Volume 48, Issue 2

Background Mothers and their offspring may benefit from lifestyle interventions during pregnancy. We systematically reviewed the literature to map and evaluate the quality of long-term offspring outcomes in follow-up cohorts of randomised controlled trials (RCTs). Methods We searched MEDLINE, EMBASE, CINAHL, Database of Abstracts of Reviews of Effects and Cochrane Central (until March 2019) for all RCTs evaluating any lifestyle (diet or exercise) intervention during pregnancy and their follow-up cohorts. Two reviews evaluated the extracted outcomes using two standardised assessment tools, one for quality of reporting (score range 0–6) and another for the variation in outcome selection. We extracted data in duplicate and reported using natural frequencies, medians, ranges, means and standard deviation (SD). Results We captured 30 long-term offspring outcomes reported in six articles (four studies). Offspring anthropometric measurements were the most commonly reported outcomes. There was a large variation in the measurement tools used. The mean overall quality score for outcome reporting was 3.33 (SD 1.24), with poor reporting of secondary outcomes and limited justification for the choice of the reported outcomes. Most studies showed selective reporting for both their primary and secondary outcomes. Conclusion The quality of reporting for long-term offspring outcomes following lifestyle interventions in pregnancy is varied with evidence of selective outcome reporting. Developing a core outcome set will help to reduce the variations in outcome reporting to optimise future research.

Background Spontaneous preterm birth (sPTB) has a detrimental impact on perinatal outcome, as well as on the resources of health systems in high-income countries. Thus, the objective of the current study was to determine the incidence of modifiable risk factors in pregnancy and their impact on the rate of sPTB. Methods All nulliparous pregnant women, in singleton pregnancies, with free medical and obstetric history, were eligible to participate in this study. The primary outcome of interest was the incidence of specific modifiable risk factors for sPTB. The correlations between these risk factors and sPTB were also investigated. Results Overall, 2027 women were eligible for the study and agreed to participate. The incidence of sPTB was 4.9%; 25.5% (n = 518) of the participants were in extreme maternal age (<20 or >35 years), 34.5% (n = 701) had an abnormal body mass index (BMI) (<18.5 or ≥25 kg/m 2 ), 4.4% (n = 89) reported use of assisted reproductive technology (ART) and 10.9% (n = 220) reported themselves as smokers in pregnancy. In the multivariate analysis, sPTB was significantly correlated with ART conception [odds ratio (OR): 2.494, 95% confidence interval (CI): 1.196–5.199]. Conclusion Approximately one in 20 primiparous pregnant women in the study had a sPTB. The study population included a high percentage of women of advanced maternal age, with abnormal BMI and smokers, but these characteristics did not affect the incidence of sPTB. On the other hand, conception following ART increased two-fold the risk of sPTB.

Three-dimensional ultrasound (3DUS) may provide additional information for prenatal assessment of twins. It may improve the diagnostic confidence of dating, nuchal translucency (NT) and chorionicity assignment in twin pregnancies. The “virtual 3DUS placentoscopy” can guide selective fetoscopic laser photocoagulation (SFLP) to treat twin-twin transfusion syndrome (TTTS). Volumetric assessment of the dysmorphic acardiac twin with the Virtual Organ Computer-aided Analysis (VOCAL) software is more accurate than the conventional ultrasound measurement. Twin anemia polycythemia (TAP) sequence and selective intrauterine growth restriction (sIUGR) may be clinically monitored with 3DUS placental volume (PV) and power Doppler vascular indices. Congenital anomalies are more common in twins. Evaluation of fetal anomalies with 3DUS could assist perinatal management. The 3DUS power Doppler can provide a better understanding of true and false umbilical cord knots, which are commonly found in monoamniotic (MA) twins. Single demise in monochorionic (MC) twin pregnancies can cause severe neurologic morbidity in the surviving co-twin. Prenatal prediction of brain injury in the surviving co-twin with unremarkable neurosonographic examination is difficult. The 3DUS power Doppler may aid in prenatal detection of subtle abnormal cerebral perfusion. Prenatal assessment of conjoined twins with 3DUS is important if emergency postnatal surgical separation is anticipated. There is no significant additional advantage in using real-time 3DUS to guide prenatal interventions. Assessment of the cervix and pelvic floor during twin pregnancies is enhanced with 3DUS. Due to lack of high-quality studies, routine prenatal 3DUS in twin pregnancies needs to be balanced with risks of excessive ultrasound exposure.

