The differences in placental pathology and neonatal outcome in singleton vs. twin gestation complicated by small for gestational age

Objective

We aimed to compare placental histopathology and neonatal outcome between dichorionic diamniotic (DCDA) twins and singleton pregnancies complicated by small for gestational age (SGA).

Methods

Medical files and placental pathology reports from all deliveries between 2008 and 2017 of SGA neonates, (birthweight?<?10th percentile), were reviewed. Comparison was made between singleton pregnancies complicated with SGA (singletons SGA group) and DCDA twin pregnancies (Twins SGA group), in which only one of the neonates was SGA. Placental diameters were compared between the groups. Placental lesions were classified into maternal and fetal vascular malperfusion lesions (MVM and FVM), maternal (MIR) and fetal (FIR) inflammatory responses, and chronic villitis. Neonatal outcome parameters included composite of early neonatal complications.

Results

The twins SGA group (n?=?66) was characterized by a higher maternal age (p?=?0.011), lower gestational age at delivery (34.9?±?3.1 vs. 37.7?±?2.6 weeks, p?<?0.001), and a higher rate of preeclampsia (p?=?0.010), compared to the singletons SGA group (n?=?500). Adverse composite neonatal outcome was more common in the twins SGA group (p?<?0.001). Placental villous lesions related to MVM (p?<?0.001) and composite MVM lesions (p?=?0.04) were more common in the singletons SGA group. On multivariate logistic regression analysis, the singletons SGA group was independently associated with placental villous lesions (aOR 3.6, 95% CI 1.9–7.0, p?<?0.001) and placental MVM lesions (aOR 2.44, 95% CI 1.29–4.61, p?=?0.006).

Conclusion

Placentas from SGA singleton pregnancies have more MVM lesions as compared to placentas from SGA twin pregnancies, suggesting different mechanisms involved in abnormal fetal growth in singleton and twin gestations.

     

Quantitative and qualitative trophectoderm grading allows for prediction of live birth and gender

Purpose

Prolonged in vitro culture is thought to affect pre- and postnatal development of the embryo. This prospective study was set up to determine whether quality/size of inner cell mass (ICM) (from which the fetus ultimately develops) and trophectoderm (TE) (from which the placenta ultimately develops) is reflected in birth and placental weight, healthy live-birth rate, and gender after fresh and frozen single blastocyst transfer.

Methods

In 225 patients, qualitative scoring of blastocysts was done according to the criteria expansion, ICM, and TE appearance. In parallel, all three parameters were quantified semi-automatically.

Results

TE quality and cell number were the only parameters that predicted treatment outcome. In detail, pregnancies that continued on to a live birth could be distinguished from those pregnancies that aborted on the basis of TE grade and cell number. Male blastocysts had a 2.53 higher chance of showing TE of quality A compared to female ones. There was no correlation between the appearance of both cell lineages and birth or placental weight, respectively.

Conclusions

The presented correlation of TE with outcome indicates that TE scoring could replace ICM scoring in terms of priority. This would automatically require a rethinking process in terms of blastocyst selection and cryopreservation strategy.

     

Advanced abdominal pregnancy: a search for consensus. Review of literature along with case report

Introduction

Intentional placental removal for abnormally invasive placenta (AIP) is fundamentally abandoned at planned surgery for it. Whether this holds true even after recent introduction of various hemostatic procedures is unclear.

Materials and Methods

We discussed on this issue based on our own experiences and also on the recent reports on various hemostatic procedures.

Results

Studies directly answering this question have been lacking. We must weigh the balance between the massive bleeding and possibility of uterus-preservation when intentional placental removal strategy is employed.

Conclusion

An almost forgotten strategy, the “intentional placental removal” for planned AIP surgery may regain its position when appropriate hemostatic procedures are concomitantly used depending on the situation. Even employing this strategy, quick decision to perform hysterectomy under multidisciplinary team may be important.

     

Is maternal anemia associated with small placental volume in the first trimester?

Aim

To clarify whether maternal anemia could reduce placental volume in the early gestation.

