Worse Perinatal Outcomes Research Articles

Maternal and perinatal outcomes following code red cesarean delivery performed among hospitals with different level of care

IntroductionCode red cesarean delivery (CD) is performed in the presence of an impending danger to maternal or fetal life. The indications, times, and procedures in this setting remain ambiguous. The aim of this study was to evaluate in a cohort of code red CD the impact of the level of care of Obstetric Units, indications, and decision to delivery interval CD on maternal and perinatal outcomes. MethodsThis was a multicenter retrospective study conducted at four maternal units (two level-2 University Hospitals and two level-1 Community Hospitals) on a cohort of women who underwent code red CD between 2018 and 2021. An independent team of experts performed retrospective audits to assess the appropriateness of indications. ResultsA cohort of 168 code red CDs were included. The most frequent indications were severely abnormal fetal heart rate patterns (41.7 %) and sentinel events (38.1 %). Decision to delivery interval (DDI) was similar between different level of care (20.7 vs 21.4 min, p = 0.66) and didn’t affect adverse perinatal outcome. Rates of appropriate indications were higher in the level-2 than level-1 hospitals (80.2 % vs 65 %, p = 0.036), with worse adverse perinatal outcome in the former than the latter (43.4 % vs 21.1 %, p = 0.002).At multivariate analysis, worse perinatal outcomes were independently associated with indications for code red CD (P = 0.01) and level-2 units (P = 0.005). ConclusionsLevel-1 hospitals guarantee a promptness of response comparable to that of level-2 centers in dealing with emergency in CD, however with lower rates of appropriate indications. Indications for code red CD but not DDI are associated with worse perinatal outcomes.

Mode of delivery according to Robson classification and perinatal outcomes in restricted and small for gestational age fetuses.

To evaluate the mode of delivery according to Robson classification (RC) and the perinatal outcomes in fetal growth restriction (FGR) and small for gestational age (SGA) fetuses. Retrospective cohort study by analyzing medical records of singleton pregnancies from two consecutive years (2018 and 2019). FGR was defined according to Delphi Consensus. The Robson groups were divided into two intervals (1-5.1 and 5.2-10). Total of 852 cases were included: FGR (n = 85), SGA (n = 20) and control (n=747). FGR showed higher percentages of newborns < 1,500 grams (p<0.001) and higher overall cesarean section (CS) rates (p<0.001). FGR had the highest rates of neonatal resuscitation and neonatal intensive care unit admission (p<0.001). SGA and control presented higher percentage of patients classified in 1 - 5.1 RC groups, while FGR had higher percentage in 5.2 - 10 RC groups (p<0.001). FGR, SGA and control did not differ in the mode of delivery in the 1-5.1 RC groups as all groups showed a higher percentage of vaginal deliveries (p=0.476). Fetuses with FGR had higher CS rates and worse perinatal outcomes than SGA and control fetuses. Most FGR fetuses were delivered by cesarean section and were allocated in 5.2 to 10 RC groups, while most SGA and control fetuses were allocated in 1 to 5.1 RC groups. Vaginal delivery occurred in nearly 60% of FGR allocated in 1-5.1 RC groups without a significant increase in perinatal morbidity. Therefore, the vaginal route should be considered in FGR fetuses.

Obstacles to Accepting Care: Understanding Why Obstetric Patients Leave against Medical Advice.

Discharge "against medical advice" (AMA) in the obstetric population is overall under-studied but disproportionally affects marginalized populations and is associated with worse perinatal outcomes. Reasons for discharges AMA are not well understood. The objective of this study is to identify the obstacles that prevent obstetric patients from accepting recommended care and highlight the structural reasons behind AMA discharges. Electronic health records of patients admitted to antepartum, peripartum, or postpartum services between 2008 and 2018 who left "AMA" were reviewed. Progress notes from clinicians and social workers were extracted and analyzed. Reasons behind discharge were categorized using qualitative thematic analysis. Fifty-seven (0.12%) obstetric patients were discharged AMA. Reasons for discharge were organized into two overarching themes: extrinsic (50.9%) and intrinsic (40.4%) obstacles to accepting care. Eleven participants (19.3%) had no reason documented for their discharge. Extrinsic obstacles included childcare, familial responsibilities, and other obligations. Intrinsic obstacles included disagreement with provider regarding medical condition or plan, emotional distress, mistrust or discontent with care team, and substance use. The term "AMA" casts blame on individual patients and fails to represent the systemic barriers to staying in care. Obstetric patients were found to encounter both extrinsic and intrinsic obstacles that led them to leave AMA. Healthcare providers and institutions can implement strategies that ameliorate structural barriers. Partnering with patients to prevent discharges AMA would improve maternal and infant health and progress towards reproductive justice.

Perinatal Outcomes and Level of Labour Difficulty in Deliveries with Right and Left Foetal Position-A Preliminary Study.

