Gestational hemodilution as a putative risk factor for postpartum depression: A large-scale nationwide longitudinal cohort study.

BACKGROUND: While anemia during pregnancy has been linked to increased postpartum depression (PPD) risk, longitudinal studies on the association between gestational hemodilution, represented by decreased hematocrit (Hct) during the transition from the 1st to 2nd trimester, and PPD risk, are scarce. The current study aimed to investigate this association in a nationwide cohort over the perinatal period. METHODS: This retrospective cohort study included 104,715 women who gave birth between January 2008 and December 2015. The cohort was followed up for new-onset PPD during the year post birth and gestational hemodilution was assessed by the change in Hct levels (Δ: 2nd-1st trimester). The cohort was divided into three hemodilution groupings: maximal and minimal 10 % of mothers and intermediate 80 %. Multivariable regression analyses were performed to estimate the association between gestational hemodilution and PPD, adjusting for confounders. RESULTS: Among the full cohort, 2.2 % (n = 2263) met the definition of new-onset PPD. Mothers with greater hemodilution had higher rates of PPD: 2.7 % (n = 269) in the maximal hemodilution group, 2.1 % (n = 1783) in the intermediate and 1.9 % (n = 211) in the minimal hemodilution group (p < 0.001). The maximal hemodilution group had higher rates of pre-gestational psychiatric disorders (p < 0.001) and higher adjusted risk for PPD [OR = 1.18, 95 % CI (1.04, 1.35)]. LIMITATIONS: Data on iron levels and supplementation were unavailable, thus it could not be adjusted for in the analysis. CONCLUSIONS: Women in the top 10th percentile of gestational hemodilution may be at risk for PPD, justifying monitoring of gestational Hct as a biomarker for PPD.

Sexual dimorphism of the fetal brain biometry: an MRI-based study.

PURPOSE: Fetal growth assessment is a key component of prenatal care. Sex-specific fetal brain nomograms on ultrasound are available and are clinically used. In recent years, the use of fetal MRI has been increasing; however, there are no sex-specific fetal CNS nomograms on MRI. The study aimed to assess the differences in fetal brain biometry and growth trajectories and to create population-based standards of the fetal brain on MRI. METHODS: In this cross-sectional study, brain structures of singleton fetuses with normal brain MRI scans were analyzed: biparietal diameter, occipitofrontal diameter, trans-cerebellar diameter, and the corpus callosum were measured and converted into centiles. Sex-specific nomograms were created. RESULTS: A total of 3848 MRI scans were performed in one tertiary medical center between 2011 and 2019; of them, 598 fetuses met the inclusion criteria, 300 males and 298 females between 28- and 37-weeks' gestation. Males had significantly larger occipitofrontal diameter than females (median 75%, IQR 54-88%; median 61%, IQR 40-77%) and biparietal diameter (median 63%, IQR 42-82%; median 50%, IQR 25-73%), respectively (p < 0.001). The cerebellum had the greatest growth rate, with a 1.5-fold increase in diameter between 28 and 37 weeks' gestation, with no measurement difference between the sexes (p = 0.239). No significant difference was found in the corpus callosum (p = 0.074). CONCLUSION: Measuring both sexes on the same nomograms may result in over-estimation of male fetuses and under-estimation of females. We provide fetal sex-specific nomograms on two-dimensional MRI.

Timing of Delivery for Twins With Growth Discordance and Growth Restriction: An Individual Participant Data Meta-analysis.

