Perinatal outcomes between immediate vs deferred selective termination in dichorionic twin pregnancies with fetal congenital anomalies: a French multicenter study

BACKGROUND

Because selective termination for discordant dichorionic twin anomalies carries a risk of pregnancy loss, deferring the procedure until the third trimester can be considered in settings where it is legal.

OBJECTIVE

To determine whether perinatal outcomes were more favorable following deferred rather than immediate selective termination.

STUDY DESIGN

A French multicenter retrospective study from 2012 to 2023 on dichorionic twin pregnancies with selective termination for fetal conditions, which were diagnosed before 24 weeks gestation. Pregnancies with additional risk factors for late miscarriage were excluded. We defined 2 groups according to the intention to perform selective termination within 2 weeks after the diagnosis of the severe fetal anomaly was established (immediate selective termination) or to wait until the third trimester (deferred selective termination). The primary outcome was perinatal survival at 28 days of life. Secondary outcomes were pregnancy losses before 24 weeks gestation and preterm delivery.

RESULTS

Of 390 pregnancies, 258 were in the immediate selective termination group and 132 in the deferred selective termination group. Baseline characteristics were similar in both groups. Overall survival of the healthy co-twin was 93.8% (242/258) in the immediate selective termination group vs 100% (132/132) in the deferred selective termination group (P<.01). Preterm birth <37 weeks gestation was lower in the immediate than in the deferred selective termination group (66.7% vs 20.2%; P<.01); preterm birth <28 weeks gestation and <32 weeks gestation did not differ significantly (respectively 1.7% vs 0.8%; P=.66 and 8.26% vs 11.4%; P=.36). In the deferred selective termination group, an emergency procedure was performed in 11.3% (15/132) because of threatened preterm labor, of which 3.7% (5/132) for imminent delivery.

CONCLUSION

Overall survival after selective termination was high regardless of the gestational age at which the procedure was performed. Postponing selective termination until the third trimester seems to improve survival, whereas immediate selective termination reduces the risk of preterm delivery. Furthermore, deferred selective termination requires an expert center capable of performing the selective termination procedure on an emergency basis if required.

A premature newborn born to an adolescent girl with acute Ebola virus disease and malaria survives in a resource-limited setting in an Ebola treatment unit in DR Congo: "A case report"

Key Clinical Message

In the acute phase of Ebola virus disease (EVD) premature neonatal survival is extremely rare. High mortality is related to prematurity, neonatal complications of Ebola, and precarious conditions of neonatal care in underresourced ETUs. This is a case of preterm neonatal survival in the setting of acute maternal EVD infection.

Abstract

This case describes rare preterm newborn survival in the setting of an Ebola treatment unit in Eastern DRC. The neonate was born vaginally to an acutely ill 17-year-old mother who was vaccinated against Ebola virus after being identified as a contact of her father, who was a confirmed case and who did not survive his infection. This woman was admitted to an Ebola treatment unit at 32 weeks of gestation and given monoclonal antibody treatment. She gave birth vaginally, succumbing to postpartum hemorrhage 14 h after delivery. This child survived despite compounding vulnerabilities of preterm birth and maternal Ebola infection. Despite a negative test for EVD, the neonate was given a single dose of monoclonal antibody therapy in the first days of life. We believe maternal vaccination and neonatal monoclonal antibody treatment contributed to the child's survival. The circumstances surrounding neonatal survival in this extremely resource-limited context must be analyzed and disseminated in order to increase rates of neonatal and maternal survival in future outbreaks. Maternal and neonatal health are critical aspects of outbreak response that have been understudied and underreported leaving clinicians severely underresourced to provide life-saving care in outbreak settings. Pregnancy and childbirth do not stop in times of disease outbreak, adequate equipment and trained staff required for quality neonatal care must be considered in future outbreak responses.

Maternal and perinatal outcome of women with early-onset severe pre-eclampsia before 28 weeks: Is expectant management beneficial in a low-resource country?-A prospective observational study

OBJECTIVE

To study the maternal and perinatal outcomes in women with severe pre-eclampsia before 28 weeks of pregnancy.

METHODS

A descriptive study from a tertiary care center. All consecutive women with severe pre-eclampsia withonset before 28 weeks of pregnancy were included. The details were collected in a predesigned structured proforma prospectively.

