Prediction of small-for-gestational-age neonates at 35-37 weeks' gestation: contribution of maternal factors and growth velocity between 20 and 36 weeks

Objective: To evaluate the performance of ultrasonographic estimated fetal weight (EFW) at 35+0 - 36+6 weeks’ gestation in the prediction of small for gestational age (SGA) neonates and assess the additive value of first, maternal risk factors and second, fetal growth velocity between 20 and 36 weeks’ gestation in improving such prediction. Methods: This was a prospective study of 44,043 singleton pregnancies that had undergone routine ultrasound examination at 19+0 - 23+6 and at 35+0 - 36+6 weeks’ gestation. Multivariable logistic regression analysis was used to determine whether addition of maternal risk factors and growth velocity, defined by a difference in EFW Z-scores or fetal abdominal circumference (AC) Z-scores between the third and second trimester scans divided by the time interval between them, improved the performance of EFW at 35+0 - 36+6 weeks in the prediction of delivery of SGA neonates with birthweight <10th and <3rd percentiles within two weeks and at any stage after assessment. Results: Screening by EFW at 35+0 - 36+6 weeks’ gestation <10th percentile predicted 63.4% (95% CI 62.0, 64.7) of neonates with birthweight <10th percentile and 74.2% (95% CI 72.2, 76.1) of neonates with birthweight <3rd percentile born at any stage after assessment, at screen positive rate of 10%. The respective values for SGA neonates born within two weeks of assessment were 76.8% (95% CI 74.4, 79.0) and 81.3% (95% CI 78.2, 84.0). In the group of fetuses with EFW <10th percentile, 43.7% were born with birthweight ≥10th percentile. For a desired 90% detection rate of SGA neonates delivering at any stage after assessment the necessary screen positive rate would be 33.7% for SGA <10th percentile and 24.4% for SGA <3rd percentile. Multivariable logistic regression analysis demonstrated that in the prediction of SGA neonates with birthweight <10th and <3rd percentiles there was a significant contribution from EFW Z-score at 35+0 - 36+6 weeks’ gestation, maternal risk factors and AC growth velocity, but not EFW growth velocity. However, the area under the receiver operating characteristic curves for SGA neonates in screening by maternal risk factors and EFW Z-score was not improved by addition of AC growth velocity. Conclusion: Screening for SGA neonates by EFW at 35+0 - 36+6 weeks’ gestation and use of a cut-off of the 10th percentile predicts 63% of affected neonates. Prediction of 90% of SGA neonates necessitates classification of about 35% of the population as being screen positive use of the 35th percentile cut-off in EFW. The predictive performance of EFW is not improved by addition of estimated growth velocity between the second and third trimesters of pregnancy

Value of routine ultrasound examination at 35–37 weeks' gestation in diagnosis of non‐cephalic presentation

