Rates Of Low Apgar Scores Research Articles

Pregnancy Outcome in Women with Decreased Fetal Movement Beyond 34 Weeks of Gestation

Introduction: The fetal movement though subjective still is considered an important sign of fetal well-being. It is used as the first method for fetal well being assessment. Decreased fetal movement (DFM) always alerts the obstetricians and needs appropriate intervention as it is generally found to be associated with poor fetomaternal outcome. This study was conducted to determine the pregnancy outcome in women with decreased fetal movements at gestational age ≥34 weeks to 42 weeks of gestation. Methods: This was a hospital- based retrospective observational study done in Obstetrics and Gynecology Department of Tribhuvan University Teaching Hospital, Kathmandu, Nepal from April 2020 to April 2021. Descriptive analysis and data processing was done by using IBM SPSS Statistics 22. Results: There were a total of 82 women with decreased fetal movement. Among these, induction of labor was done in 35.5%, while 23.1% had preterm delivery, 47.6% had cesarean delivery and 51.1% had vaginal delivery with 1.2% vaccum delivery. Though there were higher rates of low APGAR score (15.8%), meconium stained liquor (MSL) (21.9%) and Neonatal Unit admission (NNU) (21.9%), all the babies admitted were discharged except for one perinatal death (1.2%). There was no still birth. Conclusion: Although perinatal mortality was low in women with decreased fetal movement with negligible still birth, however there were increased MSL and neonatal admission. Hence raising awareness of DFM among women, its early identification, further assessment with ultrasound, cardiotocogram and structured management protocol is beneficial .

Impact of point-of-care ultrasound and routine third trimester ultrasound on undiagnosed breech presentation and perinatal outcomes: An observational multicentre cohort study.

Accurate knowledge of fetal presentation at term is vital for optimal antenatal and intrapartum care. The primary objective was to compare the impact of routine third trimester ultrasound or point-of-care ultrasound (POCUS) with standard antenatal care, on the incidence of overall and proportion of all term breech presentations that were undiagnosed at term, and on the related adverse perinatal outcomes. This was a retrospective multicentre cohort study where we included data from St. George's (SGH) and Norfolk and Norwich University Hospitals (NNUH). Pregnancies were grouped according to whether they received routine third trimester scan (SGH) or POCUS (NNUH). Women with multiple pregnancy, preterm birth prior to 37 weeks, congenital abnormality, and those undergoing planned cesarean section for breech presentation were excluded. Undiagnosed breech presentation was defined as follows: (a) women presenting in labour or with ruptured membranes at term subsequently discovered to have a breech presentation; and (b) women attending for induction of labour at term found to have a breech presentation before induction. The primary outcome was the proportion of all term breech presentations that were undiagnosed. The secondary outcomes included mode of birth, gestational age at birth, birth weight, incidence of emergency cesarean section, and the following neonatal adverse outcomes: Apgar score <7 at 5 minutes, unexpected neonatal unit (NNU) admission, hypoxic ischemic encephalopathy (HIE), and perinatal mortality (including stillbirths and early neonatal deaths). We employed a Bayesian approach using informative priors from a previous similar study; updating their estimates (prior) with our own data (likelihood). The association of undiagnosed breech presentation at birth with adverse perinatal outcomes was analyzed with Bayesian log-binomial regression models. All analyses were conducted using R for Statistical Software (v.4.2.0). Before and after the implementation of routine third trimester scan or POCUS, there were 16,777 and 7,351 births in SGH and 5,119 and 4,575 in NNUH, respectively. The rate of breech presentation in labour was consistent across all groups (3% to 4%). In the SGH cohort, the percentage of all term breech presentations that were undiagnosed was 14.2% (82/578) before (years 2016 to 2020) and 2.8% (7/251) after (year 2020 to 2021) the implementation of universal screening (p < 0.001). Similarly, in the NNUH cohort, the percentage of all term breech presentations that were undiagnosed was 16.2% (27/167) before (year 2015) and 3.5% (5/142) after (year 2020 to 2021) the implementation of universal POCUS screening (p < 0.001). Bayesian regression analysis with informative priors showed that the rate of undiagnosed breech was 71% lower after the implementation of universal ultrasound (RR, 0.29; 95% CrI 0.20, 0.38) with a posterior probability greater than 99.9%. Among the pregnancies with breech presentation, there was also a very high probability (>99.9%) of reduced rate of low Apgar score (<7) at 5 minutes by 77% (RR, 0.23; 95% CrI 0.14, 0.38). There was moderate to high probability (posterior probability: 89.5% and 85.1%, respectively) of a reduction of HIE (RR, 0.32; 95% CrI 0.0.05, 1.77) and extended perinatal mortality rates (RR, 0.21; 95% CrI 0.01, 3.00). Using informative priors, the proportion of all term breech presentations that were undiagnosed was 69% lower after the initiation of universal POCUS (RR, 0.31; 95% CrI 0.21, 0.45) with a posterior probability greater of 99.9%. There was also a very high probability (99.5%) of a reduced rate of low Apgar score (<7) at 5 minutes by 40% (RR, 0.60; 95% CrI 0.39, 0.88). We do not have reliable data on number of facility-based ultrasound scans via the standard antenatal referral pathway or external cephalic versions (ECVs) performed during the study period. In our study, we observed that both a policy of routine facility-based third trimester ultrasound or POCUS are associated with a reduction in the proportion of term breech presentations that were undiagnosed, with an improvement in neonatal outcomes. The findings from our study support the policy of third trimester ultrasound scan for fetal presentation. Future studies should focus on exploring the cost-effectiveness of POCUS for fetal presentation.

