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Objectives To identify risk factors and morbidity associated with suboptimal instrument placement at instrumental delivery. Design Observational study, nested within a randomised controlled trial. Setting Two university-affiliated maternity hospitals. Sample A cohort of 478 nulliparous women at term (≥37 weeks of gestation) undergoing instrumental delivery. Methods Univariable and multivariable logistic regression analyses were performed. Main outcome measures Risk factors for suboptimal application of vacuum or forceps, maternal and neonatal morbidity, and the sequential use of instruments, second operator, and caesarean section following failed instrumental delivery. Results Instrument placement was suboptimal in 138 of 478 (28.8%) deliveries. Factors associated with suboptimal instrument placement included fetal malposition (OR 2.44, 95% CI 1.62-3.66), mid-cavity station (OR 1.68, 95% CI 1.02-2.78), and forceps as the primary instrument (OR 2.01, 95% CI 1.33-3.04). Compared with optimal instrument placement, suboptimal placement was associated with prolonged hospital stay (adjusted OR 2.28, 95% CI 1.30-4.02) and neonatal trauma (adjusted OR 4.25, 95% CI 1.85-9.72). Suboptimal placement was associated with a greater use of sequential instruments (adjusted OR 3.99, 95% CI 1.94-8.23) and caesarean section for failed instrumental delivery (adjusted OR 3.81, 95% CI 1.10-13.16). The mean decision to delivery interval (DDI) was 4 minutes longer in the suboptimal group (95% CI 2.1-5.9 minutes). Conclusions Suboptimal instrument placement is associated with increased maternal and neonatal morbidity and procedural complications. Greater attention should be focused on instrument placement when training obstetricians for instrumental delivery. [ABSTRACT FROM AUTHOR]

Objective: To determine whether the use of ultrasound can reduce the incidence of incorrect diagnosis of the fetal head position at instrumental delivery and subsequent morbidity. Design: Two-arm, parallel, randomised trial, conducted from June 2011 to December 2012. Setting: Two maternity hospitals in the Republic of Ireland. Sample: A cohort of 514 nulliparous women at term (≥37 weeks of gestation) with singleton cephalic pregnancies, aiming to deliver vaginally, were recruited prior to an induction of labour or in early labour. Methods: If instrumental delivery was required, women who had provided written consent were randomised to receive clinical assessment (standard care) or ultrasound scan and clinical assessment (ultrasound). [Correction added on 17 April 2014, after first online publication: Sentence was amended.] Main Outcome Measure: Incorrect diagnosis of the fetal head position. Results: The incidence of incorrect diagnosis was significantly lower in the ultrasound group than the standard care group (4/257, 1.6%, versus 52/257, 20.2%; odds ratio 0.06; 95% confidence interval 0.02-0.19; P < 0.001). The decision to delivery interval was similar in both groups (ultrasound mean 13.8 minutes, SD 8.7 minutes, versus standard care mean 14.6 minutes, SD 10.1 minutes, P = 0.35). The incidence of maternal and neonatal complications, failed instrumental delivery, and caesarean section was not significantly different between the two groups. Conclusions: An ultrasound assessment prior to instrumental delivery reduced the incidence of incorrect diagnosis of the fetal head position without delaying delivery, but did not prevent morbidity. A more integrated clinical skills-based approach is likely to be required to prevent adverse outcomes at instrumental delivery. [ABSTRACT FROM AUTHOR]

Competing Interests: None declared

Understanding factors influencing microbial interactions, and designing methods to identify key taxa that are candidates for synthetic communities, or SynComs, are complex challenges for achieving microbiome-based agriculture. Here, we study how grafting and the choice of rootstock influences root-associated fungal communities in a grafted tomato system. We studied three tomato rootstocks (BHN589, RST-04-106, and Maxifort) grafted to a BHN589 scion and profiled the fungal communities in the endosphere and rhizosphere by sequencing the internal transcribed spacer (ITS2). The data provided evidence for a rootstock effect (explaining ~2% of the total captured variation, P  < 0.01) on the fungal community. Moreover, the most productive rootstock, Maxifort, supported greater fungal species richness than the other rootstocks or controls. We then constructed a phenotype-operational taxonomic unit (OTU) network analysis (PhONA) using an integrated machine learning and network analysis approach based on fungal OTUs and associated tomato yield as the phenotype. PhONA provides a graphical framework to select a testable and manageable number of OTUs to support microbiome-enhanced agriculture. We identified differentially abundant OTUs specific to each rootstock in both endosphere and rhizosphere compartments. Subsequent analyses using PhONA identified OTUs that were directly associated with tomato fruit yield and others that were indirectly linked to yield through their links to these OTUs. Fungal OTUs that are directly or indirectly linked with tomato yield may represent candidates for synthetic communities to be explored in agricultural systems. IMPORTANCE The realized benefits of microbiome analyses for plant health and disease management are often limited by the lack of methods to select manageable and testable synthetic microbiomes. We evaluated the composition and diversity of root-associated fungal communities from grafted tomatoes. We then constructed a phenotype-OTU network analysis (PhONA) using these linear and network models. By incorporating yield data in the network, PhONA identified OTUs that were directly predictive of tomato yield and others that were indirectly linked to yield through their links to these OTUs. Follow-up functional studies of taxa associated with effective rootstocks, identified using approaches such as PhONA, could support the design of synthetic fungal communities for microbiome-based crop production and disease management. The PhONA framework is flexible for incorporation of other phenotypic data, and the underlying models can readily be generalized to accommodate other microbiome or 'omics data., Competing Interests: The authors declare no conflict of interest.

