Volume 53, Issue 8

Surrogacy is a complex and evolving practice that sits at the intersection of reproductive medicine, ethics, law, and social policy. This comprehensive review traces the historical, medical, and ethical foundations of surrogacy, from its roots in early IVF experiments to its current global practice. It explores the distinctions between traditional and gestational surrogacy, outlines medical and social indications, and evaluates associated perinatal and psychological outcomes. Central to the analysis is the debate between altruistic and commercial surrogacy, highlighting the ethical tensions surrounding compensation, autonomy, and potential exploitation. The review examines global legal frameworks, with detailed attention to Israel’s uniquely regulated system, which balances reproductive liberty with strict oversight. The paper also considers religious perspectives, showing how cultural and theological differences shape national policy. The experiences of gestational carriers, commissioning couples, and children born through surrogacy are examined to underscore the psychological and social implications. While surrogacy offers hope to many, it raises profound questions about the commodification of reproduction, the fragmentation of motherhood, and the responsibilities of professionals involved in care. Ultimately, the review argues for nuanced, culturally sensitive regulation that protects all parties particularly the child, whose interests must remain central throughout the surrogacy process.

Introduction Obstructed labor is a serious obstetric emergency that can lead to uterine rupture, and significant maternal and perinatal morbidity and mortality. Bandl first described this condition, of abnormal retraction of the uterus occurring during obstructed labor, characterized by a constriction between the thinned lower uterine segment and the thick, retracted upper uterine portion. To determine the incidence and the maternal and perinatal outcome in pregnancies showing Bandl’s ring by reviewing the published literature. Content PubMed, Embase and Google Scholar Search searches were made using “Bandl’s ring.” Papers selected were assessed independently for content, data extraction and analysis. The following parameters were included for the analysis: total number of reported cases, use of ultrasound, fetal position and station, labor augmentation, modality of delivery, indications for cesarean section, neonatal complications. Summary and Outlook The literature search identified nine articles that met the established inclusion criteria and were deemed eligible for analysis and comparison, encompassing a total of 23 clinical cases. Ultrasound was used 21 % of the cases. The fetal occiput was posterior in 93 % of the cases, augmentation of labor in 39 %, cesarean section was necessary in 95.6 % of cases and there were three cases of severe neonatal complications (13 %). Bandl’s ring represents a rare yet clinically significant intrapartum pathology. This study highlights the importance of early recognition and appropriate management of Bandl’s ring. Incorporating ultrasound into the assessment of obstructed labor may enhance obstetricians’ ability to accurately identify this condition, thereby minimizing the risks associated with delayed or inappropriate intervention.

Background Necrotizing enterocolitis (NEC) is a severe gastrointestinal disease with high morbidity and mortality that predominantly affects preterm infants. Early diagnosis remains challenging due to nonspecific symptoms and delayed detection of radiological signs. Content This systematic review provides an updated overview of the available evidence on serum biomarkers for early NEC detection, focusing on their diagnostic accuracy and clinical utility. A structured search was conducted in MEDLINE, Scopus, and web of science, identifying 40 studies evaluating biomarkers across various categories, including hematological indices, acute phase reactants, immunological markers, tissue damage and tissue repair markers, and metabolic markers. Summary Our findings highlight intestinal fatty acid-binding protein (I-FABP) as a promising biomarker for NEC prediction within the first 24 h of life. Ischemia-modified albumin (IMA) and certain multi-marker panels also showed high diagnostic accuracy. Despite these promising results, small sample sizes and heterogeneity in study design, biomarker thresholds, and patient populations limit immediate clinical implementation. Outlook Future multicenter studies are essential to validate promising biomarkers, particularly I-FABP and IMA, and establish standardized cut-off values. Integrating biomarkers into multi-marker panels, alongside clinical and non-invasive approaches, may improve early NEC detection, enhance diagnostic accuracy, and guide timely interventions to optimize neonatal outcomes.

