Uncomplicated Singleton Research Articles

Association between Maternal Serum Hormones along the Maternal–Fetal Hypothalamic–Pituitary–Adrenal Axis and Successful Vaginal Delivery Measured Prior to Labor Induction

This study aimed to evaluate if maternal serum hormones along the maternal-fetal hypothalamic-pituitary-adrenal (HPA) axis, when drawn prior to labor induction, differed between women who delivered vaginally and those who underwent cesarean. This was a prospective observational study at a single perinatal center performed from August 2017 to May 2018. Nulliparous women with uncomplicated singleton pregnancies ≥39 weeks had maternal serum collected prior to induction. Corticotrophin-releasing hormone (CRH) was measured by ELISA; dehydroepiandrosterone sulfate (DHEA-S), cortisol, estriol (E3) estradiol (E2), and progesterone (P4) were measured by chemiluminescent reaction. Mean analyte concentrations as well as three ratios (E2/P4, E3/P4, and E2/E3) were compared between women who had a vaginal versus cesarean delivery. Logistic regression was used to model the relationship between CRH and the odds of vaginal birth. We estimated that a sample size of 66 would have 90% power to detect a 25% difference in mean CRH levels assuming a vaginal:cesarean ratio of 2:1 with a baseline CRH concentration of 140 (standard deviation = 36) pg/mL. Of the 88 women who had their serum analyzed, 27 (31%) underwent cesarean. Mean maternal serum CRH levels were similar between the vaginal delivery and cesarean groups (122.6 ± 95.2 vs. 112.3 ± 142.4, p = 0.73). Similarly, there were no significant differences in any other maternal serum analytes or ratios. Logistic regression showed a nonsignificant odds ratio for successful vaginal birth (p = 0.69) even when evaluating only the 16 women who had a cesarean for an arrest disorder (p = 0.08). In low-risk nulliparous women undergoing full-term labor induction, there were no differences noted in a broad array of other maternal-fetal HPA-axis hormones between women who had a vaginal or cesarean delivery.

Global longitudinal reference ranges for fetal myocardial deformation in the second half of pregnancy.

To construct longitudinal fetal reference ranges for global longitudinal myocardial deformation (strain and strain rate) of the left and right ventricles in the second half of pregnancy. A prospective, observational, longitudinal study of 120 women with uncomplicated singleton pregnancies. The participants underwent ultrasonographic scans every 4 weeks from enrolment (18-28 weeks) until delivery. Strain and strain rate were measured at each examination using velocity vector imaging. Changes in strain and strain rate as functions of gestational age (GA) were modeled using Bayesian mixed effects models. A total of 406 assessments of global longitudinal strain and strain rate were performed for 120 women. Global longitudinal strain and strain rate decreased with increasing GA in the left ventricle. There was, however, no change in strain measurements of the right ventricle over the same gestational time frame. Posterior predictive distributions were used to derive reference centiles for each week of GA. Assessment of myocardial deformation of the fetal heart is easily performed and may be useful for quantitative assessment of heart function, particularly in fetuses at risk of cardiac dysfunction.

Characterizing the Effects of Diabetes and Obesity on Insulin and Leptin Levels amongst Pregnant Women.

In this study, we assess the impact of obesity and diabetes on maternal brain and periphery, as well as fetal exposure to insulin and leptin, and two hormones that play an important role in regulating energy homeostasis. Fasting maternal plasma, fetal cord vein and artery plasma, and maternal cerebrospinal fluid (CSF) were collected in 37 women (12 lean, nondiabetic [prepregnancy body mass index (BMI): 22.9 ± 1.7 kg/m2]; 12 overweight/obese nondiabetic [BMI: 37.8 ± 7.3 kg/m2]; 13 gestational/type 2 diabetes mellitus [BMI: 29.8 ± 7.3 kg/m2]) with uncomplicated singleton pregnancies undergoing elective Cesarean delivery. HbA1C, insulin, glucose, and leptin levels were measured. Compared with lean mothers, mothers with obesity and diabetes mellitus (DM) had significantly lower CSF-to-plasma ratios of insulin. Moreover, mothers with obesity and DM had significantly lower cord arterial and cord venous to maternal plasma ratios of insulin, but not leptin, compared with lean mothers. There were no differences in CSF and cord blood insulin and leptin levels between obese and DM mothers. Compared with lean individuals, mothers with obesity and DM have relative deficiencies in insulin exposure. The patterns observed in mothers with obesity and diabetes were similar highlighting the importance of the maternal metabolic environment in obesity and suggesting obese patients warrant further clinical focus.

