Prediction of clinical outcomes in women with placenta accreta spectrum using machine learning models: an international multicenter study.

INTRODUCTION: Placenta accreta spectrum is a major obstetric disorder that is associated with significant morbidity and mortality. The objective of this study is to establish a prediction model of clinical outcomes in these women. MATERIALS AND METHODS: PAS-ID is an international multicenter study that comprises 11 centers from 9 countries. Women who were diagnosed with PAS and were managed in the recruiting centers between 1 January 2010 and 31 December 2019 were included. Data were reanalyzed using machine learning (ML) models, and 2 models were created to predict outcomes using antepartum and perioperative features. ML model was conducted using python® programing language. The primary outcome was massive PAS-associated perioperative blood loss (intraoperative blood loss ≥2500 ml, triggering massive transfusion protocol, or complicated by disseminated intravascular coagulopathy). Other outcomes include prolonged hospitalization >7 days and admission to the intensive care unit (ICU). RESULTS: 727 women with PAS were included. The area under curve (AUC) for ML antepartum prediction model was 0.84, 0.81, and 0.82 for massive blood loss, prolonged hospitalization, and admission to ICU, respectively. Significant contributors to this model were parity, placental site, method of diagnosis, and antepartum hemoglobin. Combining baseline and perioperative variables, the ML model performed at 0.86, 0.90, and 0.86 for study outcomes, respectively. Ethnicity, pelvic invasion, and uterine incision were the most predictive factors in this model. DISCUSSION: ML models can be used to calculate the individualized risk of morbidity in women with PAS. Model-based risk assessment facilitates a priori delineation of management.

Uterine Artery Laceration after Vacuum Delivery.

Post-partum hemorrhage is one of the leading causes of maternal mortality and it's etiology needs to be identified in order for adequate treatment to be provided. We report a case of a post-partum hemorrhage in a multiparous woman treated with selective coil packing embolization after identification of laceration of the right uterine artery's ascending branch. The patient was admitted to an intensive care unit in hemorrhagic hypovolemic shock and disseminated intravascular coagulation and underwent total hysterectomy due to infectious complications.

A hemorragia pós-parto é uma das principais causas de mortalidade materna e a sua etiologia deve ser identificada para um tratamento adequado. Descrevemos um caso de hemorragia pós parto numa multípara tratada com embolização selectiva após identificação de uma laceração total do ramo ascendente da artéria uterina direita. A puérpera foi admitida na unidade de cuidados intensivos em choque hipovolémico hemorrágico e coagulação intravascular disseminada que culminou numa histerectomia abdominal por complicações infeciosas.

Iodine knowledge is associated with iodine status in Portuguese pregnant women: results from the IoMum cohort study.

Lack of knowledge about iodine has been suggested as a risk factor for iodine deficiency in pregnant women, but no studies have addressed this issue in Portugal. So, the aim of this study was to investigate iodine knowledge among Portuguese pregnant women and its association with iodine status. IoMum, a prospective observational study, included 485 pregnant women recruited at Centro Hospitalar e Universitário de S. João, Porto, between the 10th and 13th gestational weeks. Partial scores for knowledge on iodine importance, on iodine food sources or on iodised salt were obtained through the application of a structured questionnaire. Then, a total iodine knowledge score was calculated and grouped into low, medium and high knowledge categories. Urinary iodine concentration (UIC) was measured in spot urine samples by inductively coupled plasma MS. Of the pregnant women, 54 % correctly recognised iodine as important to neurocognitive development, 32 % were unable to identify any iodine-rich food and 71 % presented lack of knowledge regarding iodised salt. Of the women, 61 % had a medium total score of iodine knowledge. Knowledge on iodine importance during pregnancy was positively associated with iodine supplementation and also with UIC. Nevertheless, median UIC in women who correctly recognised the importance of iodine was below the cut-off for adequacy in pregnancy (150 µg/l). In conclusion, knowledge on iodine importance is positively associated with iodine status. Despite this, recognising iodine importance during pregnancy may not be sufficient to ensure iodine adequacy. Literacy-promoting actions are urgently needed to improve iodine status in pregnancy.

The association of milk and dairy consumption with iodine status in pregnant women in Oporto region.

