Pre-gestational counselling for women living with CKD: starting from the bright side.

Pregnancy in women living with chronic kidney disease (CKD) was often discouraged due to the risk of adverse maternal-fetal outcomes and the progression of kidney disease. This negative attitude has changed in recent years, with greater emphasis on patient empowerment than on the imperative 'non nocere'. Although risks persist, pregnancy outcomes even in advanced CKD have significantly improved, for both the mother and the newborn. Adequate counselling can help to minimize risks and support a more conscious and informed approach to those risks that are unavoidable. Pre-conception counselling enables a woman to plan the most appropriate moment for her to try to become pregnant. Counselling is context sensitive and needs to be discussed also within an ethical framework. Classically, counselling is more focused on risks than on the probability of a successful outcome. 'Positive counselling', highlighting also the chances of a favourable outcome, can help to strengthen the patient-physician relationship, which is a powerful means of optimizing adherence and compliance. Since, due to the heterogeneity of CKD, giving exact figures in single cases is difficult and may even be impossible, a scenario-based approach may help understanding and facing favourable outcomes and adverse events. Pregnancy outcomes modulate the future life of the mother and of her baby; hence the concept of 'post partum' counselling is also introduced, discussing how pregnancy results may modulate the long-term prognosis of the mother and the child and the future pregnancies.

Gestational Diabetes Mellitus Subtypes Classified by Oral Glucose Tolerance Test and Maternal and Perinatal Outcomes: Results of a Mexican Multicenter Prospective Cohort Study "Cuido Mi Embarazo".

Purpose: This study explores the impact of gestational diabetes mellitus (GDM) subtypes classified by oral glucose tolerance test (OGTT) values on maternal and perinatal outcomes. Patients and Methods: This multicenter prospective cohort study (May 2019-December 2022) included participants from the Mexican multicenter cohort study Cuido mi Embarazo (CME). Women were classified into four groups per 75-g 2-h OGTT: 1) normal glucose tolerance (normal OGTT), 2) GDM-Sensitivity (isolated abnormal fasting or abnormal fasting in combination with 1-h or 2-h abnormal results), 3) GDM-Secretion (isolated abnormal values at 1-h or 2-h or their combination), and 4) GDM-Mixed (three abnormal values). Cesarean delivery, neonates large for gestational age (LGA), and pre-term birth rates were among the outcomes compared. Between-group comparisons were analyzed using either the t-test, chi-square test, or Fisher's exact test. Results: Of 2,056 Mexican pregnant women in the CME cohort, 294 (14.3%) had GDM; 53.7%, 34.4%, and 11.9% were classified as GDM-Sensitivity, GDM-Secretion, and GDM-Mixed subtypes, respectively. Women with GDM were older (p = 0.0001) and more often multiparous (p = 0.119) vs without GDM. Cesarean delivery (63.3%; p = 0.02) and neonate LGA (10.7%; p = 0.078) were higher in the GDM-Mixed group than the overall GDM group (55.6% and 8.4%, respectively). Pre-term birth was more common in the GDM-Sensitivity group than in the overall GDM group (10.2% vs 8.5%, respectively; p=0.022). At 6 months postpartum, prediabetes was more frequent in the GDM-Sensitivity group than in the overall GDM group (31.6% vs 25.5%). Type 2 diabetes was more common in the GDM-Mixed group than in the overall GDM group (10.0% vs 3.3%). Conclusion: GDM subtypes effectively stratified maternal and perinatal risks. GDM-Mixed subtype increased the risk of cesarean delivery, LGA, and type 2 diabetes postpartum. GDM subtypes may help personalize clinical interventions and optimize maternal and perinatal outcomes.

Adding creatinine to routine pregnancy tests: a decision tree for calculating the cost of identifying patients with CKD in pregnancy.

