Viable Singleton Pregnancies Research Articles

Use of labour induction and risk of cesarean delivery: a systematic review and meta-analysis.

Induction of labour is common, and cesarean delivery is regarded as its major complication. We conducted a systematic review and meta-analysis to investigate whether the risk of cesarean delivery is higher or lower following labour induction compared with expectant management. We searched 6 electronic databases for relevant articles published through April 2012 to identify randomized controlled trials (RCTs) in which labour induction was compared with placebo or expectant management among women with a viable singleton pregnancy. We assessed risk of bias and obtained data on rates of cesarean delivery. We used regression analysis techniques to explore the effect of patient characteristics, induction methods and study quality on risk of cesarean delivery. We identified 157 eligible RCTs (n = 31,085). Overall, the risk of cesarean delivery was 12% lower with labour induction than with expectant management (pooled relative risk [RR] 0.88, 95% confidence interval [CI] 0.84-0.93; I(2) = 0%). The effect was significant in term and post-term gestations but not in preterm gestations. Meta-regression analysis showed that initial cervical score, indication for induction and method of induction did not alter the main result. There was a reduced risk of fetal death (RR 0.50, 95% CI 0.25-0.99; I(2) = 0%) and admission to a neonatal intensive care unit (RR 0.86, 95% CI 0.79-0.94), and no impact on maternal death (RR 1.00, 95% CI 0.10-9.57; I(2) = 0%) with labour induction. The risk of cesarean delivery was lower among women whose labour was induced than among those managed expectantly in term and post-term gestations. There were benefits for the fetus and no increased risk of maternal death.

The usefulness of volume NT software in measuring the fetal nasal bone at 11 to 13 + 6 weeks of gestation

The objective of this study is to investigate the reproducibility of 3D ultrasound to measure the fetal nasal bone (NB) at first trimester. A group of singleton viable pregnancies attending the 11 to 13 + 6 weeks aneuploidy screening at the University of Bologna were prospectively selected. For each patient, fetal NB was measured by 2D ultrasound. Subsequently, a 3D ultrasound of the fetal head was acquired, and fetal NB was measured by offline analysis using the volume nuchal translucency software. The correlation between 2D and 3D ultrasounds and the reproducibility of fetal NB measurement at 3D ultrasound were assessed. Overall, 161 Caucasian women were included in the study. At 3D ultrasound, NB measurement showed an excellent intraobserver [Oper 1, intraclass correlation coefficient (ICC) = 0.98; Oper 2, ICC = 0.921] and interobserver agreement (rc = 0.92). The agreement between 2D and 3D measurements was moderate (rc = 0.77). A 3D ultrasound supported by the volume nuchal translucency software may provide reliable measurements of the fetal NB in the first trimester.

Abnormal sonographic appearances of the yolk sac: which can be associated with adverse perinatal outcome?

The present study aimed to determine whether yolk sacs with abnormal sonographic appearance are associated with adverse perinatal outcomes in both early and late gestation. A total of 305 viable singleton pregnancies with gestational age of 6 to 9 weeks were prospectively evaluated with respect to perinatal outcomes and sonographic characteristics of the yolk sacs. An abnormal yolk sac was found in 66 pregnancies. In pregnancies with enlarged yolk sacs a miscarriage occurred in 37.5% of cases (3/8). The pregnancies with a yolk sac diameter >/= 5 mm had a significantly higher risk of miscarriage (p = 0.005). The risk of miscarriage was statistically similar between the pregnancies with regular and those with irregular yolk sacs (p = 0.73). Miscarriage occurred in 3.8% of pregnancies with irregular yolk sacs (2/52) and none of pregnancies with echogenic yolk sacs (0/6). Adverse perinatal outcomes were not associated with either irregular or echogenic yolk sacs. An enlarged yolk sac visualized before the 7th week of gestation is strongly associated with a significantly increased risk for spontaneous miscarriage. The presence of an echogenic or irregular yolk sac appears to be unrelated to adverse perinatal outcome.

