Maternal hemoglobin drop in multiple pregnancy is associated with higher gestational age at birth and birthweight.

INTRODUCTION: This retrospective study investigated the hypothesis that maternal hemoglobin (Hb) levels in twin pregnancy fall between the first and second trimesters and that higher falls are associated with higher gestational age at birth and higher birthweight (BW). MATERIAL AND METHODS: The study population was defined as pregnant women with twin pregnancies delivering two live, phenotypically normal neonates, after 24+0 weeks of gestation, between October 2009 and September 2021 at an inner London maternity unit. Maternal Hb and mean corpuscular volume (MCV), at ≤14+0 weeks of gestation (Hb1) and again at 20+0-30+0 weeks gestation (Hb2) were recorded from the Hospital's perinatal database. MCV was used as a possible indicator of iron deficiency anemia. The association of Hb drop, defined as [Hb1(adjusted for gestational age) - Hb2], and MCV values with gestational age at birth, BW of both twins and delivery of small for gestational age (SGA) neonates, defined as BW <10th percentile for gestation, was evaluated. RESULTS: 923 pregnant women with twin pregnancies were included. Maternal Hb1 did not correlate with any outcomes measured. However, a lower Hb2 and a larger Hb drop was associated with a higher gestational age at birth (p < 0.001), a larger BW of twin 1 and 2 (p < 0.001 for both) and a reduction in the incidence of delivering one or two SGA neonates (p < 0.001 for both). MCV values did not correlate significantly with these outcomes. CONCLUSIONS: This study showed that in twin pregnancy, a larger maternal Hb drop from the first to the second trimester is associated with a higher gestational age at birth and a larger BW. This change may represent a larger plasma volume expansion.

Continued versus discontinued oxytocin stimulation in the active phase of labour (CONDISOX): individual management based on artificial intelligence - a secondary analysis.

BACKGROUND: Current guidelines regarding oxytocin stimulation are not tailored to individuals as they are based on randomised controlled trials. The objective of the study was to develop an artificial intelligence (AI) model for individual prediction of the risk of caesarean delivery (CD) in women with a cervical dilatation of 6 cm after oxytocin stimulation for induced labour. The model included not only variables known when labour induction was initiated but also variables describing the course of the labour induction. METHODS: Secondary analysis of data from the CONDISOX randomised controlled trial of discontinued vs. continued oxytocin infusion in the active phase of induced labour. Extreme gradient boosting (XGBoost) software was used to build the prediction model. To explain the impact of the predictors, we calculated Shapley additive explanation (SHAP) values and present a summary SHAP plot. A force plot was used to explain specifics about an individual's predictors that result in a change of the individual's risk output value from the population-based risk. RESULTS: Among 1060 included women, 160 (15.1%) were delivered by CD. The XGBoost model found women who delivered vaginally were more likely to be parous, taller, to have a lower estimated birth weight, and to be stimulated with a lower amount of oxytocin. In 108 women (10% of 1060) the model favoured either continuation or discontinuation of oxytocin. For the remaining 90% of the women, the model found that continuation or discontinuation of oxytocin stimulation affected the risk difference of CD by less than 5% points. CONCLUSION: In women undergoing labour induction, this AI model based on a secondary analysis of data from the CONDISOX trial may help predict the risk of CD and assist the mother and clinician in individual tailored management of oxytocin stimulation after reaching 6 cm of cervical dilation.

