Placental growth factor testing in the management of late preterm preeclampsia without severe features: a multicenter, randomized, controlled trial.

BACKGROUND: In women with late preterm preeclampsia, the optimal time for delivery remains a controversial topic, because of the fine balance between the maternal benefits from early delivery and the risks for prematurity. It remains challenging to define prognostic markers to identify women at highest risk for complications, in which case a selective, planned delivery may reduce the adverse maternal and perinatal outcomes. OBJECTIVE: This trial aimed to determine whether using an algorithm based on the maternal levels of placental growth factor in women with late preterm preeclampsia to evaluate the best time for delivery reduced the progression to preeclampsia with severe features without increasing the adverse perinatal outcomes. STUDY DESIGN: This parallel-group, open-label, multicenter, randomized controlled trial was conducted at 7 maternity units across Spain. We compared selective planned deliveries based on maternal levels of placental growth factor at admission (revealed group) and expectant management under usual care (concealed group) with individual randomization in singleton pregnancies with late preterm preeclampsia from 34 to 36+6 weeks' gestation. The coprimary maternal outcome was the progression to preeclampsia with severe features. The coprimary neonatal outcome was morbidity at infant hospital discharge with a noninferiority hypothesis (noninferiority margin of 10% difference in incidence). Analyses were conducted according to intention-to-treat. RESULTS: Between January 1, 2016, and December 31, 2019, 178 women were recruited. Of those women, 88 were assigned to the revealed group and 90 were assigned to the concealed group. The data analysis was performed before the completion of the required sample size. The proportion of women with progression to preeclampsia with severe features was significantly lower in the revealed group than in the concealed group (adjusted relative risk, 0.5; 95% confidence interval, 0.33-0.76; P=.001). The proportion of infants with neonatal morbidity was not significantly different between groups (adjusted relative risk, 0.77; 95% confidence interval, 0.39-1.53; P=.45). CONCLUSION: There is evidence to suggest that the use of an algorithm based on placental growth factor levels in women with late preterm preeclampsia leads to a lower rate of progression to preeclampsia with severe features and reduces maternal complications without worsening the neonatal outcomes. This trade-off should be discussed with women with late preterm preeclampsia to allow shared decision making about the timing of delivery.

Effect of maternal obesity on pregnancy outcomes in women delivering singleton babies: a historical cohort study.

Background Obesity in pregnancy is increasing worldwide, reaching epidemic proportions in many countries and frequently creating challenges for obstetricians. We conducted this study to assess the effects of maternal obesity on maternal and perinatal outcomes. Methods A historical cohort study was performed on 16,609 women who delivered singleton babies in a 5-year period (2013-2017). Data were retrieved from the Cruces Perinatal Database (CPD) and only women whose prepregnancy body mass index (BMI) was known were included. Women were categorized according to the World Health Organization (WHO) classification: normal weight (BMI 20-24.9 kg/m2) and obesity (BMI ≥ 30 kg/m2). Obstetric, perinatal and neonatal outcomes were compared, and adjusted odds ratios (aORs) and 95% confidence intervals (95% CIs) were calculated using the normal-weight group as the reference. Results Compared to women of normal weight (n = 9778), obese women (n = 2207) had a higher risk of preeclampsia (aOR 2.199, 95% CI: 1.46-3.29), rectovaginal group B streptococcus colonization (aOR 1.299, 95% CI: 1.14-1.47), induction of labor (aOR 1.593, 95% CI: 1.44-1.75), cesarean section (aOR 2.755, 95% CI: 2.46-3.08), cesarean section in women with a history of cesarean delivery (aOR 1.409, 95% CI: 1.03-1.92), fetal weight ≥4000 g (aOR 2.090, 95% CI: 1.803-2.422) and admission to the neonatal intensive care unit (NICU) (aOR 1.341, 95% CI: 1.12-1.59). No association was found with preterm birth (aOR 0.936, 95% CI: 0.77-1.13), stillbirth (aOR 0.921, 95% CI: 0.41-2.02) or neonatal mortality (aOR 2.205, 95% CI: 0.86-5.62). Conclusion Maternal obesity is associated with a higher risk of adverse pregnancy and perinatal outcomes. Pregnancy in this population of women should be considered and managed as high risk.

Effect of maternal intravenous fluid therapy on external cephalic version at term: a prospective cohort study.

