Umbilical cord milking and delayed cord clamping for the prevention of neonatal hypoglycaemia: a systematic review and meta-analysis.

BACKGROUND: Placental management strategies such as umbilical cord milking and delayed cord clamping may provide a range of benefits for the newborn. The aim of this review was to assess the effectiveness of umbilical cord milking and delayed cord clamping for the prevention of neonatal hypoglycaemia. METHODS: Three databases and five clinical trial registries were systematically reviewed to identify randomised controlled trials comparing umbilical cord milking or delayed cord clamping with control in term and preterm infants. The primary outcome was neonatal hypoglycaemia (study defined). Two independent reviewers conducted screening, data extraction and quality assessment. Quality of the included studies was assessed using the Cochrane Risk of Bias tool (RoB-2). Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Meta-analysis using a random effect model was done using Review Manager 5.4. The review was registered prospectively on PROSPERO (CRD42022356553). RESULTS: Data from 71 studies and 14 268 infants were included in this review; 22 (2 537 infants) compared umbilical cord milking with control, and 50 studies (11 731 infants) compared delayed with early cord clamping. For umbilical cord milking there were no data on neonatal hypoglycaemia, and no differences between groups for any of the secondary outcomes. We found no evidence that delayed cord clamping reduced the incidence of hypoglycaemia (6 studies, 444 infants, RR = 0.87, CI: 0.58 to 1.30, p = 0.49, I2 = 0%). Delayed cord clamping was associated with a 27% reduction in neonatal mortality (15 studies, 3 041 infants, RR = 0.73, CI: 0.55 to 0.98, p = 0.03, I2 = 0%). We found no evidence for the effect of delayed cord clamping for any of the other outcomes. The certainty of evidence was low for all outcomes. CONCLUSION: We found no data for the effectiveness of umbilical cord milking on neonatal hypoglycaemia, and no evidence that delayed cord clamping reduced the incidence of hypoglycaemia, but the certainty of the evidence was low.

Megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS): challenges in diagnosis and management.

Megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS) is a rare, congenital functional intestinal obstruction, characterised by megacystis (bladder distention in the absence of mechanical obstruction), microcolon and intestinal hypoperistalsis (dysmotility).We are reporting a case of a female child with normal antenatal course who presented with recurrent episodes of abdominal distension since the second day of life and underwent negative exploratory laparotomy on multiple occasions. She also had urinary retention with a grossly distended bladder, requiring drainage by clean intermittent catheterisation. Surgical procedures for bowel decompression, including gastrostomy and ileostomy, were carried out without success. Genetic analysis revealed a mutation in the human smooth muscle (enteric) gamma-actin gene (ACTG2 gene), clinching the diagnosis of MMIHS. The patient was managed with parenteral nutrition and prokinetic medications and tolerated jejunostomy feeds for a brief period before she succumbed to the illness.Female neonates or infants presenting with abdominal distension and dilated urinary tract should be investigated for MMIHS early on. A timely diagnosis will enable the early involvement of a multidisciplinary team to provide the best options available for management.

Genome-wide analysis identifies MYH11 compound heterozygous variants leading to visceral myopathy corresponding to late-onset form of megacystis-microcolon-intestinal hypoperistalsis syndrome.

