Volume 48, Issue 1

For newly born babies, especially those in need of intervention at birth, actions taken during the first minute after birth, the so-called “Golden Minute”, can have important implications for long-term outcomes. Both delivery room handling, including identification of maternal and infant risk factors and provision of effective resuscitation interventions, and antenatal care decisions regarding antenatal steroid administration and mode of delivery, are important and can affect outcomes. Anticipating risk factors for neonates at high risk of requiring resuscitation can decrease time to resuscitation and improve the prognosis. Following a review of maternal and fetal risk factors affecting newborn resuscitation, we summarize the current recommendations for delivery room handling of the newborn. This includes recommendations and rationale for the use of delayed cord clamping and cord milking, heart rate assessment [including the use of electrocardiogram (ECG) electrodes in the delivery room], role of suctioning in newborn resuscitation, and the impact of various ventilatory modes. Oxygenation should be monitored by pulse oximetry. Effects of oxygen and surfactant on subsequent pulmonary outcomes, and recommendations for provisions of appropriate thermoregulatory support are discussed. Regular teaching of delivery room handling should be mandatory.

Background The Maternal-Fetal Medicine Units (MFMU) vaginal birth after cesarean (VBAC) calculator, while accurate for candidates with high predicted success rates, is not as accurate for poor candidates. This study examines the calculator’s validity in an understudied multiracial cohort with a high proportion of poor candidates. Methods This retrospective study examined women with one or two prior cesarean deliveries who attempted VBAC at a single institution. Subjects were placed into quartiles based on MFMU-predicted success rates. For each quartile, actual and predicted success rates were compared. The calculated area under the receiver operating characteristic curve (AUC) was compared to the original AUC. Results The study included 1604 women. Actual and predicted VBAC rates were similar in the lowest and highest quartile groups, 18.2% vs. 21.2% (n = 11, P > 0.99) and 87.1% vs. 88.5% (n = 1090, P = 0.14), respectively. In the 51–75% predicted success rate group, the actual VBAC rate was higher than the predicted rate, 69.9% vs. 65.5% (n = 394) but not statistically significant (P = 0.07). In the 25–50% predicted success rate group, the actual VBAC rate was significantly higher than the predicted rate 55.1% vs. 39.6% (n = 109, P = 0.002). The actual AUC was lower than the MFMU model, 0.72 [95% confidence interval (CI) 0.69–0.75] vs. 0.77 (95% CI 0.76–0.78) (P < 0.001). Conclusion The MFMU VBAC calculator’s predicted success rates were comparable to actual success rates for candidates with predicted success rates >75%. As predicted success rates declined, the calculator was increasingly inaccurate and underestimated the success rate. Caution should be taken when using the MFMU VBAC calculator for poor candidates.

Objective To explore the relationship between endometrial thickness and perinatal outcome in assisted reproductive techniques (ART). Methods A retrospective cohort study was conducted in 1139 infertile women who underwent ART treatment from January 2011 to July 2014. Four groups were divided by endometrial thickness on the human chorionic gonadotropin (HCG) trigger day in fresh embryo transfer cycles or on the progesterone administration day in frozen embryo transfer cycles, as group A (<8 mm), group B (8–10 mm), group C (10–14 mm) and group D (≥14 mm). Two other groups were delineated according to whether uterine lesions were present. The incidence of premature rupture of membranes (PROM), postpartum hemorrhage (PPH) and other common perinatal complications were observed subsequently. Results It was found that the highest incidence of PROM and PPH was in group A (P < 0.05). The incidence of PROM in group B was higher than in groups C and D (P < 0.05). The occurrence of mothers entering the intensive care unit (ICU) was significantly higher in group A than in group B (P < 0.05). However, no significant differences were found in other adverse outcomes. There was no difference in the incidence of adverse perinatal outcome when the endometrial thickness of pre-implantation was not attenuated by uterine lesions. Conclusion The incidence of PROM and PPH increased significantly when the thickness of the endometrium was less than 10 mm before implantation. Correspondingly, the number of mothers treated in the ICU was also higher under these circumstances. To reduce such perinatal placenta-related complications, we should maximize the thickness of the endometrium before transplantation of embryos.

