Volume 53, Issue 6 - Special Issue: Perinatal Responsibility in a Fragmented World: Reflections from the 2024 IAPM Meeting; Issue Editors: Milan Stanojević, Frank A. Chervenak and Ivica Zalud

The Ian Donald International School of Ultrasound bears testament to globalization in its most successful and worthwhile form. The School was founded in Dubrovnik in 1981. Since then, the growth has been meteoric and now consists of 126 branches throughout the world. The reason for this success has been the tireless and selfless efforts of the world’s leading authorities in ultrasound who are willing to dedicate their valuable time without reimbursement to teach sonologists and sonographers throughout the world. The teachers put national, religious, political, and other parochial considerations aside as they strive to improve the care of all women and fetal patients. Our politicians in all of the myriad countries represented in the School have much to learn from the purity of spirit that exists throughout the international family of Ian Donald Schools. We believe that Ian Donald is smiling down from heaven at the School that bears his name. It is not overstating the fact to say that Donald’s innovation has changed the thinking of our age. The magnitude of this step alone is incalculable. Indeed, diagnostic ultrasound, more than any other modern technique, has made manifest that the fetus is an individual virtually from conception.

Marcus Tullius Cicero’s concept of “ius gentium,” or universal law, provides a timeless framework for understanding and defending fundamental human rights, particularly in the context of reproductive freedom. Cicero distinguished between “ius gentium” and “ius civile,” emphasizing that while civil law governs specific communities, universal law, rooted in natural reason, applies to all humanity. This philosophical foundation resonates with modern discussions on reproductive rights, where universal principles of justice and bodily autonomy are at stake. Enlightened by Immanuel Kant’s notion of innate freedom, Cicero’s philosophy challenges present day’s US states’ restrictive reproductive laws, which often contradict the universal principles of justice. Applying these concepts to contemporary issues, such as abortion rights, underscores the need to align civil laws with universal ethics, ensuring that individual freedoms are upheld against arbitrary state interventions. By advocating for policies that promote equitable access to reproductive healthcare, Cicero’s vision of universal law remains a powerful tool for advancing human dignity and autonomy in modern society.

Informed consent is a cornerstone of ethical medical practice, particularly in obstetrics where procedures like labor induction carry significant risks and require clear patient understanding. Despite legal mandates for patient materials to be accessible, many consent forms remain too complex, resulting in patient confusion and dissatisfaction. This study explores the use of Generative Artificial Intelligence (GAI) to simplify informed consent for labor induction with oxytocin, ensuring content is both medically accurate and comprehensible at an 8th-grade readability level. GAI-generated consent forms streamline the process, automatically tailoring content to meet readability standards while retaining essential details such as the procedure’s nature, risks, benefits, and alternatives. Through iterative prompts and expert refinement, the AI produces clear, patient-friendly language that bridges the gap between medical jargon and patient comprehension. Flesch Reading Ease scores show improved readability, meeting recommended levels for health literacy. GAI has the potential to revolutionize healthcare communication by enhancing patient understanding, promoting shared decision-making, and improving satisfaction with the consent process. However, human oversight remains critical to ensure that AI-generated content adheres to legal and ethical standards. This case study demonstrates that GAI can be an effective tool in creating accessible, standardized, yet personalized consent documents, contributing to better-informed patients and potentially reducing malpractice claims.

The retention of academic faculty, particularly in the field of Obstetrics and Gynecology (OB/GYN), has become a growing challenge in the post-COVID era. The healthcare landscape has been dramatically altered, leading to a “Great Exit” where a large number of faculty members are resigning or retiring early. This phenomenon is not just a financial burden as recruitment costs have skyrocketed, but also poses a threat to the stability and reputation of academic institutions. In this review article, we explore the underlying causes of faculty attrition, the predictors of resignation, and propose comprehensive strategies to retain talented faculty members. We highlight the importance of mentorship, career development opportunities, and fostering a supportive work environment that aligns with both institutional and individual values. The goal is to create a sustainable framework for faculty engagement that strengthens the academic mission and improves clinical outcomes.

