Volume 46, Issue 6

Objective: To characterize the American College of Obstetricians and Gynecologists (ACOG) contraindicated home births and the women who are receiving these births in hopes of identifying venues for intervention. Methods: The National Center for Health Statistics (NCHS) birth certificate records from 1990 to 2015 were used. “Planned home births” were defined as those births in which birthplace was coded as “residence” and birth attendant was coded as “certified nurse midwife (CNM)” or “other midwife”. Contraindicated home births were defined as “planned home births” from 1990 to 2015 that had one or more of the ACOG risk factors for home births, which include vaginal birth after prior cesarean delivery (VBAC), breech presentation and multiple gestations. Results: A review of trends in contraindicated home births from 1990 to 2015 suggests that they are increasing in number (481–1396) and as a percentage of total births (0.01%–0.04%, P<0.001). There has been an increase in the proportion of college-educated women (31%–51%, P<0.001). Most women receive prenatal care (>95%), which is most frequently initiated in the first trimester. The majority of home births were paid out-of-pocket (65%–69%). Conclusion: The increasing number of contraindicated home births in the United States requires public health action. Home births are likely a matter of choice rather than a lack of resources. It is unclear if women choose home births while knowing the risk or due to a lack of information. Prenatal education about contraindicated home births is possible, as almost all women receive prenatal care.

Aim: To assess fetal descent rates of nulliparous and multiparous women in the active phase of labor and to evaluate significant impact factors. Methods: In a retrospective cohort study at the University Hospital of Zurich, Switzerland, we evaluated 6045 spontaneous vaginal deliveries with a singleton in vertex presentation between January 2007 and July 2014 at 34 0/7 to 42 0/7 gestational weeks. Median fetal descent rates and their 10 th and 90 th percentiles were assessed in the active phase of labor and different impact factors were evaluated. Results: Fetal descent rates are exponentially increasing. Nulliparous women have slower fetal descent than multiparous women (P<0.001), ranging from 0 to 5.81 cm/h and from 0 to 15 cm/h, respectively. The total duration of fetal descent in labor is 5.42 h for nulliparous and 2.71 h for multiparous women. Accelerating impact factors are a lower fetal station, multiparity, increasing maternal weight and fetal occipitoanterior position, whereas epidural anesthesia decelerates fetal descent (P<0.001). Conclusions: Fetal descent is a hyperbolic increasing process with faster descent in multiparous women compared to nulliparous women, is highly inter individual and is associated with different impact factors. The diagnosis of labor arrest or prolonged labor should therefore be based on such rates as well as on individual evaluation of every parturient.

Background: Fetal electrocardiogram (fECG) can detect QRS signals in fetuses from as early as 17 weeks’ gestation; however, the technique is limited by the minute size of the fetal signal relative to noise ratio. The aim of this study was to evaluate precise fetal cardiac time intervals (fCTIs) with the help of a newly developed fetal ECG device (Monica Healthcare System). Methods: In a prospective manner we included 15–18 healthy fetuses per gestational week from 32 weeks onwards. The small and wearable Monica AN24 monitoring system uses standard ECG electrodes placed on the maternal abdomen to monitor fECG, maternal ECG and uterine electromyogram (EMG). Fetal CTIs were estimated on 1000 averaged fetal heart beats. Detection was deemed successful if there was a global signal loss of less than 30% and an analysis loss of the Monica AN24 signal separation analysis of less than 50%. Fetal CTIs were determined visually by three independent measurements. Results: A total of 149 fECGs were performed. After applying the requirements 117 fECGs remained for CTI analysis. While the onset and termination of P-wave and QRS-complex could be easily identified in most ECG patterns (97% for P-wave, PQ and PR interval and 100% for QRS-complex), the T-wave was detectable in only 41% of the datasets. The CTI results were comparable to other available methods such as fetal magnetocardiography (fMCG). Conclusions: Although limited and preclinical in its use, fECG (Monica Healthcare System) could be an additional useful tool to detect precise fCTIs from 32 weeks’ gestational age onwards.