OBJECTIVE: We sought to analyze whether maternal intravenous fluid therapy prior to external cephalic version (ECV) increases the amount of amniotic fluid and the success rate of the procedure. STUDY DESIGN: This was a prospective single-center cohort study of 200 women with a consecutive cohort of 100 pregnant women with a breech presentation at term who were administered intravenous fluid therapy with 2 L of hypotonic saline before the version attempt, compared to a control cohort of 100 pregnant women not given hydration treatment. RESULTS: The mean increase in the amniotic fluid index (AFI) after intravenous maternal hydration was 3.75 ± 2.71 cm. The amount of fluid before hydration was the only variable found to be associated with increases in amniotic fluid levels, both in absolute and relative terms (odds ratio, -0.21; 95% confidence interval, -0.37 to -0.05 and odds ratio, -4.62; 95% confidence interval, -6.17 to -3.06; P < .01, respectively). We did not observe any severe complications secondary to the intravenous fluid therapy. The ECV success rate was 43% in the study group compared to 47% in the control group (P = .67). The success rate was significantly lower the larger the relative increase in the AFI, although no correlation was found in absolute terms (χ(2) for linear trend = 0.03 and 0.34, respectively). CONCLUSION: Maternal intravenous fluid therapy with 2 L of hypotonic saline prior to ECV is an effective and safe technique for increasing the AFI. However, its use in ECV does not increase the success rate of the procedure.

Nitrous oxide for analgesia in external cephalic version at term: prospective comparative study.

OBJECTIVE: The objective of this study was to analyze the effect of using inhaled nitrous oxide (N2O) for analgesia in external cephalic version (ECV) at term on the success rate of the procedure, on pain, and on obstetric and perinatal outcomes. METHODS: A prospective comparative cohort study among 300 women with singleton pregnancy in breech presentation at term undergoing an ECV with inhaled N2O in a 50:50 mix with oxygen for analgesia and 150 ECVs with no analgesia. RESULTS: The success rate was 52.3% in the N2O cohort and 52.7% in the controls (P=0.94), whereas the median level of pain was statistically lower in women given N2O (median, 6; range, 4-7, vs. median, 7; range, 5-8; P<0.01). This improvement is mainly from a 49% decrease in severe pain. There were no significant differences in the rate of complications associated with the ECV, in the rate of cesarean sections, or in perinatal outcomes. Furthermore, there were no severe complications secondary to N2O inhalation. CONCLUSIONS: N2O inhalation at a concentration of 50% for analgesia during ECV decreases the level of severe pain experienced by women, appears to be safe both for mother and child, and has no influence on the success rate of ECV or the perinatal outcomes.

Influence of chorionicity in intra-partum management of twin deliveries.

OBJECTIVE: To analyze morbidity and mortality in twin pregnancies as a function of the type of delivery and chorionicity. DESIGN: Retrospective cohort study. METHODS: Analysis of the type of delivery, intertwin time interval, and perinatal variables of >1000 twin deliveries during a 10-year period. MAIN OUTCOME MEASURE: Influence of delivery type and chorionicity on perinatal outcome. RESULTS: The rate of cesarean sections was 42.4%. No differences were found as a function of chorionicity or as a function of presentation of the second twin. Cesarean sections were performed after vaginal delivery of the first twin in 1.8% of cases, being more common if the second baby was in a non-cephalic presentation (6.9% vs. 0.4%, p < 0.05). The average twin-to-twin delivery time interval was longer in the cases where the second had a cephalic presentation (8.26 ± 7.75 min vs. 6.81 ± 5.97 min, p < 0.05). The umbilical artery pH was lower the longer the interval between the birth of the twins, both in monochorionic and dichorionic. CONCLUSIONS: According to the results, vaginal delivery is as safe as elective caesarean section in twin pregnancies where the first twin is in cephalic presentation and the intrapartum management should not vary due to chorionicity.

Induction at 41 weeks increases the risk of caesarean section in a hospital with a low rate of caesarean sections.