Application of Prospect Theory in Obstetrics by Evaluating Mode of Delivery and Outcomes in Neonates Born Small or Appropriate for Gestational Age

Antenatal diagnosis of fetal weight is challenging, and the detection rate of fetal growth restriction (FGR) is low. Neonates with FGR are known to have an increased rate of obstetric intervention during labor, but the association of antenatal fetal weight estimation with mode of delivery and neonatal outcomes among neonates who are small and appropriate for gestational age (SGA and AGA) has not been reported. To evaluate the association of antenatal fetal weight estimation with mode of delivery and neonatal outcomes among neonates who are SGA and AGA, applying psychological concepts of cognitive bias and prospect theory to a model of clinical behavior. This cohort study was conducted between 2019 and 2020 using data from 2006 to 2018 at a tertiary care center in Jerusalem, Israel. Participants were 100 198 term singleton neonates without anomalies who were categorized into 4 groups according to the presence of an antenatal suspicion of FGR and final birth weight. Neonates with false positives (FPs; ie, group 1-FP: those with suspected FGR who were AGA) and neonates with true positives (TPs; ie, group 2-TP: those with suspected FGR who were SGA) were compared with neonates with AGA antenatal fetal weight estimation, including neonates with false negatives (FNs; ie, group 3-FN: those not suspected to have FGR who were SGA) and neonates with true negatives (TNs; ie, group 4-TN: those not suspected to have FGR who were AGA). Data were analyzed from July 2019 to July 2020. Fetal weight estimation was performed according to sonographic and clinical evaluation at admission to labor, with FGR defined as a birth weight less than the 10th percentile for gestational age. Sonographic fetal weight estimation was performed according to Hadlock formula. Clinical weight estimation was performed by trained obstetricians. The primary outcomes were obstetric intervention and mode of delivery; the secondary outcomes were neonatal Apgar score (with low Apgar score defined as <7) and neonatal intensive care unit (NICU) admission rates. Among 100 198 neonates eligible for the study (50941 [50.8%] male neonates), there were 5671 neonates in group 1-FP, 3040 neonates in group 2-TP, 8508 neonates in group 3-FN, and 82 979 neonates in group 4-TN. Mean (SD) maternal age was 28.6 (5.7) years. Among 8711 neonates with suspected FGR, 34.9% were below the 10th percentile at birth, while 65.1% were AGA. Neonates with suspected FGR had a significantly increased rate of induction of labor (group 1-FP: 649 neonates [11.4%] and group 2-TP: 969 neonates [31.9%]) compared with neonates in group 3-FN (1055 neonates [12.4%]) and group 4-TN (7136 neonates [8.6%]) (P < .001) and a significantly increased rate of cesarean delivery (group 1-FP: 915 neonates [16.1%] and group 2-TP: 556 neonates [18.3%] vs group 3-FN: 1106 neonates [13.0%] and group 4-TN: 6588 neonates [7.9%]; P < .001). Increased NICU admission was found for neonates who were SGA compared with neonates who were AGA (group 2-TP: 182 neonates [6.0%] and group 3-FN: 328 neonates [3.9%] vs group 1-FP: 51 neonates [0.9%] and group 4-TN: 704 neonates [0.8%]; P <.001), as was increased rate of low Apgar score (eg, at 1 minute: group 2-TP: 149 neonates [4.9%] and group 3-FN: 384 neonates [4.5%] vs group 1-FP: 124 neonates [2.2%] and group 4-TN: 1595 neonates [1.9%]; P < .001). In a multivariable model comparing group 1-FP, group 2-TP, and group 3-FN with group 4-TN, suspicion of FGR was independently associated with increased risk of caesarean delivery among neonates in group 1-FP (odds ratio, 1.72; 95% CI, 1.56-1.88; P < .001). This study found that antenatal diagnosis of FGR was independently associated with an increase in risk of caesarean delivery by 70% in neonates who were AGA without improvement in neonatal outcomes. These findings suggest that such outcomes may be explained by application of prospect theory and may be associated with cognitive bias in clinical decision-making.

