Rates Of Adverse Perinatal Outcomes Research Articles

Antenatal Corticosteroid Use and Perinatal Mortality According to Gestational Age among Preterm Singletons Born at 27 to 34 Weeks of Gestation in Hospitals in Tanzania

Background: Antenatal corticosteroid (ACS) treatment has been proven to decrease rates of adverse perinatal outcomes when administered to pregnant women at risk for preterm delivery. Given the uncertainty about the benefit of ACS according to gestational age, we aimed to examine whether there was any benefit of ACS on perinatal mortality and respiratory distress syndrome (RDS) according to different gestational ages at birth. Methods: Secondary analysis of data from an observational prospective chart review study was conducted in four hospitals located in the Mwanza region, Tanzania. The study population consisted of singleton infants delivered between 27 and 34 weeks of gestation between July 2019 and February 2020. Sociodemographic and medical data were recorded from participants’ medical records. Results: Over an eight-month period, 838 preterm singletons were delivered between 27 and 34 weeks of gestation. Three hundred and twelve (37.2%) pregnant women received at least one dose of ACS. Among infants exposed to ACS, perinatal mortality rates were significantly lower than those without exposure at the 27th week (27.8% vs 94.4%, P Conclusion: Our findings add to the literature about the benefits of ACS for preterm infants of various gestational ages in low-resource settings. Compared to unexposed infants, those exposed to ACS and born at 27th and 34th weeks of gestation experienced lower rates of perinatal mortality. Future research, especially among infants born before the 27th week of pregnancy, is a priority.

Adverse perinatal outcomes of chlamydia infections: an ongoing challenge.

Chlamydia trachomatis is one of the most common sexually transmitted diseases in the world, but there are limited data on its impact on perinatal outcomes. Our objective was to investigate the association between chlamydia infections and adverse perinatal outcomes. This is a retrospective analysis of the United States Centers for Disease Control and Prevention natality live birth database for the years 2016-2019. The rates of adverse perinatal outcomes were compared between patients with a chlamydia infection during pregnancy andpatients without such infection, using Pearson's chi-square test with the Bonferroni adjustment. A multivariate logistic regression was then used to adjust outcomes for potential confounders. Chlamydia infections were associated with small, but statistically significant, increased odds of preterm birth(<37weeks), early preterm birth (<32weeks), low birthweight (<2,500g), congenital anomalies, low 5-min Apgar score (<7), neonatal intensive care unit admission, immediate neonatal ventilation, prolonged (>6h) neonatal ventilation, and neonatal antibiotic treatment for suspected sepsis. Chlamydia infections during pregnancy are associated with adverse perinatal outcomes. These results call for increased education regarding the potential risks of pregnancies with a chlamydia infection, as well as for increased antenatal surveillance and post-natal pediatric assessment in these pregnancies.

Massive Perivillous Fibrin Deposition-A Cause of Recurrent Fetal Demise: A Case Report

Abstract Introduction/Objective Massive perivillous fibrin deposition (MPFD) and maternal floor infarction (MFI) are rare placental lesions reported in less than 1% of all pregnancies and have a significant risk of recurrence ranging from 12% to 78%. MPFD/MFI is associated with high rates of adverse perinatal outcomes including preterm delivery, severe intrauterine growth restriction, spontaneous abortion, cystic renal cell dysplasia, fetal metabolic disease with reported mutations in the LCHAD (long-chain 3-hydroxy acyl-CoA-dehydrogenase) gene, neonatal death and long- term neurological impairment. Methods/Case Report We report a case of MFPD in a 28-year-old female gravida 3 para 1 with one uncomplicated pregnancy and one therapeutic abortion. The current pregnancy was complicated by abruption resulting in intrauterine fetal demise at 32 weeks of gestation. The placenta was examined. Grossly, the placenta weighed 260 grams (small placenta for the dates) with an eccentrically inserted three vessel umbilical cord and a diffuse, firm pale grey cut surface with focal cystic areas. The histological examination revealed MPFD characterized by extensive transmural perivillous fibrinoid material with encasement of almost entire chorionic villi (transmural type). The villi were viable but fibrotic with focal syncytiotrophoblastic necrosis and focal mild chronic inflammation. The etiology of MPFD is not well understood, but risk factors that have been reported include maternal thrombophilia, coagulopathies, and autoimmune diseases. Given the clinical associations, MFI/MPFD should be reported promptly to the obstetrician and pediatrician. As per the current literature, a combination of thrombolytic therapy (aspirin and heparin), intravenous immunoglobulin and a statin (pravastatin) helps to correct angiogenic/antiangiogenic imbalance which has been thought to be associated with recurrent MFI/MPFD. Results (if a Case Study enter NA) N/A Conclusion In summary, we present this rare recurring entity of MPFD to emphasize the awareness of this condition and the importance of placental examination in all abortions and fetal abnormalities/demise.

