Comparison of maternal and fetal complications in pregnant women with breech presentation undergoing spontaneous or induced vaginal delivery, or cesarean delivery.

OBJECTIVE: Breech presentation is the most common form of malpresentation, and associated with perinatal asphyxia and mortality, and maternal morbidity. Data associated with labor induction in breech presentation are limited. The aim of this study was to compare maternal and fetal complication rates in induced and spontaneous vaginal, and cesarean delivery with breech presentation. MATERIALS AND METHODS: Pregnant women with breech presentation were grouped: spontaneous vaginal delivery (Group 1, n = 72) induced or augmented vaginal delivery (Group 2, n = 32), and cesarean delivery (Group 3, n = 253). Fetal complications were as follows: clavicle fracture, femur fracture, humerus fracture, brachial plexus injury, cephalic hematoma, pneumothorax, need for intensive care unit (ICU), and 5th minute APGAR <7. Maternal complications were as follows: vaginal hematoma, deep vaginal laceration, perineal injury (≥3rd degree), decline in hemoglobin level (>2 g/dL), and postpartum endometritis. Data were collected and analyzed retrospectively. RESULTS: The highest fetal complication rate was in Group 2, and the lowest in Group 3 (p = 0.001). Clavicle fracture was significantly less in Group 3 compared with the other groups (p = 0.024). The rate of lower APGAR scores at the 5th minute was similar in all groups. Maternal complications were significantly higher in Group 2 compared with the other groups (p = 0.001). Fetal complications were 5.66-fold higher in Group 1 than in Group 3 (p = 0.002). Fetal and maternal complications were 9.48-fold and 7.48-fold higher, respectively, in Group 2 than in Group 3 (p < 0.001). CONCLUSION: This study is the first in literature to have investigated and analyzed neonatal complications in breech delivery according to different delivery modes including induced vaginal delivery. Due to possible complications, the risks and benefits of a specific type of delivery should be considered in breech presentation.

Management of Intracranial Hemorrhage and Skull Fracture After Blunt Intrauterine Trauma.

BACKGROUND: Fetal trauma during pregnancy can have a significant impact on the developing brain. Fetal trauma can lead to several intracranial pathologies including hypoxic-ischemic injury, skull fractures, and intracranial hemorrhages. Blunt trauma to a fetus resulting in the need for neurosurgical intervention is a rare occurrence and seldom described in the literature. CASE DESCRIPTION: Here we present the case of a 28-year-old, 36-week pregnant woman who was brought to the hospital by ambulance following a high-speed motor vehicle collision as the restrained driver. On computed tomography of the abdomen, the fetus was found to have a left-sided skull fracture with intracranial hemorrhage. The fetus was emergently delivered by way of caesarean section for lack of fetal movement and indeterminate heart tracings. Postnatally, the neonate had a Glasgow Coma Scale of 7. A postnatal head computed tomography better defined the skull fractures and multiple areas of intracranial hemorrhage. The baby was taken to the operating room for evacuation of the hematomas. At 16 months of age, the baby was well with only mild developmental delay, although a ventriculoperitoneal shunt was needed in a delayed fashion at 3 months of age. CONCLUSIONS: We present a rare situation where emergent caesarean section delivery followed by neonatal craniotomy was necessary. Our case illustrates that good outcomes can be achieved with rapid identification of fetal intracranial injury and intervention.

Implementation of a multidisciplinary perinatal emergency response team improves time to definitive obstetrical evaluation and fetal assessment.

