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Peaceman AM, Mele L, Rouse DJ, Leveno KJ, Mercer BM, Varner MW, Reddy UM, Wapner RJ, Sorokin Y, Thorp JM, Ramin SM, Malone FD, O’Sullivan MJ, Dudley DJ, Caritis SN. Prediction of Cerebral Palsy or Death among Preterm Infants Who Survive the Neonatal Period. Am J Perinatol 2024; 41:783-789. [PMID: 35253117 PMCID: PMC9440945 DOI: 10.1055/a-1788-6281] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To assess whether neonatal morbidities evident by the time of hospital discharge are associated with subsequent cerebral palsy (CP) or death. STUDY DESIGN This is a secondary analysis of data from a multicenter placebo-controlled trial of magnesium sulfate for the prevention of CP. The association between prespecified intermediate neonatal outcomes (n = 11) and demographic and clinical factors (n = 10) evident by the time of discharge among surviving infants (n = 1889) and the primary outcome of death or moderate/severe CP at age 2 (n = 73) was estimated, and a prediction model was created. RESULTS Gestational age in weeks at delivery (odds ratio [OR]: 0.74, 95% confidence interval [CI]: 0.67-0.83), grade III or IV intraventricular hemorrhage (IVH) (OR: 5.3, CI: 2.1-13.1), periventricular leukomalacia (PVL) (OR: 46.4, CI: 20.6-104.6), and male gender (OR: 2.5, CI: 1.4-4.5) were associated with death or moderate/severe CP by age 2. Outcomes not significantly associated with the primary outcome included respiratory distress syndrome, bronchopulmonary dysplasia, seizure, necrotizing enterocolitis, neonatal hypotension, 5-minute Apgar score, sepsis, and retinopathy of prematurity. Using all patients, the receiver operating characteristic curve for the final prediction model had an area under the curve of 0.84 (CI: 0.78-0.89). Using these data, the risk of death or developing CP by age 2 can be calculated for individual surviving infants. CONCLUSION IVH and PVL were the only neonatal complications evident at discharge that contributed to an individual infant's risk of the long-term outcomes of death or CP by age 2. A model that includes these morbidities, gestational age at delivery, and gender is predictive of subsequent neurologic sequelae. KEY POINTS · Factors known at hospital discharge are identified which are independently associated with death or CP by age 2.. · A model was created and validated using these findings to counsel parents.. · The risk of death or CP can be calculated at the time of hospital discharge..
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Affiliation(s)
- Alan M. Peaceman
- Departments of Obstetrics and Gynecology of: Northwestern University, Chicago, IL
| | - Lisa Mele
- George Washington University Biostatistics Center, Washington, DC
| | | | | | - Brian M. Mercer
- Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH, and University of Tennessee, Memphis, TN
| | | | - Uma M. Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Ronald J. Wapner
- Thomas Jefferson University and Drexel University, Philadelphia, PA
| | | | - John M. Thorp
- University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Susan M. Ramin
- University of Texas Health Science Center at Houston-Children’s Memorial Hermann Hospital, Houston, TX
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Mi X, Michailidis AA, Shabani S, Miao KC, Klimov PV, Lloyd J, Rosenberg E, Acharya R, Aleiner I, Andersen TI, Ansmann M, Arute F, Arya K, Asfaw A, Atalaya J, Bardin JC, Bengtsson A, Bortoli G, Bourassa A, Bovaird J, Brill L, Broughton M, Buckley BB, Buell DA, Burger T, Burkett B, Bushnell N, Chen Z, Chiaro B, Chik D, Chou C, Cogan J, Collins R, Conner P, Courtney W, Crook AL, Curtin B, Dau AG, Debroy DM, Del Toro Barba A, Demura S, Di Paolo A, Drozdov IK, Dunsworth A, Erickson C, Faoro L, Farhi E, Fatemi R, Ferreira VS, Burgos LF, Forati E, Fowler AG, Foxen B, Genois É, Giang W, Gidney C, Gilboa D, Giustina M, Gosula R, Gross JA, Habegger S, Hamilton MC, Hansen M, Harrigan MP, Harrington SD, Heu P, Hoffmann MR, Hong S, Huang T, Huff A, Huggins WJ, Ioffe LB, Isakov SV, Iveland J, Jeffrey E, Jiang Z, Jones C, Juhas P, Kafri D, Kechedzhi K, Khattar T, Khezri M, Kieferová M, Kim S, Kitaev A, Klots AR, Korotkov AN, Kostritsa F, Kreikebaum JM, Landhuis D, Laptev P, Lau KM, Laws L, Lee J, Lee KW, Lensky YD, Lester BJ, Lill AT, Liu W, Locharla A, Malone FD, Martin O, McClean JR, McEwen M, Mieszala A, Montazeri S, Morvan A, Movassagh R, Mruczkiewicz W, Neeley M, Neill C, Nersisyan A, Newman M, Ng JH, Nguyen A, Nguyen M, Niu MY, O'Brien TE, Opremcak A, Petukhov A, Potter R, Pryadko LP, Quintana C, Rocque C, Rubin NC, Saei N, Sank D, Sankaragomathi K, Satzinger KJ, Schurkus HF, Schuster C, Shearn MJ, Shorter A, Shutty N, Shvarts V, Skruzny J, Smith WC, Somma R, Sterling G, Strain D, Szalay M, Torres A, Vidal G, Villalonga B, Heidweiller CV, White T, Woo BWK, Xing C, Yao ZJ, Yeh P, Yoo J, Young G, Zalcman A, Zhang Y, Zhu N, Zobrist N, Neven H, Babbush R, Bacon D, Boixo S, Hilton J, Lucero E, Megrant A, Kelly J, Chen Y, Roushan P, Smelyanskiy V, Abanin DA. Stable quantum-correlated many-body states through engineered dissipation. Science 2024; 383:1332-1337. [PMID: 38513021 DOI: 10.1126/science.adh9932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 02/13/2024] [Indexed: 03/23/2024]
Abstract
Engineered dissipative reservoirs have the potential to steer many-body quantum systems toward correlated steady states useful for quantum simulation of high-temperature superconductivity or quantum magnetism. Using up to 49 superconducting qubits, we prepared low-energy states of the transverse-field Ising model through coupling to dissipative auxiliary qubits. In one dimension, we observed long-range quantum correlations and a ground-state fidelity of 0.86 for 18 qubits at the critical point. In two dimensions, we found mutual information that extends beyond nearest neighbors. Lastly, by coupling the system to auxiliaries emulating reservoirs with different chemical potentials, we explored transport in the quantum Heisenberg model. Our results establish engineered dissipation as a scalable alternative to unitary evolution for preparing entangled many-body states on noisy quantum processors.
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Affiliation(s)
- X Mi
- Google Research, Mountain View, CA, USA
| | - A A Michailidis
- Department of Theoretical Physics, University of Geneva, Geneva, Switzerland
| | - S Shabani
- Google Research, Mountain View, CA, USA
| | - K C Miao
- Google Research, Mountain View, CA, USA
| | | | - J Lloyd
- Department of Theoretical Physics, University of Geneva, Geneva, Switzerland
| | | | - R Acharya
- Google Research, Mountain View, CA, USA
| | - I Aleiner
- Google Research, Mountain View, CA, USA
| | | | - M Ansmann
- Google Research, Mountain View, CA, USA
| | - F Arute
- Google Research, Mountain View, CA, USA
| | - K Arya
- Google Research, Mountain View, CA, USA
| | - A Asfaw
- Google Research, Mountain View, CA, USA
| | - J Atalaya
- Google Research, Mountain View, CA, USA
| | - J C Bardin
- Google Research, Mountain View, CA, USA
- Department of Electrical and Computer Engineering, University of Massachusetts, Amherst, MA, USA
| | | | - G Bortoli
- Google Research, Mountain View, CA, USA
| | | | - J Bovaird
- Google Research, Mountain View, CA, USA
| | - L Brill
- Google Research, Mountain View, CA, USA
| | | | | | - D A Buell
- Google Research, Mountain View, CA, USA
| | - T Burger
- Google Research, Mountain View, CA, USA
| | - B Burkett
- Google Research, Mountain View, CA, USA
| | | | - Z Chen
- Google Research, Mountain View, CA, USA
| | - B Chiaro
- Google Research, Mountain View, CA, USA
| | - D Chik
- Google Research, Mountain View, CA, USA
| | - C Chou
- Google Research, Mountain View, CA, USA
| | - J Cogan
- Google Research, Mountain View, CA, USA
| | - R Collins
- Google Research, Mountain View, CA, USA
| | - P Conner
- Google Research, Mountain View, CA, USA
| | | | - A L Crook
- Google Research, Mountain View, CA, USA
| | - B Curtin
- Google Research, Mountain View, CA, USA
| | - A G Dau
- Google Research, Mountain View, CA, USA
| | | | | | - S Demura
- Google Research, Mountain View, CA, USA
| | | | | | | | | | - L Faoro
- Google Research, Mountain View, CA, USA
| | - E Farhi
- Google Research, Mountain View, CA, USA
| | - R Fatemi
- Google Research, Mountain View, CA, USA
| | | | | | - E Forati
- Google Research, Mountain View, CA, USA
| | | | - B Foxen
- Google Research, Mountain View, CA, USA
| | - É Genois
- Google Research, Mountain View, CA, USA
| | - W Giang
- Google Research, Mountain View, CA, USA
| | - C Gidney
- Google Research, Mountain View, CA, USA
| | - D Gilboa
- Google Research, Mountain View, CA, USA
| | | | - R Gosula
- Google Research, Mountain View, CA, USA
| | - J A Gross
- Google Research, Mountain View, CA, USA
| | | | - M C Hamilton
- Google Research, Mountain View, CA, USA
- Department of Electrical and Computer Engineering, Auburn University, Auburn, AL, USA
| | - M Hansen
- Google Research, Mountain View, CA, USA
| | | | | | - P Heu
- Google Research, Mountain View, CA, USA
| | | | - S Hong
- Google Research, Mountain View, CA, USA
| | - T Huang
- Google Research, Mountain View, CA, USA
| | - A Huff
- Google Research, Mountain View, CA, USA
| | | | - L B Ioffe
- Google Research, Mountain View, CA, USA
| | | | - J Iveland
- Google Research, Mountain View, CA, USA
| | - E Jeffrey
- Google Research, Mountain View, CA, USA
| | - Z Jiang
- Google Research, Mountain View, CA, USA
| | - C Jones
- Google Research, Mountain View, CA, USA
| | - P Juhas
- Google Research, Mountain View, CA, USA
| | - D Kafri
- Google Research, Mountain View, CA, USA
| | | | - T Khattar
- Google Research, Mountain View, CA, USA
| | - M Khezri
- Google Research, Mountain View, CA, USA
| | - M Kieferová
- Google Research, Mountain View, CA, USA
- Centre for Quantum Software and Information (QSI), Faculty of Engineering and Information Technology, University of Technology Sydney, Sydney, NSW, Australia
| | - S Kim
- Google Research, Mountain View, CA, USA
| | - A Kitaev
- Google Research, Mountain View, CA, USA
| | - A R Klots
- Google Research, Mountain View, CA, USA
| | - A N Korotkov
- Google Research, Mountain View, CA, USA
- Department of Electrical and Computer Engineering, University of California, Riverside, CA, USA
| | | | | | | | - P Laptev
- Google Research, Mountain View, CA, USA
| | - K-M Lau
- Google Research, Mountain View, CA, USA
| | - L Laws
- Google Research, Mountain View, CA, USA
| | - J Lee
- Google Research, Mountain View, CA, USA
- Department of Chemistry, Columbia University, New York, NY, USA
| | - K W Lee
- Google Research, Mountain View, CA, USA
| | | | | | - A T Lill
- Google Research, Mountain View, CA, USA
| | - W Liu
- Google Research, Mountain View, CA, USA
| | | | | | - O Martin
- Google Research, Mountain View, CA, USA
| | | | - M McEwen
- Google Research, Mountain View, CA, USA
| | | | | | - A Morvan
- Google Research, Mountain View, CA, USA
| | | | | | - M Neeley
- Google Research, Mountain View, CA, USA
| | - C Neill
- Google Research, Mountain View, CA, USA
| | | | - M Newman
- Google Research, Mountain View, CA, USA
| | - J H Ng
- Google Research, Mountain View, CA, USA
| | - A Nguyen
- Google Research, Mountain View, CA, USA
| | - M Nguyen
- Google Research, Mountain View, CA, USA
| | - M Y Niu
- Google Research, Mountain View, CA, USA
| | | | | | | | - R Potter
- Google Research, Mountain View, CA, USA
| | - L P Pryadko
- Google Research, Mountain View, CA, USA
- Department of Physics and Astronomy, University of California, Riverside, CA, USA
| | | | - C Rocque
- Google Research, Mountain View, CA, USA
| | - N C Rubin
- Google Research, Mountain View, CA, USA
| | - N Saei
- Google Research, Mountain View, CA, USA
| | - D Sank
- Google Research, Mountain View, CA, USA
| | | | | | | | | | | | - A Shorter
- Google Research, Mountain View, CA, USA
| | - N Shutty
- Google Research, Mountain View, CA, USA
| | - V Shvarts
- Google Research, Mountain View, CA, USA
| | - J Skruzny
- Google Research, Mountain View, CA, USA
| | - W C Smith
- Google Research, Mountain View, CA, USA
| | - R Somma
- Google Research, Mountain View, CA, USA
| | | | - D Strain
- Google Research, Mountain View, CA, USA
| | - M Szalay
- Google Research, Mountain View, CA, USA
| | - A Torres
- Google Research, Mountain View, CA, USA
| | - G Vidal
- Google Research, Mountain View, CA, USA
| | | | | | - T White
- Google Research, Mountain View, CA, USA
| | - B W K Woo
- Google Research, Mountain View, CA, USA
| | - C Xing
- Google Research, Mountain View, CA, USA
| | - Z J Yao
- Google Research, Mountain View, CA, USA
| | - P Yeh
- Google Research, Mountain View, CA, USA
| | - J Yoo
- Google Research, Mountain View, CA, USA
| | - G Young
- Google Research, Mountain View, CA, USA
| | - A Zalcman
- Google Research, Mountain View, CA, USA
| | - Y Zhang
- Google Research, Mountain View, CA, USA
| | - N Zhu
- Google Research, Mountain View, CA, USA
| | - N Zobrist
- Google Research, Mountain View, CA, USA
| | - H Neven
- Google Research, Mountain View, CA, USA
| | - R Babbush
- Google Research, Mountain View, CA, USA
| | - D Bacon
- Google Research, Mountain View, CA, USA
| | - S Boixo
- Google Research, Mountain View, CA, USA
| | - J Hilton
- Google Research, Mountain View, CA, USA
| | - E Lucero
- Google Research, Mountain View, CA, USA
| | - A Megrant
- Google Research, Mountain View, CA, USA
| | - J Kelly
- Google Research, Mountain View, CA, USA
| | - Y Chen
- Google Research, Mountain View, CA, USA
| | - P Roushan
- Google Research, Mountain View, CA, USA
| | | | - D A Abanin
- Google Research, Mountain View, CA, USA
- Department of Theoretical Physics, University of Geneva, Geneva, Switzerland
- Department of Physics, Princeton University, Princeton, NJ, USA
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3
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Finnegan C, Dicker P, Asandei D, Higgins M, O'Gorman N, O' Riordan M, Dunne F, Gaffney G, Newman C, McAuliffe F, Ciprike V, Fernandez E, Malone FD, Breathnach FM. The IRELAnD study-investigating the role of early low-dose aspirin in diabetes mellitus: a double-blinded, placebo-controlled, randomized trial. Am J Obstet Gynecol MFM 2024:101297. [PMID: 38461094 DOI: 10.1016/j.ajogmf.2024.101297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 01/19/2024] [Indexed: 03/11/2024]
Abstract
BACKGROUND Although aspirin therapy is being increasingly advocated with the intention of risk modification for a wide range of pregnancy complications, women with prepregnancy diabetes mellitus are commonly excluded from clinical trials. OBJECTIVE The primary aim of this study was to examine the effect of aspirin therapy on a composite measure of adverse perinatal outcome in pregnancies complicated by pregestational diabetes mellitus. STUDY DESIGN A double-blinded, placebo-controlled randomized trial was conducted at 6 university-affiliated perinatology centers. Women with type 1 diabetes mellitus or type 2 diabetes mellitus of at least 6 months' duration were randomly allocated to 150-mg daily aspirin or placebo from 11 to 14 weeks' gestation until 36 weeks. Established vascular complications of diabetes mellitus, including chronic hypertension or nephropathy, led to exclusion from the trial. The primary outcome was a composite measure of placental dysfunction (preeclampsia, fetal growth restriction, preterm birth <34 weeks' gestation, or perinatal mortality). The planned sample size was 566 participants to achieve a 35% reduction in the primary outcome, assuming 80% statistical power. Secondary end points included maternal and neonatal outcomes and determination of insulin requirements across gestation. Data were centrally managed using ClinInfo and analyzed using SAS 9.4. The 2 treatment groups were compared using t tests or chi-square tests, as required, and longitudinal data were compared using a repeated-measures analysis. RESULTS From February 2020 to September 2022, 191 patients were deemed eligible, 134 of whom were enrolled (67 randomized to aspirin and 67 to placebo) with a retrospective power of 64%. A total of 101 (80%) women had type 1 diabetes mellitus and 25 (20%) had type 2 diabetes mellitus. Reaching the target sample size was limited by the impact of the COVID-19 pandemic. Baseline characteristics were similar between the aspirin and placebo groups. Treatment compliance was very high and similar between groups (97% for aspirin, 94% for placebo). The risk of the composite measure of placental dysfunction did not differ between groups (25% aspirin vs 21% placebo; P=.796). Women in the aspirin group had significantly lower insulin requirements throughout pregnancy compared with the placebo group. Insulin requirements in the aspirin group increased on average from 0.7 units/kg at baseline to 1.1 units/kg by 36 weeks' gestation (an average 83% within-patient increase), and increased from 0.7 units/kg to 1.3 units/kg (a 181% within-patient increase) in the placebo group, over the same gestational period (P=.002). Serial hemoglobin A1c levels were lower in the aspirin group than in the placebo group, although this trend did not reach statistical significance. CONCLUSION In this multicenter, double-blinded, placebo-controlled randomized trial, aspirin did not reduce the risk of adverse perinatal outcome in pregnancies complicated by prepregnancy diabetes mellitus. Compared with the placebo group, aspirin-treated patients required significantly less insulin throughout pregnancy, indicating a beneficial effect of aspirin on glycemic control. Aspirin may exert a plausible placenta-mediated effect on pregestational diabetes mellitus that is not limited to its antithrombotic properties.
