Search

Background: The aim of this extended review of multicenter case series is to describe the prenatal ultrasound features and pathogenetic mechanisms underlying placental and umbilical cord anomalies and their relationship with adverse perinatal outcome. From an educational point of view, the case series has been divided in three parts; Part 1 is dedicated to placental abnormalities. Methods: Multicenter case series of women undergoing routine and extended prenatal ultrasound and perinatal obstetric care. Results: Prenatal ultrasound findings, perinatal care, and pathology documentation in cases of placental pathology are presented. Conclusions: Our case series review and that of the medical literature confirms the ethiopathogenetic role and involvement of placenta abnormalities in a wide variety of obstetrics diseases that may jeopardize the fetal well‐being. Some of these specific pathologies are strongly associated with a high risk of poor perinatal outcome. [ABSTRACT FROM AUTHOR]

Objective: To estimate the prevalence and risk of stillbirths by biologic vulnerability phenotypes in a cohort of pregnant women in the municipality of São Paulo, Brazil, 2017–2019. Methods: Retrospective population‐based cohort study. Fetuses were assessed as small for gestational age (SGA), large for gestational age (LGA), adequate for gestational age (AGA), preterm (PT) as less than 37 weeks of gestation, non‐PT (NPT) as 37 weeks of gestation or more, low birth weight (LBW) as less than 2500 g, and non‐LBW (NLBW) as 2500 g or more. Relative risks (RR) with robust variance were estimated using Poisson regression. Results: In all 442 782 pregnancies, including 2321 (0.5%) stillbirths, were included. About 85% (n = 1983) of stillbirths had at least one characteristic of vulnerability, compared with 21% (n = 92524) of live births. Fetuses with all three markers of vulnerability had the highest adjusted RR of stillbirth—SGA + LBW + PT (RR 155.00; 95% confidence interval [CI] 136.29–176.30) and LGA + LBW + PT (RR 262.04; 95% CI 206.10–333.16) when compared with AGA + NLBW + NPT. Conclusion: Our findings show that the simultaneous presence of prematurity, low birth weight, and abnormal intrauterine growth presented a higher risk of stillbirths. To accelerate progress towards reducing preventable stillbirths, one must identify the circumstances of greatest biologic vulnerability. Synopsis: The simultaneous presence of prematurity, low birth weight, and abnormal intrauterine growth demonstrated an increased risk of stillbirth. [ABSTRACT FROM AUTHOR]

Aim: To present the feasibility, safety and outcomes of fetoscopic endoluminal tracheal occlusion (FETO) for the treatment of severe congenital diaphragmatic hernia (CDH). Methods: This was a single‐arm clinical trial of FETO for isolated left‐sided CDH with liver herniation and Kitano Grade 3 stomach position (>50% stomach herniation into the right chest). FETO was performed at 27–29 weeks of gestation for cases with observed/expected lung to head ratio (o/e LHR) <25% and at 30–31 weeks for cases with o/e LHR ≥25%. Results: Eleven cases were enrolled between March 2014 and March 2016, and balloon insertion was successful in all cases. The median o/e LHR at entry was 27% (range, 20–33%). The median gestational age at FETO was 30.9 (range, 27.1–31.7) weeks. There were no severe maternal adverse events. One fetus died unexpectedly at 33 weeks of gestation due to cord strangulation by the detached amniotic membrane. There were 3 cases (27%) of preterm premature rupture of membranes. In all 10 cases, balloon removal at 34–35 weeks of gestation was successful. The median gestational age at delivery was 36.5 (range, 34.2–38.3) weeks. The median duration of occlusion and the median interval between balloon insertion and delivery were 26 days (range: 17–49 days) and 43 days (range, 21–66 days), respectively. Both the survival rate at 90 days of age and the rate of survival to discharge were 45% (5/11). Conclusion: The FETO is feasible without maternal morbidity in Japan and could be offered to women whose fetuses show severe isolated left‐sided CDH to accelerate fetal lung growth. [ABSTRACT FROM AUTHOR]

