Predictive value of middle cerebral artery to umbilical artery pulsatility index ratio for neonatal outcomes in hypertensive disorders of pregnancy

Background: Hypertension may lead to notifying adverse perinatal events that should be diagnosed and managed precisely. This study aims to investigate the values of cerebroplacental ration for the prediction of adverse perinatal events in hypertensive disorders of pregnancy. Materials and Methods: The current descriptive-comparative study has been conducted on 100 singleton pregnant women with the diagnosis of preeclampsia or pregnancy-induced hypertension. The Cerebroplacental ratio (CPR) was measured for the included population and divided into normal and abnormal ranges of >1 and ≤1. The adverse perinatal outcomes, including abnormal 5 min APGAR, low birth weight, perinatal death, neonatal intensive care unit (NICU) admission, academia, seizure, emergency cesarean delivery, and Tchirikov index as the general manifestation of adverse perinatal outcomes were compared between the groups. The specificity, sensitivity, positive predictive value, negative predictive value (NPV), and accuracy were measured for the adverse perinatal outcomes. Results: The two groups were remarkably different in terms of 5 min APGAR, low birth weight, cesarean section delivery, and Tchirikov index (P < 0.05). The specificity of CPR for prediction of small-for-gestational age, poor APGAR, requirement of assisted respiration, academia, Tchirikov score and NICU admission was 93.1%, 93.1%, 67.1%, 91.8%, 71.2%, and 63%, and its sensitivity was 26%, 14.8%, 51.8%, 14.8%, 51.8%, and 37%, respectively. Conclusion: CPR seems to be an appropriate means for the prediction of adverse perinatal outcomes with diversity in the prediction values of different determinants of adverse perinatal outcomes; however, in general, it had sensitivity, specificity, PP, NPV, and accuracy of 51.8%, 71.2%, 40%, 80%, and 66%, respectively

An overview of systematic reviews of normal labor and delivery management

Background: Despite the scientific and medical advances for management of complicated health issues, the current maternity care setting has increased risks for healthy women and their babies. The aim of this study was to conduct an overview of published systematic reviews on the interventions used most commonly for management of normal labor and delivery in the first stage of labor. Materials and Methods: The online databases through March 2013, limited to systematic reviews of clinical trials were searched. An updated search was performed in April 2014. Two reviewers independently assessed data inclusion, extraction, and quality of methodology. Results: Twenty-three reviews (16 Cochrane, 7 non-Cochrane), relating to the most common care practices for management of normal labor and delivery in the first stage of labor, were included. Evidence does not support routine enemas, routine perineal shaving, continuous electronic fetal heart rate monitoring, routine early amniotomy, and restriction of fluids and food during labor. Evidence supports continuity of midwifery care and support, encouragement to non-supine position, and freedom in movement throughout labor. There is insufficient evidence to support routine administration of intravenous fluids and antispasmodics during labor. More evidence is needed regarding delayed admission until active labor and use of partograph. Conclusions: Evidence-based maternity care emphasizes on the practices that increase safety for mother and baby. If policymakers and healthcare providers wish to promote obstetric care quality successfully, it is important that they implement evidence-based clinical practices in routine midwifery care

Evaluation of the predictive value of fetal Doppler ultrasound for neonatal outcome from the 36th week of pregnancy

