Preeclampsia and risk of developing bronchopulmonary dysplasia in very preterm neonates.

OBJECTIVE: Bronchopulmonary dysplasia (BPD) is a severe common complication of preterm birth with considerable short and long-term consequences. As more evidence is emerging that dysregulation of angiogenesis is implicated in the pathogenesis of preeclampsia as well as in fetal lung development, we assessed if preeclampsia is associated with development of BPD in very preterm neonates. STUDY DESIGN: A retrospective cohort study of 308 infants born between 24+0 and 31+6 weeks of gestation in 2011 and 2012. We performed association analysis with univariable and multivariable logistic regression, adjusting for confounders. Models were additionally adjusted for intermediates, to show how an association can be disguised by over adjusting. MAIN OUTCOME MEASURE: BPD was diagnosed at 36+0 weeks postmenstrual age and defined as the need for oxygen (FiO2 > 0.21) for at least 12 h per day, for more than 28 days before or at 36+0 weeks postmenstrual age, and classified as mild, moderate or severe. RESULTS: After applying our exclusion criteria, we report our primary outcome on 247 mother-neonate pairs. Fifty-nine neonates developed BPD (23.9%) which was moderate to severe in 27 of them (10.9%). Preeclampsia was associated with BPD, adjusted odds ratio, 95% confidence interval: 4.22 (1.63, 10.91). However, after adjusting for additional intermediates no statistical significance remained, adjusted odds ratio, 95% confidence interval: 1.87 (0.49, 7.24). CONCLUSION: This study shows that early-onset preeclampsia is associated with development of BPD in the very preterm neonate. Part of this association is mediated by fetal growth restriction and mode of delivery.

Timing of elective pre-labour caesarean section: A decision analysis.

BACKGROUND: Since caesarean sections (CSs) before 39+0  weeks gestation are associated with higher rates of neonatal respiratory morbidity, it is recommended to delay elective CSs until 39+0  weeks. However, this bears the risk of earlier spontaneous labour resulting in unplanned CSs, which has workforce and resource implications, specifically in smaller obstetric units. AIM: To assess, in a policy of elective CSs from 39+0  weeks onward, the number of unplanned CSs to prevent one neonate with respiratory complications, as compared to early elective CS. MATERIALS AND METHODS: We performed a decision analysis comparing early term elective CS at 37+0-6 or 38+0-6  weeks to elective prelabour CS, without strict medical indication, at 39+0-6  weeks, with earlier unplanned CS, in women with uncomplicated singleton pregnancies. We used literature data to calculate the number of unplanned CSs necessary to prevent one neonate with respiratory morbidity. RESULTS: Planning all elective CSs at 39+0-6  weeks required 10.9 unplanned CSs to prevent one neonate with respiratory morbidity, compared to planning all elective CSs at 38+0-6  weeks. Compared to planning all elective CSs at 37+0-6  weeks we needed to perform 3.3 unplanned CSs to prevent one neonate with respiratory morbidity. CONCLUSION: In a policy of planning all elective pre-labour CSs from 39+0  weeks of gestation onward, between three and 11 unplanned CSs have to be performed to prevent one neonate with respiratory morbidity. Therefore, in our opinion, fear of early term labour and workforce disutility is no argument for scheduling elective CSs <39+0  weeks.

Maternal blood pressure and hypertensive disorders during pregnancy and childhood respiratory morbidity: the Generation R Study.

