Pregnancy Surveillance Research Articles

Comparison of determinants of morbidities of late preterms and terms

Background: To compare the determinants of neonatal morbidity in late preterms and terms.Methods: A total of 100 live late preterm (34-0/7 to 36-6/7 weeks) and 100 term infants (37-0/7 to 41-6/7 weeks) admitted in sri guru ram das institute of medical sciences and research were randomly selected to participate in this case control study. The study group include 100 neonates within gestation age of 34 0/7 to 36 6/7 weeks. Equal number of terms between 37 0/7 to 41-6/7 gestation age was taken for comparison. The maternal history including both antenatal and natal history as well as new-born profile was taken.Results: Maternal risk factors have been found to be the major determinants of morbidity in late preterms with PROM (p<0.0001), sepsis and hypertension being significant contributors. Respiratory distress, neonatal jaundice, sepsis has been found to be major morbidity factors in late preterms. The average duration of admission was higher in late preterms than terms.Conclusions: Late preterm infants have higher risks for acute metabolic complications, mortality and long-term disabilities as compared to term infants. Morbidities like respiratory distress, neonatal jaundice, sepsis, hypoglycaemia and hypothermia are more in late preterms due to their immaturity. The risks associated with late preterm birth suggest the need for refinement of obstetric paradigms to extend pregnancy duration if benefits outweigh risk to fetus and mother. There is need to make obstetricians and families aware of complications pertaining to late preterm birth and improving surveillance of high-risk pregnancies.

Minimally interactive placenta segmentation from three-dimensional ultrasound images.

Purpose: Placental size in early pregnancy has been associated with important clinical outcomes, including fetal growth. However, extraction of placental size from three-dimensional ultrasound (3DUS) requires time-consuming interactive segmentation methods and is prone to user variability. We propose a semiautomated segmentation technique that requires minimal user input to robustly measure placental volume from 3DUS images. Approach: For semiautomated segmentation, a single, central 2D slice was manually annotated to initialize an automated multi-atlas label fusion (MALF) algorithm. The dataset consisted of 47 3DUS volumes obtained at 11 to 14 weeks in singleton pregnancies (28 anterior and 19 posterior). Twenty-six of these subjects were imaged twice within the same session. Dice overlap and surface distance were used to quantify the automated segmentation accuracy compared to expert manual segmentations. The mean placental volume measurements obtained by our method and VOCAL (virtual organ computer-aided analysis), a leading commercial semiautomated method, were compared to the manual reference set. The test-retest reliability was also assessed. Results: The overlap between our automated segmentation and manual (mean Dice: , median: 0.831) was within the range reported by other methods requiring extensive manual input. The average surface distance was . The correlation coefficient between test-retest volumes was , and the intraclass correlation was . Conclusions: MALF is a promising method that can allow accurate and reliable segmentation of the placenta with minimal user interaction. Further refinement of this technique may allow for placental biometry to be incorporated into clinical pregnancy surveillance.

Diagnostic equivalency of mobile CTG devices and remote analysis to conventional on-site nonstress test.

Remote pregnancy monitoring is one of the most promising applications of telemedicine; however, the diagnostic value of self-examination using mobile cardiotocography (CTG) devices and remote analysis of the subsequent results has never been properly studied. The study aimed to compare the diagnostic usefulness of CTG self-examination using a mobile device to examination performed by a medical professional using a stationary device; and to evaluate the quality of CTG analysis performed remotely. Eighty-two pairs of CTG recordings were collected; each pair consisted of a single recording from an examination performed by a midwife using a stationary device, and another recording from an unassisted patient self-examination using a mobile device. Recordings were performed with a maximum time interval of 30 min. Each recording was analyzed twice. Primary analysis included a comparison of the assisted examination evaluated on-site vs the self-examination evaluated remotely in pairs. Secondary analysis was conducted by an independent expert who evaluated the unpaired recordings. Baseline fetal heart rate (BFHR) values were compared independently. We found that patients were more likely to perform inconclusive recordings than experienced midwives; however, the self-examination feasibility was satisfactory. The primary analysis showed 88.4% agreement of the recorded pairs; 11.6% of inconsistent pairs were due to inter-observer variability or medical reasons. The independent expert's analysis showed 97.1% agreement between the assisted and unassisted examinations. Paired t-test for BFHR values showed a statistically significant but clinically negligible mean difference between the 2 devices at 1.75 bpm. The CTG examinations performed using mobile devices present satisfactory feasibility and equivalent diagnostic value compared to conventional devices, while the remote evaluation of recordings is as reliable as on-site analysis. Remote pregnancy surveillance is safe, effective and may be implemented into everyday obstetric care.

