Tertiary Care Perinatal Center Research Articles

Exploring the clinical utility of exome sequencing/Mono, Duo, Trio in prenatal testing: a retrospective study in a tertiary care centre in South India.

With the availability of Next Generation Sequencing (NGS) diagnosis of genetic disorders has improved significantly. Its use is also applicable to ascertain diagnosis and management in a perinatal setting. The study aims to detect the genetic aetiology of various congenital structural and functional defects using NGS technology in the reproductive cohort at a tertiary centre. The secondary objective is to address challenges in the interpretation of variants. This was a retrospective study of couples who underwent exome sequencing (Mono-testing proband only or Duo-testing parents only or Trio-testing proband and parents) for suspected single gene disorders between years 2020-2022 at a tertiary care perinatal center in the South India. American College of Medical Genetics (ACMG) guidelines were followed to classify the pathogenicity of the variants identified by exome sequencing. The overall diagnostic yield as defined by pathogenic/likely pathogenic variants obtained was (23/43) 53.4 %. The individual subsets have the following diagnostic yield viz., Mono 5/6 (83 %); Carrier 16/32 (50 %); Trio 2/5 (40 %). Diagnostic yield was significantly higher in consanguineous couples. However, miscarriage history, and organ system involvement did not have a significant effect on the diagnostic yield. Prenatal diagnosis was offered for seven patients based on the exome result. One fetus was confirmed with a compound heterozygous pathogenic variant. Diagnostic yield of exome sequencing in our cohort was 53 %. The detection of pathogenic variants was maximum in those cases undergoing Mono exome sequencing. In places where there is a high prevalence of consanguinity and endogamy, NGS may be offered as first line test in the context of prenatal diagnosis.

Postnatal acetaminophen exposure and neurodevelopmental outcomes at 18-21 months corrected gestational age in preterm infants

Studies have reported prenatal acetaminophen exposure is associated with abnormal neurodevelopment. There is limited and conflicting data on neurodevelopmental outcomes following postnatal acetaminophen exposure. Our objective was to investigate the neurodevelopmental outcomes of preterm infants < 29 weeks gestation postnatally exposed to acetaminophen. Retrospective cohort study of infants born between 2008 and 2017 at a tertiary care perinatal center. Exclusion criteria included chromosomal disorders, major congenital abnormalities, and congenital infections. The primary outcome was a composite score of <85 on the cognitive, language, or motor components of the Bayley Scales of Infant and Toddler Development, 3rd edition, assessed at 18 to 21 months corrected gestational age. Multivariate logistic regression was used to assess confounders. Of the 945 infants included in the study, 120 were in the acetaminophen group. There was no difference in any of Bayley-III cognitive, language or motor composite scores of < 85 between the two groups for postnatal acetaminophen exposure, adjusted odds ratios (aORs) 1.03, 95% CI 0.60-1.78, or days of acetaminophen use, aORs 1.10, 95% CI 0.93-1.29. There was no difference in neurodevelopmental outcome between the acetaminophen exposed and non-exposed groups. Our results need validation in larger cohorts. Animal research and cohort studies have suggested that prenatal acetaminophen exposure may be associated with an elevated risk of neurobehavioral abnormalities. However, there is limited and conflicting research on the impact of postnatal acetaminophen on neurodevelopment. The results of this study suggest that postnatal acetaminophen does not negatively impact neurodevelopment at 18 to 21 months in preterm infants born at <29 weeks gestational age. While these results need validation in larger and more longitudinal studies, this study provides reassurance for the use of postnatal acetaminophen in extremely preterm infants.

Comparing Obstetric and Perinatal Outcomes Following Elective and Emergency Cervical Cerclage in Singleton and Multiple Pregnanciesin a Tertiary Care Perinatal Centre.