RESULTS

The study cohort included 145 women with a mean maternal age of 26.97 ± 5.36 years (range 19-47 years). The mean duration of prolongation of pregnancy was 13.04 ± 10.57 days (range 1-51 days). A total of 29.7% (n = 43) of women had at least one major adverse maternal outcome, and the most common was HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome (n = 24,16.6%), followed by eclampsia (n = 12,8.3%). The stillbirth rate was high (n = 103,68.7%), and most occurred in the antepartum period. Of 47 (31.3%) neonates born alive, only eight (17.02%;8/47) survived up to 28 days of life. Fetal growth restriction with Doppler abnormalities and neonatal sepsis were the most common reasons for perinatal mortality.

CONCLUSION

Expectant management should not be considered routinely when the onset of severe pre-eclampsia is before 25⁺⁶ weeks of pregnancy. Between 26 and 27⁺⁶ weeks it can be offered under close monitoring and the perinatal survival depends on the neonatal services available in their facility.

Retrospective evaluation of feline dystocia: clinicopathologic findings and neonatal outcomes in 35 cases (2009-2020)

OBJECTIVES

The aim of this study was to describe the characteristics of cases of feline dystocia presenting to a university emergency service.

METHODS

The medical records of queens presenting for dystocia between January 2009 and September 2020 were reviewed. Data collected included queen signalment, presenting complaints, treatments, and maternal and neonatal outcomes. Clinicopathologic data included serum ionized calcium concentration, blood glucose level, packed cell volume and total solids. Owing to the small sample size, descriptive statistics were used and data presented as median (range).

RESULTS

Thirty-five cases were reviewed. Dystocia was attributed to maternal factors in 69% (n = 24) and fetal factors in 31% (n = 11). Venous blood gas data from 19 queens in stage 2 labor revealed that no queens were hypocalcemic (median ionized calcium 5.4 mg/dl [range 4.9-5.8]) or hypoglycemic (median glucose 143 mg/dl [range 78-183]). Medical management was attempted in 21/35 queens. Successful medical management was achieved in 29% (n = 6/21). Thirteen queens underwent surgical management, six of these after failing medical management. Seven queens received no treatment. Fifteen queens were discharged and one queen was euthanized while still in labor. The remaining 19 queens delivered all fetuses with medical (n = 6) or surgical management (n = 13). Maternal survival was 94% (n = 33/35). A total of 136 kittens were born to all queens, with 58% (n = 79/136) born prior to initiation of treatment, 16% (n = 22/136) after medical management and 26% (n = 35/136) after surgical management. Overall neonatal survival to discharge was 66% (n = 90/136).

CONCLUSIONS AND RELEVANCE

Feline dystocia is an emergent condition that can result in up to 34% neonatal mortality for kittens delivered via both medical and surgical means. Hypoglycemia and hypocalcemia were not precipitating causes of feline dystocia in this population.

Perinatal Outcomes and Influence of Amniotic Fluid Volume Following Previable, Preterm Prelabor Rupture of Membranes (pPPROM): A Historical Cohort Study

Purpose

To determine perinatal outcomes and influence of amniotic fluid volume in pregnancies complicated by previable, preterm prelabor rupture of membranes (pPPROM).

Patients and methods

This was a historical cohort study from two tertiary-level maternity hospitals (January 1, 2009 to December 31, 2015). All pregnancies complicated by pPPROM were identified using ICD coding of discharge abstracts. Hospital charts were reviewed to collect maternal demographics, pregnancy and delivery events, and immediate postnatal outcomes (including survival). Post-processing review of stored ultrasound images was performed to evaluate the relationship between amniotic fluid volume and outcomes.

Results

A total of 113 pregnancies were eligible and 99 were included in the final analysis (74 with “expectant management” and 25 opting for elective termination). The median gestational age at pPPROM was 20+6 weeks [IQR 19+4 to 21+5]. For those choosing expectant management, the median latency between pPPROM and delivery was 7 days, median gestational at delivery was 23+1 weeks, and neonatal survival to discharge was 27.5% overall. There was a trend towards higher rates of pregnancy termination at one hospital (31.7%) compared to the other (15.4%), but no difference between sites with respect to latency, mode of delivery, or survival amongst those managed expectantly. There was a relationship between survival and gestational age at pPPROM (p<0.04), as well as initial amniotic fluid volume category: 52.6% of survivors had normal initial amniotic fluid volumes whereas the majority of previable losses had oligohydramnios and the majority of stillbirths had anhydramnios.

