Volume 50, Issue 5

Venous thromboembolism (VTE) is the third most common cause of death on Earth after myocardial infarctions and strokes, according to the World Health Organization (WHO). Pregnancy is a unique condition of woman, when enormous changes occur in functioning of the most important systems of homeostasis in a relatively short time. These are physiological hypercoagulation, slowing of blood flow, increase in circulating blood volume, etc. However, while being physiological, these changes increase the risks of venous thromboembolism by almost 6 times. In some cases, there appears an imbalance or dissociation between the functioning of natural antithrombotic systems and the activation of coagulation as a consequence of genetically or acquired determined causes (genetic thrombophilia, antiphospholipid syndrome, comorbidities, obstetric complications and other exogenous and endogenous factors). Accordingly, identification of risk factors, their systematization, and determination of VTE risks in pregnancy and puerperium is one of the most important tasks of clinical medicine. Various recommendations have appeared for practitioners during the last 10–15 years on the basis of the risk factors analysis in order to prevent VTE in pregnant women more effectively. Nevertheless, none of these recommendations can yet take into account all risk factors, although convenient scoring systems have emerged for risk assessment and clear recommendations on anti-thrombotic prophylaxis regimens in risk groups in recent years. This article will review historical understanding of thrombosis in pregnant women, progress in understanding VTE risk factors in pregnant women, and available reserves in identifying new risk factors during pregnancy and puerperium in order to stratify risks more efficiently.

The practice of maternal-fetal surgery (MFS) has expanded from lethal fetal conditions to conditions which are significantly disabling but not a lethal fetal abnormality. The inclusion of myelomeningocele within the scope of MFS in the 1990s sparked a renewed debate over the ethics of MFS. While demonstrating increasing efficacy and range of application, MFS continues to be ethically fraught due to the inherent tension between maternal and fetal interests. Ethical issues central to MFS include the patienthood of the fetus; the balance of risks and benefits between the woman and fetus; informed consent for experimental procedures; and determination of conditions that meet ethical qualifications for MFS intervention. These concerns are likely to persist and evolve as perinatal medicine continues to advance. Here we summarize the current state of MFS ethics, highlighting the major positions in the literature thus far as well as examine future directions. It is essential robust discussions of these important issues continue both to ensure ethical medical practice and to provide support to clinicians, pregnant women, and their families.

The scientific evidence about COVID-19 and pregnancy is conclusive: COVID-19 infections increase the risk of stillbirths and preterm births, and pregnant and postpartum patients are more likely to get severely ill with COVID-19 and die when compared with people who are not pregnant. Getting a COVID-19 vaccine protects from severe illness from COVID-19 and risk of death. COVID-19 vaccination is recommended for pregnant patients, those trying to conceive, and who are breastfeeding, or might become pregnant in the future. The justification for government involvement in public health measures that restrict personal liberty that we are so familiar with today emanated from a philosophical source at the same time as the progress in managing infectious disease. John Stuart Mill (1806–1873), an empiricist and a utilitarian, was not specifically addressing the ethics of public health in his classic On Liberty (1859), but his arguments have become the reference point for liberal democracies and public health measures. Mill was in search of a philosophical principle that could justify constraints on personal freedom. John Stuart Mill gives direct guidance to our approach supporting not only strong recommendations for pregnant patients to accept vaccinations against COVID-19 but also for those working in healthcare setting to be required to be vaccinated. This approach is respectful to our patient’s liberty while doing all that’s reasonable to protect them from harm. Based on our professional experience we recognize that some physicians and patients have fixed false beliefs. Physicians espousing fixed false beliefs against COVID-19 vaccines should be censured.