To compare the success, failure rates and perinatal outcomes following emergency and elective cervical cerclage in singleton and twin pregnancies at a tertiary care perinatal centre over half a decade. All pregnant women, both with singleton and twin pregnancies, who had cervical cerclage between June 2014 and May 2019were included in the retrospective study. Success rates, failure rates, maternalcomplications and perinatal outcomes were compared in both groups. There were 129 women enrolled in the study, 48 in the emergency and 81 in the elective group. A significantly greater number of multiparous women werein the elective group (97.5% versus 68.7%; p-value < 0.001). Twins were nearly four times more in the emergency group as compared tothe elective group. The mean cervical length at time ofcerclage was 2.05cm and 1.5cm; (p-value < 0.001) respectively in the elective and emergency groups. Almost half of the women in the emergency group hadbulging membranes. (52.2%). Following cerclage, mean gestational age at delivery was similar in both groups. However, more women in the elective group delivered at or beyond 34weeksin comparison to the emergency groups (71% versus 53.3%. P-value 0.05). Preterm labour leading to preterm births wasalmost twice in the emergency groupthan elective group (49% versus 22%, P-value 0.002). Rates of maternal chorioamnionitis were similar in both groups. Theoverall live birth rates were comparable (81.3% versus 84.4% P-value 0.85) in boththe groups. These results were also seen on doing subgroup analysis of elective versus emergency cerclage in singleton pregnancies only. Failure rates were also similar in both groups (18.7% versus 15.6%, P-value 0.85) Composite neonatal morbidity was more in the emergency group than in the elective group (35.5 versus 14%, P-value 0.01). Live birth rates and failure rates were comparable following elective and emergency cerclageboth overall and in singleton pregnancies. Maternal chorioamnionitis and neonatal sepsisrates were similar in both the groups. However, composite neonatal morbidity was higher in the emergency cerclage group.

73 Milking of the Cut-Cord during Stabilization of Very Preterm Infants: A Randomized Controlled Trial (The MoCC Study)

Abstract Background Delayed cord clamping (DCC) for at least 30-60 seconds after birth has been recommended as the standard of care for most preterm infants. However, DCC can be contraindicated or not optimal in certain situations (for example, in cases of interrupted placental circulation). Milking of the long-cut cord (MoCC) while providing stabilization and supporting breathing of the infant after birth is proposed as an alternative to DCC. Objectives To investigate the feasibility of MoCC during stabilization of very preterm infants after birth. Design/Methods This parallel-group, randomized controlled trial was conducted at IWK Health, which is a tertiary care perinatal centre in Halifax, Canada. Infants born to eligible, consenting women presenting in preterm labor at &amp;lt;32 weeks’ gestation were randomized to the MoCC group (where the infant received 30 seconds of DCC while initial resuscitation steps were taken by the obstetric provider, followed by milking of the long-cut cord one time over 10 seconds, with breathing supported by the neonatal team) or to the current standard of care group. For these infants, DCC for 30-60 seconds depended on whether the baby was breathing at birth or not. Primary outcome was feasibility in terms of percentage recruitment, intervention compliance, safety, and study completion. Short-term clinical outcomes were collected. Analysis was by intention-to-treat. Results Fifty infants were randomized to either MoCC (25) or DCC (25) (see Figure below). Baseline characteristics were similar. All infants completed the study. One infant in the MoCC group and five infants in the DCC group did not receive the allocated intervention. Median (IQR) time to cord milking was 62 seconds (54, 99) and median (IQR) length of the cut cord milked was 20 cm (14, 29). MoCC was not associated with adverse effects when compared with DCC (see Table). Conclusion Milking the long-cut cord one time after 30 seconds of DCC, while supporting breathing, was feasible and not associated with adverse effects. A large randomized controlled trial is required to assess the efficacy of this approach for clinical outcomes. MoCC may be especially useful when immediate clamping is indicated. Potential competing interests Dr. El-Naggar has served as a consultant for Aerogen Pharma Limited and is a site investigator of its funded study: A Partially-Blind, Randomized, Controlled, Parallel-Group, Dose-Ranging Study to Determine the Efficacy, Safety and Tolerability of AeroFactTM (SF-RI 1 surfactant for inhalation combined with a dedicated drug delivery system) in Preterm Infants at Risk for Worsening Respiratory Distress Syndrome.