Vaginal birth after a caesarean section: the development of a Western European population‐based prediction model for deliveries at term

To develop and internally validate a model that predicts the outcome of an intended vaginal birth after caesarean (VBAC) for a Western European population that can be used to personalise counselling for deliveries at term. Registration-based retrospective cohort study. Five university teaching hospitals, seven non-university teaching hospitals, and five non-university non-teaching hospitals in the Netherlands. A cohort of 515 women with a history of one caesarean section and a viable singleton pregnancy, without a contraindication for intended VBAC, who delivered at term. Potential predictors for a vaginal delivery after caesarean section were chosen based on literature and expert opinions. We internally validated the prediction model using bootstrapping techniques. Predictors for VBAC. For model validation, the area under the receiver operating characteristic curve (AUC) for discriminative capacity and calibration-per-risk-quantile for accuracy were calculated. A total of 371 out of 515 women had a VBAC (72%). Variables included in the model were: estimated fetal weight greater than the 90(th) percentile in the third trimester; previous non-progressive labour; previous vaginal delivery; induction of labour; pre-pregnancy body mass index; and ethnicity. The AUC was 71% (95% confidence interval, 95% CI = 69-73%), indicating a good discriminative ability. The calibration plot shows that the predicted probabilities are well calibrated, especially from 65% up, which accounts for 77% of the total study population. We developed an appropriate Western European population-based prediction model that is aimed to personalise counselling for term deliveries.

Obstetric implications of fetal inherited thrombophilia in thrombophilic women.

The relationship between fetal thrombophilic polymorphism and adverse pregnancy outcomes is still unclear. The aim of this study is to evaluate if fetal thrombophilia may affect obstetric and perinatal outcomes in thrombophilic women. From 2007 to 2011 all patients with a known inherited thrombophilic mutation consecutively admitted to our labor ward at ⩾25weeks of gestation with a singleton viable pregnancy were considered eligible for the purpose of the study. At the age of 1year, the infants were tested for inherited thrombophilic mutations. Patients were then divided into two groups according to the presence or absence of any neonatal mutation. The following outcome variables were then compared between the two groups: gestational age at delivery, birth weight, incidence of hypertensive disorders of pregnancy and SGA neonates. Overall, 67 pregnancies of 49 women were studied. Among them, the G20210A Prothrombin (32/67 or 47.7%) mutation and the Factor V Leiden mutation (31/67 or 46.3%) were the commonest findings, with a single patient presenting both. A thrombophilic mutation was found in 38 mother-infant pairs. The risk of all maternal and perinatal events including the incidence of hypertensive disorders disorders (5/29 or 17.2% vs 6/38 or 15.7% p=1.00) and of SGA neonates (3/29 or 10.3% vs 7/38 or 18.4%, p=0.49) was comparable between the two groups irrespective of the associated fetal thrombophilia. Our data suggest that women with inherited thrombophilia carrying a thrombophilic fetus are not at increased risk of adverse pregnancy outcomes.

PL.97 Prospective Audit for Induction of Labour with Propess

Aimto assess the success rate of IOL using propess.MethodA prospective audit of IOL was carried out in a large teaching hospital. Special data sheet was used for collection of data....

775: Which findings at the start of the second phase of labor are associated with operative delivery?

