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To assess the risk of adverse neonatal outcomes in women with gestational diabetes (GDM) by identifying subgroups of women at higher risk to recognize the characteristics most associated with an excess of risk. Observational, retrospective, multicenter study involving consecutive women with GDM. To identify distinct and homogeneous subgroups of women at a higher risk, the RECursive Partitioning and AMalgamation (RECPAM) method was used. Overall, 2736 pregnancies complicated by GDM were analyzed. The main outcome measure was the occurrence of adverse neonatal outcomes in pregnancies complicated by GDM. Among study participants (median age 36.8 years, pre-gestational BMI 24.8 kg/m2), six miscarriages, one neonatal death, but no maternal death was recorded. The occurrence of the cumulative adverse outcome (OR 2.48, 95% CI 1.59–3.87), large for gestational age (OR 3.99, 95% CI 2.40–6.63), fetal malformation (OR 2.66, 95% CI 1.00–7.18), and respiratory distress (OR 4.33, 95% CI 1.33–14.12) was associated with previous macrosomia. Large for gestational age was also associated with obesity (OR 1.46, 95% CI 1.00–2.15). Small for gestational age was associated with first trimester glucose levels (OR 1.96, 95% CI 1.04–3.69). Neonatal hypoglycemia was associated with overweight (OR 1.52, 95% CI 1.02–2.27) and obesity (OR 1.62, 95% CI 1.04–2.51). The RECPAM analysis identified high-risk subgroups mainly characterized by high pre-pregnancy BMI (OR 1.68, 95% CI 1.21–2.33 for obese; OR 1.38 95% CI 1.03–1.87 for overweight). A deep investigation on the factors associated with adverse neonatal outcomes requires a risk stratification. In particular, great attention must be paid to the prevention and treatment of obesity.

Managing cancer during pregnancy is a very critical clinical situation. It is relatively rare but once encountered, it poses several clinical and sometimes social and ethical conflicts as well. Generalizing treatment decisions is very hard and in our opinion, each case should be discussed in a multidisciplinary manner acknowledging patients' opinion as well to reach a proper decision. In this review we touch on the available evidence on managing cancer patients diagnosed during the course of pregnancy in an attempt to provide some guidance for clinicians dealing with such cases.

The COVID-19 pandemic has caused the proliferation of a highly contagious and frequently fatal pneumonia around the world.[1] COVID-19 has severely affected Italy, and at the onset of this crisis, Bergamo, a city in northern Italy, regularly reported the highest number of cases in the country for many weeks. During outbreaks of infectious disease, pregnant women represent a high-risk population due to their increased susceptibility to infections, particularly when comorbidities such as pre-gestational diabetes (present in 0.5% of pregnant populations) are present.[2,3] Few data are available on pregnant women with pre-gestational diabetes during the COVID-19 pandemic.

Objective To report mode of delivery and immediate neonatal outcome in women infected with COVID‐19. Design Retrospective study. Setting Twelve hospitals in northern Italy. Participants Pregnant women with COVID‐19‐confirmed infection who delivered. Exposure COVID 19 infection in pregnancy. Methods SARS‐CoV‐2‐infected women who were admitted and delivered from 1 to 20 March 2020 were eligible. Data were collected from the clinical records using a standardised questionnaire on maternal general characteristics, any medical or obstetric co‐morbidity, course of pregnancy, clinical signs and symptoms, treatment of COVID 19 infection, mode of delivery, neonatal data and breastfeeding. Main outcome and measures Data on mode of delivery and neonatal outcome. Results In all, 42 women with COVID‐19 delivered at the participating centres; 24 (57.1%, 95% CI 41.0–72.3) delivered vaginally. An elective caesarean section was performed in 18/42 (42.9%, 95% CI 27.7–59.0) cases: in eight cases the indication was unrelated to COVID‐19 infection. Pneumonia was diagnosed in 19/42 (45.2%, 95% CI 29.8–61.3) cases: of these, 7/19 (36.8%, 95% CI 16.3–61.6) required oxygen support and 4/19 (21.1%, 95% CI 6.1–45.6) were admitted to a critical care unit. Two women with COVID‐19 breastfed without a mask because infection was diagnosed in the postpartum period: their newborns tested positive for SARS‐Cov‐2 infection. In one case, a newborn had a positive test after a vaginal operative delivery. Conclusions Although postpartum infection cannot be excluded with 100% certainty, these findings suggest that vaginal delivery is associated with a low risk of intrapartum SARS‐Cov‐2 transmission to the newborn. Tweetable abstract This study suggests that vaginal delivery may be associated with a low risk of intrapartum SARS‐Cov‐2 transmission to the newborn., Tweetable abstract This study suggests that vaginal delivery may be associated with a low risk of intrapartum SARS‐Cov‐2 transmission to the newborn. This article includes Author Insights, a video abstract available at https://vimeo.com/rcog/authorinsights16278

