Singleton Pregnancies Research Articles

Maternal positions in childbirth - A cohort study of labouring women's movements and body positions the last 24hours before birth.

Maternal position plays an essential role in achieving labour progress as it supports the physiological mechanisms of labour. Evidence supports that adopting upright positions may facilitate physiological childbirth. To describe the use of various positionsamong nulliparous pregnant women in the last 24h before birth and describe physical positions in relation to maternal and neonatal outcomes at time of birth. Cohort study of 105 nulliparous women with an uncomplicated singleton pregnancy. Body position was measured by two triaxial accelerometers (SENS motion®), and maternal and neonatal outcomes at time of birth were obtained from medical records. Positions were described for the total population and further stratified into two groups based on time spent in sacrum non-flexible (lying, sitting) and sacrum flexible (standing, walking) positions.Descriptive analyses of maternal position in relation to birth outcomes and comparisons between the two groups were made. Lying down was the mostfrequent position adapted, with a median time of 659 (78;1208) minutes, equivalent to 11.0hours. Women spent 1152 (687;1369) minutes in sacrum non-flexible positions, equivalent to 19.2hours or 80% of the last 24hours before childbirth. More than 90% gave birth in a sacrum non-flexible position. Women spending more time in sacrum non-flexible positions had more epidural analgesia than women spending more time in sacrum flexible positions (42.6% and 21.3%, p=0.03). Women spent 80% of their time in sacrum non-flexible positions during the last 24hours before childbirth. At birth, more than 90% gave birth in sacrum non-flexible positions.

The 36-week preeclampsia risk by the Fetal Medicine Foundation algorithm is associated with fetal compromise following induction of labor.

Previous studies demonstrated that placental dysfunction leads to intrapartum fetal distress, particularly when an abnormal pattern of angiogenic markers is demonstrated at 36 weeks of gestation. Prediction of intrapartum fetal compromise is particularly important in patients undergoing induction of labor due to different indications for delivery, as this can be a useful in optimizing the method and timing of the induction. To examine whether the risk of preeclampsia assessed by the Fetal Medicine Foundation (FMF) algorithm (derived from a combination of maternal risk factors, mean arterial pressure, placental growth factor and soluble fms-like tyrosine kinase-1), associates with the risk of intrapartum fetal compromise requiring cesarean delivery, in a population of singleton pregnancies undergoing labor induction for various indications. Retrospective analysis on prospectively collected data from women with singleton pregnancies undergoing routine assessments at 35+0 to 36+6 weeks of gestation at King's College Hospital (London, UK). The study outcome was the rate of fetal compromise requiring cesarean delivery, examined in relation to the risk of preeclampsia assessed at 36 weeks by the FMF algorithm. Patients undergoing spontaneous labor and prelabor cesarean deliveries were excluded. Five risk categories for preeclampsia were created based on the 36 weeks FMF algorithm: A:˃1/2; B:1/2 -1/5; C: 1/5-1/20; D:1/20-1/50 and E:˂1/50. Based on the reason for induction, we created five categories: premature rupture of membranes; post-term (˃41 weeks), preeclampsia, fetal growth restriction (estimated fetal weight ˂5th centile), preeclampsia and fetal growth restriction. A multinomial logistic regression was used to assess the risk of fetal compromise across the FMF risk categories and accounting for all delivery outcomes (spontaneous or operative vaginal delivery and urgent cesarean delivery for fetal compromise, failure to progress or other reasons), allowing accurate and generalizable risk assessment of fetal compromise. Of 45,375 screened pregnancies, 26,597 (58.6%) had spontaneous onset of labor, 6529 (14.0%) underwent elective pre-labor cesarean delivery, and these were excluded from the analysis; 12,249 were included, of which 182 had a gestational age at birth ≤37 weeks and 1,444 had fetal compromise (crude risk 11.8%). The rate of vaginal delivery in the study population was 69.4%. The rates of fetal compromise in the five induction categories were: 9.7% (premature rupture of membranes), 13.5% (post-term), 14.8% (preeclampsia), 17.2% (fetal growth restriction), and 23.4% (preeclampsia and fetal growth restriction). Cases with vs without intrapartum fetal compromise had higher mean PE risk (1/45 vs. 1/81; p-value < 0.001). The risk of cesarean delivery for fetal compromise increased with: i) advancing gestational age (each week increase at 35-40 weeks: +1%; at 41-42 weeks: +5%); ii) nulliparity +7-10% vs multiparity iii) higher FMF risk of preeclampsia (from the low-risk <1/50 to the high-risk category ≥1/2: +18%; with greater effect for higher preeclampsia risk). In this study population, the rates of fetal compromise were lower with diagnoses of preeclampsia and rupture of membranes and higher with fetal growth restriction (alone or in combination with preeclampsia) and post-term. This study points out the clinically useful association of the 36 weeks FMF risk for preeclampsia with fetal compromise after labor induction. The combination of preeclampsia risk by the 36 weeks FMF method and major delivery indications significantly associates with intrapartum fetal compromise requiring cesarean delivery and may be used to optimize labor induction.

