BMC Pregnancy and Childbirth

BackgroundMaternal stress during pregnancy has been associated with adverse pregnancy and birth outcomes. Aiming to reduce maternal stress and to improve pregnancy and birth outcomes, different relaxation interventions have been tested during pregnancy. This systematic review and meta-analysis was conducted on studies that have tested relaxation interventions to improve maternal wellbeing, and pregnancy and birth outcomes in various settings. MethodA systematic search of PubMed, EMBASE Classic + EMBASE (Ovid), MEDLINE In-Process and Non-Indexed Citations, MEDLINE Daily, and MEDLINE (Ovid), Cumulative Index to Nursing & Allied Health Plus (CINAHL via EBSCO) and Cochrane library databases was conducted to identify studies on stress reduction relaxation interventions in pregnant women. The outcomes of interest were maternal mental health (stress, anxiety, and depression), pregnancy outcomes (gestational age, labor duration and mode of delivery) and birth outcomes (birth weight, APGAR score and term or preterm delivery). Randomized controlled trials or quasi-experimental studies with stress reduction relaxation interventions during pregnancy and ever published in English globally were eligible for inclusion. Studies with interventions in high-risk pregnancies, those including psychotropic medications, or interventions at the onset of labor and delivery were excluded. All studies were screened for quality and risk of bias. We conducted meta-analyses, using random-effects models, for three outcomes for which there was sufficient information: maternal depressive symptoms, perceived maternal stress; and birth weight. ResultNineteen studies were eligible for analysis. The studies sampled 2395 pregnant women, mostly aged between 18 and 39 years. The interventions applied were yoga therapy, music therapy, progressive muscular relaxation (PMR)/guided imagery/deep breathing exercises, mindfulness or hypnosis. The meta-analyses showed that the interventions were effective in improving maternal depressive symptoms (-2.5 points, [95% confidence interval (CI) -3.6, -1.3]) and stress symptoms (-4.1 points, [95% CI -8.1, -0.1]) during pregnancy. There was no effect of the interventions overall on birth weight (45 g, 95% CI -56, 146); however, PMR in two studies increased birth weight (181 g, 95% CI 25, 338) whereas music therapy and yoga had no benefit. Narrative syntheses of outcomes that were not amenable to meta-analysis indicated beneficial effects of music interventions on APGAR score (n=4 studies) and gestational age at birth (n=2 studies). Interventions were also reported to significantly increase spontaneous mode of delivery (n=3 studies) and decrease the rate of instrumental virginal delivery by 5%, caesarean section by 20% and duration of labor (n=2 study). DiscussionAdverse life experience during pregnancy impairs the normal adaptive changes supposed to maintain normal homeostasis during pregnancy and results in increased risk of stress, anxiety and depression. This imbalance results in increased stress hormone in the maternal-fetal circulation which is harmful to the mother and her fetus leading for adverse pregnancy and birth outcomes. Stress reduction relaxation intervention restores the normal homeostasis in pregnancy and improves normal biological and psychological wellbeing and consequently improves pregnancy and birth outcomes. ConclusionIn addition to benefits for mothers, relaxation interventions hold some promise for improving newborn outcomes; therefore, this approach strongly merits further research.

IntroductionSupine sleep position is associated with stillbirth, likely secondary to inferior vena cava compression, and a reduction in cardiac output (CO) and uteroplacental perfusion. Evidence for the effects of prone position in pregnancy is less clear. This study aimed to determine the effect maternal prone position on maternal haemodynamics and fetal heart rate, compared with left lateral position. MethodsTwenty-one women >28 weeks gestation underwent non-invasive CO monitoring (Cheetah) every 5 minutes and continuous fetal heart rate monitoring (MONICA) in left lateral (20 minutes), prone (30 minutes), followed by left lateral (20 minutes). Anxiety and comfort were assessed by questionnaires. Regression analyses (adjusted for time) compared variables between positions. The information derived from the primary study was used in an existing mathematical model of maternal circulation in pregnancy, to determine whether occlusion of the inferior vena cava could account for the observed effects. In addition, a scoping review was performed to identify reported clinical, haemodynamic and fetal effects of maternal prone position; studies were included if they reported clinical outcomes or effects or maternal prone position in pregnancy. Study records were grouped by publication type for ease of data synthesis and critical analysis. Meta-analysis was performed where there were sufficient studies. ResultsMaternal blood pressure (BP) and total vascular resistance (TVR) were increased in prone (sBP 109 vs 104 mmHg, p=0.03; dBP 74 vs 67 mmHg, p=0.003; TVR 1302 vs 1075 dyne.s-1cm-5, p=0.03). CO was reduced in prone 5.7 vs 7.1 mL/minute, p=0.003). Fetal heart rate, variability and decelerations were unaltered. However, fetal accelerations were less common in prone position (86% vs 95%, p=0.03). Anxiety was reduced after the procedure, compared to beforehand (p=0.002), despite a marginal decline in comfort (p=0.04).The model predicted that if occlusion of the inferior vena cava occurred, the sBP, dBP and CO would generally decrease. However, the TVR remained relatively consistent, which implies that the MAP and CO decrease at a similar rate when occlusion occurs. The scoping review found that maternal and fetal outcomes from 47 included case reports of prone positioning during pregnancy were generally favourable. Meta-analysis of three prospective studies investigating maternal haemodynamic effects of prone position found an increase in sBP and maternal heart rate, but no effect on respiratory rate, oxygen saturation or baseline fetal heart rate (though there was significant heterogeneity between studies). ConclusionProne position was associated with a reduction in CO but an uncertain effect on fetal wellbeing. The decline in CO may be due to caval compression, as supported by the computational model. Further work is needed to optimise the safety of prone positioning in pregnancy.