Methods

A prospective cross-sectional study was conducted. Consecutive women who visited at 11–13 + 6 weeks’ gestation were enrolled. Subjects were divided into two groups by maternal hemoglobin concentration. Cases with maternal anemia were defined as a hemoglobin level less than 11 g/dl on a blood test (cases), and the others were defined as controls. An ultrasound examination was performed to measure the placental volume and the uterine arterial blood flow. The three-dimensional volume of the placenta using virtual organ computer-aided analysis (VOCAL) technique was acquired by transabdominal ultrasonography. Placental volumes were compared in women with and without anemia.

Results

31 cases and 486 controls were analyzed. Maternal characteristics were not different between two groups except anemia. Placental volumes were 63.6 ± 22.2 and 60.9 ± 22.8 cm³ (ns), uterine arterial RIs were 0.7 ± 0.1 and 0.8 ± 0.1 (ns), and PIs were 1.7 ± 0.5 and 1.8 ± 0.6 (ns) in cases and controls, respectively.

Conclusions

Maternal anemia was not associated with reduced placental volume and uterine arterial Doppler wave form at 11–13 weeks’ gestation.

     

Viral infection,proliferation, and hyperplasia of Hofbauer cells and absence of inflammation characterize the placental pathology of fetuses with congenital Zika virus infection

Purpose

Attention is increasingly focused on the potential mechanism(s) for Zika virus infection to be transmitted from an infected mother to her fetus. This communication addresses current evidence for the role of the placenta in vertical transmission of the Zika virus.

Methods

Placentas from second and third trimester fetuses with confirmed intrauterine Zika virus infection were examined with routine staining to determine the spectrum of pathologic changes. In addition, immunohistochemical staining for macrophages and nuclear proliferation antigens was performed. Viral localization was identified using RNA hybridization. These observations were combined with the recent published results of placental pathology to increase the strength of the pathology data. Results were correlated with published data from experimental studies of Zika virus infection in placental cells and chorionic villous explants.

Results

Placentas from fetuses with congenital Zika virus infection are concordant in not having viral-induced placental inflammation. Special stains reveal proliferation and prominent hyperplasia of placental stromal macrophages, termed Hofbauer cells, in the chorionic villi of infected placentas. Zika virus infection is present in Hofbauer cells from second and third trimester placentas. Experimental studies and placentae from infected fetuses reveal that the spectrum of placental cell types infected with the Zika virus is broader during the first trimester than later in gestation.

Conclusions

Inflammatory abnormalities of the placenta are not a component of vertical transmission of the Zika virus. The major placental response in second and third trimester transplacental Zika virus infection is proliferation and hyperplasia of Hofbauer cells, which also demonstrate viral infection.

     

Correlation of Maternal Autoantibodies with Fetal Congenital Heart Block

Background

Autoimmune fetal congenital heart block (CHB) is the most severe manifestation of neonatal lupus, and it is seen when maternal autoimmune antibodies cross the placenta and damage the AV node of the fetus. CHB is mainly associated with maternal SLE with anti-Ro/SSA- and anti-La/SSB-positive status, and incidence of CHB increases when both the antibodies are present. This study was conducted to know the incidence of fetal CHB in patients of SLE who had ANA, anti-Ro/SSA and anti-La/SSB positivity.

Methods

A prospective study was conducted in a tertiary-care teaching hospital of Indian Armed Forces between Jan 2012 to Sep 2014 where 13 cases of SLE were studied. All these patients were tested for ANA, anti-Ro/SSA and anti-La/SSB antibodies and fetal heart abnormalities. Fetuses with CHB were treated with steroids.

Results

Incidence of SLE was 0.14 %, 92 % of SLE patients were positive for ANA, and 46 % had anti-Ro/SSA- and anti-La/SSB-positive status. Two fetuses had congenital heart block, and one fetus required pacemaker placement 5 months after delivery.

Conclusion

All the fetal congenital heart blocks are associated with maternal anti-Ro/SSA and anti-La/SSB and ANA antibodies. Treatment by steroids may improve the outcome in early stages of fetal CHB, and delivery with follow-up should be planned in a tertiary-care center where pacemaker placement facility is available.

