Challenges in High-Risk Pregnancy and Delivery

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Obstetrics & Gynecology".

Deadline for manuscript submissions: closed (11 January 2024) | Viewed by 32213

Special Issue Editors

Department of Obstetrics and Gynecology, Meir Medical Center, Kfar-Saba, Israel affiliated with Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
Interests: high-risk pregnancy; clinical studies; maternal–fetal medicine; perinatal outcome
1. Department of Obstetrics and Gynecology, Meir Medical Center, Kfar-Saba, Israel
2. Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
Interests: maternal–fetal medicine; high-risk pregnancy; placental pathology and obstetric issues
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Special Issue Information

Dear Colleagues,

High-risk pregnancy complicates about 6–8% of all pregnancies. It has been defined as a pregnancy in which the mother, foetus, or newborn are at risk for morbidity or mortality. In fact, there has been an increase in high-risk pregnancies in the last 20 years, which is mostly attributed to the increase in the average maternal age of those facing pregnancy.

Contributing factors for high-risk pregnancies can be divided into three main groups: a) Maternal pre-existing medical conditions such as advanced maternal age, obesity, chronic hypertension, diabetes, cardiovascular diseases, autoimmune or infectious diseases, and psychiatric disorders; b) foetal risk factors such as birth defects, genetic abnormalities, foetal growth restriction, and foetal anaemia; c) pregnancy-related complications such as preeclampsia, gestational diabetes, infections, cervical shortening and preterm birth, multiple pregnancy, and abnormal placentation. Pregnant women with comorbidities and complicated pregnancies may require lifestyle changes, medication, and hospitalisation. Multidisciplinary teams should work to guide these patients through the preconception, antepartum, delivery, and postpartum phases to ensure appropriate care for weeks to years after pregnancy.

This Special Issue will describe the clinical challenges and dilemmas of high-risk pregnancy and delivery, with the aim of increasing our understanding of how to prevent complications, as well as managing these pregnancies, in order to optimize early and late maternal and neonatal outcomes.

We sincerely welcome your submission to the Journal of Clinical Medicine.

Prof. Dr. Tal Biron-Shental
Prof. Dr. Michal Kovo
Guest Editors

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Keywords

  • pregnancy complications
  • preterm birth
  • hypertension
  • gestational diabetes
  • infectious diseases, placental-related complications
  • maternal morbidity
  • neonatal outcome

Published Papers (19 papers)