BackgroundContinuous labour support is widely acknowledged for potentially enhancing maternal and neonatal outcomes and smoothing the labour process. However, existing literature lacks a comprehensive analysis of the optimal characteristics of labour companions, particularly in comparing the effects of trained versus untrained and familiar versus unfamiliar labour companions across diverse geographical regions and pre and post-millennial. This meta-analysis addresses these research gaps by providing insights into the most influential aspects of continuous labour support. MethodologyA thorough search of PubMed, Google Scholar, Science Direct, International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, Research4Life, and Cochrane Library was conducted. Study selection utilised the semi-automated tool Rayyan. The Cochrane risk-of-bias (RoB2) tool and funnel plots gauged the risk of bias. Statistical analysis employed RevMan 5.4, using Mantel-Haenszel statistics and random effects models to calculate risk ratios with 95% confidence intervals. Subgroup analyses were performed for different characteristics, including familiarity, training, temporal associations, and geographical locations. The study was registered in INPLASY. (Registration number: INPLASY202410003) ResultsThirty-five randomised controlled trials (RCTs) were identified from 5,346 studies. The meta-analysis highlighted significant positive effects of continuous labour support across various outcomes. There was a substantial improvement in the 5-minute APGAR score < 7, with an effect size of 1.52 (95% CI 1.05, 2.20). Familiar labour companions showed a higher effect size in reducing tocophobia, 1.73 (95% CI 1.49, 2.42), compared to unfamiliar companions, 1.34 (95% CI 1.14, 1.58). Differences were noted between trained and untrained companions, favouring untrained companions in reducing tocophobia and the cesarean section rate. Studies conducted after 2000 had a more significant impact on decreasing labour duration. Geographical variations indicated more pronounced effects in Asia and Africa than in Europe. Discussion and ConclusionThe meta-analysis underscores the benefits of labour companionship, particularly in facilitating the parturient experience of spontaneous labour. The impact is more pronounced in specific subgroups, such as familiar companions, untrained companions, recent studies, and studies conducted in Asia and Africa. The study recommends integrating labour companionship into obstetric care pending further research, standardisation, and awareness initiatives to enhance maternal and neonatal outcomes. Challenges such as study heterogeneity, insufficient data on companion training, and temporal outcome variations are acknowledged.

BackgroundNausea and vomiting in pregnancy (NVP) affects 50-80% of pregnant women and is correlated to the level of human chorionic gonadotropin (hCG). Hyperemesis gravidarum (HG) is a severe condition, with an incidence of 0.2-1.5%, characterized by consistent nausea, vomiting, weight loss and dehydration continuing after the second trimester. AimThe aim of this systematic review was to investigate a potential correlation between NVP or HG with adverse pregnancy outcomes and hCG levels. MethodA systematic search in PubMed, Embase and CINAHL Complete was conducted. Studies on pregnant women with nausea in the first or second trimester, reporting either pregnancy outcomes or levels of hCG were included. The primary outcomes were preterm delivery (PTD), preeclampsia, miscarriage, and fetal growth restriction. Risk of bias was assessed using ROBINS-I. The overall certainty of evidence was assessed using GRADE. ResultsThe search resulted in 2023 potentially relevant studies; 23 were included. The evidence was uncertain for all outcomes, however women with HG had a tendency to have an increased risk for preeclampsia [odds ratio (OR) 1.18, 95% confidence of interval (CI) 1.03 to 1.35], PTD [OR 1.35, 95% CI 1.13 to 1.61], small for gestational age (SGA) [OR 1.24, 95% CI 1.13 to 1.35], and low birth weight (LBW) [OR 1.35, 95% CI 1.26 to 1.44]. Further, a higher foetal female/male ratio was observed [OR 1.36, 95% CI 1.15 to 1.60]. Meta-analyses were not performed for women with NVP; however, most of these studies indicated that women with NVP have a lower risk for PTD and LBW and a higher risk for SGA, and a higher fetal female/male ratio. ConclusionThere may be an increased risk in women with HG and a decreased risk in women with NVP for adverse placenta-associated pregnancy outcomes, however the evidence is very uncertain. PROSPERO: CRD42021281218

