Volume 44, Issue 7 - Highlight: Obstetrics

Fetal surgery involves a large number of heterogeneous interventions that vary from simple and settled procedures to very sophisticated or still-in-development approaches. The overarching goal of fetal interventions is clear: to improve the health of children by intervening before birth to correct or treat prenatally diagnosed abnormalities. This article provides an overview of fetal interventions, ethical approaches in fetal surgery, and benefits obtained from antenatal surgeries.

Objective: To describe preliminary experience with a finger-mounted fetal tissue oximetry probe during the 2 nd stage of labor. Materials and methods: A total of 30 term pregnant women without pregnancy complications were recruited. We measured fetal tissue oxygen saturation (FtO 2 ) by using a finger-mounted fetal tissue oximetry during cervical examinations in the 2 nd stage of labor. The data capturing rate of FtO 2 and the interclass correlation coefficient were also examined. The mean FtO 2 was compared to the neonatal condition assessed by the levels of umbilical cord blood. Results: FtO 2 was obtained in all cases, regardless of wetness, hair color, the part of the fetal head that was exposed, rotation of the fetus, color of amniotic fluid, and caput succedaneum. The mean FtO 2 was 65.5%±8.58% in normal neonates [Apgar score >7 (1 min), n=25]. The mean FtO 2 was significantly correlated with umbilical cord arterial pH (r=0.52, P=0.0030, n=30), but not with umbilical cord arterial partial pressure of oxygen. The interclass correlation coefficient was 0.94. Conclusions: Tissue oxygen saturation of the fetal head was obtained easily by the examiner’s finger-mounted fetal tissue oximetry.

Aims: To evaluate values of T/QRS ratio in normal pregnancies and those complicated by intrauterine growth restriction (IUGR) using non-invasive method with transabdominal electrodes. Assessment of fetal well-being in IUGR pregnancies. Methods: Fetal electrocardiograms were recorded and analyzed by KOMPOREL software from ITAM (Zabrze, Poland) and T/QRS ratios were automatically calculated. Doppler velocimetry of the middle cerebral artery and umbilical artery was carried out. The study group consisted of IUGR pregnancies with normal cerebroplacental ratios (CPRs) (n=110), IUGR pregnancies with decreased CPRs (n=29), and healthy controls (n=549). Analyses were performed between the study groups and by gestational age. T/QRS ratio variables and CPRs were calculated. Analysis of variance and linear regression were performed. Results: Maximum values, maximum minimal value differences, and standard deviations of T/QRS ratio were significantly different between the IUGR group with reduced CPRs and normal CPRs (P=0.0009, P=0.0000, P=0.0034, respectively) as well as between the IUGR group with reduced CPRs and healthy controls (P=0.0000, P=0.0001, P=0.0009, respectively). Mean maximum values in the IUGR group with reduced CPRs exceeded normal values. Conclusions: T/QRS ratio may be useful in assessing fetal well-being in IUGR pregnancies; however, future studies are needed to determine typical ranges of T/QRS ratio in pregnancies complicated by IUGR.

Objective: The objective of this study was to determine characteristics associated with cesarean delivery among women with labor induction lasting over 24 h. Study design: Women with live singleton pregnancies without prior cesarean delivery undergoing a labor induction lasting >24 h between September 2006 and March 2009 at Duke University Hospital were identified. Collected variables were compared between subjects by mode of delivery. A multivariate logistic regression model for the outcome cesarean delivery was constructed separately for nulliparous and parous women. Results: There were 303 women who met inclusion criteria. The overall cesarean delivery rate was 57% (n=172) and remained constant with time (P=0.15, test-for-trend). Nulliparous women having a cesarean delivery were more likely to be obese [adjusted OR (aOR) 2.00; 95% CI 1.05, 3.80] and have a larger fetus [aOR 1.11 (aOR for every 100 g increase in birthweight), 95% CI 1.03, 1.20] compared to those having a vaginal delivery. Conclusion: Increasing BMI and birthweight were independent predictors of cesarean delivery among nulliparous women with prolonged labor induction. Despite this, after 24 h of labor induction, the overall mean cesarean delivery rate remained constant at 57%, and did not change with time. Among women having a vaginal delivery following a prolonged labor induction, we saw high rates of shoulder dystocia, operative vaginal delivery and severe perineal laceration.

