Prenatal ultrasound diagnosis of neural tube defects in the era of intrauterine repair - Eleven years' experiences.

OBJECTIVE: To modify the current neural tube defect (NTD) classification for fetal medicine specialists, and to investigate the impact of prenatal ultrasound conus medullaris position screening on the detection rate of closed spinal dysraphism and pregnancy outcomes. MATERIALS AND METHODS: The clinical data of 112 patients prenatally diagnosed with neural tube defects in Taiji clinic from 2008 to 2018 were retrospectively analyzed. All cases were classified following the modified classification. We compared the detection rate before and after introducing the conus medullaris screening and pregnancy outcomes for NTD types. RESULTS: Closed spinal dysraphism type prevailed in our sample (43.8%). The median gestational age at the time of detection for cranial dysraphism was 13.3 weeks, open spinal dysraphism was 22.0 weeks, and closed spinal dysraphism was 22.6 weeks. All cranial dysraphism (n = 43) and open spinal dysraphism cases (n = 20) had pregnancies terminated. For closed spinal dysraphism Class 1, the live-birth rate was 100.0% in the cases without other anomalies and 33.3% in the cases with other anomalies, respectively (X2 = 17.25, p < 0.001). Similarly, for Class 2, pregnancy continuation rate was 50.0% in cases without other anomalies and 20.0% in cases with other anomalies, yet it failed to reach statistical significance (X2 = 0.9, p = 0.524). CONCLUSION: Our case series may help to improve early screening and prenatal diagnosis of NTDs. Modified classification is adjusted for use in ultrasound fetal care facilities, which could be used for predicting pregnancy outcome. We suggest promoting first-trimester anatomical screening in order to make an earlier diagnosis and therefore provide better prenatal care for open spinal dysraphism cases in the era of intrauterine repair. Our findings imply that the use of fetal conus medullaris position as a marker for closed spinal dysraphism improves the detection rate and would unlikely lead to a higher termination rate.

Announcing fetal pathology: Challenges encountered by physicians and potential role of simulation in training for breaking bad news.

BACKGROUND: Informing couples about the diagnosis of severe fetal pathologies is part of the daily routine in fetal medicine. This situation is usually complex and can put untrained professionals in an uncomfortable position. The aim of this study was to assess the perception of health care professionals when faced with the need to announce a fetal pathology in order to target their training gaps in this domain. MATERIALS AND METHODS: A questionnaire was created and disseminated on a national level among physicians practicing or collaborating with the multidisciplinary centers of prenatal diagnosis in France. The questionnaire focused on the difficulties encountered by practitioners when announcing fetal pathologies, and their potential interest in simulation sessions regarding the delivery of bad news. RESULTS: 193 participants filled the questionnaire. 65 % report not receiving any theoretical courses in this field during their initial training, 49 % admit feeling uncomfortable when a fetal anomaly needs to be announced, 79.5 % think that role-play could help them, 87.5 % believe that training sessions in communication skills would help improve their methods and 73.1 % support teaching the delivery of bad news by simulation sessions. CONCLUSION: This survey illustrates the significance of announcing a fetal pathology for fetal medicine professionals. Many of them report not being properly trained to cope with this situation and would like to improve with a more practical way of teaching. Simulation would be the ideal educational tool to meet this demand.

Individualized birth length and head circumference percentile charts based on maternal body weight and height.

Objectives Measurement of birth length and birth head circumference is part of the newborn assessment. Both measurements aid in distinguishing between proportionate and disproportionate small and large for gestational age newborns. It had been shown that birth weight is related to maternal height and weight. This study aims to analyze birth length and birth head circumference percentiles based on maternal stature. Methods This observational study analyzed birth length and birth head circumference percentiles of 2.3 million newborns stratified by maternal height and weight from the first obstetric assessment. Percentiles were calculated for sex and 22-43 gestational weeks for all infants. Eighteen subgroups based on six maternal height and three weight strata were defined and percentiles calculated from 32 to 42 gestational weeks using GAMLSS package for R. Results Newborns of mothers with height <158 cm and weight <53 kg (short stature) had a rate of preterm birth of 9%, compared to 5% in the tall stature group (height >177 cm, weight >79 kg). Small stature mothers were 1.7 years younger. Birth length differed by several centimeters for the same percentiles between groups of short and tall stature mothers, whereas birth head circumference differed up to 1.2 cm. The largest deviation of birth length was between the 97th percentiles. For male newborns born at term, birth length at the 97th percentile differed by 3.2 cm, at the 50th percentile by 2.7 cm and at the third percentile by 2.5 cm. Conclusions Birth length and birth head circumference are related to maternal height and weight. To more completely assess newborns, the maternal size should be considered.