Recém-Nascido de Muito Baixo Peso numa Unidade de Cuidados Intensivos Portuguesa Comparativamente ao Vermont Oxford Network: 15 Anos de Registo

Our neonatal service is part of a differentiated perinatal hospital and has contributed to the Vermont Oxford Network for more than 15 years. This data base includes data on the morbidity and mortality of newborns born in the member hospitals with birth weight between 401 and 1500 g and/ or from 22 to 29 weeks and six days of gestation, or those admitted to these hospitals with up to 28 days of age. It thus allows the analysis of clinical practice and its comparison with similar units. The goal of the present paper is to disclose some of our data from the past 15 years and to compare it with the Vermont Oxford Network data trying to identify areas of possible improvement and permitting other neonatal units to compare their data with our in a benchmarking process. Observational, retrospective study. It included newborns with birth weight ≤ 1500 g (very low birth weight newborns) born and treated at our hospital from 2001 to 2015. Descriptive data analysis, chi-square test and ANOVA, significance when p < 0.05. A total of 869 very low birth weight newborns were studied, median weight 1100 g and gestational age 29 weeks. Twinning was found in 37.6%. In the delivery room, 23% did not require any resuscitation, 52.2% of the newborns required invasive intubation, 78.3% had surfactant, and, since 2011, 29.7% have started noninvasive ventilation. Of the total very low birth weight newborns, 12.9% had oxygen therapy at 36 weeks of corrected age, 23% patent ductus arteriosus and late sepsis in 17.1%. There was higher neurological morbidity compared to the Vermont Oxford Network except in the case of retinopathy of prematurity. Overall mortality was 14% (122 newborns). The time of hospitalization was on average 52.7 ± 34.4 days. The 629 newborns that were discharged home had equivalent length of stay and head circumference measure but a lower weight than those in the Vermont Oxford Network, and 14.3% went home with exclusive breastfeeding. This work allowed us to study our very low birth weight newborns data and compare it with one of the largest neonatal world networks. Our population is similar from the point of view of gestational age, somatometric data, pregnancy surveillance rates and cesarean section with the most noticeable difference being the percentage of low birthweight for gestational age babies, twin pregnancies and antenatal corticosteroid treatment, superior in our center. Cardio-pulmonary and gastrointestinal disorders were overlapping. It is urgent to improve our rate of sepsis, neurologic sequelae, post-partum hypothermia control and neuroprotection with magnesium sulphate. The mortality rate and the length of stay at discharge was similar. This study allowed us to compare our population of very low birth weight newborns with those registered in the network. We have verified that we have been accompanying the evolution of Neonatology over the past years and we have identified areas for improvement.

Using Participatory Workshops to Assess Alignment or Tension in the Community for Minimally Invasive Tissue Sampling Prior to Start of Child Mortality Surveillance: Lessons From 5 Sites Across the CHAMPS Network.

