Aim
This study aims to determine whether second‐trimester uterine artery (UtA) Doppler combined with first‐trimester abnormal pregnancy‐associated plasma protein‐A (PAPP‐A) and β‐human chorionic ...gonadotropin (β‐Hcg) levels predicts adverse obstetric and neonatal outcomes.
Materials and Methods
This study of 289 pregnant women included 196 with normal PAPP‐A and free β‐HCG values (control group) and 93 with abnormal values (study group) in the first‐trimester screening test. Second‐trimester UtA Doppler sonography was done in these pregnancies. The perinatal prediction and screening potential of UtA Doppler pulsatility index (PI) parameters were examined in the study group.
Results
UtA PI >95 percentile increased birth before the 37th week by 4.46 times, birth before the 34th week by 7.44 times, preeclampsia risk by 3.25 times, fetal growth restriction (FGR) risk by 4.89 times, and neonatal intensive care unit (NICU) admission rates by 3.66 times in the study group (p < 0.05 for all). UtA PI >95 percentile had 49.2% sensitivity and 82.1% specificity for birth before 37 weeks. For birth before 34 weeks, sensitivity was 80.0% and specificity 65.0%. FGR has 70.5% sensitivity and 67.1% specificity. Screening for preeclampsia has 66.6% sensitivity and 61.9% specificity.
Conclusion
Adding UtA Doppler in the second trimester to pregnancies with abnormal PAPP‐A and/or free β‐Hcg values in the first trimester may be a useful screening method for adverse outcomes.
In our study, we found that uterine artery (UtA) pulsatility index parameters differ in abnormal PAPP‐A and/or free β‐Hcg values in maternal serum in the first trimester. We found that adding second trimester UtA Doppler to screening in these pregnancies could predict adverse obstetric outcomes. We concluded that UtA Doppler evaluation should be taken into consideration in these pregnancies.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Antiphospholipid syndrome (APS) is a rare heterogenous autoimmune disorder with severe life-threatening complications shown during pregnancy. In this analysis, we aimed to systematically compare the ...pregnancy outcomes (both maternal and fetal) in patients with APS.
Web of Science, Google Scholar, Medicus, Cochrane Central, Embase, and Medline were searched for relevant English publications. The main inclusion criteria were based on studies that compared pregnancy outcomes in patients with APS vs a control group. Statistical analysis was carried out by the RevMan software version 5.3. This analysis involved dichotomous data, and risk ratios (RR) with 95% confidence intervals (CIs) were used to represent the analysis.
Eight studies consisting of a total number of 212,954 participants were included. Seven hundred seventy participants were pregnant women with APS and 212,184 participants were assigned to the control group. Pregnancy-induced hypertension was significantly higher in women with APS (RR: 1.81, 95% CI: 1.33 - 2.45; P = .0002). The risks of fetal loss (RR: 1.33, 95% CI: 1.00-1.76; P = .05), abortion (RR: 2.42, 95% CI: 1.46-4.01; P = .0006), thrombosis (RR: 2.83, 95% CI: 1.47-5.44; P = .002), and preterm delivery (RR: 1.89, 95% CI: 1.52-2.35; P = .00001) were also significantly higher in women with APS. However, placental abruption (RR: 1.35, 95% CI: 0.78-2.34; P = .29) and pulmonary embolism were not significantly different (RR: 1.47, 95% CI: 0.11-19.20; P = .77). The risk of neonatal mortality (RR: 3.95, 95% CI: 1.98-7.86; P = .0001), infants small for gestational age (RR: 1.38, 95% CI: 1.04-1.82; P = .02), premature infants (RR: 1.86, 95% CI: 1.52-2.28; P = .0001), and infants who were admitted to neonatal intensive care unit (RR: 3.35, 95% CI: 2.29-4.89; P = .00001) were also significantly higher in women with APS.
This analysis showed APS to be associated with significantly worse pregnancy outcomes when compared to the control group. A significantly higher risk of maternal and fetal complications was observed in this category of patients. Therefore, intense care should be given to pregnant women with APS to monitor unwanted outcomes and allow a successful pregnancy.