\u201cWhen I think of mental healthcare, I think of no care.\u201d Mental Health Services as a Vital Component of Prenatal Care for Black Women

PurposeBlack people give birth joyously despite disproportionate rates of adverse perinatal outcomes. Given that group prenatal care shows promise in mitigating these inequities, we sought to solicit the opinions of Black peripartum women on how group prenatal care could be tailored to fit their specific needs. In this study, we describe attitudes about a proposed Black group prenatal care in a single focus group of 11 Black women who receive maternal health services from Black Infant Health (BIH, a state and federal funded state-wide program for Black pregnant people with the goal to improve infant and maternal health). These data were used to design a race-conscious group prenatal care curriculum specifically for Black women at UCSF.DescriptionThis study was an analysis of focus group data generated as part of a larger project focused on community involvement in Black maternal health. English speaking pregnant or recently postpartum women age 18 or older who receive services from BIH were recruited to participated in the focus group analyzed in this study. All facilitators of the focus group were Black women in order to facilitate candid conversation about racism in prenatal care.AssessmentThe need for mental health care was common thread underlying all conversations about prenatal health improvements desired by our focus groups. Participants expressed the centrality of mental health access during our discussion of other themes (e.g.: ease of access, inclusion of partners, special classes for teen moms) by discussing them in terms of their relationship to mental health. Our participants’ clear expression of the centrality of mental health care to their prenatal health guided our decision to focus on mental health as a necessary pillar of any group prenatal care intervention designed to mitigate perinatal healthcare disparities in this paper. Three themes related to mental health integration into group prenatal care emerged from thematic analysis of the transcripts. Participants expressed insufficient access and advocacy, and provider distrust.ConclusionEvidence exists supporting group prenatal care as a tool for mitigation of perinatal health disparities among Black women. There is also a large body of data describing the disproportionate burden of mental health needs among Black women. The rich data we present here from Black women on their desire for the integration of these two needs fits well into the parallel conversation occurring in the literature. To our knowledge, this is the first study investigating desires of Black women regarding group prenatal care designed specifically for them. They expressed a strong desire for more access to mental health care providers who are racially conscious and aware of white supremacy, and nuanced opinions on the role of racial concordance in health equity.

Maternal nativity and risk of adverse perinatal outcomes among Black women residing in California, 2011-2017.

Examine the risk of adverse perinatal outcomes among the United States (US)-born and foreign-born Black women in California. The study comprised all singleton live births to Black women in California between 2011 and 2017. We defined maternal nativity as US-born or foreign-born. Using Poisson regression, we computed risk ratios (RR) and 95% confidence intervals (CI) for three adverse perinatal outcomes: preterm birth, small for gestational age deliveries, and infant mortality. Rates of adverse perinatal outcomes were significantly higher among US-born Black women. In adjusted models, US-born Black women experienced an increased risk of preterm birth (RR 1.51, 95% CI 1.39, 1.65) and small for gestational age deliveries (RR 1.52, 95% CI 1.41, 1.64), compared to foreign-born Black women. Future studies should consider experiences of racism across the life course when exploring heterogeneity in the risk of adverse perinatal outcomes by nativity among Black women in the US.

Maternal cardiovascular function in the prediction of fetal distress in labor: a prospective cohort study