Many studies have shown the negative influence of the foetus's occiput posterior position during birth on the final perinatal outcome. This study aims to add to the discussion on the impact of foetus positioning on the course of labour and subjective assessment of the level of labour difficulty. The cross-sectional study took place from February 2020 to September 2021, and consisted of filling out observation forms and the assessment by the midwives and women of the level of labour difficulty. This study is based on the observation of 152 labours in low-risk women. When compared to left foetal positioning, labours in which the foetus was in the right position were longer and more frequently failed to progress (in 11.3% vs. 37.5%), and epidural was more frequently administrated (in 30.4% vs. 52.7%). Both women and midwives subjectively evaluated deliveries with a foetus in the right position as more difficult. The right positioning of the foetus was related to greater labour difficulty and worse perinatal outcomes. The position of the foetus' head in relation to the pelvis should be considered as an indicator of the difficulty of labour and a support plan for the woman should be offered accordingly.

Mapping the scientific literature on obstetrical and perinatal health among sexual and gender minoritised (SGM) childbearing people and their infants: a scoping review protocol

IntroductionSexual and gender minoritised (SGM) populations are disproportionately impacted by multilevel risk factors for obstetrical and perinatal outcomes, including structural (eg, stigma, discrimination, access to care) and individual risk factors...

Mode of delivery and peripartum outcome in women with heart disease according to the ESC guidelines: an Italian multicenter study

Introduction The European Society of Cardiology (ESC) guidelines (GL) provide indications on the mode of delivery in women with heart disease. However available data suggests that the rate of Cesarean Delivery (CD) is high and widely variable among such patients. In this study, we aimed to investigate the degree of adherence to the ESC recommendations among women delivering in four tertiary maternity services in Italy and how this affects the maternal and neonatal outcomes. Material and methods Retrospective multicenter cohort study including pregnant women with heart disease who gave birth between January 2014 and July 2020. Composite adverse maternal outcome (CAM) was defined by the occurrence of one or more of the following: major postpartum hemorrhage, thrombo-embolic or ischemic event, de novo arrhythmia, heart failure, endocarditis, aortic dissection, need for re-surgery, sepsis, maternal death. Composite Adverse Neonatal outcome (CAN) was defined as cord arterial pH <7.00, APGAR <7 at 5 min, admission to the intensive care unit, and neonatal death. We compared the incidence of CAM and CAN between the cases with planned delivery in accordance (group “ESC consistent”) or in disagreement (group “ESC not consistent”) with the ESC GL. Results Overall, 175 women and 181 liveborn were included. A higher frequency of CAN was found when delivery was not planned accordingly to the ESC guidelines [(“ESC consistent” 9/124 (7.2%) vs “ESC not consistent” 13/57 (22.8%) p = 0.002 OR 3.74 (CI 95% 1.49–9.74) , while the occurrence of CAM was comparable between the two groups. At logistic regression analysis, the gestational age at delivery was the only parameter independently associated with the occurrence of CAN (p = 0.006). Conclusion Among pregnant women with heart disease, deviating from the ESC guidelines scheduling cesarean delivery does not seem to improve maternal outcomes and it is associated with worse perinatal outcomes, mainly due to lower gestational age at birth.

A Study on Fetomaternal Outcome of Preterm Eclampsia and its Relationship with Mode of Delivery