Background: The umbilical coiling index (UCI) is a measure of the number of coils in the umbilical cord in relation to its length. Hypercoiled cords with a UCI of >0.3 coils/cm have been associated with adverse fetal and neonatal outcomes. Aims: The primary aim is to determine the accuracy of UCI measured on second trimester ultrasound in predicting UCI at birth. The secondary outcome is to investigate the association between hypercoiling of the umbilical cord on prenatal ultrasound and adverse maternal, fetal and neonatal outcomes. Methods: This was a prospective cohort study of uncomplicated singleton pregnancies. Seventy two patients were included in the study. UCI was measured in the second trimester ultrasound, and compared to UCI measured postnatally. Outcomes of patients with hypercoiled cords on ultrasound were compared to outcomes of patients with normocoiled cords. Results: Our results failed to show a strong correlation between the UCI determined with ultrasound, and the UCI determined with examination of the umbilical cord after delivery. We also did not demonstrate that measurement of the UCI on second trimester ultrasound is able to predict adverse maternal, fetal or neonatal outcomes. Conclusion: This study suggests that measurement of the umbilical coiling index should not be part of routine second trimester sonography in patients with uncomplicated singleton pregnancies, with no other medical or surgical comorbidities.

Aims: Currently one of the most widespread systems for the computerized analysis of the fetal heart rate (FHR) is the Dawes-Redman system, where the short-term variation (STV) of the FHR is measured by dividing each minute into 16 segments (STV16). Technical progress has allowed for the development of a new algorithm, which measures the STV by dividing each minute into 240 segments (STV240), thus approximating the beat-to-beat variation. The STV240 still lacks reference values. Our aim was to develop clinically relevant reference values for the STV240 and compare them to the ones for the STV16. Methods: In a single centre, observational study, a total of 228 cardiotocograms were registered and subsequently analyzed with both algorithms (STV240 and STV16). Results: The 95% confidence interval (CI) was calculated for both algorithms. The values of the STV240 were significantly lower in comparison to the ones of the STV16. Not only the mean values but also the 95 th percentile of the STV240 lay beneath the existent cut-off value for the STV16. Conclusions: Every clinician using the new algorithm must be aware that the normal values for the STV240 lie beneath the, up until now, established cut-off values for the STV16.

Background: Lactic acid dehydrogenase (LDH) is a valuable marker for some of the most important diseases in newborns and the plasma LDH activity in newborns correlates well with conditions such as asphyxia. If LDH should be considered as a useful tool also in obstetric care, key factors associated with maternal health before and during pregnancy which could affect umbilical cord LDH activity need to be known. The aims of this study were to explore relationships between selected maternal conditions and arterial lactic acid dehydrogenase activity (aLDH) in umbilical cord blood at delivery. Methods: A prospective observational study was conducted at Sodersjukhuset, Stockholm, Sweden. Included in the study were 1247 deliveries, and cord blood samples from each were analyzed for aLDH. Background, delivery and neonatal data were collected from the medical records. Results: Higher median values of aLDH were found (P=0.001) among women with chronic disorders not related to pregnancy but there was no increased frequency of high aLDH levels (>612 μ/L, P=0.30). No difference in aLDH was identified between infants born to women with pregnancy-related disorders compared with healthy women, neither in median values, nor in high values (>612 μ/L, P=0.95). Conclusion: Newborn infants born to women with non-pregnancy-related chronic disorders had a somewhat higher median value of aLDH in cord blood at delivery. The influence of common maternal conditions and diseases on umbilical cord arterial LDH levels is small compared to the increase reported in fetal distress and several other critical conditions in the newborn.

Objective To determine the frequency and type of histopathologic lesions in placentas delivered by women with a normal pregnancy outcome. Methods This retrospective cohort study included placental samples from 944 women with a singleton gestation who delivered at term without obstetrical complications. Placental lesions were classified into the following four categories as defined by the Society for Pediatric Pathology and by our unit: (1) acute placental inflammation, (2) chronic placental inflammation, (3) maternal vascular malperfusion and (4) fetal vascular malperfusion. Results (1) Seventy-eight percent of the placentas had lesions consistent with inflammatory or vascular lesions; (2) acute inflammatory lesions were the most prevalent, observed in 42.3% of the placentas, but only 1.0% of the lesions were severe; (3) acute inflammatory lesions were more common in the placentas of women with labor than in those without labor; (4) chronic inflammatory lesions of the placenta were present in 29.9%; and (5) maternal and fetal vascular lesions of malperfusion were detected in 35.7% and 19.7%, respectively. Two or more lesions with maternal or fetal vascular features consistent with malperfusion (high-burden lesions) were present in 7.4% and 0.7%, respectively. Conclusion Most placentas had lesions consistent with inflammatory or vascular lesions, but severe and/or high-burden lesions were infrequent. Mild placental lesions may be interpreted either as acute changes associated with parturition or as representative of a subclinical pathological process (intra-amniotic infection or sterile intra-amniotic inflammation) that did not affect the clinical course of pregnancy.