The Different Outcomes in Pregnant Women with Severe Features of Preeclampsia between New Onset Hypertension Group and Pre-Existing Hypertension Group

Background: There are extensive evidence that preeclampsia is the reason for many maternal and perinatal morbidities. However, there are no previous study on the different outcomes in severe preeclamptic women between new onset hypertension and chronic hypertension. Objective: To compare the rate of low Apgar score at 5 minutes and other adverse pregnancy outcomes of preeclamptic women with severe features between those who had new onset hypertension in pregnancy and those with chronic hypertension before pregnancy. Materials and Methods: A retrospective cohort study was conducted. The medical records of pregnant women diagnosed with preeclampsia with severe features and delivered at Chonburi Hospital between January 2017 and June 2020 were reviewed. The authors categorized these pregnant women into two groups, new onset hypertension and chronic hypertension. Descriptive statistics were used for the data analyses. Results: Of the 526 women diagnosed with preeclampsia with severe features, 290 met the inclusion and exclusion criteria. Eighty-nine had superimposed preeclampsia on chronic hypertension and 201 patients had new onset hypertension. The rate of low Apgar score at 5 minutes was not statistically different between the two groups (p=0.258). The incidence of impaired liver function and HELLP syndrome were increased in the new onset hypertension group at 18.9% versus 6.7% (p=0.008) and 9.5% versus 1.1% (p=0.010), respectively. Conclusion: There was no significant difference in the rate of low Apgar score between the two groups. Regarding the severity of maternal outcomes, new onset preeclampsia with severe features seems to be more severe than superimposed preeclampsia on chronic hypertension. Keywords: Low Apgar score; Preeclampsia with severe features; Chronic hypertension; Superimposed preeclampsia; Pregnancy outcomes

1164 Maternal and infant outcomes in those undergoing TOLAC by hospital setting

The objective of this study was to assess whether maternal and neonatal outcomes in those undergoing trial of labor after cesarean (TOLAC) differ significantly between hospitals in rural versus urban settings. We conducted a retrospective cohort study of singleton, non-anomalous, term deliveries in California between 2007 and 2011. We compared maternal and neonatal outcomes separately between rural and urban settings. Chi-square and multivariable logistic regression analyses were employed for statistical comparisons and a p-value of less than 0.05 was used to indicate statistical significance. 45,763 women-infant dyads were included in this study. We found the odds of operative vaginal delivery in women undergoing TOLAC were significantly higher at urban centers compared to rural hospitals (aOR: 1.00% vs 0.46%, p<0.001). In women undergoing TOLAC, rates of endometritis were significantly higher at urban hospitals than rural (0.62% vs. 0.24%, p=0.049). Rates of post-partum hemorrhage was significantly higher at urban hospitals than rural (3.07% vs 1.90%, p=0.006), although maternal transfusion rates were not significantly different. Rates of placental abruption were not significantly different between the two settings. Infants of women undergoing TOLAC were admitted to the neonatal intensive care unit (NICU) at a significantly higher rate in urban hospitals than rural hospitals (7.28% vs 3.90%, p<0.001). The remaining outcomes were not significantly different, including rates of low APGAR scores, brachial plexus injury, HIE, neonatal and infant death. In this study, we found that most outcomes in women undergoing TOLAC did not differ significantly between rural and urban settings. At hospitals in urban settings, women experienced higher rates of endometritis and post-partum hemorrhage. Neonatal outcomes were also generally not significantly different, however, infants of women in urban settings experienced higher rates of NICU admission than rural hospitals. Further research ought to be done to determine whether VBAC success rates contribute to these differences.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Adverse neonatal outcomes of adolescent pregnancy in Northwest Ethiopia.

BackgroundAdolescents have physical, social and psychological characteristics that are different from adults. Adolescent pregnancy results in pregnancy and childbirth complications- an area neglected in developing countries like Ethiopia. This study, therefore, was conducted to assess the adverse neonatal outcomes of adolescent pregnancy in Northwest Ethiopia.MethodsInstitutional-based study was conducted in East Gojjam zone, Northwest Ethiopia. A total of 374 adolescent (15–19 years) and 760 adult (20–34 years) women were included in this study. Data were collected among women who came to randomly selected health facilities in East Gojjam zone. Data were collected by trained research assistants using a structured data collection questionnaire. Descriptive statistics, chi-square test, and Student's t-tests were utilized. Bivariate and multivariable logistic regression analysis were employed to adjust for confounding factors of adverse neonatal outcomes. Statistical significance was declared when the p-value was less than 0.05.ResultsHigher proportion of adolescent than adult women were from rural area (57.2% vs 44.7%), were not married (5.1% vs 1.7%), were pregnant for the first time (91.7% vs 34.1%), didn’t attend antenatal care (ANC) follow-up (12% vs 4.5%), and had late initiation of ANC follow-up. After adjusting for known confounding factors, the odds of low birth weight (LBW) was higher among adolescents than adult women (AOR 2.14; 95% CI, 1.36, 3.36, p-value = 0.001). Similarly, the odds of preterm birth was higher among adolescents than adult women (AOR 1.65; 95% CI, 1.09, 2.49, p-value = 0.017). There was no statistically significant difference in the rate of low Apgar score at first and five minutes after birth and neonatal Intensive Care Unit (ICU) admission between babies born from adolescent and adult women.ConclusionsAdolescent women were less likely to receive ANC service. Babies born from adolescent women are at higher odds of adverse neonatal outcomes like LBW and preterm birth than babies born from adult women. Use of community- and health facility-based intervention programs that can prevent adolescent pregnancy and reduce adverse neonatal outcomes among adolescent girls is recommended.

