Fetal Metabolic Alkalosis Resulting from Maternal Vomiting.

We describe a pregnant patient with severe compulsive water ingestion and vomiting that lead to metabolic alkalosis and preterm delivery. A 21-year-old patient was hospitalized multiple times throughout pregnancy for symptoms initially thought to be related to hyperemesis gravidarum. Overtime, it became apparent that the patient induced vomiting by rapidly drinking large volumes of water. At 32 weeks' gestation, rapid ingestion of water caused 3 days of vomiting with findings of hyponatremia, hypokalemia, hypochloremia, metabolic alkalosis, and compensatory respiratory acidosis. Fetal monitoring showed minimal variability and recurrent decelerations; subsequent biophysical profile score of 2/10 prompted urgent cesarean section. A male newborn was delivered and cord blood gases reflected neonatal metabolic alkalosis and electrolyte imbalances identical to those of the mother. Compensatory hypoventilation in both mother and fetus were treated with assisted ventilation. With saline administration and repletion of electrolytes, metabolic alkalosis resolved for both patients within days. Metabolic alkalosis was transplacentally acquired by the fetus. This case demonstrates the development of metabolic alkalosis in a pregnant woman caused by vomiting severe enough to prompt preterm delivery for nonreassuring fetal status. It also demonstrates fetal dependence on both placenta and mother to maintain physiologic acid-base and electrolyte balance.

Disparities in high risk prenatal care adherence along racial and ethnic lines.

The term "high-risk pregnancy" describes a pregnancy at increased risk for complications due to various maternal or fetal medical, surgical, and/or anatomic issues. In order to best protect the pregnant patient and the fetus, frequent prenatal visits and monitoring are often recommended. Unfortunately, some patients are unable to attend these appointments for various reasons. Moreover, it has been documented that patients from ethnically and racially diverse backgrounds are more likely to miss medical appointments than are Caucasian patients. For instance, a case-control study retrospectively identified the race/ethnicity of patients who no-showed for mammography visits in 2018. Women who no-showed were more likely to be African American than patients who kept their appointments, with an odds ratio of 2.64 (4). Several other studies from several other primary care and specialty disciplines have shown similar results. However, the current research on high-risk obstetric no-shows has focused primarily on why patients miss their appointments rather than which patients are missing appointments. This is an area of opportunity for further research. Given disparities in health outcomes among underrepresented racial/ethnic groups and the importance of prenatal care, especially in high-risk populations, targeted attempts to increase patient participation in prenatal care may improve maternal and infant morbidity/mortality in these populations.

Differing prevalence of microcephaly and macrocephaly in male and female fetuses.

Objective: To compare the proportion of female and male fetuses classified as microcephalic (head circumference [HC] < 3rd percentile) and macrocephalic (>97th percentile) by commonly used sex-neutral growth curves. Methods: For fetuses evaluated at a single center, we retrospectively determined the percentile of the first fetal HC measurement between 16 and 0/7 and 21-6/7 weeks using the Hadlock, Intergrowth-21st, and NICHD growth curves. The association between sex and the likelihood of being classified as microcephalic or macrocephalic was evaluated with logistic regression. Results: Female fetuses (n = 3,006) were more likely than male fetuses (n = 3,186) to be classified as microcephalic using the Hadlock (0.4% male, 1.4% female; odds ratio female vs. male 3.7, 95% CI [1.9, 7.0], p < 0.001), Intergrowth-21st (0.5% male, 1.6% female; odds ratio female vs. male 3.4, 95% CI [1.9, 6.1], p < 0.001), and NICHD (0.3% male, 1.6% female; odds ratio female vs. male 5.6, 95% CI [2.7, 11.5], p < 0.001) curves. Male fetuses were more likely than female fetuses to be classified as macrocephalic using the Intergrowth-21st (6.0% male, 1.5% female; odds ratio male vs. female 4.3, 95% CI [3.1, 6.0], p < 0.001) and NICHD (4.7% male, 1.0% female; odds ratio male vs. female 5.1, 95% CI [3.4, 7.6], p < 0.001) curves. Very low proportions of fetuses were classified as macrocephalic using the Hadlock curves (0.2% male, < 0.1% female; odds ratio male vs. female 6.6, 95% CI [0.8, 52.6]). Conclusion: Female fetuses were more likely to be classified as microcephalic, and male fetuses were more likely to be classified as macrocephalic. Sex-specific fetal head circumference growth curves could improve interpretation of fetal head circumference measurements, potentially decreasing over- and under-diagnosis of microcephaly and macrocephaly based on sex, therefore improving guidance for clinical decisions. Additionally, the overall prevalence of atypical head size varied using three growth curves, with the NICHD and Intergrowth-21st curves fitting our population better than the Hadlock curves. The choice of fetal head circumference growth curves may substantially impact clinical care.