OBJECTIVE: First, to evaluate the risks of stillbirth and neonatal death by gestational age in twin pregnancies with different levels of growth discordance and in relation to small for gestational age (SGA), and on this basis to establish optimal gestational ages for delivery. Second, to compare these optimal gestational ages with previously established optimal delivery timing for twin pregnancies not complicated by fetal growth restriction, which, in a previous individual patient meta-analysis, was calculated at 37 0/7 weeks of gestation for dichorionic pregnancies and 36 0/7 weeks for monochorionic pregnancies. DATA SOURCES: A search of MEDLINE, EMBASE, ClinicalTrials.gov, and Ovid between 2015 and 2018 was performed of cohort studies reporting risks of stillbirth and neonatal death in twin pregnancies from 32 to 41 weeks of gestation. Studies from a previous meta-analysis using a similar search strategy (from inception to 2015) were combined. Women with monoamniotic twin pregnancies were excluded. METHODS OF STUDY SELECTION: Overall, of 57 eligible studies, 20 cohort studies that contributed original data reporting on 7,474 dichorionic and 2,281 monochorionic twin pairs. TABULATION, INTEGRATION, AND RESULTS: We performed an individual participant data meta-analysis to calculate the risk of perinatal death (risk difference between prospective stillbirth and neonatal death) per gestational week. Analyses were stratified by chorionicity, levels of growth discordance, and presence of SGA in one or both twins. For both dichorionic and monochorionic twins, the absolute risks of stillbirth and neonatal death were higher when one or both twins were SGA and increased with greater levels of growth discordance. Regardless of level of growth discordance and birth weight, perinatal risk balanced between 36 0/7-6/7 and 37 0/7-6/7 weeks of gestation in both dichorionic and monochorionic twin pregnancies, with likely higher risk of stillbirth than neonatal death from 37 0/7-6/7 weeks onward. CONCLUSION: Growth discordance or SGA is associated with higher absolute risks of stillbirth and neonatal death. However, balancing these two risks, we did not find evidence that the optimal timing of delivery is changed by the presence of growth disorders alone. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42018090866.

Predictive value of new onset versus primary meconium-stained amniotic fluid.

BACKGROUND: Transition of clear amniotic fluid to meconium-stained fluid is a relatively common occurrence during labor. However, data regarding the clinical significance and the prognostic value of the presence of meconium-stained amnionic fluid (MSAF) are scarce. This study aimed to investigate delivery and neonatal outcomes according to the presence of MSAF and the timing of the meconium passage. METHODS: We used an historical cohort study at a single tertiary medical center in Israel between the years 2011 and 2018. Women were divided into two groups according to timing of meconium passage: primary MSAF (MSAF present at membrane rupture) and secondary MSAF (clear amnionic fluid that transitioned to MSAF during labor). Neonatal complication rates were compared between groups. Composite adverse neonatal outcome was defined as arterial cord blood pH <7.1, 5 min Apgar score ≤7, and/or neonatal intensive care unit admission. RESULTS: The study cohort included 56 863 singleton term births. Of these, 9043 (15.9%) were to women who had primary MSAF, and 1484 (2.6%) to those with secondary MSAF. Secondary MSAF compared with primary MSAF increased the risks of cesarean birth and operative vaginal delivery, increased the risks of low one- and five-minute Apgar scores and low arterial cord blood pH, and increased hospital stay duration. Multivariate analysis revealed that secondary MSAF was independently associated with an increased risk of composite adverse neonatal outcome (OR1.68, 95% CI 1.25-2.24, p < 0.001) compared with primary MSAF. CONCLUSIONS: In this sample, secondary MSAF was associated with more adverse neonatal outcomes than primary MSAF. Closer monitoring of fetal well-being may be prudent in these cases.

Feasibility of Fetal Proximal Lateral Cerebral Ventricle Measurement.

OBJECTIVES: Measuring the posterior horn of the lateral ventricle in the fetus during ultrasound scans may be challenging. We aimed to examine this measurement feasibility, in relation to gestational age. METHODS: A cross-sectional study was conducted, including nonanomalous fetuses, in which both lateral ventricles measured less than 10 mm during anomaly scans. The measurements were performed according to the International Society of Ultrasound in Obstetrics and Gynecology guidelines. Success rate of measuring both ventricles was assessed at different gestational ages. Association between lateral ventricle width with contralateral ventricle width, gender, gestational age, and fetal head position were assessed. RESULTS: A total of 156 cases were recruited. The lateral ventricle distal to the probe was measured in all cases. In 10 cases proximal lateral ventricle could not be adequately measured (failed proximal ventricle measurement group). In 146 scans both ventricle measurements were available. All 10 cases of failed proximal ventricle measurement were in third trimester (30-38 weeks). Success rate of measurement of both ventricles was 100%, 96.2%, 71.4%, and 37.5% for gestational week 14-29, 30-32, 33-35, and 36-38, respectively (P <.001). Proximal lateral ventricle width was strongly associated with the distal ventricle width (B = 0.422, 95% confidence interval 0.29, 0.555, P <.001), but not with head position, fetal gender, or gestational age. CONCLUSIONS: Measurement of the proximal lateral ventricle is feasible in most cases, even during late third trimester scans. Efforts should be made to visualize both ventricles in every evaluation of the fetal brain.