OBJECTIVE: To analyse the impact of a change in the management of prolonged pregnancies from inducing labour at 42(+0) to induction at 41(0-6). DESIGN: Retrospective cohort study. METHODS: Analysis of 3563 single pregnancies with cephalic presentation of ≥ 41 weeks of gestation delivered in Cruces University Hospital (Spain). Two cohorts were compared corresponding to before and after the change in the policy on induction. MAIN OUTCOME MEASURES: Induction rate, vaginal delivery rate, newborn morbidity and mortality. RESULTS: The overall rate of caesarean sections in the patients included in the study was 12.8% (19.5% among those induced and 8.4% among those in whom the onset of labour has been spontaneous). The caesarean section rate in cohorts 41(0-6) and 42(+0) were 14.1% and 11.4%, respectively (p=0.01). Though there were more newborns with umbilical cord blood ph<7.10 in cohort 41(0-6) than in the other group (8.7% versus 4.5%; p<0.01), no significant differences were found between cohorts in 5-min Apgar score < 7, number of admissions to the neonatal care unit or perinatal mortality. CONCLUSION: The induction of labour during week 41 in prolonged pregnancies may increase the rate of caesarean sections in hospitals with low rates of caesarean sections.

Clinical score for the outcome of external cephalic version: a two-phase prospective study.

AIM: To design a score based on clinical parameters to predict the outcome of external cephalic versions (ECVs) at term. MATERIALS AND METHODS: A two-phase study was conducted (analysis/design and prospective validation) regarding 1000 versions performed between March 2002 and November 2010. The variables considered in the score were selected based on the results of multiple logistic regression models and multiple correspondence analyses published by our group. The predictive capacity was estimated through the area under the ROC curve. RESULTS: The success rates for ECV in phases 1 and 2 were 52.2 and 51.2%, respectively, making the overall success rate 51.7%. The score was designed with the variables parity, placental location, breech variety and amount of amniotic fluid giving a value for each one. A clinical recommendation, based on the result of the score, was the estimated success rate with the 95% confidence interval. The predictive capacity of the score for the outcome of ECV at term was 70.1% (95% CI 66.9-73.4). CONCLUSIONS: A score composed of four easily measurable variables enabled us to predict the outcome of ECV at term.

Oxytocin versus dinoprostone vaginal insert for induction of labor after previous cesarean section: a retrospective comparative study.

OBJECTIVE: To compare the efficacy and safety of two methods for induction of labor after previous cesarean section. METHODS: To compare 247 women with a previous cesarean section who were induced with a dinoprostone vaginal insert and 279 women with a previous cesarean section induced with oxytocin, between 2001 and 2008. We evaluated vaginal delivery rate, maternal morbidity and newborn morbidity and mortality. RESULTS: The overall rate of vaginal delivery was 65.2%. We did not find significant differences between induction with dinoprostone vaginal insert and oxytocin in the rate of cesarean section performed (35.6% vs. 34.1%, P=0.71). There were nine cases of uterine rupture (rate of 1.7%), of which four occurred with dinoprostone vaginal insert and five when using oxytocin (P=0.89). We found no significant differences in neonatal outcomes. CONCLUSIONS: Both tested methods appear to be equally safe and effective for induction of labor in women with a previous cesarean section.

Prenatal detection of congenital heart defects: a survey on clinical practice in Spain.

INTRODUCTION: Second-trimester fetal screening for congenital heart defects (CHD) included in routine obstetric care provides relevant information for decision making. The aim of this study was to describe the clinical practice of prenatal detection of CHD in terms of the process and results. METHODS: The characteristics and results of ultrasound screening for major CHD were documented using data provided by hospitals for a national survey in Spain over the period of 2004-2006. Sixty-seven percent of eligible centers (56/83), covering 36% of total births nationwide, responded to the survey; 33 of these returned complete data regarding the screening results. RESULTS: The number of major CHD occurring in the centers which provided data with results of screening was 1,060. The overall prenatal detection rate of major CHD was 65.7% (95% CI 57.8-74.7), but the detection rate in the routine second-trimester scan was 52.6% (95% CI 45.6-60.8). In 61% of these cases the parents chose to terminate the pregnancy. Two independent predictors of increased detection by center were identified: first, the uniformity and systematic character of the examination of the heart showing at least the 4-chamber view and outflow tracts (prevalence ratio 1.3, 95% CI 1.0-1.8) and second, the local availability of specialists in fetal echocardiography (prevalence ratio 1.4, 95% CI 1.1-1.9). CONCLUSIONS: The detection of major CHD in the first half of pregnancy has an important impact on parental decision making. The prenatal screening program for CHD should be globally strengthened in terms of qualifications and methodological approaches. To improve its performance locally, close collaboration with fetal heart specialists should be promoted.