Objective To explore the strength of association and the diagnostic accuracy of maternal hemodynamic parameters detected noninvasively in predicting an adverse perinatal outcome in labor. Methods Prospective cohort study of singleton women undergoing antepartum care at 37–39 weeks of gestation. A noninvasive ultrasonic cardiac output monitor (USCOM®) was used for cardiovascular assessment. The study outcome was a composite score of adverse perinatal outcome, which included at least one of the following variables: Cesarean or instrumental delivery for abnormal fetal heart monitoring, umbilical artery pH <7.10 or admission to neonatal special care unit. Attending clinicians were blinded to maternal cardiovascular indices. Multivariate logistic regression and area under the curve (AUC) analyses were used to test the diagnostic accuracy of different maternal and ultrasound characteristics in predicting adverse perinatal outcome. Results A total of 133 women were recruited. The rate of adverse perinatal outcome was 25.6% (34/133). Women who delivered without abnormal perinatal outcome (controls) were more likely to be parous, compared to those who had an adverse perinatal outcome (44.4 vs. 73.5%; p = .005). Control women had significantly lower systemic vascular resistance (SVR) (median, 1166 vs. 1352 dynes × s/cm5, p = .023) and SVR index (SVRI) (median, 2168 vs. 2627 dynes × s/cm5/m2, p = .039) compared to women who had an adverse perinatal outcome. In this latter group the prevalence of SV <50 ml was significantly higher than in the control group (38.2% (13/34) vs. 11.1%, (11/99) p = .0012). At multivariable logistic regression analysis, SVR (aOR 1.307; 95% CI 1.112–2.23), SV <50 ml (aOR 4.70; 95% CI 1.336–12.006) and parity (3.90: 95% CI 1.545–10.334) were the only variables independently associated with adverse perinatal outcome. A model considering only SVR showed an AUC of 0.631. Integration of SVR with SV <50 ml and parity significantly improves the diagnostic performance of SVR alone to predict adverse outcome (AUC 0.732; p = .016). Conclusion Pre-labor modifications of maternal cardiovascular variables are associated with adverse perinatal outcome. However, their predictive accuracy for perinatal compromise is low, and thus their use as standalone screening test for adverse perinatal outcome in singleton pregnancies at term is not supported.

Fetal cardiac Doppler changes in gestational diabetic pregnancies and its relationship with perinatal outcomes.

To examine the structural and functional changes of the fetal heart in gestational diabetes mellitus (GDM) and to evaluate the power of fetal cardiac Doppler parameters in predicting adverse perinatal outcomes in this group of pregnancy. Within the study's scope, 36 cases in the A1 GDM group, 33 cases in the A2 GDM group, and 124 cases in the control group were evaluated. The relationship between structural and functional fetal cardiac parameters and perinatal outcomes was evaluated via fetal echocardiography. Fetal left ventricular myocardial performance index (MPI) values were found to be statistically significantly higher when compared between the A1 GDM and A2 GDM groups and the control group (p = 0.000 and p = 0.000, respectively), while the E/A ratio was found to be significantly lower (p = 0.000 and p = 0.000, respectively). It was determined that the maternal blood HbA1c level showed a significant negative correlation with the fetal cardiac E/A ratio and a significant positive correlation with isovolumetric relaxation time and MPI (p = 0.000, p = 0.000, and p = 0.000, respectively). Adverse perinatal outcome rate was higher in the diabetic group (46.4%-22.6%). When the cases with GDM were examined in terms of perinatal outcomes, it was observed that there was a significant difference in HbA1c levels, E/A ratio, and MPI values between the cases in the group with adverse perinatal outcomes and the group with normal results (p = 0.001, p = 0.000, and p = 0.000, respectively). The strong relationship between abnormal cardiac function and adverse perinatal outcomes suggest that cardiac Doppler may be a valuable tool for fetal monitoring and management for the GDM patient group.

Interventional effect of dietary fiber on blood glucose and pregnancy outcomes in patients with gestational diabetes mellitus.

To investigate the effect of dietary fiber on blood glucose and pregnancy outcomes in patients with gestational diabetes mellitus (GDM). One hundred and twelve patients with GDM in the second trimester of pregnancy were recruited from Women's Hospital, Zhejiang University School of Medicine. Patients were randomized into two groups with 56 in each group: the control group received basic nutrition support; while the dietary fiber group were given additional dietary fiber ( total dietary fiber per day) before meals in addition to basic nutrition support. Intervention for all cases lasted for 8 weeks. Fasting blood glucose and postprandial blood glucose (2 h BG) were measured every week, and oral glucose tolerance test (OGTT) was performed at 42 d postpartum to evaluate the glycemic outcomes. Perinatal outcomes were recorded. The dietary fiber intervention markedly improved 2 h BG in patients with GDM and significantly elevated the glucose compliance rate from the 3rd to 8th week compared to the control group ( <0.05 or <0.01). OGTT 2 h glucose and the incidence of impaired glucose tolerance in the dietary fiber group were significantly lower than those in the control group, while the glucose compliance rate was significantly higher than that in the control group (all <0.01). Moreover, the rates of adverse perinatal outcomes, such as premature rupture of membranes and neonatal hyperbilirubinemia were declined in the dietary fiber group (<0.05 or <0.01). Dietary fiber intervention can ameliorate hyperglycemia in GDM patients, improve perinatal outcomes and reduce the incidence of postpartum impaired glucose tolerance.

