the evolution of the CT uterine surgical incision and the related outcome of a subsequent trial of labor after cesarean (TOLAC). Single center retrospective cohort study of CT scans was performed within 6weeks from cesarean delivery. Demographic characteristics of patients were recorded (age, intrapartum fever, CS data, and hospital stay length). Abdominopelvic CT scans were performed using a multidetector CT (16 or 256 slice) with intravenous contrast material. CT analysis was performed by two radiologists in consensus. The RMD seen as low attenuation gap in expected incision site was assessed for: visualization, thickness, and presence of gas. Logistic regression analysis was fitted to assess the relationship of the delivery-CT time interval with the presence of RMD and gas. Of a total of 75,791 births during the study period there were 8775 CS (11.6%). The study group consisted of 101 CTs in 84 woman after CS. RMD defined in 73 (72.2%) of all CT exams; the mean RMD thickness was 7mm±3.9, "RMD gas" observed in 15 (17.9%) of CT exams. RMD thickness or gas presence were strongly associated with a CS-1st CT exam time interval of less than 7days, OR 5.8 [CI 1.5-22.6], p=0.010, but not with maternal, delivery, or neonatal characteristics. A subsequent successful vaginal birth was achieved in 75% of the patients with no uterine rupture, regardless of the RMD gas presence. RMD gas visualization on CT is not associated with febrile morbidity, cesarean characteristics, and subsequent TOLAC results. RMD gas is a normal post-operative finding and should not lead to changes in the postpartum delivery complication management or recommendations for the future mode of delivery.

Epidural analgesia at trial of labor after cesarean (TOLAC): a significant adjunct to successful vaginal birth after cesarean (VBAC).

Epidural analgesia has been considered a risk factor for labor dystocia at trial of labor after cesarean (TOLAC) and uterine rupture. We evaluated the association between exposure to epidural during TOLAC and mode of delivery and maternal-neonatal outcomes. A single center retrospective study of women that consented to TOLAC within a strict protocol between 2006 and 2013. Epidural "users" were compared to "non-users". Primary outcome was the mode of delivery: repeat in-labor cesarean or vaginal birth after cesarean (VBAC). Secondary outcomes were maternal/neonatal morbidities. Univariate/multivariate analyses for associations between epidural and mode of delivery were adjusted for significant covariates/mediators. Of a total of 105,471 births registered, 9464 (9.0%) were eligible for TOLAC; 7149 (75.5%) women consented to TOLAC, among which 4081 (57.1%) had epidural analgesia. The in labor cesarean rate was significantly lower for the epidural "users" 8.7% vs. "non-users" 11.8%, P<0.0001, with a parallel increased rate of instrumental delivery. Uterine rupture rates were comparable: 0.4% and 0.29%, respectively (P=0.31). The adjusted multivariate model showed that epidural "users" were more likely to experience a VBAC, odds ratio (OR) 4.58 [3.67; 5.70]; P<0.0001 with a similar rate of adverse maternal-neonatal outcomes. Epidural analgesia at TOLAC may emerge as a safe and significant adjunct for VBAC.

Erratum to: Pregnancy Outcomes Following In Utero Exposure to Lamotrigine: A Systematic Review and Meta-Analysis.

Lamotrigine is used in pregnancy to control epilepsy and mood disorders. The reproductive safety of this widely used drug remains undefined and may represent a significant public health concern. We aimed to perform a systematic review and meta-analysis of existing knowledge related to malformation rates and maternal–neonatal outcomes after in utero exposure to monotherapy with lamotrigine. Relevant studies were identified through systematic searches conducted in MEDLINE (Ovid), Embase (Ovid), CENTRAL (Ovid), and Web of Science (Thomson Reuters) from database inception to July 2016; no language or date restrictions were applied. All publications of clinically relevant outcomes of pregnancies following in utero exposure to lamotrigine were included in this systematic review and meta-analysis. A total of 21 studies describing immediate pregnancy outcomes and rates of congenital malformations fulfilled the inclusion criteria. Compared with disease-matched controls (n = 1412, total number of patients) and healthy controls (n = 774,571, total number of patients), in utero exposure to lamotrigine monotherapy was found to be associated with significantly decreased rates of inborn defects (odds ratio [OR] 1.15; 95% confidence interval [CI] 0.62–2.16 and OR 1.25; 95% CI 0.89–1.74, respectively). Rates of miscarriages, stillbirths, preterm deliveries, and small for gestational age (SGA) neonates were not found to have been increased after in-utero exposure to LTG compared to the general population. Similarly, in utero exposure to lamotrigine monotherapy was not found to be associated with increased rates of inborn defects compared with in utero exposure to carbamazepine, and lamotrigine was found to be statistically significantly less teratogenic than valproic acid (n = 12,958 and 10,748; OR 0.84; 95% CI 0.68–1.03 and OR 0.32; 95% CI 0.26–0.39, respectively). No association was found between prenatal lamotrigine monotherapy and increased rates of birth defects and other explored variables related to adverse pregnancy outcomes.

