Search

Objective: The aim of this study is to evaluate the possible role of antenatal administration of corticosteroids for fetal lung maturation on short term perinatal outcomes in late FGR.Methods: This cohort study is a secondary analysis of a multicenter prospective observational study, the TRUFFLE-2 feasibility study, conducted between 2017 and 2018 in 33 European perinatal centers. We included women with singleton pregnancy from 32+0 to 36+6 weeks of gestation with a fetus considered at risk for FGR, defined as estimated fetal weight (EFW) or abdominal circumference (AC) <10th centile, or umbilico-cerebral ratio (UCR) >95th centile, or a fall of more than 40 centile points in AC measurement from the 20 weeks scan. The primary adverse outcome was a composite of abnormal condition at birth or major neonatal morbidity.Results: A total of 86 pregnancies who received antenatal corticosteroids (exposed) were matched with non-exposed pregnancies. Both groups were similar regarding gestational age at inclusion (33 weeks), EFW (1673 g) and UCR (0.68), gestational age at delivery (35.5 weeks) and birth weight (1925 g); the presented values are for both groups combined. No significant differences were observed between exposed and non-exposed for composite adverse outcome (28% vs. 24%; p=0.73) or for any of its elements.Conclusion: The present data do not show a beneficial effect of steroids on short term outcomes in fetuses with late FGR. This article is protected by copyright. All rights reserved. [ABSTRACT FROM AUTHOR]

Objectives: To identify antenatal ultrasound markers that can differentiate between simple and complex gastroschisis and assess their predictive value.Methods: This was a prospective nationwide study of pregnancies with isolated fetal gastroschisis that underwent serial longitudinal ultrasound examination at regular specified intervals between 20 and 37 weeks' gestation. The primary outcome was simple or complex (i.e. involving bowel atresia, volvulus, perforation or necrosis) gastroschisis at birth. Fetal biometry (abdominal circumference and estimated fetal weight), the occurrence of polyhydramnios, intra- and extra-abdominal bowel diameters and the pulsatility index (PI) of the superior mesenteric artery (SMA) were assessed. Linear mixed modeling was used to compare the individual trajectories of cases with simple and those with complex gastroschisis, and logistic regression analysis was used to estimate the strength of association between the ultrasound parameters and outcome.Results: Of 104 pregnancies with isolated fetal gastroschisis included, four ended in intrauterine death. Eighty-one (81%) liveborn infants with simple and 19 (19%) with complex gastroschisis were included in the analysis. We found no relationship between fetal biometric variables and complex gastroschisis. The SMA-PI was significantly lower in fetuses with gastroschisis than in healthy controls, but did not differentiate between simple and complex gastroschisis. Both intra- and extra-abdominal bowel diameters were larger in cases with complex, compared to those with simple, gastroschisis (P < 0.001 and P < 0.005, respectively). The presence of intra-abdominal bowel diameter ≥ 97.7th percentile on at least three occasions, not necessarily on successive examinations, was associated with an increased risk of the fetus having complex gastroschisis (relative risk, 1.56 (95% CI, 1.02-2.10); P = 0.006; positive predictive value, 50.0%; negative predictive value, 81.4%).Conclusions: This large prospective longitudinal study found that intra-abdominal bowel dilatation when present repeatedly during fetal development can differentiate between simple and complex gastroschisis; however, the positive predictive value is low, and therefore the clinical usefulness of this marker is limited. © 2019 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology. [ABSTRACT FROM AUTHOR]

Objective: In the TRUFFLE (Trial of Randomized Umbilical and Fetal Flow in Europe) study on the outcome of early fetal growth restriction, women were allocated to one of three groups of indication for delivery according to the following monitoring strategies: (1) reduced fetal heart rate (FHR) short-term variation (STV) on cardiotocography (CTG); (2) early changes in fetal ductus venosus (DV) waveform (DV-p95); and (3) late changes in fetal DV waveform (DV-no-A). However, many infants per monitoring protocol were delivered because of safety-net criteria, for maternal or other fetal indications, or after 32 weeks of gestation when the protocol was no longer applied. The objective of the present posthoc subanalysis was to investigate the indications for delivery in relation to 2-year outcome in infants delivered before 32 weeks to further refine management proposals.Methods: We included all 310 cases of the TRUFFLE study with known outcome at 2 years' corrected age and seven fetal deaths, excluding seven cases with inevitable perinatal death. Data were analyzed according to the allocated fetal monitoring strategy in combination with the indication for delivery.Results: Overall, only 32% of liveborn infants were delivered according to the specified monitoring parameter for indication for delivery; 38% were delivered because of safety-net criteria, 15% for other fetal reasons and 15% for maternal reasons. In the CTG-STV group, 51% of infants were delivered because of reduced STV. In the DV-p95 group, 34% of infants were delivered because of abnormal DV and, in the DV-no-A group, only 10% of infants were delivered accordingly. The majority of infants in the DV groups were delivered for the safety-net criterion of spontaneous decelerations in FHR. Two-year intact survival was highest in the DV groups combined compared with the CTG-STV group (P = 0.05 for live births only, P = 0.21 including fetal death), with no difference between DV groups. A poorer outcome in the CTG-STV group was restricted to infants delivered because of FHR decelerations in the safety-net subgroup. Infants delivered because of maternal reasons had the highest birth weight and a non-significantly higher intact survival.Conclusions: In this subanalysis of infants delivered before 32 weeks, the majority were delivered for reasons other than the allocated monitoring strategy indication. Since, in the DV group, CTG-STV criteria were used as a safety net but in the CTG-STV group, no DV safety-net criteria were applied, we speculate that the slightly poorer outcome in the CTG-STV group might be explained by the absence of DV data. The optimal timing of delivery of fetuses with early intrauterine growth restriction may therefore be best determined by monitoring them longitudinally, with both DV and CTG monitoring. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

The article focuses on the Trial of Randomized Umbilical and Fetal Flow in Europe (TRUFFLE) study which analyzed singleton pregnancies at 26–32weeks of gestation with a diagnosis of fetal growth restriction. The study primarily concluded survival without cerebral palsy or neurosensory impairment. It discusses neurodevelopmental impairment change with gestational age and its relation to neonatal morbidity.