A prospective study of the factors associated with the success rate of external cephalic version for breech presentation at term.

OBJECTIVE: To determine the factors associated with the success rate of external cephalic version (ECV) for breech presentation at term. METHODS: A prospective analysis of 500 ECV maneuvers. The variables maternal age, maternal weight, body mass index, previous cesarean delivery, gestational age, parity, amount of amniotic fluid, placental location, and type of breech were studied using logistic regression analysis. RESULTS: The success rate of ECV was 52.2% (n=261). The variables significantly associated with success were parity, placental location, amount of amniotic fluid, and type of breech (P<0.05). A parity of 2 had a 3.74-times higher probability of success than nulliparity (95% CI, 2.37-5.90); a posterior placenta increased the success rate by 2.85 times compared with an anterior placenta (95% CI, 1.87-4.36); and double footling breech presentation had a 2.77-times higher success rate compared with a frank breech presentation (95% CI, 1.16-6.62). The area under the ROC curve showed a predictive ability of 73.6% (95% CI, 69.2%-77.9%) for these 3 variables. CONCLUSION: Parity, placental location, amount of amniotic fluid, and type of breech presentation were associated with the success rate of ECV.

Análisis del dolor en la versión cefálica externa / Analysis of pain in external cephalic version

Objetivo: Analizar el dolor materno durante la versión cefálica externa. Material y métodos: Estudio prospectivo en 71 pacientes, en el Hospital de Cruces, entre abril de 2005 y abril de 2006, mediante una encuesta personal tras la versión. Esta incluía una «escala numérica» de evaluación del dolor, así como preguntas relacionadas con el procedimiento. Se han analizado los resultados en función del éxito o fracaso del procedimiento. Resultados: La tasa de éxito global fue del 50,7%. Todas las gestantes lo toleraron bien y no hubo ninguna complicación. La mediana global de dolor fue 7; fue 5 en las versiones con éxito frente a 8 en las que fracasó (p < 0,01). El 83,1% repetiría el procedimiento; siendo más del 50% por el beneficio del parto en cefálica. Conclusiones: La versión cefálica externa es un procedimiento bien tolerado, probablemente debido a su brevedad, si bien es un procedimiento no exento de dolor (AU)

Objective: To analyze the maternal perception of pain during external cephalic version. Material and methods: A prospective study was carried out on 71 patients at the Hospital de Cruces between April 2005 and April 2006, based on personal surveys conducted after the version. These surveys included a «numeric pain intensity rating scale» as well as a series of questions regarding the procedure. Results were analyzed in terms of success or failure of the procedure. Results: The overall success rate was 50.7%. The procedure was well tolerated by all pregnant women, with no complications being observed. The overall median pain stood at 7; 5 in successful versions, as opposed to 8 in unsuccessful versions (P<.01). A total of 83.1% of patients stated that they would be willing to undergo the procedure again in the future, more than 50% of them basing their decision on the benefits of cephalic delivery. Conclusions: The fact that external cephalic version is a well tolerated procedure is probably due to its brevity, although it must be noted that it is not a pain-free maneuver (AU)

Does fetal weight estimated by ultrasound really affect the success rate of external cephalic version?

OBJECTIVE. To determine whether fetal weight estimated by ultrasound on the day the external cephalic version (ECV) is related to the procedure's success rate. DESIGN. Retrospective cohort study. Setting. University hospital. POPULATION OR SAMPLE. Two hundred women with a singleton pregnancy undergoing an ECV attempt between March 2002 and March 2006. METHOD. Projected birthweight at delivery was calculated. Logistic regression analysis, by grams and by weight intervals, and multiple correspondence analysis were performed to determine whether or not the weight was related to the procedure's success. Specific statistical analysis was undertaken to minimize measurement bias in fetal weight estimation. MAIN OUTCOME MEASURE. Success of ECV in relation to estimated fetal weight. RESULTS. Measurement bias was ruled out because no statistically significant differences were identified with the Student's t-test (p>0.05), Bland-Altman's agreement analysis, and the interclass correlation coefficient analysis (ICC = 0.829; CI95% 0.772-0.871; p<0.01). By logistic regression analysis, a variable relation between fetal weight estimated by ultrasound and ECV success was detected, while multiple correspondence analysis suggested that variations in fetal weight are weakly related to the procedure's success or failure. No relation was identified between ECV and birthweight (p = 0.38) when the delivery took place in the same week as the version. CONCLUSIONS. Estimated fetal weight before ECV seems not to be related to the outcome of ECV.

