Association between high levels of comorbid anxiety and depressive symptoms and decreased likelihood of birth without intervention: A longitudinal prospective cohort study.

OBJECTIVE: To assess the association between trajectories of comorbid anxiety and depressive (CAD) symptoms assessed in each pregnancy trimester and physiological birth. DESIGN: Large longitudinal prospective cohort study with recruitment between January 2013 and September 2014. SETTING: Primary care, in the Netherlands. POPULATION: Dutch-speaking pregnant women with gestational age at birth ≥37 weeks, and without multiple pregnancy, severe psychiatric disorder or chronic disease history. METHODS: Pregnancy-specific anxiety and depressive symptoms were measured prospectively in each trimester of pregnancy using the negative affect subscale of the Tilburg Pregnancy Distress Scale and Edinburgh (Postnatal) Depression Scale. Data on physiological birth were obtained from obstetric records. Multivariate growth mixture modelling was performed in MPLUS to determine longitudinal trajectories of CAD symptoms. Multiple logistic regression analysis was used to examine the association between trajectories and physiological birth. MAIN OUTCOME MEASURES: Trajectories of CAD symptoms and physiological birth. RESULTS: Seven trajectories (classes) of CAD symptoms were identified in 1682 women and subsequently merged into three groups: group 1-persistently low levels of symptoms (reference class 1; 79.0%), group 2-intermittently high levels of symptoms (classes 3, 6 and 7; 11.2%), and group 3-persistently high levels of symptoms (classes 2, 4 and 5; 9.8%). Persistently high levels of CAD symptoms (group 3) were associated with a lower likelihood of physiological birth (odds ratio 0.67, 95% confidence interval 0.47-0.95, P = 0.027) compared with the reference group (persistently low levels of symptoms), after adjusting for confounders. CONCLUSIONS: This study is the first showing evidence that persistently high CAD levels, assessed in each pregnancy trimester, are associated with a lower likelihood of physiological birth.

Visualization of contractions: Evaluation of a new experience design concept to enhance the childbirth experience.

BACKGROUND: The purpose of this study was to develop and evaluate an innovative design proposition intended to help enhance the childbirth experience. The innovation consists of a smartphone application for birth preparation during pregnancy with information and coaching, in addition to a wall projection at the labor ward that visualizes the progress of labor based on uterine monitoring data. METHODS: We conducted a randomized controlled clinical pilot study. Singleton pregnant people pursuing a vaginal birth were recruited between 28 and 32 weeks of gestation and allocated to the intervention group (mobile application during the third trimester and wall projection at the labor ward) or to care as usual. Childbirth expectations and experiences were measured with validated questionnaires, which were completed at 32 and 36 weeks of gestation, immediately after birth, and at 4 weeks postpartum. Quantitative outcomes were analyzed and feedback about the proposition was evaluated using qualitative methods. RESULTS: The qualitative feedback from patients was largely positive; however, we could not detect any significant differences between the intervention and control groups about fear of childbirth and other outcome measures. CONCLUSION: In this pilot study, we evaluated a new experience design proposition for pregnancy and childbirth. This study generated data that will help to further improve and evaluate similar innovations in the future. This application may facilitate participatory care, promoting active involvement of parents in the healthcare processes of pregnancy and childbirth.

Right ventricular dysfunction identified by abnormal strain values precedes evident growth restriction in small for gestational age fetuses.