Abstract: Objectives: To explore whether, in early fetal growth restriction (FGR), the longitudinal pattern of fetal heart rate (FHR) short‐term variation (STV) can be used to identify imminent fetal distress and whether abnormalities of FHR recordings are associated with 2‐year infant outcome. Methods: The original TRUFFLE study assessed whether, in early FGR, delivery based on ductus venosus (DV) Doppler pulsatility index (PI), in combination with safety‐net criteria of very low STV on cardiotocography (CTG) and/or recurrent FHR decelerations, could improve 2‐year infant survival without neurological impairment in comparison with delivery based on CTG monitoring only. This was a secondary analysis of women who delivered before 32 weeks and had consecutive STV data recorded > 3 days before delivery and known infant outcome at 2 years of age. Women who received corticosteroids within 3 days of delivery were excluded. Individual regression line algorithms of all STV values, except the last one before delivery, were calculated. Life tables and Cox regression analysis were used to calculate the daily risk for low STV or very low STV and/or FHR decelerations (below DV group safety‐net criteria) and to assess which parameters were associated with this risk. Furthermore, it was assessed whether STV pattern, last STV value or recurrent FHR decelerations were associated with 2‐year infant outcome. Results: One hundred and forty‐nine women from the original TRUFFLE study met the inclusion criteria. Using the individual STV regression lines, prediction of a last STV below the cut‐off used by the CTG monitoring group had sensitivity of 42% and specificity of 91%. For each day after study inclusion, the median risk for low STV (CTG group cut‐off) was 4% (interquartile range (IQR), 2–7%) and for very low STV and/or recurrent FHR decelerations (below DV group safety‐net criteria) was 5% (IQR, 4–7%). Measures of STV pattern, fetal Doppler (arterial or venous), birth‐weight multiples of the median and gestational age did not usefully improve daily risk prediction. There was no association of STV regression coefficients, a low last STV and/or recurrent FHR decelerations with short‐ or long‐term infant outcomes. Conclusion: The TRUFFLE study showed that a strategy of DV monitoring with safety‐net criteria of very low STV and/or recurrent FHR decelerations for delivery indication could increase 2‐year infant survival without neurological impairment. This post‐hoc analysis demonstrates that, in early FGR, the daily risk of abnormal CTG, as defined by the DV group safety‐net criteria, is 5%, and that prediction is not possible. This supports the rationale for CTG monitoring more often than daily in these high‐risk fetuses. Low STV and/or recurrent FHR decelerations were not associated with adverse infant outcome and it appears safe to delay intervention until such abnormalities occur, as long as DV‐PI is within normal range. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

The aim of this Editorial is to review Level I evidence regarding the effectiveness of interventions in women identified as having short cervix on mid-trimester ultrasound, discuss some of the remaining challenges and outline areas for future research. [ABSTRACT FROM AUTHOR]

Linked article: This Correspondence comments on Burger et al. Click here to view the article. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective The use of fetal growth charts assumes that the optimal size at birth is at the 50th birth-weight centile, but interaction between maternal constraints on fetal growth and the risks associated with small and large fetal size at birth may indicate that this assumption is not valid for perinatal mortality rates. The objective of this study was to investigate the distribution and timing (antenatal, intrapartum or neonatal) of perinatal mortality and morbidity in relation to birth weight and gestational age at delivery. Methods Data from over 1 million births occurring at 28-43 weeks' gestation from singleton pregnancies without congenital abnormalities in the period from 2002 to 2008 were collected from The Netherlands Perinatal Registry. The distribution of perinatal mortality according to birth-weight centile and gestational age at delivery was studied. Results In the 1 170 534 pregnancies studied, there were 5075 (0.43%) perinatal deaths. The highest perinatal mortality occurred in those with a birth weight below the 2.3rd centile (25.4/1000 births) and the lowest mortality was in those with birth weights between the 80th and 84th centiles (2.4/1000 births), according to routinely used growth charts. Antepartum deaths were lowest in those with birth weight between the 90th and 95th centiles. Data were almost identical when the analysis was restricted to infants born at ≥ 37 weeks' gestation. Conclusion From an immediate survival perspective, optimal fetal growth requires a birth weight between the 80th and 84th centiles for the population. Median birth weight in the population is, by definition, substantially lower than these centiles, implying that the majority of fetuses exhibit some form of maternal constraint on growth. This finding is consistent with adaptations that have evolved in humans in conjunction with a large head and bipedalism, to reduce the risk of obstructed delivery. These data also fit remarkably well with those on long-term adult cardiovascular and metabolic health risks, which are lowest in cases with a birth weight around the 90th centile. Copyright © 2014 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

Objectives: To determine whether there is an association between sonographically assessed hyper- or hypocoiling of the umbilical cord and the presence of trisomy 21, to provide reference values for the antenatal umbilical coiling index (aUCI) at a gestational age of 16-21 weeks and to determine whether these measurements are reliable and reproducible. Methods: This was a prospective study of 737 pregnancies in which the aUCI was measured between 16 and 21 weeks of gestation by ultrasound at the time of amniocentesis. The aUCI was calculated as the reciprocal value of the mean length of one complete coil in centimeters. We created reference curves and studied the relationship with trisomy 21 and other chromosomal defects. In 30 pregnancies we studied the intra- and interobserver variation in measurements using Bland-Altman plots with associated 95% limits of agreement and intraclass correlation coefficients. Results: aUCI was found to be non-linearly related to gestational age at 16-21 weeks and reference curves were created for the mean aUCI and the 2.3(rd) , 10(th) , 90(th) and 97.7(th) percentiles. There was no significant difference in aUCI values between the reference group (n = 714) and cases with trisomy 21 (n = 16) or other aneuploidies (n = 7) (one-way ANOVA, P = 0.716). There was good intra- and interobserver agreement in aUCI measurements. Conclusions: The aUCI can be measured reliably and varies according to gestational age at 16-21 weeks. The aUCI was not significantly associated with trisomy 21 or other chromosomal defects. [ABSTRACT FROM AUTHOR]

Objective To assess fetal growth profiles in an unselected group of pregnant women with either Type-1 diabetes (DM1), Type-2 diabetes (DM2) or gestational diabetes (GDM), with emphasis on intergroup differences and development of disproportionate fetal growth and macrosomia. Methods Second- and third-trimester longitudinal ultrasound measurements of fetal growth were made in 77 women with DM1, 68 women with DM2 and in 99 women with GDM. Altogether 897 ultrasound examinations were performed and 145 uncomplicated pregnancies with 843 ultrasound examinations were included as controls. Ultrasound data included head circumference (HC), abdominal circumference (AC), femur length (FL) and HC/A C ratio. Results The AC, but not HC and FL, evolved differently in diabetic pregnancies, with a smaller A C in early pregnancy and larger AC at term (significant for DM1 and DM2). The most striking differences were found for the HC/AC ratio, especially in DM1 pregnancies. HC/A C growth trajectories of both macrosomic and non-macrosomic fetuses differed from that of the controls, and the HC/AC ratio at term was lower in all diabetic subgroups except in non-macrosomic DM2 cases. Conclusion We found altered (disproportionate) fetal growth in macrosomic and non-macrosomic fetuses of women with DM1, DM2 and GDM. This indicates that the abnormal intrauterine environment affects the majority of these infants. Growth profiles differed among these groups, the most prominent growth deviations being found in the fetuses of women with DM1. The latter was most probably caused by poor glucose control. In monitoring fetal growth in diabetic pregnancies the HC/A C ratio should be used to assess altered fetal growth. [ABSTRACT FROM AUTHOR]

ABSTRACT Objective To establish reference curves for size and volume of the fetal kidney, renal pelvis and adrenal gland, as measured using ultrasound from the 15th week of gestation. Methods This was a prospective, longitudinal study of 96 fetuses in low-risk singleton pregnancies, in which we performed serial ultrasound examinations at 4-week intervals. The length and anteroposterior and transverse diameters of both kidneys, the anteroposterior and transverse diameters of the renal pelvises and the length of the adrenal glands were measured three times at each examination, with the average being used for further analysis. Reference charts were constructed using multilevel statistical analysis and comparisons were made with previously published charts derived from cross-sectional data. Results We present nomograms for fetal kidney dimensions and volume, renal pelvis dimensions and adrenal gland length. The new charts show differences in shape and have narrower percentile bands in comparison to previously published reference ranges. Conclusions These new charts of measurements of the fetal kidney, renal pelvis and adrenal gland, from a prospective, longitudinal study, may be useful in the diagnosis and assessment of pathology of the kidney and adrenal gland. [ABSTRACT FROM AUTHOR]