Assessment of morbidity and mortality in newborns with late prematurity: experience of a reference maternity in the northeast of Brazil.

Late preterm infants show high rates of adverse perinatal outcomes. The aim of this study is to assess the morbidity and mortality of newborns (NBs) with late preterm birth in a reference maternity hospital in northeastern Brazil. Retrospective cohort study from March 1st to July 15th, 2017. A total of 204 NBs with gestational age between 34 and 36 weeks and six days were evaluated and compared to 205 full-term NBs (39 and 40 weeks and six days). Perinatal outcomes including neonatal morbidity were evaluated. The Student's t and ANOVA tests were used for normal variables, and the Wilcoxon, Mann-Whitney and Kruskal-Wallis tests for non-normal variables. Late preterm infants showed significant higher rates of hypothermia, hypoglycemia, respiratory distress syndrome, jaundice in need of phototherapy (67.6%), admission to the neonatal intensive care unit (ICU), and difficulty breastfeeding compared to full-term NBs (P<0.001). Respiratory distress was the main indication for the admission of late preterm infants (P<0.001) to neonatal ICU. Late preterm infants had a longer hospital stay (6.9 vs. 3.7 days, P<0.001). There were three deaths in the group of late preterm NBs, and none in the group of term NBs. Late preterm NBs presented higher rates of morbidity and mortality when compared to full-term NBs.

Oligohydramnios: how severe is severe?

Objective To investigate whether the severity of isolated oligohydramnios at term is associated with increased rates of adverse perinatal outcome. Study design A retrospective study conducted in a single medical center from 2017 to 2019. All low-risk pregnancies with incidental isolated oligohydramnios at term were included. The degree of oligohydramnios was arbitrarily classified into mild (AFI = 41–50 mm), moderate (AFI = 21–40 mm) and severe (AFI = 0–20 mm). Result A total of 610 women were included: 202 with a mild (33.1%), 287 moderate (47.0%), and 121 severe oligohydramnios (19.8%). Non-reassuring monitor requiring immediate delivery and worse composite neonatal outcome were more common among severe than mild or moderate oligohydramnios (14.0% and 6.4%, 7.3% respectively; p = .039 and 19.8%, 10.9% and 11.8%, respectively; p = .048). Conclusion Low-risk pregnancies with isolated severe oligohydramnios at term have a higher tendency toward non-reassuring fetal monitoring requiring prompt delivery and adverse neonatal outcomes, this calls for close intrapartum surveillance

1087 Risk of adverse perinatal outcomes after recovery from antepartum sepsis

Maternal sepsis causes significant morbidity and mortality, but little is known about outcomes of patients who recover from antepartum sepsis. This study evaluates perinatal outcomes of patients with sepsis who were discharged prior to delivery. We performed a retrospective cohort study of patients who delivered at our institution from 8/1/2012 to 8/1/2018 and had a prior antepartum admission for sepsis with subsequent discharge prior to delivery. Multifetal pregnancies, major fetal structural or genetic anomalies, TORCH infections, and patients who delivered during their antepartum admission were excluded. Primary outcomes were composites of obstetric and neonatal complications. Between group differences were assessed by Fisher’s exact test or t-test. 70 of 15,055 patients (0.5%) had an antepartum admission for sepsis. 59 of 70 patients (84%) were discharged without delivery. Of these, 8% were admitted to the intensive care unit (ICU), overall mortality was 1.7%, and median days from hospital discharge to delivery was 79 (IQR 34–141). Patients with sepsis were more often Black (22% vs 6%, p < 0.001), more likely to have pregestational diabetes mellitus (9% vs 2%, p = 0.003), and younger (30.6 vs 33.1 years, p < 0.001) than patients without sepsis. There were no differences in composite neonatal complications between the groups (25% vs 28%, p = 0.77). Patients with sepsis had higher rates of obstetric complications (49% vs 34%, p = 0.02), cesarean delivery (39% vs 25%, p = 0.02), postpartum hemorrhage (24% vs 14%, p = 0.04), and hypertensive disease of pregnancy (24% vs 11%, p = 0.006) than patients without sepsis. In subgroup analyses, severe sepsis defined by ICU admission was associated with earlier gestational age at delivery (36.1 vs 38.9 weeks, p = 0.01) and a trend towards more neonatal complications (60% vs 28%, p = 0.14). Patients that recover from sepsis during the antepartum period may have higher rates of adverse perinatal outcomes. Close surveillance for obstetric and neonatal complications is warranted in these patients.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Evaluation of safety and foeto-maternal outcome following non-obstetric surgery in pregnancy: a retrospective single-site Australian study.