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Affiliation(s)
- Catherine Finnegan
- RCSI Fetal Centre, Rotunda Hospital, Dublin, Ireland (PhD Finnegan, MSc Dicker, MPhil Asandei, MD Breathnach and MD Malone).
| | - Patrick Dicker
- RCSI Fetal Centre, Rotunda Hospital, Dublin, Ireland (PhD Finnegan, MSc Dicker, MPhil Asandei, MD Breathnach and MD Malone)
| | - Denisa Asandei
- RCSI Fetal Centre, Rotunda Hospital, Dublin, Ireland (PhD Finnegan, MSc Dicker, MPhil Asandei, MD Breathnach and MD Malone)
| | - Mary Higgins
- UCD Perinatal Research Centre, University College Dublin, National Maternity Hospital, Dublin, Ireland (MD Higgins and FRCOG McAuliffe)
| | - Neil O'Gorman
- Coombe Women and Infants University Hospital, Dublin, Ireland (MD O'Gorman)
| | - Mairead O' Riordan
- Infant Research Centre, Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland (MRCOG O' Riordan)
| | - Fidelma Dunne
- University College Hospital Galway, Galway, Ireland (PhD Dunne, MD Gaffney, and MD Newman)
| | - Geraldine Gaffney
- University College Hospital Galway, Galway, Ireland (PhD Dunne, MD Gaffney, and MD Newman)
| | - Christine Newman
- University College Hospital Galway, Galway, Ireland (PhD Dunne, MD Gaffney, and MD Newman)
| | - Fionnuala McAuliffe
- UCD Perinatal Research Centre, University College Dublin, National Maternity Hospital, Dublin, Ireland (MD Higgins and FRCOG McAuliffe)
| | - Vineta Ciprike
- Our Lady of Lourdes Hospital, Drogheda, Ireland (MD Ciprike)
| | | | - Fergal D Malone
- RCSI Fetal Centre, Rotunda Hospital, Dublin, Ireland (PhD Finnegan, MSc Dicker, MPhil Asandei, MD Breathnach and MD Malone)
| | - Fionnuala M Breathnach
- RCSI Fetal Centre, Rotunda Hospital, Dublin, Ireland (PhD Finnegan, MSc Dicker, MPhil Asandei, MD Breathnach and MD Malone)
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4
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Khalil A, Bellesia G, Norton ME, Jacobsson B, Haeri S, Egbert M, Malone FD, Wapner RJ, Roman A, Faro R, Madankumar R, Strong N, Silver RM, Vohra N, Hyett J, Macpherson C, Prigmore B, Ahmed E, Demko Z, Ortiz JB, Souter V, Dar P. The Role of cfDNA Biomarkers and Patient Data in the Early Prediction of Preeclampsia: Artificial Intelligence Model. Am J Obstet Gynecol 2024:S0002-9378(24)00380-6. [PMID: 38432413 DOI: 10.1016/j.ajog.2024.02.299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 02/16/2024] [Accepted: 02/22/2024] [Indexed: 03/05/2024]
Abstract
OBJECTIVE Accurate individualized assessment of preeclampsia risk enables the identification of patients most likely to benefit from initiation of low-dose aspirin at 12-16 weeks' gestation when there is evidence for its effectiveness, as well as guiding appropriate pregnancy care pathways and surveillance. The primary objective of this study was to evaluate the performance of artificial neural network models for the prediction of preterm preeclampsia (<37 weeks' gestation) using patient characteristics available at the first antenatal visit and data from prenatal cell-free DNA (cfDNA) screening. Secondary outcomes were prediction of early onset preeclampsia (<34 weeks' gestation) and term preeclampsia (≥37 weeks' gestation). METHODS This secondary analysis of a prospective, multicenter, observational prenatal cfDNA screening study (SMART) included singleton pregnancies with known pregnancy outcomes. Thirteen patient characteristics that are routinely collected at the first prenatal visit and two characteristics of cfDNA, total cfDNA and fetal fraction (FF), were used to develop predictive models for early-onset (<34 weeks), preterm (<37 weeks), and term (≥37 weeks) preeclampsia. For the models, the 'reference' classifier was a shallow logistic regression (LR) model. We also explored several feedforward (non-linear) neural network (NN) architectures with one or more hidden layers and compared their performance with the LR model. We selected a simple NN model built with one hidden layer and made up of 15 units. RESULTS Of 17,520 participants included in the final analysis, 72 (0.4%) developed early onset, 251 (1.4%) preterm, and 420 (2.4%) term preeclampsia. Median gestational age at cfDNA measurement was 12.6 weeks and 2,155 (12.3%) had their cfDNA measurement at 16 weeks' gestation or greater. Preeclampsia was associated with higher total cfDNA (median 362.3 versus 339.0 copies/ml cfDNA; p<0.001) and lower FF (median 7.5% versus 9.4%; p<0.001). The expected, cross-validated area under the curve (AUC) scores for early onset, preterm, and term preeclampsia were 0.782, 0.801, and 0.712, respectively for the LR model, and 0.797, 0.800, and 0.713, respectively for the NN model. At a screen-positive rate of 15%, sensitivity for preterm preeclampsia was 58.4% (95% CI 0.569, 0.599) for the LR model and 59.3% (95% CI 0.578, 0.608) for the NN model.The contribution of both total cfDNA and FF to the prediction of term and preterm preeclampsia was negligible. For early-onset preeclampsia, removal of the total cfDNA and FF features from the NN model was associated with a 6.9% decrease in sensitivity at a 15% screen positive rate, from 54.9% (95% CI 52.9-56.9) to 48.0% (95% CI 45.0-51.0). CONCLUSION Routinely available patient characteristics and cfDNA markers can be used to predict preeclampsia with performance comparable to other patient characteristic models for the prediction of preterm preeclampsia. Both LR and NN models showed similar performance.
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Affiliation(s)
- Asma Khalil
- Department of Obstetrics and Gynaecology, St. George's University Hospital, University of London, London, England, UK.
| | | | - Mary E Norton
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, San Francisco, CA, USA
| | - Bo Jacobsson
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg Sweden; Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg Sweden
| | - Sina Haeri
- Austin Maternal-Fetal Medicine, Austin, TX, USA
| | | | - Fergal D Malone
- Department of Obstetrics and Gynecology, Rotunda Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Columbia University Irving Medical Center, New York, NY, USA
| | - Ashley Roman
- Department of Obstetrics and Gynecology, New York University Grossman School of Medicine, New York, NY, USA
| | - Revital Faro
- Department of Obstetrics and Gynecology, Saint Peter's University Hospital, New Brunswick, NJ
| | - Rajeevi Madankumar
- Department of Obstetrics and Gynecology, Long Island Jewish Medical Center, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY, USA
| | - Noel Strong
- Department of Obstetrics and Gynecology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, UT, USA
| | - Nidhi Vohra
- Department of Obstetrics and Gynecology, North Shore University Hospital, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY, USA
| | - Jon Hyett
- Department of Obstetrics and Gynecology, Royal Prince Alfred Hospital, Western Sydney University, Camperdown, NSW, Australia
| | - Cora Macpherson
- The Biostatistics Center, George Washington University, Rockville, MD, USA
| | | | | | | | | | | | - Pe'er Dar
- Department of Obstetrics and Gynecology and Women's Health, Montefiore Medical Center, Albert Einstein College of Medicine, The Bronx, NY, USA
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5
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Tita ATN, McGee PL, Reddy UM, Bloom SL, Varner MW, Ramin SM, Caritis SN, Peaceman AM, Sorokin Y, Sciscione A, Carpenter MW, Mercer BM, Thorp JM, Malone FD, Buhimschi C. Fetal Tachycardia in the Setting of Maternal Intrapartum Fever and Perinatal Morbidity. Am J Perinatol 2024; 41:160-166. [PMID: 34670321 PMCID: PMC9018887 DOI: 10.1055/a-1675-0901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The fetal consequences of intrapartum fetal tachycardia with maternal fever or clinical chorioamnionitis are not well studied. We evaluated the association between perinatal morbidity and fetal tachycardia in the setting of intrapartum fever. STUDY DESIGN Secondary analysis of a multicenter randomized control trial that enrolled 5,341 healthy laboring nulliparous women ≥36 weeks' gestation. Women with intrapartum fever ≥ 38.0°C (including those meeting criteria for clinical chorioamnionitis) after randomization were included in this analysis. Isolated fetal tachycardia was defined as fetal heart rate (FHR) ≥160 beats per minute for at least 10 minutes in the absence of other FHR abnormalities. FHR abnormalities other than tachycardia were excluded from the analysis. The primary outcome was a perinatal composite (5-minute Apgar's score ≤3, intubation, chest compressions, or mortality). Secondary outcomes included low arterial cord pH (pH < 7.20), base deficit ≥12, and cesarean delivery. RESULTS A total of 986 (18.5%) of women in the trial developed intrapartum fever, and 728 (13.7%) met criteria to be analyzed; of these, 728 women 336 (46.2%) had maternal-fetal medicine (MFM) reviewer-defined fetal tachycardia, and 349 of the 550 (63.5%) women during the final hour of labor had validated software (PeriCALM) defined fetal tachycardia. After adjusting for confounders, isolated fetal tachycardia was not associated with a significant difference in the composite perinatal outcome (adjusted odds ratio [aOR] = 3.15 [0.82-12.03]) compared with absence of tachycardia. Fetal tachycardia was associated with higher odds of arterial cord pH <7.2, aOR = 1.48 (1.01-2.17) and of infants with a base deficit ≥ 12, aOR = 2.42 (1.02-5.77), but no significant difference in the odds of cesarean delivery, aOR = 1.33 (0.97-1.82). CONCLUSION Fetal tachycardia in the setting of intrapartum fever or chorioamnionitis is associated with significantly increased fetal acidemia defined as a pH <7.2 and base excess ≥12 but not with a composite perinatal morbidity. KEY POINTS · The perinatal outcomes associated with fetal tachycardia in the setting of maternal fever are undefined.. · Fetal tachycardia was not significantly associated with perinatal morbidity although the sample size was limited.. · Fetal tachycardia was associated with an arterial cord pH <7.2 and base deficit of 12 or greater..
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Affiliation(s)
- Alan T. N. Tita
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Paula L. McGee
- George Washington University Biostatistics Center, Washington, Dist. of Columbia
| | - Uma M. Reddy
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
| | - Steven L. Bloom
- University of Texas Southwestern Medical Center, Dallas, Texas
| | | | - Susan M. Ramin
- The University of Texas Health Science Center at Houston-Children’s Memorial Herman Hospital Houston, Texas
| | | | | | | | | | | | - Brian M. Mercer
- MetroHealth Medical Center- Case Western Reserve University, Cleveland, Ohio
| | - John M. Thorp
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Deter RL, Lee W, Dicker P, Breathnach F, Molphy Z, Malone FD. Can growth in dichorionic twins be monitored with individualized growth assessment? Ultrasound Obstet Gynecol 2023; 62:829-835. [PMID: 37488689 DOI: 10.1002/uog.26320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 06/16/2023] [Accepted: 06/22/2023] [Indexed: 07/26/2023]
Abstract
OBJECTIVE To characterize fetal growth in dichorionic twins using individualized growth assessment (IGA), a method based on individual growth potential estimates. METHODS This secondary analysis included 286 fetuses/neonates from 143 dichorionic twin pregnancies that were part of the ESPRiT (Evaluation of Sonographic Predictors of Restricted Growth in Twins) study. The sample was subcategorized according to birth weight into appropriate-for-gestational-age (AGA) (n = 243) and small-for-gestational-age (SGA) (n = 43) cohorts. Serial biometric scans evaluating biparietal diameter, head circumference (HC), abdominal circumference, femur diaphysis length and estimated weight at 2-week intervals were used to evaluate fetal growth, while measurements of birth weight, crown-heel length and HC determined neonatal growth outcome. Six abnormalities (hypoxic ischemic encephalopathy, periventricular leukomalacia, necrotizing enterocolitis, respiratory distress, sepsis and death) constituted the evaluated adverse neonatal outcomes (ANO). IGA was used to: evaluate differences in second-trimester growth velocities between singletons (from a published dataset) and dichorionic twins (138 AGA twins with normal third-trimester growth); describe the degree to which actual third-trimester growth in twins followed expected growth (111 AGA twins, normal fetal growth and neonatal growth outcomes); determine if the fetal growth pathology score 1 (-FGPS1) could detect, quantify and classify twin growth pathology (224 AGA, 42 SGA); and assess the relationship between -FGPS1 and ANO (24 SGA twins with progressive growth restriction confirmed by abnormal neonatal growth outcome). RESULTS The differences in second-trimester growth velocity between singletons and twins (means and variances) were small and not statistically significant. Percent deviations from the expected third-trimester size trajectories were within the 95% reference ranges derived from singletons at 95.7% (1677/1752) of timepoints studied. Abnormal growth was detected in 37.9% of AGA twins and 85.7% of SGA twins. Growth restriction was more heterogeneous in AGA twins, while in SGA twins progressive growth restriction was the principal type (66.7%). -FGPS1 patterns previously defined in singletons classified 97.5% of pathological twin cases. In our most severe form of growth restriction (progressive), there were only three (12.5%) ANOs related to growth abnormalities, all in cases with -FGPS1 values more negative than -2.0%. Using these criteria, the frequency of ANO was 33%. CONCLUSIONS With respect to growth, dichorionic twins can be considered as two singletons in the same uterus. Normally growing dichorionic twins have the same growth potential as singletons with normal growth outcome. These twins also follow expected third-trimester growth trajectories with the same precision as do singletons. Third-trimester growth pathology can be detected, quantified and classified using -FGPS1 as in singletons. Limited evidence of a relationship between fetal growth abnormalities and adverse neonatal outcome was found. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R L Deter
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - W Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - P Dicker
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - F Breathnach
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Z Molphy
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - F D Malone
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
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McEvoy A, Corbett GA, Nolan C, Daly R, Murnane M, Higgins S, Malone FD, O'Connell MP, Hehir MP, Walsh JM. Outcomes of Uterine Rupture in the Setting of the Unscarred Compared With the Scarred Uterus. Obstet Gynecol 2023; 141:854-856. [PMID: 36897156 DOI: 10.1097/aog.0000000000005108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/15/2022] [Indexed: 03/11/2023]
Abstract
Uterine rupture is a rare obstetric complication that is associated with maternal and neonatal morbidity and mortality. The aim of this study was to examine uterine rupture and its outcomes in the setting of the unscarred compared with the scarred uterus. A retrospective observational cohort study was performed examining all cases of uterine rupture in three tertiary care hospitals in Dublin, Ireland, over a 20-year period. The primary outcome was perinatal mortality rate with uterine rupture, which was 11.02% (95% CI 6.5-17.3). There was no significant difference in perinatal mortality between cases of scarred and unscarred uterine rupture. Unscarred uterine rupture was associated with higher maternal morbidity , defined as major obstetric hemorrhage or hysterectomy.