Diet is the first line and the main therapeutic strategy in the treatment of gestational diabetes (GDM) with the primary objective to achieve normal blood glucose levels while promoting adequate ma...

Background: Cervical dilatation is commonly documented on a partogram indicating the expected rate of progress of labor. Although deviations from such a line can be used to indicate abnormal progress, what constitutes the “normal” rate of cervical dilation is still largely unknown. The objectives of this study were to assess the variability of the rate of cervical dilation in nulliparous women and to determine whether the rate of labor was independent of dilation on admission. Methods: We analyzed a cohort of consecutive nulliparous women with spontaneous labor at term and singleton fetuses in cephalic presentation. Exclusion criteria were gestational age less than 37 weeks, induction of labor, or the presence of a uterine scar. Management of labor was standardized using set protocols of care. Active labor was diagnosed as regular contractions every 10 minutes or less, lasting more than 40 seconds, with cervical effacement more than 80 percent and dilation of 2 cm. Vaginal examinations were performed by a dedicated midwife every 2 hours. Amniotomy was performed for slow progress or arrest of dilation over 2 hours. Oxytocin was administered for arrest of cervical dilation for 2 hours with membranes ruptured. Data pertaining to cases ending in cesarean delivery were included up to the time of cesarean section. Results: The study sample comprised 1,119 women at 39.7 ± 1.1 weeks with an average duration of labor of 4.1 ± 2.4 hours. The rate of oxytocin use was 27 percent and of epidural analgesia 5 percent. The rate of oxytocin use was inversely related to cervical dilation on admission. Cesarean delivery was performed in 6 percent of women. Duration of labor at each centimeter of cervical dilation on admission showed a broad distribution (e.g., at 4 cm: median = 5.5, range: 0.8–12.5 hr). The rate of labor progression (expressed as the slope of the dilation-vs-time curve) was approximately 1.5 cm/hr, and it was essentially independent of cervical dilation on admission (r = 0.034, p = 0.267). A deceleration phase seemed to be present toward the end of the active phase of labor (approximately 9 cm). Conclusion: In our setting, the rate of labor in nulliparous women at term was highly variable, and it did not appear to be affected by cervical dilation on admission. (BIRTH 38:1 March 2011)