Validation study: evaluation of the metrological quality of French hospital data for perinatal algorithms.

OBJECTIVE: The aim of our validation study was to assess the metrological quality of hospital data for perinatal algorithms on a national level. DESIGN: Validation study. SETTING: This was a multicentre study of the French medicoadministrative database on perinatal indicators. PARTICIPANTS: In each hospital, we selected 150 discharge abstracts for delivery (after 22 weeks of gestation), in 2014, and their corresponding medical records. Overall, 22 hospitals were included. INTERVENTIONS: A single investigator performed blind data collection from medical records in order to compare data from discharge abstracts with data from medical records. Finally, 3246 discharge abstracts were studied. PRIMARY AND SECONDARY OUTCOME MEASURES: Seventy items, including maternal and delivery characteristics and maternal morbidity, were collected for each delivery stay. RESULTS: The concordance rate of maternal age at delivery was 94.8% (95% CI 93.8 to 95.4). Combining the two forms of pre-existing diabetes, the algorithm presented a PPV of 65.9% and a sensitivity of 75.7%. The concordance rate of gestational age at delivery was 91.8% (90.9 to 92.7). Regarding gestational diabetes, the PPV was 80.8% (79.4 to 82.2) and the sensitivity was 79.5% (78.1 to 80.9). Regardless of the algorithm explored, the PPV for vaginal delivery was over 99%. For the diagnosis codes corresponding to immediate postpartum haemorrhage, the PPV was 77.7% (76.3 to 79.1) and the sensitivity was 75.5% (74.0 to 77.0). The algorithm for stillbirth presented a PPV of 89.4% (88.3 to 90.5) and a sensitivity of 95.4% (94.7 to 96.1). CONCLUSIONS: This first national validation study of many perinatal algorithms suggests that the French national hospital database is an appropriate data source for epidemiological studies, except for some indicators which presented low PPV and/or sensitivity.

National survey of uterine rupture in Japan: Annual report of Perinatology Committee, Japan Society of Obstetrics and Gynecology, 2018.

AIM: To clarify the frequency of occurrence of uterine rupture and its prognosis, a nationwide survey was performed. METHODS: Cases of uterine rupture recorded for a period of 5 years were included. RESULTS: There were 152 cases of uterine rupture with an incidence rate of 0.015%. The scarred uterine rupture cases were found to have a significantly earlier occurrence of uterine ruptures in comparison to the unscarred cases: unscarred 39.0 weeks, cesarean section 37.0 weeks, myomectomy 32 weeks and adenomyomectomy 30-32 weeks. And it became apparent that the frequency of hysterectomy, cerebral palsy and neonatal death were higher in the cases of uterine rupture during labor than before delivery. Among the cases of scarred uterine rupture, neonatal prognosis was poorer in cases of pregnancy after myomectomy or adenomyomectomy in comparison with postcesarean section cases. CONCLUSION: This survey revealed the current incidence of uterine rupture in Japan.

Population attributable fractions of perinatal outcomes for nulliparous women associated with overweight and obesity, 1990-2014.

