Polyhydramnios: Causes, Diagnosis and Therapy

Hypotonia in the Neonatal Intensive Care Unit

Hypotonia is a common presenting symptom in the neonatal intensive care unit (NICU). Hypotonia can be a manifestation of an underlying systemic illness, a primary nervous system disease, or a peripheral nervous system disease. Examination and history can suggest specific causes, but rapid and accurate diagnosis remains challenging due to the broad spectrum of causes. Options for disease-targeted therapies have increased the importance of early diagnosis. This article focuses on the evaluation and diagnostic approach of the hypotonic newborn in the NICU, with an emphasis on rapid identification of treatable conditions and updated recommendations on the utilization of genetic testing.

Causes, management and outcomes of polyhydramnios at a secondary level hospital in Cape Town, South Africa

INTRODUCTION

Polyhydramnios is associated with both maternal and fetal adverse outcomes. Idiopathic polyhydramnios, regardless of its severity category, was considered not to be associated with an increase in adverse outcomes. In contrast, when conditions such as congenital and chromosomal abnormalities or diabetes mellitus are detected, neonatal and maternal adverse outcomes can be up to five times higher. We thus aimed to document the outcomes of patients with mild, moderate and severe polyhydramnios according to whether an underlying cause was found and which management protocol was followed.

METHODOLOGY

We conducted a retrospective cohort study of all patients with polyhydramnios on ultrasound examination at our secondary hospital between January 1, 2018 and December 31, 2020. Hospital folders were reviewed. We recorded demographic data, information on underlying causes, management and outcomes. We summarised categorical variables using count (percentage). We tested the association between categorical variables using the chi-square test. Statistical significance was set at p < 0.05.

RESULTS

A total of 136 patients with polyhydramnios (80 mild, 42 moderate, and 14 severe) were included. Most cases of polyhydramnios were idiopathic regardless of category [81.2% (65/80), 78% (32/42) and 78% (11/14) in the mild, moderate and severe groups, respectively]. The likelihood of occurrence of the composite adverse outcome, was higher with increasing severity of polyhydramnios, with 6.75%. 19.05%, and 35.71% in the mild, moderate and severe groups, respectively, having the composite adverse outcome (p =  0.01). Elective delivery before 40 weeks' gestation for polyhydramnios in patients with idiopathic polyhydramnios was associated with a significant reduction in the occurrence of the composite adverse outcome compared to awaiting spontaneous labor (3.77% versus 15.79%, p =  0.036),.

CONCLUSIONS

Adverse outcomes were related to severity of the polyhydramnios and were significantly lower in the mild compared to the moderate and severe groups, with the rate of adverse outcome in the mild group comparable to that of the general population. Early delivery before 40 weeks gestation may be associated with benefit in moderate and severe groups of polyhydramnios.

Maternal health and obstetric complications of genetic neuromuscular disorders in pregnancy: A systematic review

BACKGROUND

Genetic neuromuscular disorders affect muscle function and control by the nervous system, presenting significant clinical challenges, particularly during pregnancy.

OBJECTIVES

To systematically review the literature on the obstetric outcomes and complications in women with genetic neuromuscular disorders.

SEARCH STRATEGY

We searched PubMed/Medline, Scopus, and CINAHL Ultimate from inception till June 2024 using terms like "pregnancy", "genetic neuromuscular disorder", "myotonic dystrophy", "maternal health" etc. SELECTION CRITERIA: Pregnant women with genetic neuromuscular disorders.

DATA COLLECTION AND ANALYSIS

Screening, selection, and data extraction were performed independently by two reviewers.

MAIN RESULTS

A total of 28 studies from 1978 to 2023 examined pregnancy outcomes in women with genetic neuromuscular disorders. The disorders included myotonic dystrophy, spinal muscular atrophy (SMA), Charcot-Marie-Tooth disease (CMT), and others. Common complications were polyhydramnios, preterm labor, miscarriages, and cesarean sections. Myotonic dystrophy type 1 (DM1) showed higher neonatal risks than type 2 (DM2). Women with SMA faced exacerbated muscle weakness, while CMT and limb-girdle muscular dystrophy were associated with preterm labor and cesarean deliveries. Pompe disease exacerbated symptoms, and GNE myopathy showed similar pregnancy outcomes to the general population. Non-dystrophic myotonias had higher fetal distress and postpartum complications.

CONCLUSIONS

Women with genetic neuromuscular disorders face increased pregnancy complications, including preterm labor, cesarean sections, and disease symptom exacerbation. Multidisciplinary care between neurologists and obstetricians is essential in managing these high-risk pregnancies effectively, ensuring better maternal and neonatal outcomes. Further research is needed to develop standardized care protocols and improve clinical management.

Determinants of preterm prelabor rupture of fetal membrane among pregnant women in Ethiopia: A systematic review and meta-analysis

INTRODUCTION

Ethiopia is one of the countries where persistently high neonatal and maternal mortalities are reported. Preterm prelabor rupture of membrane (PPROM) plays an important contribution to these high mortalities. However, there is a paucity of comprehensive evidence about the epidemiology of PPROM in Ethiopia. Therefore, this systematic review was conducted to assess the pooled prevalence and determinants of PPROM among pregnant women in Ethiopia.

METHODS

A systematic review and meta-analysis were conducted following the PRISMA guideline. Relevant literatures were searched on African Journals Online (AJOL), PubMed, Scopus, Epistemonikos, CINAHL, Cochrane Library and gray literature. All statistical analyses were performed using STATA 17 software. The random effect meta-analysis model was employed to summarize the pooled estimates. Heterogeneity between included studies was evaluated using I2 statistic. Egger's regression test and Begg's correlation test were employed to assess publication bias, in conjunction with funnel plot. Besides, the non-parametric trim-and-fill analysis, sensitivity analysis, subgroup analysis and meta-regression were also performed.

RESULTS

A total of 13 original studies with 24,386 participants were considered in this systematic review. The pooled prevalence of PPROM was 6.58% (95% CI: 5.36, 7.79). Urinary tract infection (OR: 3.44; 95% CI: 1.81, 6.53), abnormal vaginal discharge (OR: 4.78; 95% CI: 2.85, 8.01), vaginal bleeding (OR: 2.04; 95% CI: 1.03, 4.06), history of PROM (OR: 4.64; 95% CI: 2.71, 7.95), history of abortion (OR: 3.06; 95% CI: 1.71, 5.46), malnutrition (OR: 5.24; 95% CI: 2.63, 10.44), anemia (OR: 3.97; 95% CI: 2.01, 7.85) and gestational diabetes (OR: 5.08; 95% CI: 1.93, 13.36) were significantly associated with PPROM.

CONCLUSION

This meta-analysis found a high prevalence of PPROM in Ethiopia. Urinary tract infection, abnormal vaginal discharge, vaginal bleeding, history of PROM, history of abortion, malnutrition, anemia and gestational diabetes were risk factors for PPROM. Prevention and control of antenatal infections and malnutrition are highly recommended to reduce the magnitude of PPROM in Ethiopia. Additionally, healthcare providers should emphasize the identified risk factors.

PROTOCOL REGISTRATION NUMBER

CRD42024536647.

Prenatal diagnosis of 9q34.3 microdeletion-associated Kleefstra syndrome in a pregnancy complicated by polyhydramnios: A case report and literature review

OBJECTIVE

Kleefstra Syndrome (KS) is a rare genetic disorder caused by a deletion at 9q34.3. Studies showed that various heart defects are observed in 41-43% of patients and abnormal features on brain imaging in 58-63%. To date, the prenatal phenotype in KS has yet to be defined.

CASE REPORT

We present the first prenatal diagnosis and chromosomal microarray analysis (CMA) of a case of 9q34.3 microdeletion in a fetus with increased amniotic fluid, supported by abnormal prenatal ultrasound findings, and confirmed via autopsy. CMA revealed a 2.1 Mb 9q34.3 microdeletion encompassing an OMIM gene of EHMT1, which is consistent with the diagnosis of Kleefstra syndrome and 9q subtelomeric deletion syndrome.

CONCLUSION

When a fetus with normal karyotype presents with polyhydramnios or abnormalities noted during second-trimester prenatal ultrasound screening, CMA analysis can be considered as the next step to rule out or confirm the diagnosis of chromosomal or other genetic aberrations.

Plasma Glycated CD59 and Gestational Diabetes Mellitus: A Systematic Review

AIMS

Gestational diabetes mellitus (GDM) is a common complication of pregnancy worldwide. The standard method for screening GDM is the 75 g oral glucose tolerance test (OGTT). However, the OGTT is difficult, time-consuming and requires fasting, making it an inconvenient test for GDM. Researchers have turned their attention to alternative biomarkers for GDM. This study aimed to systematically investigate the potential of plasma glycated CD59 (pGCD59) as a new biomarker for GDM and its associated adverse pregnancy outcomes.

METHODS

The systematic review was performed in the PubMed, ISI Web of Science, Scopus and Google Scholar databases from 1/1/2000 to 4/1/2024, and relevant studies were selected based on the inclusion and exclusion criteria. The quality of the studies was assessed using the Newcastle-Ottawa scale.