The Child Health and Mortality Prevention Surveillance (CHAMPS) program is a 7-country network (as of December 2018) established by the Bill & Melinda Gates Foundation to identify the causes of death in children in communities with high rates of under-5 mortality. The program carries out both mortality and pregnancy surveillance, and mortality surveillance employs minimally invasive tissue sampling (MITS) to gather small samples of body fluids and tissue from the bodies of children who have died. While this method will lead to greater knowledge of the specific causes of childhood mortality, the procedure is in tension with cultural and religious norms in many of the countries where CHAMPS works—Bangladesh, Ethiopia, Kenya, Mali, Mozambique, Sierra Leone, and South Africa. Participatory Inquiry Into Community Knowledge of Child Health and Mortality Prevention (PICK-CHAMP) is a community entry activity designed to introduce CHAMPS to communities and gather initial perspectives on alignments and tensions between CHAMPS activities and community perceptions and priorities. Participants’ responses revealed medium levels of overall alignment in all sites (with the exception of South Africa, where alignment was high) and medium levels of tension (with the exception of Ethiopia, where tension was high). Alignment was high and tension was low for pregnancy surveillance across all sites, whereas Ethiopia reflected low alignment and high tension for MITS. Participants across all sites indicated that support for MITS was possible only if the procedure did not interfere with burial practices and rituals.

Preeclampsia: Risk Factors, Diagnosis, Management, and the Cardiovascular Impact on the Offspring.

Hypertensive disorders of pregnancy affect up to 10% of pregnancies worldwide, which includes the 3%–5% of all pregnancies complicated by preeclampsia. Preeclampsia is defined as new onset hypertension after 20 weeks’ gestation with evidence of maternal organ or uteroplacental dysfunction or proteinuria. Despite its prevalence, the risk factors that have been identified lack accuracy in predicting its onset and preventative therapies only moderately reduce a woman’s risk of preeclampsia. Preeclampsia is a major cause of maternal morbidity and is associated with adverse foetal outcomes including intra-uterine growth restriction, preterm birth, placental abruption, foetal distress, and foetal death in utero. At present, national guidelines for foetal surveillance in preeclamptic pregnancies are inconsistent, due to a lack of evidence detailing the most appropriate assessment modalities as well as the timing and frequency at which assessments should be conducted. Current management of the foetus in preeclampsia involves timely delivery and prevention of adverse effects of prematurity with antenatal corticosteroids and/or magnesium sulphate depending on gestation. Alongside the risks to the foetus during pregnancy, there is also growing evidence that preeclampsia has long-term adverse effects on the offspring. In particular, preeclampsia has been associated with cardiovascular sequelae in the offspring including hypertension and altered vascular function.

Costs and cost-effectiveness analyses of mCARE strategies for promoting care seeking of maternal and newborn health services in rural Bangladesh.

ObjectiveWe examined the incremental cost-effectiveness between two mHealth programs, implemented from 2011 to 2015 in rural Bangladesh: (1) Comprehensive mCARE package as an intervention group and (2) Basic mCARE package as a control group.MethodsBoth programs included a core package of census enumeration and pregnancy surveillance provided by an established cadre of digitally enabled community health workers (CHWs). In the comprehensive mCARE package, short message service (SMS) and home visit reminders were additionally sent to pregnant women (n = 610) and CHWs (n = 70) to promote the pregnant women’s care-seeking of essential maternal and newborn care services. Economic costs were assessed from a program perspective inclusive of development, start-up, and implementation phases. Effects were calculated as disability adjusted life years (DALYs) and the number of newborn deaths averted. For comparative purposes, we normalized our evaluation to estimate total costs and total newborn deaths averted per 1 million people in a community for both groups. Uncertainty was assessed using probabilistic sensitivity analyses with Monte Carlo simulation.ResultsThe addition of SMS and home visit reminders based on a mobile phone-facilitated pregnancy surveillance system was highly cost effective at a cost per DALY averted of $31 (95% uncertainty range: $19–81). The comprehensive mCARE program had at least 88% probability of being highly cost-effective as compared to the basic mCARE program based on the threshold of Bangladesh’s GDP per capita.ConclusionmHealth strategies such as SMS and home visit reminders on a well-established pregnancy surveillance system may improve service utilization and program cost-effectiveness in low-resource settings.

