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Antenatal Idiopathic Polyhydramnios: Then what?
Objective
To study the prevalence of neonatal complications among pregnancies complicated by polyhydramnios of unidentified prenatal cause and their outcome in an attempt to introduce more active antenatal/postnatal evaluation and aid the counseling.
Methods
A retrospective descriptive study to identify all the cases of idiopathic polyhydramnios for whom there was causes between 2002 and June 2014. All the cases of polyhydramnios during the study period were reviewed and only those with no obvious antenatal cause were included in the study. Only cases where polyhydramnios diagnosed using Deepest Vertical Pocket were included. The exclusion criteria are; diabetic pregnant patients fetus who were diagnosed antenataly with congenital/genetic anomalies Polyhydramnios diagnosed using Amniotic Fluid Index and those with incomplete data. We look for the rate of preterm delivery IUFD rate of cesarean section low APGAR score admission to NICU and neonatal complications. We also use this study as an audit to identify those cases for which a genetic/congenital anomaly identified; making a proper antenatal work up as a crucial step in dealing with such cases. The collected data were put into Excel sheet (Microsoft Office 2013) and professional statistical tools were used (provided by StatPages.org) P value of 0.05 was taken as the limit for statistical significance.
Results
Total of 66 case of idiopathic polyhydramnios identified in the period from 2002 to med-2014 which account for about 0.4 in 1000 (total number of deliveries during this period was around 180000 deliveries). There were 58 cases (87.9%) with mild polyhydramnios (defined as deepest pocket of 8 to 11 cm and 8 (12.1%) cases of moderate polyhydramnios (from 11.1 to 15 cm) the mean of amniotic fluid Deepest Pocket was 9.6 cm (SD 1.%). Maternal age was variable among the cases [range from 20 to 52 years (median of 30 years and mean of 30.2 years (SD 5.7)] and those above 35 years [8 cases (12%)] all of them are mild polyhydramnios so the degree of hydramnios does not direcetly correlate with advanced maternal age. 39 cases were diagnosed before 37 weeks (59.1%) of them 32 cases had mild Idiopathic Polyhydramnios ranging from 8–11 cm with no direct correlation of increasing Mild amniotic fluid DP and decreasing gestational age as the relation was variable. 5 patients who were diagnosed before 37 weeks were of Moderate Idiopathic Polyhydramnios although the number is small but it seems Moderate IP is more prone to be present at early GA however comparing both groups; there was no statistical significance [p value 0.17] Over all the rate of preterm delivery was 10.6% (7 cases) 4 cases among mild IP (6.7%) and 3 cases among moderate IP (37.5%). As in the graphs the GA at delivery decreases as the deepest pool increases and that most prominent in moderate IP less relevant in mild form. 22 cases had a cesarean sections (33%) which relatively high compared to the overall cesarean section rate of 25%. 8 of them where as an emergency setting; 4 were in Labour and taken for failed progress 2 for fetal distress and 2 were previous cesarean came in labor and requested repeated cesarean. The remaining 14 cesarean were due to placenta previa (2 cases) repeated cesarean sections (7 cases) big baby (3 cases) transverse lie (1 case) and previous 2 shoulder dystocia (1 case). The rate of emergency cesarean section among mild IP was 8.8% (5 cases) compared to 12.5% (1 case) in the Moderate IP group however there is no statistical significant difference between the 2 groups [p value of 0.73]. Overall rate of spontaneous labor noticed in 37 cases (56.1 %) Induction of Labour was significantly high (13 cases; 19.7%) mainly due to polyhydramnios (11 cases; 16.7%) only 2 cases due to High BP. Worth noticing that despite the high rate of Induction however the rate of cesarean among induced patient was low (only 2 case; 15.4%) comparable to those who came in spontaneous labour (4 cases out of 37 patients; 10.8%). There is no statistical significant difference between the 2 groups [p value of 0.66] The rate of operative delivery was 7.7% (5 cases). All of them among those who came into spontaneous labor. On the other hand the operative delivery was noticed in 4 cases (7%) of mild IP compared to 1 case in moderate IP (12.5%) but no statistical significant difference between the 2 groups [p value of 0.59]. Over all Mean birth weight was 3503.4 grams (SD 645.4). Among the Mild IP group the mean birth weight was 3185.7 grams (SD 898.9) compared to the Moderate IP group whch was 3185.7 grams (SD 898.9); there was no statistical significant difference between the 2 groups [p value of 0.36]; however the rate of big babies (>4000 grams) was high among Mild IP (15 cases; 25.9%) the mean birth weight in such subgroup was 4175 grams (SD 229.5) there were no big babies among the moderate IP. Low birth weight ( = < 2500 grams) found in 6 cases (10.4%) of Mild IP (mean of 2166.6 (SD 367)) and 1 case (12.5%) of Moderate IP (1300 grams) there was no statistical significant difference between the 2 groups [p value of 0.85]. Low APGAR score (0–3 in the 1st 5 minutes) was found in 1 case of Mild IP (1.7%) and 1 case of moderate IP (12.5%) with no statistical significant difference between the 2 groups [p value of 0.096]. overall low APGAR score was 3%. MICU admission was 22.7 % (15 cases). 2 cases ended in neonatal death (3%) the degree of polyhydramnios did not increase NND the as in each group there is one case.Conclusion; Idiopathic polyhydramnios is an important pregnancy complication. It warrant detailed antenatal assessment including ultrasound and repeated GTT. It also urges the postnatal examination of the baby for undiscovered pathology. We recommend taking care of such pregnancies in tertiary care center.