Introduction The World Health Organisation has identified air pollution as the single biggest environmental threat to human health. There is growing evidence in the literature that air pollution is associated with negative outcomes in pregnancy. The purpose of this study was to measure pollution levels in the immediate surroundings of the three Dublin maternity hospitals by measuring fine particulate matter &lt;2.5 micrometres (PM2.5). Methods Data pertaining to levels of PM2.5 at the three Dublin maternity hospitals were obtained from Pollutrack's records for the time period 25/6/2021-2/12/2021. Results were compared to the 2021 WHO Air Quality Guidelines. Results Average PM2.5 levels were 9μg/m³ around the National Maternity Hospital, 10μg/m³ around the Coombe Hospital and 13μg/m³ around the Rotunda Hospital. Levels were higher during the day, weekdays and in December. No matter when the PM2.5 levels were measured, results were higher than those recommended by the World Health Organisation's Air Quality Guideline. Discussion Air pollution levels across Ireland's capital city are higher than recommended by the WHO. This is concerning for the public and in particular for the pregnant population. Going forward, further research is required on the relationship between levels of air pollutants and adverse pregnancy outcomes in Dublin., Competing Interests: Mr. Gilles Delaunay is a staff member at Pollutrack SAS. No funding was received for this study.

Introduction Transgender people have specific healthcare needs and experience difficulty in accessing health services. Medical students should receive teaching on general and gynaecological healthcare issues in this population. Our aim was to assess medical students' knowledge of healthcare needs of transgender people before and after a newly implemented teaching session on transgender healthcare. Method A mixed-method study was carried out over a three month period in a university obstetric and gynaecology hospital in Dublin. A one-hour teaching session was developed and delivered to final year medical students. Students completed a survey before and after receiving the lecture. Results Seventy-one students completed the pre-lecture survey and forty-three completed the post-lecture survey. Pre-lecture, 64 students (90%) reported some-to-no understanding of healthcare issues of transgender people, and only 13 (18%) reported understanding gynaecological issues faced by transgender people. Post-lecture, 41 (95%) had a better understanding of health issues faced by this population and 40 (93%) had a better understanding of gynaecological health issues faced. Most students (81%) wanted further teaching on the topic. Conclusion A one-hour teaching session was effective at improving student knowledge of care of transgender people. This teaching could be expanded to all Irish medical schools. Going forward, the teaching could be adapted for post-graduate obstetric and gynaecology teaching., Competing Interests: The authors have no conflicts of interest to declare. No funding was received for this study.

Background: Maternal obesity and depression are common and both have been associated with adverse pregnancy outcomes., Aims: The aim of this observational study was to examine the relationship between maternal body mass index (BMI) category and self-reported depression at the first antenatal visit., Methods: Women who delivered a baby weighing ≥ 500 g over nine years 2009-2017 were included. Self-reported sociodemographic and clinical details were computerised at the first antenatal visit by a trained midwife, and maternal BMI was calculated after standardised measurement of weight and height., Results: Of 73,266 women, 12,304 (16.7%) had obesity, 1.6% (n = 1126) reported current depression and 7.5% (n = 3277) multiparas reported a history of postnatal depression. The prevalence of self-reported maternal depression was higher in women who had obesity, > 35 years old, were socially disadvantaged, smokers, had an unplanned pregnancy and used illicit drugs. After adjustment for confounding variables, obesity was associated with an increased odds ratio (aOR) for current depression in both nulliparas (aOR 1.7, 95% CI 1.3-2.3, p < 0.001) and multiparas (aOR 1.8, 95% CI 1.5-2.1, p < 0.001) and postnatal depression in multiparas (aOR 1.4, 95% CI 1.3-1.5, p < 0.001). The prevalence of current depression was higher in women with moderate/severe obesity than in women with mild obesity (both p < 0.001)., Conclusions: We found that self-reported maternal depression in early pregnancy was independently associated with obesity. The prevalence of depression increased with the severity of obesity. Our findings highlight the need for implementation of strategies and provision of services for the prevention and treatment of both obesity and depression., (© 2021. The Author(s).)

Root-associated microbes are critical to plant health and performance, although understanding of the factors that structure these microbial communities and the theory to predict microbial assemblages are still limited. Here, we use a grafted tomato system to study the effects of rootstock genotypes and grafting in endosphere and rhizosphere microbiomes that were evaluated by sequencing 16S rRNA. We compared the microbiomes of nongrafted tomato cultivar BHN589, self-grafted BHN589, and BHN589 grafted to Maxifort or RST-04-106 hybrid rootstocks. Operational taxonomic unit (OTU)-based bacterial diversity was greater in Maxifort compared to the nongrafted control, whereas bacterial diversity in the controls (self-grafted and nongrafted) and the other rootstock (RST-04-106) was similar. Grafting itself did not affect bacterial diversity; diversity in the self-graft was similar to that of the nongraft. Bacterial diversity was higher in the rhizosphere than in the endosphere for all treatments. However, despite the lower overall diversity, there was a greater number of differentially abundant OTUs (DAOTUs) in the endosphere, with the greatest number of DAOTUs associated with Maxifort. In a permutational multivariate analysis of variance (PERMANOVA), there was evidence for an effect of rootstock genotype on bacterial communities. The endosphere-rhizosphere compartment and study site explained a high percentage of the differences among bacterial communities. Further analyses identified OTUs responsive to rootstock genotypes in both the endosphere and rhizosphere. Our findings highlight the effects of rootstocks on bacterial diversity and composition. The influence of rootstock and plant compartment on microbial communities indicates opportunities for the development of designer communities and microbiome-based breeding to improve future crop production. IMPORTANCE Understanding factors that control microbial communities is essential for designing and supporting microbiome-based agriculture. In this study, we used a grafted tomato system to study the effect of rootstock genotypes and grafting on bacterial communities colonizing the endosphere and rhizosphere. To compare the bacterial communities in control treatments (nongrafted and self-grafted plants) with the hybrid rootstocks used by farmers, we evaluated the effect of rootstocks on overall bacterial diversity and composition. These findings indicate the potential for using plant genotype to indirectly select bacterial taxa. In addition, we identify taxa responsive to each rootstock treatment, which may represent candidate taxa useful for biocontrol and in biofertilizers., (Copyright © 2019 American Society for Microbiology.)