OBJECTIVES: Small for gestational age (SGA) fetuses have an increased risk for adverse outcome. Placental insufficiency leads to changes in the circulation, with secondary adaptation of the fetal heart resulting in changed cardiac deformation. This deformation can be measured with 2D speckle tracking echocardiography (2D-STE). SGA is antenatally often undiagnosed. The measurement of deformation changes in the fetal heart might help in the prediction of SGA and identify fetuses in need of more intensive surveillance. METHODS: In this longitudinal prospective cohort study, global longitudinal strain (GLS) and strain rate (GLSR), measured before 23 weeks gestational age were compared between SGA and appropriate for gestational age (AGA) fetuses, based on birthweight corrected for gestational age at birth. RESULTS: The fetal heart rate was significantly increased in SGA; 158 beats per minute (146-163) vs 148 (134-156); P = 0.035 in AGA. Right ventricle GLS (RV-GLS) values were significantly increased in SGA; -15.87% (-11.69% to -20.55%) vs -20.24% (-16.29% to -24.28%); p = 0.024, respectively. CONCLUSION: RV-GLS values, measured with 2D-STE, were significantly increased in SGA, indicating systolic RV dysfunction before 23 weeks gestational age in fetuses who will become SGA later in pregnancy. A large longitudinal prospective cohort study is needed to confirm these findings.

Multi-professional simulation-based team training in obstetric emergencies for improving patient outcomes and trainees' performance.

BACKGROUND: Simulation-based obstetric team training focuses on building a system that will anticipate errors, improve patient outcomes and the performance of clinical care teams. Simulation-based obstetric team training has been proposed as a tool to improve the overall outcome of obstetric health care. OBJECTIVES: To assess the effects of simulation-based obstetric team training on patient outcomes, performance of obstetric care teams in practice and educational settings, and trainees' experience. SEARCH METHODS: The Cochrane Pregnancy and Childbirth Group's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) were searched (14 April 2020), together with references checking and hand searching the available proceedings of 2 international conferences. SELECTION CRITERIA: We included randomised controlled trials (RCTs) (including cluster-randomised trials) comparing simulation-based obstetric team training with no, or other type of training. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane, to identify articles, assess methodological quality and extract data. Data from three cluster-randomised trials could be used to perform generic inverse variance meta-analyses. The meta-analyses were based on risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs). We used the GRADE approach to rate the certainty of the evidence. We used Kirkpatrick's model of training evaluation to categorise the outcomes of interest; we chose Level 3 (behavioural change) and Level 4 (patient outcome) to categorise the primary outcomes. MAIN RESULTS: We included eight RCTs, six of which were cluster-randomised trials, involving more than 1000 training participants and more than 200,000 pregnancies/births. Four studies reported on outcome measures on Kirkpatrick level 4 (patient outcome), three studies on Kirkpatrick level 3 (performance in practice), two studies on Kitkpatrick level 2 (performance in educational settings), and none on Kirkpatrick level 1 (trainees' experience). The included studies were from Mexico, the Netherlands, the UK and the USA, all middle- and high-income countries. Kirkpatrick level 4 (patient outcome) Simulation-based obstetric team training may make little or no difference for composite outcomes of maternal and/or perinatal adverse events compared with no training (3 studies; n = 28,731, low-certainty evidence, data not pooled due to different composite outcome definitions). We are uncertain whether simulation-based obstetric team training affects maternal mortality compared with no training (2 studies; 79,246 women; very low-certainty evidence). However, it may reduce neonatal mortality (RR 0.70, 95% CI 0.48 to 1.01; 2 studies, 79,246 pregnancies/births, low-certainty evidence). Simulation-based obstetric team training may have little to no effect on low Apgar score compared with no training (RR 0.99, 95% 0.85 to 1.15; 2 studies; 115,171 infants; low-certainty evidence), but it probably reduces trauma after shoulder dystocia (RR 0.50, 95% CI 0.25 to 0.99; 1 study; moderate-certainty evidence) and probably slightly reduces the number of caesarean deliveries (RR 0.79, 95% CI 0.67 to 0.93; 1 study; n = 50,589; moderate-certainty evidence) Kirkpatrick level 3 (performance in practice) We found that simulation-based obstetric team training probably improves the performance of the obstetric teams in practice, compared with no training (3 studies; 2398 obstetric staff members, moderate-certainty evidence, data not pooled due to different outcome definitions). AUTHORS' CONCLUSIONS: Simulation-based obstetric team training may help to improve team performance of obstetric teams, and it might contribute to improvement of specific maternal and perinatal outcomes, compared with no training. However, high-certainty evidence is lacking due to serious risk of bias and imprecision, and the effect cannot be generalised for all outcomes. Future studies investigating simulation-based obstetric team training compared to training courses with a different instructional design should carefully consider how and when to measure outcomes. Particular attention should be paid to effect measurement at the level of patient outcome, taking into consideration the low incidence of adverse maternal and perinatal events.

