Correlation of fetal heart rate dynamics to inflammatory markers and brain-derived neurotrophic factor during pregnancy.

OBJECTIVES: This study aims to show the relation between biomarkers in maternal and cord-blood samples and fetal heart rate variability (fHRV) metrics through a non-invasive fetal magnetocardiography (fMCG) technique. METHODS: Twenty-three women were enrolled for collection of maternal serum and fMCG tracings immediately prior to their scheduled cesarean delivery. The umbilical cord blood was collected for measurement of biomarker levels. The fMCG metrics were then correlated to the biomarker levels from the maternal serum and cord blood. RESULTS: Brain-derived neurotrophic factor (BDNF) had a moderate correlation with fetal parasympathetic activity (0.416) and fetal sympathovagal ratios (-0.309; -0.356). Interleukin (IL)-6 also had moderate-sized correlations but with an inverse relationship as compared to BDNF. These correlations were primarily in cord-blood samples and not in the maternal blood. CONCLUSIONS: In this small sample-sized exploratory study, we observed a moderate correlation between fHRV and cord-blood BDNF and IL-6 immediately preceding scheduled cesarean delivery at term. These findings need to be validated in a larger population.

Detection of Fetal Anomalies by Remotely Directed and Interpreted Ultrasound (Teleultrasound): A Randomized Noninferiority Trial.

OBJECTIVE: To determine the accuracy and reliability of remotely directed and interpreted ultrasound (teleultrasound) as compared with standard in-person ultrasound for the detection of fetal anomalies, and to determine participants' satisfaction with teleultrasound. STUDY DESIGN: This was a single-center, randomized (1:1) noninferiority study. Individuals referred to the maternal-fetal medicine (MFM) ultrasound clinic were randomized to standard in-person ultrasound and counseling or teleultrasound and telemedicine counseling. The primary outcome was major fetal anomaly detection rate (sensitivity). All ultrasounds were performed by registered diagnostic medical sonographers and interpretations were done by a group of five MFM physicians. After teleultrasound was completed, the teleultrasound patients filled out a satisfaction survey using a Likert scale. Newborn data were obtained from the newborn record and statewide birth defect databases. RESULTS: Of 300 individuals randomized in each group, 294 were analyzed in the remotely interpreted teleultrasound group and 291 were analyzed in the in-person ultrasound group. The sensitivity of sonographic detection of 28 anomalies was 82.14% in the control group and of 20 anomalies in the telemedicine group, it was 85.0%. The observed difference in sensitivity was 0.0286, much smaller than the proposed noninferiority limit of 0.05. Specificity, negative predictive value, positive predictive value, and accuracy were more than 94% for both groups. Patient satisfaction was more than 95% on all measures, and there were no significant differences in patient satisfaction based on maternal characteristics. CONCLUSION: Teleultrasound is not inferior to standard in-person ultrasound for the detection of fetal anomalies. Teleultrasound was uniformly well received by patients, regardless of demographics. These key findings support the continued expansion of telemedicine services. KEY POINTS: · For detection of major anomalies, teleultrasound is comparable to standard ultrasound.. · Teleultrasound was well accepted by patients.. · Teleultrasound use should be expanded..

Peripartum Hypertensive Crisis Simulation and Education Initiative among Rural Emergency Departments.

