Volume 48, Issue 4

Objective The aims of this study were to determine the rate of change by type of diagnosis by transabdominal chorionic villus sampling (TA-CVS) vs. amniocentesis for aneuploidy and to describe a successful and intensive international training program for TA-CVS in ongoing pregnancies. Methods We conducted a retrospective cohort study of all deliveries from 2010 to 2018 in Sardinia. All invasive diagnostic procedures are conducted at a single regional perinatal referral center. Descriptive statistics were used to compare data across groups, and inter-correlations between variables were investigated by Pearson’s correlation coefficient. We subsequently describe the international trainee experiences in TA-CVS over a 35-year period. Results A total of 101,025 deliveries occurred over 9 years. The number of deliveries (13,413–9143, P < 0.0001) and total invasive diagnostic procedures (1506–858 per year, P = 0.019) declined over this period. The percentage of deliveries undergoing invasive diagnostic procedures remained steady (mean: 12.2%). In 2010, TA-CVS made up 32.3% of all invasive diagnostic procedures, while amniocentesis made up 67.7%. By 2018, TA-CVS made up 61.3% of the invasive diagnostic procedures, and amniocentesis, only 38.7%. The rate of TA-CVS increased over 9 years, while the rate of amniocentesis declined. A total of 236 trainees from 39 different countries and 5 different continents rotated through this site. The average length of stay was 2.4 weeks. Conclusion We demonstrate an increasing prevalence of TA-CVS vs. amniocentesis in the current era of prenatal testing and underscore the importance of continuing to train specialists skilled in TA-CVS. Our global operative experience is feasible and sustainable and will have a lasting impact on physicians conducting invasive fetal procedures.

Background Preeclampsia (PE) is a pregnancy-specific vascular endothelial disorder characterized by multi-organ system involvement. This includes the maternal kidneys, with changes such as continuous vasospasm of renal arteries and reduced renal blood flow. However, it is unclear whether similar renal vascular changes are seen in the fetus. This study sought to compare renal artery impedance in fetuses of women with and without PE. Methods This was a prospective Doppler assessment study of the fetal renal artery impedance in 48 singleton fetuses. The group with PE consisted of 24 appropriately grown fetuses in pregnancy complicated by both mild and severe PE and a control group of 24 uncomplicated pregnancies. Doppler studies included renal artery systolic/diastolic (S/D) ratio, pulsatility index (PI), resistance index (RI), and identification of end-diastolic blood flow. Results Fetuses of mothers with PE were more likely to have a lower renal artery Doppler S/D ratio (7.85 [6.4–10.2] vs. 10.8 [7.75–22.5], P = 0.03) and lower RI (0.875 [0.842–0.898] vs. 0.905 [0.872–0.957], P = 0.03). However, there was no statistically significant difference in PI. There was also no difference in the incidence of absent end-diastolic flow. Conclusion This study suggests that PE results in changes in blood flow to the renal arteries of the fetus. This may be associated with long-term adverse health effects later in adulthood.

Objective The aim of this study was to compare position-related changes in fetal middle cerebral artery (MCA) Doppler pulsatility indices (PI). Methods A prospective study of 41 women with conditions associated with placental-pathology (chronic hypertension, pregestational diabetes, and abnormal analytes) and 34 women without those conditions was carried out. Fetal MCA Doppler velocity flow waveforms were obtained in maternal supine and left lateral decubitus positions. MCA PI Δ was calculated by subtracting the PI in the supine position from the PI in the left lateral position. Secondary outcomes included a composite of adverse perinatal outcomes (fetal growth restriction, oligohydramnios, and preeclampsia). χ 2 and Student t -tests and repeated-measures analysis of variance were used. Results MCA PI Δ was significantly less for high-risk pregnant women ([P = 0.03]: high risk, left lateral PI, 1.90 ± 0.45 vs. supine PI, 1.88 ± 0.46 [Δ = 0.02]; low risk, left lateral PI, 1.90 ± 0.525 vs. supine PI, 1.68 ± 0.40 [Δ = 0.22]). MCA PI Δ was not significantly different between women who had a composite adverse outcome and women who did not have a composite adverse outcome (P = 0.843). Conclusion Our preliminary study highlights differences in position-related changes in fetal MCA PI between high-risk and low-risk pregnancies. These differences could reflect an attenuated ability of women with certain risk factors to respond to physiologic stress.