BACKGROUND: Trauma is the leading cause of nonobstetric death during pregnancy and is associated with an increased risk of maternal and fetal mortality. In an effort to improve the delivery of care to pregnant trauma patients, we developed an institutional multidisciplinary quality initiative designed to improve response times of nontrauma specialists and ensure immediate availability of resources. We hypothesized that implementation of a perinatal emergency response team (PERT) would improve time to patient and fetal evaluation and monitoring by the obstetrics (OB) team and improve both maternal and fetal outcomes. METHODS: We performed a 6-year (2012-2018) retrospective cohort analysis of consecutive pregnant trauma patients presenting to our university-affiliated, level I trauma center. Patients in the pre-PERT cohort (before April 2015) were compared with a post-PERT cohort. Variables analyzed included patient demographics, mechanism of injury, Injury Severity Score, and level of trauma activation. The main outcome measure was time to OB evaluation. Secondary outcomes included time to cardiotocometry, and mortality. RESULTS: Of 92 pregnant trauma patients, there were 50 patients (54.3%) in the pre-PERT cohort and 42 (45.7%) in the post-PERT group. Blunt injuries predominated (98.9%), with the most common mechanism being motor vehicle collisions (76.1%), followed by assaults (13%) and falls (6.5%). The mean time to obstetrical evaluation was 44 minutes in the pre-PERT cohort compared with 14 minutes in the post-PERT cohort (p = 0.001). There was a significant decrease in level I (highest acuity) trauma activations pre-PERT and post-PERT (46% vs. 21%, p = 0.01), and the time to cardiotocography was significantly decreased post-PERT implementation (72 vs. .37 min, p = 0.01) CONCLUSION: Implementation of a multidisciplinary PERT improves time to evaluation by the OB team and time to cardiotocometry in the pregnant trauma patient. LEVEL OF EVIDENCE: Retrospective review, level IV.

Secondary maternal-fetal consequences to electrical injury: A literature review.

Electrical injuries can occur in pregnant women but currently their incidence is not completely known. Notwithstanding, those represent clinical important events such maternal and fetal death, which can be avoided if properly managed. The objective of this paper is to describe the results of electrical injury (high and low voltage), in pregnant women in scientific reports. A systematic search was performed with keywords "electrical injuries", "lightning injuries", "lightning strike", "pregnant women" and "pregnancy", using the databases: MedLine, Scielo, Lilacs, Clinical key, Web of Science, Scopus, Springer, Science Direct, Embase and Medic Latina. Filters like language, time, design and availability of text were not used. Descriptive analyses were carried out for variables such as maternal-fetal consequences, voltage and type of exposure, based on the reports identified. From the total 74 cases identified, 71.1% survived after the exposition. From the total live-births 28.6% did not show any alteration, 7.1% presented maceration and burns, while 64.3% had another outcome. Electric injury leads to fetal compromise and death in exposed pregnant women, mainly in the first hours after the injury. However, monitoring should be continued for the risk of complications such as placenta abruption, oligohydramnios and fetal distress. It is possible an underreporting of these events.

Factors associated with the severity of neonatal subgaleal haemorrhage following vacuum assisted delivery.

OBJECTIVE: To evaluate factors associated with subgaleal hemorrhage (SGH) severity following attempted vacuum-assisted delivery (VAD). STUDY DESIGN: This retrospective cohort study was conducted in a tertiary medical center. The population comprised parturients who delivered at our medical center during 2009-2018, and who underwent attempted VAD with singleton pregnancies that resulted in neonatal SGH formation. SGH severity was classified as mild and non-mild (moderate or severe). The main outcome measures were determinants associated with SGH severity. RESULTS: Among 350 neonates with SGH, the degree of severity was non-mild for 48 (13.7%). Compared to the mild group, in the non-mild group, small for gestational age was more common (8.2% vs. 2.6%, p = 0.04). Compared to the mothers in the mild group, in the non-mild group, the proportion with two or more deliveries was lower (0% vs. 7.3%, p = 0.05), gestational diabetes was more common (12.5% vs. 4.6%, p = 0.02), the rate of cervical ripening was higher (27.1% vs. 12.9%, p = 0.02), the duration of the second stage of delivery was longer (mean 177 vs. 152 min, p = 0.04), and the rate of two dislodgments was higher (31.2% vs. 15.2%, p = 0.006). On multivariate analysis, only cervical ripening (adjusted odds ratio [OR]: 2.50; 95% confidence interval [CI]: 1.20-5.26; P = 0.01 and second stage duration (adjusted OR: 1.13; 95% [CI]: 1.00-1.29; P = 0.05) were independently associated with more severe SGH. CONCLUSIONS: The duration of second stage and ripening of the cervix during induction of labor are independently associated with SGH severity following attempted VAD.