Background Intra-amniotic inflammation, which is associated with adverse pregnancy outcomes, can occur in the presence or absence of detectable microorganisms, and involves activation of the inflammasome. Intra-amniotic inflammasome activation has been reported in clinical chorioamnionitis at term and preterm labor with intact membranes, but it has not yet been investigated in women with preterm prelabor rupture of membranes (preterm PROM) in the presence/absence of detectable microorganisms. The aim of this study was to determine whether, among women with preterm PROM, there is an association between detectable microorganisms in amniotic fluid and intra-amniotic inflammation, and whether intra-amniotic inflammasome activation correlates with microbial burden. Methods Amniotic fluids from 59 cases of preterm PROM were examined for the presence/absence of microorganisms through culture and 16S ribosomal RNA (rRNA) gene quantitative real-time polymerase chain reaction (qPCR), and concentrations of interleukin-6 (IL-6) and ASC [apoptosis-associated spec-like protein containing a caspase recruitment domain (CARD)], an indicator of inflammasome activation, were determined. Results qPCR identified more microbe-positive amniotic fluids than culture. Greater than 50% of patients with a negative culture and high IL-6 concentration in amniotic fluid yielded a positive qPCR signal. ASC concentrations were greatest in patients with high qPCR signals and elevated IL-6 concentrations in amniotic fluid (i.e. intra-amniotic infection). ASC concentrations tended to increase in patients without detectable microorganisms but yet with elevated IL-6 concentrations (i.e. sterile intra-amniotic inflammation) compared to those without intra-amniotic inflammation. Conclusion qPCR is a valuable complement to microbiological culture for the detection of microorganisms in the amniotic cavity in women with preterm PROM, and microbial burden is associated with the severity of intra-amniotic inflammatory response, including inflammasome activation.

Objective To determine the concentrations of soluble endoglin (sCD105) and endothelial cell-specific molecule-1 (ESM-1) in the amniotic fluid (AF) of pregnant women, and to investigate the relationship between these concentrations and neural tube defects (NTDs). Methods AF concentrations of sCD105 and ESM-1 were measured in the study group, which included 60 pregnant women complicated with NTDs, and 64 pregnant women with unaffected healthy fetuses (control group). The AF concentrations of sCD105 and ESM-1 in both groups were measured using enzyme-linked immunosorbent assay and compared. Results There were no significant differences in terms of the mean AF concentrations of sCD105 and ESM-1 between the groups (P=0.141, P=0.084, respectively). There was a significant difference between the AF sCD105 concentrations in those with gestational age <24 weeks (n=101) and ≥24 weeks (n=23) ( X ̅ <24 =76.35±126.62 vs. X ≥ 24 =39.87±58.32, P=0.041). AF ESM-1 concentrations were found to be statistically significant in the gestational age <22 weeks (n=90) and ≥22 weeks (n=34) groups ( X ̅ < 22 =135.91±19.26 vs. X ̅ ≥ 22 =148.56±46.85, P=0.035). A positive and low-level relation at a statistically significant level was determined between the gestational age and AF ESM-1 concentration in the study group (r=0.257; P=0.048). Conclusion AF concentrations of sCD105 and ESM-1 were not associated with the development of NTDs. Unlike studies that reported that ESM-1 concentrations decreased in maternal plasma with increased gestational age, we determined an increase that was proportionate to gestational age in AF.

Background We aimed to study the maternal characteristics and obstetric and neonatal outcomes in pregnant mothers with chronic hypertension (CHTN) compared to non-CHTN. Methods The study was a population-based cohort study, and a PEARL-Peristat Study (PPS) for the year of 2017. There were 20,210 total births including 19,762 singleton and 448 multiple births. We excluded multiple gestations from the analysis as they differ in fetal growth, duration of gestation and have a higher rate of obstetric and neonatal complications. We compared the maternal characteristics of mothers with pre-existing HTN with non-hypertensive mothers and studied the obstetric and neonatal outcomes including cesarean section, stillbirths, prematurity, macrosomia and postpartum hemorrhage (PPH). Results We identified 223 births of mothers with essential HTN. The overall prevalence of CHTN in our population was 1.1% (223/20,210). In regard to maternal characteristics, women with CHTN were at or above 35 years of age at the time of delivery 58.9% compared to non-CHTN women 18.7%, P-value <0.001. Pre-existing diabetes was found more in women with CHTN 15.1% compared to non-CHTN women 1.9%, P-value <0.001; while obesity was found in 64% of women with CHTN compared to 32.5% in non-CHTN women, P-value <0.001. Preterm birth was noted in 26% compared to 8% in CHTN compared to non-CHTN women, respectively, P-value <0.001. The rate of stillbirth was similar between the two groups, 0.9% compared to 0.6% in CHTN compared to non-CHTN women, respectively, P-value 0.369. Conclusion Hypertensive mothers have multiple other comorbidities. When compared to the general population, they are older, parous, diabetic and obese with an increased risk of preterm birth and cesarean deliveries. Lifestyle modification, extensive pre-conceptional counseling and multidisciplinary antenatal care are required for such a high-risk group.

