COVID-19 and Gestational Diabetes: The Role of Nutrition and Pharmacological Intervention in Preventing Adverse Outcomes

Pregnant women with GDM affected by COVID-19 seem to be at higher risk of adverse maternal and neonatal outcomes, especially those with overweight or obesity. Good glycemic control seems to be the most effective measure in reducing the risk of GDM and severe COVID-19. For such purposes, the Mediterranean diet, micronutrient supplementation, and physical activity are considered the first line of treatment. Failure to achieve glycemic control leads to the use of insulin, and this clinical scenario has been shown to be associated with an increased risk of adverse maternal and neonatal outcomes. In this review, we explore the current evidence pertaining to the pathogenesis of SARS-CoV-2 leading to the main complications caused by COVID-19 in patients with GDM. We also discuss the incidence of complications caused by COVID-19 in pregnant women with GDM according to their treatment

Fetal face shape analysis from prenatal 3D ultrasound images

3D ultrasound imaging of fetal faces has been predominantly confined to qualitative assessment. Many genetic conditions evade diagnosis and identification could assist with parental counselling, pregnancy management and neonatal care planning. We describe a methodology to build a shape model of the third trimester fetal face from 3D ultrasound and show how it can objectively describe morphological features and gestational-age related changes of normal fetal faces. 135 fetal face 3D ultrasound volumes (117 appropriately grown, 18 growth-restricted) of 24-34 weeks gestation were included. A 3D surface model of each face was obtained using a semi-automatic segmentation workflow. Size normalisation and rescaling was performed using a growth model giving the average size at every gestation. The model demonstrated a similar growth rate to standard head circumference reference charts. A landmark-free morphometry model was estimated to characterize shape differences using non-linear deformations of an idealized template face. Advancing gestation is associated with widening/fullness of the cheeks, contraction of the chin and deepening of the eyes. Fetal growth restriction is associated with a smaller average facial size but no morphological differences. This model may eventually be used as a reference to assist in the prenatal diagnosis of congenital anomalies with characteristic facial dysmorphisms

Hyperechoic amniotic membranes in patients with preterm premature rupture of membranes (p-PROM) and pregnancy outcome

Objectives The early identification of women with preterm premature rupture of membranes (p-PROM) who are at higher risk of imminent delivery remains challenging. The aim of our study was to evaluate if an increased echogenicity of the amniotic membranes may represent a sonographic marker of impending delivery in women with p-PROM. Methods This was a prospective study including women with singleton pregnancies and diagnosis of p-PROM between 22 and 37 gestational weeks. A sonographic examination was performed within 24h from the hospital admission and the appearance of the amniotic membranes close to the internal os was specifically evaluated. The membranes were defined as hyperechoic when their echogenicity was similar to that of the fetal bones or normoechoic in the other cases. The primary aim of the study was to compare the admission to spontaneous onset of labor interval and the pregnancy outcome between the cases of p-PROM with and without hyperechoic membranes. Results Overall, 45 women fulfilled the inclusion criteria with similar characteristics at admission. In women with hyperechoic membranes, the admission to spontaneous onset of labor interval was significantly shorter (11.5 [5.3-25.0] vs. 3.0 [1.5-9.0] p=0.04) compared to women with normo-echoic membranes. At binomial logistic regression after adjustment for GA at hospital admission, the presence of hyperechoic membranes was found as the only independent predictor of spontaneous onset of labor≤72h (aOR: 6.1; 95% CI: 1.0-36.9) Conclusions The presence of hyperechoic membranes is associated with a 6-fold higher incidence of spontaneous onset of labor within 72h independently from the gestational age at p-PROM

Intrapartum fetal heart rate between 150 and 160 bpm at or after 40 weeks and labor outcome

