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Objective: To validate an objective scoring system for middle cerebral artery (MCA) pulsed wave Doppler images.Method: From an image database of routine 36-week scans, a random sample of MCA Doppler images was selected. Two reviewers rated the images subjectively as acceptable or unacceptable. Subsequently they used an objective 6-point image scoring system and awarded one point for each of the following: (1) anatomical site, (2) magnification, (3) angle of insonation, (4) image clarity, (5) sweep speed adjustment, and (6) velocity scale and baseline adjustment. Image scores 4-6 were defined as good quality whereas 0-3 as poor. The subjective and objective agreement between the two reviewers was compared using the adjusted Kappa statistic.Results: A total of 124 images were assessed. Using objective scoring the agreement rate between reviewers increased to 91.9% (κ = 0.839) compared to subjective agreement 75.8% (κ = 0.516). The agreement for each criterion was: anatomical site 91.1% (κ = 0.823), magnification 95.2% (κ = 0.903), clarity 83.9% (κ = 0.677), angle 96.0% (κ = 0.919), sweep speed 98.4% (κ = 0.968), and velocity scale and baseline 94.4% (κ = 0.887).Conclusion: Objective assessment of MCA Doppler images using a 6-point scoring system has greater interobserver agreement than subjective assessment and could be used for MCA Doppler quality assurance. [ABSTRACT FROM AUTHOR]

Apparently uncomplicated low-risk pregnancies, especially first time births, account for a significant proportion of adverse birth outcomes. Improved risk stratification with a simple bedside scan on admission in early labor could potentially reduce adverse intrapartum outcomes. The aim of this feasibility study was to assess a cohort of low-risk subjects with admission ultrasonography at the onset of labor with a view to conducting a future randomized controlled trial (RCT). The objectives were three-fold; i) to determine the logistics of performing a labor admission ultrasound scan ii) to establish whether abnormal ultrasound features can be identified and iii) whether they are associated with emergency delivery and/or poor condition of the neonate at birth. We performed a prospective cohort study of 295 participants with term singleton cephalic pregnancies admitted in early labor or for labor induction with non-fetal indications. The setting was a university teaching hospital in Ireland with almost 8000 births annually. A bedside ultrasound scan was performed to assess fetal biometry, amniotic fluid volume and placental maturity. Patients and their babies were followed up until hospital discharge. The outcomes of interest included image quality, time to perform a scan, oligohydramnios (Single Deepest Pool ≤ 2 cm), small for gestational age (SGA; abdominal circumference <10th centile), mature placenta (Grannum 2 or 3), pathological CTG, emergency cesarean section (CS), fetal acidosis (cord arterial pH <7.10 or base excess <-12.0), low Apgar score <7 at 5 min and neonatal unit admission. Image quality was optimal in 274 of the 295 scans (93%) and 271 (92%) were completed in less than 10 min. Of this low-risk population, 67 of 294 (23%) had oligohydramnios, 11 (4%) were small for gestational age and 87 (30%) had a mature placenta (Grannum grade 2). The incidence of pathological CTG and emergency CS was higher among patients with oligohydramnios than those with a normal scan but did not reach statistical significance; Odds Ratio 3.40 (95% Confidence Intervals 0.55 to 20.92) and OR 1.43 (95% CI 0.66 to 3.08) respectively. The mean birthweight was significantly lower in those with oligohydramnios −139 g (95% CI −248 to −30) and admission scan detected SGA −357 g (95% CI −557 to −137). Adverse perinatal outcomes were uncommon with a higher incidence of fetal acidosis (pH < 7.10) in the oligohydramnios group. The incidence of neonatal unit admission >24 h was higher in the oligohydramnios group but not statistically significant; OR 3.75 (95% CI 0.61 to 22.97). Results for SGA alone were non-significant and results for oligohydramnios and SGA combined were similar to those for oligohydramnios alone. Admission ultrasonography is feasible in a routine clinical setting, but evidence of benefit is weak and does not currently justify a randomized controlled trial. [ABSTRACT FROM AUTHOR]

To determine the association between the occurrence of sporadic and periodic fetal heart rate accelerations during labor and acidemia at birth. This is a case–control study of fetal heart rate patterns from 364 neonates with acidemia at birth (cord blood pH <7.05 at vaginal birth, or pH <7.10 at birth after first stage cesarean delivery) and 731 controls with pH ≥7.15. The last 30–60 min of the cardiotocographic traces before birth from the neonates born with acidemia and from the corresponding stage in labor for the controls were scrutinized. Odds ratios (OR) with 95% confidence interval for acidemia at birth were determined. During the first stage, ≥2 sporadic accelerations were present in 16% of cases and 78% of controls; OR for acidemia (compared to 0–1 accelerations) 0.05 (0.02–0.10). In the second stage, the corresponding rates were 13% and 60%, OR 0.09 (0.06–0.14). Isolated periodic accelerations were infrequent. A weak negative association between ≥2 periodic accelerations and acidemia (compared with 0–1 accelerations) was found in the second stage, OR 0.51 (0.30–0.86), but was not significant in the first stage, OR 0.24 (0.04–1.4). Even among fetuses with normal fetal heart rate variability (5–25 beats per minute) the occurrence of less than two sporadic accelerations was associated with an increased risk of acidemia, OR 10.3 (7.2–14.8). Sporadic accelerations indicate a very low probability of acidosis but are absent in 40% of fetuses with normal pH during a 30–60 min second-stage recording. [ABSTRACT FROM AUTHOR]

Background: Commonly used methods of CTG classification do not reliably predict neonatal hypoxic-ischemic encephalopathy (HIE). Objective: To examine whether a relationship exists between the types of hypoxia as identified on the cardiotocograph using novel physiology-based CTG classification and patterns of injury on neonatal cerebral MRI and later neurodevelopmental outcomes. Study design: A retrospective study of term-born infants admitted to four neonatal units with HIE as part of a brain injury biomarkers study between January 2014 and December 2015. Intrapartum CTG traces were analyzed by two obstetricians trained in physiological CTG classification, blind to neonatal outcomes. Neonatal cerebral MR images were assessed independently by a neuroradiologist and an expert neonatologist. CTG traces were classified into types of hypoxia and allocated to groups; (1) chronic hypoxia or antepartum injury; (2) gradually evolving or subacute hypoxia; and (3) acute hypoxia. Results: Of 106 infants recruited to the study, records were available for 58 cases. Of these, CTGs were available for 37. All 37 had abnormal CTGs. Twenty-four infants, all of whom had received therapeutic hypothermia had cerebral MRI. Fourteen of the 24 (58%) infants had abnormal MRI. In group 1 (chronic hypoxia/antenatal injury), total brain injury was most predominant (4/6 infants). Group 2 (gradually evolving/subacute hypoxia) was associated with peripheral brain injury (5/5 infants). Group 3 (acute hypoxia) was associated with basal-ganglia thalamic injury pattern (3/3 infants). Later neurodevelopmental outcomes were available for 35 cases. Infants suspected to have a pre-labor injury on CTG (group 1) had a higher proportion of adverse neurodevelopmental outcomes (4/10, 40%) compared to groups 2 and 3 (4/25, 16%). Conclusion: Using this novel physiology-based CTG classification, we demonstrate an association between types of hypoxia observed on the CTG and MRI patterns of hypoxic brain injury. Infants with CTG trace suggestive of chronic hypoxia or other antenatal injuries were overrepresented in this cohort and were also more likely to have a poor neurodevelopmental outcome. [ABSTRACT FROM AUTHOR]