Megacystis-microcolon-hypoperistalsis-syndrome (MMIHS) is a rare and early-onset congenital disease characterized by massive abdominal distension due to a large non-obstructive bladder, a microcolon and decreased or absent intestinal peristalsis. While in most cases inheritance is autosomal dominant and associated with heterozygous variant in ACTG2 gene, an autosomal recessive transmission has also been described including pathogenic bialellic loss-of-function variants in MYH11. We report here a novel family with visceral myopathy related to MYH11 gene, confirmed by whole genome sequencing (WGS). WGS was performed in two siblings with unusual presentation of MMIHS and their two healthy parents. The 38 years-old brother had severe bladder dysfunction and intestinal obstruction, whereas the 30 years-old sister suffered from end-stage kidney disease with neurogenic bladder and recurrent sigmoid volvulus. WGS was completed by retrospective digestive pathological analyses. Compound heterozygous variants of MYH11 gene were identified, associating a deletion of 1.2 Mb encompassing MYH11 inherited from the father and an in-frame variant c.2578_2580del, p.Glu860del inherited from the mother. Pathology analyses of the colon and the rectum revealed structural changes which significance of which is discussed. Cardiac and vascular assessment of the mother was normal. This is the second report of a visceral myopathy corresponding to late-onset form of MMIHS related to compound heterozygosity in MYH11; with complete gene deletion and a hypomorphic allele in trans. The hypomorphic allele harbored by the mother raised the question of the risk of aortic disease in adults. This case shows the interest of WGS in deciphering complex phenotypes, allowing adapted diagnosis and genetic counselling.

Lethal multiple pterygium syndrome, large cystic hygroma, and cleft palate: Rare and severe fetal presentations of RYR1- and NEB-related congenital myopathies.

Congenital myopathies are a genetically heterogeneous group of neuromuscular disorders that commonly present with congenital hypotonia and weakness but can also present broadly. The most severe presentation is neonatal with arthrogryposis and, rarely, fetal akinesia and pterygia, features also seen in lethal multiple pterygium syndrome (LMPS). We describe two fetuses with similar phenotype, including hydrops fetalis, large cystic hygromas, bilateral talipes, and fetal akinesia in the second trimester. Genetic diagnoses were made using exome sequencing. Both fetuses had a severe form of congenital myopathy. In the first fetus, we identified two novel compound heterozygous likely pathogenic variants consistent with autosomal recessive RYR1-related congenital myopathy (congenital myopathy 1B). In the second fetus, we identified two likely pathogenic variants, one of which is novel, likely in trans consistent with a diagnosis of autosomal recessive NEB-related congenital myopathy. Reaching a genetic diagnosis for these fetuses allowed the families to receive accurate genetic counseling for future pregnancies. These fetuses highlight the genetic and phenotypic heterogeneity of LMPS, and support a broad approach to genetic testing.

Independent and Combined Effects of Prenatal Alcohol Exposure and Prenatal Stress on Fetal HPA Axis Development.

Prenatal alcohol exposure (PAE) and prenatal stress (PS) are highly prevalent conditions known to affect fetal programming of the hypothalamic-pituitary-adrenal (HPA) axis. The objectives of this study were to assess the effect of light PAE, PS, and PAE-PS interaction on fetal HPA axis activity assessed via placental and umbilical cord blood biomarkers. Participants of the ENRICH-2 cohort were recruited during the second trimester and classified into the PAE and unexposed control groups. PS was assessed by the Perceived Stress Scale. Placental tissue was collected promptly after delivery; gene and protein analysis for 11ß-HSD1, 11ß-HSD2, and pCRH were conducted by qPCR and ELISA, respectively. Umbilical cord blood was analyzed for cortisone and cortisol. Pearson correlation and multivariable linear regression examined the association of PAE and PS with HPA axis biomarkers. Mean alcohol consumption in the PAE group was ~2 drinks/week. Higher PS was observed in the PAE group (p < 0.01). In multivariable modeling, PS was associated with pCRH gene expression (ß = 0.006, p < 0.01), while PAE was associated with 11ß-HSD2 protein expression (ß = 0.56, p < 0.01). A significant alcohol-by-stress interaction was observed with respect to 11ß-HSD2 protein expression (p < 0.01). Results indicate that PAE and PS may independently and in combination affect fetal programming of the HPA axis.

Human cytomegalovirus (CMV) dysregulates neurodevelopmental pathways in cerebral organoids.