The role of milk and dairy products in supplying iodine to pregnant women is unknown in Portugal. The aim of this study was to evaluate the association between milk and dairy product consumption and the iodine status of pregnant women in the IoMum cohort of the Oporto region. Pregnant women were recruited between 10 and 13 weeks of gestation, when they provided a spot urine sample and information on lifestyle and intake of iodine-rich foods. Urinary iodine concentration (UIC) was determined by inductively coupled plasma MS. A total of 468 pregnant women (269 iodine supplement users and 199 non-supplement users) were considered eligible for analysis. Milk (but not yogurt or cheese) intake was positively associated with UIC, in the whole population (P = 0·02) and in the non-supplement users (P = 0·002), but not in the supplement users (P = 0·29). In non-supplement users, adjusted multinomial logistic regression analysis showed that milk consumption <3 times/month was associated with a five times increased risk of having UIC < 50 µg/l when compared with milk consumption ≥2 times/d (OR 5·4; 95 % CI 1·55, 18·78; P = 0·008). The highest UIC was observed in supplement users who reported consuming milk once per d (160 µg/l). Milk, but not yogurt or cheese, was positively associated with iodine status of pregnant women. Despite the observed positive association, daily milk consumption may not be sufficient to ensure adequate iodine intake in this population.

Prediction of success of uterus-preserving management in women with placenta accreta spectrum (CON-PAS score): A multicenter international study.

OBJECTIVE: To create a model for prediction of success of uterine-preserving procedures in women with placenta accreta spectrum (PAS). METHODS: PAS-ID is a multicenter study that included 11 centers from 9 countries. Women with PAS, who were managed between January 1, 2010 and December 31, 2019, were retrospectively included. Data were split into model development and validation cohorts, and a prediction model was created using logistic regression. Main outcome was success of uterine preservation. RESULTS: Out of 797 women with PAS, 587 were eligible. Uterus-preserving procedures were successful in 469 patients (79.9%). Number of previous cesarean sections (CS) was inversely associated with management success (adjusted odds ratio [aOR] 0.02, 95% confidence interval [CI] 0.001-3.63 with five previous CS). Other variables were complete placental invasion (aOR 0.14, 95% CI 0.05-0.43), type of CS incision (aOR 0.04, 95% CI 0.01-0.25 for classical incision), compression sutures (aOR 2.48, 95% CI 1.00-6.16), accreta type (aOR 3.76, 95% CI 1.13-12.53), incising away from placenta (aOR 5.09, 95% CI 1.52-16.97), and uterine resection (aOR 102.57, 95% CI 3.97-2652.74). CONCLUSION: The present study provides a prediction model for success of uterine preservation, which may assist preoperative and intraoperative decisions, and promote incorporation of uterine preservation procedures in comprehensive PAS protocols.

External cephalic version: Predictors of success and influence on caesarean rates.

OBJECTIVE: To evaluate the success rate of external cephalic version, predictive factors for success of this maneuver and to examine how it affects mode of delivery, pregnancy and neonatal outcome rates. STUDY DESIGN: Retrospective cross-sectional study performed in a tertiary care university hospital between January 2002 and June 2018. A total of 324 ECVs were performed in 321 pregnancies. Maternal and ultrasound data, procedure-related factors, birth characteristics and neonatal data were collected. Absolute and relative frequencies were used for descriptive analysis and the chi-square test for comparative analysis. Odds ratios with 95 % confidence intervals were calculated. RESULTS: The overall success rate of the procedure was 33,3%. Multiparity, transverse lie, unengaged breech presentation, low body mass index, soft uterus and palpable fetal head were independent risk factors for success. No statistically significant association was found with other variables. Routine use of ECV allowed a reduction in cesarean delivery rates for breech presentation, with no increase in maternal or neonatal morbidity. Operative delivery rates after successful ECV were similar to those of the general population. DISCUSSION AND CONCLUSION: Despite a relatively low overall success rate, routine use of ECV can result in reduced cesarean delivery rates with similar perinatal outcomes. Conveyed information on the success rate of ECV can be adapted to individual patient characteristics.

Twin pregnancies, crown-rump length and birthweight discordancy: the influence of chorionicity / Gestações gemelares, comprimento craniocaudal e discordância de peso ao nascimento: a influência da corionicidade

