Thrombotic microangiopathies during pregnancy : The obstetrical and neonatal perspective

Thrombotic Microangiopathies during pregnancy and puerperium are very rare and, if undiagnosed, can be lifethreating. Pregnancy and postpartum can represent a trigger in predisposed patients. Therefore, obstetricians are usually the first to observe clinical symptoms and laboratory abnormalities suggestive of Thrombotic Microangiopathies. The aim of this review is to briefly describe the obstetrical and perinatal outcome of these entities and highlight the clues for a correct diagnosis of pregnancy-related Thrombotic Microangiopathies. (C) 2019 Elsevier B.V. All rights reserved.Peer reviewe

Maternal Body Mass Index influences Umbilical Artery Doppler Velocimetry in physiologic pregnancies.

OBJECTIVES: The aim of our study was to assess whether there is a relationship between maternal body mass index (BMI) and umbilical artery Doppler velocimetry in physiologic pregnancies. METHODS: Healthy pregnancy women, referred to our center at or before 32 weeks of gestation, were recruited. According to BMI, they were divided into underweight (BMI < 18.5), normal weight (BMI 18.5-24.9), overweight (BMI 25.0-29.9) and obese women (BMI ≥ 30). At 32(+0)  weeks of gestation, maternal BMI and umbilical artery Doppler velocimetry were recorded. A correlation between pulsatility index of umbilical artery and BMI was assessed by one-way ANOVA test, multiple comparison test (Bonferroni correction) and polynomial regression. RESULTS: One hundred eighty-five women were included. Mean pulsatility index of umbilical artery at 32(+0) was significantly higher in obese women (0.95 ± 0.01 vs 0.87 ± 0.01 vs 0.67 ± 0.01; p < 0.05). We found a positive correlation between Pulsatility Index of Umbilical Artery and maternal BMI (r(2)  = 0.7; p < 0.05). CONCLUSION: There is a positive correlation between BMI and pulsatility index of umbilical artery. These findings suggest that obesity has a negative effect on feto-placetal vessels. If our data will be confirmed, maternal BMI should be considered in evaluation of umbilical Doppler velocimetry

Induction of labor at full-term in pregnant women with uncomplicated singleton pregnancy: A systematic review and meta-analysis of randomized trials

INTRODUCTION: The lowest incidence of perinatal morbidity and mortality occurs around 39-40 weeks. Therefore, some have advocated induction of uncomplicated singleton gestations once they reach full-term. The aim of the study was to evaluate the risk of cesarean delivery, and any maternal and perinatal effects of a policy of induction of labor in women with full-term uncomplicated singleton gestations. MATERIAL AND METHODS: We performed an electronic search from inception of each database to August 2018. All results were then limited to randomized trial. No restrictions for language or geographic location were applied. Inclusion criteria were randomized clinical trials of asymptomatic women with uncomplicated, singleton gestations at full-term (ie, between 39+0 and 40+6 weeks) who were randomized to either planned induction of labor or control (ie, expectant management). Only trials on asymptomatic singleton gestations without premature rupture of membranes or any other indications for induction evaluating the effectiveness of planned induction of labor in full-term singleton gestations were included. The primary outcome was the incidence of cesarean delivery. RESULTS: Seven randomized clinical trials, including 7598 participants were analyzed. Three studies enrolled only women with favorable cervix, defined as a Bishop score of ≥5 in nulliparous women or ≥4 in multiparous women. One trial included only women aged 35 years or older. Women randomized to the planned induction of labor, received scheduled induction usually at 39+0 to 39+6 weeks of gestation, whereas women in the control group received expectant management usually until 41-42 weeks of gestation, or earlier if medically indicated. Methods of induction usually included cervical ripening, with either misoprostol or Foley catheter, in conjunction with or followed by oxytocin for women with unfavorable cervix, and oxytocin and artificial rupture of membranes for those with favorable cervix. Five trials also used artificial rupture of membranes as a method for induction. Uncomplicated full-term singleton gestations that were randomized to receive induction of labor had similar incidence of cesarean delivery compared with controls (18.6% vs 21.4%; relative risk 0.96, 95% CI 0.78-1.19). Regarding neonatal outcomes, induction of labor at full-term was associated with a significantly lower rate of meconium-stained amniotic fluid (4.0% vs 13.5%; relative risk 0.32, 95% CI 0.18-0.57), and lower mean birthweight (mean difference -98.96 g, 95% CI -126.29 to -71.63) compared with the control group. There were no between-group differences in other adverse neonatal outcomes. CONCLUSIONS: Induction of labor at about 39 weeks is not associated with increased risk of cesarean delivery

