Foetal Intrapartum Compromise at Term: Could COVID-19 Infection Be Involved? A Case Report.

The impact of the SARS-CoV-2 infection on pregnancy has been studied and many reports have been published, mainly focussing on complications and in utero transmission with neonatal consequences. Although the effects of other viruses on foetuses are well known, the impact of maternal COVID-19 during pregnancy is not completely understood. We report a case of acute foetal intrapartum hypoxia without other risk factors than maternal COVID-19 disease 2 weeks previous to birth at term. Placental histological changes suggested that the viral infection could have been the culprit for the unfavourable outcome during labour. The neonate was promptly delivered by Caesarean section. Neonatal intensive care was started, including therapeutic hypothermia. The procedure was successful, the evolution of the neonate was favourable, and she was discharged after 10 days. Follow-up at 2 months of life indicated a normal neurological development but a drop in head growth. The case raises the idea that pregnancies with even mild COVID-19 symptoms may represent the cause of neonate compromise in a low-risk pregnancy. An important follow-up in the neonatal period and infancy is required to identify and treat any subsequent conditions. Further long-term studies are necessary to identify a cause-effect relationship between COVID-19 pregnancies and the whole spectrum of neonatal and infant consequences.

Crosstalk between foetal vasoactive peptide hormones and placental aminopeptidases regulates placental blood flow: Its significance in preeclampsia.

In pregnancy, placental circulation occurs through two independent circulation systems: foetoplacental and uterine (spiral artery)-placental lake. Crosstalk between the foetal peptide hormones, angiotensin II (A-II) and vasopressin (AVP), and their degrading placental aminopeptidases (APs), aminopeptidase A for A-II and placental leucine aminopeptidase for both AVP and oxytocin, primarily regulate placental circulation. On the other hand, placental circulation represents an arteriovenous shunt. In normal pregnancy, the blood pressure decreases, despite increased cardiac output and plasma volume, probably due to the arteriovenous shunt in the growing placenta. Actually, the foetal vasoactive hormones in the foetoplacental circulation are much higher than those in the maternal circulation throughout pregnancy. In normal pregnancy, AP activity derived from the placenta in maternal blood increases with gestation and placental growth. Foetal hypoxia increases the secretion of foetal both AVP and A-II. Although there is an increase in both AP activities in the maternal blood in normal pregnancy, their activities increase more than those in normal pregnancy during mild preeclampsia. However, both AP activities decline significantly compared than those in severe preeclampsia. This suggests that AP prevents leakage of increased foetal vasoactive hormones into the maternal blood in mild preeclampsia, and its protective role breaks down in severe preeclampsia, leading to a massive leak of the hormones into maternal circulation and consequent marked contraction of both the maternal vessels and the uterus. Consequently, AP activity in both placenta and maternal blood acts as the foeto-maternal barrier for foetal vasoactive hormones and thus contributes to the onset of preeclampsia.

The value of neutrophils/lymphocyte ratio in predicting foetuses that need urgent delivery in post-term pregnancies: A prospective study.

OBJECTIVE: To verify the performance of neutrophils ratio to the natural logarithm of lymphocyte ratio in detecting foetuses requiring urgent delivery in post-term pregnancies. METHODS: The prospective observational study was conducted from June 2019 to March 2020, at the University Hospital, Baghdad, Iraq, and comprised post-term pregnant females at a gestational age of 40-41+3 days who were followed up until delivery. Demographic data was recorded for each patient, and all of them were subjected to Doppler examination of biophysical profile and amniotic fluid index. Complete blood count was done to generate neutrophils ratio to the natural logarithm of lymphocyte ratio. Receiver operating characteristic curve determined the cut-off value, sensitivity and specificity of neutrophils ratio to the natural logarithm of lymphocyte ratio. RESULTS: There were 74 post-term pregnant women with a mean age of 28.95±6.71 years and the mean foetal age at delivery was 287.38±3.72 days. Of the total, 49(66.22%) women were delivered >10 days post-term, while 25(33.78%) were delivered urgently <10 days post-term because of regression in their biophysical profile score and foetal compromise. The neutrophils ratio to the natural logarithm of lymphocyte ratio showed significant correlation with biophysical profile and amniotic fluid index scores (p<0.05). The ratio cut-off value was found to be >21.6 associated with highest sensitivity and specificity of 81% and 87.5% respectively. Area under the curve was 0.89 (p<0.001). CONCLUSION: Neutrophils ratio to the natural logarithm of lymphocyte ratio identified foetuses who needed urgent termination in post-term pregnancies.

Cardiac Doppler in poorly controlled gestational diabetics and its link to markers of intra-uterine hypoxia and adverse outcome.