Feasibility of non-invasive Foetal electrocardiography in a twin pregnancy.

BACKGROUND: Twin pregnancy is associated with increased perinatal mortality. Close foetal monitoring is therefore warranted. Doppler Ultrasound cardiotocography is currently the only available method to monitor both individual foetuses. Unfortunately, the performance measures of this method are poor and erroneous monitoring of the same twin with both transducers may occur, leaving the second twin unmonitored. In this study we aimed to determine the feasibility of monitoring both foetuses simultaneously in twin gestation by means of non-invasive foetal electrocardiography (NI-fECG), using an electrode patch on the maternal abdomen. METHODS: A NI-fECG recording was performed at 25 + 3 weeks of gestation on a multiparous woman pregnant with dichorionic diamniotic twins. An electrode patch consisting of eight adhesive electrodes was applied on the maternal abdomen, yielding six channels of bipolar electrophysiological measurements. The output was digitized and stored for offline processing. The recorded signals were preprocessed by suppression of high-frequency noise, baseline wander, and powerline interference. Secondly, the maternal ECG was subtracted and segmentation into individual ECG complexes was performed. Finally, ensemble averaging of these individual ECG complexes was performed to suppress interferences. RESULTS: Six different recordings were obtained from each of the six recording channels. Depending on the orientation and distance of the fetal heart with respect to each electrode, a distinction could be made between each fetus based on the morphology of the signals. Yielding of the fetal ECGs was performed manually based on the QRS complexes of each fetus. CONCLUSION: NI-fECG with multiple electrodes allows for monitoring of the fetal heart rate and ECG of both individual fetuses in twin pregnancies.

The diagnostic value of fetal fibronectin testing in clinical practice.

AIM: To evaluate the clinical management to withhold treatment for preterm labor in symptomatic women with an intermediate cervical length and negative fetal fibronectin (fFN) testing. METHODS: A retrospective cohort study was performed in a tertiary care teaching hospital in the Netherlands. Pregnant women with a gestational age between 23+5 to 34+0 weeks, with the presence of regular uterine contractions accompanied by a cervical length between 15 and 30 mm and intact membranes, who underwent fFN testing were included to obtain the diagnostic value of fFN testing for preterm delivery within 7 days. RESULTS: Fetal fibronectin testing has an extremely high negative predictive value (100%) and sensitivity (100%) for delivery within 7 days, in singleton and multiple pregnancies. However, specificity (64%) and positive predictive value (10%) of fFN testing in singleton pregnancies are low. Blood present on the fFN sample does not affect the reliability of the fFN test; the negative predictive value remains 100%. CONCLUSION: Women with symptoms of early preterm labor, intact membranes, a cervical length between 15 and 30 mm and negative fFN testing do not deliver within 7 days. Administration of corticosteroids and tocolytics can safely be withhold. Furthermore, blood on the fFN sample does not change the reliability of the fFN test.

Normal fetal cardiac deformation values in pregnancy; a prospective cohort study protocol.

