Prolonged abdominal pregnancy incidentally discovered during cesarean section: a case report.

BACKGROUND: Abdominal pregnancy is a rare medical condition that is still missed in developing countries due to inadequate medical facilities. The clinical indicators manifest in various forms and are nonspecific, making it challenging to diagnose and often leading to delayed detection. However, obstetric ultrasound serves as an essential tool in early detection. Our objective was to share our experience dealing with this condition and emphasise the importance of early ultrasound diagnosis through efficient pregnancy monitoring in our regions. CASE PRESENTATION: 35-year-old Black African woman who had ten months of amenorrhea sought consultation due to an absence of active foetal movements. Her pregnancy was of 39 weeks with fetal demise which was confirmed following clinical examination and ultrasound. She underwent cesarean section in view of transverse position of fetus. During cesarean section, the fetus was found within the abdominal cavity with the placenta attached over the left iliac fossa including surface of left ovary. The uterus and right adnexa were within normal limits. A 2600 g macerated fetus with placenta and membranes were extracted without any complications. The maternal outcome was successful. CONCLUSIONS: Abdominal pregnancy remained an inadequately diagnosed condition in developing countries. It is imperative to increase awareness among pregnant women regarding high-quality prenatal care, including early obstetric ultrasound, from conception. Meanwhile, healthcare professionals should receive continuous training and the technical platform modernised. To ensure accurate diagnosis, the location of the gestational sac must be identified for every pregnant woman during their initial ultrasound appointment.

The role of the cerebroplacental ratio in predicting pregnancy outcomes at 40-42 gestational weeks: a prospective observational trial.

PURPOSE: The cerebroplacental ratio is a sonographic tool used to predict poor pregnancy outcomes. Data are insufficient regarding its use in postdate pregnancy. We evaluated the cerebroplacental ratio's prediction of unfavorable pregnancy outcomes in women at 40-42 weeks gestation with normal amniotic fluid index. METHODS: This prospective observational study included 101 women with low-risk singleton pregnancy and gestational age > 40 weeks who delivered in a university affiliated hospital during 2020-2021. The middle cerebral artery pulsatility index, the umbilical artery pulsatility index, and the cerebroplacental ratio, which is their quotient, were compared between women with favorable and unfavorable pregnancy outcomes. The latter included: meconium-stained amniotic fluid, cesarean or vacuum-assisted delivery due to pathological cardiotocography (category 2 or 3), 5-min Apgar score < 7, umbilical cord pH < 7.1, neonatal intensive care unit admission, and neonatal death. RESULTS: Fetal Doppler, performed at a median gestational age of 40.3 (40.0-41.6), did not differ between 75 (74.3%) women with favorable obstetrical outcomes and 26 (25.7%) with unfavorable outcomes. In multivariate analysis, advanced maternal age and a history of a cesarean section were correlated with unfavorable outcomes, while Doppler indices were not found to be predictive. Among women at 41-42 weeks' gestation, for those with intrapartum fetal monitor category 2-3 vs. category 1, the mean umbilical artery pulsatility index was higher: 0.92 ± 0.34 vs. 0.71 ± 0.11 (p = 0.044). CONCLUSION: According to the study results, fetal Doppler indices, including the cerebroplacental ratio, are not predictive of unfavorable outcome in women with pregnancies exceeding 40 weeks. Larger prospective studies are needed.

Membrane sweeping at term to promote spontaneous labor and reduce the likelihood of formal labor induction for prolonged pregnancy, in South Asia and the world: A meta-analysis.

