Postpartum antihypertensive treatment: Is there a correlation to placental lesions?

OBJECTIVE: We aimed to examine the association of clinical risk factors and placental lesions, in gestations complicated with preeclampsia, with the need for antihypertensive treatment in the early postpartum period. METHODS: The computerized files and placental reports of all singleton deliveries at 24.0-42.0 weeks complicated by preeclampsia were reviewed between January 2013 and October 2020. Obstetric characteristics and placental lesions were compared between patients who required antihypertensive treatment in the early postpartum period and those who did not (control group). Placentas were classified into maternal and fetal malperfusion lesions and inflammatory responses. RESULTS: As compared to controls (n = 200), the anti-hypertensive treatment group (n = 95) was characterized by increased rates of preterm birth, preeclampsia with severe features, and cesarean delivery (p < 0.001 for all). More placental hematomas (p = 0.01) and placental maternal vascular lesions (p = 0.03) were observed in the antihypertensive treatment group as compared to controls. In adjusted logistic regression analysis, gestational age (OR 0.86, 95% CI 0.79-0.93, p = 0.001) and preeclampsia with severe features (OR 8.89, 95% CI 3.18-14.93 p < 0.001) were found to be independently associated with the need for postpartum antihypertensive treatment. CONCLUSION: Placental vascular lesions are more common in preeclamptic patients who need postpartum antihypertensive treatment, yet only early onset of preeclampsia with severe features was found to be independently associated with antihypertensive treatment in the early postpartum period.

The effect of watching an informational video prior amniocentesis on maternal anxiety: a randomized controlled trail.

PURPOSE: This randomized controlled trial aimed to ascertain the effect of a pre-procedure informational video on anxiety, pain perception, and satisfaction levels in patients undergoing amniocentesis. METHODS: Patients were randomized into two groups: a video group who watched an informational video prior to the procedure, and a control group who received standard care. Anxiety was gauged both pre- and post-procedure via the State-Trait Anxiety Inventory (STAI) score. Post-procedure, patients' perceived pain, anxiety, and satisfaction levels were evaluated using the Visual Analog Scale questionnaire (VAS). RESULTS: Of 110 randomized patients, 100 completed the study and were included in the final analysis. No significant difference was noted in overall anxiety levels between the study and control groups. However, in-procedure anxiety was significantly lower in the video group compared to the control group (p = 0.04). Among patients undergoing amniocentesis for the first time, the subgroup analysis revealed reduced levels of anxiety during the procedure and diminished pain 10 min after the procedure in the video group compared to the control group. (p = 0.041 and p = 0.025, respectively). CONCLUSION: A pre-procedural informational video could help in alleviating anxiety and mitigating pain during amniocentesis. CLINICAL TRIAL REGISTRATION: The study was registered at 27.3.2022 in clinical-trials.gov (identifier NCT05463549).

Placental vascular lesions differ between male and female fetuses in early-onset preeclampsia.

PURPOSE: A growing body of evidence accumulate pointing to sex-specific differences in placental adaptation to pregnancy complications. We aimed to study if there is a difference in placental histopathology lesions, between female and male fetuses in pregnancies complicated with preeclampsia. METHODS: The medical files of all patients with preeclampsia, were reviewed. Placental lesions were classified to lesions related to maternal or fetal malperfusion lesions (MVM, FVM), vascular and villous changes, and inflammatory lesions. Comparison was performed between the male and the female groups. RESULTS: The study included 441 preeclamptic patients. Women in the male preeclampsia group (n = 225) had higher rate of chronic hypertension (p = 0.05) and diabetes mellitus (p < 0.005), while women in the female preeclampsia group (n = 216) had higher rate of thrombophilia. There were no between groups differences in neonatal outcome or placental histopathology lesions. The early preeclampsia cohort included 91 patients. Placentas from the female early preeclampsia group (n = 44) had more vascular changes related to MVM lesions (decidual arteriopathy), as compared to the male early preeclampsia group (n = 47), 50% vs. 25%, p = 0.01. CONCLUSIONS: Higher rate of placental MVM lesions in the female as compared to male group correspond with sex-specific difference of placental pathophysiological adaptation, in early preeclampsia.

Should the interval between doses of antenatal corticosteroids be shortened in certain cases? Factors predicting preterm delivery < 48 h from presentation.

