A protocol for a systematic review of clinical practice guidelines for the antenatal management of dichorionic diamniotic twin pregnancy

Overview: The protocol outlines the process designed to systematically review clinical practice guidelines (CPGs), addressing the antenatal management of dichorionic diamniotic (DCDA) twin pregnancies. Background: CPGs are statements that include recommendations intended to optimise patient care, that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options. CPGs are typically created by scientific institutes, organisations and professional societies, and high-quality CPGs are fundamental to improve patient outcomes, standardise clinical practice and improve the quality of care. While CPGs are designed to improve the quality of care, to achieve this, the identification and appraisal of current international CPGs is required. Because twin pregnancies are identified as high-risk pregnancies, a systematic review of the CPGs in this field is a useful first step for establishing the required high level of care. Aim: The aim of the systematic review is to identify, appraise and examine published CPGs for the antenatal management of DCDA twin pregnancies, within high-income countries. Methods: We will identify published CPGs addressing any aspect of antenatal management of care in DCDA twin pregnancies, appraise the quality of the identified CPGs using the Appraisal of Guidelines for Research and Evaluation version 2 (AGREE II) the Appraisal of Guidelines Research and Evaluation – Recommendations excellence (AGREE-REX) instruments and examining the recommendations from the identified CPGs. Ultimately, this protocol aspires to clearly define the process for a reproducible systematic review of CPGs within a high-income country, addressing any aspect of antenatal management of DCDA twin pregnancies. PROSPERO registration: CRD42021248586 (24/06/2021)

Antenatal management and maternal/fetal outcomes associated with hyperglycaemia in pregnancy (HIP) in Uganda; a prospective cohort study

Background Hyperglycaemia in pregnancy (HIP) is associated with complications for both mother and baby. The prevalence of the condition is likely to increase across Africa as the continent undergoes a rapid demographic transition. However, little is known about the management and pregnancy outcomes associated with HIP in the region, particularly less severe forms of hyperglycaemia. It is therefore important to generate local data so that resources may be distributed effectively. The aim of this study was to describe the antenatal management and maternal/fetal outcomes associated with HIP in Ugandan women. Methods A prospective cohort study of 2917 pregnant women in five major hospitals in urban/semi-urban central Uganda. Women were screened with oral glucose tolerance test (OGTT) at 24–28 weeks of gestation. Cases of gestational diabetes (GDM) and diabetes in pregnancy (DIP) were identified (WHO 2013 diagnostic criteria) and received standard care. Data was collected on maternal demographics, anthropometrics, antenatal management, umbilical cord c-peptide levels, and pregnancy outcomes. Results Two hundred and seventy-six women were diagnosed with HIP (237 classified as GDM and 39 DIP). Women had between one and four fasting capillary blood glucose checks during third trimester. All received lifestyle advice, one quarter (69/276) received metformin therapy, and one woman received insulin. HIP was associated with large birthweight (unadjusted relative risk 1.30, 95% CI 1.00–1.68), Caesarean delivery (RR 1.34, 95% CI 1.14–1.57) and neonatal hypoglycaemia (RR 4.37, 95% CI 1.36–14.1), but not perinatal mortality or preterm birth. Pregnancy outcomes were generally worse for women with DIP compared with GDM. Conclusion HIP is associated with significant adverse pregnancy outcomes in this population, particularly overt diabetes in pregnancy. However pregnancy outcomes in women with milder forms of hyperglycaemia are similar to those with normoglycaemic pregnancies. Intervention strategies are required to improve current monitoring and management practice, and more research needed to understand if this is a cost-effective way of preventing poor perinatal outcomes.

A Prospective Study of Association of Micronutrients Deficiencies during Pregnancy and Neonatal Outcome among Women after Bariatric Surgery

Little is known about the association of micronutrients deficiencies during pregnancy and neonatal outcome among women after Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). We present a prospective study of 87 consecutive women with a history of RYGB (n = 37) or SG (n = 50) who underwent complete and regular clinical and biological nutritional assessments during pregnancy. Data on maternal characteristics, biological nutritional parameters, antenatal management, and perinatal outcome were collected. The objective was to evaluate serum levels of micronutrients at the second trimester, and to assess the association between micronutrients deficiencies and neonatal outcome. After RYGB, maternal age (34.3 ± 4.9 vs. 31.1 ± 4.6 years; p = 0.003) and pregnancy timing after surgery (64.5 ± 47.0 vs. 38.1 ± 28.1 months; p = 0.002) were significantly higher, and pre-pregnancy BMI was significantly lower (29.8 ± 5.6 vs. 32.9 ± 7.1 kg/m2; p = 0.03). Maternal and neonatal outcomes were similar. Additional supplementations after blood tests were similar in groups. Zinc, selenium, vitamins A1, B1, B6, C, and E levels were not different depending on the type of surgery. Zinc deficiency (7/87) was significantly more frequent after RYGP (18.9% vs. 0%; p = 0.02) and selenium deficiency (15/87) was similar in groups (21.6% after RYGB and 14.0% after SG; p = 0.36). The mean birth weight was significantly lower in selenium deficiency cases (3137 ± 550 vs. 3535 ± 737 g; p = 0.04). Selenium deficiency was negatively correlated with birth weight (r = −0.23; p = 0.03) and with birth weight z-score (r = −0.26; p = 0.01), but not correlated after adjustment for the procedure. The levels of micronutrients surveillance along pregnancy in women with a history of bariatric surgery is necessary to decrease the risk of inadequate fetal growth in the patients.

