Volume 52, Issue 9

Artificial intelligence (AI) has emerged as a transformative technology in the field of healthcare, offering significant advancements in various medical disciplines, including obstetrics. The integration of artificial intelligence into 3D/4D ultrasound analysis of fetal facial profiles presents numerous benefits. By leveraging machine learning and deep learning algorithms, AI can assist in the accurate and efficient interpretation of complex 3D/4D ultrasound data, enabling healthcare providers to make more informed decisions and deliver better prenatal care. One such innovation that has significantly improved the analysis of fetal facial profiles is the integration of AI in 3D/4D ultrasound imaging. In conclusion, the integration of artificial intelligence in the analysis of 3D/4D ultrasound data for fetal facial profiles offers numerous benefits, including improved accuracy, consistency, and efficiency in prenatal diagnosis and care.

“ Those who cannot remember the past are condemned to repeat it. ” This maxim underscores the importance of historical awareness in medicine, particularly for obstetricians and gynecologists (ObGyns). ObGyns significantly impact societal health through their care for pregnant women, fetuses, and newborns, uniquely positioning them to advocate for health initiatives with lasting societal benefits. Despite its importance, the history of medicine is underrepresented in medical curricula, missing opportunities to foster critical thinking and ethical decision-making. In today’s climate of threatened reproductive rights, vaccine misinformation, and harmful ideologies, it is imperative for ObGyns to champion comprehensive historical education. The history of medicine, particularly in relation to societal issues – such as racism, discrimination, genocides, pandemics, and wars – provides valuable context for addressing challenges like maternal mortality, reproductive rights, vaccine hesitancy, and ethical issues. Understanding historical milestones and notable ethical breaches, such as the Tuskegee Study and the thalidomide tragedy, informs better practices and safeguards patient rights. Technological advancements in hygiene, antibiotics, vaccines, and prenatal care have revolutionized the field, yet contemporary ObGyns must remain vigilant about lessons learned from past challenges and successes. Integrating historical knowledge into medical training enhances clinical proficiency and ethical responsibility, fostering innovation and improving health outcomes. By reflecting on historical achievements and their impacts, current and future ObGyns can advance the field, ensuring comprehensive and ethically sound approaches to patient care. This paper highlights the crucial role of historical knowledge in shaping modern ObGyn practices, advocating for its integration into medical education to address contemporary health challenges and ethical considerations.

Vasa previa is a condition where unprotected fetal vessels cross the cervix within the membranes, posing a considerable risk of fetal death or severe morbidity if the membranes rupture before or during delivery. There has not been a definitive in utero treatment for this condition. Patients are typically closely monitored and hospitalized in the early third trimester and scheduled for cesarean delivery before term. This approach poses considerable physical, social, psychological, and financial challenges for pregnant patients and their families. Furthermore, fetal vessel rupture may lead to severe hypoxic-ischemic injury and consequent neurodevelopmental impairment. Finally, babies delivered early due to vasa previa may face both the short- and long-term consequences of prematurity. Recently, fetoscopic laser photocoagulation using a single-port fetoscope has emerged as a potential therapeutic option for patients with types II and III vasa previa. This innovative approach aims to reduce hospital stays, increases the chance of successful vaginal delivery, and potentially allows pregnancies to reach full term, providing lifelong benefits for the infant. Preliminary clinical studies on human subjects have demonstrated promising results concerning the feasibility, safety, and efficacy of this intervention for a subset of patients with types II and III vasa previa. After reviewing the current state of the art, we argued that offering fetoscopic laser photocoagulation in specialized centers under IRB supervision meets the ethical obligations of beneficence and non-maleficence for both pregnant and fetal patients, as well as the autonomy-based obligations for pregnant patients.