labor are associated with operative delivery? Mariette Ruckert, Myrthe Peelen, Michelle van Vliet, Mieke ten Eikelder, Nikki van Desel, Katrien Oude Rengerink, Ben Willem Mol, Irene de Graaf Diakonessenhuis, Obstetrics and Gynecology, Utrecht, Netherlands, Academic Medical Center, Obstetrics and Gynecology, Amsterdam, Netherlands, Groene Hart Hospital, Obstetrics and Gynecology, Gouda, Netherlands, Kennemer Gasthuis, Obstetrics and Gynecology, Haarlem, Netherlands OBJECTIVE: At present, there is little scientific fundament behind the interpretation of physical examination during labor and delivery. We aimed to indentify which findings at the start of the second phase of labor were associated with instrumental vaginal delivery (IVD) and emergency caesarean section (ECS). STUDY DESIGN: We performed a prospective cohort study in five hospitals in the Netherlands. Consecutive laboring women, with a viable singleton pregnancy in cephalic presentation and a gestational age of at least 34 weeks, were included. We assessed the predictive value of antepartum and intrapartum characteristics and findings at digital examination prior to the second phase of labor (start pushing) for operative delivery (OD) using logistic regression analysis. We selected variables based on literature and clinical experience. Backward selection was used to develop a prediction model, predictors with a p 0.157 remained in the final model. The discriminative ability of the model was assessed using ROC analyses (perfect when AUC 1). The correspondence between the predicted probability for OD and the observed number of operative deliveries over groups was assessed with a calibration plot (perfect when all points are on the diagonal). RESULTS: Between December 2010 and October 2011, we included 473 women, of whom 74 (16%) had a VID and 22 (5%) an ECS. For 425 women, data on all relevant variables were available. Predictors for OD at start of the second phase of labor were 10 cm dilatation, Caucasian etnicity, nulliparity, epidural analgesia, spontaneous start, molding, engagement and position of the fetal head (Table). The model including these variables showed good discriminative ability: AUC ROC 0.82 (95% CI 0.77-0.87). The model calibrated well (Figure). CONCLUSION: At start of the second phase of labor, antepartum and intrapartum characteristics can predict the need for OD. The prediction model may be implied as a useful tool for clinical decision making and assembling logistics at the delivery ward. 776 The validity of the variable “NICU admission” as an outcome measure for neonatal morbidity Nora Danhof, Melanie Wiegerinck, Anton van Kaam, Ben Willem Mol Academic Medical Center, Obstetrics & Gynecology, Amsterdam, Netherlands OBJECTIVE: The variable “neonatal intensive care (NICU) admission” is a frequently used outcome measure in clinical studies, as can be illustrated by the fact that it is reported as such in nearly one hundred Cochrane reviews from the Pregnancy and Childbirth Group. We addressed the question whether NICU admission is a valid surrogate outcome measure for neonatal morbidity, specifically when comparing different birth settings with different access to the NICU. STUDY DESIGN: We performed a retrospective cohort study among neonates admitted at the NICU of a tertiary hospital in the Netherlands during a ten-year period. The inclusion was restricted to singletons born at term, who were admitted at the NICU for delivery-related morbidity within 24 hours of birth. Patient characteristics and admission data were compared for four groups based on the line of care during delivery, i.e. home birth (group Ia), midwive lead hospital delivery (Ib), secondary care (II) and tertiary care (III). We specifically looked at the mortality rate, defined as the percentage of children that died at any time during NICU admission. RESULTS: We studied 871 newborns of which 53 were born at home, 25 under supervision of a midwife in the hospital, 166 in secondary Calibration plot, showing the average observed operative delivery rate (Y-axis) against the average calculated operative delivery rate (X-axis)

The K-P Algorithm: A New First-Trimester Growth Model – Comparison with Other Formulae and Correlations with Recorded Embryonic Lengths

Objective: To generate and validate individually fitted first-trimester growth curves using a new growth model. Secondary aims were to compare this new model with actual recorded embryonic measurements and validate its predictive accuracy. Methods: A prospective study of women presenting to the Early Pregnancy Unit in the first trimester. Women with viable singleton pregnancies at the end of the first trimester who had had at least two crown-rump length (CRL) measurements were selected. An individual power function of CRL was derived from serial CRL measurements. Individual curves were fitted using computer software to estimate a dating adjustment factor (‘k’), and a growth coefficient (‘P’) for each case. The predictive accuracy of the growth curves was then tested in a validation subset of the population that had a third CRL measurement. The population average curve from the developed model was also extrapolated to day 27 menstrual age (Carnegie stage 6), day 30 menstrual age (Carnegie stage 7) and day 84 menstrual age, and values were compared to previously reported measurements. Results: 326 viable pregnancies were selected for CRL growth curve development. The mean time interval between CRL measurements was 20.5 days (range 2–44). The mean value for ‘P’ was 2.058, and for ‘k’ 24.6. Testing the model on a subset of 81 cases showed that the average error in predicting a third CRL measurement was 1% (SD 9.1%). Conclusions: These new, individually fitted growth curves for the first trimester correlate more closely with the recorded embryonic lengths than other standards.