Objectives Traditional peer review faces critical challenges including systematic bias, prolonged delays, reviewer fatigue, and lack of transparency. These failures violate ethical obligations of beneficence, justice, and autonomy while hindering scientific progress and costing billions annually in academic labor. To propose an ethically-guided hybrid peer review system that integrates generative artificial intelligence with human expertise while addressing fundamental shortcomings of current review processes. Methods We developed the FAIR Framework (Fairness, Accountability, Integrity, and Responsibility) through systematic analysis of peer review failures and integration of AI capabilities. The framework employs standardized prompt engineering to guide AI evaluation of manuscripts while maintaining human oversight throughout all stages. Results FAIR addresses bias through algorithmic detection and standardized evaluation protocols, ensures accountability via transparent audit trails and documented decisions, maintains integrity through secure local AI processing and confidentiality safeguards, and upholds responsibility through ethical oversight and constructive feedback mechanisms. The hybrid model automates repetitive tasks including initial screening, methodological verification, and plagiarism detection while preserving human judgment for novelty assessment, ethical evaluation, and final decisions. Conclusions The FAIR Framework offers a principled solution to peer review inefficiencies by combining AI-enabled consistency and speed with essential human expertise. This hybrid approach reduces review delays, eliminates systematic bias, and enhances transparency while maintaining confidentiality and editorial control. Implementation could significantly reduce the estimated 100 million hours of global reviewer time annually while improving review quality and equity across diverse research communities.

Objectives To assess the predictive value of combining the Kurjak Antenatal Neurodevelopmental Test (KANET) with Doppler indices for early detection of neurodevelopmental delays in pregnancies of varying risk levels. Methods A prospective study was conducted on 111 pregnant women (71 low-risk, 40 high-risk) between 28 and 36 weeks of gestation. KANET was performed using 4D ultrasound. Doppler assessments included resistance indices of the middle cerebral artery (MCA) and umbilical artery (UA), and ductus venosus (DV) velocity parameters: systolic (S), diastolic (D), and S/D ratio. High-risk cases with abnormal findings underwent repeat KANET. Postnatal neurodevelopment was evaluated at 3 and 6 months using the Denver Developmental Screening Test II (DDST II). Statistical analyses included regression and ROC curve analysis. Results High-risk pregnancies showed significantly lower KANET scores (mean 13.4 ± 2.3) than low-risk pregnancies (mean 16.9 ± 1.5; p<0.001). Abnormal DV Doppler findings were present in 42 % of high-risk cases and correlated with lower KANET scores (r=0.82, p<0.01). Follow-up KANET identified progressive neurodevelopmental delays in 25 % of high-risk cases. The combined KANET-Doppler approach demonstrated superior predictive accuracy (AUC=0.89, p<0.001) compared to either method alone. Conclusions Integrating KANET with Doppler indices, particularly DV parameters, offers an effective strategy for early identification of neurodevelopmental risks in high-risk pregnancies. This approach supports more targeted prenatal monitoring and early intervention strategies.

Objectives To investigate the potential relationship between in vitro fertility and cesarean delivery among nulliparous, term, singleton, vertex pregnancies. Methods Retrospective cohort study involving nulliparous, term, singleton, vertex patients who delivered between 1/2019 and 12/2022. The primary exposure was in vitro fertility. The primary outcome was cesarean delivery. Basic inferential statistics were performed using the chi-square test of association to examine relationships between categorical variables. A logistic regression was used to model the probability of cesarean delivery as a function of in vitro fertility. Odds ratios, and their associated 95 % confidence interval (CI) were computed. An alpha value of 0.05 was considered statistically significant. Results A total of 36,703 pregnancies were included for analysis, of which 987 (2.69 %) were conceived by in vitro fertility. The overall cesarean delivery rate was 29.27 % (n=10,743). Using adjusted logistic regression, in vitro fertility was associated with 1.99 times the odds of cesarean delivery (95 % CI 1.75–2.28) compared to non-in vitro fertility pregnancies. The most frequent indications among the IVF cohort were obstetrical (40.82 %) and fetal (36.91 %). A sub-analysis of those who underwent induction of labor found that in vitro fertility was associated with 1.59 times the odds of cesarean delivery (95 % CI 1.35–1.88) compared to non-in vitro fertility pregnancies. Conclusions In vitro fertility is associated with higher rates of cesarean delivery in nulliparous, term, singleton, vertex pregnancies. Recognizing this association provides a foundation for future research and quality improvement measures to safely lower the nulliparous, term, singleton, vertex cesarean delivery rate and decrease risk to mother and infant among these highly desired pregnancies.

