Risk Of Intrauterine Fetal Demise Research Articles

PREVALENCE OF GESTATIONAL DIABETES AND RELATED COMPLICATIONS IN DISTRICT SIALKOT

Gestational diabetes mellitus (GDM) is a prevalent medical complication during pregnancy, associated with adverse maternal and neonatal outcomes. Understanding the impact of GDM on pregnancy complications is essential for effective management and care. Objective: This study aimed to compare the incidence of various complications between pregnant women with and without GDM. Method: A total of 200 pregnant women were recruited from Govt. Sardar Begum Teaching Hospital Sialkot and Civil Hospital Sialkot. These patients were given 75 g oral glucose irrespective of the meals, and their plasma glucose was estimated at two h. Patients with plasma glucose values of 140 mg/dl were labelled GDM; the rest were the control or non-GDM groups. All GDM patients were followed up and treated with diet and insulin therapy till delivery to know maternal and fetal outcomes. Results: Among the enrolled pregnant women, 70 (35%) were diagnosed with GDM. Significant differences were observed between the Non-GDM and GDM groups in terms of Cesarean section delivery (23.8% vs 55.7%, P=0.001), hypertension (13.8% vs 74.3%, P=0.031), and preterm birth (17.7% vs 24.3%, P=0.001). However, no significant difference was found in the incidence of fetal abnormalities between the two groups (9.2% vs. 8.6%, P=0.012). Additionally, the risk of intrauterine fetal demise was comparable between the Non-GDM and GDM groups (10.0% vs. 11.4%, P=0.031). Conclusion: Pregnant women with GDM are at increased risk of Cesarean section delivery, hypertension, and preterm birth compared to those without GDM. However, the incidence of fetal abnormalities and intrauterine fetal demise does not significantly differ between the two groups. Early detection and management of GDM are crucial to minimise adverse pregnancy outcomes.

Assessment of obstetric characteristics and outcomes associated with pregnancy with Turner syndrome

To assess national-level trends, characteristics, and outcomes of pregnancies with Turner syndrome in the United States. Cross-sectional study. The Healthcare Cost and Utilization Project's National Inpatient Sample. 17,865,495 hospital deliveries from 2016-2020. A diagnosis of Turner syndrome, identified according to the World Health Organization's International Classification of Disease 10th revision code of Q96. Obstetrics outcomes related to Turner syndrome, assessed with inverse probability of treatment weighting cohort and multivariable binary logistic regression modeling. Prevalence of pregnant patients with Turner syndrome was 7.0 per 100,000 deliveries (one in 14,235). Number of hospital deliveries with patients who have a diagnosis of Turner syndrome increased from 5.0 to 11.7 per 100,000 deliveries during the study period (adjusted-odds ratio [aOR] for 2020 vs 2016, 2.18, 95% confidence interval [CI] 1.83-2.60). Pregnant patients with Turner syndrome were more likely to have a diagnosis of pregestational hypertension (4.8% vs 2.8%, aOR 1.65, 95%CI 1.26-2.15), uterine anomaly (1.6% vs 0.4%, aOR 3.01 95%CI 1.93-4.69), and prior pregnancy losses (1.6% vs 0.3%, aOR 4.70, 95%CI 3.01-7.32) compared to those without Turner syndrome. For the index obstetric characteristics, Turner syndrome was associated with increased risk of intrauterine fetal demise (10.9% vs 0.7%, aOR 8.40, 95%CI 5.30-13.30), intrauterine growth restriction (8.5% vs 3.5%, aOR 2.11, 95%CI 1.48-2.99), and placenta accreta spectrum (aOR 3.63, 95%CI 1.20-10.97). For delivery outcome, pregnant patients with Turner syndrome were more likely to undergo cesarean delivery (41.6% vs 32.3%, aOR 1.53, 95%CI 1.26-1.87). Moreover, the odds of peri-viable delivery (22-25 weeks: 6.1% vs 0.4%, aOR 5.88, 95%CI 3.47-9.98) and pre-viable delivery (<22 weeks: 3.3% vs 0.3%, aOR 2.87, 95%CI 1.45-5.69) were increased compared to those without Turner syndrome. The results of contemporaneous, nationwide assessment in the United States suggests that although pregnancy with Turner syndrome is uncommon this may represent a high-risk group, particularly for intrauterine fetal demise and peri-viable delivery. Establishing society-based approach for preconception counseling and antenatal follow-up would be clinically compelling.

Managing Monoamniotic Twin Pregnancies.