Objective To select a group at high risk of placenta accreta spectrum disorders (PAS) based on the data of serum screening in the first trimester. Methods A retrospective analysis of 48 patients with abnormal placental location (AP), including placenta previa (PP) only (n = 23) and PP and PAS (n = 25), was performed. Additionally, the AP group was divided depending on the blood loss volume: not higher than 1000 mL (LBL) (n = 29) and higher than 1000 mL (HBL) (n = 19); diagnostic term of PAS by ultrasound, data pregnancy-associated plasma protein-A (РAРР-A) and free β subunit of human chorionic gonadotropin (free β-hCG) multiple of median (MоM) at 11 +0 –13 +6 weeks of gestation were evaluated. Serological markers were compared with the data of 39 healthy pregnant women with scar after previous cesarean section and normal placental location (control). Results The mean gestation at diagnostic term of PAS was 29 weeks. PAPP-Р MоM [mean (M) ± standard deviation (SD)] was: in controls, 1.07 ± 0.47; in the AP group, 1.59 ± 0.24; in PP, 1.91 ± 1.52; in PAS, 1.30 ± 0.85; in LBL, 1.37 ± 1.20; in HBL, 1.91 ± 1.24. The difference between control/AP, control/PP, control/PAS, PP/PAS, control/LBL, control/HBL and LBL/HBL was Р = 0.256, 0.145, 0.640, 0.311, 0.954, 0.025 and 0.09, respectively. Free β-hCG MoM (M ± SD) was: in controls, 1.08 ± 0.69, in AP, 1.31 ± 0.96; in PP, 1.46 ± 0.19; in PAS, 1.16 ± 0.65; in LBL, 1.30 ± 0.06; in HBL, 1.32 ± 0.78. Comparison of free β-hCG AP with controls and between subgroups did not reveal a significant difference. Conclusion Underestimation of PAS risk factors in pregnant women with AP leads to late diagnostics of pathology only in the third trimester. The assessment of the РAРР-A level in the first trimester may be helpful for the early prognosis of pathological blood loss at delivery for pregnant women with AP and for forming the high-risk group for PAS.

Background Cesarean delivery (CD) in primiparas with a term singleton vertex fetus (PTSV) is a sentinel event for the future mode of delivery and determinant of repeat CD risk. We aimed to evaluate the risk factors for primary CD in a population with a decade of sustained low rate of intrapartum CD. Methods This was a retrospective single-center cohort study between 2005 and 2014. The primary outcome of the study was the mode of delivery. PTSV who attempted vaginal delivery were identified and categorized according to the mode of delivery: vaginal delivery vs. CD. Risk factors for intrapartum CD adjusted odds ratio (aOR) [95% confidence interval (CI)] in multivariate analysis were reported. Results During the study, 121,483 deliveries were registered; 26,301 (21.6%) PTSV were admitted in labor, of which 1944 (7.4%) had an intrapartum CD. Significantly in multivariate analysis, this group had a unique risk profile as compared to those who delivered vaginally; non modifiable risks included advanced maternal age: 3.06 (2.16–4.33), P < 0.001; prior multiple (≥3) miscarriages: 1.94 (1.04–3.62), P = 0.04; low (<6) modified admission cervical score: 2.41 (2.07–2.82), P < 0.001; low birth weight (BW): 1.42 (1.00–2.01), P = 0.05 or macrosomia: 2.38 (1.77–3.21), P < 0.001; modifiable risks included induction of labor: 1.79 (1.51–2.13), P < 0.001 and oxytocin labor augmentation: 8.36 (6.84–10.22), P < 0.001. Conclusion In a population of PTSV with a sustained low risk for intrapartum cesarean maintained by a strict labor management, induction of labor remains a significant and sole potentially modifiable risk factor for CD.

Background Alongside midwifery-led care (AMC) was introduced in Germany in 2003. The aim of our study was to collect data about the utilization of AMC within North Rhine-Westfalia (NRW), Germany’s most populous state, and to collect information regarding the approach used for implementation of AMC and providers’ experiences in day-to-day work. Methods Quantitative data were collected by questionnaire, telephone interview and comparative analysis of documents created for use in AMC. Qualitative data were compiled by questionnaire and workshop. Results Seven obstetric departments offer AMC in NRW. On average, 3.4% of women gave birth in these AMC units, corresponding to 0.3% of all births in NRW. For the establishment of AMC, institutional, organizational, professional and formal arrangements were undertaken. An eligibility and transfer checklist was agreed upon between midwives and obstetricians. Both professions were faced with skepticism. Daily work in AMC resulted in improved teamwork between the two professions and increased job satisfaction for midwives. Acquisition of manual skills and time constraints were the major challenges. Conclusion The low utilization of AMC is not due to the concept of care itself or difficulties with its implementation, nor to a lack of eligible women. Reasons may be insufficient awareness about AMC or a lack of interest in this type of care.