Aeromedical retrieval for suspected preterm labour or rupture of membranes in the Northern Territory, Australia: may some cases be safely not retrieved?

BackgroundSuspected preterm labour (PTL) and prelabour rupture of membranes (PPROM) are common indications for aeromedical retrieval in the Top End, Northern Territory, Australia, where many women reside remotely and preterm birth (< 37 completed weeks of gestation) is common. The primary objective of this study was to determine rate of delivery during the index admission following aeromedical transfers from remote clinics to Royal Darwin Hospital for suspected PTL/PPROM.MethodsA retrospective cohort study of aeromedical transfers for suspected PTL/PPROM from 1 January 2020 to 31 July 2022 was undertaken. Transfers were identified through CareFlight, the regional air ambulance service, and complemented with data from hospital records. Clinical and sociodemographic characteristics were compared by delivery status during the index (post-retrieval) admission using parametric and non-parametric tests and multivariable linear regression analysis.Results238 women with singleton pregnancies were retrieved for suspected PPROM (n = 77, 32.4%) or PTL (n = 161, 67.6%), together accounting for 49.2% of all obstetric transfers (n = 483). Of 77 patients transferred for suspected PPROM, 47 (61.0%) had ruptured membranes confirmed on arrival, and 45 (95.7%) of them delivered during the index admission. None of the 30 women transferred for suspected PPROM with intact membranes on arrival delivered during the index admission. Of 161 patients transferred for suspected PTL, 13 (8.1%) had ruptured membranes confirmed on arrival, and 12 (92.3%) of them delivered during the index admission. Amongst women transferred for suspected PTL with intact membranes confirmed on arrival, 14.9% (22/149) delivered during the index admission. Prior to arrival, 120 women (50.4%) had a documented speculum examination, and 15 (6.3%) and 9 (3.8%) had cervicovaginal swab tests to assess their risks of a PPROM and PTL, respectively. Half of women who did not deliver during the index admission had received antenatal corticosteroids (n = 76).ConclusionsMany aeromedical retrievals for suspected PTL/PPROM did not result in delivery during the index admission. Women retrieved for suspected PPROM with intact membranes on arrival were less likely to deliver. Upskilling remote clinic staff and better point-of-care testing may reduce retrievals and unnecessary interventions. Prospective cohort studies designed to enable accurate prediction of which cases can be safely not retrieved are required.Trial registrationNot applicable.

COMPARISON OF PPH IN INDUCED WITH PROSTAGLANDIN E2 VERSUS SPONTANEOUS LABOUR

Postpartum haemorrhage (PPH) remains a significant obstetric complication, leading to maternal morbidity and mortality. The impact of labour induction on the incidence of PPH compared to spontaneous labour is crucial for guiding clinical practices. Objective: To compare the incidence of postpartum haemorrhage in patients undergoing induced labour versus those experiencing spontaneous labour. Methods: A randomized controlled trial was conducted from April to September 2024 in the Obstetrics and Gynecology Department of DHQ Teaching Hospital, Mirpur AJK. A total of 70 patients with term singleton pregnancies were included, with 35 undergoing spontaneous labour and 35 experiencing labour induction. The incidence of PPH was recorded in both groups. Informed consent was obtained from all participants, and ethical approval was granted by the hospital's ethics committee. Results: Among 35 patients with spontaneous labour, 88.57% (n=31) had normal vaginal deliveries, 11.43% (n=4) underwent cesarean sections, and 8.5% (n=3) experienced PPH. In contrast, of the 35 patients induced into labour, 77.14% (n=27) had normal vaginal deliveries, 22.85% (n=8) underwent cesarean sections, and 31.43% (n=8) experienced PPH. The incidence of PPH was significantly higher in the induced labour group compared to the spontaneous labour group. Conclusion: Labor induction is associated with an increased frequency of postpartum haemorrhage. Induction should be reserved for cases with strong medical indications, and safer methods, such as prostaglandins, should be preferred over artificial rupture of membranes to minimize risks.

Quantitative Cardiotocography and Doppler Ultrasound in the Detection of Hypoxia among Late-onset FGR

