Biometry and pathological ultrasound findings in multiple pregnancies / Características ecográficas y hallazgos patológicos en embarazos múltiples

Resumo Objectives: to determine the prevalence of pathological findings according to the type of chorionicity in pregnancies in two institutions in Bogotá, Colombia. Methods: descriptive, retrospective, cohort study. Biometric variables were calculated, and pathological findings were evaluated according to the type of chorionicity in multiple pregnancies. Statistical characterization was performed with absolute frequencies, calculation of relative frequencies in qualitative variables, standard deviation measures, median and interquartile range. In addition, a descriptive analysis of the information was carried out. Results: 528 studies were carried out in 141 pregnant women, 98.5% (n = 139) twins and 1.4% (n = 2) triplets. A prevalence of 35.4% of fetal complications was calculated. The most frequent was fetal growth restriction (p=0.37). According to each type of chorionicity, fetal growth restriction was presented in 50% (1/2) of the trichorionics, 16.6% (7/42) of the monochorionics, and 11.3% (11/97) of the dichorionics. Conclusion: fetal growth restriction was the most common finding, both in trichorionics, monochorionics and dichorionics pregnancies.

Resumen Objetivos: el objetivo del estudio fue determinar la prevalencia de los hallazgos patológicos ecográficos en embarazos múltiples de acuerdo con la corionicidad en dos instituciones en Bogotá-Colombia. Métodos: estudio de cohorte, descriptivo, retrospectivo. Las variables biométricas realizadas y los hallazgos patológicos se evaluaron de acuerdo con el tipo de embarazo gemelar. Se realizó caracterización estadística con frecuencias absolutas, cálculo de frecuencias relativas en variables cualitativas, medidas de desviación estándar, mediana y rango intercuartílico. Además, se realizó análisis descriptivo de la información. Resultados: se realizaron 528 estudios en 141 gestantes, encontrando 98,5% (n=139) gemelares y 1,4% (n=2) triples. Se calculó una prevalencia de 35,4% de complicaciones fetales siendo más frecuente la restricción del crecimiento fetal (p=0,37). Según la corionicidad, esta complicación se presentó en 50% (1/2) de los tricoriónicos, 16,6% (7/42) de los monocoriónicos y 11,3% (11/97) de los dicoriónicos. Conclusión: la restricción del crecimiento fetal fue el hallazgo más común en los embarazos múltiples en la población estudiada.

One Plus One is Better than Two: An Approach Towards a Single Blastocyst Transfer Policy for All IVF Patients / Um mais um é melhor que dois: Uma abordagem pela prática da transferência de embrião único para todos os pacientes de FIV

Abstract Objective It is known that the single embryo transfer (SET) is the best choice to reduce multiples and associated risks. The practice of cryopreserving all embryos for posterior transfer has been increasingly performed for in vitro fertilization (IVF) patients at the risk of ovarian hyperstimulation syndrome or preimplantation genetic testing for aneuploidy. However, its widespread practice is still controverse. The aim of this study was to evaluate how effective is the transfer of two sequential SET procedures compared with a double embryo transfer (DET) in freeze-only cycles. Methods This retrospective study reviewed 5,156 IVF cycles performed between 2011 and 2019, and 506 cycles using own oocytes and freeze-only policy with subsequent elective frozen-thawed embryo transfers (eFET) were selected for this study. Cycles having elective SET (eSET, n = 209) comprised our study group and as control group we included cycles performed with elective DET (eDET, n = 291). In the eSET group, 57 couples who had failed in the 1st eSET had a 2nd eFET, and the estimated cumulative ongoing pregnancy rate was calculated and compared with eDET. Results After the 1st eFET, the ongoing pregnancy rates were similar between groups (eSET: 35.4% versus eDET: 38.5%; p =0.497), but the estimated cumulative ongoing pregnancy rate after a 2nd eFET in the eSET group (eSET + SET) was significantly higher (48.8%) than in the eDET group (p < 0.001). Additionally, the eSET +SET group had a 2.7% rate of multiple gestations, which is significantly lower than the eDET group, with a 30.4% rate (p < 0.001). Conclusion Our study showed the association of freeze-only strategy with until up to two consecutive frozen-thawed eSETs resulted in higher success rates than a frozenthawed DET, while drastically reducing the rate of multiple pregnancies.

Resumo Objetivo Sabe-se que a transferência de embrião único (SET) é a melhor escolha para reduzir as gestações múltiplas e riscos associados. A prática da criopreservação de todos os embriões para transferência posterior tem sido cada vez mais utilizada para fertilização in vitro (FIV), em especial quando há risco de síndrome de hiperestimulação ovariana ou realização de teste genético pré-implantacional. Entretanto, sua utilização disseminada ainda é controversa. O objetivo deste estudo foi avaliar a eficácia de duas SET sequenciais em comparação com uma transferência de embrião dupla (DET) em ciclos de FIV onde todos os embriões foram criopreservados. Métodos Neste estudo retrospectivo foram revisados 5.156 ciclos de FIV realizados entre 2011 e 2019, e 506 ciclos usando oócitos próprios e criopreservação de todos os embriões com transferências eletivas subsequentes de embriões descongelados, foram selecionados para este estudo. Ciclos com transferência eletiva de embrião único (eSET, n = 209) compuseram nosso grupo de estudo e como grupo de controle incluímos os ciclos com transferência eletiva de dois embriões (eDET, n = 291). No grupo eSET, 57 casais que falharam na 1ª tentativa de eSET tiveram uma 2ª eFET e a taxa de gravidez em curso cumulativa foi estimada para o grupo eSET e comparada com o grupo eDET. Resultados Após a 1ª eFET, as taxas de gravidez em curso foram semelhantes entre os grupos (eSET: 35,4% versus eDET: 38,5%; p = 0,497), mas a taxa de gravidez em curso cumulativa estimada após a 2ª eFET no grupo eSET (eSET + SET) foi significativamente maior (48,8%) do que no grupo eDET (p <0,001). Além disso, as taxas de gestação múltipla foram expressivamente inferiores no grupo eSET + SET (2,7%) quando comparado ao grupo eDET (30,4%; p < 0,001). Conclusão Nosso estudo mostrou que a associação das estratégias de congelamento de todos os embriões com até duas eSETs sequenciais resultou em maiores taxas de sucesso do que uma DET com embriões descongelados, além de reduzir drasticamente a ocorrência de gestações múltiplas.