Monoamniotic twins comprise a rare subset of twins at risk of unique and serious complications. In addition to the risks faced by all twins (premature birth, growth restriction), all monochorionic twins (twin-to-twin transfusion syndrome), and all monozygotic twins (congenital anomalies), monoamniotic twins face the unique risk of cord entanglement, in addition to a markedly increased risk of congenital anomalies. Early diagnosis, screening for fetal anomalies and surveillance for twin-twin transfusion syndrome are critical. After fetal viability, frequent fetal monitoring reduces the risk of intrauterine fetal demise.

Idiopathic Polyhydramnios and Pregnancy Outcome: Systematic Review and Meta-analysis

ABSTRACT Amniotic fluid volume (AFV) is examined via ultrasound often several times in pregnancy and can be an indicator of the overall health of a fetus. However, disorders of amniotic fluid can arise without complications for the fetus; excess of amniotic fluid without any accompanying fetal conditions is referred to as idiopathic polyhydramnios. Previous research has shown conflicting results with regard to outcomes related to idiopathic polyhydramnios, with some finding it increases adverse outcomes and others reporting an increase in adverse outcomes only in moderate or severe cases. This study is a systematic review and meta-analysis meant to assess the relationship between idiopathic polyhydramnios and perinatal outcomes for singleton pregnancies. Eligibility criteria included studies that had a control group with normal AFV and defined polyhydramnios as an amniotic fluid index of 24 cm or greater or a single deepest pocket of 8 cm or greater. Similar methods of defining polyhydramnios were considered as long as they were evidence-based. Studies with known causes of polyhydramnios were excluded to ensure cases analyzed for this study were idiopathic. The primary outcome was intrauterine fetal demise, with secondary outcomes of neonatal death, neonatal intensive care unit (NICU) admission, macrosomia, 5-minute Apgar score, malpresentation, and cesarean delivery. Final review and analysis included 12 articles, with a total of 2392 patients with idiopathic polyhydramnios and 160,135 patients with normal AFV. Risk of bias was determined to be low for these studies, although the comparability was not well-defined. Analysis for the primary outcome included 8 of the 12 studies and showed that the risk of intrauterine fetal demise was increased in those with idiopathic polyhydramnios (odds ratio [OR], 7.64; 95% confidence interval [CI], 2.50–23.38). Secondary outcome analysis for neonatal death showed that individuals with polyhydramnios were 8.68 times more likely to experience neonatal death than controls (95% CI, 2.91–25.87). Examining other secondary outcomes, the association between NICU admission and idiopathic polyhydramnios showed that patients with polyhydramnios were more likely to be admitted to the NICU (OR, 1.94; 95% CI, 1.45–2.59). When assessing 5-minute Apgar scores, results showed that individuals with polyhydramnios were more likely to have an Apgar score of less than 7 (OR, 2.21; 95% CI, 1.34–3.62). In addition, rates of cesarean delivery were significantly higher with idiopathic polyhydramnios (OR, 2.31; 95% CI, 1.79–2.99), as was macrosomia (OR, 2.93; 95% CI, 2.39–3.59). Malpresentation was also higher in the polyhydramnios group than in the control group (OR, 2.73; 95% CI, 2.06–3.61). The authors of this meta-analysis conclude that in pregnancies with idiopathic polyhydramnios, there is an elevated risk of both intrauterine fetal demise and neonatal death. In addition, all other negative pregnancy outcomes analyzed were more common in pregnancies affected by idiopathic polyhydramnios. One limitation of this review is the heterogeneity inherent in analyzing many studies with different sample characteristics and different analysis methods. Although efforts were made to reduce bias, there is some inherent bias that cannot be accounted for completely. Further research is needed to fully characterize the clinical implications of the increased risk for adverse pregnancy outcomes shown here. This study also showed an increased risk based on the current clinical threshold for polyhydramnios, but more data are needed on accurate AFV thresholds and the clinical implications stemming from various thresholds.

Adverse pregnancy, delivery and neonatal outcomes across different advanced maternal ages: A population-based retrospective cohort study.