The aim of this paper was to evaluate the benefits of combining Doppler measurements of placental/fetal blood vessels with computerized cardiotocography (quantitative cardiotocogrpahy – qCTG) in the detection of fetal hypoxia (pH &lt; 7.20) among late-onset growth restricted (FGR) fetuses. This is a retrospective observational study, including 356 singleton pregnancies diagnosed with late-onset fetal growth restriction (FGR). The trial was undertaken between 2018 and 2021 in Second Municipal Hospital for Obstetrics and Gynecology Sheynovo, which is a tertiary referral facility, located in Sofia, Bulgaria. Women participating in the study underwent serial cardiotocographic and Doppler examinations of umbilical artery (UA), middle cerebral artery (MCA), and ductus venosus (DV). The cerebro-placental ratio (CPR) was also calculated. Analysis of cardiotocographic findings was performed by standard CTG and the “quantitative cardiotocogrpahy” (qCTG) computer algorithm. Relationships between antenatal test results and cord artery pH &lt; 7.20 were analysed using logistic regression. Three hundred and fourteen participants (88.2%) met the inclusion criteria. Logistic regression demonstrated that abnormalities in qCTG readings, CPR and DV Doppler velocimetry were independently correlated with the occurrence of fetal hypoxia (pH &lt; 7.20) in the newborn. The model obtained after elimination of variables that did not prove to be significantly correlated with the dependent variable (UA, P = 0.0882; MCA, P = 0.0592; Standard CTG, P = 0.1738) allowed the identification of neonatal hypoxia with 86.1% sensitivity and 79.5% specificity (AUC = 0.835, P &lt;0.0001). Furthermore, according to the equation derived from this final regression model, the probability of fetal hypoxia varies between a minimum of 6%, when none of the significant risk factors (DV, CPR and qCTG) are seen, to a maximum of 97% when all of them are being manifested. This is the first study to incorporate qCTG in fetal assessment of late-onset growth restriction. It demonstrates that unlike standard cardiotocography, qCTG alone correlates strongly with hypoxia (pH &lt; 7.20) at birth. We are proposing a new diagnostic algorithm, called QDSP Protocol (Quantitative cardiotocography and Doppler Surveillance of Pregnancy), based on the combined use of qCTG, CPR and DV Doppler, which seems to be more accurate in the detection of hypoxia (pH &lt; 7.20) in late-onset FGR, compared to listed Doppler modalities and standard CTG. The implementation of QDSP Protocol in clinical practice has the potential to reduce the number of unnecessary operative deliveries and lower the morbidity/mortality rates in late-onset FGR fetuses, although further prospective studies are needed to support these assumptions.

Assessment of Placental Antioxidant Defense Markers in Vaccinated and Unvaccinated COVID-19 Third-Trimester Pregnancies.

Pregnancy has been identified as a risk factor for severe COVID-19, leading to maternal and neonatal complications. The safety and effects of the SARS-CoV-2 vaccination during pregnancy, particularly on placental function and oxidative stress (OxS), remain underexplored. We investigated the impact of vaccination on third-trimester placental antioxidant defense markers. Ninety full-term pregnant women were divided into the following groups: vaccinated (n = 27) and unvaccinated (n = 25) COVID-19-positive pregnant women; control subgroups were composed of vaccinated (n = 19) or unvaccinated (n = 19) COVID-19-negative women with a healthy term singleton pregnancy with no signs of COVID-19. Placental samples were collected after delivery. Lipid peroxidation (TBARS), gene expression of HIF-1α, and catalase (CAT), superoxide dismutase-1 (SOD1) and CAT-SOD1 enzymatic activity were measured. COVID-19-positive placentae exhibited significantly higher TBARS and HIF-1α levels compared to controls, regardless of vaccination status. Vaccination significantly increased placental CAT and SOD1 expression and activity in COVID-19-positive women, suggesting enhanced antioxidant defense. Unvaccinated women showed a higher incidence of COVID-19 symptoms and lower antioxidant enzyme activity. SARS-CoV-2 infection induced placental OxS, which is countered by a placental adaptive antioxidant response. Vaccination during pregnancy enhances placental defense, further supporting the safety and benefits of COVID-19 vaccination in preventing complications and protecting fetal development.

Assessing the Agreement Between Diffusion Tension Imaging (DTI) and T2-Weighted MRI Sequence for Biometry of the Fetal Corpus Callosum.

Little is known about the advantages of Diffusion Tensor Imaging (DTI) when evaluating the fetal corpus callosum (CC), a sensitive indicator for normal brain development. This study evaluates the contribution of DTI compared to T2-weighted imaging to assess fetal CC biometry. Data from the fetal MRI exams of singleton pregnancies between July 2017 and 2019 were retrospectively analyzed. Mid-sagittal sections were used to measure the CC biometry, and inter- and intra-observer agreements were assessed using the interclass correlation coefficient (ICC), targeting an ICC above 0.85. The results from 100 patients (mean gestational age, 32.24 weeks) indicated excellent inter-observer reliability for DTI (ICC = 0.904, 95% CI = 0.815-0.952) and moderate agreement for T2-weighted imaging (ICC = 0.719, 95% CI = 0.556-0.842). Intra-observer assessments showed excellent reliability for both DTI and T2-weighted imaging (ICC = 0.967, 95% CI = 0.933-0.984 and ICC = 0.942, 95% CI = 0.884-0.971, respectively). However, a comparison between DTI and T2-weighted images for CC biometry showed poor agreement (ICC = 0.290, 95% CI = 0.071-0.476). In conclusion, the study highlights a lack of agreement between DTI and T2-weighted imaging in fetal CC biometry, suggesting the need for further research to understand this discrepancy and the role of DTI in fetal health.