Pre-eclampsia is associated with an increased risk of bronchopulmonary dysplasia, wheezing and asthma in later childhood. Currently, there are no studies available investigating maternal blood pressure measurements during multiple time-points in pregnancy and respiratory outcome measures in the child.We examined the associations of maternal blood pressure and hypertensive disorders with the risk of lower lung function, wheezing and asthma in children aged 10 years. This study among 4894 children was embedded in a population-based prospective cohort study. We used multivariate analyses, taking lifestyle and socioeconomic factors into account.We observed consistent associations per 5 mmHg higher maternal blood pressure in early pregnancy with a lower forced expiratory volume in 1 s/forced vital capacity ratio (z-score -0.03 (95% CI -0.05- -0.01)) and per 5 mmHg higher blood pressure in late pregnancy with a higher risk for current wheezing and current asthma (OR 1.07 (95% CI 1.02-1.12) and 1.06 (95% CI 1.00-1.11), respectively). We found no associations of maternal hypertensive disorders during pregnancy with child lung function, current wheezing or current asthma.Our results suggest that higher blood pressure in pregnant women is associated with lower lung function and increased risks of current wheezing and current asthma in children. The associations may be trimester specific.

[Timing of elective term caesarean sections; trends in the Netherlands]. / Timing van electieve keizersneden à terme; trends in Nederland.

OBJECTIVE: To analyse if from 2000-2010 the rate of elective caesarean sections (CS) before 39 0/7 weeks of gestation declined when compared with all elective CS, and to evaluate the possible associated factors. DESIGN: Retrospective cohort study. METHOD: Using data from The Netherlands Perinatal Registry, all term elective CS (n = 59,653) from 2000-2010 were selected. Trends in patient characteristics and in performing an elective CS before 39 0/7 weeks were analysed using regression analysis, and differences between hospitals using the χ2 test. Using multiple logistic regression analysis it was analysed which factors were associated with performing an elective CS before 39 0/7 weeks. RESULTS: The percentage of elective CS before 39 0/7 weeks decreased from 56% in 2000 to 43% in 2010 (p < 0.0001). In peripheral hospitals an elective SC was performed more often before 39+0 weeks than in academic hospitals; 53% in peripheral teaching hospitals, 57% in peripheral non-teaching hospitals, and 46% in academic hospitals. Adjusted odds ratios and 95% confidence intervals were 1.38 (1.30-1.47) in peripheral teaching hospitals, and 1.55 (1.46-1.65) in peripheral non-teaching hospitals. In hospitals where the number of deliveries per year was situated in the lower quartile, elective CS before 39 0/7 weeks was carried out more often than in hospitals where deliveries per year were in the upper quartile, 60% versus 52% (p < 0.0001). CONCLUSION: In the period 2000-2009 the timing of elective CS improved marginally. In 2010 the trend began to decline, even though 43% of elective caesarean sections were still carried out before 39 0/7 weeks. This results in a higher risk of neonatal morbidity and health problems in long-term.

Neonatal outcome following elective cesarean section of twin pregnancies beyond 35 weeks of gestation.

OBJECTIVE: We sought to assess neonatal morbidity and mortality of elective cesarean section (CS) of uncomplicated twin pregnancies per week of gestation >35(+0). STUDY DESIGN: We performed a retrospective cohort study in our nationwide database including all elective CS of twin pregnancies. Two main composite outcome measures were defined, ie, severe adverse neonatal outcome and mild neonatal morbidity. RESULTS: We report on 2228 neonates. More than 17% were born <37(+0) weeks of gestation. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for severe adverse neonatal outcome at 35(+0-6), 36(+0-6), and 37(+0-6) weeks were, OR, 9.4; 95% CI, 3.2-27.6; OR, 1.7; 95% CI, 0.5-5.3; and OR, 0.7; 95% CI, 0.2-2.0, respectively; and for mild neonatal morbidity, OR, 4.7; 95% CI, 2.6-8.7; OR, 4.9; 95% CI, 3.1-7.9; and 1.4; 95% CI, 0.9-2.1, respectively, compared to neonates born ≥38(+0) weeks of gestation. CONCLUSION: In uncomplicated twin pregnancies elective CS can best be performed between 37(+0) and 39(+6) weeks of gestation.

Neonatal outcome following elective cesarean section beyond 37 weeks of gestation: a 7-year retrospective analysis of a national registry.