Antenatal Management of Bronchopulmonary Sequestration by Intrafetal Vascular Laser Ablation under Ultrasound Control: Narrative Review of the Literature and Report of Three Cases

<b><i>Objective:</i></b> The objective of this study is to assess the effectiveness and safety of intrafetal vascular laser ablation (VLA) for fetuses with bronchopulmonary sequestration (BPS) with hydrops. <b><i>Methods:</i></b> First, we present 3 cases of fetuses with BPS and hydrops treated by VLA. Second, we aimed to conduct a narrative review to identify all reported cases of fetuses with BPS treated by intrafetal VLA. <b><i>Results:</i></b> The review of the literature identified 41 fetuses treated by VLA for BPS with hydrops. The median gestational age of the VLA was 27⁺⁰ weeks’ gestation [25⁺⁰–31⁺⁰] with an associated procedure at the same time in 43% of the cases (pleuroamniotic shunt, thoracentesis, and amniodrainage). A second procedure was required in 25% of cases for residual flow in the feeding vessel. No stillbirth or neonatal death was reported. The complications reported were a fetal thoracic hematoma complicated by fetal anemia and 4 preterm deliveries with a rate of 9%. <b><i>Conclusion:</i></b> VLA of the feeding vessel can be an effective treatment but is not without complications. In cases demonstrating cardiac output failure, intrafetal VLA should be considered as a treatment for BPS.

Nonimmune hydrops fetalis management from the perspective of fetal cardiologists: A single tertiary center experience from Egypt

BACKGROUND: Despite advances in managing nonimmune hydrops fetalis (NIHF), perinatal mortality is still significant. Fetal cardiac failure eventually occurs regardless of etiology. However, no previous study has addressed NIHF from fetal cardiologists’ perspective. Therefore, we evaluated etiology and management of a NIHF cohort requiring fetal cardiologist consultation in a developing country. METHODS: A single-center retrospective cohort study of 70 cases with NIHF that were referred to a fetal cardiology unit over four years was performed. Demographics, etiologic diagnosis, and outcomes of the cases were assessed. Antenatal management was evaluated using cardiovascular profile score (CVPS). RESULTS: The most frequent diagnosis was Idiopathic hydrops 42(62.6%), followed by hydrops due to cardiac diseases 19(28.4%), and 3 dead fetuses were detected at the first fetal echocardiography. Treatment of fetal tachyarrhythmia (n = 7) had 100% success rate in terms of antenatal hydrops resolution. Digoxin was used in cases of structural heart diseases, twin- twin transfusion syndrome, and dilated cardiomyopathy with perinatal mortality occurring in all cases (n = 9). In cases of idiopathic hydrops, 14 fetuses received digoxin with intrauterine hydrops resolution in 2/14 (14%) while non-treated cases had intrauterine or early neonatal death. CONCLUSION: Nonimmune hydrops is the worst complication of diverse etiologies. Limitations in resources for advanced investigations in developing countries increase the possibility of categorizing NIHF as idiopathic. Tachyarrhythmia induced hydrops can be entirely reversed with antenatal therapy while non-tachyarrhythmia fetal cardiac disease outcomes are unfavorable regardless of therapy. On the other hand, idiopathic hydrops shows a limited potential response to digoxin in utero.

Adverse Pregnancy Outcomes by Degree of Maternal Serum Analyte Elevation: A Retrospective Cohort Study

Objective The aim of this study was to evaluate rates of preterm birth (PTB) and obstetric complication with maternal serum analytes > 2.5 multiples of the median (MoM) by degree of elevation. Study Design Retrospective cohort study of singleton live-births participating in the California Prenatal Screening Program (2005–2011) examining PTB and obstetric complication for α-fetoprotein (AFP), human chorionic gonadotropin (hCG), unconjugated estriol (uE3), and inhibin A (INH) by analyte subgroup (2.5 to < 6.0, 6.0 to < 10.0, and ≥ 10.0 MoM vs. < 2.5 MoM). Results The risk of obstetric complication increased with increasing hCG, AFP, and INH MoM, and were greatest for AFP and INH of 6.0 to <10.0 MoM. The greatest risk of any adverse outcome was seen for hCG MoM ≥ 10.0, with relative risk (RR) of PTB < 34 weeks of 40.8 (95% confidence interval [CI]: 21.7–77.0) and 13.8 (95% CI: 8.2–23.1) for obstetric complication. Conclusions In euploid, structurally normal fetuses, all analyte elevations > 2.5 MoM confer an increased risk of PTB and, except for uE3, obstetric complication, and risks for each are not uniformly linear. These data can help guide patient counseling and antenatal management.