Maternal obesity is an emerging challenge in contemporary obstetrics. To date there has been no study analysing the relationship between specific maternal body composition measurements and foetal soft-tissue measurements. The aim of this study was to determine whether measurement of maternal body composition at booking predicts foetal soft-tissue trajectories in the third trimester. We analysed the relationship between foetal thigh in the third trimester and both maternal BMI and body composition using the Tanita digital scales in the first trimester. Foetal subcutaneous thigh tissue measurements were obtained at intervals of 28, 32 and 36 weeks of gestation. A total of 160 women were identified. There was a direct correlation between MTST at 36 weeks and BMI (p = .002). There was a positive correlation between MTST at 36 weeks and leg fat mass (p = .13) and leg fat free mass (p = .013). There was a positive correlation between arm fat free mass and MTST at 36 weeks. We showed there is an association between maternal fat distribution and foetal subcutaneous thigh tissue measurements. MTST may be more useful in determining if a child is at risk of macrosomia. Impact statement Previous studies have suggested that maternal obesity programmes intrauterine foetal adiposity and growth. The aim of this study was to examine the relationship in a high-risk obstetric population between measurements of maternal body composition in early pregnancy and the assessment of foetal adiposity in the third trimester using serial ultrasound measurements of mid-thigh soft-tissue thickness. BMI is only a surrogate measurement of fat and does not measure fat distribution. Our study shows the distribution of both maternal fat and fat-free mass in early pregnancy may be positively associated with foetal soft-tissue measurements in the third trimester. Maternal arthropometric measurements other than BMI may help predict babies at risk of macrosomia and neonatal adiposity.

Objectives: To examine associations between maternal pregnancy-specific stress and umbilical (UA PI) and middle cerebral artery pulsatility indices (MCA PI), cerebroplacental ratio, absent end diastolic flow (AEDF), birthweight, prematurity, neonatal intensive care unit admission and adverse obstetric outcomes in women with small for gestational age pregnancies. It was hypothesised that maternal pregnancy-specific stress would be associated with fetoplacental haemodynamics and neonatal outcomes., Design: This is a secondary analysis of data collected for a large-scale prospective observational study., Setting: This study was conducted in the seven major obstetric hospitals in Ireland and Northern Ireland., Participants: Participants included 331 women who participated in the Prospective Observational Trial to Optimise Paediatric Health in Intrauterine Growth Restriction. Women with singleton pregnancies between 24 and 36 weeks gestation, estimated fetal weight <10th percentile and no major structural or chromosomal abnormalities were included., Primary and Secondary Outcome Measures: Serial Doppler ultrasound examinations of the umbilical and middle cerebral arteries between 20 and 42 weeks gestation, Pregnancy Distress Questionnaire (PDQ) scores between 23 and 40 weeks gestation and neonatal outcomes., Results: Concerns about physical symptoms and body image at 35-40 weeks were associated with lower odds of abnormal UAPI (OR 0.826, 95% CI 0.696 to 0.979, p=0.028). PDQ score (OR 1.073, 95% CI 1.012 to 1.137, p=0.017), concerns about birth and the baby (OR 1.143, 95% CI 1.037 to 1.260, p=0.007) and concerns about physical symptoms and body image (OR 1.283, 95% CI 1.070 to 1.538, p=0.007) at 29-34 weeks were associated with higher odds of abnormal MCA PI. Concerns about birth and the baby at 29-34 weeks (OR 1.202, 95% CI 1.018 to 1.421, p=0.030) were associated with higher odds of AEDF. Concerns about physical symptoms and body image at 35-40 weeks were associated with decreased odds of neonatal intensive care unit admission (OR 0.635, 95% CI 0.435 to 0.927, p=0.019)., Conclusions: These findings suggest that fetoplacental haemodynamics may be a mechanistic link between maternal prenatal stress and fetal and neonatal well-being, but additional research is required., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Background: Intrauterine growth restriction accounts for a significant proportion of perinatal morbidity and mortality currently encountered in obstetric practice. The primary goal of antenatal care is the early recognition of such conditions to allow treatment and optimization of both maternal and fetal outcomes. Management of pregnancies complicated by intrauterine growth restriction remains one of the greatest challenges in obstetrics. Frequently, however, clinical evidence of underlying uteroplacental dysfunction may only emerge at a late stage in the disease process. With advanced disease the only therapeutic intervention is delivery of the fetus and placenta. The cerebroplacental ratio is gaining much interest as a useful tool in differentiating the at-risk fetus in both intrauterine growth restriction and the appropriate-for-gestational-age setting. The cerebroplacental ratio quantifies the redistribution of the cardiac output resulting in a brain-sparing effect. The Prospective Observational Trial to Optimize Pediatric Health in Intrauterine Growth Restriction group previously demonstrated that the presence of a brain-sparing effect is significantly associated with an adverse perinatal outcome in the intrauterine growth restriction cohort., Objective: The aim of the Prospective Observational Trial to Optimize Pediatric Health in Intrauterine Growth Restriction study was to evaluate the optimal management of fetuses with an estimated fetal weight <10th centile. The objective of this secondary analysis was to evaluate if normalizing cerebroplacental ratio predicts adverse perinatal outcome., Study Design: In all, 1116 consecutive singleton pregnancies with intrauterine growth restriction completed the study protocol over 2 years at 7 centers, undergoing serial sonographic evaluation and multivessel Doppler measurement. Cerebroplacental ratio was calculated using the pulsatility and resistance indices of the middle cerebral and umbilical artery. Abnormal cerebroplacental ratio was defined as <1.0. Adverse perinatal outcome was defined as a composite of intraventricular hemorrhage, periventricular leukomalacia, hypoxic ischemic encephalopathy, necrotizing enterocolitis, bronchopulmonary dysplasia, sepsis, and death., Results: Data for cerebroplacental ratio calculation were available in 881 cases, with a mean gestational age of 33 (interquartile range, 28.7-35.9) weeks. Of the 87 cases of abnormal serial cerebroplacental ratio with an initial value <1.0, 52% (n = 45) of cases remained abnormal and 22% of these (n = 10) had an adverse perinatal outcome. The remaining 48% (n = 42) demonstrated normalizing cerebroplacental ratio on serial sonography, and 5% of these (n = 2) had an adverse perinatal outcome. Mean gestation at delivery was 33.4 weeks (n = 45) in the continuing abnormal cerebroplacental ratio group and 36.5 weeks (n = 42) in the normalizing cerebroplacental ratio group (P value <.001)., Conclusion: The Prospective Observational Trial to Optimize Pediatric Health in Intrauterine Growth Restriction group previously demonstrated that the presence of a brain-sparing effect was significantly associated with an adverse perinatal outcome in our intrauterine growth restriction cohort. It was hypothesized that a normalizing cerebroplacental ratio would be a further predictor of an adverse outcome due to the loss of this compensatory mechanism. However, in this subanalysis we did not demonstrate an additional poor prognostic effect when the cerebroplacental ratio value returned to a value >1.0. Overall, this secondary analysis demonstrated the importance of a serial abnormal cerebroplacental ratio value of <1 within the <34 weeks' gestation population. Contrary to our proposed hypothesis, we recognize that reversion of an abnormal cerebroplacental ratio to a normal ratio is not associated with a heightened degree of adverse perinatal outcome., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The early detection of foetal growth restriction and macrosomia is an important goal of modern obstetric care. Aberrant foetal growth is an important cause of perinatal morbidity and mortality. Current modalities for detecting the abnormal foetal growth are often inadequate. Pulse wave analysis using applanation tonometry is a simple and non-invasive test that provides information about the cardiovascular system. Arterial elasticity has previously been implicated in the pathophysiology of pre-eclampsia and cardiovascular disease. Our study examined the relationship between maternal arterial elasticity and birthweight by using pulse wave analysis. We discovered that increased large artery elasticity predicted a larger baby at birth. Large artery elasticity therefore has the potential to act as a useful screening tool which may help in the prediction of women who are at risk of aberrant foetal growth.

