Society for Maternal-Fetal Medicine Consult Series #70: Management of short cervix in individuals without a history of spontaneous preterm birth

The majority of deliveries before 34 weeks of gestation occur in individuals with no prior history of preterm birth. Mid-trimester cervical length assessment by transvaginal ultrasound is one of the best clinical predictors of spontaneous preterm birth. This Consult provides guidance for the diagnosis and management of short cervix in an individual without a history of preterm birth. The following are Society for Maternal-Fetal Medicine recommendations: (1) we recommend that all cervical length measurements used to guide therapeutic recommendations be performed using a transvaginal approach and in accordance with standardized procedures as described by organizations such as the Perinatal Quality Foundation or the Fetal Medicine Foundation (GRADE 1C); (2) we recommend using a midtrimester cervical length of ≤ 25 mm to diagnose short cervix in individuals with a singleton gestation and no prior history of spontaneous preterm birth (GRADE 1C); (3) we recommend that asymptomatic individuals with a singleton gestation and a transvaginal cervical length of ≤ 20 mm diagnosed prior to 24 weeks of gestation be prescribed vaginal progesterone to reduce the risk of preterm birth (GRADE 1A); (4) we recommend that treatment with vaginal progesterone be considered at a cervical length of 21 to 25 mm based on shared decision-making (GRADE 1B); (5) we recommend that 17-OHPC, including compounded formulations, not be prescribed for the treatment of a short cervix (GRADE 1B); (6) in individuals without a history of preterm birth who have a sonographic short cervix (10-25 mm), we recommend against cerclage placement in the absence of cervical dilation (GRADE 1B); (7) we recommend that cervical pessary not be placed for the prevention of preterm birth in individuals with a singleton gestation and a short cervix (GRADE 1B); (8) we recommend against routine use of progesterone, pessary, or cerclage for treatment of cervical shortening in twin gestations outside the context of a clinical trial (GRADE 1B).

Extreme prematurity: Factors associated with perinatal management and morbi-mortality in western Normandy, France

BACKGROUND

Extreme prematurity (birth before 26 weeks of gestation), presents complex challenges and can lead to various complications. Survival rates of extremely preterm infants are lower in France than in other countries. The choice between active and palliative care is decisive in managing these births.

OBJECTIVE

To conduct an observational study focused on factors associated with perinatal management, mortality, and morbidity outcomes among extremely preterm births in a regional perinatal network.

METHODS

We undertook a retrospective, multicenter study within the western Normandy perinatal network, encompassing live births between 230/6 and 256/6 weeks from 2015 to 2019. Data were extracted from the perinatal network database and medical records.

RESULTS

One hundred and seven infants born from 94 women were included. In the antenatal period, 79 were exposed to corticosteroids, 66 to magnesium sulfate, and 67 to antibiotics. Active care at birth was provided to 84 neonates of whom 42 survived. In total, 65 infants died. Among the 42 surviving neonates, 9 experienced no severe morbidity, 29 displayed one and 4 exhibited two criteria of severe morbidity. Active care was associated with gestational age. Neonatal survival was correlated with antenatal exposure to antibiotics and magnesium sulfate as well as with postnatal corticosteroids. We found no significant association between mortality and gestational age at birth.

CONCLUSION

Prognostic factors must be weighed to discuss active antenatal care which is crucial for survival of extremely preterm neonates. Cooperation between obstetricians and neonatal caregivers is a cornerstone on a regional perinatal network scale.

Neonatal near-miss audits: a systematic review and a call to action

BACKGROUND

Neonatal near-miss (NNM) can be considered as an end of a spectrum that includes stillbirths and neonatal deaths. Clinical audits of NNM might reduce perinatal adverse outcomes. The aim of this review is to evaluate the effectiveness of NNM audits for reducing perinatal mortality and morbidity and explore related contextual factors.

METHODS

PubMed, Embase, Scopus, CINAHL, LILACS and SciELO were searched in February/2023. Randomized and observational studies of NNM clinical audits were included without restrictions on setting, publication date or language.

PRIMARY OUTCOMES

perinatal mortality, morbidity and NNM.

SECONDARY OUTCOMES

factors contributing to NNM and measures of quality of care. Study characteristics, methodological quality and outcome were extracted and assessed by two independent reviewers. Narrative synthesis was performed.

RESULTS

Of 3081 titles and abstracts screened, 36 articles had full-text review. Two studies identified, rated, and classified contributing care factors and generated recommendations to improve the quality of care. No study reported the primary outcomes for the review (change in perinatal mortality, morbidity and NNM rates resulting from an audit process), thus precluding meta-analysis. Three studies were multidisciplinary NNM audits and were assessed for additional contextual factors.

CONCLUSION

There was little data available to determine the effectiveness of clinical audits of NNM. While trials randomised at patient level to test our research question would be difficult or unethical for both NNM and perinatal death audits, other strategies such as large, well-designed before-and-after studies within services or comparisons between services could contribute evidence. This review supports a Call to Action for NNM audits. Adoption of formal audit methodology, standardised NNM definitions, evaluation of parent's engagement and measurement of the effectiveness of quality improvement cycles for improving outcomes are needed.

Association between One Abnormal Value on 3-Hour Oral Glucose Tolerance Test and Adverse Perinatal Outcomes in Twin Gestation

AIM

To investigate whether women with twin gestation and one abnormal value on the diagnostic 3-hour oral glucose tolerance test (OGTT) are at an increased risk of adverse perinatal outcomes.

METHODS

This was a retrospective multicenter study of women with twin gestation, comparing four groups: (1) normal 50-g screening, (2) normal 100-g 3-hour OGTT, (3) one abnormal value on the 3-hour OGTT, and (4) GDM. Multivariable logistic regressions adjusted for maternal age, gravidity, parity, previous CDs, fertility treatments, smoking, obesity and chorionicity were used.

RESULTS

The study included 2,597 women with twin gestations, of which 79.7% had a normal screen, and 6.2% had one abnormal value on the OGTT. In adjusted analyses, women with one abnormal value were found to have higher rates of preterm delivery <32 weeks, large for gestational age neonates, and composite neonatal morbidity of at least one fetus, however, similar maternal outcomes as those with a normal screen.

CONCLUSION

Our study provides evidence that women with twin gestation and one abnormal value on the 3-hour OGTT are at an increased risk of unfavorable neonatal outcomes. This was confirmed by multivariable logistic regressions. Further research is needed to determine whether interventions such as nutritional counseling, blood glucose monitoring, and treatment with diet and medication would improve perinatal outcomes in this population.