Evaluation of outcomes associated with trial of labor after cesarean delivery after a change in clinical practice guidelines in an academic hospital

Objective: To evaluate maternal–neonatal morbidity for women undergoing trial of labor after cesarean (TOLAC) following clinical practice changes based upon ACOG’s 2010 VBAC guideline. Study design: Four-year retrospective cohort analysis around implementation of a hospital guideline in women undergoing TOLAC with a live, cephalic, singleton without lethal anomaly ≥24 weeks and ≥1 prior cesarean. Maternal–neonatal outcomes pre- and post-guideline implementation were compared. Primary outcome was composite maternal morbidity (uterine rupture or dehiscence, hysterectomy, transfusion, thromboembolism, operative/delivery injury, chorioamnionitis/endometritis, shoulder dystocia, death). Secondary outcomes included neonatal morbidity. Results: Four hundred and fifty women underwent TOLAC before and 781 after guideline implementation. Post-guideline, there was a significant increase in age, body mass index, labor length, women with >1 cesarean, comorbid condition and induced labor. Composite maternal morbidity was significantly higher after the guideline (13.78% versus 18.82%, p = 0.02), possibly due to an increased rate of chorioamnionitis/endometritis, which was no longer significant after control for potential confounders in multivariable analysis. There were no differences in neonatal outcomes. Vaginal birth after cesarean (VBAC) success rates were unchanged (78.9% before versus 78.1% after, p = 0.75), however hospital VBAC rates increased after the guideline (26% versus 33%, p < 0.0001). Conclusions: Adoption of ACOG’s TOLAC practice changes can increase VBAC rates without increasing maternal–neonatal morbidity from TOLAC.

Rapid Group B streptococcus screening methods in late pregnancy and the maternal-neonatal outcomes

To study the sensitivity of the quantitative fluorescence polymerase chain reaction (QF-PCR) in detecting group B streptococcus (GBS) in late pregnant women and the influence of vaginal/rectal GBS colonization on the maternal-neonatal outcomes. A total of 2020 swabs were taken from 505 women who received routine culture and QF-PCR screening at 35 and 37 weeks of gestation from September, 2013 to April, 2014 at Peking Union Medical College Hospital.For each subject, two vaginal and two rectal swabs were collected.Samples with discordant results from these two methods were further analyzed by gene sequence determination.GBS isolates were subjected to antimicrobial susceptibility testing using the Kirby-Bauer method.The laboratory results were collected and the pregnant outcomes were followed. Of the 38 GBS positive cases , GBS could be detected for 13 by both culture and QF-PCR methods, for 24 only by QF-PCR, for 1 exclusively by culture.GBS colonization rate, sensitivity and negative predictive value (NPV) for culture were 2.8%, 36.8%, and 95.1%, respectively.GBS colonization rate, sensitivity and negative predictive value (NPV) for QF-PCR were 7.3%, 97.4%, and 99.8%, respectively.There was significant difference between the two methods (P<0.001). A higher proportion of GBS were isolated from the rectum (6.7%) as compared to the vagina (2.8%) (P<0.01). GBS isolates were all (100%) sensitive to penicillins, cephalosporins, vancomycin and linezolid.Erythromycinresistance was present in 47.4% of the GBS isolates, while clindamycin resistance was present in 36.8%.Compared with the GBS negative group, the GBS positive group had higher incidence of gestational hypertension and colpitis mycotica (all P<0.05), but had similar incidence of maternal and neonatal outcomes, like neonatal infection, septicemia, puerperal disease. QF-PCR assay provides an accurate and rapid method for detecting GBS in late pregnancy.Rectum is also an important site for detection of GBS.Penicillin therapy remains an appropriate first-line antibiotic choice for intrapartum GBS chemoprophylaxis, with erythromycin and clindamycin resistance rate being high.The relationship between maternal GBS colonization and the pregnancy outcome needs to be further studied.