A retrospective study analyzing indications and outcomes of mid-trimester emergency cervical cerclage in a tertiary care perinatal centre over half a decade.

We studied the indications, success rate, perinatal outcomes and maternal complications following mid-trimester emergency cervical cerclage. All women undergoing mid-trimester emergency cerclage at our centre during 2014-2019 were included in this retrospective study.There were 46 women in our cohort. Mean cervical length was 1.5 cm (SD ± 0.7), and 52.1% of them had bulging membranes. The mean gestational age at cerclage was 23.35 weeks (SD ± 3.341). Three were loss to follow up.Out of 43 pregnancies (23 singletons and 20 twins) analyzed, 37/43, 86.4% had livebirths. Success rate in the singletons and twins were 91.3% and 80% respectively. Maternal complications were seen in 56.5% of patients. Composite neonatal morbidity was significantly more in the twin group (p-value 0.04).Overall live birth rate was 86.4% with similar success rates in singleton and multiple pregnancies. Although, evidence for beneficial effect of prophylactic cerclage in multiple gestation is lacking, emergency cerclage may have a role in twin gestation.

Fibrinogen may aid in the early differentiation between amniotic fluid embolism and postpartum haemorrhage: a retrospective chart review

This study aimed to determine whether blood loss and fibrinogen can differentiate amniotic fluid embolism (AFE) from postpartum haemorrhage (PPH). This retrospective case–control study included nine patients with clinical AFE (“AFE group”) and 78 patients with PPH managed at our tertiary care perinatal centre between January 2014 and March 2016. Patients meeting the Japanese diagnostic criteria for AFE were stratified into cardiopulmonary collapse-type AFE and disseminated intravascular coagulation (DIC)-type AFE groups. The relationship between blood loss and fibrinogen at onset was examined to compare DIC severity. Vital signs at onset were not significantly different. The AFE group had significantly less blood loss at onset (1506 mL vs 1843 mL, P = 0.0163), significantly more blood loss 2 h post-onset (3304 mL vs 1996 mL, P < 0.0001) and more severe coagulopathy and fibrinolysis. The blood loss/fibrinogen (B/F) ratio at onset was significantly higher in the DIC-type AFE group (23.15 ± 8.07 vs 6.28 ± 3.35 mL dL/mg, P < 0.0001). AFE was complicated by catastrophic DIC irrespective of blood loss at onset. Fibrinogen exhibited the strongest correlation among test findings at onset. The B/F ratio may help differentiate PPH from DIC-type AFE and diagnose clinical AFE, facilitating optimal replacement of coagulation factors during the early stages.

Incidence of G6PD deficiency among neonates with hyperbilirubinemia requiring phototherapy at postnatal wards of a tertiary care perinatal center, Dubai, UAE: A longitudinal cross-sectional study

Incidence of G6PD deficiency among neonates with hyperbilirubinemia requiring phototherapy at postnatal wards of a tertiary care perinatal center, Dubai, UAE: A longitudinal cross-sectional study

Compliance with Fetal Fibronectin Testing at a Canadian Tertiary Care Perinatal Centre.