Introduction: Eclampsia (Greek, “shining forth”) is an acute and life-threatening complication of pregnancy, and is characterized by the appearance of tonic-clonic seizure, usually in a patient who had developed pre-eclampsia. Pre- eclampsia and eclampsia are collectively called hypertensive disorders of pregnancy and toxemia of pregnancy. This study aimed to analyze the feto-maternal outcome of preterm eclampsia and its relationship with the mode of delivery. Methods: This descriptive type of cross-sectional study was conducted at the eclampsia unit of the Department of Obstetrics and Gynecology, Dhaka Medical College Hospital, Dhaka, Bangladesh. The study was carried out from February 2012 to July 2012. A total of 92 subjects were enrolled in this study as per inclusion criteria. Result: In this study, the prevalence of eclampsia was 10.12%, and preterm eclampsia was 1.31%. The majority of the patients (48.91%) were within 20-25 years of age, and only 1.09% were &gt;30 years of age. Most of the patients were primi gravida (78.26%). The majority of the patients (54.35%) reported within 3-5 hours. Most of the patients came at 33-34 weeks gestation, but quite a significant percentage (30%) came at 28-32 weeks of gestation. A large number of patients delivered spontaneously, a fair number of patients were induced &amp; a few patients required LSCS. In both SVD &amp; induced groups, the majority of the patients (62% &amp; 66% respectively) were delivered within 7-12 hours. In the SVD group, 10% of patients were delivered within 6 hours whereas in the cesarean section group 85% of patients were delivered within 6 hours. Maximum patients (81%) had induction delivery intervals between 7-12 hours. 12 (60%) patients had LSCS done due to fetal distress, 2 (10%) due to previous H/O LSCS, 1 (5%) due to primi gravida with a twin pregnancy, and 5(25%) due to primi gravida with breech presentation. Of patients who presented at 28-32 weeks of gestation, among them 16 had SVD, 11 patients had induction of labor, and LSCS was done in only one case &amp; which was stillborn. The majority of the babies in the SVD &amp; induced group developed asphyxia (81% &amp; 90% respectively) and the majority needed admission to NICU (62% &amp; 73% respectively). PND was also high (&gt;50%) in both groups. Of patients who presented at 33-34 weeks of gestation, 19 had SVD, 15 patients had induction of labor, and only 4 patients required LSCS. A significant number of babies in all three groups (42%, 47% &amp; 100% respectively) were healthy. Although in SVD &amp; induced groups a large number of babies developed asphyxia (58% &amp; 47% respectively) and admission was required in NICU 26% in both groups. PND was few in both groups. For patients who presented at 35-36 weeks of gestation, the majority was delivered by LSCS (15) &amp; outcomes of babies were good in this group as well as in the SVD group. Only one baby developed birth asphyxia. The maternal outcome was good in all three groups (85%, 91%, &amp; 100% respectively). No maternal complication occurred in the cesarean section group. In SVD &amp; induced group few maternal complications occurred such as recurrent convulsion (12% &amp; 13% respectively), CVD (single case in both groups), pulmonary edema (1), HELLP syndrome (1), and septicemia (1). Three mothers die in SVD &amp; induced group. Conclusion: This study concluded that early-onset eclampsia has been associated with worse perinatal outcomes. Gestational age &lt;32 weeks who do not go into labor spontaneously may offer induction, as the cesarean section does not carry any good prognosis to the fetus but rather increases morbidity to the mother. When gestational age crosses &gt;33 weeks, a complete evaluation of the fetal condition, mental condition, and cervix is necessary to plan for the mode of delivery.

The ANGPTL3-4-8 Axis in Normal Gestation and in Gestational Diabetes, and Its Potential Involvement in Fetal Growth.

Dyslipidemia in gestational diabetes has been associated with worse perinatal outcomes. The ANGPTL3-4-8 axis regulates lipid metabolism, especially in the transition from fasting to feeding. In this study, we evaluated the response of ANGPTL3, 4, and 8 after the intake of a mixed meal in women with normal glucose tolerance and gestational diabetes, and we assessed their gene expressions in different placental locations. Regarding the circulating levels of ANGPTL3, 4, and 8, we observed an absence of ANGPTL4 response after the intake of the meal in the GDM group compared to its presence in the control group. At the placental level, we observed a glucose tolerance-dependent expression pattern of ANGPTL3 between the two placental sides. When we compared the GDM pregnancies with the control pregnancies, a downregulation of the maternal side ANGPTL3 expression was observed. This suggests a dysregulation of the ANGPTL3-4-8 axis in GDM, both at the circulating level after ingestion and at the level of placental expression. Furthermore, we discerned that the expressions of ANGPTL3, 4, and 8 were related to birth weight and placental weight in the GDM group, but not in the control group, which suggests that they may play a role in regulating the transplacental passage of nutrients.

The association of increasing maternal body mass index on placenta accreta spectrum disorders

Placenta accreta spectrum (PAS) is associated with high morbidity and mortality. Maternal obesity is independently associated with adverse perinatal outcomes and may augment poor obstetrical outcomes. We sought to determine if increasing maternal body mass index (BMI) is associated with worse perinatal outcomes in patients with PAS.

Colour Doppler and Adverse Perinatal Outcomes in Pregnancies with Foetal Growth Restriction: A Prospective Longitudinal Study