OBJECTIVE: We sought to evaluate number and timing of elective cesarean sections at term and to assess perinatal outcome associated with this timing. STUDY DESIGN: We conducted a recent retrospective cohort study including all elective cesarean sections of singleton pregnancies at term (n = 20,973) with neonatal follow-up. Primary outcome was defined as a composite of neonatal mortality and morbidity. RESULTS: More than half of the neonates were born at <39 weeks of gestation, and they were at significantly higher risk for the composite primary outcome than neonates born thereafter. The absolute risks were 20.6% and 12.5% for birth at <38 and 39 weeks, respectively, as compared to 9.5% for neonates born > or = 39 weeks. The corresponding adjusted odds ratios (95% confidence interval) were 2.4 (2.1-2.8) and 1.4 (1.2-1.5), respectively. CONCLUSION: More than 50% of the elective cesarean sections are applied at <39 weeks, thus jeopardizing neonatal outcome.

Fetal complications after placement of an intrauterine pressure catheter: a report of two cases and review of the literature.

BACKGROUND: Uterine contractions during labor can be monitored by external tocodynamometry or by the use of an intrauterine pressure catheter (IUPC). Since an IUPC measures the frequency of contractions as well as their strength and duration, it is thought to be more accurate than external tocodynamometry. However, limited evidence on this subject suggests that IUPC may not improve maternal or perinatal outcomes. Moreover, the use of IUPC may cause fetal complications. CASES: We describe the placement of an IUPC during induction of labor with oxytocin in two cases, one presenting with a singleton pregnancy and the other a twin pregnancy. After introduction of the IUPC, both cases were complicated by blood loss and signs of fetal distress on cardiotocography. An emergency cesarean section was performed in both cases. In the first case, extramembranous placement of the IUPC was observed, whereas in the second case, the IUPC had lacerated an arteriovenous anastomosis in the membranes, resulting in perinatal death. CONCLUSION: Placement of an intrauterine pressure catheter instead of external tocodynamometry has a small risk for serious fetal complications.

Magnetic resonance angiography of collateral blood supply to spinal cord in thoracic and thoracoabdominal aortic aneurysm patients.

OBJECTIVE: Preservation of spinal cord blood supply during descending thoracic (TAA) and thoracoabdominal aortic aneurysm (TAAA) surgery is mandatory to prevent neurologic complications. Although collateral arteries have been identified occasionally and are considered crucial for maintaining spinal cord function in the individual patient, their critical functionality is poorly understood and very little experience exists with visualization. This study investigated whether the preoperative and postoperative presence or absence of collateral arteries detected by magnetic resonance angiography (MRA) is related to spinal cord function during the intraoperative exclusion of the segmental supply to the Adamkiewicz artery. METHODS: Spinal cord MRA was used to localize the Adamkiewicz artery and its segmental supplier in 85 patients scheduled for open elective surgery for TAA or TAAA. The segmental artery to the Adamkiewicz artery was inside the cross-clamped aortic area in 55 patients, and spinal cord supply was consequently dependent on collateral supply. In these 55 patients the presence of collaterals originating from arteries outside the cross-clamped aortic segment was related to changes in the intraoperative motor-evoked potentials (MEPs) that occurred before corrective measures. Twenty-one patients returned for postoperative MRA. RESULTS: A highly significant (P < .0015) relation was found between the presence of collaterals and intraoperative spinal cord function. In 30 of 31 patients (97%) in whom collaterals were identified, MEPs remained stable. The collaterals in most patients originated caudally to the distal clamp (eg, from the pelvic arteries), which were perfused by means of extracorporeal circulation during cross-clamping. The MEPs declined in 9 of 24 patients (38%) in whom no collaterals were preoperatively visualized. Postoperatively, the 21 patients who had MRA, including 10 in whom preoperatively no collaterals were found, displayed a well-developed collateral network. CONCLUSION: Collateral arteries supplying the spinal cord can be systematically visualized using MRA. Spinal cord blood supply during open aortic surgery may crucially depend on collateral arteries. Preoperatively identified collateral supply was 97% predictive for stable intraoperative spinal cord function. Patients in whom no collaterals can be depicted preoperatively are at increased risk for spinal cord dysfunction.