National-survey for evaluation of the best screening method of late fetal growth restriction in low risk pregnancy: A prospective study

ObjectiveTo compare knowledge and practices surrounding third trimester screening of fetal growth restriction (FGR) in low risk pregnancies among Portuguese Gynecologists/Obstetricians (GOs) and General Practitioners (GPs). Primary outcome was to compare the proportion of GOs that consider the need of a third trimester ultrasound (estimation of fetal weight) for screening of FGR in low risk pregnancies and the best time to perform it with the corresponding proportion of GPs. Study designWe have conducted a prospective, observational cohort study based on application of surveys to GOs and GPs. Questionnaires were sent by e-mail to physicians and they filled them online. A second reminder e-mail was sent 7 days later. Recruitment was also done personally at scientific meetings. A total of 573 surveys were available for analysis, 298 corresponded to GOs and 275 to GPs.We used χ2 test to compare dichotomous variables and Kruskal-Wallis test for the comparison of ordinal variables. P values <0.05 were considered statistically significant. ResultsThe vast majority of GOs and GPs (93%) considered that third trimester ultrasound is useful and needed for surveillance of low risk pregnancy. A higher proportion of GOs (38%) selected 35th–37th weeks as the best time to perform the ultrasound compared to GPs (10%) (p < 0.001). GOs (51%) consider that symphysis-fundus distance is a measurement with moderate accuracy for screening of FGR while GPs (61%) attribute a low accuracy (p < 0.001). Fifty percent (50%) of GOs consider that performing a third trimester ultrasound will have no impact on cesarean delivery rate for fetal distress, while 41% of GPs consider that routine ultrasound will contribute to increase this rate (p < 0.001). The majority of GPs (52%) consider that routine ultrasound will contribute to diminish the admission rate to neonatal intensive care unit while GOs revealed a dichotomy with 43% of respondents reporting that it will diminish the rate and 40% that it will have no impact. ConclusionVaried opinions among the clinicians included in our sample reflect the controversy that remains on the best screening of FGR in low risk pregnancies.

Status of birth and pregnancy outcome capture in Health Demographic Surveillance Sites in 13 countries

ObjectivesWe compared pregnancy identification methods and outcome capture across 31 Health Demographic Surveillance System (HDSS) sites in 14 countries in sub-Saharan Africa and Asia.MethodsFrom 2009 to 2014, details on the sites and surveillance systems including frequency of update rounds, characteristics of enumerators and interviewers, acceptable respondents were collected and compared across sites.ResultsThe 31 HDSS had a combined population of over 2,905,602 with 165,820 births for the period. Stillbirth rate ranged from 1.9 to 42.6 deaths per 1000 total births and the neonatal mortality rate from 2.6 to 41.6 per 1000 live births. Three quarters (75.3%) of recorded neonatal deaths occurred in the first week of life. The proportion of infant deaths that occurred in the neonatal period ranged from 8 to 83%, with a median of 53%. Sites that registered pregnancies upon locating a live baby in the routine household surveillance round had lower recorded mortality rates.ConclusionsIncreased attention and standardization of pregnancy surveillance and the time of birth will improve data collection and provide platforms for evaluations and availability of data for decision-making with implications for national planning.

Benefits of fetal echocardiographic surveillance in pregnancies at risk of congenital heart block: single-center study of 212 anti-Ro52-positive pregnancies.

