The fetal cerebroplacental ratio in pregnancies complicated by hypertensive disorders of pregnancy.

BACKGROUND: Hypertensive disorder in pregnancy is common and the optimal ultrasound surveillance of the fetus in this setting is unclear. AIM: The aim of this study is to assess the relationship between the fetal cerebroplacental ratio (CPR) and perinatal outcomes in pregnancies complicated by maternal hypertension. MATERIALS AND METHODS: A retrospective cohort study was performed over ten years at a single centre. All women who had an ultrasound scan between 34 and 37 weeks gestation with a non-anomalous singleton pregnancy were included. The hypertensive cohorts were compared to a non-hypertensive cohort. Each cohort was divided into low CPR for gestational age, or normal/high CPR and these were correlated with intrapartum and perinatal outcomes. RESULTS: A low CPR in a hypertensive pregnancy is associated with an increased risk of induction of labour, emergency caesarean section and poor perinatal outcome. This significance persists when adjusted for gestational age and birth weight. The diagnosis of pre-eclampsia combined with a low CPR markedly increases the risk of poor perinatal outcome, with 52.6% (P < 0.001) of fetuses in this group having either neonatal intensive care unit admission, respiratory distress, low Apgar score, or acidosis. The odds ratio of a fetus with low CPR in a woman with pre-eclampsia having a poor composite outcome is 4.09 (95% CI: 1.85-9.06). CONCLUSION: There is an association between low CPR and the perinatal outcomes of pregnancies complicated by a hypertensive disorder. This association appears to be stronger in pregnancies complicated by pre-eclampsia than in other types of hypertensive disorders.

The burden of adverse obstetric and perinatal outcomes from maternal smoking in an Australian cohort.

BACKGROUND: Maternal smoking is associated with a number of adverse outcomes with a dose-dependent increase in risk. The aim of this study was to evaluate the obstetric and perinatal outcomes in women who smoked during pregnancy. METHODS: This was a retrospective cohort study of women who smoked during pregnancy and birthed at a major perinatal centre in Australia between January 2000 and April 2017. The study cohort was compared to a cohort of women who did not smoke in pregnancy. Smoking status was ascertained on history and included all types of smoking. Demographic characteristics and obstetric, intrapartum and perinatal outcomes were compared between the two groups. RESULTS: The study cohort included 20 477 (14.6%) women who smoked during pregnancy and 119 396 controls. Women who smoked tended to be younger, of higher body mass index (BMI), Caucasian and Indigenous ethnicity. Smokers were less likely to be nulliparous, but more likely to be hypertensive and have a lower socioeconomic status compared to non-smokers. Women who smoked were more likely to have a caesarean section for non-reassuring fetal status (adjusted odds ratio (aOR) 1.16, 95%CI 1.07-1.26, P < 0.001). The infants of women who smoked were more likely to be born preterm, have a lower median birth weight and birth weights <10th (aOR 1.76, 95%CI 1.66-1.86, P < 0.001) and <5th centile (aOR 2.00, 95%CI 1.86-2.16, P < 0.001). Neonatal outcomes in the smoking cohort were worse with an increase in neonatal intensive care unit admission (aOR 1.34, 95%CI 1.27-1.43, P < 0.001), severe acidosis (aOR 1.41, 95%CI 1.27-1.43, P < 0.001) and a composite of severe neonatal outcomes (18.0% vs 12.0%, aOR 1.35, 95%CI 1.28-1.43, P < 0.001). CONCLUSION: Women who smoke in pregnancy have worse obstetric and perinatal outcomes compared to controls and should be managed as high risk.

Caesarean section improves neonatal outcomes only from 24 + 0 weeks for periviable breech but not for cephalic infants.