Human cytomegalovirus (CMV) infection is the leading non-genetic aetiology of congenital malformation in developed countries, causing significant fetal neurological injury. This study investigated potential CMV pathogenetic mechanisms of fetal neural malformation using in vitro human cerebral organoids. Cerebral organoids were permissive to CMV replication, and infection dysregulated cellular pluripotency and differentiation pathways. Aberrant expression of dual-specificity tyrosine phosphorylation-regulated kinases (DYRK), sonic hedgehog (SHH), pluripotency, neurodegeneration, axon guidance, hippo signalling and dopaminergic synapse pathways were observed in CMV-infected organoids using immunofluorescence and RNA-sequencing. Infection with CMV resulted in dysregulation of 236 Autism Spectrum Disorder (ASD)-related genes (p = 1.57E-05) and pathways. This notable observation suggests potential links between congenital CMV infection and ASD. Using DisGeNET databases, 103 diseases related to neural malformation or mental disorders were enriched in CMV-infected organoids. Cytomegalovirus infection-related dysregulation of key cerebral cellular pathways potentially provides important, modifiable pathogenetic mechanisms for congenital CMV-induced neural malformation and ASD.

Secuencia anemia-policitemia en la gestación monocorial. Manejo prenatal y resultados perinatales / Twin anaemia polycythemia polycythemia sequence in monochorionic gestation. Prenatal management and perinatal outcomes

Introducción: El objetivo de este trabajo consiste en describir y analizar los resultados perinatales de una serie de casos de anemia-policitemia (TAPS) seguidos y tratados en un centro de referencia en Medicina Fetal, en términos del tipo TAPS y la conducta prenatal aplicada. Métodos: Análisis estadístico descriptivo e inferencial con el programa IBM SPSS Statistics. Resultados: Se diagnosticaron 13 casos de TAPS en un total de 510 gestaciones monocoriales. La mayoría de TAPS espontáneos se diagnosticaron en estadios precoces (5 casos), mientras que, en TAPS posláser, 3/6 casos se diagnosticaron en estadios avanzados. Cuatro fetos (4/26; 15,4%) presentaron alteraciones en la neurosonografía, 3 (3/14; 21,4%) en TAPS espontáneos y uno (1/12, 8,3%) en TAPS posláser (p = 0,308). Se detectó hipertrofia miocárdica en 7 fetos, 5 (71,4%) de los cuales correspondían a TAPS en estadios avanzados. Cuatro eran TAPS espontáneos (4/14; 28,6%) y 3 TAPS posláser (3/12; 25%) (p = 0,797). Ocho casos (8/13; 62,5%) precisaron algún procedimiento de terapia fetal. Se produjeron 3 muertes fetales anteparto y una pareja decidió interrupción legal del embarazo (19,23%). Las 5 pérdidas se produjeron en estadio IV (p=0,008).La supervivencia global fue del 80,8% (21/26 recién nacidos vivos). No hubo diferencias significativas en función del tipo TAPS (p = 0,159) y la conducta prenatal adoptada (p = 0,746). Conclusiones: El TAPS espontáneo es, por tanto, una entidad clínica con un impacto en los resultados perinatales similar al posláser. Parece que la conducta expectante y el láser consiguen mayor edad gestacional al nacimiento.(AU)

Introduction: The aim of this paper is to describe and analyze the perinatal outcomes of a series of TAPS cases followed and treated in a Fetal Medicine referral center, in terms of the type of TAPS and the prenatal behavior applied. Methods: Descriptive and inferential statistical analysis with IBM SPSS Statistics software. Results: Thirteen cases of TAPS were diagnosed in a total of 510 monocorial gestations. Most of the spontaneous TAPS were diagnosed at early stages (5 cases), whereas, in post-laser TAPS, 3/6 cases were diagnosed at advanced stages. Four fetuses (4/26; 15.4%) presented alterations in neurosonography, 3 (3/14; 21.4%) in spontaneous TAPS and one (1/12, 8.3%) in post-laser TAPS (P=0.308). Myocardial hypertrophy was detected in 7 fetuses, 5 (71.4%) of which corresponded to advanced stage TAPS. Four were spontaneous TAPS (4/14; 28.6%) and 3 were post-laser TAPS (3/12; 25%) (P=0.797). Eight cases (8/13; 62.5%) required some fetal therapy procedure. There were 3 antepartum fetal deaths and one couple decided to legally terminate the pregnancy (19.23%). All 5 losses were stage IV (P=0.008). Overall survival was 80.8% (21/26 live newborns). There were no significant differences according to the type of TAPS (P= 0.159) and the prenatal behavior adopted (P=0.746).Conclusions: Spontaneous TAPS is therefore a clinical entity with an impact on perinatal outcomes similar to post-laser. It seems that expectant management and laser achieve higher gestational age at birth.(AU)