Objective In a refugee camp on the Thai-Burmese border, accurate dating of pregnancy relies on ultrasound measurements obtained by locally trained health workers. The aim of this study was to substantiate the accuracy of fetal biometry measurements performed by locally trained health workers by comparing derived reference equations with those published for Asian and European hospitals. Methods This prospective observational study included 1090 women who had a dating crown-rump length (CRL) scan and one study-appointed ultrasound biometry scan between 16 and 40 weeks of gestation. The average of two measurements of each of biparietal diameter, head circumference, abdominal circumference and femur length was used in a polynomial regression model for the mean and SD against gestational age (GA). The biometry equations obtained were compared with published equations of professional sonographers from Asian and European hospitals by evaluation of the SD and Z-scores of differences between models. Results Reference equations of biometric parameters were found to fit cubic polynomial models. The observed SD values, for any given GA, of fetal biometric measurements obtained by locally trained health workers were lower than those previously reported by centers with professional sonographers. For nearly the entire GA range considered, the mean values of the Asian and European equations for all four biometric measurements were within the 90% expected range (mean ± 1.645 SD) of our equations. Conclusion Locally trained health workers in a refugee camp on the Thai-Burmese border can obtain measurements that are associated with low SD values and within the normal limits of published Asian and European equations. The fact that the SD values were lower than in other studies may be explained by the use of the average of two measurements, CRL dating or motivation of the locally trained sonographers. Copyright © 2012 ISUOG. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective To assess trends in levels of biochemical markers, uterine artery (UtA) pulsatility index (PI) and maternal blood pressure changes over time and study their relationships in uncomplicated first-trimester pregnancies. Methods The study population comprised 86 women with singleton pregnancies. In each woman, a blood sample was collected at 6-7, 8-9, 10-11 and 12-13 weeks' gestation. At the same visit blood pressure was measured and ultrasound examination was performed to measure the crown-rump length and Doppler flow velocity waveform patterns of both UtAs. Serum concentrations of pregnancy-associated plasma protein-A (PAPP-A), free β-human chorionic gonadotropin (β-hCG), A disintegrin and metalloprotease domain-containing protein-12 (ADAM-12), placental protein-13 (PP-13) and placental growth factor (PlGF) levels were measured in thawed specimens using an automated time-resolved fluorescence assay. Summary curves were created to describe normal ranges and trends over time. The data were analyzed with a linear mixed model with the log-transformed marker values as dependent variables. This allowed for flexible modeling of patterns over time. Results Sixty-eight pregnancies had an uneventful outcome, with the birth of an appropriate-for-gestational-age (AGA) infant. In these pregnancies serum PAPP-A, ADAM-12, PP-13 and PlGF levels increased with gestational age. The UtA-PI decreased and the mean arterial blood pressure remained constant. There were no significant correlations between maternal age, birth-weight percentile, gender and blood pressure and any of the biochemical markers. The serum markers were highly correlated with each other except for β-hCG. A negative correlation was found between most biomarkers and UtA-PI, especially from 10 weeks onwards. Serum concentrations of ADAM-12 and PP-13 were lower in a small-for-gestational-age (SGA) subgroup born at term ( n = 6), the former statistically significantly ( P = 0.031), the latter non-significantly ( P = 0.054), whereas UtA-PI was significantly higher ( P = 0.02). Biomarker concentrations in 12 women delivering a large-for-gestational age infant did not differ from those delivering AGA neonates. Conclusion There is a relationship between biochemical markers of early placentation and downstream resistance to flow in the UtAs in low-risk uncomplicated pregnancies, indicating differences in placentation. In a small series of SGA infants born at term we could demonstrate differences as compared to normal pregnancies, with potential value for screening. Copyright © 2011 ISUOG. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective To study perinatal mortality rates in a cohort of 465 monochorionic (MC) twins without twin-twin transfusion syndrome (TTS) born at 32 weeks of gestation or later since reported interauterine fetal death (IUFD) rates >32 weeks of gestations in the literature vary, leading to varying recommendations on the optimal timing of delivery, and to investigate the relation between perinatal mortality and mode of delivery. Design Multicentre retrospective cohort study. Setting Ten perinatal referral centres in the Netherlands. Population All MC twin pregnancies without TTTS delivered at ⩾32 weeks of gestation between January 2000 and December 2005. Methods The medical records of all MC twin pregnancies without TTTS delivered at the ten perinatal referral centres in the Netherlands between January 2000 and December 2005 were reviewed. Main outcome measures Perinatal mortality in relation to gestational age and mode of delivery at ⩾32 weeks of gestation. Results After 32 weeks of gestation, five out of 930 fetuses died in utero and there were six neonatal deaths (6 per 1000 infants). In women who delivered ⩾37 weeks, perinatal mortality was 7 per 1000 infants. Trial of labour was attempted in 376 women and was successful in 77%. There were three deaths in deliveries with a trial of labour (8 per 1000 deliveries), of which two were related to mode of delivery. Infants born by caesarean section without labour had an increased risk of neonatal morbidity and respiratory distress syndrome. Conclusions In MC twin pregnancies the incidence of intrauterine fetal death is low ⩾32 weeks of gestation. Therefore, planned preterm delivery before 36 weeks does not seem to be justified. The risk of intrapartum death is also low, at least in tertiary centres. [ABSTRACT FROM AUTHOR]

Objective To evaluate the modeled predictive value of three current screening markers (pregnancy-associated plasma protein-A (PAPP-A), free β-human chorionic gonadotropin (free β-hCG), and nuchal translucency (NT)) and four potential screening markers (a disintegrin and metalloprotease 12 (ADAM12), total hCG, placental protein 13 (PP13), and placental growth factor (PlGF)) for Down syndrome using different screening strategies. Methods All markers were measured in stored first-trimester serum of 151 Down syndrome cases and 847 controls. All marker levels were expressed as gestational age-specific multiples of the median (MoMs) and comparisons were made using the Mann-Whitney U-test. Detection rates (DRs) for fixed false-positive rates (FPRs) were modeled using different screening strategies. Results Significantly different median MoMs for Down syndrome cases compared to controls were found for PAPP-A (0.49 vs. 1.00; P < 0.0001), free β-hCG (1.70 vs. 1.01; P < 0.0001), ADAM12 (0.89 vs. 1.00; P < 0.0001), total hCG (1.28 vs. 1.00; P < 0.0001), PlGF (0.80 vs. 1.00; P < 0.0001) and NT (1.74 vs. 1.01; P < 0.0001). The lower PP13 MoM in Down syndrome cases (0.91 vs. 1.00) was not statistically significant ( P = 0.061). Adding the four new markers to the current screening strategy (i.e. first-trimester combined test) led to an increase in DR from 77% to 80% at a 5% FPR. The modeled application of a two-sample screening strategy (with some markers assessed early and others later in the first trimester) increased the DR to 89%. In a two-step contingent screening model, using an intermediate risk range of 1 in 100 to 1 in 2000 at biochemical screening (using all markers), the overall DR was 77%, but it was predicted that only 33% of women would require referral for NT measurement. Conclusions First-trimester Down syndrome screening may be improved by adding new markers to the current screening test and by applying different screening strategies. The application of a two-sample screening model resulted in the highest predicted DR, but this should be confirmed in population-based prospective studies. Copyright © 2011 ISUOG. Published by John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Rijken M, Rijken J, Papageorghiou A, Kennedy S, Visser G, Nosten F, McGready R. Malaria in pregnancy: the difficulties in measuring birthweight. BJOG 2011;118:671-678. Recommendations for interventions to control malaria in pregnancy are often based on studies using birthweight as the primary endpoint. Differences in birthweight may be attributable partly to methodological difficulties. We performed a structured search of the literature using 'malaria', 'pregnancy' and 'birth weight' as search terms. Of the clinical trials reporting birthweight, only 33% (14/43) gave information about the timing of the measurement and details on the scales used. Seventy seven per cent explained how gestational age was estimated. We propose a standardised method for the measurement and reporting of birthweight in future studies. [ABSTRACT FROM AUTHOR]