BACKGROUND: Even in its early stages, chronic kidney disease (CKD) is associated with adverse pregnancy outcomes. The current guidelines for pregnancy management suggest identifying risk factors for adverse outcomes but do not mention kidney diseases. Since CKD is often asymptomatic, pregnancy offers a valuable opportunity for diagnosis. The present analysis attempts to quantify the cost of adding serum creatinine to prenatal screening and monitoring tests. METHODS: The decision tree we built takes several screening scenarios (before, during and after pregnancy) into consideration, following the hypothesis that while 1:750 pregnant women are affected by stage 4-5 CKD and 1:375 by stage 3B, only 50% of CKD cases are known. Prevalence of abortions/miscarriages was calculated at 30%; compliance with tests was hypothesized at 50% pre- and post-pregnancy and 90% during pregnancy (30% for miscarriages); the cost of serum creatinine (production cost) was set at 0.20 euros. A downloadable calculator, which makes it possible to adapt these figures to other settings, is available. RESULTS: The cost per detected CKD case ranged from 111 euros (one test during pregnancy, diagnostic yield 64.8%) to 281.90 euros (one test per trimester, plus one post-pregnancy or miscarriage, diagnostic yield 87.7%). The best policy is identified as one test pre-, one during and one post-pregnancy (191.80 euros, diagnostic yield 89.4%). CONCLUSIONS: This study suggests the feasibility of early CKD diagnosis in pregnancy by adding serum creatinine to routinely performed prenatal tests and offers cost estimates for further discussion.

Q fever screening among pregnant women with pre-term delivery in northern Israel: An observational study.

The relationship between Q fever, caused by Coxiella burnetii, and obstetrical complications is debatable. Since Q fever is endemic in Israel, we aimed to assess its seroprevalence and clinical characteristics in pre-term deliveries. Between 1 August 2017 and 31 December 2019, we conducted serological screening for C. burnetii in pregnant women who presented to Rambam Health Care Campus with pre-term delivery (before 37 weeks of gestation). Anti-C. burnetii antibodies were tested first by enzyme-linked immunosorbent assay for the detection of phase I-IgG, phase II-IgG and phase II-IgM. Positive results were confirmed by indirect immunofluorescence with titre determination. Seropositivity was classified into past, acute and chronic infection. Demographic and clinical data of mothers and neonates were collected and compared between seropositive and seronegative women. Out of 386 pregnant women screened for anti-C. burnetii antibodies, 16 (4.1%) were seropositive, of whom three were diagnosed with past, 12 with acute and one with chronic infection. A higher percentage of seropositive women were immunosuppressed, 2/16 (12.5%) compared with 7/370 (1.9%) in seronegative women, (p = .05). Neonates with small for gestational age were born to 2/16 (12.5%) seropositive women compared with 29/370 (7.8%) to seronegative women, (p = .35). The seroprevalence of Q fever among pregnant women with pre-term birth reached 4% in northern Israel. This high rate in an endemic setting encourages investigating the role of routine screening for Q fever during pregnancy. Special attention should be given to pregnant immunosuppressed women at risk for exposure to Q fever.

Association between Abnormal Echocardiography and Adverse Obstetric Outcomes in Low-Risk Pregnant Women.

Maternal mortality in the United States is a public health crisis of preventable deaths among young women. The role of echocardiography in the evaluation of pregnant women with cardiovascular symptoms or risk factors without known heart disease is unclear. We retrospectively examined the clinical characteristics of consecutive pregnant patients without established heart disease who underwent echocardiography and evaluated associations between abnormal exam findings and obstetric outcomes. Among low-risk women undergoing echocardiography during pregnancy, older age, higher parity and a history of chronic hypertension are associated with a higher likelihood of echocardiographic abnormalities, which in turn are associated with a higher likelihood of adverse obstetric outcomes including caesarean section and preterm delivery.

What a paediatric nephrologist should know about preeclampsia and why it matters.

Preeclampsia is a protean syndrome causing a kidney disease characterised by hypertension and proteinuria, usually considered transitory and reversible after delivery. Its prevalence ranges from 3-5 to 10% if all the related disorders are considered. This narrative review, on behalf of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology, focuses on three reasons why preeclampsia should concern paediatric nephrologists and how they can play an important role in its prevention, as well as in the prevention of future kidney and cardiovascular diseases. Firstly, all diseases of the kidney and urinary tract diagnosed in paediatric age are associated with a higher risk of adverse pregnancy-related outcomes, including preeclampsia. Secondly, babies with low birth weights (small for gestational age, born preterm, or both) have an increased risk of developing the full panoply of metabolic diseases (obesity, hypertension, early-onset cardiopathy and chronic kidney disease) and girls are at higher risk of developing preeclampsia when pregnant. The risk may be particularly high in cases of maternal preeclampsia, highlighting a familial aggregation of this condition. Thirdly, pregnant teenagers have a higher risk of developing preeclampsia and the hypertensive disorders of pregnancy, and should be followed up as high risk pregnancies. In summary, preeclampsia has come to be seen as a window on the future health of both mother and baby. Identification of subjects at risk, early counselling and careful follow-up can contribute to reducing the high morbidity linked with this disorder.

