Term Live Births Research Articles

P–770 Two in One - Monozygotic splitting and associated perinatal outcomes after oocyte freezing; an exploratory analysis of the UK national database from 1990 to 2016

Abstract Study question Is oocyte freezing a risk factor for monozygotic splitting? Summary answer There is a trend towards a higher monozygotic splitting incidence among frozen oocytes, but this did not reach statistical significance. What is known already Laboratory techniques which involve embryo manipulation such as ICSI, assisted hatching, embryo biopsy for pre-implantation genetic testing and extended culture to the blastocyst stage appear to increase the risk of monozygotic splitting. Whilst there is some data that embryo freezing does not appear to increase the risk of monozygotic splitting, there is no comparable analysis on whether oocyte freezing increases the risk of monozygotic splitting. Study design, size, duration This was a retrospective cohort study analysing 988 015 ART (assisted reproductive technique) cycles from the HFEA anonymised database from 1990 to 2016. As frozen oocytes require ICSI, only fresh oocytes with ICSI were taken for comparison and frozen embryo transfers were excluded. Only single embryo transfers were included.[CM1] [MM2] We also noted ages of the female partner at the time of treatment, stage of embryo transfer, and whether pre-implantation genetic testing had been performed. Participants/materials, setting, methods There were 84 085 ICSI cycles with single embryo transfers using fresh oocytes and 596 using frozen oocytes. Monozygotic splitting was defined as the presence of two foetal hearts [CM1] [MM2] on ultrasound. Live birth (LB)was defined as either a singleton or a twin LB resulting from a monozygotically split embryo. Preterm birth (PTB) was defined as birth prior to 37 weeks gestation and early PTB as birth prior to 32 weeks gestation. Main results and the role of chance The frozen oocyte group had fewer women in the under–35 age group (frozen oocytes 16.6% vs fresh oocytes 53.6%, p < 0.0001) and a higher proportion of blastocyst transfers ( frozen oocytes 55.1% vs fresh oocytes 48.8%, p = 0.002) There were only 10 PGT cycles amongst monozygotically split embryos from fresh oocytes in our analysis, and none in the frozen oocyte group. Hence, this was not included as a confounder. There was a non-significant trend toward a higher incidence of monozygotic splitting amongst frozen oocytes (4/596, 2.3%, all monozygotic twins) than amongst fresh oocytes (378/27 019, 1.4%, 372 monozygotic twins and 6 monozygotic triplets); OR 1.688, 95% CI 0.623 to 4.574 and aOR 1.506, 95% CI 0.531 to 4.274 (maternal age and stage of embryo transfer adjusted as confounders). Of the 378 monozygotically split embryos from fresh oocytes, 308 (81.5%) had a LB: of which 47 (15.3%) were singletons and the rest were twins; 241 (78.2%) were PTB and 56 (18.2%) were early PTB. Of the four monozygotic twins from frozen oocytes, all reached a LB; one was a singleton term LB (Birthweight 3–3.5kg) whilst three were twin preterm LBs at 35–36 weeks, with no early PTBs and twin median birthweight 2–2.5 kg. Limitations, reasons for caution Albeit a large national database, this cohort study was restricted due to absence of data on potential confounders such as age at oocyte freezing, method of cryopreservation and length of storage.[CM1] Data was also lacking on amnionicity, obstetric risks including pre-eclampsia, twin-to-twin-transfusion syndrome, intrapartum and late effects. Wider implications of the findings: With rapid rise in egg freezing, our findings would help reassure women that eggs on ice does not predispose to significant risk of two-in-one monozygotic splitting. However, the marginal trend (from 1.4% in fresh to 2.3% in frozen oocytes), does indicate that this subject merits further research. Trial registration number Not applicable. A database based retrospective study

P–445 Successful live birth after repeated high-dose radiotherapy to the uterus

Abstract Study question It has been established that radiotherapy can increase the risk of adverse pregnancy outcomes. However, there is currently no consensus on the effective sterilizing dose for adulthood uterine radiotherapy. Summary answer Uterine fertility preservation methods should be guided by the age of the patient receiving radiotherapy and the actual dose of radiation exposure to the uterus. What is known already Many experts have suggested that a high dose of radiation to the uterus is a reason to counsel patients against future pregnancy. There are major limitations to the current literature regarding off-target radiation damage to the uterus. One study reported a relative risk of 9.1 for stillbirth and neonatal death after 10 Gy doses. Study design, size, duration Case report and review of the literature before December 2020 Participants/materials, setting, methods A case report of a 36-year-old female with three cancers and received repeated high-dose radiotherapy of 66 Gy and 50 Gy to the pelvis. We used a dose-volume histogram, the most widely used tool to calculate the radiation distribution within a volume of interest of the patient during radiotherapy. We determined that her uterus may have received the highest uterine radiation dosage for full-term live birth in current literature. Main results and the role of chance Due to iatrogenic ovarian failure, she could only use donor eggs. After endometrium preparation for 18 days, the endometrium reached 8.7 mm with a triple-line appearance. We transferred two cleavage-staged embryos and one of them implanted successfully. The course of the pregnancy was uneventful. Finally, the patient gave birth to a healthy baby via Cesarean section at 38 5/7 weeks of gestation. Limitations, reasons for caution It should be noted that the success of our case may not apply to all patients with cancer after they have received RT. We should inform patients about the increased risk of preterm birth, low birth weight infants, uterine rupture, and neonatal death. Wider implications of the findings: The patient’s age and the dose of RT exposure to the uterus are important factors for the prognosis of a future pregnancy. More well-designed studies will be needed to allow future standard guidelines for uterine fertility preservation. Trial registration number TMU-JIRB N20204149