The purpose of this study was to assess compliance with fetal fibronectin (fFN) testing recommendations at a single tertiary care perinatal centre. The secondary objective was to identify factors associated with compliance with these recommendations. A retrospective cohort study was conducted from January 1, 2016 to December 31, 2016 of all patients who presented to the IWK Health Centre with suspected preterm labour. Inclusion criteria included symptoms of preterm labour prior to 370 weeks gestation, singleton or multiple pregnancy, and established fetal wellbeing. Exclusion criteria included severe fetal anomaly, contraindications to tocolysis, transfer from community hospital, or inadequate documentation. Provider compliance was evaluated to determine: 1) whether the test was performed for appropriate indications according to provincial fFN guidelines; 2) whether fFN results were appropriately being used to inform patient care. Logistic regression was used to determine factors associated with compliance. A total of 528 patients presented with symptoms of preterm labour. The overall compliance with testing recommendations was 76.1%. Compliance for patients who met criteria for fFN testing was 73%, and compliance for those not meeting criteria was 76.4%. Of patients with a negative fFN result, 85.3% were appropriately discharged home without intervention. Gestational age, time of day, and non-obstetrician provider type were found to be associated with compliance. Despite regional and national guidelines, this study demonstrates a compliance rate of 76% in our centre, indicating a gap in provider knowledge regarding proper use and interpretation of fFN. Non-obstetrician provider type was associated with decreased compliance.

Recurrence risk of preterm births: a retrospective Indian study

Preterm birth (PTB) is the leading cause of neonatal deaths and India is the biggest contributor to the global burden of PTBs. This study aimed to determine the risk of recurrence of PTBs and factors associated with recurrence among mothers delivered at a tertiary care perinatal centre in India. This retrospective study comprised women who had delivered singleton preterm babies (24–37 weeks of gestation and weighing ≥500 g) in 2009 and 2010, and had subsequent deliveries beyond 24 weeks of gestation by the end of March 2016. Preterm births were stratified as spontaneous and those with an indication for delivery. Information on demographic data and maternal and neonatal outcomes was accessed from the case records or enquired over telephone. Among 291 eligible women, the recurrence rate of PTB was 31.6%; 29.1% for prior spontaneous and 34.0% for indicated preterm deliveries. This recurrence risk is similar to that in the western populations. In 75.0% of the cases, the type of recurrent PTB corresponded to the index PTB. Preeclampsia (PE) was significantly associated with recurrence (OR 7.10; 95% CI: 3.33, 15.11; p < .001); thus, prevention of PE is a key component in the prevention of PTB. Impact Statement What is already known on this subject? Preventing preterm birth (PTB) remains a challenge because the causes of PTBs are numerous, complex and poorly understood. Spontaneous PTB before 34 weeks of gestation is a strong predictor of subsequent spontaneous PTB. Spontaneous PTB is not only associated with increased recurrence of spontaneous but also medically indicated PTB and vice versa. Risk factors may vary by the clinical subtype of the most recent PTB. What the results of this study add? Despite the highest reported number of PTBs, there are no data on recurrence from India. This study reveals that the recurrence rate of PTBs in an Indian population appears to mirror the rates in the developed nations and preeclampsia (PE) is strongly associated with recurrence. What the implications are of these findings for clinical practice and/or future research? The results of this study are useful for counselling women who had previous PTBs regarding their future obstetric outcomes. Focussed research on prediction and prevention of PE is an essential element in the algorithm for prevention of PTBs.

Decoding stillbirths using the Relevant Condition at Death classification: Study from the developing world

Objective:To determine the stillbirth rate in 2017 at Christian Medical College, a tertiary care perinatal center in South India, and to identify causes for the various stillbirths that occurred using the Relevant Condition at Death (ReCoDe) classification.Material and Methods:Medical records of the women with stillbirths between January 1st, to December 31st, 2017, were retrieved and analyzed using the SPSS software (IBM, version 23). The study was approved by the institutional review board (minute no: 11273, retro dated: 28/3/2018).Results:Of the total 14696 deliveries between January 1st, 2017, to December 31st, 2017, there were 247 stillbirths, a rate of 16.8 per 1000 births. Maternal factors: 156 (64.2%) women were booked and the rest were un-booked. Hypertensive disorders of pregnancy were detected in 27.5% (n=67). A greater number of un-booked women had gestational hypertension as compared with booked women (41% vs 24%, p=0.005). Fetal characteristics: still births secondary to lethal congenital anomalies were seen in 18.2% (n=45). Lethal congenital anomalies were diagnosed 10 times more in the booked patients than un-booked ones (24.7% vs 2.3%, p=0.001). Obstetric factors: one or two previous miscarriages were seen in 29.5% cases. Seventeen women (6.9%) had a prior stillbirth. ReCoDe Classification: we were able to successfully classify 84.2% of the stillbirths, leaving 15.78% unclassified. Fetal growth restriction secondary to uteroplacental insufficiency was found in 25.9% cases. Of the placental causes, abruption accounted for 10.9% of cases. Medical co-morbidities were seen in 46.5% pregnancies.Conclusion:The ReCoDe method of classifying stillbirths is useful in the developing world. It helped to elucidate the cause for stillbirths in 84.2% of cases. The majority of cases in our set were due to fetal growth restriction, hypertensive disorders of pregnancy, and uteroplacental insufficiency. Stillbirths can be prevented by a comprehensive antenatal care system, early recognition, and close monitoring of high-risk pregnancies.