OBJECTIVE: To examine the prevalence across 25 years of overweight and obesity among nulliparous Australian women during early pregnancy; to estimate the proportions of adverse perinatal outcomes attributable to overweight and obesity in this population. DESIGN: Cohort study; retrospective analysis of electronic maternity data. Setting, participants: 42 582 nulliparous women with singleton pregnancies giving birth at the Royal Prince Alfred Hospital, an urban teaching hospital in Sydney, January 1990 - December 2014. MAIN OUTCOME MEASURES: Maternal body mass index (BMI), socio-demographic characteristics, and selected maternal, birth and neonatal outcomes; the proportion of adverse perinatal outcomes that could be averted by reducing the prevalence of overweight and obesity in women prior to first pregnancies (population attributable fraction, PAF). RESULTS: The prevalence of overweight among nulliparous pregnant women increased from 12.7% (1990-1994) to 16.4% (2010-2014); the prevalence of obesity rose from 4.8% to 7.3% in the same period, while the proportion with normal range BMIs fell from 73.5% to 68.2%. The PAFs for key adverse maternal and neonatal outcomes increased across the study period; during 2010-2014, 23.8% of pre-eclampsia, 23.4% of fetal macrosomia, and 17.0% of gestational diabetes were attributable to overweight and obesity. Were overweight and obese women to have moved down one BMI category during 2010-2014, 19% of pre-eclampsia, 15.9% of macrosomia, 14.2% of gestational diabetes, 8.5% of caesarean deliveries, 7.1% of low for gestational age birthweight, 6.8% of post partum haemorrhage, 6.5% of admissions to special care nursery, 5.8% of prematurity, and 3.8% of fetal abnormality could have been averted. CONCLUSIONS: Over the past 25 years, the proportions of adverse perinatal outcomes attributable to overweight and obesity have risen with the increasing prevalence of maternal overweight and obesity. A substantial proportion of these outcomes might be averted with obesity prevention strategies that reduce pre-pregnancy maternal weight.

Annual Report of the Perinatology Committee, Japan Society of Obstetrics and Gynecology, 2016: Overall report on a comprehensive retrospective study of obstetric management of preterm labor and preterm premature rupture of the membranes.

We conducted a questionnaire survey on the current obstetric management of preterm labor (PL) and preterm premature rupture of the membranes (pPROM). The questionnaire covered approximately a third of all preterm deliveries and nearly half of the preterm deliveries before 32 gestational weeks. The diagnostic criterion for PL was either painful uterine contractions or cervical dilatation. Tocolytic agents were primarily used as long-term maintenance therapy. Intrauterine infection was clinically diagnosed at most responding institutions. Amniocentesis was performed for PL or pPROM at only a small number (10%) of institutions. Prenatal steroids were administered for PL or pPROM, if indicated, at approximately 40-60% of responding institutions. Prophylactic antibiotics to maintain pregnancy were administered for pPROM at approximately 90% and for PL at approximately 20% of institutions. Maintenance therapy with a tocolytic agent was used for pPROM at approximately 90% of institutions.

Influence of Patient-Level Factors on Mode of Delivery among Operative Vaginal Delivery Candidates in Modern Practice.

Objective We aimed to evaluate which patient-level factors influence mode of delivery among candidates for operative vaginal delivery. Study Design Cross-sectional study of candidates for operative vaginal delivery from 18 hospitals over 8 years. Probabilities of mode of delivery were estimated using hierarchical logistic modeling adjusting for clustering within physician and hospital. Results Total 3,771 (64%) women delivered with forceps, 1,474 (25%) vacuums, and 665 (11%) cesareans. Odds of forceps versus vacuum were higher with induction (OR = 2.16, 95% CI: 1.76-2.65), nulliparity (OR = 2.06, 95% CI: 1.59-2.66), epidural (OR = 2.05, 95% CI: 1.19-3.56), maternal indication (OR = 1.53, 95% CI 1.16-2.02), older maternal age (OR 1.18, 95% CI 1.06-1.31 per 5 years), and longer second stage (OR = 1.10, 95% CI: 1.01-1.20 per hour).Odds of cesarean versus operative vaginal delivery were higher with maternal indication (OR = 9.0, 95% CI: 7.23-11.20), a perinatologist (OR = 2.51, 95% CI: 1.09-5.78), longer second stage (OR = 1.79, 95% CI: 1.65-1.93 per hour), older gestational age (OR = 1.10, 95% CI: 1.01-1.20 per week), and longer labor (OR = 1.02, 95% CI: 1.01-1.04 per hour). Conclusion Patient-level factors influence the decision to proceed with an operative vaginal delivery and the choice of instrument, thereby emphasizing the importance of maintaining availability of both forceps and vacuums.

