ABSTRACT OBJECTIVE: To detect serum placental growth factor levels and uterine artery doppler pulsatility index for predicting pre-eclampsia and assess their association with the severity of pre-eclampsia. DESIGN: Prospective observational study SETTING: Tertiary care centre POPULATION: All antenatal women from 11 to 13+6weeks gestation attending antenatal clinic during study period. METHODS: This involved 160 antenatal women, from 11-13+6 weeks gestation. Serum PlGF levels and UA doppler mean P.I measured and patients were followed up upto delivery and observed for the development of pre-eclampsia and its severity. MAIN OUTCOME MEASURES: PIGF Value cut-off was 40.33pg/ml with the sensitivity of 97.5 % and Specificity was 98.3%. For the PI Value of 1.85 the sensitivity was found to be 74.4% and Specificity was found to be 92.5%. RESULTS: Mean serum PlGF levels for pre-eclampsia patients was 25.09pg/ml and for normotensive patients mean PlGF level was 65.05pg/ml. Mean UA doppler P.I for pre-eclampsia patients was 2.02 and for normotensive patients was 1.39. Mean PI value increased with increasing severity of preeclampsia. CONCLUSION: Early recognition of women will help initiation of prophylactic measures and enhanced surveillance. First trimester UA Doppler with serum PlGF together with maternal characteristics can be used as a reliable screening test for preeclampsia prediction and to reduce feto-maternal morbidity KEYWORDS: uterine artery (UA) doppler pulsality index (P.I), placental growth factor levels(PlGF), pre-eclampsia, eclampsia

Objective: A prospective cohort study was conducted to investigate sleep status during the first and second trimester of pregnancy in pregnant women on adverse birth outcome, such as preterm birth (PTB), low birth weight (LBW) and small for gestational age (SGA). Design: Prospective cohort study. Setting: China. Population: Cases were singleton pregnant women aged 18-40 years from the prospective Tongji-Shuangliu Birth Cohort. Methods: Multivariable logistic regression models were used to analyze the associationof sleep status during the first and second trimester of pregnancy with adverse birth outcomes and generated the odds ratio (OR) and 95% confidence interval (CI). Main outcome measures: Birth outcomes. Results: Finally, 5,412 pregnant women were included in the analysis. In the multivariable model, compared with 8-9 hours/night, sleep less than 7 hours/night during second trimester increases the risk of PTB (OR: 1.80, 95% CI: 1.12,2.89), and the risk of PTB was decreased in pregnant women who slept ≥11 hours/night (OR: 0.53, 95% CI: 0.30,0.93). Sleep quality, napping and sleep changes in the first and second trimesters, and sleep duration in the first trimester were not statistically associated with PTB, LBW and SGA. Conclusions: Short sleep duration during pregnancy is associated with a higher risk of PTB, while longer sleep duration at night is associated with a lower risk of PTB. Sleep status during pregnancy was not associated with LBW and SGA. In order to reduce risk of adverse birth outcomes, sleep problems in pregnant women should be strengthened during pregnancy care.

A document by Nicole P. Jenkins. Click on the document to view its contents.

Objective: To develop a prediction model for labour dystocia, suitable for risk stratification at onset of labour. Design: A cohort-based registry design was employed using data from the Copenhagen Pregnancy Cohort and the Danish Medical Birth Registry. Setting: The study was conducted at Copenhagen University Hospital – Rigshospitalet, Denmark Population: Nulliparous women with a singleton pregnancy and cephalic presentation in spontaneous labour at term from 2014 to 2020. Methods: Logistic regression analysis was employed to construct the prediction model. Candidate predictors were pre-selected based on clinical reasoning and existing evidence. These were maternal age, pre-pregnancy body mass index, height, gestational age, physical activity, self-reported medical condition, WHO-5 score, and fertility treatment. Main outcome measures: The candidate predictors ability to predict labour dystocia. For model performance, we calculated the area under the receiver operating characteristics curve (AUC) for discriminative capacity and Brier score for model calibration. Results: A total of 12,445 women involving 5,525 events of labour dystocia (44%) were included. All candidate predictors were retained in the final model, which demonstrated moderate discriminative ability with AUC was 62.3% (95% CI:60.7-64.0) and Brier score of 0.24. Conclusions: Our model represents an initial advancement in the prediction of labour dystocia utilizing readily available information obtainable upon admission in active labour. As means of facilitating risk stratification the development of a user-friendly online tool for clinicians is a logical next step. Nevertheless, further model development and external testing across other populations is warranted.