Objective To investigate the correlation between aneuploidy pregnancy and the concentration of various hormones and vascular endothelial factor in follicular fluid as well as the number of acquired oocytes and to provide a scientific basis for improving ovulation induction programs. Methods In total, we collected 277 follicular fluid specimens from patients undergoing in vitro fertilization (IVF) treatment in our hospital. Eighteen cases of aneuploidy embryos were identified. The follicular fluid of these aneuploidy embryos was used for the study. According to the case and control 1:5 paired design, we selected five age-matched controls with healthy births following IVF for each aneuploidy case. Concentrations of anti-Müllerian hormone (AMH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), estrogen (E2) and vascular endothelial growth factor (VEGF) in the follicular fluid were measured. Conditional logistic regression was used to analyze the relationship between aneuploidy pregnancy and the concentrations of various hormones and VEGF in the follicular fluid as well as the number of acquired oocytes. Results Multivariate conditional logistic regression showed that of all the factors analyzed, only FSH [odds ratio (OR) = 1.300, 95% confidence interval (CI), 1.091–1.548, P = 0.003] level in the follicular fluid and the number of acquired oocytes (OR = 1.179, 95% CI, 1.070–1.299, P = 0.001) were closely related to aneuploidy pregnancy. No other factors were found to be associated with aneuploidy pregnancy. Conclusion FSH concentrations in the follicular fluid are risk factors for aneuploidy pregnancies. The higher the number of eggs, the higher the risk of aneuploidy. These findings may help improve ovulation induction programs.

Objectives To explore the influence of ambient temperature and humidity on significant bacteriuria (SB) and urinary bacterial isolates in pregnant women. Methods A retrospective observational study was conducted in the sole tertiary-care hospital in Doha, Qatar. A sample of 1588 pregnant women delivering between June 2012 and March 2013 was randomly selected. Meteorological variables including ambient average daily temperature and humidity were sourced from online meteorological data, and patient information such as demographic data, urine culture results and bacterial isolates were collected from patient files. The receptor operative curve (ROC) analysis was used to determine the cutoff for temperature and humidity. Statistical analyses of associations between SB and bacterial isolates with respect to the ambient temperature and humidity were performed using Pearson’s correlation, the chi-square (χ 2 ) test and the Kruskal-Wallis test. Results Of the 21.24% positive cultures, 11.25% had SB. SB showed a significant strong positive (r = +0.677, n = 17, P = 0.003) and moderate negative (r = −0.587, n = 17, P = 0.013) correlation with average monthly temperature and humidity, respectively, with doubling of rates noted with temperatures ≥35°C (11.3% vs. 3.6%; P < 0.0001) and humidity ≤50% (10.6% vs. 3.2%; P < 0.0001). Escherichia coli and Group B Streptococcus (GBS) were the most common isolates. Conclusion This is the first study in this region that demonstrates maternal risk with SB, with ambient temperatures of ≥35°C and humidity ≤50%. The effect of these variables on the growth of various urinary bacteria has also been shown.

Objective To explore the risk for abnormal chromosomal microarray analysis (CMA) findings in pregnancies with oligohydramnios. Methods Data from all CMA analyses performed due to oligohydramnios between 2013 and 2017 were retrospectively obtained from the Israeli Ministry of Health database. The rate of clinically significant (pathogenic and likely pathogenic) findings was compared to a local cohort of pregnancies with normal ultrasound, yielding a 1.4% rate of abnormal CMA results. In addition, a search was conducted through the PubMed database addressing the issue. Results Fifty CMA analyses were performed due to oligohydramnios. The 2% risk for clinically significant CMA finding in pregnancies with oligohydramnios did not differ from the control population of 5541 pregnancies with normal ultrasound – relative risk (RR) 1.4 [95% confidence interval (CI) 0.2–10.2]. Literature search yielded 394 titles, of which four relevant articles were selected, all using fetal karyotyping. Conclusion There is yet insufficient evidence to support invasive prenatal testing in pregnancies with isolated oligohydramnios.