Objectives Monoamniotic twins represent a high-risk pregnancy requiring intense follow-up, elective birth and careful consideration of the mode and timing of delivery. We conducted this study to evaluate the perinatal and neonatal outcomes of monoamniotic twin pregnancies in the largest tertiary hospital in Finland. Methods This was a retrospective cohort study including all monoamniotic twin pregnancies during a 17-year period (2002–2018) managed in Helsinki University Hospital. Data on mothers and children were collected from patient files. Chorionicity and amnionicity were defined in first-trimester ultrasound screening. Results There were altogether 31 monoamniotic twin pregnancies during the study period, including four cases of conjoined twins which all underwent termination of pregnancy, and three miscarriages. In the remaining 24 pregnancies that continued past 24 weeks of gestation there was 97.9% survival (one intrauterine death). Three pregnancies were complicated with twin-to-twin transfusion syndrome. All children were delivered by cesarean section with a mean gestational age of 32 + 5 weeks (27 + 1–34 + 2 weeks). Respiratory distress syndrome (RDS) was observed in 57% (27/47) of neonates and grade I–II intraventricular haemorrhage (IVH) in 6.3% (3/47) of neonates. There were no neonatal deaths and no maternal complications. Conclusions Monoamniotic twinning is a rare form of pregnancy and carries risks for perinatal and neonatal complications. With timely diagnosis, close monitoring in specialized feto-maternal unit and elective delivery at 32–34 weeks the outcome is usually excellent.

Objectives We examined the mental health of mothers after unaccompanied birth (unaccompanied group, UG) due to COVID-19-related visiting bans and compared the data with a control group with accompanied birth (AG). Additionally, a distinction was made between caesarean section (CS) and vaginal birth (VB), as existing research indicates a higher risk for mental distress after CS. Methods The cross-sectional study included 27 mothers in the UG and 27 matched controls (AG). Anxiety, depression, postpartum traumatic stress symptoms (PTSS), and psychological well-being were assessed. Additionally, emotions and attitudes related to the restrictions were measured by self-developed items. Results Psychological distress was high especially in the UG (anxiety: 23%, PTSS: 34.6%, low well-being: 42.3%, depression: 11.5%). Mothers in the AG had lower psychological distress than those in the UG, but still had enhanced rates of PTSS (11.1%) and diminished well-being (22.2%). In both groups, women with CS reported higher anxiety and trauma scores and lower well-being than women with VB. Unaccompanied mothers with CS perceived visitation restrictions as less appropriate and felt more helpless, angry, worried, and frustrated about the partner’s absence than women with VB. Conclusions The partner’s absence during, but also after childbirth has a major impact on psychological outcomes. Particularly, higher rates of anxiety and PTSS can lead to negative consequences for mothers and their children. Therefore, it is strongly recommended to relax visitation bans and avoid unaccompanied births. Psychological treatment in obstetric units is more urgently needed than ever, especially for women with a caesarean section.

Objectives Instagram (IG) is becoming one of the larger resource tools within medicine. Since the onset of the COVID-19 pandemic, it is becoming important for programs to improve virtual presence and outreach. We evaluated the adoption of IG by OB/GYN residency programs in the United States and aimed to see if highly ranked programs had higher utilization rates. Methods IG presence and engagement metrics were extracted for all ACGME accredited OB/GYN programs. Doximity residency navigator tool was used to obtain nationwide program rankings, and statistical analysis was performed to prove any significant correlation. Mann–Whitney U test, Cochran-Armitage test and Analysis of variance were used for analysis. IRB exemption was obtained. Results Seventy percent of programs (202/287) have IG presence, with the majority creating presence after the COVID pandemic began (115/202; 57%). Seventy-two percent (83/115) of these programs created their IG account once virtual interviews were announced. The top 25% of programs, as ranked on Doximity, have a higher number of posts, followers and likes when compared to the rest of the programs. Conclusions The COVID-19 pandemic has led to increased adoption of IG by residency programs. Highly ranked and reputed programs have higher rates of activity, popularity, and engagement on IG.

