Association between Increased Uterine Activity, as Recorded Noninvasively from the Anterior Abdominal Wall at 34 Weeks' Gestation, and Preterm Birth.

Background: There is a need to accurately identify pregnant women at risk for preterm birth as early as possible. Recent developments in technology enable the recording of uterine electrical activity (electrohysterogram) from the anterior abdominal wall in a non-invasive way. Objective: To investigate whether uterine activity recorded under resting conditions at a gestational age of 34 weeks could identify a risk of preterm birth. Study design: A commercial antenatal holter device with its dedicated software was used to record and store raw data of the maternal and fetal electrocardiograms and uterine activity for the Safe Passage Study. Uterine activity was recorded under resting conditions from 34 weeks' gestation in epochs of 250 ms (millisecond) for at least 30 min. From this database the raw data, recorded at a mean gestational age of 34 weeks, of 50 women who had preterm deliveries were selected for comparison with data of women who had term deliveries. Mean uterine activity, expressed in microvolt (µV)/epoch, was used for the comparison. Results: After exclusion of 25 participants where labour was induced or augmented and another three for other reasons, 36 remained in each group. The participants in each group were comparable in respect of maternal age, gravidity, parity, gestational age at recruitment and duration of recording. Uterine activity in the preterm group (60.3 µV/epoch) differed significantly (p<0.01) from that of the comparison group (52.4 µV/epoch). Using a cut-off point of 52.3 µV/epoch as obtained from receiver operator characteristic curves (area under the curve 0.72), the sensitivity and specificity of identifying risks of preterm labour were 81% and 50% respectively. Conclusion: Results of this small study are promising but need to be confirmed in larger studies and preferably at earlier gestational age.

Accelerations of the Fetal Heart Rate in the Screening for Fetal Growth Restriction at 34-38 Week's Gestation.

OBJECTIVES: To use machine learning to determine what information on Doppler velocimetry and maternal and fetal heart rates, collected at 20-24 weeks gestation, correlates best with fetal growth restriction according to the estimated fetal weight at 34-38 weeks. STUDY DESIGN: Data of 4496 pregnant women, collected prospectively for the Safe Passage Study, from August 2007 to August 2016, were used for the present analysis. Doppler flow velocity of the uterine, umbilical, and middle cerebral arteries and transabdominally recorded maternal and fetal ECGs were collected at 20-24 weeks gestation and fetal biometry collected at 34-38 weeks from which the estimated fetal weight was calculated. Fetal growth restriction was defined as an estimated fetal weight below the 10th centile. Accelerations and decelerations of the fetal and maternal heart rates were quantified as gained or lost beats per hour of recording respectively. Machine learning with receiver operative characteristic curves were then used to determine which model gives the best performance. RESULTS: The final model performed exceptionally well across all evaluation metrics, particularly so for the Stochastic Gradient Descent method: achieving a 93% average for Classification Accuracy, Recall, Precision and F1-Score to identify the fetus with an estimated weight below the 10th percentile at 34-38 weeks. Ranking determined that the most important standard feature was the umbilical artery pulsatility index. However, the excellent overall accuracy is likely due to the value added by the pre-processed features regarding fetal gained beats and accelerations. CONCLUSION: Fetal movements, as characterized by gained beats as early as 20-24 weeks gestation, contribute to the value of the flow velocimetry of the umbilical artery at 34-38 weeks in identifying the growth restricted fetus.

Smoking and drinking habits of women in subsequent pregnancies after specific advice about the dangers of these exposures during pregnancy.

BACKGROUND: Although women are informed about the dangers of drinking and smoking during pregnancy when they book for antenatal care, it is uncertain whether this advice is accepted, or whether attempts are made to apply it in subsequent pregnancies. OBJECTIVES: To assess how pregnant women respond to the advice to refrain from smoking and drinking during pregnancy in subsequent pregnancies. METHODS: Research staff were trained to obtain accurate prospective information on smoking and drinking during pregnancy in a prospective study, using well-standardised methods. Care was taken to inform participants about the dangers of smoking and drinking during pregnancy. They were also given pamphlets on these dangers in their own language and a list of telephone numbers where they could find help to quit should they need it. This information was repeated at subsequent study visits (ranging from 1 to 3, depending on the gestational age at which they enrolled). Gestational age was determined by early ultrasound. Z-scores of birthweight for gestational age were determined according to the INTERGROWTH-21st study. Pregnancy outcomes of women who enrolled twice (n=888) or three times (n=77) in the Safe Passage Study were compared with those of women in the first enrolment (n=889). RESULTS: The proportion of drinkers did not change significantly (p=0.058) from the first to the second and third enrolments (63.8%, 59.0% and 54.6%, respectively). A similar trend was found for smokers (73.3%, 72.2% and 68.4%, respectively). Cannabis use was reported by 15.1%, 9.7% and 12.0% (p<0.005) of women, respectively, and use of methamphetamine by 10.1%, 6.6% and 12.7% (p<0.005). There was an increase in the rate of preterm births from 15.5% to 17.5% and 24.7%, respectively, but the increase was not significant. Although mean birthweight was lower in the third enrolment compared with the second, the difference was not significant. The z-score of birthweight for gestational age was significantly lower in the second enrolment compared with the first. CONCLUSIONS: Detailed information on the adverse effects of smoking and drinking during pregnancy was not effective in the population studied. Other methods to reduce or stop these toxic exposures should therefore be investigated. A short inter-pregnancy interval, as demonstrated by three enrolments in 7.5 years, is associated with preterm labour and fetal growth restriction, and is probably indicative of the role played by confounders such as poor socioeconomic conditions and drug exposure during pregnancy.