Evaluation of neonatal outcomes in elective repeat cesarean delivery at term according to weeks of gestation

Our aim is to evaluate the association between gestational age at delivery and neonatal outcomes in elective cesarean delivery. A total of 1784 viable singleton pregnancies that were delivered by elective caesarean section at term were included in the study. All pregnancies were categorized according to the number of completed weeks of gestation (37(+0-6) , 38(+0-6) , 39(+0-6) and ≥40(+0) weeks). In this study, the patient groups compared in terms of demographic characteristics and neonatal outcomes. The rates of the neonatal intensive care unit admission were 8.7%. When maternal and neonatal characteristics were statistically analyzed, the incidence of advanced maternal age and previous cesarean delivery increased as gestational age at delivery decreased; the incidence of nuchal cord and delivering a baby of ≥4000 g at birth increased as gestational age at delivery increased. As compared with deliveries at 39 weeks, cesarean delivery at 37 weeks of gestation had significantly higher risk, including that of neonatal intensive care unit admission, transient tachypnea of the newborn after delivery and O(2) support. There was one perinatal death observed in the study. According to the results of our study, compared to elective cesarean delivery after 37 weeks of gestation, elective cesarean delivery at 37 weeks of gestation was associated with a statistically significant increase in neonatal mortality. Therefore, elective cesarean delivery should not be performed at 37 weeks of gestation and 39 weeks of gestation appears to be the ideal timing for elective cesarean delivery.

Prediction of abortion using three‐dimensional ultrasound volumetry of the gestational sac and the amniotic sac in threatened abortion

To determine whether gestational sac volume (GSV) or amniotic sac volume (ASV) and/or the difference between them can predict abortion in women with first-trimester threatened abortion. Ninety patients between 6 and 12 weeks of gestation presenting with vaginal bleeding were studied. Seventy-six delivered after 24 weeks of gestation (group A) and 14 aborted before 20 weeks of gestation (group B). All patients had a singleton viable pregnancy demonstrated by transvaginal ultrasound. Gestational sac and amniotic sac volumes were measured in all the patients using three-dimensional transvaginal ultrasound with Virtual Organ Computer-aided Analysis software, and the gestational sac volume - amniotic sac volume (GSV - ASV) was calculated. The groups did not differ in terms of age, parity, number of previous abortions, or term deliveries. The GSV (group A: mean 32.0 ± 27.7 cm(3) ; group B: 26.7 ± 29.1 cm(3) ) and the ASV (group A: 21.1 ± 25.5 cm(3) ; group B: 20.6 ± 26.0 cm(3) ) were not statistically different, while the GSV - ASV was significantly smaller in group B (aborting before week 20) (group A: 10.9 ± 10.9 cm(3) ; group B: 6.1 ± 8.6 cm(3) ; p < 0.05). Using receiver operator curves, the area under the curve for predicting normal pregnancy outcome of the GSV - ASV measurement was 0.654. When the GSV - ASV was 1.8 cm(3) or less, abortion was predicted with 84% sensitivity and 43% specificity. The measurement of the GSV and the ASV are not good predictors of abortion in patients with first-trimester vaginal bleeding, whereas the use of the GSV - ASV may be helpful in predicting the outcome of pregnancy.

