The effect of antenatal corticosteroids on small-for-gestational age preterm neonates.

OBJECTIVE: Treatment of preterm small-for-gestational age (SGA) neonates with antenatal corticosteroids (ACS) is not entirely straightforward. We sought to examine the effect of a full course of ACS on outcomes of SGA and non-SGA preterm singletons. PATIENTS AND METHODS: We compared maternal characteristics and outcomes of preterm births at <28 and 28 + 0-33 + 0 weeks' gestation that received a complete course of ACS within a week before birth. We further divided our cohort into those with or without a SGA neonate. RESULTS: We included 290 infants: 73 (25.2%) and 217 (74.8%) born at <28 and 28 + 0-33 + 0 weeks' gestation, respectively. Analysis of maternal characteristics showed a strong association of maternal body mass index (p = .01), along with smoking during pregnancy (OR 0.4, 95% CI 0.2, 0.9), with being SGA. Spontaneous onset of delivery more commonly occurred in non-SGA preterm neonates, whereas iatrogenic induction of labor prevailed with SGA neonates (p < .01). There was no significant difference between SGA and non-SGA infants in all the tested neonatal variables except for necrotizing enterocolitis, which prevailed in the SGA group. CONCLUSION: A full course of ACS appears to have the same effect in SGA and non-SGA preterm singletons in our studied cohort on all neonatal outcomes but for necrotizing enterocolitis, where its role in SGA preterm neonates seems to be detrimental rather than beneficial to the fetus.

Cervical cerclage after prior uterine and cervical surgery.

OBJECTIVE: To evaluate cerclage placement after uterine and cervical surgery. PATIENTS AND METHODS: We compared patients with a prior uterine surgery (with or without cervical surgery) with women having a cerclage for the "classical" indications. Under the classical indications fall history of one or more second-trimester pregnancy losses related to painless cervical dilation, prior cerclage due to painless cervical dilation in the second trimester, painless cervical dilation in the second trimester, ultrasonographic finding with a history of prior preterm birth, prior spontaneous preterm birth at less than 34 weeks of gestation and short cervical length (less than 25 mm) before 24 weeks of gestation. RESULTS: Forty-seven (44.8%) patients had uterine surgery whereas 58 (55.2%) had the "classical" indications for cerclage. The risk of birth at <37 weeks and birth weight <2500 g was similar, but lower for cerclage after previous uterine/cervical surgery for births >37 weeks (OR 0.3, 95% CI 0.1, 0.8) and hence, for birth weights >2500 g (OR 0.4, 95% CI 0.2-0.9). Both groups had similar incidence of preterm rupture of membranes, chorioamnionitis, need for induction of labor, cesarean births as well as low Apgar scores and admission rates to the NICU. CONCLUSIONS: The major goals of reducing births at <37 weeks and low birth weight of <2500 g are achievable with a cerclage in patients with a prior uterine/cervical surgery as it is in patients with a "classical" indication for cerclage placement.

Perinatal outcome of in vitro fertilization pregnancies in women with polycystic ovary syndrome by pregravid BMI.

OBJECTIVES: Given the adverse effects of either polycystic ovary syndrome (PCOS) or overweight/obesity, one could speculate that patients with both would fare worse than others. We sought to evaluate the relationship between pregravid BMI and pregnancy complications in PCOS patients conceived by assisted reproductive techniques (ART). METHODS: Maternal and fetal/neonatal outcomes of singleton pregnancies after assisted reproduction in women with and without PCOS were compared by pregravid body mass index (BMI, <24.9 vs. ≥25 kg/cm2). RESULTS: The study population comprised 185 with a BMI <24.9 kg/cm2 including 39 (21%) with PCOS and 146 (79%) without. We also included 84 patients with BMI ≥25 kg/cm2, involving 34 (40.5%) with PCOS and 50 (59.5%) without. PCOS (total 73 patients) was significantly more common among overweight/obese patients, OR 2.5 (95% CI 1.4, 4.4). Neonates >4,000 g were born only to the overweight/obese mothers in the PCOS group. A higher incidence of gestational diabetes, chronic hypertension, and gestational hypertension was related to pregravid overweight/obesity rather than PCOS. CONCLUSIONS: In this specific subgroup of patients conceived after assisted reproduction, pregravid BMI>25 kg/cm2 rather than PCOS itself appears to be associated with GDM and hypertensive disorders.

Maternal BMI and weight gain in singleton pregnancies: has something changed in the last decade?

