Volume 53, Issue 2

Introduction Prematurely born males compared to females have greater respiratory morbidiy in childhood, but differences in adolescents and young adults are less clear. Content A systematic review was undertaken to determine if there were sex differences in the lung function of prematurely born or very low birth weight born adolescents and adults Summary Seven of 1969 studies were included (766 infants). Three found no significant differences, but did not give raw lung function data. Four studies reported lung function data by sex. One found no significant differences and another only reported results for females, which were not lower than the controls. Another found males compared to females aged 16–19 years had lung function z scores indicating a more obstructive pattern [p<0.05]. The males, however, had significantly better exercise tolerance. The fourth reported worse lung function only in preterm born adult males. Outlook Male compared to female individuals born prematurely had worse lung function in adulthood, but only in two of seven studies, both reported results from patients born in the era of routine surfactant use. Further research is required to more robustly determine the effect of sex on lung function in adults born prematurely.

Objectives The seasonality of conception and birth has intrigued scientists for over 200 years. Since the 1970s, peak birth months in the northern hemisphere have shifted from early spring to late summer, influenced by oral contraceptives and socio-economic factors. The division of Germany from the end of World War II until reunification in 1990 offers a unique opportunity to analyze these influences while both regions had equal access to contraception. This study aims to identify differences in fertility trends and peak birth months between West and East Germany before and after reunification, considering political, socio-economic factors, and contraceptive availability. Methods A population-based study analyzed overall fertility rates, monthly birth data, peak birth months, and average maternal ages from 1950 to 2022. Results Fertility patterns were similar in both regions until 1970, showing a sharp increase post-1955 followed by a decline around 1965, likely due to contraception. From 1970 to 1990, East German fertility increased while West Germany’s remained lower. After reunification, East German fertility fell sharply but later rose to West German levels. The peak birth month shifted from March to August in West Germany by the mid-1980s, while East Germany experienced this change 20 years later, post-reunification. Conclusions The 20-year delay in East Germany’s shift suggests that oral contraception’s impact was influenced by other factors, particularly the age of women at childbirth. Increased control over fertility in the West allowed for more choice in conception timing, a trend adopted in the East after gaining similar autonomy.

Objectives Head to perineum distance (HPD) and angle of progression (AOP) are sonographic markers which have been investigated for the evaluation of labor progress. Here, we aimed to evaluate the predictive role of serially measured AOP and HPD during the first stage of labor in labor progress both in nulliparous and multiparous patients. Also, we firstly compared this role for labor progress. Methods This was a prospective longitudinal study including 299 patients. Patients were grouped as vaginal delivery (n=247) and cesarean section (n=52). Demographic and obstetric characteristics, HPD and AOP values, and vaginal examination findings were recorded and compared between groups. Results Slower changes in HPD and AOP values were detected in cesarean group. A HPD >38 mm predicted cesarean section with 86.9 % sensitivity and 59.2 % specificity (AUC=0.782, p<0.001) whereas AOP ≤117° predicted cesarean section with 93.5 % sensitivity and 65.1 % specificity in all patients (AUC=0.877, p<0.001). A HPD >37 mm predicted cesarean section with 84.2 % sensitivity and 55.2 % specificity (AUC=0.763, p<0.001) while AOP ≤110° predicted it with 82.7 % sensitivity and 73.3 % specificity in nulliparous patients (AUC=0.862, p<0.001). In multiparous patients, HPD>39 mm predicted cesarean section with 95.5 % sensitivity and 62.5 % specificity (AUC=0.824, p<0.001) and AOP ≤109° predicted cesarean section with 87.9 % sensitivity and 78.2 % specificity (AUC=0.909, p<0.001). AOP had superior predictive role than HPD in both nulliparous and multiparous groups (p<0.001 for both). Conclusions We suggest that differences in labor progress could be determined by using serial intrapartum sonography. However, more research is needed for the implementation of sonopartogram to the clinical obstetric practice.

