Does antenatal supplementation with omega-3 affect child development and behavior during the first six months of life? A randomized double-blind placebo-controlled trial.

BACKGROUND: Omega-3 fatty acids, especially docosahexaenoic acid (DHA), are found in different cell membranes, but more concentrated in the brain, playing an important role in child's behavior and development. AIMS: To evaluate the effect of antenatal omega-3 supplementation on child development and behavior during the first six months of life. STUDY DESIGN: Randomized double-blind placebo-controlled trial. SUBJECTS: Low-risk pregnant women with gestational age between 22 and 24 weeks were randomized in placebo (olive oil; n = 30) or omega-3 (fish oil; 1440 mg/day of DHA; n = 30) groups and supplemented until childbirth. OUTCOME MEASURES: Child development was assessed using the Survey of Well-being of Young Children in the first, fourth and sixth month of life. RESULTS: The comparison between groups showed no differences in the Developmental Milestones score at any time, but when compared to the first month, the omega-3 group showed an increase at the fourth and sixth month. Such increase was not observed in the placebo group. No differences were found between groups for Irritability and Inflexibility scores, however, higher scores for Difficulty with Routine were observed in the placebo group when compared to omega-3 at first, fourth and sixth month. CONCLUSION: There were no differences between groups for child development, but the omega-3 group showed an increase in this score over time. The placebo group had greater difficulty with routine than the omega-3 group, indicating a beneficial effect of antenatal supplementation on child behavior. TRIAL REGISTRATION: ReBec U1111-1215-7952 (June 16th 2018).

Management practices for placenta accreta spectrum patients: a Latin American hospital survey.

INTRODUCTION: Placenta accreta spectrum (PAS) causes severe morbidity and can result in maternal death. It must be managed in specialized centers with interdisciplinary groups, but few publications have described the usual management within a specific geographic region. We intend to describe the usual approach for PAS in reference centers in Latin America. METHODOLOGY: This was an observational, multicenter, cross-sectional study conducted in Latin American PAS reference centers. A standardized survey was implemented and applied to obstetric service coordinators and leaders of interdisciplinary groups with experience in PAS between September and November 2020. RESULTS: One hundred fifty-four hospitals were included. Most of them (64.3%) handle approximately one case of PAS every two months, and almost all centers (89.6%) believe that their performance could be improved. CONCLUSIONS: Most of the reference centers for PAS in Latin America attend to a small number of cases each year, and almost all of these hospitals identify opportunities to improve the management or approach for PAS in women.

Lack of experience is a main cause of maternal death in placenta accreta spectrum patients.

INTRODUCTION: Placenta accreta spectrum (PAS) is a serious condition with a mortality as high as 7%. However, the factors associated with this type of death have not been adequately described, with an almost complete lack of publications analyzing the determining factors of death in this disease. The aim of our work is to describe the causes of death related to PAS and to analyze the associated diagnosis and treatment problems. MATERIAL AND METHODS: This is an inter-continental, multicenter, descriptive, retrospective study in low- and middle-income countries. Maternal deaths related to PAS between January 2015 and December 2020 were included. Crucial points in the management of PAS, including prenatal diagnosis and details of the surgical treatment and postoperative management, were evaluated. RESULTS: Eighty-two maternal deaths in 16 low- and middle-income countries, on three continents, were included. Almost all maternal deaths (81 cases, 98.8%) were preventable, with inexperience among surgeons being identified as the most relevant problem in the process that led to death among 87% (67 women) of the cases who had contact with health services. The main cause of death associated with PAS was hemorrhage (69 cases, 84.1%), and failures in the process leading to the diagnosis were detected among 64.6% of cases. Although the majority of cases received medical attention and 50 (60.9%) were treated at referral centers for severe obstetric disease, problems were identified during treatment in all cases. CONCLUSIONS: Lack of experience and inadequate surgical technique are the most frequent problems associated with maternal deaths in PAS. Continuous training of interdisciplinary teams is critical to modify this tendency.

Pregnant Users' Perceptions of the Birth Plan Interface in the "My Prenatal Care" App: Observational Validation Study.