Conclusion

After expectant management, more than one in four newborns following pPPROM survived to hospital discharge. While gestational age at rupture was most strongly correlated with survival, normal initial amniotic fluid volumes were mostly seen in survivors whereas stillbirths more frequently had anhydramnios. These findings will help to improve counseling and care of patients with pPPROM and in guiding long-term follow-up studies.

Association between mode of delivery and infant survival at 22 and 23 weeks of gestation

BACKGROUND

Cesarean delivery is currently not recommended before 23 weeks' gestation unless for maternal indications, even in the setting of malpresentation. These recommendations are based on a lack of evidence of improved neonatal outcomes and survival following cesarean delivery and the maternal risks associated with cesarean delivery at this early gestational age. However, as neonatal resuscitative measures and obstetrical interventions improve, studies evaluating the potential neonatal benefit of periviable cesarean delivery have reported inconsistent findings.

OBJECTIVE

This study aimed to compare the survival rates at 1 year of life among resuscitated infants delivered by cesarean delivery with those delivered vaginally at 22 and 23 weeks of gestation.

STUDY DESIGN

We conducted a population-based cohort study of all resuscitated livebirths delivered between 22 0/7 and 23 6/7 weeks of gestational age in the United States between 2007 and 2013. The primary outcome was the rate of infant survival at 1 year of life for different routes of delivery (cesarean vs vaginal delivery) at both 22 and 23 weeks of gestation. The secondary outcome variables included infant survival rates for neonates who survived beyond 24 hours of life, neonatal survival, and the length of survival. A secondary analysis also included a comparison of the infant survival rates between the different routes of delivery cohorts stratified by fetal presentation, steroid exposure, and ventilation. Information about composite adverse maternal outcomes were limited to infants who were delivered between 2011 and 2013 (when these items were first reported) and were defined as a requirement for blood transfusion, an unplanned operating room procedure following delivery, unplanned hysterectomy, and intensive care unit admission; the composite adverse maternal outcomes were also compared between the different delivery route cohorts for deliveries occurring between 22 and 23 weeks of gestation. Multivariable logistic regression analysis was used to determine the association between cesarean delivery and infant survival and other neonatal and maternal outcomes.

RESULTS

Resuscitated infants delivered by cesarean delivery had higher rates of survival at 22 weeks (44.9 vs 23.0%; P<.001) and at 23 weeks (53.3 vs 43.4%; P<.001) of gestation regardless of fetal presentation. Multivariable logistic regression analysis demonstrated that infants who were delivered by cesarean delivery at 22 weeks (adjusted relative risk, 2.3; 95% confidence interval, 1.9-2.8) and 23 weeks (adjusted relative risk, 1.4; 95% confidence interval, 1.2-1.5) of gestation were more likely to survive than those delivered vaginally. When the cohort was limited to neonates who survived beyond the first 24 hours of life, vertex neonates born by cesarean delivery were not more likely to survive at 22 weeks (adjusted relative risk, 1.2; 95% confidence interval, 0.9-1.7) or 23 weeks (adjusted relative risk, 1.1; 95% confidence interval, 0.9-1.3) of gestation. An increased risk for composite adverse maternal outcomes (adjusted relative risk, 1.7; 95% confidence interval, 1.1-2.7) was associated with cesarean delivery at 22 to 23 weeks of gestation.

CONCLUSION

Cesarean delivery is associated with increased survival at 1 year of life among resuscitated, periviable infants born between 22 0/7 and 23 6/7 weeks of gestation, especially in the setting of nonvertex presentation. However, cesarean delivery is associated with increased maternal morbidity.

Veterinary Interventions to Improve Neonatal Survival on British Beef and Sheep Farms: A Qualitative Study

Neonatal lamb and calf deaths are a major issue in UK agriculture. Consistent mortality rates over several decades, despite scientific advances, indicate that socioeconomic factors must also be understood and addressed for effective veterinary service delivery to improve lamb and calf survival. This qualitative study utilised semi-structured interviews with vets and farmers to explore the on-farm mechanisms and social context, with a particular focus on the role of the vet, to manage and reduce neonatal losses in beef calves and lambs on British farms. Data were analysed using a realist evaluation framework to assess how the mechanisms and context for veterinary service delivery influence survival as the outcome of interest. A lack of a clear outcome definition of neonatal mortality, and the financial, social and emotional impact of losses on both vets and farmers, are barriers to recording of losses and standardisation of acceptable mortality levels at a population level. Despite this, there appears to be an individual threshold on each farm at which losses become perceived as problematic, and veterinary involvement shifts from preventive to reactive mechanisms for service delivery. The veterinarian-farmer relationship is central to efforts to maximise survival, but the social and economic capital available to farmers influences the quality of this relationship. Health inequalities are well-recognised as an issue in human healthcare and the findings indicate that similar inequalities exist in livestock health systems.