Please cite this paper as: Kuc S, Wortelboer E, Koster M, de Valk H, Schielen P, Visser G. Prediction of macrosomia at birth in type-1 and 2 diabetic pregnancies with biomarkers of early placentation. BJOG 2011;118:748-754. To evaluate the value of first trimester placental biomarkers (fβ -hCG, PAPP-A, ADAM12, PP13 and PlGF) and fetal nuchal translucency (NT) in the prediction of macrosomia at birth in pregestational type-1 and type-2 diabetes (PGDM). Nested case-control study. Routine first-trimester combined test. A total of 178 PGDM and 186 control pregnancies. ADAM12, PP13 and PlGF concentrations were measured in stored first-trimester serum, previously tested for fβ-hCG and PAPP-A. All concentrations were expressed as multiples of the median (MoM). Where applicable, the median MoMs of PGDM and control pregnancies were compared in relation to birthweight centiles (≤90th centile, non-macrosomic, versus >90 centile, macrosomic). Model-predicted detection rates for fixed false-positive rates were obtained for statistically significant markers, separately and in combination. Prediction of macrosomia in diabetic pregnancies. In the PGDM group, median ADAM12 MoM (0.88; P = 0.007) was lower than in the controls. Subgroup analyses showed that median MoMs of PAPP-A (0.65), ADAM12 (0.85), PP13 (0.81) and PlGF (0.91) were only reduced in the PGDM non-macrosomic birthweight subgroup ( n = 93) compared with other weight subgroups. In the PGDM macrosomic birthweight subgroup ( n = 69), MoMs of all markers were comparable with the control birthweight subgroups. The screening performance for macrosomia at birth in the PGDM group provided a detection rate of 30% for a 5% false-positive rate (FPR) and 43% for a 10% FPR. Macrosomia at birth in PGDM pregnancies may be predicted by normal levels of PAPP-A, ADAM12, PP13 and PlGF already in the first trimester of pregnancy. Fetal birthweight in PGDM offspring is partially determined by placental development during the first trimester of pregnancy. The present increase in fetal macrosomia may be related to better early glycemic control and placentation. [ABSTRACT FROM AUTHOR]

Objective To determine the clinical relevance of maternal characteristics and first-trimester serum concentrations of pregnancy-associated plasma protein A (PAPP-A) and free beta human chorionic gonadotrophin (fβ-hCG) in predicting placenta-related complications, miscarriage and preterm delivery. Design, Setting and Population A historical cohort study of data of the National Institute for Public Health and the Environment of first-trimester screening tests performed between July 2002 and May 2006 was done. Data from 28 566 (64.1%) tests were eligible for analysis. Methods By logistic regression, predictive rules were made based on PAPP-A and fβ-hCG concentrations, maternal smoking, maternal weight and age, low birth weight, stillbirth and hypertensive disorders, miscarriage and preterm birth. Predictive values were analysed with the area under the curve (AUC) of receiver operating curves (ROC). Results Predictive for placenta-related complications were low PAPP-A, low fβ-hCG, smoking and weight (AUC 54%). For miscarriage low PAPP-A, low fβ-hCG and maternal age (MA) were predictive (AUC 78%) and for preterm delivery low PAPP-A, smoking, MA and maternal weight (AUC 55%). Conclusion Only the predictive model for miscarriage had a clinically relevant predictive value of 28%. Results together do not justify closer surveillance of chromosomally normal pregnancies with PAPP-A or fβ-hCG levels below the fifth percentile. Copyright © 2010 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective: To describe the individual intrauterine growth patterns of fetuses of insulin-dependent (Type-1) diabetic women and to examine determinants of overgrowth (macrosomia) and its timing. Methods: This retrospective longitudinal study examined the developmental trajectories of fetal abdominal circumference (AC) and biparietal diameter in 76 Type-1 diabetic women with singleton pregnancies. Latent class analysis was used to identify subgroups of patients with a shared fetal AC growth trajectory. Subsequently, maternal factors, including glycemic control as assessed by glycosylated hemoglobin (HbA1c), were examined to see whether they had any effect on fetal growth. Results: Four subgroups with different AC growth patterns were identified. Differences in birth weight between the distinct subgroups were related to the shape of the AC growth velocity curve over gestation. Acceleration of AC growth commencing before or after 25 weeks' gestation was associated with the birth of a heavy or large-for-dates baby in 94 and 56% of cases, respectively. Poor glycemic control (HbA1c > 7.0%) during the periconception period or before 12 weeks' gestation was a modest predictor of midtrimester growth in AC. Other diabetes-related factors, fetal sex, parity, or maternal weight/obesity were unrelated to the fetal growth pattern. Conclusion: The findings suggest that an individual fetus's growth trajectory is set early in gestation and that the contemporaneous degree of maternal glycemia plays a role in determining birth weight. [ABSTRACT FROM AUTHOR]

The article presents a study which describes the individual intrauterine growth patterns of fetuses of Type 1 diabetic women. The study uses latent class analysis (LCA) to identify subgroups of homogeneous cases and Bayesian information criterion (BIC) to determine the optimal number of patients' clusters. The results show that growth trajectory of individual fetus is set in the early stage and the contemporaneous degree of maternal glycemia functions a role in birth weight determination.