BACKGROUND: Birth plans are meant to be a declaration of the expectations and preferences of pregnant woman regarding childbirth. The My Prenatal Care app engages pregnant women in an educational intervention for a healthy pregnancy. We hypothesized that users' positive perception of an in-app birth plan is a relevant step for establishing direct communication between pregnant women and the health care team, based on an online report available on the app. OBJECTIVE: This study aimed to evaluate pregnant women's perception about the communicability of birth-plan preparation using a mobile app. METHODS: This was an observational, exploratory, descriptive study. The methodology was user centered, and both qualitative and quantitative approaches were employed. The tools of the communicability evaluation method were applied. Overall, 11 pregnant women evaluated their experience of using a birth-plan prototype interface. The evaluation was performed in a controlled environment, with authorized video recording. There were 8 task-oriented interactions proposed to evaluate interface communicability with users when using the Birth Plan menu. For evaluating perceptions and experiences, a survey with structured and open-ended questions in addition to the free expression of participants was conducted. The primary outcomes assessed were interface communicability and user's perception of the Birth Plan prototype interface in the My Prenatal Care mobile app. Secondarily, we involved users in the prototyping phase of the interface to identify bottlenecks for making improvements in the app. RESULTS: Regarding users' performance in accomplishing previously prepared tasks, we found that 10 of 11 (91%) women were capable of completing at least 6 of 8 (75%) tasks. A positive relationship was found between the number of communicability problems and the success of completing the tasks. An analysis of the records revealed three communicability breakdowns related to the data entry, save, and scrollbar functions. The participants freely expressed suggestions for improvements such as for the save function and the process of sharing the birth-plan form upon completion. CONCLUSIONS: Users had a positive perception of the Birth Plan menu of the My Prenatal Care app. This user-centered validation enabled the identification of solutions for problems, resulting in improvements in the app.

Uromodulin: a new biomarker of fetal renal function?

INTRODUCTION: Obstructive uropathies are main diseases affecting the fetus. Early diagnosis allows to establish the appropriate therapy to minimize the risk of damage to kidney function at birth. Biochemical markers have been used to predict the prognosis of renal function in fetuses. Uromodulin, also known by Tamm-Horsfall protein (THP) is exclusively produced in the kidneys and in normal conditions is the protein excreted in larger amounts in human urine. It plays important roles in kidneys and urinary tract. Also it participates in ion transport processes, interact with various components of the immune system and has a role in defense against urinary tract infections. Moreover, this protein was proved to be a good marker of renal function in adult patients with several renal diseases. OBJECTIVE: To evaluate if uromodulin is produced and eliminated by the kidneys during fetal life by analyzing fetal urine and amniotic fluid and to establish correlation with biochemical parameter of renal function already used in Fetal Medicine Center at the Clinic Hospital of UFMG (CEMEFE/HC). METHODS: Between 2013 and 2015, were selected 29 fetuses with indication of invasive tests for fetal diagnosis in monitoring at the CEMEFE/HC. RESULTS: The determination of uromodulin was possible and measurable in all samples and showed statistically significant correlation with the osmolarity. CONCLUSION: There was a tendency of lower levels of Uromodulin values in fetuses with severe renal impairment prenatally. Thus, high levels of this protein in fetal amniotic fluid or fetal urine dosages possibly mean kidney function preserved.

Uromodulin: a new biomarker of fetal renal function? / Uromodulina: um novo biomarcador de função renal fetal?

Abstract Introduction: Obstructive uropathies are main diseases affecting the fetus. Early diagnosis allows to establish the appropriate therapy to minimize the risk of damage to kidney function at birth. Biochemical markers have been used to predict the prognosis of renal function in fetuses. Uromodulin, also known by Tamm-Horsfall protein (THP) is exclusively produced in the kidneys and in normal conditions is the protein excreted in larger amounts in human urine. It plays important roles in kidneys and urinary tract. Also it participates in ion transport processes, interact with various components of the immune system and has a role in defense against urinary tract infections. Moreover, this protein was proved to be a good marker of renal function in adult patients with several renal diseases. Objective: To evaluate if uromodulin is produced and eliminated by the kidneys during fetal life by analyzing fetal urine and amniotic fluid and to establish correlation with biochemical parameter of renal function already used in Fetal Medicine Center at the Clinic Hospital of UFMG (CEMEFE/HC). Methods: Between 2013 and 2015, were selected 29 fetuses with indication of invasive tests for fetal diagnosis in monitoring at the CEMEFE/HC. Results: The determination of uromodulin was possible and measurable in all samples and showed statistically significant correlation with the osmolarity. Conclusion: There was a tendency of lower levels of Uromodulin values in fetuses with severe renal impairment prenatally. Thus, high levels of this protein in fetal amniotic fluid or fetal urine dosages possibly mean kidney function preserved.