Drepanocitosis y planificación familiar / Sickle cell disease and family planning

Introducción: La planificación familiar en las gestantes con drepanocitosis contribuye a disminuir el número de embarazos y la morbimortalidad materno fetal. Objetivo: Analizar conceptos de planificación familiar aplicables a la gestante con drepanocitosis y proponer acciones de asesoramiento encaminadas a disminuir los indicadores de morbilidad y mortalidad materna y fetal relacionadas con esta enfermedad. Métodos: Se realizó una revisión de la literatura, en inglés y español, a través del sitio web Pubmed y el motor de búsqueda Google académico de artículos publicados en los últimos 5 años, con análisis y resumen de la bibliografía revisada. Análisis y síntesis de la información: La gran mayoría de las pacientes con drepanocitosis desconocen los conceptos de salud sexual y reproductiva, así como de planificación familiar, por lo que muchas se convierten en mujeres con múltiples gestaciones que terminan en abortos, con alto riesgo de complicaciones severas y 2,5 veces más posibilidades de muerte durante la gestación y el puerperio que una gestante no enferma. La aplicación de un grupo de medidas encaminadas a dar a conocer estos conceptos desde la consulta de hematología, acercan a estas pacientes y a su pareja a la toma correcta de decisión sobre en qué momentos y cuántos hijos tener. Conclusión: La planificación familiar como proceso de atención médica en la drepanocitosis, con participación directa del hematólogo, como médico de asistencia primario durante toda la vida de estas gestantes, contribuye a fortalecer la relación entre el trabajo del equipo asistencial, la pareja y disminuye la morbilidad y mortalidad materna fetal(AU)

Introduction: Family planning in pregnant women with sickle cell disease contributes to reducing the number of pregnancies and maternal-fetal morbidity and mortality. Objective: To analyze family planning concepts applicable to pregnant women with sickle cell disease and propose counseling actions aimed at reducing the indicators of maternal fetal morbidity and mortality related to this disease. Methods: A literature review was carried out, in English and Spanish, through the Pubmed website and the academic Google search engine of articles published in the last 5 years, with analysis and summary of the reviewed bibliography. Analysis and synthesis of information: The vast majority of patients with sickle cell disease are unaware of the concepts of sexual and reproductive health as well as FP, so many become women with multiple pregnancies that end in abortions, with a high risk of complications severe and 2.5 times more likely to die during pregnancy and the puerperium than a non-ill pregnant woman. The application of a group of measures aimed at making these concepts known from the hematology consultation, brings these patients and their partner closer to making the correct decision about when and how many children to have. Conclusion: Family planning as a medical care process in sickle cell disease, with direct participation of the hematologist, as primary care physician throughout the life of these pregnant women, contributes to strengthening the relationship between the work of the healthcare team, the couple and decreases morbidity and fetal maternal mortality(AU)

Complicaciones obstétricas y perinatales en mujeres infértiles que se embarazan / Obstetric and perinatal complications in infertile women who become pregnant

Las pacientes infértiles tienen un riesgo aumentado de resultados obstétricos y perinatales adversos que dependen de los factores de infertilidad subyacentes previos y de factores inherentes a los tratamientos recibidos para lograr el embarazo. La edad materna, las patologías previas ginecológicas, hormonales, endocrinológicas, metabólicas y anatomo funcionales son reconocidas como factores de riesgo para resultados adversos obstétricos y perinatales. Los tratamientos como la hiperestimulación ovárica y los tratamientos de reproducción asistida condicionan riesgos adicionales, especialmente por el aumento de embarazos múltiples que se generan con estas terapias. El aumento de la edad materna de pacientes tratadas por infertilidad y la necesidad creciente de tratamientos de reproducción asistida determinan probablemente, un mayor riesgo futuro de complicaciones obstétricas y perinatales. Muchos de estos factores de riesgo pueden ser modificados y manejados antes de iniciar los tratamientos con la finalidad de mejorar el pronóstico para la madre y el recién nacido. La consideración de estos factores de riesgo y sus consecuencias en el embarazo son parte esencial del consejo reproductivo que debiera recibir toda paciente que se somete a tratamientos por infertilidad.El objetivo de esta revisión es mostrar la relación existente entre las pacientes que consultan por infertilidad, los tratamientos usados y los potenciales riesgos obstétricos y perinatales cuando se produce el embarazo.

Infertile patients have an increased risk of adverse obstetric and perinatal outcomes that depend on underlying infertility factors and on those treatments recieved to become pregnant. Maternal age, hormonal, endocrinologial, metabolic and anatomic/functional gynecological diseases are widely recognized risk factors for adverse obstetric and perinatal outcomes. Infertility treatments like controlled ovarian hyperstimulation and assisted reproductive technologies add aditional risks, specially related to multiple pregnancies that are associated to. The higher maternal age of patients seeking for infertility treatment and the increasing need of assisted reproductive technologies probably determines a higher and increasing risk of obstetric and perinatal adverse outcomes. In many cases risk factors can be adequately modified and controlled before treatments are initiated thus improving maternal and neonatal prognosis. This risk factors and their consequences in pregnancy have to be strongly considered in reproductive counselling that should recieve every patient treated for infertility.The aim of this article is to show the relation between infertile patients seeking for treatment and their potential risks of obstetric and perinatal adverse outcomes when they get pregnant.

