Post-dated Breech Pregnancy in a Non-obviously Communicating Rudimentary Horn of a Bicornuate Uterus Requiring Hemi-hysterectomy.

Developmental anomalies of the Müllerian duct systems such as the bicornuate uterus are rare globally and hardly do term pregnancies occur in conjunction with these abnormalities. The occurrence of post-dated pregnancy is rarely associated with a bicornuate uterus. We present a 35-year-old un-booked multigravida with post-date pregnancy complicated by breech and intrauterine foetal death (IUFD) in a rudimentary uterine horn. She had caesarean delivery complicated by intractable postpartum haemorrhage (PPH). This together with the risks of poor uterine involution in the postpartum and obstetric outcome in the event that another pregnancy occurs in the same horn subsequently warranted a caesarean hemi-hysterectomy of the rudimentary uterine horn. Uterine bicornuate is an uncommon genital tract anomaly and a rare cause of post-date pregnancy. Postpartum bleeding warranting caesarean hemi-hysterectomy should be anticipated as the pregnant horn may not be responsive to conventional oxytocics.

The association between placenta-associated circulating biomarkers and composite adverse delivery outcome of a likely placental cause in healthy post-date pregnancies.

INTRODUCTION: Post-date pregnancies have an increased risk of adverse delivery outcome. Our aim was to explore the association between placenta-associated circulating biomarkers and composite adverse delivery outcome of a likely placental cause in clinically healthy post-date pregnancies. MATERIAL AND METHODS: Women with healthy singleton post-date pregnancies between 40+2 and 42+2  weeks of gestation were recruited to this prospective, observational study conducted at Oslo University Hospital, Norway (NCT03100084). Placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) were measured in the maternal serum samples closest to delivery. The composite adverse delivery outcome included fetal acidemia, low Apgar score (<4 at 1 min or <7 at 5 min), asphyxia, fetal death, assisted ventilation for more than 6 h, meconium aspiration, hypoxic-ischemic encephalopathy, therapeutic hypothermia, operative delivery due to fetal distress, or pathological placental histology findings. Two study-independent senior consultant obstetricians blinded to biomarker results concluded, based on clinical expert opinion, whether the adverse delivery outcomes were most likely associated with placental dysfunction ("likely placental cause") or not. Means were compared using one-way analysis of variance and Bonferroni corrected pairwise comparisons between groups. Receiver operating characteristic (ROC) curves assessed the predictive ability of PlGF, sFlt-1/PlGF ratio, and PlGF <10th centile after adjustment for gestational age at blood sampling. RESULTS: Of 501 pregnancies reviewed for predefined adverse delivery outcomes and for a likely placental cause, 468 were healthy pregnancies and subsequently assigned to either the "uncomplicated" (no adverse outcome, n = 359), "intermediate" (non-placental cause/undetermined, n = 90), or "complicated" (likely placental cause, n = 19) group. There was a significant difference in mean PlGF and sFlt-1/PlGF ratio between the "complicated", "intermediate", and "uncomplicated" groups (108, 185, and 179 pg/mL, p = 0.001; and 48.3, 23.4, and 24.6, p = 0.002, respectively). There was a higher proportion of PlGF concentration <10th centile in the "complicated" group compared with the "intermediate" and "uncomplicated" groups (42.1% vs. 11.1% and 9.5%, p = 0.001). The largest area under the ROC curve for predicting "complicated" outcome was achieved by PlGF concentration and gestational age at blood sampling (0.76; 95% CI 0.65-0.86). CONCLUSIONS: In clinically healthy post-date pregnancies, an antiangiogenic pre-delivery profile (lower PlGF level and higher sFlt-1/PlGF ratio) was associated with composite adverse delivery outcome of a likely placental cause.

Circulating angiogenic profiles and histo-morphological placental characteristics of uncomplicated post-date pregnancies.