Cost-effectiveness of a randomized controlled trial comparing low-dose aspirin to placebo for the prevention of recurrent preterm birth.

To assess the cost-effectiveness of low-dose aspirin compared to placebo for the prevention of recurrent preterm birth from a healthcare perspective. This was a cost-effectiveness analysis alongside a multicenter, randomized, double-blinded, placebo-controlled trial. We included women with a singleton pregnancy and a previous spontaneous preterm birth <37 weeks of gestation of a singleton. Women were randomized between aspirin 80 mg daily and placebo, initiated between 8 and 16 weeks of gestation. We estimated the difference in preterm births (<37 weeks of gestation), and maternal and neonatal healthcare costs using seemingly unrelated linear regression analyses. Bootstrapping was performed to estimate statistical uncertainty. A total of 387 women were included: 194 in the aspirin group and 193 in the placebo group. We observed a small, statistically non-significant difference in preterm birth (21.2% vs. 25.4%; risk difference -4.3%; 95% CI: -12.7% to 4.1%) and healthcare costs (mean -€99; 95% CI: -€2385 to €2325) in the aspirin group compared to placebo. The cost-effectiveness acceptability curve showed that the probability of aspirin being cost-effective was 54% for a willingness to pay threshold of €0 for one prevented preterm birth and 78% for €50 000 for one prevented preterm birth. Our findings suggest that aspirin is the dominant strategy over placebo for the prevention of preterm birth. However, there was substantial uncertainty around the results and definite conclusions regarding the cost-effectiveness of aspirin cannot be drawn.

Fetal Growth Associated with Maternal Rheumatoid Arthritis and Juvenile Idiopathic Arthritis.

Introduction: Patients with rheumatoid arthritis (RA) and juvenile idiopathic arthritis (JIA) are at a twice-higher risk of developing adverse pregnancy outcomes, such as preterm births and infants with a low birth weight. We aimed to evaluate fetal growth among patients with and without rheumatoid arthritis and juvenile idiopathic arthritis (RA and JIA). Materials and Methods: We conducted a population-based cohort study in Denmark from 2008-2018, which included 503,491 singleton pregnancies. Among them, 2206 were pregnancies of patients with RA and JIA. We linked several nationwide databases and clinical registries in Denmark to achieve our aim. First, we used the International Classification of Diseases-10 codes to identify pregnant patients with RA and JIA from the National Patient Registry. Next, we obtained fetal biometric measurements gathered from second-trimester fetal ultrasound scans and birthweights through the Fetal Medicine Database. Finally, we computed a fetal growth gradient between the second trimester and birth, using the mean difference in the Z-score distances for each fetal growth indicator. We also calculated the risk of small for gestational age (SGA). All outcomes were compared between pregnant individuals with and without RA and JIA, adjusted for confounders. Results: Maternal RA and JIA were not associated with a reduction in the estimated fetal weight (EFW) at 18 to 22 weeks of gestational age [adjusted mean EFW Z-score difference of 0.05 (95% CI 0.01, 0.10)]. We observed reduced mean Z-score differences in the weight gradient from the second trimester to birth among offspring of patients with RA and JIA who used corticosteroids [-0.26 (95% CI -0.11, -0.41)] or sulfasalazine [-0.61 (95% CI -0.45, -0.77)] during pregnancy. Maternal RA and JIA were also associated with SGA [aOR of 1.47 (95% CI 1.16, 1.83)] and the risk estimates were higher among corticosteroid [aOR 3.44 (95% CI 2.14, 5.25)] or sulfasalazine [(aOR 2.28 (95% CI 1.22, 3.88)] users. Conclusions: Among pregnant patients with RA and JIA, fetal growth restriction seemed to occur after 18 to 22 weeks of gestational age. The second half of pregnancy may be a vulnerable period for optimal fetal growth in this population.

The impact of caregiver and intended mode of birth on the public cost of care: Cost analysis of maternity and neonatal care in New Zealand

ProblemWomen who receive midwifery continuity-of-care require fewer interventions, generating significant cost savings for health services. Existing cost models were based on studies including low-risk pregnancies, limiting generalisability. BackgroundNew Zealand (NZ) is the only high-income country with a fully integrated midwifery continuity of care model facilitating study of real-world costs by model of care. AimTo compare healthcare utilisation and pregnancy-related public healthcare cost for private obstetricians and other community maternity caregivers (GPs, midwives), and planned caesarean compared to intended vaginal birth, within the NZ continuity-of-care maternity system. MethodsPopulation-based cohort study including singleton pregnancies under private obstetrician and community maternity care with live birth January 2016 - June 2020. Administrative data were used to identify healthcare utilisation and associated cost for mothers and their infant(s) until 1 year post birth, using generalised linear model techniques. Findings248,424 singleton pregnancies were included. Adjusted mean costs were significantly higher for private obstetricians than community maternity caregivers (mostly midwives) ($1,096, 95 % CI $813 – 1,378). Elective caesarean section was more costly than intended vaginal birth ($4,316, 95 % CI $4,105 – 4,527). Within each intended mode of birth, pregnancies cared for by private obstetricians were more costly than community maternity caregivers. DiscussionConsistent with existing literature, continuity of care by independently practicing midwives was less costly in NZ after adjustment for demographic and clinical differences. ConclusionsFunding structures and population pregnancy risk profile are important considerations in the implementation of midwifery-led continuity of care models. Statement of significanceProblem: Health systems seek to improve maternity care and contain healthcare budgets.What is already known: Women cared for by continuity-of-care midwives experience lower rates of preterm birth, obstetric intervention, and improved satisfaction compared to other models of care. It has been reported as cost-effective in a clinical trial setting among low-risk women.What this paper adds: This study uses real-world data from New Zealand, the only country with fully integrated midwifery continuity-of-care, to establish that midwifery care is cost-saving for public healthcare systems compared to maternity care provided by private obstetricians, when adjusted for obstetric risk factors.