Planned cesarean delivery vs planned vaginal delivery: a systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: There are over 145 million births worldwide, with over 30 million cesarean deliveries yearly. There are limited data comparing the perinatal and maternal outcomes between planned cesarean delivery and planned vaginal delivery. This study aimed to evaluate perinatal and maternal morbidity and mortality by meta-analysis of randomized controlled trials that randomly assigned patients to either planned cesarean delivery or planned vaginal delivery. DATA SOURCES: Scopus, PubMed, CINAHL, Cochrane Library, and the World Health Organization clinical trial databases were searched from inception through August 2022. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials that compared planned cesarean delivery with planned vaginal delivery at any gestational age and for any delivery indication were included. METHODS: Two authors independently extracted data. PRISMA guidelines were used for data extraction and quality assessment. The primary outcome was perinatal mortality. The summary measures were reported as relative risks or as mean differences with 95% confidence intervals. Pooled odds ratios and 95% confidence intervals were calculated using Mantel-Haenszel random-effects models for outcomes. RESULTS: In 15 primary randomized controlled trials, 3265 patients were randomized to planned cesarean delivery and 3353 to planned vaginal delivery. The incidence of perinatal deaths was not different (1.3% vs 1.3%; relative risk, 0.71; 95% confidence interval, 0.33-1.52). Planned cesarean delivery was associated with lower neonatal incidences of low umbilical artery pH (0.3% vs 2.4%; relative risk, 0.18; 95% confidence interval, 0.05-0.67), birth trauma (0.3% vs 0.7%; relative risk, 0.46; 95% confidence interval, 0.22-0.96), tube feeding requirement (2.5% vs 7.1%; relative risk, 0.36; 95% confidence interval, 0.19-0.66), and hypotonia (0.4% vs 3.5%; relative risk, 0.11; 95% confidence interval, 0.03-0.47), compared to planned vaginal delivery. Chorioamnionitis was less frequent in the planned cesarean delivery group (0.3% vs 1.0%; relative risk, 0.27; 95% confidence interval, 0.08-0.98). Wound infection was more common in the planned cesarean delivery group (1.9% vs 1.1%; relative risk, 1.61; 95% confidence interval, 1.04-2.52). Lower rates were observed in the planned cesarean delivery group for urinary incontinence at both ≤3 months (8.7% vs 12.2%; relative risk, 0.71; 95% confidence interval, 0.59-0.85) and 1 to 2 years (16.9% vs 22%; relative risk, 0.77; 95% confidence interval, 0.67-0.88) and for a painful perineum at 2 years (4% vs 6.2%; relative risk, 0.64; 95% confidence interval, 0.47-0.87) compared to planned vaginal delivery. Among singleton pregnancies, planned cesarean delivery was associated with a lower rate of perinatal death (0.69% vs 1.81%; relative risk, 0.45; 95% confident interval, 0.21-0.93). CONCLUSION: Planned cesarean delivery and planned vaginal delivery were associated with similar rates of perinatal and maternal mortality in this meta-analysis of randomized controlled trials. Planned cesarean delivery was associated with significant decreases in adverse neonatal outcomes such as low umbilical artery pH, birth trauma, tube feeding requirement, and hypotonia, and significant decreases in chorioamnionitis, urinary incontinence, and painful perineum. Planned vaginal delivery was associated with significant decreases in need for general anesthesia and wound infection. Further randomized trials are needed to assess the risks and benefits of planned cesarean delivery vs planned vaginal delivery in lower-risk patients and in the general population.

B-type natriuretic peptide in low-risk pregnancy and pregnancy with congenital heart disease.