Objective The aim of this study was to investigate the effect of short or long interpregnancy interval (IPI) with placental mediated pregnancy complications after already complicated first delivery. Methods We performed a retrospective cohort analysis of all women with singleton pregnancies who delivered their first three consecutive deliveries in one university-affiliated medical center (1994–2013). Placental mediated complications included placental abruption, small for gestational age, preeclampsia, gestational hypertension, or preterm delivery. Following first complicated delivery, IPI was compared stratified by second delivery outcome. Following two complicated deliveries, IPI was compared stratified by third delivery outcome. IPI was evaluated as continuous or categorical variable (>18, 18–60, >60 months). Related samples Cochrans’ Q test and Mann-Whitney analysis were used as appropriate. Results Overall, 4310 women entered analysis. Of them, 18.3%, 10.5%, and 9.3% had complicated first, second, and third delivery, consecutively. Evaluated continuously, longer IPI, but not short IPI, was associated with higher rates of complicated second delivery. Stratified to categories, IPI had no effect on recurrent complications evaluated separately or as composite. Conclusion Our results suggest that long IPI may increase risk for placental mediated pregnancy complications. Further studies are needed to evaluate this effect.

Background In monochorionic twin pregnancy, placental anastomosis and inter-twin blood transfusion can result in specific complications, such as twin-twin transfusion syndrome (TTTS) and twin anemia-polycythemia sequence (TAPS). It is well established that adverse outcomes are increased in TTTS, but reports on the neonatal and long-term outcomes of TAPS are lacking. The objective of this study was to evaluate the neonatal and neurodevelopmental outcomes in spontaneous TAPS. Methods The study population consisted of monochorionic twin pregnancies with preterm birth (24–37 weeks of gestation) between November 2003 and December 2016 and in which cord blood was taken at the time of delivery. According to the result of hemoglobin in cord blood, the study population was divided into two groups: a spontaneous TAPS group and a control group. Neonatal and neurodevelopmental outcomes were compared between the two groups. Results During the study period, 11 cases were diagnosed as spontaneous TAPS (6.4%). The TAPS group had lower gestational age at delivery and had a higher risk for cesarean delivery. However, neonates with TAPS were not at an increased risk for neonatal mortality and significant neonatal morbidity. In addition, the frequency of severe cerebral lesion during the neonatal period and the risk of cerebral palsy at 2 years of age were not different between the two groups. Conclusion The spontaneous TAPS diagnosed by postnatal diagnostic criteria was not associated with the increased risk of adverse neonatal and neurodevelopmental outcomes. Further studies are needed to evaluate the morbidity of antenatally diagnosed TAPS.

Background Tears are common after vaginal birth, and different impact factors are known. However, the impact of tears from a previous birth to the tears of a subsequent birth is unknown. Therefore, we aimed to evaluate the distribution of birth tear patterns according to the sustained tears in a previous birth, in addition to other impact factors. Methods In a retrospective cohort study, we evaluated all women up to parity 4 with subsequent vaginal, singleton births of vertex presentation at ≥37 + 0 gestational weeks between 1/2005 and 12/2016. Their tears were grouped into tear patterns and were analyzed by parity. Tear patterns in the subsequent births were analyzed in association to the patterns of the previous births and impact factors were evaluated. Results We counted 4017 births in 1855 women [P1: 1368 (34.1%), P2: 1730 (43.1%), P3: 741 (18.4%), P4: 178 (4.4%)]. The frequency of tears and episiotomies decreased with higher parity, whereas the frequency of intact perineum increased. Twenty-eight different unique tear patterns were found. We could show that birth tear patterns changed with increasing parity and were associated with sustained tears in a previous birth. In addition, some impact factors on tear patterns could be identified. Conclusion The distribution of the single tear types is in accordance with the current literature. However, it is new that distinct tear patterns are associated to sustained tear patterns of previous births. Furthermore, we demonstrated some weak associations of tear patterns to certain impact factors, such as more episiotomies, low-grade perineal or vaginal tears isolated or in combination with other tears with increasing fetal weight and head circumference in the higher parities, and with a longer duration of the second stage and the pushing phase in lower parities.