Background: Increases in clinical complications associated with maternal obesity have generated interest in increasing physical activity (PA) and exercise levels as an intervention to improve pregnancy outcomes., Aims: The objective of this study was to examine the relationship between BMI categorisation and PA and exercise levels as pregnancy advances., Methods: This was an observational study in a large university maternity hospital. Women were recruited at their convenience before they left hospital after delivering a baby weighing 500 g or more. They completed a detailed customised physical activity and exercise questionnaire. BMI categorisation was based on the measurement of weight and height in early pregnancy., Results: Of the 155 women recruited, 42.5 % (n = 66) were primigravidas and 10.3 % (n = 16) were smokers. Mean Body Mass Index (BMI) was 24.6 kg/m(2) and 14.2 % (n = 22) were obese, based on a BMI >29.9 kg/m(2). Overall, women decreased their exercise from an average 194 min (range 0-650 min) per week pre-pregnancy to 98 min antenatally (range 0-420 min) (p < 0.0001). Obese women exercised least pre-pregnancy and antenatally at 187.5 and 75 min per week, respectively, compared with 193.2 and 95.5 min per week in the normal BMI group and 239.3 and 106.7 min per week in the overweight group. The mean gestation at which all women reduced their activity levels was 29 weeks., Conclusions: We found that women decreased their PA  and exercise levels significantly in the third trimester and, thus, in the absence of a medical contra-indication there is considerable scope for an exercise intervention to improve activity  and exercise levels as pregnancy advances. However, an increase in PA levels in obese women needs further studies to determine whether it will improve the clinical outcomes for the woman and her offspring.

Purpose: Maternal obesity represents a challenge in the sonographic (US) assessment of fetal weight, and is a recognized risk factor for adverse pregnancy outcome. The objective of this secondary analysis of data from the Prospective Observational Trial to Optimize Pediatric Health in fetal growth restriction (FGR) Study (PORTO) was to describe the effect of maternal obesity on the accuracy of US in determining the estimated fetal weight (EFW) and the perinatal outcome of pregnancies affected by FGR., Methods: Between 2010 and 2012, 1,116 women with nonanomalous singleton pregnancies with an EFW in less than the tenth centile were recruited for the PORTO study. Maternal body mass index (BMI) was divided into five subcategories: normal (BMI < 24.9 kg/m(2) ), overweight (25-29.9), obese class 1 (30-34.9), obese class 2 (35-39.9), and obese class 3 (>40). The accuracy of the EFW was determined in women who delivered within 2 weeks of their last US scan. Perinatal outcomes were analyzed by BMI subcategory., Results: Of the 1,074 patients with complete records, 691 (64%) were of normal weight, 258 (24%) were overweight, 93 (9%) were in obese class 1, 32 (3%) were in obese class 2, and none were in obese class 3. Overall, the EFW determined prior to delivery was within 6% of the actual birth weight in all BMI subcategories. Overweight and obese women delivered more commonly by cesarean section and at earlier gestational ages than did women with a normal BMI (p = 0.0008), resulting in lower birth weights (p = 0.0031) and significantly increased composite perinatal morbidity (p < 0.0001) and mortality (p = 0.0215) rates., Conclusions: US examination is reliable for assessing the weight of fetuses with FGR in overweight women. Maternal obesity, however, has a significant adverse effect on perinatal outcomes. Thus, health education should focus on awareness of this adverse effect, with optimization of prepregnancy weight as its main goal., (© 2015 Wiley Periodicals, Inc.)