Post-spinal anesthesia hypotension during cesarean delivery poses significant risks to maternal cardiac output and fetal oxygenation. Although phenylephrine (PE) is the standard vasopressor, its use is linked to an increased incidence of maternal bradycardia. In contrast, norepinephrine (NE) offers a more favorable hemodynamic profile and is emerging as a promising alternative. This systematic review and meta-analysis of 18 randomized controlled trials compared NE and PE for the prevention and treatment of post-spinal hypotension in cesarean section parturients. Our findings demonstrate that while NE and PE are equally effective in managing hypotension, NE significantly reduces the incidence of maternal bradycardia (OR = 0.49 [CI: 0.38 to 0.62]) and shows a trend toward fewer adverse maternal events, such as dizziness and reactive hypertension. Additionally, neonatal outcomes indicated a lower birth weight with NE--although still within the normal range--along with tendencies toward lower umbilical arterial lactate levels and improved umbilical vein blood gas pH. These results support NE as a viable alternative to PE, particularly for lowering the incidence of maternal bradycardia, and provide crucial evidence for updating clinical practice guidelines to enhance maternal and neonatal care during cesarean deliveries. Systematic review registration ID: CRD42024593459https://www.crd.york.ac.uk/PROSPERO/view/CRD42024593459

IntroductionAntepartum fetal heart rate (FHR) patterns are routinely assessed to evaluate fetal wellbeing. Despite their clinical use, the relationship between specific FHR patterns and adverse pregnancy outcomes (APOs) remains unclear. This study aims to investigate the association between antepartum FHR patterns and APOs to improve fetal risk assessment. MethodsIn this retrospective case-control study, we extracted raw antepartum FHR traces from singleton pregnancies between 27+0 and 41+6 weeks gestation recorded at Oxford University Hospitals from January 1991 to February 2024. Adverse outcomes included acidaemia, stillbirth, asphyxia, extended neonatal care unit (NCU) admission, hypoxic-ischaemic encephalopathy (HIE), low Apgar scores and neonatal resuscitation at delivery. After applying inclusion and exclusion criteria, 938 FHR traces with APOs were matched using propensity score matching with 938 traces from normal pregnancy outcomes (NPOs), controlling for gestational age, fetal sex, maternal BMI, maternal age, parity, and trace duration. FHR patterns were extracted using a validated automated algorithm and analysed statistically. ResultsThe APO cohort showed significantly higher basal heart rates (BHR), fewer accelerations, more decelerations, lower short-term variability (STV), and spent a greater proportion of the trace in periods of low variation compared to the NPO cohort (p < 0.001). Logistic regression identified prolonged periods of low variation (odds ratio [OR] = 1.92, 95% CI 1.60-2.30, p < 0.001), increased decelerations (OR = 1.40, 95% CI 1.22-1.60, p < 0.001), reduced accelerations (OR = 0.66, 95% CI 0.55-0.78, p < 0.001), elevated BHR (OR = 0.70, 95% CI 0.61-0.80, p < 0.001), and decreased STV (OR = 0.72, 95% CI 0.57-0.91, p = 0.006) as significant predictors of APOs. ConclusionsSpecific antepartum FHR patterns are significantly associated with adverse pregnancy outcomes. Detailed analysis of these patterns can enhance fetal risk assessment and inform clinical decision-making. Adoption of standardised interpretation criteria for antepartum FHR monitoring may improve perinatal outcomes.