New Delivery Chair for Vaginal Delivery

Objectives: Compared to different upright positions, delivery in recumbent position in bed may increase the likelihood of operative delivery and other delivery complications, and also decrease levels of maternal self-control. A new delivery chair has been developed to facilitate a variety of upright positions during labour. A randomized controlled trial was conducted to evaluate the impact of the delivery chair use on selected obstetrical and neonatal outcomes, compared to traditional recumbent position. Methods: A total of 1477 women with uncomplicated singleton pregnancy ≥ 34 gestational weeks with fetus in vertex presentation were enrolled in the study: 776 in the delivery chair group, and 701 in the control group. Results: An intention-to-treat analysis showed no differences between the groups in any of the outcomes used. Of the women in the delivery chair group, 251 used the chair throughout the second stage. An as-treated analysis was performed between these 251 women and their counterparts in the control group. Women using the delivery chair had a shorter second stage of delivery, fewer episiotomies, and less need for vacuum extraction, with no difference in blood loss or neonatal outcome. However, women using the delivery chair had more third-degree tears (11 cases, or 4.4%, vs. 9 cases, or 1.8%). Conclusion: The novel delivery chair can be safely used for vaginal delivery. More attention should be given to perineal support to prevent perineal tears. There is a need for multicentre trials of the delivery chair using standardized measurements of outcomes, including maternal pain, maternal self-control, and overall satisfaction.

The efficacy of intermittent preventive therapy in the eradication of peripheral and placental parasitemia in a malaria-endemic environment, as seen in a tertiary hospital in Abuja, Nigeria.

To determine whether intermittent preventive therapy in pregnancy (IPTp) eradicates peripheral and placental malaria and improves birth weight. A cross-sectional study was conducted of 426 pregnant mothers on IPTp with sulphadoxine-pyrimethamine against malaria who presented in labor, at National Hospital Abuja, Nigeria between January and June 2017. The hospital is within the malaria-endemic zone of West Africa. Consenting pregnant women with uncomplicated singleton term pregnancy who had antenatal care in the hospital and lived in the study area for at least 6months were consecutively recruited. Peripheral and placental blood were collected and examined for malaria parasite by microscopy. Babies were weighed at birth. The prevalence of peripheral malaria parasitemia and placental parasitization were 12.9% (95% confidence interval [CI] 10.0-16.6) and 9.4% (95% CI 7.0-12.7), respectively. Parasite density in both peripheral parasitemia and placental parasitization was low among the women that took IPTp, decreasing with increasing doses, with no parasitemia or parasitization in women that took up to three doses. Birth weight was lower in babies of mothers with plasmodium infestation than in those without infestation (P<0.001, P=0.024). IPTp reduces both peripheral parasitemia and placental parasitization, with the capacity to eliminate or prevent them. IPTp also reduces low birth weight.

Reliability and characteristics of ultrasound measurement of fetal umbilical venous blood flow volume according to the site of measurement.