Objectives To assess the efficacy and safety of a two-drug regimen (2DR) with dolutegravir (DTG) and lamivudine (3TC) in maintaining viral suppression during pregnancy and breastfeeding, and to evaluate its potential as an alternative to the recommended three-drug regimen (3DR) in preventing mother-to-child transmission (MTCT) of HIV. Methods We present a case of a 34-year-old pregnant woman who, after discontinuing 3DR due to side effects and poor adherence, was switched to DTG/3TC at gestational week 23. Maternal viral load (VL) and infant HIV status were monitored throughout pregnancy and a ten-month breastfeeding period. Data on pharmacokinetic changes in pregnancy and the risks associated with 2DR were reviewed. Results The patient’s VL remained suppressed (<20 copies/mL) from gestational week 23 until the end of the breastfeeding period. A healthy HIV-negative baby was born at 39 weeks, and the child remained HIV-negative after ten months of breastfeeding. The 2DR was well-tolerated, improved adherence, and reduced fetal drug exposure. Despite limited experience with 2DR in pregnancy, no viral rebound occurred, and no adverse effects were observed. Conclusions Although 3DR remains the preferred therapy during pregnancy and breastfeeding, this case indicates that DTG/3TC may be an effective alternative for patients experiencing intolerance or poor adherence to 3DR. Further studies are needed to explore the impact of pharmacokinetic changes in pregnancy on 2DR efficacy and to confirm its safety and role in preventing MTCT.

Objectives To estimate the number of pregnancies complicated by vasa previa annually in nine developed countries, and the potential preventable stillbirths associated with undiagnosed cases. We also assessed the potential impact of universal screening for vasa previa on reducing stillbirth rates. Methods We utilized nationally-reported birth and stillbirth data from public databases in the United States, United Kingdom, Canada, Germany, Ireland, Greece, Sweden, Portugal, and Australia. Using the annual number of births and the number and rate of stillbirths in each country, and the published incidence of vasa previa and stillbirth rates associated with the condition, we estimated the expected annual number of cases of vasa previa, those that would result in a livebirth, and the potential preventable stillbirths with and without prenatal diagnosis. Results There were 6,099,118 total annual births with 32,550 stillbirths, corresponding to a summary stillbirth rate of 5.34 per 1,000 pregnancies. The total expected vasa previa cases was estimated to be 5,007 (95 % CI: 3,208–7,201). The estimated number of livebirths would be 4,937 (95 % CI: 3,163–7,100) and 3,610 (95 % CI: 2,313–5,192) in pregnancies with and without a prenatal diagnosis of VP. This implies that prenatal diagnosis would potentially prevent 1,327 (95 % CI: 850–1,908) stillbirths in these countries, corresponding to a potential reduction in stillbirth rate by 4.72 % (95 % CI: 3.80–5.74) if routine screening for vasa previa was performed. Conclusions Our study highlights the importance of universal screening for vasa previa and suggests that prenatal diagnosis of prevention could potentially reduce 4–5 % of stillbirths.

Objectives To compare the effectiveness, safety and patient satisfaction of a double balloon catheter (DB) with a synthetic osmotic cervical dilator (OD) for pre-induction cervical ripening in an outpatient setting. Methods This is a prospective, dual-center pilot study including 94 patients with an unripe cervix (Bishop Score <6) near term; 50 patients received the DB and 44 patients the OD. The primary outcomes were the difference in BishopScore (BS) and cervical shortening. Pain perception at insertion and during the cervical ripening period was evaluated by a visual analogue scale and patient satisfaction by a predefined questionnaire. Results The use of DB was associated with a significantly higher increase in BS (median 3) compared to OD (median 2; p=0.002) and resulted in significantly greater cervical shortening (median −14 mm vs. −9 mm; p=0.003). There were no serious adverse events at placement of devices or during the cervical ripening. There were no significant differences in perinatal outcomes. Pain perception during cervical ripening was significantly higher (p<0.001), and patient satisfaction regarding sleep, relaxing time and performing desired daily activities were significantly lower in patients with DB compared to patients with OD (p<0.001). Conclusions DB was superior to OD regarding cervical ripening based on BS and on sonographic measurement of the cervical length. Patients with OD experienced less pain during cervical ripening and were more satisfied with the method compared to patients with DB.