Abstract Objective The purpose of the present study was to analyze the influence of chorionicity in the biometric parameters crown-rump length (CRL), birthweight (BW), crown-rump length discordancy (CRLD) and birthweight discordancy (BWD), determine the correlation between these latter two in cases of intertwin discordancy, and to analyze the influence of chronicity in the presence of these discordancies with clinical relevance (> 10% and > 15%, respectively). Methods The present study was a retrospective study based on the twin pregnancy database of the Centro Hospitalar S. João (2010-2015), including 486 fetuses among 66 monochorionic (MC) and 177 dichorionic gestations (DC). The inclusion criteria were multiple pregnancies with 2 fetuses and healthy twin gestations. The exclusion criteria were trichorionic gestations and pregnancies with inconclusive chorionicity, multiple pregnancy with ≥ 3 fetuses and pathological twin gestations. Results No statistically significant difference was found in BW (p = 0.09) and in its discordancy (p = 0.06) nor in CRL (p = 0.48) and its discordancy (p = 0.74) between MCs and DCs. Crown-rump length discordancy and birthweight discordancy were correlated by the regression line "BWD = 0.8864 x CRLD + 0.0743," with r2 = 0.1599. Crown-rump length discordancy > 10% was found in 7.58% of monochorionic and in 13.56% of dichorionic twins. Birthweight discordancy > 15% was detected in 16.67% of monochorionic and in 31.64% of dichorionic twins. Conclusion No statistically significant influence of chorionicity was identified in both birthweight and birthweight discordancy, as in crown-rump length and crown-rump length discordancy. Birthweight discordancy was correlated to crown-rump length discordancy in 20% of cases.

Resumo Objetivo O objetivo do presente estudo foi analisar a influência da corionicidade nos parâmetros biométricos comprimento craniocaudal, peso ao nascimento, discordância de comprimento craniocaudal e discordância de peso ao nascimento, determinar a correlação entre estes dois últimos caso haja discordância intergemelar e analisar a influência da corionicidade na presença destas discordâncias com relevância clínica (> 10% e > 15%, respectivamente). Métodos O presente estudo foi um estudo retrospectivo baseado na base de dados de gestações gemelares do Centro Hospitalar S. João (2010-2015), incluindo 486 fetos de 66 gestações monocoriônicas e 177 dicoriônicas. Os critérios de inclusão foram gestações múltiplas de 2 fetos e gestações gemelares saudáveis. Os critérios de exclusão foram gestações tricoriônicas ou de corionicidade inconclusiva, gestações múltiplas com ≥ 3 fetos e gestações gemelares patológicas. Resultados Não se encontrou diferença estatisticamente significativa no peso ao nascimento (p =0,09) e sua discordância (p = 0,06) nem no comprimento craniocaudal (p = 0,48) e sua discordância (p = 0,74) entre gestações monocoriônicas e dicoriônicas. Considerando todas as gestações, as discordâncias de comprimento craniocaudal e peso ao nascimento foram correlacionadas pela reta de regressão "discordância de peso ao nascimento = 0.8864 x discordância de comprimento craniocaudal + 0.0743," com r2 = 0,1599. A discordância de comprimento craniocaudal > 10% descobriu-se em 7.58% das gestações monocoriônicas e em 13.56% das dicoriônicas. A discordância de peso ao nascimento > 15% detectou-se em 16.67% das gestações monocoriônicas e em 31.64% das dicoriônicas. Conclusão Não se identificou influência estatisticamente significativa no peso ao nascimento e sua discordância, bem como no comprimento craniocaudal e sua discordância. A discordância de peso ao nascimento correlacionou-se com a discordância de comprimento craniocaudal em 20% dos casos.

Twin Pregnancies, Crown-rump Length and Birthweight Discordancy: The Influence of Chorionicity.

OBJECTIVE: The purpose of the present study was to analyze the influence of chorionicity in the biometric parameters crown-rump length (CRL), birthweight (BW), crown-rump length discordancy (CRLD) and birthweight discordancy (BWD), determine the correlation between these latter two in cases of intertwin discordancy, and to analyze the influence of chronicity in the presence of these discordancies with clinical relevance (> 10% and > 15%, respectively). METHODS: The present study was a retrospective study based on the twin pregnancy database of the Centro Hospitalar S. João (2010-2015), including 486 fetuses among 66 monochorionic (MC) and 177 dichorionic gestations (DC). The inclusion criteria were multiple pregnancies with 2 fetuses and healthy twin gestations. The exclusion criteria were trichorionic gestations and pregnancies with inconclusive chorionicity, multiple pregnancy with ≥ 3 fetuses and pathological twin gestations. RESULTS: No statistically significant difference was found in BW (p = 0.09) and in its discordancy (p = 0.06) nor in CRL (p = 0.48) and its discordancy (p = 0.74) between MCs and DCs. Crown-rump length discordancy and birthweight discordancy were correlated by the regression line "BWD = 0.8864 x CRLD + 0.0743," with r2 = 0.1599. Crown-rump length discordancy > 10% was found in 7.58% of monochorionic and in 13.56% of dichorionic twins. Birthweight discordancy > 15% was detected in 16.67% of monochorionic and in 31.64% of dichorionic twins. CONCLUSION: No statistically significant influence of chorionicity was identified in both birthweight and birthweight discordancy, as in crown-rump length and crown-rump length discordancy. Birthweight discordancy was correlated to crown-rump length discordancy in 20% of cases.