OBJECTIVE: To determine whether the introduction of hypertensive bundles through simulation and education would result in the timely assessment and treatment of a simulated patient in a peripartum hypertensive crisis. METHODS: This prospective observational pilot study evaluates the use of simulation and education on hypertension bundled care for peripartum patients in eight rural hospitals. Unannounced simulation exercises were conducted at each hospital. Emergency department staff response was assessed with a checklist. Primary outcomes included time to first antihypertensive medication administered, time to registered nurse assessment, and time to physician assessment. After the initial simulation, nurse educators conducted an in-person didactic on the management of peripartum hypertensive crisis, providing each hospital with materials for local bundle initiation and implementation for hypertensive emergency. The nurse educators conducted the same simulation at the individual sites 3 to 4 months later. Time of intervention improvement pre- and posteducation training scores were analyzed for each of these using a paired t test followed by a Wilcoxon signed-rank test. The average time of intervention improvement among delivering hospitals versus nondelivering hospitals was compared. RESULTS: Eight training simulation and training sessions were conducted at four delivering and four nondelivering hospitals. Seventy-three healthcare workers attended training. The average time decreased from pre- to postsimulation at all of the hospitals (this was not statistically significant, however). The average reduction in time for first nurse assessment was 1.25 ± 10.05 minutes (P = 0.99). The average reduction in time to physician assessment was 4.88 ± 14.74 minutes (P = 0.45). The average reduction of time to administration of first hypertensive medication was 12.0 ± 25.79 minutes (P = 0.15). The average times for nurse or physician assessment and time to first hypertension medication administration were similar between delivering and nondelivering hospitals. CONCLUSIONS: Our study demonstrates a trend toward improved treatment of a peripartum hypertensive emergency through bundled care and simulation. The training reduced the time to first medication given and improved the selection process for the preferred hypertensive medication. The time from nurse care to physician assessment also was reduced. Education in bundled peripartum hypertension care may improve patient outcomes by decreasing hypertension-related maternal morbidity and mortality.

Placental location site and adverse antepartum pregnancy complications: a meta-analysis and review of the literature.

PURPOSE: The purpose to the study was to determine the relationship, if any, between the placental location site and antepartum complications of pregnancy. METHODS: A University research librarian conducted a comprehensive literature search using the search engines PubMed and Web of Science. The search terms were "placental location" AND "pregnancy complications" OR "perinatal complications. There were no limits put on the years of the search. RESULTS: The search identified 110 articles. After reviewing all the abstracts, relevant full articles, and references of full articles, there were 22 articles identified specific to antepartum complications. Central + fundal locations compared to all lateral were associated with a lower risk of hypertension during pregnancy RR = 0.47, 95% CI: 0.31-0.71]. Central location compared to all lateral was also associated with lower risk of hypertension during pregnancy [RR = 0.39, 95% CI: 0.26-0.59]. Placenta locations in the lower uterine segment were associated with greater risk of antepartum hemorrhage (APH) [RR = 2.99, 95% CI: 1.16-7.75] compared to above the lower uterine segment. No differences were observed in placental locations and gestational diabetes (GDM), preterm prelabor rupture of membranes (PPROM), preterm delivery (PTD) or on a placental abruption. CONCLUSION: Central and fundal location sites and central location alone decreased the risk of hypertension during pregnancy. Low uterine segment location sites increased the risk for APH. There were no effects of placenta location sites on the development of GDM, PPROM, PTD or abruption.

Accuracy and Completion Rate of the Fetal Anatomic Survey in the Super Obese Parturient.

OBJECTIVE: To determine the completion rate of ultrasound in with a body mass index (BMI) ≥ 50 to women with BMI 18.5 to 29.9. STUDY DESIGN: This study was a retrospective cohort study. Women with a singleton pregnancy, age 18 to 45 with a BMI ≥50 that delivered between 2013-2016 were compared to women with a BMI 18.5 to 29.9 during that same time period to assess the accuracy and, as a second aim, the completion rate of the fetal anatomic survey. Data were analyzed using two-sample t test, chi-square test, or logistic regression as appropriate. RESULTS: Eighty-one cases with a BMI ≥50 were compared with 81 patients with a BMI 18.5 to 29.9. Maternal demographics and timing (gestational age) at the time of the ultrasound were similar between groups. In women with a BMI 18.5 to 29.9, completion of anatomy was 58% of the time with the first ultrasound, 81% with second ultrasound, and 84% with the third ultrasound. In women with BMI ≥50, completion of anatomy was 10% of the time with the first ultrasound, 33% with the second ultrasound, and 42% with the third ultrasound. Each time frame was statistically significant. Agreement level on the accuracy to detect fetal anomalies between groups were not statistically significant between the groups. CONCLUSION: In women with a BMI ≥50 compared to women with BMI of 18.8 to 29.9, more ultrasounds are needed to complete the anatomic survey although overall accuracy in fetal anomaly detection is similar.

Cesarean Delivery Management of Stillbirth: In-Depth Analysis of 75 Cases in a Rural State.