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10 pages, 864 KiB  
Article
The Association between Term Chorioamnionitis during Labor and Long-Term Infectious Morbidity of the Offspring
J. Clin. Med. 2024, 13(3), 814; https://doi.org/10.3390/jcm13030814 - 31 Jan 2024
Viewed by 441
Abstract
Background: Chorioamnionitis during labor exposes the fetus to an intrauterine state that may alter the future immune response and may expose the offspring to future susceptibility to infectious disease. We evaluated the long-term pediatric infectious morbidity of children born at term to [...] Read more.
Background: Chorioamnionitis during labor exposes the fetus to an intrauterine state that may alter the future immune response and may expose the offspring to future susceptibility to infectious disease. We evaluated the long-term pediatric infectious morbidity of children born at term to mothers who have chorioamnionitis during labor. Methods: This was a population-based cohort analysis including only term singleton deliveries at a regional tertiary hospital between the years 1991 and 2021. Offspring to mothers with and without a diagnosis of chorioamnionitis during labor were compared. Offspring hospitalizations up to the age of 18 years involving infectious morbidity were evaluated using the Kaplan–Meier survival curve and a Cox regression model to control possible confounders. Results: A total of 331,598 deliveries were included, 988 (0.3%) of which were of mothers diagnosed with chorioamnionitis during labor. All infectious morbidity rates included in the analysis were comparable between groups. The Kaplan–Meier survival curves were similar for both groups (log-rank = 0.881) and the multivariable analysis ascertained that chorioamnionitis during labor was not a risk factor for offspring’s long-term infectious morbidity (HR 0.929, 95%CI 0.818–1.054, p = 0.254). Conclusions: In our cohort, term chorioamnionitis during labor was not associated with a higher risk of pediatric hospitalization due to infections. The infectious/inflammatory state during labor did not expose nor increase the susceptibility of the term offspring to future infectious morbidity. Full article
(This article belongs to the Special Issue Challenges in High-Risk Pregnancy and Delivery)
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10 pages, 736 KiB  
Article
Red Blood Cell Transfusion after Postpartum Hemorrhage: Clinical Variables Associated with Lack of Postpartum Hemorrhage Etiology Identification
J. Clin. Med. 2023, 12(19), 6175; https://doi.org/10.3390/jcm12196175 - 24 Sep 2023
Viewed by 825
Abstract
Postpartum hemorrhage (PPH) remains a significant obstetric emergency worldwide and a leading cause of maternal death. However, it is commonly underreported, which can represent a major concern for maternal morbidity and mortality. This retrospective case series study analyzed patients with red blood cell [...] Read more.
Postpartum hemorrhage (PPH) remains a significant obstetric emergency worldwide and a leading cause of maternal death. However, it is commonly underreported, which can represent a major concern for maternal morbidity and mortality. This retrospective case series study analyzed patients with red blood cell transfusion (RBCt) in the postpartum period over a four-year interval at a specific center. A total of 18,674 patients delivered between January 2018 and December 2021. Patients with postpartum RBCt were classified into two groups: those with identified PPH (i-PPH) and those without (non-i-PPH). Clinical variables, delivery details, blood loss data, and treatment information were collected. Statistical analysis involved a comparison of variables between the i-PPH and non-i-PPH groups. Univariate and multivariate analyses were performed, aiming to identify significant associations between the clinical variables and a lack of PPH identification. The incidence of RBCt was 1.26% (236 cases). Patients receiving RBCt had higher rates of cesarean delivery, twin pregnancy, labor induction, and previous cesarean section. Among patients with postpartum RBCt, 34.3% lacked an identified PPH. The rarity of postpartum RBCt contrasts with the increasing rates of PPH, highlighting the importance of diagnosing PPH and postpartum anemia. A strategy of systematic quantification of blood loss during delivery could help detect PPH and anemia before adverse consequences occur. Full article
(This article belongs to the Special Issue Challenges in High-Risk Pregnancy and Delivery)
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10 pages, 1114 KiB  
Article
Outcomes of Laparoscopic Cesarean Scar Defect Repair: Retrospective and Observational Study
J. Clin. Med. 2023, 12(11), 3720; https://doi.org/10.3390/jcm12113720 - 28 May 2023
Cited by 1 | Viewed by 2585
Abstract
Cesarean scar defect, also known as niche, isthmocele, uteroperitoneal fistula and uterine diverticulum, is a known complication after cesarean delivery. Due to the rising cesarean delivery rates, niche has become more common and can present as irregular bleeding, pelvic pain, infertility, cesarean scar [...] Read more.
Cesarean scar defect, also known as niche, isthmocele, uteroperitoneal fistula and uterine diverticulum, is a known complication after cesarean delivery. Due to the rising cesarean delivery rates, niche has become more common and can present as irregular bleeding, pelvic pain, infertility, cesarean scar pregnancy and uterine rupture. Treatments for symptomatic cesarean scar defect vary and include hormonal therapy, hysteroscopic resection, vaginal or laparoscopic repair, and hysterectomy. We report on the safety and efficacy of our method of repairing cesarean scar defects in 27 patients without adverse outcomes: two-layer repair where the suture does not enter the uterine cavity. Our method of laparoscopic niche repair improves symptoms in nearly 77% of patients, restores fertility in 73% of patients, and decreases the time to conception. Full article
(This article belongs to the Special Issue Challenges in High-Risk Pregnancy and Delivery)
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10 pages, 425 KiB  
Article
Term Idiopathic Polyhydramnios, and Labor Complications
J. Clin. Med. 2023, 12(3), 981; https://doi.org/10.3390/jcm12030981 - 27 Jan 2023
Cited by 1 | Viewed by 2283
Abstract
Background and Aim: Polyhydramnios is associated with an increased risk of various adverse pregnancy outcomes, yet complications during labor have not been sufficiently studied. We assessed the labor and perinatal outcomes of idiopathic polyhydramnios during term labor. Methods: Retrospective cohort study [...] Read more.