PURPOSE: Treatment with antenatal corticosteroids (ACS) to women at risk for preterm birth (PTB) is associated with a reduction in adverse neonatal outcomes. Obstetricians occasionally shorten the interval between the doses of steroids if delivery is predicted to occur before ACS are fully administered. In this study, we aimed to investigate predicting factors to identify patients that will deliver prematurely, less than 48 h from presentation. METHODS: The computerized medical files of all PTBs (< 34 weeks) were reviewed. Maternal demographics, pregnancy and delivery characteristics were compared between PTB that occurred < 48 h vs. > 48 h from triage presentation. RESULTS: In total, 494 PTB cases were included: 302 women in the study group (PTB < 48 h) and 192 women in the control group (PTB > 48 h). No significant differences were found in demographic characteristics between the groups. At presentation, the study group had higher rates of uterine contractions (p < 0.001) and cervical length < 25 mm (p < 0.001) as well as a higher rate of non-reassuring fetal (NRFHR) monitor (p < 0.001). In contrast, the control group presented with higher rates of preeclampsia (p = 0.003) and preterm premature rupture of membranes (p = 0.038). In multivariable analysis, all of the above factors remained significant after controlling for background confounders. CONCLUSIONS: Various factors at presentation can predict delivery < 48 h. These factors can be used to predict patients to whom the ACS interval should be shortened. Future prospective studies should investigate the effect of this shortening on neonatal outcomes.

Protracted postpartum urinary retention-a long-term problem or a transient condition?

INTRODUCTION AND HYPOTHESIS: Protracted postpartum urinary retention (P-PUR) is a rare puerperal complication of overt urinary retention that proceeds beyond the 3rd postpartum day. Long-term consequences of P-PUR are poorly reported. The objective of the study was to compare the long-term outcome of patients with P-PUR with a matched control group, using a validated pelvic floor distress questionnaire. METHODS: All medical files of women diagnosed with P-PUR between 2005 and 2016 were reviewed. The control group was comprised of women who had a consecutive birth, matched in a 1:2 ratio, by maternal age, parity, neonatal birth weight, analgesia, and route of delivery. All women were evaluated for long-term symptoms of urinary or fecal incontinence and pelvic-organ-prolapse-related complaints by a telephone interview, at least 1 year following their delivery, using the Pelvic Floor Distress Inventory-Short Form (PFDI-20) questionnaire. RESULTS: During the study period, there were 27 cases of P-PUR out of 52,662 deliveries (0.051%). There were no differences between the study group (n = 27) and controls (n = 54) in age, BMI (kg/m2), parity, birth weight, route of delivery, and rate of episiotomy. The majority of patients in both groups opted for epidural analgesia. Second stage of labor was longer in the study group than in controls, 134.1 ± 74.6 min vs. 73.4 ± 71.6 min, respectively, p < 0.001. The scores of the PFDI-20, UDI-6, and POPDI-6 did not differ between the groups. However, the study group had minimally elevated scores on the CARDI-8 scale (1.0 ± 2.6 vs. 0.0 ± 0.0, p = 0.012). CONCLUSIONS: P-PUR is a rare postpartum complication, yet this disturbing condition has negligible if any clinical impact on long-term urogynecologic disorders. These findings carry a reassuring message to both patients and their health care providers.

[THE EFFECT OF MAGNESIUM SULPHATE AND LABETALOL ON PLACENTAL VESSELS REACTIVITY USING THE EX-VIVO PLACENTAL PERFUSION MODEL].

BACKGROUND: The use of magnesium sulphate (MgSO4) in combination with antihypertensive drugs such as Labetalol is common in preeclampsia. OBJECTIVES: We aimed to examine the effects of MgSO4 and Labetalol on placental blood vessel reactivity in response to angiotensin II (ATII). METHODS: A dual-perfused single cotyledon model was used. Placentas from normal pregnancies were obtained. Selected cotyledons were cannulated and dually perfused. The intervillous space was infused for 60 minutes with three perfusion protocols: MgSO4 [7 mg%], MgSO4 [7 mg%], with Labetalol [1×10-4 mmol/L] and controls. After 60 minutes, ATII was injected as a bolus into the chorionic artery causing contraction/relaxation response in the fetal compartment. Perfusion pressure was measured continuously during contraction and relaxation phases. RESULTS: Twenty complete experiments were performed (9 controls, 7 with MgSO4 (7mg%) and 4 with MgSO4 [7mg%] and Labetalol [1×10-4 mmol/L]). Basal perfusion pressure did not differ between the treatment groups. Mean area under the pressure curve (AUC), the amplitude of the contraction response and the relaxation factor did not differ significantly between the groups in response to ATII administration. CONCLUSIONS: Magnesium sulphate and Labetalol did not have any effect on feto-placental vasculature reactivity.