This study aimed at assessing the reliability and characteristics of fetal umbilical venous blood flow volume (UVFV) measurement using ultrasound. We conducted a prospective study at our center from November 2017 to July 2019. We performed transabdominal ultrasound examinations at 18-34weeks' gestation in uncomplicated singleton pregnancies. UVFV was calculated using vessel diameter (D) and maximum flow velocity (V) as follows: (D/2)2 × π × V × 0.5 × 60 (Q, mL/min). Two examiners measured each value three times in the free-loop (FL) and intra-abdominal (IA) portions of the umbilical vein. Intra-rater and inter-rater reliability was evaluated by intraclass correlation coefficient (ICC) and a Bland-Altman plot. Two hundred and eight cases were measured by two examiners. The rate of complete measurement at FL and IA was not significantly different (88.5% vs. 79.3%, respectively; p = 0.113). The intra-rater reliability of D and V was high at FL and IA. Regarding inter-rater reliability, the ICC of D, V, and Q was 0.973, 0.582, and 0.963 at FL, and 0.994, 0.912, and 0.989 at IA, respectively. A Bland-Altman plot showed that D and V had greater standard deviation at FL than IA. Regarding Q, the standard deviation at FL was also larger than at IA, and measurement variance at FL increased as the measured value increased, but that at IA did not. UVFV measurement showed high intra-rater and inter-rater reliability at FL and IA, but the variance of measurements at FL became large as the measured value increased. Properties of different measurement sites should be considered when evaluating UVFV.

The Relation of Fetal Colon Diameter with Estimation of Gestational Age

Background: Conventional ultrasound dating is not very accurate after 34 weeks of gestation and has standard deviation of about 2 weeks. Objective: Verify whether fetal colon diameter can be used as a tool for estimating gestational age (GA) of fetuses between 34 to 40 weeks. Materials and Methods: This was a prospective cross-sectional study conducted at Obstetrics and Gynecology University Hospital, Damascus, Syria, during the period from September 2019-September 2020. The study enrolled 395 women with uncomplicated singleton pregnancies at 34 - 40 weeks of gestation. Fetal bi-parietal diameter, head circumference, abdominal circumference, and femoral lengths were assessed by ultrasound. In addition, descending colon diameter was assessed at the level of colonic haustra. The correlation between GA and colon diameter was assessed by the Pearson correlation test. Results: Significant correlation between fetal colon diameter and gestational age was observed P diameter and bi-parietal diameter, femoral length, head circumference and abdominal circumference were found with P values rd trimester and colon diameter was significantly stronger than the correlation between gestational age and bi-parietal diameter, head circumference, and abdominal circumference. Whereas, no significant difference was found when comparing colon diameter and femoral lengths (P = 0.089). Conclusion: The present study suggested that colon diameter can be used for predicting third trimester gestational age.

Comparison of outcomes of Foley's induced labors with different sonographic floater densities in fore-water

Background: Onset of spontaneous labor occurs on completion of fetal functional maturity at amniotic fluid optical density (AFOD) 0.98 ± 0.27 (mean ± SD). All three events occurring together at any time from 35 weeks to 42 weeks indicate the individualized term for each fetus. No failures of induction of labor were reported when labors induced at AFOD 0.98 ± 0.27. As AFOD estimation needs invasive amniocentesis, we tried to induce women with liquor with mature AFOD by observing the sonographic appearances of fore-water by transvaginal sonography. Methods: In this comparative study, three groups of gestational age and parity matched uncomplicated singleton term pregnant women, underwent fore-water trans-vaginal sonography before induction of labor with Foley's catheter. Sonographic images were divided into three grades based on floating particle densities. Each group consisted of 20 women with each grade of sonographic images. Uncentrifuged fresh AF samples collected at amniotomy were used for AFOD measurement with colorimeter at 650 nm in all groups. After Foley's expulsion, labor was augmented with vaginal misoprostol. The mean AFOD values, Foley's insertion expulsion intervals, Foley's insertion delivery intervals (FIDI), T misoprostol required, and neonatal respiratory distress were recorded in each group and compared. Results: In groups 1, 2, and 3, the mean AFOD was found to be 0.29 ± 0.09, 0.68 ± 0.14, and 1.15 ± 0.20, respectively. Mean Foley's insertion expulsion intervals were 10.57 ± 3.76 h, 5.83 ± 2.24 h, and 4.08 ± 0.86 h, respectively. Mean FIDI were 20.00 ± 6.20 h, 11.22 ± 4.20 h, and 8.95 ± 2.98 h, respectively. The mean numbers of T misoprostol required in each group was 3 ± 1, 2 ± 1, and 2 ± 1, respectively. Significant differences were observed in all outcomes between groups (P Conclusion: Labor induction with Grade 3 sonographic images of fore-water was successful in all women with shorter FIDI, and with better perinatal outcomes.