RESULTS

The study revealed that pGCD59 levels before 20 weeks and during the second trimester of pregnancy have the potential to predict the results of the OGTT and also forecast adverse pregnancy outcomes, such as postpartum glucose intolerance (PP GI), neonatal hypoglycaemia (NH) and having large for gestational age (LGA) infants. The predictive ability of pGCD59 was found to be affected by the GDM status, especially body mass index (BMI).

CONCLUSIONS

In conclusion, pGCD59 may be a promising indicator of glucose levels and could serve as a new biomarker for GDM. However, additional studies are needed to establish a reliable reference range and cut-off value for pGCD59.

Fetal Teratomas: Advances in Diagnosis and Management

Fetal teratomas, though rare, represent a significant proportion of tumors arising during fetal development. These tumors arise from pluripotent cells and can present in varying degrees of severity, ranging from incidental findings to life-threatening conditions. Prenatal imaging, via ultrasound and MRI, is necessary for diagnosis and risk assessment. The management of fetal teratomas, particularly those associated with complications like hydrops or airway obstruction, often requires a multidisciplinary approach. Interventions such as ex-utero intrapartum treatment (EXIT) procedures and minimally invasive alternatives have emerged as critical tools to improve neonatal outcomes in severe cases. Despite advances in fetal therapies, careful prenatal monitoring and individualized management remain essential, especially for tumors with high vascularity or those that risk compromising cardiac output. This review explores the diagnostic methods, management strategies, and outcomes associated with fetal teratomas, highlighting recent advancements that contribute to improving survival and reducing morbidity in affected neonates.

Genomic abnormalities in apparently isolated polyhydramnios and the role of confirmed fetal phenotype: a systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review and meta-analysis was to assess the rate of genomic abnormalities detected in pregnancies with apparently isolated hydramnios and to explore the role of confirmed fetal phenotype.

DATA SOURCES

The PubMed, Cochrane Library, Google Scholar, and Scopus databases were searched up to May 4, 2024.

STUDY ELIGIBILITY CRITERIA

Observational studies that were published after the year 2000, written in a European language, and that reported the genomic outcomes of pregnancies complicated by prenatally diagnosed isolated polyhydramnios were included in this meta-analysis.

METHODS

The main outcome was the incidence of genomic abnormalities, defined as chromosomal numerical or structural anomalies or monogenic syndromes, that were diagnosed prenatally or postnatally in neonates from pregnancies complicated by isolated polyhydramnios. Additional outcomes included the incidence of chromosomal abnormalities, including both numerical and structural aberrations of the chromosomes (detected by karyotype or chromosomal microarray), monogenic abnormalities (detected by next-generation sequencing or clinical genetic examination after the result of a normal karyotype or chromosomal microarray), genetic syndromes in general (diagnosed clinically with or without genetic confirmation), and structural abnormalities detected postnatally. Pooled proportions were calculated for each outcome.

RESULTS

A total of 12 studies (2561 pregnancies complicated by isolated hydramnios) were included in the meta-analysis. The pooled prevalence of genomic anomalies in fetuses with apparently isolated polyhydramnios (12 studies, 2634 fetuses) was 4.5% (95% confidence interval, 2.6-7.6). The pooled prevalence of chromosomal abnormalities (11 studies, 2427 fetuses) was 2.1% (95% confidence interval, 1.1-3.7). The proportion of major structural defects detected postnatally (9 studies, 1731 fetuses) was 2.9% (95% confidence interval, 1.5-5.4); in this particular subgroup (4 studies, 14 fetuses), the pooled prevalence of genomic anomalies was 29.8% (95% confidence interval, 11.3-58.6). A meta-regression analysis indicated that the rate of genomic anomalies was positively associated with the severity of hydramnios. In addition, the pooled rate of monogenic anomalies was 5.6% (95% confidence interval, 2-5; I2=58%) in the 2 studies that used next-generation sequencing for genomic diagnosis.

CONCLUSION

This meta-analysis showed that the rate of genomic anomalies in apparently isolated polyhydramnios is 4.5%; approximately half of them are chromosomal abnormalities and the other half are nonchromosomal genomic anomalies. From a clinical standpoint, chromosomal microarray analysis and possibly next-generation sequencing could be considered even in cases of apparently isolated polyhydramnios; this may be even more important in cases with incomplete fetal phenotype. Further studies using next-generation sequencing and addressing cost-effectiveness issues would fine-tune such recommendations.

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.

Induction of labor in term pregnancies with isolated polyhydramnios: Is it beneficial or harmful?

OBJECTIVE

To compare rates of adverse pregnancy outcomes in term pregnancies complicated by polyhydramnios between women who had induction of labor (IOB) versus women who had expectant management.

METHODS

This multicenter retrospective study included term pregnancies complicated by isolated polyhydramnios. Patients who underwent IOB were compared with those who had expectant management. The primary outcome was defined as a composite adverse maternal outcome, and secondary outcomes were various maternal and neonatal adverse outcomes. Univariate analyses were followed by multivariate logistic regression.

RESULTS

A total of 865 pregnancies with term isolated polyhydramnios were included: 169 patients underwent IOB (19.5%), while 696 had expectant management and developed spontaneous onset of labor (80.5%). Women who underwent IOB had significantly higher rates of composite adverse maternal outcome (23.1% vs 9.8%, P < 0.01), prolonged hospital stay, perineal tear grade 3/4, intrapartum cesarean, postpartum hemorrhage, blood products transfusion, and neonatal asphyxia compared with expectant management. While the perinatal fetal death rate was similar between the groups (0.6% vs 0.6%, P = 0.98), the timing of the loss was different. Four women in the expectant management group had a stillbirth, while in the induction group one case of intrapartum fetal death occurred due to uterine rupture. Multivariate analyses revealed that IOB was associated with a higher rate of composite adverse maternal outcome (adjusted odds ratio, 2.22 [95% CI, 1.28-3.83]; P < 0.01).

CONCLUSION

IOB in women with term isolated polyhydramnios is associated with higher rates of adverse maternal outcomes in comparison to expectant management. Further research is needed to determine the optimal approach for the management of isolated polyhydramnios at term.

Adverse pregnancy outcomes with respect to treatment modalities in women with gestational diabetes mellitus at a rural tertiary care teaching hospital

Objectives

To estimate the prevalence of gestational diabetes mellitus (GDM) and compare adverse pregnancy outcomes with respect to treatment modalities in a peri-urban teaching hospital in Telangana.

Methods

A prospective study was conducted on GDM cases delivered from January 2019 to March 2020. GDM was diagnosed using a two-step procedure of screening using IADPSG criteria. Women diagnosed with GDM were divided into four groups - diet group, metformin group, metformin plus insulin group and insulin group based on the treatment modalities. Adverse pregnancy outcomes of the women managed with different treatment modalities were recorded.

Results

Good glycaemic control (FBS, P = 0.04, 2 hrs PLBS, P = 0.01) was achieved in diet and metformin groups. Incidence of Gestational hypertension (P = 0.01) and preeclampsia (P = 0.01) were found to be higher in the insulin group when compared to the metformin and insulin group, metformin group and diet group. No difference was noted with respect to polyhydramnios, preterm birth, premature rupture of membranes, induction labour and caesarean delivery rates between the treatment groups. Apgar score at 5 min of <7 (P = 0.02), neonatal intensive care unit admissions for >24 hrs (P = 0.03) and neonatal hypoglycaemia (P = 0.01) were found to be higher in insulin-required groups. Rates of shoulder dystocia, stillbirth, early neonatal death within 1 week and respiratory distress did not vary significantly between the treatment groups.

Conclusion

Universal screening of women for GDM and multidisciplinary management of women once diagnosed tend to lessen maternal and fetal complications. Metformin can be an effective, cheaper and non-invasive alternative to insulin in the management of GDM.

Isolated polyhydramnios in the third trimester or polyhydramnios secondary to late-onset gestational diabetes: is it worth distinguishing?

OBJECTIVE

The aim of this study was to compare pregnancy outcomes of patients with polyhydramnios due to late-onset gestational diabetes mellitus and patients with isolated polyhydramnios.

METHODS

Of the women who fully participated in prenatal examinations at Etlik Lady Zübeyde Hospital between January 1, 2018, and December 31, 2019, women with polyhydramnios of nonfetal-placental origin manifesting in the third trimester were retrospectively reviewed. Women with normal 75-g oral glucose tolerance test results between 24 and 28 weeks gestation who met the inclusion criteria were enrolled in the study and divided into two groups based on the results of rescreening with the 75-g oral glucose tolerance test for polyhydramnios in the third trimester: women with isolated polyhydramnios (group 1) and women with late-onset polyhydramnios due to gestational diabetes mellitus (group 2).

RESULTS

There were a total of 295 participants, of whom 35 (11.8%) were diagnosed with polyhydramnios due to late-onset gestational diabetes mellitus. There were no differences in the main outcomes. Birthweight and gestational age at birth were identified as independent risk factors for predicting composite maternal outcome {[odds ratio (OR)=1.273, 95% confidence interval (CI) 1.063-1.524, p=0.009]} and composite neonatal outcome (OR=0.606, CI 0.494-0.744, p<0.001), respectively.