Objective The aims of this study were to ascertain the frequency of disorders of villous maturation in fetal death and to also delineate other placental histopathologic lesions in fetal death. Methods This was a retrospective observational cohort study of fetal deaths occurring among women between January 2004 and January 2016 at Hutzel Women’s Hospital, Detroit, MI, USA. Cases comprised fetuses with death beyond 20 weeks’ gestation. Fetal deaths with congenital anomalies and multiple gestations were excluded. Controls included pregnant women without medical/obstetrical complications and delivered singleton, term (37–42 weeks) neonate with 5-min Apgar score ≥7 and birthweight between the 10 th and 90 th percentiles. Results Ninety-two percent (132/143) of placentas with fetal death showed placental histologic lesions. Fetal deaths were associated with (1) higher frequency of disorders of villous maturation [44.0% (64/143) vs. 1.0% (4/405), P < 0.0001, prevalence ratio, 44.6; delayed villous maturation, 22% (31/143); accelerated villous maturation, 20% (28/143); and maturation arrest, 4% (5/143)]; (2) higher frequency of maternal vascular malperfusion lesions [75.5% (108/143) vs. 35.7% (337/944), P < 0.0001, prevalence ratio, 2.1] and fetal vascular malperfusion lesions [88.1% (126/143) vs. 19.7% (186/944), P < 0.0001, prevalence ratio, 4.5]; (3) higher frequency of placental histologic patterns suggestive of hypoxia [59.0% (85/143) vs. 9.3% (82/942), P < 0.0001, prevalence ratio, 6.8]; and (4) higher frequency of chronic inflammatory lesions [53.1% (76/143) vs. 29.9% (282/944), P < 0.001, prevalence ratio 1.8]. Conclusion This study demonstrates that placentas of women with fetal death were 44 times more likely to present disorders of villous maturation compared to placentas of those with normal pregnancy. This suggests that the burden of placental disorders of villous maturation lesions is substantial.

Background Atrial septal aneurysm (ASA) is an uncommon cardiac anomaly that increases maternal morbidity during pregnancy. ASA is related to atrial arrhythmia thromboembolism and it may accompany congenital anomalies such as an atrial septal defect (ASD) or patent foramen ovale (PFO). There are no studies examining pregnancy outcomes in pregnant women with ASA. We aimed to investigate the cardiologic parameters and obstetric outcomes of pregnant women diagnosed with ASA. Methods This prospective cohort study analyzed 45 pregnant women diagnosed with ASA, who continued their follow-ups in an obstetric tertiary care center. Results A total of 45 pregnant women were recruited; seven pregnancies ended before the 20 th gestational week (six spontaneous abortion, one fetal anomaly), 38 women gave birth. In total, there were 32 term births (≥37 weeks), six preterm births (<37 weeks), two extremely preterm births <28 weeks). Among 38 babies delivered, several obstetrical complications such as oligohydramnios, spontaneous preterm labor, intrauterine growth restriction (IUGR), preeclampsia and gestational diabetes mellitus (GDM) developed in 16 patients, while 22 women ended with term pregnancy without any complications. Deep venous thrombosis (DVT) developed in one patient. Conclusion ASA may have an increased risk for cardiac complications during pregnancy and may also be associated with poor pregnancy outcomes. Increased attention to these entities with more studies is needed in order to determine a potential risk for pregnant women.