[Digestive surgical complications during pregnancy following bariatric surgery: Experience of a center for perinatology and obesity]. / Complications digestives chirurgicales après chirurgie bariatrique pendant la grossesse : expérience d'un centre de périnatalité et de chirurgie bariatrique.

OBJECTIVE: To describe severe complications during pregnancy requiring surgery in patients with a history of obesity surgery. MATERIEL AND METHODS: A retrospective study in a hospital with tertiary care perinatology and an obesity reference center, on all pregnancies following bariatric surgery over a 10-year period, analyzing all cases of surgical complications. RESULTS: There were 8 major complications related to the procedure in 141 pregnancies with bariatric surgery. The 2 complications in women with gastric banding were band slippage resulting in severe dysphagia, one of which leading to intractable vomiting and serious hydrolectric disorders. Among the 6 complications after bypass surgery, 4 were occlusions: 3 on internal hernias of which 2 with volvulus and 1 associated with intestinal invagination, as well as one with intestinal invagination only. One patient had a laparotomy for a suspected invagination which was not confirmed. The other surgical complications after gastric bypass were a hernia and an exploratory laparotomy for suspected intussusception which was overturned. There was no case of maternal or perinatal death. CONCLUSION: Pregnancies in patients with a history of bariatric surgery are at high risk, in particular for complications related to the surgery and thus require careful interdisciplinary surveillance, and determination of predictive factors.

Procedural training opportunities for basic pediatric trainees during a 6-month rotation in a level III perinatal centre in Australia.

OBJECTIVE: We aimed to evaluate the procedural training opportunities for basic paediatric trainees in a large tertiary perinatal centre in Australia, to facilitate a realistic expectation of the procedural skills acquired during a 6-month training period. METHODS: A prospective study in which all neonatal registrars and fellows anonymously documented their opportunities for procedural practice (including IV cannulation, intubation, umbilical lines insertion etc) for each shift during a calender month. Based on the averaged number of each shift type worked in a 6-month rotation, the total exposure to each procedure for one 6-month rotation was calculated. RESULTS: During a 6-month period, the registrars had the largest number of exposures on IV cannulation (140.54), venous blood sampling (26.78), bag and mask ventilation (17.38), intubation (7.1) and lumbar puncture (6.68). For the fellows, the largest number of exposure was IV cannulation (127.92) followed by intubation (16.53) then venous blood sampling (21.02). Procedural skills to which registrars had little exposure included chest drains, chest compressions, peripherally inserted central vascular lines and placement of oro-gastric tubes. CONCLUSION: There are ample training opportunities for registrars during a 6-month period. Simulation/animal models for rare procedures will be helpful to increase the trainee's procedural competency.

Service users and care providers' experiences of tertiary combined fetal medicine clinics.

OBJECTIVE: To explore service users and care providers' experiences of combined fetal medicine and specialist paediatric clinics. METHOD: A brief survey of service users and care providers at combined fetal medicine clinics, which bring together multiple specialists and expertise for the management of pregnancies complicated by fetal cardiac, renal, neurological or surgical abnormalities. RESULTS: Two hundred and sixty-one patients and 22 health professionals participated. More than 85% of women rated the clinic highly, 61% reported that the service had changed how they viewed the abnormality, and 53% reported that they would welcome further visits to the combined clinic. The majority of health professionals reported that combined clinics improved the accuracy of parental counselling and enhanced communication between specialties involved in the management of complicated pregnancies. The clinics are generally regarded as being useful for the training of junior staff. CONCLUSION: A service model that combines fetal medicine and paediatric specialists in a single clinic can efficiently modify parental perspective on fetal anomalies and enhance professional communication and training. Condition-specific information leaflets could further enhance service quality. A larger study involving a socio-demographically stratified sample of service users is needed to provide more authoritative data.

Conditioning on intermediates in perinatal epidemiology.