CONCLUSION

Polyhydramnios in late pregnancy without evidence of pregnancy-related causes leading to polyhydramnios may be a sign of late-onset gestational diabetes mellitus in women with a normal prior oral glucose tolerance test. As pregnancy outcomes and management were indifferent, it does not seem necessary or useful to diagnose whether or not late-onset gestational diabetes mellitus is present.

Polyhydramnios Secondary to Esophageal Atresia - Cervical Cerclage and Serial Amnioreduction to Prolong Gestational Age in Select Cases

Esophageal atresia (OA) with or without tracheoesophageal fistula affects approximately 1 in 4000 births and commonly presents with polyhydramnios. This appears to be the first report regarding the utility of cervical cerclage with serial amnioreduction to prolong the gestational age of a neonate with OA, thereby improving outcomes for reconstructive surgery.

Fetal Wilm's tumor detection preceding the development of isolated lateralized overgrowth of the limb: a case report and review of literature

Fetal Wilms tumor (WT) is extremely rare, but with advances in fetal imaging, more cases are being reported. The management of these cases remains challenging. Herein, we present the case of a full-term female infant diagnosed antenatally at 32 weeks of gestation with a right solid renal mass detected on routine prenatal ultrasound without polyhydramnios. At birth, the infant was healthy, with no evidence of dysmorphic features or abnormal laboratory tests to suggest a predisposition syndrome. Her family history was also unremarkable. A successful radical right nephrectomy was performed on day 2 of life revealing a classic WT. She received vincristine as adjuvant chemotherapy without any complications. At the age of 1 month, the infant developed isolated lateralized overgrowth of the right lower limb suspicious of Beckwith-Wiedemann syndrome. At the latest follow-up of 4 years, the child is healthy and disease-free with conserved asymmetry of lower limbs. The case provides insights into the challenging diagnosis and treatment of fetal WT. A review of the literature suggests that the presence of polyhydramnios is a worse prognostic factor while the combination of best supportive care and surgery remains the best management. Fetal WT can be associated with predisposition syndromes; however, their first manifestations can develop after the diagnosis of cancer has been made, as in our patient. We propose starting active surveillance programs and genetic testing for any case of fetal WT.

Labor Induction in Women with Isolated Polyhydramnios at Term: A Multicenter Retrospective Cohort Analysis

Background: With the increasing popularity of elective induction after 39 + 0 weeks, the question of whether induction of labor (IOL) is safe in women with isolated polyhydramnios has become more relevant. We aimed to evaluate the pregnancy outcomes associated with IOL among women with and without isolated polyhydramnios. Methods: This was a multicenter retrospective cohort that included women who underwent induction of labor at term. The study compared women who underwent IOL due to isolated polyhydramnios to low-risk women who underwent elective IOL due to gestational age only. The main outcome measure was a composite adverse maternal outcome, while the secondary outcomes included maternal and neonatal adverse pregnancy outcomes. Results: During the study period, 1004 women underwent IOL at term and met inclusion and exclusion criteria; 162 had isolated polyhydramnios, and 842 had a normal amount of amniotic fluid. Women who had isolated polyhydramnios had higher rates of the composite adverse maternal outcome (28.7% vs. 20.4%, p = 0.02), prolonged hospital stay, perineal tear grade 3/4, postpartum hemorrhage, and neonatal hypoglycemia. Multivariate analyses revealed that among women with IOL, polyhydramnios was significantly associated with adverse composite maternal outcome [aOR 1.98 (1.27-3.10), p < 0.01]. Conclusions: IOL in women with isolated polyhydramnios at term was associated with worse perinatal outcomes compared to low-risk women who underwent elective IOL. Our findings suggest that the management of women with polyhydramnios cannot be extrapolated from studies of low-risk populations and that clinical decision-making should take into account the individual patient's risk factors and preferences.

The impact of the COVID-19 pandemic on antenatal care provision and associated mental health, obstetric and neonatal outcomes

OBJECTIVES

The COVID-19 pandemic imposed many challenges on pregnant women, including rapid changes to antenatal care aimed at reducing the societal spread of the virus. This study aimed to assess how the pandemic affected perinatal mental health and other pregnancy and neonatal outcomes in a tertiary unit in Queensland, Australia.

METHODS

This was a retrospective cohort study of pregnant women booked for care between March 2019 - June 2019 and March 2020 - June 2020. A total of 1984 women were included with no confirmed cases of COVID-19. The primary outcome of this study was adverse maternal mental health defined as an Edinburgh Postnatal Depression Scale score of ≥13 or an affirmative response to 'EPDS Question 10'. Secondary outcomes were preterm birth <37 weeks and <32 weeks, mode of birth, low birth weight, malpresentation in labour, hypertensive disease, anaemia, iron/vitamin B12 deficiency, stillbirth and a composite of neonatal morbidity and mortality.

RESULTS

There were no differences in the primary perinatal mental health outcomes. The rates of composite adverse neonatal outcomes (27 vs. 34 %, p<0.001) during the pandemic were higher; however, there was no difference in perinatal mortality (p=1.0), preterm birth (p=0.44) or mode of delivery (p=0.38).

CONCLUSIONS

Although there were no adverse consequences on maternal mental health during the pandemic, there was a concerning increase in neonatal morbidity potentially due to the altered model of maternity care implemented in the early COVID-19 pandemic.

Polyhydramnios associated with rare genetic syndromes: two case reports

BACKGROUND

We present two genetic causes of polyhydramnios that were challenging to diagnose due to their rarity and complexity. In view of the severe implications, we wish to highlight these rare genetic conditions when obstetricians consider differential diagnoses of polyhydramnios in the third trimester.

CASE PRESENTATION

Patient 1 is a 34-year-old Asian woman who was diagnosed with polyhydramnios at 28 weeks' gestation. First trimester testing, fetal anomaly scan, and intrauterine infection screen were normal. Subsequent antenatal ultrasound scans revealed macroglossia, raising the suspicion for Beckwith-Wiedemann syndrome. Chromosomal microarray analysis revealed a female profile with no pathological copy number variants. The patient underwent amnioreduction twice in the pregnancy. The patient presented in preterm labor at 34 weeks' gestation but elected for an emergency caesarean section. Postnatally, the baby was noted to have a bell-shaped thorax, coat hanger ribs, hypotonia, abdominal distension, and facial dysmorphisms suggestive of Kagami-Ogata syndrome. Patient 2 is a 30-year-old Asian woman who was diagnosed with polyhydramnios at 30 weeks' gestation. She had a high-risk first trimester screen but declined invasive testing; non-invasive prenatal testing was low risk. Ultrasound examination revealed a macrosomic fetus with grade 1 echogenic bowels but no other abnormalities. Intrauterine infection screen was negative, and there was no sonographic evidence of fetal anemia. She had spontaneous rupture of membranes at 37 + 3 weeks but subsequently delivered by caesarean section in view of pathological cardiotocography. The baby was noted to have inspiratory stridor, hypotonia, low-set ears, and bilateral toe polysyndactyly. Further genetic testing revealed a female profile with a pathogenic variant of the GLI3 gene, confirming a diagnosis of Greig cephalopolysyndactyly syndrome.

CONCLUSION

These cases illustrate the importance of considering rare genetic causes of polyhydramnios in the differential diagnosis, particularly when fetal anomalies are not apparent at the 20-week structural scan. We would like to raise awareness for these rare conditions, as a high index of suspicion enables appropriate counseling, prenatal testing, and timely referral to pediatricians and geneticists. Early identification and diagnosis allow planning of perinatal care and birth in a tertiary center managed by a multidisciplinary team.

Unravelling the unseen threat of polyhydramnios in patients with gestational diabetes mellitus: A case report

Polyhydramnios is defined as an increase in the amount of amniotic fluid during pregnancy. This article presents the case of a 35-year-old G4P3 lady at 28 weeks of gestation with suboptimised gestational diabetes Mellitus (GDM). Routine transabdominal ultrasound showed the presence of polyhydramnios, initially thought to be due to suboptimal glucose control. Further evaluation revealed a congenital diaphragmatic hernia with multiple soft markers. Identifying the underlying causes of polyhydramnios can be challenging in primary care settings, which can be attributed to various factors. Although primary care medical officers may not be required to perform detailed scans, they have a crucial role in identifying gross foetal abnormalities. This study highlights the potential for missed diagnoses in primary care settings and the importance of comprehensive prenatal assessments to ensure early detection and appropriate management of polyhydramnios-related conditions in women with GDM.

Amnioreduction vs expectant management in pregnancies with moderate to severe polyhydramnios

BACKGROUND

The rate of polyhydramnios is higher in pregnancies complicated by congenital anomalies. These pregnancies have higher rates of peripartum complications. Amnioreduction is offered to relieve maternal symptoms such as dyspnea, abdominal and respiratory discomfort, and other issues like satiety.

OBJECTIVE

This study aimed to report the rates of amnioreduction and its associated complications in pregnancies with moderate to severe polyhydramnios secondary to fetal anomalies. We also sought to determine if amnioreduction provided additional benefits, including prolongation of pregnancy and a decrease in the rates of peripartum morbidities associated with moderate to severe polyhydramnios.