ObjectiveThe aim of this systematic review was to examine the maternal and fetal outcomes in pregnant women with COVID-19 and also assess the incidence of maternal-fetal transmission of SARS CO-V-2 infection. Data sourcesWe searched PUMBED. Medline, Embase, MedRxiv and bioRxiv databases upto 3rd May 2020 utilizing combinations of word variants for "coronavirus" or "COVID-19" or "severe acute respiratory syndrome" or "SARS-COV-2" and "pregnancy". We also included data from preprint articles. Study eligibility criteriaOriginal case reports and case series on pregnant women with diagnosis of SARS-CoV-2 infection. Study appraisal and synthesis methodsWe included 50 studies reporting the information on 441 pregnant women and 391 neonates. The primary outcome measures were maternal health characteristics and adverse pregnancy outcomes, neonatal outcomes and SARS-CoV-2 infection in neonates was extracted. Treatments given to pregnant women with COVID-19 were also recorded. ResultsOut of 441 women affected by COVID-19 in pregnancy, 387 women have delivered. There are nine maternal deaths reported. In pregnant women with COVID-19, the most common symptoms were fever (56%), cough (43%), myalgia (19%), dyspnea (18%) and diarrhea (6%). Pneumonia was diagnosed by CT scan imaging in 96 % of COVID-19 pregnant women. Pregnancy complications included delivery by cesarean section (80%), preterm labor (26%), fetal distress (8%) and premature rupture of membranes (9%). Six still births (2%) are reported. The most common co-morbidities associated with pregnant women with COVID-19 were hypertensive disorders (10%), diabetes (9%), placental disorders (2%), co-infections (3%), scarred uterus (3%) and hypothyroidism (3%). Amongst the neonates of COVID-19 mothers, preterm birth (25%), respiratory distress syndrome (8%), pneumonia (8%) were reported. There were four neonatal deaths reported. Vertical transmission rate of SARS-CoV-2 is estimated to be 8%. ConclusionIn pregnant women with COVID-19, hypertensive disorders and diabetes are common comorbidities and there is a risk of preterm delivery and maternal death. Amongst the neonates born to mothers with COVID-19, respiratory distress syndrome and pneumonia are common occurrence. There are reports of still births and neonatal deaths. There is an evidence of vertical transmission of SARS-CoV-2 infection in women with COVID-19.

IntroductionMaternal fetal movement monitoring during pregnancy is commonly advised to assess fetal wellbeing. However, qualitative research exploring how women perceive and implement such advice is lacking, particularly in regions with the highest burden of stillbirth. This study investigates womens experiences and opinions on fetal movement monitoring during pregnancy across high- and low-stillbirth settings. MethodsWomen from three countries with low-stillbirth rates and five with high rates of stillbirth were surveyed and interviewed regarding their experiences with fetal movement monitoring advice. Open-ended answers from the surveys and interview were analysed using inductive thematic methods, while categorical answers were examined using non-parametric statistical analysis. Results234 women were included in the study. The nature and extent of fetal movement monitoring advice varied considerably by country, encompassing active monitoring methods such as kick counting, pattern awareness and movement presence detection, as well as guidance on responding to fetal movements concerns. Notably, 33% (37/112) of women in high-stillbirth countries and 8% (10/122) in low-stillbirth countries reported a lack of any fetal movement monitoring advice. Globally, half of women rated the advice easy to follow, while one-third experienced difficulty understanding their healthcare providers guidance. Key facilitators of following advice included having an active baby and a clear understanding and confidence in the received advice, whereas barriers included a lack of clarity and understanding, difficulty perceiving movements, competing time demands and challenges in identifying patterns of movements. Maternal anxiety was prevalent, with 78% of participants reporting at least occasional anxiety about fetal movements during pregnancy. ConclusionWide variation in the type and consistency of fetal movement monitoring advice across countries indicates the need for further research into the comparative effectiveness of current recommendations, particularly in high-stillbirth settings. High rates of maternal anxiety worldwide highlight the importance of providing support to women navigating fetal movement monitoring.

BackgroundResearch suggests that besides somatic factors, psychological and social factors are associated with pregnancy outcomes. The objective of this study was to determine the independent effects of psychosocial risk factors on maternal blood pressure, gestational age at birth, birthweight and Apgar score. MethodsIn a prospective cohort study, Dutch women in the first half of pregnancy were recruited at a regional hospital, a university hospital and ten midwife practices. At inclusion, participants (before 20 weeks of gestation) filled in questionnaires on social and psychological factors. Obstetric data were extracted from patient records. Associations between risk factors and pregnancy outcomes were analysed with multivariable linear and logistic regression. Results598 Women were included in the study. 14 Women did not return questionnaires and 12 women stopped study participation before delivery. In multivariable regression analysis, primiparity, Odds Ratio [OR] = 3.4 (1.5, 7.5), obstetric and somatic history, OR = 3.5 (1.5, 7.9), and diastolic blood pressure at intake, OR = 1.1 (1.0, 1.1), were independently associated with preterm delivery. Smoking status, OR = 5.5 (2.3, 13), was independently associated with a newborn small for gestational age, and primiparity, OR = 6.9 (1.1, 45), with a low Apgar score. Diastolic blood pressure at intake, OR = 1.1 (1.07, 1.14), hypertension at intake, OR = 3.6 (1.1, 11), and negative affect, OR = 1.1 (1.02, 1.14), were independently associated with gestational hypertension. Negative affect was the only psychosocial risk factor independently associated with pregnancy outcome. ConclusionAlthough psychosocial factors are important in obstetric care, measurement of these factors in early pregnancy seems to have limited independent predictive value for adverse pregnancy outcome when medical and/or obstetric history and commonly applied physical measurements are already considered.