Perinatal Outcomes of Small for Gestational Age Neonates Born With an Isolated Single Umbilical Artery.

Objective: To investigate pregnancy outcomes of small for gestational age (SGA) neonates born with isolated single umbilical artery (iSUA) compared to SGA neonates without iSUA.Study Design: This was a population-based retrospective cohort analysis. The study group was defined as a singleton SGA neonate born with iSUA, while an SGA neonate without iSUA comprised the comparison group. We evaluated adverse perinatal outcomes in all SGA neonates born at the Soroka University Medical Center between the years 1998–2013. Multiple gestations, fetuses with known congenital malformations or chromosomal abnormalities and patients with lack of prenatal care were excluded from the study. Multivariate logistic regression models were constructed to identify independent factors associated with adverse perinatal outcomes.Results: Of 12,915 SGA deliveries, 1.2% (162) were complicated with iSUA. Women in the study group were older with a significantly lower gestational age at delivery compared with the comparison group. Rates of women who conceived after infertility treatments were higher in the study group. Additionally, patients in the study group had significantly higher rates of preterm deliveries, placental abruption, cord prolapse, non-reassuring fetal heart rates and cesarean delivery were noted in the study group. These neonates had a significantly lower birth weight (1988.0 ± 697 vs. 2388.3 ± 481 p < 0.001) and higher rates of low APGAR scores at the first and fifth minutes after birth compared with controls. Perinatal mortality was also found to be significantly higher among SGA neonates complicated with iSUA. Preterm delivery as well as perinatal mortality were found independently associated with iSUA among SGA neonates (aOR 4.01, 95% CI 2.88–5.59, aOR 2.24, 95% CI 1.25–4.01, respectively).Conclusion: SGA pregnancies complicated with iSUA are at higher risk for adverse pregnancy and perinatal outcomes as compared to SGA pregnancies without iSUA.

Inter-twin delivery interval, short-term perinatal outcomes and risk of caesarean for the second twin.

To examine the association between inter-twin delivery interval and short-term perinatal outcomes of the second twin after vaginal delivery of the first twin. Retrospective cohort study including twin pregnancies with a vaginal delivery of the first twin between January 2011 and September 2017 in a tertiary hospital in Melbourne, Australia. The main outcome measure was a composite of adverse neonatal outcome (at least one of perinatal death, admission to neonatal intensive care unit (NICU), endotracheal intubation, Apgar <7 at five minutes and cord lactate >4.0 mmol/L). Proportions of adverse outcomes for the second twin were compared between groups of intervals ≤ or >10 and ≤ or >30min. The composite adverse neonatal outcome occurred in 201 (58.2%) and a caesarean section occurred in seven cases (2%) of the 345 pregnancies included. Delivery interval was associated with higher cord lactate. Low Apgar scores were more frequent with intervals >30min (17.9% vs 6.6%, P=0.03), as well as caesarean section for the second twin (10.7% vs 1.3%, P=0.01). Composite adverse outcome and admission to NICU were not significantly influenced by the delivery interval. Predictors of adverse outcome were gestational age, abnormal cardiotocography and breech delivery of the second twin. The inter-twin delivery interval is associated with higher rates of low Apgar scores and higher cord lactate for the second twin. These associations do not translate into higher rates of admission to NICU and their long-term clinical implications are uncertain.