STUDY DESIGN

This was a retrospective review of anomalous singleton pregnancies with moderate to severe polyhydramnios that were evaluated and delivered at a single center between 2013 and 2021. Peripartum outcomes were compared between pregnancies that underwent amnioreduction and those that were expectantly managed. Mann-Whitney U tests were used to compare continuous variables and Fisher's exact tests were used for categorical variables. A multiple regression model was created to understand the effects of amnioreduction on gestational age at delivery.

RESULTS

A total of 218 singleton pregnancies met the inclusion criteria of moderate to severe polyhydramnios in the study period. Of those, 110 patients (50.5%) underwent amnioreduction and 108 patients (49.5%) opted for expectant management. A total of 147 procedures were performed at a median gestational age of 32.5 weeks and a median of 1900 mL of amniotic fluid was removed per procedure. Complications occurred in 10.9% (n=16) of procedures, including preterm delivery within 48 hours in 5.4% cases (n=8). The median amniotic fluid index was higher in the amnioreduction group than in the expectant group (38.9 cm vs 35.5 cm; P<.0001). Patients who underwent amnioreduction had an earlier median gestational age at delivery (36.3 weeks vs 37.0 weeks; P=.048), however, the rates of spontaneous preterm delivery were similar. A higher percentage of women in the amnioreduction group had vaginal delivery (49.4% vs 30.5%; P=.01) and lower rates of uterine atony (2.4% vs 13.7%; P=.006). In the multiple linear regression analysis, the gestational age at delivery positively correlated with gestational age at amnioreduction after controlling for amniotic fluid volume (P<.0001; 95% confidence interval, 0.34-0.71). In addition, the patients in the amnioreduction group were twice as likely to have a vaginal delivery (P=.02).

CONCLUSION

Amnioreduction in the setting of moderate-severe polyhydramnios has a reasonably low rate of complications but does not provide any benefits in terms of prolonging the pregnancy. The procedure may increase the likelihood of vaginal delivery and lower the rates of uterine atony.

Feasibility of continuous intra-uterine pressure measurements during amnioreduction in twin-to-twin transfusion syndrome therapy

INTRODUCTION

This work explores the feasibility of simultaneous and continuous intra-abdominal, intra-uterine, and arterial blood pressure measurements to examine the hemodynamic perturbation expected during therapeutic amnioreduction and to better understand the protective role of the placenta during that treatment.

METHODS

Patients with twin-to-twin transfusion syndrome were treated with fetoscopic laser ablation followed by amnioreduction. Intra-abdominal, intra-uterine, and mean arterial pressures were simultaneously recorded during amnioreduction performed in steps of 200 mL. Placental thickness and uterine dimensions were measured before and after amnioreduction by ultrasonography.

RESULTS

Useful pressure recordings were obtained between volume reduction steps and short hands-off periods in four studies. Median amnioreduction volume was 1400 mL corresponding to a median uterine volume reduction of 1121 mL. Mean intra-uterine pressure significantly fell from 24.8 to 13.6 mmHg (p = 0.011) and intra-abdominal pressure significantly decreased from 13.4 to 9.2 mmHg after amnioreduction (p = 0.015). Uterine pressure recordings revealed transient contractions (A, in mmHg) following individual amnioreduction steps, which increased with fractional amnioreduction (F, no dimension) (A = 17.23*F + 11.81; r = 0.50, p = 0.001).

DISCUSSION

Simultaneous and continuous measurement of intra-abdominal, intra-uterine, and arterial blood pressures during amnioreduction is feasible. The dynamics reveal transient uterine contractions reaching levels comparable to those seen during childbirth which seem to oppose impending maternal hypovolemia by placental steal at the expense of temporarily reducing placental perfusion pressure and underline the importance of uterine and placental interaction.

The "FEEDS (FEeding Eating Deglutition Skills)" over Time Study in Cardiofaciocutaneous Syndrome

Feeding, eating and deglutition difficulties are key concerns in patients with cardiofaciocutaneous syndrome (CFCS). This study intends to quantify the development of feeding skills from birth to adulthood in patients with CFCS. Twenty-seven patients (eight males; mean age: 16.7 ± 8.3 years; median age: 15 years, age range: 1.5-38 years) with molecularly confirmed clinical diagnosis of CFCS were prospectively recruited from the Rare Disease Unit, Paediatrics Department, Fondazione Policlinico Agostino Gemelli-IRCCS, Rome, Italy, over a one-year period. Pathogenic variants along with key information regarding oro-motor features were collected. Sialorrhea was quantified using the Drooling Quotient 5. Feeding abilities were screened using the Italian version of the Montreal Children's Hospital Feeding Scale (I-MCH-FS). The oral sensory processing section of the Sensory Profile completed the assessment. Mild-to-profuse drooling was experienced by 25% of patients, and food taste selectivity was a constant during infancy (65%), with persistence even beyond adolescence. Nineteen percent of participants with long-term enteral feeding dependency had BRAF, KRAS and MAP2K1 mutations. These findings document that mealtime challenges in CFCS do not remain restricted only to the paediatric age, and that supportive care until adulthood plays a key role.

Effect of gestational diabetes mellitus on pregnancy outcomes among younger and older women and its additive interaction with advanced maternal age

Background

The prevalence of gestational diabetes mellitus (GDM) and advanced maternal age (AMA, ≥ 35 years) has shown an increasing trend worldwide. This study aimed to evaluate the risk of pregnancy outcomes among younger (20-34 years) and older (≥ 35 years) women with GDM and further analyze the epidemiologic interaction of GDM and AMA on these outcomes.

Methods

This historical cohort study included 105 683 singleton pregnant women aged 20 years or older between January 2012 and December 2015 in China. Stratified by maternal age, the associations between GDM and pregnancy outcomes were analyzed by performing logistic regression. Epidemiologic interactions were assessed by using relative excess risk due to interaction (RERI), attributable proportion due to interaction (AP), and synergy index (SI) with their 95% confidence intervals (95%CIs).

Results

Among younger women, individuals with GDM had a higher risk of all maternal outcomes, preterm birth (relative risk [RR] 1.67, 95%CI 1.50-1.85), low birthweight (RR 1.24, 95%CI 1.09-1.41), large for gestational age (RR 1.51, 95%CI 1.40-1.63), macrosomia (RR 1.54, 95%CI 1.31-1.79), and fetal distress (RR 1.56, 95%CI 1.37-1.77) than those without GDM. Among older women, GDM increased the risk of gestational hypertension (RR 2.17, 95%CI 1.65-2.83), preeclampsia (RR 2.30, 95%CI 1.81-2.93), polyhydramnios (RR 3.46, 95%CI 2.01-5.96), cesarean delivery (RR 1.18, 95%CI 1.10-1.25), preterm birth (RR 1.35, 95%CI 1.14-1.60), large for gestational age (RR 1.40, 95%CI 1.23-1.60), macrosomia (RR 1.65, 95%CI 1.28-2.14) and fetal distress (RR 1.46, 95%CI 1.12-1.90). Additive interactions of GDM and AMA on polyhydramnios and preeclampsia were found, with RERI of 3.11 (95%CI 0.05-6.16) and 1.43 (95%CI 0.09-2.77), AP of 0.51 (95%CI 0.22-0.80) and 0.27 (95%CI 0.07-0.46), and SI of 2.59 (95%CI 1.17-5.77) and 1.49 (95%CI 1.07-2.07), respectively.

Conclusion

GDM is an independent risk factor for multiple adverse pregnancy outcomes, and may exert additive interactions with AMA on the risk of polyhydramnios and preeclampsia.

Maternal morbidity under an absolute abortion ban: insights from a 6-year case series of fatal fetal malformations in El Salvador

BACKGROUND

A striking number of national and subnational governments that previously allowed legal abortion in cases of severe fetal anomaly have passed new legislation to explicitly remove these allowances. However, we know little about the maternal health implications of such restrictions.

OBJECTIVE

This study aimed to examine the health outcomes of pregnant individuals in El Salvador whose fetuses were diagnosed with a fatal congenital malformation and who were legally required to carry these nonviable pregnancies to term under the nation's absolute abortion ban.

STUDY DESIGN

We reviewed the charts of all 239 pregnancies with fetuses classified as having 1 of 18 congenital malformations typically considered to be incompatible with extrauterine life that were evaluated at the National Women's Hospital in El Salvador between January 1, 2013 and December 31, 2018. Because regional healthcare providers who identify pregnancy complications in El Salvador are instructed to refer those patients to the National Women's Hospital, our analysis captured the total population of lethal fetal malformations treated by the national public health system. We documented pregnant patients' socioeconomic characteristics, pregnancy-related complications, and the medical procedures used to mitigate complications.

RESULTS

Individuals who were required to carry pregnancies with severe fetal malformations to term (or until preterm labor began naturally) experienced high rates of maternal morbidity. More than half (54.9%) of pregnancies experienced at least 1 serious pregnancy-related health complication, whereas 47.9% underwent a physically-invasive medical procedure to manage complications, including cesarean deliveries, decompression amniocenteses, fetal head decompressions, and, in 1 case, a full hysterectomy. A total of 9% of patients opted to discontinue care after receiving the diagnosis of fatal fetal malformation. We also found striking variation in how physicians managed pregnancies with fatal fetal malformations, suggesting that different interpretations of the law lead to inequities in individual-level patient care.

