Felipe Moretti

Factors Associated With Increased Rates of Caesarean Section in Women of Advanced Maternal Age

OBJECTIVE To compare rates of Caesarean section between mothers of advanced age (35 to 40, and over 40 years) and those aged 20 to 34, using the Robson classification system to examine additional maternal factors. METHODS A total of 134 088 hospital deliveries in Ontario between April 1, 2011, and March 31, 2012, were grouped into Robsons 10 mutually exclusive and totally inclusive classification categories. Records from the three Robson groups that made the greatest contribution to the overall CS rate were stratified by maternal age, health condition, obstetrical complication, assisted reproductive technology usage, smoking during pregnancy, and socioeconomic status. RESULTS Rates of CS increased with advancing maternal age; in women aged 20 to 34, 35 to 40, and over 40, the rates were 26.2%, 35.9%, and 43.1%, respectively. The top three Robson groups by contribution to CS rates involved women who had one or more of the following factors: previous Caesarean section, primiparity, conception by means of assisted reproductive technology, chronic hypertension, gestational diabetes, diabetes mellitus, preeclampsia, placenta previa, placental abruption, or large for gestational age infants. The prevalence of these factors increased with advancing maternal age, yet mothers aged ≥ 35 with one or more health conditions or obstetrical complications had higher CS rates than mothers aged 20 to 34 with the same condition(s) or complication(s). CONCLUSION Health conditions and obstetrical complications alone in older women do not account for increased rates of CS. The preferences of the individual care provider and the mother on CS rates may play a key role and require further investigation.

Gastroschisis: Antenatal Sonographic Predictors of Adverse Neonatal Outcome

Objectives. The aim of this review was to identify clinically significant ultrasound predictors of adverse neonatal outcome in fetal gastroschisis. Methods. A quasi-systematic review was conducted in PubMed and Ovid using the key terms “gastroschisis,” “predictors,” “outcome,” and “ultrasound.” Results. A total of 18 papers were included. The most common sonographic predictors were intra-abdominal bowel dilatation (IABD), intrauterine growth restriction (IUGR), and bowel dilatation not otherwise specified (NOS). Three ultrasound markers were consistently found to be statistically insignificant with respect to predicting adverse outcome including abdominal circumference, stomach herniation and dilatation, and extra-abdominal bowel dilatation (EABD). Conclusions. Gastroschisis is associated with several comorbidities, yet there is much discrepancy in the literature regarding which specific ultrasound markers best predict adverse neonatal outcomes. Future research should include prospective trials with larger sample sizes and use well-defined and consistent definitions of the adverse outcomes investigated with consideration given to IABD.

The Incidence of Maternal Artefact During Intrapartum Fetal Heart Rate Monitoring

OBJECTIVE To determine the incidence of maternal heart rate artefact (MHRA) when monitoring fetal heart rate (FHR) in labour and to determine obstetrical factors associated with MHRA. METHODS In a prospective observational study, maternal and fetal heart rates were displayed simultaneously to document the superimposition of the maternal heart rate (MHR) on FHR tracings. All women in labour who were undergoing external fetal monitoring (EFM) at the Ottawa Hospital from October 2011 to March 2012 were eligible. Every episode of MHRA was documented and classified according to its clinical significance. Wilcoxon test, t tests, and chi-square tests were used to identify time-related differences and obstetrical factors (epidural analgesia, fetal presentation, multiple gestation, maternal BMI, umbilical cord arterial pH, five-minute Apgar scores) that were associated with a potential adverse outcome. RESULTS We assessed 1313 tracings with simultaneous displays of the MHR and FHR in labour. MHRA was present at least once in 721 tracings (55%). Of these tracings, 35 were classified as having one or more episodes that might have led to an adverse outcome (either false positive or false negative), giving an incidence of 2.7% of all women in labour. In 33 tracings, the MHRA masked an abnormal FHR tracing. In two tracings, the MHRA masked a normal FHR, which might have resulted in misinterpretation of the tracing (i.e., false positive), leading to unnecessary intervention. CONCLUSION The incidence of MHRA is higher than currently thought, and in more than 2% of women in labour may lead to adverse outcomes. We propose routine use of simultaneous maternal and FHR monitoring for women undergoing EFM, especially during the second stage of labour.