Objectives To describe maternal and perinatal outcomes in patients with BMI ≥30 kg/m 2 by BMI class and gestational weight gain. Methods Retrospective review of singleton pregnancies with pre-pregnancy BMI ≥30 kg/m 2 who received care at our institution between January 1, 2016 and December 31, 2021. Patients were divided into three categories based on BMI (kg/m 2 ): Class I (BMI 30.0–34.9), Class II (BMI 35–39.9), and Class III (BMI≥40) obesity. For gestational weight gain analysis, pregnancies were stratified into three groups: <11 pounds, 11–20 pounds, and >20 pounds. Maternal demographics and outcomes were compared using chi-square analysis, analysis of variance, nonparametric tests, and multivariable regression analysis. Results Of 641 patients included, 299 (46.6 %) were in Class I, 209 (32.6 %) in Class II, and 133 (20.7 %) in Class III. Readmission within 6 weeks postpartum, the only outcome found to have a significant difference between BMI categories, was higher in the Class III group (p=0.01). One hundred sixty-two (25.3 %) patients gained <11 pounds, 164 (25.6 %) gained 11–20 pounds, and 313 (48.8 %) gained ≥20 pounds. Greater gestational weight gain was associated with increased rates of cesarean delivery (p<0.001), higher quantitative blood loss (p=0.006), longer length of hospitalization (p=0.03), and higher birthweights (p<0.001). Conclusions This represents a unique and actionable opportunity for clinicians to counsel and support their patients in adhering to optimal weight gain targets throughout their pregnancy. Future studies are needed to determine the optimal gestational weight gain recommendations for obese patients.

Objectives Placental growth factor (PlGF) has been reported as a good biomaker for the prediction of preeclampsia occurring in the short term in singleton pregnancies, in women presenting with clinical suspicion of preeclampsia. This study aims to evaluate the predictive value of the PlGF in twin pregnancies. Methods Twin pregnancies with clinically suspected preeclampsia (24 weeks 0 days–36 weeks 6 days of gestation) were enrolled in this study. The threshold of PlGF for predicting preeclampsia was determined on the basis of a receiver-operating characteristic curve to predict preeclampsia and the short-term occurrence of preeclampsia. Results Within 1 week, 2 weeks, and 4 weeks of testing respectively, a cutoff value of 215 pg/mL for PlGF to predict preeclamsia in twin pregnancies suspected to have preeclampsia has a specificity of 100 %[51.7 %, 100 %], 100 %[62.9 %, 100 %], 93.8 %[667.6 %, 99.7 %], and a negative predictive value of 100 %[94.8 %, 100 %], 100 %[95.0 %, 100 %], and 98.9 %[93.0 %, 99.9 %]. Conclusions A cutoff value of 215 pg/mL for PlGF is a useful tool to exclude the development of preeclampsia within 4 weeks of measurement.

Objectives To investigate the perinatal outcomes of SR using radiofrequency ablation (RFA) in MC pregnancies, identified factors affecting these outcomes, and assessed the associated learning curve. Methods This retrospective cohort study included all consecutive MC pregnancies that required RFA from September 2013 to April 2023 at our institution. The perinatal outcomes were compared on the basis of various indications, and binary logistic regression analysis was performed to identify the risk factors for cotwin loss. Clinical datas of two periods (2013–2018 vs. 2019–2023) were compared to demonstrate the learning curve. Results The 107 cases composed of 40 (37.4 %) twin-twin transfusion syndrome (TTTS), 17 (15.9 %) selective intrauterine growth restriction (sFGR), 12 (11.2 %) twin reversed arterial perfusion sequence (TRAPS), 25 (23.4 %) fetal discordant anomalies, 10 (9.3 %) elective fetal reduction (EFR), and three (2.8 %) twin anemia polycythemia sequence (TAPS) cases. The overall live birth rate for cotwins was 83.2 %. The earliest gestational age at delivery was noted in the TTTS group (p=0.021). The procedure-to-delivery interval was the shortest in the TTTS group and the longest in the EFR group (p<0.001). Comparing the 2013–2018 period with the 2019–2023 period, we noted a significant increase in the live birth rate (p=0.01) and the procedure-to-delivery interval (p=0.003), mainly due to improved outcomes in TTTS cases. Conclusions RFA for SR is a safe and effective method for managing complicated MC pregnancies. The type of indication affects postoperative perinatal outcomes, with TTTS showing the most adverse effects. With the increasing number of cases and accumulation of experiences with simultaneous enhancement of technique proficiency, the postprocedural outcomes can be further improved.