OS083. Fetal growth and maternal vascular function in early pregnancy

Increasing evidence indicates that the rate of fetal growth is partly determined already in the first half of pregnancy. A number of authors have reported that if the fetus is smaller than expected at dating, the risk for a small for gestational age fetus increases. To investigate if maternal vascular function in early pregnancy reflects fetal growth in the first trimester. Fifty healthy women with singleton viable pregnancies were included in the study that were recorded the ultrasound department of UltraGyn Stockholm, Sweden for ultrasound dating in gestational week 11-14 . Of these, 25 women had their estimated date of delivery postponed ⩾ 7 days at ultrasound dating compared to last menstrual period in gestational week 11-14. As controls 25 women were fetal size were in accordance with the last menstrual period (defined as expected date of delivery moved less than six days) were recruited. The dating examinations were performed by specially trained midwives. To assess gestational age, biparietal diameter was used. Exclusion criteria were the use of oral contraceptives within three months before conception, uncertain date of the last menstrual period, irregular menstrual periods, fetuses that were ⩾ 21 days larger or smaller than expected, and fetal anomalies. Women that smoked were also excluded. Blood pressure was measured in the upper arm in a conventional way. The central blood pressure was calculated with a validated algorithm. Changes in skin microcirculation were measured using laser Doppler fluxmetri (LDF). Both endothelial dependent dilatation using assessment of acetylcholine (Ach) and local warming of skin to 44C for maximum micro vascular hyperaemia (MMH) and non endothelial dilatation using assessment of sodium nitroprusside (SNP) was examined. Fetuses that were smaller than expected at ultrasound dating compared to last menstrual period at gestational week 11-14, had an increased change in maximum micro vascular hyperaemia (p=0.034). There was no significant correlation between ACh-response (p=0.59) and SNP-response (p=0.23). No differences were seen in blood pressure. In the first trimester, changes in vascular function might reflect important adaptations that are required to facilitate normal fetal growth. This was highlighted by the findings of a positive correlation between fetal growth at 11-14 weeks gestation and changes in endothelial dependent microcirculation. Vascular function of these women will be followed longitudinally during pregnancy and related to obstetric outcome. If changes in microcirculation in the first trimester correlates to an increased risk for complications such as hypertensive disorders during pregnancy or intrauterine growth restriction this gives new insights into the early phase of these complications.

PP037. Family history of cardiovascular disease and maternal vascular function during early pregnancy

Women with a family history of cardiovascular disease (CVD) have an increased risk of hypertensive disorders during pregnancy. Pregnancy is associated with increased physical demands on the cardiovascular system and hemodynamic changes. Cardiac output increases by about 40-50%, blood volume by 10-20% and vascular resistance decreases. Our hypotheses was that women with a family history of CVD fail to have an adequate cardiovascular adaptation during pregnancy. Fifty healthy women with singleton viable pregnancies were included in the study who were recorded in the Ultrasound Department of UltraGyn Stockholm, Sweden for ultrasound dating in gestational week of 11-14. Of these, 25 women had a family history of CVD which was defined as having at least one first degree relative with the diagnosis of premature hypertension, myocardial infarct or stroke before the age of 55 (men) or 65 (women). Twenty five healthy women without a family history were included as controls. Smokers were excluded. Blood pressure was measured in the upper left arm in a conventional way. The pulse wave was registered in the radial artery (SphygmoCor Px and Vx, PWV Medical). The central blood pressure was calculated with a validated algorithm. The pulse wave was then registered in the femoral artery, the velocity was calculated and the arterial stiffness estimated. Flow mediated vasodilation was studied in the radial artery through measurement with ultrasound of diameter changes and blood flow before and after ischemia (Vivid 7, GE, 10MHz transducer). Systolic blood pressure in the upper left arm was significantly higher in women with a family history of CVD (median 109.5mmHg versus 105mmHg, p=0.04). Diastolic blood pressure did not differ. Aortic blood pressure also differed significantly in women with a family history of CVD, both systolic (median 95mmHg versus 86.3mmHg, p=0.0005) and diastolic (median 66mmHg versus 59.3mmHg, p=0.0024). No other results were significantly different. All values refer to examinations at gestational weeks 11-14. Changes in vascular function during the first trimester reflect important adaptations that are necessary for a normal pregnancy. Women with a family history of CVD had a significantly higher blood pressure at 11-14weeks of gestation although the values were within normal range. The pregnancy related decrease of vascular resistance may be less pronounced in women with a family history of CVD. Vascular function will be followed longitudinally during pregnancy and related to obstetric outcome in this group.