Restorative reproductive medicine for infertility in two family medicine clinics in New England, an observational study

BackgroundRestorative reproductive medicine (RRM) seeks to identify and correct underlying causes and factors contributing to infertility and reproductive dysfunction. Many components of RRM are highly suitable for primary care practice. We studied the outcomes amongst couples who received restorative reproductive medicine treatment for infertility in a primary care setting.MethodsTwo family physicians in Massachusetts trained in a systematic approach to RRM (natural procreative technology, or NaProTechnology) treated couples with infertility. We retrospectively reviewed the characteristics, diagnoses, treatments, and outcomes for all couples treated during the years 1989 to 2014. We compared pregnancy and live birth by clinical characteristics using Kaplan-Meier analysis. We employed the Fleming-Harrington weighted Renyi test or the logrank test to compare the cumulative proportion with pregnancy or with live birth.ResultsAmong 370 couples beginning treatment for infertility, the mean age was 34.8 years, the mean prior time trying to conceive was 2.7 years, and 27% had a prior live birth. The mean number of diagnoses per couple was 4.9. Treatment components included fertility tracking with the Creighton Model FertilityCare System (80%); medications to enhance cervical mucus production (81%), to stimulate ovulation (62%), or to support the luteal phase (75%); and referral to female laparoscopy by a surgeon specializing in endometriosis (46%). The cumulative live birth rate at 2 years was 29% overall; this was significantly higher for women under age 35 (34%), and for women with body mass index < 25 (40%). There were 2 sets of twins and no higher-order multiple gestations. Of the 63 births with data available, 58 (92%) occurred at term.ConclusionsFamily physicians can provide a RRM approach for infertility to identify underlying causes and promote healthy term live births. Younger women and women with body mass index < 25 are more likely to have a live birth.

Factors associated with low fifth minute Apgar score in term and preterm singleton live births in a Ghanaian hospital

IntroductionApgar score remains the most effective measure of newborn health outcomes in the first few minutes of delivery and it is useful in diagnosing perinatal asphyxia and metabolic acidosis. MethodsThis retrospective cross-sectional study was conducted on 3011 women at the Baptist Medical Centre in the North East Region of Ghana. Binary logistic regression models were used to determine the factors associated with low fifth minute Apgar score. ResultsThe majority of the newborns weighed 2.5 kg or more at birth (90.7%), were delivered through the vagina (79.8%), and a little over half of them (51.40%) were males. We found evidence that delivery at less than 37 weeks gestation, birth weight of less than 2.5 kg, and caesarean delivery were associated with increased odds of low fifth minute Apgar score. For infants born at term, being born to a multigravid mother was protective against low fifth minute Apgar score while delivery through caesarean section increased the odds of low fifth minute Apgar score among this group of newborns. Among preterm infants, our study found strong evidence that those born with low birth weight (<2.5 kg) had about 4 times the odds of suffering low fifth minute Apgar score compared to those with normal birth weight. ConclusionIn designing interventions to improve the survival and the Apgar score of newborns, measures to properly diagnose and prevent preterm delivery and low birth weight should be of great concern.

The oncological and obstetric outcomes of cervical squamous cell carcinoma at stage IA1 managed with the loop electrosurgical excision procedure

ObjectiveTo evaluate the efficacy and superiority of loop electrosurgical excision procedure (LEEP) in managing stage IA1 cervical microinvasive squamous cell carcinoma (MISCC) without lymph-vascular space invasion (LVSI). Materials and methodsThe oncological and reproductive outcomes of a series of patients affected by stage IA1 MISCC without LVSI, initially treated by LEEP between February 2006 and December 2017, were retrospectively reviewed. ResultsUltimately, 109 patients were included. The mean age at diagnosis was 35.4 years old, and 36 patients were nulliparous. Multifocal lesions were identified in 15 patients (13.8%). The mean cone depth was 17.4 mm. Resection margins were positive/unevaluable and negative in 26 (23.9%) and 83 (76.1%) cases, respectively. Among cases undergoing salvage treatments, the residual disease rate for patients with positive/unevaluable margins was significantly higher than those with negative margins (P = 0.003). During the follow-up period of 43.0 ± 28.9 months, no relapse was identified. Fifteen of 20 patients (75.0%) conceived successfully, with a full-term live birth rate of 93.3%. ConclusionsFor stage IA1 MISCC without LVSI unexpectedly found in a loop excision, initial LEEP with clear margin is efficient and adequate. For cases with multifocal MISCC, or for those young patients who wish to become pregnant in the future, LEEP is the optimal choice.