Assuming that autoimmune congenital heart block (CHB) is a progressive disease amenable to therapeutic modulation, we introduced a surveillance program for at-risk pregnancies with the dual aim of investigating if fetal atrioventricular block (AVB) could be detected and treated before becoming complete and irreversible, and to establish the incidence of AVB I, II and III in a large prospective cohort. This was a prospective study of 212 anti-Ro52 antibody-exposed pregnancies at risk of fetal AVB that were followed weekly between 18 and 24 weeks' gestation at our tertiary fetal cardiology center from 2000 to 2015. A 12-lead electrocardiogram (ECG) was recorded within 1 week after birth. Fetal Doppler atrioventricular (AV) intervals were converted to Z-scores using reference standard values derived from normal pregnancies. Each fetus was represented by the average value of the two recordings, obtained at two consecutive visits, which resulted in the longest AV interval. AV interval values were classified into normal AV conduction (Z-score ≤ 2.0) and three levels of delayed AV conduction: Z-score > 2.0 and ≤ 3.0, Z-score > 3.0 and ≤ 4.0, and Z-score > 4.0. AVB II or III developed in 6/204 (2.9%) pregnancies without a CHB history and 1/8 (12.5%) of those with a CHB history. AV intervals > 2 and ≤ 3, > 3 and ≤ 4, and > 4 were detected in 16.0%, 7.5% and 2.8% of cases, respectively, and were related to the PR interval on 185 available ECGs. Three of the five cases with AVB III and one of two cases with 2:1 AVB II developed within 1 week of AV interval Z-score of 1.0, 1.9, 2.8 and 1.9, respectively. Transplacental treatment with betamethasone was associated with restoration of 1:1 AV conduction in the two fetuses with AVB II, with a better long-term result (normal ECG vs AVB I or II) observed in the case in which treatment was started within 1 week after AVB developed. Betamethasone treatment did not reverse AVB III, although a temporary effect on AV conduction was observed in 1/5 cases. Notably, the three cases in which treatment was started within 1 week after AVB III development responded with a higher ventricular rate than the other two cases and did not require pacemaker implantation until a later age (2-5 years vs 1.5-2 months). Fetal AV interval is a poor predictor of CHB progression, but CHB surveillance still allows detection of fetuses with AVB II or III shortly after its development, allowing for timely treatment initiation and potentially better outcome. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Zika Pregnancy Surveillance: Transforming Data into Educational and Clinical Tools

ObjectiveTo describe how Zika virus (Zika) surveillance data informs and improves testing guidance, clinical evaluation and management of pregnant women and infants with possible Zika infectionIntroductionLittle was known about the maternal and fetal/infant effects of Zika infection before the 2015 outbreak in the Americas, which made it challenging for public health practitioners and clinicians to care for pregnant women and infants exposed to Zika. In 2016, CDC implemented a rapid surveillance system, the US Zika Pregnancy and Infant Registry, to collect information about the impact of Zika infection during pregnancy and inform the CDC response and clinical guidance. In partnership with state, tribal, local, and territorial health departments, CDC disseminated information from this surveillance system, which served as the foundation for educational materials and clinical tools for healthcare providers.MethodsThroughout the Zika response, CDC worked closely with health officers, epidemiologists, and clinical partners to seek expert input on the interpretation of emerging data and the evaluation and management of these vulnerable populations. In response to requests from clinical and public health partners, CDC created targeted educational materials and tools to facilitate the implementation of clinical guidance. These materials equipped healthcare providers with the information needed to care for pregnant women and infants with Zika infection. Examples of products developed included: 1) screening tools to identify pregnant women for whom testing is indicated; 2) an interactive web tool to assist with implementation and interpretation of Zika testing guidance (Pregnancy and Zika Testing Widget); 3) patient counseling scripts; and 4) videos to explain critical clinical concepts (e.g., measurement of infant head circumference). These tools were informally pre-tested with the target audiences prior to dissemination, specifically to assess usefulness in clinical settings. CDC disseminated these tools through the CDC website and through comprehensive outreach (e.g., webinars, calls, email alerts) to various audiences. Additionally, several professional organizations incorporated these tools into regular communication with their membership.ResultsThe US Zika Pregnancy and Infant Registry is currently monitoring infants from approximately 7,300 pregnancies in the US states and territories with laboratory evidence of Zika. Surveillance data provided valuable information, including clues toward the pattern of defects and other neurologic disabilities associated with congenital Zika infection, estimates of the risks associated with congenital infection, and timeframes of greatest risk during pregnancy, to help clinicians counsel pregnant patients with potential Zika exposure. CDC used these data to inform their clinical tools, particularly in pretest counseling materials and educational factsheets for healthcare providers to use with pregnant women with potential Zika exposure.After informal testing among healthcare providers, the tools received positive feedback regarding usefulness and applicability in clinical settings. Collectively, CDC’s Zika clinical tools were downloaded more than 300,000 times from CDC’s website. The Pregnancy and Zika Testing Widget was accessed and followed to an endpoint (e.g., Zika testing recommended) more than 17,000 times, with more than 75% of users self-identifying as clinicians.ConclusionsRapid implementation of Zika surveillance captured evolving data about the impact of Zika on pregnant women and their infants. These data informed the development of clinical tools for healthcare providers caring for and counseling patients with Zika exposure. These tools ensured pregnant women and infants were adequately monitored during the Zika outbreak. Health education materials and clinical tools based on surveillance data should be considered in future emergency responses, particularly when knowledge is rapidly evolving.ReferencesCDC Zika Pregnancy Website: https://www.cdc.gov/pregnancy/zika/materials/index.html