Background: Early prediction of adverse neonatal outcome would be possible by Doppler impedance indices of middle cerebral artery (MCA), umbilical artery (UmA), and descending aortal artery (AO) that result in decrease neonatal morbidity and mortality rate. The aim of the present study was a determination of optimal value for the ratio of MCA to descending aorta blood flow (MCA/AO) impedance indices and its comparison with the ratio of MCA to UmA (MCA/UmA) impedance indices and their relationship with neonatal outcome. Materials and Methods: This was a prospective cohort study on 212 pregnant women with gestational age 36 weeks or more, in three hospitals in Tehran, from April 2012 to April 2013. We investigated AO, MCA, and UmA impedance indices Doppler ultrasound every 2 weeks till delivery. The mother was monitored for adverse pregnancy outcome (hypertension [HTN], fetal growth retardation, and other maternal complications) then infant birth weight, cord blood of pH, and Neonatal Intensive Care Unit (NICU) admission during the first 24 h after delivery were assessed. Finally, we investigated relationships between Doppler indices and neonatal outcomes include neonatal body weight (NBW), cord blood of pH, and NICU admission. Results: MCA/AO resistance index (RI) and MCA/AO pulsatile index (PI) showed an area under the receiver operating characteristics curve (area under the curve) of 0.905 (95% confidence interval (CI): 0.850, 0.959) and 0.818 (95% CI: 0.679, 0.956), respectively. The cutoff values for pH (≥7.2 vs. <7.2) based on MCA/AO RI and MCA/AO PI indices were 0.951 (sensitivity, 80% and specificity, 86%) and 0.853 (sensitivity, 91% and specificity, 83%), respectively. The cutoff value for NBW (≥2500 vs. <2500 g) based on MCA/UmA PI index was 1.467 (sensitivity, 73% and specificity, 63%). The cutoff value of NICU admission of child based on MCA/AO PI index was 1.114 (sensitivity, 73% and specificity, 54%). Conclusion: In the end of third-trimester pregnancies with the assessment of MCA and AO artery Doppler ultrasonography, it is possible to prevent many cases of neonatal acidosis caused by prenatal asphyxia as well as inappropriate interventions which are applied on mother. If MCA/AO PI was <0.85, the fetus needs to be evaluated further because it is at risk for acidosis

Evaluation of the relation between cerebroplacental ratio, umbilical-cerebral ratio, and cerebro-placental-uterine ratio with the occurrence of adverse perinatal outcomes in pregnancies complicated by fetal growth restriction

Introduction: Fetal growth restriction (FGR) is a major obstetric complication associated with an increased risk of adverse perinatal outcomes. Objectives: This study aimed to evaluate the relationship between Doppler parameters, including the cerebroplacental ratio (CPR), umbilicocerebral ratio (UCR), and cerebro-placental-uterine ratio (CPUR), with adverse perinatal outcomes in singleton pregnancies complicated by FGR. Patients and Methods: This was a prospective study of 100 women with a singleton pregnancy 28 and 36.8 weeks of gestation was complicated by FGR and mild abnormalities. Feto-maternal Doppler examinations were conducted by the CPR, UCR, and CPUR parameters. Adverse outcomes were defined as Apgar score <7 at 5 minutes, preterm birth <37-week, neonatal intensive care unit (NICU) admission, fetal distress, and emergency cesarean section.These outcome parameters were checked with the results of the last ultrasound which performed 1-2 weeks before delivery. Results: Mean umbilical artery pulsatility index (UA-PI) (1.18±0.31 versus 1.04±0.21, P=0.010) and mean uterine arteries (UtAs)-PI (1.18±0.45 versus 0.96±0.36, P=0.20) were significantly higher in pregnancies that experienced adverse perinatal outcomes than those that did not experience them. Mean CPUR (1.82±1.03 versus 2.25±0.83, P=0.039) was significantly lower in pregnancies that experienced adverse perinatal outcomes versus those that did not. In binary multivariate logistic regression analysis, CPR, UCR, and CPUR parameters were evaluated with adverse perinatal outcomes. Only CPUR had a significant relationship with adverse perinatal outcomes. CPUR had a substantial relationship with Apgar score [removed

Continuing Pregnancy Despite Prenatal Diagnosis of a Life-Limiting Fetal Anomaly and Need for Perinatal Palliative Care Service Package: A Qualitative Study from Iran