INTRODUCTION: A baseline fetal heart rate between 110 and 160 bpm is considered normal. However among normal fetuses the average baseline heart rate has been shown to diminish progressively and the 90th centile of the fetal heart rate at 40 weeks of gestation has been consistently found at around 150 bpm. The aim of our study was to assess the labor and neonatal outcome of fetuses at 40 gestational weeks or beyond, whose intrapartum baseline fetal heart rate was between 150 and 160 bpm.MATERIAL AND METHODS: Retrospective cohort study including singleton pregnancies with spontaneous onset of labor, gestational age between 40+0 and 42+0 , category I CTG trace according to the FIGO guidelines 2015 with baseline fetal heart rate between 110-160 bpm during the first 60 minutes of the active labor. Exclusion criteria were maternal hyperpyrexia at admission, fetal arrhythmias, maternal tachycardia (>110 bpm) and uterine tachysystole (>5 contractions/10 minutes). The following outcomes were compared between fetuses with a baseline ranging between 110-149 bpm and those with a baseline ranging between 150-160 bpm: incidence of meconium-stained amniotic fluid, intrapartum hyperpyrexia, mode of delivery, Apgar at 5th minute<7, arterial pH<7.1 and Neonatal Intensive Care Unit admission, incidence of a composite adverse neonatal outcome.RESULTS: One-thousand and four CTG traces were included in the analysis, 860 in Group 110-149 bpm and 144 in Group 150-160. Group 150-160 bpm had a significantly higher incidence of meconium-stained amniotic fluid (OR 2.6; 95%CI 1.8-3.8), maternal intrapartum hyperpyrexia (OR 4.7; 95%CI 1.1-14.6), urgent/emergent cesarean section for suspected fetal distress (OR 13.4; 95% CI 3.3-54.3), Apgar <7 at 5th min (OR 9.13; 95%CI 1.5-55.1) and neonatal acidemia (OR 3.5; 95%CI 1.5-55.1). Logistic regression including adjusted for potential confounders showed that fetal heart rate between 150-160 bpm is an independent predictor of meconium-stained amniotic fluid (aOR 2.2; 95% CI 1.5-3.3), cesarean section during labor for fetal distress (aOR 10.7; 95%CI 2.9-44.6), neonatal acidemia (aOR 2.6; 95%CI 1.1-6.7) and adverse composite neonatal outcome (aOR 2.6; 95% CI 1.2-5.6).CONCLUSIONS: In fetuses at 40 weeks or beyond, an intrapartum fetal heart rate baseline ranging between 150 and 160 bpm seems associated with a higher incidence of labor complications

STAN: a reappraisal of its clinical usefulness

The automatic analysis of fetal ECG in labor has been introduced as an adjunct of traditional cardiotocography with the aim to improve the identification of fetuses with intrapartum hypoxia. Several randomized controlled trials and meta-analyses have produced conflicting results, with the most recent randomized controlled trial not demonstrating any improvement in either neonatal outcomes or reduction in operative birth rates. The objective of this review article is to present the state of art about the use of STAN technology in labor ward

Hemodynamic findings in normotensive women with small for gestational age and growth restricted fetuses

INTRODUCTION: Fetal growth restriction (FGR) in most instances results as a consequence of primary placental dysfunction due to inadequate trophoblastic invasion. Maternal cardiac maladaptation to pregnancy has been proposed as a possible determinant of placental insufficiency and impaired fetal growth. This study aimed to compare the maternal hemodynamic parameters between normotensive women with small-for-gestational age (SGA) and FGR fetuses and to evaluate their correlation with neonatal outcome.MATERIAL AND METHODS: observational cohort study including singleton pregnancies referred to our tertiary care center due to fetal smallness. At the time of diagnosis, fetuses were classified as SGA or FGR according to the Delphi consensus criteria and pregnant women underwent hemodynamic assessment by using cardiac output monitor (USCOM 1A Ltd). A group of women with singleton uncomplicated pregnancies ≥35 weeks of gestation were recruited as controls. Cardiac output, systemic vascular resistance, stroke volume and heart rate were measured and compared among the three groups (controls vs. FGR vs. SGA). The correlation between antenatal findings and neonatal outcome was also evaluated by multivariate logistic regression analysis.RESULTS: 51 women with fetal smallness were assessed at 34.8±2.6 weeks. SGA and FGR were diagnosed in 22 and 29 cases, respectively. The control group included 61 women assessed at 36.5±0.8 weeks of gestation. Women with FGR had a lower cardiac output -Z score (respectively, -1.3±1.2 vs. -0.4±0.8 vs. -0.2±1.0; p<.001) and a higher systemic vascular resistance Z-score compared with both SGA and controls (respectively, 1.2±1.2 vs. 0.2±1.1 vs. -0.02±1.2; p<.001), while no difference in the hemodynamic parameters was found between women with SGA and controls. The incidence of NICU admission did not differ between SGA and FGR fetuses (18.2% vs 41.4%; p=0.13), however FGR had a longer hospitalization compared to SGA fetuses (14.2±17.7 vs. 4.5±1.6 days; p=0.02). Multivariate analysis showed that the cardiac output Z-score at diagnosis (p=0.012) and the birthweight Z-Score (p= 0.007) were independent predictors of the length of neonatal hospitalization.CONCLUSIONS: Different maternal hemodynamic profiles characterize women with SGA or FGR fetuses. Furthermore, a negative correlation was found between the maternal cardiac output and the length of neonatal hospitalization

Reduced short-term variation following antenatal administration of betamethasone: Is reduced fetal size a predisposing factor?