Objective In a previous discovery study, we identified seven potential screening markers for Down syndrome (DS). Here, we report on an extended study to validate the discriminative potential of these markers. Methods Concentrations of the seven analytes were measured using bead-based multiplexed immunoassays in maternal serum from 27 DS pregnancies and 27 matched controls. Control samples were matched to the cases by gestational age (exact day), maternal weight ( ± 5 kg), and maternal age ( ± 1 year) and by closest sample date. Prediction values were obtained for current screening markers [pregnancy-associated plasma protein A (PAPP-A), free beta human chorionic gonadotrophin (fβ-hCG) and nuchal translucency (NT)] and seven markers identified before based on concentration fold ratios between DS and controls. Models were fitted based on data of the discovery study or this study and also tested on both datasets. Results A significantly higher fold ratio was only found for epidermal growth factor (EGF) (−1.96; p = 0.006). In the prediction model for the current dataset, EGF improved the detection rate (DR) of DS by 5.7% [at a fixed 5% false-positive rate (FPR)] when added to the currently used screening markers. Conclusions Validation of previously identified biomarkers only confirmed EGF for further consideration as a DS screening marker. This underlines the importance of validating biomarkers; in this study, limiting the range of plausible biomarkers to only one suitable biomarker. Copyright © 2010 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Please cite this paper as: de Graaf J, Ravelli A, Visser G, Hukkelhoven C, Tong W, Bonsel G, Steegers E. Increased adverse perinatal outcome of hospital delivery at night. BJOG 2010;117:1098–1107. Objective To determine whether delivery in the evening or at night and some organisational features of maternity units are related to perinatal adverse outcome. Design A 7-year national registry-based cohort study. Setting All 99 Dutch hospitals. Population From nontertiary hospitals ( n = 88), 655 961 singleton deliveries from 32 gestational weeks onwards, and, from tertiary centres ( n = 10), 108 445 singleton deliveries from 22 gestational weeks onwards. Methods Multiple logistic regression analysis of national perinatal registration data over the period 2000–2006. In addition, multilevel analysis was applied to investigate whether the effects of time of delivery and other variables systematically vary across different hospitals. Main outcome measures Delivery-related perinatal mortality (intrapartum or early neonatal mortality) and combined delivery-related perinatal adverse outcome (any of the following: intrapartum or early neonatal mortality, 5-minute Apgar score below 7, or admission to neonatal intensive care). Results After case mix adjustment, relative to daytime, increased perinatal mortality was found in nontertiary hospitals during the evening (OR, 1.32; 95% CI, 1.15–1.52) and at night (OR, 1.47; 95% CI, 1.28–1.69) and, in tertiary centres, at night only (OR, 1.20; 95% CI, 1.06–1.37). Similar significant effects were observed using the combined perinatal adverse outcome measure. Multilevel analysis was unsuccessful; extending the initial analysis with nominal hospital effects and hospital–delivery time interaction effects confirmed the significant effect of night in nontertiary hospitals, whereas other organisational effects (nontertiary, tertiary) were taken up by the hospital terms. Conclusion Hospital deliveries at night are associated with increased perinatal mortality and adverse perinatal outcome. The time of delivery and other organisational features representing experience (seniority of staff, volume) explain hospital-to-hospital variation. [ABSTRACT FROM AUTHOR]

The article presents a study which examines the significance of ante-natal and perinatal variables on short- and long-term result of preterm development restricted fetus with umbilical artery (UA) Doppler abnormalities. The study uses a group study of 180 neonates with birth weight over 10th percentile and gestational age at delivery greater than 34 weeks using ultrasound examination of the UA. Results show that neonatal and overall mortality were figured by low gestational age at delivery.

Objectives To study the distributions of pregnancy-associated plasma protein A (PAPP-A), the free β subunit of human chorion gonadotrophin (fβ-hCG), A Disintegrin and Metalloprotease 12 (ADAM12) and Placental Protein 13 (PP13) in first trimester twin pregnancies. Methods Serum marker concentrations were measured in monochorionic and dichorionic twin pregnancies and singleton controls to study differences in multiples of the gestation-specific normal medians (MoMs). Results Median PAPP-A and fβ-hCG MoMs were 2.03 and 1.87 for monochorionic twins ( n = 116) and 2.18 and 1.89 for dichorionic twins ( n = 650). Furthermore, ADAM12 and PP13 MoMs were 1.66 and 1.56 for monochorionic twins ( n = 51) and 1.64 and 1.53 for dichorionic twins ( n = 249). No statistically significant differences between monochorionic and dichorionic twin pregnancies were found. Correlations between markers in these pregnancies did not differ from singletons. Conclusion For first-trimester screening, different parameters for monochorionic and dichorionic twin pregnancies is not necessary. Furthermore, if ADAM12 and PP13 will be adopted as screening markers, the presented median MoM values, standard deviations and correlation coefficients for twin pregnancies may contribute to a proper twin risk estimation. Copyright © 2010 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective To determine whether Placental Protein 13 (PP13) could be an additional marker in first trimester screening for aneuploidies. Methods To evaluate differences in multiples of the gestation-specific normal median (MoMs), PP13 concentrations were measured in serum samples from Down syndrome, trisomy 18 and 13 affected pregnancies and euploid singleton pregnancies (four for each case matched for duration of storage, maternal weight and age). Results The PP13 MoM in Down syndrome cases ( n = 153) was 0.91 [not statistically significant from controls ( n = 853); P = 0.06; Wilcoxon rank sum test, two-tail]. PP13 MoMs were decreased in trisomy 18 ( n = 38-median MoM 0.64; P < 0.0001) and trisomy 13 cases ( n = 23-median MoM 0.46; P < 0.0001). There was a slight upward trend in MoM values of the Down syndrome cases with gestational weeks. The PP13 MoM was significantly correlated with the pregnancy associated plasma protein-A MoM and the free β-subunit of human chorion gonadotrophin (fβ-hCG) MoM. Conclusion PP13 does not seem to be a good marker for Down syndrome. PP13 MoMs are, however, significantly lower in trisomy 18 and 13 pregnancies. The addition of PP13 to the current screening test could be valuable for improving the discrimination of aneuploid from euploid pregnancies. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective To identify antepartum and intrapartum indicators of obstetric interventions during the expulsive second-stage arrest of labour. Design Retrospective cohort study. Setting The Netherlands. Population A cohort of 389 086 women with singleton, cephalic, term, live-birth deliveries from 2002 to 2004 who had entered the expulsive second stage of labour. Of all these deliveries, 37 899 (9.7%) were complicated by expulsive second-stage arrest of labour. Women with a prior Caesarean section or women undergoing an elective Caesarean section were excluded. Methods All deliveries in the Netherlands from 2002 to 2004 were registered in the Netherlands Perinatal Registry, which contains the linked and validated data of three databases. Uni- and multivariable logistic regression analyses were performed. Main outcome measures Ante- and intrapartum indicators for interventions during expulsive second-stage arrest of labour. Results Primiparous delivery was the most important antepartum indicator for intervention during expulsive second-stage arrest. Using multivariable analysis the following antepartum indicators were associated with intervention for expulsive second-stage arrest of primiparous labour: maternal age, gestational age, diabetes, hypertension and labour induction. Prominent intrapartum indicators for primiparous deliveries were fetal head position and oxytocin augmentation. Conclusion Multiple significant antepartum and intrapartum indicators associated with intervention for expulsive second-stage arrest of labour were identified in this large retrospective study. Prominent were the associations of parity, maternal age and fetal head position with expulsive second-stage arrest. The identified factors should be further evaluated in prospective studies that aim to develop prediction models. [ABSTRACT FROM AUTHOR]