Mesenchymal Stem Cell Identification After Delayed Cord Clamping.

We sought to determine the feasibility of identifying and quantifying mesenchymal stem cells (MSCs) from umbilical cord blood (UCB) after delayed cord clamping in preterm and term births. We obtained 3 mL of UCB at various gestational ages after delayed cord clamping. UCB separated by density gradient centrifugation within 4 h of delivery was passed through magnetic bead micro-columns to exclude the CD34 + cell population. The samples were incubated with fluorescent-tagged mesenchymal cell marker antibodies CD 29, CD44, CD73, CD105, and hematopoietic cell marker CD45. The cell populations were analyzed by flow cytometry. Viable cells were assessed with 7-aminoactinomycin-D. The results were expressed in median (minimum to maximum) MSCs and compared between preterm and term samples. A total of 12 UCB samples (32-40 weeks) were obtained, 10 of which demonstrated MSCs, accounting for 0.0174% (0-14.7%) of the viable UCB mononuclear cells. MSCs comprised 0.148% (0.0006-1.59%) and 0.116% (0-14.7%) of the viable UCB mononuclear cells in the term (n = 5), 38.4 ± 1.3 weeks, and preterm (n = 7) samples, 34.6 ± 1.1, respectively, p = 0.17. There was an overall median of 96 (0-39,574) MSCs. There was no difference in the median numbers of MSCs identified between term and preterm UCB samples, 3384 (23-6042) and 36 (0-39,574), respectively, p = 0.12. Mesenchymal stem cells were identified and quantified in 5 of 7 preterm and all 5 term UCB 3-mL samples obtained after delayed cord clamping.

The Association Between Adverse Childhood Experiences and Postpartum Depression.

Objective: Adverse childhood experiences (ACEs) are linked to worsening overall health outcomes and psychological diagnoses. Routine screening, particularly in patients with postpartum depression (PPD), would identify patients who could benefit from interventions to prevent the perpetuation of ACEs and establish a system of preventative care to mitigate the risks of adverse health outcomes associated with high ACE scores. The purpose of this study is to explore the link between ACEs and PPD to advocate for the use of the ACE questionnaire as a routine screening tool in all pregnant patients diagnosed with PPD. We hypothesize that a cohort of patients with PPD will be more likely to have high-risk ACE scores than the general female population. Study Design: Our IRB approved, retrospective cohort study identified all patients diagnosed with PPD at an academic medical center between January 2015 and December 2019. The subjects were identified using retrospective chart review. Subjects were recruited via telephone and asked to complete an ACE questionnaire. Questionnaires were sent via RedCap. ACE scores were calculated, categorized as 0, 1, 2, 3, or 4 or more ACEs, and compared to the prevalence in the original Kaiser-CDC ACE study female cohort using a chi-square goodness-of-fit test. Results: There were 132/251 surveys completed (53% response rate). In our PPD population, 19.3% had 0 ACEs, 17.0% had 1 ACE, 13.1% had 2 ACEs, 16.5% had 3 ACEs, and 34.1% had 4 or more ACEs. These percentages were significantly different from the Kaiser-CDC ACE Study percentages of 34.5, 24.5, 15.5, 10.3, and 15.2%, respectively (p < 0.001). Conclusion: Our unique study showed that women with PPD are more likely to have high-risk ACE scores than the general female population. This finding has important implications in regards to counseling, intervening to prevent perpetual ACEs, and establishing important provider-patient relationships for life-long preventative care.Non-gendered language is used when possible throughout. However, the wording from studies cited in this paper was preserved.

Differential Effects of Maternal High Fat Diet During Pregnancy and Lactation on Taste Preferences in Rats.

