Amnioreduction vs expectant management in pregnancies with moderate to severe polyhydramnios

Amnioreduction safety in singleton pregnancies; systematic review and meta-analysis

OBJECTIVES

Prenatal ultrasound identifies polyhydramnios in approximately 0.7 % of pregnancies. Polyhydramnios (defined as amniotic fluid index >24 cm) is associated with maternal symptoms and preterm delivery. However, amnioreduction (AR) can effectively alleviate symptoms and reduce preterm delivery risks; its advantages remain controversial. This study aims to assess maternal safety following AR in singleton pregnancies systematically.

METHODS

Databases searched included PubMed, Embase, Scopus, and Web of Science until April 2024. Pregnant patients with singleton pregnancy and polyhydramnios undergo AR included in our study. Statistical analyses were conducted using R software.

RESULTS

From 574 initially identified articles, seven studies with 390 singleton pregnancies who underwent AR were included. The primary outcomes showed low odds of placental abruption 0.04 (95 % CI: 0.02-0.09, I 2 =12 %) and chorioamnionitis 0.03 (95 % CI: 0.01-0.08, I 2 =0 %). Secondary outcomes indicated a mean gestational age at birth of almost 36 weeks (95 % CI: 35.51-36.41, I 2 =49 %) and low odds of cesarean delivery 0.45 (95 % CI: 0.30-0.61, I2=58 %), preterm delivery within 48 h after AR 0.10 (95 % CI: 0.07-0.15, I 2 =9 %) and PPROM within 48 h after AR 0.03 (95 % CI: 0.02-0.04, I 2 =0 %).

CONCLUSIONS

This study demonstrates that maternal complications are expected to be low following the AR procedure. However, given the lack of evidence for fetal benefit and pregnancy prolongation, future studies should directly compare the effects of AR with expectant management. Additionally, fetal survival is likely influenced more by the underlying fetal diagnosis or the etiology of polyhydramnios rather than AR itself. The current meta-analyses will serve as a guide for shared decision-making, and highlight the need for continued clinical trials powered to establish superiority or benefit with AR for singleton pregnancies.

Predicting purulent meningitis in very preterm infants: a novel clinical model

BACKGROUND

Purulent meningitis (PM) is a commonly encountered infectious condition in newborns, which unfortunately can result in infant mortality. Newborns with PM often present nonspecific symptoms. The success of lumbar puncture, an invasive test, relies on the operator's expertise. Preterm infants pose diagnostic challenges compared to full-term babies. The objective of this study is to establish a convenient and effective clinical prediction model based on perinatal factors to assess the risk of PM in very preterm infants, thereby assisting clinicians in developing new diagnostic and treatment strategies.

METHODS

This study involved very preterm infants (gestational age < 32 weeks) admitted to the Qilu Hospital of Shandong University from January 2020 to December 2023. All included infants underwent lumbar puncture. We gathered comprehensive data that included information on maternal health conditions and the clinical features of very preterm infants. The PM was diagnosed according to the diagnostic criteria. This study conducted data analysis and processing using R version 4.1.2. A stepwise regression method was applied for multivariate Logistic regression analysis to select the best predictors for PM and to develop a predictive model. Differences were considered statistically significant at P < 0.05.

RESULTS

This study enrolled a total of 201 preterm infants, including 117 boys and 84 girls. The gestational age was 28.7 ± 1.7 weeks, and the weight was 1166.2 ± 302.7 g. Ninety infants were diagnosed with PM, while 111 did not have PM. The influencing factors include birth weight, PCT within 24 h after birth, cesarean delivery, and premature rupture of membranes. These were used to construct a risk prediction nomogram and verified its accuracy. The Brier score was 0.157, the calibration slope was 1.0, and the concordance index was 0.849.

CONCLUSIONS

We developed and validated a personalized nomogram to identify high-risk individuals for early prediction of purulent meningitis in very preterm infants. This practical predictive model may help reduce unnecessary lumbar puncture procedures.

Too Much of a Good Thing: Updated Current Management and Perinatal Outcomes of Polyhydramnios

Amniotic fluid assessment is crucial in prenatal ultrasound to monitor fetal conditions, with polyhydramnios, characterized by excessive amniotic fluid, affecting 1%-2% of pregnancies. Polyhydramnios is linked to complications such as placental abruption, preterm labor, congenital anomalies, and postpartum hemorrhage, emphasizing the need for early detection and management. While idiopathic causes account for 60%-70% of cases, other causes include impaired fetal swallowing and increased urine production due to maternal, fetal, and placental conditions. Accurate amniotic fluid volume (AFV) assessment and surveying the underlying cause are important, with ultrasound methods such as deep vertical pocket (DVP) and amniotic fluid index (AFI) preferred. Polyhydramnios is defined by an AFV exceeding 2000 ml, an AFI over 24 cm, or DVP more than 8 cm. Management typically targets underlying causes, with treatments such as amnioreduction and indomethacin for severe cases. Antepartum monitoring includes detailed fetal ultrasound, genomic and genetic examinations, and tests for maternal diabetes and infections. Intrapartum management addresses complications such as malpresentation and shoulder dystocia, whereas postpartum care involves monitoring for uterine atony and hemorrhage. Perinatal outcomes in idiopathic polyhydramnios are generally poorer, with increased risks of fetal demise, preterm delivery, and neonatal complications, but these results may need further stratification and verification.

Prenatal diagnostic and intervention considerations in congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is a life-threatening birth defect with significant morbidity and mortality. The prenatal management of a pregnancy with a fetus affected with CDH is complex and requires a multi-disciplinary team approach. An improved understanding of prenatal diagnosis and management is essential to developing strategies to optimize outcomes for these patients. In this review, we explore the current knowledge on diagnosis, severity stratification, prognostic prediction, and indications for fetal intervention in the fetus with CDH.

Amnioreduction for Polyhydramnios in a Consecutive Series at a Single Center: Indications, Risks and Perinatal Outcomes

Pregnancies complicated by severe polyhydramnios are associated with a high rate of underlying fetal anomaly. Amnioreduction may be offered to alleviate maternal symptoms. This is a retrospective study of amnioreductions performed on singleton and twin gestations complicated by symptomatic polyhydramnios between 2010 and 2023 at our tertiary referral center. The indications, procedural techniques and pregnancy and neonatal outcomes were retrieved from an archive database and reviewed with the use of the maternal and child medical record chart, the hospital electronic clinical discharge report and telephone recalls. Our study comprised 86 pregnancies, 65 singletons and 21 twin pregnancies. Fetal anomalies were identified in 79% of cases, mainly gastrointestinal obstructive anomalies; 9.3% of cases were idiopathic. The median gestational age at first amnioreduction was 32.5 weeks, and peri-procedural complications were rare (1 case of placental abruption and 2 cases of preterm delivery). The median gestational age at delivery was 36.5 weeks, with a median prolongation of the pregnancy from the time of first drain until birth of 30 days. Preterm labor < 37 weeks occurred in 48.8% of procedures, with 26.7% of patients delivering before 34 weeks and pPROM < 36 weeks recorded in 23.2% of cases. In conclusion, amnioreduction offered to alleviate maternal symptoms is a reasonably safe procedure with a low complication rate. These pregnancies necessitate management in a tertiary referral center because of their need for a multidisciplinary approach both prenatally and postnatally.