Aim: This study aimed to evaluate maternal and fetal outcomes after uterine fundal pressure (UFP) in spontaneous and assisted vaginal deliveries. Methods: In a retrospective cohort study, 9743 singleton term deliveries with cephalic presentation were analyzed from 2004 to 2013. Spontaneous and assisted vaginal deliveries were analyzed separately with and without the application of UFP. Odds ratios were adjusted in a multivariate logistic regression analysis. Results: Prevalence of UFP was 8.9% in spontaneous and 12.1% in assisted vaginal deliveries. UFP was associated with a higher incidence of shoulder dystocia in both spontaneous (adjusted odds ratio [adj. OR] 2.44, confidence interval [CI] 95% 1.23–4.84) and assisted vaginal deliveries (adj. OR 6.88 CI 95% 3.50–13.53). Fetal acidosis (arterial umbilical pH<7.2) was seen more often after the application of UFP in spontaneous vaginal deliveries (adj. OR 3.18, CI 95% 2.64–3.82) and assisted vaginal deliveries (adj. OR 1.59 CI 95% 1.17–2.16). The incidence of 5′-Apgar<7 (adj. OR 2.19 CI 95% 1.04–4.6) and 10′-Apgar<7 (adj. OR 3.04 CI 95% 1.17–7.88) was also increased after the application of UFP in spontaneous deliveries. A higher incidence of anal sphincter tears (AST) (adj. OR 46.25 CI 95% 11.78–181.6) in the UFP group of spontaneous deliveries was observed. Conclusions: UFP is associated with increased occurrence of shoulder dystocia and fetal acidosis. In spontaneous deliveries, the risk for lower Apgar scores after 5 and 10 min is increased, as well as the risk for AST.

Aim: Pregnancy in women of advancing maternal age is linked to incrementally worsening perinatal outcome. The aim of this study is to assess the impact of maternal age on delivery outcome in women that spontaneously labour at term. Methods: This was a retrospective study of women that spontaneously labour at term. Women with singletons in spontaneous onset labour beyond 37 weeks of gestation were divided into five maternal age groups: <19 years, 20–24 years, 25–29 years, 30–34 years and >35 years by their age at delivery. The main outcome variables are augmentation of labour, caesarean section, assisted vaginal delivery, and perineal trauma, while admission of the newborn into the neonatal unit within 24 h following delivery was the secondary outcome measure. Results: A total of 30,022 met the inclusion criteria with primiparae and multiparae accounting for 46 and 54%, respectively. Increasing age in primiparae was associated with; augmentation of labour OR 2.05 (95% CI 1.73–2.43), second degree perineal tear 1.35 (1.12–1.61), assisted vaginal delivery 1.92 (1.53–2.41) and caesarean section 4.23 (3.19–5.12). While that for multiparae; augmentation of labour OR 1.93 (1.05–3.52), perineal trauma 2.50 (1.85–3.34), assisted vaginal delivery 4.95 (91.82–13.35) and caesarean section 1.64 (1.13–2.38). The secondary outcome measure did not reach statistical significance. Conclusion: Increasing maternal age is an independent risk factor for operative delivery, and perineal trauma. However, maternal age has no significant effect on admission of infants into the NICU during the first 24 h following delivery.

Objective: To identify maternal characteristics independently associated with pregnancies resulting in intrauterine fetal demise (IUFD). Study design: This was a population-based cohort study of all births taking place at the McGill University Health Centre in Montreal, Canada, between 2001 and 2007, using the McGill University Obstetrics and Neonatal Database. Maternal characteristics were compared between pregnancies that resulted in IUFD and control pregnancies resulting in live newborns. A logistic regression analysis was constructed to identify parameters independently associated with IUFD. Results: We identified 20,744 births during the study period, 87 of which were complicated by IUFD. Mothers with IUFD were more likely to be younger, with less formal education, higher rates of smoking during pregnancy, and more fetal anomalies (42.5% vs. 7.5%, P<0.001). After exclusion of pregnancies with congenital and/or chromosomal abnormalities, less formal education (7 vs. 13.6 school years, P<0.001) and smoking during pregnancy (24% vs. 7.7%, P<0.001) remained significantly more common in pregnancies resulting in IUFD. In the multivariable regression analysis both smoking and number of maternal school years were independently associated with IUFD pregnancies (OR 2.22 for smoking, P=0.007 and OR 0.865 for number of school years, P<0.001). Conclusion: Lower levels of education and smoking during pregnancy are independent predictors of IUFD.