Background: Undiagnosed non-cephalic presentation in labor carries increased risks for both the mother and baby. Routine pregnancy care based on maternal abdominal palpation fails to detect the majority of non-cephalic presentations. Objective: To report the incidence of non-cephalic presentation at a routine scan at 35+0 - 36+6 weeks’ gestation and subsequent management of such pregnancies. Methods: This was a retrospective analysis of prospectively collected data in 45,847 singleton pregnancies that had undergone routine ultrasound examination at 35+0 - 36+6 weeks’ gestation. Patients with breech or transverse / oblique presentation were divided into two groups, first those that would have elective cesarean section for fetal or maternal indications other than the abnormal presentation, and second, those that would potentially require ECV. The latter group was reassessed in 1-2 weeks and if there was persistence of the abnormal presentation the parents were offered the options of ECV versus elective cesarean section at 38-40 weeks’ gestation. Multivariable logistic regression analysis was carried out to determine which of the factors from maternal and pregnancy characteristics provided a significant contribution in the prediction of first, non-cephalic presentation at the 35+0 - 36+6 weeks scan, second, successful ECV from non-cephalic to cephalic presentation, and third, spontaneous rotation from non-cephalic to cephalic presentation. Results: First, at 35+0 - 36+6 weeks the fetal presentation was cephalic in 43,416 (94.7%) pregnancies, breech in 1,987 (4.3%) and transverse or oblique in 444 (1.0%). Second, multivariable analysis demonstrated that the chance of non-cephalic presentation increased with increasing maternal age and weight, decreasing height, earlier gestational age at scan, and it was higher in the presence of placenta previa, oligohydramnios and polyhydramnios, in nulliparous than parous women and lower in women of South Asian and mixed racial origin than in White women. Third, 22% of cases of non-cephalic presentation were not eligible for ECV because of planned cesarean section for indications other than the malpresentation. Fourth, of those eligible for ECV only 48.5% (646/1,332) accepted the procedure and this was successful in 39.0% (252/646) of cases. Fifth, the chance of successful ECV increased with increasing maternal age and was lower in nulliparous than parous women. Sixth, in 33.9% (738/2,179) of pregnancies with non-cephalic presentation where successful ECV was not carried out there was a subsequent spontaneous rotation to cephalic presentation. Seventh, the chance of spontaneous rotation from non-cephalic to cephalic presentation increased with increasing interval between the scan and delivery and decreased with increasing birth weight, it was higher in women of Black than White racial origin, if the presentation was transverse or oblique than breech and if there was polyhydramnios and lower in nulliparous than parous women and in the presence of placenta previa. Eighth, in 109 (0.3%) of cephalic presentations there was subsequent rotation to non-cephalic presentation and in 41% of these the diagnosis was made during labor. Ninth, in the total of 2,431 cases of non-cephalic presentation at the time of the scan the presentation at birth was cephalic in 985 (40.5%); in 738 (74.9%) this was due to spontaneous rotation and in 247 (25.1%) due to successful ECV. Tenth, prediction of non-cephalic presentation at the 35+0 - 36+6 weeks scan and successful ECV from maternal and pregnancy factors was poor, but prediction of spontaneous rotation from non-cephalic to cephalic presentation was moderately good and this could be incorporated in the counselling of women prior to undertaking ECV. Conclusions: The problem of unexpected non-cephalic presentation in labor can to a great extent be overcome by a routine ultrasound examination at 35+0 - 36+6 weeks’ gestation. The incidence of non-cephalic presentation at the 35+0 - 36+6 weeks scan was about 5%, but, in about 40% of these cases the presentation at birth was cephalic, mainly due to subsequent spontaneous rotation and to a lesser extent as a consequence of successful ECV

Polycystic ovary syndrome

The document attached has been archived with permission from the editor of the Medical Journal of Australia. An external link to the publisher’s copy is included.Polycystic ovary syndrome (PCOS) affects 5-20% of women of reproductive age worldwide. The condition is characterized by hyperandrogenism, ovulatory dysfunction and polycystic ovarian morphology (PCOM) - with excessive androgen production by the ovaries being a key feature of PCOS. Metabolic dysfunction characterized by insulin resistance and compensatory hyperinsulinaemia is evident in the vast majority of affected individuals. PCOS increases the risk for type 2 diabetes mellitus, gestational diabetes and other pregnancy-related complications, venous thromboembolism, cerebrovascular and cardiovascular events and endometrial cancer. PCOS is a diagnosis of exclusion, based primarily on the presence of hyperandrogenism, ovulatory dysfunction and PCOM. Treatment should be tailored to the complaints and needs of the patient and involves targeting metabolic abnormalities through lifestyle changes, medication and potentially surgery for the prevention and management of excess weight, androgen suppression and/or blockade, endometrial protection, reproductive therapy and the detection and treatment of psychological features. This Primer summarizes the current state of knowledge regarding the epidemiology, mechanisms and pathophysiology, diagnosis, screening and prevention, management and future investigational directions of the disorder.Robert J Norman, Ruijin Wu and Marcin T Stankiewic

Using MedLan to integrate geographical data

AbstractIn this paper we focus on the application of the declarative mediator language MedLan to the integration of geographical information systems and deductive databases. The language provides the ability to handle multiple logic theories via the notion of program expressions. We present an application example that deals with finding the best habitat for wild boars in a region of Tuscany