     

Oligoamnios and Perinatal Outcome

Objective(s)

We aimed at evaluating the predictive value of amniotic fluid index ≤5 on perinatal outcome in terms of effect on cardiotocography, mode of delivery, meconium in liquor, birth weight, fetal distress, APGAR score at birth and neonatal admission to ICU.

Method(s)

This is a prospective study of 308 antenatal women admitted to labor ward of MIMS during February 2014–December 2015 with gestational ages between 34 and 41 weeks. All women enrolled were subjected to history taking, examination, AFI estimation and compared between those with AFI ≤5 from rest.

Results

The non-reactive CTG, cesarean section rate due to fetal distress, low birth weight, APGAR score <7 and NICU admission were significantly high among those with oligoamnios than the control group.

Conclusion

Oligoamnios has a significant correlation with adverse perinatal outcome.

     

Comparison of Outcome of Normal and High-Risk Pregnancies Based Upon Cerebroplacental Ratio Assessed by Doppler Studies

Objectives

To evaluate the cerebroplacental ratio which is the ratio of pulsatility index of fetal middle cerebral and umbilical arteries, in normal and high-risk pregnancies during 30–36 weeks of gestation.

Methods

In this study, we included 70 patients, who were scanned for Doppler parameters of Middle cerebral artery and Umbilical artery pulsatility index ratio of fetus, between 30 and 36 weeks, and then were followed till delivery. Thirty-five patients with normal pregnancy and 35 patients with high-risk pregnancy were included. Perinatal outcome was evaluated in relation to indices ratio.

Results

There was cerebroplacental ratio of <1.00 in eight cases of the study group in comparison with the control group in which there is no case of <1.00 value. It was associated with poor perinatal outcome in terms of need for lower segment cesarean section for fetal distress, Apgar <8 at 5 min, and admission to nursery.

Conclusion

Cerebroplacental ratio is highly sensitive in diagnosing hemodynamically compromised fetuses and very useful for the prediction of adverse perinatal outcome in these fetuses.

     

Sirenomelia: a review on embryogenic enviromental theories,novel three-dimensional ultrasound imaging and first trimester diagnosis in a case of mosaic 69,XXX/46,XX fetus

Purpose

Sirenomelia is caused by atrophy of the lower extremities that is commonly associated with gastrointestinal and urogenital malformations.

Methods

Embryogenic environmental theories and systematic review of the literature are reported.

Results

Genetic basis of the condition has been demonstrated in the animal model. In humans, association with de novo balanced translocation has only recently been documented.

Conclusions

A case of triploidy mosaic fetus with sirenomelia and posterior fossa anomaly diagnosed at first trimester using novel three-dimensional ultrasound imaging techniques is presented.

     

Blood Transfusion Practices in Obstetrics: Our Experience

Objectives

To ascertain and analyze the indications for transfusion of blood components in obstetric practice at our center.

Materials and Methods

A prospective observational study was conducted to analyze the various indications for transfusion of blood components in a tertiary care hospital.

Results

1.3% of all obstetric patients from our center had blood components transfusion during the study period. Postpartum hemorrhage, placental causes and anemia are the commonest causes for need of transfusion in obstetric practice.

     

Antenatal ultrasound and MRI findings of Pena–Shokeir syndrome

Introduction

Pena–Shokeir syndrome is an autosomal recessive disorder characterized by arthrogryposis, facial anomalies (micrognathia), camptodactyly, polyhydramnios and lung hypoplasia.

Case report

We report prenatal ultrasonographic, antenatal MR and postnatal examination findings of a fetus with Pena–Shokeir syndrome.

Conclusion

Pena–Shokeir syndrome is a potentially lethal condition and most cases are diagnosed prenatally by ultrasound. Fetal MR can be performed to look associated neurological malformation.

     

Birthweight thresholds for increased risk for maternal and neonatal morbidity following vaginal delivery: a retrospective study

Purpose

To determine neonatal birthweight (BW) thresholds for adverse maternal and neonatal outcome following vaginal delivery.

