Reliability of last menstrual period recall, an early ultrasound and a Smartphone App in predicting date of delivery and classification of preterm and post-term births.

BACKGROUND: A reliable expected date of delivery (EDD) is important for pregnant women in planning for a safe delivery and critical for management of obstetric emergencies. We compared the accuracy of LMP recall, an early ultrasound (EUS) and a Smartphone App in predicting the EDD in South African pregnant women. We further evaluated the rates of preterm and post-term births based on using the different measures. METHODS: This is a retrospective sub-study of pregnant women enrolled in a randomized controlled trial between October 2017-December 2019. EDD and gestational age (GA) at delivery were calculated from EUS, LMP and Smartphone App. Data were analysed using SPSS version 25. A Bland-Altman plot was constructed to determine the limits of agreement between LMP and EUS. RESULTS: Three hundred twenty-five pregnant women who delivered at term (≥ 37 weeks by EUS) and without pregnancy complications were included in this analysis. Women had an EUS at a mean GA of 16 weeks and 3 days). The mean difference between LMP dating and EUS is 0.8 days with the limits of agreement 31.4-30.3 days (Concordance Correlation Co-efficient 0.835; 95%CI 0.802, 0.867). The mean(SD) of the marginal time distribution of the two methods differ significantly (p = 0.00187). EDDs were < 14 days of the actual date of delivery (ADD) for 287 (88.3%;95%CI 84.4-91.4), 279 (85.9%;95%CI 81.6-89.2) and 215 (66.2%;95%CI 60.9-71.1) women for EUS, Smartphone App and LMP respectively but overall agreement between EUS and LMP was only 46.5% using a five category scale for EDD-ADD with a kappa of .22. EUS 14-24 weeks and EUS < 14 weeks predicted EDDs < 14 days of ADD in 88.1% and 79.3% of women respectively. The proportion of births classified as preterm (< 37 weeks) was 9.9% (95%CI 7.1-13.6) by LMP and 0.3% (95%CI 0.1-1.7) by Smartphone App. The proportion of post-term (> 42 weeks gestation) births was 11.4% (95%CI 8.4-15.3), 1.9% (95%CI 0.9-3.9) and 3.4% (95%CI 1.9-5.9) by LMP, EUS and Smartphone respectively. CONCLUSIONS: EUS and Smartphone App were the most accurate to estimate the EDD in pregnant women. LMP-based dating resulted in misclassification of a significantly greater number of preterm and post-term deliveries compared to EUS and the Smartphone App.

Fetal cerebral and cardiac hemodynamics in postdate pregnancy.

Objective: We aimed to determine the fetal cerebro-placental Doppler indices and modified myocardial performance index (Mod-myocardial performance index (MPI)) in this homogenous group of postdated pregnancies. Methods: A total of 92 singleton pregnant women were included in this prospective study. The study involved three groups; full term control (Group 1, n = 42, 39 0/7 to 40 6/7 week' gestation), late term (Group 2, n = 34, 41 0/7 to 41 6/7 week' gestation) and post term (Group 3, n = 16, ≥ 42 0/7 weeks' gestation). Each participant underwent a Doppler assessment of the fetal umbilical artery (UA), middle cerebral artery (MCA), Mod-MPI. We determined the correlation of the Doppler indices and mod-MPI in patients with unfavorable outcome. Results: MCA pulcatility indices (PI), cerebroplacental ratio (CPR) values were significantly higher in the control group than those in the late-term and post-term groups (Group 1: 1.63 ± 0.3, Group 2: 1.27 ± 0.51, Group 3: 1.13 ± 0.22, respectively, p < .001). The Mod-MPI was significantly higher in the late-term and post-term groups than in the control group (Group 1:0.38 ± 0.1, Group 2: 0.59 ± 0.09, Group 3: 0.60 ± 0.08, respectively, p < .001. MCA PI and CPR were only significantly lower in patients with unfavorable outcome). The threshold value for CPR levels for predicting unfavorable outcome in postdate pregnancies was calculated as 1.11 (area under curve [AUC] 0.762, confidence interval [CI] 0.575-0.95) with 72.7% sensitivity and 71.8% specificity. Conclusions: Fetal Mod-MPI does not differ in postdate pregnancies with favorable and unfavorable outcome. The monitorization of fetal well-being with CPR may help to clinicians to select patient for expectant management in postdate pregnancies.

A pilot study to understand feasibility and acceptability of stool and cord blood sample collection for a large-scale longitudinal birth cohort.