Gran feto acardio: diagnóstico tardío de gestacion gemelar monocorial biamniótica complicada por secuencia TRAP: reporte de un caso y revisión de la literatura / Great acardiac fetus: late diagnosis of monochorionic diamniotic twin pregnancy complicated by sequence TRAP: case report and review of the literature

OBJETIVOS: reportar el caso de una paciente con gestación gemelar monocorial-biamniótica complicada por secuencia TRAP que dio lugar al nacimiento de un feto bomba de 1932 gramos sin malformaciones anatómicas y de un feto acardio anceps de 1800 gramos, y realizar una revisión sobre esta patología y la importancia de su diagnóstico y tratamiento precoces. MATERIALES Y MÉTODOS: se presenta el caso de un feto acardio en una gestante con embarazo sin control estricto en el Hospital San Pedro de Logroño en el año 2019, de interés por su diagnóstico tardío y elevado peso al nacimiento del feto acardio. Se realizó una búsqueda de la literatura en las bases de datos Medline vía PubMed, OVID, Embase y SciE-LO con las palabras clave DeCS y términos MeSH. Como criterios de inclusión se consideraron artículos tipo series y reportes de casos y artículos de revisión desde enero de 1950 hasta enero de 2020. RESULTADOS: la búsqueda incluyó 39 referencias bibliográficas sobre las que se repasaron las principales cuestiones teóricas a exponer. El peso del feto acardio de nuestro caso fue muy elevado sin provocar repercusión en el feto sano, en comparación con la bibliografía, lo que aporta singularidad al caso, siendo sólo equiparable la serie de casos de Brassard et al (1999), con pesos de los fetos acardio por encima de 1700 gramos y diferenciándose en 100 gramos del feto bomba. CONCLUSIONES: el feto acardio es una complicación infrecuente de embarazos gemelares monocoriales. Se requiere la presencia de anastomosis vasculares placentarias entre ambas circulaciones. El diagnóstico precoz es importante para disminuir la morbilidad y usar, en la medida de lo posible, técnicas terapéuticas no invasivas.

OBJECTIVES: to report the case of a patient with a monochorionic-biamniotic twin gestation complicated by TRAP sequence that gave rise to the birth of a pump fetus without anatomical malformations (1932 g) and an acardiac anceps fetus (1800 g), and to review this pathology and the importance of its early diagnosis and management. MATERIAL AND METHODS: the case of an acardiac fetus is presented in a pregnant woman without strict control at the Hospital San Pedro de Logroño in 2019, worthwhile because of its late diagnosis and high birth weight. A search of the literature was carried out in the Medline databases via PubMed, OVID, Embase and SciELO with the MeSH terms. As inclusion criteria, we considered series-type articles and case reports, cohorts and review articles from January 1950 to January 2020. RESULTS: 39 bibliographic references were included with the main theoretical questions to be reviewed. Our acardiac fetus weight was very high comparing with the bibiography and without causing repercussion in the healthy fetus, which contributes to the uniqueness of the case, only the series report by Brassard et al (1999) is comparable, with weights of the acardiac fetus above 1700 grams and differing by 100 grams from the pump fetus. CONCLUSIONS: the acardiac fetus is an infrequent complication of monochorionic twin pregnancies. The presence of placental vascular anastomoses between both circulations is required. Early diagnosis is important to decrease morbidity and to use, as far as possible, non-invasive therapeutic techniques.

Parto gemelar diferido: a propósito de un caso / Delayed twin birth: case report

INTRODUCCIÓN: Se presenta el caso de un parto diferido en una gestación gemelar en la que se consigue retrasar el parto del segundo gemelo 45 días con manejo conservador. CASO CLÍNICO: Mujer de 25 años, gestación gemelar bicorial biamniótica, con diagnóstico de muerte fetal del primer gemelo en semana 24+3 y parto del mismo tras una semana de evolución. Se decide la opción de tratamiento conservador expectante, con reposo absoluto, manteniendo tocolisis intravenosa, controles analíticos seriados, controles cardiotocográficos diarios, profilaxis antibiótica y antitrombótica. Con ello se consigue diferir el parto un total de 45 días. CONCLUSIÓN: El parto diferido en gestaciones gemelares es una práctica poco habitual, por lo que se carece de protocolos y actuaciones específicas. La bibliografía disponible difiere en cuanto al manejo de dichos casos y en el total de días que se consigue diferir el parto, pero en todos los estudios se reporta el beneficio en términos de resultados perinatales al conseguir aumentar la edad gestacional del segundo gemelo. En nuestro caso se consiguió una mejora sustancial del resultado perinatal asociado a la prematuridad sin importantes efectos adversos maternos y tras el periodo de latencia indicado.

INTRODUCTION: We report a delayed delivery of a dichorionic diamniotic twin pregnancy, in which the birth of the second twin was postponed 45 days. CASE REPORT: At 24+3 weeks of gestation, a 25-year-old woman with dichorionic diamniotic twin pregnancy presented with preterm premature rupture of membranes and intrauterine dead of the first fetus. Spontaneous delivery of the first death twin, occurred al 25+2 weeks. Tocolysis, antibiotic, antithrombotic prophylaxis, absolute rest, serial blood tests and fetal cardiotocography controls, were performed. The second twin was delivered at 31+5 weeks, after a the preterm premature rupture of membranes triggered the labor. The interval between the first and second birth was 45 days. CONCLUSION: Delayed delivery in twin pregnancies, is an uncommon clinical situation, so there are not validated medical protocols. Available bibliography offers different practices related to its management. Most studies confirm the better survival rate and perinatal outcomes of the postponed birth twin.