[Clinical practice recommendations for diabetes in pregnancy (Update 2023)]

In 1989 the St. Vincent Declaration aimed to achieve comparable pregnancy outcomes in women with diabetes and those with normal glucose tolerance. However, currently women with pre-gestational diabetes still feature a higher risk of perinatal morbidity and even increased mortality. This fact is mostly ascribed to a persistently low rate of pregnancy planning and pre-pregnancy care with optimization of metabolic control prior to conception. All women should be experienced in the management of their therapy and on stable glycemic control prior to conception. In addition, thyroid dysfunction, hypertension as well as the presence of diabetic complications should be excluded or treated adequately before pregnancy in order to decrease the risk for a progression of complications during pregnancy as well as maternal and fetal morbidity. Near normoglycaemia and HbA_1c in the normal range are targets for treatment, preferably without the induction of frequent resp. severe hypoglycaemic reactions. Especially in women with type 1 diabetes mellitus the risk of hypoglycemia is high in early pregnancy, but it decreases with the progression of pregnancy due to hormonal changes causing an increase of insulin resistance. In addition, obesity increases worldwide and contributes to higher numbers of women at childbearing age with type 2 diabetes mellitus and adverse pregnancy outcomes. Intensified insulin therapy with multiple daily insulin injections and pump treatment are equally effective in reaching good metabolic control during pregnancy. Insulin is the primary treatment option. Continuous glucose monitoring often adds to achieve targets. Oral glucose lowering drugs (Metformin) may be considered in obese women with type 2 diabetes mellitus to increase insulin sensitivity but need to be prescribed cautiously due to crossing the placenta and lack of long-time follow up data of the offspring (shared decision making). Due to increased risk for preeclampsia in women with diabetes screening needs to be performed. Regular obstetric care as well as an interdisciplinary treatment approach are necessary to improve metabolic control and ensure the healthy development of the offspring.

Gestational diabetes prevalence and outcomes in women undergoing assisted reproductive techniques (ART)

Infertility affects millions worldwide and use of assisted reproductive techniques (ART) is in high demand.

AIMS

To investigate whether women that underwent ART at our hospital had a higher incidence of GDM than women who conceived spontaneously, if the ART subtype affects the GDM rate and to study obstetrical outcomes in women with GDM in both groups.

METHODS

This was a retrospective analysis of prospectively collected data of singleton pregnancies attended at Hospital Universitari Dexeus between 2008 and 2019. Age<18 years, pregestational diabetes, metformin prior to pregnancy and multiple pregnancies were excluded.

RESULTS

A total of 29,529 patients were included. Pregnancy was achieved by ART in 2596 (8.8%): in vitro fertilisation (IVF/ICSI) 32.8%, frozen embryo transfer (FET) 37.7%, oocyte donor receptors (ODR) 17.2% and insemination 12.2%. The GDM rate was 8.9% (12.7% in ART vs 8.5% in non-ART, p<0.001). The GDM was 11.2% in IVF/ICSI, 17.7% in ODR, 13% in FET and 9.1% in the insemination group (p=0.001). In a multivariable analysis adjusting for age, parity and BMI, ART was not associated with GDM [OR 1.03 (0.90-1.19)], nor was type of ART. Pregnancy outcomes in GDM patients were similar in both groups except for C-section rates (30.0% in ART vs 15.9% in non-ART (p<0.001).

CONCLUSIONS

Despite a higher prevalence of GDM in ART pregnancies, ART was not associated with an increased risk of GDM when adjusting for age, parity and BMI. The prognosis of GDM in ART and non-ART was similar except for C-section rates.

Developing a predictive model for perinatal morbidity among small for gestational age infants

BACKGROUND

While neonates with birth weight <10th percentile are at increased risk of morbidity and mortality, most of these are constitutionally small and not at increased risk. There are no current strategies that reliably distinguish constitutionally small neonates from small neonates at the highest risk of morbidity, so additional tools for risk stratification are needed.

OBJECTIVE

Our objectives were to identify factors that are independently associated with perinatal morbidity among neonates with birth weight <10th percentile (small for gestational age, SGA) and to create predictive models of perinatal morbidity among SGA neonates based on the timing of information availability.

STUDY DESIGN

This secondary analysis of the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be, was a nested case-control study. Participants were prospectively enrolled at eight U.S. centers, with data collection occurring at three standard time points during pregnancy and again after delivery. Our analysis included neonates with birth weights <10th percentile and excluded those with major congenital malformations or suspected or confirmed aneuploidy. The primary outcome was a composite of perinatal morbidity, defined as NICU admission >48 h, NEC, sepsis, RDS, mechanical ventilation, retinopathy of prematurity, seizures, grade 3 or 4 IVH, stillbirth, or death before discharge. Cases were SGA neonates that experienced the primary outcome, and controls were SGA neonates that did not. Maternal factors for potential inclusion in predictive modeling were drawn from a broad list of variables collected as part of the NuMoM2B study, including demographic, anthropometric, clinical, ultrasound, social/behavioral, dietary, and psychological variables. Characteristics that were different in bivariate analysis between cases and controls then underwent further evaluation and refinement. Continuous and multi-category variables were assessed using multiple approaches, including as continuous variables, using standard categories (such as for BMI) as well as empirically-derived cut-points identified by receiver-operating characteristics methodology. The approach for each variable that resulted in the best performance was selected for use in modeling. After variable optimization, multivariable analysis was used to derive prediction models using factors known at mid-pregnancy (Model 1) and delivery (Model 2).

RESULTS

Of the original cohort, 865 were eligible and analyzed, with 134 (15.5%) experiencing the primary outcome. After bivariable and multivariable analysis, these variables were included in Model 1: BMI, stress level, diastolic blood pressure, narcotic use (all in 1st trimester), and uterine artery pulsatility index at 16-21 weeks. Model 2 added the following variables to Model 1: preterm delivery, preeclampsia, and suspected fetal growth restriction. When models 1 and 2 were empirically tested and compared to predicted performance to demonstrate calibration, observed morbidity rates approximately followed expected rates within deciles. Models 1 and 2 had respective areas under the receiver-operating characteristic curve of 0.72 (95% CI 0.67-0.76) and 0.84 (0.80-0.88), to predict the composite morbidity.

CONCLUSION

Using a deeply phenotyped cohort of nulliparous women, we created two models with the moderate-good prediction of perinatal morbidity among SGA neonates.

TRIAL REGISTRATION

clinicaltrials.gov ID: NCT01322529.

Onset and outcomes of spontaneous labour in low risk nulliparous women

OBJECTIVES

The objective of this study was to: 1. Establish the median gestational age of spontaneous labour for low-risk nulliparas. 2. Examine the variation in mode of delivery and short-term neonatal outcomes with gestation at onset of spontaneous labour.