IntroductionQuickening, the first sensation of fetal movements, is an important milestone for pregnant women. Information on the expected gestational age at quickening may reduce anxiety and prevent delayed detection of intrauterine demise but the available data are from the 1980s before the emergence of modern ultrasound techniques. Materials and methodsProspective observational study on nulliparous women blinded for placental location in two hospitals in Denmark. The pregnant women were enrolled at the time of nuchal translucency scan, placental location was determined at time of second trimester scanning.. The women were blinded to placenta location before time of quickening. Time of quickening were reported by 122 women, 65 with an anterior and 57 with a posterior placenta. Thirteen women had a BMI >30 (10.7%). ResultsThe mean gestational age for quickening was 19 + 0 weeks for nulliparous women. The timing depended on placental site; women with an anterior placenta experienced quickening 6.4 days later than the women with a posterior placenta. BMI > 30 was associated with a later time of quickening. ConclusionsAnterior placental location is associated with delay in experience of fetal movements of 6.4 days and this may further be delayed in women with a BMI>30.

BackgroundChildbirth at advanced maternal age (AMA) is increasing among women, and some studies have shown adverse outcomes. There is a need to map evidence on the subject to harness findings and identify research gaps for further studies. This scoping review aims to examine pertinent studies on AMA and its impact on pregnancy outcomes. MethodsThe Preferred Reporting Item for Systematic Review and Meta-Analysis (PRISMA) chart is employed for systematic data extraction. This review draws from Google Scholar, the Cochrane Library, Medline (via PubMed), and Embase (via OVID). For inclusion in this scoping review, articles must thoroughly examine and elucidate the effects, impacts, and relationships between advanced maternal age and pregnancy outcomes. A crucial prerequisite is that the articles undergo a peer-review process to ensure the reliability and credibility of the presented information. For this review, advanced maternal age is defined explicitly as women aged [&ge;]35. However, studies focusing on women aged [&ge;]40 are also considered, mainly if they are high quality. In terms of research methodology, both primary and secondary research will be eligible, encompassing systematic reviews and meta-analyses. This broad inclusion aims to capture a comprehensive overview of the existing literature on the subject. Furthermore, articles must be presented in the English language to facilitate a standardized and accessible analysis. This criterion ensures that language barriers do not impede the reviews ability to synthesize relevant information effectively. ResultsThere are significant associations between advanced maternal age and poor pregnancy outcomes, even when adjusted for confounders. ConclusionsThe adverse pregnancy outcome due to maternal age alone may be due to placental dysfunction resulting from a relative deficiency in maternal cardiovascular adaptations to pregnancy, and this provides a window for further studies.

BackgroundGDM is associated with adverse maternal and fetal complications. By the time GDM is diagnosed, continuous exposure to the hyperglycaemic intrauterine environment can adversely affect the fetus. Hence, early pregnancy prediction of GDM is important. AimTo systematically evaluate whether composite risk score prediction models can accurately predict GDM in early pregnancy. MethodSystematic review of observational studies involving pregnant women of <20 weeks of gestation was carried out. The search involved various databases, grey literature, and reference lists till August 2022. The primary outcome was the predictive performance of the models in terms of the AUC, for <14 weeks and 14-20 weeks of gestation. ResultsSixty-seven articles for <14 weeks and 22 for 14-20 weeks of gestation were included (initial search - 4542). The sample size ranged from 42 to 1,160,933. The studies were from Canada, USA, UK, Europe, Israel, Iran, China, Taiwan, South Korea, South Africa, Australia, Singapore, and Thailand. For <14 weeks, the AUC ranges were 0.59-0.88 and 0.53-0.95, respectively for models that used only maternal characteristics and for those that included biomarkers. For 14-20 weeks these AUCs were 0.68-0.71 and 0.65-0.92. Age, ethnicity, BMI, family history of diabetes, and prior GDM were the 5 most commonly used risk factors. The addition of systolic BP improved performance in some models. Triglycerides, PAPP-A, and lipocalin- 2, combined with maternal characteristics, have the highest predictive performance. AUC varied according to the population studied. Pooled analyses were not done due to high heterogeneity. ConclusionAccurate GDM risk prediction may be possible if common risk factors are combined with biomarkers. However, more research is needed in populations of high GDM risk. Artificial Intelligence-based risk prediction models that incorporate fetal biometry data may improve accuracy.