OBJETIVO: O objetivo do presente estudo foi analisar a influência da corionicidade nos parâmetros biométricos comprimento craniocaudal, peso ao nascimento, discordância de comprimento craniocaudal e discordância de peso ao nascimento, determinar a correlação entre estes dois últimos caso haja discordância intergemelar e analisar a influência da corionicidade na presença destas discordâncias com relevância clínica (> 10% e > 15%, respectivamente). MéTODOS: O presente estudo foi um estudo retrospectivo baseado na base de dados de gestações gemelares do Centro Hospitalar S. João (2010­2015), incluindo 486 fetos de 66 gestações monocoriônicas e 177 dicoriônicas. Os critérios de inclusão foram gestações múltiplas de 2 fetos e gestações gemelares saudáveis. Os critérios de exclusão foram gestações tricoriônicas ou de corionicidade inconclusiva, gestações múltiplas com ≥ 3 fetos e gestações gemelares patológicas. RESULTADOS: Não se encontrou diferença estatisticamente significativa no peso ao nascimento (p = 0,09) e sua discordância (p = 0,06) nem no comprimento craniocaudal (p = 0,48) e sua discordância (p = 0,74) entre gestações monocoriônicas e dicoriônicas. Considerando todas as gestações, as discordâncias de comprimento craniocaudal e peso ao nascimento foram correlacionadas pela reta de regressão "discordância de peso ao nascimento = 0.8864 x discordância de comprimento craniocaudal + 0.0743," com r2 = 0,1599. A discordância de comprimento craniocaudal > 10% descobriu-se em 7.58% das gestações monocoriônicas e em 13.56% das dicoriônicas. A discordância de peso ao nascimento > 15% detectou-se em 16.67% das gestações monocoriônicas e em 31.64% das dicoriônicas. CONCLUSãO: Não se identificou influência estatisticamente significativa no peso ao nascimento e sua discordância, bem como no comprimento craniocaudal e sua discordância. A discordância de peso ao nascimento correlacionou-se com a discordância de comprimento craniocaudal em 20% dos casos.

Effect of obesity on labor duration among nulliparous women with epidural analgesia.

Objective: The aim of this study was to describe the effect of obesity on the duration of labor, specifically latent and active phases of labor, and on mode of delivery, among nulliparous women with epidural analgesia.Study design: We conducted a retrospective cohort study, comparing a sample of nulliparous obese women (body mass index ≥30 kg/m2, n = 121) with a random sample of normal weight nulliparous (18.5 kg/m2 ≤body mass index ≤25 kg/m2, n = 161). Analysis included all obese women delivered at the Department of Obstetrics and Gynecology of Centro Hospitalar, São João, Porto, Portugal between 1 January and 31 December, 2016. Only women submitted to epidural analgesia were included. Information on maternal age, obstetric history, current pregnancy and labor characteristics (gestational age, birthweight, mode of delivery, total duration of labor, latent and active phases duration) was retrieved from electronic obstetrical databases and labor charts.Results: In our department, the prevalence of maternal obesity was 12.0%. Obese women had a significantly higher rate of cesarean delivery (47.1 versus 27.3%), fewer normal vaginal deliveries (28.9 versus 32.9%) and fewer instrumental vaginal deliveries (24.0 versus 39.8%). Labor induction was significantly more frequent among obese women (51.2 versus 29.2%; p = 0.001). The median (interquartile range) for length of latent phase when labor was induced with prostaglandins in the obese group was 23.3 hours (20.9). This was significantly longer than in normal weight women -15.6 hours (13.15) (p = 0.001). However, there was no significant difference in latent phase duration when labor was induced with oxytocin (12.4 versus 9.4 hours; p = 0.150). The medians (interquartile range) for length of latent phase in spontaneous delivery -6.5 hours (6.8) versus 6.6 hours (6.5) did not differ (p = 0.992). The duration of active phase was not significantly different between obese and normal weight (5.1 versus 5.1 hours; p = 0.784). For spontaneous labor, there was no difference between the two groups in the total duration of labor (11.9 versus 11.3 hours; p = 0.573). But for induced labor, the total duration was significantly higher among obese women (31.1 versus 21.4 hours; p = 0.001).Conclusion: Latent phase was longer in obese than normal weight women undergoing labor induction with prostaglandins. Obesity had no effect on duration of active phase. Obese women undergoing labor induction had a longer total duration of labor, compared to normal weight women mainly due to prolonged latent phase.