Objectives Predicting the success of vaginal delivery is an important issue in preventing adverse maternal and neonatal outcomes. This study sought to examine whether measurement of the angle of progression (AoP) can predict a successful vaginal delivery following induction of labour (IoL) among late term nulliparous women with a low (4>) Bishop score. Methods This prospective study included consecutive nulliparous pregnant women whose gestational age was 41 weeks and 1–6 days (late-term). The AoP was measured at least three times and their means were calculated. Results During the study period, data of 150 women were included in the final analysis. Thirty-eight women underwent CS due to failure to progress (n=30) or NRGHR (n=8), while the remaining 112 women underwent NVD, with four women requiring vacuum extraction. The two groups were similar with respect to age, gestational age, BMI, estimated foetal weight, and birth weight. Women undergoing NVD differed significantly from those undergoing CS with respect to a greater ultrasonographic AoP (113.8±11.9° vs. 98.1±10.9°, p=0.0001), a shorter duration of dinoprostone use, shorter time to labour contraction, and a shorter duration of labour. In ROC analysis, the cut-off value for AoP was 100° for the prediction of successful IoL for NVD, with a sensitivity of 96 % and a specificity of 63 %. Conclusions AoP may be a useful sonographic parameter for predicting successful vaginal delivery among nulliparous women at late term undergoing IoL; an AOP wider than 100° is associated with a high rate of vaginal delivery.

Objectives To develop prediction models for intrapartum caesarean section in vaginal breech birth. Methods This single-center cohort-study included 262 nulliparous and 230 multiparous women attempting vaginal breech birth. For both groups, we developed and (internally) validated three models for the prediction of intrapartum cesarean section. Results The prediction model for nulliparous women (AUC: 0.67) included epidural analgesia (aOR 2.14; p=0.01), maternal height (aOR 0.64 per 10 cm; p=0.08), birthweight ≥3.8 kg (aOR 2.45; p=0.03) and an interaction term describing the effect of OC if birthweight is ≥3.8 kg (aOR 0.24; p=0.04). An alternative model for nulliparous women which, instead of birthweight, included fetal abdominal circumference with a cut-off at 34 cm (aOR 1.93; p=0.04), showed similar performance (AUC: 0.68). The prediction model for multiparous women (AUC: 0.77) included prelabor rupture of membranes (aOR 0.31; p=0.03), epidural analgesia (aOR 2.42; p=0.07), maternal BMI (aOR 2.92 per 10 kg/m 2 ; p=0.01) and maternal age (aOR 3.17 per decade; p=0.06). Conclusions Our prediction models show the most relevant risk factors associated with intrapartum cesarean section in vaginal breech birth for both nulliparous and multiparous women. Importantly, this study clarifies the role of the OC by showing that this parameter is only associated with intrapartum cesarean section if birthweight is above 3.8 kg (or abdominal circumference is above 34 cm). Conversely, knowing the OC when the birthweight is less than 3.8 kg (or abdominal circumference is less than 34 cm) did not improve prediction of this surgical outcome.

Objectives Complementary and Alternative Medicine (CAM) is a group of diverse medical and healthcare systems, practices, and products that are not generally considered part of conventional medicine. Pregnant women are vulnerable to adverse effects of medicines, especially during the first trimester. Though it is advised to avoid unnecessary intake of medicine during pregnancy, CAM use is widespread. Methods A cross-sectional questionnaire-based study was conducted on 120 pregnant women attending the antenatal clinic of a tertiary-care teaching hospital in Udaipur district of Southern Rajasthan, India. Women of age 18 years and above were surveyed between July 2022 to December 2023 by convenient sampling strategy and data were entered in a pretested and pre-validated questionnaire. The data were analyzed using descriptive statistics, the Chi-square test was applied to compare CAM use among different demographic categories and a p-value less than 0.05 was considered statistically significant. Results Out of 120 participants, 58 (48.33 %) were using CAM therapy. Out of 58 users, 44 (75.86 %) were using herbal & traditional medicines. Twenty (34.48 %) were using CAM for a healthy baby, 18 (31.03 %) for easy delivery and 17 (29.31 %) for boosting immunity. Forty (68.96 %) participants started CAM on the advice of a relative/friend. Fifty six (46.67 %) participants believe that CAM therapy cannot cause adverse effects on the in utero child, while 32 (26.67 %) believe that CAM and modern medicines don’t interact. Conclusions CAM use among pregnant women is substantial. There is a need to raise awareness among the healthcare professionals and pregnant women regarding possible adverse effects and drug-drug interactions with CAM use.