ObjectiveStudies on psychosocial interventions for perinatal mental health and wellbeing are mostly limited to the postpartum period. However, the physiological changes associated with hypertensive disorders in pregnancy predisposes women to severe psychological distress and adverse birth outcomes. This review investigated the effectiveness of psychosocial interventions for hypertensive disorders during pregnancy. MethodsCochrane CENTRAL, Embase, MEDLINE, MIDIRS, CINAHL, PsycINFO, PsycArticles, and Web of Science were searched up to 22nd August 2021. Effect sizes on relevant health outcomes were pooled in a meta-analysis using STATA software. ResultsEight randomised trials involving 460 participants met the inclusion criteria. Included studies adopted several interventions ranging from music, exercise, cognitive behavioural therapy (CBT), spiritual care education and psychoeducation. The pooled effect showed a significant reduction in anxiety (d= -0.35 [-0.58, -0.11], p=0.004) and depression (d= -0.37 [-0.57, -0.17], p=0.0003). Spiritual care education significantly reduced postpartum stress disorder (d= -62.00 [-93.10, -30.90], p= 0.0001). However, CBT showed no effect on gestational stress (d= -2.20 [-4.89, 0.48], p= 0.11). ConclusionThis study provides satisfactory evidence that psychosocial interventions may likely reduce anxiety and depression associated with hypertensive disorders in pregnancy. However, the evidence is very uncertain about its effect on neonatal outcomes. Summary of findings O_TBL View this table: org.highwire.dtl.DTLVardef@1e79837org.highwire.dtl.DTLVardef@1ba7c46org.highwire.dtl.DTLVardef@34ff88org.highwire.dtl.DTLVardef@1744101org.highwire.dtl.DTLVardef@157c61e_HPS_FORMAT_FIGEXP M_TBL C_TBL

BackgroundThe prevalence of preterm birth (PTB) is high in lower and middle-income countries (LMIC) such as India. In LMIC, since a large proportion seeks antenatal care for the first time beyond 14-weeks of pregnancy, accurate estimation of gestational age (GA) using measures derived from ultrasonography scans in the second and third trimesters is of paramount importance. Different models have been developed globally to estimate GA, and currently, LMIC uses Hadlocks formula derived from data based on a North American cohort. This study aimed to develop a population-specific model using data from GARBH-Ini, a multidimensional and ongoing pregnancy cohort established in a district hospital in North India for studying PTB. MethodsData obtained by longitudinal ultrasonography across all trimesters of pregnancy was used to develop and validate GA models for second and third trimesters. The first trimester GA estimated by ultrasonography was considered the Gold Standard. The second and third trimester GA model named, Garbhini-GA2 is a multivariate random forest model using five ultrasonographic parameters routinely measured during this period. Garbhini-GA2 model was compared to Hadlock and INTERGROWTH-21st models in the TEST set by estimating root-mean-squared error, bias and PTB rate. FindingsGarbhini-GA2 reduced the GA estimation error by 23-45% compared to the published models. Furthermore, the PTB rate estimated using Garbhini-GA2 was more accurate when compared to published formulae that overestimated the rate by 1{middle dot}5-2{middle dot}0 times. InterpretationThe Garbhini-GA2 model developed is the first of its kind developed solely using Indian population data. The higher accuracy of GA estimation by Garbhini-GA2 emphasises the need to apply population-specific GA formulae to improve antenatal care and better PTB rate estimates. FundingCentre for Integrative Biology and Systems Medicine, IIT Madras; Department of Biotechnology, Government of India; Grand Challenges India, BIRAC. Panel: Research in ContextO_ST_ABSEvidence before this studyC_ST_ABSThe appropriate delivery of antenatal care and accurate delivery date estimation is heavily dependent on accurate pregnancy dating. Unlike GA estimation using crown-rump length in the first trimester, dating using foetal biometry during the second and third trimesters is prone to inaccuracies. This is a public health concern, particularly in low and middle-income countries like India, where nearly 40% of pregnant women seek their first antenatal care beyond 14 weeks of gestation. The dating formulae used in LMIC were developed using foetal biometry data from the Caucasian population, and these formulae are prone to be erroneous when used in ethnically different populations. Added value of this studyThis study developed a dating model, the Garbhini-GA2 model for second and third trimesters of pregnancy using multiple candidate biometric predictors measured in a North Indian population. When evaluated internally, this model outperformed the currently used dating models by reducing the errors in the estimation of gestational age by 25-40%. Further, Garbhini-GA2 estimated a PTB rate similar to that estimated by the Gold Standard in our population, while the published formulae overestimated the PTB rates. Implications of all the available evidenceOur Garbhini-GA2 model, after due validations in independent cohorts across the Southeast Asian regions, has the potential to be quickly translated for clinical use across the region. A precise dating will benefit obstetricians and neonatologists to plan antenatal and neonatal care more exactly. From an epidemiologist standpoint, using the Garbhini-GA2 dating formulae will improve the precision of the estimates of pregnancy outcomes that heavily depend on gestational age, such as preterm birth, small for gestational age and stillbirth in our population. Additionally, our dating models will improve phenotyping by reducing the risk of misclassification between outcomes for mechanistic and biomarker research.