The association between severe fetal congenital heart defects and placental vascular malperfusion lesions.

OBJECTIVE: Studies have shown an association between infant with congenital heart defects (CHD) and the risk of preeclampsia. We aimed to characterize placental histopathology from pregnancies who underwent termination of pregnancy (TOP) because of severe CHD. METHODS: This was a case control study. The medical files of all TOPs due to fetal congenital malformations were reviewed. Cases with CHD included hypoplastic left heart, transposition of great arteries, AV canal, tetralogy of Fallot, double outlet RV, and coractation of aorta. The controls included TOPs due to congenital central nervous system defects (CNS group) that were matched in a 1:1 ratio, by gestational age and maternal age. Placental lesions were classified to maternal and fetal vascular malperfusion (MVM and FVM) and inflammatory lesions. RESULTS: Higher rates of any MVM or FVM lesion were observed in placentas from the CHD group (n = 32) as compared with the CNS group (n = 32), 40.6% versus 12.5% respectively, p = .02. As compared with the CNS group, the CHD group had more abnormal coiling of umbilical cord (p = .01). CONCLUSION: Placental vascular malperfusion lesions are more common in pregnancies complicated with CHD as compared with CNS malformations. These findings support the hypothesis of similar etiopathogenetic factors, contributing to the development of preeclampsia and CHD.

The impact of a daily smartphone-based feedback system among women with gestational diabetes on compliance, glycemic control, satisfaction, and pregnancy outcome: a randomized controlled trial.

BACKGROUND: Patient compliance and tight glycemic control have been demonstrated to improve outcome in pregnancies complicated by gestational diabetes mellitus. The use of advanced technological tools, including smartphone-based platforms, to improve medical care and outcomes has been demonstrated in various fields of medicine, but only a few small studies were performed with gestational diabetes mellitus patients. OBJECTIVE: We aimed to study the impact of introducing a smartphone-based daily feedback and communication platform between gestational diabetes mellitus patients and their physicians, on patient compliance, glycemic control, pregnancy outcome, and patient satisfaction. STUDY DESIGN: This is a prospective, single-center, randomized controlled trial. Newly diagnosed gestational diabetes mellitus patients presenting to our multidisciplinary diabetes-in-pregnancy clinic were randomized to: (1) routine biweekly prenatal clinic care (control group); or (2) additional daily detailed feedback on their compliance and glycemic control from the clinic team via an application installed on their smartphone (smartphone group). The primary outcome was patient compliance defined as the actual blood glucose measurements/instructed measurements ×100. The secondary outcomes included diabetes-control parameters, pregnancy, and neonatal outcomes. The study was adequately powered to detect a 20% difference in patient compliance, based on a preliminary phase that demonstrated 70% baseline compliance to glucose measurements. RESULTS: A total of 120 newly diagnosed gestational diabetes mellitus patients were analyzed. The 2 groups did not differ in terms of age, parity, education, body mass index, family history, maternal comorbidities, oral glucose tolerance test values, and hemoglobin A1C at randomization. The smartphone group demonstrated higher level of compliance (84 ± 0.16% vs 66 ± 0.28%, P < .001); lower mean blood glucose (105.1 ± 8.6 mg/dL vs 112.6 ± 7.4 mg/dL, P < .001); lower rates of off-target measurements both fasting (4.7 ± 0.4% vs 8.4 ± 0.6%, P < .001) and 1-hour postprandial (7.7 ± 0.8% vs 14.3 ± 0.8%, P < .001); and a lower rate of pregnancies requiring insulin treatment (13.3% vs 30.0%, P = .044). The rates of macrosomia, neonatal hypoglycemia, shoulder dystocia, and other delivery and neonatal complications did not differ between the groups. Patients in the smartphone group reported excellent satisfaction from the use of the application and from their overall prenatal care. CONCLUSION: Introduction of a smartphone-based daily feedback and communication platform between gestational diabetes mellitus patients and the multidisciplinary diabetes-in-pregnancy clinic team improved patient compliance and glycemic control, and lowered the rate of insulin treatment.

Risk factors for nonreassuring fetal heart rate tracings after artificial rupture of membranes in spontaneous labor.