Introduction: Foetal Growth Restriction (FGR) accounts for a significant proportion of perinatal morbidity and mortality. The study was done to diagnose the foetuses “at risk”, so that timely intervention could prevent perinatal morbidity and mortality, as FGR foetuses with deranged velocimetry of Uterine Artery (UA), Umbilical Artery (UMA), Middle Cerebral Arteries (MCA) are associated with high perinatal morbidity and mortality. Aim: To evaluate the usefulness of blood flow velocimetry of UA, UMA, and MCA as well as a Cerebroplacental Ratio (CPR) on colour doppler and their prediction of adverse perinatal outcome. Materials and Methods: This was a prospective longitudinal study done in the Department of Obstetrics and Gynaecology, Government Medical College and Rajindra Hospital, Patiala, Punjab, India from October 2021 to March 2022. The study was conducted among 200 antenatal patients, who had a singleton pregnancy, irrespective of age and parity and had FGR foetuses. Blood flow velocities in the UA, UMA, MCA, and CPR were measured. Patients were divided into four groups with 50 patients in each group. Group I included FGR foetuses with normal blood velocities, group II included FGR foetuses with abnormal UA velocimetry, group III included FGR foetuses with abnormal UMA and MCA velocimetry and group IV included FGR foetuses with abnormal CPR. Adverse perinatal outcomes in the form of Respiratory Distress Syndrome (RDS), prematurity, Appearance, Pulse, Grimace, Activity and Respiration (APGAR) &lt;7 at 5 minutes, admission to Neonatal Intensive Care Unit (NICU), and perinatal mortality were assessed in relation to these doppler blood flow patterns. Categorical variables were analysed with the help of Chi-square test and Fisher-exact Test. Continuous variables were analysed with ANOVA when data were normally distributed otherwise Kruskal Wallis H test was used. Results: The mean birth weight was 2432±423, 2209±329, 2100±223 and 1329±403 grams in Groups-I, II, III, and IV (p-value of &lt;0.001.) The mean gestational age was 38.1±2.3, 37.3±3.2, 36±3.6 and 33.1±3.1 weeks in groups I, II, III, and IV (p-value of &lt;0.001). Perinatal morbidity in the form of RDS and prematurity were compared among four groups with 0, 3 (6%), 17 (34%), and 39 (78%) in Groups I, II, III, and IV (p-value of &lt;0.001). APGAR score &lt;7 at 5 minutes was 0, 2 (4%), 9 (18%), and 13 (26%) in groups 1, II, III, and IV (p-value of &lt;0.001). A total of 6 (12%), 16 (32%), 37 (74%) and 46 (92%) C-sections were performed in group I, II, III and IV, respectively, p-value of &lt;0.001. Maternal mortality of 1 (2%) in group III and 2 (4%) was observed in group IV. But no maternal death was there in group I and II. Conclusion: The adverse perinatal outcomes were seen with changes in Pulsatility Index (PI) value of UA, UMA, MCA. But the patients with a deranged CPR ratio had got worse perinatal outcomes than either deranged MCA, PI or UMA PI alone. Hence, doppler ultrasound especially CPR ratio should be an integral component of routine evaluation of FGR pregnancies, as it helps in obstetrical surveillance and management, and thereby improving adverse perinatal outcomes.

Perinatal outcomes of young adolescent pregnancies in an urban inner city

Although substantial efforts have been made to reduce the rates of adolescent pregnancy, the United States continues to have higher rates than other industrialized countries. Research and reporting usually focus on adolescents aged 15 to 19 years. Although less common, there are pregnant young adolescents that are ≤15 years of age, with developmental and social differences from older, high school-aged adolescents. Because adolescent pregnancies are of particular concern because of long-term socioeconomic consequences to parent and child, we sought to determine whether young adolescents (≤15 years old) had worse perinatal outcomes than older adolescents (16-19 years old) and older parents (≥20 to 34 years old) among those living in an urban inner city. This was a study of pregnant individuals who delivered a singleton pregnancy without evidence of chronic hypertension or pregestational diabetes mellitus at a safety net hospital from January 2010 to May 2021. Parents were grouped by age at the time of delivery into young adolescents (≤15 years old) and older adolescents (16-19 years old). For a comparison group, nulliparous older parents aged 20 to 34 years with singleton pregnancies were analyzed for perinatal outcomes and compared with the adolescent cohorts. When analyzing baseline parental characteristics, a preponderance of obesity was noted in the young adolescent cohort. An analysis of parental characteristics and perinatal outcomes among young adolescents with obesity vs young adolescents without obesity ≤15 years old was performed. Statistical analysis included χ2 and Student t test with P values of <.05 considered significant. Logistic regression analysis was performed to control for potentially confounding demographic variables. Overall, 10,894 adolescent women delivered, with 868 young adolescents and 10,026 older adolescents. Pairwise comparisons showed young adolescents had a different race distribution than older adolescents (P=.006) and older parents (P<.001). Young adolescents were more likely to be Hispanic or non-Hispanic Black (P<.001) and accessed prenatal care at a later gestational age (19.7±8.9 weeks) compared with older adolescents (16.7±8.6 weeks) and the comparison older cohort of parents (15.7±8.7 weeks) (P<.001) and less frequently in pregnancy (P<.001) compared with older parents. Young adolescents were more likely to have preterm birth at <37 weeks of gestation (P<.001) and eclampsia (0.5% vs 0.1%) (P=.01) than older adolescents. Therefore, low birthweights of ≤2500 g (P=.02) and neonatal intensive care unit admission (P=.048) were also increased in adolescents. When adjusted for race, ethnicity, and body mass index, preeclampsia with severe features (P<.001) and preterm birth at <37 weeks of gestation (P=.048) remained significant. Young adolescents with obesity were more likely to have preeclampsia with severe features (odds ratio, 1.81; 95% confidence interval, 1.22-2.68) and be delivered via cesarean delivery (odds ratio, 2.71; 95% confidence interval, 1.85-3.99) than adolescents without obesity. In an urban inner city, young adolescent parents were more likely to be women of color, have later presentations to prenatal care, and have increased rates of preterm birth. Young adolescents had high rates of obesity, which was associated with increased rates of hypertensive disorders of pregnancy and cesarean delivery, than adolescents without obesity.