Neurological Outcome at 30 Months of Age after Mild Hypothermia via Selective Head Cooling in Term Neonates with Perinatal Asphyxia Using Low-Cost CoolCap: A Single-Center Randomized Control Pilot Trial in India

AbstractThe objective of this study was to determine the effectiveness and safety of mild systemic hypothermia by selective head cooling in hospital born neonates with hypoxic-ischemic encephalopathy using low-cost CoolCap. The primary outcome was to determine whether selective head cooling reduces neonatal mortality and neurodevelopmental delay (NDD) at &gt; 30 months of age. The secondary outcome was to determine the serious adverse effects during selective head cooling such as thrombocytopenia requiring platelets transfusion, renal and hepatic dysfunction, bradycardia, hypoglycemia, and dyselectrolytemia (hyperkalemia, hyponatremia, and hypocalcemia). This is a single-center randomized control trial. The risk ratios, risk differences, and numbers needed to treat plus 95% confidence interval (CI) were measured. This study was done at the tertiary care perinatal center. Inborn neonates with ≥ 37 completed weeks of gestation with indicators of perinatal asphyxia and moderate to severe clinical encephalopathy were randomly allocated to hypothermia (n = 30) or standard care (n = 30) groups. The neonates were subjected to mild systemic hypothermia via selective head cooling using ice caps, the target rectal temperature being 34 to 35°C for 72 hours. Therapeutic hypothermia reduced the risk of death and NDD at ≥ 30 months of age: 6 of 30 infants (20%) in the hypothermia group and 18 of 30 infants (60%) in the control group died or had a NDD at ≥ 30 months (risk ratio: 0.33 [95% CI: 0.15–0.72]; p = 0 0.0015). The mortality rate decreased, and the survival rate free of any sensorineural disability increased. The benefits were statistically significant in moderately asphyxiated infants. Adverse effects of hypothermia were minimal. Selective head cooling with mild systemic hypothermia in term asphyxiated neonates is safe and inexpensive in low-resource setting. Hypothermia showed statistically significant reduction in mortality and NDD at ≥ 30 months of age when commenced within 6 hours of birth and was not associated with serious adverse effects. The Institutional Clinical Trial Registry number is CNMC/ETHI/317/P.

Maternal and Early Perinatal Outcomes of Triplet Pregnancy: Study of 82 Triplets from a Single Perinatal Centre in South India.