Pre-term delivery and long-term risk of heart failure in women: a national cohort and co-sibling study.

AIMS: Women who deliver pre-term have higher future risks of hypertension and ischaemic heart disease, but long-term risks of heart failure (HF) are unknown. We examined these risks in a large national cohort. METHODS AND RESULTS: All 2 201 284 women with a singleton delivery in Sweden during 1973-2015 were followed up for inpatient or outpatient HF diagnoses through 2015. Cox regression was used to compute hazard ratios (HRs) for HF associated with pregnancy duration, adjusting for other maternal factors. Co-sibling analyses assessed for confounding by shared familial (genetic and/or environmental) factors. In 48.2 million person-years of follow-up, 19 922 women were diagnosed with HF (median age: 60.7 years). Within 10 years after delivery, the adjusted HR was 2.96 [95% confidence interval (CI): 2.48-3.53] for HF associated with pre-term (gestational age: <37 weeks) compared with full-term (39-41 weeks) delivery. Stratified HRs were 4.27 (2.54-7.17) for extremely pre-term (22-27 weeks), 3.39 (2.57-4.48) for moderately pre-term (28-33 weeks), 2.70 (2.19-3.32) for late pre-term (34-36 weeks), and 1.70 (1.45-1.98) for early term (37-38 weeks). These HRs declined but remained elevated at 10-19 years (pre-term vs. full term: HR: 2.19; 95% CI: 1.94-2.46), 20-29 years (1.80; 1.67-1.95), and 30-43 years (1.56; 1.47-1.66) after delivery, and were not explained by shared familial factors. CONCLUSION: Pre-term and early term delivery were associated with markedly increased future hazards for HF, which persisted after adjusting for other maternal and familial factors and remained elevated 40 years later. Pre-term and early-term delivery should be recognized as risk factors for HF across the life course. KEY QUESTION: What are the long-term hazards for heart failure (HF) across the life course in women who deliver preterm? KEY FINDING: Preterm and early term delivery were associated with ∼3- and 1.7-fold adjusted hazards for HF in the next 10 years vs. full-term delivery. These hazards declined but remained elevated 40 years later, and were not explained by shared familial factors. TAKE HOME MESSAGE: Preterm and early term delivery were associated with increased future hazards for HF, which persisted for 40 years after adjusting for other maternal and familial factors. Preterm and early term delivery should be recognized as lifelong risk factors for HF.

Metabolic profiling of pre-gestational and gestational diabetes mellitus identifies novel predictors of pre-term delivery.

BACKGROUND: Pregnant women with gestational diabetes mellitus (GDM) or type 2 diabetes mellitus (T2DM) are at increased risks of pre-term labor, hypertension and preeclampsia. In this study, metabolic profiling of blood samples collected from GDM, T2DM and control pregnant women was undertaken to identify potential diagnostic biomarkers in GDM/T2DM and compared to pregnancy outcome. METHODS: Sixty-seven pregnant women (21 controls, 32 GDM, 14 T2DM) in their second trimester underwent targeted metabolomics of plasma samples using tandem mass spectrometry with the Biocrates MxP® Quant 500 Kit. Linear regression models were used to identify the metabolic signature of GDM and T2DM, followed by generalized linear model (GLMNET) and Receiver Operating Characteristic (ROC) analysis to determine best predictors of GDM, T2DM and pre-term labor. RESULTS: The gestational age at delivery was 2 weeks earlier in T2DM compared to GDM and controls and correlated negatively with maternal HbA1C and systolic blood pressure and positively with serum albumin. Linear regression models revealed elevated glutamate and branched chain amino acids in GDM + T2DM group compared to controls. Regression models also revealed association of lower levels of triacylglycerols and diacylglycerols containing oleic and linoleic fatty acids with pre-term delivery. A generalized linear model ROC analyses revealed that that glutamate is the best predictors of GDM compared to controls (area under curve; AUC = 0.81). The model also revealed that phosphatidylcholine diacyl C40:2, arachidonic acid, glycochenodeoxycholic acid, and phosphatidylcholine acyl-alkyl C34:3 are the best predictors of GDM + T2DM compared to controls (AUC = 0.90). The model also revealed that the triacylglycerols C17:2/36:4 and C18:1/34:1 are the best predictors of pre-term delivery (≤ 37 weeks) (AUC = 0.84). CONCLUSIONS: This study highlights the metabolite alterations in women in their second trimester with diabetes mellitus and identifies predictive indicators of pre-term delivery. Future studies to confirm these associations in other cohorts and investigate their functional relevance and potential utilization for targeted therapies are warranted.

