Fetal leg posture in uncomplicated breech and cephalic pregnancies

Background The objective of our study was to determine differences in prenatal leg posture development between breech and cephalic-born babies. Materials and methods Ten healthy fetuses in breech and ten healthy fetuses in cephalic presentation were observed by means of weekly ultrasounds from 33 weeks gestational age until birth to assess leg posture. Results The breech fetuses showed a clear preference for an extended leg position; they spent significantly more time with their knees in extension than the cephalic fetuses (p<0.001). The cephalic fetuses showed significantly more leg-crossing than the breech fetuses (p<0.01). For both findings, no significant change over time could be observed in either group. Conclusion These findings show that the intra-uterine position does influence the fetal postural and motor development. However, it seems unlikely that intra-uterine movement restriction can solely be held accountable for the observed differences in leg position between breech and cephalic fetuses. © 2008 The Author(s)

A study to find out the association between duration of preterm premature rupture of the membrane’s delivery interval and maternofetal complications

Background: The main maternal complications of preterm premature rupture of the membranes (PPROM) are chorioamnionitis, puerperal pyrexia, abruption and the neonatal complications are neonatal sepsis, congenital pneumonia, neonatal ICU stay and neonatal death. The aim of the study is to find out the association between duration of latent period in PPROM i.e. the time period between rupture of membrane to delivery and maternofetal complications.Methods: The present study was a Prospective observational study conducted on 240 preterm antenatal women with PPROM in the Department Obstetrics and Gynecology, SATH, GMC, Thiruvananthapuram. The gestational age at rupture of membranes, latent period from time rupture of membranes to delivery, gestational age at time of delivery and the maternal and neonatal outcome were compared and subjected to statistical analysis.Results: Maternal chorioamnionitis in the group with PPROM delivery interval between 2-7 days (79.3%) whereas there were (13.8%) in which PPROM delivery interval was less than 24 hrs. Puerperal pyrexia in 2-7 days delivery interval was 11.3% and in <24 hrs were 2.6%. Neonatal sepsis in 2-7 days was 28.3% and 12.5% in<24 hrs. Congenital pneumonia in 2-7 days was 16.9% and in<24 hrs was 11.6%.Conclusions: In the present study membrane rupture between 28-34 weeks gest age and latency period. 2-7 days were associated with high incidence of maternal chorioamnionitis, puerperal pyrexia congenital pneumonia, early onset neonatal sepsis and neonatal death. Undue prolongation of pregnancy may increase the risk of chorioamnionitis, neonatal sepsis and neonatal deaths

Neurocognitive outcome of monochorionic twins with different birth weights

M.D.Background: Although the long term effect of intrauterine growth restriction has been assessed in a number of singleton studies, they all suffer from multiple confounding effects. A model that utilises monozygotic twins may markedly reduce the effect of confounders as monochorionic twins share the same gestational age length, family background, gender and genetic influences on growth and cognition. Comparison of monochorionic twins with birth weight discordance of 20% or more could be used as a model of in utero growth constraint. This model will still involve certain limitations and assumptions nevertheless; we used this to determine the level of cognitive function of in-utero growth discordant monochorionic twins in later childhood along with any differences in auxology and behavioural problems. Methods: This was a retrospective cohort study. Eligible twins were identified from the Northern Survey of Twins and Multiple Pregnancies register. Cognitive function was assessed by a single observer using the British Ability Scales 2 to measure the general conceptual ability. Strength and Difficulties Questionnaire was used to identify behavioral problems. Height, weight, mid arm circumference, waist measurement and head circumference were also collected. Generalised estimating equations were used to determine the effect of birth weight on general conceptual ability scores. Statistical analyses were performed using SPSS v19. Results: Between 2000 and 2004, a total of 51 twin pairs were assessed (n=23 female) with mean birth weight discordance 664gm and mean gestational age 34.7 weeks. The mean difference in the general conceptual ability score between the heavier and lighter twins was 3 points. Significant association between within pair differences in birth weight and general conceptual ability scores was found. Increasing birth weight discordance was not associated with a decrease of general conceptual ability scores. The differences in the size seen at birth between the twins were still detectable at the age of 5-8 years. There was a trend to increased prevalence of behavioural problems in the lighter twin compared to the heavier twin as reported by both teachers and parents but this result was not statistically significant. Conclusions: The smaller twin of a monochorionic growth discrepant pair was statistically significantly more likely to have a lower cognitive score compared to their co-twin at 5-8 years of age. This suggests that growth restriction in-utero is associated with lower cognitive scores in later childhood