Characterize the risk for adverse pregnancy, delivery and neonatal outcomes among different advanced maternal ages (AMA). We conducted a population-based retrospective cohort study using data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample to characterize adverse pregnancy, delivery and neonatal outcomes among different AMA groups. Patients aged 44-45 (n=19,476), 46-49 (n=7528) and 50-54 years (n=1100) were compared to patients aged 38-43 years (n=499,655). A multivariate logistic regression analysis adjusted for statistically significant confounding variables. With advancing age, rates of chronic hypertension, pregestational diabetes, thyroid disease and multiple gestation increased (p<0.001). The adjusted risk of hysterectomy and need for blood transfusion substantially increased with advancing age, reaching up to an almost 5-fold (aOR, 4.75, 95% CI, 2.76-8.19, p<0.001) and 3-fold (aOR, 3.06, 95% CI, 2.31-4.05, p<0.001) increased risk, respectively, in patients aged 50-54 years. The adjusted risk of maternal death increased 4-fold in patients aged 46-49 years (aOR, 4.03, 95% CI, 1.23-13.17, p=0.021). Adjusted risks of pregnancy-related hypertensive disorders, including gestational hypertension and preeclampsia, increased by 28-93% across advancing age groups (p<0.001). Adjusted neonatal outcomes demonstrated up to a 40% elevated risk of intrauterine fetal demise in patients aged 46-49 years (aOR, 1.40, 95% CI, 1.02-1.92, p=0.04) and a 17% increased risk of having a small for gestational age neonate in patients aged 44-45 years (aOR, 1.17, 95% CI, 1.05-1.31, p=0.004). Pregnancies at AMA are at increased risk for adverse outcomes, particularly for pregnancy-related hypertensive disorders, hysterectomy, blood transfusion, and maternal and fetal mortality. Although comorbidities associated with AMA influence the risk of complications, AMA was demonstrated to be an independent risk factor for major complications, with its impact varying across ages. This data imparts clinicians with the ability to provide more specific counseling to patients of varied AMA. Older patients seeking to conceive must be counseled regarding these risks in order to make well-informed decisions.

Факторы риска антенатальной гибели плода у беременных женщин с отягощенным акушерским анамнезом, перенесших COVID

Objective. To investigate the significance and prognostic value of risk factors for intrauterine fetal demise (IUFD) in women with complicated obstetric history (COH) who had COVID-19 in the second and third trimesters of pregnancy. Patients and methods. A retrospective study of 5027 medical records of pregnant women, postpartum women and neonates who received treatment in obstetric institutions in Almaty with positive PCR results for SARS-CoV-2 in the second and third trimesters of pregnancy was conducted. IUFD occurred in 46 (0.9%) pregnant women. Results. The risk of IUFD increased with prolongation of COVID-19 treatment during pregnancy (OR = 8.673, 95% CI: 4.252-17.692), in the absence of therapy with low-molecular-weight heparin (OR = 4.835, 95% CI: 2.471-9. 459) and was also characteristic of moderate and severe COVID-19 (OR = 4.2667, 95% CI: 1.0603-17.1689), with history of maternal anemia and acute respiratory viral infections (ARVI) (OR = 3.524, 95% CI: 1.643-7.559 and OR = 4.117, 95% CI: 1.881-9.010, respectively). Meanwhile, the absence of antibiotic and corticosteroid therapy was associated with a lower risk of IUFD (OR = 0.415, 95% CI: 0.184-0.937 and OR = 0.278, 95% CI: 0.142-0.547, respectively). Conclusion. The risk of IUFD in pregnant women with COH and COVID-19 during pregnancy increased significantly with the duration of COVID-19 treatment, with moderate and severe course, and with the deficiency of anticoagulant therapy. At the same time, the absence of glucocorticosteroids and antibacterial agents showed a negative association with IUFD. Key words: intrauterine fetal demise, antibiotic therapy, anticoagulants, pregnancy, glucocorticosteroid therapy, COVID-19

Fetal cardiofibroelastosis - a consequence of anti-Ro maternal transfer during pregnancy. Case report and review of the literature

With scarcely any reports published on the association of fetal endocardial fibroelastosis and Ro antibodies maternal transfer during pregnancy, this subject continues to raise concern among health care providers around the world, especially when neonatal lupus syndrome is taken into consideration as the main diagnosis. Fetuses with congenital atrioventricular block have a risk of intrauterine fetal demise and the concern comes from a variety of factors that show significant association between the presence of maternal antibodies to SS-A/Ro during pregnancy and their children serum level of these antibodies. Nevertheless, fetal endocardial fibroelastosis plays an important role in altering ventricular diastolic function and ventricular development in children and neonates. Methods. Medical literature was searched on PubMed and Medline using key words such as fetal endocardial fibroelastosis, anti-Ro antibodies in pregnancy and neonatal lupus syndrome and over 200 articles were taken into consideration, with 17 of them included in the final review. The clinical case included in this paper was referred to the Department of Maternal Fetal Medicine, Filantropia Clinical Hospital in Bucharest, during the second pregnancy after a first pregnancy that resulted in stillbirth with congenital heart block and fibroelastosis as a result of the maternal diagnosis of Sjogren’s syndrome with transplacental transfer of SS-A/Ro antibodies.

Effect of Vitamin D Supplementation on the Cerebral Placental Ratio in Pregnancy Complicated with Early Fetal Growth Restriction.