To study the recent trends in maternal and perinatal outcomes of triplet pregnancy from a perinatal centre in South India. All triplet pregnancies booked at Fernandez hospital, Hyderabad (a tertiary care perinatal centre in South India), or those referred between 2000 and 2014 were included in the study. The maternal, fetal and neonatal outcome and any interventions like cerclage, steroid administration were studied. There were 82 triplet deliveries over the study period of 15 years (82 per 69,584 live births). Most of them (78%) conceived with assistance and 83% of the triplets were trichorionic triamniotic. Anaemia and pregnancy induced hypertension were the commonest medical disorders (40.2 and 22%, respectively). Mean gestational age at delivery was 32 ± 2.8 weeks and 91% were delivered by caesarean section. Preterm labour and preterm pre-labour rupture of membranes were present in 29 and 15%, respectively. Antenatal steroids were administered in 87.8 and 53.7% had a cerclage. There were 20.7% growth restricted fetuses and 5.6% still births among the triplets. The mean birthweight among the live born neonates was 1.5kg, and birthweight discordancy of >25% was seen in 14%. Among the live born neonates, 80% required admission to the neonatal intensive care unit, 11% had culture positive sepsis, 3% had bronchopulmonary dysplasia, and 4% died during the hospital stay. None of them had periventricular leukomalacia or retinopathy requiring LASER. Mothers in the spontaneous conception group were younger and had more monochorionic triamniotic pregnancies than in the assisted conception groups (11.8 vs. 2.9%, p=0.001). The incidence of PPROM was significantly more in the spontaneous conception group than in the ovulation induction, intrauterine insemination groups (29.4 vs. 2.9%, p=0.03), we do not have an explanation for this. There was no difference in the other maternal, fetal or neonatal parameters based on the mode of conception. Though triplet pregnancies are encountered infrequently, obstetricians should be familiar with their management. Appropriate antenatal, perinatal care with neonatal support can result in optimal outcome.

Identification of Fetal Growth Patterns with Customized Growth Charts: A prospective study in South India

ABSTRACTAimTo determine the diagnostic effectiveness of symphysis fundus height (SFH) measures plotted on customized growth charts for the identification of fetal growth patterns in a tertiary care perinatal center in south India.Materials and methodsSerial SFH of pregnant women with singleton babies booked for antenatal care up to 22 weeks was measured from 24 weeks of gestation and plotted on customized growth charts that were developed using the gestation related optimal weight (GROW) software downloaded from www.gestation.net to identify fetal growth patterns. Fetal growth patterns were also ascertainedusing ultrasound in the antenatal period and confirmed at birth using a neonatal growth classification. The diagnostic effectiveness of SFH was compared with ultrasound and neonatal classifications using sensitivity, specificity, area under the ROC curve and likelihood ratio testsResultsThe study included 666 pregnant women who presented at the antenatal clinics from January 2010 to October 2010. On ultrasound examination, 564 (84.6%) fetuses were AGA, 78 (11.7%) fetuses were LGA and 19 (2.9%) were SGA and 5 (0.8%) showed crossing centile from higher to lower pattern. On serial SFH measures, 426 (64.0%) of the fetuses were normal growth, 180 (27.0%) were excessive growth and 40 (6.0%) were slow growth. Serial SFH measures had a positive likelihood ratio of 4.7 (8.5 for USG) for the identification of SGA and a negative likelihood ratio of 0.06 for the detection of LGA.ConclusionThe SFH measures plotted on a customized GROW curve have the potential to develop into a low cost screening tool to identify fetuses with altered growth. The diagnostic effectiveness of SFH plotted on customized growth charts has to be improved further through the development of appropriate customized growth charts for India before application on a larger scale.How to cite this articleRadhika B, Suseela V, Nirmalan PK. Identification of Fetal Growth Patterns with Customized Growth Charts: A prospective study in South India. Int J Infertil Fetal Med 2015;6(1):30-34.

PS-298 Randomised Controlled Trial To Compare Efficacy Of Different Timing Of Antibiotics At Caesarean Section And Their Effect On Mother And Newborn