Epidemiological and pathological correlates of early neonatal mortality

INTRODUCTION Despite improved intrapartum monitoring of the fetus, the rate of cerebral palsy has not decreased. Many studies now suggest that the majority of children with such disability may sustain damage in utero. Current understanding and identification of antenatal brain injury is poor and individual vulnerability may be important. Specific genotypes such as Apolipoprotein E are disadvantageous to outcome in the context of adult brain injury and may also be important in early development.OBJECTIVES An aim of this project was to identify clinical and genetic risk factors for early neonatal mortality within the Scottish population with special consideration for those infants born in an asphyxiated condition. A further aim was to determine the prevalence of antenatal brain injury within this population and to correlate neuropathology with clinical factors.METHODS Clinical data and neuropathological specimens were collected as part of the Scottish National Perinatal Neuropathology Study from all 22 delivery units throughout Scotland. Birth asphyxia was defined and infants were classified accordingly. Neuropathological examination was performed by a single observer in Edinburgh who was blind to clinical detail. Apolipoprotein E genotype was analysed and compared with known published data for adults and healthy newborns. Comparisons of categorical data were made with the Chi-square test and numerical data were compared using the unpaired student's t-test or the Mann Whitney U test.RESULTS Clinical data was collected from 191 early neonatal deaths. Complications of pregnancy were common in all neonatal deaths. The only predictive factors for asphyxia were indicators of intrapartum fetal distress. Neuropathological examination was possible in 59 infants surviving 3 days or less. Evidence of prelabour brain injury was observed in nearly half of this cohort, and this was significantly more common in asphyxiated infants and those who developed an encephalopathy. The only clinical associations of such damage were the presence of cardiotocograph abnormalities, meconium staining and severe depression at birth. Apolipoprotein E analysis was performed in 252 perinatal deaths. There was an over representation of the s4 allele among healthy newborns compared to perinatal deaths and adults.CONCLUSIONS Brain injury occurring in utero is a common finding among neonatal deaths, particularly in those born with asphyxia. Current intrapartum indicators of fetal distress may signify a fetus who has already suffered compromise prior to the onset of labour. Differences in the Apolipoprotein s4 genotype in perinatal populations suggest that the fetus may vary in its ability to withstand fatal injury

Biomarkers of intrauterine hypoxia and perinatal asphyxia, and gestational age as predictors of neonatal outcome