Fetal growth restriction (FGR) is a complication of pregnancy connected with increased risk of intrauterine fetal demise. To increase the diagnostic accuracy, the cerebral placental ratio (CPR) is used. Vitamin D may play a role in the regulation of vascular flow in the fetus. The aim is to assess the relationship between CPR and vitamin D supplementation in fetuses with early FGR. It is a prospective cohort study. Pregnant females were divided into groups with 2000 IU and <500 IU of vitamin D. Both groups were observed for 14 days; USG was performed three times with one-week intervals. EFW and CPR were measured. Absolute CPR values were initially observed to differ significantly (p = 0.0032). Measurements on the seventh day of observation indicated that CPR was significantly higher (p = 0.0455) in fetuses of patients receiving vitamin D at a dose of 2000 IU 1.75 (IQR: 1.47; 2.06) vs. <500 IU group 1.55 (IQR: 1.04; 1.52). Similarly, on day 14: (p < 0.0001)—2.39 (IQR: 1.82; 2.69) vs. 1.21 (IQR: 0.98; 1.52). Supplementation with vitamin D at a dose of 2000 IU may have an influence on the increase in the CPR in fetuses with early FGR.

ANTENATAL SURVEILLANCE IN HIGH-RISK FETAL CARDIAC DISEASE: FREQUENCY, RESULTS AND RELATIONSHIP WITH SURVIVAL

BACKGROUND Certain congenital heart diseases (CHDs) are associated with a high risk of intrauterine fetal demise (IUFD) and post-natal death, including Ebstein's anomaly, tetralogy of Fallot with absent pulmonary valve and cardiomyopathy. Established obstetric guidelines that recommend frequent antenatal surveillance (AS) of fetal wellbeing in the case of specific maternal and fetal risk factors do not currently include fetuses with high-risk CHD. We sought to establish whether frequent antenatal surveillance could improve fetal outcomes in high-risk fetal CHD and if surveillance results are predictive of outcomes in this setting. We hypothesized that fetuses with high-risk cardiac lesions would benefit from frequent AS and that outcomes would be poorer where surveillance results were abnormal. METHODS AND RESULTS We undertook a single center, retrospective review of 61 pregnancies with high-risk fetal CHD diagnosed from 2006-2020. Data pertaining to frequency and results of AS were collected. AS was conducted using the biophysical profile score, non-stress testing and/or fetal echocardiogram. Where possible, the cardiovascular profile score (CVPS) was calculated retrospectively. Frequent surveillance was defined as at least weekly fetal wellbeing testing commencing by 28-32 weeks gestation, or from later diagnosis, until delivery. Outcome measures included survival and mode of delivery. Chi-square testing, or Fisher's exact where numbers were small, were used to determine statistical significance. Antenatal surveillance results were abnormal in 18% (10/56) of pregnancies carrying a fetus with high-risk CHD. There was a trend toward survival at last follow up when AS results were normal (72%, 33/46) compared to those in which surveillance results were abnormal (40%, 4/10), p 0.07. Where AS results were abnormal, significantly more had emergency caesarean sections for fetal indications (7/10 (70%), vs. 2/46 (4%), p < 0.001). IUFD occurred in 20% (2/10) of cases where AS results were abnormal, compared to 7% (3/46) of cases where surveillance results were normal, p 0.21. Where AS was infrequent, IUFD occurred in 13% (4/30), compared to 3% (1/31) where surveillance was frequent, p=0.20. A final CVPS of ≤7 carried a significantly higher mortality rate (11/21, 52%) than a score of ≥8 (6/31, 19%), p 0.01. CONCLUSION Abnormal AS results and/or a CVPS of ≤7 may identify compromised fetuses with high-risk cardiac lesions who could benefit from altered management or expedited delivery. Given the high rates of abnormal surveillance results in this population, frequent surveillance should be considered. A larger trial is warranted to establish whether this leads to a reduction in fetal demise. Certain congenital heart diseases (CHDs) are associated with a high risk of intrauterine fetal demise (IUFD) and post-natal death, including Ebstein's anomaly, tetralogy of Fallot with absent pulmonary valve and cardiomyopathy. Established obstetric guidelines that recommend frequent antenatal surveillance (AS) of fetal wellbeing in the case of specific maternal and fetal risk factors do not currently include fetuses with high-risk CHD. We sought to establish whether frequent antenatal surveillance could improve fetal outcomes in high-risk fetal CHD and if surveillance results are predictive of outcomes in this setting. We hypothesized that fetuses with high-risk cardiac lesions would benefit from frequent AS and that outcomes would be poorer where surveillance results were abnormal. We undertook a single center, retrospective review of 61 pregnancies with high-risk fetal CHD diagnosed from 2006-2020. Data pertaining to frequency and results of AS were collected. AS was conducted using the biophysical profile score, non-stress testing and/or fetal echocardiogram. Where possible, the cardiovascular profile score (CVPS) was calculated retrospectively. Frequent surveillance was defined as at least weekly fetal wellbeing testing commencing by 28-32 weeks gestation, or from later diagnosis, until delivery. Outcome measures included survival and mode of delivery. Chi-square testing, or Fisher's exact where numbers were small, were used to determine statistical significance. Antenatal surveillance results were abnormal in 18% (10/56) of pregnancies carrying a fetus with high-risk CHD. There was a trend toward survival at last follow up when AS results were normal (72%, 33/46) compared to those in which surveillance results were abnormal (40%, 4/10), p 0.07. Where AS results were abnormal, significantly more had emergency caesarean sections for fetal indications (7/10 (70%), vs. 2/46 (4%), p < 0.001). IUFD occurred in 20% (2/10) of cases where AS results were abnormal, compared to 7% (3/46) of cases where surveillance results were normal, p 0.21. Where AS was infrequent, IUFD occurred in 13% (4/30), compared to 3% (1/31) where surveillance was frequent, p=0.20. A final CVPS of ≤7 carried a significantly higher mortality rate (11/21, 52%) than a score of ≥8 (6/31, 19%), p 0.01. Abnormal AS results and/or a CVPS of ≤7 may identify compromised fetuses with high-risk cardiac lesions who could benefit from altered management or expedited delivery. Given the high rates of abnormal surveillance results in this population, frequent surveillance should be considered. A larger trial is warranted to establish whether this leads to a reduction in fetal demise.