The aim of the study was to investigate foetal cardiac function using the modified myocardial performance index (Mod-MPI) in poorly controlled gestational diabetics and its link with intrauterine markers for hypoxia and to an adverse outcome. In a prospective, cross sectional study, 44 consecutive women with severe or poorly controlled gestational diabetic pregnancies in their third trimester on insulin therapy were recruited and matched with 44 women with normal pregnancies which served as the control group. Using Doppler echocardiography the foetal Mod-MPI was calculated. The foetal Mod-MPI was significantly higher in the diabetic group compared to the controls indicating significant myocardial dysfunction. The Mod-MPI served as an excellent marker of adverse outcomes. Foetal myocardial function was significantly impaired in poorly controlled gestational diabetics and there was a significant link of Mod-MPI to intrauterine markers of hypoxia, as well as to an adverse outcome. Mod-MPI has the potential to improve foetal surveillance in gestational diabetes.IMPACT STATEMENTWhat is already known on this subject? Abnormal foetal cardiac function, as reflected in the modified myocardial performance index, has been reported to be significantly increased in foetuses of poorly controlled diabetics managed on insulin.What do the results of this study add? There is a significant link between abnormal foetal cardiac function to intrauterine markers of hypoxia, as well as to an adverse outcome; and that development of myocardial dysfunction could be one of the main mechanisms, inducing foetal compromise in poorly controlled gestational diabetes.What are the implications of these findings for clinical practice and/or further research? This study explores an interesting concept of foetal pathophysiology in gestational diabetes, namely the concept of "pseudo-hypoxia" in a foetus of a gestational diabetic mother, and this intrauterine "hypoxic stress" in turn leading to myocardial dysfunction. The Mod-MPI, a clinical marker for cardiac dysfunction, can therefore be used in the clinical setting to track a deteriorating metabolic state.

Epidural analgesia during birth and adverse neonatal outcomes: A population-based cohort study.

BACKGROUND: In general, epidural analgesia is considered a safe and efficient way to relieve pain during active labour and is increasingly used in childbirth. It is well documented that epidural analgesia during birth has benefits but also adverse effects. However, evidence is limited on how epidural analgesia influences neonatal outcome in a low-risk population of birthing women. AIM: To examine low Apgar score, foetal hypoxia and admission to the neonatal intensive care unit in neonates of low-risk women receiving epidural analgesia during birth. METHODS: A cohort study using registry data to investigate a population of 23,272 low-risk women giving birth at a university hospital. RESULTS: Epidural analgesia was used in 21.6% of low-risk women during birth. Low Apgar score, foetal hypoxia, and admission to the neonatal intensive care unit were found in 0.6%, 0.6%, and 10.0%, respectively in neonates of mothers receiving epidural analgesia during birth compared to 0.3%, 0.6%, and 5.6%, respectively in the non-exposed group. Epidural analgesia was associated with low Apgar score, adjusted odds ratio 1.76 (95% CI 1.07-2.90) and admission to the neonatal intensive care unit, adjusted odds ratio 1.43 (95% CI 1.26-1.62). A mediation analysis indicates the impact of epidural analgesia on adverse neonatal outcomes was mediated by obstetric complications like maternal fever, labour augmentation, and foetal malpresentation. CONCLUSION: This study found use of epidural analgesia during birth in low-risk pregnant women was associated with infant low Apgar score and admission to the neonatal intensive care unit.

Exposure to parental smoking during pregnancy and handgrip strength in 7-10-year old children.

BACKGROUND: Maternal smoking during pregnancy is a risk factor associated with intrauterine growth retardation and postnatal complications. AIM: To assess the relationship between prenatal exposure to smoking on hand grip strength in children 7-10 years of age. STUDY DESIGN: Generalized Linear Model (GLM) was used to assess the relationship between grip strength and smoking status of parents, controlling for social status, birth outcome and body size. OUTCOME MEASURES: Height, weight and hand grip strength were measured by trained staff. Smoking status of both parents during pregnancy, mother's level of education and birth outcome were reported by questionnaire. SUBJECTS: 734 records (297 boys, 437 girls) of healthy children aged 7-10 years from a survey conducted in 2001-2003 in randomly selected primary schools of Lódz. RESULTS/CONCLUSION: Boys exposed to both maternal and paternal smoking during prenatal life showed lower muscular strength at 7-10 years, but a similar relationship was not observed in girls. Intrauterine hypoxia due to maternal smoking during pregnancy and subsequent postnatal exposure to maternal and paternal smoking may have attenuated the formation and subsequent development of muscle fibres in boys.

Decision-to-delivery interval: Is 30 min the magic time? What is the evidence? Does it work?