Abstract
BACKGROUND
Subclinical hypothyroidism (SCH) and thyroid autoimmunity (TAI) are associated with adverse pregnancy outcomes such as pregnancy loss and preterm birth. However, the ability of ...levothyroxine (LT4) supplementation to attenuate the risks of these outcomes remains controversial.
OBJECTIVE AND RATIONALE
This systematic review and meta-analysis was conducted to determine the effect of LT4 supplementation on pregnancy loss rate (PLR) and preterm birth rate (PBR) among pregnant women with SCH and TAI.
SEARCH METHODS
A systematic literature search of the PubMed, EMBASE, Web of Science and Cochrane Controlled Trials Register databases and Clinicaltrials.gov was performed to identify all relevant English studies published up to April 2018. The following terms were used for the search: subclinical hypothyroidism OR thyroid autoimmunity OR thyroperoxidase antibody (TPO-Ab) OR thyroglobulin antibodies (Tg-Ab) AND (levothyroxine OR euthyrox) AND pregnancy outcome OR miscarriage OR abortion OR pregnancy loss OR preterm birth OR premature delivery OR early labo(u)r. The reference lists of the relevant publications were also manually searched for related studies. Published manuscripts were included if they reported data on pregnancy loss, preterm birth or both. We separately analysed the pooled effects of LT4 supplementation on PLR and PBR in women with SCH and TAI.
OUTCOMES
Overall, 13 eligible studies including 7970 women were included in the meta-analysis. Eight and five of these studies were randomized controlled trials (RCTs) and retrospective studies, respectively. The pooled results indicated that LT4 supplementation significantly decreased the PLR relative risk (RR) = 0.56, 95% confidence interval (CI): 0.42–0.75, I2 = 1%, 12 studies and PBR (RR = 0.68, 95% CI: 0.51–0.91, I2 = 21%, eight studies) in women with SCH and/or TAI. We further found that LT4 supplementation significantly decreased the risk of pregnancy loss (RR = 0.43, 95% CI: 0.26–0.72, P = 0.001, I2 = 0%) but not of preterm birth (RR = 0.67, 95% CI: 0.41–1.12, P = 0.13, I2 = 0%) in women with SCH. Furthermore, LT4 supplementation significantly decreased the risks of both pregnancy loss (RR = 0.63, 95% CI: 0.45–0.89, P = 0.009, I2 = 0%) and preterm birth (RR = 0.68 95% CI: 0.48–0.98, P = 0.04, I2 = 46%) in women with TAI. These results were consistent when only RCTs were included in the analysis. Further, in women with SCH, LT4 supplementation reduced the risk of pregnancy loss in pregnancies achieved by assisted reproduction (RR = 0.27, 95% CI: 0.14–0.52, P < 0.001, I2 = 14%) but not in naturally conceived pregnancies (RR = 0.60, 95% CI: 0.28–1.30, P = 0.13, I2 = 0%). By contrast, in women with TAI, LT4 supplementation reduced the risks of both pregnancy loss (RR = 0.61, 95% CI: 0.39–0.96, P = 0.03, I2 = 0%) and preterm birth (RR = 0.49, 95% CI: 0.30–0.79, P = 0.003, I2 = 0%) in naturally conceived pregnancies but not in pregnancies achieved by assisted reproduction (RR = 0.68, 95% CI: 0.40–1.15, P = 0.15, I2 = 0% for pregnancy loss and RR = 1.20, 95% CI: 0.68–2.13, P = 0.53, I2 not applicable for preterm birth).
WIDER IMPLICATIONS
This meta-analysis confirmed the beneficial effects of LT4 supplementation, namely the reduced risks of pregnancy loss and preterm birth, among pregnant women with SCH and/or TAI. The different effects of LT4 supplementation on naturally conceived pregnancies and pregnancies achieved by assisted reproduction in women with SCH and/or TAI suggest that these women should be managed separately. Due to the limited number of studies included in this meta-analysis, especially in the subgroup analysis, further large RCTs and fundamental studies are warranted to confirm the conclusions and better clarify the molecular mechanism underlying these associations.