Resumo Introdução: Uropatias obstrutivas estão entre as principais doenças que acometem o feto. O diagnóstico precoce destas doenças permite estabelecer a terapêutica adequada, visando minimizar os riscos de danos à função renal no nascimento. Os marcadores bioquímicos têm sido utilizados na predição do prognóstico da função renal em fetos. A uromodulina, também chamada de proteína de Tamm-Horsfall (THP), é produzida exclusivamente nos rins, e em condições normais, é a proteína excretada em maior volume na urina humana. Ela desempenha importantes funções nos rins e trato urinário. Participa dos processos de transporte de íons, interage com vários componentes do sistema imunológico e possui papel na defesa contra infecções do trato urinário. Além disso, se mostrou um bom biomarcador de função renal em adultos portadores de diversas doenças renais. Objetivos: Avaliar se a uromodulina é produzida e eliminada pelos rins durante a vida fetal através da análise de urina fetal e líquido amniótico, além de estabelecer correlação com o parâmetro bioquímico de função renal já utilizado no Centro de Medicina Fetal do Hospital das Clínicas da UFMG (CEMEFE/HC). Métodos: Entre 2013 e 2015, foram selecionados 29 fetos com indicação de exames invasivos para diagnóstico fetal em acompanhamento no CEMEFE/HC. Resultados: A dosagem da uromodulina foi possível e quantificável em todas as amostras e mostrou correlação significativa com a osmolaridade. Conclusão: A uromodulina mostrou uma tendência em apresentar valores reduzidos em fetos com grave comprometimento renal no pré-natal. Assim, valores elevados desta proteína em dosagens de urina fetal ou líquido amniótico podem significar uma função renal preservada.

Proposição de plano de parto informatizado para apoio a interoperabilidade e humanização / The computerized birth plan proposition to support interoperability and humanization

O Plano de Parto permite o registro das expectativas e preferências da gestante em relação ao parto. Este estudo tem como objetivo formalizar um modelo de referência para o Plano de Parto informatizado e identificar um conjunto de arquétipos para representar seus conceitos. MÉTODO: Trata-se de um estudo observacional, exploratório e descritivo. Foram identificados e analisados diversos modelos de Plano de Parto. Posteriormente foi realizada a modelagem do documento em dois níveis: um modelo de referência estruturado e a construção do template nas especificações openEHRa partir de arquétipos disponíveis em uma base de conhecimento clínico. RESULTADOS: Os conceitos clínicos do documento foram estruturados a partir de ajustes em arquétipos pré-existentes. A composição foi estruturada em sete seções abordando-se as expectativas das gestantes. CONCLUSÃO: Espera-se que esta proposta seja um ponto de partida, após sua validação na prática clínica, para viabilizar o acesso ao Plano de Parto em canais informatizados do pré-natal ao parto.

The Birth Plan enables the registry of pregnant women expectations and preferences for childbirth. This studyaims to formalize a standardized model for a computerized Delivery Plan and identify a set of archetypes to representits concepts. METHOD: This is an exploratory and descriptive observational study. We identified and analyzed several Birth Plan models and subsequently performed the document modeling at two LEVELS: a structured template and then a reference template based on openEHR specifications available in a clinical database. RESULTS: We structured the clinical concepts of the document based on pre-existing archetypes adjustments. The composition structure considered sevensections covering up the expectations of pregnant women. CONCLUSION: We expect that this standardized model serveas a starting point, after its validation in clinical practice, to enable access to the Birth Plan through computerized channels from pre-natal to childbirth.

Diagnosis of severe fetal anemia based on perinatal outcomes: a comparative analysis of the current reference values.