Fetal life occurs in a relatively hypoxic environment. During normal pregnancy, several compensatory mechanisms secure fetal oxygenation and wellbeing. In complicated pregnancies, however, intrauterine hypoxia predisposes the fetus to growth restriction, stillbirth, neurodevelopmental sequelae such as cognitive dysfunction and cerebral palsy (CP), and adverse long-term health impacts. Impairment of respiratory gas exchange—during either pregnancy or delivery—leads to tissue hypoxia, and, if prolonged, to metabolic acidosis and asphyxia. Worldwide, such asphyxia, diagnosed at birth, annually accounts for a million neonatal deaths. Furthermore, neonatal hypoxic ischemic encephalopathy (HIE) originating from perinatal asphyxia may lead to a variety of neurodevelopmental impairments. Therapeutic neuroprotective interventions such as hypothermia have significantly improved the prognosis of severe neonatal encephalopathy. Increased risk for intrauterine fetal hypoxia and perinatal asphyxia occur in various circumstances and pregnancy complications—such as intrauterine growth restriction (IUGR), which affects up to 10% of pregnancies. Timing the delivery in preterm pregnancy with severe IUGR is challenging, owing to balancing between risks related to prematurity and to fetal hypoxia. Another obstetric challenge concerns timing of delivery as well: Neonatal outcomes vary by gestational age also among term pregnancies. In pregnancies beyond 41 gestational weeks, the risk for perinatal morbidity and mortality increases, probably due to the relative insufficiency of the aging placenta. Numerous methods such as fetal Doppler assessments and computerized cardiotocography help in monitoring placental function and fetal wellbeing. These methods, however, are not unequivocally efficient in predicting adverse neonatal outcomes in IUGR or in prolonged pregnancies. Furthermore, the time window for neuroprotective treatment in birth asphyxia is narrow, and additional methods for identifying those neonates who would benefit from neuroprotective actions are essential. We thus searched for biomarkers identifying those fetuses at risk for hypoxia-caused complications, and for predicting outcome after birth asphyxia. Erythropoietin (EPO) is a biomarker of chronic hypoxia, with high levels of EPO associating with increased risk for adverse outcome. S100B is a biomarker of brain- cell damage, and its levels rise in early phases of acute asphyxia. Copeptin, a by-product of arginine vasopressin (AVP) production, is a potential biomarker of birth asphyxia and HIE. Additionally, we aimed to evaluate the association of gestational age with perinatal asphyctic complications and long-term neurologic morbidity. The biomarker studies (I-III) were conducted in the University Hospital of Helsinki, Finland. Data on maternal pregnancy and delivery characteristics, and short-term neonatal outcomes such as Apgar score, originated from hospital charts. The study populations comprised 66 pregnancies complicated by preterm IUGR, 93 low-risk term and prolonged pregnancies, and 140 term neonates with birth asphyxia. Amniotic fluid samples for EPO evaluations we obtained by amniocentesis, at cesarean section, or vaginally at amniotomy. Umbilical serum plasma samples for EPO, copeptin, and S100B assessments we collected at birth. Biomarker levels in amniotic fluid and umbilical plasma samples we measured by immunoassays. Normal amniotic fluid EPO levels we defined as < 3 IU/L, with abnormal levels exceeding 27 IU/L. We considered as normal umbilical plasma EPO levels below 40 IU/L. The register-based cohort study on asphyxia and neurologic morbidity (IV) comprised 1 138 109 women with singleton pregnancies and their newborns between 1989 and 2008 in Finland. The Finnish Medical Birth Register (MBR), maintained by the National Institute for Health and Welfare (THL), provided data for this study. Statistical analyses we performed with the Statistical Package for Social Sciences (SPSS, Chicago, IL, USA), GraphPad Prism 6 and SAS version 9.3 (SAS Institute, Inc, Cary, NC, USA). All tests were two-sided, with probability (p) values of < 0.05 as statistically significant. In IUGR pregnancies, abnormal amniotic fluid EPO levels were associated with decreased umbilical artery pH and base excess (BE) values, abnormal biophysical profile, and reversed end-diastolic flow in the umbilical artery. Most importantly, such abnormal EPO levels were associated with composite adverse neonatal outcomes defined as intraventricular hemorrhage, periventricular leukomalacia, cerebral infarction, or necrotizing enterocolitis (p < 0.001). In low-risk term and postterm pregnancies, EPO levels in amniotic fluid and in umbilical serum correlated with gestational age. Furthermore, EPO levels in amniotic fluid correlated with the levels in umbilical serum, even after vaginal delivery. Among low-risk pregnancies, however, EPO levels correlated with neither umbilical artery pH or BE, nor with other adverse pregnancy outcomes. In our study on biomarkers in birth asphyxia, only copeptin correlated with arterial pH. Its correlation with umbilical artery BE was significantly stronger than were the correlations of S100B or of EPO. Copeptin levels, significantly higher among neonates with birth asphyxia, we demonstrated to increase as a function of labor duration. In the cohort study, multivariate analysis demonstrated an increased risk for low (< 4) one- and five-minute Apgar score, CP, intellectual disability, sensorineural defects, and perinatal mortality among early-term births. Postterm birth resulted in increased risk for low one- and five-minute Apgar scores (< 4), low umbilical artery pH ≤ 7.10, and intellectual disability, whereas risks for CP, epilepsy, sensorineural defects, and perinatal mortality showed no increase. In conclusion, among preterm IUGR pregnancies, high amniotic fluid EPO levels were associated with decreased umbilical artery pH and BE, and with adverse neonatal outcomes. In selected risk-pregnancies, determining amniotic fluid EPO may thus be a useful additional tool in fetal surveillance and in optimizing delivery timing. In term pregnancies, EPO levels correlated with gestational age, probably explained by advancing gestation resulting in weakening placental function and relative hypoxemia. Among low-risk populations, however, EPO was not related to adverse delivery outcomes, and thus may not prove clinically useful in such populations. Furthermore, in cases of acute birth asphyxia, S100B and EPO as biomarkers may not prove valid. In contrast, copeptin has potential for routine use as a biomarker for acute birth asphyxia and neonatal distress. Future studies should determine the correlation of biomarker levels at birth with severity of HIE and with long-term neurological outcome following birth asphyxia. Concerning gestational age at birth, we found an increased risk for low Apgar score, increased neurologic morbidity, and perinatal mortality among early-term neonates. Among postterm births, the risk for birth asphyxia was increased. The long-term neurologic health impacts of postterm birth, however, were less important than previously expected, meaning that further studies on the optimal management of pregnancies beyond 41 gestational weeks are essential.Raskauden aikana sikiö elää verrattain vähähappisessa ympäristössä. Normaalin raskauden aikana lukuisat kompensaatiomekanismit varmistavat sikiön riittävän hapensaannin ja hyvinvoinnin. Sen sijaan komplisoituneissa raskauksissa sikiön kroonisen hapenpuutteen riski on suurentunut lisäten sikiökuoleman, kasvuhidastuman, neurologisten kehityshäiriöiden ja pitkäaikaisten terveysongelmien todennäköisyyttä. Näissä raskauksissa optimaalisen synnytysajankohdan määrittely on usein haastavaa, koska tällöin on huomioitava kohdunsisäisen hapenpuutteen, ennenaikaisen synnytyksen, sekä obstetristen toimenpiteiden aiheuttamat mahdolliset haitat. Sikiön hengityskaasujen vaihdon ongelmat raskauden tai synnytyksen aikana johtavat kudosten hapenpuutteeseen ja hiilidioksidin kertymiseen eli asfyksiaan, mikä pitkittyessään väistämättä johtaa aineenvaihdunnalliseen happamuuteen. Maailmanlaajuisesti perinataalinen asfyksia aiheuttaa vuosittain jopa miljoonan vastasyntyneen kuoleman. Asfyksian aiheuttama hypoksis-iskeeminen enkefalopatia voi myös johtaa pysyvään vammautumiseen ja vakaviin neurologisiin kehityshäiriöihin. Keskushermoston suojaamiseen tähtäävät hoitotoimenpiteet - kuten vastasyntyneen viilennyshoito - ovat olennaisesti parantaneet vastasyntyneen vaikean enkefalopatian ennustetta. Sikiön hyvinvoinnin