Use of Four-Dimensional Analysis of Power Doppler Perfusion Indices to Demonstrate Cardiac Cycle Pulsatility in Fetoplacental Flow

The aim of this study is to quantify fetoplacental cardiac cycle variation in virtual organ computer-aided analysis (VOCAL) power Doppler (PD) indices by novel application of spatio-temporal imaging correlation (STIC). We recruited 25 healthy women (20–34 weeks gestation) with uncomplicated, viable singleton pregnancies with anterior placentae. Three four-dimensional (4-D) STIC PD datasets of the fetoplacental circulation were obtained above the placental cord insertion. The vascularization index (VI), flow index (FI) and vascularization-flow index (VFI) were calculated offline using a standardized spherical sonobiopsy technique for all frames of the cardiac cycle. Clear maximum (systole) and minimum (diastole) values with progressive fluctuation were seen in the majority of datasets (VI 66/75 [88%]; FI 58/75 [77%]; VFI 68/75 [91%]). Variation from mean was: VI ± 3.33% (0.34%–9.69%); VFI ± 3.46% (0.27%–10.02%); FI ± 0.74% (0.14%–1.60%). All indices were significantly higher in systole than diastole (p < 0.001). Mean systolic:diastolic ratios were: VI 1.07 (SD 0.06), FI 1.01 (SD 0.01) and VFI 1.07 (SD 0.06). Intraclass correlation coefficients (ICCs) for the frames ascribed to systole and diastole and to the mean value across the cardiac cycle of the indices (95% confidence interval [CI]) were: systole VI 0.91 (0.83–0.96), FI 0.85 (0.72–0.92), VFI 0.92 (0.85–0.96); diastole VI 0.91 (0.84–0.96), FI 0.84 (0.71–0.92), VFI 0.92 (0.86–0.96); mean VI 0.91 (0.84–0.96), FI 0.84 (0.72–0.92), VFI 0.92 (0.86–0.96). There is clear cardiac cycle variation in VOCAL indices of fetoplacental blood flow, establishing the need to control for phase of the cardiac cycle, and raising the possibility of future 4-D evaluation of vascular flow change or impedance.

First trimester transabdominal chorionic villus sampling—does the needle matter?

To compare first-trimester transabdominal chorionic villus samples (TA-CVS) when obtained by 20-gauge amniocentesis versus lancet needles. This is a retrospective study of all women with viable singleton pregnancies undergoing TA-CVS from 01/01/2009 to 03/31/2011. All CVS were performed by a single operator using a freehand technique and amniocentesis needles from 01/01/2009 to 08/31/2010 and lancet needles from 09/01/2010 to 03/31/2011. All samples were processed by the same laboratory. There were no differences between groups regarding maternal age, weight, gestational age at CVS, indication for CVS, uterine position, or placental location. Lancet needles were associated with significantly larger samples (median 18 [range 3-40] versus 7 [range 1-33] mg, p < 0.0001), more successful in situ hybridization (96% versus 74.2%, p = 0.03), and faster result reporting (median 7 [range 5-12] versus 9 [range 6-26] days, p = 0.002). Needle type may be clinically important when selecting 20-gauge TA-CVS needles.

Is there a correlation between birth weights and first-trimester crown-rump length growth velocity?

Objective: To test the hypothesis that small- or large-for-gestational-age (SGA or LGA) newborns have anomalous crown-rump length (CRL) growth rates in the first trimester. Methods: Prospective observational study. Women in the first trimester presenting to the Early Pregnancy Unit, between November 2006 and December 2010, underwent transvaginal scan. Women with viable singleton pregnancies in the first trimester who had at least two CRL measurements > 5 mm, recorded at least 2 weeks apart, and also had birth weight data available were included in the final analysis. Birth weight percentiles were calculated and adjusted for gestational age and gender. SGA was equivalent to < 10th centile and LGA was equivalent to > 90th centile. Correlation analysis was performed between birthweight percentiles and first-trimester CRL growth-rate coefficients. In addition, we estimated early fetal growth rates (EFGR) by calculating the Δ CRL/Δ time (mm/day) to see if these differed according to the birth-weight percentiles. Results: A total of 107 women had complete data. The mean maternal characteristics were age 27.5 ± 6 years, weight 87 ± 29 kg and height 163 ± 8 cm. The mean birth weight and gestational age at delivery were 3405 g (SD = 597) and 269 days (SD = 13), respectively. The proportions of SGA and LGA were 7.5% and 18.7%, respectively. There were no significant correlations between birth-weight percentiles and any of the CRL growth rates. There were also no significant differences in the mean CRL velocities when comparing the SGA and LGA newborns birth weights. EFGR for SGA and LGA newborns were 1.34 mm/day (SD = 0.17) and 1.32 mm/day (SD = 0.24), respectively (p > 0.05). Conclusions: Newborns who are found to be SGA or LGA at delivery do not appear to have anomalous CRL growth patterns in the first trimester. The EFGR also did not correlate with birth-weight percentiles.