Objectives Streptococcus agalactiae , or Group B Streptococcus (GBS), is a leading cause of neonatal sepsis. Materno-fetal transmission of the microorganisms present in the lower genital tract/perineum is considered to be the most frequent mode for acquisition of infection. It has also been proposed that, in a subset of cases, GBS causes acute chorioamnionitis, intraamniotic infection, and fetal/neonatal sepsis. However, the evidence to support this ascending pathway is derived from microbiologic studies that rely on cultivation methods, which do not have the resolution to determine if the microorganisms causing neonatal sepsis are the same as those found in the amniotic fluid and the vaginal ecosystem. Methods We used whole genome sequencing of the microorganisms isolated from the vagina, amniotic fluid, chorioamniotic membranes, and neonatal blood (four isolates) in a case of early neonatal sepsis. Using hybrid genome assembly, we characterized the genomic features including virulence factors and antimicrobial resistance in four isolates from the same mother, placenta, and newborn. Results Whole genome sequencing revealed that the microorganisms in the four clinical isolates corresponded to S. agalactiae sequence type 1, clonal complexes 1, and serotype Ib. Comparative genomic analysis illustrated similar DNA sequences of the four genomes. Conclusions This study presents the first evidence of the genomic similarity of microorganisms in the vaginal ecosystem, the space between the chorioamniotic membranes of the placenta, amniotic fluid, and neonatal blood.

Objectives Clinical parameters along with echocardiographic markers are used to interrogate the haemodynamics in persistent pulmonary hypertension of the newborn (PPHN). The aim of this study was to compare different echocardiographic markers in recent cohort of newborn infants with and without PPHN. Methods In this retrospective study, common echocardiographic markers were examined in infants>34 weeks’ gestation with PPHN (cases) and without PPHN (controls). Infants with congenital heart disease were excluded. Binary regression testing was used to evaluate echocardiographic markers predicting PPHN and death. In addition, diagnostic accuracy testing of echocardiographic markers using ROC was also performed. Intra-observer reliability for echocardiographic markers was examined using coefficient of variation (CoV) and intraclass correlation. Results Fifty-two infants were studied; 22 (42 %) infants with PPHN had significantly higher oxygen requirement, oxygenation index and ventilation days when compared with controls. Echocardiographic markers such as TR Vmax, S/D TR, PAAT, TAPSE and eccentricity index (EI) were significantly different between cases and controls. Receiver operator characteristics analysis of echocardiographic markers revealed TR Vmax 0.96 (0.9–1.0), S/D TR 0.95 (0.87–1.0) and end systolic EI 0.94 (0.87–1.0). These markers were found to predict death in this cohort of infants. CoV and Intra-observer reliability was good for various echocardiographic markers. Conclusions Among the various echocardiographic markers studied, TR Vmax when present along with S/D TR and end systolic EI had good intra-observer reliability and were diagnostic of PPHN and predicted death in this cohort. Future trials could use these markers in studies examining PPHN.

Objectives To assess the best method for measuring the fetal pancreas, provide nomograms and evaluate the effect of GDM on it. Methods A total of 271 singleton fetuses (17–36 weeks) were included in this study. Measurements of pancreatic parameters established reference ranges. Repeatability and consistency analyzed. GDM impact on fetal pancreatic growth assessed. Results Measurements of fetal pancreatic parameters fell within the 95 % confidence interval when performed by the same or different physicians. Pancreatic midline longitudinal axis demonstrated the best intraclass correlation coefficients (ICC) and follow by the pancreatic circumference. The successful display rate and measured parameters of the integral fetal pancreas achieved 90.3 %. Pancreatic midline longitudinal axis and circumference increased with gestational age, with significant differences observed among fetuses at different gestational ages (F=2060 and F=2264, p<0.05). Pancreatic midline longitudinal axis and circumference in normal fetuses from 17 to 36 weeks of gestation were positively correlated with gestational age and abdominal circumference. Poorly controlled GDM fetuses exhibited significantly larger pancreatic midline longitudinal axis and circumference compared to the normal group fetuses (Z-values were −3.82 and −3.77, both p<0.01), while no significant differences were found between well-controlled GDM group fetuses and normal group fetuses (Z-values were −0.59 and −0.042, both p>0.05). Conclusions Ultrasound method using anatomical landmarks to measure the fetal pancreatic midline longitudinal axis and circumference is reliable. Pancreatic measurements increase with gestational age. Poorly controlled gestational diabetes can lead to enlargement of the fetal pancreas.