BACKGROUND: Membrane sweeping promotes the spontaneous onset of labor, reducing the need for formal labor induction. In addition to the safety profile, membrane sweep is a cost-effective measure in a low-resource setting like South Asia. OBJECTIVES: To the best of our knowledge, previous reviews and meta-analyses have not explored the timing and frequency of membrane sweeping or its association with the period of gestation (POG) and parity. Additionally, the results should be interpreted with caution due to the inclusion of older studies and the analyses conducted regardless of ethnicity in previous literature. We addressed these gray areas in the current study to fill the research gap. SEARCH STRATEGY: We searched PubMed, Google Scholar, Science Direct, and Cochrane Reviews. Study selection was performed using the semi-automated tool Rayyan. SELECTION CRITERIA: The selection criteria for this study encompassed the inclusion of randomized controlled trials (RCTs) published in English between January 2010 and May 2023, with accessible full-text articles. The focus was on low-risk pregnant women carrying a single fetus in a cephalic presentation at term (37-42 weeks) gestation, confirmed by reliable methods. Essential data for relative risk (RR) and 95% confidence interval (CI) calculation must be present. DATA COLLECTION AND ANALYSIS: The Cochrane risk-of-bias (RoB2) tool and funnel plots were used to assess bias. Review Manager (RevMan) 5.4 version was used for analysis. The Mantel-Haenszel statistics and random effects were used to calculate the overall effect of risk ratio with a 95% confidence interval. Study heterogeneity was calculated using the I2 statistic. Two subgroups were used in the analysis: South Asia and the rest of the world. MAIN RESULTS: A total of 13 RCTs with 2599 participants were analyzed. Overall, membrane sweep effectively reduced formal IOL with an effect size of 2.43 (95% CI: 1.51-3.91). It also promoted spontaneous labor with an effect size of 1.71 (95% CI: 1.15-2.55). In the South Asian subgroup, membrane sweeping significantly promoted the spontaneous onset of labor with an overall effect of 1.85 (95% CI: 1.37-2.51), and in the rest of the world subgroup, membrane sweeping significantly reduced formal labor induction with an overall effect of 1.93 (95% CI: 1.33-2.82). The pooled effects were significant in mulipara with a POG ≥40 W in the South Asian subgroup. CONCLUSIONS: Membrane sweeping effectively reduces the need for formal labor induction and promotes spontaneous labor. This may be particularly relevant in South Asian populations where a disproportionate ethnic contribution to stillbirth rates is noted. Due to the limited number of RCTs addressing the factors and study methodology heterogeneity, we had limited data in some subgroup analyses. Therefore, we encourage more RCTs and meta-analyses on POG, parity, timing and frequency of membrane sweeping, and ethnic differences.

Challenges in timing and mode of delivery in morbidly obese women.

Globally obesity is increasing especially in the reproductive age group. Pregnant women with obesity have higher complication and intervention rates. They are also at increased risk of stillbirth and intrapartum complications. Although organisations like NICE, RCOG, ACOG and WHO have published guidelines and recommendations on care of pregnant women with obesity the evidence from which Grade A recommendations can be made on timing and how to deliver is limited. The current advice is therefore to have discussions with the woman on risks to help her make an informed decision about timing, place, and mode of delivery. Obesity is an independent risk factor for pregnancy complications including diabetes, hypertension and macrosomia. In those with these complications, the timing of delivery is often influenced by the severity of the complication. As an independent factor, population based observational studies in obese women have shown an increase in the risk of stillbirth. This risk increases linearly with weight from overweight through to class II obesity, but then rises sharply in those with class III obesity by at least 10-fold beyond 42 weeks when compared to normal weight women. This risk of stillbirth is notably higher in obese women from 34 weeks onwards compared to normal weight women. One modifiable risk factor for stillbirth as shown from various cohorts of pregnant women is prolonged pregnancy. Research has linked obesity to prolonged pregnancy. Although the exact mechanism is yet unknown some have linked this to maternal dysregulation of the hypothalamic pituitary adrenal axis leading to hormonal imbalance delaying parturition. For these women the two dilemmas are when and how best to deliver. In this review, we examine the evidence and make recommendations on the timing and mode of delivery in women with obesity. For class I obese women there are no differences in outcome with regards to timing and mode of delivery when compared to lean weight women. However, for class II and III obesity, planned induction or caesarean sections may be associated with a lower perinatal morbidity and mortality although this may be associated with an increased in maternal morbidity especially in class III obesity. Studies have shown that delivery by 39 weeks is associated with lower perinatal mortality compared to delivering after in these women. On balance the evidence would favour planned delivery (induction or caesarean section) before 40 weeks of gestation. In the morbidly obese, apart from the standard lower transverse skin incision for CS, there is evidence that a supraumbilical transverse incision may reduce morbidity but is less cosmetic. Irrespective of the option adopted, it is important to discuss the pros and cons of each.

Maternal and fetal outcomes among women with GDMA1 before and post-date.