Objectives To determine whether placental vascular pathology and impaired placental exchange due to maturational defects are involved in the etiology of spontaneous preterm labor and delivery in cases without histologic acute chorioamnionitis. Methods This was a retrospective, observational study. Cases included pregnancies that resulted in spontaneous preterm labor and delivery (<37 weeks), whereas uncomplicated pregnancies that delivered fetuses at term (≥37–42 weeks of gestation) were selected as controls. Placental histological diagnoses were classified into three groups: lesions of maternal vascular malperfusion, lesions of fetal vascular malperfusion, and placental microvasculopathy, and the frequency of each type of lesion in cases and controls was compared. Moreover, we specifically searched for villous maturational abnormalities in cases and controls. Doppler velocimetry of the umbilical and uterine arteries were performed in a subset of patients. Results There were 184 cases and 2471 controls, of which 95 and 1178 had Doppler studies, respectively. The frequency of lesions of maternal vascular malperfusion was greater in the placentas of patients with preterm labor than in the control group [14.1% (26/184) vs. 8.8% (217/2471) (p=0.023)]. Disorders of villous maturation were more frequent in the group with preterm labor than in the control group: 41.1% (39/95) [delayed villous maturation in 31.6% (30/95) vs. 2.5% (13/519) in controls and accelerated villous maturation in 9.5% (9/95) vs. none in controls]. Conclusions Maturational defects of placental villi were associated with approximately 41% of cases of unexplained spontaneous preterm labor and delivery without acute inflammatory lesions of the placenta and with delivery of appropriate-for-gestational-age fetuses.

Objectives The aim of the present study was to evaluate a new ultrasonographic scoring method that could predict spontaneous preterm birth (sPTB) in uncomplicated twin pregnancies during routine anomaly screening in the midtrimester. Methods This prospective study included women with a monochorionic diamniotic (MCDA) or dichorionic diamniotic (DCDA) twin pregnancy gestational ages from 17 0/7 through 22 6/7 . A new ultrasonographic score between 0 and 5 points was calculated using cervical length (CL), uterocervical angle (UCA), and cervical dilatation status during routine anomaly screening in the midtrimester. The primary outcome of the study was the prediction of sPTB < 32 and <34 gestational weeks. Results A total of 118 pregnant women with twins were evaluated, 31 of whom delivered before 34 gestational weeks an 87 of whom delivered after 34 gestational weeks. The sensitivity and specificity values were separately calculated for scores of 3.5 and 2.5 for predicting sPTB < 32 gestational weeks. The cut-off value of 3.5 provided a sensitivity of 80% and a specificity of 82%. When the score was 2.5, the sensitivity and specificity were 86 and 71%, respectively. To determine a score for predicting sPTB < 34 gestational week cut-off value of 3.5 provided a sensitivity of 80% and a specificity of 90%. When the score value was 2.5, the sensitivity and specificity of the method were 83 and 81%, respectively. Conclusions Our results indicated that the midtrimester new scoring is a simple technique that can be easily used as an improved tool for predicting the risk of sPTB in women with a twin pregnancy.

Objectives To determine the impact of antenatal corticosteroids (ACS) on neonatal outcomes in a large United States population of preterm births. Methods Retrospective cohort study utilizing the United States Natality Live Birth database from the Centers for Disease Control and Prevention (2016–2017). Women with singleton preterm births were eligible for inclusion. Out-of-hospital births, fetal anomalies, and cases where ACS exposure was unknown were excluded. Neonates from reported live births were divided into two groups based on whether the mother received ACS before delivery or not. The incidence of several reported neonatal outcomes were compared between the two groups at each gestational week. Subsequently, comparisons between three gestational age groups (23 0/7 to 27 6/7, 28 0/7 to 33 6/7, and 34 to 36 6/7 weeks) were performed. Statistical analysis included use of Chi-squared test and multivariate logistic regression. Results Of the 588,077 live births included, 121,151 (20.6%) had been exposed to ACS. ACS use was associated with a significantly decreased odds of neonatal mortality and 5-min Apgar score <7, but an increased rate of several neonatal outcomes such as surfactant replacement therapy, prolonged ventilation, antibiotics for suspected neonatal sepsis, and neonatal intensive care unit (NICU) admissions. Conclusions ACS administration prior to preterm birth is associated with a decrease in neonatal mortality and low Apgar scores, and increased odds of several adverse neonatal outcomes.