Maternal, fetal and neonatal outcomes of large series of SARS-CoV-2 positive pregnancies in peripartum period: A single-center prospective comparative study

ObjectiveTo describe the proportions of asymptomatic, mild and severe diseases in infected pregnant women admitted for delivery. To compare maternal, fetal and neonatal outcomes of SARS-CoV-2 infected pregnant women with those of non-infected patients. Study designThrough an universal PCR testing for SARS-COV-2 at admission (not symptoms-based), this prospective cohort study enrolled all pregnant women admitted for delivery between 16th of June and the 16th of August 2020 in the West French Guiana Hospital Center. Results507 pregnant women were included during the study period, of which 137 (27 %) were infected with SARS-COV-2. On admission, only 34/137 (24.8 %) of these patients presented with clinical symptoms. Among asymptomatic women, 16 /103 (15 %) became symptomatic after diagnosis. Throughout the delivery hospitalization and follow-up, 87/137 (63.5 %) remained always asymptomatic, 45/137 (32.8 %) developed a mild COVID-19 and 5/137 (3.6 %) developed a severe infection.SARS-CoV-2 infected patients were more likely to have post-partum hemorrhage >500 mL (14.2 % vs 7.2 %, RR 2.0 [95 %CI 1.1–3.4]), to be transfused (5.5 % vs 1.1 %, RR 4.9 [1.5–16.6]), and to be hospitalized in ICU (3.6 % vs 0.8 %, RR 4.5 [95 %CI 1.1−18.6] than uninfected ones. Intra-uterine fetal demises were more common in infected mothers compared to controls (5.1 % vs 1.1 %, RR 4.7 [95 % CI 1.4–45.9).Among 108 neonates from infected mothers tested at birth, none tested positive (0/108). When tested between 25 and 42 h after delivery, 4/29 (13.7 %) were positive for SARS-CoV-2 RT-PCR on nasopharyngeal swabs and remained asymptomatic. ConclusionPregnant women admitted for delivery and diagnosed with a SARS-COV-2 infection through an universal screening were symptomatic in only a quarter of cases. Their risks of post-partum hemorrhage, transfusion and admission to ICU were higher than those of uninfected patients. They also presented a higher risk of intra-uterine fetal demise. There were no other differences in maternal, obstetrical or neonatal outcomes.

Both Low and High PAPP-A Concentrations in the First Trimester of Pregnancy Are Associated with Increased Risk of Delivery before 32 Weeks in Twin Gestation.

In twin gestation, the relationship between pregnancy associated plasma protein (PAPP-A) and perinatal outcome is unclear. The aim of the study was to determine if low and high concentrations of PAPP-A in the first trimester are related to perinatal outcome in twins. A retrospective study was conducted. Medical data of women in twin pregnancies who delivered between 2013 and 2018 were analyzed. PAPP-A concentrations were measured between 10 + 0 and 13 + 6 weeks. The associations between low (<10th percentile) and high (>90th percentile) values of PAPP-A and pregnancy complications were analyzed. A total of 304 patients were included. PAPP-A <10th percentile was associated with a high risk of preterm delivery (OR 6.14; 95% CI 2.1–18), delivery <34 weeks (OR 2.39; 95% CI 1.1–5.1) or <32 weeks (OR3.06; 95% CI 1.4–6.8). Significant relations between PAPP-A >90th percentile and delivery <34 weeks (OR4.09; 95% CI 1.8–9.1) or <32 weeks (OR 2.83; 95% CI 1.2–6.6) were found. PAPP-A >90th percentile was related to high risk of intrauterine fetal demise (OR 10; 95% CI 2.4–42.5). Both low and high PAPP-A concentrations seem to be related to pregnancy outcome. Further research is needed to investigate evaluation of risk of pregnancy complications according to PAPP-A concentrations as a continuous variable.