Objectives The present systematic review aims to investigate the diagnosis, prognosis, delivery assistance, pregnancy results and postnatal management in gastroschisis. Study design The following data sources were evaluated: The CINAHL, Embase and MEDLINE/PubMed databases were searched, observational and intervention studies published over the past 20 years. The quality of the studies was assessed using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE). Results A total of 3770 infants diagnosed with gastroschisis were included (44 studies); 1534 fetuses were classified as simple gastroschisis and 288 as complex gastroschisis. Intrauterine fetal demise occurred in 0.47% and elective termination occurred in 0.13%. Preterm delivery occurred in 23.23% and intrauterine growth restriction in 4.43%. Cesarean section delivery was performed in 54.6%. Neonatal survival was 91.29%. The main neonatal complications were: sepsis (11.78%), necrotizing enterocolitis (2.33%), short bowel syndrome (1.37%), bowel obstruction (0.79%), and volvulus (0.23%). Immediate surgical repair was performed in 80.1% with primary closure in 69%. The average to oral feeding was 33 (range: 11–124.5) days. Average hospital duration was 38 days and 89 days in neonates with simple and complex grastroschisis, respectively. Conclusions The present systematic review provides scientific data for counseling families with fetal gastroschisis. [ABSTRACT FROM AUTHOR]

Introduction Several adjuvant interventions have been evaluated for improving the success rate of the external cephalic version (ECV) and reducing the rate of cesarean delivery (CD). Evidence regarding the effect of Nitrous oxide is limited to a small number of participants with inconsistent results on pain score and success rate. This study aims to examine the effect of inhaled nitrous oxide on the success rate and pain score for women undergoing ECV. Material and methods Survey on ECV reports from inception till June 2020 were made from MEDLINE, EMBASE, PubMed, Ovid Medline, ClinicalTrials.gov, the Cochrane Library and Google Scholars. Peer-review studies that examined the success rate of ECV from the application of nitrous oxide during ECV attempts compared with or without the use of other analgesic agents were obtained. The study population comprising women with singleton pregnancies having a non-vertex presentation at least 36 weeks, were categorized into one of two treatment groups: ECV attempt with nitrous oxide (nitrous oxide group) and ECV attempt with or without another analgesia (control group). The primary outcome was the ECV success rate, defined by conversion to vertex-presentation following the procedure. The secondary outcomes were pain scores during ECV attempt and CD rate. The study quality scores were evaluated as a source of heterogeneity by fitting meta-regression models to the individual study effect sizes. Results Of the 26 records identified, two randomized trials and one prospective cohort study (720 women; 434 in the nitrous oxide group and 286 controls) were deemed adequate for meta-analysis. ECV success rate did not differ significantly between the nitrous oxide group and the control group (p = .825; OR 1.036; 95% CI, 0.756, 1.419). In addition, the use of nitrous oxide did not affect pain scores during ECV attempt (p = .457; OR 0.759; 95% CI, −1.240, 2.759) and there was no difference in the incidence of CD as well (p = .943; OR 1.013; 95% CI, 0.703, 1.46). Conclusion The use of nitrous oxide during ECV attempts was not associated with an increase in ECV success rate and does not affect pain scores [ABSTRACT FROM AUTHOR]

Objective To determine the feasibility of rescue cerclage and amnioreduction at advanced cervical dilation or gestational age. Methods We present a retrospective case series of women who underwent rescue cerclage at either an advanced gestational age (24 + 0 to 24 + 6 weeks) or cervical dilation (≥4 cm), with a subset undergoing amnioreduction prior to cerclage placement. Results Nine women were included and amnioreduction was performed in 7 (78%). A bi-modal distribution of obstetric outcomes was observed, with 5 (56%) women delivering ≥34 weeks gestation, 3 (33%) of which delivered at term. Two (22%) women experienced intra-operative rupture of membranes and subsequent perinatal deaths. Two (22%) women delivered extremely premature, with one resulting in infant death. Discussion Our data show that rescue cerclage with amnioreduction may be successful at advanced gestational ages or cervical dilations, suggesting that these women should be included in prospective studies to better establish the efficacy and safety of this procedure. [ABSTRACT FROM AUTHOR]

Objective: To investigate abnormal vaginal and suture-based bacterial flora for associations with spontaneous preterm birth in high-risk singleton pregnancies with an ultrasound-indicated or emergency cervical cerclage. Materials and methods: A retrospective study of 196 singleton pregnancies with an ultrasound-indicated or emergency cerclage at the Royal Women’s Hospital, Australia, from 2004 to 2018. High vaginal swabs were collected regularly between 14 and 26 weeks’ gestation, including pre- and post-cerclage insertion, and sent for microscopy and culture. Cervical suture was cultured upon removal. Primary outcomes were spontaneous preterm birth <37, <34 and <30 weeks. Results: 43.4% (85/196) of women delivered preterm. The acquisition and persistence of vaginal Escherichia coli following cerclage insertion were independently associated with spontaneous preterm birth <37 weeks (p =.0225, p =.0477). Escherichia coli growth from the cervical suture upon removal was associated with spontaneous preterm birth <34 weeks (p =.0458). The acquisition of vaginal mixed anaerobes post-cerclage was independently associated with spontaneous preterm birth <34 weeks (p =.0480) Conclusion: For singleton pregnancies with an ultrasound-indicated or emergency cerclage, the presence of vaginal or suture-based Escherichia coli following cerclage insertion yields increased risk of cerclage failure and spontaneous preterm birth. Objective: To investigate abnormal vaginal and suture-based bacterial flora for associations with spontaneous preterm birth in high-risk singleton pregnancies with an ultrasound-indicated or emergency cervical cerclage. Materials and methods: A retrospective study of 196 singleton pregnancies with an ultrasound-indicated or emergency cerclage at the Royal Women’s Hospital, Australia, from 2004 to 2018. High vaginal swabs were collected regularly between 14 and 26 weeks’ gestation, including pre- and post-cerclage insertion, and sent for microscopy and culture. Cervical suture was cultured upon removal. Primary outcomes were spontaneous preterm birth <37, <34 and <30 weeks. Results: 43.4% (85/196) of women delivered preterm. The acquisition and persistence of vaginal Escherichia coli following cerclage insertion were independently associated with spontaneous preterm birth <37 weeks (p ¼ .0225, p ¼ .0477). Escherichia coli growth from the cervical suture upon removal was associated with spontaneous preterm birth <34 weeks (p ¼ .0458). The acquisition of vaginal mixed anaerobes post-cerclage was independently associated with spontaneous preterm birth <34 weeks (p ¼ .0480) Conclusion: For singleton pregnancies with an ultrasound-indicated or emergency cerclage, the presence of vaginal or suture-based Escherichia coli following cerclage insertion yields increased risk of cerclage failure and spontaneous preterm birth. [ABSTRACT FROM AUTHOR]

Fetal therapy term has been described for any therapeutic intervention either invasive or noninvasive for the purpose of correcting or treating any fetal malformation or condition. Fetal therapy is a rapidly evolving specialty and has gained pace in last two decades and now fetal intervention is being tried in many malformations with rate of success varying with the type of different fetal conditions. The advances in imaging techniques have allowed fetal medicine persons to make earlier and accurate diagnosis of numerous fetal anomalies. Still many fetal anomalies are managed postnatally because the fetal outcomes have not changed significantly with the use of fetal therapy and this approach avoids unnecessary maternal risk secondary to inutero intervention. The short-term maternal risk associated with fetal surgery includes preterm labor, premature rupture of membranes, uterine wall bleeding, chorioamniotic separation, placental abruption, chorioamnionitis, and anesthesia risk. Whereas, maternal long-term complications include risk of infertility, uterine rupture, and need for cesarean section in future pregnancies. The decision for invasive fetal therapy should be taken after discussion with parents about the various aspects like postnatal fetal outcome without fetal intervention, possible outcome if the fetal intervention is done, available postnatal intervention for the fetal condition, and possible short-term and long-term maternal complications. The center where fetal intervention is done should have facility of multi-disciplinary team to manage both maternal and fetal complications. The major issues in the development of fetal surgery include selection of patient for intervention, crafting effective fetal surgical skills, requirement of regular fetal and uterine monitoring, effective tocolysis, and minimizing fetal and maternal fetal risks. This review will cover the surgical or invasive aspect of fetal therapy with available evidence and will highlight the progress made in the management of fetal malformations in last two decades. [ABSTRACT FROM AUTHOR]