Background: Although caesarean delivery at periviable gestations may minimize birth trauma, it may not necessarily improve perinatal outcomes. The aim of this study was to assess the impact of mode of birth on outcomes for breech versus cephalic presentation at 22 + 0-25 + 6 weeks.Methods: Retrospective cohort study of single, nonanomalous infants at 22 + 0-25 + 6 weeks gestation born at a tertiary center in Australia. Neonatal outcomes were analyzed comparing both breech and cephalic presentation and mode of delivery.Results: Six hundred and eighty eight women fulfilled the inclusion criteria with 39.7% (273/688) breech and 60.3% (415/688) cephalic infants. Survival was 31.5% (86/273) and 38.1% (158/415) in the breech and cephalic cohorts respectively. Vaginal breech infants had reduced odds of survival compared to the vaginal cephalic group (aOR 0.37, 95% CI 0.17-0.75, p < .01) with no difference in survival if delivery occurred by caesarean section. Vaginal breech birth had higher odds of very low Apgar scores, stillbirth, and neonatal death. At 22 + 0-22 + 6 weeks, outcomes were universally fatal. At 24 + 0-24 + 6 and 25 + 0-25 + 6 weeks, vaginal breech birth had lower odds of survival (aOR 0.33, 95% CI 0.13-0.84, p < .05 and aOR 0.10, 95% CI 0.03-0.34, p < .001 respectively) compared to caesarean breech births.Conclusions: Caesarean section improves perinatal outcomes for periviable breech infants > 24 + 0 weeks.

Prenatal therapy for fetal cardiac disorders.

Fetal cardiac abnormalities are some of the commonest congenital disorders seen in prenatal life. They can be anatomical or functional and can develop de novo or as a consequence of either maternal or fetal disease. Untreated, morbidity and mortality rates are high for hypoplastic left heart disorders and for some fetal tachy and bradyarrhythmias. Optimum management strategies are often not clear because of the lack of knowledge about the precise natural history of some of these conditions. Prenatal therapy ranges from invasive fetal cardiac intervention to maternal administration of drugs for transplacental transfer to the fetus. This comprehensive review covers many fetal cardiac disorders and various prenatal therapeutic options that are available.

Obstetric and perinatal outcomes in pregnancies with isolated foetal congenital heart abnormalities.

Objective: To determine obstetric, intrapartum, and perinatal outcomes for pregnancies with isolated foetal congenital heart defects (CHDs). Methods: This was a retrospective cohort study of women that delivered an infant with an isolated major CHD between January 2010 and April 2017 at a major Australian perinatal centre. The study cohort was compared with a cohort of women with infants without CHD. Cardiac abnormalities were broadly subdivided into the following five categories using the International Classification of Diseases Tenth Revision (ICD-10) as a guide - transposition of the great arteries (TGA), septal defects, right heart lesions (RHL), left heart lesions (LHL), and "other". Demographic characteristics and obstetric, intrapartum, and perinatal outcomes were compared between the two cohorts. Results: The final study cohort comprised of 342 infants with isolated CHD and 68,911 controls. Of the infants with CHD, 20.4% (70/342) had transposition of the great vessels, 23% (79/342) had septal lesions, 14.6% (50/342) had right sided lesions, 23.3% (80/342) left sided, and 18.4% (63/342) categorised as "other". Women with foetal CHD had a higher BMI and had higher rates of cardiac disease, diabetes mellitus, and hypertension, be smokers and consume alcohol compared to controls. The CHD cohort had lower odds of spontaneous vaginal delivery (SVD) (OR 0.73, 95%CI 0.58-0.90) and higher odds of caesarean for nonreassuring foetal status (aOR 1.65, 95%CI 1.07-2.55), birth weight <5th (aOR 3.44, 95%CI 2.38-4.98) and <10th (aOR 2.49, 95%CI 1.82-3.40) centiles, neonatal intensive care unit (NICU) admission (aOR 109.14, 95%CI 74.44-160.02), severe respiratory distress (aOR 2.90, 95%CI 2.33-3.76), 5 minutes Apgar score <7 (aOR 2.48, 95%CI 1.46-4.20), severe acidosis (aOR 1.80, 95%CI 1.14-2.85), stillbirth (aOR 4.09, 95%CI 1.62-10.33), neonatal death (aOR 24.30, 95%CI 13.24-44.61), and overall perinatal death (aOR 13.42, 95%CI 8.08-22.30). Infants with TGA had the lowest overall risk of complications whilst infants with RHL, LHL, and "others" had the highest risk of adverse outcomes, particularly death. Conclusion: Infants with CHD have overall worse obstetric and perinatal outcomes compared with controls. Infants with TGA have the best perinatal outcomes of all the CHD subcategories.