Intrauterine big toenail imprints: A new cause of congenital skin dimples.

Congenital skin dimples (SD) are small cutaneous depressions that can be noted on any part of the body and may be caused by traumatic, mechanical, metabolic, and genetic factors as well as by exposure to infections or drugs. We describe 3 cases of unrelated healthy newborns displaying SD and discuss as a possible explanation the persistent friction of the big toenail onto the immature skin of the fetus during intrauterine life causing as depression in the skin.

Myelomeningocele sac associated with worse lower-extremity neurological sequelae: evidence for prenatal neural stretch injury?

OBJECTIVE: To determine whether the presence of a myelomeningocele (MMC) sac and sac size correlate with compromised lower-extremity function in fetuses with open spinal dysraphism. METHODS: A radiology database search was performed to identify cases of MMC and myeloschisis (MS) diagnosed prenatally in a single center from 2013 to 2017. All cases were evaluated between 18 and 25 weeks. Ultrasound reports were reviewed for talipes and impaired lower-extremity motion. In MMC cases, sac volume was calculated from ultrasound measurements. Magnetic resonance imaging reports were reviewed for hindbrain herniation. The association of presence of a MMC sac and sac size with talipes and impaired lower-extremity motion was assessed. Post-hoc analysis of data from the multicenter Management of Myelomeningocele Study (MOMS) randomized controlled trial was performed to confirm the study findings. RESULTS: In total, 283 MMC and 121 MS cases were identified. MMC was associated with a lower incidence of hindbrain herniation than was MS (80.9% vs 100%; P < 0.001). Compared with MS cases, MMC cases with hindbrain herniation had a higher rate of talipes (28.4% vs 16.5%, P = 0.02) and of talipes or lower-extremity impairment (34.9% vs 19.0%, P = 0.002). Although there was a higher rate of impaired lower-extremity motion alone in MMC cases with hindbrain herniation than in MS cases, the difference was not statistically significant (6.6% vs 2.5%; P = 0.13). Among MMC cases with hindbrain herniation, mean sac volume was higher in those associated with talipes compared with those without talipes (4.7 ± 4.2 vs 3.0 ± 2.6 mL; P = 0.002). Review of the MOMS data demonstrated similar findings; cases with a sac on baseline imaging had a higher incidence of talipes than did those without a sac (28.2% vs 7.5%; P = 0.007). CONCLUSIONS: In fetuses with open spinal dysraphism, the presence of a MMC sac was associated with fetal talipes, and this effect was correlated with sac size. The presence of a larger sac in fetuses with open spinal dysraphism may result in additional injury through mechanical stretching of the nerves, suggesting another acquired mechanism of injury to the exposed spinal tissue. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Hoyuelos cutáneos tras amniocentesis traumática / Skin dimpling due to traumatic amniocentesis

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Implications of Prenatal Exposure to the Spring 2011 Alabama and Missouri Tornadoes on Birth Outcomes.

OBJECTIVE: Despite emerging evidence of the detrimental effects of natural disasters on maternal and child health, little is known about exposure to tornadoes during the prenatal period and its impact on birth outcomes. We examined the relationship between prenatal exposure to the spring 2011 tornado outbreak in Alabama and Joplin (Missouri) and adverse birth outcomes. METHODS: We conducted a retrospective, cross-sectional cohort study using the 2010-2012 linked infant births and deaths data set from the National Center for Health Statistics for tornado-affected counties in Alabama (n=126,453) and Missouri (Joplin, n=6,897). Chi-square and logistic regression analyses were performed to estimate associations between prenatal exposure to tornadoes and birth outcomes. RESULTS: Prenatal exposure to the tornado incidents did not influence birth weight outcomes. Women exposed to Alabama tornadoes were less likely to have a preterm birth compared to unexposed mothers (OR: 0.93, 95% CI: 0.91, 0.96). Preterm births among Joplin-tornado exposed mothers were slightly higher (13%) compared with unexposed mothers (11.2%). Exposed mothers from Joplin were also more likely to have a cesarean section compared to their counterparts (OR: 1.14, 95% CI: 1.02, 1.26). CONCLUSIONS: We found no association between tornado exposure and adverse birth weight and infant mortality rates. Our findings suggest that prenatal exposure can amplify the odds for a cesarean section. (Disaster Med Public Health Preparedness. 2019;13:279-286).