There exists a need to research new diagnostic and therapeutic approaches that consider hemolytic disease of fetus and newborn (HDFN)’s physiopathology and focus not only on the pregnant person’s immune system but also on the fetal immune system. This implies, in the final sense, to view the fetus as our patient. In spite of having found a safe and efficient method of prevention of HDFN more than 50 years ago, HDFN continues to be a relevant cause of perinatal morbidity and mortality, due to lack of access to immunoprophylaxis. In light of the above, we should strive to prevent sensitization and HDFN by ensuring certain health policies across the globe, especially in countries and regions of high morbidity and mortality.

Viability refers to an infant’s ability to survive outside the womb, which is influenced by both developmental maturity and the quality of medical care received. The concept of periviability, which has evolved alongside medical advancements, describes the stage between viability and nonviability, typically spanning from 20 0/7 to 25 6/7 weeks of gestation. While the chances of survival are extremely low at the earlier end of this range, the possibility of surviving without significant long-term complications improves towards the later end. The effectiveness of various antenatal and postnatal care practices, particularly those considered to be part of an active approach, plays a crucial role in influencing survival rates and mitigating morbidities. However, the decision to provide such active care is heavily influenced by national guidelines as well as international standards. The variability in guideline recommendations from one country to another, coupled with differences based on gestational age or accompanying risk factors, prevents the establishment of a standardized global approach. This variability results in differing practices depending on the country or institution where the birth occurs. Consequently, healthcare providers must navigate these discrepancies, which often leads to complex ethical dilemmas regarding the balance between potential survival and the associated risks. This review article explores the evolution of the definition of viability, the vulnerabilities faced by periviable infants, and the advancements in medical care that have improved survival rates. Additionally, it examines the viability and periviability definitions, the care and outcomes of periviable infants and recommendations in guidelines.

The timing of umbilical cord clamping has stirred much greater debate and evolution in the field of obstetrics and neonatology, spurred by advances in medical science as well shifting clinical paradigms. This review seeks to address the history, physiology and clinical applications of different umbilical cord clamping practices around a common theme. The history of these practices and their effects on the mothers as well as new-borns have been addressed in this article along with how modern evidence has been shaping our guidelines. By examining the physiological mechanisms underlying umbilical cord clamping (UCC) and the evolving clinical standards, this article seeks to inform healthcare providers and policymakers on the best approaches for optimizing maternal and neonatal health.

Thrombotic thrombocytopenic purpura (TTP) is a rare but life-threatening hemolytic disorder with severe implications during pregnancy, characterized by microangiopathic hemolytic anemia (MAHA), severe thrombocytopenia, and systemic microvascular thrombosis. The condition arises from a severe deficiency in the ADAMTS13 enzyme, whether congenital or acquired, leading to the accumulation of ultra-large von Willebrand factor (vWF) multimers and widespread platelet aggregation. Pregnancy itself exacerbates TTP due to physiological reductions in ADAMTS13 activity, necessitating a high degree of clinical vigilance. This review addresses the etiology, diagnostic challenges, clinical presentation, and management of TTP in pregnancy, focusing on clinical relevance and emphasizing the importance of prompt therapeutic plasma exchange (TPE) and interdisciplinary care to optimize maternal and fetal outcomes.

Objectives Rare diseases (RDs) collectively affect approximately 400 million individuals globally, including newborns and children. These conditions often involve genetic, metabolic, or congenital disorders and are challenging to diagnose and manage due to their subtle or non-specific symptoms. Aim is to emphasize the need for specialized, multidisciplinary, and technology-driven approaches to improve outcomes for neonates with RD. Methods A comprehensive review of the infrastructure, diagnostic approaches, and clinical care strategies for RDs in neonates was conducted. The Department of Neonatology and Rare Diseases at the Medical University of Warsaw was analyzed as a model for centralized care, integrating prenatal consultations, advanced diagnostics, and multidisciplinary treatment. Results The department offers specialized care for neonates with RDs, including intensive care, advanced diagnostic tools, and personalized therapies such as pharmacological interventions and surgery. Collaboration with a perinatology center ensures prenatal consultations, delivery planning, and early interventions, while the proximity of operating rooms to neonatal units enhances outcomes. Genetic counseling plays a pivotal role in supporting families and expanding newborn screening programs with emerging osmic technologies which can significantly improve early diagnosis and management. Conclusions Centralized, multidisciplinary care and advancements in diagnostic technologies are essential for improving outcomes for neonates with RD. The integration of clinical care, genetic counseling, and innovative screening programs highlights the importance of specialized centers in addressing the unique challenges of these conditions.