BACKGROUND: Myocardial deformation imaging offers the potential to measure myocardial function. Remodelling, the change in size, shape and function, appears as a result of pressure or volume changes and is thought to be the first sign of fetal adaptation to placental dysfunction. Deformation can be measured using speckle tracking echocardiography (STE). STE in the fetus might be useful for detection and follow up of the fetus endangered by placental dysfunction. Reference values for fetal myocardial deformation during gestation have not been comprehensively described and need further investigation before STE can be introduced in daily clinical practice. The aim of this study is to determine reference values for fetal myocardial deformation throughout gestation in uncomplicated pregnancies. METHODS: A longitudinal cohort will be performed. 150 Women, pregnant from a non-anomalous singleton, will be included from 19 to 21 + 6 weeks gestational age. Thereafter, fetal heart ultrasounds will be performed 4 weekly, until 41 weeks gestational age or delivery. Ultrasound data will be analysed using STE software to determine reference values for fetal cardiac deformation during gestation. DISCUSSION: Measuring cardiac deformation changes in pregnancy can be a promising tool to detect preclinical cardiac adaptation to placental dysfunction. However, previous studies used different ultrasound scans and STE software resulting in incomparable and contradictory results on deformation values. In this prospective study reference values during pregnancy, cardiac deformation values will be assessed with the same ultrasound and software package in 150 uncomplicated pregnancies. TRIAL REGISTRATION: National Trial Register number: NTR7132. Date of inclusion: 2018/04/06.

Acceptance of a new non-invasive fetal monitoring system and attitude for telemedicine approaches in obstetrics: a case-control study.

PURPOSE: Reduction of maternal morbidity and mortality is a major worldwide objective anchored in the millennium goals of the United Nations. To improve fetal and maternal care, a constant attempt to discover groundbreaking technologies is ongoing. One approach is the enhancement of non-invasive fetal ECG devices. Most importantly, acceptance of new technologies by pregnant women is a prerequisite for successful implementation. METHODS: This questionnaire-based study conducted at the University Hospital Heidelberg, Germany between May and June 2017 evaluates pregnant women's attitudes towards a new device for fetal ECG monitoring and its potential home usage. The study population was questioned after exposure to the Parides/Atlantis prototype (Nemo Healthcare, Veldhoven, The Netherlands), whereas the maternal and gestational age-matched control group was left to envision telemedical topics. RESULTS: The prototype and its potential usage in a clinical and telemedical setting was highly accepted, and its comfort and appearance satisfied participants. Its use caused significantly improved telemedical understanding as envision increased (p = 0.0015). Implementation and integration of telemedical devices into antenatal care was significantly preferred by the study group (p = 0.0011), though participants desire more specific features for their personal use. Optional home-based self-monitoring to reduce scheduled doctoral visits (p = 0.0004) as well as self-assessment prior to self-initiated, unscheduled consultation (p < 0.0001) could be affected positively by such a device. Furthermore, it could reduce face-to-face interaction with the care provider (p = 0.0163). CONCLUSIONS: The positive feedback on remote self-monitoring might open options for a more "patient as partners" oriented prenatal care in the future. Safety and reliability remain a major issue. More comprehensive studies with new technologies are needed to diligently ensure quality of care. Finally, results for new technologies must be communicated to pregnant women for their acceptance and usage of new devices.

Tocogram characteristics of uterine rupture: a systematic review.

PURPOSE: Timely diagnosing a uterine rupture is challenging. Based on the pathophysiology of complete uterine wall separation, changes in uterine activity are expected. The primary objective is to identify tocogram characteristics associated with uterine rupture during trial of labor after cesarean section. The secondary objective is to compare the external tocodynamometer with intrauterine pressure catheters. METHODS: MEDLINE, EMBASE, and the Cochrane library were systematically searched for eligible records. Moreover, clinical guidelines were screened. Studies analyzing tocogram characteristics of uterine rupture during trial of labor after cesarean section were appraised and included by two independent reviewers. Due to heterogeneity, a meta-analysis was only feasible for uterine hyperstimulation. RESULTS: Thirteen studies were included. Three tocogram characteristics were associated with uterine rupture. (1) Hyperstimulation was more frequently observed compared with controls during the delivery (38 versus 21 % and 58 versus 53 %), and in the last 2 h prior to birth (19 versus 4 %). Results of meta-analysis: OR 1.68 (95 % CI 0.97-2.89), p = 0.06. (2) Decrease of uterine activity was observed in 14-40 % and (3) an increasing baseline in 10-20 %. Five studies documented no changes in uterine activity or Montevideo units. A direct comparison between external tocodynamometer and intrauterine pressure catheters was not feasible. CONCLUSIONS: Uterine rupture can be preceded or accompanied by several types of changes in uterine contractility, including hyperstimulation, reduced number of contractions, and increased or reduced baseline of the uterine tonus. While no typical pattern has been repeatedly reported, close follow-up of uterine contractility is advised and hyperstimulation should be prevented.