Objective To analyze the behavior of fetal longitudinal myocardial fibers assessed by speckle tracking (STE) after fetal viability. Methods A cross-sectional study was performed in 156 women with normal singleton pregnancies from 22 to 31 weeks of gestation. Strain (S) and strain rate (SR) values were measured in both ventricles during the fetal cardiac cycle. The population was divided into five gestational age groups based on 2-week intervals. The correlations of maternal variables with the S and SR variables and intra-observer analysis were performed. Results There was a significant difference in the S and SR values of the left ventricle (LV) among the gestational age groups (P = 0.007). Significantly higher S and SR values were observed in early age groups demonstrating reductions in LV S and SR values at 26 weeks, followed by stabilization. For the right ventricle (RV), there was no significant difference between gestational age groups. Significant intra-observer agreement was observed for S values of the RV (P = 0.008) and LV (P = 0.0004) and SR values of the RV (P = 0.0001) and LV (P = 0.015). Conclusion Decreases in the S and SR values of the LV occurred after 26 weeks, followed by stabilization. No significant difference was observed in the S or SR value of the RV among the gestational age groups, and no significant association of any maternal variable evaluated with S and SR values was observed. Significant intra-observer agreement was obtained among the results.

Objective The primary objective was to evaluate if the administration of ibuprofen and acetaminophen at regularly scheduled intervals impacts pain scores and total opioid consumption, when compared to administration based on patient demand. Methods A retrospective chart review was performed comparing scheduled vs. as-needed acetaminophen and ibuprofen regimens, with 100 women included in each arm. Demographics and delivery characteristics were collected in addition to pain scores and total ibuprofen, acetaminophen and oxycodone use at 24, 48 and 72 h postoperatively. Results The scheduled dosing group was found to have a statistically significant decrease in pain scores at all time intervals. Acetaminophen and ibuprofen usage were also noted to be higher in this group while narcotic use was reduced by 64%. Conclusion Scheduled dosing of non-narcotic pain medications can substantially decrease opioid usage after cesarean delivery and improve post-operative pain.

Objective To compare the accuracy of cord blood lactate measurement using gas analyzer and portable devices in order to assess possibility of implementation of these devices in clinical practice. Methods We performed a prospective observational study using 30 umbilical cord samples which were obtained immediately after birth. Portable electrochemical devices Lactate Scout (SensLab GmbH, Leipzig, Germany) and StatStrip Lactate (NOVA Biomedical, Waltham, MA, USA) were used to determine lactate level. A gas analyzer ABL800 FLEX (Radiometer Medical ApS, Brønshøj-Husum, Denmark) was used as a reference. Base excess (BE), pH, partial oxygen (pO 2 ) and carbon dioxide (pCO 2 ) pressure, hemoglobin (ctHb) and bilirubin (ctBl) levels were measured. Results The mean umbilical cord blood lactate level determined by the gas analyzer was 5.85 ± 2.66 mmol/L (ranging from 1.4 mmol/L to 13.4 mmol/L). Lactate level estimated by Lactate Scout was 5.66 ± 2.65 mmol/L and did not significantly differ from the reference method level (P = 0.2547). The mean lactate level determined by StatStrip Lactate was significantly lower than by the gas analyzer – 4.81 ± 2.38 mmol/L (P < 0.0001). Umbilical cord blood pH, BE, pO 2 and pCO 2 , ctHb and ctBl levels did not affect the accuracy of the lactate measurement in absolute units (mmol/L). Conclusion Umbilical cord blood lactate level measured by StatStrip Lactate was lower than estimated by the ABL800 FLEX gas analyzer. This shows the necessity to develop decision-making reference points separately for each device. Umbilical cord blood pH, BE, pO 2 and pCO 2 , ctHb and ctBl levels did not affect the accuracy of measurements by electrochemical portable devices.

Background This study aimed to identify the perinatal mortality coefficient, the epidemiological profile, causes and avoidable factors at a reference public maternity hospital in southern Brazil. Methods In this cross-sectional study, 334 medical records of postpartum women and newborns were evaluated between January 1 st , 2011 and December 31 st , 2015. The Expanded Wigglesworth Classification was used to assess the causes of perinatal mortality and the International Statistical Classification of Diseases and Related Health Problems (ICD-10/SEADE Foundation) was used for the preventable perinatal mortality analysis. Absolute numbers and percentages were used for data analysis. The perinatal mortality formula was used to calculate the perinatal mortality rate. Results The perinatal mortality rate was 13.2/1000 total births, with a predominance of white race/color; mothers were 21–30 years of age, had experienced their first pregnancy and had completed their high school education. Conclusion The main factors associated with perinatal death were antepartum fetal death in 182 (54.49%) cases, and avoidable death through appropriate prenatal care in 234 (70.05%) cases.