Placental abruption has classically been defined as the premature separation of a normally located placenta before delivery of the fetus. Traditionally, this diagnosis was based on clinical symptoms, including vaginal bleeding, pain, and fetal distress. This definition, however, preceded the advent of obstetric ultrasound. Ultrasound frequently identifies various hemorrhagic lesions, such as retroplacental, subchorionic, intraamniotic, intraplacental, and preplacental hematomas in both symptomatic and asymptomatic patients. These variable ultrasound findings lead to new challenges as to what to define as an abruption, particularly in the absence of symptoms. This ambiguity in defining placental abruption affects clinical decision-making and hinders our understanding of the pathophysiology of abruption, presenting challenges in studying abruption. It is likely that these varying sonographic findings may precede the classic presentation of vaginal bleeding and pain and therefore are often concealed abruptions. This commentary highlights the importance of developing clear diagnostic guidelines for placental abruption, given its association with severe outcomes including a high rate of perinatal mortality and maternal morbidity. We aim to elucidate the complexities of ultrasound diagnosis in placental abruption, advocating for precise criteria to better guide clinical practice. We propose that these ultrasound findings of hemorrhagic placental lesions after 20 weeks of gestation in asymptomatic patients should be considered part of the spectrum of abruption, while in symptomatic patients should be taken as confirmation of the diagnosis of abruption.

Objectives Prenatal ultrasound identifies polyhydramnios in approximately 0.7 % of pregnancies. Polyhydramnios (defined as amniotic fluid index >24 cm) is associated with maternal symptoms and preterm delivery. However, amnioreduction (AR) can effectively alleviate symptoms and reduce preterm delivery risks; its advantages remain controversial. This study aims to assess maternal safety following AR in singleton pregnancies systematically. Methods Databases searched included PubMed, Embase, Scopus, and Web of Science until April 2024. Pregnant patients with singleton pregnancy and polyhydramnios undergo AR included in our study. Statistical analyses were conducted using R software. Results From 574 initially identified articles, seven studies with 390 singleton pregnancies who underwent AR were included. The primary outcomes showed low odds of placental abruption 0.04 (95 % CI: 0.02–0.09, I 2 =12 %) and chorioamnionitis 0.03 (95 % CI: 0.01–0.08, I 2 =0 %). Secondary outcomes indicated a mean gestational age at birth of almost 36 weeks (95 % CI: 35.51–36.41, I 2 =49 %) and low odds of cesarean delivery 0.45 (95 % CI: 0.30–0.61, I2=58 %), preterm delivery within 48 h after AR 0.10 (95 % CI: 0.07–0.15, I 2 =9 %) and PPROM within 48 h after AR 0.03 (95 % CI: 0.02–0.04, I 2 =0 %). Conclusions This study demonstrates that maternal complications are expected to be low following the AR procedure. However, given the lack of evidence for fetal benefit and pregnancy prolongation, future studies should directly compare the effects of AR with expectant management. Additionally, fetal survival is likely influenced more by the underlying fetal diagnosis or the etiology of polyhydramnios rather than AR itself. The current meta-analyses will serve as a guide for shared decision-making, and highlight the need for continued clinical trials powered to establish superiority or benefit with AR for singleton pregnancies.