Risks of Maternal Obesity in Pregnancy: A Case-control Study in a Portuguese Obstetrical Population.

OBJECTIVE: The present study aims to understand to what extent obesity is related to adverse maternal, obstetrical, and neonatal outcomes in a Portuguese obstetrical population. METHODS: A retrospective case-control study was conducted at the Department of Obstetrics of a differentiated perinatal care facility. The study compared 1,183 obese pregnant women with 5,399 normal or underweight pregnant women for the occurrence of gestational diabetes, hypertensive pregnancy disorders, and preterm birth. Mode of delivery, birthweight, and neonatal intensive care unit (ICU) admissions were also evaluated. Mean blood glucose values were evaluated and compared between groups, in the first and second trimesters of pregnancy. Only singleton pregnancies were considered. RESULTS: The prevalence of obesity was 13.6%. Obese pregnant women were significantly more likely to have cesarean sections (adjusted odds ratio [aOR] 2.0, p < 0.001), gestational diabetes (aOR 2.14, p < 0.001), hypertensive pregnancy disorders (aOR 3.43, p < 0.001), and large-for-gestational age or macrosomic infants (aOR 2.13, p < 0.001), and less likely to have small-for-gestational age newborns (aOR 0.51, p < 0.009). No significant differences were found in terms of preterm births, fetal/neonatal deaths, low birthweight newborns, and neonatal ICU admissions among cases and controls. Maternal obesity was significantly associated with higher mean blood glucose levels, in the first and second trimesters of pregnancy. CONCLUSION: Obesity is associated with increased risks of adverse pregnancy and neonatal outcomes. These risks seem to increase progressively with increasing body mass index (BMI) class. Female obesity should be considered a major public health issue and has consequences on maternal-fetal health.

OBJETIVO: O presente estudo pretende avaliar em que medida a obesidade influencia os desfechos maternos, obstétricos e neonatais em uma população obstétrica portuguesa. MéTODOS: Um estudo caso-controle retrospectivo foi realizado no departamento de obstetrícia de um centro perinatal diferenciado. O estudo comparou 1.183 grávidas obesas com 5.399 grávidas normoponderais ou com baixo peso para a ocorrência de diabetes gestacional, doenças hipertensivas da gravidez e parto pré-termo. Via de parto, peso ao nascimento e admissão na unidade de cuidados neonatais também foram avaliados. Os valores glicêmicos médios foram avaliados e comparados entre os dois grupos, no primeiro e segundo trimestres de gravidez. Apenas as gravidezes unifetais foram avaliadas. RESULTADOS: A prevalência da obesidade foi de 13.6%. As grávidas obesas tiveram risco significativamente superior a ter uma cesariana (odds ratio ajustado [Ora] 2.0, p < 0.001), diabetes gestacional (ORa 2.14, p < 0.001), doenças hipertensivas da gravidez (ORa 3.43, p < 0.001), recém-nascidos grandes para a idade gestacional ou macrossômicos (ORa 2.13, p < 0.001) e menor probabilidade de ter recém-nascidos pequenos para a idade gestacional (ORa 0.51, p < 0.009). Não houve diferença estatisticamente significativa quanto aos partos pré-termo, mortes fetais/neonatais, baixo peso ao nascer e admissão à unidade de cuidados intensivos neonatais. O odds ratio foi ajustado para a idade, número de gestações, paridade, ganho ponderal, doenças hipertensivas da gravidez e diabetes gestacional. A obesidade materna esteve significativamente associada a valores glicêmicos médios superiores, no primeiro e segundo trimestres de gravidez. CONCLUSãO: A obesidade está associada a maior risco de desfechos adversos na gravidez e neonatais. Este risco parece aumentar progressivamente com o aumento do índice de massa corporal (IMC). A obesidade feminina deve ser considerada um importante problema de saúde pública e que tem repercussões na saúde materno-fetal.