Intrahepatic cholestasis of pregnancy (ICP) is characterized by maternal pruritus, and elevated serum transaminases and bile acids. Genetic defects in at least 6 canalicular transporters have been ...found. Association studies stress the variability of genotypes, different penetrance, and influence of environmental factors. Serum autotaxin is a sensitive, specific, and robust diagnostic marker. Elevated maternal bile acids correlate with fetal complications. Long-term sequelae for mothers include the gallstone risk and chronic liver disease. There is an association between ICP and hepatitis C. Current treatment is ursodeoxycholic acid, owing to benefits on pruritus, liver function, safety, and decreased rates of adverse effects.
Introduction Prenatal diagnosis (PND) via amniocentesis or chorionic villus sampling may result in the identification of a sex chromosome abnormality, often as an incidental finding. Aims To ...ascertain the incidence of sex chromosome abnormalities detected by prenatal diagnosis in the Grampian and the West of Scotland (WoS) regions and to determine the characteristics and outcomes of these cases. Methods Retrospective review of all cases of prenatal diagnoses that revealed a sex chromosome abnormality between 2000 and 2012. Results Over the period of 12 years, 166 positive cases were identified. The indication for PND was an abnormal ultrasound scan in 95(57%), high-risk first trimester screening results in 31(19%), age related aneuploidy risk in 24(14%), maternal anxiety in 9(5%) and a family history of a chromosomal abnormality in 7(4%). Of the 166 cases, 79(48%) cases were 45, X, 24(14%) were 47, XXY, 14(8%) were 48, XXX, 9(5%) were 45, X/46, XX,, 8(5%) had a structurally abnormal X chromosome, 7(4%) were 45X/46XY, 6(4%) were 48, XYY, 2(1%) were 46, XX/46XY and 17(11%) had other variations of sex chromosomes. Of the 166, 73(44%) pregnancies were terminated and of these cases, 47(64%) had a karyotype of 45, X. An additional 7 pregnancies(4%) were associated with an intrauterine death and 5 of these were 45, X. Based on a combined birth rate of 40,000 births per year for these regions, it is estimated that there was one positive case for 3,500 births and approximately half of these led to a live birth. Conclusions 1:7000 births are associated with a prenatally diagnosed sex chromosome abnormality. 45, X is the most commonly encountered abnormality. Given the rare incidence, there is a need to improve our understanding of the care of these cases during the pregnancy as well as afterwards.
Peripartum cardiomyopathy is a pregnancy-associated myocardial disease characterized by the development of heart failure due to marked left ventricular systolic dysfunction. Although the disease is ...relatively uncommon, its incidence is increasing, and it can be associated with important and lasting morbidity and with mortality. Peripartum cardiomyopathy seems to affect women in different parts of the world but with considerable differences in clinical presentation. The purposes of this review are to describe the clinical profile of peripartum cardiomyopathy in the United States and to provide recommendations for the diagnosis and the management of this disease.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPCLJ, UPUK, ZAGLJ, ZRSKP
Objective
To validate externally five approaches to predict ectopic pregnancy (EP) in pregnancies of unknown location (PUL): the M6P and M6NP risk models, the two‐step triage strategy (2ST, which ...incorporates M6P), the M4 risk model, and beta human chorionic gonadotropin ratio cut‐offs (BhCG‐RC).
Design
Secondary analysis of a prospective cohort study.
Setting
Eight UK early pregnancy assessment units.
Population
Women presenting with a PUL and BhCG >25 IU/l.
Methods
Women were managed using the 2ST protocol: PUL were classified as low risk of EP if presenting progesterone ≤2 nmol/l; the remaining cases returned 2 days later for triage based on M6P. EP risk ≥5% was used to classify PUL as high risk. Missing values were imputed, and predictions for the five approaches were calculated post hoc. We meta‐analysed centre‐specific results.
Main outcome measures
Discrimination, calibration and clinical utility (decision curve analysis) for predicting EP.