Emergency caesarean section is required when delivery can reduce the risk to the life of the mother or foetus. When a caesarean section is indicated for foetal compromise, a decision-to-delivery interval of 30 min (or less) has been suggested as the ideal time frame within which an obstetric team should achieve delivery. In theory, a short decision-to-delivery interval may minimise intra-uterine hypoxia and improve neonatal outcome. Current medical evidence does not support this time frame. There are certain indications for caesarean section that necessitate a much shorter decision-to-delivery interval, but evidence suggests that the majority of neonates may be safely delivered within a longer interval of time. Current tools available for the diagnosis of foetal distress are imperfect, and the concept of foetal distress is poorly defined. Future research should focus on finding accurate means of diagnosing foetal distress in labouring women and establishing universally agreed evidence-based decision-to-delivery targets without compromising maternal or foetal safety.

Unexpected and sudden death due to undiagnosed medulloblastoma in twin pregnancy: A case report.

The authors describe an unusual case of sudden and unexpected death caused by a medulloblastoma in a woman aged 28, native of South America, at the 33rd week of twin pregnancy, with neurological signs appeared a month before death. The initial symptoms were attributed to epiphenomena of pregnancy. Two weeks after hospitalization, the woman showed an acute frontal headache that prevented movement and caused a rapid lowering of arterial oxygen saturation. The patient died around 3h later, despite resuscitation. Immediately after, a caesarean section was performed but it was not enough to prevent the death of the two foetuses. The autopsy revealed the presence of a tumour between the left lobe of the cerebellum and the vermis. Histological examination enabled to identify a medulloblastoma. Death was attributed to acute cardio-respiratory insufficiency caused by compression of the brain stem. Foetuses showed no malformation and their death was due to an acute hypoxia resulting from the mother cardiovascular arrest.

Neurological damage arising from intrapartum hypoxia/acidosis.

Complications occurring at any level of foetal oxygen supply will result in hypoxaemia, and this may ultimately lead to hypoxia/acidosis and neurological damage. Hypoxic-ischaemic encephalopathy (HIE) is the short-term neurological dysfunction caused by intrapartum hypoxia/acidosis, and this diagnosis requires the presence of a number of findings, including the confirmation of newborn metabolic acidosis, low Apgar scores, early imaging evidence of cerebral oedema and the appearance of clinical signs of neurological dysfunction in the first 48 h of life. Cerebral palsy (CP) consists of a heterogeneous group of nonprogressive movement and posture disorders, frequently accompanied by cognitive and sensory impairments, epilepsy, nutritional deficiencies and secondary musculoskeletal lesions. Although CP is the most common long-term neurological complication associated with intrapartum hypoxia/acidosis, >80% of cases are caused by other phenomena. Data on minor long-term neurological deficits are scarce, but they suggest that less serious intellectual and motor impairments may result from intrapartum hypoxia/acidosis. This chapter focuses on the existing evidence of neurological damage associated with poor foetal oxygenation during labour.

Admission cardiotocography: Its role in predicting foetal outcome in high-risk obstetric patients.

BACKGROUND: Routine and continuous electronic monitoring of foetal heart rate (FHR) in labour has become an established obstetric practice in high-risk pregnancies in industrialised countries. However, the same may not be possible in non-industrialised countries where antenatal care is inadequate with a large number of high-risk pregnancies being delivered in crowded settings and inadequate health care provider to patient ratios. AIMS: The objective of this study was to evaluate the predictive value of the admission cardiotocogram (CTG) in detecting foetal hypoxia at the time of admission in labour and to correlate the results of the admission CTG with the perinatal outcome in high-risk obstetric cases. METHOD: This was a prospective observational study conducted in the labour and maternity ward of a hospital in Gangtok, India, during the period 2008 to 2010. The study included high-risk pregnant women, admitted via the emergency or outpatient department with a period of gestation ≥36 weeks, in first stage of labour with foetus in the cephalic presentation. All women were subjected to an admission CTG, which included a 20 minute recording of FHR and uterine contractions. RESULTS: One hundred and sixty patients were recruited. The majority of women were primigravida in the 21-30 years age group. About 42% patients were postdated pregnancy followed by pregnancy-induced hypertension (PIH) (15.6%) and premature rupture of membranes (PROM) (11.3%) as the major risk factors. The admission CTG were 'reactive' in 77%, 'equivocal' in 14.4% and 'ominous' in 8.7% women. Incidence of foetal distress, moderate-thick meconium stained liquor and neonatal intensive care unit (NICU) admission was significantly more frequent among patients with ominous test results compared with equivocal or reactive test results on admission. Incidence of vaginal delivery was more common when the test was reactive. CONCLUSION: The admission CTG appears to be a simple non-invasive test that can serve as a screening tool in 'triaging' foetuses of high-risk obstetric patients in non-industrialised countries with a heavy workload and limited resources.