The association between preterm labour, perinatal mortality and infant death (during the first year) in Bishop Lavis, Cape Town, South Africa.

BACKGROUND: We present further analyses from the Safe Passage Study, where the effect of alcohol exposure during pregnancy on sudden infant death syndrome and stillbirth was investigated. OBJECTIVES: To describe pregnancy and neonatal outcome in a large prospective study where information on the outcome of pregnancy was known in >98.3% of participants and ultrasound was used to determine gestational age (GA). METHODS: As part of the Safe Passage Study of the PASS Network in Cape Town, South Africa, the outcomes of 6 866 singleton pregnancies were prospectively followed from recruitment in early pregnancy until the infant was 12 months old to assess pregnancy outcome. Fetal growth was assessed by z-scores of the birth weight, and GA at birth was derived from early ultrasound assessments. The effects of fetal growth restriction and preterm delivery on pregnancy outcome were determined. RESULTS: There were 66 miscarriages, 107 stillbirths at ≥22 weeks' gestation, 66 stillbirths at ≥28 weeks' gestation, 29 and 18 neonatal deaths at ≥22 and ≥28 weeks' gestation, respectively, and 54 post-neonatal deaths (28 days - 12 months). The miscarriage rate was 9.6/1 000 and the infant mortality rate 12.4/1 000. Of the births, 13.8% were preterm. For deliveries at ≥22 and ≥28 weeks, the stillbirth rates were 15.7 and 9.8/1 000 deliveries, respectively. For deliveries at ≥22 and ≥28 weeks, the neonatal death rates were 4.3 and 2.7/1 000 live births, respectively. For these pregnancies the perinatal mortality rates were 20.0/1 000 (≥22 weeks) and 12.5/1 000 (≥28 weeks), respectively. Only 15.9% of stillbirths occurred during labour (in 15.9% of cases it was uncertain whether death had occurred during labour). In the majority of cases (68.2%) fetal death occurred before labour, and 82.2% of stillbirths and 62.1% of neonatal deaths occurred in deliveries before 37 weeks. Including the miscarriages, stillbirths and infant deaths, there were 256 pregnancy losses; 77.3% were associated with deliveries before 37 weeks. Only 1.8% of all the women were HIV-positive, whereas the HIV-positive rate was 3.7% among those who had stillbirths. Birth weight was below the 10th centile in 25.6% of neonatal and post-neonatal deaths compared with 17.7% of survivors. CONCLUSIONS: Preterm birth and fetal growth restriction play significant roles in fetal, neonatal and infant losses.

Effects of alcohol, cigarettes, methamphetamine and marijuana exposure during pregnancy on maternal serum alpha-fetoprotein levels at 20-24 weeks'gestation.

OBJECTIVE: To examine the effects of cigarette, marihuana and methamphetamine smoking and consumption of alcohol during pregnancy on maternal serum alpha-fetoprotein (MSAFP) levels at 20-24 weeks. STUDY DESIGN: In the Safe Passage Study (SPS) more than 12,000 pregnant women were prospectively followed up during pregnancy and until the infant was one year old to examine the effects of exposure to alcohol during pregnancy on stillbirth and sudden infant death syndrome. The present study is a cross-sectional secondary analysis of MSAFP analyses done at 20-24 weeks gestation in 1,679 SPS participants, recruited at the Bishop Lavis Community Health Centre, Cape Town, South Arica. RESULTS: Low or moderate alcohol consumption with or without smoking, nor methamphetamine or marihuana use affected mean MSAFP levels. High MSAFP levels were associated with high alcohol consumption, young age, low body mass index (BMI) (<18 kg/m2) or small mid upper arm circumference (MUAC) (<230mm). High MSAFP levels were associated with stillbirth, preterm birth, abruption and a birth weight z-score of less than -1. CONCLUSION: The study confirms the association between high MSAFP levels and adverse pregnancy outcomes but, although exposure to smoking or drinking is associated with adverse pregnancy outcomes including stillbirth, MSAFP levels were not affected by any of these exposures except for continued high consumption of alcohol. The observed association between higher MSAFP levels and maternal nutritional status (as demonstrated by the lower MUAC and BMI) could explain some of the correlations of poor socioeconomic conditions with higher stillbirth rates effect.

Bereaved mothers' attitudes regarding autopsy of their stillborn baby.