BACKGROUND: Few data are available to guide biological sample collection around the time of birth for large-scale birth cohorts. We are designing a large UK birth cohort to investigate the role of infection and the developing immune system in determining future health and disease. We undertook a pilot to develop methodology for the main study, gain practical experience of collecting samples, and understand the acceptability of sample collection to women in late pregnancy. METHODS: Between February-July 2014, we piloted the feasibility and acceptability of collecting maternal stool, baby stool and cord blood samples from participants recruited at prolonged pregnancy and planned pre-labour caesarean section clinics at University College London Hospital. Participating women were asked to complete acceptability questionnaires. RESULTS: Overall, 265 women were approached and 171 (65%) participated, with ≥1 sample collected from 113 women or their baby (66%). Women had a mean age of 34 years, were primarily of white ethnicity (130/166, 78%), and half were nulliparous (86/169, 51%). Women undergoing planned pre-labour caesarean section were more likely than those who delivered vaginally to provide ≥1 sample (98% vs 54%), but less likely to provide maternal stool (10% vs 43%). Pre-sample questionnaires were completed by 110/171 women (64%). Most women reported feeling comfortable with samples being collected from their baby (<10% uncomfortable), but were less comfortable about their own stool (19% uncomfortable) or a vaginal swab (24% uncomfortable). CONCLUSIONS: It is possible to collect a range of biological samples from women around the time of delivery, and this was acceptable for most women. These data inform study design and protocol development for large-scale birth cohorts.

[Posterm pregnancy]. / Potermínové tehotenství.

UNLABELLED: This review presents the up-to-date information from published resources on the issue of Posterm pregnancy (Medline, Cochrane Database, ACOG, RCOG, SOGC) and complements the presented guidelines. The most of resources are using the term "postterm pregnancy" for pregnancy reaching or exceeding 42+0 weeks and days of gestation, while late pregnancy is defined as a period in between 41+0 and 41+6.The exact determination of gestational age is necessary for exact diagnosis and appropriate management of late and postterm pregnancy, because these pregnancies have increased risk of perinatal morbidity and mortality. DESIGN: Review.

Diagnosis, antenatal surveillance and management of prolonged pregnancy: current perspectives.

Prolonged pregnancy is defined as a pregnancy that extends beyond 42 weeks of gestation (294 days) from the first day of the last normal menstrual period. An accurate estimation of the 'natural' incidence of prolonged pregnancy would require meticulous early pregnancy dating. The use of ultrasound to establish gestational age reduces the number of pregnancies that are classified as prolonged. Prolonged pregnancy is associated with an increased perinatal mortality and morbidity in pregnancies which appear to be otherwise low risk. Postterm births are easily preventable by intervening to deliver with the use of induction of labor. Thus, this potentially problematic condition deserves further attention and careful consideration. The focus of this article is to review and challenge some current concepts surrounding the diagnosis and management of prolonged pregnancy. We outline how to identify those women with prolonged pregnancy and which is the appropriate moment to start monitoring the fetal wellbeing. Finally we address the question of benefits and hazards of induction of labor strategies.

Determinants of number-specific recall error of last menstrual period: a retrospective cohort study.

OBJECTIVE: To assess the digit preference for last menstrual period (LMP) dates, associated determinants and impact on obstetric outcome. DESIGN: Retrospective cohort study. SETTING: University medical centre (the Netherlands). POPULATION: Cohort of 24 665 LMP records and a subgroup of 4630 cases with known crown-rump length (CRL) measurement, and obstetric outcome. METHODS: Digit preference was determined by comparing the observed to expected counts of each day. Associated determinants were identified by multivariate regression analysis. Differences in obstetric outcome between LMP and CRL dating were analysed. MAIN OUTCOME MEASURES: (Non)deprived neighbourhood, cycle irregularity, certainty of LMP date, maternal age, smoking, body mass index, parity and ultrasound investigator. Preterm and post-term delivery. RESULTS: LMP digit preference for the first [odds ratio (OR), 1.28; 95% confidence interval (95% CI), 1.20-1.36], fifth (OR, 1.10; 95% CI, 1.03-1.17), 10th (OR, 1.17; 95% CI, 1.09-1.25), 15th (OR, 1.31; 95% CI, 1.23-1.40), 20th (OR, 1.22; 95% CI, 1.15-1.30) and 25th (OR, 1.08; 95% CI, 1.01-1.15) days of the month occurred more often than expected. Digit preference occurred more frequently in women living in a deprived neighbourhood (OR, 1.21; 95% CI, 1.06-1.39), with uncertain LMP (OR, 2.03; 95% CI, 1.63-2.52) or irregular cycle (OR, 1.24; 95% CI, 1.06-1.44). More post-term (≥42 weeks) deliveries (OR, 1.27; 95% CI, 1.05-1.54) were observed in LMP dating. This effect was larger in women with a digit preference (OR, 1.56; 95% CI, 1.03-2.37). CONCLUSIONS: LMP digit preference occurs more often in women living in deprived neighbourhoods, with uncertain LMP or an irregular cycle. LMP-dated pregnancies are associated with more post-term pregnancies.