Dawes and Redman (DR) based their definition of short-term variation (STV) on the successive differences of mean inter-beat intervals dividing 1 min of cardiotocography recordings in 16 epochs of 3.75 s each. In contrast, heart rate variability (HRV) is based on the inter-beat intervals of discrete R peaks, also referred to as normal-to-normal (NN) intervals. Despite the historical achievements of DR in providing a robust method with the equipment available at the time to encourage the widespread use and creation of large databases, one must ask whether the STV (DR) parameter is reproducible using a different method of recording, and how much temporal information is actually lost by applying the averaging algorithm sketched above. We simultaneously performed both standard Oxford cardiotocography and transabdominal fetal electrocardiography recordings in 26 patients with low-risk singletons. In addition, we revisited our database of 418 standard fetal magnetocardiographic recordings, applying the DR algorithm to the fetal NN data and compared them to standard HRV parameters. The correlation between STV (DR) from cardiotocography and fetal electrocardiography was stronger that of either with short term fHRV from NN intervals. The methodological trade-off to gain STV as a robust parameter from heart rate traces of limited temporal resolution is accompanied by a loss of temporal information that, at the moment, only fetal magnetocardiography and, to a lesser extent, fetal electrocardiography may provide.

Aims: To compare the outcomes of term gestations with oligohydramnios in the absence of other underlying disorders and term gestations with normal amniotic fluid. Methods: A retrospective analysis of obstetric outcomes in 27,708 term pregnancies. We compared three groups: labor induced because of oligohydramnios, spontaneous onset of labor with normal amniotic fluid, and labor induced because of late term pregnancy with normal amniotic fluid. We excluded pregnancies with maternal or fetal diseases or disorders potentially related with amniotic fluid alterations. The main outcome measures were mode of delivery, neonatal birth weight, umbilical artery blood pH, Apgar scores and neonatal discharge status. Results: Compared to spontaneous labor, induction of labor because of oligohydramnios was associated with a higher risk of cesarean delivery and small size of the fetus for gestational age (SGA). Compared to induction because of late term pregnancy there were no significant differences in neonatal, although neonates had a higher risk of being SGA. Conclusion: The only perinatal outcome for which the risk was higher in term pregnancies with isolated oligohydramnios was SGA. The systematic induction of labor in these pregnancies should be questioned.

Aims: The aim of this study was to evaluate the factors responsible for epidural analgesia (EA) refusal among parturient patients. Methods: In this prospective cross-sectional study of six months, we included all consenting postpartum patients having a non-operative delivery in the obstetric unit of our hospital. Data were collected on a predesigned questionnaire and included information such as parity, education, reasons for delivering with or without EA, source of information and patient satisfaction. Knowledge regarding EA was assessed from patients delivering without EA. Results: From 933 patients enrolled, 730 (78.2%) delivered without EA, and 203 (21.7%) with EA. Only 11 (1.5%) patients refused EA for the reason of having natural birth process. Otherwise common reasons were misconceptions (65.9%) and lack of awareness about EA (20.5%); 70.5% had no knowledge of common side effects of EA. Among patients delivering with EA, 92.6% were offered EA by health care providers and had obstetricians and anesthesiologists as their sources of information. Conclusions: Patients in developing countries are laboring without EA, even in centers where there is a provision for it. The main reasons for not availing themselves of EA are lack of awareness and knowledge and misconceptions, rather than the desire to have un-medicated natural birth.

Aim: To investigate whether the cervical length measured by transvaginal ultrasound at 35 to 36 weeks of gestation is predictive of spontaneous early onset of labor in pregnancies scheduled for elective cesarean section (CS). Study design: This was a prospective observational study on 167 women scheduled for elective CS at 39 weeks of gestation. The cervical length was measured ultrasonographycally at 35 to 36 weeks of gestation and the pregnancies characteristics were recorded. The presence or absence of spontaneous onset of labor before the time scheduled for elective CS was related to cervical length and pregnancies characteristics. Results: Of the 167 pregnancies enrolled, 25 (14.97%) underwent early spontaneous onset of labor before the time scheduled for the elective CS. The cervical length was significantly shorter in these women when compared with those delivering with an elective CS (21 vs. 30 mm z=5.49 P<0.0001). The presence of ≥2 previous CS as an indicator for elective CS resulted a significant predictor of early onset of labor in univariate analysis (P=0.01). Multivariate logistic regression analysis showed that cervical length (adjusted odds ratio 1.40; 95% confidence interval (CI) 1.22–1.61; P≤0.0001) was the only predictor for the early onset of labor. The area under the receiver–operating characteristics curve for the prediction of early onset of labor was 0.844 (95% CI 0.738–0.950) for cervical length as test variable. Kaplan-Meier analysis demonstrated that a cervical length <24 mm was significantly associated with a short time interval to delivery (log rank test χ 2 =99,98; P≤0.0001). Conclusion: Cervical length at 35–36 weeks of gestation provides information about the likelihood of spontaneous early onset of labor in pregnancies scheduled for CS and may be useful in individualizing the gestational age for elective CS.