603: Prediction of labor dystocia indicated primary cesarean delivery in women undergoing induction of labor

Induction of labor (IOL) is one of the most frequent interventions in obstetrics. Our objective was to determine if fetal biometric parameters obtained near term and antenatal factors predicted labor dystocia-indicated PCD in women who experienced IOL. Analysis of a prospective multicenter NIH-sponsored National Fetal Growth Study-Singletons. Women with a non anomalous,uncomplicated singleton gestation who underwent IOL at ≥37 0/7 weeks were included. Serial sonographic exams with the final exam at 37.5 +/- 1.9 weeks were performed. Estimated fetal weight (EFW), individual biometric parameters, derived measures of fetal asymmetry (i.e biparietal diameter (BPD) - abdominal diameter (AD) difference), and amniotic fluid deepest vertical pocket measured at the last scan and categorized as < 10th, 10th- 90th(reference), >90th percentiles were compared for women who had labor dystocia-indicated PCD versus spontaneous vaginal delivery. Multivariable logistic regression analysis was conducted to assess the association of fetal biometric parameters with labor dystocia-indicated PCD. A model with optimal predictive ability measured by area under the curve (AUC) was determined. Of 1,472 pregnancies analyzed, 396 (28.3%) underwent IOL. Compared to the reference group, EFW >90thpercentile tripled the odds of labor dystocia-indicated PCD (Table 1). The best predictive model for labor dystocia-indicated PCD (AUC 0.89) was composed of maternal gestational weight gain (OR 1.11; 95% CI 1.02, 1.22), multiparity(OR 0.01; 95% CI 0.00, 0.15), occipital-frontal diameter >90thpercentile (OR 16.17; 95% CI 1.45, 180.18), humerus length >90thpercentile (OR 0.09; 95% CI 0.01, 0.70), and EFW >90thpercentile (OR 11.63; 95% CI 1.97, 68.75). Sensitivity, specificity, positive and negative predictive values were 80%, 80%, 39%, and 97.6%, respectively for this model. Specific fetal biometric parameters along with multiple antenatal factors were relevant predictors of labor dystocia-indicated PCD in women undergoing IOL, and this model might have potential utility in clinical practice.

449: Longitudinal measurements of proprotein convertase subtilisin kexin 9 (PCSK-9) in patients with and without preeclampsia

Cholesterol (CHOL) synthesis is necessary for healthy fetal and placental maturation and growth in pregnancy, and adverse pregnancy outcomes (APO) have been identified in women with significantly elevated or depressed lipid profiles. Proprotein convertase subtilisin kexin 9 (PCSK-9) enzyme degrades the low density receptor (LDL)-receptor found in hepatic and endothelial tissue, thus increases serum LDL through decreased receptor binding and is a surrogate marker for CHOL metabolism. Elevated PCSK-9 levels are associated with hypercholesterolemia and atherosclerosis but its characteristics during pregnancy are not well established. Our goal was to measure PCSK-9 during and late after normal and preeclamptic pregnancy to characterize biomarker levels associated with normal and abnormal pregnancy. We performed a single institution prospective cohort study. Inclusion criteria were women with singleton pregnancies > 23 weeks and diagnosis of preeclampsia with severe features (PEC), per ACOG guidelines. Controls were women with uncomplicated singleton gestations > 23 weeks. We excluded women with known hyperlipidemia. Longitudinal data were collected during pregnancy (2015) and non-pregnancy 4 years later (2019). Statistical analyses were performed using a paired t-test for longitudinal data, and all parametric and nonparametric data were analyzed appropriately with Graphpad, Version 8. The sample size was adequate to detect significance at p< 0.05 with a power of 80%. Demographic characteristics between groups were similar except for race (Table). There was a statistically significant decrease in longitudinal PCSK-9 levels from pregnancy to 4 year follow up (non-pregnancy), (114 (32.3) vs 63 (11.3), p=0.004). In contrast, this longitudinal decrease was not observed in patients with preeclampsia, (83 (19.0) vs 75 (24.4), p=0.381). (Figure) PCSK-9 levels are higher during normal pregnancy than in the non-pregnant state. However, patients with PEC do not have a higher level. PCSK-9 and CHOL metabolism should be further evaluated for associations with APO.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

