M Kollmann

Perinatal complications and long-term neurodevelopmental outcome of infants with intrauterine growth restriction

OBJECTIVE The objective of the study was to evaluate perinatal and long-term complications of fetuses with intrauterine growth restriction (IUGR) compared with constitutionally small for gestational age (SGA) ones. STUDY DESIGN The outcome of infants with IUGR and SGA born at the Medical University Graz (Austria) between 2003 and 2009 was retrospectively analyzed. Group assignment was based on birthweight, Doppler ultrasound, and placental morphology. The primary outcome was neurodevelopmental delay at 2 years corrected age. The secondary outcomes were perinatal complications. RESULTS We included 219 IUGR and 299 SGA infants for perinatal and 146 and 215 for long-term analysis. Fetuses with IUGR were delivered earlier (35 vs 38 weeks) and had higher rates of mortality (8% vs 1%; odds ratio [OR], 8.3) as well as perinatal complications (24.4% vs 1.0%; OR, 31.6). The long-term outcome was affected by increased risk for neurodevelopmental impairment (24.7% vs 5.6%; OR, 5.5) and growth delay (21.2% vs 7.4%; OR, 3.4). CONCLUSION IUGR infants are subject to an increased risk for adverse short- and long-term outcome compared with SGA children.

Maternal and neonatal outcomes in pregnant women with PCOS: comparison of different diagnostic definitions

STUDY QUESTION Does the prevalence of adverse maternal and neonatal outcomes vary in women diagnosed with polycystic ovary syndrome (PCOS) according to different definitions? SUMMARY ANSWER A comparison of different criteria revealed that there is a substantial risk for perinatal complications in PCOS women, regardless of the used definition. WHAT IS KNOWN ALREADY Pregnant women with PCOS are susceptible to perinatal complications. At present, there are three main definitions for PCOS. So far, we are aware of only one study, which found that the elevated risk for complications varied widely depending on the different phenotypes and features but only considered a relatively small sample size for some of the phenotypes. STUDY DESIGN, SIZE, DURATION Retrospective matched cohort study. PARTICIPANTS/MATERIALS, SETTING, METHODS Data of primiparous women with PCOS according to ESHRE/ASRM 2003 criteria and healthy controls giving birth to neonates ≥500 g were included. A total of 885 women were analysed: out of 177 women with PCOS, 85 (48.0%) met the National Institutes of Health (NIH) 1990 criteria, another 14 (7.9%) featured the additional phenotypes defined by The Androgen Excess and PCOS Society (AE-PCOS) 2006 criteria, 78 (44.1%) were classified as PCOS exclusively by the ESHRE/ASRM 2003 definition, and 708 represented the control group. MAIN RESULTS AND THE ROLE OF CHANCE The prevalence of adverse maternal (49.4 versus 64.3 versus 60.3%, P = 0.313) and neonatal (27.1 versus 35.7 versus 23.1%, P = 0.615) outcomes did not differ within the three PCOS groups (ESHRE/ASRM, NIH, AE-PCOS, respectively). Compared with healthy controls, the risk for maternal complications was increased in PCOS patients [odds ratio (OR) 2.57; 95% confidence interval (CI) 1.82-3.64; P < 0.001] while there was no difference in neonatal complications (OR 0.83; 95% CI 0.56-1.21; P = 0.343). LIMITATIONS, REASONS FOR CAUTION A limitation of our study is its retrospective design and the relatively small sample size, particularly in the AE-PCOS subgroup. WIDER IMPLICATIONS OF THE FINDINGS Since women with PCOS have, regardless of the used definition, a high risk of maternal and neonatal complications they should be informed and advised to follow regular checks in units where problems can be detected early to allow specialized care. STUDY FUNDING/COMPETING INTERESTS Marietta Blau Grant (Austrian Agency for International Cooperation in Education and Research; OeAD-GmbH) and mobility scholarship (Medical University of Graz).

Prenatal management of monoamniotic twin pregnancies.

