Is Assisted Reproductive Technology Linked to Fetal Asphyxia? A Retrospective Italian Case-Control Study.

Several risk factors are associated with fetal asphyxia. The main aim of this retrospective, analytical, case-control study was to determine whether assisted reproductive technologies (ART) could be considered one of these factors. In total, 162 cases of fetal asphyxia were compared to 361 controls where this event did not occur. We included 32 ART pregnancies, of which 12 were obtained through egg donations. Overall, 75% (24) of ART pregnancies experienced fetal asphyxia, suggesting ART increases the risk of fetal asphyxia by about 7 times. This finding is consistent with the literature. The pathogenesis of fetal asphyxia in ART pregnancies is currently unknown. Accordingly, this topic should be further investigated.

Cardiotocography pattern: not always a true friend.

Fetal well-being in labor could be assessed trough cardiotocography (CTG). Some doubts have been raised about its unequivocal applicability. Pathological CTG is in most cases connected to fetal acidosis at birth, but other potential causes must be considered in the differential diagnosis. A 31-years-old G2P1 patient referred to our Department of Obstetrics and Gynecology for her scheduled post-term CTG at 40 weeks and 3 days of gestation. The pregnancy was uneventful. CTG was classified as suspicious, and after pharmacological induction, it switched as pathological: an emergency cesarean section was performed. Venous and arterial blood sample taken from the umbilical cord were normal. The next assessments revealed that Atrial Flutter (AFL) occurred at birth. Suspicious CTG is not always associated to neonatal asphyxia. Cardiotocography can help not only in the evaluation of fetal distress, but also in the assessment of global fetal cardiac activity. The presence of a fetal heart defect should be considered when CTG is suspicious.

Intrapartum cardiotocography: an exploratory analysis of interpretational variation.

Our aim was to evaluate the intra- and inter-operator agreement in cardiotocography (CTG) traces analysis using the 2015 FIGO classification guidelines, and whether the educational background and the knowledge of anamnestic data can influence the interpretation of CTG traces. A retrospective interpretation of 73 intrapartum CTGs at time 0 (T0) for a first blind interpretation and at time 1 (T1) two months later with additional anamnestic pregnancy information was made by eight different operators (four obstetricians and four midwives with different years of work experience). The intra-observer agreement demonstrates that midwifes are more concordant than obstetricians with a mean of 77.05% versus a mean of 65.75%. There is moderate inter-observer agreement in classifying a CTG trace as 'normal'; on the contrary, there is no consensus on the 'suspect' and 'pathological' classification category.IMPACT STATEMENTWhat is already known on this subject? Interpretation of intrapartum CTG is affected by significant subjective variables with relevant intra- and inter-observer lack of optimal agreement, especially in case of abnormal o pathologic findings.What do the results of this study add? Clinical data seem to play a role in interpretation of suspicious and pathological traces while they do not affect the rate of agreement for normal traces. Midwives tend to be less influenced by anamnestic data in visual CTG interpretation. Instead, obstetricians tend to be more focussed on clinical data and clinical setting that, as a consequence, tend to have great impact on CTG trace interpretation.What are the implications of these findings for clinical practice and/or further research? Cooperation among obstetricians and between obstetricians and midwives should be encouraged in order to optimise CTG reading and improve maternal and neonatal outcomes. Regarding the influence of clinical parameters in classification of intrapartum CTG traces, especially in case of abnormal CTG traces, it should be conceivable to improve medical skills in CTG blind interpretation and further investigate which clinical parameters are mainly related with an augmented risk of foetal asphyxia and adverse neonatal outcomes.

The Application of Intrauterine Resuscitation Maneuvers in Delivery Room: actual and expected Use.

BACKGROUND: In case of suspicious CTG in labor a conservative attitude is recommended, when possible, through intrauterine resuscitation maneuvers. AIMS: This study aims to evaluate the use of intrauterine resuscitation maneuvers (IRM) at two Italian hospitals; the secondary outcome is the assessment of the agreement in their application. MATERIALS AND METHODS: Retrospective analysis was performed on the data of 80 deliveries (40 vs 40) from two different Italian hospitals, located in Novara (group 1) and in Borgomanero (group 2). In order to evaluate a varied series of CTG traces (normal and pathological), we randomly extracted 13 cases of neonatal asphyxia (2015-2020). The normal CTG traces were identified among the deliveries of the same day of these cases, in a ratio of 1: 4. One gynecologist and one midwife for the group 1 and one other gynecologist and one midwife for the group 2 were given a file with anonymous patient's clinical data, and the CTG registered during labor. Then, they classified the CTG trace, and they stated what they would have done if they had been present. RESULTS: Maternal position was changed for 58 patients, especially in group 2 (25/40 vs 33/40) (p = 0.046). Intravenous fluid administration was performed for 35 patients, more in group 2 (8/40 vs 27/40) (p < 0.001). Oxytocin was used for 21/80 patients: in 7/21 cases were discontinued (p = 0.241). Clark's test was used only in 2 cases, in group 2. No one used tocolysis, oxygen, or amnioinfusion. The concordance rate among operators showed poor agreement regarding the use of IRM, group 2 showed increased general concordance rates. CONCLUSIONS: The use of IRM in labor is recommended but underused and with poor concordance rate in the application, based on our results.