OBJECTIVE: To investigate adverse pregnancy outcomes in patients complicated with GDMA1 who delivered at term before or after 40 weeks of gestation. STUDY DESIGN: A population-based cohort study including all women with GDMA1 during pregnancy was conducted. Deliveries occurred between 1988 and 2016 at a large university tertiary medical center. RESULTS: During the study period, 11,765 women with GDMA1 met the inclusion criteria. Of these, 1303 (11 %) delivered after 40 weeks (post-date, study group), while 10,462 (89 %) delivered at term before 40 weeks of gestation (before date, control group). Those who delivered after 40 weeks of gestation (the study group) had a significantly lower percent of cesarean deliveries (CD), higher rates of spontaneous vaginal deliveries and induction of labor in comparison to those who delivered before 40 weeks of gestation (the control group). The control group had significantly higher rates of preeclampsia and intrauterine growth restriction than the study group. Using a multivariable logistic regression model, delivery after 40 weeks was noted as an independent protective factor for CD (adjusted OR = 0.78, 95 %CI 0.66-0.92, p value = 0.001). Delivery after 41 + 0 weeks had a significantly higher rate of CD and LGA. CONCLUSION: No significant increase in adverse pregnancy outcomes at term post-date pregnancies complicated with GDMA1 was demonstrated. Furthermore, there was no increase in the rate of CD with the increase in gestational age until 41 weeks of gestation.

Successful post-term pregnancy in scared bicornuate uterus: case report.

Pregnancies in the bicornuate uterus are usually considered high-risk because of their association with poor reproductive outcomes such as recurrent pregnancy loss, cervical insufficiency, low birthweight, preterm birth, malpresentation, cesarean delivery, and uterine rupture. The objective of the report was to show that patients with a scared bicornuate uterus at post-term could have successful pregnancy outcomes. We are presenting a 28-year-old gravida III para II lady with a bicornuate scared uterus at post-term. She has a history of early third-trimester pregnancy loss, and her second pregnancy was delivered via cesarean section. In her first pregnancy, the patient's uterus was not identified as bicornuate. However, an ultrasound during her second pregnancy revealed that she had a bicornuate uterus, which led to the diagnosis. At term, the lady had a successful cesarean section. Lastly, for the current post-term pregnancy she had no prenatal check-up. Even though this, she was coming at the latent first stage of labor and an emergency cesarean section was done.Conclusion Successful outcomes could be achieved in patients with the bicornuate uterus at post-term gestation.

Meconium-stained amniotic fluid and neonatal morbidity in nulliparous patients with prolonged pregnancy.

INTRODUCTION: Our objective was to study the strength of the association between meconium-stained amniotic fluid and severe morbidity among neonates of nulliparas with prolonged pregnancies. MATERIAL AND METHODS: This was a secondary analysis of the NOCETER randomized trial that took place between 2009 and 2012 in which 11 French maternity units included 1373 nulliparas at 41+0 weeks of gestation onwards with a single live fetus in cephalic presentation. This analysis excluded patients with a cesarean delivery before labor and those with bloody amniotic fluid or of unreported consistency. The principal end point was a composite criterion of severe neonatal morbidity (neonatal death, 5-minute Apgar <7, convulsions in the first 24 h, meconium aspiration syndrome, mechanical ventilation ≥24 h, or neonatal intensive care unit admission for 5 days or more). The neonatal outcomes of pregnancies with thin or thick meconium-stained amniotic fluid were compared with those with normal amniotic fluid. The association between the consistency of the amniotic fluid and neonatal morbidity was tested by univariate and then multivariate analysis adjusted for gestational age at birth, duration of labor, and country of birth. RESULTS: This study included 1274 patients: 803 (63%) in the group with normal amniotic fluid, 196 (15.4%) in the thin amniotic fluid group, and 275 (21.6%) in the thick amniotic fluid group. The neonates of patients with thick amniotic fluid had higher rates of neonatal morbidity than those of patients with normal amniotic fluid (7.3% vs. 2.2%; p < 0.001; adjusted relative risk [aRR] 3.3, 95% confidence interval [CI] 1.7-6.3), but those of patients with thin amniotic fluid did not (3.1% vs. 2.2%; p = 0.50; aRR 1.0, 95% CI, 0.4-2.7). CONCLUSIONS: Among nulliparas at 41+0 weeks onwards, only thick meconium-stained amniotic fluid is associated with a higher rate of severe neonatal morbidity.