Background Our aim was to determine the prevalence of tobacco smoking and e-cigarettes and cannabis use during pregnancy, whether these were influenced by ethnicity, and their relationship to perinatal outcomes. Methods A study was carried out in 4465 infants whose mothers delivered during 2017 and 2018. Self-reported maternal smoking, e-cigarette and cannabis use at booking were recorded. Outcome measures were birthweight and head circumference z-scores and admission to the neonatal intensive care unit (NICU). Results Two hundred and five women reported smoking cigarettes (4.7%), five were using e-cigarettes (0.11%) and 106 were using cannabis (2.43%). Women were most likely to smoke if young (15–19 years old) or from a mixed-race or White background. Cigarette smoking was associated with a lower mean z-score for birthweight (−0.587 vs. −0.064) and head circumference (−0.782 vs. −0.157) (both outcomes P < 0.0001). Young, mixed-race women were most likely to be both smoking and using cannabis during pregnancy and their infants had a lower birthweight mean z score (−0.989 vs. −0.587, P = 0.028) and head circumference z score (−1.33 vs. 0.782, P = 0.025) than cigarette use alone. Conclusion Young, mixed-race women were most likely to be both smoking and using cannabis during pregnancy and should be targeted for cessation programmes.

Background Neurologic complications including hemorrhage, ischemia, and infarction are often identified in neonates undergoing extracorporeal membrane oxygenation (ECMO) and may contribute to the high morbidity observed in ECMO survivors. Screening for intracranial complications is reliant on bedside transcranial ultrasound (CUS) prior to and during ECMO therapy, and advanced imaging [i.e. computed tomography (CT)/magnetic resonance imaging (MRI)] is recommended after completion of ECMO support. The goal of this study is to describe the correlation of intracranial complications identified on CUS during ECMO and MRI after completion of ECMO. Methods Fifty-five neonates underwent ECMO support at the Children’s Hospital of Georgia at Augusta University from January 1, 2012 to December 31, 2017. Forty-four (80%) had a brain MRI performed prior to transfer or discharge. Ultrasound studies were reviewed by a single blinded pediatric radiologist and MRIs were reviewed by a single blinded neuro-radiologist. Results Of the 44 neonates with post-ECMO MRI, CUS during ECMO identified intracranial lesions in nine neonates, which were all confirmed on post-ECMO MRI. Sixteen subjects (46%) with unremarkable CUS during ECMO had identifiable lesions on post-ECMO MRI, yielding a sensitivity of 36% and a specificity of 100% for CUS in the detection of intracranial lesions. Despite the lack of correlation between CUS and MR, 84.6% of survivors exhibited normal development at 24 months of age. Conclusion While necessary for the identification of intracranial lesions during neonatal ECMO, CUS demonstrated low correlation with post-ECMO MRI in the identification of intracranial lesions, which supports Extracorporeal Life Support Organization (ELSO) recommendations.

Background To meet the nutritional needs of preterm infants, multicomponent nutrient fortifiers are added to human milk. The fortified human milk (FHM) product changes the physical and biochemical characteristics of the milk. We questioned whether such physical-chemical changes in the milk would alter intrinsic probiotic bacterial activity. The objective of the study was to evaluate the effect of osmolality and pH on the growth of probiotic bacterial species intrinsic to human milk. Methods Human milk samples (n = 26) were collected from mothers in the neonatal intensive care unit (NICU) and stored at −20°C until analyzed. The samples were thawed and divided into three portions. Human milk fortifiers (HMFs) were added to two portions to prepare concentrations of FHM. The remaining portion was the unfortified control sample. Each sample was then divided into two parts. One part (baseline) was used to measure the osmolality and pH and plated on selective agar to enumerate the growth of lactobacilli and bifidobacteria species. The remaining part was incubated at 37°C for 24 h to further test bacterial integrity (post-incubation) and then the same measurements were made (osmolality, pH, bacterial colony counts). Results When compared with unfortified milk at baseline, osmolality increased and pH decreased significantly after the addition of HMFs. Lactobacilli and bifidobacteria colony counts did not differ among the groups pre-incubation. Post-incubation lactobacilli and bifidobacteria increased in all the groups. Conclusion The appropriate addition of HMFs differentially affected the osmolality and pH of the milk. These physical changes did not affect the growth of probiotic bacterial species.