A propósito de un caso de síndrome de Fraser. Autopsia de un feto de 37 semanas de gestación con múltiples malformaciones / About a case of Fraser syndrome. Autopsy of a 37 weeks gestation fetus with multiple malformations

El síndrome de Fraser o síndrome criptoftalmos/sindactilia es una enfermedad genética rara, cuyo diagnóstico se basa en una serie de criterios clínicos mayores y menores, y que puede apoyarse en pruebas genéticas. En este artículo se presenta el caso de una autopsia fetal de 37 semanas de gestación con sospecha de síndrome de CHAOS (síndrome obstructivo congénito de las vías aéreas altas). (AU)

Fraser syndrome or cryptophthalmos-syndactyly syndrome is a rare genetic disease, the diagnosis of which is based on a series of major and minor clinical criteria and that can be supported by genetic tests. This article presents the case of a fetal autopsy at 37 weeks of gestation with suspicion of CHAOS syndrome (congenital obstructive syndrome of the upper airways). (AU)

A propósito de un caso de síndrome de Fraser. Autopsia de un feto de 37 semanas de gestación con múltiples malformaciones / About a case of Fraser syndrome. Autopsy of a 37 weeks gestation fetus with multiple malformations

El síndrome de Fraser o síndrome criptoftalmos/sindactilia es una enfermedad genética rara, cuyo diagnóstico se basa en una serie de criterios clínicos mayores y menores, y que puede apoyarse en pruebas genéticas. En este artículo se presenta el caso de una autopsia fetal de 37 semanas de gestación con sospecha de síndrome de CHAOS (síndrome obstructivo congénito de las vías aéreas altas). (AU)

Fraser syndrome or cryptophthalmos-syndactyly syndrome is a rare genetic disease, the diagnosis of which is based on a series of major and minor clinical criteria and that can be supported by genetic tests. This article presents the case of a fetal autopsy at 37 weeks of gestation with suspicion of CHAOS syndrome (congenital obstructive syndrome of the upper airways). (AU)

Gestational alloimmune liver disease with alpha thalassaemia in a neonate.

A term baby presented with cholestatic jaundice since birth. She was diagnosed as gestational alloimmune liver disease-neonatal haemochromatosis (GALD-NH) on evaluation. The baby received intravenous immunoglobulin (IVIG) and recovered gradually from the illness. She was also diagnosed with alpha thalassaemia during the course of evaluation, confirmed by genetic testing. NH is a very rare disorder that results in fetal loss or neonatal death due to liver failure. NH is now known to be a phenotypic expression of GALD. Worldwide, NH is seen in less than one in a million pregnancies. The mortality rate of GALD has traditionally been around 80% with almost all babies needing liver transplantation, with advent of maternal and neonatal IVIG treatment, this has reduced significantly. There is no reported case of GALD-NH treated successfully with IVIG from India. Here, we report an interesting case of GALD-NH with alpha thalassaemia.

Design of a Stem Cell-Based Therapy for Ependymal Repair in Hydrocephalus Associated With Germinal Matrix Hemorrhages.