Risks of maternal obesity in pregnancy: A case-control study in a portuguese obstetrical population / Riscos da obesidade materna na gravidez: um estudo caso-controle em uma oopulação obstétrica portuguesa

Abstract Objective The present study aims to understand to what extent obesity is related to adversematernal, obstetrical, and neonatal outcomes in a Portuguese obstetrical population. Methods A retrospective case-control study was conducted at the Department of Obstetrics of a differentiated perinatal care facility. The study compared 1,183 obese pregnant womenwith 5,399 normal or underweight pregnantwomen for the occurrence of gestational diabetes, hypertensive pregnancy disorders, and preterm birth. Mode of delivery, birthweight, and neonatal intensive care unit (ICU) admissionswere also evaluated. Mean blood glucose values were evaluated and compared between groups, in the first and second trimesters of pregnancy. Only singleton pregnancies were considered. Results The prevalence of obesity was 13.6%. Obese pregnant women were significantly more likely to have cesarean sections (adjusted odds ratio [aOR] 2.0, p< 0.001), gestational diabetes (aOR 2.14, p< 0.001), hypertensive pregnancy disorders (aOR 3.43, p< 0.001), and large-for-gestational age ormacrosomic infants (aOR 2.13, p< 0.001), and less likely to have small-for-gestational age newborns (aOR 0.51, p< 0.009). No significant differences were found in terms of pretermbirths, fetal/neonatal deaths, low birthweight newborns, and neonatal ICU admissions among cases and controls. Maternal obesity was significantly associated with higher mean blood glucose levels, in the first and second trimesters of pregnancy. Conclusion Obesity is associated with increased risks of adverse pregnancy and neonatal outcomes. These risks seem to increase progressively with increasing body mass index (BMI) class. Female obesity should be considered a major public health issue and has consequences on maternal-fetal health.

Resumo Objetivo O presente estudo pretende avaliar em que medida a obesidade influencia os desfechos maternos, obstétricos e neonatais em uma população obstétrica portuguesa. Métodos Um estudo caso-controle retrospectivo foi realizado no departamento de obstetrícia de um centro perinatal diferenciado. O estudo comparou 1.183 grávidas obesas com 5.399 grávidas normoponderais ou com baixo peso para a ocorrência de diabetes gestacional, doenças hipertensivas da gravidez e parto pré-termo. Via de parto, peso ao nascimento e admissão na unidade de cuidados neonatais também foram avaliados. Os valores glicêmicos médios foram avaliados e comparados entre os dois grupos, no primeiro e segundo trimestres de gravidez. Apenas as gravidezes unifetais foram avaliadas. Resultados A prevalência da obesidade foi de 13.6%. As grávidas obesas tiveramrisco significativamente superior a ter uma cesariana (odds ratio ajustado [Ora] 2.0, p < 0.001), diabetes gestacional (ORa 2.14, p < 0.001), doenças hipertensivas da gravidez (ORa 3.43, p < 0.001), recém-nascidos grandes para a idade gestacional ou macrossômicos (ORa 2.13, p < 0.001) e menor probabilidade de ter recém-nascidos pequenos para a idade gestacional (ORa 0.51, p < 0.009). Não houve diferença estatisticamente significativa quanto aos partos pré-termo, mortes fetais/neonatais, baixo peso ao nascer e admissão à unidade de cuidados intensivos neonatais. O odds ratio foi ajustado para a idade, número de gestações, paridade, ganho ponderal, doenças hipertensivas da gravidez e diabetes gestacional. A obesidade materna esteve significativamente associada a valores glicêmicos médios superiores, no primeiro e segundo trimestres de gravidez. Conclusão A obesidade está associada a maior risco de desfechos adversos na gravidez e neonatais. Este risco parece aumentar progressivamente com o aumento do índice de massa corporal (IMC). A obesidade feminina deve ser considerada um importante problema de saúde pública e que tem repercussões na saúde maternofetal.

Metformin in overweight and obese women with gestational diabetes: a propensity score-matched study.

PURPOSE: Obesity and gestational diabetes mellitus (GDM) have an independent negative impact in pregnancy outcomes. Excessive gestational weight gain (GWG) represents an additional high-risk condition for adverse outcomes. The aims of this study were to evaluate the potential effect of metformin in GWG in overweight or obese women with GDM, to report our experience and to assess metformin's safety in this population. METHODS: Retrospective observational cohort study involving pregnant women with GDM and pregestational overweight or obesity. Demographic, anthropometric, glycemic control data, obstetric, fetal and neonatal outcomes were evaluated. The sample was divided into two groups according to metformin treatment. A propensity score-matched analysis was performed using age, initial body mass index (BMI), trimester at GDM diagnosis and previous history of GDM or macrosomia as covariates. RESULTS: Of the 457 enrolled in the study, 177 (38.7%) were treated with metformin. Two groups of 130 well matched patients were balanced regarding baseline characteristics. Women in metformin group had significantly less excessive GWG (29.23% vs. 42.31%, OR 0.56, 95% CI 0.34-0.94, p = 0.028) and more adequate GWG (36.92% vs. 23.08%, OR 1.95, 95% CI 1.14-3.35, p = 0.015). No significant differences were found between both groups regarding glycemic control, rate of insulinization, and obstetric, fetal, and neonatal outcomes. CONCLUSIONS: This study highlights metformin as an important and safe tool to prevent excessive GWG and promote adequate GWG in overweight or obese women with GDM, regardless of age, BMI, timing of GDM diagnosis, previous history of GDM or macrosomia.