STUDY DESIGN

This is a retrospective observational cohort study conducted at a tertiary obstetric unit. The study population was 12, 323 low risk nulliparous women with singleton pregnancies who experienced spontaneous onset of labour. The study period was over seven years, from Jan 1st 2011 to 31st Dec 2017. Exclusion criteria were multiparity, multi-fetal pregnancy, booking after 14 weeks gestation, antepartum or intrapartum death, or any obstetric or fetal indication for delivery with the exception of post-maturity. Gestation of onset of spontaneous labour, demographic variables and maternal and neonatal outcomes were collected. The primary outcome was median gestational age at onset of spontaneous labour and its distribution at term. Secondary outcomes were mode of delivery and neonatal outcomes including low-apgar score and NICU admission.

RESULTS

12, 323 patients were eligible for inclusion. Median gestation for onset of labour was 40.1 weeks gestation, with 80.5% of spontaneous labour occurs by 41 + 0 weeks gestation. The risk of assisted delivery (RR 1.32, 95% CI 1.23 - 1.42), caesarean section (RR 2.17, 95% CI 1.88-2.51) and low-apgar scores (RR 3.13 95% CI 1.50-6.55) increased significantly with spontaneous labour after 41 weeks' gestation.

CONCLUSIONS

Nulliparous women with low-risk pregnancies are most likely to experience spontaneous labour between 40 + 0 and 40 + 6. 80.5% of spontaneous labour occurred by 41 + 0 weeks gestation. Assisted vaginal delivery, caesarean section and low-apgar scores were significantly more likely with spontaneous labour after 41 weeks' gestation.

Comparison of respiratory distress syndrome amongst preterm twins (28-34 Weeks) born within and after two weeks of completion of single antenatal corticosteroid course: A bidirectional cohort study

BACKGROUND

The literature on neonatal outcomes in preterm twins delivered before 34 weeks but within and after 14 days of a single initial steroid course is limited.

MATERIAL AND METHODS

This bidirectional (226 prospective and 42 retrospectives) cohort study was performed at a tertiary care teaching hospital in South India. We compared the respiratory distress syndrome and neonatal death amongst preterm twins from 28 to 34 weeks born < 14 days (Group A, n=268) and after 14 days (Group B, n=268) of completion of a single course of antenatal steroids. We used multivariable regression analysis (log-binomial model) to adjust for confounding variables. We generated a propensity-matched score with probit regression to analyse outcomes (respiratory distress and neonatal deaths).

RESULTS

The two groups had significant differences in the distribution of birthweight, gestation period and mode of delivery. On adjusted analysis, the period of gestation below 33 weeks and weight below 1.5 kg had the maximum influence on respiratory and other morbidities, and weight less than 1 kg on neonatal death. [adjusted relative risk (ARR) 26.06, (95%CI=2.37-285.5), p=0.008]. On propensity scoring after matching all these variables, we found an [ARR of 2.0 (95% CI: 1.03-3.88), P=0.017] for neonatal death after 14 days of steroid injection. The ARR for respiratory distress syndrome was 1.13 in those born after 14 days of steroids, though it did not reach statistical significance.

CONCLUSION

On propensity scoring, the steroid-delivery interval more than 14 days was associated with a significantly increased risk (ARR of 2) of neonatal death.

Inequities in Adverse Maternal and Perinatal Outcomes: The Effect of Maternal Race and Nativity

OBJECTIVES

To evaluate the effect of race and ethnicity on differences in maternal and perinatal outcomes among U.S.-born and foreign-born women, as well as racial and ethnic disparities in outcomes within these groups.

METHODS

This retrospective study analyzed singleton pregnancies (n = 11,518) among women delivering at Boston Medical Center from January 2010-March 2015. Outcomes of interest included preterm birth, early preterm birth, cesarean delivery, hypertensive disorders, diabetes, low birth weight at term (LBW, < 2500 g), NICU admission and intrauterine fetal demise (IUFD). Prevalence ratios and 95% confidence intervals comparing outcomes between U.S.- and foreign-born women were calculated and stratified by race. Obstetric outcomes among Black and Hispanic women were compared to those of white women within both U.S.- and foreign-born groups.

RESULTS

Preterm birth, hypertensive disorders, LBW and NICU admission were more likely to occur among U.S.-born women and their neonates compared to foreign-born women. Controlling for sociodemographic characteristics did not significantly impact these disparities. Among foreign-born women, Black women had a higher prevalence of many maternal and neonatal complications, while Hispanic women had a lower prevalence of some complications compared to white women. Black woman and infants consistently exhibit worse outcomes regardless of their nativity, while Hispanic women foreign-born women experience less disparate outcomes.

CONCLUSIONS FOR PRACTICE

Overall, women born in the United States are at higher risk of several adverse perinatal outcomes compared to foreign-born women. Racial and ethnic disparities in birth outcomes exist in both groups. However, the complex interplay between biopsychosocial influences that mediate these inequities appear to have different effects among U.S- and foreign- born women. A better understanding of these factors can be used to combat disparities and improve outcomes for all women.

Recurrence Risk of Fetal Growth Restriction: Management of Subsequent Pregnancies

Fetal growth restriction (FGR) is a common obstetric complication that predisposes to mortality across the lifespan. Women with a prior pregnancy affected by FGR have a 20% to 30% risk of recurrence, but effective preventive strategies are lacking. Pharmacologic interventions to prevent FGR are lacking. Low-dose aspirin may be somewhat effective, but low-molecular-weight heparin and sildenafil are not. Surveillance in a subsequent pregnancy may consist of serial ultrasonography with timing and frequency determined by the clinical severity in the index pregnancy. Once FGR is diagnosed, the principal management strategy consists of close surveillance and carefully timed delivery.

Effects of Asherman Syndrome on Maternal and Neonatal Morbidity with Evaluation by Conception Method

STUDY OBJECTIVE

Create a comprehensive summary of maternal and neonatal morbidities from patients previously treated for Asherman syndrome and evaluate for differences in perinatal outcomes based on conception method.

DESIGN

Retrospective cohort.

SETTING

Community teaching hospital affiliated with a large academic medical center.

PATIENTS

Total of 43 singleton births identified from 40 patients previously treated at our institution for Asherman syndrome.

INTERVENTIONS

Review of fertility and obstetric data to summarize the maternal and neonatal outcomes in singleton births from patients with Asherman syndrome who had been treated with hysteroscopic adhesiolysis.