Pregnancy-associated stroke \u2013a systematic review of subsequent pregnancies and maternal health

BackgroundPregnancy-associated stroke is a rare but life-threatening event, with an estimated incidence of 30/100000 deliveries. Data on the risk of stroke recurrence and the risk of other adverse pregnancy outcomes are essential for adequate counselling and surveillance in subsequent pregnancies. The aim of this systematic review is to describe the implications of a pregnancy-associated stroke for the future health of these women.MethodsWe searched Ovid Medline, PubMed, Cochrane Library and CINAHL for articles published in 1980–2018. Articles including women with pregnancy-associated stroke and information on at least one of the following outcomes were included: 1) recurrence of stroke during subsequent pregnancy, 2) number and course of subsequent pregnancies and their outcomes and 3) subsequent cardiovascular health.ResultsTwelve articles were included in the review, with six providing information on subsequent pregnancies, four on subsequent maternal health and two on both. The included articles varied greatly in terms of study design, length of follow up and reported outcomes. We found 252 women with pregnancy-associated stroke for whom the outcomes of interest were reported: 135 women with information on subsequent pregnancies and 123 women with information on future health. In total, 55 pregnancies after stroke were found. In the majority of studies, the incidence of pregnancy complications was comparable to that of the general population. The risk of stroke recurrence during pregnancy was 2%. Data on subsequent health of these women were limited, and the quality of the data varied between the studies.ConclusionsData on subsequent pregnancies and health of women with a history of pregnancy-associated stroke are limited. Further research on this topic is essential for adequate counselling and secondary prevention.

Use of real-world evidence from healthcare utilization data to evaluate drug safety during pregnancy.

Because preapproval clinical trials typically exclude pregnant women, the evidence on drug safety during pregnancy required to inform drug labeling must come from postapproval controlled observational studies. Common designs have included pregnancy registries and case-control studies. Recently, pregnancy cohorts nested within healthcare utilization databases are increasingly being used. Despite clear advantages, these databases share some important limitations that may threaten the validity of studies emerging from them. This paper describes the distinctive methodological aspects of conducting drug safety studies in healthcare utilization databases with special emphasis on design and analytic approaches to minimize biases. We describe considerations for study design, cohort definition, and follow-up. We then address issues related to exposure ascertainment based on prescription fills, including the importance of the etiologically relevant window and of properly accounting for preterm births. This is followed by a discussion of advantages and challenges when ascertaining maternal and infant outcomes based on secondary data. We then explore useful approaches to address confounding within the context of pregnancy research and of the potential for selection bias when restricting the cohort to live births. Finally, we consider issues related to external validity and statistical significance. The examples are mainly drawn from a pregnancy cohort nested in the Medicaid Analytic Extract. The approaches presented provide guidance regarding the important methodological considerations that need to be attended to in order to generate valid, minimally biased risk when using large healthcare utilization databases for drug safety surveillance in pregnancy.

Does Fetal Testing Decrease Fetal Demise in Pregnancies Complicated by Obesity? [14E