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Affiliation(s)
- Aoife McEvoy
- National Maternity Hospital, the Coombe Women and Infants University Hospital, the Rotunda Hospital, the Royal College of Surgeons in Ireland, and the University College Dublin, Dublin, Ireland
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Ryan A, Malone EC, Murphy S, Maher N, Malone FD. Epilepsy in pregnancy – patient safety challenges in contemporary practice. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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9
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Mackin D, Cuzzilla R, Boyle M, Colleran G, Hassett S, Healy M, Hickey A, Malone FD, Mullers S. Mind the gap: identifying opportunities for fetal intervention for congenital diaphragmatic hernia in Ireland. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.1061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Nicholson SM, Oprescu C, El Nimr S, Dicker P, Molphy Z, Hatt S, Curtin E, Doyle L, Flood K, Malone FD. Labour roulette: probability of achieving spontaneous onset of labour in low risk nulliparous pregnancies. Am J Obstet Gynecol 2023. [DOI: 10.1016/j.ajog.2022.11.685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Ryan GA, Finnegan C, McAuliffe FM, Malone FD, Müllers SM, Corcoran S, Mulcahy C, Dalrymple J, Donnelly J, Walsh J, Mcparland P, Martin A, Carroll S, Kent E. Fetoscopic Laser Ablation for Twin-to-Twin Transfusion Syndrome: A 15-year Review of Perinatal Survival. Ir Med J 2022; 115:595. [PMID: 35696199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Objective Twin to twin transfusion syndrome (TTTS) complicates 5-15% of monochorionic twin pregnancies and untreated is associated with a 90% mortality rate. The aim was to present the perinatal survival of patients with TTTS treated with laser ablation, by a national fetal medicine team. Methods This was a review of all cases of TTTS treated with fetoscopic laser ablation performed from March 2006 through to December 2020. All patients treated with fetoscopic laser were identified from the hospital database. The perinatal outcomes for the overall cohort and the individual Quintero stages were determined. Results A total of 155 cases of TTTS underwent fetoscopic laser ablation during the study period. The median gestational age at diagnosis was 19+1 weeks, with a mean growth discordance of 23.6%. The Quintero stage at diagnosis was: Stage 1 6.5% (10/155), Stage 2 49% (76/155), Stage 3 38.7% (60/155), Stage 4 5.8% (9/155). There was at least one survivor in 83.2% (129/155) of pregnancies, with dual survival in 52.9% (82/155). An increase in the rate of any survivor was observed from 75% (2006-2014) to 94% (2014-2020) (p<0.05). Dual survival decreased with increasing Quintero Stage (p<0.05). 80.6% (125/155) of pregnancies delivered prior to 34+6 weeks gestation. Conclusion Fetoscopic laser ablation is the recommended first line treatment for severe TTTS. We observed a survival rate of at least one twin in 83.2% pregnancies which is comparable to internationally published data on single-centre outcomes.
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Affiliation(s)
- G A Ryan
- Department of Obstetrics and Gynaecology, The National Maternity Hospital, Dublin, Ireland
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - C Finnegan
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin, Ireland
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Dublin, Ireland
| | - F M McAuliffe
- Department of Obstetrics and Gynaecology, The National Maternity Hospital, Dublin, Ireland
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - F D Malone
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin, Ireland
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Dublin, Ireland
| | - S M Müllers
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin, Ireland
| | - S Corcoran
- Department of Obstetrics and Gynaecology, The National Maternity Hospital, Dublin, Ireland
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - C Mulcahy
- Department of Obstetrics and Gynaecology, The National Maternity Hospital, Dublin, Ireland
| | - J Dalrymple
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin, Ireland
| | - J Donnelly
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin, Ireland
- UCD Obstetrics & Gynaecology, University College Dublin, Ireland
| | - J Walsh
- Department of Obstetrics and Gynaecology, The National Maternity Hospital, Dublin, Ireland
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - P Mcparland
- Department of Obstetrics and Gynaecology, The National Maternity Hospital, Dublin, Ireland
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - A Martin
- UCD Obstetrics & Gynaecology, University College Dublin, Ireland
- Department of Obstetrics and Gynaecology, The Coombe Women And Infants University Hospital, Dublin, Ireland
| | - S Carroll
- Department of Obstetrics and Gynaecology, The National Maternity Hospital, Dublin, Ireland
| | - E Kent
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin, Ireland
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Daly R, Nicholson SM, Smyth S, Dicker P, Malone FD. A Losing Game? – Recent trends in success rates of vaginal birth after Caesarean Section. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Dar P, MacPherson C, Jacobsson B, Egbert M, Malone FD, Wapner RJ, Roman AS, Khalil A, Faro R, Madankumar R, Edwards L, Strong N, Haeri S, Silver RM, Vohra N, Hyett J, Clifton R, Kao C, Martin K, Demko Z, Norton ME. cfDNA prenatal screening for Cri-Du-Chat, Prader-Willi/Angelman and 1p36del syndromes in 10,971 pregnancies with genetic confirmation. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Deter RL, Lee W, Dicker P, Tully EC, Cody F, Malone FD, Flood KM. Third-trimester growth diversity in small fetuses classified as appropriate-for-gestational age or small-for-gestational age at birth. Ultrasound Obstet Gynecol 2021; 58:882-891. [PMID: 33998089 DOI: 10.1002/uog.23688] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 04/01/2021] [Accepted: 05/10/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE We have shown previously that third-trimester growth in small fetuses (estimated fetal weight (EFW) < 10th percentile) with birth weight (BW) < 10th percentile is heterogeneous using individualized growth assessment (IGA). We aimed to test our hypothesis that individual growth patterns in small fetuses with BW > 10th percentile are also variable but in different ways. METHODS This was a study of 191 cases with EFW < 10th percentile and BW > 10th percentile (appropriate-for-gestational-age (AGA) cohort), derived from the PORTO study. Composite size parameters were used to quantify growth pathology at individual third-trimester timepoints (individual composite prenatal growth assessment score (-icPGAS)). The fetal growth pathology score 1 (-FGPS1), calculated cumulatively from serial -icPGAS values, was used to characterize third-trimester growth patterns. Vascular-system evaluation included umbilical artery (UA) and middle cerebral artery (MCA) Doppler velocimetry. Outcome variables were birth age (preterm/term delivery) and BW (expressed as growth potential realization index for weight (GPRIWT ) and percentile). The findings from the AGA cohort were compared with those from small fetuses (EFW < 10th percentile) with BW < 10th percentile (small-for-gestational-age (SGA) cohort). RESULTS The AGA cohort was found to have 134 fetuses (70%) with normal growth pattern and 57 (30%) with growth restriction based on IGA criteria. Seven growth-restriction -FGPS1 patterns were observed, including the previously defined progressive, late, adaptive and recovering types. The recovering type was the most common growth pattern in the AGA cohort (50.9%). About one-third of fetuses without any evidence of growth restriction had significant unexplained abnormalities in the UA (34%) and MCA (31%) and elevated mean GPRIWT values (113 ± 12.5%). Comparison of the AGA and SGA cohorts indicated a significant difference in the distribution of -FGPS1 growth patterns (P = 0.0001). Compared with the SGA cohort, the AGA cohort had more fetuses with a normal growth pattern (70% vs 38%) and fewer cases with growth restriction (30% vs 62%). While the recovering type was the most common growth-restriction pattern in the AGA cohort (51%), the progressive type was the primary growth-restriction pattern in the SGA cohort (44%). No difference in the incidence of MCA or UA abnormality was found between the SGA and AGA cohorts when comparing subgroups of more than 10 fetuses. CONCLUSIONS Both normal-growth and growth-restriction patterns were observed in the AGA cohort using IGA, as seen previously in the SGA cohort. The seven types of growth restriction defined in the SGA cohort were also identified in AGA cases, but their distribution was significantly different. In one-third of cases without evidence of growth pathology in the AGA cohort, Doppler abnormalities in the UA and MCA were seen. This heterogeneity underscores the difficulty of accurate classification of fetal and neonatal growth status using conventional population-based methods. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- R L Deter
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - W Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - P Dicker
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - E C Tully
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - F Cody
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - F D Malone
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - K M Flood
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
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15
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Murphy CA, O'Reilly DP, Edebiri O, Weiss L, Cullivan S, El-Khuffash A, Doyle E, Donnelly JC, Malone FD, Ferguson W, Drew RJ, O'Loughlin J, Neary E, Maguire PB, Kevane B, NíAinle F, McCallion N. Haematological parameters and coagulation in umbilical cord blood following COVID-19 infection in pregnancy. Eur J Obstet Gynecol Reprod Biol 2021; 266:99-105. [PMID: 34601263 PMCID: PMC8454187 DOI: 10.1016/j.ejogrb.2021.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/01/2021] [Accepted: 09/17/2021] [Indexed: 11/15/2022]
Abstract
Objective The aim of this study was to evaluate infants, born to women with SARS-CoV-2 detected during pregnancy, for evidence of haematological abnormalities or hypercoagulability in umbilical cord blood. Study design This was a prospective observational case-control study of infants born to women who had SARS-CoV-2 RNA detected by PCR at any time during their pregnancy (n = 15). The study was carried out in a Tertiary University Maternity Hospital (8,500 deliveries/year) in Ireland. This study was approved by the Hospital Research Ethics Committee and written consent was obtained. Umbilical cord blood samples were collected at delivery, full blood count and Calibrated Automated Thrombography were performed. Demographics and clinical outcomes were recorded. Healthy term infants, previously recruited as controls to a larger study prior to the outbreak of COVID-19, were the historical control population (n = 10). Results Infants born to women with SARS-CoV-2 had similar growth parameters (birth weight 3600 g v 3680 g, p = 0.83) and clinical outcomes to healthy controls, such as need for resuscitation at birth (2 (13.3%) v 1 (10%), p = 1.0) and NICU admission (1 (6.7%) v 2 (20%), p = 0.54). Haematological parameters (Haemoglobin, platelet, white cell and lymphocyte counts) in the COVID-19 group were all within normal neonatal reference ranges. Calibrated Automated Thrombography revealed no differences in any thrombin generation parameters (lag time (p = 0.92), endogenous thrombin potential (p = 0.24), peak thrombin (p = 0.44), time to peak thrombin (p = 0.94)) between the two groups. Conclusion In this prospective study including eligible cases in a very large population of approximately 1500 women, there was no evidence of derangement of the haematological parameters or hypercoagulability in umbilical cord blood due to COVID-19. Further research is required to investigate the pathological placental changes, particularly COVID-19 placentitis and the impact of different strains of SARS-CoV-2 (particularly the B.1.1.7 and the emerging Delta variant) and the severity and timing of infection on the developing fetus.
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Affiliation(s)
- Claire A Murphy
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Neonatology, Rotunda Hospital, Dublin, Ireland; Conway-SPHERE Research Group, Conway Institute, University College Dublin, Ireland.
| | - Daniel P O'Reilly
- Department of Neonatology, Rotunda Hospital, Dublin, Ireland; Conway-SPHERE Research Group, Conway Institute, University College Dublin, Ireland
| | - Osasere Edebiri
- Conway-SPHERE Research Group, Conway Institute, University College Dublin, Ireland; School of Medicine, University College Dublin, Ireland
| | - Luisa Weiss
- Conway-SPHERE Research Group, Conway Institute, University College Dublin, Ireland
| | - Sarah Cullivan
- Conway-SPHERE Research Group, Conway Institute, University College Dublin, Ireland; Department of Hematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Afif El-Khuffash
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Neonatology, Rotunda Hospital, Dublin, Ireland
| | - Emma Doyle
- Department of Pathology, Rotunda Hospital, Dublin, Ireland
| | - Jennifer C Donnelly
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin, Ireland; Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fergal D Malone
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin, Ireland; Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Wendy Ferguson
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Neonatology, Rotunda Hospital, Dublin, Ireland; Department of Paediatric Infectious Diseases, Children's Health Ireland at Temple Street, Dublin, Ireland
| | - Richard J Drew
- Irish Meningitis and Sepsis Reference Laboratory, Children's Health Ireland at Temple Street, Dublin, Ireland; Clinical Innovation Unit, Rotunda Hospital, Dublin, Ireland; Department of Microbiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - John O'Loughlin
- Department of Laboratory Medicine, Rotunda Hospital, Dublin, Ireland
| | - Elaine Neary
- Department of Neonatology, Liverpool Women's Hospital, Liverpool, United Kingdom; Department of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Patricia B Maguire
- Conway-SPHERE Research Group, Conway Institute, University College Dublin, Ireland
| | - Barry Kevane
- Conway-SPHERE Research Group, Conway Institute, University College Dublin, Ireland; Department of Hematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Fionnuala NíAinle
- Conway-SPHERE Research Group, Conway Institute, University College Dublin, Ireland; School of Medicine, University College Dublin, Ireland; Department of Hematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Naomi McCallion
- Department of Paediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland; Department of Neonatology, Rotunda Hospital, Dublin, Ireland
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Finnegan C, Smyth S, Smith O, Flood K, Dalrymple J, Breathnach FM, Malone FD. PCR vs karyotype for CVS and amniocentesis-the experience at one tertiary fetal medicine unit. Ir J Med Sci 2021; 191:1259-1262. [PMID: 34283385 PMCID: PMC9135887 DOI: 10.1007/s11845-021-02715-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 07/07/2021] [Indexed: 11/29/2022]
Abstract
Purpose Despite the rise of non-invasive screening tests for fetal aneuploidy, invasive testing during pregnancy remains the definitive diagnostic tool for fetal genetic anomalies. Results are rapidly available with polymerase chain reaction (PCR) tests, but cases have been reported whereby initial results were not confirmed after pregnancy termination and the fetal karyotype was ultimately normal. We sought to examine the potential discordance between PCR and karyotype for fetal aneuploidy. Methods The results from all amniocentesis and CVS tests performed over a 6-year period in a large tertiary level fetal medicine unit were reviewed. The results of PCR and karyotype were recorded and discrepancies examined. Pregnancy outcomes were also recorded. Results A total of 1222 invasive tests were performed (716 amniocentesis and 506 CVS). Within the cohort having amniocentesis, 11 had discrepant results (normal QF-PCR result but with a subsequent abnormal karyotype). There was 1 case among this group which QF-PCR should have identified. Within the CVS group, 7 patients had discrepant results. All had a diploid QF-PCR and would not have been identified as abnormal by it. Conclusion PCR can be reliably used to determine aneuploidy of chromosomes 13, 18, and 21. However, in cases of sex chromosome aneuploidy, its performance is less reliable and warrants waiting for a complete karyotype. Given such discordance, we advise waiting for karyotype for all invasive tests performed in the presence of a normal ultrasound before advising a patient of a diploid QF-PCR result or potentially terminating a normal pregnancy.