OBJECTIVE: To analyze the characteristics surrounding women who underwent cesarean delivery for stillbirth management in the rural, southern US state of Arkansas. METHODS: This was a planned secondary analysis of a retrospective descriptive study evaluating mode of delivery following the stillbirth of singleton pregnancies without anomalies or aneuploidy delivered in our state between July 2015 and June 2019. Data were extracted from a statewide reproductive health monitoring system and reviewed by the first three authors. Summary statistics were presented as means and standard deviations for continuous measures and frequencies and percentages for categorical variables. RESULTS: There were 861 patients diagnosed as having stillbirth between July 2015 and June 2019 in 44 hospitals in Arkansas. Seventy-five of those patients (8.7%) underwent cesarean delivery and are the basis for this analysis. Common indications for cesarean delivery were prior cesarean delivery (41%), malpresentation (18.7%), and abruption or hemorrhage (13.1%). Sixty-five percent of patients had a prior cesarean delivery. The most common complications were infection and hemorrhage, which accounted for 64.3% of known complications. The overall complication rate was 18.7% among stillbirths delivered via cesarean. CONCLUSIONS: This study demonstrates that cesarean delivery remains a common mode of delivery for management of stillbirth and that there is maternal morbidity associated with an abdominal delivery because 22.7% of the women undergoing a cesarean had an operative complication. It also highlights that prior cesarean delivery remains a common indication for a repeat abdominal delivery following a stillbirth despite the lack of fetal benefit.

Evidence for Prophylactic Transfusion during Pregnancy for Women with Sickle Cell Disease.

The objective of this study was to examine prior studies on maternal and neonatal outcomes with prophylactic compared with emergent blood transfusion in pregnant women with sickle cell disease. A review of the literature was performed. Twenty-one articles were identified and included in the analysis. A generalized linear mixed-effects model was used to analyze the outcomes. Pregnancy outcomes assessed were preeclampsia, pneumonia, pyelonephritis, pain crises, intrauterine growth restriction, neonatal death, perinatal death, and maternal mortality. Women who underwent emergent transfusion were more likely than women who underwent prophylactic transfusion to have the following adverse perinatal outcomes: preterm delivery (adjusted odds ratio [aOR 2.04], 95% confidence interval [CI] 1.14-3.63), pneumonia (aOR 2.98, 95% CI 1.44-6.15), pain crises (aOR 1.67, 95% CI 1.18-2.38), and perinatal death (aOR 1.84, 95% CI 1.06-3.07). Prophylactic transfusion should be reexamined as a potentially beneficial approach to the management of sickle cell disease in pregnancy.

Accuracy of the Ultrasound Estimate of the Amniotic Fluid Volume (Amniotic Fluid Index and Single Deepest Pocket) to Identify Actual Low, Normal, and High Amniotic Fluid Volumes as Determined by Quantile Regression.

OBJECTIVES: To identify abnormal amniotic fluid volumes (AFVs), normal volumes must be determined. Multiple statistical methods are used to define normal amniotic fluid curves; however, quantile regression (QR) is gaining favor. We reanalyzed ultrasound estimates in identifying oligohydramnios, normal fluid, and polyhydramnios using normal volumes calculated by QR. METHODS: Data from 506 dye-determined or directly measured AFVs along with ultrasound estimates were analyzed. Each was classified as low, normal, or high for both the single deepest pocket (SDP) and amniotic fluid index (AFI). A weighted κ statistic was used to assess the level of agreement between the AFI and SDP compared to actual AFVs by QR. RESULTS: The overall level of agreement for the AFI was fair (κ = 0.26), and that for the SDP was slight (κ = 0.19). Although not statistically significant (P = .792), the positive predictive value to classify a low volume using the AFI was lower compared to the SDP (35% vs 43%). The positive predictive value for a high volume was higher using the AFI compared to the SDP (55% versus 31%) but not statistically significant. The missed-call rate for high-volume identification by the SDP versus AFI was statistically significant (odds ratio, 5.5; 95% confidence interval, 2.04-14.97). The missed-call rate for low-volume identification by the AFI versus SDP was not statistically significant (odds ratio, 3.3; 95% confidence interval, 0.96-11.53). CONCLUSIONS: Both the AFI and SDP identify actual normal AFVs by QR, with sensitivity higher than 90%. The SDP is superior for identification of oligohydramnios, and the AFI superior for identification of polyhydramnios.