Methods

A retrospective cohort study of all women with singleton pregnancies who underwent vaginal delivery in a university-affiliated tertiary hospital (1996–2015). The association between BW and adverse outcome in neonates with BW ≥?3500 g (>?90th centile BW at 37 weeks’ gestation) with 100 g-increment groups was explored. Pregnancies complicated by diabetes mellitus, fetal anomalies or cesarean deliveries were excluded. The composite neonatal outcome was defined as shoulder dystocia or brachial plexus injury. The composite maternal outcome was defined as postpartum hemorrhage or third- or fourth-degree perineal tears.

Results

Of the 121,728 deliveries during the study period, 26,920 (22.1%) met inclusion criteria. Of these, 1024 (3.8%) had a composite adverse maternal outcome and 947 (3.5%) had a composite adverse neonatal outcome. The rates of composite maternal outcomes increased significantly only at a BW of 4800 g and above. The composite neonatal outcomes increased significantly only at a BW of 4400 g and above. In multivariate analysis, after subcategorizing our cohort into 3 BW groups [3500–3999 g (control, n?=?23,030); 4000–4399 g (n?=?3494);?≥?4400 g (n?=?396)], BW was associated with adverse neonatal outcomes in a dose-dependent manner. In the BW?≥?4400 g group, to prevent one case of shoulder dystocia or Erb’s palsy, 12 cesarean deliveries needed to be performed.

Conclusion

For non-diabetic mothers who deliver vaginally, neonatal BW?≥?4400 g was associated with a significant increase in adverse neonatal outcomes, whereas neonatal BW?≥?4800 g was associated with a significant increase in adverse maternal outcomes.

     

Adverse neonatal and maternal outcome following vacuum-assisted vaginal delivery: does indication matter?

Purpose

To estimate the impact of indication for vacuum-assisted vaginal delivery on neonatal and maternal adverse outcome.

Methods

Retrospective analysis of women carrying singleton-term pregnancies undergoing vacuum-assisted vaginal delivery in a tertiary hospital (2007–2014). Cohort was stratified by indication: non-reassuring fetal heart rate or prolonged second stage. Primary outcome was adverse neonatal outcome and secondary outcome was maternal morbidity. Logistic regression analysis was utilized to adjust for potential confounders.

Result

Overall, 4931 women met inclusion criteria. Delivery indication was prolonged second stage in 3143 (64%) cases and non-reassuring fetal heart rate in 1788 (36%). In the non-reassuring fetal heart rate group, there were higher rates of cephalohematoma, low 5-min Apgar-score, and asphyxia. In the prolonged second-stage group, there were higher rates of sepsis and post-partum hemorrhage. Composite neonatal birth trauma and maternal morbidity were higher for vacuum-assisted vaginal delivery following prolonged second stage. Following adjustment for confounders cephalohematoma (aOR 1.21, 95% CI 1.04–1.41), low 5-min Apgar-score (aOR 2.91, 95% CI 1.26–4.67) and asphyxia (aOR 1.81 95% CI 1.35–2.44) remained significant in the non-reassuring fetal heart rate group and neonatal sepsis remained significant for the prolonged second-stage group (aOR 1.77, 95% CI 1.38–2.27), p?<?0.05 for all. However, there was no longer difference in the composite birth trauma, other neonatal or maternal morbidity.

Conclusion

The indication for vacuum-assisted vaginal delivery has an impact on neonatal outcome. While cephalohematoma, low 5′ Apgar score, and asphyxia were more common in the non-reassuring fetal heart rate group, neonatal sepsis was more common in cases of prolonged second stage of labor.

     

Management of cesarean scar pregnancy with suction curettage: a report of four cases and review of the literature

Purpose

To present the outcomes of four cases of cesarean scar pregnancy treated with suction curettage.

Methods

Four patients were ultrasonographically diagnosed with cesarean scar pregnancies treated with suction curettage in a tertiary care center.

Results

Serum β-human chorionic gonadotropin levels ranged between 1,681 and 15,573 mU/mL, gestational sac diameter measured from 10 to 24 mm and scar thickness was between 4.7 and 6.8 mm. All patients underwent suction curettage under general anesthesia with transabdominal ultrasonography guidance. No complications were observed during or after operation.