Background and Aim: Polyhydramnios is associated with an increased risk of various adverse pregnancy outcomes, yet complications during labor have not been sufficiently studied. We assessed the labor and perinatal outcomes of idiopathic polyhydramnios during term labor. Methods: Retrospective cohort study at a tertiary medical center between 2010 and 2014. Women with idiopathic polyhydramnios defined as an amniotic fluid index (AFI) greater than 24 cm or a deep vertical pocket (DVP) > 8 cm (cases) were compared with women with a normal AFI (5–24 cm) (controls). Statistics: Descriptive, means ± SDs, medians + IQR. Comparisons: chi-square, Fisher’s exact test, Mann–Whitney Test, multivariate logistic models. Results: During the study period 11,065 women had ultrasound evaluation completed by a sonographer within two weeks of delivery. After excluding pregnancies complicated by diabetes (pre-gestational or gestational), fetal anomalies, IUFD, multifetal pregnancies, elective cesarean deliveries (CD) or missing data, we included 750 cases and 7000 controls. The degree of polyhydramnios was mild in 559 (75.0%) cases (AFI 24–30 cm or DVP 8–12 cm), moderate in 137 (18.0%) cases (30–35 cm or DVP 12–15 cm) and severe in 54 (7.0%) cases (AFI >35 cm or DVP > 15 cm). Idiopathic polyhydramnios was associated with a higher rate of CD 9.3% vs. 6.2%, p = 0.004; a higher rate of macrosomia 22.8% vs. 7.0%, p < 0.0001; and a higher rate of neonatal respiratory complications 2.0% vs. 0.8%, p = 0.0001. A multivariate regression analysis demonstrated an independent relation between polyhydramnios and higher rates of CD, aOR 1.62 (CI 1.20–2.19 p = 0.002) and composite adverse neonatal outcome aOR 1.28 (CI 1.01–1.63 p = 0.043). Severity of polyhydramnios was significantly associated with higher rates of macrosomia and CD (p for trend <0.01 in both). Conclusions: The term idiopathic polyhydramnios is independently associated with macrosomia, CD and neonatal complications. The severity of polyhydramnios is also associated with macrosomia and CD. Full article
(This article belongs to the Special Issue Challenges in High-Risk Pregnancy and Delivery)
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13 pages, 1645 KiB  
Article
The Predictive Role of Maternal Biological Markers and Inflammatory Scores NLR, PLR, MLR, SII, and SIRI for the Risk of Preterm Delivery
J. Clin. Med. 2022, 11(23), 6982; https://doi.org/10.3390/jcm11236982 - 26 Nov 2022
Cited by 8 | Viewed by 2200
Abstract
In many countries, preterm birth, defined as birth before 37 completed weeks of gestation, is the primary cause of infant death and morbidity. An increasing body of research suggests that inflammation (both clinical and subclinical) plays a significant role in inducing preterm labor [...] Read more.
In many countries, preterm birth, defined as birth before 37 completed weeks of gestation, is the primary cause of infant death and morbidity. An increasing body of research suggests that inflammation (both clinical and subclinical) plays a significant role in inducing preterm labor or developing pregnancy problems that lead to premature birth. Consequently, the purpose of this research was to determine the predictive value of the Neutrophil-Lymphocyte Ratio (NLR), derived Neutrophil-Lymphocyte Ratio (dNLR), Monocytes-to-Lymphocyte Ratio (MLR), Platelets-to-Lymphocyte Ratio (PLR), Systemic immune-inflammation index (SII), and systemic inflammatory response index (SIRI), for premature delivery. A retrospective study analyzed a total of 243 eligible pregnancies that resulted in a preterm birth during 2020 and 2021. A control group without a history of preterm birth was matched by age and trimester of laboratory analysis at a 1:1 ratio. Although the number of comorbidities was similar among study groups, the body-mass index estimated for the week of gestation was significantly higher among the patients from the prematurity group, as well as the prevalence of urinary tract infections and smoking. Laboratory data showed that patients with a preterm birth had significantly higher white blood cell count and monocytes, but significantly lower lymphocytes, platelets, and hemoglobin. The NLR, dNLR, PLR, and MLR scores showed to be significantly higher among patients from the prematurity group, but SII and SIRI were not significantly different between the study groups. It was observed that the AUC values of NLR, dNLR, PLR, and MLR were higher than 0.600, respectively NLR had the highest value among the tested scores (AUC = 0.694) and the highest sensitivity in this study (71%). The highest sensibility was achieved by dNLR, with 70%, and an AUC value of 0.655 (p-value = 0.022). PLR had the second-highest AUC value (0.682) and the best score in terms of sensitivity (70%) and sensibility (69%) (p-value = 0.015). Lastly, MLR had the lowest significant AUC score (0.607) and lowest sensitivity/sensibility. The significant cut-off values for the inflammatory scores were 9.0 for NLR, 9.8 for dNLR, 250 for PLR, and 4.07 for MLR. After evaluating the importance of these inflammatory scores, further clinical applications should be conducted to confirm the results and improve therapy and care to reduce the burden of premature deliveries. Full article
(This article belongs to the Special Issue Challenges in High-Risk Pregnancy and Delivery)
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12 pages, 1815 KiB  
Article
Factors Affecting Clinical over and Underestimation of Fetal Weight—A Retrospective Cohort
J. Clin. Med. 2022, 11(22), 6760; https://doi.org/10.3390/jcm11226760 - 15 Nov 2022
Cited by 2 | Viewed by 1148
Abstract
Clinical estimation of fetal weight is an integral component of obstetric care that might dictate the timing and mode of delivery. Inaccurate fetal weight estimation might result in unnecessary interventions or in underestimating potential risks, resulting in inappropriate intrapartum care. This retrospective study [...] Read more.
Clinical estimation of fetal weight is an integral component of obstetric care that might dictate the timing and mode of delivery. Inaccurate fetal weight estimation might result in unnecessary interventions or in underestimating potential risks, resulting in inappropriate intrapartum care. This retrospective study assessed factors associated with under- or overestimation of birthweight and evaluated the obstetric implications. It included singleton births ≥24 w with clinically estimated fetal weight (EFW) up to 1 week before delivery, during 2014–2020. Estimates >±10% of the actual birthweight were considered inaccurate and categorized as overestimation (>10% heavier than the actual birthweight) or underestimation (>10% smaller than the birthweight). Multivariable logistic regression was performed to reveal factors associated with inaccurate EFW. Maternal characteristics and obstetric outcomes were compared. The primary outcomes for the overestimation group were the neonatal composite adverse outcome, induction of labor and cesarean delivery rates. The primary outcomes for the underestimation group were rates of shoulder dystocia, 3rd- or 4th-degree perineal lacerations, and failed vacuum extraction. Among 38,615 EFW, 5172 (13.4%) were underestimated, 6695 (17.3%) were overestimated and 27,648 (69.3%) accurate. Multivariable logistic regression found increasing gestational age as an independent risk-factor for underestimation (odds ratio (OR) 1.15 for every additional week, 95% confidence interval (CI) 1.12–1.2). Major factors independently associated with overestimation were nulliparity (OR 1.95, CI 1.76–2.16), maternal obesity (OR 1.52, CI 1.33–1.74), smoking (OR 1.6, CI 1.33–1.93), and oligohydramnios (OR 1.92, CI 1.47–2.5). Underestimation was an independent risk-factor for shoulder dystocia (OR 1.61, CI 1.05–2.46) and 3rd- or 4th-degree perineal lacerations (OR 1.59, CI 1.05–2.43). Overestimation was an independent risk-factor for neonatal composite adverse outcome (OR 1.15, CI 1.02–1.3), induced labor (OR 1.30, CI 1.21–1.40) and cesarean delivery (OR 1.59, CI 1.41–1.79). Clinicians should be aware of factors and adverse obstetric implications associated with over- or underestimation of birthweight. Full article
