Lisa Story

Survival of pregnancies with small for gestational age detected before 24 weeks gestation

OBJECTIVEnCounselling women where severe growth abnormalities are detected early in the pregnancy is often difficult due to a paucity of outcome data of this specific subset of early onset disease. This study therefore aimed to assess the outcome of pregnancies where an estimated fetal weight less than the third centile were detected prior to 24 weeks gestation.nnnSTUDY DESIGNnA retrospective study in two London teaching hospitals, over an eight year period was performed, analysing all pregnancies with an ultrasound estimated fetal weight less than the third centile prior to 24 weeks gestation. Outcome data: intrauterine death, neonatal death, survival to discharge, gestation at delivery and birthweight were collected.nnnRESULTSnOut of 20 pregnancies included in the analysis, six died in utero, two died in the neonatal period and 12 (60%) survived until discharge. Of the livebirths, 67% delivered preterm and 100% percent of livebirths were delivered by Caesarean Section.nnnCONCLUSIONnWhen severe growth abnormalities were detected before 24 weeks, more than half of pregnancies resulted in survival to neonatal discharge. There was an increased incidence of preterm delivery, caesarean section and neonatal unit admission. This information is useful in counselling parents.

Preterm pre-eclampsia: What every neonatologist should know

Although pre-eclampsia affects 5-10% of pregnancies globally and is responsible for substantial maternal and perinatal morbidity and mortality, currently there is no cure other than delivery of the baby. Predictive screening tests based on clinical risk factors, with or without the addition of biomarkers and imaging, have been developed, but adoption into clinical practice is limited by suboptimal test performance. Once established pre-eclampsia is diagnosed, a woman is usually managed expectantly prior to 37weeks gestation to reduce perinatal morbidity and mortality associated with iatrogenic prematurity until maternal or fetal triggers for delivery mean that risks of pregnancy prolongation outweigh the benefits. Associated fetal growth restriction is a common feature of pre-eclampsia, particularly with early-onset disease, and will influence decisions for delivery and subsequent neonatal course. Prematurity and fetal growth restriction both have potential short and long-term consequences for the infant and child.

Influence of birthweight on perinatal outcome in fetuses with antenatal diagnosis of congenital heart disease

The incidence of congenital heart disease (CHD) accounts for the largest proportion of infant mortality attributable to birth defects. Associations have previously been reported between CHD and low birthweight. Low birthweight is independently associated with adverse outcome and has characteristically been calculated using population‐based charts. This aim of this study was to determine the incidence of small for gestational age (SGA) in fetuses with CHD utilizing customized birthweight centiles and to determine the effect of SGA on adverse outcome.

Cervical cerclage: an established intervention with neglected potential?

Cervical cerclage is a common obstetric procedure, performed in an attempt to reduce the likelihood of late miscarriage and preterm delivery. Many questions still remain unanswered, however, regarding its efficacy and the populations most likely to benefit. Existing studies often use endpoints such as preterm delivery, but associations between preterm birth and more long-term health effects such as neurodevelopmental sequelae are well reported. Such endpoints have often not been addressed in many of the studies to date. This article reviews and appraises the literature and evidence regarding cervical cerclage as well as addressing the questions that, as yet, remain unanswered.

Placenta Maps: In Utero Placental Health Assessment of the Human Fetus

The human placenta is essential for the supply of the fetus. To monitor the fetal development, imaging data is acquired using (US). Although it is currently the gold-standard in fetal imaging, it might not capture certain abnormalities of the placenta. (MRI) is a safe alternative for the in utero examination while acquiring the fetus data in higher detail. Nevertheless, there is currently no established procedure for assessing the condition of the placenta and consequently the fetal health. Due to maternal respiration and inherent movements of the fetus during examination, a quantitative assessment of the placenta requires fetal motion compensation, precise placenta segmentation and a standardized visualization, which are challenging tasks. Utilizing advanced motion compensation and automatic segmentation methods to extract the highly versatile shape of the placenta, we introduce a novel visualization technique that presents the fetal and maternal side of the placenta in a standardized way. Our approach enables physicians to explore the placenta even in utero. This establishes the basis for a comparative assessment of multiple placentas to analyze possible pathologic arrangements and to support the research and understanding of this vital organ. Additionally, we propose a three-dimensional structure-aware surface slicing technique in order to explore relevant regions inside the placenta. Finally, to survey the applicability of our approach, we consulted clinical experts in prenatal diagnostics and imaging. We received mainly positive feedback, especially the applicability of our technique for research purposes was appreciated.