Objectives Many autoimmune diseases negatively affect pregnancies. Studies report conflicting data about the effects of psoriatic arthritis (PsA) in pregnancy. We sought to evaluate the pregnancy, delivery, and neonatal outcomes among women with PsA. Methods We conducted a retrospective population-based study using data from the Healthcare Cost and Utilization Project-Nationwide Inpatient Sample (HCUP-HIS). Cases of PsA were identified using the ICD code 696.0. Pregnancies complicated with PsA were compared with the other pregnancies. A multivariate logistic regression was used to adjust for confounding variables. Results A total of 9,096,369 control births and 419 with PsA occurred during the study period. Women with PsA were more likely to be older, Caucasian, obese, have a higher income, and private insurance (p-value <0.0001 all). Also, they were more likely to start their pregnancy with chronic hypertension, pregestational diabetes, thyroid disorders, inflammatory bowel disease, and depression. Rates of pregnancy induced hypertension (PIH) (aOR 1.58, 95% CI 1.13–2.21) and small for gestational age (SGA) (aOR 2.42, 95% CI 1.49–3.93) were higher in PsA. There were no differences in the rates of most outcomes including: preeclampsia, gestational diabetes, preterm delivery, preterm premature rupture of membranes (PPROM), placenta previa, abruption, modes of delivery, hemorrhage, deep vein thrombosis (DVT), pulmonary embolism (PE), chorioamnionitis, intrauterine fetal death, or congenital anomalies (p>0.05 all). Conclusions Women with PsA should be reassured about their pregnancy outcomes as only PIH and SGA were more common. Healthcare providers should take appropriate surveillance and preventive methods to mitigate the effect of these two complications in pregnancies complicated with PsA.

Objectives Pregnancy outcomes in women with inflammatory myopathies (IM) are not well studied. The purpose of this study is to evaluate the effects of IM on maternal and neonatal outcomes. Methods We conducted a retrospective cohort study using data from the Healthcare Cost and Utilization Project – Nationwide Inpatient Sample (HCUP-NIS) from 1999 to 2015. Among all pregnant women who delivered during this period, those with a diagnosis of IM were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) coding, which included all patients with dermatomyositis and polymyositis. Maternal and neonatal outcomes were compared in pregnant women with and without IM. Multivariate logistic regression analysis was used to estimate the adjusted effects of IM on these outcomes. Results A total of 13,792,544 pregnant women delivered between 1999 and 2015, of which 308 had a diagnosis of IM, for an overall prevalence of 2 per 100,000 pregnant women, with rates increasing over the study period. Pregnant women with IM were more likely to be older, African American and suffer from other autoimmune connective tissue diseases. IM in pregnancy was associated with greater risk of preeclampsia, caesarean delivery, major postpartum infections, urinary tract infections and longer hospital stay. Neonates born to mothers with IM had greater risk of prematurity, small for gestational age and intrauterine fetal demise. Conclusions Pregnant women with IM are at higher risk of adverse maternal and neonatal outcomes and should be closely followed in specialized centers with collaboration between maternal-fetal medicine and rheumatology.