875: The role of proprotein convertase subtilisin kexin 9 (PCSK9) in preeclampsia with severe features

Cholesterol (CHOL) metabolism is essential in fetal and placental health. PCSK9 enzyme plays a critical role in the degradation of the low-density lipoprotein (LDL)-receptor in hepatocytes and endothelial tissue thereby controlling the number of receptors available for LDL metabolism, and in turn controls the level of circulating LDL-CHOL. Abnormal lipid profiles, specifically LDL, are associated with adverse pregnancy outcomes; thus, PCSK9 may provide insight into CHOL metabolism in pregnancy. We aimed to compare the lipid profiles and PCSK9 levels of patients with preeclampsia with severe features (PEC) to healthy pregnant controls. We conducted a single institution observational cohort study. Inclusion criteria for cases were singleton pregnancies > 23 weeks with diagnosis of PEC per current ACOG guidelines. Uncomplicated singleton pregnancies > 23 weeks served as controls. Women with known hyperlipidemia or on statins prior to pregnancy were excluded. Venipuncture and serum lipid panel studies were collected during pregnancy at active disease and compared between groups. A subgroup of this cohort was randomly chosen and underwent testing for serum PCSK9 levels to determine association with PEC. Statistical analyses were performed using appropriate parametric and non-parametric test. The sample size was adequate to detect significance at p< 0.05 with a power of 80% in both groups. We included 53 women with PEC and 39 controls for lipid studies. Maternal demographics were similar between groups with the exception of race with more black women in the PEC cohort (Table). 12 controls and 17 PEC were chosen for PCSK9 analysis. When compared to healthy pregnancy, PCSK9 and LDL levels were lower in PEC when compared to healthy controls (Table). In PEC, there are lower levels of serum PCSK9 and correspondingly lower levels of circulating lipoproteins, specifically LDL. PCSK9 may give insight into abnormal CHOL metabolism and LDL availability. Further studies of PCSK9 and CHOL at the placental level are needed to determine its role in preeclampsia.

604: Fetal biometry to predict labor dystocia indicated term primary cesarean delivery: NICHD fetal growth studies

Labor dystocia is the commonest indication of primary cesarean delivery (PCD). Our objective was to determine whether fetal biometry obtained close to delivery was associated with or predicted term labor dystocia-indicated PCD in a low risk population. Analysis of a prospective multicenter NIH-sponsored study. Women with a non-anomalous and uncomplicated singleton gestation delivering at ≥37 0/7 weeks were included. Serial sonographic exams with the final exam at 37.5 +/- 1.9 weeks were performed. Estimated fetal weight (EFW), individual biometric parameters, derived fetal asymmetry measurements (i.e. biparietal diameter (BPD) - abdominal diameter (AD) difference), and amniotic fluid deepest vertical pocket measured at this last scan and categorized as < 10th, 10th- 90th(reference), >90th percentiles were compared between women who had labor dystocia-indicated PCD versus spontaneous vaginal delivery. Multivariable logistic regression analysis was conducted to assess the association of fetal biometry with labor dystocia-indicated PCD. A model providing optimal predictive ability measured by area under the curve (AUC) was determined. Of 1,472 pregnancies analyzed, 126 (8.5%) had labor dystocia-indicated PCD. Compared to the reference group, EFW and head circumference (HC) >90th, and BPD-AD difference < 10th percentile doubled the odds of labor dystocia-indicated PCD (Table). A model that included fetal HC >90th percentile (OR [95% CI]: 3.00 [1.34, 6.71]), maternal age (1.08 [1.03,1.13]), gestational weight gain (1.06 [1.02,1.10]), gestational age at delivery (1.26 [0.97, 1.64]), induction of labor (1.76 [1.03, 3.01]), and nulliparity (21.95 [8.59, 56.11]) predicted labor dystocia-indicated PCD with an AUC of 0.84. Sensitivity, specificity, positive and negative predictive values of this model were 76%, 76%, 23%, and 97%, respectively. Several fetal biometric parameters were associated with labor dystocia-indicated PCD. Large fetal HC (>90th percentile) at term along with multiple maternal factors constituted the best predictive model of labor dystocia-indicated PCD.