Pre-Term Delivery and Risk of Ischemic Heart Disease in Women.

BACKGROUND: Women who deliver pre-term have been reported to have increased future risks of cardiometabolic disorders. However, their long-term risks of ischemic heart disease (IHD) and whether such risks are due to shared familial factors are unclear. A better understanding of these risks may help improve long-term clinical follow-up and interventions to prevent IHD in women. OBJECTIVES: The purpose of this study was to determine the long-term risks of IHD in women by pregnancy duration. METHODS: A national cohort study was conducted of all 2,189,190 women with a singleton delivery in Sweden from 1973 to 2015, who were followed up for IHD through the end of 2015. Cox regression was used to compute adjusted hazard ratios (aHRs) for IHD associated with pregnancy duration, and cosibling analyses assessed the influence of shared familial (genetic and/or environmental) factors. RESULTS: In 47.5 million person-years of follow-up, 49,955 (2.3%) women were diagnosed with IHD. In the 10 years following delivery, the aHR for IHD associated with pre-term delivery (<37 weeks) was 2.47 (95% confidence interval [CI]: 2.16 to 2.82), and further stratified was 4.04 (95% CI: 2.69 to 6.08) for extremely pre-term (22 to 27 weeks), 2.62 (95% CI: 2.09 to 3.29) for very pre-term (28 to 33 weeks), 2.30 (95% CI: 1.97 to 2.70) for late pre-term (34 to 36 weeks), and 1.47 (95% CI: 1.30 to 1.65) for early-term (37 to 38 weeks), compared with full-term (39 to 41 weeks). These risks declined but remained significantly elevated after additional follow-up (pre-term vs. full-term, 10 to 19 years: aHR: 1.86; 95% CI: 1.73 to 1.99; 20 to 29 years: aHR: 1.52; 95% CI: 1.45 to 1.59; 30 to 43 years: aHR: 1.38; 95% CI: 1.32 to 1.45). These findings did not appear attributable to shared genetic or environmental factors within families. Additional pre-term deliveries were associated with further increases in risk. CONCLUSIONS: In this large national cohort, pre-term delivery was a strong independent risk factor for IHD. This association waned over time but remained substantially elevated up to 40 years later. Pre-term delivery should be recognized as a risk factor for IHD in women across the life course.

Longitud cervical o puntaje de bishop en la predicción de parto pretérmino inminente en pacientes sintomáticas / Cervical length or bishop score in prediction of imminent preterm delivery in symptomatic patients