Congenital-pulmonary-airway-malformation (CPAM) and bronchopulmonary-sequestration (BPS) are rare conditions. The objective of this study was to describe the sonographic characteristics and prenatal course of fetal lung mass. A retrospective study on 20 pregnancies with CPAM and BPS diagnosed during 2018–2018 was performed. Data evaluated included gestational age (GA) at diagnosis, size of lesion, CPAM-volume-ratio (CVR), associated sonographic findings and pregnancy outcome. Fourteen cases of CPAM and six cases of BPS were evaluated. The average GA at diagnosis was 22 weeks'-gestation (range 17–26). 66% were macrocystic–multicystic. Five cases of BPS (71.4%) had other structural anomalies. None of the fetuses with CPAM had additional anomalies. Four pregnancies (20%) underwent termination due to severe hydrops fetalis. Two cases of CPAM (15%) had spontaneous resolution by 30 week's-gestation; three cases (20%) continued to grow during pregnancy and all the rest reached their largest size at 25–28 week's-gestation. Most cases delivered at term (average 37.6 range 32.2–41.4). Two children had lobectomy at 11 and 12 months of life. Careful follow-up during pregnancy may result in term delivery of adequate-for-gestational-age newborns, with no need for admission to the NICU, with only 10% need for lobectomy during the first year of life. [ABSTRACT FROM AUTHOR]

The purpose of this study was to evaluate the clinical evolution, structural anomalies associated and neonatal outcomes of fetal neck hyperextension in two cases with prenatal ultrasound diagnosis in two different gestational ages. In 2019, two cases of fetal hyperextension came to our attention. Follow-up information was obtained from hospital medical records and obstetrical care providers. Two woman were investigated in our institution for the presence of fetal abnormalities in the II and III trimester, respectively. In both cases, fetal attitude presented persistent fetal neck hyperextension. One of the two fetuses had a mild ventriculomegaly and suspected for micrognathia. Both had an amniotic fluid increase. One of two had no movement in the lower and upper limbs in ultrasound scans associated with club foot and suspected scoliosis. Both were born by cesarean section with pretty different prognosis: one healthy baby had a retarded psychomotor development and the other one died after 6 months. A precise diagnosis was possible only in one case. The early identification of a fetus with persistent hyperextension of the fetal head should require a detailed ultrasound exam for structural abnormalities and a careful prenatal counseling due to possible postnatal outcome. [ABSTRACT FROM AUTHOR]

Epidural analgesia has been associated with more frequent intrapartum fever as well as neonatal antibiotic therapy. We examined whether intrapartum fever carries the same risk for neonatal sepsis with and without epidural. This is a retrospective cohort study of 34,371 deliveries at a single institution. Primary outcome variables included neonatal sepsis, Apgar scores, neonatal intensive care (NICU) admission, postpartum hemorrhage, prolonged labor, and cesarean delivery. Univariate analysis and multivariable logistic regression were used to assess the risk of sepsis while controlling for possible confounding covariables. A total of 34,371 patients were included in the study, 16,917 (49.9%) of whom had epidural anesthesia. Of the patients who had an epidural, 2103 (12.4%) had an intrapartum fever, compared to 446 (2.6%) of those who did not have an epidural (p <.001). Overall, there was a decreased risk of neonatal sepsis in the setting of intrapartum fever with an epidural after controlling for potential confounders. (aOR 0.53 [95% CI 0.29–0.98]). In preterm patients, an epidural was associated with a decreased risk for neonatal sepsis (5.7% vs. 10.0%, p =.04), 5-minute Apgar score <7 (23.5% vs. 33.6%, p =.006), and NICU admission (66.6% vs. 76.5%, p =.008) compared to those born in the setting of a fever without an epidural. Neonates were less likely to sustain a diagnosis of sepsis in the setting of an epidural-associated fever compared to those in the setting of an intrapartum fever without an epidural. These data may be used by providers in counseling and guideline creation. [ABSTRACT FROM AUTHOR]

Infants prenatally suspected of having a choledochal cyst (CDC) typically undergo ultrasound imaging shortly after birth. This study sought to evaluate features on the initial postnatal ultrasound (IPU) that could identify newborns at risk for early complications. Following IRB approval, patients from four US fetal centers with prenatal suspicion for CDC and postnatal imaging from 2000 to 2017 were reviewed. Imaging and clinical courses were assessed. Forty-two patients had prenatal ultrasounds suspicious for CDC. Nineteen (45.2%) were excluded due to diagnostic revision (n = 9), cyst resolution (n = 5), lack of IPU measurements (n = 3), or lack of follow-up (n = 2). The 23 remaining patients were included in the study. Of these, five (21.7%) developed symptoms at a median age of 16.5 days (IQR 16–19 days), and 18 (78.3%) remained asymptomatic throughout the first year after birth. Five patients (21.7%) had cysts ≥ 4.5 cm on IPU (Symptomatic: n = 3; Asymptomatic: n = 2). Eighteen patients (78.3%) had cysts < 4.5 cm on IPU (Symptomatic: n = 2; Asymptomatic: n = 16). An IPU cyst size ≥ 4.5 cm was associated with neonatal symptom manifestation (p = 0.048), with 88.9% specificity (95% CI 65.3–98.6%) and 60% sensitivity (95% CI 14.7–94.7%). In newborns with prenatally diagnosed CDC, a cyst size ≥ 4.5 cm on IPU is associated with symptom development during the first month after birth and therefore early cyst excision is recommended. [ABSTRACT FROM AUTHOR]

Introduction: Centralization of very preterm deliveries to level 3 hospitals is recommended to improve infant survival and prevent brain injury. We studied the clinical practices of centralization from level 2 to level 3 hospitals in cases of threatening very preterm delivery in Finland. Materials and methods: Obstetricians in all 16 level 2 hospitals in Finland were invited to participate in an online survey regarding antenatal transfer to level 3 hospitals among women with threatened delivery below 32 gestational weeks. We report clinical thresholds used as indications and contraindications for antenatal transfers, and logistical factors related to transfers. Results: Twelve out of 16 (75%) hospitals completed the survey. The lower gestational age threshold for antenatal transfer ranged from 22+0 to 23+0 weeks. All hospitals regarded preterm premature rupture of membranes, chorioamnionitis, and severe pre-eclampsia as indications for antenatal transfer to a level 3 hospital. Most hospitals reported transferring women in spite of regular contractions (interval over 5 min) or cervical dilatation up to 4 cm. Suspicion of placental abruption, abnormal cardiotocography tracing and poor maternal condition were the most frequently reported contraindications for antenatal transfer. The time to arrange antenatal transfer was less than 2 h in all hospitals, and overcrowding of level 3 hospitals rarely hindered antenatal transfer. Conclusions: Successful centralization of very preterm deliveries is reached in Finland by rapid and active antenatal transfers. This study identified clinical thresholds used by obstetricians in a setting of long distances and high centralization rate. [ABSTRACT FROM AUTHOR]

Assessing the wellbeing of newborns at birth with base deficit (BD)/base excess(BE) is well anchored in clinicians' practice. However, clinicians may not fully understand the concepts behind BD and the concerns regarding the validity of BD results provided by the hospital laboratory. These concerns are linked to the inconsistencies between the equations to calculate BD, and that these equations do not consider the aspects of acid-base physiology at birth. Additionally, the evidence-based supporting BD threshold in the literature to help physicians in making decisions is rather insufficient. These considerations support the need to review practice guidelines that use BD to guide decisions and bring to an end to clinicians to sail blindly in a thick fog. [ABSTRACT FROM AUTHOR]