(This article belongs to the Special Issue Challenges in High-Risk Pregnancy and Delivery)
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6 pages, 213 KiB  
Article
Are There Similarities in Pregnancy Complications and Delivery Outcomes among Sisters?
J. Clin. Med. 2022, 11(22), 6713; https://doi.org/10.3390/jcm11226713 - 13 Nov 2022
Viewed by 981
Abstract
This retrospective cohort study evaluated pregnancy outcomes and similarities between pairs of nulliparous sisters with a singleton fetus who delivered between 2013 and 2020. The “Sister-1 group” was defined as the sibling who delivered first, while the “Sister-2 group” included the siblings who [...] Read more.
This retrospective cohort study evaluated pregnancy outcomes and similarities between pairs of nulliparous sisters with a singleton fetus who delivered between 2013 and 2020. The “Sister-1 group” was defined as the sibling who delivered first, while the “Sister-2 group” included the siblings who gave birth after Sister-1. Obstetrical complications and delivery outcomes were compared. The relative risk for recurrence of a complication in Sister-2 was calculated. The study included 743 sister pairs. There were no between-group differences in maternal BMI, gestational age at delivery, gravidity, smoking, or epidural rates. The Sister-2 group was older than the Sister-1 group (26.4 ± 5 vs. 25.8 ± 4.7 years, respectively, p = 0.05). Higher birthweights and more large-for-gestational-age infants characterized the Sister-2 group compared with the Sister-1 group (3241 ± 485 g vs. 3148 ± 536 g, p < 0.001 and 7.7% vs. 4.8%, p = 0.025, respectively). There were no between-group differences in the rate of small-for-gestational-age, gestational diabetes, hypertensive disorders, pre-term births, vacuum extraction, or cesarean deliveries. Logistic regression analysis found that if Sister-1 underwent vacuum extraction, her sibling had an increased risk for vacuum delivery (adjusted RR 3.03, 95% CI 1.4–6.7; p = 0.003) compared with those whose sibling (Sister-1) did not. There was a three-fold risk of vacuum extraction delivery between sisters. This finding could be related to biological inheritance, environmental factors, and/or psychological issues that may affect similarities between siblings’ delivery outcomes. Full article
(This article belongs to the Special Issue Challenges in High-Risk Pregnancy and Delivery)
13 pages, 624 KiB  
Article
Pregnancies and Gynecological Follow-Up after Solid Organ Transplantation: Experience of a Decade
J. Clin. Med. 2022, 11(16), 4792; https://doi.org/10.3390/jcm11164792 - 16 Aug 2022
Cited by 1 | Viewed by 1283
Abstract
In recent years, solid organ transplantations, such as kidney or lung grafts, have been performed worldwide with an improvement of quality of life under immunosuppressive therapy and an increase in life expectancy, allowing young women to consider childbearing. In the current study, we [...] Read more.
In recent years, solid organ transplantations, such as kidney or lung grafts, have been performed worldwide with an improvement of quality of life under immunosuppressive therapy and an increase in life expectancy, allowing young women to consider childbearing. In the current study, we conduct a retrospective study in two French centers for kidney and lung transplantations to evaluate the rate and outcomes of pregnancies, contraception and gynecological monitoring for women under 40 years old who underwent solid organ transplantation. Among 210 women, progestin was the most widely used contraceptive method. Of the 210 women, 24 (11.4%) conceived 33 pregnancies of which 25 (75.8%) were planned with an immunosuppressant therapy switch. Of the 33 pregnancies, 7 miscarried (21.2%) and 21 (63.7%) resulted in a live birth with a high rate of pre-eclampsia (50%). No graft rejections were observed during pregnancies. Among the deliveries, 19 were premature (90.5%, mostly due to induced delivery) and the C-section rate was high (52.4%). No particular pathology was identified among newborns. We conclude that pregnancies following solid organ transplantation are feasible, and while they are at an increased risk of pre-eclampsia and prematurity, they should still be permitted with close surveillance by a multidisciplinary care team. Full article
(This article belongs to the Special Issue Challenges in High-Risk Pregnancy and Delivery)
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11 pages, 582 KiB  
Article
Factors Associated with Failed Trial of Labor after Cesarean, among Women with Twin Gestation—A Multicenter Retrospective Cohort Study
J. Clin. Med. 2022, 11(15), 4256; https://doi.org/10.3390/jcm11154256 - 22 Jul 2022
Cited by 3 | Viewed by 1605
Abstract
Objective: Twin trial of labor after a cesarean section (TOLAC) is associated with a lower success rate of vaginal delivery than singleton TOLAC, and a higher rate of adverse outcomes in comparison to an elective repeat cesarean delivery. This study aims to investigate [...] Read more.
Objective: Twin trial of labor after a cesarean section (TOLAC) is associated with a lower success rate of vaginal delivery than singleton TOLAC, and a higher rate of adverse outcomes in comparison to an elective repeat cesarean delivery. This study aims to investigate the factors associated with failed TOLAC, among women with twin gestation. Study design: A multicenter retrospective cohort study was undertaken. All women with twin pregnancies attempting a trial of labor after a previous cesarean in two university-affiliated obstetrical centers, between 2005 and 2021 were included. The study population included women with a twin gestation where twin A presented in the vertex position, a single previous low segment transverse section, and those who were eligible for a vaginal delivery. Labor, maternal, and neonatal characteristics were compared. A univariate analysis was undertaken, followed by multivariate analysis (aORs; [95% CI]). Results: A total of 160 women attempting a twin TOLAC were included. Vaginal birth after cesarean was achieved in 86.3% of these cases. Assisted reproductive technology (ART), the lack of oxytocin use for augmentation during labor, the lack of epidural analgesia, and preterm birth before 34, 32, and 28 gestational weeks were all found to be associated with failed TOLAC. In the multivariate analysis, cervical dilation on admission (aOR 0.6 [0.40–0.82], p < 0.01), no use of oxytocin (aOR 5.2 [1.36–19.73], p = 0.02), gestational age at delivery (aOR 0.8 [0.65–1.00], p = 0.047) and lack of epidural analgesia (aOR 4.5 [1.01–20.16], p = 0.049), were all found to be significantly associated with failed TOLAC. Conclusion: In the investigated population of women with twins undergoing TOLAC, the use of epidural analgesia, the use of oxytocin and increased cervical dilation to the delivery room are associated with a higher rate of vaginal delivery, and may reduce the risk of repeat cesarean delivery. Full article
(This article belongs to the Special Issue Challenges in High-Risk Pregnancy and Delivery)
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15 pages, 1941 KiB  
Article
Implications of Decreased Expression of miR-125a with Respect to Its Variant Allele in the Pathogenesis of Recurrent Pregnancy Loss: A Study in a High Incidence Zone
J. Clin. Med. 2022, 11(13), 3834; https://doi.org/10.3390/jcm11133834 - 01 Jul 2022
Cited by 2 | Viewed by 1318