Background: Previous spontaneous preterm birth (sPTB) is an important risk factor for recurrent PTB, yet consensus on the lower limit of PTB is lacking. This complicates the identification of patients at risk for recurrent PTB. Objectives: To assess the risk of recurrent preterm birth following spontaneous extreme PTB between 16 +0 - 27 +6 weeks and the association with the interpregnancy interval. Design: A nationwide retrospective cohort study. Setting: Data from the Perinatal Registry of the Netherlands. Population: Nulliparous women with a singleton pregnancy that ended in sPTB between 16 +0 and 27 +6 weeks of gestation without congenital anomalies or antenatal death between 2010-2014 and had a subsequent pregnancy in the 5 years following. Main outcome measures: Recurrent preterm birth < 37 weeks. Results: 1011 women with linked pregnancies were included. The risk of PTB < 37 weeks with prior spontaneous birth between 16 +0-19 +6, 20 +0-23 +6, and 24 +0-27 +6 weeks was respectively 19.0%, 29.5% and 27.6%. The risk of subsequent PTB < 24 weeks was 5.7%, 7.2% and 4.3%. A short interpregnancy interval of 0-3 months was associated with increased odds for recurrent PTB < 32 weeks (OR 2.3 95% CI 1.4-3.7) and PTB < 37 weeks (OR 1.8 95% CI 1.2-2.6). Conclusion: Patients with previous sPTB from 16 weeks GA onwards are at high risk for recurrent PTB and should be regarded as such in the consideration of preventive measures to prevent recurrent adverse pregnancy outcomes.

Objective: To build a computer vision model that can automatically detect sleeping position in the third trimester under real-world conditions. Design: This study used data from an ongoing observational study and a previous cross-sectional study. Setting: Participants’ homes. Sample: Pregnant participants in the third trimester and their bed partners. Methods: Real-world overnight video recordings were collected from an ongoing, Canada-wide, prospective, four-night, home sleep apnea study and controlled-setting video recordings were used from a previous study. Images were extracted from the videos and body positions were annotated. Five-fold cross validation was used to train, validate, and test a model using state-of-the-art deep convolutional neural networks. Main Outcome Measures: Precision and recall of the model for detecting thirteen pre-defined body positions. Results: The dataset contained 39 pregnant participants, 13 bed partners, 12,930 images, and 47,001 annotations. The model was trained to detect pillows, twelve sleeping positions, and a sitting position in both the pregnant person and their bed partner simultaneously. The model significantly outperformed a previous similar model for the three most commonly occurring natural sleeping positions in pregnant and non-pregnant adults, with an 82-to-89% average probability of correctly detecting them and a 15-to-19% chance of failing to detect them when any one of them is present. Conclusions: The model holds potential to solve yet unanswered research and clinical questions regarding the relationship between sleeping position and pregnancy outcomes.