Trajectories of antenatal maternal psychological stress and their association with gestational age and neonatal anthropometry: A prospective cohort study of multi-ethnic Asian women in an urban setting.

To determine common temporal change patterns (i.e., trajectories) of perceived antenatal psychological stress throughout the pregnancy, and to examine associations between these identified trajectories and neonatal birth outcomes. 926 participants from a prospective cohort study of multi-ethnic Asian women from an urban setting with uncomplicated singleton pregnancies completed the Perceived Stress Scale in their first, second, and third trimesters, and just prior to parturition. Gestational age, neonatal weight, length, and head circumference were recorded at birth. Longitudinal trajectories of antenatal psychological stress were characterized with group-based trajectory modelling; associations between trajectories and neonatal outcomes were assessed with analyses of covariance and covariate-adjusted linear regressions. Three distinct non-fluctuating trajectories of antenatal psychological stress were identified, with 43 % of women experiencing significant levels of stress throughout the pregnancy. Women in this persistently-higher stress trajectory delivered neonates who were 57.5 g lighter and with head circumferences of 20 mm less than their counterparts in the other trajectories. Each one-point increase on the Perceived Stress Scale was associated with a decrease of 5.64 g in birthweight and a decrease of 0.4 mm in head circumference. This study delineated three meaningful trajectories of antenatal psychological stress. The persistently-higher antenatal psychological stress trajectory, experienced by two in five women, was associated with lower birthweight and possibly smaller head circumference. While further research is needed to better appreciate the clinical relevance of these findings, it highlights the importance of psychosocial support even for healthy pregnant women with uncomplicated pregnancies in Asian settings.

Induction of labour using prostaglandin E2 as an inpatient versus balloon catheter as an outpatient: a multicentre randomised controlled trial.

To compare clinical outcomes following induction of labour (IOL) using a balloon catheter and going home, versus prostaglandin (PG) as an inpatient. Randomised controlled trial. Eight Australian maternity hospitals. Women with uncomplicated term singleton pregnancies undergoing IOL for low-risk indications including post-term, advanced maternal age and 'social' reasons. Between September 2015 and October 2018, 347 women were randomised to a balloon outpatient group and 348 to a PG inpatient group. The PG group received Dinoprostone, either 2mg gel or 10mg controlled-release tape. The balloon group had a double-balloon catheter inserted and went home. The primary outcome was a composite neonatal measure comprising nursery admission, intubation/cardiac compressions, acidaemia, hypoxic ischaemic encephalopathy, seizure, infection, pulmonary hypertension, stillbirth or death. Clinical and process outcomes are reported. There were no statistically significant differences in the primary outcome comparing balloon with PG (18.6% versus 25.8%; relative risk=0.77, 95% CI 0.51-1.02; P=0.070), cord arterial pH <7.10 (3.5% versus 9.2%; P=0.072), nursery admissions (12.6% versus 15.5%; P=0.379), neonatal antibiotic use (12.1% versus 17.6%; P=0.103), or mode of birth. Nulliparous women in the balloon group had lower rates of the primary outcome (20.4% versus 31.0%;P=0.032); Parous women were less likely to have an unassisted vaginal birth (77.6% versus 92.3%; P=0.045). Balloon catheters may be a superior method of cervical priming for nulliparous women, whereas this may not be the case for parous women. It is feasible that nulliparous women go home after commencing balloon catheter IOL, and the likelihood of adverse outcomes is low. Multicentre trial shows outpatient induction using balloon catheter is safe and feasible for nulliparous women.