Role of prenatal fetal echocardiography in the assessment of intrauterine growth restriction

BackgroundIntrauterine growth restriction (IUGR) is a common diagnosis in obstetrics and carries an increased risk of perinatal mortality and morbidity. Identification of IUGR is crucial because proper evaluation and management can result in a favourable outcome. Cardiovascular dysfunction and remodelling is a central feature of IUGR. The aim of the study was to use the left modified myocardial performance index (MPI), assess cardiac function in foetuses with intrauterine growth restriction (IUGR) compared to healthy foetuses, and to connect the relationship between changes in MPI and perinatal outcome. A prospective study was conducted with 60 singleton foetuses between 24 and 40 weeks of gestation without foetal chromosomal abnormalities or major malformations, divided into two groups: 30 women with intrauterine growth restriction (30 women) and another 30 women with normal pregnancies (foetal growth pattern appropriate for gestational age and normal heart findings with normal sinus rhythm) who were matched for gestational age and served as the controls. Trans-abdominal ultrasound examination was done with 3.5–7-MHz curvilinear Probe (GE Medical US equipment). The umbilical arteries, middle cerebral artery, and ductus venosus all had blood flow velocity waveforms recorded. The pulsatility index (PI), cerebroplacental ratio (CPR), and Doppler velocimetry (DV) of the umbilical artery were all measured. All foetuses had their myocardial performance index assessed. Normal and abnormal umbilical artery(UA) Doppler, as well as normal and abnormal MCA Doppler, were used to examine the intrauterine growth restriction group. Foetal growth restrictions (FGR) foetuses' Mod-MPI values were compared to gestation-matched controls. The outcomes of the perinatal period were documented.ResultsIntrauterine growth restriction foetuses with defective umbilical arteries Doppler had a substantially higher mean left myocardial performance index (mean 0.58 SD 0.093) than healthy foetuses (mean 0.45SD 0.070) (P 0.001). When compared to the control group, IUGR foetuses with abnormal left myocardial performance index had a significantly worse perinatal outcome and higher morbidity. When compared to intrauterine growth restriction foetuses with normal MPI, intrauterine growth restriction foetuses with defective left MPI had a significantly worse perinatal outcome (whether the UA Doppler was normal or abnormal). Based on the perinatal result, the foetal myocardial performance index was linked to the severity of foetal impairment in intrauterine growth restriction foetuses.ConclusionMPI has the potential to be a useful technique for evaluating IUGR pregnancies and predicting neonatal outcome. Within the IUGR foetuses, MPI foetal echocardiographic characteristics can define a high-risk group.

Adolescent pregnancy in Sao Tome and Principe: are there different obstetric and perinatal outcomes?

BackgroundAdolescent childbirth is a major public health problem in Sao Tome and Principe (STP). Adolescent pregnancy and childbirth can carry a risk of morbidity associated with the physiological and sociological characteristics of teenage girls. This study aims to identify the main adverse obstetric and perinatal outcomes for adolescent pregnancies in the Hospital Dr. Ayres de Menezes (HAM), the only hospital in STP.MethodsAn institution-based cross-sectional study. Pregnant women ≤ 19 years of age (n = 104) were compared to non-adolescent women (n = 414). The obstetric and perinatal outcomes were compared between groups using the t test. Odds ratio (OR) were calculated through Cochran’s and Mantel–Haenszel statistics test for odds ratio equal to 1, 95% confidence intervals (CI) and p values (p < 0.05) were considered significant.ResultsThe adverse perinatal outcomes imputable to adolescent births were foetal distress with low first minute Apgar score < 7 (OR 1.94, 95% CI 1.18–3.18, p = 0.009) and performance of neonatal resuscitation manoeuvres (OR 2.4, 95% CI 1.07–5.38, p = 0.032). Compared to older mothers, teenage girls were likely to have a non-statistically significant threefold higher risk of having an obstructed labour (OR 3.40, 95% CI 0.89–12.94, p = 0.07). Other perinatal outcomes as neonatal asphyxia, risk for cerebral palsy, premature birth, early neonatal infection, and neonatal death were identical between groups as well as maternal anaemia, mode of delivery or other obstetrical outcomes.ConclusionAdolescent pregnancies were associated with worse perinatal outcomes as foetal distress and higher need for neonatal resuscitation manoeuvres. This study may support STP health authorities in their efforts to make Sustainable Development Goals 3 (good health and wellbeing), 4 (quality education) and 5 (gender equality) a reality by 2030, since it identifies specific problems that need to be addressed to improve maternal adolescent health.

Perinatal outcomes in children born after fresh or frozen embryo transfer using donated oocytes.