CONCLUSION

Laws prohibiting abortions in cases of severe fetal malformation can increase risks to pregnant patients by requiring clinicians to subject healthy patients to a course of treatment that generates morbidity.

Estimate of genetic variants using CNV-Seq for fetuses with oligohydramnios or polyhydramnios

BACKGROUND

Oligohydramnios or polyhydramnios, is associated with chromosomal aberrations, particularly aneuploidy. However, its correlation with copy number variation (CNV) remains unclear.

METHODS

We retrospectively analyzed 428 cases with an abnormal level of amniotic fluid, comprising of 139 cases of single ultrasound findings (SU group) and 289 cases of multiple ultrasound findings (MU group), by CNV sequencing (CNV-Seq) and followed their pregnancy outcomes.

RESULTS

The overall detection rate of clinically significant findings was 8%, with 5% in the SU group and 11% in MU group. Besides, 18 microdeletion/microduplication syndromes were detected, with the highest rate of renal cysts and diabetes syndrome (22%, 4/18). Also, the rate of termination of pregnancy in MU group was much higher than that in the SU group (29% vs. 10%, ***p < 0.001), and in the MU-oligohydramnios subgroup, it was the highest (34%), regardless of cases with chromosomal anomaly and lost to follow-up.

CONCLUSION

Our results showed that the abnormal level of amniotic fluid, especially combined with other ultrasound abnormalities, is closely related to chromosomal abnormalities and genetic CNVs. CNV-Seq may be useful in investigating pregnancies with an abnormal amniotic fluid level.

Complications of Hypertriglyceridemia in Pregnancy and Its Impact on Neonates: a Hospital-Based Study From Odisha

Objective

Hypertriglyceridemia (HTG) in pregnancy causes an increased risk for maternal and fetal complications. But, reports on the impact of HTG in pregnancy on maternal and fetal outcomes are scarce in developing countries. We aim to determine the maternal and neonatal complications of HTG in pregnancy.

Materials and methods

This prospective observational study was conducted on 150 pregnant women with HTG in the department of obstetrics and gynecology, KIMS, Bhubaneswar, from December 2019 to November 2020. Measurement of triglycerides during the first trimester, second trimester, and delivery was done. Maternal complications and neonatal outcomes in HTG mothers and mothers with normal triglyceride levels were compared.

Results

Out of 150 HTG cases, hypothyroidism, preeclampsia, acute pancreatitis, and sickle cell crisis occurred in 41 (27.3%), 22 (14.7%), six (4%), and three (2%) cases, respectively. The triglyceridemia (TG) levels raised from 133.7±48.2 mg/dl in the first trimester to 232.8±151.0 mg/dl in the third trimester. There is a significant increase in TG levels at the time of delivery compared to the first and second trimesters (p< .001). Out of 140 neonates, 30 (21.4%) were preterm, eight (5.7%) had intrauterine growth restriction (IUGR), and four (6.06%) were macrosomic. Intrauterine death, preterm, and macrosomia are significantly associated with maternal HTG compared to normal mothers (p < .032). All mortalities were due to acute pancreatitis (6; 4%) among mothers and four intrauterine fetal death.

Conclusion

There is a steady increase in TG levels in the successive trimesters of pregnancy. Gestational severe hypertriglyceridemia causes life-threatening complications. HTG-induced acute pancreatitis needs to be managed aggressively to prevent maternal death. Neonates of HTG mothers suffer from complications like prematurity, IUGR, and macrosomia.

Fetal Bowel Abnormalities Suspected by Ultrasonography in Microvillus Inclusion Disease: Prevalence and Clinical Significance

Microvillus inclusion disease (MVID) is a rare, inherited, congenital, diarrheal disorder that is invariably fatal if left untreated. Within days after birth, MVID presents as a life-threatening emergency characterized by severe dehydration, metabolic acidosis, and weight loss. Diagnosis is cumbersome and can take a long time. Whether MVID could be diagnosed before birth is not known. Anecdotal reports of MVID-associated fetal bowel abnormalities suspected by ultrasonography (that is, dilated bowel loops and polyhydramnios) have been published. These are believed to be rare, but their prevalence in MVID has not been investigated. Here, we have performed a comprehensive retrospective study of 117 published MVID cases spanning three decades. We find that fetal bowel abnormalities in MVID occurred in up to 60% of cases of MVID for which prenatal ultrasonography or pregnancy details were reported. Suspected fetal bowel abnormalities appeared in the third trimester of pregnancy and correlated with postnatal, early-onset diarrhea and case-fatality risk during infancy. Fetal bowel dilation correlated with MYO5B loss-of-function variants. In conclusion, MVID has already started during fetal life in a significant number of cases. Genetic testing for MVID-causing gene variants in cases where fetal bowel abnormalities are suspected by ultrasonography may allow for the prenatal diagnosis of MVID in a significant percentage of cases, enabling optimal preparation for neonatal intensive care.

Transient Polyhydramnios during Pregnancy Complicated with Gestational Diabetes Mellitus: Case Report and Systematic Review

Polyhydramnios is an obstetrical condition defined as a pathological increase in the amniotic fluid and is associated with a high risk of maternal-fetal complications. Common causes of polyhydramnios include fetal anatomical and genetic abnormalities, gestational diabetes mellitus, and fetal viral infections. We present the case of a 30-year-old Caucasian woman with transient polyhydramnios associated with gestational diabetes mellitus and obstetric complications. The diagnosis was based on the ultrasound assessment of amniotic fluid volume during a common examination at 26 weeks. Two weeks prior, the patient had been diagnosed with gestational diabetes mellitus. After 4 days, the patient was examined, and the amniotic fluid index returned to normal values. At 38 weeks, the patient presented to the emergency room due to lack of fetal active movement. Ultrasound revealed polyhydramnios, the patient was admitted for severe fetal bradycardia, and fetal extraction through emergency cesarian section was performed. Six weeks after birth, the patient underwent an oral glucose tolerance test with normal values, confirming gestational diabetes mellitus. We performed a systematic review of the literature on polyhydramnios, from January 2016 to April 2022, to analyze all recent published cases and identify the most common etiological causes and important aspects related to maternal-fetal outcomes.

Risk of Gestational Diabetes Due to Maternal and Partner Smoking

Pregnant women are among the most vulnerable to environmental exposure to tobacco smoke (EET); which has been linked to problems in the mothers’ health; one of the most frequent is gestational diabetes (GD). For this reason, there are specific interventions and prevention strategies designed to reduce this exposure risk. However, currently, they are mostly aimed only at aiding the pregnant women with smoking cessation during pregnancy and do not assess or address the risk from passive exposure due to partner smoking. The aim of this work is to study the exposure to EET of pregnant women considering active and passive smoking and to evaluate its effect on the development of GD. This is an observational case-control study within a retrospective cohort of pregnant women. Information on smoking habits was obtained from both personal interviews and recorded medical history. In total, 16.2% of mothers and 28.3% of partners declared having been active smokers during pregnancy; 36.5% of the women presented EET during pregnancy when both active and passive smoking were considered. After adjustments, the association with the EET and GD of the mother was (aOR 1.10 95% CI: 0.64–1.92); for the EET of the partner, it was (aOR 1.66 95% CI: 1.01–2.77); for both partners, it was (aOR 1.82 95% CI: 1.15–2.89), adjusted by the mother’s age and body mass index. There is a lack of education regarding the effects of passive exposure to tobacco smoke. It is essential that pregnant women and their partners are educated on the risks of active and passive smoking; this could improve the effectiveness of other GD prevention strategies.

Chronic Polyhydramnios: A Medical Entity Which Could Be a Model of Muscle Development in Decreased Mechanical Loading Condition

Polyhydramnios is a condition related to an excessive accumulation of amniotic fluid in the third trimester of pregnancy and it can be acute and chronic depending on the duration. Published data suggest that during muscle development, in the stage of late histochemical differentiation decreased mechanical loading cause decreased expression of myosin heavy chain (MHC) type 1 leading to slow-to-fast transition. In the case of chronic polyhydramnios, histochemical muscle differentiation could be affected as a consequence of permanent decreased physical loading. Most affected would be muscles which are the most active i.e., spine extensor muscles and muscles of legs. Long-lasting decreased mechanical loading on muscle should cause decreased expression of MHC type 1 leading to slow-to-fast transition, decreased number of muscle fiber type I especially in extensor muscles of spine and legs. Additionally, because MHC type 1 is present in all skeletal muscles it could lead to various degrees of hypotrophy depending on constituting a percentage of MHC type 1 in affected muscles. These changes in the case of preexisting muscle disorders have the potential to deteriorate the muscle condition additionally. Given these facts, idiopathic chronic polyhydramnios is a rare opportunity to study the influence of reduced physical loading on muscle development in the human fetus. Also, it could be a medical entity to examine the influence of micro- and hypogravity conditions on the development of the fetal muscular system during the last trimester of gestation.