Antenatal mother-infant bonding scores are related to maternal reports of infant crying behaviour.

OBJECTIVE: To assess the relation between antenatal mother-infant bonding scores and maternal reports of infant crying behaviour. BACKGROUND: Crying is normal behaviour and it is important for parent-infant bonding. Even though bonding starts antenatally, the relation between antenatal bonding scores and infant crying behaviour has never been studied. METHOD: A secondary analysis was performed on data that were gathered in a large prospective study within our region. Bonding was assessed using an antenatal bonding questionnaire at 32 weeks gestational age. The crying behaviour of infants was assessed with three questions at six weeks postpartum. Crying was termed excessive (EC+) when mothers perceived the crying to be 'every day', 'often' or 'very often', and with 'crying episodes lasting more than 30 minutes'; in other words, when mothers scored high on all three questions. The relation between bonding and crying was examined using a multiple logistic regression analysis, including adjustment for relevant variables, especially maternal depression as measured with the Edinburgh Depression Scale. RESULTS: In total, 894 women were included of whom 47 reported EC+ infants (5.3%). Antenatal bonding scores were significantly related to the reporting of crying behaviour, even after adjustment for relevant variables (p = 0.02). Each extra point on the bonding scale reduced the EC+ risk with 14% (OR = 0.86, 95% CI [0.76-0.97]). CONCLUSION: Mothers with lower antenatal bonding scores were more likely to report an EC+ infant. Future research should further explore the concept of antenatal bonding, its relation with EC and risks associated with EC.

Normal ranges for fetal electrocardiogram values for the healthy fetus of 18-24 weeks of gestation: a prospective cohort study.

BACKGROUND: The fetal anomaly ultrasound only detects 65 to 81 % of the patients with congenital heart disease, making it the most common structural fetal anomaly of which a significant part is missed during prenatal life. Therefore, we need a reliable non-invasive diagnostic method which improves the predictive value for congenital heart diseases early in pregnancy. Fetal electrocardiography could be this desired diagnostic method. There are multiple technical challenges to overcome in the conduction of the fetal electrocardiogram. In addition, interpretation is difficult due to the organisation of the fetal circulation in utero. We want to establish the normal ranges and values of the fetal electrocardiogram parameters in healthy fetuses of 18 to 24 weeks of gestation. METHODS/DESIGN: Women with an uneventful singleton pregnancy between 18 and 24 weeks of gestation are asked to participate in this prospective cohort study. A certified and experienced sonographist performs the fetal anomaly scan. Subsequently, a fetal electrocardiogram recording is performed using dedicated signal processing methods. Measurements are performed at two institutes. We will include 300 participants to determine the normal values and 95 % confidence intervals of the fetal electrocardiogram parameters in a healthy fetus. We will evaluate the fetal heart rate, segment intervals, normalised amplitude and the fetal heart axis. Three months postpartum, we will evaluate if a newborn is healthy through a questionnaire. DISCUSSION: Fetal electrocardiography could be a promising tool in the screening program for congenital heart diseases. The electrocardiogram is a depiction of the intimate relationship between the cardiac nerve conduction pathways and the structural morphology of the fetal heart, and therefore particularly suitable for the detection of secondary effects due to a congenital heart disease (hypotrophy, hypertrophy and conduction interruption).

Increased levels of depressive symptoms among pregnant women in The Netherlands after the crash of flight MH17.