BACKGROUND: We aimed to characterize factors associated with nonreassuring fetal heart (FHR) tracings after artificial rupture of membranes (AROM), during the active phase of labor. METHODS: Delivery charts of patients who presented in spontaneous labor, at term, between 2015 and 2016 were reviewed. We identified cases in which AROM was performed during the active stage of labor. We compared deliveries with a normal FHR and those who developed nonreassuring FHR. Nonreassuring FHR was defined as fetal tracing that necessitated intrauterine resuscitation, which included: oxytocin withheld, amnioinfusion, or immediate instrumental or cesarean birth. RESULTS: Of 664 deliveries, nonreassuring FHR occurred in 141 (21.2%) and normal FHR in 523 (78.7%). Both groups were notable for similar maternal characteristics and a similar gestational age. Epidural block was significantly more common in the nonreassuring FHR group (P < .001), as was meconium during delivery (P = .01). Deliveries in the nonreassuring FHR group were characterized by significantly lower Bishop scores at AROM. Mean birthweight was significantly lower in the nonreassuring FHR group (3201 ± 418 vs 3342 ± 376 g, P < .001), yet, neonatal outcome did not differ between the groups. In a multivariate logistic regression model, nulliparity, AROM at a station lower than -2, and increased birthweight were all significantly associated with a decreased rate of nonreassuring FHR, while prolonged duration from AROM to delivery and oxytocin augmentation significantly increased the risk for nonreassuring FHR. DISCUSSION: Nonreassuring FHR after AROM during delivery is associated with parity, fetal station at AROM, birthweight, and oxytocin augmentation.

Single versus repeat doses of misoprostol for treatment of early pregnancy loss-a randomized clinical trial.

STUDY QUESTION: Does repeat administration of misoprostol for early pregnancy loss increase the treatment success rate? SUMMARY ANSWER: Repeat administration of misoprostol does not increase the treatment success rate, and is associated with more analgesics use. WHAT IS KNOWN ALREADY: Misoprostol reduces the need for surgical evacuation and shortens the time to complete expulsion in patients with early pregnancy loss. However, the impact of repeat doses of misoprostol is not clear. STUDY DESIGN, SIZE, DURATION: A randomized clinical trial was conducted in a single tertiary hospital, recruiting women with early pregnancy loss (<12 weeks), seeking medical treatment, between August 2015 and June 2016. A sample size of 160 patients was sufficient to detect a 30% decrease in treatment success. PARTICIPANTS/MATERIALS, SETTING, METHODS: Participants received 800 µg of misoprostol vaginally on Day 1, and were then randomly assigned into two groups: Patients in the single-dose group were evaluated on Day 8. Patients in the repeat-dose group were evaluated on Day 4, when they were given a repeat dose if required, and scheduled for re-evaluation on Day 8. If complete expulsion was not achieved on Day 8 (endometrial thickness >15 mm or the presence of gestational sac on transvaginal sonography), participants underwent surgical evacuation. The primary outcome was treatment success, defined as no need for surgical intervention up to Day 8. MAIN RESULTS AND THE ROLE OF CHANCE: Final analysis included 87 participants in the single-dose group and 84 participants in the repeat-dose group, out of whom 41 (48.8%) received a second dose. Treatment succeeded in 67 (77%) patients in the single-dose group and 64 (76%) patients in the repeat-dose group (RR 0.98; 95% CI 0.83-1.16; P = 0.89). Patients in the repeat-dose group reported more use of over the counter analgesics (82.1% versus 69.0%, P = 0.04). LIMITATIONS, REASONS FOR CAUTION: The study was not blinded and our definition of complete expulsion may be debated. Follow-up time was not equal in all participants, since some had a complete expulsion on Day 4 and some underwent emergent D&C before Day 8. This, however, should not affect the primary outcome. WIDER IMPLICATIONS OF THE FINDINGS: Our results suggest that a single-dose protocol is superior to a repeat-dose protocol due to a comparable success rate and more favorable outcomes regarding the need for analgesic drugs. STUDY FUNDING/COMPETING INTEREST(S): We did not receive funding for this study and we declare no conflict of interest. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov (NCT02515604). TRIAL REGISTRATION DATE: 2 August 2015. DATE OF FIRST PATIENT'S ENROLMENT: 19 August 2015.

The Association between Disproportionate Birth Weight to Placental Weight Ratio, Clinical Outcome, and Placental Histopathological Lesions.