To the Editor: We read with great interest the large, multicenter series by van Mieghem et al, published in the September issue of Obstetrics & Gynecology. These data provide new and better-quality information than those already published on this question. In the absence of a randomized trial, we agree that monoamniotic pregnancies will need to be managed based on results from observational studies. However, we think that their results must be very carefully interpreted, and we would stress this sentence from the Discussion section: “Given the rarity of the primary outcome, however, strong management recommendations cannot be made based on this study.” Here, the conclusion is based solely on the occurrence of two double intrauterine fetal deaths, at 33.9 and 34.1 weeks of gestation. The risk of neonatal death in the case of systematic cesarean deliveries at 32 or 33 weeks (one case in the series at 33 weeks) is not discussed. Moreover, it is a retrospective series in eight tertiary care maternity centers in six countries, where practices, organization of care, and patient behavior all vary quite substantially. This heterogeneity in recruitment and obstetric practices, certainly, limits extrapolation of the results. In addition, because cases were included regardless of gestational age at referral, some may well not have received the monitoring the authors propose and may even have been admitted late, with complications already developing. Finally, to justify their conclusion, the authors provide a curve (their Fig. 1) that visually reinforces the reader’s impression that the risk of intrauterine death starts to increase at 33 weeks. This increase is nonetheless not significant, and the shape of the curve is determined by a mathematical formula that must be somewhat distant from the reality of the data. These points do not call into question the results the authors report. In our opinion, however, they should have resulted in greater care in the interpretation of the results and in a more prudent conclusion. In 2004, we published in BJOG: An International Journal of Obstetrics and Gynaecology a single-center cohort of 19 women with monoamniotic twins that reached different conclusions. Since that publication, our cohort has grown from 19 to 38 women seen at our center by 22 weeks of gestation. No intrauterine fetal deaths occurred after 29 weeks. Among the 26 women reaching 32 weeks, 24 (88%) gave birth at or after 34 weeks and the mean gestational age at delivery was 35.1 week. We think that continuing monoamniotic twin pregnancies past 32 weeks and trial of vaginal delivery are both reasonable options if the parents agree and conditions are optimal.

Counting ovarian follicles: updated threshold for diagnosis of hyperandrogenic anovulation.

The first description of the association between enlarged ovaries and subfertility was reported almost 300 years ago, when Vallisneri described a ‘young peasant woman’ who was ‘moderately plump, infertile, with ovaries larger than normal that, like doves’ eggs, were lumpy, shiny and whitish’1. The more common term used to describe such ovaries – ‘polycystic ovaries’ – was not introduced until 19352 and since the mid-1950s the associated health conditions, including subfertility, menstrual disorders and hyperandrogenism3, have been referred to as ‘polycystic ovary syndrome’ (PCOS)4,5. PCOS is reported to occur in 5–10% of women of reproductive age, and the prevalence is even higher in obese women6.

Procedure-related complications after genetic amniocentesis and chorionic villus sampling.

PURPOSE Amniocentesis (AC) and chorionic villus sampling (CVS) play an important role in the diagnosis of genetic anomalies. The aim of this study was to evaluate presentable numbers of procedure-related complications of genetic interventions in a tertiary referral hospital. MATERIALS AND METHODS The pregnancy outcome of women who underwent genetic AC or CVS during 2003-2010 at the Department of Obstetrics and Gynecology, Medical University of Graz, Austria, was analyzed retrospectively. The primary outcome was miscarriage or membrane rupture after an invasive procedure. Only singleton gestations were included. RESULTS 1,569 AC procedures and 334 CVS procedures (234 transabdominal, 99 transcervical, 1 with undocumented route) were performed. Of these, 57 cases were excluded from further analysis because of severe anomalies. Complete outcome data were available for 93.17% of cases. In 164 (8.89%) cases the pregnancy was terminated due to genetic anomalies or severe malformations. In the remaining collective 10 of 1,342 (0.75%) AC procedures, 3 of 150 (2.00%) transabdominal CVS procedures and 2 of 64 (3.13%) transcervical CVS procedures lead to complications resulting in miscarriage < 24 weeks (n = 13) or rupture of membranes (n = 2) within 2 weeks after procedure. Complication rates were significantly higher after CVS than after AC (OR 3.19). CONCLUSION Over an observation period of seven years, the complication rates after AC, transabdominal CVS and transcervical CVS were 0.75%, 2.00% and 3.13%, respectively. These results are comparable to recent international investigations.