It is common practice in perinatal epidemiology to calculate gestational-age-specific or birth-weight-specific associations between an exposure and a perinatal outcome. Gestational age or birth weight, for example, might lie on a pathway from the exposure to the outcome. This practice of conditioning on a potential intermediate has come under critique for various reasons. First, if one is interested in assessing the overall effect of an exposure on an outcome, it is not necessary to stratify, and indeed, it is important not to stratify, on an intermediate. Second, if one does condition on an intermediate, to try to obtain what might conceived of as a "direct effect" of the exposure on the outcome, then various biases and paradoxical results can arise. It is now well documented theoretically and empirically that, when there is an unmeasured common cause of the intermediate and the outcome, associations adjusted for the intermediate are subject to bias. In this paper, we propose 3 approaches to facilitate valid inference when effects conditional on an intermediate are in view. These 3 approaches correspond to (i) conditioning on the predicted risk of the intermediate, (ii) conditioning on the intermediate itself in conjunction with sensitivity analysis, and (iii) conditioning on the subgroup of individuals for whom the intermediate would occur irrespective of the exposure received. The second and third approaches both require sensitivity analysis, and they result in a range of estimates. Each of the 3 approaches can be used to resolve the "birth-weight paradox" that exposures such as maternal smoking seem to have a protective effect among low-birth-weight infants. The various methodologic approaches described in this paper are applicable to a number of similar settings in perinatal epidemiology.

Perinatal morbidity after in vitro fertilization is lower with frozen embryo transfer.

OBJECTIVE: To study the association of perinatal outcome and IVF transfer type in a group of infertility patients with standardized treatment and similar prognosis. DESIGN: Retrospective cohort study. SETTING: University-based infertility center, January 1998 to June 2006. PATIENT(S): Two hundred eighteen IVF pregnancies after fresh embryo transfer (ET); 122 IVF pregnancies after frozen ET. INTERVENTION(S): Assessment of perinatal outcome in fresh versus frozen ET pregnancies. MAIN OUTCOME MEASURE(S): Pregnancy outcomes after fresh versus frozen embryo transfer (ET). Primary outcome was a composite of three events: preterm delivery, intrauterine growth restriction, or low birth weight. Secondary outcomes were subtypes of pregnancy loss. Associations were assessed using multivariate logistic regression. RESULT(S): The final sample included 340 pregnancies: 218 fresh and 122 frozen ETs. Singleton pregnancy was less likely after transfer of fresh embryos (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.23-0.67), and pregnancies after fresh ET were more likely to end in first-trimester loss (OR 1.82, 95% CI 1.05-3.13). Composite adverse outcome after transfer of fresh (44.0%) versus frozen (32.6%) embryos was higher (OR 1.52, 95% CI 0.90-2.56) and was strongly associated with twin gestation (OR 23.82, 95% CI 11.16-50.82). CONCLUSION(S): Perinatal morbidity is higher in IVF pregnancies conceived after a fresh ET compared with a frozen ET. Although some differences are related to conception with twin gestations, these findings suggest that adverse outcomes may be related to differences in IVF procedures.

Practice patterns in the management of isolated oligohydramnios: a survey of perinatologists.

OBJECTIVE: Optimal management of isolated oligohydramnios (IO) remains debatable. We surveyed Society for Maternal-Fetal Medicine (SMFM) members regarding their opinions and practice patterns. STUDY DESIGN: Questionnaires were mailed to perinatologists across the US. IO was defined as sonographic low fluid (per the practitioner's definition) in the absence of intrauterine growth restriction, fetal anomaly or significant maternal comorbidity. RESULTS: The overall response rate was 35% (n = 632). Ninety-two percent of respondents consider IO to be a risk factor for various adverse outcomes. With a favourable cervix, 34% and 82% would consider inducing labour without documented lung maturity prior to 37 and 39 weeks, respectively. When asked whether induction of labour in cases of IO reduces perinatal morbidity, 45% were unsure and 21.4% thought it would not. Only 33% believe induction could decrease adverse outcomes. Newer members of SMFM (<10 years) and those of private practice were more likely to believe that induction is efficacious in decreasing morbidity. CONCLUSION: There is significant divergence regarding the management of IO. Despite being unsure of its benefit, most practitioners lean towards intervention. The available literature is insufficient to make firm recommendations supporting intervention for IO.