BACKGROUND: In preterm birth germinal matrix hemorrhages (GMHs) and the consequent posthemorrhagic hydrocephalus (PHH), the neuroepithelium/ependyma development is disrupted. This work is aimed to explore the possibilities of ependymal repair in GMH/PHH using a combination of neural stem cells, ependymal progenitors (EpPs), and mesenchymal stem cells. METHODS: GMH/PHH was induced in 4-day-old mice using collagenase, blood, or blood serum injections. PHH severity was characterized 2 weeks later using magnetic resonance, immunofluorescence, and protein expression quantification with mass spectrometry. Ependymal restoration and wall regeneration after stem cell treatments were tested in vivo and in an ex vivo experimental approach using ventricular walls from mice developing moderate and severe GMH/PHH. The effect of the GMH environment on EpP differentiation was tested in vitro. Two-tailed Student t or Wilcoxon-Mann-Whitney U test was used to find differences between the treated and nontreated groups. ANOVA and Kruskal-Wallis tests were used to compare >2 groups with post hoc Tukey and Dunn multiple comparison tests, respectively. RESULTS: PHH severity was correlated with the extension of GMH and ependymal disruption (means, 88.22% severe versus 19.4% moderate). GMH/PHH hindered the survival rates of the transplanted neural stem cells/EpPs. New multiciliated ependymal cells could be generated from transplanted neural stem cells and more efficiently from EpPs (15% mean increase). Blood and TNFα (tumor necrosis factor alpha) negatively affected ciliogenesis in cells committed to ependyma differentiation (expressing Foxj1 [forkhead box J1] transcription factor). Pretreatment with mesenchymal stem cells improved the survival rates of EpPs and ependymal differentiation while reducing the edematous (means, 18% to 0.5% decrease in severe edema) and inflammatory conditions in the explants. The effectiveness of this therapeutical strategy was corroborated in vivo (means, 29% to 0% in severe edema). CONCLUSIONS: In GMH/PHH, the ependyma can be restored and edema decreased from either neural stem cell or EpP transplantation in vitro and in vivo. Mesenchymal stem cell pretreatment improved the success of the ependymal restoration.

The association between fetal intracranial hemorrhages detected on MRI and neurodevelopment.

PURPOSE: Fetal intracranial hemorrhage is rarely identified in prenatal imaging. When identified, sparse data regarding neurodevelopmental outcomes worsens prenatal dilemmas. This MRI-based study aimed to assess prenatal characteristics and neurodevelopmental outcomes of fetal intracranial hemorrhage. METHODS: A historical cohort study which identified fetal intracranial hemorrhage in 22 individual fetal MRI scans, as part of the assessment of abnormal prenatal sonographic findings. Severity was graded by the grading system commonly used in neonates, with modifications. Prenatal data was collected. Neurodevelopmental outcome was assessed clinically by Vineland-II Adaptive Behavior Scales. RESULTS: Eight fetuses had intraventricular hemorrhage grade I-II, twelve had intraventricular hemorrhage grade III-IV, and two had infratentorial hemorrhage. The most prevalent risk factors were maternal chronic diseases and chronic use of medications. There was male predominance. Pregnancy was terminated in eleven cases. No surviving child who participated in the Vineland assessment had a grade IV hemorrhage. Vineland scores were normal in 9/11 children and moderately low in 2/11. The mean composite score of the cohort was not different from the mean score expected for age. Clinically, one child had hypotonia. CONCLUSIONS: Prognosis for fetuses with ICH without parenchymal involvement is potentially more favorable than expected from the intraventricular hemorrhage grading-scale adopted from the preterm neonates. Parenchymal involvement may predict a worse outcome, but it is not the sole predicting feature. This information may be valuable during prenatal counseling.

miR-375-3p targets YWHAB to attenuate intestine injury in neonatal necrotizing enterocolitis.