Maternal Undernutrition Effect on Pregnancy-Associated Glycoprotein (PAG) Concentration in Sheep Carrying Single and Multiple Fetuses.

To the best of our knowledge, no studies in the literature have reported on the relationship between the pregnancy-associated glycoprotein (PAG) concentration and undernutrition during pregnancy in sheep. Therefore, the aim of this study was to investigate the effects of undernutrition on the blood concentration of PAGs in pregnant ewes carrying single and multiple fetuses, undergoing either dietary energy restriction or receiving 100% of their energy requirements during the period of maximal placenta growth. From d 24 to 100 of pregnancy, the ewes were fed ryegrass hay and two different iso-proteic concentrates, fulfilling either 100% of the ewes' energy requirements (control group; n = 30, 14 singleton pregnancies, 16 multiple pregnancies) or only 50% (feed-restricted group; n = 29; 11 singleton pregnancies, 18 multiple pregnancies). Blood samples were collected from all the ewes the day before intravaginal sponge insertion (T0) and, thereafter, every 30 days starting from d 24 of gestation (T1) until d 30 after parturition (T6), to determine the PAG, progesterone, NEFA, total protein, and glucose concentrations. Our results showed that PAG concentrations are not only influenced by the number of fetuses, but also by the ewe's diet. In particular, the PAG marginal means were higher in the feed-restricted group than in the control group (7.8 ± 0.6 and 10.8 ± 0.9 ng/mL for the control and feed-restricted groups, respectively; p = 0.040). This finding confirms that a dietary restriction between d 24 and d 100 of gestation leads to a growth in placental functions as inferred from the increase in the concentration of the PAG levels. Therefore, the measurement of PAG concentrations, in addition to serving as a marker of pregnancy, can also serve as a marker of placental functionality.

Dihydroartemisinin-piperaquine versus sulfadoxine-pyrimethamine for intermittent preventive treatment of malaria in pregnancy: a systematic review and individual participant data meta-analysis.

High-grade Plasmodium falciparum resistance to sulfadoxine-pyrimethamine in East and Southern Africa has prompted numerous trials evaluating intermittent preventive treatment in pregnancy (IPTp) with dihydroartemisinin-piperaquine as an alternative to sulfadoxine-pyrimethamine. We conducted individual participant data meta-analyses of randomised trials comparing IPTp with dihydroartemisinin-piperaquine to sulfadoxine-pyrimethamine on maternal, birth, and infant outcomes. We searched the WHO International Clinical Trials Registry Platform, ClinicalTrials.Gov, PubMed, and the Malaria in Pregnancy Consortium Library. Eligible trials enrolled HIV-uninfected pregnant women, followed participants to delivery, included participants with no prior IPTp use during the current pregnancy, and were conducted in areas with high-level parasite resistance to sulfadoxine-pyrimethamine (i.e., PfDHPS 540E≥90% and/or 581G>0%). Only singleton pregnancies were analysed. Meta-analyses used a two-stage approach: first, study-specific estimates were generated and then pooled using a random-effects model. Gravidity subgroup analyses were performed. Causal mediation analyses were used to investigate the maternal mechanisms underlying the effect of IPTp regimens on birth outcomes. The meta-analysis is registered in PROSPERO (CRD42020196127). Of 85 screened records, six trials (one multi-country trial) contributed data on 6646 pregnancies. Compared to sulfadoxine-pyrimethamine, dihydroarteminsinin-piperaquine was associated with a 69% [95% CI: 45%-82%] lower incidence of clinical malaria during pregnancy, a 62% [37%-77%] lower risk of placental parasitaemia, and a 17% [0%-31%] lower incidence of moderate maternal anaemia (Hb<9 g/dL). In contrast, sulfadoxine-pyrimethamine was associated with higher mean weekly maternal weight gain (34 grams/week [17-51]). There were no statistically significant differences in the composite adverse pregnancy outcome between the two IPTp regimens (RR=1·05 [95% CI: 0·92-1·19]; I 2=48%), although the risk of small-for-gestational-age was 15% [3%-24%] lower in the sulfadoxine-pyrimethamine arm. Among multigravidae, participants of the sulfadoxine-pyrimethamine arm were 20% [8%-30%] and 35% [17%-49%] less likely to have stunted and underweight infants by two months compared to the dihydroartemisinin-piperaquine arm. Infant wasting by two months was 13% [3%-22%] lower in the sulfadoxine-pyrimethamine arm, regardless of gravidity. Mediation analyses indicated that 15% [0%-19%] of sulfadoxine-pyrimethamine's superior effect on reducing small-for-gestational-age risk was mediated by its greater impact on gestational weight gain. In areas of high P. falciparum sulfadoxine-pyrimethamine resistance, dihydroartemisin-inpiperaquine is a more efficacious antimalarial than sulfadoxine-pyrimethamine. However, replacing sulfadoxine-pyrimethamine with dihydroartemisinin-piperaquine alone will not result in better maternal, birth, or infant outcomes. It could increase the risk of SGA, since much of the effect of sulfadoxine-pyrimethamine may be exerted through non-malarial mechanisms. Future research evaluating the alternative strategies for IPTp are needed, including with the combination of sulfadoxine-pyrimethamine and dihydroartemisinin-piperaquine. This work was supported by the Bill and Melinda Gates Foundation and Eunice Kennedy Shriver National Institute of Child Health and Human Development.