Análisis de los determinantes sociales de la salud en el maltrato prenatal en Cataluña / Analysis of social health factors that determine prenatal abuse in Catalonia

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Respuesta de los autores: Análisis de los determinantes sociales de la salud en el maltrato prenatal en Cataluña / Authors reply: Analysis of social health factors that determine prenatal abuse in Catalonia

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Role for Cystathionine γ Lyase (CSE) in an Ethanol (E)-Induced Lesion in Fetal Brain GSH Homeostasis.

Earlier, we reported that gestational ethanol (E) can dysregulate neuron glutathione (GSH) homeostasis partially via impairing the EAAC1-mediated inward transport of Cysteine (Cys) and this can affect fetal brain development. In this study, we investigated if there is a role for the transulfuration pathway (TSP), a critical bio-synthetic point to supply Cys in E-induced dysregulation of GSH homeostasis. These studies utilized an in utero E binge model where the pregnant Sprague⁻Dawley (SD) rat dams received five doses of E at 3.5 g/kg by gastric intubation beginning embryonic day (ED) 17 until ED19 separated by 12 h. The postnatal day 7 (PN7) alcohol model employed an oral dosing of 4 g/kg body weight split into 2 feedings at 2 h interval and an iso-caloric and iso-volumic equivalent maltose-dextrin milk solution served as controls. The in vitro model consisted of cerebral cortical neuron cultures from embryonic day (ED) 16⁻17 fetus from SD rats and differentiated neurons from ED18 rat cerebral cortical neuroblasts. E concentrations were 4 mg/mL. E induced an accumulation of cystathionine in primary cortical neurons (PCNs), 2nd trimester equivalent in utero binge, and 3rd trimester equivalent PN7 model suggesting that breakdown of cystathionine, a required process for Cys supply is impaired. This was associated with a significant reduction in cystathionine γ-lyase (CSE) protein expression in PCN (p < 0.05) and in fetal cerebral cortex in utero (53%, p < 0.05) without a change in the expression of cystathionine ß-synthase (CBS). Concomitantly, E decreased Cse mRNA expression in PCNs (by 32% within 6 h of exposure, p < 0.05) and in fetal brain (33%, p < 0.05). In parallel, knock down of CSE in differentiated rat cortical neuroblasts exaggerated the E-induced ROS, GSH loss with a pronounced caspase-3 activation and cell death. These studies illustrate the importance of TSP in CSE-related maintenance of GSH and the downstream events via Cys synthesis in neurons and fetal brain.

Análisis del maltrato prenatal en Cataluña entre los años 2011 y 2014 / Analysis of prenatal abuse in catalonia between the years 2011 and 2014

Introducción: El maltrato prenatal es aquel acto intencionado o negligente que causa un efecto nocivo al feto. Es un tipo de maltrato difícil de diagnosticar y manejar. Algunos indicadores de sospecha son la ausencia de control gestacional, el consumo materno de tóxicos o la problemática social del entorno materno. Objetivo: Analizar los casos de maltrato prenatal registrados en Cataluña entre 2011 y 2014 para identificar el perfil de riesgo. Métodos: Estudio descriptivo de corte transversal de una muestra de 222 casos de maltrato prenatal registrados en Cataluña entre 2011 y 2014. Resultados: La edad media materna fue de 28,11 años. El 63% de los casos eran de nacionalidad española, un 76% estaba sin trabajo, el 60% no había seguido un correcto control gestacional, un 76% tenía interrupciones de embarazo previas, un 20% manifestaba haber sido maltratada por la pareja. Fueron frecuente los antecedentes de problemática social (76% intervención social; 30,5% retenciones de hijos previos; 13% tutela de la madre por la administración; 7% privación de libertad), con tasas elevadas de infección por enfermedades de transmisión vertical (VIH 4,95%, VHC 9%, coinfección VIH + VHC 1,8%), el 73% manifestó consumo de tóxicos (por orden de frecuencia cannabis, cocaína y heroína). En los neonatos, destacó el alto índice de prematuridad (26,3%) y el diagnóstico de síndrome de abstinencia en 34 casos. En el 51,6% el hijo está en la actualidad con su madre. Conclusiones: En nuestra población de referencia con diagnóstico de maltrato prenatal destacan unos índices elevados de consumo materno de tóxicos, infección por VIH-VHC, desempleo, antecedentes de intervención social previa y mal control gestacional (AU)