Conclusion

Suction curettage is a viable alternative for conservative treatment in selected cases of patients who are diagnosed with CSP early in gestation and who have a myometrial thickness of more than 4.5 mm.

     

Is the yolk sac a new marker for chromosomal abnormalities in early pregnancy?

Introduction

Abnormal yolk sac size is associated with fetal miscarriage. This is a case report of two pregnancies with abnormal yolk sacs.

Materials and methods

In one case, a twofold sac was found; in the other case, the yolk sac was not of spherical form.

Conclusion

Currently available publications demonstrate a correlation between abnormal yolk sac size and miscarriage. However, in both cases a trisomy was confirmed. It should therefore be discussed whether form and size of the yolk sac could be a marker for chromosomal abnormalities of the fetus.

     

A prospective cohort study on the prediction of the diagnosis-to-delivery time in preeclamptic pregnancies: should the sFlt-1/PlGF ratio be added to routine evaluations?

Purpose

To analyze the clinical and laboratory factors that potentially affect the diagnosis-to-delivery time in preeclamptic pregnancies.

Methods

In this cross-sectional study, we followed 24 early onset preeclampsia (E-PE) and 26 late-onset preeclampsia (L-PE) cases. Maternal serum samples were obtained at the time of diagnosis and stored at ??80 °C until ELISA analysis for soluble fms-like tyrosine kinase-1 (SFlt-1) and placental growth factor (PlGF) levels.

Results

The median follow-up duration was 68 (1–339) h in the E-PE group and 330 (7–1344) h in the L-PE group. Maternal mean arterial pressure (MAP) at hospitalization was the strongest variable, and the sFlt-1/PlGF ratio added significantly to the Cox regression model. In the E-PE cases, the median sFlt-1/PlGF ratio was significantly higher in the subgroup with a follow-up duration?>?48 h than in the subgroup of cases with a follow-up duration?≤?48 h (5109 vs. 2080; p?=?0.038), and none of the seven cases with an sFlt-1/PlGF ratio?≥?75th percentile delivered during the first 48 h. Neither the 24-h proteinuria nor the gestational age at diagnosis added to the predictive power of the MAP at hospitalization.

Conclusion

Incorporation of the sFlt-1/PlGF ratio to the routine evaluation of preeclamptic pregnancies may help in the prediction of progression and management planning.

     

Endometrial thickness influences neonatal birth weight in pregnancies with obstetric complications achieved after fresh IVF–ICSI cycles

Purpose

Pregnancy-associated complications, duration of gestation and parity are well-known predictors of neonatal birth weight. Assisted reproductive technology (ART) affects neonatal birth weight as well. Endometrial thickness as measured on the day of HCG triggering may therefore impact on the neonatal birth weight.

Methods

The data of 764 singleton deliveries achieved after fresh transfer between November 1997 and 2014 were collected retrospectively with the intention to analyze the relationship of maternal and neonatal characteristics with endometrial thickness and the possible predictive value of endometrial thickness on neonatal birth weight.

Results

Higher maternal age (p < 0.001), diminished ovarian reserve (p < 0.001), endometriosis (p = 0.008) and hypogonadotropic hypogonadism (p < 0.001) predicted thin endometrium. Neonatal birth weight (p = 0.004), longer duration of pregnancy (p = 0.008), parity (p = 0.026) and higher maternal BMI (p = 0.003) were correlated significantly with the degree of endometrial proliferation. Endometrial thickness strongly predicted neonatal birth weight (p = 0.004). After adjusting regression analysis for maternal age and BMI, parity, neonatal gender and pregnancy duration, endometrial thickness remained predictive for neonatal birth weight in pregnancies with obstetric complications (p = 0.017). In uneventful pregnancies duration and parity are determinants of neonatal birth weight.

Conclusions

Our findings suggest that endometrial thickness is an additional ART-related factor influencing neonatal birth weight. This finding should be confirmed in large cohort studies.