Objectives To assess the pretest and negative post-test probability for placenta accreta spectrum (PAS) in a group of patients with high-risk clinical factors. Methods We included patients with suspected and/or confirmed PAS at our institution over 8 years. Sonography performed by maternal-fetal medicine specialists, and selected patients underwent MRI. Imaging was considered positive if either sonography or MRI suggested PAS. Histopathology was the gold standard for diagnosis of PAS. We assessed the pretest and negative imaging-test probability, and resources required. Results We identified 82 high-risk patients with the following: (1) a history of ≥1 cesarean section and/or intrauterine gynecologic procedure and placenta previa in the index pregnancy; (2) a history of >3 cesarean deliveries and/or gynecologic procedures regardless of placental location; (3) prior PAS disorder, or retained placenta requiring manual extraction and/or curettage, complicated by postpartum hemorrhage; and (4) suspected cesarean section scar pregnancy. Histopathology confirmed PAS in 52 patients, with pretest probability of 63%. Imaging correctly identified 44/50 cases with PAS, and excluded this condition in 24/30 cases. Thus, the positive and negative post-test probability for PAS following negative imaging was 88 and 20%, respectively. Of the six patients with false-negative imaging, all had either surgical complications or required care beyond that for routine cesarean section. Conclusions Although diagnostic imaging is sensitive, the negative posttest probability remains high in women with high pretest probability for PAS. Therefore, women at high risk for PAS should be managed in experienced centers by a multidisciplinary team even if imaging is negative.

Objectives Among patients with placenta retention, the risk factors of massive blood loss remain unclear. In this study, a secondary data analysis was conducted to construct a predictive risk model for postpartum hemorrhage (PPH) in this particular population. Methods A prediction model based on the data of 13 hospitals in the UK, Uganda, and Pakistan, from December 2004, to May 2008 was built. A total of 516 patients and 14 potential risk factors were analyzed. The least absolute shrinkage and selection operator regression (LASSO) model was used to optimize feature selection for the PPH risk model. Multivariable logistic regression analysis was applied to build a prediction model incorporating the LASSO model. Discrimination and calibration were assessed using C-index and calibration plot. Results Among patients with placenta retention, the incidence of PPH was 62.98% (325/526). Risk factors in the model were country, number of past deliveries, previous manual removal of placenta, place of placenta delivery, and how the placenta was delivered. In these factors, patients in the low-income country (i.e., Uganda) (OR: 1.753, 95% CI=1.055–2.915), retained placentas delivered in the theater (OR: 2.028, 95% CI=1.016–4.050), and having placentas partially removed by controlled cord traction (cct), completely removed manually (OR: 4.722, 95% CI=1.280–17.417) were independent risk factors. The C-statistics was 0.702. Conclusions By secondary data analysis, our study constructed a prediction model for PPH in patients with placenta retention, and identified the independent risk factors.

Objectives To identify antenatal risk factors that may predict the need for insulin treatment upon diagnosis of gestational diabetes (GDM), that is, to identify the specific characteristics of women diagnosed with GDM who did not achieve good glycemic control through lifestyle modifications. Methods We performed a comprehensive literature search in PubMed, Science Direct, Ebsco, and Scielo for studies evaluating the associations between antenatal factors and the need for insulin treatment published until January 28th, 2021. Random-effects models were used to estimate risk ratios and their 95% confidence interval. The quality of studies was assessed using the Newcastle-Ottawa Scale. Random-effects models were used to estimate outcomes, and effects reported as risk ratio and their 95% confidence interval. The systematic review and meta-analysis were registered in the International Prospective Register of Systematic Reviews. Results Eighteen observational studies were selected, reporting 14,951 women with GDM of whom 5,371 received insulin treatment. There were statistically significant associations between the need for insulin treatment and BMI ≥ 30 (RR:2.2; 95%CI: 1.44–3.41), family history of type 2 diabetes mellitus (RR:1.74; 95%CI: 1.56–1.93), prior personal history of GDM (RR:2.10; 95%CI: 1.56–2.82), glycated hemoglobin value at GDM diagnosis (RR:2.12; 95%CI: 1.77–2.54), and basal glycemia obtained in the diagnostic curve (RR: 1.2; 95%CI: 1.12–1.28). Nulliparity and maternal age were not determinants factor. There was moderate-to-high heterogeneity among the included studies. Conclusions the strong causal association between BMI ≥ 30, family history of type 2 diabetes mellitus, prior history of GDM and glycosylated hemoglobin with the need for insulin treatment was revealed.