Introduction: Foetal abuse is that intentional or negligent act that causes a harmful effect to the foetus. It is a type of abuse difficult to diagnose and handle. Some indicators of suspicion are the absence of gestational control, the maternal consumption of toxic substances, or the problematic maternal social environment. Objective: To analyse the cases of foetal abuse registered in Catalonia between 2011 and 2014 to identify the risk profile. Methods: A cross-sectional descriptive study was conducted on a sample of 222 cases of prenatal abuse registered in Catalonia between 2011 and 2014. Results: The mean maternal age was 28.11 years, with 63% of Spanish nationality, 76% were unemployed, 60% had not followed correct gestational control, 76% had previous pregnancy interruptions, 20% reported to have been mistreated by the partner, had history of social problems (76% social intervention, 30.5% previous child retention, 13% custody of the mother by the administration, 7% deprivation of liberty), with high rates of mother-to-child transmission of infection (HIV 4.95%, HCV 9%, HIV + HCV co-infection 1.8%), and 73% reported toxic use (in order of frequency, cannabis, cocaine and heroin). In newborns, the rate of prematurity (26.3%) is highlighted, as well as the diagnosis of withdrawal syndrome in 34 cases. Just over half (51.6%) of the infants are currently with their mother. Conclusions: In our reference population with a diagnosis of prenatal abuse, there are high rates of maternal toxic consumption, HIV-HCV infection, unemployment, history of previous social intervention, and poor gestational control (AU)

Treatment of Autoimmune Bullous Disorders in Pregnancy.

Autoimmune bullous diseases (AIBD), including pemphigus, bullous pemphigoid, epidermolysis bullosa acquisita, mucous membrane pemphigoid, and pemphigoid gestationis, pose significant therapeutic challenges, especially in pregnant and post-partum breastfeeding patients or those planning to conceive. Data on the safety and efficacy of therapeutic interventions during the perinatal period are lacking because randomized controlled trials are typically not performed in this setting. However, many of the treatments for AIBD are also used in other diseases, so data can be extrapolated from studies or case reports in these other patient populations. It appears that many of the treatments for AIBD can adversely affect the fetus or neonate, and alterations in immune status caused by pregnancy-associated hormonal changes can negatively impact disease control. This article summarizes and weighs the risks and benefits of the various agents used to treat AIBD during pregnancy. We also present the available information on lactation as well as effects on male fertility.

Fetal brain imaging following laser surgery in twin-to-twin surgery.

OBJECTIVE: To describe the incidence and nature of prenatal brain damage following fetoscopic laser selective coagulation (FLSC) of placental vessels for twin-to-twin transfusion syndrome (TTTS). DESIGN: Retrospective observational study. SETTING: Single center cohort. POPULATION: All consecutive cases referred for TTTS treated by FLSC between 2003 and 2015. METHODS: After the FLSC, patients were followed weekly by ultrasound. Fetal magnetic resonance imaging (MRI) scans were systematically planned at 30-32 weeks of gestation. MAIN OUTCOME MEASURES: Brain damage diagnosed prenatally by ultrasound or MRI. RESULTS: In total, 1023 cases were reviewed. Brain damage was diagnosed prenatally in 22/1023 (2.1%) cases. Diagnosis was performed by ultrasound prior to MRI in 18 (82%) cases. All lesions were within the spectrum of ischaemic haemorrhagic lesions. Postoperative twin anaemia polycythaemia sequence and recurrence of TTTS were significantly associated with brain damage. CONCLUSION: The incidence of prenatal brain damage is low following FSLC, and is strongly associated with incomplete surgery. TWEETABLE ABSTRACT: Following FSLC for TTTS, prenatal brain damage occurs in 2% of cases and is associated with incomplete surgery.