Self-Reported Reproductive Health Experiences in Women with Von Willebrand Disease: A Qualitative Interview-Based Study

Background: Women with von Willebrand disease (VWD) may experience multiple reproductive health challenges, particularly related to menstruation and pregnancy. Patient-reported experiences in this setting have not been well characterized.Aim: To elicit patient-reported menstrual health experiences in women with VWD.Methods: We conducted a physician-administered telephone survey of women seen at Mayo Clinic for workup and/or management of VWD. Patients were asked to discuss their diagnosis of VWD and questioned about menstrual health, contraception, and pregnancy and asked to describe how their VWD had impacted their reproductive health experiences. Quantitative data were analyzed using R (version 3.2.0). Qualitative comments were analyzed by frequency of response (specific adjectives) and general thematic elements.Results: Of 130 women diagnosed with VWD, 82 (63%) agreed to participate, including 58 (71%) with type 1, 9 (11%) with type 2A, 4 (5%) with type 2B, 8 (10%) with type 2M, 1 (1%) with type 2N, and 3 (2%) with type 3. 89% of women self-reported a history of heavy menstrual bleeding; for 23 (28%) this was their first bleeding event. 28 women (34%) ultimately underwent hysterectomy for heavy menstrual bleeding. Women used several forms of contraception, most commonly estrogen-containing oral contraceptives (61, 74%) and intrauterine device (9, 11%). 65 women (79%) reported at least one pregnancy. There were 200 total pregnancies (median 3 per woman, range 1-10). 142 pregnancies (71%) resulted in live term birth, 47 (24%) in spontaneous abortion (at a median of 12 weeks), 9 (4%) in a live preterm birth, and 2 (1%) in therapeutic abortion. Patients' self-reported comments are described in the Table, with responses in bold indicating the same themes were used by more than one patient. Women used primarily negative adjectives to describe heavy menstrual bleeding and reported a significant negative impact on their academic, home, and sexual lives. Despite this, women often reported that they “just dealt with it” and “thought it was normal.” Regarding pregnancy and VWD, women again used primarily negative adjectives to describe their experiences. Many described pregnancy-associated bleeding events (generally postpartum hemorrhage). Overall, women reported that it was often “uncomfortable” to discuss their reproductive concerns with their medical providers (including hematologists). One woman reported that she “wished [she] had been more confident speaking with [her] doctor” and another that “it is important to be your own advocate.”Conclusions: VWD is a relatively common bleeding condition which appears to significantly impact women's reproductive health. In this qualitative interview study, women often used negative adjectives to describe their reproductive experiences as related to VWD. Additionally, many were uncomfortable discussing their reproductive health with their providers. Physicians (particularly hematologists and obstetrician-gynecologists) should be trained to recognize the impact of VWD on reproductive health and include reproductive health as part of their essential health maintenance conversations with their patients. More compassionate and informational patient-physician conversations may help to optimize reproductive health experiences and outcomes in women with VWD. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Maternal and fetal vascular lesions of malperfusion in the placentas associated with fetal and neonatal death: results of a prospective observational study