Abstract
Pregnancy is controlled by several types of genes and the regulation of their expression is tightly controlled by miRNAs. The present study was carried out to explore the association between miR-125a polymorphic sequence variation and its expression and recurrent pregnancy loss (RPL) compared [...] Read more.
Pregnancy is controlled by several types of genes and the regulation of their expression is tightly controlled by miRNAs. The present study was carried out to explore the association between miR-125a polymorphic sequence variation and its expression and recurrent pregnancy loss (RPL) compared to full-term healthy controls. A total of 150 women that had experienced two or more RPLs and 180 healthy controls (two or more full-term pregnancies) were recruited, along with 50 product of conception (POC) samples from the corresponding RPL patients, and evaluated for miR-125a SNPs by the polymerase chain reaction-restriction fragment length polymorphism method (PCR-RFLP), which was confirmed by high resolution melting (HRM)/DNA sequencing. Additionally, the expression of miR-125a was quantified with q–PCR in the maternal plasma of 40 corresponding RPL patients against healthy controls. The frequency of variant genotype CC was significantly higher in RPL cases (19.3%) than controls (10.5%), with an odds ratio of >2 (p = 0.025). The expression levels of miR-125a were markedly decreased in RPL cases compared to healthy controls (p < 0.05). Variant genotype CC was found significantly more often in RPL cases than controls (0.34 vs. 0.20; p < 0.05).In this study, miR-125a rs12976445 C/T revealed that the homozygous CC genotype and C allele were associated with the risk of RPL and significant expression indicates that miR-125a has an important role in RPL etiopathogenesis. Full article
(This article belongs to the Special Issue Challenges in High-Risk Pregnancy and Delivery)
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12 pages, 3999 KiB  
Article
The Value of Fetal Head Station as a Delivery Mode Predictor in Primiparous Women at Term before the Onset of Labor
J. Clin. Med. 2022, 11(12), 3274; https://doi.org/10.3390/jcm11123274 - 08 Jun 2022
Cited by 1 | Viewed by 1548
Abstract
Objective: Our objective was to demonstrate the role of the clinical determination of fetal head station (FHS) at term to predict the delivery mode in primiparous women before the onset of labor. Methods: This prospective study included unselected primiparous women at term who [...] Read more.
Objective: Our objective was to demonstrate the role of the clinical determination of fetal head station (FHS) at term to predict the delivery mode in primiparous women before the onset of labor. Methods: This prospective study included unselected primiparous women at term who presented at our tertiary maternity. We excluded multiparous patients, pregnancies with a planned Cesarean section, non-cephalic presentations, and multiple pregnancies. The protocol included weekly clinical examinations to assess the FHS. The results were used to describe the clinical fetal head descent at term. We correlated the fetal head station determinations at each week with labor outcome, including the evaluations performed within the week before delivery. Results: The data show no significant differences between vaginal (VD) and Cesarean section delivery (CS) cases regarding FHS determined at each week at term. The median determinations at the gestational ages (GW) from 37 to 41 were −2 and −3, similar between the two groups, with a more consistent difference at 41 GW: station -1 for VD compared to −3 for CS. There were significant differences between the “week before delivery” evaluations of the two groups. The determinations showed for both groups similar minimum (−5), maximum (+1), and median (−2) FHS values. Most vaginal deliveries cases presented at weekly examinations with increasing rates toward more advanced stations: from 10% at station −4 to 35% at station −1. Although we investigated a low-risk group, we found significant differences between the vaginal and Cesarean groups in terms of age, weight, and BMI. We provided a multiple logistic regression equation that considered the predictive clinical variables at term: the fetal head situation, age, weight, height, and BMI. Conclusion: The clinical evaluation of fetal head station in primiparous before labor onset has a limited value regarding the prediction of the delivery mode. There is a potential benefit for the determinations performed within the week before delivery, but such a policy would require weekly assessments of the FHS at term, which is unlikely to be implemented. Another potential benefit would involve estimating labor outcomes in late-term or prolonged pregnancy. The fine tuning of the logistic prediction should be achieved by increasing the studied population and the number of centers involved before counseling primiparous women at term based on the clinical fetal engagement data. Full article
(This article belongs to the Special Issue Challenges in High-Risk Pregnancy and Delivery)
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13 pages, 2826 KiB  
Article
Parity-Adjusted Term Neonatal Growth Chart Modifies Neonatal Morbidity and Mortality Risk Stratification
J. Clin. Med. 2022, 11(11), 3097; https://doi.org/10.3390/jcm11113097 - 30 May 2022
Cited by 1 | Viewed by 1384
Abstract
Objective: To investigate the impact of parity-customized versus population-based birth weight charts on the identification of neonatal risk for adverse outcomes in small (SGA) or large for gestational age (LGA) infants compared to appropriate for gestational age (AGA) infants. Study design: Observational, retrospective, [...] Read more.
Objective: To investigate the impact of parity-customized versus population-based birth weight charts on the identification of neonatal risk for adverse outcomes in small (SGA) or large for gestational age (LGA) infants compared to appropriate for gestational age (AGA) infants. Study design: Observational, retrospective, cohort study based on electronic medical birth records at a single center between 2006 and 2017. Neonates were categorized by birth weight (BW) as SGA, LGA, or AGA, with the 10th and 90th centiles as boundaries for AGA in a standard population-based model adjusted for gestational age and gender only (POP) and a customized model adjusted for gestational age, gender, and parity (CUST). Neonates defined as SGA or LGA by one standard and not overlapping the other, are SGA/LGA CUST/POP ONLY. Analyses used a reference group of BW between the 25th and 75th centile for the population. Results: Overall 132,815 singleton, live, term neonates born to mothers with uncomplicated pregnancies were included. The customized model identified 53% more neonates as SGA-CUST ONLY who had significantly higher rates of morbidity and mortality compared to the reference group (OR = 1.33 95% CI [1.16–1.53]; p < 0.0001). Neonates defined as LGA by the customized model (LGA-CUST) and AGA by the population-based model LGA-CUST ONLY had a significantly higher risk for morbidity compared to the reference (OR = 1.36 95% CI [1.09–1.71]; p = 0.007) or the LGA POP group. Neonatal mortality only occurred in the SGA and AGA groups. Conclusions: The application of a parity-customized only birth weight chart in a population of singleton, term neonates is a simple platform to better identify birth weight related neonatal risk for morbidity and mortality. Full article