Aim: To assess the trend of the pregravid body mass index (BMI), pregnancy weight gain, and BMI gain in singleton pregnancies delivered at ≥38 completed weeks during the last decade.Materials and methods: We used data from a population-based dataset for the period of 2006-2015. Linear regression was used to assess the relationship between BMI, pregnancy weight gain, and BMI change over time.Results: A total of 70,866 women were included and stratified as primiparous and multiparous. The average BMI in the primiparous women increased 0.52 kg/m2 in the past decade, increasing for 0.05 kg/m2 every year. The average pregnancy weight gain in this group decreased in this period by 0.7 kg, consequently lowering for 0.07 kg per year, the average BMI change during pregnancy decreased overall by 0.26 kg/m2 (0.026 kg/m2/year). However, in multiparous women, the average pregravid BMI did not change over time, but the average pregnancy weight gain decreased by 0.21 kg (0.021 kg/year), and the average BMI change decreased for 0.10 kg/m2.Conclusions: Our study showed that the pregravid BMI is increasing in the pregnant primiparous women, but the BMI gain, as well as the pregnancy weight gain, decreased irrespective of parity. Given that the range of differences is not clinically significant, we conclude that pregravid BMI, pregnancy weight gain, and BMI change during pregnancy did not change in the last decade.

Maternal characteristics of preterm singleton birth following assisted reproduction: a population-based study.

OBJECTIVE: To identify pregestational maternal characteristics that are associated with an increased risk for preterm births (PTB) of assisted reproductive technology (ART) singleton pregnancies. PATIENTS AND METHODS: We evaluated the Slovenian National Perinatal Information System (NPIS). We included all ART singletons born during the period 2006-2015. We compared births before and after 36 completed weeks' gestation for maternal age, parity, prepregnancy BMI, height, previous PTB, preexisting hypertension and diabetes, and history of uterine gynecological operations. RESULTS: Chronic hypertension (OR 2.5, 95% CI 1.3-4.8), previous preterm birth (OR 2.4, 95% CI 1.5-3.7), pregravid obesity (OR 1.6, 95% CI 1.2-2.1) and an existing indication for cerclage (OR 6.2, 95% CI 3.7-10.5) were associated with an increased risk of PTB. CONCLUSIONS: Chronic hypertension, previous PTB, pregravid obesity and an existing indication for cerclage are associated with increased risk of PTB among ART pregnancies.

The contribution of twins conceived by in vitro fertilization to preterm birth rate: observations from a quarter of century.

Objective Little information exists related to the contribution of assisted reproductive technology (ART) twins to the preterm and very preterm birth rate. We sought to examine this contribution over a period of more than two decades in a tertiary perinatal center. Methods We identified all preterm births from 1993 to 2017, born at <37 or <32 weeks' gestation, by mode of conception [in vitro fertilization (IVF) vs. non-IVF pregnancies]. We generated trend lines of the annual change of the dependent variable (% preterm birth). Results We evaluated 74,299 births, including 3934 (5.3%) preterm births at <37 and 826 (1.1%) at <32 weeks' gestation. In this period, 1019 (1.4%) twin pairs were born including 475 (46.6%) and 80 (7.8%) at <37 and <32 weeks, respectively. There were 213 (5.4%) IVF pregnancies among the preterm births at <37 weeks, including 88 (41.3%) twins. Fifteen (1.8%) births of all IVF gestations were at <32 weeks, and all were twins. Whereas the annual rate of spontaneous twins did not change, a significant increase over time exists for IVF twins (P < 0.05, R2 = 0.6). We demonstrated an increase in IVF twin births at <37 weeks but not for spontaneously conceived twins. Whereas the twin birth rate at <32 weeks did not change over time, all preterm births at <32 weeks following IVF were twins. Conclusions The risk of twins after ART increasingly contributes to preterm births at <37 weeks and ART twins are at significant risk for preterm births at <32 weeks.

Gestational diabetes mellitus in underweight women.

Objective: To compare outcomes of pregnancies complicated by gestational diabetes mellitus (GDM) in underweight women with those of normal pregravid BMI.Methods: We used a population-based dataset to identify singleton pregnancies complicated by GDM in underweight and normal weight women.Results: Among women with GDM, we identified 301 and 6494 women with pregravid underweight and normal BMI. Underweight women were younger, more often nulliparous, and had lower birth weight (p < .05) and lower incidence of birth weight > 4000 g (OR 0.3, 95% CI 0.1, 0.6) as compared to normal weight GDM women.Conclusions: It appears that pregravid maternal weight rather than GDM might be responsible for larger babies. A dose-response relationship should be established, however.

The effect of interaction between parity, gestational diabetes, and pregravid obesity on the incidence of preeclampsia.