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Affiliation(s)
- Catherine Finnegan
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Parnell Square, Dublin 1, Ireland.
| | - Suzanne Smyth
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Parnell Square, Dublin 1, Ireland
| | - Orla Smith
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Parnell Square, Dublin 1, Ireland
| | - Karen Flood
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Parnell Square, Dublin 1, Ireland
| | - Jane Dalrymple
- Fetal Medicine Department, Rotunda Hospital, Parnell Square, Dublin 1, Ireland
| | - Fionnuala M Breathnach
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Parnell Square, Dublin 1, Ireland
| | - Fergal D Malone
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Parnell Square, Dublin 1, Ireland
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Ismail KI, Burke N, Burke G, Breathnach F, McAuliffe FM, Morrison JJ, Turner MJ, Dornan S, Higgins JR, Cotter A, Geary M, McParland P, Daly S, Cody F, Mulcahy C, Dicker P, Tully E, Malone FD. The prediction of morbidity related to vaginal delivery in nulliparous women - A secondary analysis from the genesis multicenter trial. Eur J Obstet Gynecol Reprod Biol 2021; 264:276-280. [PMID: 34343773 DOI: 10.1016/j.ejogrb.2021.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 07/13/2021] [Accepted: 07/15/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE In the prospective multicenter Genesis study, we developed a prediction model for Cesarean delivery (CD) in term nulliparous women. The objective of this secondary analysis was to determine whether the Genesis model has the potential to predict maternal and neonatal morbidity associated with vaginal delivery. STUDY DESIGN The national prospective Genesis trial recruited 2,336 nulliparous women with a vertex presentation between 39 + 0- and 40 + 6-weeks' gestation from seven tertiary centers. The prediction model used five parameters to assess the risk of CD: maternal age, maternal height, body mass index, fetal head circumference and fetal abdominal circumference. Simple and multiple logistic regression analyses were used to develop the Genesis model. The risk score calculated using this model were correlated with maternal and neonatal morbidity in women who delivered vaginally: postpartum hemorrhage (PPH), obstetric anal sphincter injury (OASI), shoulder dystocia, one- and five-minute Apgar score ≤ 7, neonatal intensive care (NICU) admission, cephalohematoma, fetal laceration, nerve palsy and fractures. The morbidities associated with spontaneous vaginal delivery were compared with those associated with operative vaginal delivery (OVD). The likelihood ratios for composite morbidity and the morbidity associated with OVD based on the Genesis risk scores were also calculated. RESULTS A total of 1,845 (79%) nulliparous women had a vaginal delivery. A trend of increasing intervention and morbidity was observed with increasing Genesis risk score, including OVD (p < 0.001), PPH (p < 0.008), NICU admission (p < 0.001), low Apgar score at one-minute (p < 0.001) and OASI (p = 0.009). The morbidity associated with OVD was significantly higher compared to spontaneous vaginal delivery, including NICU admission (p < 0.001), PPH (p = 0.022), birth injury (p < 0.001), shoulder dystocia (p = 0.002) and Apgar score of<7 at one-minute (p < 0.001). The positive likelihood ratios for composite outcomes (where the OVD was excluded) increases with increasing risk score from 1.005 at risk score of 5% to 2.507 for risk score of>50%. CONCLUSION In women who ultimately achieved a vaginal birth, we have shown more maternal and neonatal morbidity in the setting of a Genesis nomogram-determined high-risk score for intrapartum CD. Therefore, the Genesis prediction tool also has the potential to predict a more morbid vaginal delivery.
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Affiliation(s)
- Khadijah I Ismail
- Department of Obstetrics and Gynecology, Graduate Entry Medical School, University of Limerick, Limerick, Ireland.
| | - Naomi Burke
- Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Gerard Burke
- Department of Obstetrics and Gynecology, Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | | | - Fionnuala M McAuliffe
- UCD Perinatal Research Centre, Obstetrics & Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | | | - Michael J Turner
- UCD Center for Human Reproduction Coombe Women and Infants University Hospital, Dublin, Ireland
| | | | - John R Higgins
- University College Cork, Cork University Maternity Hospital, Cork, Ireland
| | - Amanda Cotter
- Department of Obstetrics and Gynecology, Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Michael Geary
- UCD Perinatal Research Centre, Obstetrics & Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Peter McParland
- UCD Perinatal Research Centre, Obstetrics & Gynaecology, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Sean Daly
- Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Fiona Cody
- Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | | | - Pat Dicker
- Epidemiology & Public Health, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Elizabeth Tully
- Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fergal D Malone
- Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
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Ó Maoldomhnaigh C, Cox DJ, Phelan JJ, Malone FD, Keane J, Basdeo SA. The Warburg Effect Occurs Rapidly in Stimulated Human Adult but Not Umbilical Cord Blood Derived Macrophages. Front Immunol 2021; 12:657261. [PMID: 33927724 PMCID: PMC8076563 DOI: 10.3389/fimmu.2021.657261] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 03/19/2021] [Indexed: 12/19/2022] Open
Abstract
The Warburg effect, defined as increased glycolysis and decreased oxidative phosphorylation, occurs in murine macrophages following LPS stimulation and is required for activation. There are differences between human and murine macrophage metabolic responses to stimulation, with peak metabolite concentrations occurring earlier in humans than mice. Complex changes occur in the human immune system with age, resulting in the very young and the very old being more susceptible to infections. Anti-bacterial immune responses in umbilical cord immune cells are considered deficient but there is a paucity of data on the role that metabolism plays. We hypothesized that metabolic responses in human macrophages occur early during activation. In addition, we hypothesized that umbilical cord derived macrophages have an altered immunometabolic response compared with adult macrophages. We demonstrate that adult and cord blood monocyte derived macrophages (MDM) immediately increase glycolysis in response to stimulation with LPS or Mycobacterium tuberculosis (Mtb), however only adult MDM decrease oxidative phosphorylation. At 24 hours post stimulation, glycolysis remains elevated in both adult and cord blood MDM, oxidative phosphorylation remains unchanged in the cord blood MDM and has normalized in the adult MDM stimulated with Mtb. However, LPS stimulated adult MDM have increased oxidative phosphorylation at 24 hours, illustrating differences in metabolic responses to different stimuli, time-dependent variation in responses and differences in macrophage metabolism in adults compared with umbilical cord blood. We compared the phenotype and function of macrophages derived from adult or cord blood. Cord blood MDM secreted less TNF following Mtb stimulation and more IL-6 following LPS stimulation compared with adult MDM. Our findings demonstrate that whilst cord blood MDM exhibit an immediate increase in glycolytic flux in response to stimulation, similar to adult MDM, cord blood MDM do not concomitantly decrease oxygen consumption. This indicates that adult macrophages shift to Warburg metabolism immediately after stimulation, but cord blood macrophages do not. Understanding the differences in the metabolic profiles of macrophages over a human lifetime will enable the translation of immunometabolism into effective immuno-supportive therapies that could potentially be targeted at vulnerable populations, such as the very old and the very young.
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Affiliation(s)
- Cilian Ó Maoldomhnaigh
- TB Immunology Group, Department of Clinical Medicine, Trinity Translational Medicine Institute, St James's Hospital, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Donal J Cox
- TB Immunology Group, Department of Clinical Medicine, Trinity Translational Medicine Institute, St James's Hospital, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - James J Phelan
- TB Immunology Group, Department of Clinical Medicine, Trinity Translational Medicine Institute, St James's Hospital, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Fergal D Malone
- Obstetrics & Gynecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Joseph Keane
- TB Immunology Group, Department of Clinical Medicine, Trinity Translational Medicine Institute, St James's Hospital, Trinity College Dublin, The University of Dublin, Dublin, Ireland
| | - Sharee A Basdeo
- TB Immunology Group, Department of Clinical Medicine, Trinity Translational Medicine Institute, St James's Hospital, Trinity College Dublin, The University of Dublin, Dublin, Ireland
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Kane D, D'Alton ME, Malone FD. Rare chromosomal abnormalities: Can they be identified using conventional first trimester combined screening methods? Eur J Obstet Gynecol Reprod Biol X 2021; 10:100123. [PMID: 33733087 PMCID: PMC7937980 DOI: 10.1016/j.eurox.2021.100123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 02/25/2021] [Indexed: 11/07/2022] Open
Abstract
Objective To evaluate the performance of first trimester combined screening for the detection of rare chromosomal abnormalities, other than Trisomies 21, 18 or 13 or 45 × . Study design A database containing 36,254 pregnancies was analyzed. These patients were recruited at 15 US centers and included singleton pregnancies from 10 3/7–13 6/7 weeks. All patients had a nuchal translucency (NT) scan and those without a cystic hygroma (N = 36,120) underwent a combined first trimester screening test ('FTS' - NT, PAPP-A and fbHCG). A risk cut-off of 1:300, which was used for defining high risk for Trisomy 21, was also used to evaluate the detection rate for rare chromosomal abnormalities using the combined FTS test. Results 36,120 patients underwent combined FTS. Of these, 123 were found to have one of the following chromosomal abnormalities: Trisomy 21, Trisomy 18, Trisomy 13 or Turner syndrome. This study focuses on 40 additional patients who were found to have ‘other’ rare chromosomal abnormalities such as triploidy, structural chromosomal abnormalities, sex chromosome abnormalities or unusual chromosomal abnormalities (e.g. 47XX + 16), giving an incidence of 1.1 in 1000 for these rare chromosomal abnormalities. Of these 40 pregnancies, only 2 (5%) had an NT measurement of ≥3 mm. The detection rate for combined FTS, using a risk cut-off of ≥1:300, was 35 % (14 of 40 cases). Therefore, 65 % of cases of rarer fetal chromosomal abnormalities had a ‘normal’ combined FTS risk (<1:300) and 95 % had a ‘normal’ NT (<3 mm). Conclusion Traditional FTS methods are unable to identify the vast majority of rare chromosomal abnormalities. Our data do not support the potential detection of rare fetal chromosomal abnormalities as a reason to favour nuchal translucency-based first trimester screening over NIPT.
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Affiliation(s)
- Daniel Kane
- Royal College of Surgeons in Ireland, Rotunda Hospital Dublin, Ireland
| | - Mary E D'Alton
- Columbia University Medical Center, New York, NY, United States
| | - Fergal D Malone
- Royal College of Surgeons in Ireland, Rotunda Hospital Dublin, Ireland
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Finnegan C, Smyth S, Smith O, Malone E, Malone FD. 434 Asymptomatic covid-19 in pregnancy – does “lockdown” work? Am J Obstet Gynecol 2021. [PMCID: PMC7848572 DOI: 10.1016/j.ajog.2020.12.455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Dar P, Jacobsson B, Egbert M, Malone FD, Wapner RJ, Roman A, Khalil A, Faro R, Madankumar R, Edwards L, Strong N, Haeri S, Silver RM, Vohra N, Hyett J, Martin K, Clifton R, Kao C, Norton ME. 67 Multicenter prospective study of SNP-based cfDNA for 22q11.2 deletion in 18,289 pregnancies with genetic confirmation. Am J Obstet Gynecol 2021. [DOI: 10.1016/j.ajog.2020.12.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Murphy NC, Burke N, Dicker P, Cody F, Nafisee SA, Deleau D, Kent E, Ramaiah S, Tully EC, Malone FD, Breathnach FM. Reducing emergency cesarean delivery and improving the primiparous experience: Findings of the RECIPE study. Eur J Obstet Gynecol Reprod Biol 2020; 255:13-19. [PMID: 33065516 DOI: 10.1016/j.ejogrb.2020.09.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/19/2020] [Accepted: 09/21/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The ability to predict the need for emergency Cesarean delivery holds the potential to facilitate birth choices. The objective of the RECIPE study (Reducing Emergency Cesarean delivery and Improving the Primiparous Experience) was to externally validate a Cesarean delivery risk prediction model. This model, developed by the Genesis study, identified five key predictive factors for emergency Cesarean delivery: maternal age, maternal height, BMI, fetal head circumference (HC) and fetal abdominal circumference (AC). STUDY DESIGN This prospective, observational study was conducted in two tertiary referral perinatal centers. Inclusion criteria were as follows: primiparous women with a singleton, cephalic presentation fetus in the absence of fetal growth restriction (FGR), oligohydramnios, pre-eclampsia, pre-existing diabetes mellitus or an indication for planned Cesarean delivery. Between 38 + 0 and 40 + 6 weeks' gestational age, participants attended for prenatal assessment that enabled the determination of an individualized risk calculation for emergency Cesarean delivery during labour based on maternal height, BMI, fetal HC and AC, with crucially both participants and care providers being blinded to the resultant risk prediction score. Labor, delivery and postnatal outcomes were ascertained. Calibration and receiver operator curves were generated to determine the predictive capacity for emergency Cesarean delivery of the Genesis risk prediction model in this cohort. RESULTS 559 primiparous participants were enrolled from May 2017 to April 2019, of whom 142 (25 %) had an emergency Cesarean delivery during labour. Participants with a low predicted risk score (<10 %) had a mean predicted rate of 8% (+/- standard deviation of 2%) and a similarly low actual observed rate of Cesarean delivery (8%). Participants with a high predicted risk (>50 %) had a mean predicted Cesarean delivery rate of 64 % (+/- standard deviation of 9%) and also had a high actual observed Cesarean delivery rate (62 %). The calibration curve and receiver operating characteristic curve demonstrated that this validation study had comparable discriminatory power for emergency Cesarean delivery to that described in the original Genesis study. The Area Under the Curve (AUC) in Genesis was 0.69, whereas the AUC in RECIPE was 0.72, which reflects good predictive capacity of the risk prediction model. CONCLUSION The accuracy of the Genesis Cesarean delivery prediction tool is supported by this validation study.
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Affiliation(s)
- Niamh C Murphy
- Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Naomi Burke
- Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Patrick Dicker
- Epidemiology & Public Health, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fiona Cody
- Obstetrics & Gynaecology, Rotunda Hospital, Dublin, Ireland
| | - Sarah Al Nafisee
- Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Dylan Deleau
- Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Etaoin Kent
- Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Sunitha Ramaiah
- Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Elizabeth C Tully
- Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fergal D Malone
- Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
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Deter RL, Lee W, Dicker P, Tully EC, Cody F, Malone FD, Flood KM. Growth patterns and cardiovascular abnormalities in SGA fetuses: 3. Late, adaptive and recovering growth restriction. J Matern Fetal Neonatal Med 2020; 35:2808-2817. [PMID: 32938245 DOI: 10.1080/14767058.2020.1803262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To characterize abnormal growth processes and their associated cardiovascular abnormalities in SGA fetuses using Individualized Growth Assessment (IGA). METHODS This longitudinal investigation utilized a SGA cohort [EFW and BW <10th percentile] derived from the PORTO study. Fetuses categorized by their Fetal Growth Pathology Score [FGPS1] patterns [Pattern 2 {n = 12}, Pattern 3 {n = 11}, Pattern 5 {n = 13}] were evaluated. Growth pathology was measured using the -FGPS1 and the individual composite Prenatal Growth Assessment Score {-icPGAS]. Paired cardiovascular assessments utilized measurements of the Pulsatility Index [umbilical artery {UA}, middle cerebral artery {MCA}, ductus venosus {DV}] and the myocardial performance index [MPI; heart]. Outcome variables were birth age [preterm or, term] and birth weight [small or normal (IGA criteria)]. RESULTS Pattern 2 was usually characterized by a single, growth abnormality (67% of cases) of variable magnitude that occurred within two weeks of delivery {median onset age: 37.6 weeks}. The incidence of UA abnormalities was low (25%) while those of MCA and DV/MPI were high {60%, 42%}. Most neonates were of normal size (67%) and delivered at term (67%). Pattern 3 had an initial progressive growth restriction phase, followed by constant but abnormally low growth. Growth pathology had an early onset (median age: 31.6 weeks), was moderate but persistently abnormal. The incidences of cardiovascular abnormalities were moderate [30-50%]. Most neonates were abnormally small (80%) but delivered at term (90%). Pattern 5 had an initial progressive phase with an early onset [onset age {median}: 31.6 weeks]. However, this process was arrested and returned toward normal. Growth pathology magnitudes were minor as were the incidences of cardiovascular abnormalities. Neonatal size was usually normal and all fetuses delivered at term. CONCLUSIONS Characteristics of SGA Growth Restricted, Patterns 2, 3 and 5 are clearly different from those found in SGA Normal or SGA Growth Restricted Pattern 1 groups. They also differed from one another, indicating that growth restriction can manifest itself in several different ways. Pattern 2 is similar to "late" growth restriction reported previously. Patterns 3 and 5 are novel and have been designated as "adaptive" and "recovering" types of growth restriction.