Background During caesarean section, prophylactic antibiotics are usually given after cord clamping (instead of prior to skin incision) for fear of antibiotics having adverse effects on the newborn and promoting resistant strains. Objective To compare efficacy of intravenous cefazoline administered during caesarean section either before skin incision or after cord clamping, on mother and newborn. Setting Tertiary care perinatal centre in south India. Methods Term gestation mothers posted for caesarean section were randomised to receive two medicinesIV cefazoline/ placeboone prior to skin incision, one after cord clamping. Mothers and babies were monitored for evidence of infection or adverse events during hospital stay. They were reviewed at 45 days to look for complications. Results 1106 mothers were recruited. At baseline, mothers and babies in both groups were similar. The mean (SD) duration of hospital stay for mothers in both groups was 5.3(1.5) days. Mothers who received antibiotics prior to skin incision had less post operative complications compared to mothers who received antibiotics after cord clamping (p = 0.000). Mothers who received antibiotics after cord clamping stayed longer in hospital (p = 0.008). Babies in both groups had similar rates of nursery admissions, sepsis, NEC and hospital readmission following discharge. Conclusions IV antibiotics can be safely administered to mothers prior to skin incision which decreases postoperative infectious morbidity without adverse effects in babies.

Vitamin D status and adequacy of standard supplementation in preterm neonates from South India.

The aim of this study was to assess vitamin D status of preterm babies at birth and adequacy of daily supplementation with vitamin D. This prospective cohort study recruited 111 preterm babies, 25 to 32 weeks' gestation from a tertiary care perinatal center in south India. Cord blood was assayed for serum calcium, phosphate, alkaline phosphatase, and 25-hydroxyvitamin D (25(OH)D). All of the babies were fed unfortified breast-milk and supplemented daily with calcium, phosphate, and 400 IU of vitamin D. At 6 weeks serum calcium, phosphate, alkaline phosphatase, parathyroid hormone, and 25(OH)D levels were estimated. Of 111 preterm babies recruited, a total of 90 (81%) of the preterm babies were followed up until 6 weeks. The median (interquartile range) vitamin D level in the preterm group was 34.7 (25.6-50.1) and 19.3 (13.9-27.1) ng/mL at birth and 6 weeks, respectively. Using a cutoff value of <20 ng/mL to determine vitamin D insufficiency (VDI), it was observed that 12.6% of the babies were vitamin D insufficient at birth. This increased to 52.2% at 6 weeks despite the recommended supplementation with vitamin D (P < 0.001). The prevalence of VDI was not high at birth; however, a large proportion of preterm babies were vitamin D insufficient at 6 weeks despite being supplemented with vitamin D 400 IU/day. The recommended vitamin D supplementation of 400 IU appears to be inadequate to prevent VDI, and hence randomized controlled trials looking at higher doses of vitamin D supplementation are needed.

Outcome of very low birth weight infants with abnormal antenatal doppler flow patterns: A prospective cohort study

Fetal growth restriction and abnormal Doppler flow studies are commonly associated. Neonatal outcomes are not well known particularly in developing countries, where the burden of the disease is the highest. To determine outcomes of preterm infants with history of absent/reversed end-diastolic umbilical artery Doppler flow (AREDF) vs. infants with forward end-diastolic flow (FEDF). Cohort study. Tertiary care perinatal center in India. 103 AREDF very low birth weight (<1500 gm) (VLBW) infants and 117 FEDF VLBW infants were prospectively enrolled. At 40 weeks adjusted post-menstrual age, AREDF vs. FEDF group had a higher risk for death in the NICU (12% vs. 1%), respiratory distress syndrome (33% vs. 19%), and cystic periventricular leukomalacia (12% vs. 1%). At 12-18 months corrected age, AREDF vs. FEDF group had a trend towards increased risk for cerebral palsy (7% vs. 1%, P=0.06). After logistic regression analysis, adjusting for confounders, AREDF was independently associated only with mortality in the NICU. AREDF is an independent predictor of adverse outcomes in preterm infants in a developing country setting.