Neural tube defects (NTDs) carry a heavy burden for affected individuals and their family. Physical and neurological outcome measures may help in counselling couples. The aim of this audit was to review all cases of NTDs seen at a tertiary referral foetal medicine unit. Cases were identified from obstetric, neonatal and neurosurgical records. Thirty-six cases of NTDs were identified. Of the 36, 25% (n = 9, one trisomy 18) opted for termination of pregnancy abroad. Of the remaining 27, 19% (n = 5) died in the antepartum period. 81% (n = 22) were liveborn with four neonatal deaths (one trisomy 18). Of 15 cases, 14 had neurosurgical repair within a median time of 3 days and 9 of these also had a ventriculoperitoneal shunt inserted. Antenatal ultrasound accurately diagnosed lesion level in the majority of cases. The survival rate for babies diagnosed with non-lethal neural tubes defects is high when multidisciplinary care is initiated early.

Objective: This study sought to determine whether ultrasound assessment of fetal head circumference (FHC) at the onset of labor can predict the likelihood of operative delivery., Methods: We performed a prospective cohort study of 200 nulliparous women with singleton, cephalic, term pregnancies in an Irish Maternity Hospital. Transabdominal ultrasound assessment of FHC was performed when spontaneous labor was diagnosed or immediately prior to induction. Odds ratios for operative delivery (instrumental delivery or cesarean section) and maternal and neonatal morbidity were calculated using logistic regression with FHC categorized at a ≥350-mm cut-off (90th percentile)., Results: Ultrasound assessment of FHC at the onset of labor was highly correlated with post-delivery neonatal head circumference (NHC) (Pearson's correlation coefficient 0.74), suggesting that it can be measured reliably. FHC ≥350 mm was associated with more than twice the risk of any operative delivery (OR 2.5, 95% CI 1.0-6.2) and a two-fold increased risk of cesarean section for dystocia (OR 2.0, 95% CI 1.0-4.3). Differences in maternal and neonatal morbidity were not statistically significant., Conclusion: These preliminary data suggest that ultrasound assessment of FHC at the onset of labor may be useful in identifying women at greater risk of intrapartum intervention and warrant further research.

Objective: We sought to determine the cause of adverse perinatal outcome in fetal growth restriction (FGR) where umbilical artery (UA) Doppler was normal, as identified from the Prospective Observational Trial to Optimize Pediatric Health (PORTO). We compared cases of adverse outcome where UA Doppler was normal and abnormal., Study Design: The PORTO study was a national multicenter study of >1100 ultrasound-dated singleton pregnancies with an estimated fetal weight <10th centile. Each pregnancy underwent intensive ultrasound, including multivessel Doppler. UA Doppler was considered abnormal when the pulsatility index was >95th centile or end-diastolic flow was absent/reversed. Adverse perinatal outcome was defined as a composite of intraventricular hemorrhage, periventricular leukomalacia, hypoxic ischemic encephalopathy, necrotizing enterocolitis, bronchopulmonary dysplasia, sepsis, or death., Results: In all, 57 (5.0%) of the 1116 fetuses had an adverse perinatal outcome. Nine (1.3%) of 698 fetuses with normal UA Doppler had an adverse outcome, compared with 48 (11.5%) of 418 with abnormal UA Doppler (P < .0001). There were 2 perinatal deaths in the normal group and 6 in the abnormal group (P = .01). The perinatal deaths in the normal group were 1 case of pulmonary hypoplasia after prolonged preterm rupture of the membranes from 12 weeks' gestation and a case of placental abruption. Gestation at delivery was 33 ± 3 vs 31 ± 4 weeks (P = .05) and mean birthweight was 1830 ± 737 vs 1146 ± 508 g (P = .001) in the respective groups. Neonatal sepsis was the commonest adverse outcome in both groups: 0.1% and 0.4%, respectively (P = .01)., Conclusion: Adverse perinatal outcome is uncommon in FGR with normal UA Doppler. The cases we identified were associated with heterogenous pathologies. FGR with normal UA blood flow is a largely benign condition., (Copyright © 2014. Published by Elsevier Inc.)

Objective: The purpose of this study was to examine the relationship between prenatal measures of subcutaneous tissue as surrogate markers of fetal nutritional status and correlate them with neonatal total body composition., Methods: This prospective longitudinal study of 62 singleton pregnancies obtained serial biometry and subcutaneous tissue measurements at 28, 33 and 38 weeks gestation. These measurements were then correlated with neonatal body composition, which was analysed using the PEAPOD™ Infant Body Composition System (Cosmed USA, Concord, CA, USA)., Results: At 38 weeks gestation, fetal abdominal subcutaneous tissue (FAST) in millimetres was significantly associated with infant fat mass at delivery (+64 g per mm of FAST, p < 0.001). Thigh fat (TF) at 28 weeks gestation was associated with infant fat mass at delivery (+79 g/mm TF, p = 0.023). TF at 38 weeks gestation was associated with infant fat mass (+63/mm TF, p = 0.004). TF and FAST at 38 weeks were also predictive of both birth weight and increased abdominal circumference (AC) (p = 0.001) with FAST measurement predicting an additional 5.7 mm in AC per millimetre of FAST (p = 0.002) and TF predicting an additional 6.9 mm per mm of TF (p = 0.002)., Conclusion: We believe that this study further validates the use of prenatal measures of subcutaneous tissue and may help to highlight fetuses at risk of newborn adiposity and metabolic syndrome., (© 2014 John Wiley & Sons, Ltd.)