Fetal neurology is evolving as an area of great interest in prenatal diagnosis and fetal medicine. The identification and diagnosis of brain damage prenatally has been a great challenge in obstetrics for many years. Investigations of fetal behavior in comparison with morphological studies led to the conclusion that fetal behavioral patterns directly reflect developmental and maturational processes of the fetal central nervous system (CNS). Four-dimensional (4D) ultrasound has greatly improved the assessment of the quality of the fetal spontaneous movements, and enabled a better evaluation of fetal behavior. The assessment of normal neurobehavioral development by 4D ultrasound provided the opportunity to investigate functional characteristics of the fetus that could predict neurological developmental dysfunction. Some studies have already been carried out to evaluate this new methodology in the observation of fetal behavior during different stages of gestation, in an attempt to better understand the relationships between the maturation of the CNS of the fetus and its implications on its behavior pattern. We present a review of literature on fetal behavior by 4D ultrasound.

Objectives: This study aimed to determine maternal and obstetric factors associated with emergency caesarean section (CS) for non-reassuring foetal status (NRFS). Materials and methods: This was a retrospective analysis of term singleton births between January 2007 and December 2015 at the Mater Mother’s Hospital in Brisbane. The study group comprised all cases of emergency CS for NRFS, and the control cohort comprised all other births meeting the inclusion criteria but excluding those in the study cohort. Results: Over the study period, there were 74,177 births fulfilling the inclusion criteria. The overall rate of emergency CS for NRFS was 4.2% (3132/74,177). Multivariate analysis showed that being overweight and obese, Indian and “other” ethnicity, artificial reproductive techniques, smoking, induction of labour and gestation at 39–42 weeks were associated with an increased risk, whereas being underweight, female sex, hypertension and birth without labour conferred a lower risk. Conclusion: Many maternal and obstetric factors were associated with emergency CS for NRFS and influenced adverse perinatal outcomes. Recognition of these risk factors could help risk stratify women prior to labour.

Aim: To evaluate the success rate and protocol of the Bakri balloon for postpartum hemorrhage (PPH) in the course of a prospective observational multicenter cohort study in South China. Methods: At 20 hospitals in South China, women with postpartum bleeding who failed to respond to the first-line conservative management and received the Bakri balloon were recruited for the study. Maternal characteristics, PPH characteristics, PPH management and outcomes in regard to the Bakri balloon use were recorded. Results: A total of 472 women had a Bakri balloon tamponade and 407 (86.23%) women were enrolled (67 after vaginal delivery and 340 either during or after cesarean delivery). The success rate of the Bakri balloon in this study was 91.65% (373/407 women). During vaginal deliveries, the group with a hemorrhage >2000 mL before balloon insertion had significantly more blood loss (551.67±635.17 mL vs. 242.06±313.69 mL, P=0.039) and lower maternal hemoglobin (73±21.77 g/L vs. 92.06±19.60 g/L, P=0.029) after using Bakri balloon than the group with a hemorrhage <1000 mL. Similar data were found during cesarean deliveries. The blood loss before and after balloon insertion were significantly higher in the Bakri balloon failure group (1700±1429.88 mL before and 1209.58±1139.72 mL after using the balloon) than those in the success group [918±493.92 mL before (P=0.002) and 266.57±361.60 mL after using the balloon (P=0.001)]. Conclusion: Rapid diagnosis or prognosis of PPH, in combination with early usage of the Bakri postpartum balloon is more effective for the management of PPH.