Anterior uterocervical angle: is it an ultrasonographic screening tool that estimates the latent phase duration in post term pregnancies?

OBJECTIVES: In recent years, in addition to cervical length measurement, a new ultrasonographic parameter has been defined as uterocervical angle (UCA), which can be used in the prediction of preterm labor. In this study,we evaluated the place of uterocervical angle in predicting the latent phase duration in postterm pregnancies. MATERIAL AND METHODS: This prospective study consists of 90 pregnant women aged between 18 to 40 years who were hospitalized with a diagnose of late term pregnancy. Pregnant women with a latent phase duration of 1200 minutes or less were defined as Group 1. Patients with latent phase duration over 1200 minutes were defined as Group 2. All patients' age, BMI, smoke, cervical length measurements, uterocervical angle, latent and active phase of labor durations, length of the third stage and delivery types were compared. RESULTS: The UCA median value of group 1 was 120 (94-147), and group 2 was 99 (94-105) (p < 0.001). CL medians of Groups 1 and 2 were 29 (17-43) and 28 (27-41) respectively (p: 0.871). UCA (AUC: 0.917, p < 0.0001) significantly predicted prolonged latent phase duration. Optimal cut off value was obtained at the value of 105 degree (100% sensitivity, 75% specificity) for UCA. Kaplan-Meier survival analysis showed that duration of labor was significantly higher in a group with low UCA (p: 0.013). CONCLUSIONS: UCA can be a successful tool that can be used to predict duration of labor in cases of postterm pregnancies with medical induction.

Prolonged pregnancy and stillbirth among women with overweight or obesity - a population-based study in Sweden including 64,632 women.

BACKGROUND: The proportion of overweight or obese pregnant women is increasing in many countries and babies born to a mother who is overweight or obese are at higher risk for complications. Our primary objective was to describe sociodemographic and obstetric factors across Body Mass Index (BMI) classifications, with secondary objective to investigate stillbirth and other pregnancy outcomes in relation to BMI classifications and gestational week. METHODS: This population-based cohort study with data partly based on a cluster-randomized controlled trial includes 64,632 women with singleton pregnancy, giving birth from 28 weeks' gestation. The time period was January 2016 to 30 June 2018 (2.5 years). Women were divided into five groups according to BMI: below 18.5 underweight, 18.5-24.9 normal weight, 25.0-29.9 overweight, 30.0-34.9 obesity, 35.0 and above, severe obesity. RESULTS: Data was obtained for 61,800 women. Women who were overweight/obese/severely obese had lower educational levels, were to a lesser extent employed, were more often multiparas, tobacco users and had maternal diseases to a higher extent than women with normal weight. From 40 weeks' gestation, overweight women had a double risk of stillbirth compared to women of normal weight (RR 2.06, CI 1.01-4.21); the risk increased to almost four times higher for obese women (RR 3.97, CI 1.6-9.7). Women who were obese or severely obese had a higher risk of almost all pregnancy outcomes, compared to women of normal weight, such as Apgar score < 7 at 5 min (RR1.54, CI 1.24-1.90), stillbirth (RR 2.16, CI 1.31-3.55), transfer to neonatal care (RR 1.38, CI 1.26-1.50), and instrumental delivery (RR 1.26, CI 1.21-1.31). CONCLUSIONS: Women who were obese or severely obese had a higher risk of almost all adverse pregnancy outcomes and from gestational week 40, the risk of stillbirth was doubled. The findings indicate a need for national guidelines and individualized care to prevent and reduce negative pregnancy outcomes in overweight/obese women. Preventive methods including preconception care and public health policies are needed to reduce the number of women being overweight/obese when entering pregnancy.

Impact of prolonged use of adjuvant tocolytics after cervical cerclage on late abortion and premature delivery.