MEASUREMENTS AND MAIN RESULTS

Primary outcomes of maternal morbidity (i.e., hypertensive disease, gestational diabetes, ruptured membranes, postpartum hemorrhage, morbidly adherent placenta [MAP]) and secondary outcomes of neonatal morbidity (i.e., gestational age at birth, method of delivery, weight, length, 1- and 5-minute Apgar score oxygen requirement, anatomic malformations, length of neonatal admission) were evaluated. We identified 40 patients who completed successful treatment of Asherman syndrome and went on to carry a singleton gestation within our institution: 20 (50%) with mild disease, 18 (45%) with moderate disease, and 2 (5%) with severe disease under the March classification system. In total, 43 singleton births were examined, with 27 of 43 (62.8%) conceived without in vitro fertilization (IVF) (group A: non-IVF conception) and 16 of 43 (37.2%) conceived through IVF (group B: IVF conception). The overall rate of preterm birth in Asherman pregnancies was 11.6%, with no difference between the 2 conception groups. We documented 9.3% cases with intrauterine growth restriction, with no difference based on conception groups. The rate of MAP in patients with Asherman syndrome was 14.0%, and the rate of postpartum hemorrhage was 32.6%, with no differences between the conception groups. Newborn anatomic malformations of any cause were documented in 18.6% of all singleton births, with no difference between the conception groups.

CONCLUSION

Our series indicates a higher incidence of intrauterine growth restriction, MAP, postpartum hemorrhage, and newborn anatomic malformations in Asherman syndrome pregnancies than that reported in pregnancies within the general population. However, we found no significant differences in the maternal and neonatal outcomes of patients with Asherman syndrome who conceived with or without IVF after being treated with hysteroscopic adhesiolysis.

Impact of maternal central adiposity on infant anthropometry and perinatal morbidity: A systematic review

Overweight and obesity during pregnancy are risk factors for a large number of perinatal complications, both for the mother and the infant. Risk stratification and early interventions are therefore highly clinically important to minimize future complications. Currently, body mass index (BMI) in early pregnancy is used for risk stratification of pregnant women, but a disadvantage of BMI is that it does not distinguish muscle from fat tissue and central from peripheral adiposity. Maternal fat distribution is suggested to be a better predictor than BMI of obesity-related adverse pregnancy outcomes, with central adiposity posing a greater risk than peripheral subcutaneous fat. With this study, we aimed to systematically review the evidence of what impact maternal central adiposity in early to mid-pregnancy or at most 365 days prior to conception has on infant anthropometry and perinatal morbidity.

The databases PubMed/MEDLINE, Web of Science Core Collection, CINAHL, SCOPUS, Clinical Trials, and Open Grey were searched from inception until November 2019. Eligible studies assessed the association between maternal central adiposity, in early to mid-pregnancy or at most 365 days prior to conception, and any of the following infant outcomes: preterm delivery (< 37 weeks of gestation), birthweight, macrosomia, large for gestational age, congenital malformations, hypoglycemia, hyperbilirubinemia, care at neonatal intensive care unit, and death. Two authors independently screened titles and abstracts, read the included full-text studies, and extracted data. The Newcastle-Ottawa Quality Assessment Scale for cohort studies was used to evaluate the quality of and risk of bias in the studies.

A total of 720 records were identified, 20 full-text studies assessed for eligibility, and 10 cohort studies included in the review. The results suggest that central adiposity in early to mid-pregnancy or at most 365 days prior to conception may contribute to increased birthweight and increased likelihood of delivery by cesarean section. There is also some evidence of associations between central adiposity and preterm delivery (< 37 weeks of gestation), and admission to neonatal intensive care unit. A meta-analysis was not possible to perform due to substantial heterogeneity among the included studies regarding the exposure, outcome, and statistical methods used.

Hence, central adiposity in early to mid-pregnancy or at most 365 days prior to conception could be a possible risk marker in addition to BMI for risk stratification of pregnant women. However, since the topic is only scarcely researched, and the results not unanimous, more studies are needed to further clarify the associations between maternal central adiposity and adverse neonatal complications, before any altered recommendations of guidelines could be made. To enable a future meta-analysis, studies using similar methods for central adiposity assessment,and similar outcome measures, are required.

[Psychomotor development in late premature newborns at five years. Comparison with term newborns using the ASQ3®]

INTRODUCTION

Late prematures (LP) belong to a subgroup of many premature babies with a risk of delayed psychomotor development (PMD). Many subtle changes pass unnoticed if adequate assessment tools are not used. The Ages & Stages Questionnaires 3® (ASQ3®) for parents appears simple and useful for the detection of risk of impairment of PMD, and is recommended by scientific societies that study LP.

OBJECTIVES

To evaluate the risk of impaired PMD in LP at 5years-old, and compare them with term newborns (TNB) using the ASQ3.

PATIENTS AND METHODS

Data were collected on the LP born in a third level hospital in 2010, as well as 2TNB of the same gender for each LP. The prenatal and postnatal morbidity variables were compared. At 5years, their families (excluding those with other neurological risks) were asked to complete the ASQ3. The cut-off point was determined for the total score of the ASQ3 that would discriminate the risk of PMD impairment using ROC analysis. The cut-off point to determine a change in each domain was obtained according to the ASQ3 manual.

RESULTS

The ASQ3 was completed for 88 (47%) and 131 (35%) TNB. All the overall mean scores and those for domains were lower in LP, with no significant differences found between the two groups. A risk of PMD impairment (≤253 points) was observed in 7LP compared to 4TNB, with no significant difference. More maternal, foetal, and neonatal illnesses were observed in 195LP than in the 390TNB. In the univariate analysis, male gender and restricted uterine growth (RUG) were factors associated with a risk of PMD impairment and only RUG in the multivariate analysis.

CONCLUSION

The risk of PMD impairment between LP and TNB at 5years appears not to be shown, with no significant differences between both, and with the values obtained in the ASQ3 being slightly lower in the LP. Male gender and RUG negatively influence this risk.

A comparison of placental pathology between small for gestational age infants at < 5 % versus 5-9

INTRODUCTION

Among SGA newborns, those < 5th % for GA are more likely to have adverse outcomes than those at 5-9th %. The differential morbidity and mortality may be due to abnormal placental pathology between groups. Our purpose was to compare placental pathology characteristics and composite placental pathology among SGA infants with birth weights <5th % vs. 5-9th %.

METHODS

This study is a secondary analysis of a multicenter, retrospective cohort study. Placental pathological variables and composite placental pathology (CPP) among SGA infants <5th % and 5-9th % were compared. Multivariable logistic regression was used to model the probability of an infant's birth weight being classified as <5th % based on pathology characteristics.

