A new definition of recurrent implantation failure on the basis of anticipated blastocyst aneuploidy rates across female age.

Objective: To present a definition of recurrent implantation failure that accounts for the effects of female age and anticipated blastocyst euploidy rates on cumulative implantation rates. Design: Mathematical modeling. Setting: Not applicable. Patient(s): Not applicable. Intervention(s): Mathematical modeling of cumulative implantation probability on the basis of published blastocyst euploidy rates across categories of female age. Main Outcome Measure(s): The number of blastocysts required to achieve 95% cumulative implantation probability under the assumption of the absence of any other factor affecting implantation. Result(s): When the euploidy status of the transferred embryo is unknown (i.e., not subjected to preimplantation genetic testing for aneuploidies), our simulation shows that no age category reaches 95% cumulative probability of implantation of at least one embryo until after transfer of seven blastocysts. The number of blastocysts required to reach the same threshold is higher for older patients. For example, women older than 38 years require transfer of more than 10 untested blastocysts for the upper range of predictive probability to meet the threshold of 95%. On the other hand, if the implantation rate for a euploid blastocyst is assumed to be 55%, then 4 blastocysts are enough to reach a cumulative probability rate greater than 95%, regardless of age. Conclusion(s): The term "recurrent implantation failure"should be a functional term guiding further management. We suggest that recurrent implantation failure should not be called until implantation failure becomes reasonably likely to be caused by factors other than embryo aneuploidy, the leading cause of implantation failure. We propose a new definition that factors in anticipated blastocyst euploidy rates across categories of female age, euploid blastocyst implantation rate, and a specified threshold of cumulative probability of implantation

Risk of operative delivery for intrapartum fetal compromise in small-for-gestational-age fetuses at term: external validation of the IRIS algorithm.

OBJECTIVES: Small-for-gestational-age fetuses (SGA) are at high risk of intrapartum fetal compromise requiring operative delivery. In a recent study, we developed a model using a combination of three antenatal (gestational age at delivery, parity, cerebroplacental ratio) and three intrapartum (epidural use, labor induction and augmentation using oxytocin) variables for the prediction of operative delivery due to presumed fetal compromise in SGA fetuses - the Individual RIsk aSsessment (IRIS) prediction model. The aim of this study was to test the predictive accuracy of the IRIS prediction model in an external cohort of singleton pregnancies complicated by SGA. METHODS: This was an external validation study using a cohort of pregnancies from two tertiary referral centers in Spain and England. The inclusion criteria were singleton pregnancies diagnosed with an SGA fetus, defined as estimated fetal weight (EFW) below the 10th centile for gestational age at 36 weeks or beyond, which had fetal Doppler assessment and available data on their intrapartum care and pregnancy outcomes. The main outcome in this study was the operative delivery for presumed fetal compromise. External validation was performed using the coefficients obtained in the original development cohort. The predictive accuracies of models were investigated with receiver operating characteristics (ROC) curves. The Hosmer-Lemeshow test was used to test the goodness-of-fit of models and calibration plots were also obtained for visual assessment. A mobile application using the combined model algorithm was developed to facilitate clinical use. RESULTS: Four hundred twelve singleton pregnancies with an antenatal diagnosis of SGA were included in the study. The operative delivery rate was 22.8% (n = 94). The group which required operative delivery for presumed fetal compromise had significantly fewer multiparous women (19.1 versus 47.8%, p < 0.001 in the total study population; 19.0 versus 43.5 and 19.2 versus 49.6%, UK and Spain cohort, respectively), lower cerebroplacental ratio (CPR) multiples of median (MoM) (median: 0.77 versus 0.92, p < 0.001 in the total study population; 0.77 versus 0.92 and 0.77 versus 0.92, UK and Spain cohort, respectively), more inductions of labor (74.5 versus 60.1%, p = 0.010 in the total study population; 85.7 versus 77.2 and 71.2% and 53.1, UK and Spain cohort, respectively) and more use of oxytocin augmentation (57.4 versus 39.3%, p = 0.002 in the total study population; 19.0 versus 12.0 and 68.5 and 50.4%, UK and Spain cohort, respectively) compared to those who did not require operative delivery due to presumed fetal compromise. When the original antenatal model was applied to the present cohort, we observed moderate predictive accuracy (AUC: 0.70, 95% CI: 0.64-0.76), and no signs of poor fit (p = 0.464). The original combined model, when applied to the external cohort, had moderate predictive accuracy (AUC: 0.72, 95% CI: 0.67-0.77) and also no signs of poor fit (p = 0.268) without the need for refitting. A statistically significant increase in the predictive accuracy was not achieved via refitting of the combined model (AUC 0.76 versus 0.72, p = 0.060). CONCLUSIONS: Using our recently published model, the predictive accuracy for fetal compromise requiring operative delivery in term fetuses thought to be SGA was modest and showed no signs of poor fit in an external cohort. The IRIS tool for mobile devices has been developed to facilitate wide clinical use of this prediction model