Fetal heart rate monitoring and neonatal outcome in a population of early- and late-onset intrauterine growth restriction

AIM: The early-onset intrauterine growth restriction (IUGR) is associated with severe placental insufficiency and Doppler abnormalities. The late-onset IUGR is associated with mild placental insufficiency and normal Doppler velocimetry. The computerized cardiotocographic (cCTG) monitoring is used to evaluate the fetal well-being in pregnancies complicated by IUGR. Our aim was to investigate the cardiotocographic characteristics of IUGR fetuses and to identify every cCTG difference between Healthy and IUGR fetuses. METHODS: Four hundred thirty pregnant women were enrolled starting from the 28th week of gestation until the time of delivery: 200 healthy and 230 IUGR fetuses. Fetal heart rate (FHR) baseline (FHR), short-term variability (STV), long-term irregularity (LTI), delta, interval index (II), approximate entropy (ApEn), high frequency (HF), low frequency (LF), movement frequency (MF), LF/(HF + MF) ratio (LF/(HF + MF)) and number of decelerations were examined. Newborn baby data were also collected. RESULTS: The parameters of short- and medium-term variability discriminate between IUGR and healthy fetuses before 36 weeks including FHR, STV, LTI and delta discriminate between each subgroup of IUGR were compared to each one of the other two (P < 0.05). CONCLUSION: cCTG is a useful tool for the evaluation of chronic hypoxemia, which causes a delay in the maturation of all components of the autonomic and central nervous system. However, cCTG requires integration with fetal ultrasound and Doppler vessels evaluation to improve the ability to predict the neonatal outcome

Celiac disease and obstetric complications: a systematic review and metaanalysis

The aim of this metaanalysis was to evaluate the risk of the development of obstetric complications in women with celiac disease. We searched electronic databases from their inception until February 2015. We included all cohort studies that reported the incidence of obstetric complications in women with celiac disease compared with women without celiac disease (ie, control group). Studies without a control group and case-control studies were excluded. The primary outcome was defined a priori and was the incidence of a composite of obstetric complications that included intrauterine growth restriction, small for gestational age, low birthweight, preeclampsia and preterm birth. Secondary outcomes included the incidence of preterm birth, intrauterine growth restriction, stillbirth, preeclampsia, small for gestational age, and low birthweight. The review was registered with PROSPERO (CRD42015017263) before data extraction. All authors were contacted to obtain the original databases and perform individual participant data metaanalysis. Primary and secondary outcomes were assessed in the aggregate data analysis and in the individual participant data metaanalysis. We included 10 cohort studies (4,844,555 women) in this metaanalysis. Four authors provided the entire databases for the individual participant data analysis. Because none of the included studies stratified data for the primary outcome (ie, composite outcome), the assessment of this outcome for the aggregate analysis was not feasible. Aggregate data analysis showed that, compared with women in the control group, women with celiac disease (both treated and untreated) had a significantly higher risk of the development of preterm birth (adjusted odds ratio, 1.35; 95% confidence interval, 1.09-1.66), intrauterine growth restriction (odds ratio, 2.48; 95% confidence interval, 1.32-4.67), stillbirth (odds ratio, 4.84; 95% confidence interval, 1.08-21.75), low birthweight (odds ratio, 1.63; 95% confidence interval, 1.06-2.51), and small for gestational age (odds ratio, 4.52; 95% confidence interval, 1.02-20.08); no statistically significant difference was found in the incidence of preeclampsia (odds ratio, 2.45; 95% confidence interval, 0.90-6.70). The risk of preterm birth was still significantly higher both in the subgroup analysis of only women with diagnosed and treated celiac disease (odds ratio, 1.26; 95% confidence interval, 1.06-1.48) and in the subgroup analysis of only women with undiagnosed and untreated celiac disease (odds ratio, 2.50; 95% confidence interval; 1.06-5.87). Women with diagnosed and treated celiac disease had a significantly lower risk of the development of preterm birth, compared with undiagnosed and untreated celiac disease (odds ratio, 0.80; 95% confidence interval, 0.64-0.99). The individual participant data metaanalysis showed that women with celiac disease had a significantly higher risk of composite obstetric complications compared with control subjects (odds ratio, 1.51; 95% confidence interval, 1.17-1.94). Our individual participant data concurs with the aggregate analysis for all the secondary outcomes. In summary, women with celiac disease had a significantly higher risk of the development of obstetric complications that included preterm birth, intrauterine growth restriction, stillbirth, low birthweight, and small for gestational age