OBJECTIVE: To perform a longitudinal assessment of B-type natriuretic peptide (BNP) and its association with cardiac function in low-risk pregnant women and in pregnant women with congenital heart disease (CHD). METHODS: Longitudinal study in low-risk pregnancy and pregnancy in women with CHD seen at 10-14, 18-22, and 30-34 weeks of pregnancy for BNP quantification and exercise studies using impedance cardiography (ICG). RESULTS: Forty-three low-risk women with longitudinal samples (129 samples, 43 in each trimester) and 30 pregnant women with CHD with convenience samples (first trimester, five samples; second trimester, 20 samples; third trimester, 21 samples) were included. Women with CHD delivered earlier by 6 days (P = 0.002) and their newborns had lower birth weight independent of gestational age (birth weight centile 30.0 vs 55.0, P = 0.005). In low-risk women, BNP levels were lower in the third trimester (P < 0.001). There were no statistically significant differences in BNP concentrations across trimesters in the CHD group, no differences in BNP concentrations between the two groups, and no significant correlations between BNP concentration in each trimester with cardiac output, stroke volume, or heart rate (at rest/with exercise). CONCLUSION: This study assessed BNP longitudinally in the first, second and third trimesters in singleton low-risk pregnancy, and showed that BNP concentration decreased with advancing gestational age, with no participants with levels greater than 40.0 pg/mL in the third trimester. BNP concentrations were similar in women with and without congenital heart disease. We found no correlation between circulating levels of BNP and maternal hemodynamics at rest or with exercise measured by ICG to support its use as a marker of cardiac function.

Risk factors for a serious adverse outcome in neonates: a retrospective cohort study of vaginal births.

OBJECTIVE: To investigate the hypothesis that risk factors in addition to an abnormal fetal heart rate pattern (aFHRp) are independently associated with adverse neonatal outcomes of labour. DESIGN: Observational prospective cohort study. SETTING: 17 UK maternity units. SAMPLE: 585 291 pregnancies between 1988 and 2000 inclusive. METHODS: Adjusted odds ratios (OR) with 95% confidence intervals (95% CI) were estimated from multivariable logistic regression. MAIN OUTCOME MEASURES: Adverse neonatal outcome at term (5-minute Apgar score <7, and a composite measure comprising 5-minute Apgar score <7, resuscitation by intubation and/or perinatal death). RESULTS: Analysis was based on 302 137 vaginal births at 37-42 weeks inclusive. We found a higher odds of Apgar score at 5 minutes <7 with suspected fetal growth restriction (OR 1.34, 95% CI 1.16-1.53), induction of labour (OR 1.41, 95% CI 1.25-1.58), nulliparity (OR 1.48, 95% CI 1.34-1.63), booking body mass index ≥30 (OR 1.18, 95% CI 1.02-1.37), maternal age <25 (OR 1.23, 95% CI 1.10-1.39), black ethnicity (OR 1.21, 95% CI 1.03-1.43), early-term birth at 37-38 weeks (OR 1.13, 95% CI 1.02-1.25), late-term birth at 41-42 weeks (OR 1.14, 95% CI 1.01-1.28), use of oxytocin (OR 1.27, 95% CI 1.14-1.41), maternal pyrexia (OR 1.87, 95% CI 1.46-2.40), aFHRp and presence of meconium (aFHRp without meconium: OR 2.40, 95% CI 2.15-2.69; meconium without aFHRp: OR 2.20, 195% CI.94-2.49; both aFHRp and meconium: OR 4.26, 95% CI 3.74-4.87). The results were similar when the composite adverse outcome was considered. CONCLUSIONS: A range of risk factors, including suspicion of fetal growth restriction, maternal pyrexia and presence of meconium, are implicated in poor birth outcomes in addition to aFHRp. Interpretation of the fetal heart rate pattern alone is insufficient as a basis for decisions about escalation and intervention.

Direct current cardioversion in pregnancy: a multicentre study.