ja istukan toiminnan seurannassa käytetään lukuisia menetelmiä, kuten sikiön sydänäänten monitorointia ja Doppler-ultraäänitutkimuksia. Käytössä olevilla menetelmillä ei kuitenkaan aina pystytä yksiselitteisesti ennustamaan vastasyntyneen epäsuotuisaa lopputulemaa riskiraskauksissa. Vastasyntyneen asfyksiadiagnoosin asetuksen ja keskushermostoa suojaavien hoitojen käynnistämisen aikaikkuna on kapea, eikä kaikkia intensiivistä tehohoitoa tarvitsevia vastasyntyneitä löydetä nykymenetelmien avulla ajoissa. Uusia menetelmiä kaivataan sekä hapenpuutteen riskissä olevien sikiöiden, että intensiivisestä tehohoidosta hyötyvien vastasyntyneiden tunnistamiseen ja ennusteen arviointiin. Erytropoietiini (EPO) on punasolujen muodostumista lisäävä hormoni, jota käytetään myös hapenpuutteen merkkiaineena. Napaplasman ja lapsiveden kohonneet EPO-pitoisuudet liittyvät vastasyntyneen huonoon lopputulemaan. S100B-proteiini on aivokudoksen soluvaurion merkkiaine, jonka pitoisuudet nousevat myös asfyksiaan liittyvien vaurioiden ilmaantuessa. Vasopressiini on elimistön nestetasapainoa ylläpitävä hormoni, jonka eritys lisääntyy monentyyppisissä stressitilanteissa. Kopeptiini on vasopressiini-erityksen sivutuote, jota pidetään potentiaalisena perinataalisen asfyksian ja hypoksis-iskeemisen aivovaurion merkkiaineena. Tutkimuksessamme selvitimme näiden valikoitujen biomerkkiaineiden käyttöä hapenpuutteen riskissä olevien sikiöiden tunnistamisessa, sekä näiden merkkiaineiden käytettävyyttä perinataalisen asfyksian diagnostiikassa ja vastasyntyneen ennusteen arvioinnissa. Lisäksi selvitimme raskauden keston vaikutuksia perinataalisen asfyksian ja pitkäaikaisen neurologisen sairastavuuden esiintyvyyteen täysiaikaisissa ja yliaikaisissa raskauksissa. Sikiön kasvuhidastumaa ennenaikaisissa raskauksissa käsittelevässä tutkimuksessamme (n=66) totesimme kohonneiden lapsiveden EPO-pitoisuuksien liittyvän napavaltimon vakava-asteisiin virtausmuutoksiin, sekä vastasyntyneen alentuneisiin napavaltimon pH- ja BE-arvoihin. Lisäksi kohonneet EPO-pitoisuudet liittyivät vastasyntyneen vakavaan sairastavuuteen, mukaan lukien vaikea-asteiset aivokammioverenvuodot, aivoinfarktit, periventrikulaarinen leukomalasia, sekä nekrotisoiva enterokoliitti (p < 0.001). Matalan riskin täysiaikaisissa ja lasketun ajan ohittaneissa raskauksissa (≥41 raskausviikkoa) (n=93) EPO-pitoisuudet korreloivat raskauden keston kanssa. Näissä raskauksissa emme todenneet yhteyttä lapsiveden EPO-pitoisuuden ja vastasyntyneen huonon lopputuleman välillä. Asfyktisilla vastasyntyneillä (n=140) totesimme selvästi korkeammat kopeptiinipitoisuudet kuin hyväkuntoisilla vastasyntyneillä. Kopeptiinipitoisuudet myös nousivat synnytyksen keston myötä. Rekisteritutkimuksemme asfyksiasta ja neurologisesta sairastavuudesta kattoi 1 138 109 raskautta vuosina 1989 – 2008. Totesimme varhaiseen täysiaikaiseen syntymään (raskausviikoilla 37+0-38+6) liittyvän matalien Apgarin pisteiden, CP-vamman, älyllisen kehitysvammaisuuden, aistitoimintojen vammojen, sekä perinataalikuolleisuuden suurentuneen riskin. Yliaikainen raskaus (≥42 raskausviikkoa) lisäsi matalan syntymä-pH:n, matalien Apgarin pisteiden, sekä älyllisen kehitysvammaisuuden riskiä, mutta ei liittynyt yleiseen neurologiseen sairastavuuteen eikä lisännyt perinataalikuolleisuutta. Johtopäätöksenä totesimme, että tietyissä riskiraskauksissa lapsiveden EPO-pitoisuuden määrittäminen saattaa olla hyödyllinen lisämenetelmä sikiön voinnin ja synnytyksen ajankohdan arvioinnissa. Toisaalta matalan riskin raskauksissa EPO-pitoisuuden määrityksestä ei vaikuttaisi olevan hyötyä edes lasketun ajan ylittämisen jälkeen. Kopeptiini vaikuttaa erittäin lupaavalta vastasyntyneen asfyksian ja hypoksis-iskeemisen enkefalopatian biomerkkiaineelta, joskin kopeptiinin käytettävyys pitkäaikaisennusteen arvioinnissa edellyttää jatkotutkimuksia. Kohorttitutkimuksessamme totesimme varhaiseen täysiaikaisuuteen liittyvän suurentuneen riskin vastasyntyneen sairastavuuteen ja kuolleisuuteen, sekä pitkäaikaiseen neurologiseen sairastavuuteen. Löydös tukee nykyistä hoitosuositusta synnytyksen ajoittamisesta mahdollisuuksien mukaan lasketun ajan tuntumaan. Toisaalta laajassa kotimaisessa kohortissamme yliaikaisuuden vaikutukset lapsen pitkäaikaiseen neurologiseen terveyteen olivat oletettua vähäisemmät