Background: Cord blood umbilical artery (Ua) pH, base deficit (BD), and pH eucapnic Blickstein/Green-50 may mislead clinicians to identify newborns at risk for hypoxic-ischemic encephalopathy. Neonatal eucapnic pH (pH euc-n Racinet-54) may be a comprehensive alternative. The goal of the study is to compare the predictive performance of these four biomarkers for the combined primary outcome of hypoxic-ischemic encephalopathy/death.Methods: This retrospective cohort study includes newborns ≥35 weeks gestational age. Receiver operating characteristics curves analysis was performed for Ua cord pH, BD, pH euc-n Racinet-54, and pH eucapnic Blickstein/Green-50 for the global cohort and for two subgroups of newborns with Ua cord pH ≤ 7.15. Cutoff values were derived for all four markers.Results: From the original cohort of 61,037 newborns born between 1 January 2007 and 31 December 2016, we excluded cases with major congenital malformations and missing/incomplete data. The global cohort includes 51,286 newborns and 60 newborns afflicted with hypoxic-ischemic encephalopathy (HIE)/death. The area under the curves (AUC) derived from the global cohort were comparable between Ua cord pH (0.95; 95%CI = 0.94-0.95), BD (0.93; 95%CI = 0.93-0.93), pH euc-n Racinet-54 (0.93; 95% CI = 0.93-0.93), and lower for pH Blickstein/Green-50 (0.78; 95% CI = 0.77-0.78) (p < .05). Within newborn with severe acidemia (pH ≤ 7.00) and moderate acidemia (7.00 ≤ pH ≤ 7.15), pH euc-n Racinet-54 had the largest AUC and best positive likelihood ratios especially for sensitivity ≥ 0.80 to minimize false negative cases.Conclusion: In this large retrospective study, predictive performance for Ua cord pH, BD, and pH euc-n Racinet-54 are comparable when applied to the global group. For newborns with Ua cord pH ≤ 7.00 and Ua cord 7.00 ≤ pH ≤ 7.15, pH euc-n Racinet-54 appears better to identify those with HIE/death, especially when the target is sensitivity > 80%. Prospective studies will confirm if pH euc-n Racinet-54 is a better alternative to Ua cord pH and BD to evaluate newborn acid-base physiology. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to evaluate the strategy of screening for preeclampsia (PE) in the first trimester based on maternal characteristics, and estimated placental volume (EPV).Methods: A prospective cohort study was performed with 351 women enrolled, of which 13 women developed PE. This study analyzed the risk of PE according to ultrasonography findings of the placenta, maternal characteristics, and serum markers. The placental ultrasound exam and maternal serum pregnancy-associated plasma protein A (PAPP-A) was determined at 11+0 to 13+6 weeks and the serum alpha-fetoprotein (MSAFP), human chorionic gonadotropin (hCG), unconjugated estriol (uE3), and inhibin A were assayed at 14+0 to 22+0 weeks. We reviewed all antenatal medical screening records and assessed the relationships of EPV of ultrasound examination, maternal characteristics, and serum markers by using multiple logistic regression analysis.Results: Thirteen of the 351 women (3.7%) developed PE in singleton pregnancy. The gestational age at delivery was significantly different between the normal and PE group (p < .001). In the PE group, the placental weight at delivery was not statistically different between the normal and the PE group. The EPV at the first trimester was significantly lower in women with PE compared to those without PE (p = .002). In addition, we predicted PE using combined maternal age, BMI, and EPV, which were achieving an area under the curve of 0.83 overall.Conclusion: A risk prediction model of PE, which combined maternal age, BMI, and EPV can be adopted for the screening of PE at the first trimester in singleton pregnancy. [ABSTRACT FROM AUTHOR]

Objective: The cardiotocograph (CTG) or electronic fetal monitoring (EFM) was developed to prevent fetal asphyxia and subsequent neurological injury. From a public health perspective, it has failed these objectives while increasing emergency operative deliveries (emergency operative deliveries (EODs) – emergency cesarean delivery or operative vaginal delivery) for newborns, who in retrospect, actually did not require the assistance. EODs increase the risks of complications and stress for patients, families, and medical personnel. A safe reduction in the need for EOD will likely reduce both the overall Cesarean section rate as well as the risk of fetal neurological injury during labor to which it is related. We have developed the fetal reserve index (FRI), which is more comprehensive than CTG as a new screening method for early identification of the fetus at-risk of both neurological harm and the need to "rescue" by means of an EOD. Here, we compare prospectively the need for EOD in two groups of parturients undergoing a trial of labor at term. One group was managed conventionally, the other by the principles of the FRI. Study design: We compared the need for EOD of 800 parturients with singleton cases undergoing a trial of labor at term entering with normal CTG patterns (ACOG category 1). Patients were either treated routinely (400 – "early cases") or in a second group seen later actively managed using the principles of the FRI (400 – "late cases"). The FRI includes measurements of five components of the CTG: rate, variability, decelerations, accelerations, and abnormal uterine activity combined with the presence of medical, obstetrical, and fetal risk factors. The 8-point metric categorizes cases as "green", "yellow", and "red" with the latter being at risk. Results: All 800 patients delivered babies, who were discharged in the usual time course with no untoward outcomes noted. The incidence of red zone scores was comparable in the two groups (≈25%), but the use of intrauterine resuscitation (IR) when reaching the red zone in the late group (47%) was more than double the incidence in the early group (20%) (p <.001). Despite (or because of) this, EODs were significantly reduced in the late group, from 17.3 to 4.0% (p <.001). Further, the late group spent less time in the red zone without increasing overall time in labor. Overall, EOD cases averaged >1 h in the red zone versus 0.5 h for non-EODs. Conclusions: The FRI may provide a metric to reduce EODs and by extension also reduce the risks of both cesarean delivery and adverse fetal/neonatal outcomes. The safe avoidance of EOD would seem to be an important metric to assess the quality of intrapartum management. This study represents the first attempt to apply the principles of the FRI "live" for the concurrent management of patients during labor. These promising results, if confirmed, in larger sample sizes, set the stage for our computerization of the FRI for widespread study. Benefits appear to come from identification and early, conservative management of fetal deterioration before the need to "rescue" the fetus by EOD. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate and describe the spectrum and rate of congenital thoracic malformations (CTMs) diagnosed by early prenatal sonography (gestational age (GA) less than 16 weeks). Methods: A retrospective, cross-sectional analysis of prenatal ultrasound screening tests in a community-based clinic. Results: In 2001-2017, 31 261 prenatal ultrasound tests detected 31 CTMs at a gestational age of 15.2 (range, 11.6-16.0) weeks. The most common malformation was congenital pleural effusion (CPE) (15 fetuses, 0.48/1000), followed by congenital diaphragmatic hernia (CDH) (10 fetuses, 0.32/1000). Pulmonary hypoplasia (PH), congenital pulmonary airway malformation and broncho-pulmonary sequestration appeared in much smaller proportions (three, two and one fetuses, respectively). Most CTMs were associated with additional fetal lesions (15 fetuses, 48%). All early CDH (10 fetuses) and PH (three fetuses) and 6/15 with CPE had termination of pregnancy or missed abortions. Conclusions: Prenatal ultrasound before 16 GA was able to detect CTMs in 0.99/1000 of screening ultrasound (US) performed. Most CTMs tended to appear with multiple lesions and were associated with unfavorable outcomes. Earlier prenatal diagnosis may enable early termination of pregnancy in fetuses with lethal malformations. [ABSTRACT FROM AUTHOR]

Objective: The objective of this study is to assess retrospectively the predictive value of fetal scalp pH and base excess (BE) for fetal acidosis and poor neonatal outcome in term, low-risk, spontaneous deliveries with suspicious or pathological intrapartum cardiotocography (CTG) tracings.Methods: Umbilical artery pH and BE values obtained immediately after delivery and Apgar score were the outcomes under consideration. Statistics included receiver-operating characteristic curve (ROC) and multiple logistic regression analysis.Results: Four hundred and six deliveries were included in the study. Scalp pH < 7.20 predicted umbilical pH ≤7.1 with 64.3% sensitivity and 92.9% specificity (p < .001). The corresponding positive-predictive value (PPV) was 24.3% and the negative-predictive value (NPV) was 98.6%. Scalp BE ≤ -7 mmol/l (a cut-off value provided by ROC curve analysis) predicted Apgar score ≤ 7 at 5 min with 61.9% sensitivity and 91.7% specificity (p < .001). The corresponding PPV and NPV were 29.5 and 97.7%, respectively. Neither scalp pH nor BE was significantly associated with umbilical BE values. Infants with intrapartum BE ≤ -7 mmol/l were 30 times on an average more likely to get a low Apgar score, independently of intrapartum pH values.Conclusion: Our study supports the consideration of both scalp pH and BE values, when fetal blood sampling (FBS) is used. [ABSTRACT FROM AUTHOR]