Objective: To examine the effect of parity, prepregnancy obesity and gestational diabetes on the incidence of preeclampsia in singleton pregnancies using a population-based dataset.Methods: We used the national perinatal information system (NPIS) to identify singleton pregnancies complicated by preeclampsia and analyzed dichotomous-independent variables: being obese or normal weight before pregnancy, being primiparous or multiparous, and being without gestational diabetes mellitus (GDM), with GDMA1, or GDMA2.Results: We found a significantly higher incidence of pregravid obesity among primiparas with preeclampsia (OR 1.6, 95% CI 1.55, 1.66). The data indicate that multiparas had always a significantly lower incidence of preeclampsia, regardless if the women had GDMA1, GDMA2 or had no GDM, and regardless of being of normal weight or obese before pregnancy. The data indicate that the incidence of preeclampsia was not influenced by GDM status, irrespective of parity pregravid BMI category.Conclusions: Our data indicate that GDM is not significantly associated with the development of preeclampsia.

Abuse of pregnant women in the healthcare system.

Objective: The purpose of this study was to determine the incidence of abuse in healthcare system during pregnancy and its impact on pregnancy outcomes.Materials and methods: A validated screening Norvold Abuse Questionnaire for the identification of female victims of four kinds of abuse: emotional, physical, sexual, and the abuse in the healthcare system was anonymously offered to all women in the first 2 days postpartum.Results: The study group consisted of 1018 women, 6.2% of which reported experiencing abuse in healthcare system during pregnancy. Affected women had a higher incidence of preterm delivery (OR 2.4; 95% CI 1.2-4.8) and cesarean section rate (OR 2.0; 95% CI 1.1-3.6). Sexual abuse and abuse in healthcare system during childhood were associated with abuse in healthcare system during pregnancy (OR 4.4; CI 95% 1.2-16.2 and OR 6.9; CI 95% 1.3-35.4, respectively).Conclusions: Our study indicates that as many as 6.2% of pregnant women experience abusive encounters with perinatal care providers. These pregnancies eventually end more often preterm and by cesarean section. This possibly causal relationship should be further explored.

Neonatal morbidity and mortality among growth-discordant dichorionic twins, classified according to birth weight of the smaller twin: a population-based cohort study.

Objective: To examine the outcomes among discordant dichorionic (DC) twins, where the smaller twin is small for gestational age (SGA) or non-SGA.Materials and methods: We used the national perinatal registry to compare the relationship between selected maternal characteristics (age, parity, body mass index, gestational diabetes, hypertensive disorders, and gestational age at delivery) and neonatal outcomes in discordant >25% DC twins. Chorionicity was established by standard ultrasound criteria and confirmed postpartum. The smaller of the twins was further classified as SGA or non-SGA. The neonatal outcomes included 5-min Apgar score <7, admission to neonatal intensive care unit, early neonatal death and neonatal morbidities.Results: We identified 377 pairs of DC discordant twins >25% born during the 15 years study period, 270 (71.6%) of which included an SGA smaller twin and 107 (28.4%) were non-SGA smaller twin. Maternal characteristics and neonatal morbidities were unrelated to the smaller discordant twin being SGA. A significantly increased incidence of stillbirth was found in the SGA group. Early neonatal deaths were only found in the SGA group.Conclusion: When the smaller twin is SGA, the growth discordant DC twin pair is associated with increased incidence of perinatal deaths. These appear unrelated to maternal characteristics and neonatal morbidity.

Effect of gender on growth-restricted fetuses born preterm.

Objective To assess the effect of fetal gender in small-for-gestational age (SGA) neonates with birth weight less than the fifth percentile by gestational age. Methods We compared male and female SGA neonates for maternal and neonatal outcomes in the following gestational age subgroups: at <32 + 6, 33 + 0-36 + 6 and at ≥37 + 0 weeks of gestation. Results We examined 159, 154 and 2363 SGA neonates born at <32 + 6, 33 + 0 to 36 + 6 and ≥37 weeks of pregnancy, respectively, whose birth weight was below the fifth percentile for gestational age and who met our inclusion criteria. Overall, there were no significant differences between the mothers of males and females, except that there were more males at term and the incidence of nulliparas was greater among the mothers of males. In terms of outcomes, males had a similar incidence of respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH) and admissions to intensive care. Interestingly, low Apgar scores were more common in preterm females born at 33-37 weeks and vice versa in births over 37 weeks. Conclusion Our data do not support an advantage of either gender in preterm birth of infants who are most likely growth restricted.

Quantitative and qualitative assessment of maternal sexuality during pregnancy.