Developmental trajectories of general and breathing movements in fetal twins.

This study examined the developmental trajectories of general and breathing movements in fetal twins. Fetal movement patterns were assessed from real-time ultrasound recordings performed at 12-15, 20-23, and 28-32 weeks of gestation in 42 twin pairs. Results indicated that both general movements and breathing movements followed a curvilinear, inverted U-shaped curve. Developmental trajectories were unrelated within pairs of twins and were not associated with gestational age at birth and birth weight. However, sex differences were found for general movements with males displaying more time making general movements at 21 weeks and a steeper decline in time spent making general movements during the second half of pregnancy than females. These age-related changes in fetal movements may reflect CNS development. These findings also suggest that twins' behavioral development is largely independent of co-twin development, gestational age at birth, and birth weight, but not of fetal sex.

Thrombolysis in pregnancy: a literature review.

BACKGROUND: Changes in the coagulation system during pregnancy and puerperium produce a physiological hypercoagulable state. These changes are thought to be the cause of the higher rates of deep vein thrombosis (DVT), pulmonary embolism (PE), stroke, and mechanical prosthetic valve thrombosis (PVT) during pregnancy. Thrombolysis can be a treatment option in this case. However, there are no available data from randomized controlled trials in pregnant patients and information about the security of thrombolytics in pregnancy is missing. OBJECTIVE: The aim of this review is to summarize the available data regarding the use of thrombolytic agents in pregnancy, describing maternal and fetal outcomes. METHODS: A systematic review was performed, searching the electronic database MEDLINE for relevant studies published up to April 2017. The search included MeSH terms "thrombolytic therapy" OR "fibrinolysis" OR "streptokinase" OR "tissue plasminogen activator" AND "pregnancy". All publications that reported the use of a thrombolytic agent for DVT, PE, stroke or PVT in pregnancy were included in the review. Data on the type and total dose of the thrombolytic agent, gestational week, outcome of mothers and children, preterm delivery and bleeding complications were described. RESULTS: Sixty-five articles have been published describing outcomes in 141 pregnant women with serious thrombotic events. There have been no randomized trials involving the use of thrombolytics in pregnancy. Only one prospective study was found. Four maternal deaths (2.8%), 12 major bleeding episodes (8.5%), 13 mild/moderate bleeding episodes (9.2%), two fetal death (1.4%), one child death (0.7%), nine miscarriages (6.4%), and 14 preterm delivery (9.9%) were described. CONCLUSIONS: The risk of using thrombolytics in pregnancy seems reasonable taking into account the risk of death in a life-threatening event, with the majority of cases presented in this article resulting in encouraging outcomes. The complication rate of thrombolytic treatment does not seem higher in pregnant women than in the nonpregnant. Poor fetal outcome occurred in mothers with poor prognosis. Specific consensus recommendations are needed in the use of thrombolytics in pregnancy.

Neonatal outcome in preterm deliveries before 34-week gestation - the influence of the mechanism of labor onset.

Purpose: To evaluate neonatal outcomes in preterm infants with less than 34 weeks after spontaneous labor, preterm premature rupture of membranes (PPROM) or iatrogenic delivery and to clarify whether the mechanism of labor onset is a risk factor for adverse short-term neonatal outcome. Methods: We performed a retrospective case-control study, which included 266 preterm newborns with less than 34-week gestation, between 2011 and 2015. Neonatal outcomes were compared according to the mechanism of labor onset. Our primary outcomes were neonatal death, sequelae on hospital discharge and a composite of these two variables (combined neonatal outcome). Results: Compared to spontaneous preterm labor, iatrogenic preterm newborns were at increased risk of respiratory distress syndrome (RDS) [Odds Ratio (OR) 3.05 (95%CI 1.31; 7.12)], and need of exogenous surfactant administration [OR 3.87 (95%CI 1.60; 9.35)]. PPROM was associated with higher risk of neonatal sepsis [OR 12.96 (95%CI 1.18; 142.67)]. There were no differences regarding the combined outcome for iatrogenic [OR 0.94 (95%CI 0.33; 2.71)] or PPROM [OR 1.11 (95%CI 0.35; 3.49)] groups. Conclusions: In our study, the different mechanisms of labor onset are associated with different neonatal outcomes. Iatrogenic preterm birth was associated with an increased risk of RDS and a higher need of exogenous surfactant administration than spontaneous group. The rate of neonatal sepsis was significantly higher in PPROM group along with a higher prevalence of histological chorioamnionitis.

