Maddalena Incerti

Factors associated with umbilical artery acidemia in term infants with low Apgar scores at 5 min

OBJECTIVEnTo evaluate predictors of umbilical artery acidemia in term neonates with low Apgar score.nnnSTUDY DESIGNnFrom a cohort of term singleton deliveries over a 13-year period, we selected neonates with 5-min Apgar score < 7. Acidemia was defined as umbilical artery pH < 7.00 or base excess (BE) < or = -12 mmol/L. Three pathogenic processes of neonatal acidemia were evaluated: (1) intrauterine vascular disease, defined as preeclampsia, clinical diagnosis of placental abruption, birth weight < 10th centile, or histologic evidence of placental infarction or severe vascular pathology, (2) intrauterine infection, defined as clinical chorioamnionitis, histologic chorioamnionitis, or early neonatal sepsis, and (3) acute intrapartum events, which included cases of cord prolapse, amniotic fluid embolism, uterine rupture, sudden and sustained fetal bradycardia or absence of FHR variability with a previously normal pattern, shoulder dystocia or complicated breech extraction. The associations of such processes with umbilical artery evidence of acidemia were tested using chi(2), Fishers exact test, Students t-test, and logistic regression, with P < 0.05 or odds ratio (OR) with 95% confidence interval (CI) not inclusive of the unity considered significant.nnnRESULTSnAmong the 27,395 neonates in the cohort, an Apgar score at 5 min < 7 was recorded in 94 (0.32%) and it was associated with umbilical artery acidemia in 33 cases. Logistic regression analysis showed that intrauterine vascular disease was independently associated with umbilical cord acidemia (P=0.035, OR=3.2, 95% CI=1.1-9.7) whereas intrauterine infection (OR=1.1, 95% CI 0.4-3.4) and acute intrapartum events (OR=2.1 95% CI 0.6-7.0) were not.nnnCONCLUSIONSnUmbilical artery evidence of acidemia is present in 38% of term babies with low Apgar score and it is predominantly associated with chronic antepartum vascular disease. Neither intrauterine infection nor acute intrapartum events are significantly associated with umbilical artery acidemia.

Head-to-body delivery interval using 'two-step' approach in vaginal deliveries: effect on umbilical artery pH.

Objective.u2003To assess the duration of head-to-body interval using a ‘two-step’ approach to delivery that include waiting for the next contraction to deliver the shoulders; and its effect on umbilical artery pH and neonatal outcome. Study design.u2003Prospective observational study on vaginal deliveries with singleton cephalic fetuses at term from June to December 2005. Clinical variables were evaluated in reference to umbilical artery pH and evidence of neonatal acidemia, defined as pHu200a≤u200a7.10 or base excess (BE)u200a≤u200a−12 in a multivariate model. Results.u2003Head-to-body interval was timed and recorded in 789 deliveries. The mean head-to-body interval was 88u200a±u200a61u2009s. Although head-to-body interval was significantly correlated to umbilical artery pH (pu200a=u200a0.02), the decline in umbilical artery pH in relation to the head-to-body interval was clinically not significant (0.0078 units for every additional minute of the interval). At the multivariate analysis, umbilical artery pHu200a≤u200a7.10 and/or BEu200a≤u200a−12 were significantly related to abnormal fetal heart rate tracing during the second stage (pu200a=u200a0.012) and operative vaginal delivery (pu200a=u200a0.045), but not to head-to-body interval (pu200a=u200a0.25). Shoulder dystocia occurred in three cases (0.38%). Conclusion.u2003A ‘two-step’ approach to birth does not significantly increase the risk of neonatal acidemia.