OBJECTIVE: Direct current cardioversion (DCCV) in pregnancy is rarely required and typically only documented in single case reports or case series. A recent UK confidential enquiry reported on several maternal deaths where appropriate DCCV appeared to have been withheld. DESIGN: Retrospective cohort study. SETTING: Seventeen UK and Ireland specialist maternity centres. SAMPLE: Twenty-seven pregnant women requiring DCCV in pregnancy. MAIN OUTCOME MEASURES: Maternal and fetal outcomes following DCCV. RESULTS: Twenty-seven women had a total of 29 DCCVs in pregnancy. Of these, 19 (70%) initial presentations were to Emergency Departments and eight (30%) to maternity settings. There were no maternal deaths. Seventeen of the women (63%) had a prior history of heart disease. Median gestation at DCCV was 28 weeks, median gestation at delivery was 35 weeks, with a live birth in all cases. The abnormal heart rhythms documented at the first cardioversion were atrial fibrillation in 12/27 (44%) cases, atrial flutter in 8/27 (30%), supraventricular tachycardia in 5/27 (19%) and atrial tachycardia in 2/27 (7%). Fetal monitoring was undertaken following DCCV on 14/29 (48%) occasions (10 of 19 (53%) at ≥26 weeks) and on 2/29 (7%) occasions, urgent delivery was required post DCCV. CONCLUSIONS: Direct current cardioversion in pregnancy is rarely required but should be undertaken when clinically indicated according to standard algorithms to optimise maternal wellbeing. Once the woman is stable post DCCV, gestation-relevant fetal monitoring should be undertaken. Maternity units should develop multidisciplinary processes to ensure pregnant women receive the same standard of care as their non-pregnant counterparts.

Continued versus discontinued oxytocin stimulation in the active phase of induced labour: Factors associated with unexpectedly high rates of conversion to open label oxytocin in the CONDISOX trial.

OBJECTIVE: To examine the factors associated with unexpectedly high rates of conversion to open label oxytocin in the CONDISOX trial of continuation versus discontinuation of oxytocin infusion during induced labour. DESIGN: Secondary retrospective analysis of data from a prospective randomised controlled trial. SETTING: Nine hospitals in Denmark and one in the Netherlands between 8 April 2016 and 30 June 2020. POPULATION OR SAMPLE: 1200 women having labour induced. METHODS: Analysis of outcomes by actual management. MAIN OUTCOME MEASURES: Mode of delivery and associated variables. RESULTS: Switching to open label oxytocin (42.4% overall) was associated with nulliparity, an unripe cervix, larger babies and higher rates of delivery by caesarean section. CONCLUSIONS: In the CONDISOX trial, slow labour was associated with features suggesting a higher 'resistance to progress', often prompting the use of open-label oxytocin infusion rather than study medication.

A case-control study of the interaction of fetal heart rate abnormalities, fetal growth restriction, meconium in the amniotic fluid and tachysystole, in relation to the outcome of labour.

OBJECTIVE: To quantify the incidence of intrapartum risk factors in labours with an adverse outcome, and compare them with the incidence of the same indicators in a series of consecutive labours without adverse outcome. DESIGN: Case-control study. SETTING: Twenty-six maternity units in the UK. POPULATION OR SAMPLE: Sixty-nine labours with an adverse outcome and 198 labours without adverse outcome. METHODS: Observational study. MAIN OUTCOME MEASURES: Incidence of risk factors in hourly assessments for 7 hours before birth in the two groups. RESULTS: A risk score combining suspected fetal growth restriction, tachysystole, meconium in the amniotic fluid and fetal heart rate abnormalities (baseline rate and variability, presence of decelerations) gave the best indication of likely outcome group. CONCLUSIONS: Accurate risk assessment in labour requires fetal heart rate abnormalities to be considered in context with additional intrapartum risk factors.

Screening for late-onset gestational diabetes: Are there any clinical benefits?