Prenatal diagnosis of fetal growth restriction with polyhydramnios, etiology and impact on postnatal outcome

To assess the spectrum of different etiologies, the intrauterine course, outcome and possible prognostic markers in prenatally detected fetal growth restriction (FGR) combined with polyhydramnios. Retrospective study of 153 cases with FGR combined with Polyhydramnios diagnosed by prenatal ultrasound over a period of 17 years. Charts were reviewed for ultrasound findings, prenatal and postnatal outcome. All cases were categorized into etiological groups and examined for differences. Five etiological groups were identified: chromosomal anomalies (n = 64, 41.8%), complex malformation syndromes (n = 37, 24.1%), isolated malformations (n = 24, 15.7%), musculoskeletal disorders (n = 14, 9.2%) and prenatal non-anomalous fetuses (n = 14, 9.2%). Subgroups showed significant disparities in initial diagnosis of combination of both pathologies, Ratio AFI/ gestational weeks and Doppler ultrasound examinations. Overall mortality rate was 64.7%. Fetuses prenatally assigned to be non-anomalous, showed further complications in 42.9% (n = 6). Fetuses prenatally diagnosed with FGR combined with polyhydramnios are affected by a high morbidity and mortality. Five etiologic groups can be differentiated, showing significant disparities in prenatal and postnatal outcome. Even without recognizable patterns prenatally, long-term-follow up is necessary, as neurodevelopmental or growth delay may occur.

Preterm birth risk in women with skeletal dysplasias and short stature

PURPOSE

The primary objective was to estimate the risk of preterm delivery in a population of women with a skeletal dysplasia and short stature. The secondary outcome was to identify factors that increase the risk of preterm delivery.

METHODS

A cross sectional survey was performed asking detailed pregnancy and reproductive health questions, aimed at a convenience sample of women who were little people, administered through Little People of America, Little People UK, Little People Canada, and the World Dwarf Games. Comparisons were made on gestational age at delivery between pregnancies with and without the outcomes.

RESULTS

The survey had a response rate of 74% (117/158). There was a total of 55 eligible subjects who had 72 live births. Delivery prior to 37 weeks occurred in 19/72 live births, which equates to a preterm birth rate of 26.4%. Besides short stature, no single factor was identified that could solely explain the elevated preterm birth risk in the study population.

CONCLUSION

The risk of preterm delivery in women with skeletal dysplasias and short stature is elevated compared to the general population. This information will assist healthcare providers in pregnancy management and counseling.

Two cases of microvillus inclusion disease caused by MYO5B deficiency with prenatal abnormalities

BACKGROUNDS

Microvillus inclusion disease (MVID) characterizes as intractable life-threatening watery diarrhea malnutrition after birth. MATERIALS & METHODS: Here we describe two patients with prenatal ultrasound findings of bowel dilation or increased amniotic fluid volume presented intractable diarrhea after birth. Exome sequencing and Intestinal biopsy were performed for the patients and their parents to reveal the underlying causes. The mutations were verified by Sanger sequencing and quantitative polymerase chain reaction.

RESULTS

Exome sequencing revealed that both of the patients carrying MYO5B compound heterozygote mutations that were inherited from their parents.

CONCLUSION

Here we describe two cases with MVID caused by MYO5B deficiency, which was the most common caused with prenatal ultrasound findings of bowel dilation and increased amniotic fluid volume. Due to the lack of effective curative therapies, early diagnosis even in prenatal of MVID can provide parents with better genetic counseling on the fetal prognosis.

Endothelin-1 axes in the framework of predictive, preventive and personalised (3P) medicine

Endothelin-1 (ET-1) is involved in the regulation of a myriad of processes highly relevant for physical and mental well-being; female and male health; in the modulation of senses, pain, stress reactions and drug sensitivity as well as healing processes, amongst others. Shifted ET-1 homeostasis may influence and predict the development and progression of suboptimal health conditions, metabolic impairments with cascading complications, ageing and related pathologies, cardiovascular diseases, neurodegenerative pathologies, aggressive malignancies, modulating, therefore, individual outcomes of both non-communicable and infectious diseases such as COVID-19. This article provides an in-depth analysis of the involvement of ET-1 and related regulatory pathways in physiological and pathophysiological processes and estimates its capacity as a predictor of ageing and related pathologies,a sensor of lifestyle quality and progression of suboptimal health conditions to diseases for their targeted preventionand as a potent target for cost-effective treatments tailored to the person.

Metabolic Profile and Neurogenic Potential of Human Amniotic Fluid Stem Cells From Normal vs. Fetus-Affected Gestations

Human amniotic fluid stem cells (hAFSCs) possess some characteristics with mesenchymal stem cells (MSCs) and embryonic stem cells and have a broader differentiation potential compared to MSCs derived from other sources. Although hAFSCs are widely researched, their analysis mainly involves stem cells (SCs) obtained from normal, fetus-unaffected gestations. However, in clinical settings, knowledge about hAFSCs from normal gestations could be poorly translational, as hAFSCs from healthy and fetus-diseased gestations may differ in their differentiation and metabolic potential. Therefore, a more thorough investigation of hAFSCs derived from pathological gestations would provide researchers with the knowledge about the general characteristics of these cells that could be valuable for further scientific investigations and possible future clinical applicability. The goal of this study was to look into the neurogenic and metabolic potential of hAFSCs derived from diseased fetuses, when gestations were concomitant with polyhydramnios and compare them to hAFSCs derived from normal fetuses. Results demonstrated that these cells are similar in gene expression levels of stemness markers (SOX2, NANOG, LIN28A, etc.). However, they differ in expression of CD13, CD73, CD90, and CD105, as flow cytometry analysis revealed higher expression in hAFSCs from unaffected gestations. Furthermore, hAFSCs from “Normal” and “Pathology” groups were different in oxidative phosphorylation rate, as well as level of ATP and reactive oxygen species production. Although the secretion of neurotrophic factors BDNF and VEGF was of comparable degree, as evaluated with enzyme-linked immunosorbent assay (ELISA) test, hAFSCs from normal gestations were found to be more prone to neurogenic differentiation, compared to hAFSCs from polyhydramnios. Furthermore, hAFSCs from polyhydramnios were distinguished by higher secretion of pro-inflammatory cytokine TNFα, which was significantly downregulated in differentiated cells. Overall, these observations show that hAFSCs from pathological gestations with polyhydramnios differ in metabolic and inflammatory status and also possess lower neurogenic potential compared to hAFSCs from normal gestations. Therefore, further in vitro and in vivo studies are necessary to dissect the potential of hAFSCs from polyhydramnios in stem cell-based therapies. Future studies should also search for strategies that could improve the characteristics of hAFSCs derived from diseased fetuses in order for those cells to be successfully applied for regenerative medicine purposes.

Initial resuscitation of a neonate with congenital maxillomandibular syngnathia: A case report and literature review

We report a full-term male neonate found to have undiagnosed syngnathia requiring extensive resuscitation at birth followed by urgent tracheostomy. We conducted a systematic literature review to study the presentation, resuscitation methods, and outcomes of neonates with congenital syngnathia. Of the 174 cases reported to date, 91 had initial resuscitation data available. Extensive resuscitation was required in 16 of these 91 infants (18%). This ranged from nasal intubation to emergent tracheostomy. These neonates are potentially higher risk deliveries for which methods in addition to those recommended by the American Heart Association neonatal resuscitation guidelines may be needed.

Congenital anomalies in breech presentation: A nationwide record linkage study

Our study aimed to determine if congenital anomalies are associated with breech presentation at delivery. We conducted a nationwide, retrospective population-based record linkage study and analyzed all singleton births in Finland from 1996 to 2016 using the mandatory health register data collected by the Finnish Institute for Health and Welfare. We compared all major congenital anomalies detected during pregnancy, birth, or the first year of life according to the fetus's presentation at the time of delivery using X² -square statistic and Student's t test. We adjusted the results for known risk factors for congenital anomalies to estimate adjusted odds ratios and 95% confidence intervals. Fetuses in breech presentation at delivery had an increased risk for congenital anomalies (6.5%) compared with fetuses in cephalic presentation (3.6%), P < .001. Breech presentation was associated with nearly all types of examined congenital anomalies. The strongest associations were observed with congenital deformities of the hip, the central nervous system, the respiratory system, and the musculoskeletal system. Our study supports the theory that breech presentation is, in many cases, a symptom of a fundamental problem in fetal morphogenesis or function. Neonates born in the breech presentation have a higher risk of congenital anomalies and should undergo a postnatal screening.

A Rare Cause of Refractory Severe Polyhydramnios: Antenatal Bartter Syndrome

Background: Antenatal Bartter syndrome is an autosomal recessive disorder causing severe polyuria that leads to severe polyhydramnios and preterm labor. Prenatal diagnosis of antenatal Bartter syndrome is difficult because the genetic diagnosis can only be confirmed following a clinical diagnosis in infants. Reports of prenatal diagnosis and treatment of antenatal Bartter syndrome are limited. Case Presentation: We present the case of a 33-year-old pregnant woman with refractory polyhydramnios at 31 weeks of gestation. There were no structural anomalies or placental problems on ultrasonography; therefore, antenatal Bartter syndrome was suspected. With repeated amniocentesis and indomethacin therapy, the pregnancy continued to 36 weeks of gestation. The clinical features of the infant and subsequent genetic testing confirmed the diagnosis of antenatal Bartter syndrome. The baby was in good clinical condition at the 3-month follow-up visit. Conclusions: For pregnant women with early onset and refractory severe polyhydramnios without morphological anomalies, antenatal Bartter syndrome should be highly suspected.