BackgroundPregnancy preparation, to establish a healthy lifestyle within the preconception period, has been shown to reduce adverse maternal and neonatal outcomes. Despite its importance, we know very little about if and how people prepare for pregnancy in the UK. MethodsAs part of the P3 study, women in the UK were invited to complete an online survey about pregnancy preferences, including the Desire to Avoid Pregnancy (DAP) Scale. 274 participants were currently trying, thinking, or maybe thinking about getting pregnant and were asked about pregnancy preparations. The changes that women, and their partners, made in preparation for pregnancy, reasons for not preparing, and associations with sociodemographics were investigated in univariate and multivariate analyses. ResultsOf the 274 women, less than half (n=134, 49%) reported making any changes in preparation for pregnancy, with the most common changes being "eating healthier" (55%) and "folicacid" (54%). The main reason for not preparing was "only thinking about getting pregnant" (38%). 92 women answered questions about partner preparations; only 24% of partners were preparing, with the most common changes being "eating healthier" (64%) and "reducing alcohol" (50%). The main reason for partners not preparing was "already healthy" (51%). DAP score was the only significant factor affecting pregnancy preparation; every one- point increase in DAP score reduced the odds of a woman preparing for pregnancy by 78% (OR 0.22, 95%CI 0.15-0.34). ConclusionInterventions addressing pregnancy preparation for women, and their partners, are needed. These strategies should target women thinking about pregnancy, to ensure the full benefits of preconception care are received.

BackgroundPre-eclampsia (PE) is a significant cause of maternal and perinatal morbidity and mortality worldwide. The clinical course and severity of PE can vary depending on the gestational age at onset. However, limited data from developing countries including Bangladesh stratify outcomes by onset timing, hindering context-specific management. This study aimed to differentiate maternal and perinatal outcomes associated with early-onset PE (EO-PE, <34 weeks) versus late-onset PE (LO-PE, [&ge;]34 weeks) in a tertiary care setting in Bangladesh. MethodsA cross-sectional study was conducted at Faridpur Medical College Hospital, Faridpur, Bangladesh, from March to August 2023. Data were collected from hospital records and through pre-structured telephone questionnaires for 255 mothers diagnosed with PE (EO-PE: n=121; LO-PE: n=134). Maternal, fetal and neonatal outcomes were compared between the EO-PE and LO-PE groups. ResultsThe prevalence of PE was 11.28%. EO-PE was associated with more adverse perinatal outcomes compared to LO-PE, including higher rates of prematurity, low birth weight, and increased need for neonatal hospital admission. Maternal complications such as eclampsia (31% vs 19%) and placental abruption (20% vs 10%) were more frequent in the EO-PE group. In multivariable regression, EO-PE was not independently associated with maternal adverse outcomes but showed significantly higher odds of stillbirth (aOR: 17.7, 95% CI: 6.15-66.7, p<0.001) and neonatal adverse outcomes (aOR: 5.33, 95% CI: 2.96-9.83, p<0.001). ConclusionsEarly-onset PE is associated with more severe adverse perinatal outcomes compared to late-onset PE. Onset-based classification, early screening, and targeted management strategies are recommended to reduce the burden of pre-eclampsia.

We investigated the association between systole and diastole, and outpatient portal use during pregnancy. We used electronic and administrative data from our academic medical center. We categorized patients into two groups: (<140 mm Hg; <90 mm Hg), and out-of-range ([&ge;]140 mm Hg, [&ge;] 90 mm Hg). Random effects linear regression models examined the association between mean trimester blood pressure (BP) levels and portal use, adjusting for covariates. As portal use increased, both systole and diastole levels decreased for the out-of-range group. These differences were statistically significant for patients who were initially out-of-range. For the in-range group, systole and diastole levels were stable as portal use increased. Results provide evidence to support a relationship between outpatient portal use and BP outcomes during pregnancy. More research is needed to expand on our findings, especially those focused on the implementation and design of outpatient portals for pregnancy.