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Affiliation(s)
- Russell L Deter
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Patrick Dicker
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Elizabeth C Tully
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fiona Cody
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fergal D Malone
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Karen M Flood
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
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Horgan R, Monteith C, McSweeney L, Ritchie R, Dicker P, El-Khuffash A, Malone FD, Kent E. The emergence of a change in the prevalence of preeclampsia in a tertiary maternity unit (2004-2016). J Matern Fetal Neonatal Med 2020; 35:3129-3134. [PMID: 32924665 DOI: 10.1080/14767058.2020.1813707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Pre-eclampsia (PET) affects 2-3% of all pregnancies, rising to 5-7% in nulliparous women. This study aimed to investigate the prevalence of PET over a 13-year period. METHODS A retrospective review was performed over a 13-year period (2004-2016) via interrogation of the annual clinical reports of The Rotunda Hospital, Dublin. RESULTS There was a fall in the overall incidence of PET (nulliparous and multiparous), from a peak of 3.8% in 2007 to 1.5% in 2015. Comparing the first and second halves of the study time-period this decrease was statistically significant (p < .0001). In nulliparous women, the thirteen-year mean was 4.4% for the study period, with a similar observed reduction from a peak of 5.3% in 2005 to a trough of 2.4% in 2015. DISCUSSION In our institution, we have shown a decrease in preeclampsia rates over a 13-year period. While the reason for this trend remains unclear, a similar trend has been observed in another tertiary unit and additional research is required to explain the etiology behind these observations.
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Affiliation(s)
- Rebecca Horgan
- Department of Obstetrics & Gynaecology, The Rotunda Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Cathy Monteith
- Department of Obstetrics & Gynaecology, The Rotunda Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Lisa McSweeney
- Department of Obstetrics & Gynaecology, The Rotunda Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ruth Ritchie
- Department of Midwifery, The Rotunda Hospital, Dublin, Ireland
| | - Patrick Dicker
- Department of Obstetrics & Gynaecology, The Rotunda Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland.,Department of Public Health and Epidemiology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fergal D Malone
- Department of Obstetrics & Gynaecology, The Rotunda Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Etaoin Kent
- Department of Obstetrics & Gynaecology, The Rotunda Hospital, Royal College of Surgeons in Ireland, Dublin, Ireland
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Deter RL, Dicker P, Lee W, Tully EC, Cody F, Malone FD, Flood KM. Growth patterns and cardiovascular abnormalities in SGA fetuses: 2. Normal growth and progressive growth restriction. J Matern Fetal Neonatal Med 2020; 35:2818-2827. [PMID: 32924675 DOI: 10.1080/14767058.2020.1807506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES To characterize growth processes and their associated cardiovascular abnormalities in SGA fetuses with normal growth and progressive growth restriction patterns as defined by Individualized Growth Assessment (IGA). METHODS A SGA cohort (EFW and BW < 10th percentile) was derived from the PORTO study that included 47 fetuses with normal growth outcome (SGA Normal) and 34 fetuses with progressive growth restriction (SGA Growth Restricted, Pattern 1). Composite fetal size parameters were used to quantify growth pathology at individual third trimester time points (individual composite Prenatal Growth Assessment Score {icPGAS}) and calculated cumulatively during the third trimester (Fetal Growth Pathology Score 1{FGPS1}). Paired Doppler evaluations of the umbilical artery (UA), middle cerebral artery (MCA), ductus venosus (DV) and myocardial performance index (MPI) were used to detect cardiovascular anomalies. Outcome variables were birth age and birth weight. RESULTS Ranking fetuses with respect to the severity of the 3rd trimester growth pathology (-FGPS1) revealed three subgroups in each of these two groups. In SGA Normal, no (51%), minimal (19%) or minor (30%) growth abnormalities were present. Although vascular flow abnormalities occurred without growth abnormalities (UA: 38%; MCA: 35%), they increased with minor growth disturbances (UA: 64%; MCA: 50%). All fetuses delivered at term and in only 7 cases (minor growth abnormalities subgroup) were the neonates abnormally small based on IGA criteria. In SGA Growth Restricted, Pattern 1, the progression of growth restriction was slow (47%), moderate (21%) and rapid (32%). Corresponding median -FGPS1 values were -1.34%, -2.67% and -4.88%, respectively. The median age of onset was 33.6, 29.7 and 29.7 weeks in these three subgroups. UA abnormalities occurred infrequently in the first two subgroups but were found in all cases of rapidly progressing pathology. Similar results were found for the MCA and DV + MPI Doppler parameters (rapid progression: MCA = 50%; DV + MPI = 50%). Premature delivery occurred less frequently with slow progression but was nearly 100% in the moderately and rapidly progressive subgroups. CONCLUSIONS Negative FGPS1 growth restriction patterns can be used to classify SGA fetuses. Subgroups, based on ranked -FGPS1 values in both SGA Normal and SGA Growth Restricted Pattern 1 groups had marked differences in cardiovascular abnormalities and neonatal outcomes. The characteristics of these two groups are consistent with small, normally growing fetuses and fetuses with "early" growth restriction, respectively.
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Affiliation(s)
- Russell L Deter
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Patrick Dicker
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Elizabeth C Tully
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fiona Cody
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fergal D Malone
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Karen M Flood
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
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Murphy NC, Burke N, Dicker P, Cody F, Kent E, Tully EC, Malone FD, Breathnach FM. The RECIPE study: reducing emergency Caesareans and improving the Primiparous experience: a blinded, prospective, observational study. BMC Pregnancy Childbirth 2020; 20:431. [PMID: 32727490 PMCID: PMC7390864 DOI: 10.1186/s12884-020-03112-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 07/15/2020] [Indexed: 11/13/2022] Open
Abstract
Background The RECIPE study aims to validate a risk prediction model for intrapartum caesarean delivery which has been developed by our group. The Genesis study was a prospective observational study carried out by the Perinatal Ireland Research Consortium across 7 clinical centres in Ireland between October 2012 and June 2015. Genesis investigated a range of maternal and fetal parameters in a prospective blinded study of 2336 singleton pregnancies between 39 + 0–41 + 0 weeks’ gestational age. This resulted in the development of a risk prediction model for Caesarean Delivery in nulliparous women at term. The RECIPE study now proposes to provide external validation of this risk prediction tool. Methods In order to externally validate the model, we aim to include a centre which was not involved in the original study. We propose a trial of risk-assignment for intrapartum caesarean amongst nulliparous women with a singleton pregnancy between 38 + 0 and 40 + 6 weeks’ gestational age who are planning a vaginal birth. Results of the risk prediction tool will be concealed from participants and from midwives and doctors providing labour care.. Participants will be invited for an ultrasound scan and delivery details will be collated postnatally. The principal aim of this study is to externally validate the risk prediction model. This prediction model holds the potential to accurately identify nulliparous women who are likely to achieve an uncomplicated vaginal birth and those at high prospect of requiring an unplanned caesarean delivery. Discussion Validation of the Genesis prediction model would enable more accurate counselling for women in the antenatal setting regarding their own likelihood of requiring an intrapartum Caesarean section. It would also provide valuable personalised information to women about the anticipated course of their own labour. We believe that this is an issue of national relevance that will impact positively on obstetric practice, and will positively empower women to make considered, personalised choices surrounding labour and delivery.
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Affiliation(s)
- Niamh C Murphy
- Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland.
| | - Naomi Burke
- Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Patrick Dicker
- Epidemiology & Public Health, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fiona Cody
- Obstetrics & Gynaecology, Rotunda Hospital, Dublin, Ireland
| | - Etaoin Kent
- Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Elizabeth C Tully
- Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fergal D Malone
- Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Dublin, Ireland
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Murphy NC, Burke N, Breathnach FM, Burke G, McAuliffe FM, Morrison JJ, Turner MJ, Dornan S, Higgins J, Cotter A, Geary MP, Cody F, McParland P, Mulcahy C, Daly S, Dicker P, Tully EC, Malone FD. Inter-hospital comparison of Cesarean delivery rates should not be considered to reflect quality of care without consideration of patient heterogeneity: An observational study. Eur J Obstet Gynecol Reprod Biol 2020; 250:112-116. [PMID: 32438274 DOI: 10.1016/j.ejogrb.2020.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 04/29/2020] [Accepted: 05/02/2020] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Contemporary approaches to monitoring quality of care in obstetrics often focus on comparing Cesarean Delivery rates. Varied rates can complicate interpretation of quality of care. We previously developed a risk prediction tool for nulliparous women who may require intrapartum Cesarean delivery which identified five key predictors. Our objective with this study was to ascertain if patient heterogeneity can account for much of the observed variation in Cesarean delivery rates, thereby enabling Cesarean delivery rates to be a better marker of quality of care. MATERIALS AND METHODS This is a secondary analysis of the Genesis study. This was a large prospective study of 2336 nulliparous singleton pregnancies recruited at seven hospitals. A heterogeneity score was calculated for each hospital. An adjusted Cesarean delivery rate was also calculated incorporating the heterogeneous risk score. RESULTS A cut-off at the 90th percentile was determined for each predictive factor. Above the 90th percentile was considered to represent 'high risk' (with the exception of maternal height which identified those below the 10th percentile). The patient heterogeneous risk score was defined as the number of risk factors > 90th percentile (<10th percentile for height). An unequal distribution of high-risk patients between centers was observed (p < 0.001). The correlation between the Cesarean delivery rate and the patient heterogeneous risk score was high (0.76, p < 0.05). When adjusted for patient heterogeneity, Cesarean delivery rates became closer aligned. CONCLUSION Inter-institutional diversity is common. We suggest that crude comparison of Cesarean delivery rates between different hospitals as a marker of care quality is inappropriate. Allowing for marked differences in patient characteristics is essential for correct interpretation of such comparisons.
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Affiliation(s)
| | - Naomi Burke
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Gerard Burke
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Fionnuala M McAuliffe
- UCD School of Medicine and Medical Science, National Maternity Hospital, Dublin, Ireland
| | | | - Michael J Turner
- UCD Centre for Human Reproduction Coombe Women and Infants University Hospital, Dublin, Ireland
| | | | - John Higgins
- University College Cork, Cork University Maternity Hospital, Cork, Ireland
| | - Amanda Cotter
- Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | | | | | - Peter McParland
- UCD School of Medicine and Medical Science, National Maternity Hospital, Dublin, Ireland
| | - Cecelia Mulcahy
- UCD School of Medicine and Medical Science, National Maternity Hospital, Dublin, Ireland
| | - Sean Daly
- Coombe Women and Infants University Hospital, Dublin, Ireland
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O'Leary BD, Kane DT, Kruseman Aretz N, Geary MP, Malone FD, Hehir MP. Use of the Robson Ten Group Classification System to categorise operative vaginal delivery. Aust N Z J Obstet Gynaecol 2020; 60:858-864. [PMID: 32350863 DOI: 10.1111/ajo.13169] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/04/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Operative vaginal delivery (OVD), either vacuum or forceps, can be used to expedite vaginal delivery. While rates of OVD have been reducing worldwide, rates in Ireland remain high. The Robson Ten Group Classification System (TGCS) was originally created to compare rates of caesarean delivery between healthcare units, although no similar system exists for the analysis of OVD. AIMS We sought to examine rates of OVD using the TGCS in an effort to understand which patient groups make significant contributions to the overall rate of OVD. MATERIALS AND METHODS This is a retrospective cohort study of all women delivering in a tertiary-level university institution in Dublin, Ireland, from 2007 to 2016. Mode of delivery for all patients was extracted from contemporaneously recorded hospital records. Rates of OVD were analysed according to the TGCS, and the contribution of each group to the overall hospital population was calculated. RESULTS There were 86 191 deliveries of women in our institution, of which 19.3% (16 673/86 191) had an OVD. Women in Group 1 (singleton, cephalic, nulliparous women at term in spontaneous labour) contributed the most to the overall rate of OVD, accounting for almost half of all OVDs (46.1% (7679/16 673)). Nulliparous women with a singleton, cephalic fetus at term who were induced (Group 2) were more likely to have an OVD than similar patients who laboured spontaneously (Group 1). CONCLUSION OVD accounts for almost one in five deliveries in our population and is predominately performed in nulliparous women. These groups may be the subject of interventions to lower rates of OVD. The Robson TGCS is a freely available tool to hospitals and birthing centres to facilitate comparison of rates of OVD on local and national levels.
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Affiliation(s)
- Bobby D O'Leary
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin 1, Ireland
| | - Daniel T Kane
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin 1, Ireland
| | | | - Michael P Geary
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin 1, Ireland
| | - Fergal D Malone
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin 1, Ireland
| | - Mark P Hehir
- Department of Obstetrics and Gynaecology, Rotunda Hospital, Dublin 1, Ireland
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Varner MW, Costantine MM, Jablonski KA, Rouse DJ, Mercer BM, Leveno KJ, Reddy UM, Buhimschi C, Wapner RJ, Sorokin Y, Thorp JM, Ramin SM, Malone FD, Carpenter M, O’sullivan MJ, Peaceman AM, Dudley DJ, Caritis SN. Sex-Specific Genetic Susceptibility to Adverse Neurodevelopmental Outcome in Offspring of Pregnancies at Risk of Early Preterm Delivery. Am J Perinatol 2020; 37:281-290. [PMID: 30731481 PMCID: PMC6685763 DOI: 10.1055/s-0039-1678535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate sex-specific genetic susceptibility to adverse neurodevelopmental outcome (ANO, defined as cerebral palsy [CP], mental, or psychomotor delay) at risk for early preterm birth (EPTB, < 32 weeks). STUDY DESIGN Secondary case-control analysis of a trial of magnesium sulfate (MgSO4) before anticipated EPTB for CP prevention. Cases are infants who died by the age of 1 year or developed ANO. Controls, matched by maternal race and infant sex, were neurodevelopmentally normal survivors. Neonatal DNA was evaluated for 80 polymorphisms in inflammation, coagulation, vasoregulation, excitotoxicity, and oxidative stress pathways using Taqman assays. The primary outcome for this analysis was sex-specific ANO susceptibility. Conditional logistic regression estimated each polymorphism's odds ratio (OR) by sex stratum, adjusting for gestational age, maternal education, and MgSO4-corticosteroid exposures. Holm-Bonferroni corrections, adjusting for multiple comparisons (p < 7.3 × 10-4), accounted for linkage disequilibrium between markers. RESULTS Analysis included 211 cases (134 males; 77 females) and 213 controls (130 males; 83 females). An interleukin-6 (IL6) polymorphism (rs2069840) was associated with ANO in females (OR: 2.6, 95% confidence interval [CI]: 1.5-4.7; p = 0.001), but not in males (OR: 0.8, 95% CI: 0.5-1.2; p = 0.33). The sex-specific effect difference was significant (p = 7.0 × 10-4) and was unaffected by MgSO4 exposure. No other gene-sex associations were significant. CONCLUSION An IL6 gene locus may confer susceptibility to ANO in females, but not males, after EPTB.