Purpose: To identify obstetric risk factors of delivering a neonate with poor neonatal adaptation at birth.Material and Methods: Nested case-control study. Poor neonatal adaptation was defined for presence of at least: umbilical cord artery pH <7.10, base deficit ≥12 mmol/L, Apgar score at 1' ≤5. Controls were selected from the same population and matched with cases. The association between clinical parameters and poor neonatal adaptation was analyzed by logistic regression.Results: One hundred and thirty three women (2.1% of all live births) with a neonate presenting a poor neonatal adaptation were matched with 133 subsequent controls. Significant contributions for the prediction of poor neonatal adaptation were provided by maternal age ≥35 years (p ≤ .001, odds ratio (OR) 3.9 [95%CI: 2.3-6.8]), nulliparity (p ≤ .001, OR 3.3 [95%CI: 1.8-6]), complications during pregnancy (p = .032, OR 2.2 [95%CI: 1.1-4.4]), gestational age at delivery <37 weeks (p = .008, OR 5.2 [95%CI: 1.5-17.8]) and cardiotocography category II or III (p ≤ .001, OR 36.3 [95%CI: 16.5-80.1]). The receiver operative characteristic curve was 0.91 [95%CI: 0.87-0.95], and detection rates 82.7% and 89.5% at 10% and 20% of false positive rates, respectively.Conclusions: Several obstetric risk factors before and during labor can identify a subgroup of newborns at higher risk of a poor neonatal adaptation at birth. [ABSTRACT FROM AUTHOR]

Objective: Our aim was to compare perinatal outcomes in twin pregnancies complicated by premature asymptomatic cervical dilatation treated with rescue cerclage and expectant management.Methods: A retrospective cohort study was conducted at a single tertiary referral center between 2003 and 2014 and included all women with twins found to have a dilated cervix with intact membranes before 25-week gestation. Pregnancy outcomes were compared between women with rescue cerclage and those managed expectantly. A total of 36 women were eligible for the study, 27 (75.0%) of whom had a rescue cerclage compared to 9 (25.0%) women managed expectantly. Student's t-test was used to compare continuous variables between the groups and the chi-square and Fisher's exact tests were used for categorical variables as appropriate. Statistical analysis was performed with the SPSS v21.0 software (IBM Corp; Armonk, NY). Differences were considered significant when the p value was less than .05.Results: Among the 27 women with a rescue cerclage, the mean gestational age at time of cerclage insertion was 21.5 ± 2.6 weeks. The intervention and control groups were similar with respect to the degree of cervical dilatation at presentation (2.6 ± 1.3 versus 3.0 ± 1.5 cm, p = .5). Women in the cerclage group gave birth at a more advanced gestation (28.9 ± 6.1 versus 24.2 ± 2.6 weeks, respectively, p = .03) and were less likely to give birth at <34 and  <28 weeks (66.7 versus 100.0%, p = .046, and 59.3 versus 100.0%, p = .02, respectively). The mean latency from the placement of cerclage to delivery was 7.3 ± 5.5 weeks. Similar findings were observed when analysis was limited to women with cervical dilatation of ≤3 cm at presentation.Conclusions: In asymptomatic women with twin pregnancies and cervical dilatation before 25 weeks of gestation, rescue cerclage can prolong pregnancy and improve perinatal outcomes when compared to expectant management. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the performance of fetal scalp stimulation (FSS) compared to fetal blood sampling (FBS) as a second line test of fetal wellbeing in labor.Study Design: A prospective cohort study was conducted including 298 fetal blood sampling procedures performed due to abnormal fetal cardiotocography (CTG). Two independent observers interpreted the CTG following stimulation. The FSS test was classified as normal when an elicited acceleration and/or provoked fetal heart rate variability was recorded. The FBS was classified as normal (pH ≥7.25), borderline (pH 7.21-7.24), and abnormal (pH ≤7.20).Results: Of the 298 procedures, 249 (84%) had a normal scalp pH result, 199 (67%) had an acceleration in response to FSS and 255 (86%) had an acceleration or normal variability in response to FSS. All 11 of the neonates classified as normal by FSS, but abnormal by FBS were born with normal Apgar scores and cord pH results. The consistency between FSS and FBS was "fair" (kappa 0.28) while the consistency between either test and cord arterial pH was "poor".Conclusions: This study suggests that FSS has the potential to be a reliable alternative to FBS. The findings require evaluation in a well-designed randomized controlled trial. [ABSTRACT FROM AUTHOR]

Aim: Congenital portosystemic shunts (CPSS) are rare, congenital malformations that are increasingly often discovered during the fetal period, and for which, the manifestations and evolution are poorly understood. The objective of this review is to describe the phenotype and evolution of forms diagnosed in the antenatal period.Materials and Methods: We performed a systematic review of the literature cited in Pubmed between 1982 and 2016 for CPSS cases diagnosed during the fetal period.Results: We identified 123 cases. The median age at diagnosis was 25 GA (14-38 weeks GA). Eighty patients had 128 associated congenital anomalies. The congenital abnormalities most frequently associated with antenatal diagnosis of CPSS were congenital cardiac disease (30 cases), intrauterine growth restriction (21 cases), vascular anomalies (14 cases), and trisomy 21 (7 cases). Seventy-five complications were reported in the literature. The most frequent were antenatal hemodynamic abnormalities (27 cases), neonatal cholestasis (11 cases), and hyperammonemia (10 cases). Twenty-nine patients had no complications. The choice of treatment was conservative in 29/56 cases, interventional radiology in 15 cases and surgery in 15 cases (three of the latter after failure of embolization).Conclusion: From this review, we propose an algorithm for the perinatal management of this congenital abnormality. [ABSTRACT FROM AUTHOR]

Purpose: This retrospective case-control study is aimed to extract predictors of preterm delivery after rescue cerclage.Materials and Methods: We collected the data from all the pregnant women who underwent rescue cerclage before 26+0 gestational weeks at our facility between July 2006 and July 2016. These women were divided into "delivery at <34 weeks" group (n = 12) and "delivery at ≥34 weeks" group (n = 12). Multiple factors that had been detected at the time of cerclage were compared between these two groups.Results: "Gestational weeks at cerclage ≥23" and "positive vaginal culture at cerclage" were significantly more prevalent in the "delivery at <34 weeks" group than in the "delivery at ≥34 weeks" group. "Prolapsed membranes at cerclage" tended to be more prevalent in the "delivery at <34 weeks" group than in the "delivery at ≥34 weeks" group. "Positive vaginal culture at cerclage" was the only independent risk factor associated with eventual preterm delivery before 34 gestational weeks.Conclusions: Simple aerobic bacterial culture of the vaginal swab sampled at the time of cerclage could be used as a reliable test to predict subsequent preterm delivery before 34 gestational weeks. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether incomplete umbilical cord blood gas (UCBG) analysis occurs more often than the incomplete reporting of the Apgar score, and risk factors associated with the incomplete values.Methods: A total of 8824 infants born alive after 26 weeks' gestation between January 2009 and April 2013 were included. We extracted data on five-minute Apgar score, UCBG analysis, gestational age, mode of delivery, time of delivery and multiple pregnancy. Univariate and multivariable logistic regression analyses were performed.Results: Five-minute Apgar score was incomplete in 15 cases (0.2%) and UCBG analysis in 1960 cases (22.2%), p < 0.05. Incomplete UCBG analysis was significantly more likely to occur in situations with Apgar score below seven (Odds ratio (OR) 1.68, 95% CI;1.29-2.19), gestational age between 26 to 27 6/7 and 28 to 31 6/7 weeks (OR 3.14, 95% CI; 2.13-4.62 and OR 1.91, 95% CI; 1.57-2.32), cesarean section (OR 1.31, 95% CI; 1.11-1.55), and multiple pregnancy (OR 2.02, 95% CI; 1.69-2.43). Deliveries during night time had a lower risk of incomplete UCBG analysis (OR 0.78, 95% CI; 0.69-0.88).Conclusions: Measuring five-minute Apgar score generated less incomplete data compared with UCBG analysis. The risk factors associated with incomplete UCBG analysis were noted. Study outcomes with UCBG analysis as neonatal assessment tool should be interpreted with caution. [ABSTRACT FROM AUTHOR]