INTRODUCTION: High and low birth weight (BW) to placental weight (PW) ratios (BW/PW) have been proposed as markers of placental malfunction. We studied the association of clinical outcome and placental histopathology lesions with BW/PW ratios. MATERIALS AND METHODS: During the period between 2008 and 2013, placentas from deliveries at gestational age (GA) ≥37 weeks, including both complicated and uncomplicated pregnancies, were sent for histopathology evaluation. Maternal and labor characteristics and pathological reports of the high BW/PW ratio group (>90th), normal BW/PW ratio group (10-90), and low BW/PW ratio group were compared (<10th). RESULTS: The BW/PW ratio increased as GA increased, with an average GA of 39.4 ± 1.2 weeks in the normal BW/PW ratio group (p < 0.001). Patients with diabetes mellitus and smokers were more common in the low BW/PW ratio group (p < 0.001). Placental maternal stromal vascular lesions and villitis of unknown etiology (VUE) were more common in the high BW/PW ratio group (p < 0.001 and p = 0.03, respectively). By logistic regression analysis, GA, placental maternal stromal vascular lesions, and VUE were found to be independently associated with a high BW/PW ratio, while diabetes mellitus and smoking were independently associated with a low BW/PW ratio. DISCUSSION: The BW/PW ratio increases significantly beyond 39th weeks, and is associated with an increased rate of placental maternal stromal vascular lesions and VUE.

Fetal anomaly diagnosis and termination of pregnancy in Ireland: a service evaluation following implementation of abortion services in 2019.

BACKGROUND: Approximately 3% of pregnancies are diagnosed with a fetal anomaly, of which a proportion is fatal or life-limiting. The introduction of legislation for termination of pregnancy in Ireland in 2019 for conditions "likely to lead to the death of the fetus" made termination of pregnancy for "fatal fetal anomaly" an option for pregnant women in Ireland. OBJECTIVE: This study examined all cases of termination of pregnancy performed for major fetal anomaly over the first 3 years of service implementation, including cases that did not meet the legal criteria, resulting in women traveling outside Ireland for abortion care. STUDY DESIGN: A retrospective service evaluation of tertiary fetal medicine clinics in 2 tertiary maternity hospitals between 2019 and 2021 was undertaken. We compared pregnancies of patients diagnosed with fatal fetal anomaly who underwent termination of pregnancy in Ireland with those of patients who did not meet the legal criteria and hence traveled outside Ireland for termination of pregnancy. RESULTS: Overall, 139 pregnancies met the inclusion criteria; 83 (59.7%) patients had termination of pregnancy in the tertiary maternity hospital (local), and 56 (40.3%) traveled abroad, mainly to the United Kingdom. Demographic characteristics were similar between the 2 groups, as was gestation at diagnosis and delivery. All cases where termination of pregnancy was local were discussed at fetal medicine multidisciplinary meetings, as opposed to 34% of cases of patients who ultimately traveled outside Ireland for termination of pregnancy. The most common indication (25/83; 30.1%) for local termination of pregnancy was trisomy 18, followed by anencephaly. Traveling to obtain abortion care was mainly due to diagnosis of trisomy 21 (30/56; 53.6%), followed by other multiple structural anomalies/syndromes deemed locally as not meeting the legal criteria. CONCLUSION: Legislation for termination of pregnancy for fetal anomaly, restricted to fatal diagnoses, is difficult to implement, requires significant multidisciplinary input, and can lead to limited services for pregnancies diagnosed with major fetal anomalies. Our findings emphasize the impact of legislative barriers to abortion care for fetal anomaly and the need for policies and services that support women's access to termination of pregnancy for fetal anomaly.

Fetal growth restriction, neonatal morbidity and placental pathology in dichorionic twins-a comparison of twin-specific versus singleton growth charts .

INTRODUCTION: Fetal growth restriction (FGR) in dichorionic diamniotic (DCDA) twin gestations is a known complication associated with adverse neonatal outcomes. The international guidelines have no consensus on whether to use singleton or twin-specific growth charts. Thus, we aimed to compare growth charts in correlation with pregnancy outcomes and placental histopathology. METHODS: The medical files of all DCDA twin deliveries between 2010 and 2020 were reviewed. Birthweight percentile for gestational age (GA) for each individual neonate was assigned using the updated local singleton and twin-specific growth chart. We then divided the study population into two groups, neonates that were FGR based on the local singleton charts (FGR-singleton group) versus FGR on both twin-specific and singleton charts (FGR-twin group). Placental lesions were classified as lesions related to maternal or fetal malperfusion lesions (MVM, FVM), vascular and villous changes, and inflammatory lesions. RESULTS: Overall, 185 neonates met the inclusion criteria. The FGR-twin group (59/185) had a higher rate of PE, lower GA at delivery, lower birthweight, and a higher rate of neonatal composite adverse outcomes compared to the FGR-singleton group. Moreover, placental pathology of the FGR-twin group demonstrated a higher rate of MVM lesions (p = 0.035). DISCUSSION: In our cohort, neonates considered FGR based on twin-specific charts had worse neonatal outcomes with underlying placental insufficiency demonstrated by a higher rate of placental malperfusion vascular lesions. Our findings support using a twin-specific chart to diagnose FGR that is more clinically relevant.