RESUMEN OBJETIVO: Comparar la longitud cervical con el puntaje de Bishop en la predicción de parto pretérmino inminente en pacientes sintomáticas. MÉTODOS: Se seleccionaron mujeres con embarazos simples de 24 - 35 semanas, con amenaza de parto pretérmino y membranas integras. Antes del inicio de cualquier tratamiento, todas fueron sometidas a examen digital del cuello uterino y determinación ecográfica transvaginal de la longitud cervical. La principal variable de estudio fue la frecuencia de parto inminente (en los 7 días siguientes a la evaluación). Se evaluaron las características generales, puntaje de Bishop y valores de la longitud cervical RESULTADOS: Fueron seleccionadas 481 mujeres, 119 participantes presentaron parto pretérmino inminente (grupo A) y 362 pacientes presentaron partos más allá de los 7 días (grupo B). El intervalo entre la evaluación y el parto fue de 4,3 +/- 1,6 días en el grupo A y 56,3 +/- 27,2 días en el grupo B (p < 0,0001). Las pacientes del grupo A tenían valores más bajos de longitud cervical comparado con las pacientes del grupo B (p < 0,0001). Este grupo también presentó valores más elevados de puntaje de Bishop (p < 0,0001). La longitud cervical tenía un área bajo la curva mayor para la predicción (0,972, intervalo de confianza 95%, 0,772 - 1,000) comparado con el puntaje de Bisho (0,825, intervalo de confianza 95%, 0,783 - 0,870; p = 0,0137). CONCLUSIÓN: La longitud cervical es más útil en la predicción de parto pretérmino inminente en pacientes sintomáticas comparado con el puntaje de Bishop.

ABSTRACT OBJECTIVE: To compare the cervical length with Bishop score in prediction of imminent preterm delivery in symptomatic patients. METHODS: Women with single pregnancies of 24-35 weeks were selected, with the diagnosis of threatened preterm labor and intact membranes. Before the start of any treatment, all were submitted to the cervical digital examination and transvaginal ultrasound determination of cervical length. The main variable of the study was the frequency of imminent delivery (in the 7 days following evaluation). General characteristics, Bishop score, and cervical length values were evaluated. RESULTS: A total of 481 women were selected, 119 patients presented imminent delivery (group A) and 362 patients delivered after 7 days (group B). the interval between evaluation and delivery was 4.3 +/- 1.6 days in group A and 56.3 +/- 27.2 days in group B (p <0.0001). Patients in group A had lower values of cervical length compared with patients in group B (p <0.0001). This group also presented higher values of Bishop score (p <0.0001). Cervical length had a mayor area under for prediction (0.972, 95% confidence interval, 0.772-1.000) compared with Bishop score (0.825, 95% confidence interval, 0.783-0.870, p = 0.0137). CONCLUSION: Cervical length is more useful in the prediction of imminent preterm delivery in symptomatic patients compared to the Bishop score.n.

Obstetric outcomes in patients who have undergone excisional treatment for high-grade cervical squamous intra-epithelial neoplasia.

OBJECTIVE: To evaluate the relationships between excisional treatment for high-grade cervical intra-epithelial neoplasia (CIN2+) and obstetric outcomes in terms of preterm delivery risk, premature rupture of membrane (PROM) and type of delivery, and between pre-term delivery and the type of excisional technique (radio frequency excision, laser conization). METHODS: This was a retrospective study of the obstetric outcomes of 2316 women aged 25-45 years who underwent excisional treatment for CIN2+ at the Obstetric and Gynecological Clinic of Ospedale Maggiore della Carità in Novara and at the Obstetric and Gynecological Department of Ospedale Sant'Anna in Torino in the period 2005-2014 and were evaluated until April 2016, and 57,937 untreated women of the same age, from the same centers. RESULTS: After treatment, 320 women had at least one pregnancy leading to delivery after a mean of 3.35 years. Treatment significantly increased the risk of preterm delivery. Compared with no treatment, the risk of preterm birth was higher in women who had undergone treatment (33.13% vs. 6.60%). Techniques removing or ablating more tissue, such as large loop excision of the transformation zone, were associated with worse outcomes (OR 2.96, 95% IC 1.72-5.10). Smoking habits significantly increase the risk of preterm delivery in the treated women (OR 2.82, 95% IC 1.61-4.9). The risk of premature rupture of the membranes (PROM) (40% vs. 23.22%), the risk of preterm PROM (pPROM) (13.13% vs. 2.71%) and dystocic births (18.75% vs 4.48%) were also significantly increased after treatment. Caesarean sections were less frequent among the treated women (15.94% vs. 32.41%). CONCLUSIONS: Our findings reveal a relationship between cervical excisional treatment and pre-term delivery, PROM, and the method of delivery. In order to minimise risk and guarantee the best obstetric outcome, patient treatment and follow-up should be personalised.

Associations of serum markers screening for Down's syndrome with pregnancy outcomes: A Chinese retrospective cohort study.