BACKGROUND: Here we present additional information from the Safe Passage Study, where the effect of alcohol exposure during pregnancy on sudden infant death syndrome and stillbirth was investigated. OBJECTIVE: To explore bereaved mothers' attitudes toward obtaining an autopsy on their stillborn baby, and the future implications of consenting or non-consenting to autopsy in retrospect. METHODS: Demographic data was obtained by a questionnaire. A largely qualitative mixed-methods approach was used to meet the aims of the study, using an exploratory and descriptive research design to provide a detailed description of maternal attitudes. A semi-structured questionnaire based on information from literature and reflections on practice was administered during individual interviews. RESULTS: We interviewed 25 women who had had a recent stillbirth. The time interval between the time of consenting to autopsy and completing this study ranged from 6 to 18 months. Most participants reported that autopsy results provided peace of mind and helped alleviate their feelings of blame. Participants who were unable to comprehend the results reported negative reactions to receiving autopsy results. The majority of participants were of the opinion that they benefited from consenting to autopsy. CONCLUSION: Autopsy and the disclosure of its results generally contribute positively to coping following stillbirth.

Fetal heart rate patterns at 20 to 24 weeks gestation as recorded by fetal electrocardiography.

INTRODUCTION: With advancing technology it has become possible to accurately record and assess fetal heart rate (FHR) patterns from gestations as early as 20 weeks. The aim of our study was to describe early patterns of FHR, as recorded by transabdominal fetal electrocardiogram according to the Dawes-Redman criteria. Accordingly, short-term variability, basal heart rate, accelerations and decelerations were quantified at 20-24 weeks gestation among women with uncomplicated pregnancies. METHODS: This study was conducted in a subset of participants enrolled in a large prospective pregnancy cohort study. Our final data set consisted of 281 recordings of women with good perinatal outcomes who had undergone fetal electrocardiographic assessment as part of the Safe Passage Study. RESULTS: The success rate of the recordings was 95.4%. The mean frequency of small and large accelerations was 0.5 and 0.1 per 10 min, respectively and that of small and large decelerations 0.3 and 0.008 per 10 min, respectively. The mean and basal heart rates were both equal to 148.0 bpm at a median gestation of 161 days. The mean short term variation was 6.2 (SD 1.4) ms and mean minute range 35.1 (SD 7.1) ms. CONCLUSION: The 20-24-week fetus demonstrates FHR patterns with more accelerations and decelerations, as well as higher baseline variability than was anticipated. Information from this study provides an important foundation for further, more detailed, studies of early FHR patterns.

The effect of alpha-amylase on the acrosomal membrane of human sperm.

PURPOSE: Sperm capacitation and the acrosome reaction are prerequisites to accomplishing fertilization. The object of this research was to induce capacitation and the acrosome reaction of human sperm, comparing the acrosome status of fertile and infertile men, using alpha-amylase. METHODS: Acrosome status was measured using indirect immunofluorescence (IIF; monoclonal antibody GB24, Thèramex), hemizona assay (HZA), and transmission electron microscopy (TEM). RESULTS: Acrosome-reacted sperm without alpha-amylase treatment was significantly more abundant in the fertile versus the infertile group utilizing IIF, HZA, and TEM. alpha-Amylase-treated spermatozoa from the fertile and infertile groups showed a significant increase in the number of sperm bound to the hemizona (P < 0.05). CONCLUSIONS: The percentage of acrosome-reacted sperm in the infertile group was significantly enhanced by alpha-amylase, utilizing IIF and TEM.

Micromanipulation at an infertility centre.

AIM: Human in vitro fertilisation (IVF) and gamete intrafallopian transfer have been used in the management of various forms of infertility. In cases of severe male-factor infertility, fertilisation can be a factor. In this study micromanipulation was used to increase fertilisation in such cases. METHODS: Two micromanipulation techniques, subzonal sperm injection (SUZI) and partial zona dissection (PZD), were used to assist fertilisation in patients with abnormal semen parameters. Ten couples with severe oligo-, terato- and asthenozoospermia participated in the SUZI programme. Seventy-three oocytes were obtained from these 10 patients. PZD was used on day 1 oocytes in cases of male infertility as well as a rescue attempt on day 2 oocytes when fertilisation had failed after routine insemination. RESULTS: The SUZI technique had a fertilisation rate of 37.7%. In this group, a biochemical pregnancy was achieved. Differences between the fertilisation rate of conventional IVF (33.3%) and PZD (56.3%) in cases of male infertility, were not statistically significant although a clinical difference could be detected. PZD was statistically effective in facilitating fertilisation (37.5% v. 8.3%) in couples where this procedure was introduced to reinseminate 24-hour-old unfertilised oocytes. Four patients received PZD reinseminated embryos. An average of 1.45 PZD embryos were replaced and 1 implantation pregnancy was confirmed. CONCLUSION: The micromanipulation results are encouraging and seemed to increase the efficiency of IVF in humans. Furthermore, our data support the conclusion that micromanipulation procedures can bring about pregnancies.