Placenta praevia: incidence, risk factors and outcome

Abstract Objective: Aim of this study was to evaluate the incidence, potential risk factors and the respective outcomes of pregnancies with placenta praevia. Methods: Data were prospectively collected from women diagnosed with placenta praevia in 10 Austrian hospitals in in the province of Styria between 1993 and 2012. We analyzed the incidence, potential risk factors and the respective outcomes of pregnancies with placenta praevia. Differences between women with major placenta praevia (complete or partial placenta praevia) and minor placenta praevia (marginal placenta praevia or low-lying placenta) were evaluated. Results: 328 patients with placenta praevia were identified. The province wide incidence of placenta praevia was 0.15%. Maternal morbidity was high (ante-partum bleeding [42.3%], post-partum hemorrhage [7.1%], maternal anemia [30%], comorbid adherent placentation [4%], and hysterectomy [5.2%]) and neonatal complications were frequent (preterm birth [54.9%], low birth weight <2500 g [35.6%], Apgar-score after five minutes <7 [5.8%], and fetal mortality [1.5%]. Women with major placenta praevia had a significant higher incidence of preterm delivery, birthweight <2500 g and Apgar-score after five minutes <7. Conclusions: Placenta praevia was associated with adverse maternal (34.15%) and neonatal (60.06%) outcome. The extent of placenta praevia was not related with differences regarding risk factors and maternal outcome.

Terms and thresholds for the ultrasound evaluation of the ovaries in women with hyperandrogenic anovulation

Dear Sir, We enjoyed reading the insightful and informative article by Dewailly et al. (2014) and want to congratulate them for considering and clarifying one of the most contentious subjects in reproductive medicine. Their results are of great value and elegantly demonstrate the need to update the current diagnostic criteria used to describe and define polycystic ovarian syndrome (PCOS). These findings will hopefully lead to a revision of the present criteria and some long overdue changes. Their recommendation to use ≥25 follicles per ovary as suspicion of hyperandrogenemia (HA) should be adopted promptly as it is clear that the former threshold of 12 follicles is obsolete due to the improvement in the resolution of ultrasound achieved through both software and hardware developments (Lujan et al., 2013). We would, however, like to raise one other issue and one that we passionately believe is no less important than the question of diagnostic criteria and thresholds: the misnomer given to the associated health condition. Whatever the final threshold agreed the ovaries that many sonographers recognize so easily, know so well and are all trying to describe do not contain ‘cysts’ but rather multiple follicles which are arrested in their development: the term ‘polycystic’ is without question misleading. Many women, and indeed some healthcare practitioners, are confused by a diagnosis of ‘polycystic ovaries’: some patients even ask whether there is a need for surgery to physically remove these ‘cysts’ and many of them return for a new ultrasound after the intervention to evaluate whether the cysts had disappeared or not. The ovarian appearance would be better described as ‘multifollicular’, as the only difference is an increase in the number of antral follicles. And PCOS would be better termed ‘hyperandrogenic anovulation’, as this better describes what it is: an endocrine disorder with reproductive features. This term is much more easily explained and understood, causing less harm. We are not alone on this. The primary recommendation from the first Evidence-Based Methodology Workshop on Polycystic Ovary Syndrome in 2012, sponsored by the National Institutes of Health (NIH) Office for Disease Prevention, was to change the name of the syndrome (Dunaif and Fauser, 2013). They proposed a nosological ‘two-state solution’: those with primarily reproductive concerns should continue to be called PCOS while those with metabolic consequences should have a new name (Dunaif and Fauser, 2013). We agree that the name of the syndrome needs reconsideration, but we think the term ‘polycystic’ in connection with this health condition should be removed. This may seem a step too far but it would add credibility to any new definition and related diagnostic criteria and help healthcare practitioners explain to patients the difference between something evident on ultrasound and a clinical condition with multiple implications. A cross-sectional study, which aimed to determine perceptions held by women and primary healthcare physicians about key clinical features and attitudes toward current and alternative names for the syndrome, showed that among women with this health condition, 47% incorrectly identified ovarian cysts as a key finding, 48% felt the current name was confusing and 51% supported new terminology (Teede et al., 2014). We also have to be aware that the correct threshold for HA should not have to be the same as the one used for identifying women at risk of an excessive response to controlled ovarian stimulation. It is important that we know these are two different conditions and a much lower threshold should be used to identify the latter: women with a total antral follicle count .20 already have a higher risk of developing ovarian hyperstimulation syndrome (Jayaprakasan et al., 2009; Polyzos et al., 2013). The last point we want to raise is that many women without hyperandrogenic features and/or anovulation will probably undergo an ultrasound scan of the ovaries for some reason during their reproductive age; some of them will have more than 25 follicles in at least one ovary. What should we do in this situation? Our beliefs were nicely summarized by Dewailly et al. when they say that the meaning of the ultrasound appearance of such ovaries in ‘. . . asymptomatic general population is unknown at present’. It is time we stood up and made it very clear that we really do not know the clinical consequence of this ultrasound finding and as such should be mindful not to then label someone and more importantly not to label them as having a condition that is factually incorrect namely ‘polycystic’. To summarize, we wholeheartedly welcome the call to update the current criteria but feel there is an equally important need to change the misnomer given to this enigmatic health condition. Why not do both at the same time?