Situación de la salud perinatal: República Argentina 2007 / Situation of the perinatal health: Argentina Republic 2007

Objetivo: Difundir indicadores globales de Salud Perinatal de Argentina del año 2007. Material y Métodos: Análisis de Estadísticas Vitales. Ministerio de Salud de la Nación. Resultados: La tasa de natalidad fue de 17,8 por mil y el promedio de hijos por mujer son 2,2. Las madres adolescentes representaron el 15,8 por ciento, las analfabetas funcionales el 9,5 por ciento y las no asociada a sistemas de salud el 47,4 por ciento. 99,2 por ciento de los 700.929 niños nacieron en partos institucionales, de los cuales 57,9 por ciento pertenecían al sector público. El bajo peso al nacer (< 2.500 g) fue el 7,2 por ciento y los prematuros el 8 por ciento. Las principales causas de muerte en mujeres en edad fértil fueron accidentes, cáncer de mama, suicidios, cáncer de cuello uterino, SIDA y causas maternas. La mortalidad materna ascendió al 44 por cien mil (306 mujeres) asociadas al aborto (24 por ciento), infecciones (15 por ciento), hipertensión (14 por ciento) y hemorragias (8 por ciento). La Mortalidad Infantil fue del 13,3 por mil, con sus componentes Neonatal 8,5 por mil y Postneonatal 4,8 por mil. Casi la mitad de la mortalidad infantil se produjo en la primera semana de vida. Los recién nacidos de bajo peso contribuyen al 50 por ciento de la mortalidad infantil por lo que la prematurez es la primera causa de muerte en la infancia. Las causas perinatales y las malformaciones congénitas producen las 2/3 partes de la mortalidad infantil. El uso de surfactante ha disminuido en un 31 por ciento la mortalidad por Enfermedad de Membrana Hialina y la fortificación de harinas con ácido fólico mostró una disminución de las malformaciones congénitas. La mortalidad fetal mostró un descenso muy leve.

Situación de la salud perinatal: República Argentina 2007 / Situation of the perinatal health: Argentina Republic 2007

Objetivo: Difundir indicadores globales de Salud Perinatal de Argentina del año 2007. Material y Métodos: Análisis de Estadísticas Vitales. Ministerio de Salud de la Nación. Resultados: La tasa de natalidad fue de 17,8 por mil y el promedio de hijos por mujer son 2,2. Las madres adolescentes representaron el 15,8 por ciento, las analfabetas funcionales el 9,5 por ciento y las no asociada a sistemas de salud el 47,4 por ciento. 99,2 por ciento de los 700.929 niños nacieron en partos institucionales, de los cuales 57,9 por ciento pertenecían al sector público. El bajo peso al nacer (< 2.500 g) fue el 7,2 por ciento y los prematuros el 8 por ciento. Las principales causas de muerte en mujeres en edad fértil fueron accidentes, cáncer de mama, suicidios, cáncer de cuello uterino, SIDA y causas maternas. La mortalidad materna ascendió al 44 por cien mil (306 mujeres) asociadas al aborto (24 por ciento), infecciones (15 por ciento), hipertensión (14 por ciento) y hemorragias (8 por ciento). La Mortalidad Infantil fue del 13,3 por mil, con sus componentes Neonatal 8,5 por mil y Postneonatal 4,8 por mil. Casi la mitad de la mortalidad infantil se produjo en la primera semana de vida. Los recién nacidos de bajo peso contribuyen al 50 por ciento de la mortalidad infantil por lo que la prematurez es la primera causa de muerte en la infancia. Las causas perinatales y las malformaciones congénitas producen las 2/3 partes de la mortalidad infantil. El uso de surfactante ha disminuido en un 31 por ciento la mortalidad por Enfermedad de Membrana Hialina y la fortificación de harinas con ácido fólico mostró una disminución de las malformaciones congénitas. La mortalidad fetal mostró un descenso muy leve.(AU)