Existing data on safety of non-obstetric surgery during pregnancy appear limited and conflicting. This study aimed to assess perinatal outcomes and complications in pregnant women undergoing non-obstetric surgeries. A single-site Australian study was performed utilizing a 10-year data (2009-2018) collected retrospectively. Descriptive statistics were used to summarize the characteristics of the study population. Statistical analyses between groups were conducted by independent t-test or Mann-Whitney (for means between groups) and by chi-squared/Fisher's exact test (for categorical variables). A total of 108 pregnant women underwent non-obstetric surgery, with an increasing trend in annual numbers since 2014. The majority of women (91%) underwent surgeries as an emergency procedure, and under general anaesthesia (69.8%). Procedures during the first trimester comprised 45%, making it the most common trimester for non-obstetric surgeries. The most common cause for surgery arose in the gastrointestinal/digestive tract (39%). Overall perinatal complication rate was 19% with the rate of miscarriage/foetal loss, preterm birth and intrauterine growth restriction/small for gestational age being 4.7%, 10.4% and 3.8%, respectively. A total of 46 patients underwent intra-abdominal surgery. The most common surgery in the laparoscopy group was appendicectomy (56%), whereas adnexal pathology (54%) contributed to the majority of laparotomies. Subgroup comparison showed no significant difference in perinatal outcomes except for caesarean delivery rate (24% versus 67% for laparoscopy versus open, respectively (P = 0.04)). With an overall perinatal complication rate of 19%, the rate of adverse perinatal outcomes following non-obstetric surgery during pregnancy in our study was low and comparable to those of the general population.

856 Differences in perinatal outcomes among rural women by county composition

Residents of rural counties have lower health status and generally worse health outcomes than non-rural counterparts. Perinatal outcomes are known to differ by maternal race/ethnicity. Less is known about the health status and outcomes of women of color in rural counties and among rural counties that are minority majority. We conducted a retrospective cohort study with 2015 national vital statistics birth certificate data. Maternal county of residence was identified in this data file and counties <50,000 people were identified as rural. We then identified a cohort of women from minority majority counties which we defined as <50% white women delivering in that county. We compared perinatal outcomes of pregnancies within these minority majority counties to those of women from counties that are majority white. Bivariate analysis and multivariable logistic regression were performed. We identified 77 (4.7%) counties meeting criteria for minority majority. Of the 404,434 rural women, 46,386 (11.5%) were from minority majority counties. Women of minority majority counties were more likely to be /=35 years (10.8% vs 10.0%; p<0.001), have less than a high school education (19.8% vs 15.6%; p<.001), and to be unmarried (53.8% vs 41.1%; p<0.001) (Table 1). Minority-majority rural residence was also associated with higher rates of adverse perinatal outcomes including SGA (12.3% vs 9.3%; p<.001), NICU admission (6.7% vs 5.8%; p<.001), preterm birth (9.6% vs 7.9%; p<0.001), and infant death (0.57% vs 0.43%; p<.001). These findings persisted when controlling for potential confounders (Figure 1). We observed worse markers of baseline health status and an increased incidence of adverse perinatal outcomes among women residing in minority majority rural counties. Additional study is warranted to better understand the etiology of these differences. Such differences may pose a unique opportunity to focus attention and resources to improve outcomes for women in these counties.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