[Factors predicting unsuccessful labor induction with dinoprostone in post-term pregnancy with unfavorable cervix]. / Facteurs prédictifs d'échec d'entrée en travail par dinoprostone en cas de grossesse prolongée et de conditions locales défavorables.

OBJECTIVE: To identify predictive factors for unsuccessful induction of labor within 24hours after dinoprostone insertion in post-term pregnancy with unfavorable cervix. MATERIAL AND METHODS: We retrospectively reviewed 325 singleton pregnancies with a diagnosis of post-term pregnancy and unfavorable cervix (Bishop score<6) during the period January 2012-Decembre 2012. Patients were classified into 2 groups: successful labor, defined as cervical ripening, within 24hours after dinoprostone insertion (Group R; n=248; 76.3 %) or failure group (Group E; n=77; 23.7 %). Antepartum and perpartum characteristics of women were compared. RESULTS: Nulliparity (74.0 versus 56.0 %; OR=2.23; 95 % CI: 1.27-4.00; P=0.005), gestational age ≤41 SA+4 (53.2 versus 33.9 %; OR=2.22; 95 % CI: 1.32-3.74; P=0.003) and history of dilatation and curettage (27.3 versus 10.5 %; OR=3.19; 95 % CI: 1.66-6.11; P=0.0005) were significantly associated with unsuccessful induction of labor. Bishop score was significantly higher in Group R (3.6 versus 1.9; P=0.001). Also, consistency (74.0 versus 44.4 %; OR=3.57; 95 % CI: 2.04-6.40; P<10(-5)) and absence of dilatation of the cervix (59.7 versus 23.0 %; OR=4.97; 95 % CI: 2.89-8.56; P<10(-6)) were identified as significant predictive factors for unsuccessful induction of labor. CONCLUSION: Nulliparity, gestational age ≤41 SA+4, history of dilatation and curettage and Bishop score, in particular consistency and dilatation, are correlated with failure of cervical ripening in post-term pregnancy with unfavorable cervix.

Practice bulletin no. 146: Management of late-term and postterm pregnancies.

Postterm pregnancy refers to a pregnancy that has reached or extended beyond 42 0/7 weeks of gestation from the last menstrual period (LMP), whereas a late-term pregnancy is defined as one that has reached between 41 0/7 weeks and 41 6/7 weeks of gestation (). In 2011, the overall incidence of postterm pregnancy in the United States was 5.5% (). The incidence of postterm pregnancies may vary by population, in part as a result of differences in regional management practices for pregnancies that go beyond the estimated date of delivery. Accurate determination of gestational age is essential to accurate diagnosis and appropriate management of late-term and postterm pregnancies. Antepartum fetal surveillance and induction of labor have been evaluated as strategies to decrease the risks of perinatal morbidity and mortality associated with late-term and postterm pregnancies. The purpose of this document is to review the current understanding of late-term and postterm pregnancies and provide guidelines for management that have been validated by appropriately conducted outcome-based research when available. Additional guidelines on the basis of consensus and expert opinion also are presented.

Pregnancy-associated plasma protein A levels and neonatal complications in post-date pregnancies.

OBJECTIVES: To assess the association between serum pregnancy-associated plasma protein A (PAPP-A) and free ß-human chorionic gonadotropin (free ß-hCG) in the first trimester and perinatal complications in post-date pregnancies. METHODS: A total of 4948 women, who delivered after 40 gestational weeks, were included. Labour was not induced routinely until 42 weeks. Serum levels of PAPP-A and free ß-hCG were determined at the first-trimester screening for Down syndrome. Neonatal complications were obtained from specific registration forms filled out by senior neonatologists. RESULTS: In post-date pregnancies, PAPP-A < 0.4 multiples of the median was associated with Apgar score of less than 7 at 5 min (ORadj 5.4, 95% CI 2.0-14.3), admission to the neonatal intensive care unit (ORadj 1.5, 95% CI 1.0-2.3) and newborn hypoglycaemia (ORadj 3.4, 95% CI 1.8-6.4). In small for gestation (SGA) neonates, the risk of hypoglycaemia was further increased (OR 14.6, 95% CI 3.4-58.0). Similar analyses were made with free ß-hCG, but no statistically significant associations were found. CONCLUSIONS: Low first-trimester serum PAPP-A was associated with increased neonatal morbidity in post-date pregnancies, particularly in newborns with SGA. Thus, PAPP-A may qualify the timing of induction of labour in these pregnancies.