Induction of labour at 41 weeks versus expectant management and induction of labour at 42 weeks (SWEdish Post-term Induction Study, SWEPIS): multicentre, open label, randomised, superiority trial

ObjectiveTo evaluate if induction of labour at 41 weeks improves perinatal and maternal outcomes in women with a low risk pregnancy compared with expectant management and induction of labour at...

Influence of maternal HIV infection on fetal thymus size.

Objective To reveal the effect of a maternal human immunodeficiency virus (HIV) infection on the fetal thymus size. Methods The sonographic fetal thymus size was measured retrospectively in 105 pregnancies with maternal HIV infection and in 615 uncomplicated singleton pregnancies. The anteroposterior thymic and the intrathoracic mediastinal diameter were determined in the three-vessel view and their quotient, the thymic-thoracic ratio (TT ratio), was calculated. The study group was subdivided into three groups by the maternal viral load on the date of ultrasound (<50 cop./mL, 50-1000 cop./mL, >1000 cop./mL). Furthermore, an association between prognostic factors of the HIV infection such as the lymphocyte count, CD4/CD8 ratio, HIV medication and the thymus size, was investigated using correlation analyses. Results Fetal thymus size in pregnancies of HIV-positive mothers showed to be noticeably larger than in uncomplicated pregnancies. The mean TT ratio in the HIV-positive group was 0.389 and in the control group 0.345 (P < 0.001). There was no association between any maternal HIV parameter or medication and the size of the thymus gland. Conclusion Maternal HIV infection was associated with an increased fetal thymus size. Further consequences of intrauterine HIV exposure for fetal outcome and the development of the immune system of HIV-exposed uninfected (HEU) infants must be discussed.

Maternal morbidity following caesarean deliveries with barbed suture for uterine closure.

Information regarding the use of barbed suture in gynecologic surgery is limited. Our aim was to compare maternal morbidity following caesarean deliveries performed with barbed compared with non-barbed suture for uterine closure. A historical cohort study from a single tertiary institution. The study group composed of all women that underwent term, uncomplicated singleton caesarean deliveries, where uterine closure was performed with ETHICON's Stratafix®, a polydioxanone barbed suture, compared with caesarean deliveries where uterine closure was performed with ETHICON's VICRYL®, a Polyglactin 910 non-barbed suture. The primary outcomes were the rate of maternal morbidity including the rate of red packed cells transfusion and a composite of infectious morbidity. Operation duration was also evaluated. An analysis restricted to elective caesarean deliveries was performed comparing the suture types. Three thousand and sixty patients were included in the study; 1337 in the study group and 1723 in the control group. There was no significant difference in the rate of the primary outcomes (red packed cells transfusion: 2.5% in the barbed suture vs. 2.1% in the non-barbed suture groups; p = 0.47; composite maternal morbidity: 3.8% vs. 4.8%, respectively; p = 0.18). Barbed suture was associated with reduced risk of postoperative ileus compared with the non-barbed suture (0.3% vs. 1.0%, respectively; p = 0.02) and a longer operation time (31 vs. 29min, respectively; p < 0.001). In the analysis restricted to elective caesarean deliveries only the duration of operation remained significantly different between the groups. The rate of short term maternal morbidities among patients undergoing uterine closure with barbed suture during caesarean delivery is similar to the non-barbed suture.

Ultrasound cesarean scar assessment oneyear postpartum in relation to one- or two-layer uterine suture closure.