Fetal death is one of the major adverse pregnancy outcomes and is common in low- and middle-income countries. Placental lesions may play an important role in the etiology of fetal and neonatal deaths. Previous research relating placental lesions to fetal death causation was hindered by a lack of agreement on a placental classification scheme. The Amsterdam consensus statement that was published in 2016 focused its attention on malperfusions in the maternal and fetal placental circulations. This study aimed to investigate the relationships of placental maternal and fetal vascular malperfusions in fetal and neonatal deaths, focusing on the most important maternal clinical conditions in the pathway to fetal and neonatal deaths, such as maternal hypertension, antepartum hemorrhage, and decreased fetal growth. This was a prospective, observational cohort study conducted at 2 Asian sites. The data collected included clinical history, gross and histologic evaluations of the placenta, and several other investigations and were used to determine the cause of death. The placenta was evaluated at both sites using the Amsterdam consensus framework. We estimated the risk of placental maternal and fetal vascular malperfusions in fetal and neonatal deaths. Between July 2018 and January 2020 in India and Pakistan, 1633 women with placentas available for the study provided consent. Of these women, 814 had fetal deaths, 618 had preterm live births and subsequent neonatal deaths, and 201 had term live births. The prevalence of maternal vascular malperfusion was higher in the placentas associated with fetal deaths (58.4%) and preterm neonatal deaths (31.1%) than in the placentas associated with term live births (15.4%). Adjusting for site, maternal vascular malperfusion had a relative risk of 3.88 (95% confidence interval, 2.70-5.59) in fetal deaths vs term live births and a relative risk of 2.07 (95% confidence interval, 1.41-3.02) in preterm neonatal deaths vs term live births. Infarcts and distal villous hypoplasia were the most common histologic components of maternal vascular malperfusion. Compared with maternal vascular malperfusion (58.4%), fetal vascular malperfusion was less common in the placentas associated with fetal deaths (19.0%). However, there were higher frequencies of fetal vascular malperfusion in the placentas associated with fetal deaths (19.0%) than in placentas associated with neonatal deaths (8.3%) or term live birth (5.0%). Adjusting for site, fetal vascular malperfusion had a relative risk of 4.09 (95% confidence interval, 2.15-7.75) in fetal deaths vs term live births and a relative risk of 1.77 (95% confidence interval, 0.90-3.49) in preterm neonatal deaths vs term live births. Furthermore, there was a higher incidence of maternal vascular malperfusion in cases of maternal hypertension (71.4%), small for gestational age (69.9%), and antepartum hemorrhage (59.1%) than in cases of fetal deaths with none of these conditions (43.3%). There was no significant difference in the occurrence of fetal vascular malperfusion in the 4 clinical categories. Histologic examination of the placenta, especially for malperfusion disorders, is crucial in elucidating pathways to fetal and neonatal deaths in preterm infants. In particular, focusing on placental maternal and fetal vascular malperfusions during pregnancy is a means to identify fetuses at risk of fetal death and is an important strategy to reduce the risk of fetal death early delivery. We hope that the increased risk of fetal and neonatal deaths in these pregnancies can be reduced by the development of an intervention that reduces the likelihood of developing maternal and fetal vascular malperfusion.

Epidemiological evidence that severe obese women (pre-pregnancy BMI ≥40 kg/m2) should lose weight during their pregnancy

Objectives Defining the optimal gestational weight gain (optGWG) allowing to have “normal shaped” babies (10% of Small for gestational age, SGA, and10% of large LGA babies) in severe obese women (pre-pregnancy BMI ≥40 kg/m2). Study design South-Reunion University’s maternity (Reunion Island, Indian Ocean). 20 year-observational cohort study (2001–2019). Epidemiological perinatal data base with information on obstetrical and neonatal risk factors. All consecutive term (37–42 weeks gestation) singleton pregnancies (>21 weeks) live birth pregnancies delivered in the maternity. Main outcome measures OptGWG to obtain newborns as close as possible of the 10% SGA/LGA goal for each BMI categories, 15–19.9, 20–24.9 …, as well as severe obese ≥40 kg/m2. Results Of the 71,318 singleton term live births (37 weeks onward), we could define the maternal pre-pregnancy body mass index and the GWG in of 61,764 patients (86.6%). Severe obese 40 kg/m2 losing 5–9.9 kg have 12.9% of LGA and 11.9% of SGA babies. Those losing 10 kg and more 12.7% of LGA and 7.3% of SGA. Our formerly proposed linear equation (validated from 15 to 40 kg/m2) may be prolonged at 45 kg/m2. opGWG ( kg ) = − 1.2 pp BMI ( Kg / m 2 ) + 42 ± 2 kg Conclusion In our population, a 32 kg/m2 obese should gain 3.6 kg (instead of 5–9 kg, IOM 2009). A very obese 40 kg/m2 should lose 6 kg, and a severe obese 45 kg/m2 lose 12 kg.

The neonatal respiratory morbidity associated with early term caesarean section – an emerging pandemic

To examine the impact of early term caesarean section (CS) on respiratory morbidity and early neonatal outcomes when elective caesarean section was carried out before 39 completed weeks gestation in our population. A one-year population-based retrospective cohort analysis using routinely collected hospital data. Livebirths from women who had elective lower segment cesarean section (ELSCS) for uncomplicated singleton pregnancies at early term (ET) 37+0 to 38+6 weeks were compared to full term (FT)≥39+0 weeks gestation. Exclusion criteria included diabetes, antenatal corticosteroid use, stillbirths, immediate neonatal deaths, normal vaginal deliveries and emergency caesareans sections. The outcomes were combined respiratory morbidity (tachypnea [TTN] and respiratory distress syndrome [RDS]), Apgar <7 at 5min of age, respiratory support, duration of respiratory support and NICU admission. Out of a total of 1,466 elective CS with term livebirths, the timing of CS was early term (ET) n=758 (52%) and full term (FT) n=708 (48%). There was a higher incidence of respiratory morbidities and neonatal outcomes in the ET in comparison to FT newborns. In the univariable analysis, significant risks for outcomes were: the need for oxygen support OR 2.42 (95% C.I. 1.38-4.22), respiratory distress syndrome and/or transient tachypnea of newborn (RDSF/TTN) OR 2.44 (95% C.I. 1.33-4.47) and neonatal intensive care unit (NICU) admission OR 1.91 (95% C.I. 1.22-2.98). Only the need for oxygen support remained (OR 1.81, 95% C.I. 1.0-3.26) in the multivariable analysis. These results were observed within the context of a significantly higher proportion of older, multiparous, and higher number of previous caesarean sections in the early term CS group. There is a significant risk of respiratory morbidities in infants born by elective cesarean section prior to full term gestation. Obstetricians should aim towards reducing the high rate of women with previous multiple cesarean sections including balancing the obstetric indication of early delivery among such women with the evident risk of neonatal respiratory morbidity.