RESULTS

Of 11,487 live singleton births, 925 SGA infants met inclusion criteria. Placental pathology was available for review in 407 (44 %) SGA infants: 210 (51.6 %) <5th % and 197 (48.4 %) 5-9th %. A decreased placental weight for GA, was more common in the <5th % group compared to the 5-9th % group (p = 0.0019). No significant differences in the distribution of pathological variables or in CPP (p = 0.3) was observed between the two centile groups. A decreased placental weight was the only reliable predictor of an infant's birth weight centile group (p = 0.0018).

CONCLUSIONS

Placental hypoplasia, reflected by a decreased placental weight for GA, was significantly more common among SGA infants < 5th % compared to the 5-9th %. There was no difference in placental pathological features or CPP between the two centile groups of SGA infants.

Revisiting the management of term breech presentation: a proposal for overcoming some of the controversies

Background

The debate surrounding the management of term breech presentation has excessively focused on the mode of delivery. Indeed, a steady decline in the rate of vaginal breech delivery has been observed over the last three decades, and the soundness of the vaginal route was seriously challenged at the beginning of the 2000s. However, associations between adverse perinatal outcomes and antenatal risk factors have been observed in foetuses that remain in the breech presentation in late gestation, confirming older data and raising the question of the role of these antenatal risk factors in adverse perinatal outcomes. Thus, aspects beyond the mode of delivery must be considered regarding the awareness and adequate management of such situations in term breech pregnancies.

Main body

In the context of the most recent meta-analysis and with the publication of large-scale epidemiologic studies from medical birth registries in countries that have not abruptly altered their criteria for individual decision-making regarding the breech delivery mode, the currently available data provide essential clues to understanding the underlying maternal-foetal conditions beyond the delivery mode that play a role in perinatal outcomes, such as foetal growth restriction and gestational diabetes mellitus. In view of such data, an accurate evaluation of these underlying conditions is necessary in cases of persistent term breech presentation. Timely breech detection, estimated foetal weight/growth curves and foetal/maternal well-being should be considered along with these possible antenatal risk factors; a thorough analysis of foetal presentation and an evaluation of the possible benefit of external cephalic version and pelvic adequacy in each specific situation of persistent breech presentation should be performed.

Conclusion

The adequate management of term breech pregnancies requires screening and the efficient identification of breech presentation at 36 weeks of gestation, followed by thorough evaluations of foetal weight, growth and mobility, while obstetric history, antenatal gestational disorders and pelvis size/conformation are considered. The management plan, including external cephalic version and follow-up based on the maternal/foetal condition and potentially associated disorders, should be organized on a case-by-case basis by a skilled team after the woman is informed and helped to make a reasoned decision regarding delivery route.

Adverse perinatal outcomes in 665,244 term and post-term deliveries-a Norwegian population-based study

OBJECTIVE

To assess the prevalence and risk of adverse perinatal outcomes in early-term (37⁺⁰-38⁺⁶ weeks), full-term (39⁺⁰-40⁺⁶ weeks), late-term (41⁺⁰-41⁺⁶ weeks), and post-term (>42⁺⁰ weeks) deliveries with spontaneous labor onset.

STUDY DESIGN

A population-based cohort with data from the Medical Birth Registry Norway (MBRN) and Statistics Norway (SSB) was conducted. The study population consisted of 665,244 women with cephalic singleton live births at term or post-term with spontaneous labor onset during the period of 1999-2014 in Norway. Maternal, obstetric, and fetal characteristics were obtained from the MBRN. Maternal education data were obtained from the SSB. The prevalence rates of adverse perinatal outcomes for each gestational age (GA) group were estimated. Inter-group differences were detected with Chi square tests. Multivariable regression analysis adjusted for maternal age, educational level, smoking, parity, maternal diabetes, and preeclampsia was used to assess adverse outcome prevalence for early- late-, and post-term births compared to full-term births.

RESULTS

Deliveries at early-term were associated with an increased prevalence of neonatal jaundice, polyhydramnios, small for gestational age (SGA) status, respiratory support, and neonatal intensive care unit (NICU) admission compared with deliveries at GAs of 39-43 weeks (p < 0.001). Low 5-min Apgar scores and newborn antibiotic treatment occurred at an increased prevalence in both early-term and post-term infants, relative to the full-term group (p < 0.001). The prevalence of oligohydramnios, meconium-stained amniotic fluid, and newborn birth injuries increased with increasing GA.

CONCLUSIONS

More perinatal morbidity was observed among early-term infants compared to infants with later term deliveries, underscoring the need for cautious management of low-risk early-term deliveries.

Decreased fetal movements: Perinatal and long-term neurological outcomes

BACKGROUND

While maternal perception of decreased fetal movements during advanced stages of pregnancy may be an indicator for adverse perinatal outcome, the long-term neurological outcome of offspring of affected pregnancies remains largely unknown.

OBJECTIVE

To examine whether maternal complaint of decreased fetal movements is associated with adverse perinatal outcomes, and to assess the implications of decreased fetal movements on long-term neurological morbidity of the offspring.

STUDY DESIGN

A single center cohort analysis including deliveries between the years 1991-2014 was conducted. The association between decreased fetal movements and adverse perinatal outcome was evaluated using a general estimation equation (GEE) multivariable analyses. Incidence of hospitalizations (up to age 18 years) due to various neurological conditions was compared between offspring of affected pregnancies, and those who were not, using a Kaplan-Meyer survival curve. A Cox proportional hazards model was used to control for confounders.

RESULTS

439 (0.18%) of 242,342 deliveries included in this study were accompanied by maternal complaint of decreased fetal movements. Perinatal outcome was comparable between the groups, with no cases of perinatal mortality observed among the exposed group. Total neurological-related hospitalization rate of the offspring, as well as hospitalizations due to movement disorders, were higher among the exposed group (Kaplan-Meyer log-rank test P < 0.05). This association between decreased fetal movements and increased long-term neurological hospitalization proved to be independent of potential confounders with an adjusted hazard ratio of 1.54 (95% CI 1.0-2.37).

CONCLUSION

Maternal complaint of decreased fetal movements does not predict adverse perinatal outcome but is associated with an elevated risk for long-term neurological morbidity of the offspring.

Adverse perinatal outcomes are associated with severe maternal morbidity and mortality: evidence from a national multicentre cross-sectional study

PURPOSE

To assess the association between maternal potentially life-threatening conditions (PLTC), maternal near miss (MNM), and maternal death (MD) with perinatal outcomes.