Early Amniocentesis: The Resurrection!
Introduction
The aim of prenatal diagnosis is to detect fetal structural and genetic abnormalities. Some changes can be registered on chromosome level (chromosome mutations) or at the level of DNA (genetic or genomic mutations) which in turn can produce somatic malformations. When amniocentesis for fetal karyotyping was first performed it was limited to gestations at or beyond 16 weeks because it was associated with higher failure rate in obtaining amniotic fluid at earlier gestation. A major disadvantage of second trimester amniocentesis is late diagnosis beyond 17 weeks' gestation when surgical termination of pregnancy becomes risky. Earlier options include chorionic villus sampling (CVS) and early amniocentesis. Early amniocentesis (9 to 14 weeks' gestation) was introduced in the late 1980s. It is technically the same as a ‘late’ procedure except that less amniotic fluid is removed which reported to result in laboratory failure varied between 0% and 20% however such observation decreased with advanced genetic technologies and experience of the practetioners.
Objectives
To study the feasibility and reproducibility of early amniocentesis (define as below 15 weeks) by studying the failure rate of the Amniocytes culture and the need to repeat the procedure. The aim is to fine an alternative way of invasive testing in case of difficult CVS and need for early diagnosis. Material and methods. It is a retrospective study. Diamniotic twins case were collected in the period from of September 2003 to October 2014 these cases were seen in the Feto-Maternal Unit which I specialized unit in the Obstetrics and Gynecology department started on 2003 and serving high risk pregnancies including fetal anomalies maternal diseases and prenatal intervention.. etc After obtaining permission for the Medical Research Center. The ultrasound data was collected form the ultrasound software (Astraia. Astraia Software GmbH Occamstr.20 80802 Munich Germany). Data were collected and kept in password protected Excel sheet (© 2010 Microsoft Corporation) and the analysis carried using online statistics tools (http://www.numberempire.com/statisticscalculator.php http://www.evanmiller.org/ab-testing/) P value below 0.05 was considered for statistical significance.
Results
Total of 1263 amniocentesis was done during the study period of them 50 cases was done before 15 weeks (encompass) 9 case excluded due to incomplete data. The mean gestational age at the procedure was 14 weeks and 2 day (SD of 4 days) median was 14 weeks and 3 days (Range of 2 weeks and 5 days). There were 11 cases (26.8%) under 14 weeks (between 12 weeks+1 day and 13 weeks+6 days. The indications of the prenatal testing was high nuchal translucency or cystic hygroma in 32% fetal anomaly in 27% previous baby with genetic disease (mainly trisomy 21 Thalasimia sickle cell disease …etc) in 19% Maternal age (more than 40 years) in 17 % and family history of genetic diseases in 5% (Mucolipidosis Hematological diseases) Placenta was anterior in 22 cases (53.6%) and posterior in 19 (46.4%) with no statistical deference (p value 0.51) however the approach was Transamniotic in 33 cases (80.5%) and Transplacental in 8 cases (19.6%). Among all the case only one case (2.4%) of Amniocytes culture failure was reported with need to repeat the test after 15 weeks she had a family history of thalassemia and the procedure was Transplacental with bloody stained fluid; processed in the genetic lab and the results were inconclusive. The rest was reproducible with 13 cases showed abnormal karyotype and managed accordingly. There were no reported cases of miscarriages after the procedure (excluding 10 cases “those who had an elective termination due to positive genetic diseases after ethical committee approval)
Conclusion
Early amniocentesis is a feasible and reproducible procedure with very minimal failure rate and in an experienced hand and with advanced genetic technology can substitute difficult CVS after proper counseling.