BACKGROUND: We examined the associations between Down's serum screening analytes and pregnancy outcomes in Chinese women. METHODS: A retrospective cohort study of 2470 pregnant women was conducted. Maternal serum triple tests (AFP, fß-hCG, uE3), maternal characteristics and pregnancy outcomes were recorded from our prenatal screening and hospitalization information system, respectively. RESULTS: The elevated concentration of uE3 in the early-second trimester was associated with increased risk of LGA infants and macrosomia, decreased risk of PE and small SGA infants (for LGA: OR: 1.34, 95% CI: 1.09-1.65; for macrosomia: OR:1.39, 95% CI: 1.08-1.78; for PE: OR: 0.61, 95% CI: 0.40-0.95; for SGA: OR: 0.35, 95% CI: 0.25-0.49). The increased ratio of AFP/uE3 was associated with reduced risk of GDM in the study populations (BMI ≥ 25; OR: 0.96, 95% CI: 0.0.93-1.00). The higher ratio of AFP/fß-hCG + uE3 associated with increased risk of SGA infants and ICP in these subjects (BMI ≥ 25) was also observed (for SGA: OR: 1.11, 95% CI: 1.03-1.18; for ICP: OR: 1.27, 95% CI: 1.06-1.53). CONCLUSIONS: Down's serum screening analytes were associated with pregnancy outcomes in Chinese population and might provide an alternative tools for risk estimates on these unfavorable outcomes.

A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology.

Kidney transplantation (KT) is often considered to be the method best able to restore fertility in a woman with chronic kidney disease (CKD). However, pregnancies in KT are not devoid of risks (in particular prematurity, small for gestational age babies, and the hypertensive disorders of pregnancy). An ideal profile of the potential KT mother includes "normal" or "good" kidney function (usually defined as glomerular filtration rate, GFR ≥ 60 ml/min), scant or no proteinuria (usually defined as below 500 mg/dl), normal or well controlled blood pressure (one drug only and no sign of end-organ damage), no recent acute rejection, good compliance and low-dose immunosuppression, without the use of potentially teratogen drugs (mycophenolic acid and m-Tor inhibitors) and an interval of at least 1-2 years after transplantation. In this setting, there is little if any risk of worsening of the kidney function. Less is known about how to manage "non-ideal" situations, such as a pregnancy a short time after KT, or one in the context of hypertension or a failing kidney. The aim of this position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology is to review the literature and discuss what is known about the clinical management of CKD after KT, with particular attention to women who start a pregnancy in non-ideal conditions. While the experience in such cases is limited, the risks of worsening the renal function are probably higher in cases with markedly reduced kidney function, and in the presence of proteinuria. Well-controlled hypertension alone seems less relevant for outcomes, even if its effect is probably multiplicative if combined with low GFR and proteinuria. As in other settings of kidney disease, superimposed preeclampsia (PE) is differently defined and this impairs calculating its real incidence. No specific difference between non-teratogen immunosuppressive drugs has been shown, but calcineurin inhibitors have been associated with foetal growth restriction and low birth weight. The clinical choices in cases at high risk for malformations or kidney function impairment (pregnancies under mycophenolic acid or with severe kidney-function impairment) require merging clinical and ethical approaches in which, beside the mother and child dyad, the grafted kidney is a crucial "third element".

Evolution of linear and nonlinear fetal heart rate indices throughout pregnancy in appropriate, small for gestational age and preterm fetuses: A cohort study.

BACKGROUND AND OBJECTIVES: To assess the evolution of linear and nonlinear fetal heart rate (FHR) analysis throughout pregnancy in appropriate (AGA), small for gestational age (SGA) and preterm (PTB) fetuses. METHODS: A prospective cohort study was carried out in 171 singleton pregnancies divided in three groups: AGA (n = 147), SGA (n = 13) fetuses and spontaneous PTB (n = 11). FHR was recorded with an external sensor from the 24th to the 40th week of gestation. Linear time- and frequency-domain and nonlinear FHR indices were computed on 10-min segments. Longitudinal analysis of indices throughout pregnancy was performed with generalized estimating equations, and receiver operating characteristic (ROC) curves were calculated for the prediction of SGA and PTB fetuses. RESULTS: Increasing gestational age significantly affected most FHR indices, with a general increase in variability and entropy indices, and a decrease in mean FHR. The PTB group exhibited a significantly lower short-term variation, and no monotonic increase in the sympatho-vagal balance as observed in the AGA group. The SGA group exhibited higher long-term irregularity and lower short-term irregularity than the AGA group throughout gestation. In prediction of SGA and PTB, the largest areas under the ROC curves obtained were 0.76 and 0.78, respectively. CONCLUSIONS: Linear and nonlinear FHR analysis provides useful information on the evolution of fetal autonomic nervous and complexity control systems throughout pregnancy, in relation with AGA, SGA and PTB fetuses, which may be helpful in clinical practice.