Iter diagnostico e terapeutico delle amenorree

L’amenorrea è la mancanza di ciclo mestruale; bisogna tener presente, tuttavia, che esistono periodi della vita della donna nei quali tale mancanza è fisiologica, ovvero prima della pubertà, dopo la menopausa, durante la gravidanza e, per un periodo più o meno lungo, durante l’allattamento. Al di fuori di questi casi, l’amenorrea è dovuta a situazioni patologiche che causano un’alterazione delle condizioni generali, oppure a malattie dell’apparato genitale, o ancora l’amenorrea può essere causata anche da gravi traumi psichici. La persistenza di un flusso mestruale regolare richiede la presenza di un asse endocrino ipotalamo-ipofisi-ovaio integro, di una regolare responsività recettoriale dell’endometrio uterino ai segnali ormonali e una regolarità del tratto di deflusso ematico. La completa assenza o la cessazione della mestruazione, definita appunto amenorrea, richiede un’attenta valutazione e gestione. Un’accurata valutazione anamnestica e un attento esame clinico sono essenziali per agevolare la diagnosi e quindi scegliere il trattamento più indicato.La gestione terapeutica ha come target il ripristino dei cicli ovulatori e la prevenzione delle conseguenze a breve e lungo termine provocate dallo squilibrio ormonale

Recenti acquisizioni su distocia di spalla e paralisi perinatale del plesso brachiale

La distocia di spalla (DS) rappresenta una grave complicanza del parto, possibile causa di gravi lesioni per la madre ed il neonato, ma si ritiene non prevedibile, né prevenibile, motivo per cui è indispensabile una tempestiva e corretta assistenza ostetrica. È una patologia rara, la cui frequenza (in media 1,5% delle nascite) varia in relazione a numerosi fattori correlati alla definizione di DS e dipendenti sia dalla gravida che dal feto. Non vi è concordia in letteratura sulla definizione e sulla valutazione della severità della DS. La paralisi del plesso brachiale è una paralisi flaccida del braccio presente alla nascita i cui segni clinici sono correlati alla sede (superiore, media e inferiore) ed alla severità della lesione (totale e parziale). La maggior parte dei neonati guarisce entro il primo mese di vita, ma nel 25-30% vi è lesione permanente con disabilità e può essere impossibile predire quale neonato manifesterà la paralisi brachiale persistente. La valutazione della lesione neurologica è pluridisciplinare e se la guarigione non si manifesta entro il mese di vita è necessario inviare il neonato ai Centri di riferimento. Dal punto di vista della condotta ostetrica è indispensabile l’adeguato management della DS, una volta manifestatasi. L’ostetrico dovrebbe essere allertato dal rilievo di fattori di rischio pre- ed intrapartum per DS e dalle anomalie del travaglio, che tuttavia non sono presenti nel 50% dei casi. Questo concorre a determinare la DS come non prevedibile. Numerosi studi evidenziano che paralisi del plesso brachiale sono descritte dopo un parto normale (senza eccessiva trazione sulla testa fetale) per l’esistenza di fattori intrauterini materni e fetali tali da determinare in utero la paralisi del plesso brachiale o rappresentare un fattore predisponente alla lesione neurologica nonostante un parto con normale assistenza ostetrica. Anche l’osservazione che un numero non trascurabile di lesioni del plesso brachiale è descritto dopo taglio cesareo (anche elettivo) supporta questa ipotesi. Dal punto di vista del management ostetrico la rarità della DS fa sì che siano pochi coloro che nella realtà abbiano un’esperienza significativa, sebbene alcuni studi indichino che gli esiti non si correlino all’esperienza dell’operatore. Vi è comunque condivisione, nel caso di potenziale DS o qualora manifestatisi, che venga messo in atto da parte degli operatori più anziani una sequenza sistematica e condivisa di manovre ostetriche per la risoluzione della stessa. Le linee guida della varie Società Scientifiche non sempre sono concordi sulle raccomandazioni. È comunque indispensabile annotare dettagliatamente nella cartella clinica manovre, sequenza e tempi delle stesse. L’utilizzo delle check-list si potrebbe dimostrare utile. Poiché numerosi dati indicano con chiarezza che non sempre la lesione del plesso brachiale è conseguente a DS e la paralisi del plesso brachiale è descritta dopo taglio cesareo (anche elettivo), il termine di paralisi ostetrica del plesso brachiale del neonato dovrebbe essere abbandonato poiché non rispondente alle conoscenze attuali, ha implicita una connotazione negativa sull’assistenza al parto e impedisce una corretta e proficua collaborazione tra medici e coppia