Objective: To validate an intrapartum Cesarean Section Classification System (ICSCS). Design: Nationwide prospective observational study. Setting: Twenty-five Norwegian maternity units Population or Sample: Singleton cephalic pregnancies with spontaneous or induced labour at ≥ 37 weeks gestation delivering February-August 2017. Methods:. After training of all collaborators, Cesarean section (CS) after spontaneous or induced labour were classified based on fetal status, dynamic progress in labour, use of oxytocin, frequency of contractions and linked to denominator data collected and centralized by the Norwegian Medical Birth Registry. Main Outcome Measures: Cohens kappa as measure of agreement for correct application of the classification. Prevalence of the different groups using the ICSCS within the Ten Group Classification System (Robson groups). Results: Of 49 trained experts, 40 (82%) had a κ >0.6 indicating good or very good level of agreement when the classification was applied. A total of 1425 CS were classified: CS classified as fetal indication (no oxytocin) was more common in induced (Group 2a, 4a, 5b) compared to spontaneous labours (Group 1, 3, 5a). CS classified as dystocia related to inefficient uterine action and poor response to oxytocin occurred more often in induced as compared to spontaneous labours. The prevalence of CS classified as dystocia with efficient uterine action (malposition or cephalopelvic disproportion) was low in all Robson groups. Conclusions: The ICSCS was successfully validated in a national study. It may become a valuable objective tool for analyzing the management of labour and explaining differences in the prevalence of CS between different groups of women.

Background Spontaneous preterm birth is the leading global cause of neonatal death, and countless efforts have failed to establish a single effective treatment for preterm labor, partly because the mechanisms that regulate the uterus and the cervix during pregnancy are not well understood. When a post-term pregnancy truly exists, its cause is mostly unknown. Objective To support the hypothesis. Study Design: This study investigated the current evidence-based literature and research that may support the hypothesis, accompanied by 40-second 3D animations. Results Light-dark cycle modulation of interactive inhibitory and stimulatory systems divides gestation into five clinical phases: growth, maturation, transition, parturition, and involution. During the maturation phase (30–40 weeks), nocturnal synchronisation and synergy of the inhibitory and stimulatory systems, secondary to light-dark cycle modulation, make the cervix progressively transform into the lower uterine segment and lose its strength, eventually causing EUWT failure. The clock that measures the duration of pregnancy consists of two interacting timers, an interval timer measuring the overall length of gestation and a circadian timer that defines when a 24-hour cycle birth occurs. Pregnancy intervals and circadian timers are achieved by a single mechanism, namely EUWT failure, secondary to the complete loss of cervical strength nocturnally. Inhibitory system malfunction causes preterm labor, and most of the current therapeutic modalities for preterm labor focus on delaying or preventing EUWT failure. Stimulatory system malfunctions cause post-term pregnancy. Conclusion The creation, autonomic maintenance, and eventually autonomic EUWT termination make pregnancy an autonomic cycle with constant intervals and circadian timers where its malfunctions change the timing of birth and pregnancy duration. Laplace’s law measures EUWT, which might be the law of physics that controls pregnancy duration.

Background Our hypothesis suggests another view regarding the following: Labor physiology. Labor progress. Labor dystocia. Objective To support the hypothesis. Study Design This study investigated the current evidence-based literature and research that may support the hypothesis. Results Intrinsic myometrial cell character ensures that parturition is an autonomic, intrinsic, and interactive repetitive contraction and relaxation cycle, secondary to myometrial tension changes that cause labor progression and protect the foetus against hypoxia. The progress during the first stage of labor and what is called cervical dilatation is the complete transformation of the cervix into the LUS, which has a clinical and radiological presentation. The clinical presentation is effacement, and dilatation. Radiologically, the cervix transforms into the LUS through an inverted inside-out TYVU and an inverted U pattern formation. In the second stage of labor, the cervix has completely transformed into the LUS which is a wedge-shaped birth canal that extends from the vaginal vault (cervicovaginal junction) into the physiologic retraction ring. All these changes reverse instantly after foetal delivery, and the cervix returns to its anatomical site and regains its full anatomical shape. Concomitant malfunctions of the inhibitory and stimulatory systems cause labor dystocia. Conclusion Labor dystocia is the failure of the complete transformation of the cervix into the lower uterine segment secondary to combined inhibitory and stimulatory system malfunction. Most of the cervical transformation into the LUS takes place during the third trimester and is completed during the first stage of labor. So, the treatment of labor dystocia should focus on the causes of the stimulatory system’s malfunction before the onset of labor. There is evidence to support the hypothesis, and it should be in the interest of obstetricians, physiologists, midwives, neonatologists, and those with a research interest in maternal and family welfare.