Introduction: Severe early-onset fetal growth restriction is an obstetric condition with significant risks of perinatal mortality, major and minor neonatal morbidity, and long-term health sequelae. The prognosis of a fetus is influenced by the extent of prematurity and fetal weight. Clinical care is individually adjusted. In literature, survival rates vary and studies often only include live-born neonates with missing rates of antenatal death. This systematic review aims to summarize the literature on mortality and morbidity.Material and Methods: A broad literature search was conducted in OVID MEDLINE from 2000 to 26 April 2019 to identify studies on fetal growth restriction and perinatal death. Studies were excluded when all included children were born before 2000 because (neonatal) health care has considerably improved since this period. Studies were included that described fetal growth restriction diagnosed before 32 weeks of gestation and antenatal mortality and neonatal mortality and/or morbidity as outcome. Quality of evidence was rated with the GRADE instrument.Results: Of the 2604 publications identified, 25 studies, reporting 2895 pregnancies, were included in the systematic review. Overall risk of bias in most studies was judged as low. The quality of evidence was generally rated as very low to moderate, except for 3 large well-designed randomized controlled trials. When combining all data on mortality, in 355 of 2895 pregnancies (12%) the fetus died antenatally, 192 died in the neonatal period (8% of live-born neonates) and 2347 (81% of all pregnancies) children survived. Of the neonatal morbidities recorded, respiratory distress syndrome (34% of the live-born neonates), retinopathy of prematurity (13%) and sepsis (30%) were most common. Of 476 children that underwent neurodevelopmental assessment, 58 (12% of surviving children, 9% of all pregnancies) suffered from cognitive impairment and/or cerebral palsy.Conclusions: When combining the data of 25 included studies, survival in fetal growth restriction pregnancies, diagnosed before 32 weeks of gestation, was 81%. Neurodevelopmental impairment was assessed in a minority of surviving children. Individual prognostic counseling on the basis of these results is hampered by differences in patient and pregnancy characteristics within the included patient groups. [ABSTRACT FROM AUTHOR]

Background: Pregnant women infected with HEV develops adverse pregnancy outcomes like, abortions, intrauterine fetal death, still births, neonatal deaths, preterm delivery and maternal mortality. Aim: To correlate oestrogen and its receptors ESR1α and ESR2β levels with HEV‐associated feto‐maternal outcomes. Material & Methods: A total of 142 pregnant women with HEV infection and 142 pregnant controls were included in study from Department of Obstetrics & Gynaecology and Department of Medicine, Maulana Azad Medical College (MAMC) and associated Lok Nayak Hospital (LNH), New Delhi. Three millilitre of blood sample was collected in plain for quantification of oestrogen, and its receptors ESR1α and ESR2β using commercially available third‐generation ELISA kits. Results: The levels of oestrogen, ESR1α and ESR2β were considerably higher in HEV‐infected pregnant women (20.11 ± 18.19 ng/mL, 10.58 ± 3.27 ng/mL, 10.42 ± 4.71 ng/mL respectively) than pregnant controls (11.74 ± 6.42 ng/mL, 9.11 ± 1.63 ng/mL, 9.01 ± 1.18 ng/mL respectively)(P < 0.0001). It was found that oestrogen levels were significantly higher in pregnant women infected with HEV who had preterm delivery, low birth weight babies and fetal loss (19.64 ± 17.60 ng/mL, 19.71 ± 17.63 ng/mL, 33.62 ± 23.20 ng/mL respectively) than who had full term delivery, average birth weight babies and live babies (11.71 ± 8.77 ng/mL, 11.99 ± 9.44 ng/mL, 16.58 ± 14.98 ng/mL respectively)(P < 0.05). A significant negative correlation was observed between baby birth weight and oestrogen levels in HEV‐infected pregnant women. Conclusion: The high level of oestrogen plays an important role in preterm delivery, low birth weight babies and fetal mortality in pregnant women with HEV infection through placental dysfunction. Moreover, oestrogen level is a significant predictor for preterm delivery and maternal mortality and ESR2β levels is a significant predictor for maternal mortality in pregnant women infected with HEV. See Editorial on Page 621 [ABSTRACT FROM AUTHOR]