Embarazo multiple en utero didelfo y bicollis.. Reporte de caso / Multiple pregnancy in uterus didelphys and bicollis. Case report

El útero didelfo forma parte del grupo de anomalías müllerianas. Este se produce posterior a una falla en la fusión de los conductos müllerianos, resultando dos cavidades uterinas diferentes y dos cérvix que se unen en el extremo uterino inferior. En la mayoría de los casos esta malformación se asocia a un tabique vaginal longitudinal. Todo esto debido a deficiencias en el proceso de formación de los conductos müllerianos. Los embarazos gemelares en úteros didelfos se estiman en uno por cada millón de embarazos, pero en la actualidad se encuentran reportados pocos casos en el mundo. Esta revisión relata el caso de una paciente con útero didelfo, quién presentó un embarazo múltiple con un feto en cada uno de los hemiúteros. Sin ningún método de apoyo para la concepción del embarazo, se obtuvieron dos recién nacidos sanos, tras cesárea de emergencia por iniciar trabajo de parto y ruptura de membranas, con distocia de partes blandas ocasionada por el tabique vaginal

The didelphys uterus is part of the group of Müllerian anomalies. This occurs after a failure in the fusion of the Müllerian ducts, resulting in two different uterine cavities and two cervix that unite at the lower uterine end. In most cases this malformation is associated with a longitudinal vaginal septum. All this due to deficiencies in the process of formation of the Müllerian ducts. Twin pregnancies in didelphys uteri are estimated at one per million pregnancies, but few cases are currently reported in the world. This review reports the case of a patient with a didelphic uterus, who presented a multiple pregnancy with a fetus in each of the hemi-uteri. Without any support method for the conception of pregnancy, two healthy newborns were obtained, after emergency cesarean section due to initiation of labor and rupture of membranes, with soft tissue dystocia caused by the vaginal septum

Pattern of live births in Rio de Janeiro State, Brazil, according to Robson groups and the Kotelchuck index classification - 2015/2016 / Padrão de nascidos vivos no estado do Rio de Janeiro, Brasil, segundo os grupos Robson e a classificação do índice Kotelchuck - 2015/2016

Abstract Objective To investigate the patterns of hospital births in the state of Rio de Janeiro (RJ), Brazil, between 2015 and 2016; considering the classification of obstetric characteristics proposed by Robson and the prenatal care index proposed by Kotelchuck. Methods Data obtained from the Information System on Live Births of the Informatics Department of the Brazilian Unified Health System (SINASC/DATASUS, in the Portuguese acronym) databases were used to group pregnant women relatively to the Robson classification. A descriptive analysis was performed for each Robson group, considering the variables: maternal age, marital status, schooling, parity, Kotelchuck prenatal adequacy index and gestational age. A logistic model estimated odds ratios (ORs) for cesarean sections (C-sections), considering the aforementioned variables. Results Out of the 456,089 live births in Rio de Janeiro state between 2015 and 2016, 391,961 records were retained, 60.3% of which were C-sections. Most pregnant women (58.6%) were classified in groups 5, 2 or 3. The percentage of C-sections in the Robson groups 1, 2, 3, 4, 5 and 8 was much higher than expected. Prenatal care proved to be inadequate for women who subsequently had a vaginal delivery, had an unfavorable family structure and a lower socioeconomic status (mothers without partners and with lower schooling), compared with those undergoing cesarean delivery. For a sameRobson group, the chance of C-section increases when maternal age rises (OR = 3.33 for 41-45 years old), there is the presence of a partner (OR = 1.81) and prenatal care improves (OR = 3.19 for "adequate plus"). Conclusion There are indications that in the state of RJ, from 2015 to 2016, many cesarean deliveries were performed due to nonclinical factors.

Resumo Objetivo Investigar os padrões dos partos hospitalares no estado do Rio de Janeiro (RJ), Brasil, entre 2015 e 2016, considerando a classificação de características obstétricas de Robson e a dos cuidados pré-natais proposta por Kotelchuck. Métodos Dados sistema de informações sobre nascidos vivos (SINASC) do departamento de informática do sistema único de saúde (DATASUS) foram utilizados para agrupar gestantes relativamente à classificação de Robson. Foi efetuada uma análise descritiva para cada grupo de Robson, considerando-se as variáveis idade materna, estado civil, escolaridade, paridade, o índice de Kotelchuck de adequação do pré-natal e a idade gestacional. Também foi realizado o cálculo de razão de chances (RC) para parto cesáreo, considerando-se um modelo logístico. Resultados Dos 456.089 nascimentos vivos ocorridos no RJ de 2015 a 2016, foram incluídos 391.961 registros, sendo 60,3% cesáreas, com maioria de gestantes (58,6%) nos grupos 5, 2 ou 3. O percentual de cesáreas nos grupos 1, 2, 3, 4, 5 e 8 foi bem superior ao sugerido pela literatura. Para gestantes de um mesmo grupo (controladas as demais características), a chance de cesárea se eleva quando aumenta a idade materna (RC = 3,33 para 41-45 anos), existe a presença de um companheiro (RC = 1,81), o nível de escolaridade é maior (RC = 3,11 para ≥ 12 anos) e o pré-natal é mais cuidadoso (RC= 3,19 para "adequado plus"). Conclusão Há indícios que no RJ, de 2015 a 2016, muitos partos cesáreos foram realizados sob influência de fatores extraclínicos.