Association of the Cerebro-Placental Ratio With Adverse Outcomes in Pregnancies Affected by Gestational Diabetes Mellitus.

OBJECTIVES: Cerebro-placental ratio (CPR) is a doppler tool contributes to clinical decision-making in pregnancies affected by small for gestational age weight (SGA). Pregnancies affected by gestational diabetes mellitus (GDM) tend to have higher newborn weight, but greater risk of adverse perinatal outcomes. We hypothesized that in GDM-complicated-pregnancies CPR will be associated with adverse perinatal outcomes even in the absence of SGA. METHODS: This prospective single-center cohort study included non-anomalous singleton pregnancies in women with GDM. Those with pre-pregnancy diabetes mellitus, hypertensive disorder or suspected SGA were excluded. Routine fetal sonographic assessment included CPR-defined as middle cerebral artery pulsatilty index/umbilical artery pulsatilty index. Masked CPR measurement closest to birth was used, classified as >10th (normal) or ≤10th centile (low). Primary outcome was a composite, consisting of stillbirth, Caesarean birth due to abnormal fetal heart rate pattern, 5-minute Apgar <7, cord arterial pH < 7.0, hypoxic ischemic encephalopathy, or NICU admission >24 hours. RESULTS: Of 281 participants, 24 (8.5%) had low CPR, at a mean gestational age of 36.3 weeks (IQR 34.0-37.4). Birthweight percentile was significantly lower among the low CPR group (35th [IQR 16-31] versus 60th [IQR 31-82]; P = .002). There was no statistically difference in the primary composite outcome between the groups (8.3% versus 7.0%, P = .68). Low CPR was significantly associated with a higher risk of neonatal hypoglycemia (adjusted odds ratio 3.2, 95% CI 1.2-8.3). CONCLUSION: In pregnancies affected by GDM, CPR ≤10th percentile was not associated with adverse perinatal outcome but was associated with neonatal hypoglycemia.

Do fertility treatments affect labor induction success rate? A retrospective cohort study.

PURPOSE: To evaluate labor induction success rate by Foley catheter (FC) on patients who conceived spontaneously, as compared to those who underwent fertility treatments. MATERIALS AND METHODS: This retrospective cohort study included all pregnant women hospitalized at a single tertiary care center between January 2011 and May 2018 for induction of labor with FC. The study groups included patients with a singleton pregnancy who conceived after fertility treatments: controlled ovarian hyperstimulation (COH) or in vitro fertilization (IVF), while control group included patients who conceived spontaneously. Our primary outcome was the rate of cesarean deliveries. Regression analysis was conducted on the following parameters: age, gravidity, parity, the gestational week, and IVF. RESULTS: The study groups included 59, 321, and 3159 patients who conceived following COH, IVF, or spontaneously, respectively. While 72.1% of patients who conceived spontaneously had a vaginal delivery, only 62.7% and 58% of patients who conceived by COH and IVF had successful labor induction (respectively, p < .01). Similarly, significantly higher cesarean section (CS) rates were demonstrated by patients who conceived by COH and IVF (28.8% and 30%, respectively), compared to the control group (18.7%, p < .01). Regression analysis demonstrated that although age, parity, and the gestational week were significantly related to cesarean sections, no statistically significant association was found regarding fertility treatments (p = .050). CONCLUSIONS: The possible association between fertility treatments and cesarean delivery remains an important dilemma for obstetricians and fertility experts. While unadjusted analysis demonstrated such association among patients who undergo labor induction by FC, adjusted analysis has not supported that finding. Further studies focusing on the causes of failed vaginal delivery are needed to further expand our knowledge and to improve patient consultation.

The effect of mode of delivery in twin pregnancies on the latency period between diagnosis of preterm labor and birth.