Maternal intake of high fat diet (HFD) increases risk for obesity and metabolic disorders in offspring. Developmental programming of taste preference is a potential mechanism by which this occurs. Whether maternal HFD during pregnancy, lactation, or both, imposes greater risks for altered taste preferences in adult offspring remains a question, and in turn, was investigated in the present study. Four groups of offspring were generated based on maternal HFD access: (1) HFD during pregnancy and lactation (HFD); (2) HFD during pregnancy (HFD-pregnancy); (3) HFD during lactation (HFD-lactation); and (4) normal diet (ND) during pregnancy and lactation (ND). Adult offspring 70 days of age underwent sensory and motivational taste preference testing with various concentrations of sucrose and Intralipid solutions using brief-access automated gustometers (Davis-rigs) and 24 h two-bottle choice tests, respectively. To control for post-gestational diet effects, offspring in all experimental groups were weaned on ND, and did not differ in body weight or glucose tolerance at the time of testing. Offspring exposed to maternal HFD showed increased sensory taste responses for 0.3, 0.6, 1.2 M sucrose solutions in HFD and 0.6 M in HFD-pregnancy groups, compared to animals exposed to ND. Similar effects were noted for lower concentrations of Intralipid in HFD (0.05, 0.10%) and HFD-pregnancy (0.05, 0.10, 0.5%) groups. The HFD-lactation group showed an opposite, diminished responsiveness for sucrose at the highest concentrations (0.9, 1.2, 1.5 M), but not for Intralipid, compared to ND animals. Extended-access two-bottle tests did not reveal major difference across the groups. Our study shows that maternal HFD during pregnancy and lactation has markedly different effects on preferences for palatable sweet and fatty solutions in adult offspring and suggests that such developmental programing may primarily affect gustatory mechanisms. Future studies are warranted for determining the impact of taste changes on development of obesity and metabolic disorders in a "real" food environment with food choices available, as well as to identify specific underlying mechanisms.

Accuracy of fetal anatomy survey in the diagnosis of velamentous cord insertion: a case-control study.

OBJECTIVE: Our objective was to determine the accuracy of ultrasound at the time of the fetal anatomy survey in the diagnosis of velamentous cord insertion (VCI). STUDY DESIGN: This retrospective case-control study identified placentas with VCI (cases) and randomly selected placentas with normal placental cord insertion (PCI) (controls) as documented by placental pathology for mothers delivered from 2002 through 2015. Archived ultrasound images for PCI at the time of the fetal anatomy survey were reviewed. Data analysis was by calculation of sensitivity, specificity, and accuracy and their 95% CI for the ultrasound diagnosis of VCI. RESULTS: The prevalence of VCI was 1.6% of placentas submitted for pathologic examination. There were 122 cases of VCI and 347 controls with normal PCI. The performance criteria calculated for the diagnosis of VCI at the time of fetal anatomy survey were as follows: sensitivity 33.6%; 95% CI: 25.3, 42.7; specificity 99.7%; 95% CI: 98.4, 99.9 and accuracy 82.5; 95% CI: 80.5, 82.9. CONCLUSION: The identification of a VCI at the time of fetal anatomy survey is highly specific for the presence of a VCI as documented by placental pathology. The sensitivity in this study was less than expected. Sensitivity could be improved by reducing the number of nonvisualized PCIs, creating an awareness of risk factors for VCI, and obtaining more detailed images in the case of an apparent marginal PCI.

Hemorrhage from Umbilical Cord Ulceration Identified on Real-Time Ultrasound in a Fetus with Duodenal Atresia.

Umbilical cord ulceration has been associated with congenital upper intestinal (duodenal or jejunal) atresia and can lead to fatal fetal intrauterine hemorrhage. We report a case of spontaneous hemorrhage from the umbilical cord, incidentally noted at the time of ultrasound in a 33-week fetus with suspected duodenal atresia, in which immediate delivery resulted in a good outcome. Despite many reports in the literature of congenital upper intestinal atresia and its association with umbilical cord ulceration, the propensity for this lesion for fetal hemorrhage, and the resulting perinatal morbidity and mortality, there appears to be a gap in the dissemination of this knowledge. In fetuses with suspected congenital upper intestinal atresia, recognition of the entity of umbilical cord ulceration may be improved by ultrasound with special attention to the amount of Wharton's jelly within the cord. Routine antepartum fetal surveillance may reduce perinatal morbidity and mortality from this condition. A high index of suspicion is needed to make the diagnosis of umbilical cord ulceration in association with congenital upper intestinal atresia. The role of amniotic fluid bile acids in the genesis of this disorder needs further study.