PURPOSE: Necrotizing enterocolitis (NEC) is a significant contributor to neonatal mortality. This study aimed to investigate the role of high levels of miR-375-3p in breast milk in the development of NEC and elucidate its mechanism. METHODS: Differential expression of miR-375-3p in the intestines of breast-fed and formula-fed mice was confirmed using real-time polymerase chain reaction (RT-PCR). NEC mice models were established, and intestinal injury was assessed using HE staining. RT-PCR and Western blot were conducted to examine the expression of miR-375-3p, tyrosine 3-monooxygenase/tryptophan 5-monooxygenase activation protein ß (YWHAB), as well as the inflammatory in IEC-6 cells, and intestinal tissues obtained from NEC mice and patients. Flow cytometry and cell counting kit-8 (CCK-8) were employed to elucidate the impact of miR-375-3p and YWHAB on cell apoptosis and proliferation. RESULTS: Breastfeeding increases miR-375-3p expression in the intestines. The expression of miR-375-3p in NEC intestinal tissues exhibited a significant decrease compared to the healthy group. Additionally, the expression of interleukin-6 (IL-6), interleukin-10 (IL-10), and tumor necrosis factor-α (TNF-α) was higher in the NEC group compared to the control group. Down-regulation of miR-375-3p inhibited IEC-6 cell proliferation, increased apoptosis, and elevated secretion of inflammatory factors. Bioinformatics revealed that YWHAB may be a target of miR-375-3p. RT-PCR and Western blot indicated a down-regulation of YWHAB expression in intestines of NEC patients and mice. Furthermore, YWHAB was found to be positively connected with miR-375-3p. Knockdown miR-375-3p down-regulated YWHAB expression in cells. Inhibition of YWHAB exhibited similar effects to miR-375-3p in IEC-6 cells. YWHAB plasmid partially reverse cellular functional impairment induced by miR-375-3p knockdown. CONCLUSIONS: Breastfeeding elevated miR-375-3p expression in intestines in neonatal mice. MiR-375-3p leads to a decrease in apoptosis of intestinal epithelial cells, an increase in cell proliferation, and a concomitant reduction in the expression of inflammatory factors partly through targeting YWHAB.

Severe skeletal dysplasia caused by a novel FLNB gene mutation.

A late adolescent primigravida was found to have a fetus with a cystic hygroma and significant shortening of the limbs on first-trimester ultrasound. She underwent chorionic villus sampling with normal microarray result. In the early second trimester, the fetus was found to have the absence of all four limbs and a thorough skeletal dysplasia workup was pursued, identifying a variant in the FLNB gene (c.62C>G). The patient underwent termination of pregnancy. The care of this patient was expedited by first-trimester sonographic evidence of limb abnormalities enabling timely clinical management.

First intrauterine transfusion in Rh isoimmunised triplet pregnancy.

G3P2L1, 28+4 weeks of gestation rhesus (Rh) isoimmunised pregnant women, was referred with trichorionic triamniotic triplet pregnancy with Rh antibody titres of 1:32. Nuchal translucency and anomaly scan were within normal limits with no major malformation for any of the fetuses. Obstetric colour Doppler with middle cerebral artery peak systolic volume revealed foetal anaemia in all three fetuses having velocities corresponding to around 1.5 times the median. Decision of intrauterine transfusion of blood to all three fetuses was taken. Access to fetuses was challenging and expertise in interventional ultrasound was required for transfusion. The patient tolerated the procedure well and eventually went on to deliver uneventfully at 34 weeks of gestation for worsening pre-eclampsia. After birth, all three triplets received triple-surface intensive phototherapy and intravenous immunoglobulin at a dosage of 1 g/kg. Phototherapy was gradually reduced and discontinued within 72 hours, and the infants were discharged from the neonatal intensive care unit at 96 hours of age.

Fetal anemia causes placental and maternal cellular damage: a lesson from fetal hemoglobin Bart's disease.