INTRODUCTION: The optimal mode of delivery in twin pregnancies presenting with preterm labor is controversial. Current literature regarding these cases is based on observational studies, innately prone to bias. A possibly substantial, yet hitherto unexplored, source of bias is an effect of mode of delivery on the timing of delivery. The aim of our study is to examine whether the mode of delivery affects the latency period between preterm labor (PTL) presentation and actual delivery and to assess the possible effect of latency on neonatal outcome. MATERIAL AND METHODS: A retrospective cohort study at a single tertiary center from the year 2011 to 2018. All twin pregnancies (dichorionic or monochorionic-diamniotic) between 24 and 36 weeks of gestation admitted due to PTL were included in the study. RESULTS: A total of 469 twin deliveries met the study criteria, of them, 204 delivered by cesarean section and 265 delivered vaginally. Cesarean delivery significantly decreased the chances of reaching a latency period of 1 or more days (OR = 0.53, 95% CI = 0.33-0.84), 2 or more days (OR = 0.47, 95% CI = 0.27-0.82) and 3 or more days (OR = 0.28, 95% CI = 0.09-0.9). In a regression model adjusting for gestational age at delivery, mode of delivery was not associated with neonatal morbidity or mortality. However, in a regression model adjusting for gestational age at PTL presentation, thereby accounting for differences in the latency period, cesarean delivery was found to significantly increase the risk of respiratory distress syndrome (OR = 1.62, 95% CI = 1.04-2.54). CONCLUSIONS: In PTL of twin pregnancies, the latency period is significantly longer in vaginal deliveries compared to cesarean deliveries. The possibility of longer latency period in vaginal deliveries should be considered when counseling patients on the mode of delivery in preterm twin pregnancies.

"One-stop shop" for the evaluation of the infertile patient: hystero-salpingo foam sonography combined with two and three dimensional ultrasound and sonohysterography.

Hysterosalpingo-foam sonography (HyFoSy) is considered an acceptable alternative for hysterosalpingography (HSG). By combining HyFoSy with two and three-dimensional (2D and 3D) ultrasound and hysterosonography, a complete fertility work-up can be done. We aimed to evaluate the value of a combined ultrasound examination for fertility work-up. During the study period 113 women were examined. Five of 113 (4.4%) examinations were abandoned due to intra-uterine adhesions that were detected by hysterosonography, and five (4.4%) were abandoned due to technical difficulties. Of 103 women who had completed the examination, 2D ultrasound revealed six patients with hydrosalpinx (5.8%) and sonographic signs of adenomyosis in 13 (12.6%) patients. By combining 2D ultrasound with hysterosonography, two (1.9%) fibroids that were penetrating the uterine cavity and seven (6.8%) endometrial polyps were detected. HyFoSy showed bilateral patent tubes in 58 patients (56.3%), unilateral tubal occlusion in 29 (28.1%) and bilateral tubal occlusion in 16 (15.5%). This study shows that the 'one-stop shop' examination is feasible. The combined examination had detected 16 pathological findings that would have not been detected by HyFoSy alone. Hence, it should be offered to couples undergoing routine infertility work-up.IMPACT STATEMENTWhat is already known on this subject? The accuracy of the HyFoSy alone has been evaluated in different studies, but this presented ultrasound scan is integrating 4 different modalities in one exam (2D scanning of the pelvis, 3D scanning of the uterus, hysterosonography and HyFoSy) and we were able to evaluate the female pelvic organs, including the uterine cavity, the tubes and the ovaries, in order to expand the range of diagnosed pathologies.What do the results of this study add? The concept of 'one-stop shop' for the evaluation of female pelvis in couples suffering from infertility is feasible, has comparable accuracy as HSG for tubal occlusion, and higher detection rate for uterine malformations.What are the implications of these findings for clinical practice and/or further research? We suggest to incorporate this examination in routine fertility work-up.

Isolated Fallopian Tube Torsion: An Underdiagnosed Entity with Debatable Management.

STUDY OBJECTIVE: To study features of isolated fallopian tube torsion (IFTT) to promote early diagnosis of this entity and describe options for management. DESIGN: Retrospective cohort study from October 2017 through October 2020. SETTING: Tertiary care hospital. PATIENTS: All patients with surgically confirmed adnexal torsion or IFTT during the study period. INTERVENTIONS: All of the patients underwent gynecological examination, imaging, and laparoscopy. MEASUREMENTS AND MAIN RESULTS: During this 3-year period, 64 patients underwent laparoscopy owing to confirmed torsion, of which 55 had adnexal torsion, and 9 had IFTT. Patients with IFTT tended to be younger (21.2 years ± 8.2 vs 29.1 years ± 11.9, p = .06) and had more fever on admission (p = .007). On ultrasound examination, isolated hydrosalpinx was demonstrated only in patients with IFTT (p <.001). During surgery, more para-ovarian cysts were observed in patients with IFTT (44.4% vs 10.9%, p = .01), whereas patients with adnexal torsion had more ovarian cysts (52.7% vs 0%, p = .003). The most common procedure was detorsion in both groups. Most patients that underwent detorsion of the tube had a normal ultrasound scan on follow-up examination. CONCLUSION: IFTT is probably underdiagnosed. Its clinical presentation is more equivocal than adnexal torsion, and ovaries are usually of normal size on ultrasonography. Hydrosalpinx or para-ovarian cysts should raise suspicion toward IFTT. Detorsion of the tube is probably a valid management option, although further research with long-term follow-up analyzing tubal patency is necessary to define the optimal management for this condition.