637 Gestational age specific risks for obese women with and without other risk factors

Obesity is one of the most preventable pre-pregnancy risk factors for adverse perinatal events. Despite this, there are few body-mass-index (BMI) specific prognostic models for timing of delivery associated with the lowest number of adverse perinatal events. Our aim was to build a model to estimate gestational age-specific rates of adverse perinatal outcomes in obese women with and without additional risk factors. This was a retrospective cohort study of all singleton births at ≥34 weeks’ gestation in British Columbia, Canada, 2008-2017. Data were obtained from the British Columbia Perinatal Database Registry. A multivariable Cox proportional hazards model including demographic and obstetric risk factors was used to estimate gestational age specific risk of composite perinatal mortality and severe morbidity for women at various weight classes. Interactions between obesity and other important risk factors were assessed on both the additive and multiplicate scales. Among all women (n=283,697), 13.1% were obese (pre-pregnancy BMI ≥30m/kg2), and 60.1% had normal BMI (18.5-24.9 m/kg2). As a fraction of ongoing pregnancies, adverse outcomes increased with increasing gestational age at delivery in women of all weights. There was a dose-response relationship with increasing BMI with those morbidly obese (BMI ≥ 40m/kg2) at the highest risk. Other key risk factors included nulliparity, chronic hypertension and diabetes mellitus. Obese women with any of these additional risk factors exhibited far worse outcomes than those without with increasing disparities at later delivery. There was additive interaction between nulliparity, chronic hypertension and diabetes mellitus and obesity, but no multiplicate interactions. Obese women are at increased risk of worse perinatal outcomes at all gestational ages. These risks are compounded by other known risk factors of adverse perinatal outcomes, especially closer to term.

679 Associations between race/ethnicity and perinatal outcomes in Hawai‘i

The primary objective was to evaluate for associations between perinatal outcomes and race/ethnicity in an ethnically diverse population in Hawai‘i. This is a retrospective cohort study of pregnant/postpartum women (within 6 weeks of delivery) who delivered in Hawai‘i from 2012-2017. All Patient Refined Diagnosis Related Groups codes were used to identify hospitalizations from the Hawai‘i Health Information Corporation inpatient database. Race/ethnicity was self-reported and categorized as non-Hispanic White, Asian, Filipino, Native Hawaiian and Pacific Islander (NHPI), and Other. Perinatal outcomes were extracted using International Classification of Diseases 9th and 10th Revision codes. Associations between patient characteristics and race/ethnic group were evaluated by chi-square tests with statistical significance set to p<0.05, followed by a post-hoc analysis with adjusted significance level set to p<0.0125 based on Bonferroni correction. Non-Hispanic White was used as the reference group to assess for racial/ethnic disparities. Our study included 90,399 hospitalizations of pregnant/postpartum women age 12-50. There were statistically significant differences between most of the outcomes measured (p<0.01, see Table 1). Asian, Filipino, and NHPI women were more likely to have pre-existing diabetes or gestational diabetes than White women. Asian, Filipino and NHPI women were more likely to have chronic hypertension than White women. Filipino and NHPI women were more likely to have a pregnancy-induced hypertension disorder or placental abruption compared to White women. Our study found that Asian, Filipino and NHPI women had higher rates of adverse perinatal outcomes than White women in Hawai‘i, adding to the limited data available on perinatal outcomes in these race/ethnic groups. At a time when minority health remains a critical issue, our findings re-emphasize the need for higher vigilance when caring for these race/ethnic groups and their associated comorbidities.

Absence of heterozygosity detected by single-nucleotide polymorphism array in prenatal diagnosis.

To investigate the general occurrence and clinical significance of absence of heterozygosity (AOH), detected by single-nucleotide polymorphism (SNP) array on prenatal diagnosis. We recruited pregnancies undergoing invasive prenatal diagnosis at our fetal medicine center over a 6-year period. All fetuses underwent SNP array using the Affymetrix CytoScan HD array platform. AOH was defined as a chromosomal homozygosity segment with neutral copy number. Cases with AOH over 10 Mb in size or with suspected pathogenicity were further analyzed, and the clinical features and outcome were reviewed. Of 10 294 recruited fetuses, 100 (0.97%) with AOH were identified; in 81 (81.0%) of these, AOH occurred in a single chromosome, while 19 (19.0%) patients had multiple AOHs in different chromosomes. AOH was observed in all chromosomes, chromosomes X, 2 and 16 being the most frequently involved. The length of AOH ranged from partial chromosome (9.002-80.222 Mb) to the entire chromosome. Similar AOH regions displayed varied clinical manifestations. In total, 55 patients presented with concomitant ultrasound abnormalities, the most common being multiple abnormalities (14/55 (25.5%)), genitourinary malformations (8/55 (14.5%)), skeletal malformations (5/55 (9.1%)) and small-for-gestational age (5/55 (9.1%)). Notably, the rate of adverse perinatal outcome (including termination of pregnancy, neonatal death, fetal death, selective reduction and miscarriage) in fetuses with AOH and ultrasound abnormalities (30/48 (62.5%)) was higher than in those without ultrasound abnormalities (6/40 (15.0%)) (P < 0.001). Further non-invasive prenatal testing using cell-free fetal DNA from maternal blood indicated chromosomal copy number abnormalities in 11 patients; however, they were confirmed as AOH by SNP array of the amniotic fluid. Genetic counseling regarding a prenatal diagnosis of AOH remains challenging. To evaluate comprehensively its significance, we propose a management strategy involving further serial ultrasound examinations, parental verification, whole-exome sequencing, placental study and effective follow-up. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Retrograde Flow in the Aortic Isthmus: Trigger to Deliver Growth Restricted Fetuses Between 30 and 34 Weeks of Gestation?