Objective Recent studies have shown that among women with uterine scars from previous caesarean section of any type, induction of labour is associated with increased risk of uterine rupture compared with spontaneous labour. We have assessed the risk of uterine rupture in a cohort of women with a previous low transverse caesarean section in whom induction and management of labour were performed according to a strict protocol. Design Cohort study. Setting University Hospital. Population All women with a singleton pregnancy and a previous low transverse caesarean section requiring induction of labour from 1/1/1992 to 12/30/2001 (n= 310) were compared with a control cohort during the same study period constituted of women with a previous low transverse caesarean section in spontaneous labour (n= 1011). Methods Clinical characteristics and rate of uterine rupture of women with previous caesarean section undergoing induction of labour were compared with those of women with previous caesarean section in spontaneous labour. Main outcome measure Incidence of uterine rupture. Results Uterine rupture occurred in 0.3% in the previous caesarean section—induction group versus 0.3% in the previous caesarean section—spontaneous labour group (P= 0.9). Logistic regression analysis showed no significant difference in the rate of uterine rupture between the induction and spontaneous labour group (P= 0.67) after controlling for maternal age, parity, duration of labour, gestational age at delivery and birthweight. Conclusion Among women with a previous low transverse caesarean section, induction of labour is not associated with significantly higher rates of uterine rupture compared with spontaneous labour, provided a consistent protocol with strict criteria for intervention is adopted.

Objective To evaluate the effects of anamnestic factors and sonographic findings on the patient's decision regarding amniocentesis in a cohort of women at genetic risk because of advanced age. Methods All women 35 years of age or older registered for prenatal care between January 1990 and December 1998 were asked about their attitude towards genetic amniocentesis during the course of individual genetic counseling and once again after ultrasound examination inclusive of markers of aneuploidies (nuchal fold thickness greater than 6 mm, renal pyelectasis, choroid plexus cysts, and hyperechogenic bowel). Their attitudes towards genetic amniocentesis before and after ultrasound examination were compared using chi-square, Fisher's exact test, Mann–Whitney U-test, and logistic regression analysis, with a two-tailed p < 0.05 or an odds ratio (OR) with 95% confidence interval (CI) not inclusive of the unity considered significant. Results Among the 1486 women in the cohort, 1368 (97%) expressed an opinion towards genetic testing at the time of counseling: 501 (37%) were in favor and 867 (63%) were against having the procedure. After ultrasonographic examination, 33% (446/1368) of women opted for amniocentesis, 36% (146/402) after abnormal findings and 31% (300/966) after normal ultrasound findings. Significantly more women with abnormal than normal ultrasound findings opted for diagnostic testing in both groups. Overall, only 8% (115/1368) of women changed their attitude towards diagnostic testing after ultrasonographic examination. Normal sonographic findings were three times more likely to change the attitude of women initially interested in amniocentesis than abnormal sonographic findings did in women a priori not interested in the procedure (20% versus 7%, p < 0.001, OR = 3.2, 95% CI 1.8; 5.8). Conclusions In a cohort of women at genetic risk because of advanced age, the key determinant of the choice regarding genetic amniocentesis is the a priori opinion of the woman towards the procedure, which was expressed by 93% of women. Ultrasonography plays a secondary role in changing or confirming women's attitude towards invasive diagnostic testing. Normal sonographic findings affect women's decisions more powerfully than abnormal sonographic findings, suggesting that ultrasonography has an important reassuring function for the woman. Copyright © 2002 John Wiley & Sons, Ltd.

Objective: To evaluate the variables associated with changes in cesarean delivery (CD) rates in a University Hospital with standardized and unchanged protocols of care. Methods: Retrospective analysis of consecutive deliveries between two triennia 10 years apart. The Robson classification of CD was used, and the analysis focused on factors affecting Robson's classes 1 and 2 combined (term singleton cephalic nulliparae) and class 5 (previous CD). Results: A total of 8237 deliveries occurred in the 1st period, and 8420 in the 2nd. CD increased from 12.5 to 18% (p < 0.001). Robson's classes 1 and 2 combined contributed more than other classes to CD rates (32 vs 36%; p < 0.001). At multivariate analysis, BMI (Odds ratio [OR]: 1.08; 95% CI: 1.06-1.1) and maternal age (OR: 1.06; 95% CI: 1.05-1.08) were independently related to CD. In Robson class 5, the rate of CD increased from 34 to 46%, p < 0.001, mostly due to an increase in elective CD (39 vs 67.5%; p < 0.001). At multivariate analysis, BMI (OR: 1.06 95% CI: 1.02-1.1) and more than one previous CD (OR: 18.7; 95% CI: 9.6-36.4) were independently related to CD. Conclusions: BMI and maternal age are independent factors associated to the increasing rate of CD in nulliparae with spontaneous or induced labor at term. In women with previous CD, BMI and more than one previous CD are factors associated with the increasing rate of CD.