Ultrasonographic diagnosis of twins in two pregnant bitches: case report / Diagnóstico ultrassonográfico de gestação gemelar em duas cadelas: relato de caso

Multiple pregnancies in humans account for only 3% of pregnancies, 97-98% of which are twin pregnancies and the morbimortality is higher in the monochorionic twins when compared to dichorionic ones. The canine species is naturally multiparous, but the diagnosis of monochorionic twin pregnancy is not common. The objective of this report was to describe the ultrasonographic diagnosis of monochorionic twin pregnancies in two bitches [Pug (case 1) and Shih tzu (case 2)]. It was possible to verify the presence of one gestational vesicle containing two fetuses in each female by observing two heads or two bodies within the same placental site. These fetuses presented adequate viability and normal organogenesis. Their development was similar to the other fetuses. In case 1 they were stillborn and smaller than the other five live-born fetuses. The twins in case 2 were born alive, but they also appeared smaller when compared to the littermates. The gestational risks associated with this condition in pregnant bitches are still unknown, however, there are reports of fetal death in monochorionic pregnancies in this species. Therefore, ultrasonographic exam during pregnancy allows an early monochorionic diagnosis and monitoring the fetal viability could bring health benefits to both the female and the littermates.(AU)

As gestações múltiplas em humanos correspondem a apenas 3% das gestações, sendo 97-98% dessas gestações gemelares. Sabe-se que a morbimortalidade fetal é maior em gêmeos monocoriônicos do que nos dicoriônicos. A espécie canina é naturalmente multípara, mas o diagnóstico gestacional de gêmeos monocoriônicos não é comum. O objetivo deste relato é descrever o diagnóstico ultrassonográfico de gêmeos monocoriônicos em duas cadelas, sendo uma da raça Pug (caso 1) e outra da raça Shih-Tzu (caso 2). Foi possível verificar a presença de uma única vesícula gestacional contendo dois fetos em cada cadela, por meio da visibilização de duas cabeças ou de dois corpos dentro de uma mesma placenta. Esses fetos apresentavam viabilidade e organogênese adequadas e o grau de desenvolvimento era similar aos demais fetos da ninhada. No caso 1, os gêmeos nasceram mortos e de tamanho menor que os outros cinco fetos nascidos vivos. Os gêmeos do caso 2 nasceram vivos, mas também eram pequenos em relação aos irmãos da ninhada. Os riscos gestacionais associados a essa condição em cadelas ainda não são conhecidos, no entanto já existem relatos de morte fetal em gestação monocoriônica nessa espécie. Portanto, o exame ultrassonográfico durante a gestação permite um diagnóstico precoce da monocorionicidade, e a monitorização da viabilidade fetal pode trazer benefícios para a saúde da matriz, assim como para o restante da ninhada.(AU)

Exploring obstetrical interventions and stratified cesarean section rates using the Robson classification in tertiary Care hospitals in the united arab emirates

Abstract Objective The objective of the present study was to explore obstetric management in relation to clinical, maternal and child health outcomes by using the Robson classification system. Methods Data was collected from obstetrics registries in tertiary care hospitals in Dubai, United Arab Emirates (UAE). Results The analysis of > 5,400 deliveries (60% of all the deliveries in 2016) in major maternity hospitals in Dubai showed that groups 5, 8 and 9 of Robson's classification were the largest contributors to the overall cesarean section (CS) rate and accounted for 30% of the total CS rate. The results indicate that labor was spontaneous in 2,221 (45%) of the women and was augmented or induced in almost 1,634 cases (33%). The birth indication rate was of 64% for normal vaginal delivery, of 24% for emergency CS, and of 9% for elective CS.The rate of vaginal birth after cesarean was 261(6%), the rate of external cephalic version was 28 (0.7%), and the rate of induction was 1,168 (21.4%). The prevalence of the overall Cesarean section was 33%; with majority (53.5%) of it being repeated Cesarean section. Conclusion The CS rate in the United Arab Emirates (UAE) is higher than the global average rate and than the average rate in Asia, which highlights the need for more education of pregnant women and of their physicians in order to promote vaginal birth. A proper planning is needed to reduce the number of CSs in nulliparous women in order to prevent repeated CSs in the future. Monitoring both CS rates and outcomes is essential to ensure that policies, practices, and actions for the optimization of the utilization of CS lead to improved maternal and infant outcomes.

Trends in Birth Weight and the Incidence of Low Birth Weight and Advanced Maternal Age in Korea between 1993 and 2016

BACKGROUND: As the aging society progresses, the average age of mothers is also increasing. Advanced maternal age has been known to be associated with perinatal outcomes, as well as birth weight (BW). In this study, we aimed to investigate the perinatal factors associated with low birth weight infants (LBWIs) using birth statistics of the Korean population. METHODS: Birth statistics between 1993 and 2016 from the Korean Statistical Information Service were reviewed. We investigated 12,856,614 data points, which included the number of births, BWs, percentage of preterm births and LBWIs, multiple pregnancies, and maternal age. RESULTS: The proportion of LBWIs delivered by mothers of advanced maternal age has gradually increased since 1993. In addition, the proportion of older mothers (≥ 35 years old) giving birth to LBWIs has increased over the years. Average BW has a negative correlation with the ratio of preterm births, LBW, multiple births, and advanced maternal age. The mean BW also has a negative correlation with maternal age. CONCLUSION: This study shows that the average BW continues to decline, and the incidence of LBWIs is increasing in Korea since 1993. This study also revealed that several perinatal factors, including percentage of preterm births, LBWIs, multiple births, and maternal age influence the mean BW. Although this study did not investigate the effects of decreasing mean BW on perinatal health, future research is worth discussing.