Maternal and neonatal outcomes associated with multiple repeat cesarean deliveries: A registry-based study from Qatar
Background: Cesarean delivery (CD) is associated with increased maternal and neonatal morbidity compared to vaginal delivery particularly in cases classified as emergency procedures or when there are multiple CDs. This retrospective cohort study aims to examine the incidence of maternal and neonatal complications in women with multiple CDs.Methods: This study used data from a national perinatal database obtained from a single tertiary maternity care hospital. Women who delivered a singleton live birth after 24 weeks of gestation by CD were stratified into five groups based on the number of CDs with the last group having five or more CDs. The women were divided into those with five or more CDs (Group 5) versus those with fewer than five (Groups 1 to 4). The maternal outcomes included intra-operative surgical complications blood loss and intensive care unit (ICU) admission. The neonatal outcomes included preterm birth neonatal ICU (NICU) admission respiratory distress syndrome (RDS) and perinatal death.Results: Of the 6316 women in the study 2608 (41.3%) had a primary CD. 30.3% 17.5% and 7.3% of the cohort had their second third and fourth CDs respectively. Women undergoing the 5th CD and above formed the remaining 3.5% (227). Women in Group 5 had the highest risk of suffering a surgical complication (3.1% p = 0.015) and postpartum hemorrhage (7.5% p = 0.010). 24% of babies in Group 5 were born preterm (p < 0.001). They also had a 3.5 times higher risk of having a surgical complication (RR = 3.5 95% CI 1.6-7.6 p = 0.002) a 1.8 times higher risk of developing postpartum hemorrhage (RR = 1.8 95% CI 1.1-2.9 p = 0.014) a 1.7 times higher risk of delivering between 32-37 weeks of gestation (RR = 1.7 95% CI 1.3-2.2 p < 0.001) a higher risk of the baby getting admitted to NICU (RR = 1.3 95% CI 1.0-1.6 p = 0.038) and developing RDS (RR = 1.5 95% CI 1.2-2.0 p = 0.002) compared to Groups 1-4. The risks of neonatal outcomes such as NICU admission (RR 2.9 95% CI 2.1-4.0) and RDS (RR 3.5 95% CI 2.3-5.5) were much higher in elective CDs performed at term compared to preterm births (p < 0.001 for both).Conclusion: Maternal morbidity significantly increases with the increasing number of CD. The increased risk of RDS and NICU admissions in the neonate with multiple CDs reflects lower gestational age and birthweight in these groups—consideration of preoperative steroids for lung maturation in these women to reduce neonatal morbidity warrants further discussion.
Impact of bariatric surgery on maternal gestational weight gain and pregnancy outcomes in women with obesity: A population-based cohort study from Qatar
Background: Bariatric surgery is performed in obese women of reproductive age to help achieve a healthy prepregnancy weight to reduce the complications associated with obesity in pregnancy. However these procedures can impact maternal nutrition and gestational weight gain (GWG). This study evaluates the maternal and neonatal outcomes in women with prepregnancy bariatric surgery and determines the impact on GWG. Methods: This study included 24 weeks gestation or more pregnancies with a maternal BMI at delivery of 30 kg/m2 or more. It was categorized into two groups based on whether they had prepregnancy bariatric surgery (exposed) or not (unexposed). The outcomes included gestational diabetes (GDM) gestational hypertension (GHT) mode of delivery preterm birth (PTB) GWG birthweight (BW) and customized BW centiles low birthweight (LBW) congenital anomalies and admission to the neonatal intensive unit (NICU). Categorization was also done based on the adequacy of GWG (low adequate and excess). Results: A total of 8323 women were included in the study 194 of whom had prepregnancy bariatric surgery. After adjusting for confounders the exposed group had a mean GWG 1.33 kg higher than the unexposed group (95% CI 0.55-2.13 p = 0.001). The exposed group had higher odds of PTB (aOR 1.78 95% CI 1.16-2.74 p = 0.008) CD (aOR 6.52 95% CI 4.28-9.93 p < 0.001) LBW in term babies (aOR 2.60 95% CI 1.34-5.03 p = 0.005) congenital anomalies (aOR 2.64 95% CI 1.21-5.77 p = 0.015) low APGAR score (aOR 3.75 95% CI 1.12-12.5 p = 0.032) and 80.4g lesser birthweight (95% CI -153.0 -5.8; p = 0.034). More women in the low GWG category had LBW babies (28.6% versus 6.7% in the high GWG group p = 0.033) lowest mean BW and median BW centiles (2775 grams versus 3289 grams in the high GWG group p = 0.004 and 57.5% versus 74.5% in the high GWG group p = 0.040 respectively). Conclusion: The findings of this study highlight differences in perinatal outcomes such as preterm birth low birth weight congenital anomalies cesarean deliveries and gestational weight gain between post-bariatric women and controls. These insights can help inform the planning and provision of appropriate maternity care to enhance patient safety and outcomes. The results of this study can also guide the counseling of reproductive age-group women who are planning to undergo bariatric surgery.