Background Despite a considerable body of literature gathered from the few species that have been studied, the mechanisms responsible for the maintenance of pregnancy and the initiation of parturition have not been fully elucidated. Failure to understand uterine function during pregnancy is a major shortcoming in healthcare. Objective To support the hypothesis. Study Design This study investigated the current evidence-based literature and research that may support the hypothesis, accompanied by 40-second 3D animations. Results The isthmus of the cervix does not seem to exist embryologically, anatomically, histologically, or functionally. The isthmus of the cervix may be a flaw in the concept of human parturition, which creates a block barrier that prevents understanding of uterine function. Mechanotransduction is the process by which cells sense physical forces and translate them into biochemical and biological responses. Uterine mechanotransduction has functional and molecular components, wherein intrinsic myometrial cell character (IMCC) is the molecular component and Exponential uterine wall tension (EUWT) is the functional component. IMCC enables the uterus to control its functions autonomically and intrinsically, secondary to changes in tension, where high tension induces relaxation and low tension induces contraction. EUWT is created and maintained by a complex interaction between the gestational sac, uterus, and cervix, for which the primary function is to maintain EUWT. EUWT mechano-transduction and progesterone/estrogen induce the stretch-dependent inhibitory system, and indirectly, they also induce the stimulatory system by inducing myometrial hyperplasia and hypertrophy. Pregnancy is mainly maintained through a stretch-dependent inhibitory system, in addition to direct myometrial relaxants. Contractions of the stimulatory system in the presence of the foetus create direct and indirect uterine-cervical interactions (DIDUCI). DIDUCI transforms the cervix into the lower uterine segment through TYVU pattern formation and causes EUWT failure. So, the functional components of the stimulatory system (DIDUCI) are the uterus corpus, fetus, cervix, and bony pelvic inlet. Conclusion Pregnancy is a state of balance between the two opposing and interactive inhibitory and stimulatory systems secondary to EUWT mechanotransduction and progesterone/estrogen stimulation. EUWT is measured using Laplace’s law, which might be the law of physics that controls uterine function during pregnancy.

Objective: To calculate the incidence and assess risk factors leading to permanent brachial plexus birth injury (BPBI) in Southern Finland Design: Retrospective population-based study Setting: Helsinki University Women’s Hospital and Helsinki University New Children’s Hospital, Finland Sample: All children born from 2006 to 2022 in Southern Finland with a permanent BPBI and their mothers Methods: Birth information of all mothers and their children born from 2006 to 2022 in Southern Finland were gathered from the national database and compared to prospectively collected data from mothers and their children with a permanent BPBI delivered within the same period. Permanent injury was defined as limited active or passive range of motion or decreased strength in the affected limb detected at one year of age. The severity of the injury was assessed using the 3-month Toronto test score. Main outcome measures: Permanent brachial plexus birth injury Results: Altogether, 298 428 children were born within the study period, of which 100 acquired a permanent BPBI. The incidence of a permanent BPBI was 0.4 per 1000 vaginal live births (0.34 all births), with a declining trend. Children born to immigrant mothers and women of Black ethnicity had a higher incidence of permanent injury (0.85 and 1.52 per 1000). Non-white background and immigrant status correlated with a more severe injury (β=-1.12 range, -2.17 to -0.07, p=0.004), with children to Black mothers having the least favorable outcome (β= -1.64 range, -2.79 to -0.49, p=0.005). Conclusion: The overall incidence of permanent BPBI is declining. Immigrant status and Black ethnicity increase the risk of a permanent BPBI.