METHODS

Cross-sectional study in 27 Brazilian referral centers from July, 2009 to June, 2010. All women presenting any criteria for PLTC and MNM, or MD, were included. Sociodemographic and obstetric characteristics were evaluated in each group of maternal outcomes. Childbirth and maternal morbidity data were related to perinatal adverse outcomes (5th min Apgar score < 7, fetal death, neonatal death, or any of these). The Chi-squared test evaluated the differences between groups. Multiple regression analysis adjusted for the clustering design effect identified the independently associated maternal factors with the adverse perinatal outcomes (prevalence ratios; 95% confidence interval).

RESULTS

Among 8271 cases of severe maternal morbidity, there were 714 cases of adverse perinatal outcomes. Advanced maternal age, low level of schooling, multiparity, lack of prenatal care, delays in care, preterm birth, and adverse perinatal outcomes were more common among MNM and MD. Both MNM and MD were associated with Apgar score (2.39; 1.68-3.39); maternal hemorrhage was the most prevalent characteristic associated with fetal death (2.9, 95% CI 1.81-4.66) and any adverse perinatal outcome (2.16; 1.59-2.94); while clinical/surgical conditions were more related to neonatal death (1.56; 1.08-2.25).

CONCLUSION

We confirmed the association between MNM and MD with adverse perinatal outcomes. Maternal and perinatal issues should not be dissociated. Policies aiming maternal care should include social and economic development, and improvements in accessibility to specialized care. These, in turn, will definitively impact on childhood mortality rates.

[Comparison of obstetric prognosis of attempts of breech delivery: Spontaneous labor versus induced labor]

OBJECTIVES

Delivery mode in breech presentation (BP) is often controversial. Spontaneous labor, when vaginal birth seems safe, allows to better estimate uterus contractility, fetus' accommodation to maternal pelvis and optimize monitoring with a partograph. Induced labor in BP was usually contra-indicated. Lack of strong scientific evidence on this matter has permitted a progressive and careful evolution in obstetrical management, with the introduction of induced labor in BP. The aim of our study is to compare vaginal birth rates when labor is induced versus when spontaneous in BP. Maternal and fetal morbidity and mortality parameters were also evaluated.

METHODS

In this retrospective study were included 206 patients carrying fetuses in BP, between June 2012 and June 2017. 182 of them had spontaneous labor and 24 experienced induced labor. Inclusion criteria were singleton pregnancy, BP after 34 weeks of gestation and vaginal delivery authorized by a senior obstetrician. Multiple pregnancy, birth before 34 weeks of gestation, uterine scar, planned caesarian section for BP, intra-uterine fetal death and medical termination of pregnancy were excluded. Induction of labor was performed for medical reason on a favorable cervix.

RESULTS

There was no significant difference in cesarean section rates between the two "induced" and "spontaneous" labor groups in BP (OR=1.69 [CI95%: 0.71-4.04]). We observed no difference between the two groups in neither perineum trauma nor post-partum hemorrhage. No difference was found between the two groups in rates of Apgar score<7 5minutes after birth, neonatal transfer, fetal trauma and pH at birth.

CONCLUSION

Despite our small population, it seems acceptable to propose induced labor for medical reason if cervix is favorable in BP if a protocol is available stating acceptability criteria for vaginal birth. It can avoid unnecessary caesarian section and allow better obstetrical outcome. It would be interesting to study fetal and maternal morbidity and mortality criteria in induced labor versus planned cesarean section when patients could be eligible for induced labor in BP.

Screening for spontaneous preterm birth and resultant therapies to reduce neonatal morbidity and mortality: A review

Despite considerable effort aimed at decreasing the incidence of spontaneous preterm birth, it remains the leading cause of perinatal morbidity and mortality. Screening strategies are imperfect. Approaches used to identify women considered by historical factors to be low risk for preterm delivery (generally considered to be women with singleton pregnancies without a history of a previous preterm birth) as well as those at high risk for preterm birth (those with a previous preterm birth, short cervix, or multiple gestation) continue to evolve. Herein, we review the current evidence and approaches to screening women for preterm birth, and examine future directions for clinical practice. Further research is necessary to better identify at-risk women and provide evidence-based management.

Nudge me, help my baby: on other-regarding nudges

There is an increasing interest in the possibility of using nudges to promote people's health. Following the advances in developmental biology and epigenetics, it is clear that one's health is not always the result of one's own choices. In the period surrounding pregnancy, maternal choice behaviour has a significant influence on perinatal morbidity and mortality as well as the development of chronic diseases later in life. One's health is thus a matter of one's own as well as one's maternal choices. Therefore, self-regarding and other-regarding nudges should be considered as viable strategies to promote health. In this article, we introduce the concept of other-regarding nudges. We use the harm principle and the principle of beneficence to justify these other-regarding nudges. We conclude by stressing the importance of a fair assessment of expectations towards the nudgee, when determining whether a nudge is aimed at preventing harm or promoting a good.

Geographical differences in perinatal health and child welfare in the Netherlands: rationale for the healthy pregnancy 4 all-2 program

Background

Geographical inequalities in perinatal health and child welfare require attention. To improve the identification, and care, of mothers and young children at risk of adverse health outcomes, the HP4All-2 program was developed. The program consists of three studies, focusing on creating a continuum for risk selection and tailored care pathways from preconception and antenatal care towards 1) postpartum care, 2) early childhood care, as well as 3) interconception care. The program has been implemented in ten municipalities in the Netherlands, aiming to target communities with a relatively disadvantageous position with regard to perinatal and child health outcomes. To delineate the position of the ten participating municipalities, we present municipal and regional differences in the prevalence of perinatal mortality, perinatal morbidity, children living in deprived neighbourhoods, and children living in families on welfare.

Methods

Data on all singleton births in the Netherlands between 2009 and 2014 were analysed for the prevalence of perinatal mortality and morbidity. In addition, national data on children living in deprived neighbourhoods and children living in families on welfare between 2009 and 2012 were analysed. The prevalence of these outcomes were calculated and ranked for 62 geographical areas, the 50 largest municipalities and the 12 provinces, to determine the position of the municipalities that participate in HP4All-2.

Results

Considerable geographical differences were present for all four outcomes. The municipalities that participate in HP4All-2 are among the 25 municipalities with the highest prevalence of perinatal mortality, perinatal morbidity, children living in deprived neighbourhoods, or children in families on welfare.

Conclusion

This study illustrates geographical differences in perinatal health and/or child welfare outcomes and demonstrates that the HP4All-2 program targets municipalities with a relative unfavourable position. By targeting these municipalities, the program is expected to contribute most to improving the care for young children and their mothers at risk, and hence to reducing their risks and health inequalities.

Electronic supplementary material

The online version of this article (doi:10.1186/s12884-017-1425-2) contains supplementary material, which is available to authorized users.