Is Umbilicocerebral Ratio better than Cerebroplacental Ratio for Predicting Adverse Pregnancy and Neonatal Outcomes?

Objective A secondary analysis of the trial of randomized umbilical and fetal flow in Europe suggested that the umbilicocerebral ratio (UCR) provides better differentiation of neurodevelopmental outcome in the abnormal range compared with that of the cerebroplacental ratio (CPR).1 However, the reported superiority of UCR is controversial.2 This study aimed to compare the CPR and the UCR for predicting operative delivery for presumed fetal compromise and prolonged neonatal unit (NNU) admission in term fetuses suspected to be small for gestational age (SGA). Study Design This study was a retrospective analysis of singleton pregnancies with estimated fetal weight less than the 10th centile (SGA) at 36 weeks’ gestation or beyond at St George’s Hospital in London between 1999 and 2015. CPR was calculated as the ratio of middle cerebral artery and umbilical artery pulsatility index, whereas UCR was calculated as the inverse of CPR. The outcomes were operative delivery for presumed fetal compromise and prolonged NNU admission (admission to the NNU for longer than 48 hours).3 Multiples of medians (MoMs) were calculated using the reference ranges reported by Acharya et al.4 The predictive accuracy was assessed using receiver operating characteristic curves. Results The analysis included 958 pregnancies. The incidence rates of operative delivery and prolonged NNU admission were 17.6% (169 of 958) and 4.7% (45 of 958), respectively. The CPR (median: 1.63 vs 1.51) and UCR (median: 0.61 vs 0.66) values were significantly different in fetuses who underwent operative delivery for presumed fetal compromise compared with those who did not (P=.015 for both). There were no statistically significant differences in either UCR or CPR between those with and without prolonged NNU admission (P=.230 for both). The number of outlier values without MoM correction was significantly more with UCR compared with CPR in those who did not have operative delivery for presumed fetal compromise (5.6%, 44 of 789, vs 1.6%,13 of 789; P<.001) and prolonged NNU admission (5.0%, 46 of 913, vs 1.5%, 14 of 913; P<.001). The area under the curve (AUC) values of UCR and CPR for predicting operative delivery for presumed fetal compromise (AUC, 0.56; 95% confidence interval [CI], 0.51–0.61) and prolonged NNU admission (AUC, 0.55; 95% CI, 0.46–0.64) were the same (Figure)

Interobserver reproducibility of intracranial anatomy assessment during second trimester sonographic scan