Objectives To prospectively validate the diagnostic performance of a non-invasive point-of-care tool (Rapid IAI System), including vaginal alpha-fetoprotein and interleukin-6, to predict the occurrence of intra-amniotic inflammation in a Spanish cohort of patients admitted with a diagnosis of preterm labor and intact membranes. Methods From 2017 to 2022, we prospectively evaluated a cohort of pregnant women diagnosed with preterm labor and intact membranes admitted below 34+0 weeks who underwent amniocentesis to rule-in/out intra-amniotic infection and/or inflammation. Vaginal sampling was performed at the time of amniocentesis or within 24–48 h. Amniotic fluid IL-6, vaginal alpha-fetoprotein and vaginal IL-6 concentrations were measured using a point-of-care tool provided by Hologic Inc., “Rapid IAI System”. We defined intra-amniotic inflammation when amniotic fluid IL-6 values were greater than 11.3 ng/mL. During recruitment, clinicians were blinded to the results of the point-of-care tool. The original prediction model proposed by Hologic Inc. to predict intra-amniotic inflammation was validated in this cohort of patients. Results We included 151 patients diagnosed with preterm labor and intact membranes. Among these, 29 (19.2 %) had intra-amniotic inflammation. The algorithm including vaginal IL-6 and alpha-fetoprotein showed an area under curve to predict intra-amniotic inflammation of 80.3 % (±5.3 %) with a sensitivity of 72.4 %, specificity of 84.6 %, positive predictive valuve (PPV) of 52.5 %, negative predictive value (NPV) of 92.9 %, and a positive likelihood ratio (LR+) of 4.6 and negative likelihood ratio (LR−) of 0.33. Conclusions External validation of a non-invasive rapid point-of-care tool, including vaginal alpha-fetoprotein and IL-6, showed very good diagnostic performance for predicting the absence of intra-amniotic inflammation in women with preterm labor and intact membranes.

Objectives To study the clinical and placental correlations in diabetic pregnancies in which placental histopathology included routine double E cadherin/CD34 immunostaining. Methods Retrospective study of 229 cases of diabetic pregnancies, mostly with gestational diabetes mellitus. The cases were individually matched for gestational age at delivery with non-diabetic pregnancies to yield a comparative group of 229 cases. 23 independent clinical and 50 placental phenotypes (variables) were statistically compared by analysis of variance or chi-square with application of the Bonferroni correction for multiple comparisons. Results The study group showed statistically significantly more common gestational hypertension, chronic hypertension, polyhydramnios, umbilical cord compromise, cesarean sections, macerated stillbirths, neonatal deaths, and fetal malformations. About a third of cases in each group showed lesions of maternal and fetal vascular malperfusion (FVM), the latter more common than reported in literature. The CD34 component of the double immunostaining increased the sensitivity of placental examination by highlighting clustered endothelial fragmentation of recent fetal vascular malperfusion or increasing the grade of fetal vascular malperfusion (on-going distal villous fetal vascular malperfusion with temporal heterogeneity). Conclusions With the double immunostaining, FVM is as common as maternal vascular malperfusion pattern of placental injury in diabetic pregnancies with high prevalence of fetal congenital malformations. This is likely due to umbilical cord compression evoked by mass-forming fetal anomalies. Recognizing placental FVM may sensitize to the increased risk of neonatal systemic thrombotic pathology. However, several hypoxic lesions and patterns as well as those of shallow placental implantation were also seen with increased frequencies in diabetic pregnancies.

Objectives This study investigates the relationship between the cerebro-placental ratio (CPR) measured at 40+0 weeks’ gestation and perinatal outcomes to determine a CPR cut-off that may justify induction of labor at term in appropriately grown fetuses (AGA). Although CPR is used for monitoring growth-restricted fetuses, its role in guiding labor induction decisions for AGA pregnancies at term remains unclear. Methods A retrospective cohort study was conducted using data from 491 singleton pregnancies with intended vaginal deliveries between 2015 and 2021. CPR was assessed at the actual estimated date of delivery (40+0 weeks’ gestation). Adverse pregnancy outcome (APO) as the primary endpoint was defined by admission to neonatal intensive care unit (NICU), umbilical cord blood pH<7.1, 5-min APGAR<7 or interventions-due-to-fetal-distress during labor (IDFD=vaginal-operative delivery or emergency caesarean section). Results APO nearly doubled (adjOR 1.7; CI 1.007–2.905) when CPR was below our calculated cut-off of 1.269 (18.4 vs. 32.3 %, p=0.002) and NICU admissions (4.8 vs. 11.1 %, p=0.020) and IDFD (12.5 vs. 21.2 %, p=0.027) significantly increased. The positive predictive value for the presence of APO using our cut-off was 32.4 %, and the negative predictive value 81.6 %. Conclusions Our data confirm a predictive value of a reduced CPR at term with impaired perinatal outcome. The cut-off of CPR<1.269 may guide decision-making regarding induction of labor. Further prospective studies are needed to confirm these findings.