Introduction: Monoamniotic twin pregnancies are high-risk pregnancies, and management by inpatient or frequent outpatient care is recommended. We report the outcomes of a national cohort of monoamniotic twin pregnancies managed primarily as outpatients.Material and Methods: We prospectively analyzed the recorded data from the Danish Fetal Medicine Database, local databases, and medical records of all monoamniotic twin pregnancies diagnosed at the first trimester scan or later, and managed at the six major fetal medicine centers in Denmark over a 10-year period.Results: Sixty-one monoamniotic twin pregnancies were included. Thirteen pregnancies were terminated early. Of the remaining 48 pregnancies with a normal first trimester scan, there were 36 fetal losses (25 spontaneous miscarriages <22+0  weeks, 3 late terminations and 8 intrauterine deaths >22 weeks) and 60 liveborn children (62.5%), all of whom were delivered by cesarean delivery at a median gestational age of 33+0  weeks. Three children had minor malformations and there was 1 pregnancy with twin-to-twin transfusion syndrome. After 26+0  weeks, 78.8% were managed as outpatients. Intrauterine death occurred in 3.8% of outpatients and in 28.6% of inpatients (admitted due to complications). At weeks 32, 33 and 34, the prospective risk of intrauterine death was 6.9%, 4.2% and 5.9%, respectively.Conclusion: In this nationwide, unselected population, only 62.5% of fetuses with a normal first trimester scan were born alive. In contrast, the mortality was 3.8% after 26 weeks among the 78.8% of the cohort that was managed as outpatients. More knowledge is still needed to predict which pregnancies are at the highest risk of intrauterine death. [ABSTRACT FROM AUTHOR]

Hydrallantois is the excessive accumulation of fluid in the allantoic cavity in a pregnant animal and is associated with fetal death. We recently identified a recessive missense mutation in the solute carrier family 12, member 1 ( SLC12A1) gene (g.62382825G>A, p.Pro372Leu) that is associated with hydrallantois in Japanese Black cattle. Unexpectedly, we found a case of the homozygous risk-allele for SLC12A1 in a calf, using a PCR-based direct DNA sequencing test. The homozygote was outwardly healthy up to 3 months of age and the mother did not exhibit any clinical symptoms of hydrallantois. In order to validate these observations, we performed confirmation tests for the genotype and a diuretic loading test using furosemide, which inhibits the transporter activity of the SLC12A1 protein. The results showed that the calf was really homozygous for the risk-allele. In the homozygous calf, administration of furosemide did not alter urinary Na+ or Cl− levels, in contrast to the heterozygote and wild-type calves in which these were significantly increased. These results demonstrate that the SLC12A1 (g.62382825G>A, p.Pro372Leu) is a hypomorphic or loss-of-function mutation and the hydrallantois with this mutation shows incomplete penetrance in Japanese Black cattle. [ABSTRACT FROM AUTHOR]