Objective To assess lifestyle characteristics among parental electronic cigarette (e-cigarette), marijuana and tobacco users. Methods A total of 1214 parents (77% mothers and 23% fathers) were surveyed and categorized into five exposure groups: e-cigarette use only (1%), marijuana use only (3%), tobacco products only (10%), multi-exposed [11% (marijuana, e-cigarette and tobacco)], and non-users [75% (no e-cigarette, tobacco or marijuana)]. Results Similar to non-users, the e-cigarette group had no illicit drug use. Further, e-cigarette users were more likely, in adjusted models, to self-identify as non-smokers and exercise compared with tobacco and multi-exposed groups. Although marijuana users also had higher odds of self-identifying as non-smokers compared to tobacco and multi-exposed groups, they were more likely than non-users to drink alcohol. Conclusion E-cigarette and marijuana using parents were less likely to identify as smokers. E-cigarette users had healthier lifestyle characteristics than the other exposed groups. Clinicians should consider specifically screening for parental e-cigarette and marijuana use as assessing for only “smoking” may underrepresent first-and second-hand exposure. Additionally, clinicians should be aware that marijuana using parents are more likely to drink alcohol and should counsel accordingly.

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

Background The main objective of this retrospective analysis in a large tertiary center was the clinical outcome of prenatally diagnosed cardiac rhabdomyomas as well as the identification of factors influencing fetal prognosis. Methods A total of 45 cases of fetuses with prenatally suspected rhabdomyoma and their clinical outcome were analyzed retrospectively. A review of the literature was also performed. Results In five cases, after a tuberous sclerosis complex (TSC) mutation had been confirmed, termination of pregnancy was chosen. In 30 cases postnatal data were available. In 93% TSC was confirmed clinically or by mutational analysis. Two thirds of fetuses presented with multiple tumor while one third presented with a solitary tumor. In two fetuses mild pericardial effusions were observed. Another three fetuses presented with extrasystoles prenatally. No hydrops fetalis or fetal perinatal demise were observed. After birth 41% of the children suffered from arrhythmia including supra- and ventricular tachycardia, Wolff-Parkinson-White syndrome and atrioventricular block. One child received a Fontan procedure with Glenn anastomosis. Another child with a dilatative cardiomyopathy and a left ventricular ejection fraction of 15% died. Fifty-two percent of the children with TSC suffered from epilepsy ranging from absence epilepsy and West syndrome to generalized seizures with a frequency of up to 40 per day. Two children underwent neurosurgery to remove the epileptogenic focus. One child suffered from TSC and Lesch-Nyhan disease. In another case Beckwith-Wiedemann syndrome was identified as the causative disorder. Conclusion Rhabdomyoma are rare, benign tumors. There is an association with TSC. In the majority of cases rhabdomyoma are not hemodynamically relevant and do not increase in size. The quality of life of affected patients is impaired particularly due to epilepsy and psychomotor retardation.

Background Extremely premature infants often need invasive respiratory support from birth, but have low nutritional reserves and high metabolic demands. Our aim was to determine if there was a relationship between prolonged ventilation and reduced postnatal growth in such infants. Methods A retrospective, observational study was undertaken. Data from infants born at less than 28 weeks of gestational age and ventilated for 7 days or more were collected and analysed including gestational age, gender, birth and discharge weight, birth and discharge head circumference, days of invasive mechanical ventilation and use of postnatal corticosteroids. The duration of invasive mechanical ventilation and the differences in weight (ΔWz) and head circumference (ΔHz) z-score from birth to discharge were calculated. Results Fifty-five infants were studied with a median [interquartile range (IQR)] gestational age at birth of 25.3 (24.3–26.7) weeks and birth weight of 0.73 (0.65–0.87) kg. The median duration of mechanical ventilation was 45 (33–68) days. Both ΔWz and ΔHz were significantly negatively correlated to the number of invasive mechanical ventilation days (P = 0.01 and P = 0.03, respectively), but not to the use of postnatal corticosteroids. Conclusion Poor postnatal growth is significantly negatively associated with a longer duration of mechanical ventilation in extremely prematurely born infants.