Objective: The aim of this study was to determine gene expression and splicing changes associated with parturition and regions (visceral vs. subcutaneous) of the adipose tissue of pregnant women. Study design: The transcriptome of visceral and abdominal subcutaneous adipose tissue from pregnant women at term with (n=15) and without (n=25) spontaneous labor was profiled with the Affymetrix GeneChip Human Exon 1.0 ST array. Overall gene expression changes and the differential exon usage rate were compared between patient groups (unpaired analyses) and adipose tissue regions (paired analyses). Selected genes were tested by quantitative reverse transcription-polymerase chain reaction. Results: Four hundred and eighty-two genes were differentially expressed between visceral and subcutaneous fat of pregnant women with spontaneous labor at term (q-value <0.1; fold change >1.5). Biological processes enriched in this comparison included tissue and vasculature development as well as inflammatory and metabolic pathways. Differential splicing was found for 42 genes [q-value <0.1; differences in Finding Isoforms using Robust Multichip Analysis scores >2] between adipose tissue regions of women not in labor. Differential exon usage associated with parturition was found for three genes ( LIMS1 , HSPA5, and GSTK1 ) in subcutaneous tissues. Conclusion: We show for the first time evidence of implication of mRNA splicing and processing machinery in the subcutaneous adipose tissue of women in labor compared to those without labor.

Aim: To compare different classification systems in a cohort of stillbirths undergoing a comprehensive workup; to establish whether a particular classification system is most suitable and useful in determining cause of death, purporting the lowest percentage of unexplained death. Methods: Cases of stillbirth at gestational age 22–41 weeks occurring at the Department of Gynecology and Obstetrics of Foggia University during a 4 year period were collected. The World Health Organization (WHO) diagnosis of stillbirth was used. All the data collection was based on the recommendations of an Italian diagnostic workup for stillbirth. Two expert obstetricians reviewed all cases and classified causes according to five classification systems. Results: Relevant Condition at Death (ReCoDe) and Causes Of Death and Associated Conditions (CODAC) classification systems performed best in retaining information. The ReCoDe system provided the lowest rate of unexplained stillbirth (14%) compared to de Galan-Roosen (16%), CODAC (16%), Tulip (18%), Wigglesworth (62%). Conclusion: Classification of stillbirth is influenced by the multiplicity of possible causes and factors related to fetal death. Fetal autopsy, placental histology and cytogenetic analysis are strongly recommended to have a complete diagnostic evaluation. Commonly employed classification systems performed differently in our experience, the most satisfactory being the ReCoDe. Given the rate of “unexplained” cases, none can be considered optimal and further efforts are necessary to work out a clinically useful system.

Objective: To evaluate recent trends of out-of-hospital births in the US from 2009 to 2014. Methods: We accessed data for all live births occurring in the US from the National Vital Statistics System, Natality Data Files for 2009–2014 through the interactive data tool, VitalStats. Results: Out-of-hospital (OOH) births in the US increased from 2009 to 2014 by 80.2% from 32,596 to 58,743 (0.79%–1.47% of all live births). Home births (HB) increased by 77.3% and births in freestanding birthing centers (FBC) increased by 79.6%. In 2014, 63.8% of OOH births were HB, 30.7% were in FBC, and 5.5% were in other places, physicians offices, or clinics. The majority of women who had an OOH birth in 2014 were non-Hispanic White (82.3%). About in one in 47 non-Hispanic White women had an OOH in 2014, up from 1 in 87 in 2009. Women with a HB were older compared to hospital births (age ≥35: 21.5% vs. 15.4%), had a higher live birth order(≥5: 18.9% vs. 4.9%), 3.48% had infants <2500 g and 4.66% delivered <37 weeks’ gestation. 4.34% of HB were patients with prior cesarean deliveries, 1.6% were breech, and 0.81% were twins. Conclusions: Since 2004 the number of women delivered out of the hospital, at home and in freestanding birthing centers has significantly increased in the US making it the country with the most out of hospital births among all developed countries. The root cause of the increase in planned OOH births should be identified and addressed by the medical community.