INTRODUCTION: Maternal obesity complicates over 30% of pregnancies, and is a risk factor for fetal demise (FD). Some have advocated increased fetal surveillance in pregnancies complicated by maternal obesity. The objective of this study is to determine if a protocol for fetal testing in obese women decreases the risk of FD. METHODS: This was a retrospective cohort study of women who delivered at Boston Medical Center, from 2006-2018, and deemed exempt by th IRB. FD rates in obese women (BMI≥30) with no other pregnancy complications, were compared to low risk pregnancies. Obese patients were scheduled for growth ultrasounds every 4 weeks and weekly fetal testing starting at 36 weeks. RESULTS: There were 3,037 women in the obese group, and 13,980 women in the uncomplicated group. There was no significant difference in FD between the two groups. The obese group had a fetal death rate of 3/1000 (n=10) after 24 weeks gestation, and 1/1000 after 36 weeks gestation (n=2) compared to a FD rate in the normal group of 5/1000 (n=66) after 24 weeks gestation and 2/1000 (n=31) after 36 weeks gestation. The obese group had an increased median number of fetal tests (4 vs 2, P<0.01), and cesarean deliveries (35% vs 24%, p<0.01). CONCLUSION: Despite a known increased incidence of FD in pregnancies complicated by obesity, a protocol of intensive antepartum fetal testing resulted in a FD incidence similar to a low risk population. This suggests that increased fetal testing should be offered for all pregnancies complicated by obesity.

Tales of two cities: legislating pregnancy and marriage among foreign domestic workers in Singapore and Hong Kong

ABSTRACT This article compares the ‘power geometry’ (Massey [1994]. Space, Place and Gender. Minneapolis: University of Minnesota Press) of mobility/immobility of foreign domestic workers in Singapore and Hong Kong. In both contexts, the policing and surveillance of pregnancy and marriage reflect and reinforce power inequalities of gender paired with migratory, ethnic/racial and employment status. Pregnancy is considered incompatible with employment, but the specifics differ. In Singapore pregnancy results in automatic expulsion of the worker, while in Hong Kong workers are protected by antidiscrimination laws and some labour rights. Legislation of marriages to locals contrast greatly as well, producing subtle but significant differences in im/mobility and citizenship rights. These differences reveal unequal social positioning and different state priorities and regimes of control. While both states aim to restrict migrant workers, Confucian and familial notions of hierarchy reinforce Singapore’s approach, while neoliberalism and individual responsibility play a greater role in Hong Kong.

Role of doppler velocimetry in fetomaternal surveillance of pregnancy with pre-eclampsia

Role of doppler velocimetry in fetomaternal surveillance of pregnancy with pre-eclampsia

Pharmacoepidemiologic Evaluation of Birth Defects from Health-Related Postings in Social Media During Pregnancy.

IntroductionAdverse effects of medications taken during pregnancy are traditionally studied through post-marketing pregnancy registries, which have limitations. Social media data may be an alternative data source for pregnancy surveillance studies.ObjectiveThe objective of this study was to assess the feasibility of using social media data as an alternative source for pregnancy surveillance for regulatory decision making.MethodsWe created an automated method to identify Twitter accounts of pregnant women. We identified 196 pregnant women with a mention of a birth defect in relation to their baby and 196 without a mention of a birth defect in relation to their baby. We extracted information on pregnancy and maternal demographics, medication intake and timing, and birth defects.ResultsAlthough often incomplete, we extracted data for the majority of the pregnancies. Among women that reported birth defects, 35% reported taking one or more medications during pregnancy compared with 17% of controls. After accounting for age, race, and place of residence, a higher medication intake was observed in women who reported birth defects. The rate of birth defects in the pregnancy cohort was lower (0.44%) compared with the rate in the general population (3%).ConclusionsTwitter data capture information on medication intake and birth defects; however, the information obtained cannot replace pregnancy registries at this time. Development of improved methods to automatically extract and annotate social media data may increase their value to support regulatory decision making regarding pregnancy outcomes in women using medications during their pregnancies.

Vaccine safety surveillance in pregnancy in low- and middle-income countries using GAIA case definitions: A feasibility assessment