Objective: The aim of the Prospective Observational Trial to Optimize Pediatric Health in IUGR Study was to evaluate the optimal management of fetuses with an estimated fetal weight less than the 10th centile. The objective of this secondary analysis was to describe the role of the cerebroplacental ratio (CPR) in the prediction of adverse perinatal outcome., Study Design: More than 1100 consecutive singleton pregnancies with intrauterine growth restriction (IUGR) were recruited over 2 years at 7 centers, undergoing serial sonographic evaluation including multivessel Doppler measurement. CPR was calculated using the pulsatility and resistance indices of the middle cerebral and umbilical artery. Adverse perinatal outcome was defined as a composite of intraventricular hemorrhage, periventricular leukomalacia, hypoxic ischemic encephalopathy, necrotizing enterocolitis, bronchopulmonary dysplasia, sepsis, and death., Results: Data for CPR calculation was available in 881 cases, which was performed at a mean gestational age of 33 weeks (interquarile range, 28.7-35.9). Of the 146 cases with CPR less than 1, 18% (n = 27) had an adverse perinatal outcome. This conferred an 11-fold increased risk (odds ratio, 11.7; P < .0001) when compared with cases with normal CPR (2%; 14 of 735). An abnormal CPR was present in all 3 cases of mortality. Prediction of adverse outcomes was comparable when using all definitions of abnormal CPR., Conclusion: Irrespective of the CPR calculation used, brain sparing is significantly associated with an adverse perinatal outcome in IUGR. This adds further weight to integrating CPR evaluation into the clinical assessment of IUGR pregnancies. The impact of this finding on long-term neurodevelopmental outcomes in this patient cohort is underway., (Copyright © 2014 Mosby, Inc. All rights reserved.)

Objective: To evaluate opinions among Irish obstetricians and obstetric trainees regarding the optimal definition, assessment and management of pregnancies affected by intrauterine growth restriction (IUGR)., Study Design: An anonymous, structured, web-based survey that comprised 14 questions was sent to 200 obstetricians and obstetric trainees in Ireland., Results: Of the 113 participants (57% response rate), the majority (50%) were consultants, with over 10 years' clinical experience (46%), who worked in large maternity units (58%) with neonatal units providing care for preterm IUGR fetuses (94%). Eighty-three clinicians (74%) agreed that an estimated fetal weight (EFW) below the 10th centile constitutes small-for-gestational age (SGA). The majority (n=93; 82%) would deliver the SGA fetus between 37(+0) and 39(+6) weeks gestation. In total, the survey yielded 30 different IUGR definitions; the top three definitions were (i) an EFW below the 5th centile (n=18; 16%), (ii) an EFW below the 10th centile with oligohydramnios and abnormal umbilical artery (UA) Doppler (n=16; 14%), and (iii) an EFW below the 10th centile (n=12; 11%). In the evaluation of the preterm IUGR fetus with abnormal UA Doppler, the assessment of amniotic fluid volume, middle cerebral artery, ductus venosus, cardiotocograph (CTG) and biophysical profiling was performed in 74%, 60%, 60%, 54% and 52% respectively. The majority of clinicians applied three or more assessment modalities and 60% referred to a maternal-fetal medicine (MFM) subspecialist. Interestingly, even among MFM subspecialists there was no common consistent management approach. Most doctors (81%) would deliver the IUGR fetus for CTG abnormalities but MFM subspecialists more commonly deliver on the basis of absent end-diastolic flow in the UA alone (37% vs. 10%; p=0.006). Two-thirds of doctors (n=74) would implement customised growth charts if they became available for their population and over 80% thought that a national guideline on IUGR would be beneficial., Conclusion: The results of this survey confirm the inconsistencies surrounding the clinical management of IUGR pregnancies and highlight the need for standardisation of terminology and antenatal surveillance, implementation of fetal weight customisation and national guidance for Ireland., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Background: Intrauterine growth restriction (IUGR) is the single largest contributing factor to perinatal mortality in non-anomalous fetuses. Advances in antenatal and neonatal critical care have resulted in a reduction in neonatal deaths over the past decades, while stillbirth rates have remained unchanged. Antenatal detection rates of fetal growth failure are low, and these pregnancies carry a high risk of perinatal death., Methods: The Prospective Observational Trial to Optimize Paediatric Health in IUGR (PORTO) Study recruited 1,200 ultrasound-dated singleton IUGR pregnancies, defined as EFW <10th centile, between 24+0 and 36+6 weeks gestation. All recruited fetuses underwent serial sonographic assessment of fetal weight and multi-vessel Doppler studies until birth. Perinatal outcomes were recorded for all pregnancies. Case records of the perinatal deaths from this prospectively recruited IUGR cohort were reviewed, their pregnancy details and outcome were analysed descriptively and compared to the entire cohort., Results: Of 1,116 non-anomalous singleton infants with EFW <10th centile, 6 resulted in perinatal deaths including 3 stillbirths and 3 early neonatal deaths. Perinatal deaths occurred between 24+6 and 35+0 weeks gestation corresponding to birthweights ranging from 460 to 2260 grams. Perinatal deaths occurred more commonly in pregnancies with severe growth restriction (EFW <3rd centile) and associated abnormal Doppler findings resulting in earlier gestational ages at delivery and lower birthweights. All of the described pregnancies were complicated by either significant maternal comorbidities, e.g. hypertension, systemic lupus erythematosus (SLE) or diabetes, or poor obstetric histories, e.g. prior perinatal death, mid-trimester or recurrent pregnancy loss. Five of the 6 mortalities occurred in women of non-Irish ethnic backgrounds. All perinatal deaths showed abnormalities on placental histopathological evaluation., Conclusions: The PNMR in this cohort of prenatally identified IUGR cases was 5.4/1,000 and compares favourably to the overall national rate of 4.1/1,000 births, which can be attributed to increased surveillance and timely delivery. Despite antenatal recognition of IUGR and associated maternal risk factors, not all perinatal deaths can be prevented.