Cohort study of the relationship between individual psychotherapy and pregnancy outcomes

IntroductionAntenatal depression is associated with poor obstetric outcomes, but it has not been determined if treatment improves these outcomes. We hypothesized that psychotherapy for antenatal depression would decrease rates of low Apgar score, preterm birth, low birthweight, and high maternal weight gain. MethodsUsing longitudinal clinical data from the electronic health record (EHR) of a large academic medical center, we examined the association between exposure to psychotherapy during pregnancy among women with a history of major depressive disorder and obstetric outcomes. We compared outcomes between women with and without psychotherapy treatment during pregnancy, and included a dose response analysis. ResultsOf 50,856 women with pregnancies between 1998 and 2013, 5413 had a lifetime diagnosis of depression (948 had a diagnosis of depression during pregnancy), and 536 received psychotherapy at least once during pregnancy. Women who received one or more psychotherapy sessions during pregnancy had increased odds of preterm delivery and decreased odds of high maternal weight gain (more than 40 pounds). Individuals who received four or more psychotherapy sessions during pregnancy had increased odds of preterm birth and low infant birth weight and decreased odds of high maternal weight gain. LimitationsPatients may have pursued treatment outside of this hospital's EHR data, and we cannot control for the quality of treatment or type of psychotherapy. DiscussionPsychotherapy was associated with negative obstetric outcomes. While treatment of depression in pregnant women has been shown to benefit the mother, the absence of benefit in terms of pregnancy outcomes merits further investigation.

Social, obstetric and environmental determinants of low Apgar score among infants born in four selected hospitals in Ibadan, Nigeria

Little information exists about socio-economic, environmental or occupational determinants of low Apgar scores among Nigerian neonates.Mothers in lying-in wards of four hospitals in Ibadan were interviewed on socio-demographic characteristics, obstetric history and work activities during index pregnancy. Apgar scores and clinical data were extracted from case notes. Of the 1349 respondents, 20% had Apgar score <7 at one minute, 4% at five minutes. Lower education, cooking with kerosene, physical exertion at work, nulliparity, hypertension in pregnancy, prolonged rupture of membranes, breech presentation and caesarean section were predictors for low Apgar scores at one minute; nulliparity, male infant and breech presentation at five minutes. Occupations with lower socio-economic status or those requiring physical exertion; tailoring, catering and hairdressing recorded higher rates of low Apgar scores at one minute (p = .08). Physical exertion at work and cooking with kerosene may be predictive of low Apgar scores and require further study.

Does SSRI Antidepressant Use Influence APGAR Scores? [29N

INTRODUCTION: SSRIs have been associated with low APGAR scores, independent of maternal depression, and with preterm birth. Our objective was to determine the association of SSRIs with low APGARs. METHODS: We performed a retrospective matched cohort study on patients who delivered at a tertiary care center from 2009–2014. Women who reported SSRI use on admission were matched to contemporary controls in a 2:1 fashion by completed weeks of gestation and mode of delivery. Fetal anomalies, stillbirths, and multiple gestations were excluded. Odds ratios and 95% confidence intervals were calculated. Fisher's exact test was used to determine significance in the number of APGAR scores <7. RESULTS: 112 SSRI users (2% of deliveries) and 224 controls were included. Women reported using the following: citalopram (n=23), escitalopram (n=4), paroxetine (n=2), fluoxetine (n=34), and sertraline (n=49). 25% delivered preterm. Infants exposed to SSRIs had an increased rate of low APGAR scores at 1 minute (OR 2.0, 95% CI 1.1–3.5, P=.02) and 5 minutes (OR 8.8, 95% CI 2.4–32.0, P=.0009). 1 minute APGAR scores <7 (24% vs 14%, P=.02) and 5 minutes (11% vs 1%, P=.0002) were significantly higher in the SSRI group. CONCLUSION: SSRIs are associated with an increased risk of APGAR scores <7 at 1 and 5 minutes, with an almost 9-fold increased risk of 5 minute APGAR <7. APGAR scores <7 have previously been associated with future cognitive impairment. Further investigation into the impact of SSRI exposure is essential.

Birth after caesarean section.