Factors Associated with the Type of Cesarean Section in Greece and Their Correlation with International Guidelines

BACKGROUND

Cesarean section (CS) rates have been increasing worldwide with different effects on maternal and neonatal health. Factors responsible for the growing trend of CSs, include maternal characteristics, medical insurance and convenient scheduling or financial incentives. Effective interventions and guidelines are required to reduce CS rates.

OBJECTIVE

The aim of this research was to investigate the factors contributing to CS rate increase and their correlation with international guidelines.

METHODS

The performed analysis included the available socio-demographic and medical information retrieved from the medical records and a related questionnaire in both emergency and elective CSs.

RESULTS

Out of the included 633 births, the cesarean delivery rate was 58%. Women with a previous CS showed higher percentages for Elective CS (66.1%) compared to Emergency CSs for the same reasons (8.9%). Furthermore, 23% of the patients underwent an Emergency CS because of failure of labor to progress while 18% of CSs were due to maternal desire.

CONCLUSION

The high rates of CS in Greece demonstrate the lack of use of international obstetric protocols, national strategies, Cesarean Section audits and a significant shortage of midwives. A decrease in iatrogenic and non-iatrogenic factors leading to the primary CS will decrease CS rates.

Perinatal characteristics and early childhood follow up after ex-utero intrapartum treatment for head and neck teratomas by prenatal diagnosis

BACKGROUND

Ex utero intrapartum treatment (EXIT) is utilized for safe delivery when a baby has a compromised airway. The purpose of this retrospective study was to examine the indications and outcomes of 11 children presenting with airway occluding oropharyngeal and cervical teratomas.

METHODS

Study of all children with an airway occluding teratoma delivered via EXIT (2001-2018) in our unit. Primary outcomes included survival and tracheostomy at discharge. Data are reported using descriptive statistics as median (range) and rate (%).

RESULTS

We performed 45 EXIT procedure performed between January 2001 and April 2018. Of these, eleven were for cervical and/or upper airway teratoma. Ten (91%) cases had associated polyhydramnios, two (18%) developed nonimmune hydrops, and eight (72%) delivered preterm. Six (45.5%) were performed as an emergency. Estimated blood loss was 1000 ml (500, 1000). The neonatal mortality rate was 18% (2/11) and 33% (3/9) of the survivors were discharged with a tracheostomy.

CONCLUSION

EXIT is a reasonable option for delivery of babies with an occlusive upper airway mass. Neonatal survival depends on individualized factors but may be as high as 82% in those with teratoma.

Prenatal Diagnosis of a Mosaic Paternal Uniparental Disomy for Chromosome 14: A Case Report of Kagami-Ogata Syndrome

The Kagami-Ogata syndrome (KOS) is a rare imprinting disorder with a distinct clinical phenotype. In KOS, polyhydramnios is associated with a small bell-shaped thorax and coat-hanger ribs. The genetic etiology of KOS includes paternal uniparental disomy 14 [upd(14)pat], epimutations, and microdeletions affecting the maternally derived imprinted region of chromosome 14q32.2. More than 77 cases of KOS have been reported; however, only one mosaic upd(14)pat case has been reported. Here we report a second mosaic upd(14)pat case. The prognosis of upd(14)pat patients is poor because of severe respiratory insufficiency. We summarized prenatal ultrasound findings of KOS to raise awareness of this condition for possible diagnosis of KOS prenatally when polyhydramnios combination with a small bell-shaped thorax and other related features are first observed. Prenatal diagnosis using methylation-specific multiplex ligation-dependent probe amplification (MLPA) or a single-nucleotide polymorphism-based microarray analysis is recommended.

Endometrial cavity fluid is associated with deleterious pregnancy outcomes in patients undergoing in vitro fertilization/intracytoplasmic sperm injection: a retrospective cohort study

Background

The effects of endometrial cavity fluid (ECF) on in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) pregnancy outcomes following embryo transfer (ET) are still controversial. We conducted the present study to investigate whether the presence of ECF in infertile patients scheduled to undergo IVF or ICSI was associated with pregnancy outcomes.

Methods

A retrospective cohort study design was used. Among infertile patients undergoing IVF/ICSI, those with and without ECF were matched 1:1 using propensity score matching (PSM). After ensuring that the baseline levels of the two matched groups were consistent, the pregnancy and obstetrical outcomes of the two groups were compared.

Results

Patients with ECF had significantly lower clinical rates of pregnancy (1,061/1,862, 57% vs. 1,182/1,862, 63.5%; P<0.001), live birth (902/1,862, 48.4% vs. 1,033/1,862, 55.5%; P<0.001), biochemical pregnancy (1,182/1,862, 63.5% vs. 1,288/1,862, 69.2%; P<0.001), and embryo implantation (1,500/3,740, 40.1% vs. 1,661/3,740, 44.4%, P<0.001) than patients without ECF. Also, patients with ECF had a higher incidence of gestational diabetes (17/78, 22% vs. 8/94, 9%, P=0.014). However, there were no differences in gestational weeks at delivery or birth weight between the two groups.

Conclusions

ECF was significantly associated with adverse pregnancy outcomes but showed no significant association with adverse obstetric outcomes (except for gestational diabetes).

Prenatal ultrasonographic findings of esophageal atresia: potential diagnostic role of the stomach shape

Objective

We investigated prenatal sonographic characteristics of esophageal atresia (EA) with advancing gestation. We focused on the degree of polyhydramnios and the stomach shape.

Methods

This study included 27 EA cases (EA group) and 81 idiopathic polyhydramnios cases (non-EA group). The non-EA group consisted of cases without any fetal structural anomaly, musculoskeletal disorder, chromosomal abnormality, or maternal diabetes. Both groups included only singleton pregnancies. Amniotic fluid index (AFI) and width/length (W/L) ratio as well as the product of width and length (W×L) of stomach were serially assessed during gestation and compared between the 2 groups. To predict EA using W/L ratio and W×L, receiver operating characteristic curve analysis was performed.

Results

Polyhydramnios was evident in 77.8% of EA cases. We observed 25.9% and 22.2% EA cases with an absent stomach and a small visible stomach, respectively. After 28 weeks, the EA group manifested significantly higher AFI than the non-EA group. After 32 weeks, W/L ratio in the EA group tended to be lower than that in the non-EA group (32–36 weeks: 1.36 vs. 1.72, P=0.092; >36 weeks: 1.43 vs. 1.63, P=0.024). To predict EA, the calculated area under the curve for W/L ratio was 0.651 after 32 weeks. The diagnosis of EA using a cut-off value of W/L ratio <1.376 showed sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio to be 84.6%, 52.9%, 1.796, and 0.081, respectively.

Conclusion

A low W/L ratio of stomach after 32 weeks with progressive idiopathic polyhydramnios may be used to predict EA.

Prenatal Prediction of Outcome by Fetal Gastroschisis in a Tertiary Referral Center

The aim of this study was to find a prenatal parameter to be able to predict possible prenatal complications or postnatal surgical options, thus allowing the fetal medicine specialist, together with pediatric surgeons and neonatologists, to improve the counseling of the parents and to determine the timing of delivery and therapy. This was a retrospective analysis of prenatal diagnosis and outcome of fetuses with 34 cases of gastroschisis between the years 2007 and 2017. A total of 34 fetuses with gastroschisis were examined and 33 outcomes registered: 22 cases of simple gastroschisis (66.7%) and 11 cases of complex gastroschisis (33.3%). A cut-off value of 18 mm for intraabdominal bowel dilatation (IABD) showed a positive predictive value (PPV) of 100% for predicting simple gastroschisis. IABD gives the best prediction for simple versus complex gastroschisis (cut-off of 18 mm). Extra-abdominal bowel dilatation (EABD) cut-off values of 10 mm and 18 mm showed low sensitivity and specificity to predict complex gastroschisis.

Severe Polyhydramnios with Consistent Fetal Full Bladder: A Novel Sign of Antenatal Bartter's Disease

Bartter's disease, an inherited renal tubular disorder is due to a defect in ion transport across the ascending limb of the loop of Henle leading to failure of the ability of kidneys to concentrate urine and hence polyuria. We present three fetuses of mothers with severe polyhydramnios with normal maternal blood sugar profile, routine Toxoplasma, Rubella, Cytomegalovirus, Herpes (TORCH) serology. The ultrasound showed no structural anomaly in the fetus, but consistent overdistended bladder with severe polyhydramnios was observed without any evidence of obstructive uropathy. The biochemical test on amniotic fluid was suggestive of Bartter's disease in case 1 and borderline in case 2, and next-generation sequencing confirmed a mutation of KCNJ1 associated with Bartter's disease Type II in case 1 and a mutation in SLC21A1 in case 2. Amniotic fluid biochemistry was inconclusive in case 3. A consistent full bladder with severe polyhydramnios with onset around 24 to 25 weeks was a novel finding which was observed due to fetal polyuria and can be used as a clue to investigate cases with severe polyhydramnios with no structural anomaly. Antenatal diagnosis will help in the proper management of child and genetic counseling for the next pregnancy.