Objective To evaluate healthcare utilisation by children who were exposed to antidepressant drug use during pregnancy and those whose mothers stopped using antidepressants before pregnancy compared with a control group. Design Cohort study. Setting Health insurance records in the Netherlands. Population A total of 38 602 children born between 2000 and 2005. Methods Survey of child healthcare utilisation in relation to gestational antidepressant use. Main outcome measure Healthcare utilisation rates during the first year of life, with special emphasis to medical care related to cardiac disease. Results Children of mothers who used antidepressants during pregnancy showed increased healthcare use during the first year of life, independent of the mother’s healthcare use. The relative risk of more than two visits to general practitioners was 1.5 (95% confidence interval, CI: 1.3–1.8) in the continuous antidepressant users group and 1.3 (95% CI: 1.2–1.5) in the group of children whose mothers stopped taking medication. In both study groups there was a trend towards more drug use for infections and inflammation compared with the control group. Children continuously exposed to antidepressants had an increased risk of cardiac interventions such as cardiovascular surgery or heart catheterisation, relative risk of 5.6 (95% CI: 1.8–17.4). The risk of physiotherapy was twice as high in the antidepressant group compared with the control group (relative risk 2.0; 95% CI: 1.5–2.6). Conclusion Antidepressant use during pregnancy is associated with increased child healthcare utilisation and increased risk of major cardiac interventions in early childhood. [ABSTRACT FROM AUTHOR]

Objectives: Ultrasound examination of the fetus is a powerful tool for assessing gestational age and detecting obstetric problems but is rarely available in developing countries. The aim of this study was to assess the intraobserver and interobserver agreement of fetal biometry by locally trained health workers in a refugee camp on the Thai-Burmese border.Methods: One expatriate doctor and four local health workers participated in the study, which included examinations performed on every fifth pregnant woman with a singleton pregnancy between 16 and 40 weeks' gestation, and who had undergone an early dating ultrasound scan, attending the antenatal clinic in Maela refugee camp. At each examination, two examiners independently measured biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC) and femur length (FL), with one of the examiners obtaining duplicate measurements of each parameter. Intraobserver measurement error was assessed using the intraclass correlation coefficient (ICC) and interobserver error was assessed by the Bland and Altman 95% limits of agreement method.Results: A total of 4188 ultrasound measurements (12 per woman) were obtained in 349 pregnancies at a median gestational age of 27 (range, 16-40) weeks in 2008. The ICC for BPD, HC, AC and FL was greater than 0.99 for all four trainees and the doctor (range, 0.996-0.998). For gestational ages between 18 and 24 weeks, interobserver 95% limits of agreement corresponding to differences in estimated gestational age of less than +/- 1 week were calculated for BPD, HC, AC and FL. Measurements by local health workers showed high levels of agreement with those of the expatriate doctor.Conclusions: Locally trained health workers working in a well organized unit with ongoing quality control can obtain accurate fetal biometry measurements for gestational age estimation. This experience suggests that training of local health workers in developing countries is possible and could allow effective use of obstetric ultrasound imaging. [ABSTRACT FROM AUTHOR]

The article presents a study on the function of left ventricular size (LV) in fetuses with isolated left-sided congenital diaphragmatic hernia (CDH) and the effect of endoluminal tracheal occlusion (FETO) on the fetal heart. It notes that 27 fetuses with isolated left-sided CDH were assessed to determine cardiac axis, LV diameters, ejection fraction, shortening fraction, mitral E/A index and myocardial performance index (MPI). CDH and FETO were found to have no impact in LV cardiac function.

The article presents a study which aims to determine which prenatal ultrasound findings can predict the survival and mental and motor functioning of children with spina bifida. The study uses sample of 41 live-born children who were prenatally diagnosed with spina bifida. Results of the study show that lesion levels and head circumference on prenatal ultrasound are predictive factors to survival of children with spina bifida.

Objective To evaluate the potential of maternal serum A Disintegrin And Metalloprotease 12-S (ADAM12s) as an additional marker for the combined test in the Dutch first-trimester national Down syndrome (DS) screening program. Methods Serum samples were collected between 2004 and 2007 as part of the national program. A total of 218 singleton cases of trisomy 21 (DS), 62 trisomy 18 (Edwards syndrome) and 29 trisomy 13 (Patau syndrome) were identified. All cases were matched with controls for gestation, maternal weight and maternal age. The serum concentration of ADAM12s was determined 'blind' to outcome and expressed in multiples of the gestation-specific median for controls (MoM). Results The median ADAM12s was 1.00 MoM in controls and in the DS cases at 8, 9, 10, 11, 12, 13 weeks it was 0.45 ( n = 3), 0.73 (22), 0.74 (53), 0.85 (37), 0.92 (71), 1.06 (32) MoM, respectively. The median for trisomy 18 was 0.85 MoM and for trisomy 13 0.63 MoM. Conclusion The ADAM12s MoM values were clearly reduced in early first-trimester for all trisomies. However, the screening performance for DS did not greatly improve adding ADAM12s. ADAM12s could be an additional biochemical marker for first-trimester screening for trisomies other than DS. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives To identify new discriminative biomarkers for Down syndrome (DS) pregnancies using a bead-based multiplexed immunoassay, and to use the newly identified biomarkers to construct a prediction model for non-invasive DS screening. Methods Maternal serum samples of 14 DS pregnancies and 15 matched controls were analyzed with a bead-based multiplexed immunoassay containing immunoassays for 90 different analytes. Potential biomarkers were selected on the basis of concentration fold ratios between DS and control samples. For these markers and the current screening markers (pregnancy-associated plasma protein-A, PAPP-A; free beta subunit of human chorion gonadotrophin (fβ-hCG) and nuchal translucency) prediction values were obtained and used to calculate detection rates (DR) at a 5% false positive rate. Results Seven potential biomarkers of which the fold ratio exceeded 1.3 or −1.3 were selected for further analysis. All 14 DS cases in this study were detected using the combination of all currently used and newly identified markers. The modelled DR for all markers extrapolated to the general pregnant population was 82.5%, compared to a modelled DR of 56.2% for the current screening markers. Conclusion This study demonstrates the possibility of improving the performance of the current first-trimester DS screening by addition of new biomarkers, which were identified using bead-based multiplexed immunoassays. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The article presents a quantitative study on the quality of the nuchal translucency (NT) measurements in The Netherlands in 2005-2006 and its relevance to screening performance. Analysis of quality standards is done to study the record of NT measurements from the Dutch Institute for Public Health and the Environment (RIVM). Results show that only 22% met the requirements of quality standards. It concludes that monitoring prompted improvements in the accuracy of NT measurements.