Fatores associados ao nascimento pré-termo: da regressão logística à modelagem com equações estruturais / Factores asociados con el nacimiento prematuro: de la regresión logística al modelo de ecuaciones estructurales / Factors associated with preterm birth: from logistic regression to structural equation modeling

O estudo propôs a aplicação da modelagem com equações estruturais (MEE) para estudar variáveis associadas ao nascimento pré-termo com base em um modelo teórico analisado previamente pela regressão logística hierarquizada. Os dados foram provenientes da pesquisa observacional do tipo caso-controle populacional sobre nascidos vivos hospitalares de mães residentes em Londrina, Paraná, Brasil (junho de 2006 a março de 2007). Para a MEE foi considerada a associação de características socioeconômicas e aspectos psicossociais sobre história reprodutiva, trabalho e atividade física, intercorrências durante a gestação e características fetais. Considerou-se, ainda, a relação dessas associações sobre o desfecho nascimento pré-termo mediado pela adequação da assistência pré-natal. Foram utilizados estimadores de mínimos quadrados ajustados pela média e variância (WLSMV), para dados categóricos, e a máxima verossimilhança robusta (MLR), para obter razões de chances. Foram criadas três variáveis latentes: vulnerabilidade socioeconômica, vulnerabilidade familiar e não aceitação da gravidez. O efeito da vulnerabilidade socioeconômica, da família e da não aceitação da gravidez sobre a prematuridade ocorreu de modo indireto por meio da inadequação da assistência pré-natal. A metodologia proposta possibilitou utilizar construtos, verificar o papel de mediação da inadequação da assistência pré-natal e identificar efeitos diretos e indiretos das variáveis sobre o desfecho nascimento pré-termo.

Este estudio propuso la aplicación de modelos de ecuaciones estructurales (SEM) para investigar las variables asociadas con el parto prematuro basándose en un modelo teórico previamente analizado mediante regresión logística jerárquica. Los datos provienen de un estudio observacional de casos y controles de base poblacional de nacidos vivos en hospitales de madres que residen en Londrina, estado de Paraná, Brasil (junio de 2006 a marzo de 2007). Para el SEM, el estudio consideró la asociación entre las características socioeconómicas y los aspectos psicosociales relacionados con el historial reproductivo, el trabajo y la actividad física, las complicaciones durante el embarazo y las características fetales. También consideró la relación entre estas asociaciones y el parto prematuro mediado por la adecuación de la atención prenatal. Se utilizó el estimador de los mínimos cuadrados ponderados ajustados por la media y variancia (WLSMV) para datos categóricos y la probabilidad máxima robusta (MLR) para los odds ratios. Se crearon tres variables latentes: vulnerabilidad socioeconómica, vulnerabilidad familiar y embarazo no deseado. El efecto de la vulnerabilidad socioeconómica y familiar y el embarazo no deseado en la prematuridad ocurrió indirectamente por la insuficiencia de la atención prenatal. La metodología propuesta permitió usar constructos, verificar el papel de la mediación por la insuficiencia de la atención prenatal e identificar los efectos directos e indirectos de las variables sobre el resultado "parto prematuro".

This study proposed the application of structural equation modeling (SEM) to investigate variables associated with preterm birth based on a theoretical model analyzed previously by hierarchical logistic regression. The data came from a population-based case-control observational study of hospital births to mothers residing in Londrina, Paraná State, Brazil (June 2006 to March 2007). For the SEM, the study considered the association between socioeconomic characteristics and psychosocial aspects pertaining to reproductive history, work and physical activity, complications during the pregnancy, and fetal characteristics. It also considered the relationship between these associations and the outcome preterm birth mediated by adequacy of prenatal care. The weighted least square mean and variance adjusted estimator (WLSMV) was used for categorical data and robust maximum likelihood (MLR) for odds ratios. Three latent variables were created: socioeconomic vulnerability, family vulnerability, and unwanted pregnancy. The effect of socioeconomic and family vulnerability and unwanted pregnancy on prematurity occurred indirectly through inadequacy of prenatal care. The proposed methodology allowed using constructs, verifying the role of mediation by inadequacy of prenatal care, and identifying the variables' direct and indirect effects on the outcome preterm birth.

Protocolos de Vigilancia de las embarazadas y muertes en mujeres en edad fértil para la identificación de muerte materna. No. 13 / Surveillance protocols for pregnant women and deaths in women of childbearing age for the identification of maternal death. No. 13

Estos protocolos están dirigido a personal médico, paramédico y otros profesionales que realizan acciones gerenciales y operativas de vigilancia epidemiológica en los servicios de salud del país, y están divididos en varios tomos para dar a conocer y actualizar la identificación y medidas de control para diversos padecimientos a fin de continuar con el mejoramiento de las capacidades técnicas de los trabajadores de salud, que permita planificar la prestación de servicios con decisiones partiendo de un enfoque epidemiológico comprobado, para responder a los cambios de tendencias epidemiológicas y con ello contribuir al fortalecimiento de prácticas asertivas de la salud pública de nuestro país. Este protocolo, considera que, toda embarazada se considera de riesgo, sin embargo existen condiciones que hacen necesaria una vigilancia más estrecha entre las edades tempranas y tardías de la vida reproductiva, embarazos múltiples, antecedentes de afecciones previas y durante el embarazo. La identificación de factores que puedan incidir en un aumento de riesgo obstétrico que pueda desencadenar complicaciones y en el peor de los casos la muerte, se constituye en prioridad para el desarrollo de estrategias de vigilancia y atención en el país. Su objetivo es el de identificar embarazadas en condiciones de riesgo que ameriten vigilancia más estrecha o referencia oportuna a un servicio con mejor capacidad resolutiva. Y específicamente, registrar y analizar las variables epidemiológicas de las embarazadas

Avaliação da transferência de imunidade passiva e de constituintes séricos de cordeiros Santa Inês nascidos de partos simples e gemelares no semiárido paraibano / Evaluation of passive immunity transfer and serum constituents of Santa Ines lambs born of single and twin pregnancies in the semiarid region of Paraiba, Brazil