Objectives Our study aims to underpin the safety of ambulatory management for 24 h after PROM at term. Patient data from 2021 were compared with data from 2010 to 2013, when ambulatory management was first introduced at the Women’s Clinic of the University Hospital of Basel. Methods In this retrospective study with historical control groups, we compared a cohort of women who underwent outpatient management of PROM at term in 2021, n=78 with two previous cohorts with inpatient management in 2010–2012, n=202 and outpatient management in 2013, n=37, respectively. Results The maternal and foetal outcomes of our cohort were comparable to those of the previous cohorts. The expected difference in shorter hospital stay was confirmed. Conclusions The study confirms the safety of an outpatient approach in the management of PROM at term. Further studies, especially RCTs, are needed for a definitive evaluation.

Objectives Global guidelines increasingly support breastfeeding among women living with HIV (WLWH) under optimized conditions. However, outcome data from high-resource settings remain limited. Methods We retrospectively analyzed WLWH who delivered at Charité – Universitätsmedizin Berlin between 2017 and 2023. Eligibility for breastfeeding required VL<50 cop/mL. Results Of 409 WLWH, 365 (89.2 %) were eligible and 77 (18.8 %) initiated breastfeeding. No case of mother-to-child transmission (MTCT) was observed. Sustained viral suppression and ART adherence were key. Exclusive breastfeeding was associated with longer duration (p=0.001), midwifery care promoted exclusivity (p=0.009), and vaginal delivery was linked to longer duration (p=0.005). Conclusions Breastfeeding with VL<50 cop/mL appears safe in high-resource settings. Findings support individualized counseling, close monitoring, and multidisciplinary care. The increasing breastfeeding trend reflects a shift in clinical practice.

Objectives To analyze the effectiveness and safety of a multifaceted intervention to reduce cesarean section (CS) rates. Methods This interrupted time series study involved six public hospitals with pre-intervention CS rates>35 %. We collected monthly data on overall and Robson group CS rates of 37,031 women who gave birth at the six hospitals during 30 months in the pre-intervention (12 months, n=14,836 women), intervention (6 months, n=6,431 women), and post-intervention (12 months, n=15,764 women) study periods. The intervention bundle included six components: audit and feedback using the Robson classification, goal setting for overall CS rate, distribution of evidence-based guidelines, informative meetings with hospital coordinators, newsletters, and inter-hospital mentoring. Results There were no significant changes in mean overall CS rates between the three periods. However, five of the six hospitals had a significant decrease in CS rates in at least one Robson group during the study period: groups 1 and 5a (2 hospitals), group 2a (1 hospital), groups 4 and 4a (1 hospital), and group 5b (1 hospital). There were no significant increases in adverse events (maternal and perinatal mortality, neonatal asphyxia) in any of the hospitals with reductions in CS rates. Conclusions The multifaceted intervention did not significantly reduce the overall CS rate in the participating hospitals. However, five of the six hospitals had significant reductions in CS rates in at least one Robson group, without increasing adverse maternal or perinatal outcomes.

Objectives To compare the rates of chronic lung disease (CLD) between premature infants weaned with either continuous positive airway pressure (CPAP) or high velocity nasal cannula (HVNC). Methods This was a retrospective, observational cohort study at a level IV NICU including infants <34 weeks gestational age (GA) on NIV (noninvasive ventilation) for at least 5 days. Maternal and infant demographics and clinical data from the infant’s hospital course were collected. Infants were assigned to CPAP (n=175) and HVNC (n=48) cohorts based on which modality they were treated with for most of their time on NIV. Results Demographics and clinical characteristics were similar between the CPAP group and the HVNC group. The rates of CLD were significantly higher in the HVNC group as compared to the CPAP group (58.3 vs. 24.6 %, p<0.001). After logistic regression analysis was performed accounting for GA, invasive respiratory support requirement, sepsis and administration of antenatal corticosteroids, the HVNC group was found to be almost 4 times more likely to develop CLD. Further analysis using propensity score matching yielded similar results. Conclusions When used as the primary modality of noninvasive support, preterm infants on HVNC were more likely to develop CLD than those on CPAP.