Objective To study the performance of the first-trimester combined test between 2004 and 2006 compared to a previous period to investigate changes in time and identify reasons for sub-optimal performance. Methods Serum samples were analysed for pregnancy-associated plasma protein A (PAPP-A) and the free β subunit of human chorionic gonadotrophin (fβ-hCG). Nuchal translucency (NT) was measured between 10 and 14 weeks. Tests were considered screen positive, if their calculated Down syndrome (DS) risk was at least 1 in 250 at term. Results A total of 20 293 singleton pregnancies were included in the analysis. The median maternal age fell from 35.7 to 34.3 years. The overall median weight-corrected multiple of the median (MoM) values of PAPP-A and fβ-hCG were 1.12 and 1.03, respectively. The median MoM value of NT was 0.89 and increased from 0.82 to 0.96. Sixty-six DS cases were detected by the screening test. The detection rate (DR) for DS was 75.9%, with a FPR of 3.3%. Conclusion The performance of the first-trimester test has improved over the years. A better performance of the NT measurement was the main reason, although NT assessment should further be improved. In addition, a better setting of the medians for the biochemical parameters may contribute to a higher DR. Copyright © 2009 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objective The objective of this study was to quantify inter- and intra-observer agreement on classification of the intrapartum cardiotocogram (CTG) and decision to intervene following STAN guidelines. Design A prospective, observational study. Setting Obstetrics Department of a tertiary referral hospital. Population STAN recordings of 73 women after 36 weeks of gestation with a high-risk pregnancy, induced or oxytocin-augmented labour, meconium-stained amniotic fluid or epidural analgesia. Methods Six observers classified 73 STAN recordings and decided if and when they would suggest an intervention. Proportions of specific agreement (Ps) and kappa values ( K) were calculated. Main outcome measures Agreement upon classification of the intrapartum CTG and decision to perform an intervention. Results Agreement for classification of a normal and a (pre)terminal CTG was good (Ps range 0.50–0.84), but poor for the intermediary and abnormal CTG (Ps range 0.34–0.56). Agreement on the decision to intervene was higher, especially on the decision to perform ‘no intervention’ (Ps range 0.76–0.94). Overall inter-observer agreement on the decision to intervene was considered moderate in five of six observer combinations according to the kappa ( K range 0.42–0.73). Intra-observer agreement for CTG classification and decision to intervene was moderate ( K range 0.52–0.67 and 0.61–0.75). Conclusions Inter-observer agreement on classification of the intrapartum CTG is poor, but addition of information regarding fetal electrocardiogram, especially in case of intermediary or abnormal CTG traces, results in a more standardised decision to intervene. [ABSTRACT FROM AUTHOR]

The article presents a study on predictive value of cervical length using transvaginal ultrasonography (TVS) in supine and upright positions for the delivery mode and induction-to-delivery interval. It also discusses the comparison of the measurements with its predictive value and Bishop score after labor at term induction.. The study was performed in 68 nulliparous and 34 parous women before labor at term induction. Results show that the cervical length measured are the significant predictor.

The feasibility and accuracy of long-term transabdominal fetal electrocardiogram (fECG) recordings throughout pregnancy were studied using a portable fECG monitor. Fifteen-hour recordings of fetal heart rate (FHR) were performed in 150 pregnant women at 20–40 weeks of gestation and 1-hour recordings were performed in 22 women in labour and compared with simultaneous scalp electrode recordings. When ≥60% of fECG signals was present, the recording was defined as good. Eighty-two percent (123/150) of antenatal recordings were of good quality. This percentage increased to 90.7 (136/150 recordings) when only the night part (11 p.m.–7 a.m.) was considered. Transabdominal measurement of FHR and its variability correlated well with scalp electrode recordings ( r= 0.99, P < 0.01; r= 0.79, P < 0.01, respectively). We demonstrated the feasibility and accuracy of long-term transabdominal fECG monitoring. [ABSTRACT FROM AUTHOR]

The article discusses a study which examines the reliability of transperineal cervical length (CL) measurement during the third trimester of pregnancy. The subject of the study were women who attended outpatient clinic for CL measurement and preferred transvaginal ultrasound. The study found that transvaginal ultrasound is less painful, most feasible and most accurate. Transperineal ultrasound is deemed a feasible alternative.

The article discusses a study which aims to predict spontaneous onset of labor through serial transvaginal ultrasound measurement of cervical length (CL) in nulliparous women. Women with singleton pregnancies who were examined at weekly intervals from 36 weeks of pregnancy to delivery. CL was measured by transvaginal ultrasound and a decrease in CL before delivery was noticed. The study revealed that onset of labor before 41 weeks can be determined using CL measurement.

The article discusses a study which will determine gestational age (GA) estimation within the first-trimester Down syndrome prenatal screening is standardized in the Netherlands. The last menstrual period (LMP) and the crown-rump length (CRL) were evaluated. The study found that GA estimation is not standardized in Netherlands. Researchers suggest that in prenatal screening for Down syndrome, ultrasound test should be the basis for estimation of GA.

Objective This report provides an overview of 15 years prenatal screening for Down syndrome (DS). Methods Between 1991 and 2005, blood samples for the triple test were sent for analysis to our laboratory. Test results were considered screen-positive for neural tube defects (NTDs) if the serum alpha-1-fetoprotein ≥ 2.50 MoM for singleton pregnancies or screen-positive for DS if the calculated risk was at least 1 in 250. Results As many as 42 554 tests were performed. Data on the pregnancy outcome were available for 30 290 screening tests (71.2%). In 1991, most requests (93%) came from the university hospitals; thereafter a shift toward midwives occurred. Until 2001, the number of requests rose to 3500 a year. Most samples were collected between 15 and 17 weeks of gestation. The median age of women for whom a test was requested increased from 30.5 to 34.5. The detection rate (DR) for DS remained stable over the years (80%), with a false positive rate of about 13%. The DR for Trisomy 13, 18, and NTD was 50, 68, and 70%, respectively. Conclusion Based on the results of this study, the triple test may be considered a fairly good second trimester screening test. Here it is shown that health practitioners got more acquainted with the test through the years. This may have served the swift introduction of a formal national screening program that started in January 2007. Copyright © 2008 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

The article investigates the value of abnormal umbilical artery Doppler findings in predicting the outcome of uncomplicated monochorionic (MC) twin pregnancies. Research findings show that a subgroup of MC twins at risk for neonatal morbidity, low birth weight and preterm delivery is identified by the abnormal Doppler flow of the umbilical artery. Also cited are the issues' implications for ultrasound in obstetrics.

Objective To evaluate mortality and morbidity in a large cohort of twin pregnancies according to chorionicity. We aimed to estimate the optimal time of delivery. Design Historical cohort design. Setting Two teaching hospitals. Population Twin pregnancies delivered in the University Medical Centre, Utrecht, and the St Elisabeth Hospital, Tilburg (1995–2004), The Netherlands ( n = 1407). Methods Pregnancy outcomes were documented according to chorionicity. Mortality ≥32 weeks was reviewed carefully with special attention to antenatal fetal monitoring, autopsy and placental histopathology to find an explanation for adverse outcome. Main outcome measures Perinatal mortality and morbidity in monochorionic (MC) and dichorionic (DC) twins. Results Perinatal mortality was 11.6% in MC twin pregnancies and 5.0% in DC twin pregnancies. After 32 weeks, the risk of intrauterine death (IUD) was significantly higher in MC twins than in DC twins (hazard ratio 8.8, 95% CI 2.7–28.9). In most of these cases of IUD, no antenatal signs of impaired fetal condition had been present. Median gestational age was 1 week longer in DC twins than in MC twins, and the mean birthweight was 221 g higher. Severe birthweight discordancy (>20%) occurred more often in MC twins than in DC twins (OR 1.23, 95% CI 0.97–1.55). The incidence of necrotising enterocolitis (NEC) was higher in MC twins, after adjustment for age and weight at birth (OR 4.05, 95% CI 1.97–8.35). There was a trend towards higher neuromorbidity in MC twins. Conclusions This is the largest cohort study of twin pregnancies evaluating outcome according to chorionicity thus far. MC twins are at increased risk for fetal death (even at term), NEC and neuromorbidity. Current antenatal care is insufficient to predict and prevent this excess perinatal mortality and morbidity. Planned delivery at or even before 37 weeks of gestation seems to be justified for MC twins. [ABSTRACT FROM AUTHOR]