BackgroundGlobal efforts to adequately monitor safety of new vaccines for pregnant women in low and middle-income countries (LMICs) are needed. The Global Alignment of Immunization Safety Assessment in pregnancy (GAIA) project recently published case definitions based on levels of diagnostic certainty for pregnancy- and neonatal outcomes and maternal vaccination. As a preliminary step to assessing the applicability of these definitions in LMICs, WHO selected sites and conducted a feasibility assessment to evaluate their ability to identify and classify selected outcomes (preterm birth, neonatal death, neonatal invasive bloodstream infection (NI-BSI), stillbirth) and maternal vaccination. MethodsCandidate sites were initially screened using a questionnaire. For each outcome, eligible sites were asked to retrospectively identify and collect information for three individuals born in 2016. Subsequently, outcomes were classified by level of diagnostic certainty. ResultsFifty-one sites (15 countries) were screened; 32 of them (9 countries) participated in the assessment and identified 315 subjects with the outcomes of interest. Twenty-four sites (8 countries) identified at least one subject per outcome and agreed to continue participating. The majority (80%) of preterm births, neonatal deaths, and NI-BSI subjects, but only 50% of stillbirths, could be assessed for diagnostic certainty. The main reasons for not classifying stillbirths were insufficient information to distinguish between antepartum and intrapartum stillbirth (29%); or that not all data for one subject fit into a single level of diagnostic certainty (35%). Forty-nine percent of mothers were considered vaccinated, 6% not-vaccinated, and vaccination status could not be assessed in 44% of them. DiscussionGAIA case definitions for four neonatal outcomes and maternal vaccination were successfully piloted in 24 sentinel sites across four WHO regions. Our assessment found that modification of the stillbirth definition could help avoid potential misclassification. Vaccine safety monitoring in LMICs will benefit from systematic recording of all vaccinations during pregnancy.

Predictive accuracy of cerebroplacental ratio for adverse perinatal and neurodevelopmental outcomes in suspected fetal growth restriction: systematic review and meta-analysis.

The cerebroplacental ratio (CPR) has been proposed for the routine surveillance of pregnancies with suspected fetal growth restriction (FGR), but the predictive performance of this test is unclear. The aim of this study was to determine the accuracy of CPR for predicting adverse perinatal and neurodevelopmental outcomes in suspected FGR. PubMed, EMBASE, CINAHL and Lilacs were searched from inception to 31 July 2017 for cohort or cross-sectional studies reporting on the accuracy of CPR for predicting adverse perinatal and/or neurodevelopmental outcomes in singleton pregnancies with FGR suspected antenatally based on sonographic parameters. Summary receiver-operating characteristics (ROC) curves, pooled sensitivities and specificities, and summary likelihood ratios (LRs) were generated. Twenty-two studies (including 4301 women) met the inclusion criteria. Summary ROC curves showed that the best predictive accuracy of CPR was for perinatal death and the worst was for neonatal acidosis, with areas under the summary ROC curves of 0.83 and 0.57, respectively. The predictive accuracy of CPR was moderate to high for perinatal death (pooled sensitivity and specificity of 93% and 76%, respectively, and summary positive and negative LRs of 3.9 and 0.09, respectively) and low for composite of adverse perinatal outcomes, Cesarean section for non-reassuring fetal status, 5-min Apgar score < 7, admission to the neonatal intensive care unit, neonatal acidosis and neonatal morbidity, with summary positive and negative LRs ranging from 1.1 to 2.5 and 0.3 to 0.9, respectively. An abnormal CPR result had moderate accuracy for predicting small-for-gestational age at birth (summary positive LR of 7.4). CPR had a higher predictive accuracy in pregnancies with suspected early-onset FGR. No study provided data for assessing the predictive accuracy of CPR for adverse neurodevelopmental outcome. CPR appears to be useful in predicting perinatal death in pregnancies with suspected FGR. Nevertheless, before incorporating CPR into the routine clinical management of suspected FGR, randomized controlled trials should assess whether the use of CPR reduces perinatal death or other adverse perinatal outcomes. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Ultrasound surveillance in twin pregnancy: An update for practitioners.

Ultrasound has revolutionised the management of multiple pregnancies and their complications. Increasing frequency of twin pregnancies mandates familiarity of all clinicians with the relevant pathologies and evidence-based surveillance and management protocols for their care. In this review, we summarise the latest evidence relating to ultrasound surveillance of twin pregnancies including first trimester assessment and screening, growth surveillance and the detection and management of the complications of monochorionic pregnancies including twin-to-twin-transfusion syndrome, selective fetal growth restriction, twin reversed arterial perfusion sequence and conjoined twinning.