Oesophageal atresia: sonographic signs may prenatally predict surgical complexity.

OBJECTIVE: Oesophageal atresia (OA) is a major anomaly of varying severity. The complexity of surgical correction highly depends on the gap length of missing oesophagus and the presence of a distal fistula. The aim of this study was to identify antenatal sonographic findings associated with presence of a distal fistula and type of surgical repair METHODS: Prenatal medical records of neonates postnatally diagnosed with OA were reviewed. Sonographic signs of OA (small/absent stomach, polyhydramnios, oesophageal pouch) and the trimester at sign detection were recorded and compared between (1) OA with and without a distal fistula and (2) early one-step versus delayed two-step anastomosis. Multivariate analysis was performed. RESULTS: Overall, 80 cases of OA were included. Absence of a distal fistula was significantly associated with higher rates of small/absent stomach (100% vs 28.6%, P<0.0001), oesophageal pouch (100% vs 24.3%, P<0.0001) and severe polyhydramnios (66.7% vs 22.9%, P=0.006), compared with OA with a distal fistula.Cases requiring a delayed two-step repair had higher rates of small/absent stomach (84.2% vs 16.7%, P>0.0001), severe polyhydramnios (47.4% vs 16.7%, P=0.008) and oesophageal pouch (73.7% vs 18.5%, P<0.0001), compared with those corrected in an early one-step anastomosis.Multivariate logistic regression found small/absent stomach and pouch to be significantly and independently associated with a delayed two-step anastomosis. CONCLUSION: OA without a distal fistula is associated with higher rates of prenatal sonographic signs. Both small/absent stomach and a pouch are independently associated with a delayed two-step anastomosis. These findings may help improve antenatal parental counselling regarding the anticipated surgical repair.

The added value of third trimester fetal brain MRI in cases of isolated ventriculomegaly.

OBJECTIVES: To assess the added value of third trimester fetal brain MRI, performed in one tertiary referral center, in cases of isolated ventriculomegaly as established by a dedicated multiplanar neurosonography. METHODS: Fetal brain MRI scans performed in a single tertiary center during a 3-year period were assessed for possible inclusion. Only cases diagnosed with ventriculomegaly without additional findings in a neurosonography preceding the MRI were included. Fetal MRI was performed at a median gestational of 32 weeks (IQR 31-34 weeks). RESULTS: A total of 68 cases met the inclusion criteria. Of them, in four cases MRI identified additional findings including three cases of intraventricular hemorrhage and one case of cortical infarction. The overall rate of MRI-findings in the study population was (5.9%, 95% CI 2.3-14.2%). No additional findings were detected in cases of mild ventriculomegaly, 6.1% in moderate and 25% in severe ventriculomegaly. The combined rate of additional findings in mild to moderate ventriculomegaly was 3.3% (95%CI 0.9-11.4%). CONCLUSIONS: MRI was able to detect additional findings in 5.9% of cases with seemingly isolated ventriculomegaly after a dedicated neurosonography. The severity of ventriculomegaly is associated with a higher chance of detecting abnormalities in fetal brain MRI.

Comparative analysis of ultrasound and MRI in the diagnosis of placenta accreta spectrum.

OBJECTIVES: Placenta accreta spectrum constitutes one of the most complicated challenges in modern obstetrics. Given the conflicting data regarding the added value of MRI in the diagnosis of invasive placentation, we aim to assess individual and combined ability of multiple sonographic and MRI signs to diagnose placenta accreta spectrum in suspected cases. METHODS: We assessed 28 cases of suspected placenta accreta spectrum in the third trimester. All cases underwent ultrasound assessment as well as MRI scan. Diagnosis was confirmed during surgery. The value of sonographic and MRI signs in the detection of placenta accreta spectrum was assessed. RESULTS: A total of 23 cases were diagnosed with placenta accreta spectrum during cesarean delivery. Overall, ultrasound was found to be more sensitive and specific compared to MRI (sensitivity of 0.96 and specificity of 0.6 in ultrasound vs. sensitivity of 0.83 and specificity of 0.4 in MRI). However, the use of a post-hoc structured model improved MRI performance to a similar level of ultrasound (sensitivity of 0.96 and specificity of 0.6). CONCLUSIONS: Ultrasound is superior to MRI in the detection of placenta accreta spectrum. However, MRI performance can be greatly improved by the use of a structured scoring system.