On July 17, 2014, Malaysia Airlines flight MH17 was shot down, a tragedy that shocked the Dutch population. As part of a large longitudinal survey on mental health in pregnant women that had a study inclusion period of 19 months, we were able to evaluate the possible association of that incident with mood changes using pre- and postdisaster data. We compared mean Edinburgh Depression Scale (EDS) scores from a group of women (n = 126 cases) at 32 weeks' gestation during the first month after the crash with mean scores from a control group (n = 102) with similar characteristics who completed the EDS at 32 weeks' gestation during the same summer period in 2013. The mean EDS scores of the 126 case women in the first month after the crash were significantly higher than the scores of 102 control women. There were no differences in mean EDS scores between the 2 groups at the first and second trimesters. The present study is among the first in which perinatal mental health before and after the occurrence of a disaster has been investigated, and the results suggest that national disasters might lead to emotional responses.

The HAPPY study (Holistic Approach to Pregnancy and the first Postpartum Year): design of a large prospective cohort study.

BACKGROUND: The HAPPY study is a large prospective longitudinal cohort study in which pregnant women (N ≈ 2,500) are followed during the entire pregnancy and the whole first year postpartum. The study collects a substantial amount of psychological and physiological data investigating all kinds of determinants that might interfere with general well-being during pregnancy and postpartum, with special attention to the effect of maternal mood, pregnancy-related somatic symptoms (including nausea and vomiting (NVP) and carpal tunnel syndrome (CTS) symptoms), thyroid function, and human chorionic gonadotropin (HCG) on pregnancy outcome of mother and foetus. METHODS/DESIGN: During pregnancy, participants receive questionnaires at 12, 22 and 32 weeks of gestation. Apart from a previous obstetric history, demographic features, distress symptoms, and pregnancy-related somatic symptoms are assessed. Furthermore, obstetrical data of the obstetric record form and ultrasound data are collected during pregnancy. At 12 and 30 weeks, thyroid function is assessed by blood analysis of thyroid stimulating hormone (TSH), free thyroxine (FT4) and thyroid peroxidase antibodies (TPO-Ab), as well as HCG. Also, depression is assessed with special focus on the two key symptoms: depressed mood and anhedonia. After childbirth, cord blood, neonatal heel screening results and all obstetrical data with regard to start of labour, mode of delivery and complications are collected. Moreover, mothers receive questionnaires at one week, six weeks, four, eight, and twelve months postpartum, to investigate recovery after pregnancy and delivery, including postpartum mood changes, emotional distress, feeding and development of the newborn. DISCUSSION: The key strength of this large prospective cohort study is the holistic (multifactorial) approach on perinatal well-being combined with a longitudinal design with measurements during all trimesters of pregnancy and the whole first year postpartum, taking into account two physiological possible markers of complaints and symptoms throughout gestation: thyroid function and HCG. The HAPPY study is among the first to investigate within one design physiological and psychological aspects of NVP and CTS symptoms during pregnancy. Finally, the concept of anhedonia and depressed mood as two distinct aspects of depression and its possible relation on obstetric outcome, breastfeeding, and postpartum well-being will be studied.

Development of the Childbirth Perception Scale (CPS): perception of delivery and the first postpartum week.

Some caregivers suggest a more positive experience of childbirth when giving birth at home. Since properly developed instruments that assess women's perception of delivery and the early postpartum are missing, the aim of the current study is to develop a Childbirth Perception Scale (CPS). Three focus groups with caregivers, pregnant women, and women who recently gave birth were conducted. Psychometric properties of 23 candidate items derived from the interviews were tested with explorative factor analysis (EFA) (N = 495). Confirmatory factor analysis (CFA) was performed in another sample of women (N = 483) and confirmed a 12-item CPS. The EFA in sample I suggested a two-component solution: a subscale 'perception of delivery' (six items) and a subscale 'perception of the first postpartum week' (six items). The CFA in sample II confirmed an adequate model fit and a good internal consistency (α = .82). Multivariate linear regression showed a positive effect of home delivery on perception of delivery in multiparous but not in primiparous women. The 12-item CPS with two dimensions (perception of delivery and perception of first postpartum week) has adequate psychometric properties. In multiparous women, home delivery showed to be independently related to more positive perception of delivery.