Objectives Intraamniotic infection is a major cause of preterm labor. While ascending infection from the urogenital tract is well recognized, hematogenous transmission in which pathogens travel from the maternal circulation to the intraamniotic environment has been proposed. Listeria monocytogenes is a common bacterium causing Listeriosis and is believed to cause intraamniotic infection via the maternal bloodstream. However, molecular evidence supporting this route is limited. Methods A complete microbiologic workup was performed, including cultures from amniotic fluid, vagina, maternal and neonatal blood, and the placenta in a patient with intraamniotic infection. Whole genome hybrid sequencing was utilized to characterize the genomic features including virulence factors and antimicrobial resistance. Placental pathology, Brown–Hopps, Warthin–Starry staining, and calorimetric in situ hybridization were performed to detect the presence of Listeria in the placenta. Results L. monocytogenes was detected in both the amniotic fluid and chorioamniotic membranes but not in the vaginal fluid. Whole genome sequencing identified the two isolates as L. monocytogenes sequence type 1, clonal complexes 1, and serotype 4b. Placental pathology demonstrated extensive acute intervillositis with intracellular rod-shaped bacteria in the intervillous space of the placenta identified by Brown-Hopps and Warthin-Starry staining. Calorimetric in situ hybridization confirmed the presence of L. monocytogenes in the intervillous space. Conclusions This study provides the first molecular evidence supporting a hematogenous route of intraamniotic infection by L. monocytogenes Evidence in support includes the presence of acute intervillositis and the detection of L. monocytogenes in the amniotic fluid and intervillous space of the placenta combined with the absence of this organism in the vagina.

Objectives To compare pregnancy prolongation and neonatal outcomes in women with signs of threatened preterm birth (PTB) and intact membranes by administration of low-doses of prednisone for 3 weeks compared to women who received standard protocols of tocolysis and respiratory distress syndrome (RDS) prophylaxis in a pilot randomized controlled trial. Methods We randomized 26 women with signs of threatened PTB and intact membranes between 24 and 34 weeks of gestation to either continued prednisone administration for 3 weeks following the initiation of the standard protocol (intervention group) or standard therapy for threatened PTB (control group). The primary outcome was the gestational length in women with and without using low-doses of prednisone. The secondary outcome included incidence of RDS, intraventricular hemorrhage, necrotizing enterocolitis, the need for mechanical ventilation, and perinatal mortality in newborns from both study groups. Results Participants in the intervention group had significantly longer pregnancy prolongation than the control group (65.38 vs. 40.54 days, p=0.001). Although the difference was not statistically significant (p=0.153), the gestational age at delivery in the intervention group (38.35 weeks) was 10 days longer than in the control group (36.89 weeks). There were no significant differences between the groups in neonatal outcomes. Conclusions The first pilot randomized controlled study on low-dose prednisone in threatened PTB and intact membranes suggests it may prolong pregnancy without adverse neonatal outcomes. Due to the small sample size and single-centre design, these preliminary findings should be interpreted with caution and confirmed in larger, adequately powered trials.

Objectives Preeclampsia is a multisystem syndrome that involves various genetic and environmental factors in its pathogenesis and pathophysiology. Its etiopathogenesis remains to be fully understood. This study aimed to investigate whether the level of pentraxin-3 (PTX3) in maternal peripheral blood during the second and third trimesters can predict its role in the aetiology of preeclampsia. Methods This prospective study analysed data from 96 mothers who gave birth between September 2020 and 2021 at the Department of Obstetrics at Umraniye Training and Research Hospital. Blood PTX3 levels were measured for each participant. Of 96, 50 preeclampsia patients were in the study group, and 46 normotensive healthy pregnancies were in the control group. The associations between preeclampsia and PTX3 levels were investigated. Results A total of 96 pregnant women were evaluated. The overall mean age was 28.9 ± 6.4years. As compared with mothers with healthy women, preeclampsia women had significantly a higher PTX3 level (5.919 ng/mL vs. 2.828 ng/mL, respectively; p=0.0001) in maternal peripheral blood. In addition, the PTX3 level was similar among varying forms of preeclampsia (p>0.05). In ROC analysis, the cut-off value for Pentraxin-3 to predict preeclampsia was established at 4.16 ng/mL, with a sensitivity of 95.9 %, a specificity of 97.8 %, a PPV of 97.9 % and an NPV of 95.7 %. Conclusions Our findings suggest the expression of PTX3 in the peripheral blood was associated with the pathogenesis of PE. The PTX3 may prove useful in predicting preeclampsia in women with a PTX3 level higher than 4.16 ng/mL.