Introduction: The objective of this investigation was to study fetal thigh volume throughout gestation and explore its correlation with birth weight and neonatal body composition. This novel technique may improve birth weight prediction and lead to improved detection rates for fetal growth restriction., Materials and Methods: Fractional thigh volume (TVol) using 3D ultrasound, fetal biometry and soft tissue thickness were studied longitudinally in 42 mother-infant pairs. The percentages of neonatal body fat, fat mass and fat-free mass were determined using air displacement plethysmography. Correlation and linear regression analyses were performed., Results: Linear regression analysis showed an association between TVol and birth weight. TVol at 33 weeks was also associated with neonatal fat-free mass. There was no correlation between TVol and neonatal fat mass. Abdominal circumference, estimated fetal weight (EFW) and EFW centile showed consistent correlations with birth weight. Thigh volume demonstrated an additional independent contribution to birth weight prediction when added to the EFW centile from the 38-week scan (p = 0.03)., Conclusion: Fractional TVol performed at 33 weeks gestation is correlated with birth weight and neonatal lean body mass. This screening test may highlight those at risk of fetal growth restriction or macrosomia.

Objective: An objective of the Prospective Observational Trial to Optimize Pediatric Health in IUGR (PORTO) study was to evaluate multivessel Doppler changes in a large cohort of intrauterine growth restriction (IUGR) fetuses to establish whether a predictable progressive sequence of Doppler deterioration exists and to correlate these Doppler findings with respective perinatal outcomes., Study Design: More than 1100 unselected consecutive ultrasound-dated singleton pregnancies with estimated fetal weight (EFW) less than the 10th centile were recruited between January 2010 and June 2012. Eligible pregnancies were assessed by serial Doppler interrogation of umbilical (UA) and middle cerebral (MCA) arteries, ductus venosus (DV), aortic isthmus, and myocardial performance index (MPI). Intervals between Doppler changes and patterns of deterioration were recorded and correlated with respective perinatal outcomes., Results: Our study of 1116 nonanomalous fetuses comprised 7769 individual Doppler data points. Five hundred eleven patients (46%) had an abnormal UA, 300 (27%) had an abnormal MCA, and 129 (11%) had an abnormal DV Doppler. The classic pattern from abnormal UA to MCA to DV existed but no more frequently than any of the other potential pattern. Doppler interrogation of the UA and MCA remains the most useful and practical tool in identifying fetuses at risk of adverse perinatal outcome, capturing 88% of all adverse outcomes., Conclusion: In contrast to previous reports, we have demonstrated multiple potential patterns of Doppler deterioration in this large prospective cohort of IUGR pregnancies, which calls into question the usefulness of multivessel Doppler assessment to inform frequency of surveillance and timing of delivery of IUGR fetuses. These data will be critically important for planning any future intervention trials., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objective: The aim of this study was to profile longitudinal changes in thigh muscle and fat with gestation and to determine whether thigh measurements can improve the prediction of birth weight (BW)., Methods: A prospective longitudinal study of subcutaneous soft tissue measurements was conducted in 328 singleton fetuses at 28 and 37 weeks gestation. Estimated fetal weight (EFW) was calculated using abdominal circumference, femur length, biparietal diameter, and head circumference., Results: The fetal abdominal subcutaneous tissue (FAST) and thigh muscle and fat show an increase with gestation. At 28 weeks gestation, the abdominal circumference, thigh fat, FAST, and EFW percentile were found to be significant predictors of BW. A combination of EFW percentile and thigh fat were found to be the optimal multivariate model at 28 weeks for predicting BW. At 37 weeks, BW prediction using EFW percentile, FAST, and thigh fat was the most accurate. The results revealed acceptable reproducibility for fetal thigh muscle and fat., Conclusion: This study provides reference ranges for thigh fat and muscle at 28 and 37 weeks gestation. The inclusion of fetal thigh fat in the algorithm improves the predictive power for birth weight. This information is important to explore the role of fetal thigh in the detection of aberrant growth., (© 2013 John Wiley & Sons, Ltd.)

The aim of the study was to analyse gestational weight gain (GWG) according to body mass index (BMI) category and to explore the relationship between GWG and pregnancy complications. Women were recruited in the 1st trimester. Weight and height were measured and BMI calculated. Weight was measured at 38 weeks' gestation and GWG calculated. Clinical details were obtained prospectively. Of the 604 women recruited, 45.5% were primigravidas and 25.2% were obese. The overall mean GWG was 11.6 kg (SD 6.0). In obese women, the mean GWG was 10.4 kg (SD 7.5) compared with 12.6 kg (SD 5.7) in the normal BMI category (p < 0.001). Maternal obesity but not increased GWG was associated with an increased risk of induction of labour, caesarean section and pre-eclampsia. It was concluded that obese women were more likely to exceed GWG recommendations, despite lower GWG than non-obese women. Maternal obesity and not GWG increased the risk of pregnancy complications.

The objective of the study was to identify those women attending for antenatal care who would have benefited from prepregnancy rubella vaccination. It was a population-based observational study of women who delivered a baby weighing < or = 500 g in 2009 in the Republic of Ireland. The woman's age, parity, nationality and rubella immunity status were analysed using data collected by the National Perinatal Reporting System. Of the 74,810 women delivered, the rubella status was known in 96.7% (n = 72,333). Of these, 6.4% (n = 4,665) women were not immune. Rubella seronegativity was 8.0% (n = 2425) in primiparous women compared with 5.2% (n = 2239) in multiparous women (p < 0.001), 14.7% (n = 10653) in women < 25 years old compared with 5.0% (n = 3083) in women < or = 25 years old (p < 0.001), and 11.4% (n = 780) in women born outside the 27 European Union (EU27) countries compared with 5.9% (n = 3886) in women born inside the EU27 countries (p < 0.001). Based on our findings we recommend that to prevent Congenital Rubella Syndrome, the health services in Ireland should focus on women who are young, nulliparous and born outside the EU.