A Retrospective Cohort Study of Maternal and Fetal Outcomes in Pregnancies Complicated by Acute Pancreatitis [02N

INTRODUCTION: Acute pancreatitis is a rare condition that can be associated with significant complications. In pregnancy, pancreatitis can be linked with poor maternal and fetal outcomes. The objective of this study is to better understand the complications associated with acute pancreatitis (AP) in pregnancy. METHODS: A retrospective cohort study using the Healthcare Cost and Utilization Project – National Inpatient Sample from the United States was performed. All pregnant women admitted with AP were identified using International Classification of Disease-9 coding from 1999 to 2015. The maternal and neonatal outcomes among women diagnosed with AP in pregnancy were compared to women without acute pancreatitis who delivered using multivariate logistic regression adjusting for baseline maternal characteristics. RESULTS: There were 14,258 admissions for AP in pregnancy among 13,815,919 births in our study period for an overall incidence of 10.3 cases per 10,000 births. Women admitted with AP in pregnancy were more likely to require transfusions, OR 2.58 (95% CI 2.32–2.87), develop pre-eclampsia, 3.81 (3.33–4.36), deliver prematurely, 4.27 (3.83–4.77), develop venous thromboembolisms, 3.97 (3.30–4.78), develop acute respiratory failure, 21.99 (19.08–25.34), develop disseminated intravascular coagulation, 7.66 (5.48–10.69), and to suffer from maternal death, 9.15 (6.05–13.85) as compared to women without AP. Acute pancreatitis in pregnancy was also associated with an increased risk of intrauterine fetal demise, 2.60 (1.86–3.62). CONCLUSION: Acute pancreatitis in pregnancy is associated with severe maternal and newborn complications and thus should be managed in tertiary level centers capable of providing with adequate maternal care for this condition as well and appropriate fetal and premature neonatal care.

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

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

837: Large-for-gestational-age as a marker for adverse perinatal outcomes in pregnancy complicated by gestational diabetes mellitus

We sought to examine the strength of large-for-gestational-age (LGA) measuring neonates as a marker for adverse perinatal outcomes associated with poor glycemic control in women with gestational diabetes mellitus (GDM). A retrospective cohort study of 141,670 women in California with singleton, vertex, non-anomalous gestations was performed in order to assess prevalence of adverse perinatal outcomes in GDM with LGA neonates. LGA was defined as birth weight greater than or equal to the 90th percentile for a given gestational age. Maternal outcomes examined included preeclampsia, post-partum hemorrhage (PPH) and chorioamnionitis. Neonatal outcomes examined included respiratory distress syndrome (RDS), hypoglycemia, jaundice and intrauterine fetal demise (IUFD). Confounding variables including pre-gestational diabetes mellitus were controlled for and a p-value of less than 0.05 was considered statistically significant. Overall, LGA gestation in women with GDM was a reliable marker for an increased risk of perinatal complications (Table 1). Statistically significant increased complications included neonatal RDS (2.64% vs 1.77% p=0.001), hypoglycemia (1.06% vs 0.05% p< 0.001), jaundice (21.52% vs 19.18% p=0.003), IUFD (0.49% vs 0.14% p< 0.001), PPH (4.07% vs 2.95% p=0.001) and a decreased risk of chorioamnionitis (1.87% vs 2.68% p=0.014). Most notably, the risk of IUFD (Figure 1) and RDS steadily increase as the size of the fetus increases proportional to gestational age. Maternal complications were less statistically significant in the extremes of LGA. Large-for-gestational-age measurements in women with GDM are reliable markers for adverse perinatal outcomes. Of particular concern is the risks of IUFD and RDS, which decidedly increase with LGA centile greater than 90th. Women should be counseled about these risks and providers prepared to give additional respiratory support to neonates at delivery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Excessively long umbilical cord: a preventive factor of miserable outcomes of pregnancies with true umbilical cord knots