Perinatal outcome of infants born to diabetic mothers in a developing country-comparison of insulin and oral hypoglycemic agents

To study the perinatal outcomes of infants born to mothers with gestational diabetes treated with insulin or oral hypoglycemic agents in a developing country. Prospective observational cohort study. Tertiary-care perinatal center in southern India. Babies born to mothers with gestational diabetes. Maternal details were obtained and physical examination was performed on the neonates. Babies were given hourly feeds soon after birth and blood glucoses checked at 1, 3, 5, 9 and 12 hours of life; hematocrit and calcium levels were also measured. Perinatal outcomes were compared between mothers who required insulin or an oral hypoglycemic agent for treatment of diabetes. Of the 10,394 mothers who delivered during the study period, 574 (5.5%) were diagnosed to have gestational diabetes. 137 were treated with insulin and 141 with oral hypoglycemic agents. 44 (15.8%) babies were born preterm, 97 (35%) were large for gestational age, 13 (4.7%) were small for gestational age and 9 (3.2%) were macrosomic. Hypoglycemia was seen in 26 (9.3%) babies, congenital anomalies in 15 (5.4%) and birth injuries in 7 (2.5%). There was no difference between the two groups in any of the outcomes except for hyperbilirubinemia, which was more in the insulin group (13.7% vs 6.5%, P=0.04). There was no difference in the perinatal outcome whether the mother received insulin or an oral hypoglycemic agent for treatment of gestational diabetes other than the increased incidence of hyperbilirubinemia in the insulin group.

Neonatal outcomes are associated with latency after preterm premature rupture of membranes

To determine factors associated with latency time to birth after preterm premature rupture of membranes (PPROM) and the impact on neonatal outcomes. Data on singleton pregnancies with PPROM (n=1535 infants) were prospectively collected in a computerized perinatal/neonatal database at a tertiary care perinatal center. Latency was characterized as ≤72h versus >72 h after PPROM. The percentage of women with latency to birth >72 h decreased from 67% in very preterm (gestational age (GA) 25 to 28 weeks) to 10% in late preterm women (GA 33 to 36 weeks). PPROM women with latency ≤72 h were more likely to have pregnancy-induced hypertension and birth weight <3%; PPROM women with latency >72 h were more likely to have received steroids and develop clinical chorioamnionitis. PPROM <32 weeks GA with latency ≤72 h was associated with a two-fold higher incidence of severe neonatal morbidity, while PPROM between 29 to 34 weeks GA and latency ≤72 h was associated with a higher incidence of moderate neonatal morbidity. A latency period >72 h was associated with a decreased incidence of adverse neonatal outcomes up to 32 weeks GA for severe and 34 weeks GA for moderate morbidity indices.

682: Geographical information systems (GIS) mapping indicates access to tertiary care perinatal centers in the United States is regionally maldistributed

As current trends in the maternal-fetal medicine (MFM) workforce exacerbate supply-demand problems, access to care will require increasing attention. Geographic distribution of MFM providers and tertiary care centers are determinants of access to care. The objective of this investigation was to determine the percentage of reproductive-age women living within 30 and 60 minute driving times to the nearest tertiary care perinatal center within all regions of the United States.

Clinical symptoms and laboratory parameters do not predict adverse maternal and fetal outcomes in HELLP

Aim To determine the ability of clinical symptoms and laboratory parameters to predict adverse outcomes in HELLP syndrome. Methods A retrospective chart analysis of pregnant women diagnosed with HELLP during a 5 year (2005–2009) period at a tertiary care perinatal center. The diagnosis of HELLP was based on Sibai’s criteria and categorized based on the Mississippi classification. Clinical symptoms and the presence of maternal and fetal adverse events were noted from the records. Receiver operator characteristics, likelihood ratios and adjusted odds ratios were used to determine the predictive ability of clinical symptoms and laboratory parameters. Results The medical records of 74 pregnant women with HELLP were analyzed. Any adverse (maternal and/or fetal) event was present in 40 (54.1%, 95% CI: 42.4%, 65.7%) pregnancies with HELLP syndrome in this population. One in four pregnancies with HELLP resulted in an adverse maternal event and 35% of pregnancies with HELLP in an adverse fetal event. There were no maternal deaths in this series and the perinatal mortality rate was 149 per 1000 births. Clinical symptoms or laboratory parameters were not predictive of adverse events. Conclusions Further research is needed to identify factors that can predict adverse perinatal outcomes in HELLP.