(This article belongs to the Special Issue Challenges in High-Risk Pregnancy and Delivery)
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9 pages, 584 KiB  
Article
Maternal and Neonatal Outcomes of Women Conceived Less Than 6 Months after First Trimester Dilation and Curettage
J. Clin. Med. 2022, 11(10), 2767; https://doi.org/10.3390/jcm11102767 - 13 May 2022
Viewed by 1962
Abstract
Objective: To evaluate the maternal and neonatal outcomes of pregnancies conceived ≤6 months after first trimester (<14 weeks) dilation and curettage (D&C). Methods: A retrospective computerized database study of women who conceived ≤6 months following a missed abortion and delivered in a single [...] Read more.
Objective: To evaluate the maternal and neonatal outcomes of pregnancies conceived ≤6 months after first trimester (<14 weeks) dilation and curettage (D&C). Methods: A retrospective computerized database study of women who conceived ≤6 months following a missed abortion and delivered in a single tertiary medical center between 2016 and 2021. The maternal and neonatal outcomes of women who had D&C were compared to those of women who had non-medical or spontaneous miscarriages. The primary outcome of this study was the rate of preterm birth (<37 weeks). Secondary outcomes were adverse maternal and neonatal outcomes. Univariate analysis was followed by multiple logistic regression models; adjusted odds ratios (aORs) and 95% confidence intervals (CIs) were calculated. Results: During the study period, 1773 women met the inclusion criteria; of those, 1087 (61.3%) women gave birth following D&C. We found no differences between the study groups in any maternal or neonatal parameter examined including preterm birth (PTB), miscarriage to pregnancy interval, fertility treatments, hypertension disorders of pregnancy, placental complications, mode of delivery and neonatal birth weights. This was confirmed on a multivariate analysis as well [aOR 1.74 (0.89–3.40), p = 0.11] for preterm birth. Conclusion: Watchful waiting or the medical treatment of a first trimester missed abortion present no more risks than D&C to pregnancies conceived within six months of the index miscarriage. Further studies in other settings to strengthen these findings are needed. Full article
(This article belongs to the Special Issue Challenges in High-Risk Pregnancy and Delivery)
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8 pages, 808 KiB  
Article
Vaginal Dinoprostone Insert versus Cervical Ripening Balloon for Term Induction of Labor in Obese Nulliparas—A Randomized Controlled Trial
J. Clin. Med. 2022, 11(8), 2138; https://doi.org/10.3390/jcm11082138 - 11 Apr 2022
Cited by 4 | Viewed by 1536
Abstract
Data regarding the preferred induction method in women with obesity is scarce. The current study was aimed at comparing pharmacological and mechanical induction in this population. This prospective randomized controlled trial was conducted between 2016–2020, in nulliparas with a pre-pregnancy body mass index [...] Read more.
Data regarding the preferred induction method in women with obesity is scarce. The current study was aimed at comparing pharmacological and mechanical induction in this population. This prospective randomized controlled trial was conducted between 2016–2020, in nulliparas with a pre-pregnancy body mass index >30. Inclusion criteria were singleton-term pregnancies, bishop score < 5, and indication for induction. Patients were randomized to induction by a cervical ripening balloon (CRB) or a 10 mg vaginal dinoprostone insert. The primary outcome was delivery rate within 24 h. Secondary outcomes included time to delivery, cesarean section rate, maternal and neonatal outcomes, satisfaction, and anxiety. The study population comprised of 83 women in the CRB group and 81 in the dinoprostone group. There was a significant difference in delivery rates within 24 h and time to delivery between the dinoprostone and CRB groups (45% vs. 71%, p = 0.017 and 49.3 ± 6.8 h vs. 23.5 ± 5.9 h, p = 0.003, respectively). There were no differences in cesarean delivery rates or maternal and neonatal outcomes, though CRB induction was associated with a significantly lower rate of tachysystole. Induction with CRB was accompanied by higher satisfaction and lower anxiety. In summary, CRB induction is associated with shorter time to delivery, higher satisfaction, and lower anxiety compared to PGE2 in women with obesity, without compromising maternal or neonatal outcomes. Full article
(This article belongs to the Special Issue Challenges in High-Risk Pregnancy and Delivery)
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11 pages, 361 KiB  
Article
Impact of Maternal Age on Singleton Pregnancy Outcomes in Primiparous Women in South Korea
J. Clin. Med. 2022, 11(4), 969; https://doi.org/10.3390/jcm11040969 - 12 Feb 2022
Cited by 3 | Viewed by 2515
Abstract
We aimed to determine the association between maternal age and pregnancy outcomes in singleton primigravidae in South Korea. We reviewed the medical data of singleton primigravidae women who gave birth between 2013 and 2018 and underwent the National Health Screening Examination using the [...] Read more.
We aimed to determine the association between maternal age and pregnancy outcomes in singleton primigravidae in South Korea. We reviewed the medical data of singleton primigravidae women who gave birth between 2013 and 2018 and underwent the National Health Screening Examination using the administrative database from the National Health Insurance claims data. As advanced maternal age is associated with various comorbidities that could affect pregnancy outcomes, we divided the patients according to their age and comparatively analyzed the prevalence of high-risk pregnancy complications including rates of cesarean delivery, after adjusting for maternal demographics. Perinatal and postpartum complications according to maternal age were also investigated. Overall, 548,080 women were included in this study: 441,902 were aged <35 years; 85,663, 35–39 years; 20,515, ≥40 years. Patients’ demographics differed according to their age. Increasing maternal age was significantly associated with higher income levels and higher rates of obesity, pre-existing diabetes, and hypertension. With the increasing maternal age, the rate of obstetric complications, including gestational diabetes, preeclampsia, placenta previa, placental abruption, and cesarean delivery, increased. Maternal age was also positively correlated with perinatal morbidity including preterm birth and low birth weight. Additionally, advanced maternal age was a risk factor for hospitalization before delivery, more frequent outpatient visits, and readmission after delivery. These observations were maintained in the multivariate analysis results. Advanced maternal age appears to be associated with various adverse obstetric outcomes for primigravidae women, and the frequency of hospitalizations was higher in this group. Considering the current social environment of late pregnancies and childbirth in South Korea, effective policy consideration is required to support safe childbirth in women with advanced maternal age. Full article
(This article belongs to the Special Issue Challenges in High-Risk Pregnancy and Delivery)
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Review