How will transitioning from cytology to HPV testing change the balance between the benefits and harms of cervical cancer screening? Estimates of the impact on cervical cancer, treatment rates and adverse obstetric outcomes in Australia, a high vaccination coverage country.

Primary HPV screening enables earlier diagnosis of cervical lesions compared to cytology, however, its effect on the risk of treatment and adverse obstetric outcomes has not been extensively investigated. We estimated the cumulative lifetime risk (CLR) of cervical cancer and excisional treatment, and change in adverse obstetric outcomes in HPV unvaccinated women and cohorts offered vaccination (>70% coverage in 12-13 years) for the Australian cervical screening program. Two-yearly cytology screening (ages 18-69 years) was compared to 5-yearly primary HPV screening with partial genotyping for HPV16/18 (ages 25-74 years). A dynamic model of HPV transmission, vaccination, cervical screening and treatment for precancerous lesions was coupled with an individual-based simulation of obstetric complications. For cytology screening, the CLR of cervical cancer diagnosis, death and treatment was estimated to be 0.649%, 0.198% and 13.4% without vaccination and 0.182%, 0.056% and 6.8%, in vaccinated women, respectively. For HPV screening, relative reductions of 33% and 22% in cancer risk for unvaccinated and vaccinated women are predicted, respectively, compared to cytology. Without the implementation of vaccination, a 4% increase in treatment risk for HPV versus cytology screening would have been expected, implying a possible increase in pre-term delivery (PTD) and low birth weight (LBW) events of 19 to 35 and 14 to 37, respectively, per 100,000 unvaccinated women. However, in vaccinated women, treatment risk will decrease by 13%, potentially leading to 4 to 41 fewer PTD events and from 2 more to 52 fewer LBW events per 100,000 vaccinated women. In unvaccinated women in cohorts offered vaccination as 12-13 year olds, no change to lifetime treatment risk is expected with HPV screening. In unvaccinated women in cohorts offered vaccination as 12-13 year olds, no change to lifetime treatment risk is expected with HPV screening. HPV screening starting at age 25 in populations with high vaccination coverage, is therefore expected to both improve the benefits (further decrease risk of cervical cancer) and reduce the harms (reduce treatments and possible obstetric complications) associated with cervical cancer screening.

Short interpregnancy intervals, maternal folate levels, and infants born small for gestational age: a preliminary study in a Canadian supplement-using population.

Short interpregnancy intervals (SIPI) have been associated with increased risks for adverse neonatal outcomes including preterm delivery and infants small for gestational age (SGA). It has been suggested that mechanistically, adverse neonatal outcomes after SIPI arise due to insufficient recovery of depleted maternal folate levels prior to the second pregnancy. However, empirical data are lacking regarding physiological folate levels in pregnant women with SIPI and relationships between quantified physiological folate levels and outcomes like SGA. Therefore, we sought to test 2 hypotheses, specifically that compared with controls women with SIPI would: (i) have lower red blood cell folate (RBCF) levels and (ii) be more likely to have SGA infants (defined as <10th percentile). Using data collected in British Columbia, Canada, for a larger study on perinatal psychopathology, we documented supplementation use and compared prenatal RBCF levels and proportion of SGA infants between women with SIPI (second child conceived ≤24 months after previous birth, n = 26) and matched controls (no previous pregnancies, or >24 months between pregnancies, n = 52). There were no significant differences in either mean RBCF levels (Welch's t test, p = 0.7) or proportion of SGA infants (Fisher's exact test, p = 0.7) between women with SIPI and matched controls. We report the first data about RBCF levels in the context of SIPI. If confirmed, our finding of no relationship between these variables in this population suggests that continued folic acid supplementation following an initial pregnancy mitigates folate depletion. We found no relationship between SIPI and SGA.