Evaluation of a two-step ultrasound examination protocol for the detection of major fetal structural defects

Objective: To evaluate a two-step screening protocol of ultrasound examinations (11–14 and 20–24 weeks) for the detection of major fetal structural defects. Methods: Retrospective study in a private maternity hospital. Women with viable singleton pregnancies having both first trimester scan and anomaly scan at our department and subsequently delivered at our hospital were included. Major fetal structural defects were defined as those requiring medical or surgical treatment or those causing mental handicap. Results: A total of 3,902 pregnancies included 61 fetuses with structural defects (1.56%). Twenty-six (42.6%) were diagnosed in the first trimester and 29 (47.5%) in the second. Six anomalies were detected in the third trimester or after birth. Overall detection rate of the two-step program was 90.2%. Conclusions: Detailed examination of fetal anatomy at 11–14 weeks resulted in the early diagnosis of about 40% of major structural defects

Carbetocin versus syntometrine in the management of third stage of labor following vaginal delivery

To assess and compare the efficacy and safety of a single intramuscular dose of carbetocin to a single intramuscular dose of syntometrine in managing the third stage of labor following vaginal delivery among women with low risk factors for postpartum hemorrhage. Prospective double-blind randomized controlled study. The study included 240 healthy women with viable normal singleton pregnancies achieving normal vaginal delivery at or beyond 37 weeks' gestation during the period from May 2009 to December 2009 at TAIBA Hospital in Kuwait. Women were randomized to receive either a single dose of carbetocin or syntometrine intramuscularly following the delivery of the anterior shoulder of the baby. Outcome measures compared included postpartum hemorrhage requiring additional uterotonic therapy, incidence of postpartum hemorrhage, amount of intrapartum blood loss as well as adverse effects profile. There was a statistically highly significant difference in the estimated mean blood loss between the carbetocin and syntometrine groups, with a blood loss of 81.5 ml higher in the syntometrine group. The mean drop of hemoglobin concentration 24 h after delivery was 0.8 g/dl in carbetocin group and 1.1 g/dl in syntometrine group, and the difference was statistically highly significant. Women in the carbetocin group were less likely to experience nausea and vomiting. Single dose of intramuscular carbetocin 100 μg may be more effective as compared to a single intramuscular dose of syntometrine in reducing postpartum blood loss with a smaller drop in hemoglobin levels and less adverse effects.

Thyroperoxidase and Thyroglobulin Antibodies in Early Pregnancy and Placental Abruption

To estimate the relationship between thyroid antibodies and placental abruption. This cohort study assesses thyroperoxidase and thyroglobulin antibodies in relation to placental abruption among 10,062 women with singleton viable pregnancies (from the First and Second Trimester Risk of Aneuploidy [FaSTER] trial). A thyroperoxidase antibody cutoff of 50 international units/mL is used for comparison with published data from another cohort. Women with elevated thyroperoxidase antibody levels in the first and second trimesters have a higher rate of placental abruption than antibody-negative women. This relationship is less strong in the first trimester (1.51% compared with 0.83%; odds ratio [OR], 1.83; 95% confidence interval [CI], 0.99-3.37) than in the second trimester (1.78% compared with 0.82%; OR, 2.20; 95% CI, 1.21-3.99). A similar, but weaker, relationship is present for thyroglobulin antibodies. Sixty-four of 782 thyroperoxidase antibody-positive pregnancies without abruption become negative by the second trimester; one pregnancy with abruption becomes antibody-positive. Odds ratios for pregnancies with both thyroperoxidase and thyroglobulin antibody elevations are also higher (first trimester: OR, 2.10; 95% CI, 0.91-4.86; second trimester: OR, 2.73; 95% CI, 1.17-6.33). The present data confirm an association between thyroid antibody elevations and placental abruption described in a recent report. These findings, however, do not provide support for recommending routine testing for thyroid antibodies during pregnancy. II.