Objectives To establish and verify the prediction model of recurrent preeclampsia (PE) in pregnant women with a history of PE. Methods Totally 130 pregnant women with a history of PE from Jan 2021 to Jan 2023 were selected retrospectively. The patients were randomly matched according to the proportion of 1:4 to establish a verification group (nasty 26) and a modeling group (nasty 104). The modeling patients were divided into two groups according to the occurrence of preeclampsia: recurrent group (nasty 50) and non-recurrent group (nasty 54). Multivariate logistic regression analysis of influencing factors was established. Calibration curve was performed to verify, decision curve analysis (DCA) was used to evaluate the clinical practicability of the prediction model, and ROC analysis was used to show the prediction value of the model. Results Multivariate logistic regression analysis showed that there were significant differences in age, gestational age, gestational interval, systolic blood pressure and diastolic blood pressure of previous pregnancy. (p<0.05) According to the results of logistic regression analysis, a prediction model was constructed. Logit(P)=(0.910Age)+(0.987Age of onset of previous pregnancy)+(1.167Gestational interval)+(1.186Systolic blood pressure in previous pregnancy)+(0.970Diastolic blood pressure in previous pregnancy).The slope of the calibration curve was close to one in the training set and verification set. The results showed that the prediction of recurrent PE risk of pregnant women with history of eclampsia was consistent with the actual risk. ROC analysis showed that the area under curve was 0.991. The results of DCA analysis showed that the model had good clinical practicability. Conclusions In this study, a prediction model is successfully established and verified according to the influencing factors.

Objectives To develop predictive models for gestational diabetes mellitus (GDM) using maternal clinical and ultrasonographic parameters, as well as fetal ultrasonographic measurements obtained during routine second-trimester obstetric examination. Methods Our prospective case-control study included 80 pregnant participants (32 with GDM and 48 healthy controls) between 24 and 28 weeks of gestation. We evaluated maternal parameters including anthropometric measurements such as neck circumference and waist-hip ratio, ultrasonographic measurements like maternal adipose thickness, as well as fetal ultrasonographic parameters including pancreatic hyperechogenicity, soft tissue measurements, and cardiac parameters. Following ultrasonographic examination, all participants underwent a 75-g oral glucose tolerance test (OGTT). Two separate logistic regression models were developed for maternal and fetal parameters to evaluate their association with the presence or absence of GDM. Results The maternal model achieved 90.0 % accuracy through a stepwise integration of suprapubic subcutaneous adipose tissue thickness (OR=1.35, 95 % CI: 1.11–1.64), visceral adipose tissue (OR=1.68, 95 % CI: 1.18–2.40), gravidity (OR=2.09, 95 % CI: 1.32–3.33), and family history of diabetes. The fetal model reached 82.5 % accuracy using two parameters: pancreatic hyperechogenicity (OR=0.02, 95 % CI: 0.00–0.14) and fetal abdominal subcutaneous tissue thickness (OR=5.09, 95 % CI: 1.75–14.78). The maternal model demonstrated excellent discriminative ability with an AUC of 0.95. Conclusions Both maternal and fetal ultrasonographic parameters can serve as effective predictors of GDM when combined with clinical risk factors. These models, which can be easily incorporated into routine second-trimester ultrasound examinations, offer potential for early identification of high-risk patients without additional patient visits or invasive testing.

Objectives Depending on risk profile, pregnant women can freely choose their preferred birthplace, especially in the case of a normal pregnancy. In addition to obstetric maternity units in a hospital, options may include out-of-hospital births (such as births at home or in a freestanding midwifery unit. To our knowledge, there is no study comparing the outcomes of peripartum transfers from different places. Methods Between 2020 and 2021, all births transferred internally from the AMU of the University Hospital of Leipzig (n=74) were retrospectively analyzed and compared with births transferred from external (home or an FMU; n=72). The main outcome measures were morbidity and interventions. Results 86.1 % were transfers from an FMU and 13.9 % were transfers of planned home births. There were significantly less spontaneous vaginal births in planned OH births (55.6 %) compared to planned AMU births (73.7 %, p<0.001). For the FMU births, we found a significantly higher rate of caesarean section (20.8 %, to 6.6 %, p<0.001) and postpartum neonatal transfers (8.3–4.1 %, p=0.025). The duration of labor was significantly longer in transferred OH (p<0.001). Conclusions In case of an intrapartum transfer, there was a decreased likelihood of spontaneous vaginal birth and increased likelihood of secondary caesarean section compared to internally transferred AMU births. Furthermore, OH transfers were associated with a higher morbidity. Hence, pregnant women should be given an informed choice of birthplace, including the likelihood of intrapartum transfer. Out-of-hospital deliveries are associated with a higher rate of adverse perinatal outcome.