Jump to: Research, Other

26 pages, 715 KiB  
Review
Challenges of Pituitary Apoplexy in Pregnancy
J. Clin. Med. 2023, 12(10), 3416; https://doi.org/10.3390/jcm12103416 - 11 May 2023
Viewed by 1961
Abstract
Our purpose is to provide new insights concerning the challenges of pituitary apoplexy in pregnancy (PAP) and the postpartum period (PAPP). This is a narrative review of the English literature using a PubMed search. The inclusion criteria were clinically relevant original studies (January [...] Read more.
Our purpose is to provide new insights concerning the challenges of pituitary apoplexy in pregnancy (PAP) and the postpartum period (PAPP). This is a narrative review of the English literature using a PubMed search. The inclusion criteria were clinically relevant original studies (January 2012–December 2022). Overall, we included 35 original studies: 7 observational studies (selected cases on PA) and 28 case reports, including 4 case series (N = 49; PAP/PAPP = 43/6). The characteristics of PAP patients (N = 43) are as follows: maternal age between 21 and 41 (mean of 27.76) years; 21/43 subjects with a presentation during the third trimester (only one case during first trimester); average weak of gestation of 26.38; most females were prim gravidae; 19 (out of 30 patients with available data on delivery) underwent a cesarean section. Headache remains the main clinical feature and is potentially associated with a heterogeneous panel (including visual anomalies, nausea, vomiting, cranial nerve palsies, diabetes insipidus, photophobia, and neck stiffness). Pre-pregnancy medication included dopamine agonists (15/43) and terguride (1/43) in addition to subsequent insulin therapy for gestational diabetes (N = 2) and type 1 diabetes mellitus (N = 1). Overall, 29/43 females received the conservative approach, and 22/43 women had trans-sphenoidal surgery (TSS) (and 10/22 had the initial approach). Furthermore, 18/43 patients had a pituitary adenoma undiagnosed before pregnancy. Most PA-associated tumors were prolactinomas (N = 26/43), with the majority of them (N = 16/26) being larger than 1 cm. A maternal–fetal deadly outcome is reported in a single case. The characteristics of PAPP patients (N = 6) are as follows: mean age at diagnosis of 33 years; 3/6 subjects had PA during their second pregnancy; the timing of PA varied between 5 min and 12 days after delivery; headache was the main clinical element; 5/6 had no underlying pituitary adenoma; 5/6 patients were managed conservatively and 1/6 underwent TSS; pituitary function recovered (N = 3) or led to persistent hypopituitarism (N = 3). In conclusion, PAP represents a rare, life-threatening condition. Headache is the most frequent presentation, and its prompt distinction from other conditions associated with headache, such as preeclampsia and meningitis, is essential. The index of suspicion should be high, especially in patients with additional risk factors such as pre-gestation treatment with dopamine agonists, diabetes mellitus, anticoagulation therapy, or large pituitary tumors. The management is conservative in most cases, and it mainly includes corticosteroid substitution and dopamine agonists. The most frequent surgical indication is neuro-ophthalmological deterioration, although the actual risk of pituitary surgery during pregnancy remains unknown. PAPP is exceptionally reported. To our knowledge, this sample–case series study is the largest of its kind that is meant to increase the awareness to the benefit of the maternal–fetal outcomes from multidisciplinary insights. Full article
(This article belongs to the Special Issue Challenges in High-Risk Pregnancy and Delivery)
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Other