Early prediction of gestational diabetes mellitus using maternal demographic and clinical risk factors.

OBJECTIVE: To build and validate an early risk prediction model for gestational diabetes mellitus (GDM) based on first-trimester electronic medical records including maternal demographic and clinical risk factors. METHODS: To develop and validate a GDM prediction model, two datasets were used in this retrospective study. One included data of 14,015 pregnant women from Máxima Medical Center (MMC) in the Netherlands. The other was from an open-source database nuMoM2b including data of 10,038 nulliparous pregnant women, collected in the USA. Widely used maternal demographic and clinical risk factors were considered for modeling. A GDM prediction model based on elastic net logistic regression was trained from a subset of the MMC data. Internal validation was performed on the remaining MMC data to evaluate the model performance. For external validation, the prediction model was tested on an external test set from the nuMoM2b dataset. RESULTS: An area under the receiver-operating-characteristic curve (AUC) of 0.81 was achieved for early prediction of GDM on the MMC test data, comparable to the performance reported in previous studies. While the performance markedly decreased to an AUC of 0.69 when testing the MMC-based model on the external nuMoM2b test data, close to the performance trained and tested on the nuMoM2b dataset only (AUC = 0.70).

Feasibility and reliability of fetal two dimensional speckle tracking echocardiography at 16 weeks gestational age: A pilot study.

BACKGROUND: Fetal two-dimensional speckle tracking echocardiography (2D-STE) is an emerging technique for assessing fetal cardiac function by measuring global longitudinal strain. Alterations in global longitudinal strain may serve as early indicator of pregnancy complications, making 2D-STE a potentially valuable tool for early detection. Early detection can facilitate timely interventions to reduce fetal and maternal morbidity and mortality. Therefore, the aim of this study was to investigate the feasibility of performing 2D-STE at 16 weeks gestational age. METHODS: This pilot study utilized 50 ultrasound clips of the fetal four-chamber view recorded between 15+5 and 16+2 weeks gestational age from a prospective cohort study. A strict protocol assessed three parameters essential for 2D-STE analysis: fetal four-chamber view ultrasound clip quality, region of interest, and frame rates. Two independent researchers measured global longitudinal strain in all adequate fetal four-chamber view ultrasound clips to determine inter- and intra-operator reliability. RESULTS: Out of the 50 ultrasound clips, 37 (74%) were feasible for 2D-STE analysis. The inter-operator reliability for global longitudinal strain measurements of the left and right ventricles was moderate (ICC of 0.64 and 0.74, respectively), while the intra-operator reliability was good (ICC of 0.76 and 0.79, respectively). CONCLUSIONS: Our findings demonstrate that fetal 2D-STE analysis at 16 weeks gestational age is feasible when adhering to a strict protocol. However, further improvements are necessary to enhance the inter- and intra-operator reliability of 2D-STE at this gestational age.

Transferring an extremely premature infant to an extra-uterine life support system: a prospective view on the obstetric procedure.

To improve care for extremely premature infants, the development of an extrauterine environment for newborn development is being researched, known as Artificial Placenta and Artificial Womb (APAW) technology. APAW facilitates extended development in a liquid-filled incubator with oxygen and nutrient supply through an oxygenator connected to the umbilical vessels. This setup is intended to provide the optimal environment for further development, allowing further lung maturation by delaying gas exposure to oxygen. This innovative treatment necessitates interventions in obstetric procedures to transfer an infant from the native to an artificial womb, while preventing fetal-to-neonatal transition. In this narrative review we analyze relevant fetal physiology literature, provide an overview of insights from APAW studies, and identify considerations for the obstetric procedure from the native uterus to an APAW system. Lastly, this review provides suggestions to improve sterility, fetal and maternal well-being, and the prevention of neonatal transition.