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Affiliation(s)
- Michael W. Varner
- Department of Obstetrics and Gynecology, University of
Utah, Salt Lake City, Utah
| | - Maged M. Costantine
- Department of Obstetrics and Gynecology, University of
Texas Medical Branch, Galveston, Texas
| | - Kathleen A. Jablonski
- Department of Epidemiology and Biostatistics, George
Washington University Biostatistics Center, Washington, Disctrict of Columbia
| | - Dwight J. Rouse
- Department of Obstetrics and Gynecology, University of
Alabama at Birmingham, Birmingham, Alabama
| | - Brian M. Mercer
- Department of Obstetrics and Gynecology, MetroHealth
Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Kenneth J. Leveno
- Department of Obstetrics and Gynecology, University of
Texas Southwestern Medical Center, Dallas, Texas
| | - Uma M. Reddy
- Eunice Kennedy Shriver National Institute of Child Health
and Human Development, Bethesda, Maryland
| | - Catalin Buhimschi
- Department of Obstetrics and Gynecology, The Ohio State
University, Columbus, Ohio
| | - Ronald J. Wapner
- Department of Obstetrics and Gynecology, Thomas Jefferson
University, Philadelphia, Pennsylvania
- Department of Obstetrics and Gynecology, Drexel
University, Philadelphia, Pennsylvania
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State
University, Detroit, Michigan
| | - John M. Thorp
- Department of Obstetrics and Gynecology, University of
North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Susan M. Ramin
- Department of Obstetrics and Gynecology, University of
Texas Health Science Center at Houston, Houston, Texas
| | - Fergal D. Malone
- Department of Obstetrics and Gynecology, Columbia
University, New York, New York
| | - Marshall Carpenter
- Department of Obstetrics and Gynecology, Brown
University, Providence, Rhode Island
| | - Mary J. O’sullivan
- Department of Obstetrics and Gynecology, University of
Miami, Miami, Florida
| | - Alan M. Peaceman
- Department of Obstetrics and Gynecology, Northwestern
University, Chicago, Illinois
| | - Donald J. Dudley
- Department of Obstetrics and Gynecology, University of
Texas Health Science Center, San Antonio, Texas
| | - Steve N. Caritis
- Department of Obstetrics and Gynecology, University of
Pittsburgh, Pittsburgh, Pennsylvania
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Kane D, Shanahan I, Dicker P, Malone FD, Geary MP, Burke N, Kent E. 1038: Is there a correlation between maternal co-morbidity and the increasing cesarean section rates? Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.1053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Daly R, Dicker P, Unterscheider J, Daly S, Geary MP, Kennelly M, Mcauliffe FM, O’Donoghue K, Hunter A, Morrison J, Burke G, Tully E, Malone FD. 314: Femur length ratios as predictors of adverse outcome in fetuses: Results from the PORTO Study. Am J Obstet Gynecol 2020. [DOI: 10.1016/j.ajog.2019.11.329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Mone F, Mulcahy C, McParland P, Downey P, Culliton M, Maguire OC, Mooney EE, Clarke P, Fitzgerald D, Tully E, Malone FD, McAuliffe FM. Evaluation of the Effect of Low-Dose Aspirin on Biochemical and Biophysical Biomarkers for Placental Disease in Low-Risk Pregnancy: Secondary Analysis of a Multicenter RCT. Am J Perinatol 2019; 36:1387-1393. [PMID: 30646422 DOI: 10.1055/s-0038-1677476] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To assess the effect of aspirin use in low-risk pregnancy on: (1) pregnancy-associated plasma protein-A (PAPP-A) and placental-like growth factor (PLGF); (2) urinary albumin-to-creatinine ratio (ACR) and blood pressure; (3) fetal growth parameters; and (4) placental histopathology. STUDY DESIGN This secondary analysis from the T rial of low-dose aspirin with an E arly S creening T est for preeclampsia and growth restriction randomized controlled trial was based on low-risk nulliparous women randomized at 11 weeks to (1) aspirin 75 mg; (2) no aspirin; and (3) aspirin based on the preeclampsia Fetal Medicine Foundation screening test. At baseline, women underwent assessment of blood pressure, PAPP-A, PLGF, and ACR, repeated 9 to 10 weeks postaspirin, in addition to fetal growth assessment. Gross and histopathological placental analyses were performed in line with Amsterdam criteria. RESULTS A total of 445 subjects were included (aspirin n = 163 [36.6%]; no aspirin n = 282 [63.4%]). Although the fetal-to-placental weight ratio was significantly greater in the aspirin group (7.5 [±1.3] vs. 7.3 [±1.4], p = 0.045), as was change in ultrasound assessed estimated fetal weight from second to third trimesters (1,624.5 g [±235.1] vs. 1,606.2 [±189.4], p = 0.042), this was invalidated by the lack of a difference in birth weight. Aspirin did not significantly impact on change in serum or urine preeclampsia biomarkers, maternal blood pressure, or placental histopathology. CONCLUSION Aspirin use in low-risk pregnancy does not appear to impact on preeclampsia biomarkers, fetal growth, or placental pathology.
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Affiliation(s)
- Fionnuala Mone
- UCD Perinatal Research Centre, School of Medicine, National Maternity Hospital, University College Dublin, Dublin, Ireland
| | - Cecilia Mulcahy
- UCD Perinatal Research Centre, School of Medicine, National Maternity Hospital, University College Dublin, Dublin, Ireland
| | - Peter McParland
- UCD Perinatal Research Centre, School of Medicine, National Maternity Hospital, University College Dublin, Dublin, Ireland
| | - Paul Downey
- Department of Pathology and Laboratory Medicine, National Maternity Hospital, Dublin, Ireland
| | - Marie Culliton
- Department of Pathology and Laboratory Medicine, National Maternity Hospital, Dublin, Ireland
| | - Orla C Maguire
- Department of Pathology and Laboratory Medicine, National Maternity Hospital, Dublin, Ireland
| | - Eoghan E Mooney
- Department of Pathology and Laboratory Medicine, National Maternity Hospital, Dublin, Ireland
| | - Philip Clarke
- Department of Pathology and Laboratory Medicine, National Maternity Hospital, Dublin, Ireland
| | - David Fitzgerald
- Department of Pharmacy, National Maternity Hospital, Dublin, Ireland
| | - Elizabeth Tully
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fergal D Malone
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fionnuala M McAuliffe
- UCD Perinatal Research Centre, School of Medicine, National Maternity Hospital, University College Dublin, Dublin, Ireland
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Deter RL, Lee W, Dicker P, Tully EC, Cody F, Malone FD, Flood KM. Growth patterns and cardiovascular abnormalities in small for gestational age fetuses: 1. Pattern characteristics. J Matern Fetal Neonatal Med 2019; 34:3029-3038. [PMID: 31630585 DOI: 10.1080/14767058.2019.1677592] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Fetal growth restriction is being defined as either "early" or "late" depending on age of onset. A recent investigation using individualized assessment has identified five different growth restriction patterns. No previous study has related these patterns to cardiovascular abnormalities. OBJECTIVES To determine growth patterns in small fetuses (BW < 10th percentile) using Individualized Growth Assessment (IGA) and to relate cardiovascular abnormalities found with Doppler ultrasound to these patterns. STUDY DESIGN A secondary analysis was carried out in 126 fetuses from the PORTO data set having both estimated weights and birth weights below the 10th percentile. Only fetuses with 2nd and 3rd trimester biometry scans appropriate for IGA and cardiovascular assessments were studied. There was one-to-one matching of biometry and Doppler evaluations in the 3rd trimester. Composite growth parameters were used to quantify growth pathology at individual time points (individual composite Prenatal Growth Assessment Score (icPGAS)) and during the 3rd trimester (Fetal Growth Pathology Score {FGPS1}). Normal and growth restriction patterns were identified using plots of FGPS1 values. Doppler measurements were classified as normal or abnormal based on published cross-sectional standards. Outcome variables were birth weight and birth age. RESULTS In these SGA cases, 38.2% showed normal fetal growth and 61.8% had growth restriction. In the latter, seven different patterns were observed. Pattern 1 was most common (43.5%), followed by Patterns 5 (16.7%), 2 (15.4%) and 3 (14.1%). The characteristics of Pattern 1 indicated progressive growth restriction while Pattern 5 demonstrated recovery from an initial growth abnormality. Cardiovascular abnormalities were quite variable, with those in the umbilical artery being most frequent in Patterns 1 and 3. Pattern 2 had the highest incidence of middle cerebral artery abnormalities. Umbilical artery abnormalities were similar in the Normal and Pattern 5 groups as were those for the middle cerebral artery. Other cardiovascular abnormalities had low frequencies except in Pattern 2 where the ductus venosus incidence was high. Abnormally small neonates, as identified with IGA, were seen primarily in Patterns 1, 3 and 6 (80-88%). Premature deliveries occurred most frequently in Pattern 1 (56%), followed by Pattern 2 (33%). CONCLUSIONS Growth in this SGA Group was very heterogeneous with a significant proportion of these small fetuses growing normally. Growth restriction did not appear to be a single process but was manifest as seven different FGPS1 patterns. Both growth pathology and cardiovascular abnormalities differed among patterns. Further investigation will be required to determine how specific growth abnormalities are related to fetal cardiovascular changes over time.
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Affiliation(s)
- Russell L Deter
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Wesley Lee
- Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX, USA
| | - Patrick Dicker
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Elizabeth C Tully
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fiona Cody
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fergal D Malone
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Karen M Flood
- Department of Obstetrics & Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
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Monteith C, Flood K, Pinnamaneni R, Levine TA, Alderdice FA, Unterscheider J, McAuliffe FM, Dicker P, Tully EC, Malone FD, Foran A. An abnormal cerebroplacental ratio (CPR) is predictive of early childhood delayed neurodevelopment in the setting of fetal growth restriction. Am J Obstet Gynecol 2019; 221:273.e1-273.e9. [PMID: 31226291 DOI: 10.1016/j.ajog.2019.06.026] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 06/05/2019] [Accepted: 06/12/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Fetal growth restriction accounts for a significant proportion of perinatal morbidity and death. The cerebroplacental ratio is gaining much interest as a useful tool in differentiating the "at-risk" fetus in both fetal growth restriction and appropriate-for-gestational-age pregnancies. The Prospective Observational Trial to Optimize Pediatric Health in Fetal Growth Restriction group has demonstrated previously that the presence of this "brain-sparing" effect is associated significantly with adverse perinatal outcomes in the fetal growth restriction cohort. However, data about neurodevelopment in children from pregnancies that are complicated by fetal growth restriction are sparse and conflicting. OBJECTIVE The aim of the Prospective Observational Trial to Optimize Pediatric Health in Fetal Growth Restriction NeuroDevelopmental Assessment Study was to determine whether children born after fetal growth-restricted pregnancies are at additional risk of adverse early childhood developmental outcomes compared with children born small for gestational age. The objective of this secondary analysis was to describe the role of cerebroplacental ratio in the prediction of adverse early childhood neurodevelopmental outcome. STUDY DESIGN Participants were recruited prospectively from the Perinatal Ireland multicenter observational Prospective Observational Trial to Optimize Pediatric Health in Fetal Growth Restriction study cohort. Fetal growth restriction was defined as birthweight <10th percentile with abnormal antenatal umbilical artery Doppler indices. Small for gestational age was defined similarly in the absence of abnormal Doppler indices. Cerebroplacental ratio was calculated with the pulsatility indices of the middle cerebral artery and divided by umbilical artery with an abnormal value <1. Children (n=375) were assessed at 3 years with the use of the Ages and Stages Questionnaire and the Bayley Scales of Infant and Toddler Development, 3rd edition. Small-for-gestational-age pregnancies with normal Doppler indices were compared with (1) fetal growth-restricted cases with abnormal umbilical artery Doppler and normal cerebroplacental ratio or (2) fetal growth restriction cases with both abnormal umbilical artery and cerebroplacental ratio. Statistical analysis was performed with statistical software via 2-sample t-test with Bonferroni adjustment, and a probability value of .00625 was considered significant. RESULTS Assessments were performed on 198 small-for-gestational-age children, 136 fetal growth-restricted children with abnormal umbilical artery Doppler images and normal cerebroplacental ratio, and 41 fetal growth-restricted children with both abnormal umbilical artery Doppler and cerebroplacental ratio. At 3 years of age, although there were no differences in head circumference, children who also had an abnormal cerebroplacental ratio had persistently shorter stature (P=.005) and lower weight (P=.18). Children from fetal growth restriction-affected pregnancies demonstrated poorer neurodevelopmental outcome than their small-for-gestational-age counterparts. Fetal growth-restricted pregnancies with an abnormal cerebroplacental ratio had significantly poorer neurologic outcome at 3 years of age across all measured variables. CONCLUSION We have demonstrated that growth-restricted pregnancies with a cerebroplacental ratio <1 have a significantly increased risk of delayed neurodevelopment at 3 years of age when compared with pregnancies with abnormal umbilical artery Doppler evidence alone. This study further substantiates the benefit of routine assessment of cerebroplacental ratio in fetal growth-restricted pregnancies and for counseling parents regarding the long-term outcome of affected infants.
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Affiliation(s)
- Cathy Monteith
- Department of Obstetrics & Gynecology, Royal College of Surgeons, Ireland, Dublin Ireland.