IntroductionThis study compared healing of the scars after cesarean section during the first postpartum year using a single‐ or double‐layer suturing technique. Scarring was assessed by a transvaginal ultrasound. We explored the appearance and localization of uterine scars with regard to the obstetric history. Our aim was to compare the position of the scar or defect, if present, its dimensions, and any residual myometrium with respect to the suturing technique during the cesarean section.Material and methodsWomen with uncomplicated singleton pregnancies indicated for elective or acute cesarean section were randomly allocated to the uterine closure technique group. During the first postpartum year, their lower uterine segment was examined with a transvaginal ultrasound in three consecutive visits at 6 weeks, 6 months and 12 months.Results324 women attended the 12‐month visit; of these, 149 underwent single‐layer closure of the uterine incision and 175 double‐layer technique. A higher proportion of the defects is seen in the single‐layer closure technique of suturing. Defects in the single‐layer group were wider (0.002) and the residual myometrial thickness in the single‐layer group were thinner (0.019). Women who underwent cesarean section at the stage of full cervical dilation had scars that were closer to the external cervical os (0.000). The position of the uterus varies greatly between controls (0.000). The combination of uterine position and scar defect presence changed significantly between controls (0.001), and was significantly dependent on the suturing method (0.003). Defects with or without contact with the uterine cavity changed statistically between controls (0.017). Both types of defects were more common in the single‐layer closure technique group.ConclusionsThe findings of this study demonstrate that double‐layer technique with the first continuous nonlocking suture followed by a second continuous nonlocking suture is associated with better suture healing and greater residual myometrial thickness. No difference was observed between single‐ and double‐layer closure for the presence of maternal infectious morbidity, wound infection or blood transfusion.

Identifying trajectories of antenatal depression in women and their associations with gestational age and neonatal anthropometry: A prospective cohort study

ObjectiveThe present study sought to determine the longitudinal trajectories of antenatal depression and examine their associations with birth outcomes. Method926 healthy women with uncomplicated singleton pregnancies within 14 weeks of gestation participated in this prospective cohort study. Women completed a sociodemographic and medical questionnaire and the locally-validated Edinburgh Postnatal Depression Scale (EPDS) in their first, second, and third trimesters, and prior to parturition. Gestational age and neonatal weight, length, and head circumference were recorded at birth. Group-based trajectory modelling characterized trajectories of antenatal depression. Analyses of covariance and covariate-adjusted linear regressions identified associations between trajectories and neonatal outcomes. ResultsFour distinct non-fluctuating trajectories of depressive symptoms were identified, with 9% women suffering from probable clinical depression throughout the pregnancy. Women in this persistently-moderate depression trajectory delivered 2.48 days earlier than in other trajectories; a one-point increase in EPDS scores was associated with an adjusted reduction of 5.82 g in birthweight. ConclusionsAlthough meaningful trajectories were identified, no clinically relevant associations between persistently-moderate depressive symptoms with neonatal outcomes were found. The stability of these trajectories, however, suggests the importance of screening for depressive symptoms early in pregnancy to identify women who may benefit from greater formal and informal support.

Sex differences in fetal growth and immediate birth outcomes in a low-risk Caucasian population

BackgroundAccording to the WHO Multicentre Growth Reference Study Group recommendations, boys and girls have different growth trajectories after birth. Our aim was to develop gender-specific fetal growth curves in a low-risk population and to compare immediate birth outcomes.MethodsFirst, second, and third trimester fetal ultrasound examinations were conducted between 2002 and 2012. The data was selected using the following criteria: routine examinations in uncomplicated singleton pregnancies, Caucasian ethnicity, and confirmation of gestational age by a crown-rump length (CRL) measurement in the first trimester. Generalized Additive Model for Location, Scale and Shape (GAMLSS) was used to align the time frames of the longitudinal fetal measurements, corresponding with the methods of the postnatal growth curves of the WHO MGRS Group.ResultsA total of 27,680 complete scans were selected from the astraia© ultrasound database representing 12,368 pregnancies. Gender-specific fetal growth curves for biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL) were derived. The HC and BPD were significantly larger in boys compared to girls from 20 weeks of gestation onwards (p < 0.001) equating to a 3-day difference at 20–24 weeks. Boys were significantly heavier, longer, and had greater head circumference than girls (p < 0.001) at birth. The Apgar score at 1 min (p = 0.01) and arterial cord pH (p < 0.001) were lower in boys.ConclusionsThese longitudinal fetal growth curves for the first time allow integration with neonatal and pediatric WHO gender-specific growth curves. Boys exceed head growth halfway of the pregnancy, and immediate birth outcomes are worse in boys than girls. Gender difference in intrauterine growth is sufficiently distinct to have a clinically important effect on fetal weight estimation but also on the second trimester dating. Therefore, these differences might already play a role in early fetal or immediate neonatal management.