We evaluated the impact of cervical cerclage combined with one or more uterine contraction inhibitors in persistent inhibition of uterine contraction for the treatment of late abortion and premature delivery. This retrospective case series study analysed the medical data of 58 patients who underwent cervical cerclage for cervical insufficiency and simultaneously received one or more uterine contraction inhibitors (indomethacin, ritodrine, and atosiban) and magnesium sulphate at the Zibo Maternal and Child Health Hospital between January 2019 and December 2020.Patients are normal pregnancy who received cervical cerclage without complications. The rate of successful treatment was 74.14% (43/58). The prolonged gestation duration was 16.42 ± 7.84 weeks, and the average delivery gestational age was 35.91 ± 5.16 weeks. The longest duration of treatment with a uterine contraction inhibitor or inhibitors in combination or with magnesium sulphate alone was 15.34 ± 13.16 days, and nine cases developed adverse reactions. Persistent uterine contraction inhibition after cervical cerclage could prolong pregnancy and improve pregnancy outcomes.Impact statementWhat is already known on this subject? A crucial reason for treatment failure of cervical cerclage is that uterine contraction was not effectively inhibited.What do the results of this study add? Persistent inhibition of uterine contraction after cervical cerclage prolonged pregnancy duration, increased gestational age at delivery, and improved pregnancy outcomes.What are the implications of these findings for clinical practice and/or further research? This study may provide a clinical basis for prolonging gestational age, preventing late abortion and premature delivery, and improving the survival rate and quality of life of premature infants.

The incidence and risk factors of meconium amniotic fluid in singleton pregnancies: an experience of a tertiary hospital in Iran.

BACKGROUND: Several common maternal or neonatal risk factors have been linked to meconium amniotic fluid (MAF) development; however, the results are contradictory, depending on the study. This study aimed to assess the prevalence and risk factors of MAF in singleton pregnancies. METHODS: This study is a retrospective cohort that assessed singleton pregnant mothers who gave birth at a tertiary hospital in Bandar Abbas, Iran, between January 1st, 2020, and January 1st, 2022. Mothers were divided into two groups: 1) those diagnosed with meconium amniotic fluid (MAF) and 2) those diagnosed with clear amniotic fluid. Mothers with bloody amniotic fluid were excluded. Demographic factors, obstetrical factors, and maternal comorbidities were extracted from the electronic data of each mother. The Chi-square test was used to compare differences between the groups for categorical variables. Logistic regression models were used to assess meconium amniotic fluid risk factors. RESULTS: Of 8888 singleton deliveries during the study period, 1085 (12.2%) were MAF. MAF was more common in adolescents, mothers with postterm pregnancy, and primiparous mothers, and it was less common in mothers with GDM and overt diabetes. The odds of having MAF in adolescents were three times higher than those in mothers 20-34 years old (aOR: 3.07, 95% CI: 1.87-4.98). Likewise, there were significantly increased odds of MAF in mothers with late-term pregnancy (aOR: 5.12, 95% CI: 2.76-8.94), and mothers with post-term pregnancy (aOR: 7.09, 95% CI: 3.92-9.80). Primiparous women were also more likely than multiparous mothers to have MAF (aOR: 3.41, 95% CI: 2.11-4.99). CONCLUSIONS: Adolescents, primiparous mothers, and mothers with post-term pregnancies had a higher risk of MAF. Maternal comorbidities resulting in early termination of pregnancy can reduce the incidence of MAF.

Delivery outcomes in women with morbid obesity, where induction of labour was planned to prevent post-term complications.

Morbid obesity and prolonged pregnancy are independently associated with adverse delivery and perinatal outcomes. We conducted a retrospective observational study on otherwise uncomplicated women with a body mass index (BMI) ≥ 40 kg/m2 where, having reached term, induction of labour (IOL) was planned, to prevent prolonged pregnancy. The primary aim was to describe delivery outcomes and short-term maternal and perinatal adverse events. Of 117 cases included, 69 (59%) laboured spontaneously before the induction date, while 48 (41%) required an IOL. Of 48 patients that underwent an IOL, 22 (45.8%) achieved vaginal delivery, compared to 55 (79.7%) who laboured spontaneously (p = <.001). Twenty-two (18.8%) of the 117 babies weighed more than 4000 g, with 13 of these delivered vaginally. Overall, term patients with morbid obesity who laboured spontaneously before requiring induction, had a high rate of vaginal delivery. However, when IOL was required, the rate of caesarean delivery rose dramatically.Impact statementWhat is already known on this subject? Morbid obesity and prolonged pregnancy are independently associated with adverse delivery and perinatal outcomes. Induction of labour (IOL) increases the workload in busy units.What do the results of this study add? These results help inform accurate counselling on delivery outcomes, which is integral to respectful care, for the continuously increasing numbers of morbidly obese pregnant women.What the implications are of these findings for clinical practice and/or further research? It is preferable to avoid semi- or urgent caesarean deliveries in morbidly obese women after IOL. The outcomes of earlier induction of labour from 39- or 40-weeks' gestation requires investigation. Earlier induction may reduce the numbers of caesarean deliveries for abnormal cardiotocograph during the process.