Objective: To examine the validity of a growth trajectory method to discriminate between pathologically and constitutionally undergrown fetuses using repeated measures of estimated fetal weight., Methods: In a prospective, observational, multicenter study in Ireland, 1,116 women with a growth-restricted fetus diagnosed participated with the objective of evaluating ultrasound findings as predictors of pediatric morbidity and mortality. Fetal growth trajectories were based on estimated fetal weight., Results: Between 22 weeks of gestation and term, two fetal growth trajectories were identified: normal (96.7%) and pathologic (3.3%). Compared with the normal trajectory, the pathologic trajectory was associated with an increased risk for preeclampsia (odds ratio [OR] 8.1, 95% confidence interval [CI] 2.6-23.4), increased umbilical artery resistance at 30 weeks of gestation (OR 12.6, 95% CI 4.6-34.1) or 34 weeks of gestation (OR 28.0, 95% CI 8.9-87.7), reduced middle cerebral artery resistance at 30 weeks of gestation (OR 0.33, 95% CI 0.12-0.96) or 34 weeks of gestation (OR 0.14, 95% CI 0.03-0.74), lower gestational age at delivery (mean 32.02 weeks of gestation compared with 38.02 weeks of gestation; P<.001), and higher perinatal complications (OR 21.5, 95% CI 10.5-44.2). In addition, 89.2% of newborns with pathologic fetal growth were admitted to neonatal intensive care units compared with 25.9% of those with normal growth., Conclusions: Fetal growth trajectory analysis reliably differentiated fetuses with a pathologic growth pattern among a group of women with growth-restricted fetuses. With further development, this approach could provide clarity to how we define, identify, and ultimately manage pathologic fetal growth., Level of Evidence: II.

This study examined variations in caesarean section (CS) rates associated with a woman's birthplace and differences in maternal adiposity. Women were enrolled in the 1st trimester. Maternal adiposity was assessed by body mass index (BMI) and bioelectrical impedance analysis (BIA). Irish women were compared with women born in the 14 countries who joined the European Union (EU) before 2004 (EU 14), and with those born in 12 countries who joined following enlargement (EU 12). Of the 2,811 women enrolled, 2,235 women were born in Ireland, 100 in EU 14 countries and 476 in EU 12 countries. Based on a BMI > 29.9 kg/m(2), maternal obesity was higher in Irish (19.8%; n = 443) and EU 14 women (19.0%; n = 19) compared with EU 12 women (9.5%; n = 45), p < 0.001. BIA of maternal body composition confirmed increased adiposity in both the Irish and EU 14 women. Variations in emergency CS rates in primigravidas based on the woman's birthplace were associated with maternal adiposity and induction of labour, both modifiable risk factors for CS. We recommend, therefore, that induction of labour in obese primigravidas should be undertaken only in carefully considered clinical circumstances. Our findings also suggest economic development in Europe may drive an increase in the CS rates mediated through increased levels of maternal obesity and, therefore, public health interventions should focus on optimising a woman's prepregnancy weight.

Objective: The objective of the Prospective Observational Trial to Optimize Pediatric Health in Intrauterine Growth Restriction (IUGR) (PORTO Study), a national prospective observational multicenter study, was to evaluate which sonographic findings were associated with perinatal morbidity and mortality in pregnancies affected by growth restriction, originally defined as estimated fetal weight (EFW) <10th centile., Study Design: Over 1100 consecutive ultrasound-dated singleton pregnancies with EFW <10th centile were recruited from January 2010 through June 2012. A range of IUGR definitions were used, including EFW or abdominal circumference <10th, <5th, or <3rd centiles, with or without oligohydramnios and with or without abnormal umbilical arterial Doppler (pulsatility index >95th centile, absent or reversed end-diastolic flow). Adverse perinatal outcome, defined as a composite outcome of intraventricular hemorrhage, periventricular leukomalacia, hypoxic ischemic encephalopathy, necrotizing enterocolitis, bronchopulmonary dysplasia, sepsis, and death was documented for all cases., Results: Of 1116 fetuses, 312 (28%) were admitted to neonatal intensive care unit and 58 (5.2%) were affected by adverse perinatal outcome including 8 mortalities (0.7%). The presence of abnormal umbilical Doppler was significantly associated with adverse outcome, irrespective of EFW or abdominal circumference measurement. The only sonographic weight-related definition consistently associated with adverse outcome was EFW <3rd centile (P = .0131); all mortalities had EFW <3rd centile. Presence of oligohydramnios was clinically important when combined with EFW <3rd centile (P = .0066)., Conclusion: Abnormal umbilical artery Doppler and EFW <3rd centile were strongly and most consistently associated with adverse perinatal outcome. Our data call into question the current definitions of IUGR used. Future studies may address whether using stricter IUGR cutoffs comparing various definitions and management strategies has implications on resource allocation and pregnancy outcome., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Detecting aberrant fetal growth has long been an important goal of modern obstetrics. Failure to diagnose abnormal fetal growth results in perinatal morbidity or mortality. However, the erroneous diagnosis of abnormal growth may lead to increased maternal anxiety and unnecessary obstetric interventions. We review the aetiology of deviant fetal growth and its implications both for the neonatal period and later in adult life. We examine maternal factors that may influence fetal growth such as obesity, glycaemic control and body composition. We discuss novel ways to improve our detection of abnormal fetal growth with a view to optimising antenatal care and clinical outcomes. These include using customised centiles or individualised growth assessment methods to improve accuracy. The role of fetal subcutaneous measurements as a surrogate marker of the nutritional status of the baby is also discussed. Finally, we investigate the role of Doppler measurements in identifying growth-restricted babies.

Objective: The purpose of this nested cohort study was to compare the rate of pre-pregnancy supplementation in obese women with that of women with a normal BMI., Methods: Pregnant women were enrolled at their convenience in a large university hospital. Weight and height were measured in the first trimester and BMI categorised., Results: Of the 288 women, 35.1% were in the normal, 29.5% in the overweight and 35.4% in the obese BMI categories. Only 45.1% (n = 46) of the obese women took pre-pregnancy folic acid compared with 60.4% (n = 61) of women with a normal BMI (p < 0.03). The lower incidence of folic acid supplementation in obese women was associated with an unplanned pregnancy in 36.3% of women compared with 22.8% in the normal BMI category (p < 0.04)., Conclusions: Obese women should take folate supplements whether they are planning to conceive or not.