Birth after caesarean section (CS) is an issue of growing importance. As a consequence of increasing CS rates, more women having experienced a prior CS will need counselling about preferred second delivery mode. There are two choices: elective repeat caesarean section (ERCS) or trial of labour (TOL). It is well known, that a TOL ending in an emergency CS carries the largest risks for mother and child. We wanted to investigate for which women and infants it would be safest to recommend an ERCS or a TOL. We assumed, that underlying conditions/indications for the first CS performed would often recur in the second pregnancy and be important for the second delivery outcome. Therefore, a hierarchical system was developed, in which efforts were made to classify according to underlying conditions instead of focusing on conditions appearing during labour, in an attempt to diminish the subjective impact of diagnoses recorded after delivery. The hierarchical system was used through the four papers. We investigated women in the Swedish medical birth register with their first two deliveries 1987-2007 (Paper I-III), or giving birth at least twice, including one CS and at least one delivery after the CS 1992-2011 (Paper IV). In Papers I-III, we have shown that all first CS indications had a statistically significant risk to recur in the second pregnancy/ delivery. Women with a first CS were older, shorter, and had a higher body mass index than women with a first vaginal delivery. The risk for unplanned CS in TOL increased by the women’s age, body mass index, and smoking, while increasing height lowered the risk. Women with a prior CS had an all-over increased risk for unplanned CS in TOL, compared with primiparous women. Infants born to mothers with one prior CS had an almost doubled risk for low Apgar score and perinatal death compared with infants of women with one prior vaginal birth. The risk was lower but still statistically significant after adjustment for possible maternal and fetal/infant confounders. For infants of women with one previous CS, the risk for low Apgar score was higher after a TOL than after an ERCS. In all studies, the risk for adverse outcomes differed substantially between hierarchical indications for the first CS performed. When the first CS was performed without medical indication, no inreased risk for low Apgar score or perinatal death could be detected. The results suggest that underlying conditions, not the previous CS per se, contributed to the risk increase. In Paper IV, we validated a widely used prediction model for chance of successful TOL after CS, developed by Grobman et al. (2007) for US conditions. As the original model was not directly applicable for Swedish settings, we modified it stepwise. The final, new model included maternal age, body mass index, prior vaginal birth, prior vaginal birth after CS, maternal height, first CS hierarchical indication, and the rates of ERCS and unplanned CS in the respective delivery wards. We reached an excellent predictability for vaginal birth in TOL after CS. Counselling about the safest delivery mode after one CS is a challenge. Our study results, combined with previous findings, add important scientific knowledge. However, non-medical factors are vital in the decision-making after one CS, and a trust between the woman, her partner, the obstetrician and the midwife is fundamental. Considering the new information would possibly make counselling easier and, hopefully, lower the rate of unplanned CS in TOL after CS and decrease the rate of low Apgar score and perinatal death in the birth after a caesarean delivery. (Less)

Novel pathological findings of placenta with fetal heart failure associated with congenital heart disease

Novel pathological findings of placenta with fetal heart failure associated with congenital heart disease

Polyhydramnios and Adverse Perinatal Outcome

Polyhydramnios complicates 1% to 3% of all pregnancies, and approximately 50% to 60% of cases are idiopathic. Although many fetal and maternal causes of polyhydramnios are known, idiopathic polyhydramnios is defined as that with no identifiable etiology. Amniotic fluid is commonly assessed using the amniotic fluid index (AFI), with polyhydramnios defined as an AFI of 24 cm or greater or 25 cm or greater, which is in the 95th or 97.5th percentile in normal singleton pregnancies. Polyhydramnios is subdivided into mild (24–30), moderate (30.1–35), and severe (AFI > 35). This retrospective cohort study was performed to reevaluate the cutoff point for polyhydramnios and identify a specific value associated with an increased risk for adverse outcomes. All patients enrolled had a sonographic assessment during pregnancy, and all had a singleton fetus at 20 weeks’ gestation or later with an AFI of greater than 10 cm. The patients were stratified into 5 groups according to the AFI: 10 to 19, 20 to 23, 24 to 27, 28 to 31, and 32 or greater. The group with AFI of less than 20 cm was the comparison group. Pregnancy characteristics, complications, and perinatal outcomes were compared among the groups. A total of 14,813 deliveries were enrolled: 9974 (67.3%) had 10 to 19, 2771 (18.7%) had 20 to 23, 1315 (8.8%) had 24 to 27, 494 (3.3%) had 28 to 31, and 260 (1.7%) had AFI of 32 or greater. Preterm labor, placental abruption, cesarean delivery, and malpresentation were more prevalent in a linear fashion as the AFI increased, with the highest prevalence in the group with AFI of 32 or greater. A nonlinear but significant difference between the groups was observed for prior cesarean delivery, gestational diabetes mellitus, postterm pregnancies, and macrosomia. With these complications, the prevalence increased as AFI increased up to an AFI of 31, with a relative decrease in the group with AFI of 32 or greater. A significantly increased rate of perinatal mortality was noted as AFI increased. The rate of low Apgar scores at 1 and 5 minutes was significantly higher and fetal pH tended to be lower in the groups with increased AFI. An Apgar score of less than 7 at 1 and 5 minutes showed a linear association with increased AFI. Three multiple logistic regression models using preterm labor, Apgar of less than 5 at 7 minutes, and perinatal mortality were constructed. All models exhibited a linear increase in the risk for adverse perinatal outcome with increasing AFI. The main finding of the study is the increased adverse perinatal outcome as AFI rises in a dose-response manner from AFI of greater than 20. The widely accepted cutoff for polyhydramnios is AFI of greater than 24, with established associations between polyhydramnios and adverse perinatal outcomes. A diagnosis of polyhydramnios requires additional evaluation to detect fetal anatomic or chromosomal anomalies or maternal conditions such as diabetes. The accepted definition of polyhydramnios as AFI of greater than 24 should be further reevaluated.