Do children born after vitrified-thawed embryo transfers (ETs) using donated oocytes have worse perinatal outcomes when compared with fresh ET? No significant difference in birthweight and prematurity rates between fresh or frozen embryo transfers (FETs) in newborns after oocyte donation was found. Autologous singletons born after fresh ET have been previously associated with higher rates of preterm birth and low birthweight, while FETs seem to confer a higher risk of hypertensive disorders during pregnancy and macrosomia. However, studies comparing these outcomes using autologous oocytes are unable to adequately disentangle the putative detrimental consequences of embryo vitrification from the possible effects that ovarian stimulation and endometrial preparation may have on endometrial receptivity prior to ET. The oocyte donation model is, for this reason, a more appropriate setting to study these hypotheses; however so far, the information available regarding neonatal outcomes in this patient population is limited to either small and/or heterogeneous studies. We performed a multicentre retrospective cohort study including 5848 singletons born between 2009 and February 2020 following oocyte donation and single blastocyst transfer, subdivided according to whether a fresh ET or FET was performed. We also performed two additional sensitivity analyses, subgrouping the sample according to the type of endometrial preparation (natural versus artificial) and whether the donated oocytes had previously been vitrified or not. Patients with a first singleton livebirth after single blastocyst transfer were compared using multivariable regression analysis to account for potential confounding factors. The primary outcome was birthweight. Secondary outcomes were birthweight z-scores and percentiles, small/large for gestational age, gestational age at delivery, gender, prematurity (<37 weeks and <32 weeks), neonatal morbidity (Apgar scores and need for neonatal intensive care) and maternal morbidity (gestational hypertensive disorders, gestational diabetes and caesarean delivery). There was no significant difference between the fresh ET and FET groups in terms of mean birthweight (3215 g versus 3200 g) and birthweight z-scores (0.03 versus 0.1), in both the unadjusted and confounder-adjusted models. However, artificial endometrial preparation was associated with a higher birthweight (3220 g versus 3105 g) and birthweight z-scores (0.06 versus -0.13) when compared with a transfer in a natural cycle. Although a 1-day statistically significant difference in gestational age at birth (275 versus 274 days) was detected, premature birth rates (<37 weeks) did not vary significantly between groups (9.9% and 11.2% for fresh ET and FET, respectively). No other statistically significant differences were found in the remaining neonatal and maternal outcomes studies between the fresh ET and FET groups. This study is limited by its retrospective design and lack of information regarding congenital malformations. Moreover, the sample selection criteria that were used may limit the generalizability of our results. Perinatal outcomes did not seem to be affected significantly by the embryo vitrification process in an oocyte donation model. Hence, other factors may contribute to the hindered perinatal outcomes described in ART, particularly the potential effect that ovarian stimulation and endometrial preparation may have on endometrial receptivity. No specific funding was obtained for this study. All authors have no conflicts to declare. N/A.

Early- and late-onset selective fetal growth restriction in monochorionic twin pregnancy with expectant management

ObjectiveThis study aimed to identify selective fetal growth restriction (sFGR) in monochorionic twin (MCT) pregnancy with expectant management. MethodsWe retrospectively analyzed cases of sFGR between January 2015 and December 2019 in Peking University Third Hospital. We included sFGR according to the International Society of Ultrasound in Obstetrics and Gynecology diagnostic criteria. We excluded those cases where a significant fetal structural abnormality, twin reversed arterial perfusion (TRAP), genetic syndrome or aneuploidy; cases terminated for maternal complications or for personal reasons; pregnancies that had a fetal intervention, such as fetoscopic laser photocoagulation (FLP) for vascular anastomoses, fetal reduction by radiofrequency ablation (RFA) and microwave ablation (MVA). We didn't excluded those cases that had amnioreduction therapy. According to the gestational age at onset (before 24 weeks or after), data were analyzed to identify the risk factors associated with fetal prognostic outcomes. Primary outcomes included survival of at least one twin and both twins. Secondary outcomes included gestational age of delivery, live birth weight, Apgar <7 in 5 min, admission to the neonatal unit and neonatal death. Kruskal-Wallis rank tests were used to compare non-normally distributed data, whereas categorical data were matched using Fisher's exact test or χ2 tests. ANOVA was used to compare normally distributed data, followed by a post-hoc Bonferroni analysis. Multivariate binary logistic regression was used to identify the factors connected with intrauterine death. ResultsThere were 119 pregnancies that qualified for investigation, 75 (63.0%) were categorized as early-onset sFGR and 44 (37.0%) as late-onset sFGR. The rate of survival of at least one twin (82.7% vs. 95.5%), survival of both twins (73.3% vs. 88.6%) were all reduced in the early-onset sFGR group, compared to the late-onset sFGR group. Babies born alive of fetal growth restriction (FGR) and appropriate growth for gestational age (AGA) fetuses showed similar results in the two groups regarding birth weight, 5-min Apgar score <7, neonatal death, and 28-day survival rate. A multivariable model was used to predict the intrauterine death of at least one twin. The odds ratio were significantly higher for superimposed twin-twin transfusion syndrome (TTTS) (OR 17.915, 95%CI 3.699∼86.756) and Types Ⅱ/Ⅲ sFGR (OR 4.619, 95%CI 1.074∼19.869). ConclusionsIn MCT pregnancies, early-onset sFGR had a poorer survival of at least one or both twins, but there was no statistical difference in the prognosis after live birth, neither for FGR babies nor those of AGA. Superimposed TTTS and Types Ⅱ/Ⅲ sFGR had a worse perinatal outcome. This information could be provided to the parents during prenatal counselling.