Objective To evaluate the incidence and clinical relevance of intermittent absent and/or reversed diastolic flow on umbilical artery Doppler in different groups of monochorionic twin pregnancies. Methods This was a prospective study involving three groups of monochorionic pregnancies: Group 1: controls followed fortnightly from the first trimester (n = 80); Group 2: cases with selective intrauterine growth restriction (n = 40); and Group 3: cases with severe twin-twin transfusion syndrome (n = 50). The presence and persistence over time of intermittent absent and/or reversed end- diastolic flow on umbilical artery Doppler was recorded. Placentas were examined and placental sharing and the presence of large arterioarterial anastomoses (AAA) was assessed. Perinatal outcome was recorded in all cases. Results Intermittent absent and/or reversed diastolic flow was present in 5% (4/80) of cases in Group 1, 45% (18/40) in Group 2 and 2% (1/50) in Group 3 (P < 0.0001, Group 2 vs. 1 and 3). Placental examination was performed in 76.4% (130/170) of cases and sharing was 58% for Group 1, 81% for Group 2 and 73% for Group 3 (P < 0.0001, Groups 2 and 3 vs. 1). Large AAA were identified in all examined cases with intermittent flow (18/18) and in 3.6% (4/112) of those without. The in-utero mortality rate was 0% in Group 1 and in Group 2 fetuses without intermittent flow. However, it was 19.4% in Group 2 cases with intermittent diastolic flow. Conclusions Intermittent absent and/or reversed end-diastolic flow may be considered to be a characteristic sign of monochorionic pregnancy, and seems to result from the existence of large AAA. Its incidence is significantly increased in the context of selective intrauterine growth restriction, indicating a high risk for poor pregnancy outcome in these cases. [ABSTRACT FROM AUTHOR]

Background The objective of this study was to evaluate the temporal trends in pregnancy-associated myocardial infarction (PAMI) in the State of California and explore potential risk factors and mechanisms. Methods and Results The California State Inpatient Database was analyzed from 2003 to 2011 for patients with International Classification of Diseases, Ninth Revision ( ICD-9 ) codes for acute myocardial infarction and pregnancy or postpartum admissions; risk factors were analyzed and compared with pregnant patients without myocardial infarction. A total of 341 patients were identified with PAMI from a total of 5 266 380 pregnancies (incidence of 6.5 per 100 000 pregnancies). Inpatient maternal mortality rate was 7%, and infant mortality rate was 3.5% among patients with PAMI. There was a nonsignificant trend toward an increase in PAMI incidence from 2003 to 2011, possibly attributable to higher incidence of spontaneous coronary artery dissection, vasospasm, and Takotsubo syndrome. PAMI, when compared with pregnant patients without myocardial infarction, was significant for older age (aged >30 years in 72% versus 37%, P <0.0005), higher preponderance of Black race (12% versus 6%, P <0.00005), lower socioeconomic status (median household income in lowest quartile 26% versus 20%, P =0.04), higher prevalence of hypertension (26% versus 7%, P <0.0005), diabetes (7% versus 1%, P <0.0005), anemia (31% versus 7%, P <0.0001), amphetamine use (1% versus 0%, P <0.00005), cocaine use (2% versus 0.2%, P <0.0001), and smoking (6% versus 1%, P =0.0001). Conclusions There has been a trend toward an increase in PAMI incidence in California over the past decade, with an increasing trend in spontaneous coronary artery dissection, vasospasm, and Takotsubo syndrome as mechanisms. These findings warrant further investigation.

There are few reports on the prognosis of prenatally diagnosed trisomy 13 in relation to postnatal management. The aim of this study was to report on the prenatal and postnatal outcomes and postnatal management of trisomy 13 fetuses that were prenatally diagnosed at our center between 2003 and 2015. The data were retrospectively reviewed from medical records. Of the 31 cases of trisomy 13, 12 patients were diagnosed before 22 weeks of gestation, and 19 were diagnosed at or after 22 weeks of gestation. Nine families opted for termination of the pregnancy, 14 fetuses died, and 8 were born alive. Aggressive treatment was requested in two of the live births, with one patient achieving long-term survival (7 years). The other died during infancy (Day 61). One out of four who received palliative treatment is alive at two years of age with only nutrition supplementation. These three patients who achieved neonatal survival had few structural anomalies. Fetal death and early neonatal death are common in trisomy 13; however, fetuses that receive medical treatment for cases without major ultrasound abnormalities may achieve neonatal survival. Therefore, it is useful to provide comprehensive information, including precise ultrasound findings and treatment options, to parents with trisomy 13 fetuses during genetic counseling., (© 2017 Wiley Periodicals, Inc.)