Placental thickness on ultrasound and neonatal birthweight.

Objective To investigate the relationship between maximal placental thickness during routine anatomy scan and birthweight at delivery. Methods This retrospective descriptive study analyzed 200 term, singleton deliveries in 2016 at Penn State Hershey Medical Center. We measured maximal placental thickness in the sagittal plane from the ultrasound images of the placenta obtained at the 18-21-week fetal anatomy screen. The relationship between placental thickness and neonatal birthweight was assessed using Pearson's correlation coefficient (r) with 95% confidence interval (CI). Logistic regression was used to assess the association between placental thickness and secondary binary outcomes of neonatal intensive care unit (NICU) admission and poor Apgar scores. Two-sample t-tests, or exact Wilcoxon rank-sum test for non-normally distributed data, were used to assess for differences attributable to medical comorbidities (pre-gestational diabetes, gestational diabetes, chronic hypertension, gestational hypertension, preeclampsia and eclampsia). Results Placental thickness had a positive correlation with neonatal birthweight [r=0.18, 95% CI=(0.05, 0.32)]. The mean placental thickness measured 34.2±9.7 mm. The strength of the correlation remained similar when adjusting for gestational age (r=0.20) or excluding medical comorbidities (r=0.19). There was no association between placental thickness and NICU admission, Apgar scores <7 or medical comorbidities. Conclusion Our study demonstrated a positive correlation between sonographic placental thickness and birthweight. Future prospective studies are warranted in order to further investigate whether a clinically significant correlation exists while adjusting for more covariates.

Are gestational and type II diabetes mellitus associated with the Apgar scores of full-term neonates?

OBJECTIVE: To compare Apgar scores of full-term newborns of mothers with gestational (GDM) or type II diabetes mellitus (T2DM) with scores of newborns of mothers without impaired glucose tolerance. STUDY DESIGN: This was a retrospective data collection study (n=297). We reviewed 1-minute and 5-minute neonatal Apgar scores of newborns of mothers with GDM (n=100) or T2DM (n=97). Our control group consisted of newborns of mothers without a prior history of impaired glucose tolerance (n=100). ANOVA and linear model with corrected errors were used and adjusted for newborn sex and weight, and maternal age. Chi-squared analysis was performed for newborn sex. RESULTS: The mean 1-minute and 5-minute Apgar scores were 7.8 and 8.9 for the GDM group and 7.7 and 8.9 for the T2DM group, respectively. There was no statistical difference in the 1-minute and 5-minute Apgar scores between the GDM group and controls (P=0.89 and P=0.13, respectively) nor in the scores between the T2DM group and controls (P=0.67 and P=0.40, respectively). CONCLUSION: Maternal history of GDM and T2DM does not appear to be associated with the 1-minute and 5-minute Apgar scores of full-term newborns of mothers with GDM and T2DM as compared to newborns of mothers without a history of impaired glucose tolerance.

Comparison of healthcare utilization and outcomes by gestational diabetes diagnostic criteria.

OBJECTIVE: To compare healthcare utilization and outcomes using the Carpenter-Coustan (CC) criteria vs. the National Diabetes Data Group (NDDG) criteria for gestational diabetes mellitus (GDM). METHODS: This is a retrospective cohort study. Prior to 8/21/2013, patients were classified as "GDM by CC" if they met criteria. After 8/21/2013, patients were classified as "GDM by NDDG" if they met criteria and "Meeting CC non-GDM" if they met CC, but failed to reach NDDG criteria. "Non-GDM" women did not meet any criteria for GDM. Records were reviewed after delivery. RESULTS: There was a 41% reduction in GDM diagnosed using NDDG compared to CC (P=0.01). There was no significant difference in triage visits, ultrasounds for growth or hospital admissions. Women classified as "Meeting CC non-GDM" were more likely to have preeclampsia than "GDM by CC" women [OR 11.11 (2.7, 50.0), P=0.0006]. Newborns of mothers "Meeting CC non-GDM" were more likely to be admitted to neonatal intensive care units than "GDM by CC" [OR 6.25 (1.7, 33.3), P=0.006], "GDM by NDDG" [OR 5.56 (1.3, 33.3), P=0.018] and "Non-GDM" newborns [OR 6.47 (2.6, 14.8), P=0.0003]. CONCLUSION: Using the NDDG criteria may increase healthcare costs because while it decreases the number of patients being diagnosed with GDM, it may also increase maternal and neonatal complications without changing maternal healthcare utilization.