Objective To investigate the quantitative and qualitative measures of the complex relationship between sexuality and the pregnant state. Methods An anonymous questionnaire [comprising the Female Sexual Function Index questionnaire, the Evaluation and Nurturing Relationship Issues, Communication and Happiness (ENRICH) Marital Satisfaction Scale, scale of attitudes toward sexuality, the World Health Organization (WHO) Well-Being Index and the scale of body image] was given to 243 women during antenatal classes. Results We evaluated 200 primiparous women, with an average age of 30.5 years (range 21-44), at an average gestational age of 31.6 weeks (range 19-38). We found that sexual intercourse during pregnancy is less frequent and less satisfying compared to the pre-pregnancy period. Sexuality or certain aspects of sexuality (arousal and satisfaction with sexuality) are associated with the fear of hurting the fetus, satisfaction with intimate partner relationship, general attitude toward sexuality, physical self-image and general well-being. Women who are more satisfied with their intimate partner relationship are also more satisfied with their sexuality. Conclusion Sexuality and sexual well-being during pregnancy are associated with the fear of hurting the fetus, satisfaction with intimate partner relationship, attitude toward sexuality, physical self-image and general well-being.

Stillbirths in women with pre-gravid obesity.

Objective To determine the association between pre-gravid obesity and stillbirth. Methods A retrospective study of a population-based dataset of births at ≥34 weeks' gestation. We excluded fetal deaths due to lethal anomalies and intrapartum fetal deaths. We calculated the incidence of stillbirths, neonatal respiratory distress syndrome (RDS) and neonatal intensive care unit (NICU) admissions per ongoing pregnancies for each gestational week in the two body mass index (BMI) categories (≥30 vs.<30). Results Pre-pregnancy obesity (BMI≥30), pre-pregnancy diabetes, oligo- and polyhydramnios, being small for gestational age (SGA) and preeclampsia were significantly associated with stillbirth. However, the only pre-gravid factor that is amenable to intervention was obesity [adjusted odds ratio (OR) 2.0; 95% confidence interval (CI) 1.20, 3.3]. The rates of stillbirth seem to increase with gestational age in both BMI categories. RDS and NICU admission would be presented. Conclusion Birth near term might reduce stillbirths and decrease NICU admissions occurring in term and in post-term obese women. This presumable advantage might be offset by the potential risk of labor induction and cesarean section among obese women. Women of childbearing age with a BMI≥30 should be counseled about these risks of obesity during pregnancy and childbirth.

Effect of pre-gravid body mass index on outcomes of pregnancies following in vitro fertilization.

PURPOSE: To examine the effect of pre-gravid body mass index (BMI) on perinatal outcomes in in vitro fertilization (IVF) singleton pregnancies. METHODS: Retrospective population-based cohort study. All singleton pregnancies delivered at ≥ 22 weeks' in Slovenia between 2002 and 2015 were included. Logistic regression analysis was used to examine the relationship between BMI category and outcomes, controlling for potential confounding variables. Interaction term was included to evaluate whether effects of obesity on perinatal outcomes differ in IVF vs. non-IVF pregnancies. We counted the frequencies of hypertensive disorders of pregnancy, gestational diabetes, cesarean delivery, preterm births, and small as well as large for gestational age neonates, neonatal respiratory distress syndrome, neonatal intraventricular hemorrhage, and perinatal deaths. RESULTS: Pre-gravid overweight and obesity were associated with higher rates of hypertensive disorders, gestational diabetes, and cesarean deliveries in both IVF and non-IVF pregnancies. Pre-gravid underweight was associated with small for gestational age neonates in IVF and non-IVF pregnancies. There was a significantly lower effect of pre-gravid obesity on the incidence of hypertensive disorders (odds ratio (OR) 0.7; 95% confidence interval (CI) 0.5-0.9) and cesarean delivery (OR 0.8; 95% CI 0.7-0.99) in IVF vs. non-IVF pregnancies. The effect of pre-gravid obesity on neonatal mortality was significantly greater in IVF compared to non-IVF pregnancies (OR 4.6; 95% CI 1.4-15.8). CONCLUSIONS: Pre-gravid BMI has an important effect on perinatal outcomes in pregnancies following IVF.

First trimester ß-hCG and estradiol levels in singleton and twin pregnancies after assisted reproduction.

Objective To compare levels of ß-hCG and estradiol collected during the first trimester in singleton and twin pregnancies following assisted reproduction technologies (ART). Methods We prospectively evaluated 50 singleton and 47 dichorionic twin pregnancies that eventually ended in live births. Patients were recruited from a single ART center with standard treatment protocols followed by fresh embryo transfers. Hormone measurements were performed within a narrow gestational age range and analyzed in a single laboratory thus minimizing inter- and intra-assay variability. We measured serum ß-hCG at 13 days after embryo transfer as well as samples of ß-hCG and estradiol at 8-9 weeks+6 days. Results No significant differences existed between singletons and twins in respect to demographic and cycle characteristics. ß-hCG and estradiol were all significantly higher in twins (P<0.05). Conclusion The data confirms the higher levels of ß-hCG and estradiol in twins, pointing to the potential role of these placental hormones in early support of a twin pregnancy.