Background: Historically, pregnancies among women with prosthetic heart valves have been associated with an increased incidence of adverse outcomes., Objectives: Systematic review to assess risk of adverse pregnancy outcomes among women with a prosthetic heart valve(s) over the last 20 years., Search Strategy: Electronic literature search of Medline, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature and Embase to find recent studies., Selection Criteria: Studies of pregnant women with heart valve prostheses including trials, cohort studies and unselected case series., Data Collection and Analysis: Primary analysis calculated absolute risks and 95% confidence intervals (CI) for pregnancy outcomes using a random effects model. The Freeman-Tukey transformation was utilised in secondary analysis due to the large number of individual study outcomes with zero events., Main Results: Eleven studies capturing 499 pregnancies among women with heart valve prostheses, including 256 mechanical and 59 bioprosthetic, were eligible for inclusion. Pooled estimate of maternal mortality was 1.2/100 pregnancies (95% CI 0.5-2.2), for mechanical valves subgroup 1.8/100 (95% CI 0.5-3.7) and bioprosthetic subgroup 0.7/100 (95% CI 0.1-4.5), overall pregnancy loss 20.8/100 pregnancies (95% CI 9.5-35.1), perinatal mortality 5.0/100 births (95%CI 1.8-9.8) and thromboembolism 9.3/100 pregnancies (95% CI 4.0-16.5)., Conclusions: Women with heart valve prostheses experienced higher rates of adverse outcomes than expected in a general obstetric population; however, lower than previously reported. Women with bioprostheses had significantly fewer thromboembolic events compared to women with mechanical valves. Women should be counselled pre-pregnancy about risk of maternal death and pregnancy loss. Vigilant surveillance by a multidisciplinary team throughout the perinatal period remains warranted for these women and their infants., Tweetable Abstract: Metaanalysis suggests improvement in #pregnancy outcomes among women with #heartvalveprostheses., (© 2015 Royal College of Obstetricians and Gynaecologists.)

Estimates of the burden of disease assess the mortality and morbidity that affect a population by producing summary measures of health such as quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs). These measures typically do not include stillbirths (fetal deaths occurring during the later stages of pregnancy or during labor) among the negative health outcomes they count. Priority-setting decisions that rely on these measures are therefore likely to place little value on preventing the more than three million stillbirths that occur annually worldwide. In contrast, neonatal deaths, which occur in comparable numbers, have a substantial impact on burden of disease estimates and are commonly seen as a pressing health concern. In this article we argue in favor of incorporating unintended fetal deaths that occur late in pregnancy into estimates of the burden of disease. Our argument is based on the similarity between late-term fetuses and newborn infants and the assumption that protecting newborns is important. We respond to four objections to counting stillbirths: (1) that fetuses are not yet part of the population and so their deaths should not be included in measures of population health; (2) that valuing the prevention of stillbirths will undermine women's reproductive rights; (3) that including stillbirths implies that miscarriages (fetal deaths early in pregnancy) should also be included; and (4) that birth itself is in fact ethically significant. We conclude that our proposal is ethically preferable to current practice and, if adopted, is likely to lead to improved decisions about health spending., (© 2014 John Wiley & Sons Ltd.)