Objectives Multiple techniques have been proposed for functional fetal cardiology, including pulsed-wave (PW) and tissue Doppler imaging (TDI), Myocardial Performance Index (MPI), annular plane systolic excursion (TAPSE/MAPSE) and spatiotemporal image correlation (STIC). We aimed to compare these techniques’ achievability and reproducibility to determine their clinical utility for each cardiac side. Methods Uncomplicated pregnancies from 22 to 39 weeks were recruited and images and volumes stored for offline analysis. PWD-MPI values were calculated using previously demonstrated automation algorithms, and the remaining volumes were evaluated by two experienced operators. Results Seventy-nine women were scanned generating 222 volumes, with high achievability (>86 %) for all three modalities on both cardiac sides; highest for TAPSE/MAPSE (94 %). Repeatability (ICC) on the right side of the heart was highest for TAPSE (inter-observer 0.86; intraobserver 0.73), compared to PWD-MPI (0.69) and TDI-MPI (0.83). For the left side, repeatability was high for both PWD-MPI (0.80) and TDI-MPI (0.86) though low for MAPSE (inter-observer 0.7, intra-observer 0.69). There was poor correlation between PWD-MPI and TDI-MPI values. Conclusions TAPSE appears most reliable for evaluation of right heart function, compared to PWD-MPI for the left. As TDI-MPI correlates poorly with PWD-MPI, the latter appears to be the functional tool of choice.

Objectives This study aims to analyze the impact of COVID-19 on pregnancy and labor, focusing on its effects on maternal and child health. The research explores the relationships between coronavirus infection and clinical and laboratory parameters, as well as the risks of pregnancy complications and adverse birth outcomes. Methods The study involved 60 pregnant women diagnosed with COVID-19. A comprehensive evaluation of clinical and laboratory indicators was conducted, employing correlation, regression, logistic analyses to determine risk factors. Results There was a strong inverse correlation between carbon dioxide levels and haematocrit (−0.76), and a direct correlation between blood pH and partial pressure of oxygen (0.73). COVID-19 was associated with increased risks of preterm labor (OR=1.82), stillbirth (OR=2.11), pre-eclampsia (OR=1.46), and foetal distress. Multivariate analysis revealed a 200 g reduction in neonatal birth weight and higher risks of hospitalisation (OR=1.8), postpartum hemorrhage (OR=2.3), and preterm delivery (OR=2.5). Comorbid conditions such as cardiovascular abnormalities, diabetes, obesity, thrombophilias exacerbated the risks of complications, including pre-eclampsia, neonatal respiratory distress syndrome, venous thromboembolism. Conclusions COVID-19 infection increases the likelihood of pregnancy complications and adverse outcomes, especially in women with comorbidities. These findings highlight the need for preventive strategies and risk management protocols for pregnant women during future outbreaks, emphasizing the importance of further research in this field.

Objectives To assess the sonographic visualization of the fetal optic chiasm (OC) and optic tracts (OTs), establish mid-trimester reference values, and assess the relationship between OC and OT dimensions and cavum septum pellucidum (CSP) measurements. Methods This prospective cross-sectional study included 154 morphologically normal fetuses between 19 and 23 weeks of gestation. The diameters of the fetal OC and OTs were measured using two-dimensional transabdominal ultrasound in a transventricular axial section angled approximately 20–40° caudally. CSP length as well as anterior, middle, and posterior widths were measured by placing the cursor on the inner surfaces in the transventricular section. The average CSP width was included in the analysis. Results The OC and OTs were successfully visualized in 109 fetuses and included in the analysis. Visualization success in transabdominal axial sections at 19–23 weeks was 70.8 %, with high intraobserver and interobserver reproducibility. Additionally, visualization rates were higher in advanced gestational weeks and in fetuses with breech presentation (p=0.007 and p=0.017, respectively). OC and OT dimensions were positively correlated with CSP length and width, biparietal diameter (BPD), head circumference (HC), and gestational age (p<0.05, for all). Conclusions The OC and OTs were successfully visualized transabdominally in axial sections with high intraobserver and interobserver reproducibility. Additionally, OC and OT dimensions were positively correlated with gestational age, as well as with BPD, HC, and CSP measurements.