To evaluate the reproducibility of mid-trimester intracranial anatomy assessment. Women undergoing mid-trimester scan (between 18th to 25th gestational weeks) for fetal anatomy assessment were included in the study. Measurements of lateral ventricle (LV), cisterna magna (CM) and transverse cerebellar diameter (TCD) were obtained for reproducibility analyses. Inter-observer reproducibility analysis was made with correlation coefficients. A total of 162 women were included in the analysis while one woman was excluded from the study due to diagnosis of vermian agenesis. Correlation coefficient (CC) of cisterna magna measurements have shown weak to moderate interclass correlation (r=0.28, P=0.001). Measurements of lateral ventricle have shown moderate to strong interclass correlation (r=0.73, P<0.0001). Transverse cerebellar diameter measurements have shown the best interclass correlation (r=0.88, respectively P<0.0001). Mean difference between different observers were-0.4 mm (95% CI:-3.0 to 2.1 mm), 0.7mm (95% CI:-1.0 to 2.5 mm) and 0.53 mm (95% CI:-2.5 to 3.6 mm) for measurements of cerebellum, lateral ventricle and cisterna magna, respectively. When grouped according to BMI (Over 30 kg/m2 and lower than 25 kg/m2) and presentation (cephalic and breech), there were no differences between groups regarding the prevalence of an absolute difference gre ater than 1 mm between paired measurements by different observers. Measurements of TCD, LV and CM during mid-trimester scan have good interobserver reliability with the exception of CM measurements. Methods used for measuring these structures have shown good consistency between different BMI categories and different fetal presentations during ultrasound scans

Cantrell pentalojisi

Cantrel pentalojisi nadir görülen bir sendromdur. Gelişen teknoloji ile birlikte son yıllarda erken haftalarda tanı konabilmektedir. Tanı konulan hastalarda gebeliğin sonlandırılması önerilmekte ve bir çok hastada terminasyon uygulanmaktadır. Ancak nadiren de olsa aile terminasyon seçeneğini kabul etmediğinden dolayı terme ulaşan fetuslar görülmektedir. Bizim vakamız da terme kadar ulaşan ve doğum esnasında kaybedilen bir Cantrel pentalojisi vakasıdı

Ultrasound in labor admission to predict need for emergency cesarean section: a prospective, blinded cohort study

Objective: To assess whether assessment with ultrasound could improve the detection of emergency cesarean section (ECS) in laboring women. Methods: Women who presented with symptoms of active labor or women in need of labor induction were invited to participate in the study. Women included in the study were evaluated with ultrasonography for fetal biometry and vaginal examinations for Bishop score assessment. The main aim in this study was determining factors associated with ECS due to fetal distress and obstructed labor. Results: No fetal biometry variable was associated with ECS due to any indication (fetal distress and obstructed labor combined) in the univariate analysis. In multivariate analyses, biometry variables were adjusted for Bishop score at admission and only abdominal circumference percentile showed a significant association with the odds of ECS due to any indication (OR:1.02, 95% CI: 1.01-1.03). Biparietal diameter and abdominal circumference variables were associated with the odds of ECS due to obstructed labor in both univariate and multivariate analyses (p < .05 for all). However, the predictive accuracy of biparietal diameter percentile (area under the curve (AUC): 0.55, 95% CI: 0.46-0.63) and abdominal circumference percentile (AUC: 0.56, 95% CI: 0.48-0.64) without adjunct variables were poor. Moreover, the addition of fetal biometry parameters to Bishop score did not improve the predictive accuracy of Bishop score. Conclusion: Ultrasound assessment at admission, in addition to Bishop score assessment, did not significantly improve the prediction of ECS. Also, the fetal biometry alone had poor predictive capability for ECS. Routine ultrasound assessment at labor admission appears to be ineffective for predicting ECS. Precis Fetal biparietal diameter and abdominal circumference showed an association with emergency cesarean due to obstructed labor but the predictive accuracy of fetal biometry was low. Routine ultrasound examination at admission, in addition to Bishop score assessment, may not useful for assessing the risk of emergency section in unselected populations

Home blood pressure monitoring in the antenatal and postpartum period: A systematic review meta-analysis

Recent evidence suggests that home blood pressure monitoring (HBPM) is an effective way of managing women with hypertensive disorders of pregnancy (HDP) without increasing adverse outcomes. The aim of this systematic review and meta-analysis was to investigate the safety and efficacy of HBPM during pregnancy