Background: Prenatal diagnosis of fetal anomalies leads to parental psychological stress and decision-making challenges to continue or terminate pregnancy. Continuing pregnancy despite fetal anomaly can cause confusion, anxiety and depression in parents, so it seems necessary to be aware of their needs and appropriately respond to them. This study was conducted to exploring experiences about Continuation Pregnancy despite fetal anomaly in the socio-cultural context of Iran. Methods: Qualitative exploratory descriptive study, 35 participants including 15 pregnant women with Life-Limiting fetal anomaly diagnosis, 5 family members and 15 perinatal care providers were selected purposefully. Data were gathered by individual interview and were written, important phrases were coded, by grouping same codes, main and sub categories were extracted. Results: In this study, 4 main categories, each with a number of subcategories were extracted. The main categories included: ``mental health counseling, support parents to accept and cope with event, ethical consideration during end-of-life care of baby, providing perinatal palliative care)''. Conclusion: The results showed that parents who forcibly or voluntarily continue pregnancy after a wearing of fetal anomalies, have extensive care needs during pregnancy and after birth that are not sufficiently met. Therefore, it seems that a comprehensive service package of perinatal palliative care appropriate for Iran socio- cultural context is necessary

Is preterm placental calcification related to adverse maternal and foetal outcome?

This prospective cohort study aimed to evaluate the role of premature placental calcification in adverse pregnancy outcomes and identify its associated potential risk factors. We consecutively enrolled 293 women who presented to three academic medical centres from September 2011 to March 2013. Participants underwent transabdominal sonographies between 28–36 weeks of gestation in an attempt to determine placental maturity. We compared maternal and foetal outcomes between two groups of women, those with grade III placenta (n = 69) and those without grade III placenta (n = 224). Passive smoking was the only predictor of early placental calcification. There were more abnormal Doppler, low birth weight (LBW) and caesarean section (CS) deliveries observed in the preterm calcification group. No definite relationship existed between maternal hypertension (HTN), diabetes and other medical diseases with placental calcification. In conclusion, umbilical artery (UA) resistance index (RI) and absent or reversed end-diastolic velocity (AREDV) were observed more often in preterm placental calcification. Serious antepartum follow-up should be advised for these mothers.Impact Statement  • Placental calcification is a physiological phenomenon but normally, a grade III placenta is not frequently found until 36 weeks of gestation (so is called preterm placental calcification – PPC). There is currently a lack of consistent evidence on the clinical significance of PPC and pregnancy outcome. The present study was designed to evaluate the role of PPC in adverse pregnancy outcomes.  • In our study, although none of the pregnant women were smokers, we found that passive smoking was the only predictor of PPC. Abnormal umbilical artery Doppler waveforms considerably and absent end diastolic velocity pattern significantly were observed more often in the PPC group.  • We observed that PPC can be a landmark for high-risk pregnancy and an alarm sign for placental dysfunction. So, close antepartum follow up should be advised for these mothers. Regular and frequent foetal wellbeing tests should be done to prevent pregnancy complications. Certainly larger and more extensive study can provide more valid results

Relationship between false positive screening results of down syndrome and adverse pregnancy outcomes

Background: Maternal serum sample screening in the first and second trimesters has been commonly used to identify women who are at risk of fetal trisomy 21. In addition, these serum markers are associated with adverse perinatal outcomes. Hence, the present study was conducted to determine the relationship between false positive screening results of Down syndrome and adverse pregnancy outcomes. Material and Methods: This prospective, two-group, cohort study was conducted on 608 pregnant women who had undergone fetal contingent screening. They were selected through convenience sampling in the twentieth week of pregnancy and were followed up until delivery. The raw Odd Ratios (OR), Relative Risk (RR), and adjusted OR of adverse pregnancy outcomes were calculated in the false positive and true negative groups. Results: The adjusted OR of developing preeclampsia was 1.98 (95% CI: 1.14–3.42), and its RR was 2.13 (95% CI: 1.34–3.38) times higher in the false positive group. Moreover, the adjusted OR of Small for Gestational Age (SGA) was 2.80 (95% CI: 1.76–4.47), and its RR was 2.28 (95% CI: 1.54–3.36) times higher in the false positive group. The adjusted OR of Low Birth Weight (LBW) was 3.34 (95% CI: 1.97–5.64), and its RR was 2.65 (95% CI: 1.72–4.11) times higher in the false positive group. In addition, no significant difference was observed between false positive and true negative groups in terms of preterm birth. Conclusions: Women with a false positive fetal screening test result are more likely to suffer from preeclampsia, SGA, and LBW and require planned prenatal care