PURPOSE: Pregnancy-associated breast cancer (PABC) is one of the most common malignancies during pregnancy (one in 3,000 pregnancies); up to 3% of breast cancers are diagnosed in pregnancy. Our objective is to verify if women with pregnancy-associated breast cancer (PABC) have poorer outcome than nonpregnant women with breast cancer. METHODS: We register in a Cancer and Pregnancy Registry the clinical course, treatment, and disease outcome of nonpregnant women with breast cancer and of women with PABC. In a retrospective control study (2:1) we compared the women with PABC (65 cases) with nonpregnant women with breast cancer (130 cases) matched for age at diagnosis, stage of disease and year of surgery. RESULTS: Of 65 cases diagnosed, 45 was early cancer and 20 was locally advanced or metastatic cancer. The pregnancy ended in a spontaneus miscarriage in 3 patients (5%), and 15 (23%) pregnancy were interrupted. The mean age at diagnosis was 36 ± 4.2 years. Treatment was started during pregnancy in 32 (49%) patients and after delivery in 33 (51%) patients. Of 65 cases, 49 (75%) women received chemotherapy, 52 (80%) women received radiotherapy and 46 (71%) women were diagnosed with an estrogen/progesterone receptors-positve tumor. The mean gestational age at delivery was 35.4 ± 2.1 weeks. Eleven women (17%) are deceased and 21 (32%) progressed with a median follow-up of 48 months. There are no difference between cases and control in term of biological features of cancer and treatment. CONCLUSIONS: The treatment of breast cancer in pregnancy should be executed by experienced specialists in a multidisciplinary setting and should adhere as closely as possible to standard protocols. As more women postpone child bearing until later in life, it is expected that PABC will become increasingly more common. The prognosis in pregnant women with breast cancer is worse than in nonpregnant women.

Objective To study the relationship between prenatal ultrasound features and postnatal course of meconium peritonitis. Study Design We reviewed our cohort of cases of meconium peritonitis (MP) (n = 13/37, 225 pregnancies or 0.3/1000) as well as those published in the English literature with prenatal ultrasonographic findings and postnatal follow-up (n = 56). The total number of cases (n = 69) was divided into 4 grades of progressive severity based on the number of pertinent sonographic findings: grade 0, isolated intra-abdominal calcifications (n = 18); grade 1, intra-abdominal calcifications and ascites (n = 17) or pseudocyst (n = 2) or bowel dilatation (n = 6); grade 2, two associated findings (n = 20); and grade 3, all sonographic features (n = 6). Presence of polyhydramnios was also recorded. Prenatal predictors of need for neonatal surgery and risk of neonatal death were identified using Chi-square and Fisher exact test, with P < 0.05 considered significant. Results Neonatal surgical intervention was required in 0% (0/18) of newborns with grade 0 MP; in 52% (13/25) of those with grade 1; in 80% (16/20) with grade 2; and in 100% (6/6) with grade 3 MP (P < 0.001, Chi-square for trend). Moreover, neonatal surgery was more frequent in the presence than absence of polyhydramnios [69% (18/26) vs 37% (16/43); P = 0.007]. Neonatal mortality was 6% (4/69; 3 after surgery and 1 for premature delivery) and it was confined to the subgroup with polyhydramnios (4/26, 15%). Conclusions Prenatal sonographic features are related to postnatal outcome. Persistently isolated intra-abdominal calcifications have an excellent outcome. Delivery in a tertiary care center is recommended when calcifications are associated with other sonographic findings. Copyright © 2007 John Wiley & Sons, Ltd.