Pre-induction cervical ripening with different initial doses of intravaginal misoprostol: time to delivery and peri-natal outcomes

From 2016 to 2018, a total of 300 pregnant women underwent induction of labour. Those women were allocated in two groups according to the initial dose of misoprostol. Group I (150 women) received intravaginally 50 µg misoprostol followed by 25 µg every four hours, up to a maximum of four doses whereas in group II (150 women) the initial dose was 25 μg intravaginal followed by the same dose every four hours up to a maximum of four doses. Women with previous uterine scar, abnormal foetal heart rate, severe foetal malformation, foetal growth restriction or multiple pregnancy were excluded. The aim of study was to compare the effectiveness (hours until delivery) and perinatal outcomes of both schemes of cervical ripening. Initial doses of 50 μg of misoprostol reduced the time until delivery (17.65 ± 8.2 hours vs. 20.85 ± 9.3 hours; p=.007) and the need of oxytocin (34.6% vs. 46.67%; p=.046), compared to the use of 25 μg misoprostol in all doses. No differences were observed regarding perinatal outcomes. In conclusion, starting with 50 µg of misoprostol in the first dose reduced time to vaginal delivery and decreased the use of oxytocin without worse perinatal outcomes. Impact Statement What is already known on this subject? The rate of labour induction is increasing. Mechanical and medical methods try to establish the active phase of labour as quickly and safely as possible. For this reason, there are numerous studies assessing different protocols, dosages and indications. What do the results of this study add? Despite the numerous studies, due to ethical restrictions, it is difficult to carry out prospective studies. For this reason, studies like this help to establish the most appropriate dose of misoprostol in two of the most common indications for induction of labour. We demonstrated that increasing initial doses up to 50 mg of misoprostol are safer and more effective. What are the implications of these findings for clinical practice and/or further research? This study could be useful for future prospective and randomised studies as well for including these data in a meta-analysis. In addition, these results may update the clinical protocols and reduce hospital stay without worse perinatal outcomes.

Gynecologic care utilization in asylum-seeking women in New York City

IntroductionOver 25,000 individuals are granted asylum status in the United States annually. Gender-based violence (GBV) has historically been supported as a claim for persecution to apply for asylum. In women, GBV is a known risk factor for sexually transmitted infections, poor mental health, and worse perinatal outcomes. Less is known about the links between GBV, asylum seekers, and gynecologic outcomes or care utilization. Reported rates of gynecologic care-seeking are low in asylum-seeking women and women with histories of GBV often experience barriers to care. We hypothesized that asylum-seeking women with a history of GBV at the Libertas Center, a comprehensive center for survivors of torture in New York City, would receive low rates of recommended gynecologic screening and infrequent gynecologic care. Materials and methodsThis retrospective cross-sectional study included adult self-identified female patients who had completed intake at the Libertas Center from 2005-2020. In order to examine the relationship between GBV and gynecologic care use, patients were included if they had an electronic medical record (EMR) at Elmhurst Hospital, were female, 18 years of age and older, and had ever experienced GBV in their lifetime. EMRs were reviewed for medical and psychiatric diagnoses as well as routine components of gynecologic care and were linked to intake data from the Libertas Center characterizing patients’ torture history. The primary outcome of this study was whether or not patients attended a gynecology visit. Demographic characteristics, medical histories, adequacy of gynecologic care, and gynecologic care-seeking behavior were compared between the gynecologic care group and the no gynecologic care group. ResultsA total of 249 female patients were seen at the Libertas Center from December 2005 until January 2020 at the time of data collection. The prevalence of GBV in this population was 48%. Among women who suffered GBV, 81 received medical care at Elmhurst Hospital and 44 (54%) received gynecologic care. Nearly 50% of those patients who sought care at Elmhurst carried a diagnosis of post-traumatic stress disorder or depression. Women who received gynecologic care were significantly more likely than those who did not receive gynecologic care to have had an Emergency Room visit (68% vs. 41%), an obstetric visit (32% vs 3%), and/or have been seen by a social worker (46% vs 24%; all p < 0.05). Women who saw a gynecologist were significantly more likely to have completed four basic gynecologic care measures (Pap smear, gonorrhea/chlamydia screen, pelvic exam, and mammogram if applicable) compared to women who did not (77% vs 8%, p < 0.05). ConclusionThis study characterizes the gynecologic care utilization of female patients within a comprehensive care center for survivors of torture. We found a high lifetime rate of gender-based violence of 48% in this population. Adequate gynecologic care was uncommon among those who experienced GBV. However, gynecologic care was significantly more likely in patients receiving gynecologic specialty care, which frequently occurred after initial interaction with another provider (i.e. Emergency Department providers). These findings highlight the importance of trauma-informed care and establishing pathways to help asylum seeking and refugee women receive adequate gynecologic care. Further research is needed to explore specific barriers to gynecologic care in this population, how programs for asylum-seekers can integrate gynecologic care into existing structures for medical and mental healthcare, and how to increase awareness amongst providers on the prevalence of GBV and the gynecologic needs of these patients.