The effect of paternal and maternal factors on the prognosis of live birth in couples with recurrent pregnancy loss.

INTRODUCTION: Currently, recurrent pregnancy loss (RPL) examinations focus on the woman, although paternal factors are also involved. Men in couples with RPL have higher sperm DNA fragmentation levels than fertile men, but the effect of sperm DNA damage on couple's later prognosis is unknown. Advanced maternal age and obesity are associated with RPL, but paternal lifestyle factors are less studied. Therefore, we aimed to study the associations of couples' lifestyle factors, causes of RPL, and sperm DNA fragmentation with their prognosis of future live birth. MATERIAL AND METHODS: This descriptive cohort study comprised 506 couples investigated for RPL at Helsinki University Hospital, Finland, between 2007 and 2016, linked with national health and population registers. The primary outcome was couple's live birth after RPL investigations. Data on couple's background factors, including age, body mass index, smoking, and alcohol use, were collected from medical records. Sperm DNA fragmentation index was analyzed from 211 men using the sperm chromatin dispersion test. The associations between background factors, sperm DNA fragmentation, and cumulative probability of live birth over time were analyzed using cross-tabulations and age-adjusted Cox regression. RESULTS: In all, 352 of 506 couples (69.6%) achieved live birth. Maternal age, unexplained RPL, prolonged pregnancy attempts before investigations, paternal obesity, and maternal smoking were associated with prognosis: unadjusted hazard ratio for couple's live birth for women aged 35-39 vs younger than 30 years was 0.63 (95% confidence interval [CI] 0.47-0.84), and for 40 years or older was 0.36 (95% CI 0.22-0.58). Age-adjusted hazard ratio for unexplained vs explained RPL was 1.39 (95% CI 1.12-1.72), for couple's pregnancy attempt at least 4 years vs less than 2 years was 0.50 (95% CI 0.33-0.76), for paternal body mass index at least 30 kg/m2 vs less than 25 kg/m2 was 0.67 (95% CI 0.46-0.98), and for maternal smoking was 0.71 (95% CI 0.51-0.99). Altogether, 96/135 (71.1%) couples with normal (<15%), 38/60 (63.3%) with intermediate (15-30%), and 11/16 (68.8%) with high sperm DNA fragmentation index achieved live birth (p = 0.56). CONCLUSIONS: In couples with RPL, prolonged pregnancy attempts, a cause found in RPL examinations, lifestyle factors, and maternal age are negatively associated with their prognosis of future live birth. Sperm DNA fragmentation was not associated, but the number of men with damaged spermatozoa was small. We suggest that clinicians include women and men in RPL counseling because couple's joint lifestyle seems to determine their later prognosis.

Effectiveness and safety of membrane sweeping in the prevention of post-term pregnancy: a randomised controlled trial.

There is a rising concern with increasing rates of pharmacologically induced labour and its complications. Membrane sweeping is a simple and less invasive means of initiating spontaneous labour onset. We compared the safety and efficacy of membrane sweeping. A total of 186 women (62 in each arm) were recruited at the antenatal clinic at 39 weeks. The intervention groups had membrane sweeping once and twice weekly respectively while the control arm had no membrane sweeping. They were all monitored and followed up till delivery. The trial was registered with the South Africa registry www.pactr.org (PACTR202112841108933) The incidence of prolonged pregnancy was 32.3%, 19.4% and 11.7% among the control, once-weekly, and twice-weekly groups respectively. The sweeping to the delivery interval was significantly shorter for the twice-weekly group (7.4 days) compared to once weekly (8.8 days) and the control group (10.6 days). There were significantly higher odds of spontaneous labour onset in the twice-weekly group (HR 1.53, p = .029) compared to the control group (HR 0.65, p = .033) and the once-weekly group using once weekly as reference. Membrane sweeping is a safe and effective means of preventing prolonged pregnancy. Twice-weekly sweeping of foetal membranes is more effective than once-weekly or no sweeping without added adverse feto-maternal outcomes.IMPACT STATEMENTWhat is already known about the subject? There is no evidence supporting any increase in maternal or foetal morbidity suggesting that membrane sweeping is a safe procedure to offer to all low-risk pregnant women so as to initiate spontaneous labour onset.What do the results of the study add? Membrane sweeping twice weekly after 39weeks for low-risk pregnant women is more effective than once weekly or no sweep with no added adverse maternal or perinatal risks.What are the implications of these findings for clinical practice and or further research? Twice-weekly membrane sweeping is encouraged in selected patients to reduce the risks associated with post-term pregnancy.