Background: Before 2012, few studies had addressed pregnancy outcomes following maternal influenza vaccination; however, the number of publications on this topic has increased recently., Objectives: To review comparative studies evaluating fetal death or preterm birth associated with influenza vaccination during pregnancy., Search Strategy: We searched bibliographic databases from inception to April 2014., Selection Criteria: Experimental or observational studies assessing the relationship between influenza vaccination during pregnancy and fetal death or preterm birth., Data Collection and Analysis: Two reviewers independently abstracted data from studies meeting the inclusion criteria., Main Results: We included one randomised clinical trial and 26 observational studies. Meta-analyses were not considered appropriate because of high clinical and statistical heterogeneity. Three studies of fetal death at any gestational age reported adjusted effect estimates in the range 0.56-0.79, and four of five studies of fetal death at <20 weeks reported adjusted estimates between 0.89 and 1.23, all with confidence intervals including 1.0. Adjusted effect estimates for four of five studies of fetal death at ≥20 weeks ranged from 0.44 to 0.77 (two with confidence intervals not crossing 1.0), whereas a fifth reported a non-significant effect in the opposite direction. Among 19 studies of preterm birth, there was no strong evidence suggesting any increased risk, and meta-regression did not explain the moderate between-study heterogeneity (I(2) = 57%)., Authors' Conclusions: Most studies reported no association between fetal death or preterm birth and influenza vaccination during pregnancy. Although several reported risk reductions, results may be biased by methodological shortcomings of observational studies of influenza vaccine effectiveness., (© 2014 Royal College of Obstetricians and Gynaecologists.)

Objectives: To evaluate and compare perinatal outcome after intrauterine transfusions (IUT) performed before and after 20 weeks of gestation. To analyse contributing factors., Design: Retrospective analysis., Setting: The Dutch referral centre for fetal therapy., Population: IUTs for fetal alloimmune anaemia., Methods: Fetuses were divided into two groups: fetuses requiring the first IUT before 20 weeks of gestation (Group 1) and those in which the IUTs started after 20 weeks (Group 2). The cause of perinatal loss was classified as procedure-related (PR) or not procedure-related (NPR). The cohort was divided into two periods to describe the change of perinatal loss over time., Main Outcome Measures: Perinatal loss of fetuses requiring the first IUT before 20 weeks of gestation, compared with perinatal loss later in gestation., Results: A total of 1422 IUTs were performed in 491 fetuses. Perinatal loss rate in Group 1 was higher (7/29 24% versus 35/462 8%, P = 0.002). Especially NPR was higher for IUTs performed before 20 weeks (4/37 11% versus 19/1385 1%, P < 0.001). Kell alloimmunisation was overrepresented in Group 1 (7/29 24% versus 52/462 11%, P = 0.04). In a multivariate regression analysis, only hydrops was independently associated with perinatal loss (P = 0.001). In recent years, a decline in total perinatal loss was found (36/224 16% versus 6/267 2%, P < 0.001), but perinatal loss in Group 1 did not decline (4/224 1.8% versus 3/267 1.1%, P = 0.5)., Conclusions: Perinatal loss after IUT performed before 20 weeks of gestation is increased compared with loss after IUT performed later in gestation. In addition, we confirmed earlier observations that hydrops is a major contributor to adverse outcome. Early and timely detection and treatment may prevent hydrops and improve outcome., (© 2013 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2013 RCOG.)

Objective: To assess perinatal outcomes after expectant management in the case of preterm prelabour rupture of membranes (PPROM) before 25 weeks of gestation, according to the rate of termination of pregnancy (TOP)., Design: Retrospective comparative cohort study., Population: Singleton pregnancies complicated by PPROM between 15(0/7) and 24(6/7) weeks of gestation, from January 2003 to January 2007., Methods: Comparison of perinatal outcomes in two French tertiary care referral centres presumed to have different rates of TOP., Main Outcome Measure: Rates of TOP, survival and survival without major morbidity., Results: A total of 113 women experienced PPROM (49 in centre A and 64 in centre B). A lower proportion of patients opted for TOP in centre A (40.8%) than in centre B (56.3%). The baseline characteristics of patients and pregnancies, and gestational age at PPROM, were not different between the two centres. Mean gestational age at delivery (28.1 versus 25.4 weeks of gestation; P < 0.01), mean latency period (45.5 versus 16.1 days; P < 0.01), mean birthweight (1295 versus 929 g; P = 0.04) and survival (46.9 versus 20.3%; P < 0.01) were significantly higher in centre A than in centre B. The percentage of neonates alive without major morbidity was also higher in centre A than in centre B (42.9 versus 20.3%; P = 0.01)., Conclusions: Perinatal outcomes of pregnancies managed expectantly were not better in the centre where the TOP rate was higher. The perinatal risk of pregnancies complicated by pre-viable PPROM remains high., (© 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.)