We investigated the effect of body size, parental behaviour and timing of breeding on the chick growth and energetics of three precocial shorebird (Charadrii) species in a warm sub-tropical environment: the Kittlitz's Plover Charadrius pecuarius, Blacksmith Lapwing Vanellus armatus, and Crowned Lapwing V. coronatus. The three species exhibited slower growth, longer pre-fledging periods and lower energy expenditure during the pre-fledging period than Arctic and temperate zone relatives of similar size. It was found that relative growth rates of charadriid and scolopacid species increased by 1.77% per degree latitude. Blacksmith and Crowned Lapwings are of similar size (i.e. about 160 g), about four times the mass of Kittlitz's Plovers. Taking body mass into account, the resting metabolic rate and daily energy expenditure of the three study species were similar. The relative amounts of energy needed for chicks to grow from a hatchling to a fledgling were low for the three species studied. The relative amount of energy needed to complete growth in charadriid and scolopacid species increased by 2.54% per degree latitude. Because Crowned Lapwings exhibited faster growth than Blacksmith Lapwings but similar daily energy expenditure we suggest that Blacksmith Lapwings compensate for greater energy expenditure in colder weather by growing more slowly. We suggest that small growth rate coefficient, low resting metabolic rate and low daily energy expenditure are adaptations to lower food availability and milder ambient temperatures in sub-tropical breeding habitats compared to temperate or Arctic regions. [ABSTRACT FROM AUTHOR]

Objective To examine detailed intrapartum events in cases of neonatal metabolic acidosis despite monitoring using STAN® (cardiotocography [CTG] plus ST waveform analysis of fetal electrocardiogram [ECG]). Design Retrospective case review. Setting High-risk pregnancies monitored by STAN®. Methods Case note review was performed in newborns with metabolic acidosis where no significant ST changes in the fetal ECG occurred prior to birth. Main outcome measures Metabolic acidosis. Results Detailed review of three cases identified poor signal quality, difficulties in CTG interpretation, failure to comply with STAN® clinical guidelines and deterioration of the CTG without ECG alert as the leading causes of these adverse outcomes. Conclusions The cases illustrate some of the pitfalls associated with the clinical application of the STAN® technology which prevent severe metabolic acidosis being eradicated completely. It may be useful to expand the STAN® guidelines protocol towards the identification of exceptional clinical situations, such as in our cases, and towards appropriate additional interventions, as this may lead to a further reduction in adverse neonatal outcomes. [ABSTRACT FROM AUTHOR]

Objective To identify short-term factors influencing psychological outcome of termination of pregnancy for fetal anomaly, in order to define those patients most vulnerable to psychopathology. Study Design A prospective cohort of 217 women and 169 men completed standardized questionnaires 4 months after termination. Psychological adjustment was measured by the Inventory of Complicated Grief (ICG), the Impact of Event Scale (IES), the Edinburgh Postnatal Depression Scale (EPDS), and the Symptom Checklist-90 (SCL-90). Results Women and men showed high levels of posttraumatic stress (PTS) symptoms (44 and 22%, respectively) and symptoms of depression (28 and 16%, respectively). Determinants of adverse psychological outcome were the following: high level of doubt in the decision period, inadequate partner support, low self-efficacy, lower parental age, being religious, and advanced gestational age. Whether the condition was Down syndrome or another disability was irrelevant to the outcome. Termination did not have an important effect on future reproductive intentions. Only 2% of women and less than 1% of men regretted the decision to terminate. Conclusion Termination of pregnancy (TOP) for fetal anomaly affects parents deeply. Four months after termination a considerable part still suffers from posttraumatic stress symptoms and depressive feelings. Patients who are at high risk could benefit from intensified support. Copyright © 2007 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate whether the antenatal umbilical coiling index (aUCI) as measured by ultrasonography predicts the postnatal umbilical coiling index (pUCI) and adverse pregnancy outcome. Methods: In a prospective study in 117 pregnancies, the aUCI was measured between 28 weeks and term by ultrasonography. The aUCI was calculated as the reciprocal value of the mean pitch of one complete coil. The pUCI was calculated as the number of coils divided by the cord length in cm. The correlation between aUCI and pUCI was assessed and likelihood ratios for adverse pregnancy outcome were calculated. Results: We had complete data on 81 subjects. Mean aUCI +/- SD was 0.30 +/- 0.09 and mean pUCI +/- SD was 0.17 +/- 0.08. The correlation coefficient between aUCI and pUCI was 0.66, P < 0.001. Limits of agreement were 0-0.28 coils/cm. The positive likelihood ratio for small-for-gestational-age infants was 2.6 (95% confidence interval (CI) 0.6-11.6) for ultrasound hypocoiling, and 5.7 (95% CI 1.3-24.8) for ultrasound hypercoiling. The positive likelihood ratio for interventional delivery for non-reassuring fetal status was 1.2 (95% CI 0.2-9.0) for ultrasound hypocoiling, and 10.3 (95% CI 2.1-50.2) for ultrasound hypercoiling. Conclusions: Strong correlation coefficients comparing the aUCI and pUCI do not reflect agreement. Since the limits of agreement were almost as wide as the full range for the pUCI, the aUCI does not predict the pUCI with sufficient precision. Larger prospective studies are required to confirm the predictive potential of the aUCI for adverse pregnancy outcome. [ABSTRACT FROM AUTHOR]

Stimulus-induced rhythmic EEG discharges (SIRDs) is a recently reported phenomenon in critically ill patients and little is known about their evolution. We found SIRDs in three patients with encephalopathy and followed them with serial EEGs. SIRDs appeared between 4 and 13 days after the onset of illness and persisted for 2–3 days. The discharges were elicited by tactile or nociceptive stimuli and lasted for 20–120 s. They were detected in 2/6, 1/3 and 2/11 EEGs performed between 9 and 32, 2 and 4 and 3 and 15 days, respectively, after the onset of illness. Their morphology varied: blunt triphasic waves, rhythmic delta activity and rhythmic sharp wave complexes. The background EEG activity was slowed or suppressed in all. One patient had acute disseminated encephalomyelitis (ADEM) with good recovery and the other two had fatal hypoxic ischemic encephalopathy. SIRDs appear to be a transient phenomena occurring in patients with encephalopathy, appearing hours to few days after the onset of illness. This is the first report of SIRDs in ADEM. Serial EEGs and repeated testing of EEG response to tactile and nociceptive stimuli is required for their detection. Larger number of patients with SIRDs need to be studied to assess their prognostic significance. [ABSTRACT FROM AUTHOR]