Postpartum post-traumatic stress symptoms during the COVID-19 period: exposure and fear as mediating factors.

Background: Post-traumatic stress symptoms (PTSS) following childbirth are common within a stressful environment and are mitigated by social support. During the COVID-19 pandemic, an increase in such symptoms has been reported. The current study aims to longitudinally model the influence of general and pandemic-specific risk and protective factors on the temporal unfolding of symptoms among postpartum women.Methods: Participants were 226 women following a liveborn, term birth during the first lockdown in Israel. Participants completed questionnaires 10 weeks (T1) and 6 months (T2) after delivery. PATH analyses included predictors of symptoms in T1: demographics, exposure to traumatic events, medical complications during delivery or pregnancy, exposure to COVID-19-related events and their subjective impact, fear of COVID-19, and social support. Predictors of symptoms in T2 were: T1 predictors, both as direct effects and mediated by T1 PTSS, as well as predictors measured again in T2.Results: Results showed the suggested model fit the data. The effect of COVID-19-related fear and subjective impact at T1 on symptoms at T2 were fully mediated by PTSS in T1, as were the effects of marriage and high social support at T1. COVID-19-related fear at T2 positively predicted symptoms at T2, while social support at T2 had the opposite effect. Medical complications during pregnancy negatively predicted symptoms in T2 only.Discussion: Persistent fear appears to be a risk factor and supports a consistent buffer in postpartum PTSS during the COVID-19 pandemic. Medical complications during pregnancy served as a protective factor, possibly due to habituation to medical settings.

Post-traumatic stress symptoms (PTSS) following childbirth during the COVID-19 pandemic may unfold in a unique manner, relating to pandemic-related stressors and fears.Women who experience stressful pandemic-related events are not at heightened risk of developing PTSS within the six months following birth, but those reporting COVID-19 related fears are.Women who had medical complications during pregnancy, but not delivery, are at lower risk of developing subsequent PTSS, perhaps due to their ongoing contact with medical facilities despite the pandemic.

Perinatal outcomes and placental histology in small-for-gestational-age pregnancies-A comparison of population-based and universal growth charts.

OBJECTIVE: To assess obstetric, perinatal, and placental histologic findings in small-for-gestational-age (SGA) neonates according to different growth charts. METHODS: A retrospective cohort of singleton deliveries from 2008 to 2019 were divided into SGA neonates according to the local population-based chart, SGA according to universal standard growth charts (but appropriate for gestational age [AGA] according to local charts) and AGA deliveries according to both charts. RESULTS: A total of 626 local population SGA deliveries, 132 universal SGA and 468 AGA deliveries were compared. The local population SGA group had a significantly higher rate of preterm and cesarean deliveries. An adverse neonatal outcome occurred in 27.2% of the local population SGA group, 9.8% of the universal SGA group and 6.7% of the AGA group (P < 0.001). In the local population SGA group, placental weight was lower, birth weight to placental weight ratio was highest, and the rate of maternal malperfusion lesions was highest-55.4% versus 45.4% in the universal SGA group and 39.1% in the AGA group (P < 0.001). Villitis of unknown etiology was significantly more common and histologic chorioamnionitis was significantly less common in the local population SGA group. CONCLUSIONS: Our findings support the use of a local population-based growth chart for the diagnosis of fetal growth restriction.

Is there an impact of fetal sex in dichorionic discordant twins on placental histopathological abnormalities?