La episiotomía en España. Datos del año 2006 / Episiotomy in Spain: Data from 2006

En una encuesta realizada por la Sección de Medicina Perinatal de la SEGO, se ha podido comprobar que durante el año 2006, la tasa de episiotomías en los partos eutócicos fue del 54,08% y en los partos instrumentales del 92,62%

A survey performed by the Perinatal Medicine Section of the Spanish Society of Obstetrics and Gynecology found that the rate of episiotomies was 54.08% in uneventful deliveries and was 92.62% in instrumental deliveries

Resultados perinatales de las gestaciones triples comparadas con las gestaciones gemelares / Perinatal results of triple pregnancies compared with twin pregnancies

Objetivos: Conocer y comparar entre sí los resultados perinatales de 194 gestaciones múltiples (97 embarazos gemelares y 97 embarazos triples). Pacientes y métodos: Se estudian de forma retrospectiva los resultados perinatales de 97 gestaciones triples atendidas en nuestro hospital entre enero de 1989 y diciembre de 2004. En el grupo control se han incluido 97 embarazos gemelares atendidos durante el mismo período, escogiendo siempre el más próximo en cuanto a fecha del parto respecto de cada triple analizado. Resultados: Los embarazos triples tienden a ser más frecuentemente consecutivos a técnicas de reproducción asistida que los dobles y presentan una edad gestacional (34 ± 2,9 frente a 36 ± 3,5 semanas) y un peso al nacimiento (1.782 ± 523 frente a 2.215 ± 619 g) significativamente menor que los gemelares. Sin embargo, la prematuridad extrema (< 28 semanas) es similar en ambos grupos. No hay diferencias en cuanto al índice de malformaciones, valoración neonatal al nacimiento ni mortalidad perinatal. De las complicaciones obstétricas, la amenaza de parto pretérmino presenta una incidencia similar en ambos grupos y sólo la colestasis intrahepática (9 casos entre las gestaciones triples y ninguna entre los embarazos dobles) se presenta con una incidencia mayor entre las gestaciones triples que en las gemelares. Conclusiones: La morbimortalidad de los recién nacidos de gestaciones múltiples depende fundamentalmente de la prematuridad y, por tanto, de la duración del embarazo, por lo que el control obstétrico debe centrarse en intentar alcanzar la mayor duración. Todos los embarazos múltiples son embarazos de riesgo, pero triples y gemelos tienen un pronóstico similar cuando se ajustan por edad gestacional

Objectives: To determine and compare the perinatal results of 104 multiple pregnancies (97 twin pregnancies and 97 triple pregnancies). Patients and methods: The perinatal results of 97 triple pregnancies attended in our hospital between January 1989 and December 2004 were retrospectively studied. As a control group, 97 twin pregnancies attended during the same period were used. In all cases, the twin pregnancy closest to the delivery date of the triple pregnancy analyzed was chosen. Results: Triple pregnancies tended to occur more frequently after assisted reproduction techniques than twin pregnancies. Gestational age (34 ± 2.9 versus 36 ± 3.5 weeks) and birth weight (1782 ± 523 versus 2215 ± 619 g) were significantly lower in triple pregnancies than in twin pregnancies. However, extreme prematurity (< 28 weeks) was similar in both groups. No differences were found in the rate of malformations, neonatal evaluation at birth or perinatal mortality. Among obstetric complications, the threat of preterm delivery was similar in both groups. Only the incidence of intrahepatic cholestasis was higher among triple pregnancies than among twin pregnancies (9 cases among triple pregnancies and none among twin pregnancies). Conclusions: Morbidity and mortality among neonates of multiple pregnancies depends mainly on prematurity and therefore on pregnancy duration. Consequently, pregnancy follow-up should aim to achieve the longest duration possible. All multiple pregnancies are high-risk. However, triple and twin pregnancies have a similar prognosis when adjusted by gestational age