O presente trabalho teve por objetivo avaliar a influência do tipo de parto sobre a transferência de imunidade passiva e de alguns constituintes séricos de cordeiros recém-nascidos, alimentados naturalmente com colostro materno, criados no semiárido paraibano em sistema extensivo. Foram utilizados 34 cordeiros clinicamente sadios, da raça Santa Inês, os quais foram identificados e pesados imediatamente após o nascimento e separados em dois grupos experimentais com 17 animais cada. O grupo PS (nove machos e oito fêmeas) formado por animais nascidos de partos simples e o grupo PG (seis machos e onze fêmeas) formado por cordeiros nascidos de partos gemelares. A ingestão de colostro se deu de forma natural e voluntária em suas respectivas mães. Foram coletados 10 mL de sangue de cada animal, mediante punção da veia jugular, em tubos siliconizados a vácuo, 48 horas após o nascimento. Após centrifugação, as alíquotas de soro foram separadas e permaneceram congeladas a -15°C até o momento das análises. Para o estudo comparativo dos constituintes séricos, foram constituídos dois grupos experimentais distribuídos em um delineamento inteiramente casualizado, no esquema fatorial 2x2 (tipo de parto e sexo). Os dados obtidos foram submetidos à análise de variância, cujas médias foram comparadas pelo teste de Tukey a 5%. Foram determinadas as atividades séricas das enzimas aspartato aminotransferase (AST) e gamaglutamiltransferase (GGT) e as concentrações séricas de proteína total, albumina, ureia, creatinina, cálcio, fósforo e magnésio, utilizando-se conjuntos de reagentes comerciais e as leituras das amostras em espectrofotômetro automático. As atividades séricas de AST, GGT e as concentrações séricas de proteína total, albumina e globulinas dos cordeiros dos grupos PS e PG não foram influenciadas pelo tipo de gestação e sexo. A partir da concentração sérica de proteína total, verificou-se falha de transferência de imunidade passiva (FTIP) nos cordeiros do grupo PG, utilizando-se o valor 5,0g/dL como ponto de corte. Com exceção do cálcio, as concentrações séricas da ureia, creatinina, fósforo e magnésio apresentaram o mesmo padrão de comportamento. Embora esses constituintes não tenham apresentado diferença significativa entre os grupos estudados e o sexo, pôde-se observar valores mais elevados nos animais nascidos de partos simples, sugerindo que a ausência de concorrência pela ingestão voluntária de colostro materno pode ter sido o fator determinante. Pode-se concluir que cordeiros Santa Inês nascidos de partos gemelares e criados extensivamente no semiárido paraibano apresentam falha na transferência de imunidade passiva e alterações/diminuições marcantes nos teores séricos de alguns constituintes bioquímicos, suscitando a necessidade de interferência humana nestes casos.(AU)

This study is concerned with an evaluation of the influence of mode of birth on the transfer of passive immunity and some serum constituents to newborn lambs, naturally fed with colostrum, breed in the semiarid region of the State of Paraiba (Brazil) on an extensive system. Thirty-four clinically healthy Santa Ines lambs were employed, identified and weighted immediately after birth, and divided into two experimental groups of seventeen animals each. The PS group (nine males and eight females) included lambs born of single pregnancies and the PG group (six males and eleven females) comprised of lambs born of twin pregnancies. The colostrum intake occurred naturally and voluntarily at their mothers. Forty-eight hours after birth, 10 mL of blood were collected in siliconized tubes from each animal by puncture of the jugular vein, and maintained under vacuum. After centrifugation, aliquots of sera were separated and kept frozen at -15°C until analyzed. For the comparative study of serum constituents, two experimental groups were formed, distributed in a completely randomized lineation, 2x2 factorial (type of birth and sex). The data were subjected to analysis of variance, whose means were compared by Tukey test at 5%. The serum activities of AST and GGT, and the total protein serum, albumin, urea, creatinine, calcium, phosphorus and magnesium concentrations were determined by using sets of commercial reagents; the samples were read by an automatic spectrophotometer. The serum activities of AST, GGT and serum concentrations of total protein, albumin and globulins of the PS and PG lambs groups were not influenced by the type of pregnancy and sex. From the serum concentration of total protein, FTIP was found in the lambs of PG group, using the value of 5.0g/dL as the cutoff point. With the exception of calcium, serum concentrations of urea, creatinine, phosphorus and magnesium showed the same pattern. Although these constituents did not showed significant differences between groups and sex, higher values were observed in animals born of single pregnancies, suggesting that the absence of competition for the voluntary ingestion of colostrum may have been the determining factor. It can be concluded that lambs born twin deliveries and breed extensively in the semiarid region of the State of Paraiba failed to transfer passive immunity and showed significant reduction in serum levels of some biochemical constituents, indicating the need for human interference in these cases.(AU)

Risk Factors for Premature Birth among Premature Obstetric Labor Women: A Prospective Cohort Study

PURPOSE: To identify risk factors for premature birth among premature obstetric labor women. METHODS: Participants were 129 hospitalized women who were diagnosed with potential premature obstetric labor with 20 weeks to 37 weeks of gestation. Data were analyzed using descriptive statistics, χ2 test, t-test, and binary logistic regression. RESULTS: Of 129 women, 78(60.5%) gave premature birth and 51 (39.5%) gave full-term birth. Risk factors for premature birth were education level (≤bachelor's degree), abnormal bowel condition (constipation or diarrhea), time firstly diagnosed with a premature obstetric labor (below 28 weeks of pregnancy), and multiple pregnancy. There were also increased risks of premature birth for participants with high level of anxiety and high level of prenatal stress. In social support, there was an increased risk of premature birth for participants with low level of social support. CONCLUSION: Prenatal nursing programs should consider not only psychosocial factors such as anxiety, prenatal stress, and social support, but also some general and obstetric factors such as education level, abnormal bowel condition, time firstly diagnosed with a premature obstetric labor, and multiple pregnancy to increase maternal and child health.