Violence before pregnancy and the risk of violence during pregnancy.

OBJECTIVE: To investigate the relationships among different forms of violence before and during pregnancy. MATERIAL AND METHODS: An anonymous questionnaire (adapted NorAQ) was given to 1269 women after childbirth. RESULTS: The response rate was 80% (n=1018). Different forms of violence were experienced by 46.9% of the women; 9.2% reported violence in pregnancy. Suffering from the consequences of violence was reported by 43.8% of the women; sexual (76.6%) and psychological (54.1%) ranked the highest. Past experience of any form of violence increased the risk of violence in pregnancy, violences experienced in adulthood even more than that in childhood [odds ratio (OR) 4.2, 95% confidence interval (CI) 2.7-6.5 vs. OR 1.9, 95% CI 1.2-2.9]. The onset of violence during pregnancy is rare. Violence was most frequently exerted by the intimate partner. CONCLUSION: Healthcare systems have access to most women of reproductive age, thus they have the unique opportunity to identify and adequately manage violence against women and its consequences.

The impact of inter-pregnancy interval on subsequent risk of preterm birth.

OBJECTIVE: The aim of the study was to assess optimal time to conceive after previous delivery associated with smallest risk of preterm birth. METHODS: We selected all women (n = 2723) with their first and second singleton delivery between the years 2004 and 2012. Inter-pregnancy interval was defined as that between live birth and subsequent conception. We performed logistic regression analyses to assess the risk of preterm birth adjusted for maternal age and body mass index. RESULTS: Association between inter-pregnancy interval and the natural logarithm of the adjusted relative risk of preterm birth had a J-shaped curve with lowest risk at 15 months after last birth. CONCLUSION: The optimal time to conceive after a previous delivery is 15 months, as longer or shorter interval are associated with increased risk of preterm birth. Women with short or long inter-pregnancy intervals were 1.6 times more likely to experience preterm birth.

The effect of gestational diabetes, pre-gravid maternal obesity, and their combination ('diabesity') on outcomes of singleton gestations.

OBJECTIVE: To assess the effect of the combination of gestational diabetes mellitus (GDM) and pre-gravid obesity ('diabesity') in singleton gestations. METHODS: We compared perinatal outcomes of singleton gestations in mothers with GDM and pre-gravid obesity, with GDM but with normal pre-gravid BMI, and obese mothers without GDM. RESULTS: We compared diabesity mothers (n = 1525, 24.4% of mothers with GDM, 9.9% of all obese women) to mothers with GDM but with normal BMI (n = 4704, 75.6% of mothers with GDM) and to obese mothers without GDM (n = 13,937, 90.1% of all obese mothers). Obesity, with and without GDM, increased the odds of having chronic hypertension whereas preeclampsia appears to be influenced by obesity only, as were the risk of births at <33 weeks' gestation, of birth weight >4000 g, low 5-min Apgar scores and NICU admissions. CONCLUSION: Obesity (without diabetes) is more frequently associated with adverse perinatal outcomes than diabesity or GDM in non-obese mothers. A campaign to decrease pre-gravid obesity should have at least the same priority as any campaign to control GDM.

Tokophobia (fear of childbirth): prevalence and risk factors.

OBJECTIVE: To identify the prevalence of and to determine the risk factors for developing a fear of childbirth (tokophobia). METHODS: We evaluated 191 pregnant women during Parenting and Childbirth Classes. Participants were approached when attending Parenting and Childbirth Classes between June 2014 and September 2014 and were asked to complete several questionnaires related to depression (CES-D), anxiety (STAI X1 and X2), satisfaction with life (SWLS), delivery expectation/experience (W-DEQ), and specific fears. RESULTS: Most (90%) of the responders were nulliparous. As many as 75% of the participants reported low to moderate tokophobia, whereas 25% exhibited high or very high fear of childbirth. Pathological fear occurred in 1.6% of the participants. The most significant was the fear of having an episiotomy followed by fear of having no control on the situation and fear of pain. An association exists between a preferred elective cesarean birth and tokophobia. CONCLUSIONS: The results draw attention to the need for early detection and treatment of fear of childbirth. The data may help identifying women at risk that require prenatal psychological intervention.