| | - Karen Flood
- Department of Obstetrics & Gynecology, Royal College of Surgeons, Ireland, Dublin Ireland
| | | | - Terri A Levine
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland
| | - Fiona A Alderdice
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, Northern Ireland; National Perinatal Epidemiology Unit, University of Oxford, Oxford, United Kingdom
| | - Julia Unterscheider
- Department of Obstetrics & Gynecology, University of Melbourne, Royal Women's Hospital, Melbourne, Australia
| | - Fionnuala M McAuliffe
- Obstetrics & Gynecology, UCD Perinatal Research Centre, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Patrick Dicker
- Department of Epidemiology & Public Health, Royal College of Surgeons, Ireland, Dublin Ireland
| | - Elizabeth C Tully
- Department of Obstetrics & Gynecology, Royal College of Surgeons, Ireland, Dublin Ireland
| | - Fergal D Malone
- Department of Obstetrics & Gynecology, Royal College of Surgeons, Ireland, Dublin Ireland
| | - Adrienne Foran
- Department of Neonatology, Royal College of Surgeons, Ireland, Dublin Ireland
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Hehir MP, Burke N, Burke G, Turner MJ, Breathnach FM, Mcauliffe FM, Morrison JJ, Dornan S, Higgins J, Cotter A, Geary MP, Mcparland P, Daly S, Cody F, Dicker P, Tully E, Malone FD. Sonographic markers of fetal adiposity and risk of Cesarean delivery. Ultrasound Obstet Gynecol 2019; 54:338-343. [PMID: 30887629 DOI: 10.1002/uog.20263] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 03/10/2019] [Accepted: 03/12/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVE Increased fetal size is associated with shoulder dystocia during labor and subsequent need for assisted delivery. We sought to investigate if increased fetal adiposity diagnosed sonographically in late pregnancy is associated with increased risk of operative delivery. METHODS This secondary analysis of the Genesis Study recruited 2392 nulliparous women with singleton pregnancy in cephalic presentation, in a prospective, multicenter study, to examine prenatal and intrapartum predictors of Cesarean delivery. Participants underwent ultrasound and clinical evaluation between 39 + 0 and 40 + 6 weeks' gestation. Data on fetal biometry were not revealed to patients or to their managing clinicians. A fetal adiposity composite of fetal thigh adiposity and fetal abdominal wall thickness was compiled for each infant in order to determine whether fetal adiposity > 90th centile was associated with an increased risk of Cesarean or operative vaginal delivery. RESULTS After exclusions, data were available for 2330 patients. Patients with a fetal adiposity composite > 90th centile had a higher maternal body mass index (BMI) (25 ± 5 kg/m2 vs 24 ± 4 kg/m2 ; P = 0.005), birth weight (3872 ± 417 g vs 3585 ± 401 g; P < 0.0001) and rate of induction of labor (47% (108/232) vs 40% (834/2098); P = 0.048) than did those with an adiposity composite ≤ 90th centile. Fetuses with adiposity composite > 90th centile were more likely to require Cesarean delivery than were those with adiposity composite ≤ 90th centile (P < 0.0001). After adjusting for birth weight, maternal BMI and need for induction of labor, fetal adiposity > 90th centile remained a risk factor for Cesarean delivery (P < 0.0001). A fetal adiposity composite > 90th centile was more predictive of the need for unplanned Cesarean delivery than was an estimated fetal weight > 90th centile (odds ratio, 2.20 (95% CI, 1.65-2.94; P < 0.001) vs 1.74 (95% CI, 1.29-2.35; P < 0.001). Having an adiposity composite > 90th centile was not associated with an increased likelihood of operative vaginal delivery when compared with having an adiposity composite ≤ 90th centile (P = 0.37). CONCLUSIONS Fetuses with increased adipose deposition are more likely to require Cesarean delivery than are those without increased adiposity. Consideration should, therefore, be given to adding fetal thigh adiposity and abdominal wall thickness to fetal sonographic assessment in late pregnancy. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- M P Hehir
- Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - N Burke
- Rotunda Hospital, Dublin, Ireland
| | - G Burke
- Department of Obstetrics and Gynaecology, Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - M J Turner
- University College Dublin Centre for Human Reproduction, School of Medicine and Medical Science, Coombe Women and Infants Maternity Hospital, Dublin, Ireland
| | - F M Breathnach
- Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - F M Mcauliffe
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - J J Morrison
- Department of Obstetrics and Gynaecology, National University of Ireland, Galway, Ireland
| | - S Dornan
- Royal Jubilee Maternity Hospital, Belfast, Ireland
| | - J Higgins
- University College Cork, Cork University Maternity Hospital, Cork, Ireland
| | - A Cotter
- Department of Obstetrics and Gynaecology, Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | | | - P Mcparland
- National Maternity Hospital, Dublin, Ireland
| | - S Daly
- Coombe Women and Infants Maternity Hospital, Dublin, Ireland
| | - F Cody
- Rotunda Hospital, Dublin, Ireland
| | - P Dicker
- Epidemiology & Public Health, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - E Tully
- Rotunda Hospital, Dublin, Ireland
| | - F D Malone
- Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
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Finnegan CL, Burke N, Breathnach F, Burke G, McAuliffe F, Morrison JJ, Turner MJ, Dornan S, Higgins JR, Cotter A, Geary M, McParland P, Daly S, Cody F, Dicker P, Smyth S, Tully E, Malone FD. Defining the upper limit of the second stage of labor in nulliparous patients. Am J Obstet Gynecol MFM 2019; 1:100029. [PMID: 33345793 DOI: 10.1016/j.ajogmf.2019.100029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND Increased duration of the second stage of labor provides clinical challenges in decision-making regarding the optimal mode of delivery that minimizes maternal and neonatal morbidity. OBJECTIVE In a large cohort of uncomplicated nulliparous singleton cephalic labors, we sought to examine the effect of increasing duration of second stage on delivery and perinatal outcome. STUDY DESIGN The GENESIS Study recruited 2336 nulliparous patients with vertex presentation in a prospective double-blinded study to examine prenatal and intrapartum predictors of delivery. Metrics included maternal demographics, duration of second stage, mode of delivery, and associated maternal and neonatal outcomes. Indicators of morbidity included third- or fourth-degree tear, postpartum hemorrhage, neonatal intensive care unit admission, low Apgar scores, cord pH <7.20 and a composite of birth injury that included cephalohematoma, fetal laceration, brachial plexus palsy, facial nerve palsy, and fetal fracture. RESULTS Of 2336 recruited nulliparous participants, 1872 reached the second stage of labor and had complete data for analysis. Increased maternal age (P=.02) and birthweight (P<.001) were found to be associated with a longer second stage. Increasing second stage duration was found to impact on mode of delivery, such that at <1 hour duration the spontaneous vaginal delivery rate was 63% vs 24% at >3 hours (P<.001). Operative vaginal delivery increased from 35% at <1 hour to 65% at >3 hours (P<.001). The rate of cesarean delivery increased with duration of the second stage from 1.2% at <1 hour to 11% at >3 hours (P<.001). The rates of third- or fourth-degree tear increased with second stage duration (P=.003), as did postpartum hemorrhage (P<.001). The composite neonatal birth injury rate increased from 1.8% at <1 hour to 3.4% at >3 hours. The maximum rate of birth injury was 6.5% at 2-3 hours (P<.001). Multiple logistic regression analysis that controlled for maternal age and birthweight confirmed that operative vaginal delivery, perineal trauma, postpartum hemorrhage, and neonatal birth injury remained significantly more likely with increasing second stage duration. CONCLUSION In a prospective cohort of nulliparous pregnancies, increasing duration of second stage of labor was associated with increased rates of operative vaginal and cesarean delivery. Although almost 90% of term nulliparous women with a second stage of labor >3 hours will succeed in achieving a vaginal birth, this success comes at a maternal morbidity cost, with a 10% risk of severe perineal injury and an increasing rate of significant neonatal injury.
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Affiliation(s)
| | - Naomi Burke
- Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | | | - Gerard Burke
- Department of Obstetrics and Gynecology, Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Fionnuala McAuliffe
- UCD School of Medicine and Medical Science, National Maternity Hospital, Dublin, Ireland
| | | | - Michael J Turner
- UCD Center for Human Reproduction Coombe Women and Infants University Hospital, Dublin, Ireland
| | | | - John R Higgins
- University College Cork, Cork University Maternity Hospital, Cork, Ireland
| | - Amanda Cotter
- Department of Obstetrics and Gynecology, Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Michael Geary
- Obstetrics & Gynecology, St. Michael's Hospital, Toronto, University of Toronto, Toronto, Canada
| | | | - Sean Daly
- Coombe Women and Infants University Hospital, Dublin, Ireland
| | - Fiona Cody
- Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Pat Dicker
- Coombe Women and Infants University Hospital, Dublin, Ireland; Epidemiology & Public Health, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Suzanne Smyth
- Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Elizabeth Tully
- Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fergal D Malone
- Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
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Mulcahy C, Mone F, McParland P, Breathnach F, Cody F, Morrison JJ, Higgins J, Daly S, Dornan S, Cotter A, Dicker P, Tully E, Malone FD, McAuliffe FM. The Impact of Aspirin on Ultrasound Markers of Uteroplacental Flow in Low-Risk Pregnancy: Secondary Analysis of a Multicenter RCT. Am J Perinatol 2019; 36:855-863. [PMID: 30396226 DOI: 10.1055/s-0038-1675208] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE This article evaluates the effect of low-dose aspirin on uterine artery (UtA) Doppler, placental volume, and vascularization flow indices in low-risk pregnancy. STUDY DESIGN In this secondary analysis of the TEST randomized controlled trial, low-risk nulliparous women were originally randomized at 11 weeks to: (1) routine aspirin 75 mg; (2) no aspirin; and (3) aspirin based upon the preeclampsia Fetal Medicine Foundation screening test. UtA Doppler, three-dimensional (3D) placental volume, and vascularization flow indices were assessed prior to and 6 weeks postaspirin commencement. RESULTS A total of 546 women were included (aspirin n = 192, no aspirin n = 354). Between first and second trimesters, aspirin use was not associated with a change in UtA Doppler, placental volume, or vascular flow indices. There was no significant difference in the change in UtA Doppler pulsatility index (PI) Z-scores or notching (PI Z-score -0.2 vs. -0.2, p = 0.17), nor was there a significant change in placental volume Z-score and vascular flow indices (volume Z-score change: 0.74 vs. 0.62, p = 0.34). CONCLUSION Low-dose aspirin commenced at 11 weeks in low-risk women does not appear to improve uterine and placental perfusion or placental volume. Any perceived effect on uteroplacental vasculature is not reflected in changes in placental volume nor uteroplacental flow as assessed by two-dimensional and 3D ultrasound.
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Affiliation(s)
- Cecilia Mulcahy
- Department of Fetal Medicine, National Maternity Hospital, Dublin, Ireland
| | - Fionnuala Mone
- UCD Perinatal Research Centre, School of Medicine, National Maternity Hospital, University College Dublin, Dublin, Ireland
| | - Peter McParland
- UCD Perinatal Research Centre, School of Medicine, National Maternity Hospital, University College Dublin, Dublin, Ireland
| | - Fionnuala Breathnach
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fiona Cody
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - John J Morrison
- Department of Obstetrics and Gynaecology, National University of Ireland, Galway, Ireland
| | - John Higgins
- Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
| | - Sean Daly
- Department of Obstetrics and Gynaecology, Coombe Women's and Infant's University Hospital, Dublin, Ireland
| | - Samina Dornan
- Royal Jubilee Maternity Hospital, Belfast, United Kingdom
| | - Amanda Cotter
- Department of Obstetrics and Gynaecology, Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | - Patrick Dicker
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Elizabeth Tully
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fergal D Malone
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fionnuala M McAuliffe
- UCD Perinatal Research Centre, School of Medicine, National Maternity Hospital, University College Dublin, Dublin, Ireland
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Mone F, O'Mahony JF, Tyrrell E, Mulcahy C, McParland P, Breathnach F, Morrison JJ, Higgins J, Daly S, Cotter A, Hunter A, Dicker P, Tully E, Malone FD, Normand C, McAuliffe FM. Preeclampsia Prevention Using Routine Versus Screening Test-Indicated Aspirin in Low-Risk Women. Hypertension 2019; 72:1391-1396. [PMID: 30571234 DOI: 10.1161/hypertensionaha.118.11718] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective was to evaluate whether routine aspirin 75 mg is more cost-effective than the Fetal Medicine Foundation screen-and-treat approach for preeclampsia prevention in low-risk nulliparous women. A health economic decision analytical model was devised to estimate the discounted net health and cost outcomes of routine aspirin versus Fetal Medicine Foundation screening test-indicated aspirin for a cohort of 100 000 low-risk nulliparous women. Both strategies were compared with no intervention. A subanalysis also compared disaggregated components of the algorithm. The analysis used data from hospital administration, literature, and a randomized controlled trial. Sensitivity analyses assessed the impact of aspirin adherence, test cost, and accuracy on study results. Presumed rates of preeclampsia were 3.75% with no intervention versus 0.45% with aspirin use. Results found that routine aspirin was the preferred strategy, in terms of greater health gains and larger cost savings. It provided 163 quality-adjusted life-years relative to no intervention, whereas the screen-and-treat policy achieved 108 quality-adjusted life-years. Routine aspirin would result in an estimated cost saving of €14.9 million annually relative to no intervention, whereas screen-and-treat approach would result in a smaller cost saving of €3.1 million. When the analysis was extended to consider alternative screen-and-treat strategies, routine aspirin remained the optimally cost-effective approach. In conclusion, routine aspirin use in low-risk nulliparous women has a greater health gain and cost saving compared with both the Fetal Medicine Foundation and other screen-and-treat approaches.
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Affiliation(s)
- Fionnuala Mone
- From the UCD Perinatal Research Centre, National Maternity Hospital, Obstetrics and Gynaecology, School of Medicine, University College Dublin, Ireland (F.M., C.M., P.M., F.M.M.)
| | - James F O'Mahony
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Ireland (J.F.O., E.T., C.N.)
| | - Ella Tyrrell
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Ireland (J.F.O., E.T., C.N.)
| | - Cecilia Mulcahy
- From the UCD Perinatal Research Centre, National Maternity Hospital, Obstetrics and Gynaecology, School of Medicine, University College Dublin, Ireland (F.M., C.M., P.M., F.M.M.)
| | - Peter McParland
- From the UCD Perinatal Research Centre, National Maternity Hospital, Obstetrics and Gynaecology, School of Medicine, University College Dublin, Ireland (F.M., C.M., P.M., F.M.M.)
| | - Fionnuala Breathnach
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin (F.B., P.D., E.T., F.D.M.)
| | - John J Morrison
- Department of Obstetrics and Gynaecology, National University of Ireland, Galway (J.J.M.)
| | - John Higgins
- Department of Obstetrics and Gynaecology, University College Cork, Ireland (J.H.)
| | - Sean Daly
- Department of Obstetrics and Gynaecology, Coombe Women's and Infant's University Hospital, Dublin, Ireland (S.D.)
| | - Amanda Cotter
- Department of Obstetrics and Gynaecology, Graduate Entry Medical School, University of Limerick, Ireland (A.C.)
| | - Alyson Hunter
- Department of Fetal Medicine, Royal Jubilee Maternity Hospital, Belfast, United Kingdom (A.H.)
| | - Patrick Dicker
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin (F.B., P.D., E.T., F.D.M.)
| | - Elizabeth Tully
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Ireland (J.F.O., E.T., C.N.).,Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin (F.B., P.D., E.T., F.D.M.)
| | - Fergal D Malone
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin (F.B., P.D., E.T., F.D.M.)
| | - Charles Normand
- Centre for Health Policy and Management, School of Medicine, Trinity College Dublin, Ireland (J.F.O., E.T., C.N.).,Cicely Saunders Institute, King's College London, United Kingdom (C.N.)
| | - Fionnuala M McAuliffe
- From the UCD Perinatal Research Centre, National Maternity Hospital, Obstetrics and Gynaecology, School of Medicine, University College Dublin, Ireland (F.M., C.M., P.M., F.M.M.)
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Breatnach CR, Bussmann N, Levy PT, Vincent DF, Malone FD, McCallion N, Franklin O, El-Khuffash A. Postnatal Myocardial Function in Monochorionic Diamniotic Twins with Twin-to-Twin Transfusion Syndrome following Selective Laser Photocoagulation of the Communicating Placental Vessels. J Am Soc Echocardiogr 2019; 32:774-784.e1. [PMID: 30910308 DOI: 10.1016/j.echo.2019.02.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Indexed: 02/01/2023]
Abstract
BACKGROUND Monochorionic diamniotic (MCDA) twins are at risk for developing twin-to-twin transfusion syndrome (TTTS) throughout pregnancy. This may lead to myocardial dysfunction in the recipient and/or donor twin that persists beyond delivery. Selective laser photocoagulation of the communicating placental vessels (SLPCV) attempts to mitigate the cardiovascular outcomes. The objective of this study was to characterize early postnatal myocardial performance in MCDA twins with TTTS with and without SLPCV. METHODS A prospective study was performed of four MCDA twin groups: (1) uncomplicated MCDA twins, (2) MCDA twins with selective fetal growth restriction, (3) MCDA twins with TTTS following SLPCV (TTTS with SLPCV), and (4) MCDA twins with TTTS who did not undergo SLPCV (TTTS without SLPCV). Fifty-four twin pairs were enrolled: 23 uncomplicated MCDA twin pairs, 15 pairs with selective fetal growth restriction, seven TTTS pairs with SLPCV, and seven TTTS pairs without SLPCV. In each group, twin pairs were divided by birth weight into donor (smaller) and recipient (larger) and compared. Echocardiography was performed on day 1, day 2, and between days 5 and 7 of age, and myocardial performance was characterized by speckle-tracking echocardiography-derived left ventricular and right ventricular longitudinal strain (LS) and systolic strain rate (LSR). Longitudinal strain and longitudinal systolic strain rate are expressed as absolute values. RESULTS Compared with all recipient groups, recipient TTTS without SLPCV infants had lower left ventricular LS (16 ± 3% vs 22%-24%, P < .01) and right ventricular LS (15 ± 5% vs 21%-24%, P < .01) on day 1 that persisted throughout the first week of age. Left ventricular LSR (1.7 ± 0.3 vs 2.3 ± 0.3 sec-1, P < .05) and right ventricular LSR (1.5 ± 0.4 vs 1.7 ± 0.5 sec-1, P < .05) were both lower in the recipient compared with the donor twin in the TTTS without SLPCV group. LS and LSR measurements were similar among all four donor twin groups. CONCLUSIONS Biventricular performance is diminished in recipient MCDA twins with TTTS who are not treated with SLPCV, highlighting the need for close monitoring of their hemodynamic status during the early neonatal period.