Hospital Annual Delivery Volume and Presence of Graduate Medical Education Influence Mode of Delivery after Stillbirth.

OBJECTIVES: To evaluate the statewide experience in mode of delivery for pregnancies complicated by stillbirth by annual delivery volume and presence of graduate medical education programs. METHODS: This is a descriptive study of all stillbirths without known congenital anomalies or aneuploidy born in our state from July 1, 2015 to June 30, 2019. Stillbirths were ascertained by the State Reproductive Health Monitoring System, a population-based surveillance system. Stillbirths were identified by the State Reproductive Health Monitoring System from medical facilities and fetal death certificates; trained staff abstracted records. All of the stillbirths with a gestational age of >20 weeks or a birth weight of >500 g if birth weight was unknown and without congenital anomalies or aneuploidy were eligible for this study. RESULTS: There were 861 stillbirths from July 2015 through June 2019, 75 (8.7%) of which were delivered by cesarean section. Low-volume hospitals (<1000 deliveries) experienced a higher proportion of their stillbirths delivered by cesarean compared with high-volume hospitals (>1000 deliveries; 13.4% vs 5.5%; P < 0.0001). Before adjusting for maternal characteristics, stillbirths delivered at high-volume hospitals had a 59% lower risk of delivery by cesarean section compared with those delivered at low-volume hospitals (relative risk [RR] 0.41, 95% confidence interval 0.20-0.86, P = 0.02). The cesarean cohort had a higher proportion of Black mothers (44% vs 31.3%, P = 0.025), greater parity (P < 0.0001), and greater gravidity (P < 0.0001) compared with the vaginal group. The gestational age at delivery for stillbirths delivered by cesarean was much higher compared with those who were delivered vaginally (34.8 weeks vs 28.6 weeks; P < 0.0001). The RR of the cesarean delivery of a stillbirth at teaching institutions compared with nonteaching institutions was significantly reduced (RR 0.45, 95% confidence interval 0.28-0.73, P = 0.0011). CONCLUSIONS: Annual hospital delivery volumes and residency teaching programs in obstetrics influence the mode of delivery in the management of stillbirth. Advancing gestational age, Black race, and parity are associated with an increased risk of cesarean delivery after stillbirth.

Is There a Difference in Sonographic Estimation of Amniotic Fluid Volume When Measuring With the Probe Perpendicular to the Floor Compared With Perpendicular to the Uterine Contour?

OBJECTIVE: This study sought to determine whether there is a significant difference in amniotic fluid measurements when measuring perpendicular to the floor compared with perpendicular to the uterine contour using both amniotic fluid index and single deepest pocket. METHODS: This was a single-centre, prospective study of women with singleton gestation who were undergoing fetal ultrasound examination. A total of 240 women were enrolled, and single deepest pocket and amniotic fluid index were measured with both techniques. Correlation coefficient and intraclass correlation coefficient were used to assess the agreement between the values using the two methods of measurement (Canadian Task Force Classification II-2). RESULTS: A strong correlation was found between amniotic fluid index measurements (correlation coefficient 0.82; intraclass correlation coefficient 0.7). A strong correlation also was found between single deepest pocket measurements (correlation coefficient 0.7; intraclass correlation coefficient 0.6). CONCLUSION: The measurement of amniotic fluid index and single deepest pocket can be performed either perpendicular to the floor or perpendicular to the uterine contour. There is no significant difference between these measurements and they correlate well.

Nonimmune Hydrops Fetalis.

Nonimmune hydrops fetalis (NIHF) poses a significant challenge in perinatal care due to its high mortality rates and diverse etiologies. This comprehensive review examines the pathophysiology, etiology, antenatal diagnosis and management, postnatal care, and outcomes of NIHF. NIHF arises from numerous underlying pathologies, including genetic disorders, cardiovascular causes, and fetal infections, with advances in diagnostic techniques improving identification rates. Management strategies include termination of pregnancy for severe cases and fetal therapy for selected treatable etiologies, and neonatal care involves assessing and treating fluid collections and identifying underlying causes. Prognosis depends on factors such as gestational age at diagnosis and the extent of resuscitation needed, with challenges remaining in improving outcomes for affected infants.