Scientific and clinical evidence for the use of fetal ECG ST segment analysis (STAN)

Fetal electrocardiogram waveform analysis has been studied for many decades, but it is only in the last 20years that computerization has made real-time analysis practical for clinical use. Changes in the ST segment have been shown to correlate with fetal condition, in particular with acid-base status. Meta-analysis of randomized trials (five in total, four using the computerized system) has shown that use of computerized ST segment analysis (STAN) reduces the need for fetal blood sampling by about 40%. However, although there are trends to lower rates of low Apgar scores and acidosis, the differences are not statistically significant. There is no effect on cesarean section rates. Disadvantages include the need for amniotic membranes to be ruptured so that a fetal scalp electrode can be applied, and the need for STAN values to be interpreted in conjunction with detailed fetal heart rate pattern analysis.

Maternal, fetal and perinatal characteristics of preeclampsia cases with and without abnormalities in uterine artery Doppler indexes

Objective: To compare the maternal and fetal characteristics and perinatal outcome in mild and severe preeclampsia cases with and without uterine artery Doppler abnormalities.Methods: Two hundred and fifty-nine mild and severe preeclampsia cases were evaluated retrospectively. Doppler measurements were done in the section where uterine artery raised from the hypogastric artery. Pulsatility index above the 95th percentile of the corresponding gestational age was accepted as abnormal.Results: In mild and severe preeclampsia cases with abnormal Doppler (AD), the rate of intrauterine growth restriction, preterm birth and low birth weight was higher than, but the neonatal intensive care unit stay was similar to the cases with normal Doppler. Base excess was higher in the AD group, in mild and severe preeclampsia. The rate of low Apgar score at 5 min and perinatal mortality was higher in the AD group, in the mild preeclampsia. The strongest independent predictor of the perinatal morbidity and mortality was the presence of prematurity and of the prematurity was the presence of abnormal uterine artery Doppler.Conclusions: Maternal and perinatal morbidity and perinatal mortality increase in mild to severe preeclampsia cases with abnormal uterine artery Doppler. The abnormal uterine artery Doppler increases the morbidity and mortality by increasing the risk of prematurity.

Neonatal outcomes after preterm birth by mothers’ health insurance status at birth: a retrospective cohort study

BackgroundPublicly insured women usually have a different demographic background to privately insured women, which is related to poor neonatal outcomes after birth. Given the difference in nature and risk of preterm versus term births, it would be important to compare adverse neonatal outcomes after preterm birth between these groups of women after eliminating the demographic differences between the groups.MethodsThe study population included 3085 publicly insured and 3380 privately insured, singleton, preterm deliveries (32–36 weeks gestation) from Western Australia during 1998–2008. From the study population, 1016 publicly insured women were matched with 1016 privately insured women according to the propensity score of maternal demographic characteristics and pre-existing medical conditions. Neonatal outcomes were compared in the propensity score matched cohorts using conditional log-binomial regression, adjusted for antenatal risk factors. Outcomes included Apgar scores less than 7 at five minutes after birth, time until establishment of unassisted breathing (>1 minute), neonatal resuscitation (endotracheal intubation or external cardiac massage) and admission to a neonatal special care unit.ResultsCompared with infants of privately insured women, infants of publicly insured women were more likely to receive a low Apgar score (ARR = 2.63, 95% CI = 1.06-6.52) and take longer to establish unassisted breathing (ARR = 1.61, 95% CI = 1.25-2.07), yet, they were less likely to be admitted to a special care unit (ARR = 0.84, 95% CI = 0.80-0.87). No significant differences were evident in neonatal resuscitation between the groups (ARR = 1.20, 95% CI = 0.54-2.67).ConclusionsThe underlying reasons for the lower rate of special care admissions in infants of publicly insured women compared with privately insured women despite the higher rate of low Apgar scores is yet to be determined. Future research is warranted in order to clarify the meaning of our findings for future obstetric care and whether more equitable use of paediatric services should be recommended.

Neonatal complications in public and private patients: a retrospective cohort study

ObjectiveTo use propensity score methods to create similar groups of women delivering in public and private hospitals and determine any differences in mode of delivery and neonatal outcomes between the...