Effects of maternal exposure to fine particulate matter on birth weight in 16 counties across China: a quantile regression analysis

The adverse effects of air pollution during pregnancy have been studied intensively, but mainly utilizing linear and logistic models, which generally yield little information about how air pollution may change the distribution of birth weight in populations. We aimed to examine the effects of fine particulate matter (PM2.5) on quantiles of birth weight, and if effects were heterogeneous in different populations and regions. We used a prospective cohort study of 196 283 singleton term live births from 16 counties across China during 2014–2018. PM2.5 exposure for full gestation, each trimester and last gestational month were assessed by Inverse Distance Weighting interpolation. Linear and quantile regression were conducted to estimate associations between PM2.5 exposure and mean birth weight, as well as birth weight distribution, with birthweight z-score as the main outcome. Stratified analyses and Cochran Q tests were conducted by maternal and geographical characteristics. Each 10 µg m−3 increase in average PM2.5 over the entire pregnancy was associated with reduced birthweight z-score (−0.010, 95% CI: −0.015, −0.005) and birth weight (−3.21 g, 95% CI: −5.27, −1.15). In quantile regression, more pronounced effects were observed in lower and intermediate quantiles, with a decrease of 0.021 (95% CI: 0.033, 0.009) and 0.009 (95% CI: 0.015, 0.002) in the 5th and 50th quantiles of birthweight z-score, respectively. Additionally, we observed stronger associations among well-educated, migrant and primiparous mothers as well as in coastal areas. Maternal exposure to PM2.5 was associated with reduction in birth weight, especially for those with very low birth weight. Well-educated, migrant and primiparous mothers, as well as births in coastal areas may be more sensitive to PM2.5 in our study population. The results may be relevant to targeted public health interventions to reduce maternal exposure to air pollution.

The effect of prenatal temperature and PM2.5 exposure on birthweight: Weekly windows of exposure throughout the pregnancy

BackgroundBirthweight is a strong predictor of normal growth, healthy development, and survival. Several studies have found associations between temperature, fine particulate matter (PM2.5), and birth weight. However, the relevant timing of exposures varies between studies and is yet unclear. Therefore, we assessed the difference in term birthweight (TBW) associated with weekly exposure to temperature and PM2.5 throughout 37 weeks of gestation. MethodsWe included all singleton live term births in Massachusetts, U.S between 2004 and 2015 (n = 712,438). Weekly PM2.5 and temperature predictions were estimated on a 1 km grid from satellite-based models. We utilized a distributed lag nonlinear model (DLNM) to estimate the difference in TBW associated with weekly exposures from the last menstrual period to 37 weeks of gestation. ResultsWe found a nonlinear association with prenatal temperature exposure. Larger effects were observed in warmer temperatures, where higher temperatures were negatively associated with TBW. Temperature effects were larger in the first and final weeks of gestation. We observed a negative difference in TBW associated with PM2.5 exposure. Overall, a 1 µg/m3 increase in prenatal exposure was associated with 3.9 g lower TBW (95% CI −5.0 g; −2.9 g). PM2.5 effects were larger in the final weeks of gestation. ConclusionWe found heat and PM2.5 exposure to be related to lower TBW. Our findings suggest that women are more susceptible to both exposures towards the end of pregnancy. Susceptibility to heat was higher in the initial weeks of pregnancy as well. These critical windows of susceptibility can be communicated to pregnant women during routine prenatal visits to increase awareness and target interventions to reduce exposures.