Increasing Access: Telehealth and Rural Obstetric Care.

Parturients in rural areas face many barriers in access to care, including distance to maternity care sites and lack of maternity providers. Expanding telehealth modalities is recommended to help expand access to care. Although there is increasing evidence in support of telehealth in rural America, the success of telehealth lies in infrastructure (broadband network availability), regional support, and funding.

Window to the Womb: Amniotic Fluid and Postnatal Outcomes.

Amniotic fluid volumes are tightly regulated, and amniotic fluid derangement can indicate maternal complications or fetal abnormalities. Ultrasound estimate of amniotic fluid provides a tool to evaluate the maternal-fetal-placental interface in real-time. Oligohydramnios and polyhydramnios are associated with adverse maternal and neonatal outcomes. Oligohydramnios is associated with adverse maternal and neonatal outcomes including cesarean delivery, operative vaginal delivery, induction of labor, postpartum hemorrhage, small for gestational age neonate, intrauterine demise, neonatal death, NICU admission, and APGAR less than 7 at. 5 minutes of life Polyhydramnios is associated with adverse outcomes including cesarean delivery, induction of labor, placental abruption, shoulder dystocia, cord prolapse, postpartum hemorrhage, intrauterine fetal demise, NICU admission, neonatal death, APGAR less than 7 at 5 minutes of life, large for gestational age neonate, and respiratory distress syndrome. Therefore, Amniotic fluid should be evaluated when maternal or fetal well-being is in question.

Alternate Birth Strategies.

Community birth is defined as birth that occurs outside the hospital setting. Birthing in a birth center can be safe for certain patient populations. Home birth can also be safe in well-selected patient with a well-established transfer infrastructure should an emergency occur. Unfortunately, many areas of the United States and the world do not have this infrastructure, limiting access to safe community birth. Immersion during labor has been associated with decreased need for epidural and pain medication. Delivery should not occur in water due to concerns for infection and cord avulsion. Umbilical cord non-severance (also called lotus birth) and placentophagy should be counseled against due to well-documented risks without clear benefit. Birth plans and options should be regularly discussed during pregnancy visits.

Assessing uterine electrophysiology prior to elective term induction of labor.

Objective: The purpose of this study was to determine if uterine electrophysiological signals gathered from 151 non-invasive biomagnetic sensors spread over the abdomen were associated with successful induction of labor (IOL). Study design: Uterine magnetomyogram (MMG) signals were collected using the SARA (SQUID Array for Reproductive Assessment) device from 33 subjects between 37 and 42 weeks gestational age. The signals were post-processed, uterine contractile related MMG bursts were detected, and parameters in the time and frequency domain were extracted. The modified Bishop score calculated at admission was used to determine the method of IOL. Wilcoxon's rank-sum test was used to compare IOL successes and failures for differences in gestational age (GA), parity, modified Bishop's score, maximum oxytocin, and electrophysiological parameters extracted from MMG. Results: The average parity was three times (3x) higher (1.53 versus 0.50; p = 0.039), and the average modified Bishop score was 2x higher (3.32 versus 1.63; p = 0.032) amongst IOL successes than failures, while the average GA and maximum oxytocin showed a small difference. For the MMG parameters, successful IOLs had, on average, 3.5x greater mean power during bursts (0.246 versus 0.070; p = 0.034) and approximately 1.2x greater mean number of bursts (2.05 versus 1.68; p = 0.036) compared to the failed IOLs, but non-significant differences were observed in mean peak frequency, mean burst duration, and mean duration between bursts. Conclusion: The study showed that inductions of labor that took less than 24 h to deliver have a higher mean power in the baseline electrophysiological activity of the uterus when recorded prior to planned induction. The results are indicative that baseline electrophysiological activity measured prior to induction is associated with successful induction.

The effect of maternal pregestational diabetes on fetal autonomic nervous system.