Two novel deleterious variants of Angiotensin-I-converting Enzyme gene identified in a family with recurrent anhydramnios

Background

Anhydramnios results from the poor development of the placenta or problems with intrauterine development of the kidneys or urinary tract. Complete lack of amniotic fluid indicates a severe problem with the organs of the urinary system. The genes associated with anhydramnios show very diversity and are not yet well defined.

Methods

Whole‐exome sequencing (WES) was used for an aborted male case around the 20th week of gestation diagnosed with anhydramnios. The resulted deleterious variants were verified by Sanger sequencing. Pathogenicity of deleterious variants was explored by in silico analysis.

Results

A maternally inherited deleterious frameshift variant, c.1454_1455insC, p.(S486Ffs29) in exon 9 and two paternally inherited missense variants c.1037C > G, p.(Ser346Trp) in exon 7 and c.1465A > G, p.(Asn489Asp) in exon 9 of Angiotensin‐I‐Converting Enzyme (ACE) gene were found and confirmed by Sanger sequencing. c.1454_1455insC, p.(S486Ffs29) and c.1037C > G, p.(Ser346Trp) were identified as two novel compound heterozygous deleterious variants. The pathogenicity of these deleterious variants was determined by in silico analysis and both the deleterious variants disrupt the structure of the ACE protein.

Conclusion

Two novel compound heterozygous variants were identified in the case with anhydramnios, which may be associated with pathogenicity of anhydramnios. Our data also revealed that the WES approach may provide helpful information for genetic counseling of the families with anhydramnios.

Prospective growth and developmental outcomes in infants born to mothers with multiple sclerosis

BACKGROUND

The importance of supporting pregnancy-related decisions in multiple sclerosis (MS) patients has increasingly been recognized and hence the need for prospective data on pregnancy and pediatric outcomes in this patient population.

OBJECTIVE

To assess prospective growth and developmental outcomes of infants born to mothers with multiple sclerosis (IMS).

METHODS

PREG-MS is a prospective multicenter cohort study in New England, United States. We followed 65 women with MS and their infants with up to 12 months consistent pediatric follow-up. Pediatric, neurologic, and demographic information was obtained via structured telephone interviews and validated with medical records.

RESULTS

No differences in infant weights and lengths with World Health Organization (WHO) 50th percentile standards were observed (p > 0.05). However, larger head circumference (HC) measurements than WHO standards were reported in cohort infants (p < 0.05). There was no association between HC and markers of maternal MS activity, demographic, or social factors. No irreversible pediatric developmental abnormalities were observed.

CONCLUSION

This first prospective study on pediatric anthropometry in IMS suggests a possible increase in HC compared to WHO standards without an increase in irreversible developmental abnormalities. The observations are exploratory and require confirmation with larger prospective studies in diverse groups of MS patients.

Effects of gestational diabetes mellitus on risk of adverse maternal outcomes: a prospective cohort study in Northwest Ethiopia

Background

Gestational diabetes mellitus is a leading medical condition woman encounter during pregnancy with serious short- and long-term consequences for maternal morbidity. However, limited evidence was available on potential impacts of gestational diabetes mellitus using updated international diagnostic criteria on adverse maternal outcomes. Therefore, this study aimed to assess the effects of gestational diabetes mellitus on the risk of adverse maternal outcomes in Northwest Ethiopia.

Methods

A prospective cohort study was conducted among pregnant women followed from pregnancy to delivery. Gestational diabetes mellitus status was determined by using a two-hour 75 g oral glucose tolerance test and based on updated international diagnostic criteria. Multivariable log-binomial model was used to examine the effects of gestational diabetes mellitus on the risk of adverse maternal outcomes.

Results

A total of 694 women completed the follow-up and included in the analysis. Women with gestational diabetes mellitus had a higher risk of composite adverse maternal outcome (ARR=1.58, 95% CI: 1.22, 2.04), caesarean delivery (ARR=1.67; 95%: 1.15, 2.44), pregnancy induced hypertension (ARR= 3.32; 95%: 1.55, 7.11), premature rupture of membranes (ARR= 1.83; 95%: 1.02, 3.27), antepartum hemorrhage (ARR= 2.10; 95%: 1.11, 3.98) and postpartum hemorrhage (ARR= 4.85; 95%:2.28, 10.30) compared to women without gestational diabetes mellitus.

Conclusions

Gestational diabetes mellitus increased the risk of adverse maternal outcomes. This implies that maternal care and intervention strategies relating to women with gestational diabetes mellitus should be strengthened.

Understanding Factors Leading to Primary Cesarean Section and Vaginal Birth After Cesarean Delivery in the Friuli-Venezia Giulia Region (North-Eastern Italy), 2005-2015

Although there is no evidence that elevated rates of cesarean sections (CS) translate into reduced maternal/child perinatal morbidity or mortality, CS have been increasingly overused almost everywhere, both in high and low-income countries. The primary cesarean section (PCS) has become a major driver of the overall CS (OCS) rate, since it carries intrinsic risk of repeat CS (RCS) in future pregnancies. In our study we examined patterns of PCS, pl compared with planned TOLAC anned PCS (PPCS), vaginal birth after 1 previous CS (VBAC-1) and associated factors in Friuli Venezia Giulia (FVG), a region of North-Eastern Italy, collecting data from its 11 maternity centres (coded from A to K) during 2005-2015. By fitting three multiple logistic regression models (one for each delivery mode), we calculated the adjusted rates of PCS and PPCS among women without history of CS, whilst the calculation of the VBAC rate was restricted to women with just one previous CS (VBAC-1). Results, expressed as odds ratio (OR) with 95% confidence interval (95%CI), were controlled for the effect of hospital, calendar year as well as several factors related to the clinical and obstetric conditions of the mothers and the newborn, the obstetric history and socio-demographic background. In FVG during 2005-2015 there were 24,467 OCS (rate of 24.2%), 19,565 PCS (19.6%), 7,736 PPCS (7.7%) and 2,303 VBAC-1 (28.4%). We found high variability of delivery mode (DM) at hospital level, especially for PCS and PPCS. Breech presentation was the strongest determinant for PCS as well as PPCS. Leaving aside placenta previa/abuptio placenta/ante-partum hemorrhage, further significant factors, more importantly associated with PCS than PPCS were non-reassuring fetal status and obstructed labour, followed by (in order of statistical significance): multiple birth; eclampsia/pre-eclampsia; maternal age 40-44 years; placental weight  600-99 g; oligohydramios; pre-delivery LoS 3-5 days; maternal age 35-39 years; placenta weight 1,000-1,500 g; birthweight < 2,000 g; maternal age ≥ 45 years; pre-delivery LoS ≥ 6 days; mother's age 30-34 years; low birthweight (2,000-2,500 g); polyhydramnions; cord prolaspe; ≥6 US scas performed during pregnancy and pre-term gestations (33-36 weeks). Significant factors for PPCS were (in order of statistical significance): breech presentation; placenta previa/abruptio placenta/ante-partum haemorrhage; multiple birth; pre-delivery LoS ≥ 3 days; placental weight ≥ 600 g; maternal age  40-44 years; ≥6 US scans performed in pregnancy; maternal age ≥ 45 and 35-39 years; oligohydramnios; eclampsia/pre-eclampsia; mother's age 30-34 years; birthweight <2,000 g; polyhydramnios and pre-term gestation (33-36 weeks). VBAC-1 were more likely with gestation ≥ 41 weeks, placental weight <500 g and especially labour analgesia. During 2005-2015 the overall rate of PCS in FVG (19.6%) was substantially lower than the corresponding figure reported in 2010 for the entire Italy (29%) and still slightly under the most recent national PCS rate for 2017 (22.2%). The VBAC-1 rate on women with history of one previous CS in FVG was 28.4% (25.3% considering VBAC on all women with at least 1 previous CS), roughly three times the Italian national rate of 9% reported for 2017. The discrepancy between the OCS rate at country level (38.1%) and FVG's (24.2%) is therefore mainly attributable to RCS. Although there was a marginal decrease of PCS and PPCS crudes rates over time in the whole region, accompained by a progressive enhancement of the crude VBAC rate, we found remarkable variability of DM across hospitals. To further contain the number of unnecessary PCS and promote VBAC where appropriate, standardized obstetric protocols should be introduced and enforced at hospital level. Decision-making on PCS should be carefully scrutinized, introducing a diagnostic second opinion for all PCS, particularly for term singleton pregancies with cephalic presentation and in case of obstructed labour as well as non-reassuring fetal status, grey areas potentially affected by subjective clinical assessment. This process of change could be facilitated with education of staff/patients by opinion leaders and prenatal counseling for women and partners, although clinical audits, financial penalties and rewards to efficient maternity centres could also be considered.