Objective: To determine which parameter of the umbilical arterial cord gas analysis, pH, base deficit (BD) or lactate has a bigger predictive ability for neonatal morbidity at term.Method: We conducted a four-year retrospective cohort study including all non-anomalous, singleton, vertex, term births with neonatal acidemia (umbilical arterial cord gas pH ≤ 7.1). The primary outcomes were a composite neurological morbidity and a composite systemic morbidity. The predictive ability of lactate, BD and pH was compared using receiver operator characteristic (ROC) curves. Optimal cutoff values of lactate, BD and pH were estimated based on their maximal Youden Index.Results: We identified 466 acidemic neonates who had paired and validated cord blood gas data. The ROC curve analysis revealed that pH, BD and lactate had a similar predictive ability for neurological (AUC: 0.81; 0.78; 0.83, respectively) and systemic neonatal morbidity (AUC: 0.77; 0.82; 0.82, respectively). The combination of pH ≤ 7.0 and lactate ≥ 7.0 mmol/L presented similar validity to that of pH ≤ 7.0 and BD ≥ 12 mmol/L, but both were comparable to pH alone.Conclusions: pH, BD and lactate have similar predictive ability for adverse neonatal outcomes among acidemic neonates. Umbilical arterial lactate could replace BD as a measure of the metabolic component in acidemic neonates. However, neither BD nor lactate demonstrated in this study to improve the predictive ability of pH alone for short-term neonatal outcomes. [ABSTRACT FROM AUTHOR]

Objective: To elucidate the factors that contribute to prolonged pregnancy and promote neonate survival in women with bulging fetal membranes.Methods: A database was reviewed to identify women with singleton pregnancies who underwent amniocentesis on admission to determine amniotic fluid neutrophil elastase levels before 26 + 0 weeks gestation between July 2001 and January 2015. Following delivery, the placentas of these patients were examined for histologic chorioamnionitis.Results: Ninety-seven women delivered before 28 weeks gestation, and 117 women delivered at or after 28 weeks gestation. Rescue cerclage performed via the McDonald procedure (adjusted odds ratio [aOR]: 3.78; 95% confidence interval [CI]: 1.35-11.80) was associated with a higher likelihood of reaching at least 28 weeks gestation before delivery, whereas protruding membranes (aOR: 0.38; 95% CI: 0.18-0.78), elevated amniotic neutrophil elastase levels (≥0.15 μg/ml) (aOR, 0.41; 95% CI: 0.20-0.82) and elevated peripheral C-reactive protein levels (≥0.4 mg/dl) (aOR: 0.34; 95% CI: 0.180.65) were associated with a significantly reduced likelihood of reaching this gestational age before delivery. Among women who underwent rescue cerclage, amniorrhexis was associated with a negative prognosis (aOR: 0.18; 95% CI: 0.05-0.51).Conclusions: Intra-amniotic inflammation, protrusion of fetal membranes and amniorrhexis are factors that may prevent pregnancy prolongation. Rescue cerclage improves pregnancy outcomes. [ABSTRACT FROM AUTHOR]

Objective: To compare maternal, cord blood erythropoietin (EPO), and copeptin levels in low-risk term deliveries which are complicated by meconium-stained amniotic fluid (MSAF) to those with clear amniotic fluid. Also, to evaluate the relations between these markers and cord blood pH values. Methods: Low-risk term pregnant women with MSAF at an active phase of labor were defined as the study group (n = 39). Pregnant women with clear amniotic fluid were selected for the control group (n = 41). The two groups were matched for age, body mass index and gestational age. Maternal, cord blood EPO and copeptin levels with cord blood pH values were also measured. Results: Maternal, cord blood EPO, and copeptin levels of study and control groups were 42.6 ± 9.0 versus 40.7 ± 9.2, 134.2 (20.5–834.6) versus 38.4 (10.3–114.2), 4.9 (0.1–31.1) versus 4.0 (3.1–28.4), and 4.7 (2.6–25.5) versus 3.6 (2.0–23.2), respectively. The differences were statistically significant for cord blood EPO, maternal and cord blood copeptin levels (p < 0.001,p = 0.004,p < 0.001, respectively). The study group had a statistically and significantly lower cord blood pH values (7.25 ± 0.05 versus 7.34 ± 0.04,p < 0.001). Moreover, cord blood EPO and maternal and cord blood copeptin levels were inversely correlated with cord blood pH values in the study group (p < 0.001,p = 0.005, andp = 0.009, respectively). Conclusion: We suggest that higher cord blood EPO and maternal and cord blood copeptin levels may be an indicator of fetal acidosis in low-risk term deliveries complicated by MSAF. [ABSTRACT FROM PUBLISHER]

Objective: To evaluate prenatal predictors of postnatal survival in fetuses with agenesis of ductus venosus (ADV).Methods: This retrospective study reviewed our experience and the literature between 1991 and 2015. Prenatal findings were evaluated and perinatal morbidity and mortality was documented.Results: A total of 259 cases were included in the present analysis from our centers and 49 published studies (15 patients from our retrospective cohort review and 244 from literature review). The intrahepatic and extrahepatic shunts were present in 32.0% (73/226) and 67.7% (153/226), respectively. Cardiomegaly (n = 64/259, 24.7%), hydrops (n = 31/259, 12.0%) and amniotic fluid abnormalities (n = 22/259, 8.5%) were among the most frequent initial ultrasound findings. One hundred and forty-seven fetuses (56.8%) had ADV without structural anomalies while 112 (43.2%) had associated anomalies (cardiac anomalies (n = 66), extra-cardiac anomalies (n = 19) and both cardiac and extra-cardiac anomalies (n = 27)). The mean gestational age (GA) at ultrasound diagnosis was 22.9 ± 6.9 weeks while the mean GA at delivery was 34 ± 7.5 weeks. The overall neonatal survival was 57.1% (n = 148/259). The following factors were associated with survival: advanced maternal age, earlier GA at diagnosis, prematurity, increased nuchal translucency, pericardial effusion, associated cardiac defects (especially AVSD), chromosomal abnormalities, hydrops, hygroma and limb anomalies.Conclusion: Fetal hydrops, the presence of associated congenital anomalies and premature delivery are associated with poor prognosis in fetuses with ADV. [ABSTRACT FROM AUTHOR]

Objective: To clarify the effects of 3-h hypothermia on learning ability and motor function after growth, employing neonatal rat models with hyperthermic hypoxic-ischemic encephalopathy (HIE).Methods: We divided all rats into three groups: N (adult rats after neonatal hyperthermic HIE without subsequent 3-h hypothermia), H (adult rats after neonatal hyperthermic HIE with subsequent 3-h hypothermia) and Sham (S) groups. We evaluated their malfunctions with the rota-rod test and the step-down passive avoidance test. We also analyzed the cerebrum width and the hippocampal CA1 area of the insulted hemisphere.Results: In the rota-rod test, the result of the N group was significantly worse than that of the S group. In the step-down passive avoidance test, the result of the N group was significantly worse than those of the S and H groups. The longest cerebrum width and the hippocampal CA1 area of the insulted hemisphere of the N group were significantly smaller than those of the S and H groups.Conclusion: Neonatal hyperthermic hypoxic-ischemic insult restricts motor function and learning ability after growth, and such neuronal malfunctions can be relieved by hypothermia for 3 h soon after neonatal HIE. [ABSTRACT FROM AUTHOR]