Heart rate variability assessment of neonates of pregestational diabetic mothers have shown alterations in the autonomic nervous system (ANS). The objective was to study the effect of maternal pregestational diabetes on ANS at the fetal stage by combining cardiac and movement parameters using a non-invasive fetal magnetocardiography (fMCG) technique. This is an observational study with 40 participants where fetuses from a group of 9 Type 1, 19 Type 2 diabetic, and 12 non-diabetic pregnant women were included. Time and frequency domain fetal heart rate variability (fHRV) and coupling of movement and heart rate acceleration parameters related to fetal ANS were analyzed. Group differences were investigated using analysis of covariance to adjust for gestational age (GA). When compared to non-diabetics, the Type 1 diabetics had a 65% increase in average ratio of very low-frequency (VLF) to low-frequency (LF) bands and 63% average decrease in coupling index after adjusting for GA. Comparing Type 2 diabetics to non-diabetics, there was an average decrease in the VLF (50%) and LF bands (63%). Diabetics with poor glycemic control had a higher average VLF/LF (49%) than diabetics with good glycemic control. No significant changes at p < 0.05 were observed in high-frequency (HF) frequency domain parameters or their ratios, or in the time domain. Fetuses of pregestational diabetic mothers exhibited some differences in fHRV frequency domain and heart rate-movement coupling when compared to non-diabetics but the effect of fHRV related to fetal ANS and sympathovagal balance were not as conclusive as observed in the neonates of pregestational diabetic mothers.

Maternal features at time of preterm prelabor rupture of membranes and short-term neonatal outcomes.

OBJECTIVE: The objective of this study was to assess if maternal and obstetric characteristics other than gestational age at the time of rupture impact short-term neonatal outcomes. METHODS: This is a retrospective observational study from a single tertiary care referral center. This study reviewed women with a singleton pregnancy complicated by preterm prelabor rupture of membranes over a 3-year period from May of 2014 through May of 2017. Maternal characteristics and short term neonatal outcomes were collected. RESULTS: We identified 210 pregnancies complicated by preterm prelabor rupture of membranes. Eighteen of these patients had rupture of membranes prior to viability. Of the maternal characteristics at time of admission studied, gestational age at rupture and race influenced short term neonatal outcomes. Women who identified as race other than white had neonates with lower rates of intubation than neonates born to white patients. Gestational age at rupture significantly influenced the neonatal intensive care unit length of stay. Each additional week gained before rupture occurred was associated with a 17.1% decrease in length of stay. Maternal age, gravidity, parity, body mass index, single deepest pocket, and amniotic fluid index did not influence short term neonatal outcomes. CONCLUSIONS: Gestational age at rupture of membranes is the most predictive factor associated with short term neonatal outcomes. Race may also influence short term neonatal outcomes. Other maternal characteristics do not seem to influence short term neonatal outcomes. This information can assist with patient counseling on admission for preterm prelabor rupture of membranes and expected neonatal course.

Are the Diagnosis and Treatment of Acute Cystitis in the Premenopausal, Pregnant, and Postmenopausal Women the Same? A Review of the Literature.

Importance: Acute cystitis is a common condition diagnosed in women. The diagnosis and treatment of this condition change throughout a woman's life. Understanding the differences in diagnosis and treatment in premenopausal, pregnant, and postmenopausal woman increases the likelihood of treatment success and decreases risk of complications from untreated or suboptimally treated infections. Objective: The aim of this review is to describe the incidence, risk factor, pathophysiology, diagnosis, and management of acute cystitis and the similarities and differences of these aspects of the condition in the premenopausal, pregnant, and postmenopausal woman. Evidence Acquisition: A PubMed, Web of Science, and CINAHL search was undertaken with the years 1990 to 2020 searched. Results: There were 393 articles identified, with 103 being the basis of review. Multiple risk factors for acute cystitis have been identified and are largely consistent throughout a woman's lifetime with few exceptions. The diagnoses by group with common diagnostic tools, such as urinalysis, vary in specificity and sensitivity between these groups. Management also varies between groups, with pregnancy having specific limitations related to drug safety in regard to possible fetal effects posed by certain medications commonly used to treat acute cystitis. Conclusions: Acute cystitis not only varies in presentation throughout a woman's lifespan, but also in appropriate diagnosis and treatment. Treatment of acute cystitis does have some commonalities between the groups; however, there are contraindications unique to each group. These differences are paramount to not only ensuring appropriate treatment but also treatment success. Relevance: Acute cystitis is a common condition with different diagnostic and management recommendations throughout a woman's lifespan.