Objectives. To compare current criteria for severe fetal anemia diagnosis. Methodology. A cohort study analyzed 105 alloimmunized fetuses that underwent cordocentesis due to risk of anemia. Concordance among the diagnostic criteria for severe fetal anemia, hemoglobin deficit >7 g/dL, hemoglobin deficit ≥5 g/dL, and hemoglobin concentration <0.55 MoM, was analyzed using Cohen's Kappa index. Perinatal mortality, fetal hydrops, and fetal acidosis were used to discuss discordances. Results. There was fair concordance among the three criteria analyzed: 0.80 (Kappa index, IC 95%: 0.67 to 0.93) when comparing hemoglobin deficit >7.0 g/dL and hemoglobin concentration <0.55 MoM criteria, 0.63 (Kappa index, IC 95%: 0.47 to 0.69) when comparing hemoglobin deficit ≥5.0 g/dL and hemoglobin deficit >7.0 g/dL reference, and 0.77 (Kappa index, IC 95%: 0.64 to 0.90) when comparing hemoglobin deficit≥5.0 g/dL and hemoglobin concentration <0.55 MoM standards. Eighteen cases were classified differently depending on the criteria used. The cut-off point of hemoglobin deficit ≥5 g/dL was the best criterion to discriminate fetuses with poor perinatal outcome in our study. Conclusions. Relevant discordances in classification of severe fetal anemia were pointed out. Some criteria may underestimate the real gravity of fetal anemia.

Predictive factors of perinatal mortality in transfused fetuses due to maternal alloimmunization: what really matters?

INTRODUCTION: Alloimmunization is the main cause of fetal anemia. There are not many consistent analyses associating antenatal parameters to perinatal mortality in transfused fetuses due to maternal alloimmunization. The study aimed to determine the prognostic variables related to perinatal death. MATERIAL AND METHODS: A cohort study analyzed 128 fetuses treated with intrauterine transfusion (IUT), until the early neonatal period. Perinatal mortality was associated with prognostic conditions related to prematurity, severity of fetal anemia and IUT procedure by univariated logistic regression. Multiple logistic regression was used to compute the odds ratio (OR) for adjusting the hemoglobin deficit at the last IUT, gestational age at birth, complications of IUT, antenatal corticosteroid and hydrops. RESULTS: Perinatal mortality rate found in this study was 18.1%. The hemoglobin deficit at the last IUT (OR: 1.26, 95% CI: 1.04-1.53), gestational age at birth (OR: 0.53, 95% CI: 0.38-0.74) and the presence of transfusional complications (OR: 5.43, 95% CI: 142-20.76) were significant in predicting fetal death. CONCLUSION: Perinatal mortality prediction in transfused fetuses is not associated only to severity of anemia, but also to the risks of IUT and prematurity.

Antenatal ultrasonographic anteroposterior renal pelvis diameter measurement: is it a reliable way of defining fetal hydronephrosis?

Purpose. It was to quantify the intraobserver and interobserver variability of the sonographic measurements of renal pelvis and classify hydronephrosis severity. Methods. Two ultrasonographers evaluated 17 fetuses from 23 to 39 weeks of gestation. Renal pelvis APD were taken in 50 renal units. For intraobserver error, one of them performed three sequential measurements. The mean and standard deviation from the absolute and percentage differences between measurements were calculated. Bland-Altman plots were used to visually assess the relationship between the precision of repeated measurements. Hydronephrosis was classified as mild (5.0 to 9.9 mm), moderate (10.0 to 14.9 mm), or severe (≥15.0 mm). Interrater agreement were obtained using the Kappa index. Results. Absolute intraobserver variation in APD measurements was 5.2 ± 3.5%. Interobserver variation of ultrasonographers was 9.3 ± 9.7%. Neither intraobserver or interobserver error increased with increasing APD size. The overall percentage of agreement with the antenatal hydronephrosis diagnosis was 64%. Cohen's Kappa to hydronephrosis severity was 0.51 (95% CI, 0.33 to 0.69). Conclusion. Inter and intraobserver APD measurement errors were low in these group, but the agreement to hydronephrosis diagnosis and classification was fair. We suggest that standard and serial APD measurement can better define and evaluate fetal hydronephrosis.