The value of ultrasound spectra of middle cerebral artery and umbilical artery blood flow in adverse pregnancy outcomes.

To evaluate the diagnostic value of ultrasound spectra of the middle cerebral artery (MCA) and umbilical artery (UA) blood flow in predicting adverse pregnancy outcomes. Data from 202 late singleton pregnancies (32-34weeks gestation) were analyzed. Group A included 155 normal pregnancies, while Group B comprised 47 high-risk pregnancies. Color Doppler ultrasonography was used to measure and compare pulsatility index (PI), resistance index (RI), and end-systolic peak/end-diastolic peak (S/D) ratios of fetal MCA and UA between the groups. UA-related parameters (PI, RI, and S/D) were significantly higher in Group B compared to Group A, whereas MCA-related parameters (PI, RI, and S/D) were significantly lower in Group B than in Group A. In pregnancies with adverse outcomes, fetal UtA and UA-related parameters were elevated, while MCA parameters were decreased compared to those with favorable outcomes. Ultrasound spectra of MCA and UA blood flow provide valuable clinical information for assessing fetal intrauterine growth and predicting adverse pregnancy outcomes.

A novel approach for the early prediction and prevention of placenta accreta spectrum and severe peripartum hemorrhage in patients with complete placenta previa: leveraging three-dimensional placental topography, cervical length, and dilatation parameters on magnetic resonance imaging

BackgroundTo evaluate the reliability of placental volume and other magnetic resonance imaging (MRI) markers for predicting placenta accreta spectrum and severe peripartum hemorrhage in patients with complete placenta previa.MethodsThis single-center retrospective cohort study was conducted at a tertiary care facility and included 216 pregnant women diagnosed with complete placenta previa. Two radiologists, blinded to each other’s assessments, independently evaluated the prenatal placental magnetic resonance imaging (pMRI) findings of 150 singleton pregnancies that met the inclusion criteria and were delivered in the third trimester. The three-dimensional placental volume (from the S1 and S2 sectors), cervical canal length (CCL), and degree of cervical canal dilatation (CCD) were compared with clinical and pathological findings. Univariate and multivariate logistic regression analyses identified risk factors for placenta accreta spectrum (PAS) and severe peripartum hemorrhage (SPPH). Receiver operating characteristic (ROC) curve analysis determined the cutoff values of significant predictors.ResultsUnivariate analysis revealed significant risk factors for PAS, including decreased cervical canal length (odds ratio [OR] = 1.330, p < 0.001), increased cervical canal dilation (OR = 1.869, p < 0.001), decreased S1 volume (OR = 1.008, p < 0.001), and increased S2 volume (OR = 1.008, p < 0.001). Multivariate analysis confirmed that cervical canal length was an independent risk factor (odds ratio [OR] = 1.253, p = 0.03). Significant predictors of severe peripartum hemorrhage included decreased cervical canal length (odds ratio [OR] = 0.406, p = 0.006), increased cervical canal dilatation (OR = 3.22, p < 0.001), decreased S1 volume (OR = 1.079, p = 0.017), and increased S2 volume (OR = 1.032, p < 0.001), all of which were confirmed as independent risk factors. ROC analysis demonstrated high precision for MRI markers, with area under the curve values above 0.8 for critical predictors of PAS and severe peripartum hemorrhage, confirming their reliability (all p < 0.001).ConclusionThis study emphasizes the pivotal role of three-dimensional placental volume measurements in the S1 and S2 sectors, along with cervical canal length and dilation, in predicting PAS and severe peripartum hemorrhage in patients with complete placenta previa. Integrating these advanced MRI markers into prenatal care can enhance early detection, improve clinical decision-making, and ultimately improve maternal and fetal outcomes.