Preventing the human factor: organizational aspects linked to fetal asphyxia.

BACKGROUND: Perinatal asphyxia can cause cerebral palsy and hypoxic-ischemic encephalopathy. They are public health problems because they cause permanent disability. METHODS: This is a retrospective, analytical, observational study. Overall, 162 cases of mothers whose children experienced fetal asphyxia were compared to 361 controls where this condition did not occur. The variables analyzed were classified as: prepartum, intrapartum and organizational. RESULTS: Assisted reproductive technology obtained pregnancies, smoking, maternal body mass index, lack of one-to-one assistance during labor, birth on a day of high-volume activity increased the risk of fetal asphyxia, as well as other traditionally linked factors like shoulder dystocia or age over 35 years. CONCLUSIONS: Cerebral palsy cannot always be prevented because it is a syndrome with a multitude of potential causes. But a small number of cases is likely to be linked to acute intrapartum events that could be limited by changing organizational policies such as staff training and implementing teamwork and discussion. Our paper proposes strategies to try and modify organizational risk factors and therefore limit the incidence of fetal asphyxia.

What may happen if you are pregnant during COVID-19 lockdown? A retrospective study about peripartum outcomes.

BACKGROUND: One of the provisions implemented to contain the spread of COVID-19 infections in Italy was the lockdown. Effects of the lockdown on childbirth outcomes and on the well-being of both the mother and the child have not yet been defined. An inadequate diet during pregnancy and a reduced physical activity can predispose women to become overweight or obese and trigger the development of various complications and maternal-fetal adverse outcomes. METHODS: This is a retrospective study including all consecutive patients who delivered at the Maggiore della Carità Hospital in Novara, Italy, in April-May 2017 (group 1, N.=294), a period prior to the pandemic, and during the same months in 2020 (group 2, N.=256) during and immediately after lockdown. Clinical data were extracted from the report "Childbirth Assistance Certificate (CedAP) - Birth Event Analysis." RESULTS: Demographic characteristics were similar between the two study groups, except for a decreased number of married couples in group 2 (P=0.018) and an increased percentage of patients with clinical checkups at family planning facilities in 2020 (P=0.04). The number of hospitalizations during pregnancy was 26 (8.9%) vs. 10 (3.9%) with a significative reduction during 2020 (P=0.004). Regarding obstetric outcomes, we observed a significant increase in induction of labour in 2020 (23.9% vs. 35.9%; P=0. 002), a reduction of amniorrhexis (11.3% vs. 5.5% P=0.015), a reduction of supine positions with an increase of vertical and all four positions in 2020 (49.3% vs. 61.9% and 9.5% vs. 12.4% respectively, P=0.023), and a reduction of left occipito-anterior presented part (63.2% vs. 55.4%) in favor of right occipito-anterior (34.7% vs. 41.2%, P=0.019). CONCLUSIONS: There were no significant differences either for antepartum or intrapartum complications. Long-term studies are needed to evaluate psychological, behavioral, and epigenetic effects of maternal physical inactivity on obstetric outcomes.

The perception of Italian pregnant women and new mothers about their psychological wellbeing, lifestyle, delivery, and neonatal management experience during the COVID-19 pandemic lockdown: a web-based survey.

BACKGROUND: In response to the COVID-19 pandemic, drastic measures for social distancing have been introduced also in Italy, likely with a substantial impact in delicate conditions like pregnancy and puerperium. The study aimed to investigate the changes in lifestyle, access to health services, and mental wellbeing during the first Italian lockdown in a sample of Italian pregnant women and new mothers. METHODS: We carried out a web-based survey to evaluate how pregnant women and new mothers were coping with the lockdown. We collected data about healthy habits (physical exercise and dietary habits), access to health services (care access, delivery and obstetric care, neonatal care, and breastfeeding), and mental wellbeing (psychological well-being and emotive support). Descriptive analysis was performed for both groups of participants, whereas a Poisson analysis was used to measure the association between some structural variables (age, education, socio-economic data, partner support, contact, free time, previous children, and pregnancy trimester) and anxiety or depression, difficulties in healthy eating and reduction in physical activity after lockdown started. Chi2 and Adjusted Prevalence Ratios were estimated only for pregnant women. RESULTS: We included 739 respondents (response rate 85.8 %), 600 were pregnant (81.2 %), and 139 (18.8 %) had delivered during lockdown (new mothers). We found a high score for anxiety and depression in 62.8 % of pregnant women and 61.9 % of new mothers. During the lockdown, 61.8 % of pregnant women reduced their physical exercise, and 44.3 % reported eating in a healthier way. 94.0 % of new mothers reported to have breastfed their babies during the hospital stay. Regarding the perceived impact of restrictive measures on breastfeeding, no impact was reported by 56.1 % of new mothers, whereas a negative one by 36.7 %. CONCLUSIONS: The high prevalence of anxiety and depressive symptoms in pregnant women and new mothers should be a public health issue. Clinicians might also recommend and encourage "home" physical exercise. On the other hand, about half of the sample improved their approach towards healthy eating and a very high breastfeeding rate was reported soon after birth: these data are an interesting starting point to develop new strategies for public health.