[Analysis of prenatal abuse in catalonia between the years 2011 and 2014]. / Análisis del maltrato prenatal en Cataluña entre los años 2011 y 2014.

INTRODUCTION: Foetal abuse is that intentional or negligent act that causes a harmful effect to the foetus. It is a type of abuse difficult to diagnose and handle. Some indicators of suspicion are the absence of gestational control, the maternal consumption of toxic substances, or the problematic maternal social environment. OBJECTIVE: To analyse the cases of foetal abuse registered in Catalonia between 2011 and 2014 to identify the risk profile. METHODS: A cross-sectional descriptive study was conducted on a sample of 222 cases of prenatal abuse registered in Catalonia between 2011 and 2014. RESULTS: The mean maternal age was 28.11 years, with 63% of Spanish nationality, 76% were unemployed, 60% had not followed correct gestational control, 76% had previous pregnancy interruptions, 20% reported to have been mistreated by the partner, had history of social problems (76% social intervention, 30.5% previous child retention, 13% custody of the mother by the administration, 7% deprivation of liberty), with high rates of mother-to-child transmission of infection (HIV 4.95%, HCV 9%, HIV+HCV co-infection 1.8%), and 73% reported toxic use (in order of frequency, cannabis, cocaine and heroin). In newborns, the rate of prematurity (26.3%) is highlighted, as well as the diagnosis of withdrawal syndrome in 34 cases. Just over half (51.6%) of the infants are currently with their mother. CONCLUSIONS: In our reference population with a diagnosis of prenatal abuse, there are high rates of maternal toxic consumption, HIV-HCV infection, unemployment, history of previous social intervention, and poor gestational control.

A Rare Fetal Firearm Injury.

Firearm injury (FAI) in pregnant women is reported in the literature; however, no reference to date was found to address the neonatal abdominal surgery performed after maternal FAI. FAI during fetal life is extremely rare and very few cases have been reported. We present a report of a 37-week gestation newborn whose mother had an accidental FAI. The neonate was delivered by emergency caesarian section along with emergency laparotomy of the newborn. The baby presented at eight hours of life, who was managed surgically in emergency for multiple small and large bowel perforations and a piece of bullet was recovered from anterior part of thigh.

Blunt prenatal trauma resulting in fetal epidural or subdural hematoma: case report and systematic review of the literature.

Blunt prenatal trauma is known to have consequences to the developing brain, and can result in subdural hematoma (SDH) or epidural hematoma (EDH). The authors present a case of blunt prenatal trauma resulting in a fetal SDH, intraparenchymal hematoma, and intraventricular hemorrhage, and perform a systematic review of the literature. This systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Relevant studies (up to April 2016) that reported on cases of fetal SDH or EDH after blunt prenatal trauma were identified from the PubMed database. The primary outcome was fetal mortality, and the secondary outcome was neurological outcome. Fourteen studies were included in the analysis, comprising a total of 14 patients including the present case. The average gestational age at discovery of hemorrhage was 30.1 weeks. Nine mothers were in a motor vehicle collision and 3 were assaulted; the mechanism of injury for 2 mothers was not defined. Twelve patients had SDH, 1 had EDH, and 1 had conflicting reports. Three patients had intrauterine fetal demise, and 3 died in the neonatal period after birth. Three patients had persistent neurological deficit, and 5 were neurologically intact. Fetal SDH or EDH after blunt trauma to the mother trauma is rare and is associated with mortality. However, a significant number of patients can have good neurological outcomes.