Influence of paternal age on assisted reproductive technology cycles and perinatal outcomes

To characterize paternal age among assisted reproductive technology (ART) cycles performed in the United States and to evaluate the influence of paternal age on ART cycles and perinatal outcomes. Retrospective cohort. Not applicable. All reported fresh, nondonor, noncancelled invitro fertilization (IVF) cycles performed in 2017. Not applicable. The primary outcomes were intrauterine pregnancy, live birth (≥20 weeks), and miscarriage (<20 weeks) per cycle start and per embryo transfer. The secondary outcomes were full-term live birth (≥37 weeks) among singleton and twin gestations. Modified Poisson regression was performed to estimate associations between paternal age and cycle and perinatal outcomes, overall and stratified by maternal age. Among 77,209 fresh nondonor, noncancelled IVF cycles, the average paternal age was 37.8 ± 6.3 years and the average maternal age was 35.5 ± 4.6 years. Compared with paternal age ≤45 years, paternal age ≥46 years was associated with a lower likelihood of pregnancy per cycle (adjusted risk ratio [aRR] 0.81; 95% confidence interval [CI] 0.76-0.87) and per transfer (aRR 0.85; 95% CI 0.81-0.90), as well as a lower likelihood of live birth per cycle (aRR 0.76; 95% CI 0.72-0.84) and per transfer (aRR 0.82; 95% CI 0.77-0.88) after controlling for maternal age and other confounders. When restricted to women aged <35 years, there were no significant differences in the rates of live birth or miscarriage among couples in which the men were aged ≤45 years compared with those aged ≥46 years. Compared with paternal age ≤45 years, paternal age ≥46 years is associated with a lower likelihood of pregnancy and live birth among couples undergoing IVF. The negative effect of paternal age is most notable among women aged ≥35 years, likely because maternal age is a stronger predictor of ART outcome.

The risk of recurrent small-for-gestational-age infants at term is dependent on the number of previously affected births

Small-for-gestational-age infants are at a substantially increased risk of perinatal complications, but the risk of recurrent small-for-gestational-age is not well known, particularly because there are many demographic and obstetrical factors that interact and modify this risk. We investigated the relationship between previous small-for-gestational-age births and the risk of recurrence at term in a large Australian cohort. We aimed to identify key demographic and obstetrical variables that influence the risk of recurrence of a small-for-gestational-age infant at term. The primary outcome measure was the odds of recurrence of small-for-gestational-age in subsequent pregnancies up to a maximum of 4 consecutive term births. This was a retrospective analysis of women who had more than 1 consecutive nonanomalous, singleton, term live births between July 1997 and September 2018 at the Mater Mother's Hospital in Brisbane, Australia. Women with multiple pregnancy, preterm birth, or major congenital malformations were excluded. Small-for-gestational-age was defined as birthweight at the <10th centile. We calculated the odds of recurrence depending on the number of previous small-for-gestational-age infants and if only the preceding infant was small-for-gestational-age. The study population was dichotomized into small-for-gestational-age and non-small-for-gestational-age for each consecutive pregnancy. Univariate analyses compared baseline demographic and obstetrical characteristics followed by logistic regression modeling to determine the odds of recurrence in the second, third, and fourth pregnancies. The final study comprised 24,819 women. The proportion of women who had a small-for-gestational-age infant in their first pregnancy was 9.4%, whereas the proportion of women who had a small-for-gestational-age infant in their second, third, and fourth pregnancies after the birth of a previous small-for-gestational-age infant were 20.5% (479 of 2338), 24.6% (63 of 256), and 30.4% (14 of 46), respectively. Regardless of parity, the odds of recurrence increased if the preceding infant was small-for-gestational-age. The odds of recurrence increased markedly if there was more than 1 previous small-for-gestational-age infant. In women with 3 previous small-for-gestational-age infants, the adjusted odds of another small-for-gestational-age infant were 66.00 (95% confidence interval, 11.35-383.76). Maternal age, body mass index, ethnicity, and smoking were significant risk factors for recurrent small-for-gestational-age. However, maternal diabetes mellitus or hypertension, either in a previous or current pregnancy, did not influence the risk of recurrence. The risk of recurrence in a subsequent pregnancy increased if there was a previous small-for-gestational-age birth. Women with consecutive small-for-gestational-age infants were at the highest risk of recurrence. Our results highlight that women with a previous small-for-gestational-age infant are at a substantial risk of another small infant and need to be counseled and monitored appropriately.

Childbirth and motherhood in women with motor disability due to a rare condition: an exploratory study