Weight gain regardless of pre-pregnancy BMI and influence of fetal gender in response to labor induction in postdate pregnancy.

OBJECTIVE: To evaluate whether maternal weight and body mass index (BMI) and their increase throughout pregnancy are associated with the response to labor induction in postdate pregnancies. METHODS: A total of 376 nulliparous women carrying singleton postdate pregnancies with unfavorable cervix were enrolled. We considered as primary outcome vaginal delivery within 24 h after induction, and outcomes were divided into responders (n = 258) and non-responders (n = 107) to the induction of labor to perform the statistical analyses. RESULTS: In the total population of study, women who successfully delivered within 24 h differed significantly from the remaining patients in terms of maternal weight gain (p = 0.009) and BMI increase (p = 0.02) during pregnancy. In addition, males were significantly more (p = 0.005) than females among newborns of women not responding to induction of labor. In the multivariate analysis, maternal weight gain and fetal sex significantly influenced the induction response. The occurrence of a failed induction of labor was more likely in patients presenting a greater maternal weight gain (cut-off 12 kg) and male fetus. CONCLUSION: Weight gain over 12 kg regardless of pre-pregnancy weight and male fetal gender are two novel potential risk factors for the prediction of failure to induction of labor in postdate pregnancy.

[Definitions of expected date of delivery and post-term delivery]. / Comment définir la date présumée de l'accouchement et le dépassement de terme ?

The duration of pregnancy is between 280 and 290 days from the first day of the last menstrual period and varies according to the literature, the authors, the calculation methods and the characteristics of women. Assuming that the date of beginning of pregnancy is known, the expected date of delivery varies depending on the length of gestation. Thus, in literature and in obstetric practice, there is no consensus on the definition of expected date of delivery. From a medical point of view, it seems important to fix the date from which the monitoring should start and from which an induction of labour should be considered. Thus, arbitrarily, we can consider that the term period corresponds to a time interval located between 37(+0) SA and 41(+6) SA and the post-term period begins from 42(+0) SA. Because maternal and fetal risks increase at the end of the pregnancy, one can speak, arbitrarily, of prolonged pregnancy from 41(+0) SA (expert opinion).

[Prolonged pregnancy: when should surveillance be started and what should be the frequency?]. / Grossesses prolongées (termes dépassés) : à partir de quand doit-on surveiller et à quelle fréquence ?

OBJECTIVE: To determine when surveillance should be started in prolonged pregnancy and what would be the more appropriate frequency for it. STUDY DESIGN: Systematic searches of Medline and the Cochrane Library were performed. RESULTS: Fetal mortality diminishes from 37 weeks of gestation to a nadir of one death for 1000 births at 40(+0) weeks. It increases thereafter up to three deaths for 1000 births at 43(+0) weeks. Perinatal mortality rates show same pattern and is estimated to be of two and four to six deaths for 1000 births at 41(+0) and 43(+0) weeks, respectively. However, current available data does not allow for the determination of a gestational age cut-off associated with major increase of perinatal mortality and on which surveillance of prolonged pregnancy should be genuinely started. French epidemiological data from 2003 indicate that although 52.5% of pregnant women have reached 40(+0) weeks only 20,7% and 1% have reaches 41(+0) and 42(+0) weeks, respectively. Intrauterine fetal growth associated with prolonged pregnancy increases perinatal mortality. In most randomized trials having compared labour induction with expectant management, fetal surveillance was started at 41(+0) weeks. CONCLUSION: Due to the increased risk of perinatal mortality, it seems appropriate that fetal surveillance is started at 41(+0) weeks (expert opinion). This implies a rational organization of care to support surveillance of 20% of pregnant women. The frequency of this monitoring consisting of at least twice-weekly cadiotocography and ultrasound estimation of amniotic fluid (expert opinion).

[Different methods for the induction of labour in postterm pregnancy]. / Modalités du déclenchement dans les grossesses prolongées.