Eosinophilic gastroenteritis in pregnancy: A review of the literature.

Eosinophilic gastroenteritis (EGE) is an uncommon and heterogeneous disease characterized by eosinophilic infiltration of the gastrointestinal tract. There are very few reports in literature describing pregnancies in EGE patients, and no review has ever been published. We found a total of 12 cases including one that occurred in our clinic. In 5 out of 12 cases, EGE was diagnosed after delivery and pregnancies are described as uneventful. Of the 5 patients who already had a diagnosis of EGE before pregnancy, only one registered an improvement of symptoms during gestation, while the rest had no significant changes, and their pregnancies needed to be monitored as high risk. Regarding pregnancy complications, only two patients had a pre-term delivery. Both patients had not only EGE, but a remarkable obstetrical history, that could slightly complicate the interpretation of the events that occurred in their pregnancies. More studies are necessary to demonstrate if EGE is connected with pre-term onset of labor. It's not easy to define the reasons of some patient's pre term labor, and we could suppose that a combination of different mechanisms leads to this condition of breakdown of maternal-fetal tolerance. Nevertheless, we know that spontaneous preterm labor is a syndrome attributable to multiple pathologic processes and most of them are yet to be understood. However, we cannot exclude that EGE is related to late preterm delivery. We hope that this review will provide some measures of guidance to those clinicians who must satisfy the questions of young female patients diagnosed with EGE and wishing for a pregnancy.

The use of Complementary and Alternative Medicine (CAM) among Italian children: A cross-sectional survey.

OBJECTIVE: To examine prevalence and modalities of CAM use in children living in Novara, a northern Italian city, and to estimate the prescription rate from paediatricians. METHOD: We administered a phone questionnaire to the parents of a sample of 147 children, asking questions about CAM use, children's health profile, parental socio-economic status, use modalities, effectiveness perceptions, and motivations. A parallel survey was conducted by e-mail by investigating family paediatricians attitudes about CAM. RESULTS: Among 147 children whose families responded to our survey 48.3% was treated with CAM at least once in life and 38,1% during the previous year. Children treated with CAM were on average younger than those who were not. The types of CAM used were herbal medicine and homeopathy. Parents who choose CAM for their children were more skeptical about vaccinations. CAM were most frequently used to treat pathologies of ear, nose and throat. 85.9% of parents was willing to use CAM in future, 78.9% would pass to conventional medicine if CAM failed. Among paediatricians 81.5% prescribed CAM at least once, but only 13.6% received specific CAM training. CONCLUSION: The prevalence of children using CAM in Novara is high, in line with investigations conducted in Northern European countries. The distribution of pathologies treated with CAM, parental socio-economic status and general scepticism towards vaccination are consistent with the literature. Physicians should keep themselves up-to-date also about evidence-based CAM therapies and, most importantly, should have an open dialogue about CAM with their patients.

The role of antenatal education for the prevention of excessive weight gain during pregnancy.

BACKGROUND: Excessive weight gain (EWG) during pregnancy is associated to adverse maternal-fetal outcomes. The aim of this study was to analyze the situation in a single high intensity care center in Eastern Piedmont, north of Italy. METHODS: This is a cohort study including 715 patients classified into four classes corresponding to pregestational BMI values. Based on the WHO's weight gain for each class, women were subdivided into three groups: inadequate, adequate and excessive increase. RESULTS: EWG was significant in overweight (43.9%) and obese women (37.3%). There was a significant correlation with gestational diabetes (P=0.046), hypertension (P=0.0001), preterm birth (P=0.047), intake of antihypertensive drugs (P=0.0001), maternal study degree (P=0.005), profession (P=0.015), civil status (P=0.003), parity (P=0.039) and paternal ethnicity (P=0.027). Participation at antenatal education for childbirth (AEC) had a positive impact leading to an appropriate weight gain (P=0.004). CONCLUSIONS: If adequately counselled, women understand the consequences of excessive weight gain during pregnancy, comply more to therapy and modify their lifestyle.

MMR vaccine in the postpartum does not expose seronegative women to untoward effects.

BACKGROUND: The aim of this study was to assess whether rubella vaccination immediately after delivery could expose seronegative women to specific untoward effects. METHODS: 163 rubella-seronegative women received Measles-Mumps-Rubella (MMR) vaccine in the immediate postpartum period; they were evaluated at one month and at three months thereafter through telephone interviews. As controls, we matched 163 rubella-seropositive women, who might experience similar symptoms for any reason in the same timeframe. RESULTS: No relevant difference was still observed in the frequency of arthralgia and myalgia at one and three months. Instead, a statistically significant difference in the frequency of cervical lymphadenopathy and cutaneous rash at one month (p = 0.028 and p = 0.005, respectively), was observed between cases and controls. However, no statistical differences were reported at three months for the same symptoms. CONCLUSIONS: Postpartum rubella vaccination with MMR is safe and advisable to avoid congenital rubella syndrome.