Objectives To identify when obstetricians would deliver a fetus with antenatal hydronephrosis and normal liquor. Designed as snap-shot survey. Setting: Survey Monkey link. Population/sample were obstetrics and fetal medicine consultants who received the survey link via closed professional forums on the North West Coast Maternity Clinical Network, Facebook, and publicly on Twitter. Methods Survey link publicised as above, obstetric consultants were asked at what gestation would they deliver a fetus with antenatal hydronephrosis and normal liquor; and what criteria would they use to make that decision. Main outcome measures were number of years in practice, gestation at delivery, anteroposterior diameter (APD) of renal pelvis. Results A total of 44/102 respondents (43%) would deliver prior to 40 weeks (median no. of years as consultant 10 years [IQR 5–17]) vs. those who would not (median years as consultant 5.5 [IQR 3–12]). Re APD threshold of delivery: 17 indicated delivery if the APD were 20 mm, 10 if it were 21–30 mm and 16 if it were >30 mm. Re gestation at which they would deliver: 13 indicated 37–38 weeks, 13 indicated 38–39 weeks and 17 indicated 39–40 weeks. Reasons selected for delivery before term were obstetric anxiety n=2, maternal request n=2, maternal anxiety n=2 and concern about fatal renal damage/renal damage n=34. Conclusions A surprising number of respondents would consider early delivery of a fetus with hydronephrosis and normal liquor despite the lack of evidence of benefit. The evidence supporting term delivery means that early term delivery is only indicated for obstetric reasons in this scenario.

Objectives To evaluate the association between low regional cerebral oxygen saturation (rScO2) and neurodevelopment in preterm infants classified as no brain injury (NBI). Methods We retrospectively reviewed data of rScO2 monitoring during the first 3 days of life of infants with a gestational age (GA)<28 weeks or birth weight (BW)<1,000 g, with and without brain injury (BI). BI was defined as intraventricular haemorrhage, cystic periventricular leukomalacia or cerebellar haemorrhage. Univariate and multivariate analyses were used to study the association of rScO2<55% for more than 10 h in the first 3 days of life (NIRS<55% >10H ) and the 24 months neurodevelopment. Results Of the 185 patients who met the inclusion criteria, 31% were classified as BI infants and 69% NBI. BI compared to NBI infants had a significantly lower GA and a higher incidence of complications of prematurity. Mean rScO2 in the first 72 h of life was significantly lower in BI than NBI. NIRS<55% >10H in NBI patients was negatively associated with neurodevelopmental scores both at the univariate and multivariate analysis (p<0.05). NBI infants with NIRS<55% >10H were found to have lower systemic oxygenation than their counterparts with rScO2<55% for less than 10 h. Conclusions NIRS<55% >10H in NBI small preterm infants was found to be an independent predictor of neurodevelopment at 24 months and it was associated with low systemic saturation values.

Objectives To examine the relationship between postpartum depression (PPD), mode of delivery (MOD), and indication for unscheduled cesarean delivery (uCD). Methods Patients with antenatal and postpartum Edinburgh Postnatal Depression Scale (EPDS) scores were compared by MOD and indication for uCD if applicable. Patients with an antenatal EPDS>12 were excluded to ascertain the incidence of new depression. The primary outcome was EPDS≥13 by MOD. The secondary outcome was EPDS≥13 by indication for uCD. Results Seven hundred and thirty eight patients met inclusion criteria. There were statistically significant differences in MOD by age, race, BMI, and multi-gestation pregnancy. Patients delivered via uCD had a higher rate of peripartum complications and NICU admission. There were no differences in medical comorbidities or use of psychiatric medications by MOD. There was no difference in EPDS by MOD. The rate of PPD was higher in patients with uCD for non-reassuring fetal heart tones (NRFHT) compared to other indications for uCD (p=0.02). Conclusions While there was no difference in the incidence of PPD by MOD, the incidence of PPD was higher among patients delivered via uCD for NRFHT. These findings may have implications for patient counseling, post-operative mental health surveillance, and support of postpartum patients.