Evaluating the Intra- and Interobserver Reliability of Three-Dimensional Ultrasound and Power Doppler Angiography (3D-PDA) for Assessment of Placental Volume and Vascularity in the Second Trimester of Pregnancy

Three-dimensional (3-D) power Doppler angiography (3-D-PDA) allows visualisation of Doppler signals within the placenta and their quantification is possible by the generation of vascular indices by the 4-D View software programme. This study aimed to investigate intra- and interobserver reproducibility of 3-D-PDA analysis of stored datasets at varying gestations with the ultimate goal being to develop a tool for predicting placental dysfunction. Women with an uncomplicated, viable singleton pregnancy were scanned at 12, 16 or 20 weeks gestational age groups. 3-D-PDA datasets acquired of the whole placenta were analysed using the VOCAL software processing tool. Each volume was analysed by three observers twice in the A plane. Intra- and interobserver reliability was assessed by intraclass correlation coefficients (ICCs) and Bland Altman plots. At each gestational age group, 20 low risk women were scanned resulting in 60 datasets in total. The ICC demonstrated a high level of measurement reliability at each gestation with intraobserver values >0.90 and interobserver values of >0.6 for the vascular indices. Bland Altman plots also showed high levels of agreement. Systematic bias was seen at 20 weeks in the vascular indices obtained by different observers. This study demonstrates that 3-D-PDA data can be measured reliably by different observers from stored datasets up to 18 weeks gestation. Measurements become less reliable as gestation advances with bias between observers evident at 20 weeks. (E-mail: nia1jones@googlemail.com)

Timing of elective cesarean section and neonatal respiratory distress syndrome

Objective To compare the neonatal outcomes of different gestational age at which elective cesarean sections at term were performed. Methods All the cases of cesarean section registered in Peking Union Medical College Hospital from September 2002 to November 2009 were collected. Women with viable singleton pregnancies delivered before the onset of labor and without recognized indications for cesarean section after 37 weeks at term were included and their general information and outcomes were compared with one-way ANOVA. All the maternal data and neonatal adverse events were compared with Cochran-Armitage test among different gestational weeks, including respiratory complications （respiratory distress syndrome or transient tachypnea of the newborn）, infections, admission to the neonatal intensive care unit （NICU）, and hospitalization in NICU〉5 d. Results Of 8122 primary cesarean sections and 594 repeat cesarean sections at term, 4565 and 409 cases were performed electively as the primary or repeat cesarean section. Among the 4565 women underwent primary elective cesarean sections, 2194 （48.1%） were before 39 gestational weeks,and 1828 （40.0%） at 39-39＋6 weeks. While, among the 409 repeat elective cesareans sections, these figures were 275 （67.2%） and 120 （29.3%）, respectively. No fetal or neonatal death occurred during perinatal period. Compared with births at 39-39＋6 weeks, births at 37-37＋6 weeks or 38-38＋6 weeks were associated with increased risk of the neonatal adverse events. For the primary cesarean section cases, the odds ratio （OR） for births at 37-37＋6 weeks and 38-38＋6 weeks was 1.4 （95% CI： 0.9-2.0） and 1.1 （95% CI： 0.9-1.4）, respectively. For the repeat cesarean section cases, OR for births at 37-37＋6 weeks and 38-38＋6 weeks was 2.5 （95% CI： 1.1-5.8） and 1.3 （95% CI： 0.6-2.7） respectively. Conclusions Elective cesarean section before 39 weeks of gestation is popular and associated with adverse neonatal outcomes. Elective cesarean section performed after 39-39＋6 gestational weeks might decrease the risk of adverse neonatal outcomes. Key words: Cesarean section Infant,newborn Respiratory tract diseases Surgical procedure,elective