Background There are numerous significant physiological changes occurring in circulation during labor. To detect these rapid hemodynamic changes, invasive and intermittent measurement techniques are not reliable. To suggest a suitable delivery method for pregnancy with cardiac disease, this study analyzed how each delivery method influences cardiac function using a noninvasive and continuous measurement technique. Methods A prospective study was accomplished at the National Cerebral and Cardiovascular Center in Japan from October 1, 2014, to November 30, 2018. The classification of the healthy heart pregnant women was according to the delivery method: vaginal delivery (VD) without epidural anesthesia, VD with epidural anesthesia, and caesarean section (CS). The hemodynamic parameters cardiac index (CI), stroke volume index (SI), and heart rate (HR) were evaluated regularly throughout delivery by noninvasive electrical cardiometry monitor. Results Ten cases were examined for each group. CI and HR were significantly increased before VD, while the increase in CI and HR was mild in the epidural group in comparison to the nonepidural group. SI was increased toward the delivery in the epidural group, and it was constant in the nonepidural group. However, there was no alteration in the level of outcomes of the two groups. In CS, SI increased and HR decreased before delivery. After delivery, SI continued to increase, while HR did not change but CI increased. Conclusion In VD, the increase in venous circulation according to the autotransfusion is managed by increasing HR. By epidural anesthesia, the increase in HR was suppressed and SI was increased. However, as epidural anesthesia increases the vascular capacity, the level of SI outcome was comparable. In CS, the HR was decreased because of the spinal anesthesia and the SI was increased because of many factors like hydration. As there are many factors to control in CS, VD with epidural anesthesia will be the first preference for most cardiac patients.

Objective To assess the success rates of five fetal cardiac views using HDlive Flow (Silhouette) with spatiotemporal image correlation (STIC) in the second and third trimesters of pregnancy, and to verify the feasibility of obtaining five cardiac views by volumes. Methods One hundred and eighteen normal fetuses at 18–21 and 28–31 weeks of gestation were studied using HDlive Flow (Silhouette) with STIC to assess the success rates of five fetal cardiac views (frontal, spatial three-vessel, panoramic, posterior, and right lateral views). Target structures in each cardiac view were evaluated. “Good” was assigned when all structures were noted, “Fair” when only one structure was missed, and “Poor” when two and more structures could not been detected. Results There were no significant differences in success rates of each cardiac view between 18–21 and 28–31 weeks of gestation. The rate of “Good” with a spatial three-vessel view was significantly higher than that with other cardiac views at 18–21 and 28–31 weeks, respectively (P < 0.05). Conclusion Five cardiac views using HDlive Flow (Silhouette) with STIC may become an adjunctive and useful tool in fetal cardiac examination.

Objective To assess whether fetal brain structures routinely measured during the second and third trimester ultrasound scans, particularly the width of the cavum septi pellucidi (CSP), differ between fetuses small for gestational age (SGA), fetuses very small for gestational age (VSGA) and normal controls. Methods In this retrospective study, we examined standard ultrasound measurements of 116 VSGA, 131 SGA fetuses and 136 normal controls including the head circumference (HC), transversal diameter of the cerebellum (TCD), the sizes of the lateral ventricle (LV) and the cisterna magna (CM) from the second and third trimester ultrasound scans extracted from a clinical database. We measured the CSP in these archived ultrasound scans. The HC/CSP, HC/LV, HC/CM and HC/TCD ratios were calculated as relative values independent of the fetal size. Results The HC/CSP ratio differed notably between the controls and each of the other groups (VSGA P = 0.018 and SGA P = 0.017). No notable difference in the HC/CSP ratio between the VSGA and SGA groups could be found (P = 0.960). The HC/LV, HC/CM and HC/TCD ratios were similar in all the three groups. Conclusion Relative to HC, the CSP is larger in VSGA and SGA fetuses than in normal controls. However, there is no notable difference between VSGA and SGA fetuses, which might be an indicator for abnormal brain development in this group.

Objective To investigate the possible predictive value of fetal fraction in the cell-free DNA (cfDNA) test in pregnancies with early- and late-onset fetal growth restriction (FGR). Methods This retrospective study comprised 247 women who were screened using the cfDNA test for aneuploidies during the first or second trimester and had deliveries at our institution from January 2016 to December 2019. The fetal fractions of women with early- (n = 14) and late-onset (n = 83) FGR and those with uncomplicated pregnancies (n = 150) were compared. Results The median fetal fractions for the early-onset FGR, late-onset FGR, and control groups were 5.7 [interquartile range (IQR) 2.65], 7 (IQR 5), and 7.35 (IQR 3.65), respectively. The fetal fractions were significantly lower in the early-onset FGR group than in the late-onset FGR and control groups (P = 0.047 and P = 0.037, respectively). There was no difference in fetal fractions between the late-onset FGR and control groups (P = 1.00). Conclusion As a placenta-related disease, early-onset FGR had lower fetal fractions in the cfDNA test than uncomplicated pregnancies. For clinical use, lower fetal fractions can contribute as a biomarker for screening asymptomatic women for possible placenta-related diseases, such as early-onset FGR. However, more studies are needed to define the “lower” limit.