109: The association between mid-trimester cervical length and cesarean delivery at term

109 The association between mid-trimester cervical length and cesarean delivery at term Emily Miller, William Grobman Northwestern University, Obstetrics and Gynecology, Chicago, IL OBJECTIVE: An ultrasonographically diagnosed short cervix has been associated with an increased risk of preterm birth, but the obstetric consequences of longer cervical lengths have been less well defined. The objective of this study was to determine the association between cervical length and cesarean delivery among women at term. STUDY DESIGN: This is a cohort study of women with a singleton gestation who underwent routine mid-pregnancy transvaginal cervical length assessment and delivered at term. Women who underwent planned cesarean delivery without intent to labor were excluded from analysis. Women were grouped into quartiles based on cervical length, and the association of their cervical length quartile with cesarean delivery was determined in both univariable and multivariable analysis. RESULTS: 5806 subjects were included in this analysis, of whom 58.1% were nulliparous. There were multiple differences among women in the different cervical length quartiles (Table). The frequency of cesarean delivery among the cohort was 18.9%. As cervical length increased, the chance of cesarean delivery increased as well (14.7%, 19.5%, 19.1%, and 22.4% from the 1st through 4th quartiles, respectively). After controlling for potential confounding factors, cervical length quartile remained significantly associated with an increased odds of cesarean for the second (aOR 1.49, 95% CI 1.18-1.88), third (aOR 1.47, 95% CI 1.16-1.85) and fourth (aOR 1.89, 95% CI 1.502.38) quartiles, compared to the first quartile. This relationship held true for nulliparous as well as multiparous women. CONCLUSION: Increasing mid-trimester cervical length is associated with increasing frequency of cesarean delivery in both nulliparas and multiparas. Preparatory uterine changes that enable successful labor may be initiated as early as the mid-trimester. 110 Evidence to support the safety and efficacy of vaginal delivery of twins gestation complicated by very low birthweight of second twin Eran Barzilay, Hila de Castro, Jigal Haas, Eyal Sivan, Eyal Schiff, Shali Mazaki-Tovi, Yoav Yinon Sheba Medical Center, Tel-Aviv University, Obstetrics and Gynecology, TelHashomer, Israel OBJECTIVE: To determine whether neonatal outcome is associated with the mode of delivery in very low birthweight twins. STUDY DESIGN: This was a retrospective cohort study. Inclusion criteria included: 1) twin gestation; 2) second twin birthweight of 1500 grams. Exclusion criteria included: 1) gestational age at delivery of less than 24 gestational weeks 2) fetal demise of one or both twins. A total of 206 twin gestations met the criteria and patients were classified into 2 groups according to the planned mode of delivery: 1. Cesarean delivery (n 152) and 2. Vaginal delivery (n 54). In the vaginal delivery group 24 pairs were cephalic-cephalic, 28 pairs were cephalic-non cephalic, and 2 pairs were non cephalicnon cephalic. The rates of Apgar score 7 at 5 minutes and cord blood PH 7.1 in either twin A or B were determined in the two groups. RESULTS: The mean gestational age at delivery was 31 weeks in the cesarean delivery group compared to 30 weeks of gestation in the vaginal delivery group (p 0.01). However, the mean birthweight of both twins was similar among the two groups (Twin A: 1452 grams vs. 1358 grams, p 0.18 and Twin B: 1186 grams vs. 1182 grams, p 0.9 respectively). There were no significant differences between the cesarean and vaginal delivery groups in the rates of low Apgar score (Twin A: 4.0% vs. 1.9%, p 0.5 and Twin B: 9.7% vs. 3.7%, p 0.2) and cord PH 7.1 (Twin A: 2.4% vs. 0%, p 0.3 and Twin B: 1.7% vs. 0%, p 0.4). A sub-group analysis of the vaginal delivery group revealed comparable rates of cesarean section (8.3% Vs 3.3%, p 0.4) as well as neonatal Apgar score 7 among the cephalic-cephalic and cephalicnon cephalic groups (Twin A: 4.2% vs. 0%, p 0.3 and Twin B: 0 vs. 6.7%, p 0.2). CONCLUSION: Vaginal delivery of very low birthweight twins is a safe regardless of second twin presentation. This information should provide reassurance for pregnant women and clinicians alike.

The effect of vacuum operator’s experience on Apgar scores

To determine the effect of a vacuum operator's experience on Apgar scores. A historical cohort study was conducted. All women who delivered by vacuum extraction between January 2003 and December 2007 at Songklanagarind Hospital were recruited. Vacuum operators were divided into two groups: staff doctors and residents. Comparisons of Apgar scores and rates of low Apgar scores (≤7) between the two groups were studied. A multivariate logistic regression analysis was used to control confounding variables for low Apgar scores. The percentages for the procedure performed by the staff doctors and residents were 76.9 and 23.1%. At 1 min, the rates of low Apgar scores in the staff and resident groups were 6.7 and 24.1% (p<0.001), and at 5 min, the rates of low Apgar scores were 0.6 and 5.2% (p<0.001). Multivariate logistic regression analysis showed that the operator's experience was an independent risk factor for low Apgar scores. The residents had a 2.9-fold increased risk of low Apgar scores at 1 min compared with the staff doctors (adjusted odds ratio 2.9; 95% confidence interval 1.7-6.8). In the resident group, the third year residents had the lowest risk of low Apgar scores. The vacuum operator's experience was an independent risk factor for low Apgar scores. Improvement of the residency training program is mandatory.