OBJECTIVE: To assess the association between fetal size and the incidence of reduced short-term variability (STV) following bethametasone administration for fetal lung maturity. STUDY DESIGN: This was a retrospective, multicenter, cohort study conducted in two Tertiary University Units. Only uncomplicated singleton pregnancies admitted for threatened preterm labor between 26 and 34 weeks and submitted to betamethasone for fetal lung maturity were included. Delivery occurring within 72h from betamethasone administration represented criteria for exclusion. Computerized cardiotocography was carried out on a daily basis. Cases were identified by persistently reduced STV, defined as <5th percentile for gestational age and lasting for at least 72h after the first dose of betamethasone. The primary outcome was estimated fetal weight (EFW) at ultrasound in fetuses with normal and in those with persistently reduced STV. Pregnancy outcomes were also evaluated. RESULTS: Persistently reduced STV occurred in 33/405 of the included patients (8.1%). Compared to women with normal STV, those with persistently reduced STV had significantly lower EFW (1472±435 vs 1812±532g, p 0.04), lower birthweight (2353±635 vs 2857±796g, p<0.01) and earlier gestational age at delivery (35.1±4.2 vs 37.3±2.4weeks, p<0.01), whereas all the other variables including gestational age on admission were comparable. CONCLUSIONS: Reduced STV following maternal betamethasone administration among appropriately grown fetuses seems to correlate with lower fetal size. Furthermore, fetuses with such abnormal response to steroids seem to carry a higher risk of perinatal complications, including lower birthweight and earlier gestational age at delivery

Randomised Italian Sonography for Occiput POSition Trial Ante Vacuum (R.I.S.POS.T.A.)

Objective: To assess whether sonographic diagnosis of fetal head position before instrumental vaginal delivery can reduce the risk of failed vacuum extraction and improve delivery outcome. Methods: Randomised Italian Sonography for occiput POSition Trial Ante vacuum (R.I.S.POS.T.A.) is a randomized controlled trial of term (37 + 0 to 41 + 6 weeks' gestation) singleton pregnancies with cephalic presentation requiring instrumental delivery by vacuum extraction, which was conducted between April 2014 and June 2017 and involved 13 Italian maternity hospitals. Patients were randomized to assessment of fetal head position before attempted instrumental delivery by either vaginal examination (VE) alone or VE plus transabdominal sonography (TAS). Primary outcome was incidence of emergency Cesarean section due to failed vacuum extraction. A sample size of 653 women per group was planned to compare the primary outcome between the two groups. The sample size estimation was based on the hypothesis that the risk of failed vacuum delivery in the VE group would be 5% and that ultrasound assessment of fetal position prior to vacuum extraction would decrease this risk to 2%. Results: On interim analysis, the trial was stopped for futility. During this period, 222 women were randomized and 221 were included in the final data analysis, of whom 132 (59.7%) were randomized to evaluation of fetal head position by VE only and 89 (40.3%) to assessment by VE plus TAS prior to vacuum extraction. No significant differences were observed between the two groups with respect to incidence of emergency Cesarean section due to failed instrumental delivery and other maternal and fetal outcomes. Women randomized to assessment by VE plus TAS showed higher incidence of non-occiput anterior position of the fetal head at randomization and lower incidence of incorrect diagnosis of occiput position compared with women undergoing assessment by VE alone. A higher rate of episiotomy was noted in the women undergoing both VE and TAS compared with those in the VE-only group. Conclusions: Our prematurely discontinued randomized controlled trial did not demonstrate any benefit in terms of reduced risk of failed instrumental delivery or maternal and fetal morbidity in women undergoing sonographic assessment of fetal head position prior to vacuum extraction. Copyright \ua9 2018 ISUOG. Published by John Wiley & Sons Ltd