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Affiliation(s)
- Colm R Breatnach
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Neidin Bussmann
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland
| | - Phillip T Levy
- Division of Newborn Medicine, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | | | - Fergal D Malone
- Department of Obstetrics and Gynecology, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Naomi McCallion
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland; School of Medicine, Department of Pediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Orla Franklin
- Department of Cardiology, Our Lady's Children's Hospital Crumlin, Dublin, Ireland
| | - Afif El-Khuffash
- Department of Neonatology, The Rotunda Hospital, Dublin, Ireland; School of Medicine, Department of Pediatrics, Royal College of Surgeons in Ireland, Dublin, Ireland.
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Buhimschi CS, Jablonski KA, Rouse DJ, Varner MW, Reddy UM, Mercer BM, Leveno KJ, Wapner RJ, Sorokin Y, Thorp JM, Ramin SM, Malone FD, Carpenter MW, O'Sullivan MJ, Peaceman AM, Saade GR, Dudley D, Caritis SN, Buhimschi IA. Cord Blood Haptoglobin, Cerebral Palsy and Death in Infants of Women at Risk for Preterm Birth: A Secondary Analysis of a Randomised Controlled Trial. EClinicalMedicine 2019; 9:11-18. [PMID: 31143877 PMCID: PMC6510719 DOI: 10.1016/j.eclinm.2019.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 03/08/2019] [Accepted: 03/11/2019] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Antenatal exposure to intra-uterine inflammation results in precocious Haptoglobin (Hp) expression (switch-on status). We investigated the relationships between foetal Hp expression at birth with newborn and childhood outcomes. METHODS We evaluated cord blood samples from 921 newborns of women at imminent risk for preterm delivery randomised to either placebo (n = 471, birth gestational age (GA) median [min-max]: 31 [24-41] weeks) or magnesium sulphate (n = 450, GA 31 [24-42] weeks]). Primary outcome was infant death by 1 year and/or cerebral palsy (CP) ≥ 2 years of corrected age. Adjusted odd ratios (aOR) for neonatal and childhood outcomes were calculated controlling for GA, birth weight, sex, and magnesium exposure. FINDINGS Primary outcome occurred in 2.8% of offspring. Newborns were classified in three pre-defined categorisation groups by cord blood Hp switch status and IL-6 levels: inflammation-nonexposed (Category 1, n = 432, 47%), inflammation-exposed haptoglobinemic (Category 2, n = 449, 49%), and inflammation-exposed anhaptoglobinemic or hypohaptoglobinemic (Category 3, n = 40, 4%). Newborns, found anhaptoglobinemic or hypohaptoglobinemic (Category 3) had increased OR for intraventricular haemorrhage (IVH) and/or death (aOR: 7.0; 95% CI: 1.4-34.6, p = 0.02) and for CP and/or death (aOR: 6.27; 95% CI: 1.7-23.5, p = 0.006) compared with Category 2. Foetal ability to respond to inflammation by haptoglobinemia resulted in aOR similar to inflammation-nonexposed newborns. Hp1-2 or Hp2-2 phenotypes protected against retinopathy of prematurity (aOR = 0.66; 95% CI 0.48-0.91, p = 0.01). INTERPRETATION Foetal ability to switch-on Hp expression in response to inflammation was associated with reduction of IVH and/or death, and CP and/or death. Foetuses unable to mount such a response had an increased risk of adverse outcomes.Trial Registration: clinicaltrials.gov Identifier: NCT00014989.
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Affiliation(s)
- Catalin S. Buhimschi
- Department of Obstetrics and Gynaecology, The Ohio State University, Columbus, OH, United States of America
- Corresponding author at: Department of Obstetrics & Gynecology, University of Illinois at Chicago, Chicago, IL 60612, United States of America.
| | - Kathleen A. Jablonski
- The George Washington University Biostatistics Center, Washington, DC, United States of America
| | - Dwight J. Rouse
- University of Alabama at Birmingham, Birmingham, AL, United States of America
| | | | - Uma M. Reddy
- the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, United States of America
| | - Brian M. Mercer
- Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH, United States of America
- University of Tennessee, Memphis, TN, United States of America
| | | | - Ronald J. Wapner
- Thomas Jefferson University, Philadelphia, PA, United States of America
- Drexel University, Philadelphia, PA, United States of America
| | - Yoram Sorokin
- Wayne State University, Detroit, MI, United States of America
| | - John M. Thorp
- University of North Carolina at Chapel Hill, Chapel Hill, NC, United States of America
| | - Susan M. Ramin
- University of Texas Health Science Center at Houston, Houston, TX, United States of America
| | | | | | | | | | - George R. Saade
- University of Texas Medical Branch, Galveston, TX, United States of America
| | - Donald Dudley
- University of Texas at San Antonio, San Antonio, TX, United States of America
| | - Steve N. Caritis
- University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Irina A. Buhimschi
- Centre for Perinatal Research, The Research Institute at Nationwide Children's Hospital, Columbus, OH, United States of America
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Healy EF, Burke N, Burke G, Breathnach F, McAuliffe F, Morrison J, Turner MJ, Dornan S, Higgins J, Cotter A, Geary G, McParland P, Daly S, Dicker P, Tully E, Malone FD. 772: A comparison of low and high-dose oxytocin for induction of labor in term nulliparous women. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Monteith C, Pinnamaneni R, Levine TA, Unterscheider J, McAuliffe FM, Alderice F, Dicker P, Tully EC, Malone FD, Foran A, Flood K. 111: An abnormal Cerebro-Placental-Ratio is predictive of early childhood delayed neurodevelopment in fetal growth restricted infants. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Hehir MP, Burke N, Burke G, Breathnach FM, McAuliffe FM, Morrison JJ, Turner M, Dornan S, Higgins JR, Cotter A, McParland P, Daly S, Cody F, Dicker P, Tully E, Malone FD. 1047: Increased abdominal circumference to head circumference ratio in late pregnancy is predictive of shoulder dystocia. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.1071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Kruseman NN, Ryan R, Naguleswaran K, Malone FD, Geary MP, Hehir MP. 976: Novel use of the Robson Ten Group Classification System to categorize operative vaginal delivery. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.1000] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Mone F, McAuliffe FM, Malone FD. Application of a preeclampsia screening algorithm in a low-risk nulliparous population. Am J Obstet Gynecol 2018; 219:506. [PMID: 29885306 DOI: 10.1016/j.ajog.2018.05.042] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 05/31/2018] [Indexed: 10/14/2022]
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Mone F, Mulcahy C, McParland P, Breathnach F, Downey P, McCormack D, Culliton M, Stanton A, Cody F, Morrison JJ, Daly S, Higgins J, Cotter A, Hunter A, Tully EC, Dicker P, Alfirevic Z, Malone FD, McAuliffe FM. Trial of feasibility and acceptability of routine low-dose aspirin versus Early Screening Test indicated aspirin for pre-eclampsia prevention ( TEST study): a multicentre randomised controlled trial. BMJ Open 2018; 8:e022056. [PMID: 30056389 PMCID: PMC6067363 DOI: 10.1136/bmjopen-2018-022056] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Evaluate the feasibility and acceptability of routine aspirin in low-risk women, compared with screening-test indicated aspirin for the prevention of pre-eclampsia and fetal growth restriction. DESIGN Multicentre open-label feasibility randomised controlled trial. SETTING Two tertiary maternity hospitals in Dublin, Ireland. PARTICIPANTS 546 low-risk nulliparous women completed the study. INTERVENTIONS Women underwent computerised randomisation to: Group 1-routine aspirin 75 mg from 11 until 36 weeks; Group 2-no aspirin and; Group 3-aspirin based on the Fetal Medicine Foundation screening test. PRIMARY AND SECONDARY OUTCOME MEASURES: (1) Proportion agreeing to participate; (2) compliance with protocol; (3) proportion where first trimester uterine artery Doppler was obtainable and; (4) time taken to issue a screening result. Secondary outcomes included rates of pre-eclampsia and small-for-gestational-age fetuses. RESULTS 546 were included in the routine aspirin (n=179), no aspirin (n=183) and screen and treat (n=184) groups. 546 of 1054 were approached (51.8%) and enrolled. Average aspirin adherence was 90%. The uterine artery Doppler was obtained in 98.4% (181/184) and the average time to obtain a screening result was 7.6 (0-26) days. Of those taking aspirin, vaginal spotting was greater; n=29 (15.1%), non-aspirin n=28 (7.9%), OR 2.1 (95% CI 1.2 to 3.6). Postpartum haemorrhage >500 mL was also greater; aspirin n=26 (13.5%), no aspirin n=20 (5.6%), OR 2.6 (95% CI 1.4 to 4.8). CONCLUSION Low-risk nulliparous women are open to taking aspirin in pregnancy and had high levels of adherence. Aspirin use was associated with greater rates of vaginal bleeding. An appropriately powered randomised controlled trial is now required to address the efficacy and safety of universal low-dose aspirin in low-risk pregnancy compared with a screening approach. TRIAL REGISTRATION NUMBER ISRCTN (15191778); Post-results.
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Affiliation(s)
- Fionnuala Mone
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Cecilia Mulcahy
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Peter McParland
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
| | - Fionnuala Breathnach
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Paul Downey
- Department of Pathology and Laboratory Medicine, National Maternity Hospital, Dublin, Ireland
| | - Dorothy McCormack
- Department of Pharmacy, National Maternity Hospital, Dublin, Ireland
| | - Marie Culliton
- Department of Pathology and Laboratory Medicine, National Maternity Hospital, Dublin, Ireland
| | - Alice Stanton
- Molecular and Cellular Therapeutics, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fiona Cody
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - John J Morrison
- Department of Obstetrics and Gynaecology, National University of Ireland, Galway, Ireland
| | - Sean Daly
- Department of Obstetrics and Gynaecology, Coombe Women's and Infant's University Hospital, Dublin, Ireland
| | - John Higgins
- Department of Obstetrics and Gynaecology, University College Cork, Cork, Ireland
| | - Amanda Cotter
- Department of Obstetrics and Gynaecology, Graduate Entry Medical School, University of Limerick, Limerick, Ireland
| | | | - Elizabeth C Tully
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Patrick Dicker
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Zarko Alfirevic
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Fergal D Malone
- Department of Obstetrics and Gynaecology, Royal College of Surgeons in Ireland, Rotunda Hospital, Dublin, Ireland
| | - Fionnuala M McAuliffe
- UCD Perinatal Research Centre, School of Medicine, University College Dublin, National Maternity Hospital, Dublin, Ireland
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Monteith C, Jadauji J, Abu H, McHugh AM, Donnelly JC, Mooney C, Enright S, Hayes N, Malone FD. 332: Can a point-of-care hemoglobin device replace complete blood count for fetal blood sampling during intrauterine transfusion? Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.10.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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48
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Hehir MP, Burke N, Burke G, Breathnach FM, McAuliffe FM, Morrison JJ, Turner MJ, Dornan S, Higgins J, Cotter A, Geary MP, Cody F, McParland P, Daly S, Dicker P, Tully EC, Malone FD. 578: Right instrument, right patient, right time: vacuum and forceps vs. forceps alone. Am J Obstet Gynecol 2018. [DOI: 10.1016/j.ajog.2017.11.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Corcoran SM, Achamallah N, Loughlin JO, Stafford P, Dicker P, Malone FD, Breathnach F. First trimester serum biomarkers to predict gestational diabetes in a high-risk cohort: Striving for clinically useful thresholds. Eur J Obstet Gynecol Reprod Biol 2018; 222:7-12. [PMID: 29328940 DOI: 10.1016/j.ejogrb.2017.12.051] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 12/18/2017] [Accepted: 12/30/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Screening and diagnosis of gestational diabetes (GDM) has been a source of controversy. The prevalence has increased in line with an obesity epidemic and a trend towards delayed child-bearing. Treatment of even modest glycaemic impairment in pregnancy has been shown to be beneficial in preventing its clinical sequalae. However the cumbersome nature and timing of the oral glucose tolerance test coupled with debate around universal versus risk factor based screening have been problematic. This group aimed to investigate a panel of biomarkers which have shown promise in the literature to predict GDM from the first trimester in a group of high risk women. METHODS Serum samples were drawn on 248 women deemed at risk of GDM before 15 weeks' gestation to measure C-reactive protein, sex hormone binding globulin, adiponectin and 1,5 anhydroglucitol. Patients underwent an oral glucose tolerance test as per IADPSG criteria at 28 weeks' gestation. Multiple logistic regression was used to examine the link between incidence of GDM and early pregnancy serum biomarkers. RESULTS Adiponectin levels in the first trimester are independently linked to the risk of GDM. Serum adiponectin <8.9 μg/ml gives an odds ratio of 3.3 for GDM.Mean 1,5 AG levels are significantly lower in those that go on to develop GDM. SHBG levels measured in the first trimester were linked to the risk of GDM. However, this was no longer statistically significant once BMI, ethnicity and family history were taken into consideration. First trimester measurement of CRP is not a useful indicator of GDM risk. CONCLUSIONS First trimester measurement of Adiponectin and 1,5 Anhydroglucitol are potential early biomarkers for the later onset of GDM. Risk stratification using these biomarkers may facilitate early diagnosis and management of GDM to mitigate against its complications.
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Affiliation(s)
| | | | | | - Philip Stafford
- Department of Biochemistry, Dublin Institute of Technology, Ireland
| | - Pat Dicker
- RCSI Department of Public Health and Epidemiology, Ireland
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50
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Breatnach CR, Monteith C, McSweeney L, Tully EC, Malone FD, Kent E, Doherty A, Franklin O, El-Khuffash A. The Impact of Maternal Gestational Hypertension and the Use of Anti-Hypertensives on Neonatal Myocardial Performance. Neonatology 2018; 113:21-26. [PMID: 28954269 DOI: 10.1159/000480396] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/17/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND Assessment of myocardial performance in neonates using advanced techniques such as deformation imaging and rotational mechanics has gained considerable interest. The applicability of these techniques for elucidating abnormal myocardial performance in various clinical scenarios is becoming established. We hypothesise that term infants born to mothers with gestational hypertension (GH) may experience impaired performance of the left and right ventricles during the early neonatal period. OBJECTIVES We aimed to assess left and right ventricular (LV and RV) function using echocardiography in infants born to mothers with GH and compare them to a control group. METHODS Term infants (>36+6 weeks) born to mothers with GH underwent assessment to measure biventricular function using ejection fraction (EF), deformation imaging, left-ventricle rotational mechanics (apical rotation, basal rotation, twist, twist rate, and untwist rate), and right ventricle-specific functional parameters (tricuspid annular plane systolic excursion and fractional area change) in the first 48 h after birth. A control group comprising infants born to healthy mothers was used for comparison. RESULTS Fifteen infants with maternal GH and 30 age-matched controls were enrolled. The GH infants exhibited no differences in birthweight or LV or RV length, but they had lower EF (54 vs. 61%; p < 0.01), LV global longitudinal strain (-20 vs. -25%; p < 0.01), and LV twist (11 vs. 16°; p = 0.04). There were no differences in any of the RV functional parameters. CONCLUSION Infants born to mothers with GH exhibited lower LV function than healthy controls, while RV function appeared to be preserved. This relationship warrants further exploration in a larger cohort.
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Affiliation(s)
- Colm R Breatnach
- Departmens of Neonatology, The Rotunda Hospital, Dublin, Ireland
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