Multi-modal functional MRI to explore placental function over gestation: Hutter et al.

To investigate, visualize and quantify the physiology of the human placenta in several dimensions ‐ functional, temporal over gestation, and spatial over the whole organ.

The use of antenatal fetal magnetic resonance imaging in the assessment of patients at high risk of preterm birth

Preterm birth, defined as birth occurring prior to 37 weeks gestation is a common obstetric complication affecting 8% of pregnancies and is associated with significant morbidity and mortality. Infection/inflammation has been implicated in both the aetiology of preterm birth itself and associated neonatal pulmonary and neurological morbidity. Treatment options are currently limited to prolongation of the pregnancy using cervical cerclage, pessaries or progesterone or administration of drugs including steroids to promote lung maturity and neuroprotective agents such as magnesium sulphate, the timing of which are highly critical. Although delivery is expedited in cases of overt infection, decisions regarding timing and mode of delivery in subclinical infection are not clear-cut. This review aims to explore the use of magnetic resonance imaging (MRI) in the antenatal assessment of pregnancies at high risk of preterm birth and its potential to guide management decisions in the future.

An assessment of mode of delivery in history indicated versus ultrasound indicated vaginally placed cervical cerclage

OBJECTIVEnTreatment modalities to reduce the incidence of preterm birth are currently limited. Cerclage, is a common and established intervention in most obstetrics units worldwide, however, many questions regarding its efficacy, with respect to pregnancy outcomes remain unanswered. This study aims to investigate whether an antenatal placed cerclage affects the subsequent mode of delivery in women at high risk of preterm birth who labour.nnnSTUDY DESIGNnA retrospective case controlled study was performed at St Thomass Hospital London. Women who had undergone cervical cerclage were identified using a pre-existing database (n=152). Cases were excluded where a C-section had been performed prior to labour (n=26), datasets were incomplete (n=5) or a rescue cerclage was performed (n=2). Remaining cases were categorised into those who had: history indicated (n=68) or ultrasound indicated (n=51) cerclage. Control cases were obtained from the same database who also laboured but had not undergone cerclage, matched according to gestational age at delivery and parity (n=114). Demographic details and outcome data were recorded. Groups were compared using Chi Squared analysis for discrete variables and t-test for continuous variables using IBM SPSS Statistics version 22.nnnRESULTSnThere was no statistical difference in the emergency C-section rate between history indicated and ultrasound indicated cerclage, or between patients who received cerclage and those who had not (p=0.592). The emergency C-section rate for each group was: history indicated, 25%, ultrasound indicated 18% and no cerclage 18%.nnnCONCLUSIONSnWomen at risk of preterm birth have high rates of emergency C-section despite the fact that the majority were multiparous. However, they can be reassured that cervical cerclage does not increase this risk.

Perinatal Brain Injury

Perinatal brain injury is an important cause of both early and long term morbidity and mortality. The pathophysiology of perinatal brain injury is complex, and often gestation dependent. Ultrasound has traditionally been the imaging modality of choice used to diagnose these lesions; however, the advent of Magnetic Resonance Imaging (MRI) has improved diagnosis and has enabled the correlation of lesions in the neonatal period with longer term neurodevelopmental sequelae. This review aims to address injury in both the term and pre-term brain, its relationship with long term outcome as well as discussing potential treatment strategies which may be deployed in the future.