Objective: Comparing the value of umbilical cord arterial blood gas (UC-ABG) analysis in the prediction of neonatal mortality and morbidity in the preeclamptic versus healthy pregnancies with preterm birth. Methods: Eight hundred sixteen preterm (born at <37 gestational weeks) neonates with no other morbidities who were born by cesarean section were evaluated. Immediately after delivery, UC-ABG analysis was performed and the neonates were followed. Results: Preeclamptic women had lower umbilical cord blood (UCB) pH (7.2 4 ± 0.1 versus 7.2 7 ± 0.08, p = 0.008) and higher UCB base deficit (BD) (3.5 ± 3.7 versus 2.2 ± 3.4, p = 0.005) compared with controls. In the preeclamptic group, UCB metabolic acidosis (pH < 7.15 and B.D > 8) was not independently associated with neonatal morbidity or mortality, while in the control group UCB metabolic acidosis was independently associated with low 10-min Apgar (OR, 4.9; 95%CI 1.37-18.03), respiratory distress syndrome (OR, 2.37; 95%CI 1.05-6.17), intraventricular hemorrhage (OR, 3.01; 95%CI 1.13-7.99), and neonatal mortality (OR, 17.33; 95%CI 4.51-66.53). Conclusions: The preterm neonates born to preeclamptic mothers have lower UCB pH and higher BD. In these neonates, UCB acidosis is not independently associated with any adverse neonatal outcomes. In contrast, in the preterm neonates born to healthy mothers, UCB metabolic acidosis is independently associated with neonatal mortality and morbidity. [ABSTRACT FROM AUTHOR]

Objective: To determine if absence of sub-clinical intra-amniotic inflammation improves the prognosis of rescue cerclage in cases of bulging membranes.Methods: Cohort study with all women with bulging membranes admitted into our hospital between 2009 and 2013. Patients underwent amniocentesis to quantify amniotic glucose, leukocytes, IL-6 and leukocyte esterase levels and for microbiological culture. All patients without intra-amniotic inflammation or sub-clinical chorioamnionitis were proposed a physical examination-indicated cervical cerclage. Those who did not accept were treated with bed rest.Results: We enrolled 31 women. Median gestational age at diagnosis was 23 + 1 (21–25 + 4) weeks. Median interval until delivery was 12 (3–52.5) d. IL-6 had the highest diagnostic accuracy for good prognosis. Patients with IL6 <2.90 ng/ml were diagnosed later in pregnancy and presented a longer interval until delivery (89 versus 4 d), higher gestational age at delivery (35 + 1 versus 23 + 3 weeks) and a lower rate of prematurity (54.5% versus 100%) and perinatal mortality (0% versus 80%) than those with IL-6 ≥2.90 ng/ml. Rescue cerclage and low Il-6 were the best predictors of good outcome.Conclusion: IL-6 levels in amniotic fluid may be of clinical value for individualizing the management of patients with bulging membranes for placement of rescue cerclage. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the effectiveness of emergency cervical cerclage (ECC) and its effect on the mode of delivery. Patients and methods: Between April 2007 and July 2011 patients attending MH Diyarbakir Obstetrics and Gynecology Hospital and MH Seferihisar State Necat Hepkon Hospital who underwent ECC were included in this retrospective analysis. Results: At the time of ECC, the mean gestational age, cervical length and cervical dilatation were 21.4 ± 2.2 weeks, 4.3 ± 0.8 cm and 11 ± 2.4 mm, respectively. The average time between the procedure and birth was 13.8 ± 4.9 weeks and this period was sufficient to maintain a viable pregnancy ( p < 0.05). In this study, 12 patients (60%) were delivered vaginally and eight (40%) patients delivered with CS (40%). the difference was statistically insignificant ( p = 0.371). Regarding the gestational age at time of delivery, 55% of patients delivered at 36 weeks, 70% at 32 weeks, and 80% of them delivered at 28 weeks. The total live birth rate was 90%. Conclusion: ECC provides satisfactory time for the fetus to gain sufficient viability. Pregnancies with emergency cerclage show no difference in terms of birth method, whether cesarean or vaginal birth, and delivery type does not appears to be linked to ECC. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effectiveness of emergency cervical cerclage and to determine predictors of failure or success in women with cervical incompetence. Methods: Medical records were reviewed for clinical and demographic data, gestational age at time of cerclage, cerclage-delivery interval, gestational age at time of delivery; and birth weight. Predictors of success and failure were analyzed. Result: Forty-three pregnant women between 18 and 25 weeks of gestation were recruited. The mean gestational age at time of cerclage was 21 weeks. The mean cerclage-delivery interval was 64 days. The mean gestation at delivery was 31 weeks and the mean neonatal birth weight was 2166 g. Whether cerclage done before or after 20 weeks, the difference in cerclage-delivery interval was insignificant while the difference in gestational age at time of delivery and neonatal birth weight was significant. Presence of infection, presence of symptoms, membranes through the cervix and dilated cervix >3 cm are frequently associated with failure. Conclusion: Emergency cervical cerclage is effective in prolonging pregnancy and improving neonatal outcome in patient with cervical incompetence. However, large prospective randomized controlled studies are recommended. [ABSTRACT FROM AUTHOR]

Objective: To assess the risk of intra-uterine death (IUD) after external cephalic version (ECV). Methods: In this retrospective cohort study, 1078 consecutive ECVs performed between January 1994 and March 2011 in an University teaching hospital were extracted from the computerized database to examine the risk of IUD after ECV. Results: A total of 1078 consecutive ECVs were performed over the study period. The overall successful rate was 72.8%, the successful rate was 63.1% in nulliparous and 82.7% in multiparous, respectively ( p < 0.001). There was no IUD identified within 24 h after the procedure and there was only one case of IUD (0.09%) that occurred 4 weeks after an uncomplicated ECV. Conclusions: ECV is a safe procedure that does not increase the risk of IUD within and after 24 h of enrolment irrespective of outcome of ECV. Our findings have important clinical implication in terms of patient counseling regarding the decision on term breech management. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to evaluate risk factors for caesarean section (CS) in nulliparous women and to determine the effect of physical activity on ease of labour. Methods: A prospective observational study, including 282 nulliparous women at 37-41 gestational weeks was conducted. Maternal demographic characteristics, obstetric history and Modified Grimby scale for evaluation of physical activity were noted. Patients were classified into spontaneous labour and induction group. Multiple logistic regression model was used to assess independent risk factors for type of delivery. Results: Caesarean rate was increasing with higher educational status ( p < 0.001). Maternal height, maternal and paternal age were higher, whereas dilatation on admission was lower in CS group ( p < 0.05). Maternal age, weight gain and CS rate were higher in induction group ( p < 0.05). Fetal distress as a cause of CS was detected higher in induction group ( p < 0.05). Physical activity has no significant effect on mode of delivery ( p > 0.05). Maternal height ( p = 0.011), and cervical dilatation on admission ( p = 0.004) were identified as predictor factors for CS. Conclusion: Cervical dilatation is the most important negative predictive factor for CS, whereas, moderate physical activity has no effect on mode of delivery. Fetal distress was the most frequent cause of CS in induction group. [ABSTRACT FROM AUTHOR]

Objective. To determine the role of 4-D ultrasonography in prenatal assessment of fetal neurobehavior and in prediction of adverse neurological outcome. Design. Prospective cohort study. Setting. Women Hospital, Hamad Medical Corporation, Qatar. Population. Forty pregnant women between 20 and 38 weeks of gestation with high risk for neurological abnormalities and 40 low risk cases were included. Methods. Prenatal fetal neurological assessment using Kurjak antenatal neurodevelopmental test (KANET). Postnatal neurological assessment was performed using Amiel-Tison's neurological assessment at term (ATNAT) for all live-borns. Main outcome measures. Prediction of fetuses at neurological risk. Results. The difference in the range of KANET score was significant. A significant difference was shown for isolated head anteflexion, isolated eye blinking, facial expressions, mouth movements, isolated hand movements, hand to face movement, finger movements, and general movements. For isolated leg movement and cranial sutures, the difference was not significant. All cases with abnormal KANET proved to be abnormal postnatally. Conclusion. 4-D ultrasonography may have an important role in prenatal assessment of fetal neurobehavior and prediction of adverse neurological outcome. However, further large studies are recommended before the test could be recommended for wider clinical practice. [ABSTRACT FROM AUTHOR]