Vasa previa: diagnosis and management

Vasa previa is a rare condition that is associated with a high rate of fetal or neonatal death when not diagnosed antenatally. The majority of available studies are either small, do not include antepartum data, limited to single institutions, or are biased by inclusion of patients from registries and online vasa previa support groups. The purpose of this study was to investigate the diagnostic and management strategies for this potentially catastrophic entity and to describe further maternal and placental risk factors that may aid in the establishment of a screening protocol for vasa previa. This was a retrospective multicenter descriptive study that included all pregnancies that were complicated by vasa previa that delivered between January 1, 2000, and December 31, 2012. Nine maternal fetal medicine practices and the hospitals in which they practice participated in data collection of diagnosis, treatment, and maternal-neonatal outcomes. Sixty-eight pregnancies were identified that included the diagnosis of vasa previa or "possible vasa previa" either in the ultrasound record or in the hospital record at the time of delivery. Four cases (5.8%) appeared to resolve on repeat ultrasound examination. Fifteen of the 64 cases that were suspected of having vasa previa could not be verified or were not documented at delivery. Of the remaining 49 cases, where vasa previa was documented, 47 cases (96%) were diagnosed by ultrasound scanning antenatally. Known risk factors for vasa previa were present in 41 of 47 cases (87%). Of the 49 cases, 41 were delivered by planned cesarean delivery at a mean gestational age of 34.7 weeks, and 8 cases required emergent cesarean delivery at a mean gestational age of 34.6 weeks (range, 32.4-36.0 weeks gestation). Seven of these emergent cesarean deliveries had been diagnosed previously; 1 case had not. All of the emergent cesarean deliveries were for vaginal bleeding; 1 case was also for a concerning fetal heart rate, but only 1 of the known cases had a documented ruptured fetal vessel. None of these cases were found to have cervical shortening before the onset of bleeding. One of the undiagnosed cases resulted in a ruptured fetal vessel and a baby with no heart beat at birth who survived but had periventricular leukomalacia at 1 month of age with mild white-matter atrophy. Of the remaining neonates in this group, there were no deaths and no major complications beyond mild respiratory distress syndrome in 9 cases. There were no other major neonatal complications, which included no cases of periventricular leukomalacia, neonatal sepsis, necrotizing enterocolitis, or any grade of intraventricular hemorrhage in the confirmed cases of vasa previa. This study confirms most current recommendations that include risk-based ultrasound screening, early hospitalization at 30-34 weeks gestation, antenatal corticosteroids at 30-32 weeks gestation, and elective delivery at 33-34 weeks gestation. Thus, with these recommendations for current identification and management of vasa previa in this series of geographically diverse mostly private practice maternal fetal medicine practices, we have confirmed recent reports that show a dramatic improvement in neonatal survival and complications compared with earlier reports.

Risk-adjusted operative delivery rates and maternal-neonatal outcomes as measures of quality assessment in obstetric care: a multicenter prospective study.