Objectives Previous studies have reported that mode of delivery, particularly cesarean delivery (CD), is associated with neurodevelopmental outcomes in children. This study evaluates behavioral and neuropsychological test scores in children based on mode of delivery. Methods Children enrolled in the Raine Study from Western Australia, born between 1989 and 1992 by instrumental vaginal delivery (IVD), elective CD, and non-elective CD, were compared to those with spontaneous vaginal delivery (SVD). The primary outcome was the Child Behavior Checklist (CBCL) administered at age 10. Secondary outcomes included evaluations of language, motor function, cognition, and autistic traits. Multivariable linear regression was used to evaluate score differences by mode of delivery adjusted for sociodemographic and clinical characteristics, and Poisson regression was used to evaluate for increased risk of clinical deficit. Results Of 2,855 children, 1770 (62.0 %) were delivered via SVD, 480 (16.8 %) via IVD, 346 (12.1 %) via elective CD, and 259 (9.1 %) via non-elective CD. Non-elective CD was associated with higher (worse) CBCL Internalizing (+2.09; 95 % CI 0.49, 3.96; p=0.01) scores, and elective CD was associated with lower (worse) McCarron Assessment of Neuromuscular Development (MAND) (−3.48; 95 % CI −5.61, −1.35; p=0.001) scores. Differences were not seen in other outcomes, and increased risk of clinical deficit was not observed with either the CBCL Internalizing or MAND scores. Conclusions Differences in behavior and motor function were observed in children delivered by CD, but given that score differences were not associated with increased incidence of clinical deficit, clinical significance may be limited.

Objectives Perinatal depression (PD) affects individuals during pregnancy and early parenthood, resembling major depression. Recent research highlights paternal perinatal depression (PPD) in fathers. PPD has adverse effects on fathers and their children. This study assesses the Turkish version of the Edinburgh Postnatal Depression Scale (EPDS) for Turkish fathers, aiming to provide a tool for PPD identification. Methods This methodological study validates the EPDS for Turkish fathers and explores associations with demographic and psychosocial factors. The study involved 295 fathers with infants aged 2 weeks to 12 months. The EPDS, originally designed for perinatal depression and validated in Turkish women, was used. Fathers completed a participant information questionnaire, the EPDS, and the Beck Depression Inventory (BDI) during clinic visits. Data on sociodemographic factors, paternal roles, and pregnancy and postpartum support were collected. Mothers also completed the EPDS. Descriptive statistics, exploratory factor analysis, confirmatory factor analysis, and correlation tests were used. Results The study included fathers with an average age of 30.5 years, mostly with a high school education or higher. The EPDS had a mean total score of 3.1. Factor analysis suggested a three-factor structure for the EPDS in Turkish fathers, including anhedonia, anxiety, and depression. Confirmatory factor analysis validated the three-factor structure, with acceptable model fit indices. Positive correlations were found between fathers’ EPDS scores, maternal EPDS scores, and paternal BDI scores. The EPDS effectively discriminated between different levels of depression severity. Various factors, such as education level and lack of support during pregnancy and after childbirth, were associated with higher EPDS scores. Conclusions These findings emphasize the significance of assessing and addressing PPD in fathers, supporting the use of the EPDS as a valid tool in the Turkish context. The three-factor structure aligns with international research, highlighting the importance of a multi-dimensional approach to PPD assessment. Early intervention can mitigate PPD’s impact on fathers, mothers, and children, benefiting mental health and well-being.