Trends in labor induction indications: A 20-year population-based study.

INTRODUCTION: Use of labor induction has increased rapidly in most middle- and high-income countries over the past decade. The reasons for the stark rise in labor induction are largely unknown. We aimed to assess the extent to which the rising rate of labor induction is explained by changes in rates of underlying indications over time. MATERIAL AND METHODS: The study was based on nationwide data from the Icelandic Medical Birth Register on 85 620 singleton births from 1997 to 2018. The rate of labor induction and indications for induction was calculated for all singleton births in 1997-2018. Change over time was expressed as relative risk (RR), using Poisson regression with 95% confidence intervals (CI) adjusted for maternal characteristics and indications for labor induction. RESULTS: The crude rate of labor induction rose from 12.5% in 1997-2001 to 23.9% in 2014-2018 (crude RR = 1.91, 95% CI 1.81-2.01). While adjusting for maternal characteristics had little impact, adjusting additionally for labor induction indications lowered the RR to 1.43 (95% CI 1.35-1.51). Induction was increasingly indicated from 1997-2001 to 2014-2018 by gestational diabetes (2.4%-16.5%), hypertensive disorders (7.0%-11.1%), prolonged pregnancy (16.2%-23.7%), concerns for maternal wellbeing (3.2%-6.9%) and maternal age (0.5%-1.2%). No indication was registered for 9.2% of inductions in 2014-2018 compared with 16.3% in 1997-2001. CONCLUSIONS: Our results show that the increase in labor induction over the study period is largely explained by an increase in various underlying conditions indicating labor induction. However, indications for 9.2% of labor inductions remain unexplained and warrant further investigation.

Maternal plasma levels of vitamin D in postterm pregnancy.

This study was conducted to examine the levels of vitamin D in postterm pregnancy. The study consisted of two groups: Group 1: women with postterm pregnancy in whom labour has not started (n = 40). Group 2: pregnant women with spontaneous labour between 37 and 41 weeks of gestation (n = 40). Demographic characteristics of individuals, age, body mass index, gravida, parity, living child, number of abortions and birth characteristics were recorded. Prepartum and postpartum haemoglobin (Hb) and haematocrit (Hct) values ​​and vitamin D levels of pregnant women were measured. We found no significant differences in vitamin D levels, smoking, mode of delivery, induction of labour, methods of cervical ripening and maternal and perinatal complications between the groups (p > .05). D vitamin in the model had a statistically significant effect on prepartum Hb (p < .05). Vitamin D levels seem not to be associated with postterm pregnancy. Vitamin D had a statistically significant effect on prepartum Hb.IMPACT STATEMENTWhat is already known on this subject? The aetiology of post term pregnancy is not clearly known, factors such as foetal anencephaly, foetal sex, placental sulfatase deficiency, genetic factors, and high pre-pregnancy body mass index play a role.What do the results of this study add? Vitamin D levels seem not to be associated with postterm pregnancy. Vitamin D had a statistically significant effect on prepartum Hb.What are the implications of these findings for clinical practice and/or further research? Further studies are needed to clarify the relationship between vitamin D levels and postterm pregnancy.

Morphological and functional changes in placentas from prolonged pregnancies.