BackgroundAlthough the evaluation of caesarean delivery rates has been suggested as one of the most important indicators of quality in obstetrics, it has been criticized because of its controversial ability to capture maternal and neonatal outcomes. In an “ideal” process of labor and delivery auditing, both caesarean (CD) and assisted vaginal delivery (AVD) rates should be considered because both of them may be associated with an increased risk of complications.The aim of our study was to evaluate maternal and neonatal outcomes according to the outlier status for case-mix adjusted CD and AVD rates in the same obstetric population.MethodsStandardized data on 15,189 deliveries from 11 centers were prospectively collected. Multiple logistic regression was used to estimate the risk-adjusted probability of a woman in each center having an AVD or a CD. Centers were classified as “above”, “below”, or “within” the expected rates by considering the observed-to-expected rates and the 95% confidence interval around the ratio. Adjusted maternal and neonatal outcomes were compared among the three groupings.ResultsCenters classified as “above” or “below” the expected CD rates had, in both cases, higher adjusted incidence of composite maternal (2.97%, 4.69%, 3.90% for “within”, “above” and “below”, respectively; p = 0.000) and neonatal complications (3.85%, 9.66%, 6.29% for “within”, “above” and “below”, respectively; p = 0.000) than centers “within” CD expected rates. Centers with AVD rates above and below the expected showed poorer and better composite maternal (3.96%, 4.61%, 2.97% for “within”, “above” and “below”, respectively; p = 0.000) and neonatal (6.52%, 9.77%, 3.52% for “within”, “above” and “below”, respectively; p = 0.000) outcomes respectively than centers with “within” AVD rates.ConclusionsBoth risk-adjusted CD and AVD delivery rates should be considered to assess the level of obstetric care. In this context, both higher and lower-than-expected rates of CD and “above” AVD rates are significantly associated with increased risk of complications, whereas the “below” status for AVD showed a “protective” effect on maternal and neonatal outcomes.

Continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDI) of rapid-acting insulin analogues and detemir in type 1 diabetic (T1D) pregnant women

Objective: To compare glycemic control, maternal-neonatal outcomes and fetal fat body mass growth of type 1 diabetic pregnant women treated with continuous subcutaneous insulin infusion (CSII) or multiple daily injections (MDI) with the long-acting insulin analogue detemir as basal insulin.Methods: Retrospective study of 53 women, attending the Unit of Prenatal Medicine of Careggi University Hospital, Florence, from 2009 to 2012: 35 treated with CSII, 18 with MDI-detemir. Each woman performed daily blood glucose self-monitoring, had an individualized nutritional therapy, weekly prenatal visits and ultrasound scans (US) according to the Tuscan guidelines. US were also performed every two weeks from 28 to 38 weeks of gestation to assess fetal fat body mass growth. Student’s t-test and Chi-square test were performed to compare the groups’ results.Results: No significant differences were observed in metabolic control, in any maternal and neonatal outcome nor fetal fat body mass growth for either group. The MDI group needed higher daily doses of insulin (MDI: 1.00 ± 0.32 UI/kg versus CSII: 0.75 ± 0.29 UI/kg, p = 0.007) to reach results comparable to the CSII group.Conclusions: MDI therapy with detemir is a safe and effective alternative, with a good benefit–cost ratio compared to insulin pumps.

Maternal neonatal outcome in relation to placental location, dimensions in early pregnancy

Background: Placenta, which is the vital link between mother and fetus, is critical for maternal neonatal well-being. Its study in early pregnancy may provide information about maternal neonatal disorders. Aim: The study aimed to evaluate the relationship of placental location and dimensions in early pregnancy with maternal neonatal outcomes. Subjects and Methods: Primigravida (801) with singleton pregnancy at 10-weeks gestation and no past/present medical and obstetric disorder had ultrasonography for placental location and dimensions and were followed by ultrasonographic (USG) examination (at 20th week and 30th week), clinically for maternal-neonatal outcome. Statistical analysis was done by Epi 6 software (version 6.0, developed by Centres for Disease Control and Prevention, Atlanta, Georgia, USA) using Chi-square test and Fischer exact test for determining the statistical significance of the observations. P values of 55 cm2 6.8% (13/190), had hypertensive disorders. area 55 cm2 3.7% (7/190) had placental abruption. With thick placenta, 39.2% (58/148), thin, 9.4% (9/96), and normal placenta, 5.2% (29/562) had hypertensive disorders. With thick, 11.5% (17/148), thin 16.7% (16/96), and normal placenta 2.7% (15/562) had placental abruption. With anterior 0.5% (1/200), posterior 14.6% (18/123), fundal placenta 10.55% had preterm births. With anterior 7.5% (15/200), posterior 23.6% (29/123), fundal placenta 18% (58/322) had CS.With placental surface area 55 cm2 14% (28/200) had CS. With thin 27% (25/91), with thick 36.1% (53/148), with normal placenta none had CS for fetal distress. Conclusions: Study of placental location and dimensions in early pregnancy is useful in identifying risks. Keywords: Dimensions, early pregnancy, location, maternal-neonatal outcome, placenta