Fetomaternal or neonatal alloimmune thrombocytopenia (NAIT) is a rare but serious condition associated with significant fetal and neonatal morbidity and mortality. The most useful predictor of severe disease is a history of a sibling with an antenatal intracranial haemorrhage. However, NAIT can occur during the first pregnancy and may not be diagnosed until the neonatal period. Antenatal treatment options include maternal intravenous immunoglobulin (IVIG) and corticosteroid treatment, fetal blood sampling (FBS) and intrauterine platelet transfusion (IUT) and early delivery. FBS (with or without IUT) can be used to direct and monitor response to therapy, and to inform mode and timing of delivery. However, this procedure is associated with significant risks, including fetal death, and is generally now reserved for high-risk pregnancies. This review highlights the current understanding of the epidemiology and pathophysiology of NAIT and summarises current approaches to investigation and management. It also introduces the newly established Australian NAIT registry. Owing to the relative rarity of NAIT, accruing sufficient patient numbers for studies and clinical trials at an institutional level is difficult. This national registry will provide an opportunity to collect valuable information and inform future research on this condition., (© 2011 The Authors. Australian and New Zealand Journal of Obstetrics and Gynaecology © 2011 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Aims: To determine the efficacy and safety of nicotine replacement therapy (NRT) with or without behavioural support when used to support smoking cessation in pregnancy., Design, Setting and Participants: A systematic review of randomized controlled trials (RCTs) in which NRT was used with or without behavioural support to promote smoking cessation; trials providing unequal behavioural support to different trial groups were excluded., Efficacy: self-reported smoking cessation in later pregnancy, validated where possible by biochemical measures with appropriate cut-points; infants' safety: mean and low birth weights (LBW), preterm birth, fetal demise and neonatal intensive care unit (NICU) admissions., Findings: Five trials, enrolling 695 pregnant, regular smokers were included in the review. The pooled risk ratio (RR) and 95% confidence Interval (CI) for smoking cessation in later pregnancy after using NRT was 1.63 (0.85, 3.14). Subgroup analysis comparing studies at lower risk of bias (placebo-RCTs) with those at higher risk of bias (non-placebo-RCTs) found that efficacy estimates varied with trial design [RR (95% CI) for cessation in placebo-RCTs 1.17 (0.83, 1.65) versus 7.81 (1.51, 40.35) for non-placebo-RCTs]. Five of the seven safety outcomes were more positive among infants born to women who had used NRT, but none of the observed differences between trial groups reached statistical significance., Conclusions: There is currently insufficient evidence to determine whether or not nicotine replacement therapy is effective or safe when used in pregnancy for smoking cessation; further research and, in particular, placebo-randomized controlled trials are required., (© 2010 The Authors, Addiction © 2010 Society for the Study of Addiction.)