Association between level of training and reliability of intrapartum transperineal ultrasound measurement of angle of progression.

OBJECTIVES: Intrapartum transperineal ultrasound (ITU) is an accepted tool for assessing fetal head position and station prior to operative vaginal delivery attempt. However, the validity of intrapartum ultrasound in real-life obstetrics with operators at different proficiency level is yet to be established. We aimed to investigate the association between operator level of training and reliability of angle of progression (AOP) measurements in real-life obstetrics. METHODS: This was a retrospective study in one university medical center. We included women who underwent ITU for the measurement of AOP, before vacuum assisted delivery from November 2017 to September 2020. AOP measurements performed by residents and their correlation to head station were compared to those performed by specialists. RESULTS: A total of 320 cases met the inclusion criteria. In 234 of them, AOP measurements were performed by specialists and in 86 by residents. Average AOP for each station was similar between the specialists and the residents groups, indicating similar accuracy. However, measurements in the residents group were more scattered (median deviation 11.4° vs. 8.9°, respectively, p = .021), indicating poorer precision. CONCLUSIONS: AOP measurements performed by obstetrics and gynecology (OBGYN) specialists are more precise than those performed by residents. Efforts should be taken to improve ITU training and to implement assessment of performance programs.

Relaparotomy post-cesarean delivery: characteristics and risk factors.

PURPOSE: Relaparotomy following cesarean delivery (CD) is performed at a rate of 0.2-1% of CD. The objective of the present study was to identify risk factors for relaparotomy following CD, and to examine whether there is a difference in the risk of relaparotomy between CD performed during different hours of the day. METHODS: A retrospective study on all CD over 10 years compared pregnancies that underwent laparotomy within 1 week following CD to those that did not. RESULTS: Sixty-four patients underwent relaparotomy out of 24,239 CDs (0.26%). In univariate analysis, relaparotomy was significantly associated with pregnancies following assisted-reproductive-technologies odds ratio (OR) 95% confidence interval (CI) 3.15 (1.90-5.22), hypertensive disorders of pregnancy OR 3.05 (1.62-5.72), twin pregnancies OR 95% CI 3.78 (2.21-6.48), preterm deliveries OR 95% CI 2.44 (1.46-4.10), placenta previa OR 95% CI 6.41(2.55-16.09) and urgent CD 1.74 (1.06-2.86), especially during the second-stage of labor OR 95% CI 2.73 (1.34-5.54). The time of day of CD did not influence the rate of relaparotomy. In a multivariable-regression analysis, the adjusted odds ratio for relaparotomy was 10.24 in CD due to placenta previa, and 5.28 in CD performed at the second-stage of delivery. At relaparotomy, active bleeding was found in 50 patients (78.1%), nearly half received packed cells, 12.5% developed consumptive coagulopathy, and 17.2% needed hospitalization in the intensive care unit. 6.3% underwent a second relaparotomy, mainly due to bleeding. CONCLUSION: Placenta previa, and urgent CDs mainly those performed at the second stage of labor are risk factors for relaparotomy after CD.

The association between level of physical activity and pregnancy rate after embryo transfer: a prospective study.