Etiology and perinatal outcome of polyhydramnios.

PURPOSE To determine causes of polyhydramnios and the respective perinatal outcome. MATERIALS AND METHODS We retrospectively analyzed cases with polyhydramnios at the Medical University Graz, Austria from 2003 - 2011. Inclusion criteria were single deepest pocket ≥ 8  cm, amniotic fluid index ≥ 25  cm, each of the latter parameters > 95th percentile or subjective impression. Etiologies, including TORCH infection, diabetes and congenital malformations, as well as perinatal outcome were evaluated. RESULTS Out of 860 singleton pregnancies with polyhydramnios, 2.9 % had positive TORCH serology, 8.5 % had congenital anomalies, 19.8 % had maternal diabetes, and 68.8 % were idiopathic. The most common fetal anomalies were cardiac defects (32.9 %). Elective caesarean sections were more common in the groups with malformations and maternal diabetes. Low birth weight combined with severe polyhydramnios or maternal diabetes was associated with malformations. CONCLUSION Diagnosis of polyhydramnios should prompt glucose-tolerance testing, detailed sonography including fetal echocardiography, and TORCH serology. Especially pregnancies with polyhydramnios and small fetuses as well as those with maternal diabetes should be carefully evaluated for malformations.

Early skin-to-skin contact after cesarean section: A randomized clinical pilot study

Objective Early bonding by skin-to-skin contact (SSC) has been demonstrated to be beneficial for mothers and newborns following vaginal delivery. The aim of this study was to investigate the impact of intraoperative bonding (early SSC) after cesarean section on neonatal adaptation, maternal pain and stress response. Study design This prospective, randomized-controlled pilot study was performed at a single academic tertiary hospital (Department of Obstetrics and Gynecology, Medical University of Graz, Austria) between September 2013 and January 2014. Women were randomly assigned to intraoperative (“early”) SCC (n = 17) versus postoperative (“late”) SCC (n = 18). Main variables investigated were neonatal transition (Apgar score, arterial oxygen saturation, heart rate and temperature), maternal pain perception and both maternal and neonatal stress response by measuring the stress biomarkers salivary free cortisol and salivary alpha amylase. Results There was no evidence for differences in parameters reflecting neonatal transition or stress response between the ‘Early SSC Group’ and the ‘Late SSC Group’. Maternal salivary cortisol and alpha-amylase levels as well as maternal wellbeing and pain did not differ between the groups. However, the rise of maternal salivary alpha-amylase directly after delivery was higher in the ‘Early SSC Group’ compared to the ‘Late SSC Group’ (p = 0.004). Conclusions This study did not reveal significant risks for the newborn in terms of neonatal transition when early SSC is applied in the operating room. Maternal condition and stress marker levels did not differ either, although the rise of maternal salivary alpha-amylase directly after delivery was higher in the ‘Early SSC Group’ compared to the ‘Late SSC Group’, which may indicate a stressor sign due to intensive activation of the sympathetic-adreno-medullary-system. This needs to be further evaluated in a larger prospective randomized trial. Trial registration ClinicalTrials.gov NCT01894880

OP28.02: Prevalence and prenatal detection rate of congenital diaphragmatic hernia: a population based study

The measurement was performed with conventional M-mode and/or STIC M-mode as necessary. Results: 49 cases of fetal cardiac defect or disorder were collected. Diagnoses included conotruncal defects such as TGA; valve defects such as pulmonary and aortic stenoses and Ebstein anomalies, great vessels defects such as aortic coarctations; ventricle defects including single ventricle and cardiomyopathy; atrial defects such as cor triatriatum; extra-cardiac anomalies including agenesis of the ductus venosus and diaphragmatic hernias; and functional pathologies such as hydrops, IUGR, pleural effusion, and TTTS. These cases were plotted against over 300 previously performed F-TAPSE examinations on normal fetuses of comparable gestational ages. In 16 cases F-TAPSE measures were found to deviate significantly from normal. Atrioventricular valve flow, ductus venosus flow, and mod-MPI were also evaluated, and in some cases only F-TAPSE showed deviation from normal values. Conclusions: F-TAPSE shows characteristic changes in CHD and functional disorders. F-TAPSE is easy to perform and available on all ultrasound machines; in machines equipped with STIC the volume can be rotated to optimize scan angle. We suggest its addition to fetal right heart functional evaluation.