INTRODUCTION: The objectives of this study were to describe the histo-morphology of post-date placentas in clinically uncomplicated pregnancies without adverse delivery outcomes and the association with maternal circulating pre-delivery Placental Growth Factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1), as well as the sFlt-1/PlGF ratio. METHODS: Post-date placentas (gestational week ≥40+2, n = 87) were macroscopically and histo-morphologically assessed according to the international, standardized Amsterdam Workshop Consensus Group criteria. Inter-rater agreement was evaluated by percentage of agreement. PlGF and sFlt-1 concentrations were available from maternal serum sampled close to delivery, and were compared by Mann-Whitney U test. Linear regression analyses were adjusted for predefined potential confounders. RESULTS: The majority of the post-date placentas showed morphological signs of delayed maturation. About half of the placentas showed increased syncytial knotting and fibrin. In placentas with increased presence of intervillous fibrin, median maternal PlGF level was significantly lower (p = 0.004), median sFlt-1 level higher and sFlt-1/PlGF ratio significantly higher (p = 0.002) compared to those with normal fibrin amounts. Increased placental syncytial knotting was associated with lower levels of PlGF, higher sFlt-1 and higher sFlt-1/PlGF ratio compared to those with normal knotting. DISCUSSION: Our standardized morphological study of post-date placentas in clinically healthy women with uncomplicated pregnancies and delivery outcomes revealed delayed maturation in the majority of placentas. Increased pre-delivery circulating anti-angiogenic profile was associated with increased intervillous fibrin and syncytial knotting. We propose that circulating maternal angiogenic biomarkers may be of future use in clinical post-date pregnancy assessment, as they reflect important aspects of placental health and function.

Acupuncture in Postdate Pregnancy Management.

OBJECTIVES: Pharmacological labor induction is obtained through prostaglandins application and/or oxytocin infusion; however, the use seems to be related to fetal and maternal side effects. Traditional Chinese Medicine advocates the use of acupuncture to soften the cervix and induce uterine contractions. at which presented for The primary outcome was the rate of women admitted for labour induction in case of prolonged pregnancy at 41 + 5 weeks, and the secondary outcome was the rate of induction planning for other indications. METHODS: After obtaining informed consent, 375 undelivered women after 40 + 2 gestational age were enrolled for the study: 112 women received acupuncture and 263, routine care. Acupuncture was applied every odd day starting from 40 + 2 weeks up to 41 + 4 weeks. Women allocated to the control group received standard care. At 41 + 5 weeks, a pharmacological induction was planned. RESULTS: The rate of labor induction significantly differed between acupuncture and observation groups (19.6% vs. 38%; p < 0.01); in particular, women receiving acupuncture showed a lower rate of induction, indicating prolonged pregnancy (5.3% vs. 10.1%; p < 0.01). As far as the pharmacological device is concerned, no differences were observed with regard to the prostaglandins use, whereas oxytocin infusion rate was lower in the acupuncture group than in the observation group. CONCLUSIONS: The present study suggested that acupuncture applied at term of pregnancy seems to be effective in reducing the rate of labor induction which is performed for prolonged pregnancy at 41 + 5 weeks. Moreover, acupuncture also seems to be able to reduce oxytocin use; such a "saving" effect could play a role in childhood, considering that a recent study underlined the adverse effect of oxytocin on birth outcomes.

When should pregnancies that extended beyond term be induced?

OBJECTIVE: To compare maternal and neonatal outcomes associated with a policy for induction of labor at ≥ 41 versus at ≥42 weeks'. STUDY DESIGN: Retrospective cohort study of a 2 years' period before and after policy change from induction of labor at ≥ 42 gestational weeks' versus ≥41 gestational weeks. RESULTS: During the 41-policy period (N = 968), the induction rate was higher, 60% versus 40% (p < 0.0001) while the cesarean delivery (CD) rate was lower, 15% versus 19.4% (p = 0.0135). Moreover, among women that were induced, the rate of CD was lower during the 41-policy period, 19% versus 27% (p = 0.0067). No significant differences in maternal or neonatal outcomes were noted. There was one case of intrauterine fetal death at 41 + 4 weeks during the 42-policy period. CONCLUSION: As a policy for induction of labor at ≥ 41 reduces the rate of CD without any adverse maternal or neonatal outcomes, such a policy seems to be superior to a policy for induction at ≥ 42 weeks.

Predicting the spontaneous onset of labour in post-date pregnancies: a population-based retrospective cohort study.