Comparison between Single and Double Cleavage-Stage Embryo Transfers, Single and Double Blastocyst Transfers in a South East Asian In Vitro Fertilisation Centre

INTRODUCTION@#This study investigated the differences in clinical pregnancy rate (CPR), live birth rate (LBR) and multiple pregnancy rate (MPR) between double cleavage-stage embryo transfers compared to single and double blastocysts stage embryo transfers in a single academic medical centre.@*MATERIALS AND METHODS@#This was a retrospective cohort study performed at the KK Women's and Children's Hospital In Vitro Fertilisation (KKIVF) Centre of all women who underwent fresh-cycle in vitro fertilisation/intracytoplasmic sperm injection (IVF/ICSI) cycles over a 5-year period. The outcome measures were CPR, LBR and MPR. The study included 5294 cycles, of which 539 patients underwent single embryo transfer (SET); 4533 patients underwent double embryo transfer (DET); 84 patients underwent double blastocyst embryo transfer (DBT); and 65 patients underwent single blastocyst embryo transfer (SBT).@*RESULTS@#The mean age of patients undergoing single blastocysts stage embryo transfer was lower than the other 2 groups. The DET, single and double blastocysts stage embryo transfer groups achieved similar LBR (33.9%, 38.7%, 35.4%, >0.05) and CPR (42.4%, 46.2%, 46.9%).@*CONCLUSION@#We found that single blastocysts stage embryo transfer is associated with similar LBR and CPR compared to double blastocysts stage embryo transfer and DET, with lower MPRs, and should be offered as standard practice, where possible.

Experience of Decision Making about Selective Fetal Reduction among Women Who Conceived through Assisted Reproductive Techniques / 임상간호연구

PURPOSE: This study aimed to explore and understand the experience of decision making among women undergoing or forgoing selective fetal reduction who have higher-order multiple pregnancies through assisted reproductive techniques. METHODS: A qualitative study was conducted from August 1, to October 30, 2013. Eight participants were interviewed and the interviews were audio-recorded and transcribed verbatim. Six persons participated in in-depth interviews in person and two participated over the telephone. A thematic analysis was conducted. RESULTS: Four themes were identified and carefully named: Confusion after higher-order multiple pregnancy; Obstacles to choice: Uncertain safety; Weighing between reality and ideality and; Influences of medical professionals. CONCLUSION: The results demonstrated a wide range of factors considered by women when making decisions about selective fetal reduction, and mothers'feelings of conflict and distress in the decision-making process. The results suggest that it is important for nurses to provide emotional support and consolation, in addition to sufficient information. These findings will help nurses improve their counseling techniques by understanding the situation of infertile couples.

The trends and risk factors to predict adverse outcomes in gestational diabetes mellitus: a 10-year experience from 2006 to 2015 in a single tertiary center

OBJECTIVE: To investigate the change of maternal characteristics, delivery and neonatal outcomes in gestational diabetes mellitus (GDM) over recent 10 years and to identify the risk factors associated with adverse outcome. METHODS: Consecutive GDM patients (n=947) delivered in our institution were included. Research period was arbitrarily divided into 2 periods (period 1: from 2006 to 2010, period 2: from 2011 to 2015). Multiple pregnancies or preexisting diabetes were excluded. Maternal baseline characteristics, delivery and neonatal outcomes were reviewed. Fetal biometric findings by prenatal ultrasonography were collected. Adverse pregnancy outcome (APO) was defined by the presence of one of the followings; shoulder dystocia, neonatal macrosomia (>4 kg), neonatal hypoglycemia (< 35 mg/dL), respiratory distress syndrome (RDS), and admission to the neonatal intensive care unit (NICU) in term pregnancy. RESULTS: Period 2 was associated with older maternal age (34 vs. 33, P < 0.001) and higher proportion of GDM A2 compared to period 1 (30.9% vs. 23.0%, P=0.009). By univariate analysis, APO was associated with increased body mass index (BMI) at pre-pregnancy (23.4 kg/m² vs. 21.8 kg/m², P=0.001) or delivery (27.9 kg/m² vs. 25.8 kg/m², P < 0.001), higher HbA1c at diagnosis (5.6% vs. 5.3%, P < 0.001) or delivery (5.8% vs. 5.5%, P=0.044), and larger fetal biometric findings (abdominal circumference [AC] and estimated fetal weight, P=0.029 and P=0.007, respectively). Multivariate analysis showed pre-pregnancy BMI (odds ratio [OR], 1.101; 90% confidence interval [CI], 1.028–1.180) and fetal AC (OR, 1.218; 90% CI, 1.012–1.466) were independently associated with adverse outcomes. CONCLUSION: Our study demonstrated the trends and relevant factors associated with the adverse outcomes.

The Risk of Spontaneous Preterm Birth according to Maternal Pre-pregnancy Body Mass Index in Twin Gestations

BACKGROUND: Maternal obesity is a well-known risk factor for both total preterm birth (PTB) and spontaneous PTB in singleton gestation, whereas this association is not well determined in multiple pregnancy. The objective of this study was to determine the risk of spontaneous PTB according to the pre-pregnancy body mass index (BMI) in twin gestations. METHODS: The association between the risk of PTB and pre-pregnancy BMI was determined in women pregnant with twins between 2004 and 2014. Pre-pregnancy BMI values were divided into three groups (underweight/normal/overweight and obese). PTB was classified as spontaneous PTB (following preterm premature rupture of membranes, preterm labor, or cervical insufficiency) or medically indicated PTB (cesarean section or induction of labor because of maternal/fetal indications). RESULTS: A total of 1,959 women were included in the analysis, and the percentages of total PTB and spontaneous PTB were 13.1% and 9.3%. The percentages of total PTB and spontaneous PTB in three groups were 14.1%, 11.9%, 16.3%, respectively, and 11.0%, 8.0%, 12.5% (P < 0.05 between normal and overweight/obese women). The risks of total and spontaneous PTB in overweight/obese women were higher than those in women with normal weight, even after adjustment for prior history of PTB, age, maternal height, parity, in vitro fertilization-embryo transfer (IVF-ET) (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.01–2.03; OR, 1.58; 95% CI, 1.05–2.36). CONCLUSION: The risks of both total and spontaneous PTB were significantly greater in the overweight/obese group than in the normal BMI group.