The relationship between the use of the partograph and birth outcomes at Korle-Bu teaching hospital

Objectivematernal mortality represents the single greatest health disparity between high and low income countries. This inequity is especially felt in low income countries in sub Saharan Africa and Southeast Asia where 99% of the global burden of maternal death is borne. A goal of MDG 5 is to reduce maternal mortality and have a skilled attendant at every birth by 2015. A critical skill is ongoing intrapartum monitoring of labour progress and maternal/fetal well-being. The WHO partograph was designed to assess these parameters. Design and settinga retrospective review of charts (n=1,845) retrieved consecutively over a 2 month period in a tertiary teaching hospital in Ghana was conducted to assess the adequacy of partograph use by skilled birth attendants and the timeliness of action taken if the action line was crossed. WHO guidelines were implemented to assess the adequacy of partograph use and how this affected maternal neonatal outcomes. Further, the timeliness and type of action taken if action line was crossed was assessed. Findingspartographs were adequately completed in accordance with WHO guidelines only 25.6% (472) of the time and some data appeared to be entered retrospectively. Partograph use was associated with less maternal blood loss and neonatal injuries. When the action line was crossed (464), timely action was taken only 48.7% of the time and was associated with less assisted delivery and a fewer low Apgar scores and NICU admissions. Conclusionwhen adequately used and timely interventions taken, the partograph was an effective tool. Feasibility of partograph use requires more scrutiny; particularly identification of minimum frequency for safe monitoring and key variables as well as a better understanding of why skilled attendants have not consistently ‘bought in’ to partograph use. Frontline workers need access to ongoing and current education and strategically placed algorhythims.

Effect of induction delivery on maternal-neonatal outcomes in 41 gestational weeks primiparae

To estimate the maternal-neonatal morbidity associated with induction deliveries compared with spontaneous deliveries in 41 gestational weeks uncomplicated primiparae. Three hundred and seventy-four uncomplicated primiparous deliveries at 41 gestational weeks at Peking Union Medical College Hospital from Sept 2002 to Apr 2007 were reviewed, including 225 women undergoing induced labor and 149 women undergoing spontaneous labor. The induction methods included drug induction (173), rupture of membrane induction (5) and combined drug with rupture of membrane induction (47). The maternal morbidity, delivery method, maternal cost on hospital stay and neonatal asphyxia associated with induction deliveries or spontaneous deliveries were retrospectively analyzed. (1) There was no maternal death. The caesarean section rate in the induction group (44.0%, 99/225) was significantly higher than that of spontaneous group (18.1%, 27/149; P<0.05). (2) No statistically significant difference (P>0.05) was observed between induction group and spontaneous group in the following puerperal complications: postpartum hemorrhage (2.7%, 6/225 and 1.3%, 2/149 respectively), puerperal morbidity (0.9%, 2/225 and 0.7%, 1/149 respectively), severe amniotic fluid contamination (11.6%, 26/225 and 13.4%, 20/149 respectively), wound infection (0.9%, 2/225 and 0.7%, 1/149 respectively) ,urinary retention(4.4%, 10/225 and 3.4%, 5/149 respectively), traumata (0.4%, 1/225 and 0 respectively) and neonatal asphyxia (1.3%, 3/225 and 2.0%, 3/149 respectively). (3) The average duration of first stage of labor in the induction group (413 min) was not significantly different from that of spontaneous group (461 min; P>0.05). In the induction group, more women had precipitate labors (P<0.05) and the average duration of the second stage of labor was shorter than that of spontaneous group (40 min and 48 min, P<0.05). (4) Spontaneous group had shorter maternal hospital stay [(5.7 +/- 1.9) days vs (6.9 +/- 2.7) days, P<0.05] and caesarean section after induction had the highest hospital expense (P<0.05). Induction delivery at 41 weeks of gestation increases the rates of caesarean section, precipitate labor, clinical workload and hospital costs. Induction delivery as a prevention method of over due labor needs to be further discussed. Uncomplicated pregnancies of 41 weeks should be intentionally monitored if continued surveillance is possible. They should wait for spontanous delivery, and decision of induction should be made based on its benefit to the case.