INTRODUCTION: Growth discordancy in dichorionic diamniotic (DCDA) twin gestations is a known complication associated with adverse neonatal outcomes. We aimed to study the differences in placental pathology, in relation to fetal sex, in DCDA twin gestations complicated with growth discordancy. METHODS: The medical files of all DCDA twin deliveries complicated by growth discordancy between 2010 and 2020 were reviewed. Growth discordance was defined as a gap between twin birthweights > 20%. A comparison was made between female vs. male growth discordant twins. Placental lesions were classified as lesions related to maternal or fetal malperfusion lesions (MVM, FVM), vascular and villous changes, and inflammatory lesions. RESULTS: Included 174 DCDA twins. Eighty-eight were in the discordant female group and eighty-six in the discordant male group. The groups did not differ in maternal demographics, pregnancy characteristics, and neonatal outcome. The discordant male group had a higher rate of placental MVM lesions as compared to the discordant female group (p = 0.003). The increased rate of placental MVM lesions in the discordant male group compared to the discordant female group did not change whether its co-twin was of similar or opposite sex. DISCUSSION: Higher rate of MVM lesions characterizes growth discordant male neonates in DCDA twin gestations. This finding could represent a different adaptation of male fetuses to a hostile intrauterine environment.

An informative video before planned cesarean delivery and maternal anxiety-a multicenter randomized controlled trial.

BACKGROUND: Cesarean delivery is one of the most common procedures performed in obstetrics, and although cesarean delivery is a blissful occasion, it is commonly associated with fear and anxiety for the new mother. OBJECTIVE: We aimed to study the impact of watching a detailed, informative video on maternal anxiety levels, childbirth experience, and patient satisfaction in patients undergoing a primary cesarean delivery. STUDY DESIGN: We performed a multicenter randomized control trial. Women scheduled to undergo a primary nonemergent cesarean delivery were recruited. All participants in the intervention group watched an informative video on recruitment. This 4-minute video described in detail the expected cesarean delivery process: preparations before entering the operation room, regional anesthesia administration, sterile covering, the surgical procedure itself, and recovery (including mobilization and lactation). Situation-specific anxiety was measured at recruitment, before exposure to the video (S1), at the day of the operation (S2), and at postpartum day 1 (S3) using the State-Trait Anxiety Inventory score. In addition, participants answered a 10-item Childbirth Experience Questionnaire. A sample size of 63 per group was planned to achieve 80% power to detect a difference of 5 points in the primary outcome (State-Trait Anxiety Inventory score on the day of the operation). RESULTS: Overall, 154 participants from 4 medical centers were randomized, and 132 participants were analyzed after completing all questionnaires, 64 participants in the video group and 68 participants in the control group. The groups did not differ in demographics and delivery characteristics and had similar baseline anxiety levels (S1). On operation day (S2, the primary outcome), significantly lower anxiety levels were reported in the video group than in the control group (State-Trait Anxiety Inventory scores, 41.3±9.5 vs 49.3±10.3; P<.001). Moreover, anxiety levels in postpartum day 1 (S3) remained significantly lower in the video group (P<.001). No difference between the groups in childbirth experience score or patient satisfaction was demonstrated. CONCLUSION: A detailed informative video shown to patients before primary cesarean delivery decreased maternal anxiety levels before and after the procedure.

Smartphone-based counseling and support platform and the effect on postpartum lactation: a randomized controlled trial.

BACKGROUND: Human milk lactation provides health benefits for both the mother and infant. Patients commonly report stopping breastfeeding sooner than they planned. Interventions with proper accessible counseling and support to the mother can potentially increase lactation rates and duration. OBJECTIVE: This study aimed to investigate the impact of introducing a smartphone-based daily feedback and counseling platform between women after delivery and a multidisciplinary lactation support team on lactation rates and various maternal and neonatal outcomes. Counseling was provided via a specifically developed application from a multidisciplinary team (obstetricians, nurses, lactation counselors, and psychologist) in an attempt to assist and counsel to maintain lactation. STUDY DESIGN: This was a prospective, single-center, randomized controlled trial. Women planning to lactate were recruited at postpartum day 1 and were randomized to (1) routine lactation counseling and support (control group) or (2) additional daily detailed counseling and feedback on lactation from the team via the application (App group). The primary outcome was partial or full lactation at 3 months after delivery. The secondary outcomes included lactation at additional time points up to 6 months after delivery. The study was adequately powered to detect a 15% difference in the primary outcome. RESULTS: A total of 197 patients were recruited, 97 in the App group and 100 in the control group. The 2 groups did not differ in any background or delivery characteristics. The App group showed higher rates of lactation 6 weeks after delivery (96.9% vs 82.0%; P<.001) and 3 months after delivery (81.4% vs 69.0%; P=.049) than the control group. Patients in the App group reported excellent satisfaction from the use of the application and their overall postnatal care. CONCLUSION: Our study has provided further information on the growing efficacy of technology platforms in obstetrical care. The introduction of a smartphone-based daily feedback and counseling platform between postpartum patients and a multidisciplinary lactation support team increased the lactation rates after delivery with excellent patient satisfaction.