INTRODUCTION: The studies about effect of fetal anemia on placental and maternal molecular changes have rarely been published. This study aimed to compare oxidative stress levels and mitochondrial function in the placenta and maternal peripheral blood mononuclear cell (PMBCs) between anemic fetuses (using fetal Hb Bart's disease as a study model) and non-anemic fetuses. METHODS: A cross-sectional study was conducted on pregnancies affected by Hb Bart's disease and non-anemic fetuses between 16 and 22 weeks of gestation. Placental tissue and maternal blood for PBMCs were collected after pregnancy termination for determination of oxidative stress and mitochondrial function. RESULTS: A total of 18 pregnancies affected by Hb Bart's disease and 12 non-anemic fetuses were enrolled. Placental thickness was significantly greater (p-value <0.001) in the affected pregnancies, whereas all Doppler indices of uteroplacental blood flow were comparable. Mitochondrial dysfunction was significantly increased (p-value <0.001) in the placenta of the affected fetuses. In the mothers of affected fetuses, there was an increase in mitochondrial oxidative stress levels with a significant increase in mitochondrial dysfunction in isolated PBMCs (p-value <0.001). DISCUSSION: In the presence of normal uteroplacental Doppler studies, fetal anemia can induce a significant increase in oxidative stress and mitochondrial dysfunction in the placentas and mothers. The findings support that the placenta can be a source of oxidative stress agents which are released into systemic circulation prior to development of maternal adverse outcomes, and may explain pathophysiology of subsequent preeclampsia in late gestation, as commonly seen in pregnancies affected by fetal Hb Bart's disease, if pregnancy is not terminated.

Maternal and congenital human cytomegalovirus infection: laboratory testing for detection and diagnosis.

Human cytomegalovirus (CMV) is the leading cause of congenital infection worldwide and the most common cause of non-genetic sensorineural hearing loss. As there is no vaccine or other specific intervention to prevent congenital CMV infection, there is a need to identify maternal and congenital infections with sensitive and specific testing as early as possible. There is no widely accepted practice for screening during pregnancy or in all newborns for identification of possible cases of congenital CMV. Currently, screening during pregnancy is limited to those identified as at risk followed by fetal and/or neonatal testing when congenital infection is suspected. This review focuses primarily on the current status of laboratory testing for diagnosis of maternal and congenital CMV infections. Primary maternal infection is best diagnosed using serologic testing, including CMV IgM, IgG, and avidity testing, while fetal infection should be assessed by nucleic acid amplification testing (NAAT) of amniotic fluid. Urine and saliva NAATs are the mainstay for diagnosis of congenital CMV in the first 3 weeks of life. Testing of dried blood spots can be useful for diagnosis of congenital CMV outside of the newborn period. The gaps in knowledge such as the prognostic value of viral loads in various sample types are addressed.

Artificial intelligence based cardiotocogram assessment during labor.

OBJECTIVE: To assess whether artificial intelligence, inspired by clinical decision-making procedures in delivery rooms, can correctly interpret cardiotocographic tracings and distinguish between normal and pathological events. STUDY DESIGN: A method based on artificial intelligence was developed to determine whether a cardiotocogram shows a normal response of the fetal heart rate to uterine activity (UA). For a given fetus and given the UA and previous FHR, the method predicts a fetal heart rate response, under the assumption that the fetus is still in good condition and based on how that specific fetus has responded so far. We hypothesize that this method, when having only learned from fetuses born in good condition, is incapable of predicting the response of a compromised fetus or an episode of transient fetal distress. The (in)capability of the method to predict the fetal heart rate response would then yield a method that can help to assess fetal condition when the obstetrician is in doubt. Cardiotocographic data of 678 deliveries during labor were selected based on a healthy outcome just after birth. The method was trained on the cardiotocographic data of 548 fetuses of this group to learn their heart rate response. Subsequently it was evaluated on 87 fetuses, by assessing whether the method was able to predict their heart rate responses. The remaining 43 cardiotocograms were segment-by-segment annotated by three experienced gynecologists, indicating normal, suspicious, and pathological segments, while having access to the full recording and neonatal outcome. This future knowledge makes the expert annotations of a quality that is unachievable during live interpretation. RESULTS: The comparison between abnormalities detected by the method (only using past and present input) and the annotated CTG segments by gynecologists (also looking at future input) yields an area under the curve of 0.96 for the distinction between normal and pathological events in majority-voted annotations. CONCLUSION: The developed method can distinguish between normal and pathological events in near real-time, with a performance close to the agreement between three gynecologists with access to the entire CTG tracing and fetal outcome. The method has a strong potential to support clinicians in assessing fetal condition in clinical practice.