OBJECTIVE: To determine whether screening for gestational diabetes mellitus (GDM) in the third trimester and managing those who are screen positive on a diabetes pathway affects obstetric and neonatal outcomes. DESIGN: Retrospective study of prospectively collected data. SETTING: London Teaching Hospital. POPULATION OR SAMPLE: A total of 14 366 women delivering between 1 January 2018 and 31 December 2020. METHODS: Retrospective chart analysis. MAIN OUTCOME MEASURES: Diagnosis of late-onset GDM, obstetric and neonatal outcomes. RESULTS: Five hundred and thirty-one women were tested by home glucose monitoring for late-onset GDM from 33 weeks of gestation. In all, 244 were diagnosed as having GDM (group 1) and managed accordingly, and 287 (group 2) were returned to normal care. A total of 1415 women had GDM diagnosed by oral glucose tolerance test before 33 weeks of gestation (group 3). Of the women in group 2, 49.5% had a spontaneous onset of labour compared with only 25.8% and 27% in groups 1 and 3. However, women in group 2 were significantly more likely to have a macrosomic baby (≥4000 g, 25.4%) than groups 1 (16.0%) or 3 (7.2%), and their babies were more likely to be admitted to special care (5.2% versus 2% in group 1). Macrosomic babies were associated with significantly higher rates of shoulder dystocia, third- and fourth-degree tears and postpartum haemorrhage. CONCLUSIONS: Apparent late-onset GDM affects a significant proportion of women, and targeted intervention was associated with better obstetric and neonatal outcomes. These results suggest that all pregnancies with risk factors for late-onset GDM might benefit from active GDM management irrespective of specific glucose thresholds. TWEETABLE ABSTRACT: Women with risk factors for GDM in the third trimester, and their babies, would probably benefit from active management of their blood sugars irrespective of threshold values.

Maternal and fetal outcomes in women with cerebrovascular malformations in pregnancy: A multicentre retrospective cohort study.

OBJECTIVE: To determine maternal, obstetric and neonatal outcomes in a cohort of women with cerebrovascular malformations (CVMs) that include arterial venous malformations (AVMs) and cavernomas. DESIGN: Retrospective cohort study. SETTING: Six specialist centres managing pregnant women with neurological disorders. POPULATION: Sixty-three women with CVMs in 83 pregnancies of ≥20 completed weeks' gestation. METHODS: Retrospective case notes review. MAIN OUTCOME MEASURES: Neurological outcomes including rates of acute cerebral bleeding in pregnancy and reported seizures during pregnancy. Maternal outcomes included number of women with a livebirth and the proportion of women being delivered by caesarean section. RESULTS: Most women had a good pregnancy outcome with high rates of vaginal delivery (73%) at term. There were no maternal deaths. Six women had an acute cerebral bleed, all of whom were delivered by planned caesarean section. In total, ten women had seizures in pregnancy (of whom four also had a bleed). Six (7%) babies were admitted to a neonatal unit. There was no significant difference in outcomes between women with AVMs and those with cavernomas. CONCLUSION: In the majority of cases, pregnancy outcomes were favourable, with most women having a vaginal delivery. All cases of cerebral bleeds that occurred were at a remove from the peripartum period. TWEETABLE ABSTRACT: Women with cerebrovascular malformations have high rates of vaginal delivery.

Mechanical heart valves and pregnancy: Issues surrounding anticoagulation. Experience from two obstetric cardiac centres.

BACKGROUND: Pregnant women with mechanical heart valves are at significant risk of obstetric/cardiac complications. This study compares the anticoagulation management in two obstetric cardiac centres. METHODS: Retrospective case-note review from Chelsea and Westminster/Royal Brompton Hospitals (CR) and Erasmus Medical Centre (EMC). Main outcome measure was mechanical heart valve thrombosis. RESULTS: Nineteen pregnancies from CR and 25 pregnancies from EMC were included. Most women were on low-molecular-weight heparin (LMWH) throughout pregnancy at CR, whereas at EMC most had LMWH in the first trimester and vitamin K antagonists in subsequent trimesters. Peak anti-factor Xa were performed monthly at CR, levels 0.39-1.51 IU/mL (mean 0.82 IU/mL). Anticoagulation management peri-partum was inconsistent. Delivery was mainly by caesarean section at CR (74%) and vaginal delivery at EMC (64%). No maternal deaths and only one mechanical heart valve thrombosis at CR. Two mechanical heart valve thromboses and one maternal death at EMC. CONCLUSION: Peri-partum anticoagulation strategies, anticoagulation monitoring and mode of delivery inconsistencies reported.