OBJECTIVES: Define methods of induction of labour for the population of pregnant women at the end of 41 SA and beyond, including membranes sweeping, mechanical and pharmacological procedures as oxytocin, prostaglandin E1 (misoprostol) and E2 (dinoprostone) and other methods as well for the scarred uterus. METHODS: Bibliographic research done by consulting databases PubMed, and Cochrane. RESULTS: Membrane sweeping reduces by 41% the need of induction of labour at 41 SA and 72% for postterm (42 SA). Membrane sweeping is a technique with some discomfort for the patient but has advantages. This procedure should not be imposed on patients in a systematic visit because it presents inconveniences (contractions, bleeding, pain). Oxytocin remains the gold standard used for labour induction and requires well-codified rationale protocols in maternity for increasing doses. Most of the trials show that this product is appropriate when the cervix is considered as favorable (Bishop ≥ 6). In the presence of intact membranes, induction by oxytocin must be associated with amniotomy for a significant reduction in "induction-delivery" period. The Foley catheter is a mechanically reliable, reproducible method for inducing labour with less uterine hyperstimulation without increasing the rate of caesarean sections. It is an interesting process but maternal and neonatal infectious morbidity appears to be possibly increased. The non-vaginal PGE2 (cervical) are no longer recommended. The PGE2 vaginal gel or pessary are comparable methods to induce labour. They can be used to successfully induce labour regardless of cervical Bishop score. In case of unfavorable cervical conditions, PGE2 can reduce the use of oxytocin and decrease the required doses. Misoprostol is a molecule that may be proposed for induction of labour provided to know the doses, risks and side effects and to adapt materno-fetal monitoring. The optimal route of administration remains yet to be assessed because of a higher risk of hyperstimulation or tachysystole. Initial doses should be 25 µg. However, misoprostol did not have the authorization in this indication and merit some caution when using it. Prostaglandin E1 is associated with a high risk of uterine rupture and should not be used after caesarean section. Acupuncture, homeopathy NO donors, breast stimulation or sexual intercourse are methods ineffective in all conditions or assessment is insufficient to conclude with evidence based medicine. CONCLUSION: In postterm, different procedures could be performed for induction of labour. Furthermore membrane sweeping, oxytocin is the drug of choice for induction on favourable cervix and one of the most commonly used drugs. Vaginal prostaglandins E2 are effective whatever the cervical conditions. Misoprostol is a very interesting pharmacological molecule without authorization in this indication but has real advantages on efficacy, cost, storage and administration. Other studies with high power have to remain on track and to focus on the optimal and route doses because of increased risk of tachysystole or hyperstimulation with effects on the FHR. Minimal doses at 25µg seem to be safe. The Foley catheter is a reliable method without any pharmacological effect and opening interesting perspectives but with caution about the possible increased infectious risks.

[Management of post-term pregnancies: the role for AFI, biophysical score and doppler]. / Place de l'évaluation de la quantité de liquide amniotique, du score biophysique et du doppler dans la surveillance des grossesses prolongées.

OBJECTIVE: To evaluate the role of ultrasound and doppler assessment in the management of prolonged pregnancies and to state its modalities. METHOD: Medline, PubMed, embase and the Cochrane library were searched using terms prolonged pregnancy, post date pregnancy amniotic fluid, ultrasound assessment, doppler, biophysical profile. RESULTS: Single deepest vertical pool measurement is the method of choice of the assessment of amniotic fluid. Indeed, when this method was used, significantly fewer case of oligohydramnios were diagnosed and fewer women had inductions of labor. However, this method is not superior to the amniotic fluid index in the prevention of poor perinatal outcomes. There is a significant difference in the incidence of fetal distress, meconium stained fluid and caesarean section for fetal distress when the amniotic fluid is reduced as compared with normal amniotic fluid. However, sensibility and predictive positive value of oligohydramnios to predict poor perinatal outcomes is moderate. Similary, in most studies, diagnosis of an abnormal uterine, umbilical, aortic or cerebral blood flow doppler was associated with a weak prediction of a poor perinatal outcome. Therefore, we do not recommend its use in management of prolonged pregnancy. There were significantly more diagnosis of oligoamnios and more abnormal antenatal monitoring results in the modified biophysical profile group as compared with the group managed with only single deepest pool but no differences in cord blood gases, neonatal outcome, or in outcomes related to labour and delivery were noted between the two groups. Therefore, biophysical profile including AFI offers no advantage in detecting adverse outcomes and may cause more interventions. CONCLUSION: Close monitoring of fetal condition including assessment of amniotic fluid by single deepest pool twice a week from 41 weeks of gestation is recommended in the management of prolonged pregnancy. Induction of labor could be considered when oligohydramnios is diagnosed by single deepest pool less than 2 cm.