Objectives Obesity in pregnancy is associated with several risks during vaginal delivery. Several guidelines advise early epidural placement. This systematic review summarizes evidence on the maternal and perinatal outcome of epidural analgesia (EA) for vaginal delivery in obese women. Methods A systematic literature search was conducted to identify studies reporting EA during vaginal delivery in obese women. Study information, baseline characteristics, and outcomes were extracted. Results Eleven studies (31,325 patients total) were included. Newcastle-Ottawa Scale quality scores ranged from 2/8 to 7/8. Studies varied in study group choice, baseline characteristics, and outcome measures. Five studies reported patient-oriented outcomes, nine reported technical outcomes regarding catheter placement. One study compared obese women with early vs. late vs. no EA and reported similar incidence of instrumental deliveries (5.3 vs. 1.8 % vs. 0 %, p=0.315) and similar Apgar scores (8.37 ± 1.17 vs. 8.43 ± 1.28 vs. 8.08 ± 2.02, p=0.519). Other studies used a comparison of obese with non-obese women, both receiving EA. Incidence of instrumental deliveries was similar, but the incidence of cesarean delivery and several other outcomes was increased in obese women. Conclusions The selected literature predominantly reports on technical difficulties regarding EA. In many studies but one, we found a sub-optimal comparison of obese and non-obese women with EA. Side effects of EA in obese women are suggested in some studies, but we believe that the true influence of EA in obese parturients is insufficiently reported. To fully understand associated risks and benefits for these women, this population should be studied separately, and more evidence is needed.

Objectives Congenital diaphragmatic hernia (CDH) often coexists with fetal growth restriction (FGR). The observed-to-expected (O/E) total fetal lung volume (TFLV) is used to assess CDH severity, predict outcomes, and direct fetal interventions. Expected TFLV measurements traditionally rely only on gestation age (GA). This simulation assesses how incorporating weight-adjusted GA norms affects O/E TFLV calculations in patients with isolated CDH and FGR. Methods A simulated dataset (n=1,005) utilized published mean fetal weight and TFLV references. Computer-generated variables included observed weights (3rd-10th %ile), O/E TFLV (10–65 %), and percent liver herniation (0–42 %). GA estimates were corrected by weight and used to calculate corrected O/E TFLV. Estimated mortality probabilities and CDH severity were compared pre- and post-adjustment. Results Standard vs. corrected O/E TFLV means differed significantly (36.2% vs. 43.5 %) (p<0.001), as did corrected mortality probabilities (60.2% vs. 58.6 %) (p<0.001). CDH severity shifted: severe to moderate (17.1 %) and moderate to mild (8.6 %) with corrected O/E TFLV. Two-week corrections had greater impact than 1-week. Positive correlation existed between O/E TFLV and percent difference in values, while GA showed a negative correlation with the percent differences. Conclusions This simulation shows how using weight-adjusted GA norms affects O/E TFLV calculations. For fetuses with isolated CDH and FGR, adjusted GA increases O/E TFLV, reduces mortality estimates, and changes CDH severity classification, possibly affecting fetal intervention eligibility. Real patient studies are needed to confirm these findings.