Objective To determine whether the receipt of therapeutic services of very-low-birth-weight (VLBW; ≤1500 g) neonates inadvertently delivered at community Level 2 and 3 neonatal intensive care units (NICUs) compared with those born at a well-baby nursery (WBN; Level 1) differed. Methods This is a retrospective study of neonates who were born at Level 1 (WBN), 2, 3, and 4 NICUs and discharged from a Level 4 hospital (n = 529). All infants were evaluated at the Regional Neonatal Follow-up Program at 12 ± 1 months corrected gestational age (CA) and assessed for use of therapeutic services including: early intervention (EI), occupational therapy (OT), physical therapy (PT), speech therapy (ST), and special education (SE). Results Compared to infants born at community Level 2 and 3 NICU hospitals, those outborn at a community Level 1 WBN had significantly higher utilization of EI (90% vs. 62%) and PT (83% vs. 61%) at 12 months CA. This association persisted when controlling for covariates. Infants who required EI had significantly lower Bayley-III cognitive scores at 3 years of age. Conclusion VLBW infants outborn at WBN (Level 1) hospitals required more outpatient therapeutic services than those born at hospitals with NICU facilities. These results suggest that delivering at the appropriate community hospital level of care might be advantageous for long-term outcomes.

Objective Little information exists related to the contribution of assisted reproductive technology (ART) twins to the preterm and very preterm birth rate. We sought to examine this contribution over a period of more than two decades in a tertiary perinatal center. Methods We identified all preterm births from 1993 to 2017, born at <37 or <32 weeks’ gestation, by mode of conception [in vitro fertilization (IVF) vs. non-IVF pregnancies]. We generated trend lines of the annual change of the dependent variable (% preterm birth). Results We evaluated 74,299 births, including 3934 (5.3%) preterm births at <37 and 826 (1.1%) at <32 weeks’ gestation. In this period, 1019 (1.4%) twin pairs were born including 475 (46.6%) and 80 (7.8%) at <37 and <32 weeks, respectively. There were 213 (5.4%) IVF pregnancies among the preterm births at <37 weeks, including 88 (41.3%) twins. Fifteen (1.8%) births of all IVF gestations were at <32 weeks, and all were twins. Whereas the annual rate of spontaneous twins did not change, a significant increase over time exists for IVF twins (P < 0.05, R 2  = 0.6). We demonstrated an increase in IVF twin births at <37 weeks but not for spontaneously conceived twins. Whereas the twin birth rate at <32 weeks did not change over time, all preterm births at <32 weeks following IVF were twins. Conclusion The risk of twins after ART increasingly contributes to preterm births at <37 weeks and ART twins are at significant risk for preterm births at <32 weeks.

Background Informed by the person-environment transactional model of stress, the purpose of the study was to explore the relationships of environment-related moral distress and person-related anxious and avoidant adult attachment insecurities, and personality proneness to guilt and shame with burnout in neonatal intensive care unit (NICU) nurses. Methods This was a multicenter cross-sectional self-report questionnaire cohort study comprising 142 NICU nurses currently working on six Level 3–4 NICUs in New South Wales, Australia. Results Burnout was reported by 37% of NICU nurses. Moral distress, anxious and avoidant attachment, and guilt- and shame-proneness had moderate-large zero-order correlations with burnout. Overall, these predictor variables explained 40% of the variance in burnout. Moral distress (β = 0.40, P < 0.001), anxious attachment (β = 0.18, P < 0.05) and shame-proneness (β = 0.22, P < 0.01) were unique predictors of burnout. Shame-proneness partially mediated the effect of anxious attachment on burnout [indirect effect, B  = 0.12, confidence interval (CI) (0.051–0.201)]. Conclusion The management of burnout in NICU nurses requires attention not only to environment-related moral distress but also to person-related anxious and avoidant adult attachment insecurities and personality proneness to guilt and shame.