Objectives To elucidate the effects of the timing of fetal head rotation on the labor progress and outcomes. Methods A paired ultrasound measurement was performed at each of the three stages of labor: latency stage, active stage, and full-cervical-dilatation stage. The measurements included fetal head position, head-perineum distance (HPD) and the angle of progression (AOP). Results A total of 46 pregnancy women were included and a total of 102 effective measurements were collected. The cases in occipital anterior position were all eutocia. The rate of cesarean section in the left transverse occipital group was the highest (15.7 %, 3/19). There were 13 cases (37.1 %) with fetal head rotation occur during active phase, changing from occipital transverse to anterior. Ten cases (28.6 %) rotated in the second stage of labor. The average rotation degree of occipital transverse to anterior position was 62.6°. When AoP <95°, 100 % of the women were occipital transverse; When AoP ≥125°, 66.7 % was occipital anterior. The rate of oxytocin utilization and epidural analgesia in the occipital posterior group was higher than that in the other groups (71.4 and 85.7 %, respectively). Conclusions Occipital transverse is the most common fetal head position in the early stage of labor and fetal head rotation occurs mostly in the active phase and the second stage of labor. Sufficient time should be given in labor management for women that who tried vaginal delivery without contraindications.

Objectives The purpose of the study is to estimate factors affecting survival in prenatally diagnosed hypoplastic left heart syndrome (HLHS) and echocardiographic features predicting poor prognosis and early neonatal death. Methods This study was designed as a retrospective cohort study. Cases of hypoplastic left heart syndrome diagnosed in the prenatal period between 2014 and 2023 were extracted from electronic medical records. Demographic data, echocardiographic features, results of genetic testing, pregnancy outcomes, and postnatal outcomes were analyzed. Results Eighty-three prenatally diagnosed fetal HLHS cases were analyzed. Overall, survival during the study period was 26.5 %, and survival among live births was 35.4 %. Survival analysis has shown that the majority of deaths occurred during the neonatal period. Out of 62 live births, 47 had Norwood procedures, six had balloon procedures and three had hybrid procedures. Eleven out of 47 who had the Norwood procedures went on to have a Glenn operation, and only three had full Fontan palliation. The presence of additional extra-cardiac anomaly, need for extracorporeal membrane oxygenation (ECMO), bidirectional flow at pulmonary veins on color Doppler, and low birth weight are associated with survival and early neonatal death. Tricuspid regurgitation, restrictive foramen ovale, and fetal growth restriction (FGR) are not associated with survival. HLHS evolved from critical aortic stenosis has better survival rates. Conclusions Extra-cardiac anomaly, need for ECMO, bidirectional flow at pulmonary veins, and low birth weight were negatively associated with survival and early neonatal death. The survival rate was higher among HLHS cases that had evolved from critical aortic stenosis.

Objectives To evaluate the diagnostic value of ultrasound spectra of the middle cerebral artery (MCA) and umbilical artery (UA) blood flow in predicting adverse pregnancy outcomes. Methods Data from 202 late singleton pregnancies (32–34 weeks gestation) were analyzed. Group A included 155 normal pregnancies, while Group B comprised 47 high-risk pregnancies. Color Doppler ultrasonography was used to measure and compare pulsatility index (PI), resistance index (RI), and end-systolic peak/end-diastolic peak (S/D) ratios of fetal MCA and UA between the groups. Results UA-related parameters (PI, RI, and S/D) were significantly higher in Group B compared to Group A, whereas MCA-related parameters (PI, RI, and S/D) were significantly lower in Group B than in Group A. In pregnancies with adverse outcomes, fetal UtA and UA-related parameters were elevated, while MCA parameters were decreased compared to those with favorable outcomes. Conclusions Ultrasound spectra of MCA and UA blood flow provide valuable clinical information for assessing fetal intrauterine growth and predicting adverse pregnancy outcomes.