Prenatal Treatment Prevents Learning Deficit in Down Syndrome Model

Down syndrome is the most common genetic cause of mental retardation. Active fragments of neurotrophic factors release by astrocyte under the stimulation of vasoactive intestinal peptide, NAPVSIPQ (NAP) and SALLRSIPA (SAL) respectively, have shown therapeutic potential for developmental delay and learning deficits. Previous work demonstrated that NAP+SAL prevent developmental delay and glial deficit in Ts65Dn that is a well-characterized mouse model for Down syndrome. The objective of this study is to evaluate if prenatal treatment with these peptides prevents the learning deficit in the Ts65Dn mice. Pregnant Ts65Dn female and control pregnant females were randomly treated (intraperitoneal injection) on pregnancy days 8 through 12 with saline (placebo) or peptides (NAP 20 µg +SAL 20 µg) daily. Learning was assessed in the offspring (8–10 months) using the Morris Watermaze, which measures the latency to find the hidden platform (decrease in latency denotes learning). The investigators were blinded to the prenatal treatment and genotype. Pups were genotyped as trisomic (Down syndrome) or euploid (control) after completion of all tests. Statistical analysis: two-way ANOVA followed by Neuman-Keuls test for multiple comparisons, P<0.05 was used to denote statistical significance. Trisomic mice who prenatally received placebo (Down syndrome -placebo; nu200a=u200a11) did not demonstrate learning over the five day period. DS mice that were prenatally exposed to peptides (Down syndrome-peptides; nu200a=u200a10) learned significantly better than Down syndrome -placebo (p<0.01), and similar to control-placebo (nu200a=u200a33) and control-peptide (nu200a=u200a30). In conclusion prenatal treatment with the neuroprotective peptides (NAP+SAL) prevented learning deficits in a Down syndrome model. These findings highlight a possibility for the prevention of sequelae in Down syndrome and suggest a potential pregnancy intervention that may improve outcome.

Comparative analysis of cesarean delivery rates over a 10-year period in a single Institution using 10-class classification.

Objective: To evaluate the variables associated with changes in cesarean delivery (CD) rates in a University Hospital with standardized and unchanged protocols of care. Methods: Retrospective analysis of consecutive deliveries between two triennia 10 years apart. The Robson classification of CD was used, and the analysis focused on factors affecting Robson’s classes 1 and 2 combined (term singleton cephalic nulliparae) and class 5 (previous CD). Results: A total of 8237 deliveries occurred in the 1st period, and 8420 in the 2nd. CD increased from 12.5 to 18% (p < 0.001). Robson’s classes 1 and 2 combined contributed more than other classes to CD rates (32 vs 36%; p < 0.001). At multivariate analysis, BMI (Odds ratio [OR]: 1.08; 95% CI: 1.06–1.1) and maternal age (OR: 1.06; 95% CI: 1.05–1.08) were independently related to CD. In Robson class 5, the rate of CD increased from 34 to 46%, p < 0.001, mostly due to an increase in elective CD (39 vs 67.5%; p < 0.001). At multivariate analysis, BMI (OR: 1.06 95% CI: 1.02–1.1) and more than one previous CD (OR: 18.7; 95% CI: 9.6–36.4) were independently related to CD. Conclusions: BMI and maternal age are independent factors associated to the increasing rate of CD in nulliparae with spontaneous or induced labor at term. In women with previous CD, BMI and more than one previous CD are factors associated with the increasing rate of CD.

Induction of labor: comparison of a cohort with uterine scar from previous cesarean section vs. a cohort with intact uterus.

Objective. To compare the risk of uterine rupture between a cohort of women with previous low-transverse cesarean section (CS) and a cohort with intact uterus. Methods. All women with a singleton pregnancy and previous low-transverse CS requiring induction of labor from January 1, 1992 to December 30, 2001 (n = 310) were compared with a cohort of women with intact uterus undergoing induction of labor during the same study period (n = 5420). Protocols of induction using prostaglandin E2 gel and oxytocin infusion were consistent within groups, but differed between the previous CS and the intact uterus group. Results. Uterine rupture occurred in 0.3% in the previous CS group vs. 0.03% in the intact uterus group (p = 0.37). Logistic regression analysis showed no significant difference in rate of uterine rupture between the previous CS vs. intact uterus group (p = 0.16) after controlling for maternal age, parity, gestational age at delivery, Bishop score on admission, use of prostaglandin and oxytocin, and birth weight. Our study had adequate power to detect a 0.38% difference in rate of uterine rupture between the two groups (α = 0.05, β = 0.80). Conclusion. Induction of labor is not associated with significantly higher rates of uterine rupture among women with previous low-transverse CS compared with women with intact uterus provided a consistent protocol with strict intervention criteria is adopted.