RESEARCH QUESTION: Is physical activity after embryo transfer, as assessed by a smart band activity tracker, associated with decreased pregnancy rates? DESIGN: Prospective observational cohort study comprising infertile women aged < 38 years, who had undergone fewer than three previous embryo transfers, achieved a good ovarian response and were undergoing frozen-thawed embryo transfer in a tertiary-referral centre. A validated smart band activity tracker was used to assess physical activity level immediately after the embryo transfer and until the pregnancy test. No specific recommendations were given to participants on level or intensity of physical activity. Physicians and patients were blinded to the data stored in the pedometer. Primary outcome was ongoing pregnancy rate. RESULTS: Fifty women met the inclusion criteria. Ongoing pregnancy rate was 30%. In a pooled analysis, participants walked significantly fewer steps per day on the day of embryo transfer compared with the first 2 days after embryo transfer (4075, interquatile range [IQR] 2932-5592 versus 5204, IQR4203-8584, P = 0.01). No significant difference was observed between pregnant women and non-pregnant women in the median steps per day after embryo transfer until serum beta-HCG was measured (7569, IQR 6008-10884 versus 6572.5, IQR 5299-8786, P = 0.43). No significant difference was observed in the median number of steps on the day of embryo transfer or the first 2 days after embryo transfer between pregnant and non-pregnant women. CONCLUSIONS: A quantitative objective assessment of the association between physical activity and pregnancy rates after frozen-thawed embryo transfer was conducted. Ambulation after embryo transfer has no adverse effect on pregnancy rates and, therefore, women should resume regular activity immediately after embryo transfer.

Twin discordance: a study of volumetric fetal brain MRI and neurodevelopmental outcome.

OBJECTIVE: This study employed magnetic resonance imaging (MRI) to compare brain volumes of discordant twins and examined their neurodevelopment after birth by using a validated exam. STUDY DESIGN: A prospective historical cohort study of discordant dichorionic diamniotic (DCDA) or monochorionic diamniotic (MCDA) twin fetuses, who undergone an MRI scan to evaluate growth restriction in the discordant twin (weight < 10th centile) during 6 years period, at a single tertiary center. Twenty-seven twin pairs were included in the volumetric study and 17 pairs were included in the neurodevelopmental outcome examination. The volumes of the supratentorial brain region, both hemispheres, eyes, and the cerebellum were measured by 3D MRI semi-automated volume measurements. Volumes were plotted on normal growth curves and discordance was compared between weight at birth and brain structure volumes. Neurodevelopmental outcome was evaluated using the VABS-II questionnaire at a mean age of 4.9 years. RESULTS: The volume of major brain structures was significantly larger in the appropriate-for-gestational-age twins (AGA) compared to the small-for-gestational-age (SGA) co-twins (p < 0.001). The birth weight discordance was 32.3% (24.9-48.6) and was significantly greater (p < 0.001) than the discordance of the prenatal supratentorial brain (13.6% [5.6-18]), cerebellum volume (21.7% [9.5-30.8]). Further neurodevelopmental outcome evaluation found no significant difference between the AGA twin and the SGA twin. CONCLUSION: In discordant twins, the smaller twin showed a "brain-preserving effect," which in our study was not associated with a worse neurodevelopmental outcome. The use of MRI in such cases may aid in decision-making and parental consultation. KEY POINTS: • Weight discordance at birth was significantly greater compared to intrauterine brain volume discordance measured by 3D MRI. • Small-for-gestational-age (SGA) fetuses preserve brain development. • In highly discordant twins, there was no long-term difference in neurodevelopmental outcome at a mean age of 4.9 years.

Cleavage vs blastocyst stage embryos: how are they interrelating?

PURPOSE: To assess the variables that may predict which cleavage-stage embryo may develop into a blastocyst, and vice versa, to determine whether the cleavage-stage embryo morphology should be taken into consideration when transferring the embryo at the blastocyst stage. METHODS: A single center, retrospective cohort study. The study cohort included 3072 patients undergoing 3607 retrieval cycles and 23,124 embryos at the cleavage stage. We assessed the blastulation rate and evaluated which variables impact the ongoing pregnancy rate. RESULTS: High blastulation rate correlates with higher embryos' grading (I > II > III > IV > V) and higher number of blastomeres (8 > 7 > 6 > 5 > 4). 949 patients had fresh single blastocyst transfers. The ongoing pregnancy rate was 28.9% per transfer. Patients with ongoing pregnancies were significantly younger (34.3 vs. 36 years, p < 0.001), had higher number of oocyte yield (9.8 vs. 9, p = 0.02), and an increased rate of good-quality embryos transferred (70.7% vs. 47.7%, p = 0.001). When evaluating embryos progression, we found that whenever embryo developed to a good-quality blastocyst, its appearance at the cleavage stage did not affect ongoing pregnancy rate. CONCLUSION: Higher the number of blastomeres and better embryo grading were found to correlate with a higher blastulation rate. Nevertheless, if the embryo has already developed to a top-quality blastocyst, its morphology at the cleavage stage did not impact ongoing pregnancy rate.