Background: The outcomes of pregnancy in patients with cirrhosis are poorly described. Our objective was to assess obstetric outcomes in cirrhotic women and their infants from a population-based perspective., Methods: We analysed the 1993-2005 US Nationwide Inpatient Sample database to identify obstetric hospitalizations among patients with cirrhosis (n=339) and controls matched on age, hospital and year (n=6625). The effect of cirrhosis on maternal and fetal outcomes was evaluated using regression models with adjustment for patient and hospital factors., Results: Between 1993 and 2005, 114 antepartum and 225 delivery admissions in cirrhotic patients were identified. The estimated mean number of deliveries nationwide increased from 68 to 106 annually between 1993 and 1999 and 2000 and 2005 (P=0.0004). Patients with cirrhosis were more likely to deliver by caesarean [42 vs. 28%; adjusted odds ratio (OR) 1.41; 95% confidence interval (CI) 1.06-1.88]. Maternal (1.8 vs. 0%; P<0.0001) and fetal mortality (5.2 vs. 2.1%; P<0.0001), antepartum admission (OR 2.97; 95% CI 2.24-3.96), and maternal (OR 2.03; 95% CI 1.60-2.57) and fetal complications (OR 3.66; 95% CI 2.74-4.88) were greater among cirrhotic patients than controls. Gestational hypertension, placental abruption and uterovaginal haemorrhage were more common in patients with cirrhosis; their infants had higher rates of prematurity and growth restriction. Hepatic decompensation occurred in 15%, including ascites in 11% and variceal haemorrhage in 5%. In women with decompensation, maternal and fetal mortality were 6 and 12% respectively., Conclusions: Although rare, pregnancies among women with cirrhosis are increasing. Cirrhotic patients and their infants have an increased risk of obstetric complications, emphasizing the importance of close maternal-fetal monitoring during pregnancy.

Aims: To report the perinatal outcomes of a large series of twin pregnancies with severe twin-twin transfusion syndrome (TTTS) managed with laser ablation surgery in an Australian tertiary perinatal centre and to compare the outcome with other large cohorts., Methods: The outcomes of 100 consecutive pregnancies with severe TTTS managed with selective fetoscopic laser ablation from March 2002 to June 2007 were examined. Survival and neonatal morbidity were analysed. Comparisons were made with the results from other studies of laser surgery with at least 100 pregnancies., Results: There were 100 women with TTTS treated with laser ablation; 34 stage II, 44 stage III and 22 at stage IV. Median gestation at time of laser was 21 weeks (range 18-28) and median gestation at delivery was 31 weeks (range 20-39). Overall perinatal survival rate was 151 of 200 (75.5%). Eighty five per cent had one or more surviving twins. The survival rate for stage IV TTTS was 88.6%, significantly better than for stage II (69.1%) and stage III (73.9%) pregnancies. The perinatal mortality rate for donors (30%) was not significantly different from recipients (19%), but the fetal death rate for donors was significantly greater than that for recipients (P = 0.03). Severe cerebral abnormalities were present in only 2.8% of newborns. The overall survival rate was comparable to other large series., Conclusions: These results for the management of severe TTTS are comparable to the best reported international series. Long-term follow-up is required and more research needs to be undertaken to further improve these results.

Objective: To assess perinatal and long-term outcomes for pregnancies complicated by early onset, severe fetal growth restriction with absent or reverse end-diastolic flow velocity waveform (AREDF) in the umbilical artery., Methods: A retrospective cohort study of 36 singleton pregnancies with AREDF when the estimated fetal weight (EFW) is less than 501 g at presentation., Results: At presentation, the median gestational age and EFW were 24 (18-29) weeks and 364 (167-496) g, respectively. The median interval between presentation and live birth or diagnosis of intrauterine fetal death (IUFD) was 13 (0-60) days. Delivery was for IUFD in 19 cases (53%), fetal indications in 13 cases (36%) and maternal indications in four cases (11%). Caesarean section (CS) was performed for the 17 live births of which 10 (59%) were by classical CS. Of the total cohort, five infants survived to hospital discharge giving an overall perinatal survival rate of 14%. All survivors had short-term morbidity. The cognitive function in four children was assessed as normal at two years of age. One survivor had developmental delay. None of the surviving children had any evidence of cerebral palsy., Conclusion: The overall perinatal survival rate for pregnancies complicated by early onset, severe growth restriction with an EFW of < 501 g and AREDF is low. When delivery occurs for fetal indications, the majority of these women require classical CS. Short-term neonatal morbidity is high though none of the survivors had cerebral palsy.