Complications of Induction of Labour with Foley's Catheter in Patients with a Previous Cesarean Section

Background: Management of IUFD has immense significance in today’s obstetric practice. To summarize, dinoprostone gel, misoprostol and intra cervical catheter can be used for induction of labour in second and third trimester IUFD. Mechanical methods, i.e. the use of Foley’s catheter balloon, though effective have not gained much popularity because of the fear of infection. Objective: To observed the complications of induction of labor with Foley's catheter in patients with a previous cesarean section. Materials and Methods: The observational study was carried out in the Department of Obstetrics &amp; Gynecology, Dhaka Medical College Hospital. Dhaka, Bangladesh. Total 52 patients with singleton pregnancy with IUFD, at ≥28 weeks of gestation was attending in the Department of Obstetrics &amp; Gynae were included in this study. Details of history, general physical and systemic examination, ultrasonography, basic laboratory investigations like haemoglobin level, and DIC profile were recorded. Results: Forty three (82.7%) received augmentation with oxytocin, 3(5.8%) developed scar tenderness and 8(15.4%) had failed induction. Failed ICC was found 8 cases, among them 5(62.5%) had dinoprostone gel used followed by vaginal birth, 2(25.0%) had LUCS and 1(12.5%) had laparotomy. Induction delivery interval was found 16.3±5.5 hours. Regarding maternal outcome 49(94.2%) patients had normal vaginal delivery, 4(7.7%) had PPH, 3(5.8%) had fever, 2(3.8%) were ICU admission, 1(1.9%) had laparotomy and 1(1.9%) had rupture uterus. Conclusion: Common maternal complications were PPH, fever, ICU admission, laparotomy and rupture uterus. Induction can be done safely in carefully selected cases of previous LSCS with Foley’s Balloon.

Maternal Morbidity Associated with Early Preterm Birth in Low-Risk Singleton Pregnancies.

Background/Objectives: While neonatal morbidities associated with early preterm birth are known, the risks of maternal morbidities in these births remain unclear. Thus, we set out to assess the risk of maternal morbidities associated with early preterm births. Methods: Retrospective cohort study utilizing the United States (US) Natality Live Birth database from the Centers for Disease Control and Prevention (2016-2021). Low-risk singleton pregnancies were included. High-risk conditions such as out-of-hospital births, fetal anomalies, pregestational and gestational diabetes, and hypertensive disorders of pregnancy were excluded. The rates of several maternal morbidities were compared among three gestational age at birth groups: 23 0/7-27 6/7 (i.e., extreme preterm), 28 0/7-33 6/7 (i.e., early preterm), and 37 0/7-41 6/7 (i.e., term, reference group) weeks. Multivariable logistic regression was used to adjust outcomes for potential confounders. Data were presented as adjusted odds ratios (aORs) with a 95% confidence interval (CI). Results: 18,797,394 live births were analyzed. Extreme and early preterm birth were associated with increased odds of maternal transfusion (aOR 3.32, 95% CI 3.13-3.53 and aOR 2.96, 95% CI 2.86-3.07), uterine rupture (aOR 3.75, 95% CI 3.14-4.48 and aOR 4.13, 95% CI 3.76-4.54), unplanned hysterectomy (aOR 5.60, 95% CI 4.85-6.48 and aOR 5.92, 95% CI 5.47-6.40), and maternal admission to the intensive care unit (ICU, aOR 10.58, 95% CI 9.97-11.54 and aOR 10.13, 95% CI 9.77-10.50) compared to term birth. The odds of third- or fourth-degree perineal lacerations were decreased in both preterm birth groups compared to term birth. Conclusions: In addition to the known prematurity-related neonatal morbidities, extreme and early preterm births also impose a risk for maternal morbidities. Higher odds of maternal transfusion, uterine rupture, unplanned hysterectomy, and maternal admission to the ICU were detected in our cohort. These data should be taken into consideration when caring for patients with preterm births.

Continuous Risk Assessment of Late and Term Preeclampsia Throughout Pregnancy: A Retrospective Cohort Study.

Background and Objectives: To evaluate the diagnostic accuracy of widely available biomarkers longitudinally measured throughout pregnancy to predict all and term (delivery at ≥37 weeks) preeclampsia (PE). Materials and Methods: This is a longitudinal retrospective study performed at Hospital Universitario de Torrejón (Madrid, Spain) and Shterev Hospital (Sofia, Bulgaria) between August 2017 and December 2022. All pregnant women with singleton pregnancies and non-malformed live fetuses attending their routine ultrasound examination and first-trimester screening for preterm PE at 11 + 0 to 13 + 6 weeks' gestation at the participating centers were invited to participate in a larger study for the prediction of pregnancy complications. The dataset was divided into two subsets to develop and validate a joint model of time-to-event outcome and longitudinal data, and to evaluate how the area under the receiving operating characteristic curve (AUROC) evolved with time. Results: 4056 pregnancies were included in the training set (59 all PE, 40 term PE) and 944 in the validation set (23 all PE, 20 term PE). For the joint model and all PE, the AUROC was 0.84 (95% CI 0.73 to 0.94) and the detection rate (DR) for a 10% screening positive rate (SPR) was 56.5 (95% CI 34.5 to 76.8). For term PE, AUROC was 0.80 (95% CI 0.69 to 0.91), and DR for a 10% SPR was 55.0 (95% CI 31.5 to 76.9). The AUROC using only information from the first trimester was 0.50 (95% CI 0.37 to 0.64) and it increased to 0.84 (0.73 to 0.94) when using all information available. Conclusions: Routinely measuring MAP and UtA-PI throughout pregnancy may improve the predictive prediction power for all and term-PE.