Risk factors associated with adverse perinatal outcome in planned vaginal breech labors at term: a retrospective population-based case-control study

BACKGROUND

Vaginal breech delivery is associated with adverse perinatal outcome. The aim of this study was to identify factors associated with adverse perinatal outcome in term breech pregnancies, and to provide clinicians an aid in selecting women for a trial of vaginal labor with the fetus in breech position.

METHODS

We conducted a retrospective, nationwide, Finnish population-based case-control study. All planned singleton vaginal deliveries at term with the fetus in breech position between the years 2005 and 2014 were analyzed. The study's end point was a composite set of adverse perinatal outcomes. All infants with an adverse outcome were compared to the infants with normal outcomes. A multivariate logistic regression model was used to analyze the data.

RESULTS

An adverse perinatal outcome was recorded for 73 (1.5%) infants. According to the study results fetal growth restriction (adjusted odds ratio, 2.94; 95% CI, 1.30-6.67), oligohydramnios (adjusted odds ratio, 2.94; 95% CI, 1.15-7.18), a history of cesarean section (adjusted odds ratio, 2.94; 95% CI, 1.28-6.77, gestational diabetes (adjusted odds ratio, 2.89; 95% CI, 1.54-5.40), epidural anesthesia (adjusted odds ratio, 2.20; 95% CI, 1.29-3.75) and nulliparity (adjusted odds ratio, 1.84; 95% CI, 1.10-3.08) were associated with adverse perinatal outcome.

CONCLUSIONS

Adverse perinatal outcome in planned vaginal breech labor at term is associated with fetal growth restriction, oligohydramnios, previous cesarean delivery, gestational diabetes, nulliparity and epidural anesthesia.

Association of previous severe low birth weight with adverse perinatal outcomes in a subsequent pregnancy among HIV-prevalent urban African women

OBJECTIVE

To evaluate the association between severity of prior low birth weight (LBW) delivery and adverse perinatal outcomes in the subsequent delivery among an HIV-prevalent urban African population.

METHODS

A retrospective cohort study was conducted among 41 109 women who had undergone two deliveries in Lusaka, Zambia, between February 1, 2006, and May 31, 2013. The relationship between prior LBW delivery (<2500 g) and a composite measure of adverse perinatal outcome in the second pregnancy was assessed using multivariate logistic regression.

RESULTS

Women with prior LBW delivery (n=4259) had an increased risk of LBW in the second delivery versus those without prior LBW delivery (n=37 642). Such risk correlated with the severity of first delivery LBW. The adjusted odds ratio (AOR) was 2.89 (95% confidence interval [CI] 2.05-4.09) for a birth weight of 1000-1499 g, 3.05 (95% CI 2.42-3.86) for a birth weight of 1500-1999 g, and 2.02 (95% CI 1.81-2.27) for a birth weight of 2000-2499 g. Previous LBW delivery also increased the risk of adverse perinatal outcome, with an AOR of 1.4 (95% CI 1.2-1.7).

CONCLUSION

Severe prior LBW delivery conferred substantial risk for adverse perinatal outcomes in a subsequent pregnancy.

[Use of fetal movements counting for prolonged pregnancy: A comparative preliminary cohort study before and after implementation of an information brochure]

OBJECTIVES

Compare the number of consultations with the consultation's delay in relation with the sensation of decrease active fetal movements (AFM) in case of late pregnancy, according to the fact if the patients use or not the AFM's count.

MATERIALS AND METHODS

We have compared a "control" group made up of 160 patients who received a classic information and observation (from December 18th, 2013 to February 28th, 2014) versus an "educated" group made up of 160 patients who have been educated to the AFM count (from March 1st, 2014 to August 12th, 2014).

RESULTS

The consultations for AFM decrease, were significantly more frequent in the "control" group than in the "educated" group (36 versus 8, P=0.0009). Inducing labor due to AFM reduction was not statistically different between both groups (13 patients in the "educated group" versus 7 patients in the "control" group P=0.97).

CONCLUSION

Learning a count method seems to decrease the number of consultations for AFM reduction without increasing the perinatal morbidity but maybe at the cost of an increase of obstetric interventions.

Type of Labour in the First Pregnancy and Cumulative Perinatal Morbidity

OBJECTIVE

To estimate cumulative perinatal morbidity among infants delivered at term, according to the type of labour in the first pregnancy, when the first pregnancy was low risk.

METHODS

In a 26-year population-based cohort study (1988-2013) using the Nova Scotia Atlee Perinatal Database, we identified the type of labour in successive pregnancies in low-risk, nulliparous women at term in their first pregnancy (who had at least one subsequent pregnancy), and also identified perinatal outcomes in subsequent deliveries according to the type of labour in the first pregnancy.

RESULTS

A total of 37 756 pregnancies satisfied inclusion and exclusion criteria; of these, 1382 (3.7%) had a Caesarean section without labour in the first pregnancy. Rates of most adverse perinatal outcomes were low (≤ 1%). The risks for stillbirth were low in subsequent deliveries, including those that followed CS without labour in the first pregnancy, and the risks for the overall severe perinatal morbidity outcome were less than 10% for all subsequent deliveries.

CONCLUSION

The absolute risks for severe perinatal morbidity outcomes in a population of low-risk women (with up to four additional pregnancies) were small, regardless of type of labour in the first pregnancy. This finding provides important information on perinatal outcomes in subsequent pregnancies when considering type of labour in the first pregnancy.

[Clinical practice recommendations for diabetes in pregnancy (Diabetes and Pregnancy Study Group of the Austrian Diabetes Association)]

Twenty-six years ago the St. Vincent Declaration aimed for an achievement of a comparable pregnancy outcome in diabetic and non-diabetic women. However, current surveys clearly show that women with pre-gestational diabetes still feature a much higher risk of perinatal morbidity and even increased mortality. This fact is mostly ascribed to a persistently low rate of pregnancy planning and pre-pregnancy care with optimization of metabolic control prior to conception. In addition, obesity increases worldwide, contributing to a growing number of women with type 2 diabetes at a childbearing age, and a further deterioration in outcome in diabetic women. Development of diabetic embryopathy and fetopathy are known to be related to maternal glycemic control (target: normoglycemia and normal HbA1c, if possible without hypoglycemia). The risk for hypoglycemia is at its greatest in early pregnancy and decreases with the progression of pregnancy due to the hormonal changes leading to a marked increase of insulin resistance. Intensified insulin therapy with multiple daily insulin injections and pump treatment are equally effective in reaching good metabolic control during pregnancy. All women should be experienced in the management of their therapy and on stable glycemic control prior to the conception. In addition, thyroid dysfunction, hypertension as well as the presence of diabetic complications should be excluded before pregnancy or treated adequately in order to decrease the risk for a progression of complications during pregnancy as well as for maternal and fetal morbidity.