Objective: To analyze data from a registry of Japanese neonates with hypoxic respiratory failure associated with pulmonary hypertension (PH) to compare the effectiveness of inhaled nitric oxide (iNO) in neonates born <34 weeks vs. ≥34 weeks gestational age (GA). Materials and methods: iNO was administered according to approved Japanese product labeling. Study data were collected before iNO administration and at predefined intervals until discontinuation. Results: A total of 1,114 neonates were included (n=431, <34 weeks GA; n=675, ≥34 weeks GA; n=8, missing age data). Mean decrease from baseline oxygenation index (OI) was similar in both age groups. OI reduction was more pronounced in the <34 weeks subgroups with baseline OI ≥25. Survival rates were similar in the <34 weeks GA and ≥34 weeks GA groups stratified by baseline OI (OI<15, 89% vs. 93%; 15≤OI<25, 85% vs. 91%; 25≤OI≤40, 73% vs. 79%; OI>40, 64% vs. 66%). Conclusion: iNO improved oxygenation in preterm neonates as effectively as in late preterm and term neonates, without negative impact on survival. If clinically significant PH is present, as measured by pulse oximetry or echocardiography, a therapeutic trial of iNO might be indicated for preterm neonates.

Context: Significant controversy exists surrounding the possible association between recent packed red blood cell (PRBC) transfusion and the subsequent development of necrotizing enterocolitis (NEC) in infants. Previous studies and meta-analyses reporting a statistically significant association led to a practice change to withhold enteral feeds in the peri-transfusion period in many centers in an effort to prevent NEC; however, results from more recent studies do not support the existence of an association and, thus, question the validity of this practice change. Objective: This study aimed to perform a systematic review and meta-analysis to determine whether exposure to recent PRBC transfusion (defined as within 48 h) is associated with the subsequent development of NEC stage ≥II (Bell’s criteria) in infants. Methods: Medline, Embase, CINAHL, and the Cochrane Library were searched from inception to October 7, 2015. A gray literature search was also performed. Studies comparing the risk of NEC in infants exposed and unexposed to recent PRBC transfusion were included. Thirteen studies met eligibility criteria, and 10 (n=15,675 infants) were included in the meta-analysis. Three authors independently extracted data, and meta-analysis was performed using a random effects model. Results: We found a statistically significant 45% reduction in the unadjusted odds of NEC in infants exposed to a recent PRBC transfusion (odds ratio=0.55, 95% confidence interval=0.31–0.98). Conclusion: Our results show a protective effect of recent PRBC transfusion on the subsequent development of NEC. The practice of withholding enteral feeds during the peri-transfusion period should be re-evaluated in light of these results.

Background: The number of observational studies that report an association between packed red blood cell (PRBC) transfusions and necrotizing enterocolitis (NEC) has increased. The primary objective of this study was to evaluate the association between PRBC transfusions and NEC in observational studies. Methods: Medline, Embase and Cochrane Library databases as well as the Pediatrics Academic Societies abstract archives were systematically searched to identify observational studies that investigated the association between PRBC transfusions and NEC. Key search terms included premature infant, blood transfusion and necrotizing enterocolitis. The generic inverse variance method with a random-effects model was used to meta-analyze selected studies. Odds ratios (ORs) and confidence intervals (CIs) were calculated. Results: A meta-analysis of 17 observational studies that reported the association between PRBC transfusions and NEC was performed. The meta-analysis revealed no evidence of an association between PRBC transfusions and a higher risk of NEC (OR: 0.96; 95% CI: 0.53–1.71; P=0.88). The effect estimates that suggested an association between PRBC transfusion and NEC in matched case-control studies (OR: 1.20; 95% CI: 0.58–2.47; P=0.63) differed from those reported in cohort studies (OR: 0.51; 95% CI: 0.34–0.75; P=<0.01). Conclusions: This updated meta-analysis of predominantly low-to-moderate quality observational studies suggests that there is no significant association between PRBC transfusions and NEC. A higher quality of evidence on this topic is needed.

Zika virus (ZIKV), first discovered in 1947, is the most recent member of the TORCH family. It usually causes an asymptomatic or mildly symptomatic disease in infected adults but can lead to severe brain abnormalities in fetuses who are infected in utero by vertical transmission of the virus through the placenta. The constellation of these fetal/neonatal abnormalities is named as congenital Zika syndrome (CZS). Although horizontal transmission of ZIKV is largely dependent on the presence of the vector (i.e. Aedes mosquitoes), women residing in non-endemic areas are still at risk of acquiring the infection once they travel to an endemic region or have unprotected sexual contact with an infected male. Therefore, it is important for physicians practicing in non-endemic regions to be familiar with the clinical and neuroimaging manifestations of CZS and to consider this diagnosis as a potential etiology for congenital microcephaly and other fetal central nervous system abnormalities.