BackgroundRare diseases may result in motor impairment, which in turn may affect parenthood. Our purpose was to evaluate perinatal outcomes, parenting needs, mother-infant interactions and infant development in a set of volunteer women with motor impairment due to a rare disease. In a parenting support institution, we recruited a consecutive series of 22 volunteer pregnant women or young mothers, recorded perinatal outcomes, and followed mother-infant interaction and relationship and infant development up to 14 months postpartum. Cases with intellectual or psychic disability were not included.ResultsThere were 11 genetic diseases (2 Spinal Muscular Atrophy, 1 Charcot-Marie-Tooth, 1 autosomal dominants myopathy, 1 mitochondrial disease, 2 Elhers-Danlos, 1 Friedreich ataxia, 1 spinocerebellar ataxia, 1 tetrahydrobiopterine deficiency,1 Ectrodactyly), and 11 rare non-genetic conditions (2 spine tumors, 2 strokes, 1 juvenile chronic arthritis, 3 birth injuries, 1 inflammatory myopathy, 1 congenital amputation, and 1 traumatic amputation). These resulted in 10 impairments of four limbs, 4 impairments of both lower limbs, 7 unilateral impairments, and one distal tremor. Social deprivation Epices score, Cutrona social support scale, Edinburg Postnatal Depression scale, and Spielberger State/Trait Anxiety Inventory were unremarkable. Perinatal outcome: 4 gestational diabetes, 1 pre-eclampsia, 9 caesareans, 6 assisted and 7 spontaneous vaginal deliveries, 20 term live-births and 2 premature deliveries (35–36 weeks). Twelve women declared they were self-sufficient for daily activities; six declared they were self-sufficient to provide basic care to their baby. Distribution of the Brunet-Lezine child development score was normal. The parent-infant relationship global assessment scale (PIR-GAS) was well adapted in 2 cases, adapted in 8, perturbed in 7, significantly perturbed in 2, and distressed in 3 (mean 71.8; 95% CI 49.6–93.9). This was unrelated to any somatic or emotional characteristics of the participants. Coding interactive behavior revealed that infant engagement was lower and infant avoidance greater than in controls (p < 0.05).ConclusionInfant development was normal, but mother-infant interactions were altered in half of the participants independently from the degree of motor impairment, underscoring the need for parenting support, even for parents who are self-sufficient in daily activities.

Fertility preservation in men and women: Where are we in 2021? Are we rising to the challenge?

Demand for fertility preservation in women for oncologic, nononcologic, and personal reasons has increased dramatically. Meeting that demand is a major challenge, and we are rising to the challenge. Mature oocyte cryopreservation after ovarian stimulation and ovarian tissue cryopreservation are both methods endorsed by the American Society for Reproductive Medicine (formerly The American Fertility Society), and numerous papers confirmed their efficacy. In girls and women with leukemia or cancers who are at a high risk of ovarian metastasis and who may not be eligible for ovarian tissue transplantation, restoration of fertility can only be achieved by invitro methods. Male fertility preservation has also become a pressing issue and is extensively reviewed in the present journal issue.

Biosensor for Detecting Fetal Growth Restriction in a Low-Resource Setting

One strategy for improving detection of fetal growth restriction (FGR) is developing biosensors identifying placental dysfunction as a leading pathogenesis for FGR. The aim of this pilot study was to investigate the performance of a biosensor specified to detect placental dysfunction by means of maternal arterial turbulence acoustics in a low-resource setting. A cohort of 147 singleton pregnant women were prospectively followed with double-blinded biosensor tests, sonographic estimation of fetal weight (EFW) and Doppler flow at 26–28, 32–34 and 37–39 weeks of pregnancy. Full term live births with recorded birth weights (BWs) and without major congenital malformations were included. Outcomes were defined as (A) a solitary biometric measure (BW &lt; 3rd centile) and as (B) a biometric measure and contributory functional measure (BW &lt; 10th centile and antenatally detected umbilical artery pulsatility index &gt; 95th centile). Data from 118 women and 262 antenatal examinations were included. Mean length of pregnancy was 40 weeks (SD ± 8 days), mean BW was 3008 g (SD ± 410 g). Outcome (A) was identified in seven (6%) pregnancies, whereas outcome (B) was identified in one (0.8%) pregnancy. The biosensor tested positive in five (4%) pregnancies. The predictive performance for outcome (A) was sensitivity = 0.29, specificity = 0.97, p = 0.02, positive predictive value (PPV) was 0.40 and negative predictive value (NPV) was 0.96. The predictive performance was higher for outcome (B) with sensitivity = 1.00, specificity = 0.97, p = 0.04, PPV = 0.20 and NPV = 1.00. Conclusively, these pilot-study results show future potential for biosensors as screening modality for FGR in a low-resource setting.

Successful live birth after repeated high-dose radiotherapy to the uterus

Research questionIt has been established that radiotherapy can increase the risk of adverse pregnancy outcomes. However, there is currently no consensus on the effective sterilizing dose of adulthood uterine radiotherapy. DesignThis is a case report of a 36-year-old women with three different cancer types who received repeated high-dose radiotherapy of 66 Gy and 50 Gy to the pelvis. The study used a dose–volume histogram, the most widely used tool to calculate the radiation distribution within a volume of interest in a patient during radiotherapy. It was determined that the current patient's uterus might have received the highest uterine radiation dosage for full-term live birth that has been reported in the current literature. ResultsDue to iatrogenic ovarian failure, the woman was only able to use donor eggs. After preparation of the endometrium for 18 days, it had reached 8.7 mm in thickness with a triple-line appearance. Two cleavage-stage embryos were transferred, one of which implanted successfully. The course of the pregnancy was uneventful. Finally, the patient gave birth to a healthy baby via Caesarean section at 38+5 weeks of gestation. ConclusionsThe uterus may be more resistant to radiotherapy than previously understood. Uterine fertility preservation methods should be guided by the age of the patient receiving radiotherapy and the actual dose of radiation exposure of the uterus. Future studies should implement a dose–volume histogram to calculate the radiation exposure of the reproductive organs.