Abstract Objective To evaluate the association of aortic isthmus (AoI) circulation assessed by doppler imaging in growth restricted fetuses with perinatal outcome. Design Prospective longitudinal observational study. Setting Tertiary referral center. Population Fetal growth restriction (FGR) (n = 38) between 24 and 36 weeks’ gestation. Methods Doppler examination of the aortic isthmus, umbilical artery (UA), middle cerebral artery, and ductus venosus (DV) was performed. The relationship between perinatal outcomes and antegrade (n = 25) and retrograde flow (n = 13) in the AoI and other Doppler parameters was analysed. Results Retrograde AoI group had higher rates of adverse perinatal outcome (92.3% vs. 72%) with 63.1% sensitivity and 87.5% specificity. Overall perinatal mortality (intrauterine death and neonatal death) was higher in the retrograde group (23%). No perinatal mortality was seen in the antegrade AoI group. Cases with absent end diastolic flow (AEDF) or reverse end diastolic flow (REDF) in the UA and retrograde flow in the AoI and normal DV flow had 40% prenatal mortality as 25% in those with abnormal DV Doppler. Conclusion Retrograde blood flow in the AoI is associated with adverse perinatal outcome, particularly intrauterine fetal demise, neonatal death, Respiratory Distress Syndrome (RDS) and increased duration of Neonatal Intensive Care Unit (NICU) stay. Even if DV flow is normal, adverse outcome might be suspected in fetuses with AEDF/REDF in the UA and retrograde flow in the AoI. Consequently, retrograde flow in the AoI might be considered as an additional trigger for delivering FGR fetuses at 30–34 weeks with AREDF in the UA. Larger longitudinal studies are, however, required to vaidate this.

Insulin Dosing, Glycemic Control, and Perinatal Outcomes in Pregnancies Complicated by Type-2 Diabetes.

This study aimed to evaluate the prevalence of severe insulin resistance (insulin requirements ≥2 units/kg) at delivery and the relationship between severe insulin resistance, glycemic control, and adverse perinatal outcomes in pregnant women with type-2 diabetes mellitus. This is a retrospective cohort study of women with type-2 diabetes mellitus who delivered between January 2015 and December 2017 at a tertiary academic medical center. Maternal demographic information, self-monitored blood sugars, and insulin doses were abstracted from the medical record. Multivariable logistic regression was used to identify maternal baseline characteristics associated with severe insulin resistance at delivery. Overall 72/160 (45%) of women had severe insulin resistance. Women in the severe insulin resistance group demonstrated evidence of suboptimal glycemic control as evidenced by higher mean hemoglobin A1c (HbA1c) values (7.2 [ ± 1.1] vs. 6.6 [ ± 1.3%], p = 0.003), higher mean fasting (104.0 [ ± 17.4] vs. 95.2 [ ± 11.7 mg/dL], p < 0.001) and postprandial glucose values (132.4 [ ± 17.2] vs. 121.9 [ ± 16.9 mg/dL]), p < 0.001), and a higher percentage of total glucose values that were elevated above targets (37.7 [95% confidence interval (CI): 26.8-50] vs. 25.6 [95% CI: 13.3-41.3%], p < 0.001). Maternal HbA1c ≥6.5% and insulin use prior to pregnancy were associated with a higher prevalence of severe insulin resistance, while Hispanic ethnicity and non-White race were associated with a lower prevalence of severe insulin resistance. The rates of adverse perinatal outcomes including large for gestational age (LGA) birth weight, cesarean delivery, and hypertensive disorders of pregnancy did not differ between groups. Severe insulin resistance is common among pregnant women with type-2 diabetes, and it is associated with suboptimal glycemic control. Future studies are necessary to develop strategies to identify women with severe insulin resistance early in pregnancy and facilitate adequate insulin dosing. · Severe insulin resistance is common.. · BMI does not predict severe insulin resistance.. · Suboptimal glycemic control is common..