Objectives Considerable variation and little objective evidence exists to guide the use of supplemental oxygen therapy in infants with neonatal chronic lung disease (nCLD) after hospital discharge. We developed a new policy utilizing regular oximetry downloads to help determine commencement and titration of low flow oxygen. The aim of this policy is to improve safety and uniformity in practice and potentially lead to improvements in outcomes including the number of infants being discharged on home oxygen therapy (HOT) and length of stay (LOS). Methods This single-centre pre- and post-implementation study included 86 and 94 infants <32 weeks’ gestation (pre- vs. post-implementation) meeting definition of nCLD. The primary outcomes were (1) successful implementation of the new policy, (2) changes in number of patients discharged on HOT and (3) in LOS. Secondary outcomes were changes in feeding mode at discharge, total length of HOT, readmission to hospital within the first year of life and neurodevelopmental outcomes at 8 months post menstrual age amongst infants treated with HOT. Results The policy was successfully implemented with 100 % of infants with nCLD receiving downloads in the post-implementation epoch. Pre-implementation 36 % (31 of 85) of infants with nCLD were treated with HOT vs. 17 % (16 of 94) post-implementation (p=0.03). There was no significant difference in LOS or any of the secondary outcomes. Conclusions A protocolised approach to decision making using predetermined parameters regarding the need for supplemental oxygen in neonates with nCLD is practical and achievable and may result in fewer neonates requiring HOT.

Objectives To investigate the effectiveness of placing an indicator light indicating inadequate ventilation near the face mask during positive-pressure ventilation with respiratory function monitors (RFMs) in neonatal resuscitation. The study is a three-group, randomised, controlled, crossover simulation trial. Methods Paediatrics residents, neonatology fellows, and attending neonatologists at a single neonatal intensive care unit. A ventilation simulation with a manikin was performed three times consecutively using the same scenario with three different ventilation evaluation methods (A) RFM plus indicator light and conventional methods (heart rate and chest rise) (B) RFM and conventional methods, and (C) conventional methods alone. Results The ratio of gaze duration on the manikin to the total trial duration was recorded using an eye-tracking device. The proportion of trials with adequate ventilation (expiratory tidal volume [VTe], 4–10 mL/kg; peak inspiratory pressure <30 cm H 2 O; leak <40 %) was determined. After excluding incomplete data, 63 simulations (22 participants) were analysed. The ratios of the gaze duration on the manikin to the total trial duration were significantly different among settings A (0.60 [95 % confidence interval: 0.52–0.67] s/s), B (0.51 [0.43–0.59] s/s), and C (0.80 [0.76–0.84] s/s). Ventilation with adequate VTe and less leakage was more frequent in settings A and B than in setting C (adequate VTe: A, 91 %; B, 91 %; and C, 83 %; less leak: A, 76 %; B, 78 %; and C, 57 %). Conclusions An indicator light close to the facemask with an RFM directed the eyesight towards the manikin without compromising the ventilation quality during the simulation of neonatal resuscitation.

Objectives To determine Dysphoric Milk Ejection Reflex (DMER) incidence. Secondary objectives were to describe the symptom profiles and patient characteristics of DMER and assess DMER familiarity. Methods A prospective observational study of people who initiated breastfeeding after delivery between December 2022 and May 2023 at two hospitals in New York. Participants filled out an Initial Survey, assessing prior DMER familiarity, and recurring DMER Symptoms Surveys, assessing symptom presence, severity, and transiency. Medical records were reviewed for patient demographics and clinical history. Descriptive and basic inferential statistics were performed. A p<0.05 was considered statistically significant. Results Based on the DMER definition utilized, incidence was 26.9 % (n=21), and symptom severity was mostly very mild to moderate. Those with DMER had similar baseline characteristics to those without, apart from a significantly higher rate of having delivered via cesarean section (71.4.0 vs. 33.3 %, p<0.01). Among the 55 patients who completed the initial survey, 61.8 % were unfamiliar with the condition. Conclusions DMER is described as brief, abrupt, negative emotions experienced by breastfeeding individuals prior to milk letdown. We found that more than 1 in 4 participants screened positive. Future research could better define, quantify, qualify, and publicize this condition to inform clinical practices and facilitate successful breastfeeding relationships.