Objective. To explore whether epidural analgesia (EA) in labor is independent risk factor for neonatal pyrexia after controlling for intrapartum pyrexia. Methods. Retrospective observational study of 480 consecutive term singleton infants born to mothers who received EA in labor (EA group) and 480 term infants delivered to mothers who did not receive EA (NEA group). Results. Mothers in the EA group had significantly higher incidence of intrapartum pyrexia [[54/480 (11%%) vs. 4/480 (0.8%%), OR == 15.1, p < 0.0001]] and neonatal pyrexia [[68/480 (14.2%%) vs. 15/480 (3.1%%), OR == 5.1, p < 0.0001]]. Neonates in the EA group had a median duration of pyrexia of 1 h (maximum 5 h) with a peak temperature within 1 h. Stepwise logistic regression analysis showed that maternal EA was independent risk factor for neonatal pyrexia (>37.5°C) after controlling for intrapartum pyrexia (>37.9°C) and other confounders (OR == 3.44, CI == 1.9-6.3, p < 0.0001). Sepsis work-up was performed significantly more frequently in infants in the EA group [[11.7%% vs. 2.5%%, OR == 5.2, CI == 2.7-9.7, p < 0.0001]] with negative blood cultures. Conclusions. EA in labor is an independent risk factor for pyrexia in term neonates. It is unnecessary to investigate febrile offspring of mothers who have had epidurals unless pyrexia persists for longer than 5 h or other signs or risk factors for neonatal sepsis are present. [ABSTRACT FROM AUTHOR]

Objective. The purpose of this study was to determine whether there is a relationship between the frequency of meconium-stained amniotic fluid (MSAF) and the duration of labor in term singleton gestation. Methods. The clinical characteristics of women who delivered term singleton live newborns between 2001 and 2006 were examined. The cases involving neonates with major congenital anomalies were excluded. Results. (1) The frequency of MSAF in term pregnancies was 18.4%% (806/4376); (2) MSAF was found in only 2.8%% (28/1008) of women who delivered by elective cesarean, but in 23.1%% (778/3368) of women who delivered after the onset of labor ( p < 0.001); (3) The longer the duration of labor (first stage, second stage, or total), the higher the frequency of MSAF ( p < 0.001 for each); this remained significant after adjusting for other confounding variables such as parity, duration of rupture of membranes, gestational age at delivery, and mode of delivery ( p < 0.001 for each). Conclusion. MSAF was found in only 2.8%% (28/1008) of women who delivered before the onset of labor, but in 23.1%% (778/3368) of women who delivered after the onset of labor. The longer the duration of labor, the higher the risk of MSAF in term singleton gestation. [ABSTRACT FROM AUTHOR]

In this case report, we present prenatal and postnatal neurological evaluation of a fetus and newborn from pregnancy complicated with intrauterine growth restriction, fetal hypoxemia, and preterm labor. Despite unfavorable intrauterine conditions, this premature infant showed normal early neurological development that was verified not only by postnatal tests but also with a new prenatal neurological screening test. [ABSTRACT FROM AUTHOR]

Objective. We compared fetal behavior (FB) in high risk and normal pregnancies using four dimensional ultrasound (4DUS). Methods. For assessment of FB in high risk and normal pregnancies, we used a scoring system of Kurjak's antenatal neurological test (KANET). The newborns were assessed by a postnatal neurological test, Amiel-Tison neurological assessment at term (ATNAT). The scores of KANET in high risk ( N = 116) and in normal pregnancies ( N = 110) were compared. After delivery, the results of KANET from both groups were compared with ATNAT test. Results. There was a statistically significant difference between group of high risk and normal pregnancies, for 8 out of 10 parameters in KANET: isolated anteflection of the head, eye blinking, facial expressions, mouth movements, isolated hand movement, hand to face movement, fist and finger movements, general movements. There was no difference for cranial sutures and isolated leg movements. Comparison of KANET and ATNAT showed statistically significant, moderate correlation between the two tests, which means that the neuropediatric exam (ATNAT) confirmed the prenatal 4DUS finding (KANET). Conclusion. The difference of FB between the high risk and normal pregnancies was evident. These preliminary results are promising but further studies have to be done before the test could be recommended for wider clinical practice. [ABSTRACT FROM AUTHOR]

Background. Calcium channel blockers (CCBs) are not licensed for use in pregnancy but are used without robust surveillance to treat hypertension in pregnancy and preterm labour. The objective of this study was to evaluate the fetomaternal safety of CCB in pregnancy by a quantitative systematic review. Methods. Medline (1996–2005), EMBASE (1996–2003), BIOSIS (1993–2003), Current contents (1995–2003), DERWENT DRUGFILE (1983–2003) and Cochrane Library (2005: issue 3). The number of women reporting an adverse event was used to compute a percentage of the total number of women in whom the occurrence of that event or confirmation of its absence was reported. Meta-regression with generalised estimation equations modelling explored reasons for heterogeneity, seeking factors that increased the rates of the most commonly reported adverse events. Findings. Of 269 relevant reports, including 5607 women, adverse fetomaternal events varied according to the total dose of nifedipine and study design. Adverse events were highest amongst women given more than 60 mg total dose of nifedipine [odds ratio (OR) 3.78, 95% confidence interval (CI) 1.27–11.2, p = 0.017] and in reports from case series compared to controlled studies (OR 2.45, 95% CI 1.17–5.15, p = 0.018). Interpretation. Adverse event rates generated from this study provide an evidence base for clinical guidelines and informed patient consent for CCB use in pregnancy. [ABSTRACT FROM AUTHOR]

Objective . To review the literature and evaluate the role of the amniotic fluid index (AFI) on the success of an external cephalic version (ECV). Study design . A computerized search of MEDLINE and Cochrane databases were conducted using ‘breech’, ‘version’, ‘external cephalic version’, ‘amniotic fluid’, and ‘amniotic fluid index’. References from the identified publications were manually searched to identify additional relevant articles. Articles from 1987 to 2004 were included. Results . Of the initial 33 articles discovered, only three remained after exclusions. These articles used different AFI ranges for ‘borderline’ or ‘low–normal’ fluid measurements and therefore could not be combined for analysis. All three studies demonstrated a lower success rate of ECV with lower amniotic fluid volume estimates (AFI 5–8, <10, or <8.6), although none reached statistical significance. Conclusion . Due to limited and dissimilar data, it is impossible to define the lower AFI threshold for an unsuccessful ECV compared with the success of a normal AFI. Although not statistically significant, an AFI <10 may correlate with lower success rates for an ECV. [ABSTRACT FROM AUTHOR]

Background: We aimed to establish if epidural analgesia is associated with a higher incidence of operative vaginal delivery, longer duration of labor and more frequent use of oxytocin than labor without analgesia. Methods: We analyzed a cohort of 207 women with no risk factors who delivered with epidural analgesia in the labor unit of Spedali Civili, Brescia, Italy, during 2001. Length of the first and second stage of labor, mode of delivery, neonatal cord blood pH, neonatal Apgar score and neonatal outcomes were evaluated. Results: Epidural analgesia was performed on request in 6%: in this group (group A) there were 141 (68%) nulliparae and 66 (32%) pluriparae; mean ( ± standard deviation) gestational age at delivery was 39.4 ± 1.3 weeks (range: 34.1-41.5 weeks). In this group, 184 (89%) had vaginal delivery and 23 (11%) delivered by Cesarean section. Among controls (group B), 368 (89%) had a vaginal delivery and 46 (11%) delivered by Cesarean section; vacuum extraction was used in 18 deliveries (9%) in group A and in 13 deliveries (3%) in group B. The duration of the second stage of spontaneous labor in the nulliparae of group A was significantly longer than in group B. No statistically significant differences were found between mean umbilical artery pH values of groups A and B. Conclusion: Our results confirm that epidural analgesia does not affect the rate of Cesarean delivery, while increasing the use of oxytocin augmentation, the duration of the second stage of labor and the rate of instrumental vaginal delivery. [ABSTRACT FROM AUTHOR]