Jump to: Research, Review

12 pages, 2221 KiB  
Systematic Review
Aspirin at 75 to 81 mg Daily for the Prevention of Preterm Pre-Eclampsia: Systematic Review and Meta-Analysis
J. Clin. Med. 2024, 13(4), 1022; https://doi.org/10.3390/jcm13041022 - 10 Feb 2024
Viewed by 386
Abstract
Background: Aspirin at 150 mg daily, initiated in the 1st trimester of pregnancy, prevents preterm pre-eclampsia. We aimed to estimate whether a dose of 75 to 81 mg daily can help to prevent preterm pre-eclampsia as well. Methods: A systematic search [...] Read more.
Background: Aspirin at 150 mg daily, initiated in the 1st trimester of pregnancy, prevents preterm pre-eclampsia. We aimed to estimate whether a dose of 75 to 81 mg daily can help to prevent preterm pre-eclampsia as well. Methods: A systematic search was conducted using multiple databases and meta-analyses of randomized controlled trials (RCTs) that compared aspirin initiated in the first trimester of pregnancy to placebo or no treatment, following the PRISMA guidelines and the Cochrane risk of bias tool. Results: We retrieved 11 RCTs involving 13,981 participants. Five RCTs had a low risk of bias, one at unclear risk, and fiver had a high risk of bias. A pooled analysis demonstrated that doses of 75 to 81 mg of aspirin, compared to a placebo or no treatment, was not associated with a significant reduction in preterm pre-eclampsia (8 studies; 12,391 participants; relative risk, 0.66; 95% confidence interval: 0.27 to 1.62; p = 0.36), but there was a significant heterogeneity across the studies (I2 = 61%, p = 0.02). Conclusion: It cannot be concluded that taking 75 to 81 mg of aspirin daily reduces the risk of preterm pre-eclampsia. However, given the significant heterogeneity between the studies, the true effect that such a dose of aspirin would have on pregnancy outcomes could not be properly estimated. Full article
(This article belongs to the Special Issue Challenges in High-Risk Pregnancy and Delivery)
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9 pages, 607 KiB  
Systematic Review
Placental Chorangiocarcinoma a Specific Histological Pattern of Uncertain Incidence and Clinical Impact: Systematic Review of the Literature
J. Clin. Med. 2023, 12(9), 3065; https://doi.org/10.3390/jcm12093065 - 23 Apr 2023
Cited by 1 | Viewed by 1242
Abstract
Chorangiocarcinoma is a very rare and misdiagnosed placental neoplasm. The unique morphologic features of the lesion distinguish it from other trophoblastic tumors and vascular abnormalities. We present a systematic review of the literature to provide clarity on chorangiocarcinoma entity and biology. A literature [...] Read more.
Chorangiocarcinoma is a very rare and misdiagnosed placental neoplasm. The unique morphologic features of the lesion distinguish it from other trophoblastic tumors and vascular abnormalities. We present a systematic review of the literature to provide clarity on chorangiocarcinoma entity and biology. A literature search was carried out in December 2022 using the keywords “Placental chorangiocarcinoma”, “Chorangioma”, “Placenta”, and “Throphoblast proliferation”. Articles published from 1988 to 2022 were obtained from Scopus, Google Scholar, and PUBMED. In our review, we examined maternal age, gestational age at the time of delivery, parity, type of pregnancy, placental weight, ultrasound features of the placenta, macroscopic examination and tumor size, microscopic examination, immunostaining, maternal beta-human chorionic gonadotropin, fetal and maternal outcome. Eight manuscripts were detected. They are all case reports. The macroscopic characteristics of the lesions were represented by the presence of a grey-yellow-white color well-demarcated round nodule. Microscopically, all the authors described typical aspects of malignancy as a high rate of mitosis, nuclear atypia and necrotic areas. In some cases, the presence of AE1/AE3 cytoplasmic positivity, p63 nuclear staining, and beta-human chorionic gonadotropin (BHCG) were reported. A good fetal outcome was reported in all cases of newborns with normal birth weight, except one with fetal growth restriction. Maternal outcome was good in all cases except one with maternal lung metastasis three months after delivery. The clinical course has probably underestimated the real incidence of the pathology. Only greater knowledge of its histology and its clinical course will allow us to evaluate the real prevalence of the disease. Full article
(This article belongs to the Special Issue Challenges in High-Risk Pregnancy and Delivery)
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22 pages, 1469 KiB  
Systematic Review
The Association of Placental Abruption and Pediatric Neurological Outcome: A Systematic Review and Meta-Analysis
J. Clin. Med. 2023, 12(1), 205; https://doi.org/10.3390/jcm12010205 - 27 Dec 2022
Cited by 1 | Viewed by 3454
Abstract
Placental histopathology provides insights, or “snapshots”, into relevant antenatal factors that could elevate the risk of perinatal brain injury. We present a systematic review and meta-analysis comparing frequencies of adverse neurological outcomes in infants born to women with placental abruption versus without abruption. [...] Read more.
Placental histopathology provides insights, or “snapshots”, into relevant antenatal factors that could elevate the risk of perinatal brain injury. We present a systematic review and meta-analysis comparing frequencies of adverse neurological outcomes in infants born to women with placental abruption versus without abruption. Records were sourced from MEDLINE, Embase, and the CENTRAL Trials Registry from 1946 to December 2019. Studies followed the PRISMA guidelines and compared frequencies of neurodevelopmental morbidities in infants born to pregnant women with placental abruption (exposure) versus women without placental abruption (comparator). The primary endpoint was cerebral palsy. Periventricular and intraventricular (both severe and any grades of IVH) and any histopathological neuronal damage were the secondary endpoints. Study methodologic quality was assessed by the Ottawa–Newcastle scale. Estimated odds ratios (OR) and hazards ratio (HR) were derived according to study design. Data were meta-analyzed using a random effects model expressed as pooled effect sizes and 95% confidence intervals. We included eight observational studies in the review, including 1245 infants born to women with placental abruption. Results of the random effects meta-analysis show that the odds of infants born to pregnant women with placental abruption who experience cerebral palsy is higher than in infants born to pregnant women without placental abruption (OR 5.71 95% CI (1.17, 27.91); I2 = 84.0%). There is no statistical difference in the odds of infants born to pregnant women with placental abruption who experience severe IVH (grade 3+) (OR 1.20 95% CI (0.46, 3.11); I2 = 35.8%) and any grade of IVH (OR 1.20 95% CI (0.62, 2.32); I2 = 32.3%) vs. women without placental abruption. There is no statistically significant difference in the odds of infants born to pregnant women with placental abruption who experience PVL vs. pregnant women without placental abruption (OR 6.51 95% CI (0.94, 45.16); I2 = 0.0%). Despite our meta-analysis suggesting increased odds of cerebral palsy in infants born to pregnant women with placental abruption versus without abruption, this finding should be interpreted cautiously, given high heterogeneity and overall poor quality of the included studies. Full article
(This article belongs to the Special Issue Challenges in High-Risk Pregnancy and Delivery)
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