Objective: We examined the clinical significance of pregnancies with true umbilical cord knots related to umbilical cord length.Methods: The material reviewed consisted of the total population of Japanese women who gave birth to singleton babies at 34–41 weeks’ gestation at Japanese Red Cross Katsushika Maternity Hospital between 2002 and 2017.Results: During the study period, there were 32,315 Japanese women who gave birth to singleton babies at 34–41 weeks’ gestation. Of these, true umbilical cord knots were recognized in 209 cases (0.6%). In addition, excessively long umbilical cords were recognized in 98 of the 209 cases (46.9%). On multivariate analysis, true umbilical cord knots were associated with intrauterine fetal demise (adjusted OR 5.65, 95% confidence interval [CI] 1.9–17, p = .02) and excessively long umbilical cord (adjusted OR 8.26, 95% CI 6.0–11, p < .01). The incidence of intrauterine fetal demise in cases with the excessively long umbilical cord (0%) was significantly lower than that without excessively long umbilical cord (4.2%, p = .04), and it was not different measurably from that without true umbilical cord knots (0.3%, p = 1.00).Conclusions: Excessively long umbilical cords may contribute to the decreased risk of intrauterine fetal demise in singleton pregnancies delivered at ≥34 weeks’ gestation.

Antenatal Testing for Women With Preexisting Medical Conditions Using Only the Ultrasonographic Portion of the Biophysical Profile.

To report the utility of the ultrasonographic biophysical profile, which includes all the components of a biophysical profile minus the nonstress test, in women with maternal indications for antepartum surveillance. We conducted a case series reviewing the records of all women at 32 weeks of gestation or greater with at least one indication for antenatal testing (per the American College of Obstetricians and Gynecologists) delivered by a single maternal-fetal medicine practice between 2006 and 2018. Indications included diabetes, hypertension, lupus, antiphospholipid syndrome, sickle cell disease, renal disease, heart disease, hyperthyroidism, isoimmunization, inherited thrombophilia, and prior intrauterine fetal demise. Weekly ultrasonographic biophysical profiles were initiated at 32 weeks of gestation. We calculated the test-positive rate, the percentage of women delivered for an abnormal ultrasonography biophysical profile, and the intrauterine fetal demise rate (false-negative rate). Nine hundred eighty-five women underwent 3,981 ultrasonographic biophysical profiles (four per woman; range 1-11). Sixteen women had an abnormal ultrasonographic biophysical profile, for a test positive rate of 1.6% (95% CI 1.0-2.6%) per woman, or 0.4% (95% CI 0.3-0.7%) per ultrasonographic biophysical profile. Of the 16 women with abnormal ultrasonographic biophysical profiles, 13 were delivered with good outcomes and three women had normal follow-up testing and uncomplicated deliveries at a later date. There were three women with intrauterine fetal demise (false-negative rate of 0.3%, 95% CI 0.1-0.9%). One woman with intrauterine fetal demise had a factor V Leiden mutation, fetal ventriculomegaly, and fetal growth restriction. The second woman with intrauterine fetal demise had advanced maternal age, a factor V Leiden mutation, and fetal growth restriction. The third woman with intrauterine fetal demise had class B diabetes. All three intrauterine fetal demises were diagnosed antepartum with an interval from normal ultrasonographic biophysical profile to intrauterine fetal demise of 7, 7, and 6 days, respectively. The use of ultrasonographic biophysical profile in a high-risk cohort is associated with a very low test-positive rate and a very low incidence of intrauterine fetal demise. In women with preexisting medical conditions that place them at higher risk for intrauterine fetal demise, ultrasonographic biophysical profile can be used for antenatal testing.

Chemotherapy and Optimal Timing of Delivery for Women with Triple Negative Breast Cancer [16D

INTRODUCTION: Data are limited regarding the optimal management of breast malignancy in pregnancy, particularly for the more aggressive subtype of triple negative breast cancer (TNBC). We sought to compare strategies for the management of TNBC and to determine the optimal gestational age for induction in regards to chemotherapy status and maternal-fetal outcomes. METHODS: A decision-analytic model was designed for women with TNBC at 20 weeks electing to continue their pregnancies, comparing 32 different strategies for scheduled delivery between 24-39 weeks gestation, with chemotherapy induction either at 24 weeks or delayed until after delivery. Baseline estimates of stage-specific mortality and the impact of delayed cancer treatment on 5-year survival rates were obtained from the literature. Outcomes factored into the model included the risk of intrauterine fetal demise, spontaneous delivery, respiratory distress syndrome, cerebral palsy, and neonatal demise at each gestational age. RESULTS: For women assigned to antepartum chemotherapy, overall QALYs were maximized with delivery at term, with minimal additional benefit beyond 37 weeks. For women with TNBC deferring chemotherapy until the postpartum period, 5-year survival was maximized by immediate delivery, although maternal QALYs were maximized with delivery at 36 weeks for stage I, 31 weeks for stage II, and 26 weeks for stage III disease. Our model was heavily driven by the baseline probability of maternal death within 5 years, in addition to the expected progression of disease and decrease in survival rates with each week of non-treatment, and remained robust across reasonable ranges for all variables of interest. CONCLUSION: For women with TNBC diagnosed in early pregnancy, initiation of chemotherapy and delivery at 37 weeks should be considered.