Optimal timing for induction of labor in normotensive women: A retrospective cohort study.

Labor induction is offered to reduce the risk of stillbirth at late term (41+0 to 41+6) but earlier induction in normotensive singleton pregnancies is supported by weak evidence. The aim of the present study was to investigate the optimal timing for induction in normotensive women. This was a retrospective cohort study including 70 293 singleton term births in Iceland during 1997-2018. Women with serious pre-gestational comorbidity, hypertension, stillbirth or previous cesarean birth were excluded. The risk of adverse maternal and neonatal outcomes for induction at each week from gestational age 37-41 weeks was compared with expectant management, defined as deliveries at a later gestational age. Risk ratios (RRs) and 95% confidence intervals (95% CI) were calculated using log-binomial regression adjusting for sociodemographics, parity, and pregnancy complications. The risk of cesarean was lower with induction at ≥40+0 than expectant management, especially at late term (RR 0.73, 95% CI: 0.63-0.83). Respiratory distress was diagnosed in 4.4% of infants after induction from 37+0 to 37+6 but 1.3% in the expectant management group (RR 3.08, 95% CI: 1.97-4.81). Induction between 37+0 and 38+6 compared with expectant management was associated with a reduced risk of shoulder dystocia, but this was non-significant in births of infants with normal birthweight. Labor induction from 40+0 compared with expectant management was associated with reduced risk of cesarean birth in Icelandic women without an increase in risk of adverse maternal or neonatal outcomes. No additional benefit appeared to be from inducing at earlier gestations in low-risk pregnancies.

MRI of Caval Compression During Left-Lateral Tilt in Singleton and Twin Pregnancies

(Eur J Anaesthesiol. 2024;41:122–128. doi:10.1097/EJA.0000000000001937) Women with twin pregnancies often undergo cesarean delivery (CD) and have a higher chance of supine hypotension than women with singleton pregnancies, due to the increase in aortocaval compression by a larger gravid uterus. It is usually recommended to use at least 15 degrees left pelvic tilt during CD to avoid aortocaval compression. However, this optimal left-lateral tilt angle practice has recently been questioned, especially for women pregnant with twins.

Obstetric and neonatal outcomes in the management of twin pregnancies with gestational diabetes using the IADPSG criteria for singleton pregnancies

BackgroundThis study evaluates the effectiveness of the International Association of Diabetes and Pregnancy Study Groups (IADPSG) criteria, typically applied to singleton pregnancies, in managing gestational diabetes mellitus (GDM) in twin pregnancies. Focusing on a Chinese cohort, it contrasts the clinical outcomes and complications in twin pregnancies with and without GDM.MethodsWe conducted a retrospective cohort study at our hospital from January 2019 to December 2021, including all twin deliveries except those before 28 weeks of gestation, with prior diabetes, or unknown GDM status. GDM was diagnosed using a 75 g oral glucose tolerance test based on the IADPSG criteria, and management involved dietary or insulin interventions. We assessed outcomes such as hypertensive disorders (gestational hypertension, preeclampsia, and eclampsia), membrane rupture, preterm birth, small for gestational age (SGA), large for gestational age (LGA), and neonatal intensive care unit (NICU) admissions.ResultsAmong 1003 twin pregnancies, 21.7% had GDM, with 11.5% receiving insulin. GDM was associated with older maternal age, higher BMI, and a family history of diabetes. Pregnant women with GDM had lower weekly weight gain (0.44 kg/week vs. 0.58 kg/week, p < 0.001) and experienced a higher risk of SGA neonates (aOR = 1.68, 95% CI: 1.06–2.67) and increased NICU admissions (aOR = 1.30, 95% CI: 1.00-1.69) compared to those without GDM. Additionally, dichorionic twins with GDM showed higher risks of SGA and NICU admissions, while monochorionic twins had no significant differences. A U-shaped relationship was identified between weekly weight gain and the rates of SGA and NICU admissions, with the lowest risk observed at a weekly weight gain of 0.75 kg for SGA and 0.57 kg for NICU admissions.ConclusionsApplying singleton-derived IADPSG criteria to twin pregnancies may mitigate some maternal risks but elevates the risk for SGA neonates, suggesting a need for tailored diagnostic and management strategies for twin pregnancies.Trial registrationRetrospectively registered.