A Study of Hepatitis E in Pregnancy: Maternal and Fetal Outcome

PURPOSE

HEV infection, a major public health concern, is known to cause large-scale epidemic and sporadic cases of acute viral hepatitis in developing countries. The infection occurs primarily in young adults and is generally mild and self-limiting; however, the case fatality rate is reportedly higher among women, especially during the second or third trimesters of pregnancy.

METHODS

This study, a prospective observational study, was conducted at the Dr. D. Y. Patil Medical College Hospital and Apple Saraswati Multispeciality hospital, in Kolhapur for over a period of 3 years (Jan 2010 to Jan 2013) to find out the prevalence and clinical outcome in a series of HEV-infected pregnant women.

RESULTS

A total of fifty-five symptomatic Anti-HEV IgM-positive women were included, and the maternal-fetal outcome was analyzed. The maternal mortality was 5 % including one antenatal death. Prematurity (80 %) and PROM (11 %) were the commonest fetal complications noted with a vertical transmission rate of 28 %.

CONCLUSION

Variations in maternal morbidity and mortality between different studies indicate a need to subtype the viral genotype according to its virulence and morbidity.

To what extent do English language RCT meta-analysis justify induction of low-risk pregnancy for postdates?

Induction for postdates in low-risk pregnancy was adopted with the intent to prevent post-term antepartum stillbirth, the most common cause of perinatal death, based on evidence derived in English language RCT meta-analysis. Systematic English language meta-analysis of RCT studies of induction for postdates in low-risk pregnancy report perinatal mortality rates (PMRs) for low-risk pregnancy ranging from 2.6 to 7.6/1000, based on 2-5 stillbirths among 13-16 perinatal deaths, including diabetic pregnancies as well as other high-risk pregnancies irrelevant to the study question. Baseline PMR≥41 weeks in large international databases for high and low risk pregnancies before routine induction 1998-2003 range from 0.9 to 2.4/1000 or about 300% lower than the reported PMR rates for postdate pregnancies in the expectant management arm in English language RCT meta-analysis. Deaths in the first week far exceed stillbirths in the RCT meta-analysis, the opposite of what is expected. These 2 implausible results bring into question the evidence used to justify induction for postdates≥41 weeks.

Incidence and risk factors for early neonatal mortality in newborns with severe perinatal morbidity in Uganda

OBJECTIVE

To determine the incidence and risk factors for early neonatal death among newborns with severe perinatal morbidity.

METHODS

A prospective cohort study was performed of 341 newborns with severe perinatal morbidity admitted to the neonatal intensive care unit of Mulago Hospital, Uganda. All newborns were followed up for 7 days or until time of death. Information surrounding the mother's obstetric history and pregnancy, the birth, and the neonatal history was collected using an interviewer-administered questionnaire and by review of relevant records. Multivariate logistic regression analysis was performed to assess factors independently associated with early neonatal death.

RESULTS

A total of 37 (10.9%) neonates died within 7 days, giving an incidence of early neonatal death of 109 deaths per 1000 live births (3 per 100 person-days). In multivariate analysis, respiratory distress (adjusted risk ratio [aRR] 31.29; 95% CI, 4.17-234.20; P=0.001) and inadequate fetal heart monitoring during labor (aRR 6.0; 95% CI 1.40-25.67; P=0.016) were significantly associated with an increased risk of early neonatal death.

CONCLUSION

Approximately one in 10 neonates with severe perinatal morbidity died within 7 days of birth. Respiratory distress and poor monitoring of labor were risk factors for early neonatal death.

Individualised care for women with assisted conception pregnancies and midwifery practice implications: An analysis of the existing research and current practice

OBJECTIVE

the aim is to explore the psychosocial needs of women who are pregnant after assisted conception, specifically in vitro Fertilisation and whether their needs are being addressed within the current maternity care service.

DESIGN

critical review of the literature using a narrative approach.

FINDINGS AND KEY CONCLUSIONS

15 papers were identified. These included both qualitative and quantitative studies, literature reviews and surveys. The findings of this limited narrative review imply that women who undergo assistive reproductive techniques to achieve pregnancy have higher levels of anxiety in pregnancy and may have some difficulties in the transition to parenthood leading to perinatal morbidity. It appears that for this group of women it is important that their history in achieving pregnancy is known to the care providers, to enable the alleviation of some of the anxieties they face. Various aspects of antenatal care have been identified as possible areas which if addressed may reduce these levels of anxiety leading to a reduction in perinatal morbidity.

IMPLICATIONS FOR PRACTICE

currently, there is insufficient evidence to suggest that providing specialist midwifery care reduces morbidity in these women. However, maternity service providers should consider offering additional antenatal and postnatal services to meet the needs of this group in advance of further research in this area.

[Perinatal outcome of monochorionic and dichorionic twin gestations: a study of 775 pregnancies at Reunion Island]

OBJECTIVES

To compare the perinatal mortality and morbidity of infants born from monochorionic versus dichorionic twin pregnancies (TP).

PATIENTS AND METHODS

Retrospective, comparative study of monochorionic and dichorionic TP over 10 years in the south of Reunion Island. Information regarding demographic, gestational and perinatal variables of mothers and infants was collected from the hospital perinatal database.

RESULTS

Six hundred and twenty dichorionic and 155 monochorionic TP were analyzed. In case of monochorionic TP, mothers had higher rates of pregnancy-related hypertension (OR=1.82, 95%CI=[1.02-3.29] ; P=0.03) and hospitalization (OR=1.48, 95%CI=[1.02-2.16]; P=0.03). Newborns from monochorionic TP had higher morbidity for : very preterm birth (birth before 33 weeks gestation) (OR=1.65, 95%CI=[1.02-2.66]; P=0.02), very low birth weight (birth weight<1500g) (OR=1.73, 95%CI=[1.57-3.13]; P<0.001), Apgar<7 at 1 minute (OR=1.76, 95%CI=[1.18-2.61]; P<0.01) and hospitalization (OR=2.08, 95%CI=[1.58-2.73]; P<0.001). Perinatal mortality was also significantly higher (OR=2.47, 95%CI=[1.54-3.94]; P<0.001), as well intrauterine fetal death (OR=3.96, 95%CI=[1.95-8.05]; P<0.001) CONCLUSION: This study confirms that few differences exist among dichorionic and monochorionic TP with regard to maternal morbidity, while neonatal morbidity and mortality are higher in twins born from monochorionic pregnancies.