Prolonged pregnancy describes a pregnancy that progresses beyond 42 weeks' gestation (294 days). In humans, prolonged pregnancy is associated with increasing perinatal mortality, neonatal compromise and birth by Caesarean section. The underpinning reasons behind these increased risks are unknown; one potential explanation is reduced placental function due to ageing processes. This review describes the structural and functional changes seen in prolonged pregnancy in humans and in animal models. Prolonged pregnancies are associated with reduced placental growth, leading to an increase in fetal to placental weight ratio. Microscopic changes include aggregation of syncytiotrophoblast nuclei, reduced villous vascularity with a concomitant impairment of trophoblast transport processes (reduced pinocytosis); this is associated with increased evidence of oxidative stress, with downstream consequences including cellular senescence, autophagy and apoptosis; importantly many of these changes are similar to fetal growth restriction and pre-eclampsia. Thus, we argue that these observations provide evidence of ageing within the placenta, which may initially be adaptive but can become pathological leading to a reduction in placental function. This provides a biological basis for the increased risk of adverse outcomes observed in prolonged pregnancies. Greater insight into the effects and risks of placental ageing may be useful to guide clinicians on the management of prolonged pregnancies.

Risk of complications in the late vs early days of the 42nd week of pregnancy: A nationwide cohort study.

INTRODUCTION: Uncertainty remains about the most appropriate timing of induction of labor in late-term pregnancies. To address this issue, this study aimed to compare the risk of neonatal morbidity and pregnancy- and birth-related complications between gestational age (GA) 41+4 -42+0 and GA 41+0 -41+3  weeks. MATERIAL AND METHODS: This nationwide registry-based cohort study included singleton births without major congenital malformations, with registered GA, and with intended vaginal delivery at GA 41+0 - 42+0  weeks between 2009 and 2018 in Denmark. Logistic regression models were used to estimate the crude risk ratio and adjusted risk ratio (RRA ) of neonatal and obstetric adverse outcomes in births at GA 41+4 - 42+0  weeks compared with GA 41+0 - 41+3  weeks. The results were adjusted for relevant confounders, including induction of labor. RESULTS: A higher incidence of neonatal morbidity and birth complications was observed in births at GA 41+4 -42+0  weeks than in births at GA 41+0 -41+3  weeks. Neonatal morbidities included an increased risk of low Apgar score (Apgar 0-6 after 5 min; RRA 1.17, 95% confidence interval [CI] 1.01-1.34), meconium aspiration (RRA 1.25, 95% CI 1.06-1.48), need for respiratory support (continuous positive airway pressure; RRA 1.09, 95% CI 1.03-1.15), and a composite outcome of need for comprehensive treatment at a neonatal department or neonatal death (RRA 1.65, 95% CI 1.29-2.11). Birth complications included emergency cesarean section (RRA 1.17, 95% CI 1.14-1.21), severe lacerations (RRA 1.11, 95% Cl 1.04-1.17), and increased blood loss after birth (RRA 1.13, 95% CI 1.06-1.21). CONCLUSIONS: Births at GA 41+4 -42+0  weeks were associated with an increased risk of neonatal morbidity and birth complications compared with births at GA 41+0 -41+3  weeks. The results of this study may aid clinicians in deciding when to recommend induction of labor in late-term pregnancies.

Against medical advice for induction of labor due to post-term pregnancies - the impact on pregnancy outcome.

OBJECTIVE: To determine the impact of deciding against medical advice and refusing labor induction in post-term pregnancies on pregnancy outcome. METHODS: Maternal and neonatal outcomes of women who refused induction of labor due to post term pregnancy (study group) were retrospectively compared to a control group of women who agreed labor induction (1:2 ratio) in a university-affiliated tertiary single medical center. RESULTS: A total of 83 women who refused labor induction were identified and compared to 166 womenwho consented to labor induction. Women who refused labor induction had higher rates of cesarean deliveries (21.7 vs. 10.2% p = .04), longer post-delivery hospitalization (2.9 vs. 2.4 days p < .05) and more advanced gestational age at delivery (41 + 6 vs. 41 + 4 days, p < .05). No significant differences were found in the rate of operative vaginal deliveries, need for antibiotics treatment or blood transfusion between the studied groups. Adverse neonatal outcomes among women who refused labor induction were significantly higher with higher rates of meconium (44.6 vs. 15.7%, p < .01), admission to NICU (9.6 vs. 5%, p < .01) and need for mechanical ventilation (4.8 vs. 0.6%, p < .01). CONCLUSION: Refusing induction of labor due to post- term pregnancy is associated with higher rate of adverse maternal and neonatal outcomes, with a significant higher risk for cesarean section.

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.