Effect of oxytocin during labor on neonatal acidemia

Abstract Objective: To assess the factors affecting neonatal acidemia, including occurrence of tachysystole/hypertonus in fetuses exposed to oxytocin during labour and with continuously-monitored fetal heart rate (FHR) tracings. Methods: Prospective observational study of all women with term pregnancies who received oxytocin for induction/augmentation of labour. FHR tracings were prospectively classified using ACOG classification. Independent predictors of neonatal acidemia were identified using multivariate linear regression with pu2009<u20090.05 considered significant. Results: We included 430 women, 236 of whom (54.9%) had spontaneous onset of labour. The duration of active phase of the second stage of labour and the presence of abnormal FHR tracing during labour were significantly associated with UA pH (pu2009<u20090.001) and BE (pu2009<u20090.001), while maximum dose of oxytocin (pu2009<u20090.17; pu2009<u20090.7) and tachysystole (pu2009<u20090.9; pu2009<u20090.8) were not. At logistic regression, the duration of active phase of the second stage of labour was independently predictive of neonatal acidemia (pu2009<u20090.009) while abnormal FHR tracing approached significance (pu2009<u20090.088). Conclusions: In women receiving oxytocin during labour, the duration of active phase of the second stage of labour correlates with neonatal acidemia, whereas maximum dose of oxytocin, duration of oxytocin administration and occurrence of tachysystole during labour do not.

What is the effect of intertwin delivery interval on the outcome of the second twin delivered vaginally

Abstract Objective: Optimal management of twin deliveries is controversial. We aimed to assess if intertwin delivery interval, after vaginal delivery of the first twin, may have an influence on adverse neonatal outcomes of the second twin Study design: This is a retrospective observational study including diamniotic twin pregnancies with vaginal delivery of the first twin, between January 2000 and July 2017. Inclusion criteria were diamniotic pregnancies and vaginal delivery of the first twin. We excluded higher twin order, monoamniotic pregnancies, cesarean delivery of the first twin and patients with missing data. Results: A number of 400 diamniotic twin pregnancies met the inclusion criteria and were divided, considering intertwin delivery interval into (1) ≤30 minutes (nu2009=u2009365); and (2) >30u2009minutes (nu2009=u200935). Considering the two study groups, maternal and first twin characteristics and outcomes were similar. Second twin reported higher incidence of cesarean section and vacuum delivery, but similar incidence of neonatal adverse outcomes, in case of intertwin interval >30 minutes. At multivariate analysis, a difference between second and first twin weight ≥25% was correlated to neonatal adverse outcome, while we did not found this correlation with a cut-off of 30 minutes. Conclusions: In our study, growth discrepancy between twins was significantly correlated to adverse neonatal outcomes, while intertwin delivery time was not an influencing factor. So, in line with this result, in our clinical practice, we do not use a fixed time in which both twins should be delivered, neither in monochorionic nor in dichorionic pregnancies, when fetal wellbeing was demonstrated during labor.

Influence of weight gain, according to Institute of Medicine 2009 recommendation, on spontaneous preterm delivery in twin pregnancies

BackgroundsMaternal total weight gain during pregnancy influences adverse obstetric outcomes in singleton pregnancies. However, its impact in twin gestation is less understood. Our objective was to estimate the influence of total maternal weight gain on preterm delivery in twin pregnancies.MethodsWe conducted a retrospective cohort study including diamniotic twin pregnancies with spontaneous labor delivered at 28u2009+u20090xa0weeks or later. We analyzed the influence of total weight gain according to Institute of Medicine (IOM) cut-offs on the development of preterm delivery (both less than 34 and 37xa0weeks). Outcome were compared between under and normal weight gain and between over and normal weight gain separately using Fisher’s exact test with Holm-Bonferroni correction.ResultsOne hundred seventy five women were included in the study and divided into three groups: under (52.0%), normal (41.7%) and overweight gain (6.3%). Normal weight gain was associated with a reduction in the rate of preterm delivery compared to under and over weight gain [less than 34xa0weeks: under vs. normal OR 4.97 (1.76–14.02), over vs. normal OR 4.53 (0.89–23.08); less than 37xa0weeks: OR 3.16 (1.66–6.04) and 6.51 (1.30–32.49), respectively].ConclusionsNormal weight gain reduces spontaneous preterm delivery compared to over and underweight gain.

Cesarean delivery rates and obstetric culture – an Italian register‐based study

Cesarean delivery rates are rising due to multiple factors, including less use of operative vaginal delivery and vaginal birth after cesarean delivery, which often reflect local obstetric practices. Objectives of the study were to analyze the relations between cesarean delivery, these practices, and perinatal outcomes.