Objective. To compare the risk of uterine rupture between a cohort of women with previous low-transverse cesarean section (CS) and a cohort with intact uterus. Methods. All women with a singleton pregnancy and previous low-transverse CS requiring induction of labor from January 1, 1992 to December 30, 2001 (n = 310) were compared with a cohort of women with intact uterus undergoing induction of labor during the same study period (n = 5420). Protocols of induction using prostaglandin E-2 gel and oxytocin infusion were consistent within groups, but differed between the previous CS and the intact uterus group. Results. Uterine rupture occurred in 0.3% in the previous CS group vs. 0.03% in the intact uterus group (p = 0.37). Logistic regression analysis showed no significant difference in rate of uterine rupture between the previous CS vs. intact uterus group (p = 0.16) after controlling for maternal age, parity, gestational age at delivery, Bishop score on admission, use of prostaglandin and oxytocin, and birth weight. Our study had adequate power to detect a 0.38% difference in rate of uterine rupture between the two groups (alpha = 0.05, beta = 0.80). Conclusion. Induction of labor is not associated with significantly higher rates of uterine rupture among women with previous low-transverse CS compared with women with intact uterus provided a consistent protocol with strict intervention criteria is adopted.

The aim was to delineate the significance and natural history of fetal arrhythmias and provide information about their management. A cohort of 114 infants with fetal arrhythmias detected during prenatal ultrasound (US) screening were studied. All subjects underwent echocardiography and were treated as clinically indicated. Postnatal outcome was obtained in 100% of infants until 1 year of age. The incidence of fetal arrhythmias was 0.3%. Among the 87 fetuses with atrial extrasystoles, 2.3% developed supraventricular tachycardia (SVT) in utero. Of the 10 SVT cases, only five required antiarrhythmic therapy in utero with digoxin and propafenone, which successfully restored sinus rhythm in 100% of fetuses, both nonhydropic and hydropic. Sinus bradycardia was associated with structural anomalies in 5 of 6 patients and only 2 of 4 fetuses with atrioventricular block survived. It is concluded that prognosis is good for most fetal tachyarrhythmias, whereas it is less favorable for bradyarrhythmias.

Objective: To assess the accuracy of fluorescent in situ hybridization (FISH) on amniocytes in fetuses affected by structural malformations suggestive of chromosomal anomalies. Methods: FISH of uncultured amniotic fluid cells and conventional cytogenetic analysis were performed on 48 pregnancies with ultrasonographic (US) evidence of fetal anomalies. The AneuVysion® assay (Vysis) with specific probes for chromosomes 13, 18, 21, X and Y, was used. Amniotic fluid samples were obtained between the 14th and 34th weeks of gestation. Results: In cases with a single abnormal US finding (n = 15), 5 aneuploidies were detected (1 case of trisomy 13 and 4 of trisomy 21). In the group with two or more malformations (n = 33) there were 15 aneuploidies (9 cases of trisomy 18, 2 of trisomy 21, 2 monosomy X, 1 trisomy 13, and 1 triploidy). In this group, conventional cytogenetic analysis revealed two additional chromosomal anomalies not detectable by FISH (1 trisomy 16 mosaic, and a terminal deletion 4p). No sex aneuploidies were observed. Conclusions: The lack of false-positive diagnosis in the FISH analysis in our sample prompts us to consider interphase FISH as a useful tool in pregnancies at high risk for chromosomal aneuploidies. When FISH analysis is normal, the overall risk of chromosomal abnormalities is significantly reduced. However, the finding of two chromosomal anomalies undetectable by AneuVysion® assay confirms the need for conventional chromosome analysis to complement FISH results. Moreover, the results collected here, in agreement with those already reported in the literature, indicate that FISH analysis on uncultured amniocytes can play an important role in counselling and decision-making, especially in cases at risk for aneuploidies, such as those with structural abnormalities at US.