Suspected Fetal Growth Restriction at 37 Weeks: A Comparison of Doppler and Placental Pathology.

Objective. Our objective was determining if abnormal Doppler evaluation had a higher prevalence of placental pathology compared to normal Doppler in suspected fetal growth restriction (FGR) of cases delivered at 37 weeks. Study Design. This retrospective cohort study of suspected FGR singletons with antenatal Doppler evaluation delivered at 37 weeks had a primary outcome of the prevalence of placental pathology related to FGR. Significance was defined as p ≤ 0.05. Results. Of 100 pregnancies 46 and 54 were in the abnormal and normal Doppler cohorts, respectively. Placental pathology was more prevalent with any abnormal Doppler, 84.8% versus 55.6%, odds ratio (OR) 4.46, 95% confidence interval (CI): 1.55, 13.22, and p = 0.002. Abnormal middle cerebral artery (MCA) Doppler had a higher prevalence: 96.2% versus 54.8%, OR 20.7, 95% CI: 2.54, 447.1, and p < 0.001. Conclusion. Abnormal Doppler was associated with more placental pathology in comparison to normal Doppler in fetuses with suspected FGR. Abnormal MCA Doppler had the strongest association.

US term stillbirth rates and the 39-week rule: a cause for concern?

BACKGROUND: More than a decade ago an obstetric directive called "the 39-week rule" sought to limit "elective" delivery, via labor induction or cesarean delivery, before 39 weeks 0 days of gestation. In 2010 the 39-week rule became a formal quality measure in the United States. The progressive adherence to the 39-week rule throughout the United States has caused a well-documented, progressive reduction in the proportion of term deliveries occurring during the early-term period. Because of the known association between increasing gestational age during the term period and increasing cumulative risk of stillbirth, however, there have been published concerns that the 39-week rule-by increasing the gestational age of delivery for a substantial number of pregnancies-might increase the rate of term stillbirth within the United States. Although adherence to the 39-week rule is assumed to be beneficial, its actual impact on the US rate of term stillbirth in the years since 2010 is unknown. OBJECTIVE: To determine whether the adoption of the 39-week rule was associated with an increased rate of term stillbirth in the United States. STUDY DESIGN: Sequential ecological study, based on state data, of US term deliveries that occurred during a 7-year period bounded by 2007 and 2013. The patterns of the timing of both term childbirth and term stillbirth were determined for each state and for the United States as a whole. RESULTS: A total of 46 usable datasets were obtained (45 states and the District of Columbia). During the 7-year period, there was a continuous reduction in all geographic entities in the proportion of term deliveries that occurred before 39 weeks of gestation. The overall rate of term stillbirth, when we compared 2007-2009 with 2011-2013, increased significantly (1.103/1000 vs 1.177/1000, RR 1.067, 95% confidence interval 1.038-1.096). Furthermore, during the 7-year period, the increase in the rate of US term stillbirth appeared to be continuous (estimated slope: 0.0186/1000/year, 95% confidence interval 0.002-0.035). Assuming 3.5 million term US births per year, and given 6 yearly "intervals" with this rate increase, it is possible that more than 335 additional term stillbirths occurred in the United States in 2013 as compared with 2007. In addition, during the 7-year period, there was a progressive shift in the timing of delivery from the 40th week to the 39th week. Absent this confounding factor, the magnitude of association between the adoption of the 39-week rule and the increase in rate of term stillbirth might have been greater. CONCLUSIONS: Between 2007 and 2013 in the United States, the adoption of the 39-week rule caused a progressive reduction in the proportion of term births occurring before the 39th week of gestation. During the same interval the United States experienced a significant increase in its rate of term stillbirth. This study raises the possibility that the 39-week rule may be causing unintended harm. Additional studies of the actual impact of the adoption of the 39-week rule on major childbirth outcomes are urgently needed. Pressures to enforce the 39-week rule should be reconsidered pending the findings of such studies.