Lateral Compression-I Pelvic Ring Injury: Not Benign to the Developing Fetus.

To determine whether certain patterns of pelvic ring injury are associated with more frequent intrauterine fetal demise (IUFD). Retrospective review. Level 1 trauma center. Of 44 pregnant patients with pelvic and/or acetabular fractures, 40 had complete records that allowed determination of fetal viability. χ2 tests were used for categorical variables (Fisher exact tests when expected cell counts were fewer than 5), and t tests were used for continuous variables. Fetal or maternal death. Sixteen patients had isolated acetabular fractures, 25 had isolated pelvic ring injuries, and 3 had acetabular fractures with concomitant pelvic ring injuries. Maternal and fetal mortality were 2% and 40%, respectively. No patients with isolated acetabular fractures experienced IUFD, compared with 68% (15/22) of those with isolated pelvic ring injuries (P < 0.0001). Eight (53%) of 15 IUFDs were associated with lateral compression (LC)-I pelvic ring injuries (Orthopaedic Trauma Association/Arbeitsgemeinschaft für Osteosynthesefragen 61-B2). Of the 13 LC-I pelvic ring injuries, 8 (62%) resulted in IUFD. Pelvic ring stability, Young-Burgess classification, and operative treatment were not associated with IUFD. Maternal Glasgow Coma Scale (average 13.2) and Injury Severity Score (average 18.2) at admission were predictive of IUFD. The most frequent pelvic fractures in gravid trauma patients are LC-I. Although the rate of maternal mortality was low, the risk of IUFD was quite high (40%). LC-I pelvic ring injuries often had catastrophic outcomes, with IUFD in 62% of cases. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Cardiac function and dysfunction in the fetus.

Evaluation of fetal cardiac function is one of the most important components of fetal echocardiography. Fetal cardiac dysfunction is closely linked to risk of intrauterine fetal demise, in many, but not all cases is indicative of worse postnatal prognosis and may prompt the use of medications or interventions to optimize outcomes. There may be implications for termination versus continuation of pregnancy, an indication for early delivery, a change in location and even mode of delivery. In extreme cases, fetal cardiac dysfunction may prompt prenatal or early neonatal listing for cardiac transplantation. There are several important differences between the fetal and postnatal circulatory physiology which affect echocardiographic assessment of cardiac dysfunction. In this review, we examine the echocardiographic findings according to their underlying pathophysiology with reference to common causes.

Risk of donor demise after laser therapy for twin–twin transfusion when complicated by growth discordance and abnormal umbilical artery Doppler findings*

Objective: To investigate the natural course of abnormal umbilical artery Doppler (UAD) findings in donor fetuses after laser surgery and the prognostic significance of resolution, persistence, or new onset UAD abnormalities with and without the presence of preoperative growth discordance.Study design: Retrospective cohort study of all monochorionic-diamniotic multi-fetal gestations diagnosed with twin-twin transfusion syndrome (TTTS) undergoing laser surgery at a single large metropolitan referral center from 2010-2016. The estimated fetal weight was measured preoperatively and the UAD were measured both pre- and postoperatively (median = 8 days). Patients were grouped according to the presence of abnormal UAD with or without growth discordance pre- and postoperatively. Risk ratios (RR) were calculated for each group for risk of intrauterine fetal demise compared to the pre- and postoperative normal UAD groups as the referents.Results: There were eighty-one women who met inclusion criteria throughout the study period. Forty-three (53.1%) patients had abnormal donor twin UAD preoperatively and 33 (40.7%) were diagnosed with growth discordance. However, 13 (44.8%) had normalization of the UAD postoperatively (median = 8 days) with a similar rate of donor fetal demise as the non-discordant preoperative normal UAD group (7.7% versus 10.3%, p = .79). Abnormal preoperative UAD was associated with an increased risk of donor demise (RR 3.6, CI 1.1–12.1), which was further elevated in the presence of growth discordance (RR 5.2, CI 1.7–16.3). The greatest risk for donor demise was seen if the UAD remained abnormal postoperatively with concomitant growth discordance (RR 10.3, CI 2.5–41.6). Conclusions: Preoperative abnormal donor UAD is a significant risk for donor demise post-laser therapy for TTTS. Persistent postoperative abnormal UAD with concomitant growth discordance confers the greatest risk for donor demise. However, resolution of abnormal UAD has a similar rate of donor demise when compared to patients with normal UAD preoperatively.