217 Creating a calculator to estimate risk of cesarean delivery in patients undergoing induction of labor

To determine the characteristics associated with cesarean delivery among patients undergoing induction of labor (IOL), and to develop and validate a calculator that estimates the risk of intrapartum cesarean delivery. A retrospective chart review was performed to identify all patients with term (≥37 0/7 weeks), singleton, cephalic pregnancies who underwent IOL at an academic institution from January 2017 to December 2018. Patients with prior cesarean delivery, prelabor rupture of membranes, and spontaneous labor were excluded. The primary outcome was mode of delivery. Data on all variables of interest were abstracted and the association between each variable and mode of delivery was investigated with individual logistic regression. Variables with a significant association (p<0.1) then underwent multivariable logistic regression and stepwise selection to determine inclusion in the final model. The receiver operating characteristic curve C-statistic was calculated for the model, and bootstrap resampling was performed to obtain a bias-corrected C-statistic. There were 3905 term live births during the study period. Of these, 919 (23.5%) patients met inclusion criteria. 182 patients (19.8%) delivered by cesarean delivery. Thirteen variables of interest were found to have significant associations with mode of delivery. Six variables were included in the final model - pre-pregnancy body mass index (BMI), maternal age, gestational age, parity, total weight gain in pregnancy and modified Bishop score. The model achieved a C-statistic of 0.84 and the bias-corrected C-statistic was 0.83, thus validating the model in this population. This validated model predicts the risk of cesarean delivery during induction of labor. In contrast to an existing model, it does not include race as a predictive factor for mode of delivery, as that may reflect and perpetuate existing racial disparities in obstetrics. This user-friendly online calculator may be used as an individualized objective tool during prenatal counseling on delivery planning.

Surpoids ou obésité : influence sur les résultats de la première tentative de FIV/ICSI

ObjectivesTo evaluate the influence of overweight and obesity on the results of the first in vitro fertilization attempt, without or with intracytoplasmic microinjection (IVF/ICSI), in terms of live births. MethodsRetrospective observational study concerning the first IVF/ICSI attempts from 01/01/2006 to 31/12/2017 carried out at the Assisted Reproductive Technology of the CHU of Besançon, studying the delivery rate (excluding frozen embryos transfers), and the data of Assisted Reproductive Technology attempts, in overweight (BMI 25 to 29.9kg/m2) and obese women (BMI≥30kg/m2), compared to women with a standard BMI (18 to 24.9kg/m2). ResultsA total of 3192 patients were included. At the end of their first IVF/ICSI attempt, the delivery rate of women with standard BMI was 34.7%. The delivery rate was significantly lower in overweight women (29.5%, p=0.011) and comparable in obese women (32.4%, p=0.476). The birth rate of women with a BMI≥25 kg/m2 was also significantly lower than that of women with a standard BMI (30.4% versus 34.7%, p=0.019). After multivariate analysis, the delivery rate in overweight patients remained significantly lower compared to the population with standard BMI (OR=0.707; 95% CI 0.561–0.890), and comparable in obese patients (OR=0.796; 95% CI 0.585–1.084). ConclusionThe delivery rate was lower in overweight women, whereas it was not significantly different in obese women.

Anogenital Distance in Newborns with Hypospadias

Hypospadias is a very common congenital anomaly in which the urethra opens onto the ventral aspect of the penis rather than at the tip. It has an incidence of less than 1% of live male births. In humans, anogenital distance (AGD) is a sexually dimorphic measure of genital development. In this study, we intended to examine the association between AGD and hypospadias using a homogenous group of patients. The same investigator examined all male newborns in our hospital, and anthropometric measurements of the anogenital distance were recorded. All the measurements were made in millimeters (mm) with a sliding digital caliper (graduated in millimeters) used for measuring the distance between the base of the scrotum to the center of the anus; defined as AGD. During the period Jan 2015 to December 2019 (both inclusive), there were 28,426 (14,615 males and 13,811 females) full-term live births in our hospital. The gestational age of the newborns ranged from 37 to 42 weeks. The mean AGD was 21.06±5.57 (range 12.11 to 33.14) mm in newborns without hypospadias, 9.92±1.90 (range 8.0 – 13.9) in newborns with proximal hypospadias and 17.03±1.95 (range 14.0 to 19.9) mm with distal hypospadias. In humans, hypospadias is associated with reduced anogenital distance. AGD further decreases with the severity of hypospadias.