Maternal serum leptin, adiponectin, resistin and monocyte chemoattractant protein-1 levels in different types of diabetes mellitus

ObjectiveEvaluation of serum concentration of leptin, adiponectin, resistin, and MCP-1 in pregnant patients with different types of diabetes mellitus (DM) considering preconception planning and method of DM correction in 11–14th and 30–34th weeks of pregnancy. Study designLongitudinal, prospective study included 130 pregnant women divided into the following comparison groups: type 1 DM (T1DM, n = 40), type 2 DM (T2DM, n = 35), GDM (n = 40), and the control group (n = 15). The ELISA method defined the levels of leptin, resistin, adiponectin, and MCP-1 concentration in serum, which was assessed in 11–14th and 30–34th weeks of pregnancy. Statistical analysis was accomplished using SPSS 23.0 and "Prism 8-GraphPad" software. ResultsThe leptin level in the 1st trimester was the highest in T2DM insulin group compared to the control due to gestational age, hence in the 3rd trimester in all groups its serum concentrations appeared higher than in healthy patients (p = 0.0001). In the 1st trimester leptin levels directly correlated with women's BMI, newborns’ weight and macrosomia rate, in the 3rd trimester – with OGTT levels, HbA1c, gestational hypertension, and preeclampsia rates. Resistin levels in the 1st and 3rd trimesters were increased in almost all DM groups compared to the control group (p = 0.0001). The study established direct positive correlation between resistin and HbA1c, birth weight, and preeclampsia. In the 1st trimester, adiponectin demonstrated the lowest levels in T2DM insulin compared to T1DM and the control group (p = 0.0001) while in the 3rd trimester, adiponectin levels declined alongside gestational age in DM patients and all the groups compared to the control group (p < 0.05). Adiponectin negatively correlated with BMI, OGTT levels, and preeclampsia rate. MCP-1 levels in T2DM appeared higher than in T1DM patients and the control group in the 1st trimester, whereas in the 3rd trimester MCP-1 declined, correlating with BMI, preeclampsia and OGTT levels. ConclusionHigh rate of adverse perinatal outcomes in diabetic pregnancy might be developed due to more severe metabolic failures and further disturbances of adipokines expression.

Temporizing management vs immediate delivery in early‐onset severe preeclampsia between 28 and 34 weeks of gestation (TOTEM study): An open‐label randomized controlled trial

IntroductionThere is little evidence to guide the timing of delivery of women with early‐onset severe preeclampsia. We hypothesize that immediate delivery is not inferior for neonatal outcome but reduces maternal complications compared with temporizing management.Material and methodsThis Dutch multicenter open‐label randomized clinical trial investigated non‐inferiority for neonatal outcome of temporizing management as compared with immediate delivery (TOTEM NTR 2986) in women between 27+5 and 33+5 weeks of gestation admitted for early‐onset severe preeclampsia with or without HELLP syndrome. In participants allocated to receive immediate delivery, either induction of labor or cesarean section was initiated at least 48 hours after admission. Primary outcomes were adverse perinatal outcome, defined as a composite of severe respiratory distress syndrome, bronchopulmonary dysplasia, culture proven sepsis, intraventricular hemorrhage grade 3 or worse, periventricular leukomalacia grade 2 or worse, necrotizing enterocolitis stage 2 or worse, and perinatal death. Major maternal complications were secondary outcomes. It was estimated 1130 women needed to be enrolled. Analysis was by intention‐to‐treat.ResultsThe trial was halted after 35 months because of slow recruitment. Between February 2011 and December 2013, a total of 56 women were randomized to immediate delivery (n = 26) or temporizing management (n = 30). Median gestational age at randomization was 30 weeks. Median prolongation of pregnancy was 2 days (interquartile range 1‐3 days) in the temporizing management group. Mean birthweight was 1435 g after immediate delivery vs 1294 g after temporizing management (P = .14). The adverse perinatal outcome rate was 55% in the immediate delivery group vs 52% in the temporizing management group (relative risk 1.06; 95% confidence interval 0.67‐1.70). In both groups there was one neonatal death and no maternal deaths. In the temporizing treatment group, one woman experienced pulmonary edema and one placental abruption. Analyses of only the singleton pregnancies did not result in other outcomes.ConclusionsEarly termination of the trial precluded any conclusions for the main outcomes. We observed that temporizing management resulted in a modest prolongation of pregnancy without changes in perinatal and maternal outcome. Conducting a randomized study for this important research question did not prove feasible.