A best practice position statement on the role of the nephrologist in the prevention and follow-up of preeclampsia: the Italian study group on kidney and pregnancy.

Preeclampsia (PE) is a protean syndrome causing a transitory kidney disease, characterised by hypertension and proteinuria, ultimately reversible after delivery. Its prevalence is variously estimated, from 3 to 5% to 10% if all the related disorders, including also pregnancy-induced hypertension (PIH) and HELLP syndrome (haemolysis, increase in liver enzyme, low platelets) are included. Both nephrologists and obstetricians are involved in the management of the disease, according to different protocols, and the clinical management, as well as the role for each specialty, differs worldwide. The increased awareness of the role of chronic kidney disease in pregnancy, complicating up to 3% of pregnancies, and the knowledge that PE is associated with an increased risk for development of CKD later in life have recently increased the interest and redesigned the role of the nephrologists in this context. However, while the heterogeneous definitions of PE, its recent reclassification, an emerging role for biochemical biomarkers, the growing body of epidemiological data and the new potential therapeutic interventions lead to counsel long-term follow-up, the lack of resources for chronic patients and the increasing costs of care limit the potential for preventive actions, and suggest tailoring specific interventional strategies. The aim of the present position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature and to try to identify theoretical and pragmatic bases for an agreed management of PE in the nephrological setting, with particular attention to the prevention of the syndrome (recurrent PE, presence of baseline CKD) and to the organization of the postpartum follow-up.

Twin pregnancy in women above the age of 45 years: maternal and neonatal outcomes.

Childbearing age continues to rise and, with the increasing implementation of assisted reproductive technology (ART), the number of multiple pregnancies has also risen. This is a retrospective cohort study on maternal and neonatal outcomes of the twin pregnancies of 57 women aged ≥45 years compared to 114 younger women who gave birth in our institution between January 2011 and August 2015. Data were extracted from the real-time computerized database. The rates of hypertensive complications and pre-eclampsia (PE) were much higher in the study group compared to the controls (24/57 vs. 19/114, P=0.000 and 15/57 vs. 13/114, P=0.013, respectively). The respective incidence of very low birth weight (VLBW) was also significantly higher (14/114 vs. 12/228, P=0.021). Infants in the study group required four times more intubation and had a higher admission rate to the neonatal intensive care unit (NICU) compared to control infants (14/114 vs. 6/228 P=0.000 and 42/114 vs. 57/228, P=0.023, respectively). We conclude that women older than 45 years with twin pregnancies have higher maternal and perinatal complications with worse outcomes in comparison with younger women. When pregnancy is attempted via ART, embryo transfer of only one embryo should be considered in this age group.

Early Teenage Pregnancy: Is it Safe?

AIM: To compare obstetric and perinatal outcomes of early and late teenage pregnancies of Omani nulliparous women with singleton pregnancies cared for and delivered at a tertiary teaching hospital. METHOD: In this retrospective study, we reviewed obstetric and perinatal outcomes of early teenage pregnancies (14-16 years), (n = 20) delivered at Sultan Qaboos University Hospital, Muscat, Oman, between 1 July 2006 and 30 June 2013 and compared their outcomes with outcomes of late teenage pregnancies (17-19 years), (n = 287) delivered at the same hospital during same period. RESULTS: When compared with late teenage pregnant women, early teenagers were found to have no significant differences in prevalence of very preterm delivery <32 weeks (P = 0.62), preterm rupture of membranes (P = > 0.99), and anemia (P = 0.34). When compared to late teenagers, early teenagers had similar cesarean sections rates (P = >0.99), instrumental delivery rates (P = 0.56) and spontaneous vaginal delivery rates (P > 0.99). Both groups had similar birth weights (P = 0.87), low birth weights, (P = 0.55), and very low birth weights babies (P = 0.56 %). Perinatal mortality rate was similar in both groups. CONCLUSION: We may conclude that early teenage pregnant Omani women are not at increased risk of obstetric and perinatal complication compared to older teenagers.