THE ROLE OF PLACENTAL GROWTH FACTOR IN EARLY ONSET PREECLAMPSIA

Obstetrics and Gynaecolog

Maternal and perinatal outcomes of pregnancies with isolated borderline oligohydramnios versus uncomplicated normal amniotic fluid index

BACKGROUND AND OBJECTIVES: In some instances the volume of amniotic fluid may fall far below the normal limits. Amniotic fluid is measured using amniotic fluid index. Borderline Oligohydramnios is defined as amniotic fluid index of five to eight centimetres. Various methods like non-stress test, acoustic stimulation, and foetal Doppler velocimetry are helpful in assessment of foetal well being and identifying those pregnancies at risk of adverse perinatal outcome. Various studies have shown increased incidence of adverse perinatal outcome like foetal distress, meconium stained liquor, low Apgar score, low birth weight, neonatal morbidity and mortality. This study is undertaken to know the adverse perintatal outcome in pregnancy women with borderline oligohydramnios and to evaluate the value of AFI in predicting the subsequent foetal distress and caesarean delivery. METHODS: This is a prospective case control study done for a period of twelve months at PSG IMS &R, coimbatore. It consists of analysis of pregnancy outcome in 60 cases with diagnosis of borderline oligohydramnios by ultrasound in third trimester compared with 60 controls with no oligohydramnios and matched for other variables like age, parity, gestational age and any pregnancy complication. Inclusion criteria are Singleton pregnancy, AFI between 5.1 to 8 cm, Antenatal mothers in third trimester and exclusion criteria are medical co morbidities like diabetes, hypertension, overt hypothyroid, preeclampsia and multiple pregnancies, premature rupture of membranes. Various outcome results were recorded and tabulated. The results were statistically analysed using parameters like mean, standard deviation and chi square test. RESULTS: There was significant difference between two groups in occurrence of non reactive and reactive NST pattern. There is increased incidence of labour induction in women with AFI 5-8cm and than women with AFI >8cm. There is increased rate of caesarean section in pregnant women with borderline oligohydramnios. There is increased occurrence of low birth weight (≤2.5kg) in women with oligohydraminos. CONCLUSION: An amniotic fluid index of 5-8cm detected in third trimester is an indicator of poor perinatal outcome. Determination of AFI can be used as an adjunct to other foetal surveillance methods. Determination of AFI is a valuable screening test for predicting foetal distress in labour requiring caesarean section