Recurrent Massive Perivillous Fibrin Deposition and Chronic Intervillositis Treated With Heparin and Intravenous Immunoglobulin: A Case Report

BACKGROUND Massive perivillous fibrin deposition (MPVFD) and chronic intervillositis (CI) are related rare pathological correlates of severe intrauterine growth restriction (IUGR) and fetal loss with high recurrence rates. No standard management has been established. CASE A patient underwent termination of pregnancy at 21 weeks for severe early onset IUGR. Placental histology showed mixed CI with MPVFD. Several months later, the patient became pregnant and was managed with prednisone and aspirin (ASA) but miscarried at 16 weeks. Placental pathology showed MPVFD and focal CI. For two subsequent pregnancies, she was treated with intravenous immunoglobulin (IVIG), heparin, and ASA. Both pregnancies resulted in healthy near-term deliveries with normal placentas. CONCLUSION IVIG, heparin, and ASA can be an option in patients with recurrent pregnancy loss due to MPVFD and CI.

Growth Restriction, Osteopenia, Placental Massive Perivillous Fibrin Deposition With (or Without) Intervillous Histiocytes and Renal Tubular Dysgenesis—An Emerging Complex

We describe a case of a pregnancy complicated by early onset asymmetric growth restriction with anhydramnios with termination occurring at 21 weeks. Fetal autopsy showed demineralization of bones and renal tubular dysgenesis. Placental pathology showed features of massive perivillous fibrin deposition and chronic histiocytic intervillositis. We review prior documentation of this association and briefly discuss potential pathogenesis.

The 5As of healthy pregnancy weight gain: possible applications in the Brazilian context to improve maternal-fetal health.

Thus, there is a need to promote healthy pregnancy weight gain in an effort to optimize mater-nal-fetal outcomes and secure the future of public health in Brazil.A large body of evidence supports the importance of a healthy lifestyle (i.e. healthy eating behaviour, adequate sleep, stress management, regular physical activity and limiting sedentary behaviour) during pregnancy for both mother and fetus.

Placental Stem Cells and Culture Methods

Recently, the placenta, an organ known for its essential role in fetal development, has been recognized as a source of mesenchymal stem/stromal cells (MSCs) with applications in regenerative medicine. Among many unique features of this organ, its wound healing properties as well as its immunomodulatory effects to treat inflammatory diseases have been well documented. Placental tissue is easily procured without invasive procedures, and it does not elicit ethical debate for clinical applications. Whereas, the use of some of the other stem cell types such as embryonic stem cells (ESCs) and adult stem cells (ASCs) is associated with various concerns. For instance, ESCs are known for significant ethical considerations and tumorigenicity; and ASCs display limitations in self-renewal and potential.

P30.05: Diagnosis of placenta accreta in early pregnancy: case report and review of literature

Placenta accreta is an obstetric condition with management challenges and significant perinatal morbidity and mortality. The incidence has been rising in developing countries due to increased rates of cesarean section. We report a case of a 13 week gestation who had had a previous cesarean section. She presented at emergency room with vaginal bleeding and suspicion of incomplete abortion. Obstetric Ultrasound showed a live fetus and anterior placenta previa with sonographic findings of disruption of the placental-uterine interface, compatible with placenta accreta. After extensive counselling regarding adverse perinatal outcomes, the pregnancy is ongoing and the outcome will be reported. A few cases of early diagnosis of placenta accreta have been reported in the literature. Many of those cases, the Ultrasound were performed due to early symptoms such as vaginal bleeding or abdominal pain. Complication of placenta accreta has been a dilemma management due to serious consequences with maternal and fetus life threatening. Hysterectomy, uterine rupture, excessive blood loss and coagulopathy have been reported in the first trimester. We have reviewed the literature from July 1995 to June 2009 of placenta accreta diagnosed at first trimester of pregnancy. Risk factors, diagnostic ultrasound findings, management, complications and pregnancy outcome are discussed in this article. Given high incidence of complications of placenta accreta, we believe that it is feasible and recommended early ultrasound screening in patient with high risk for placenta accreta.