Maternal and perinatal outcomes in midtrimester rupture of membranes

OBJECTIVE

The aim of this study was to assess neonatal and maternal adverse outcomes following expectant management of preterm prelabor rupture of membranes (PPROM) between 18 and 26 weeks and to identify maternal morbidity and prognostic factors for neonatal outcomes.

METHODS

Data were collected from all pregnant women who presented PPROM between 18⁺⁰ and 26⁺⁰ weeks admitted into two tertiary centers in Brazil from 2005 to 2016. The neonatal adverse outcomes (mortality or the development of a severe morbidity) and maternal adverse outcomes were analyzed and compared among four groups (18^0/7 to 20^0/7 weeks, 20⁺¹ to 22^0/7 weeks, 22⁺¹ to 24^0/7 weeks and 24⁺¹ to 26^0/7 weeks). A multiple logistic regression was performed for each predictor of neonatal adverse outcomes, and the area under the receiver operating characteristics curves for birth weight and gestational age at birth were calculated.

RESULTS

Of the 101 women with PPROM during the study period, 97 fulfilled the eligible criteria. Among these patients, 30 (30.9%) had a miscarriage or stillbirth. Overall there were 67/97 (69.1%) livebirths, 45/97 newborns survived to discharge (46.3%), and 53/97 (54.6%) experienced severe neonatal adverse outcome. The median latency period was seven days, with 36 (37.1%) patients ending the pregnancy in 2-14 days. Among 29 patients with PPROM at 24⁺¹ to 26^0/7 weeks, only 13 (44.8%) delivered between 2 and 14 days. Multivariate analysis has demonstrated that the independent predictor for adverse neonatal outcome was birthweight. The maternal morbidity was high; however, the expectant management did not increase the rate of severe maternal morbidity.

CONCLUSIONS

PPROM between 18⁺⁰ and 26⁺⁰ weeks has high morbidity and mortality, and the only significant independent predictor of severe adverse neonatal outcomes is birthweight. Maternal morbidity is high, however, the expectant management is not increased by expectant management.

Maternal and neonatal outcomes following expectant management of preterm prelabor rupture of membranes before viability

Purpose: To provide center-based outcome data on obstetric and neonatal complications arising from expectantly managed pregnancies affected by preterm prelabor rupture of membranes (PPROM) before viability.Materials and methods: We collected data on 130 consecutive pregnancies complicated by spontaneous rupture of membranes before 24 week's gestation, occurring over a 7-year period. These were women who delivered >24 h after membrane rupture, and had no signs of chorioamnionitis or advanced labor at admission. Women with amniocentesis-induced PPROM (n = 7) were analyzed separately. The descriptive statistics of obstetrics and neonatal outcomes were reported.Results: The overall neonatal survival to discharge rate was 33.8%. Stratification of patients into early (12 to 19⁺⁶ weeks' gestation) and late pre-viable PPROM (20 to 23⁺⁶ weeks' gestation) revealed a 3.6-fold increase in survival rate in the latter group (12.2% versus 43.8%, p < .001). Pre-viable PPROM following amniocentesis predicted a 100% survival outcome, however anhydramnios impacted negatively. The most common neonatal morbidities of those admitted to intensive care unit were respiratory distress syndrome (78.7%) and bronchopulmonary dysplasia (84.4%). The most common maternal morbidities affecting pre-viable PPROM were clinical chorioamnionitis (47.7%), histological chorioamnionitis (81.8%), retained products of conception (39.3%) and preterm labor (45.4%).Conclusions: Later gestational ages at PPROM were associated with better survival rates, however neonatal morbidity remained high. Women experiencing pre-viable PPROM following amniocentesis can be reassured, while those with anhydramnios at any time during the latency period should be adequately counseled regarding poorer outcomes.