Postpartum Depression in COVID-19 Days: Longitudinal Study of Risk and Protective Factors.

COVID-19 impacted the childbirth experience and increased the rates of postpartum depression (PPD). We assessed the longitudinal effects of the pandemic on the rates of PPD and evaluated the PPD causes and symptoms among women who delivered during the first COVID-19 quarantine in Israel. The participants completed online questionnaires 3 (T1) and 6 months (T2) following delivery. We used the 'COVID-19 exposure' questionnaire, while PPD symptoms, situational anxiety, and social support were evaluated with the EPDS, STAI, and MSPSS questionnaires. The mean EPDS scores increased between T1 and T2 (6.31 ± 5.6 vs. 6.92 ± 5.9, mean difference −0.64 ± 4.59 (95% CI (−1.21)−(−0.06)); t (244) = −2.17, p = 0.031), and the STAI scores decreased (45.35 ± 16.4 vs. 41.47 ± 14.0, t(234) = 4.39, p = 0.000). Despite the exposure to an increased number of COVID-19 events (3.63 ± 1.8 vs. (6.34 ± 2.3)), the impact of exposure decreased between T1 and T2 (8.91 ± 4.6 vs. 7.47 ± 4.1), p < 0.001). In the MSPSS, significant differences were noted on the family scale between the T1 (6.10 ± 1.3) and T2 (5.91 ± 1.4) scores; t (216) = 2.68, p = 0.0008. A regression analysis showed three statistically significant variables that correlated with increased EPDS scores: the MSPSS family subscale (F (1212.00) = 4.308, p = 0.039), the STAI scores (F (1212.00) = 31.988, p = 0.000), and the impact of exposure to COVID-19 (F (1212.00) = 5.038, p = 0.026). The rates of PPD increased for women who delivered during the first COVID-19 lockdown. Further research is warranted to help reduce PPD among these women.

Management of pregnancies with suspected preeclampsia based on 6-hour vs 24-hour urine protein collection-a randomized double-blind controlled pilot trial.

BACKGROUND: Traditionally, the diagnosis of preeclampsia requires elevated blood pressure measurements and proteinuria demonstrated in a 24-hour urine collection. This prolonged urine collection is associated with patient discomfort, a delay in diagnosis, and in some cases, hospitalization for further management of outcomes. OBJECTIVE: We aimed to assess the feasibility, reliability, and association between maternal and neonatal outcomes of pregnancies managed according to a 6-hour vs 24-hour urine protein collection for suspected preeclampsia. STUDY DESIGN: This was a randomized controlled trial conducted at a tertiary university hospital between January 2019 and January 2021 (ClinicalTrials.gov Identifier: NCT03724786). Patients who were hospitalized for preeclampsia workup were asked to participate and randomized at a 1:1 ratio to 6- and 24-hour urine protein collection groups. Both groups collected urine for 24 hours, during which the collection was also tested after 6-hours. After 24 hours, both results were reviewed by one of the research staff, and either the 6- or 24-hour collection result was reported to the patient's managing physician and was documented in the patient's medical record. Both patient and the managing physician were blinded to group allocation. Unblinding was undertaken in cases of a discrepancy between the results (1 of 2 results of >300 mg protein), and the results were analyzed by intention to treat. The primary study outcome was defined as a composite of adverse maternal outcomes. The sample size was set empirically as per proof on concept design. RESULTS: During the study period, 115 patients participated in the trial, 101 of whom completed the follow-up and were analyzed-51 in the 6-hour group and 50 in the 24-hour group. Patient demographics were similar between the study groups. Unblinding occurred in 7 cases in the 6-hour group, in which the initial 6-hour result ranged from 168 to 475 mg. The rates of composite adverse maternal outcomes were 15.6% and 12.0% in the 6- and 24-hour groups, respectively (P=.59). No significant difference was demonstrated in the rate of adverse neonatal outcomes, cesarean delivery, induction of labor, gestational age at delivery, betamethasone treatment, or neonatal birthweight. CONCLUSION: Managing pregnancies suspected of preeclampsia with a 6-hour urine protein collection is feasible and associated with similar maternal and neonatal outcomes. In cases where the 6-hour result is in the 168 to 475 mg range, we propose completing a 24-hour collection.