Perinatal and 2-year neurodevelopmental outcome in late preterm fetal compromise: the TRUFFLE 2 randomised trial protocol

Introduction: Following the detection of fetal growth restriction, there is no consensus about the criteria that should trigger delivery in the late preterm period. The consequences of inappropriate early or late delivery are potentially important yet practice varies widely around the world, with abnormal findings from fetal heart rate monitoring invariably leading to delivery. Indices derived from fetal cerebral Doppler examination may guide such decisions although there are few studies in this area. We propose a randomised, controlled trial to establish the optimum method of timing delivery between 32 weeks and 36 weeks 6 days of gestation. We hypothesise that delivery on evidence of cerebral blood flow redistribution reduces a composite of perinatal poor outcome, death and short-term hypoxia-related morbidity, with no worsening of neurodevelopmental outcome at 2 years. Methods and analysis: Women with non-anomalous singleton pregnancies 32+0 to 36+6 weeks of gestation in whom the estimated fetal weight or abdominal circumference is &lt;10th percentile or has decreased by 50 percentiles since 18-32 weeks will be included for observational data collection. Participants will be randomised if cerebral blood flow redistribution is identified, based on umbilical to middle cerebral artery pulsatility index ratio values. Computerised cardiotocography (cCTG) must show normal fetal heart rate short term variation (≥4.5 msec) and absence of decelerations at randomisation. Randomisation will be 1:1 to immediate delivery or delayed delivery (based on cCTG abnormalities or other worsening fetal condition). The primary outcome is poor condition at birth and/or fetal or neonatal death and/or major neonatal morbidity, the secondary non-inferiority outcome is 2-year infant general health and neurodevelopmental outcome based on the Parent Report of Children's Abilities-Revised questionnaire. Ethics and dissemination: The Study Coordination Centre has obtained approval from London-Riverside Research Ethics Committee (REC) and Health Regulatory Authority (HRA). Publication will be in line with NIHR Open Access policy. Trial registration number: Main sponsor: Imperial College London, Reference: 19QC5491. Funders: NIHR HTA, Reference: 127 976. Study coordination centre: Imperial College Healthcare NHS Trust, Du Cane Road, London, W12 0HS with Centre for Trials Research, College of Biomedical &amp; Life Sciences, Cardiff University. IRAS Project ID: 266 400. REC reference: 20/LO/0031. ISRCTN registry: 76 016 200

Cesarean delivery: an evidence-based review on of the technique

The cesarean section is utilized to deliver babies since the late 19th century. Nowadays, the frequency of cesarean section is enormously increased, mainly because of the low rate of complications and for the increasing demand from future mothers, scared by the idea of painful labor. Although the technique to perform cesarean section has been refined over time, infections, hemorrhage, pain and other consequences still represent matter of debate. To try to reduce the incidence of these complications many trials, randomized or not, have been performed, with the aim to analyse different technical aspects of this surgery. The aim of our review is to resume all the evidence-based instructions on how to best approach to cesarean section practice, in a step-to-step fashion, considering pre-operative actions, opening and closing steps, and post-operative prophylaxis

Placenta accreta: incidence and risk factors in an area with a particularly high rate of cesarean section

Placenta accreta is a rare and potentially life-threatening complication of pregnancy characterized by abnormal adherence of the placenta to the uterine wall. A previously scarred uterus or an abnormal site of placentation in the lower segment is a major risk factor. The aim of this study was to investigate the change in the incidence of placenta accreta and associated risk factors along four decades, from the 1970s to 2000s, in a tertiary south Italian center. We analyzed all cases of placenta accreta in a sample triennium for each decade. The incidence increased from 0.12% during the 1970s, to 0.31% during the 2000s. During the same period, cesarean section rates increased from 17 to 64%. Prior cesarean section was the only risk factor showing a significant concomitant rise. Our results reinforce cesarean section as the most significant predisposing condition for placenta accreta