     

Perinatal follow-up of children born after preimplantation genetic diagnosis between 1995 and 2014

Purpose

We aim to evaluate the safety of PGD. We focus on the congenital malformation rate and additionally report on adverse perinatal outcome.

Methods

We collated data from a large group of singletons and multiples born after PGD between 1995 and 2014. Data on congenital malformation rates in live born children and terminated pregnancies, misdiagnosis rate, birth parameters, perinatal mortality, and hospital admissions were prospectively collected by questionnaires.

Results

Four hundred thirty-nine pregnancies in 381 women resulted in 364 live born children. Nine children (2.5%) had major malformations. This percentage is consistent with other PGD cohorts and comparable to the prevalence reported by the European Surveillance of Congenital Anomalies (EUROCAT). We reported one misdiagnosis resulting in a spontaneous abortion of a fetus with an unbalanced chromosome pattern. 20% of the children were born premature (<?37 weeks) and less than 15% had a low birth weight. The incidence of hospital admissions is in line with prematurity and low birth weight rate. One child from a twin, one child from a triplet, and one singleton died at 23, 32, and 37 weeks of gestation respectively.

Conclusions

We found no evidence that PGD treatment increases the risk on congenital malformations or adverse perinatal outcome.

Trial registration number

NCT 2 149485

     

Peripartum events associated with severe neurologic morbidity and mortality among acidemic neonates

Purpose

To identify peripartum events that may predict the development of short-term neurologic morbidity and mortality among acidemic neonates.

Methods

Retrospective case–control study conducted at a single-teaching hospital on data from January 2010 to December 2015. The study cohort group included all acidemic neonates (cord artery pH ≤ 7.1) born at ≥ 34 weeks. Primary outcome was a composite including any of the following: neonatal encephalopathy, convulsions, intra-ventricular hemorrhage, or neonatal death. The study cohort was divided to the cases group, i.e., acidemic neonates who had any component of the primary outcome, and a control group, i.e., acidemic neonates who did not experience any component of the primary outcome.

Results

Of all 24,311 neonates born ≥ 34 weeks during the study period, 568 (2.3%) had a cord artery pH ≤ 7.1 and composed the cohort study group. Twenty-one (3.7%) neonates composed the cases group. Multivariate logistic regression analysis revealed that cases were significantly more likely to have experienced placental abruption (OR 18.78; 95% CI 5.57–63.26), born ≤ 2500 g (OR 13.58; 95% CI 3.70–49.90), have meconium (OR 3.80; 95% CI 1.20–11.98) and cord entanglement (OR 5.99; 95% CI 1.79–20.06). The probability for developing the composite outcome rose from 3.7% with isolated acidemia to 97% among neonates who had all these peripartum events combined with intrapartum fetal heart rate tracing category 2 or 3.

Conclusion

Neonatal acidemia carries a favorable outcome in the vast majority of cases. In association with particular antenatal and intrapartum events, the short-term outcome may be unfavorable.

     

Cumulative pregnancy and live birth rates through assisted reproduction in women 44–45 years of age: is there any hope?

Purpose

The purpose of the study is to calculate the cumulative pregnancy rate and cumulative live birth rate in women undergoing in vitro fertilization (IVF) at ages 44–45.

Methods

The study calculated cumulative live pregnancy rate and cumulative live birth rate of 124 women aged 44 to 45 years old who commenced IVF treatment.

Main outcome measures

The main outcome measures are cumulative live pregnancy rate and cumulative live birth rate.

Results

Cumulative live pregnancy rates following 1, 2, 3, and 4 cycles were 5.6, 11, 17, and 20%, respectively, with no additional pregnancies in further cycles. Cumulative live birth rates following 1, 2, and 3 cycles were 1.6, 3, and 7%, respectively, with no additional live births in further cycles.

Conclusions

The cumulative pregnancy rate rises during the first 4 cycles and cumulative live birth rate rises during the first 3 cycles, with no additional rise in pregnancies or deliveries thereafter, suggesting that it is futile to offer more than 3 cycles of treatment to 44–45-year-old women.