Ductus venosus agenesis and fetal malformations: what can we expect? - a systematic review of the literature.

Background The ductus venosus agenesis (DVA) is a rare condition with a variable prognosis that relies partly on the presence of associated conditions. The purpose of our study was to analyze the literature regarding the post-natal outcome of fetuses with DVA associated with fetal malformations, in order to discuss the best management options for couples. Methods We performed a systematic review of the literature of MEDLINE and SCOPUS electronic databases in a 25-year period from 1992 to September 2017. Methods We found 340 cases of DVA associated with fetal abnormalities. The most common chromosomal abnormalities were: monosomy X (12/48, 25%), trisomy 21 (11/48, 22.9%) and trisomy 18 (6/48, 12.5%). From the 340 cases with DVA, in 31 cases the umbilical venous shunt type was not reported. Of the fetuses, 60.8% (188/309) had an extrahepatic umbilical venous drainage while 39.2% (121/309) presented an intrahepatic connection. The DVA was associated in 71 cases (23.0%) with cardiac abnormalities, in 82 cases (26.5%) with extracardiac abnormalities and in 85 cases (27.5%) with both cardiac and extracardiac abnormalities. Conclusion DVA associated with both cardiac and extracardiac malformations may confer a poorer fetal outcome, a clinically relevant fact that should clarify what can be expected from this entity and help prenatal counseling.

Effect of antenatal corticosteroids on morbidity and mortality of preterm singletons and twins.

PURPOSE: To compare the effect of antenatal corticosteroids (ACS) on neonatal outcomes among singleton and twin pregnancies and the impact of completeness and timing of ministration. MATERIALS AND METHODS: Retrospective cohort study involving 951 preterm deliveries (25+0-34+6 weeks), between 2006 and 2015. Neonatal outcomes were evaluated according to completeness of ACS ("Complete" n = 441; "Rescue" n = 38; "Incomplete" n = 175; "No ACS" n = 98) and timing of therapy related to delivery ("Before 7 days" n = 260; "After 7 days" n = 181). RESULTS: On respiratory distress syndrome (RDS), odds ratio (OR) for twins was 0.172, 95% confidence interval (CI) was 0.047; 0.591 and for singletons 0.390 (95%CI 0.214; 0.703) for complete or rescue courses, and 0.280 (95%CI 0.069; 1.066) for twins and 0.906 (95%CI 0.482; 1.698) for singletons for incomplete courses. About the need for mechanical ventilation (MV), twins had an OR of 0.189 (95%CI 0.052; 0.642) and singletons of 0.404 (95%CI 0.222; 0.727) for complete or rescue courses and twins had OR = 0.225 (95%CI 0.053; 0.874) and singletons of 0.404 (95%CI 0.222; 0.727) for incomplete courses. About timing, group "After 7 days" had OR = 2.00 for RDS (95%CI 1.21; 3.30) and 2.32 (95%CI 1.42; 3.78) for MV. CONCLUSIONS: ACS improves neonatal outcomes both in singleton and twins. Delivering 7 days after a complete course decreased neonatal morbidity.

Periconceptional CMV infection prevention in Portugal: population subgroup study in a tertiary perinatal care center.

Currently in Portugal, universal screening of pregnant women for Cytomegalovirus (CMV) infection is not performed. However, it is recommended to screen all women attending preconception care. We aimed to assess women's attendance to preconception care and if their serologic status regarding CMV was known and/or investigated in that consultation. In this cross-sectional study, we interviewed 240 women admitted to the obstetrical ward of a hospital in the Metropolitan Area of Porto (Portugal) about their adherence to preconception care and collected data regarding their CMV serologic status and its investigation. We found that 71.3% of the women who attended preconception care were not screened for CMV infection. Among primigravida, the screening rate was only of 30.4% (upper limit of CI 95%: 44.8%). There were no statistically significant differences between the private and public sectors of healthcare. We observed attendance to preconception care is high (73.1%). For the population subgroup of the metropolitan area of Porto, attendance to preconception care is at least 66%, with a 95% confidence level. Portuguese guidelines stating a woman's serologic status regarding CMV should be investigated in preconception care are not properly implemented. This suggests guidelines should assure the screening of previously non-screened women during pregnancy.