Perinatal outcomes of pre-adolescent pregnancies

Because adolescent pregnancies are of particular concern due to long-term socioeconomic consequences to mother and child, we sought to determine whether pre-adolescent mothers (≤15 years old) had worse perinatal outcomes than older adolescent mothers (16-19 years old) and non-adolescent mothers (≥20-34 years old).

Perinatal Outcome of Second Twin in Third Trimester of Pregnancy.

With increasing trend of twin pregnancy and along with increasing advancement in neonatal care, survival rate of twin pregnancy has increased. However there is worse perinatal outcome in second twin in comparison with the first twin. Hospital based observational cross-sectional study of 42 pregnant women with twin pregnancy at Paropakar Maternity and Women's Hospital was conducted from November 2019 to October 2020. The outcome of second twin was assessed in relation to gestational age, chorionicity, mode of delivery, delivery interval. McNemar test was used for analysis with 0.05 as the level of significance. Among 42 pair of twins, Apgar score of the second twin was found to be lower than the first twin (p=0.00) in general and in preterm gestation (p=0.115). Among twin who had monochorionic placenta; higher number of twin 1 had Apgar score of ?7(p=0.004). Among twin who had inter-delivery interval of <30min; higher number of twin1 had Apgar score of ?7 at 5 minutes. (p=0.00). Second twin has lower Apgar score in relationship to period of gestation, mode of delivery, inter-delivery interval, and chorionicity.

P–287 Uterine adenomyosis does not affect perinatal outcomes in ART treatments

Abstract Study question Is adenomyosis associated with worse clinical and perinatal outcomes in ovum donation cycles? Summary answer Adenomyosis was associated with reduced live birth rate per embryo transfer but not with increased risk of miscarriage or worse perinatal outcomes than controls. What is known already The effect of adenomyosis on IVF/ICSI outcomes are controversial as studies addressing this issue are limited in number and heterogeneous. Conclusions withdrawn from previous works differ regarding the prospective or retrospective design of the study. Two different metanalysis conducted showed that adenomyosis reduced implantation and clinical pregnancy rate and increased miscarriage risk. However, current data regarding perinatal outcomes of assisted reproduction techniques cycles in patients diagnosed with uterine adenomyosis is scarce. Study design, size, duration A retrospective cohort study in which 3307 patients undergoing ovum donation cycles were included. Patients who underwent single embryo transfer (SET) between years 2018 and 2019 were included and divided into two groups: adenomyosis (n = 179) and controls (n = 3218). Participants/materials, setting, methods Inclusion criteria consisted of patients in an oocyte donation program who had fresh SET on day 5 blastocyst stage development. Patients diagnosed with miomas and/or severe endometriosis and those who had undergone previous uterine surgical interventions were excluded from the study. Cases consisted of patients with a history of either focal or diffuse adenomyosis diagnosed via transvaginal ultrasonography (TVUS). Main results and the role of chance Clinical pregnancy rate per embryo transfer was 82/179 (45.8%) in those women diagnosed with adenomyosis versus 1869/3218 (59.8%) in control group (OR = 0.57 95% CI. 0.41–0.78, p &amp;lt; 0.001). Miscarriage rate was similar in the two study groups and differences found were not statistically significant, being 15/82 (18.3%) for adenomyosis and 309/1869 (16.5%) for control group. A lower live birth rate per embryo transfer was observed in women diagnosed with adenomyosis versus control, being 68/179 (38%) and 1560/3128 (49.9%) respectively (OR = 0.615 95% CI 0.44–0.85, p = 0.002). There were no statistically significant differences between childbirth delivery methods (vaginal versus caesarean section). Furthermore, means of gestational age at the time of delivery, newborn size and weight and incidences of low birth weight, preterm birth and admission in neonate intensive care unit (NICU) did not differ between the two groups. In addition, IVF and perinatal outcomes were similar in patients with diffuse adenomyosis compared to focal adenomyosis. Limitations, reasons for caution This is an observational study and thus possible confounders cannot be completely excluded. Diagnostic of adenomyosis is complex and, despite imaging via TVUS is both sensitive and specific, different criteria may be combined in order to fully assess the diagnostic. Wider implications of the findings: Published literature has described how adenomyosis negatively impacts clinical outcomes in ART cycles; however, data regarding perinatal results is scarce. This study is of interest as it provides a first insight for clinicians showing that adenomyosis affects clinical but not perinatal outcomes in ovum donation cycle. Trial registration number Not applicable