Results
Of 2899 eligible women, the primary analysis excluded 297 (10%) women who were lost to follow up. The area under the ROC curve for EP was 0.89 (95% CI 0.86–0.91) for M6P, 0.88 (0.86–0.90) for 2ST, 0.86 (0.83–0.88) for M6NP and 0.82 (0.78–0.85) for M4. Sensitivities for EP were 96% (M6P), 94% (2ST), 92% (N6NP), 80% (M4) and 58% (BhCG‐RC); false‐positive rates were 35%, 33%, 39%, 24% and 13%. M6P and 2ST had the best clinical utility and good overall calibration, with modest variability between centres.
Conclusions
2ST and M6P performed best for prediction and triage in PUL.
Tweetable
The M6 model, as part of a two‐step triage strategy, is the best approach to characterise and triage PULs.
Tweetable
The M6 model, as part of a two‐step triage strategy, is the best approach to characterise and triage PULs.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Introduction Abnormal vaginal flora (AVF) before 14 gestational weeks is a risk factor for preterm birth (PTB). The presence of aerobic microorganisms and an inflammatory response in the vagina may ...also be important risk factors.
Aim The primary aim of the study was to investigate the differential influences of AVF, full and partial bacterial vaginosis, and aerobic vaginitis in the first trimester on PTB rate. The secondary aim was to elucidate why treatment with metronidazole has not been found to be beneficial in previous studies.
Setting Unselected women with low‐risk pregnancies attending the prenatal unit of the Heilig Hart General Hospital in Tienen, Belgium, were included in the study.
Materials and methods At the first prenatal visit, 1026 women were invited to undergo sampling of the vaginal fluid for wet mount microscopy and culture, of whom 759 were fully evaluable. Abnormal vaginal flora (AVF; disappearance of lactobacilli), bacterial vaginosis (BV), aerobic vaginitis (AV), increased inflammation (more than ten leucocytes per epithelial cell) and vaginal colonisation with Candida (CV) were scored according to standardised definitions. Partial BV was defined as patchy streaks of BV flora or sporadic clue cells mixed with other flora, and full BV as a granular anaerobic‐type flora or more than 20% clue cells. Vaginal fluid was cultured for aerobic bacteria, Mycoplasma hominis and Ureaplasma urealyticum. Outcome was recorded as miscarriage ≤13 weeks + 6 days early miscarriage (EM), n = 8 (1.1%), between 14 + 0 and 24 weeks + 6 days late miscarriage (LM), n = 7 (0.9%), delivery or miscarriage ≤34 weeks + 6 days n = 29 (3.8%), ≤36 weeks + 6 days n = 70 (9.2%). PTB between 25 + 0 and 36 weeks + 6 days was further divided in severe PTB (SPTB, 25 + 0 to 34 weeks + 6 days) and mild PTB (MPTB, 35 + 0 to 36 weeks + 6 days).
Results Women without abnormalities of the vaginal flora in the first trimester had a 75% lower risk of delivery before 35 weeks compared with women with AVF odds ratio (OR) 0.26; 95% confidence interval (CI) 0.12–0.56. The absence of lactobacilli (AVF) was associated with increased risks of PTB (OR 2.4; 95% CI 1.2–4.8), EPTB (OR 6.2; 95% CI 2.7–14) and miscarriage (OR 4.9; 95% CI 1.4–17). BV was associated with increased risks of PTB (OR 2.4; 95% CI 1.1–4.7), EPTB (OR 5.3; 95% CI 2.1–12.9) and miscarriage (OR 6.6; 95% CI 2.1–20.9) and coccoid AV was associated with increased risks of EPTB (OR 3.2; 95% CI 1.2–9.1) and miscarriage (OR 5.2; 95% CI 1.5–17). In women with BV, partial BV had a detrimental effect on the risk of PTB for all gestational ages, but full BV did not. Preterm deliveries later than 24 weeks+ 6 days were more frequent when M. hominis was present (EPTB OR 13.3; 95% CI 3.2–55).
Discussion Bacterial vaginosis, AV and AVF are associated with PTB, especially LM and severe PTB between 25 and 35 weeks. The absence of lactobacilli (AVF), partial BV and M. hominis, but not full BV, were associated with an increased risk of preterm delivery after 24 weeks+ 6 days. As metronidazole effectively treats full BV, but is ineffective against other forms of AVF, the present data may help to explain why its use to prevent PTB has not been successful in most studies.
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BFBNIB, FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
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