Objectives To evaluate the incidence of abnormal external genitalia of the fetus and discuss the accuracy of its prenatal diagnosis using two-(2D)/three-(3D) dimensional ultrasound in second- and third-trimester fetal screenings. Methods During the 24 months, second- and third-trimester fetal screenings were performed at 18–21+6 and 28–31+6 weeks of gestation, respectively, in 1,623 pregnant women. Fetal external genitalia were assessed using 2D/3D ultrasound. After birth, cross-examination was performed by pediatric experts to check the external genitalia. Results Twelve cases of abnormal genitalia (hypospadias: 3; hypospadias with penoscrotal web: 1; micropenis: 3; buried penis: 2; clitoromegaly: 2; genital tumor: 1) were suspected prenatally (0.74 %). In 9 fetuses with suspected abnormal male genitalia, the penile length was below the lower 90th confidence interval. In 2 fetuses with suspected clitoromegaly, the clitoral length was above 6.5 mm. In the 9 fetuses with suspected abnormal male external genitalia, only 6 (hypospadias: 2; penoscrotal web with mild chordee: 1; micropenis: 1; buried penis: 2) were diagnosed postnatally (66.7 %), whereas 3 were diagnosed as normal. Mixed gonadal dysgenesis (45X/46XY) was diagnosed in 1 neonate with hypospadias. One neonate with a micropenis had a right aortic arch and persistent foramen ovale. In 3 fetuses with suspected abnormal female external genitalia, prenatal findings were considered transient, and normality was confirmed after birth. Conclusions Prenatal diagnosis of abnormal external genitalia may still be difficult even with 3D ultrasound. Postnatal cross-examination by pediatric experts should be mandatory when abnormal external genitalia are suspected prenatally.

Objectives Fetal responses to auditory stimuli remain a relatively understudied area in prenatal care. This study investigates the effects of personalized fetal music therapy by employing Doppler ultrasound to assess fetal cardiac and hemodynamic responses to specific musical stimuli. By integrating AI-based pattern recognition, we aim to establish a novel framework for prenatal acoustic stimulation that may support neurological development and enhance maternal-fetal bonding. Methods Thirty pregnant participants between 32 and 37 weeks of gestation underwent Doppler ultrasound recordings while exposed to two distinct musical pieces: Brahms ’ Lullaby (representing slow, soothing stimuli) and Mozart ’ s Symphony No. 40 (representing fast, dynamic stimuli). Each session included baseline fetal heart rate (FHR) and Doppler waveform measurements – peak systolic velocity (PS), end-diastolic velocity (ED), and time-averaged maximum velocity (TAMax) – recorded before, during, and after music exposure. AI-driven analysis was used to evaluate heart rate variability and blood flow dynamics, and statistical methods (paired t-tests and ANOVA) were applied to identify significant variations in fetal responses. Results Fetal heart rate significantly decreased during Brahms ’ Lullaby , indicating a calming effect, and increased during Mozart ’ s Symphony , suggesting arousal. Corresponding changes in Doppler waveform metrics reflected stimulus-dependent modulation of fetal cardiovascular function. Conclusions AI-assisted Doppler ultrasound analysis confirms that fetal music therapy modulates cardiac responses based on musical characteristics. These findings establish a foundation for personalized prenatal music interventions with potential benefits for in utero neurological priming and stress reduction.

Objectives The aim of this study was to assess the effect of low-dose nicotine on the expression of brain-derived neurotrophic factor (BDNF) mRNA, its antisense alternative splice form brain-derived neurotrophic factor antisense (BDNF-AS), and its protein levels after global hypoxia in newborn piglets. This study also sought to explore the regulatory role of BDNF-AS on BDNF mRNA. Methods A total of 41 newborn piglets were randomised after hypoxia to one of two different infusions of nicotine (18 or 46 μg/kg/h, respectively) or to a control group receiving saline. After 4 h of infusion, the piglets were euthanized and brain samples from the hippocampus and temporal cortex were collected for quantification of BDNF mRNA, BDNF-AS and BDNF protein. Results In the hippocampus, significant lower expression of BDNF mRNA was observed in the animals treated with 46 μg/kg/h of nicotine compared to the group receiving 18 μg/kg/h (p=0.047) and the control group (p=0.017). The BDNF mRNA and BDNF-AS showed a strong correlation (r=0.63, p<0.001) in the hippocampus samples and moderate, but significant, correlation (r=0.36, p=0.021) in the samples from the cortex. We found no differences in BDNF mRNA between the groups in the cortex samples. Protein levels of BDNF were similar in all three groups in both the hippocampus and cortex samples. Conclusions Our results suggest that low concentrations of nicotine might have a short-term effect on the expression of BDNF mRNA. However, the BDNF protein levels remained unchanged at the same time point and the long-term impact on the nervous system remains unclear.