Electrohysterographic evaluation of preterm contractions in a patient with a unicornuate uterus.

Women with Müllerian anomalies are at increased risk of preterm labor. The analysis of parameters derived by the electrohysterogram such as its conduction velocity are promising for preterm delivery prediction. However, an electrohysterogram has never been measured in Müllerian anomalies. A multiparous woman with a unicornuate uterus presented at 28 weeks of gestation with preterm contractions. Three electrohysterogram recordings were performed between 28 and 30 weeks of gestation, 4 weeks before delivery. The conduction velocity values were in line with previous literature and differed significantly (p < 0.001) showing an increase between the first and last two recordings. The parameters derived from the electrohysterogram such as conduction velocity and power density spectrum peak frequency are promising ones to follow the evolution of pregnancy towards labor, and to distinguish between productive and unproductive uterine contractions, in the case of a unicornuate uterus as well as one that is normally developed.

Towards improving uterine electrical activity modeling and electrohysterography: ultrasonic quantification of uterine movements during labor.

The electrohysterogram is a potential new tool for diagnosing preterm labor. Parameters from the electrohysterogram may be influenced by uterine movement. An observational study was performed quantifying uterine movement during labor as a step towards improving electrohysterogram analysis for predicting preterm labor. The uterine wall was continuously tracked by ultrasound imaging during first stage of labor while an accelerometer recorded external abdominal accelerations in six women. A cyclic cranial-caudal movement of the uterine wall, caused by maternal respiration, was observed. This is reported and quantified for the first time. Average frequency, amplitude, and peak speed were 0.27 ± 0.07 Hz, 0.68 ± 0.84 cm, and 1.04 ± 1.20 cm/s, respectively. The accelerometer signal correlated with uterine movement and therefore can possibly provide a reference for removing movement-induced artifacts. There is a need to model and measure the effect of uterine movement on the electrohysterogram parameters and make measurements more robust to movement artifacts.

Simulation-Based Training in Emergency Obstetric Care in Sub-Saharan and Central Africa: A Scoping Review.

Background: Every day approximately 810 women die from complications related to pregnancy and childbirth worldwide. Around two thirds of these deaths happen in sub-Saharan Africa. One of the strategies to decrease these numbers is improving the quality of care by emergency obstetric simulation-based training. The effectiveness of such training programs depends on the program's instructional design. Objective: This review gives an overview of studies about emergency obstetric simulation-based training and examines the applied instructional design of the training programs in sub-Saharan and Central Africa. Methods: We searched Medline, Embase and Cochrane Library from inception to May 2021. Peer-reviewed articles on emergency obstetric, postgraduate, simulation-based training in sub-Saharan and Central Africa were included. Outcome measures were categorized based on Kirkpatrick's levels of training evaluation. The instructional design was evaluated by using the ID-SIM questionnaire. Findings: In total, 47 studies met the inclusion criteria. Evaluation on Kirkpatrick level 1 showed positive reactions in 18 studies. Challenges and recommendations were considered. Results on knowledge, skills, and predictors for these results (Kirkpatrick level 2) were described in 29 studies. Retention as well as decay of knowledge and skills over time were presented. Results at Kirkpatrick level 3 were measured in 12 studies of which seven studies demonstrated improvements of skills on-the-job. Improvements of maternal and neonatal outcomes were described in fifteen studies and three studies reported on cost-estimations for training rollout (Kirkpatrick level 4). Instructional design items were heterogeneously applied and described. Conclusions: Results of 47 studies indicate evidence that simulation-based training in sub-Saharan and Central Africa can have a positive impact across all four levels of Kirkpatrick's training evaluation model. However, results were not consistent across all studies and the effects vary over time. A detailed description of instructional design features in future publications on simulation-based training will contribute to a deeper understanding of the underlying mechanisms that determine why certain training programs are more effective in improving maternal and neonatal healthcare outcomes than other.