OBJECTIVE: To estimate the probability of spontaneous onset of labour (SOL) among women with uncomplicated pregnancies who have reached 41+0 weeks and to examine the influence of maternal characteristics on this event. METHODS: We conducted a population-based retrospective cohort study of women with uncomplicated singleton pregnancies in cephalic presentation between 41+0 and 42+0 weeks' gestation. Detailed clinical information was obtained from the British Columbia Perinatal Data Registry. We determined the time from 41+0 weeks to the exact day and time of SOL, pre-labour Caesarean section, or onset of labour following induction. A Kaplan-Meier curve was created to estimate the probability of SOL. A Cox regression model was used to assess the independent influence of maternal age, parity, BMI, and pregnancy weight gain on the SOL, and to assess the extent to which prediction of SOL could be individualized according to a woman's characteristics. RESULTS: Among 15 253 women undelivered at 41+0 weeks, there was a 67.6% (95% CI 66.4% to 68.7%) chance of SOL by 41+6 weeks. Although SOL was statistically more likely in younger women, higher parity, lower BMI, and lower weight gain (P<0.01), the multivariable model's predictive ability was poor (c-statistic 0.56). CONCLUSION: Maternal characteristics were not a strong determinant for successful individualized prediction of SOL in women with uncomplicated pregnancies reaching 41+0 weeks of gestation. Our population-based estimates of the daily occurrence of SOL can be used to inform discussions with women on when to offer induction of labour.

Objectif : Estimer la probabilité du travail d'apparition spontanée (TAS) chez les femmes qui connaissent une grossesse exempte de complications atteignant 41+0 semaines et examiner l'influence des caractéristiques maternelles sur cet événement. Méthodes : Nous avons mené une étude de cohorte rétrospective en population générale qui portait sur les femmes connaissant une grossesse monofœtale exempte de complications en présentation céphalique entre 41+0 et 42+0 semaines de gestation. Nous avons tiré des renseignements cliniques détaillés du British Columbia Perinatal Data Registry. Nous avons déterminé le délai entre 41+0 semaines de gestation et la date et l'heure exactes du TAS, de la tenue d'une césarienne prétravail ou de l'apparition du travail à la suite d'un déclenchement. Une courbe Kaplan-Meier a été tracée pour estimer la probabilité du TAS. Un modèle de régression de Cox a été utilisé pour évaluer l'influence indépendante de l'âge maternel, de la parité, de l'IMC et du gain pondéral pendant la grossesse sur le TAS, ainsi que pour évaluer la mesure dans laquelle la prévision du TAS pourrait être personnalisée en fonction des caractéristiques de la patiente. Résultats : Chez 15 253 femmes n'ayant toujours pas accouché à 41+0 semaines, la probabilité de voir se manifester un TAS d'ici à 41+6 semaines était de 67,6 % (IC à 95 %, 66,4 % - 68,7 %). Bien que le TAS ait été plus probable sur le plan statistique chez les femmes présentant un âge moindre, une parité accrue, un IMC moindre et un gain pondéral moindre (P < 0,01), la valeur de prévision du modèle multivarié était faible (c-statistic : 0,56). Conclusion : Les caractéristiques maternelles ne constituaient pas un déterminant solide aux fins de la réussite de la prévision personnalisée du TAS chez les femmes qui connaissaient une grossesse exempte de complications atteignant 41+0 semaines de gestation. Nos estimations en population générale quant à la manifestation quotidienne du TAS peuvent être utilisées pour éclairer les discussions menées avec les femmes quant à la détermination du moment propice à l'offre d'un déclenchement du travail.

Acupuncture in post-date pregnancy: a pilot study.

AIM: Pharmacological labor induction is obtained through intracervical/vaginal prostaglandins and/or oxytocin infusion; however, the use of these agents produces fetal and maternal side effects. Traditional Chinese medicine advocates the use of acupuncture to soften the cervix and induce uterine contractions. The aim of the present study is to investigate the effect of acupuncture to induce labor. Acupuncture was applied in post-date pregnancies one week before a planned induction; the primary outcome was the rate of women submitted to labor induction for prolonged pregnancy at week 41 + 5. METHODS: After informed consent, 221 undelivered women ranging between 40 + 2/40 + 6 gestational age were considered eligible for the study and 202 were randomized to receive acupuncture or observation. Sessions of acupuncture were planned every odd day from the randomization till 41a week plus 4 days. At 41 + 5 week a pharmacological induction of labor was planned. RESULTS: The total rate of labor induction did not significantly differ between observation and acupuncture group (20% versus 17%). Moreover no differences were found as far as the indications to induce labor, in particular "prolonged pregnancy" was similar between groups (8/96 versus 5/99). To investigate between-group differences in time elapsed between inclusion and delivery, survival analysis was performed excluding women requiring labor induction: women receiving acupuncture showed a trend to deliver earlier than women in the observation group (p < 0.09). CONCLUSION: The present study demonstrated that acupuncture applied every odd day for one week seems ineffective in reducing the rate of labor induction performed for prolonged pregnancy at 41 + 5 weeks. Previous reports reached similar conclusions, independently of the different timing, duration and mode of stimuli application.