ObjectivesTo determine temporal trends in the rates of preterm birth and its sub-types in Sweden and assess the contribution of known-risk factors. DesignA population-based register study. SettingSweden. Participants (Instead of patients or subjects)3,264,146 pregnancies registered in the Swedish Medical Birth Registry with information on pregnancy duration and onset of labour (1991 - 2021). Main outcome measuresThe primary outcomes were the overall, spontaneous and iatrogenic preterm birth rates between 1991 - 2021, stratified on singleton and multiple births, as well as for extremely preterm (<28 weeks, <196 days), very preterm (28-31 weeks, 196 - 224 days), moderately preterm (32 - 33 weeks, 224 - 238 days), and late preterm (34 - 36 weeks, 238 - 259 days) births. Using logistic regression models, we investigated whether maternal age at conception, use of artificial reproductive technologies, smoking, parity, and maternal continent of birth were associated with the observed trends. ResultsThe overall preterm birth rate was stable between 1991 - 2005 at 5.50% (95% CI: 5.37%, 5.63% in 1991) but decreased thereafter to 4.78% (95% CI: 4.66%, 4.91%) in 2021, a finding confined to spontaneous preterm births. The largest decline was observed in late preterm births, from 3.92% (95% CI: 3.80%, 4.05%) in 2005 to 3.52% (95% CI: 3.41%, 3.63%) in 2021. Moderately preterm birth also declined (0.70%, 95% CI: 0.65%, 0.76% in 2005 to 0.53%; 95% CI: 0.49%, 0.58% in 2021), whereas very-extremely preterm birth did not. Decreased spontaneous preterm birth rates were observed in women born in European, Asian and African countries, with largest decline observed in the latter (rate in 1991 = 2.65%, 95% CI: 1.74%, 3.86%; rate in 2021 = 1.72%, 95% CI: 1.42%, 2.07%). Adjusting for maternal and obstetric risk factors didnt alter these associations. ConclusionsWhile rates of preterm birth have been stable or increased globally, they have decreased in Sweden from 2006 - 2021, despite the lack of any nation-wide preventive strategy during this period. Understanding the reasons for this decline will provide useful strategies to make the decline a rule, rather than an exception.

ObjectivePulmonary edema is a feature of preeclampsia with severe features (SPEC), but it is unknown whether oxygen saturation (O2 sat) levels can predict pulmonary edema in patients with SPEC. The purpose of this study is to evaluate and compare O2 sat trends in patients with SPEC with and without pulmonary edema. Study DesignThis is a nested case-control study within a retrospective cohort of all patients with SPEC who delivered at a tertiary academic hospital in 2019. Cases were defined as a clinical diagnosis of pulmonary edema (based on imaging findings or clinical concern coupled with empiric treatment with IV diuretic) on postpartum day 0 (PPD0). Controls were patients with SPEC and without pulmonary edema on PPD0. All patients with at least 25 oxygen saturation levels recorded on PPD0 were included. O2 sat trends as well as demographic and clinical features of patients with and without pulmonary edema were compared. Results238 patients in total were included. Five patients (2.1%) were diagnosed with pulmonary edema on PPD0. There were no significant differences in demographic or major obstetric characteristics of patients with and without pulmonary edema. There were also no significant differences between groups in the number of patients with at least one abnormal O2 sat, with a large volume of abnormal O2 sat values in both groups. Significant differences were seen in the minimum oxygen saturation level recorded (92 v. 89, p < 0.04) and the overall percent of abnormal values (7.0% abnormal values without pulmonary edema compared to 46.0% with pulmonary edema, p < 0.01). ConclusionsIndividual O2 sat values are poorly predictive of pulmonary edema in patients at risk, but trends may be more prognostic. Algorithms that employ real-time data trending may position O2 sat as a better surveillance tool for pulmonary edema in patients with SPEC.

BackgroundFetal birth weight and placental weight have been extensively studied and used for clinical assessment of fetal development and maternal health. The ratio of fetal and placental weight as a tool for clinical use in human pregnancy is less studied. We compared the fetal birth weight, placental weight and fetal placental ratio in term pregnancy to see if fetal and placental ratio is useful in assessment of maternal health and pregnancy complication as well as fetal growth and development in singleton pregnancy. Material and methodsWe have collected the fetal birth data, maternal pregnancy data and placental pathology data from March 2000 to November 2021 in a single urban hospital. We compared the fetal birth weight, placental weight and fetal placental ratio in assessment of fetal growth, maternal pregnancy complications, and placental pathology with special emphasis on the role of fetal placental ratio. ResultsA total 3302 pairs of neonates and placentas from term singleton pregnancy were reviewed and fetal birth weight and placental weight were moderately correlated with Pearmans correlation coefficiency R=0.66. Fetal placental ratio as a proxy of placental efficiency was significantly associated with various pregnancy complications and placental pathology, and these associations were different from those of fetal birth weight or placental weight alone. High placental efficiency (90 percentile or greater) was associated with ethnic White, SARS-CoV2 status, category 2 fetal heart tracing and maternal inflammatory response in placenta while low placental efficiency (less than 10 percentile) was associated with ethnic Black, Asian and Hispanic, preeclampsia/pregnancy induced hypertension and gestational diabetes mellitus. ConclusionFetal placental ratio was shown to be a useful indicator different from fetal birth weight and placental weight alone. Maternal and environmental factors were shown to have differential effects on fetal and placental growth. Understanding the mechanism of differential fetal and placental growth will help better manage the clinical relevant conditions such as IUGR and macrosomia.