Treatment modalities in recurrent miscarriages without diagnosis.

Recurrent miscarriage is defined as the loss of three consecutive pregnancies before 20 weeks' gestational age. Patients are referred to subspecialists such as reproductive endocrinology or maternal fetal medicine to exclude the most common causes of recurrent miscarriage including autoimmune disorders, structural uterine pathology, metabolic derangements, hematologic conditions, and chromosomal abnormalities. Unfortunately, this extensive list of conditions accounts for less than 50% of patients affected by recurrent miscarriage, leaving the remaining 50% without answers. Multiple treatment modalities, including supplementation with progesterone, human chorionic gonadotropin, aspirin with and without heparin, and immune modulators have been tested for this large percentage of patients with very few answers. In fact, the only successful intervention addressed in the literature consists of supportive care at a dedicated recurrent miscarriage clinic. Without large randomized clinical trials, there is no evidence to support the use of supplemental medications in this patient population.

Management of gestational hypertension - the impact of HYPITATa.

AIMS: The objective of this study was to examine the impact of one trial (the HYPITAT trial) on management of gestational hypertension. STUDY DESIGN: This is a retrospective cohort study of 5077 patients delivered at our institution from 7/1/2008 to 6/15/2011. "Pre-HYPITAT" was defined as 7/1/2008-9/30/2009 and "Post-HYPITAT" as 10/1/2009-6/15/2011. The primary outcome is the rate of delivery intervention for gestational hypertension. Secondary maternal and neonatal outcomes were analyzed in patients with gestational hypertension only. Statistical analyses included the χ2-test, Fisher's exact test, and the two-sample t-test. RESULTS: The rate of delivery intervention Pre-HYPITAT was 1.9%, compared to 4% Post-HYPITAT (P<0.001). There was no significant change in secondary outcomes. CONCLUSION: There was a statistically significant increase in delivery intervention for gestational hypertension at our institution after the publication of the HYPITAT trial. There was no significant change in immediate maternal or neonatal outcomes for patients with gestational hypertension.

Overview and Long-term Outcomes of Patients Born With Twin-to-Twin Transfusion Syndrome.

Twin-to-twin transfusion syndrome (TTTS) results from a disproportionate blood supply between two (or more) fetuses that share a single placenta. Multiple complications can occur as a result of the syndrome, including intrauterine growth restriction in the donor twin, cardiomyopathies in recipients, and neurodevelopmental morbidities in survivors. Studies indicate that patients with TTTS have higher incidences of congenital heart disease compared with the unaffected population, and even when compared with uncomplicated monochorionic diamniotic twins. If managed properly, TTTS can result in a positive outcome for most patients.

Treatment of hyperemesis gravidarum.

Hyperemesis gravidarum, or pernicious vomiting of pregnancy, is a complication of pregnancy that affects various areas of the woman's health, including homeostasis, electrolytes, and kidney function, and may have adverse fetal consequences. Recent research now provides additional guidelines for protection against and relief from hyperemesis gravidarum. Alterations to maternal diet and lifestyle can have protective effects. Medicinal methods of prevention and treatment include nutritional supplements and alternative methods, such as hypnosis and acupuncture, as well as pharmacotherapy.

Type 1 diabetes mellitus and pregnancy.

Diabetes complicates up to 10% of all pregnancies in the United States. Of these, 0.2% to 0.5% are patients with type 1 diabetes mellitus (T1DM). Pregnancies affected by T1DM are at increased risk for preterm delivery, preeclampsia, macrosomia, shoulder dystocia, intrauterine fetal demise, fetal growth restriction, cardiac and renal malformations, in addition to rare neural conditions such as sacral agenesis. Intensive glycemic control and preconception planning have been shown to decrease the rate of fetal demise and malformations seen in pregnancies complicated by T1DM. Recent advances in insulin formulations and delivery methods have increased the number of options available to the obstetric team. Insulin regimens should be tailored to each individual patient to maximize compliance and ensure proper glycemic control. Intensive preconception counseling with frequent follow-up visits emphasizing tight glucose control is recommended for adequate management.