ABSTRACT Objective To evaluate the impact of screening and treating asymptomatic pregnant women for C. trachomatis and N. gonorrhoeae infections on the frequency of preterm birth or low birth weight infants in Botswana. Design Non-randomized, cluster-controlled trial. Setting Four antenatal care clinics in Gaborone, Botswana. Population Pregnant women aged ≥15 years, attending a first antenatal care visit, ≤27 weeks gestation, and without urogenital symptoms were eligible. Methods Participants in the intervention clinics received screening (GeneXpert®, Cepheid) during pregnancy and at the post-natal visit. Participants in the standard-of-care clinics received screening at the postnatal visit only. We used multivariable logistic regression and post-estimation predictive margins analysis. Post-hoc analysis was conducted among sub-samples stratified by parity. Main outcome measures Preterm birth (<37 weeks gestation) and low birth weight (<2500g). Results After controlling for parity, hypertension, antenatal care visits, and clinic site, the predicted prevalence of preterm or low birth weight was lower in the intervention arm (11%) compared to the standard-of-care (16%) (AOR: 0.59; 95% CI: 0.28 to 1.24), but confidence intervals were wide. In post-hoc analysis, the intervention was more effective than the standard-of-care (AOR: 0.20; 95% CI: 0.07-0.64) among nulliparous participants. Conclusion A C. trachomatis and N. gonorrhoeae infection screening and treatment intervention among asymptomatic pregnant women did not significantly reduce preterm or low birth weight outcomes. Post hoc analysis found the intervention reduced adverse outcomes among nulliparous participants.

Objective Investigate maternal and neonatal outcomes associated with breech presentation in planned community births in the United States Design Cohort analysis of a national perinatal data registry Setting Homes and birth centres, United States Sample Medical records of individuals with a term, singleton gestation (N=71,943) planning community birth at labour onset Methods Descriptive statistics to calculate associations between types of breech presentation and perinatal outcomes Main Outcome Measures Maternal: intrapartum/postpartum transfer, hospitalization, caesarean, haemorrhage, severe perineal laceration, duration of labour stages and membrane rupture Neonatal: transfer, hospitalization, NICU admission, congenital anomalies, umbilical cord prolapse, birth injury, intrapartum/neonatal death Results One percent (n=695) of individuals experienced breech birth, with most (57%) presenting frank breech (19% complete, 18% incomplete, 5% unknown breech type). Among all breech labours, there were high rates of intrapartum transfer and caesarean (OR 9.0, 95% CI 7.7-10.4 and OR 18.6, 95% CI 15.9-21.7, respectively), with no substantive difference based on parity, planned site of birth, or level of health system integration. Risk of nearly all assessed neonatal outcomes was higher for all breech presentation types, including hospital transfer, NICU admission, birth injury, and umbilical cord prolapse. Breech presentation was also associated with increased risk of intrapartum/neonatal death (OR 8.5, 95% CI 4.4-16.3), even after excluding congenital anomalies. Conclusions All types of breech presentation in community birth settings are associated with increased risk of adverse neonatal outcomes. Findings contribute to informed decision-making and reinforce the need for accessible, high-quality care for planned vaginal breech birth in hospitals.

A document by Berhe Tesfai. Click on the document to view its contents.

Objective To validate a serum biomarker developed in the USA for preterm birth (PTB) risk stratification in Viet Nam. Design Case-cohort study Setting Tu Du Hospital, Ho Chi Minh City, Viet Nam Population Women with a viable singleton pregnancy (n=5000). Methods Maternal serum was collected between 19 +0-22 +6 weeks’ gestation and participants followed to neonatal discharge. Relative insulin-like growth factor binding protein 4 (IGFBP4) and sex hormone binding globulin (SHBG) abundances were measured by mass spectrometry and their ratio compared between PTB cases and term controls. Discrimination (area under the receiver operating characteristic curve, AUC) and calibration for PTB <37 and <34 weeks were tested, with model tuning using clinical factors. Main outcomes measures All PTBs (any birth ≤37 weeks’ gestation) and spontaneous PTBs (birth ≤37 weeks’ gestation with clinical signs of initiation of parturition). Results Complete data were available for 4984 (99.7%), cohort PTB rate=6.7%; n=335. We observed an inverse association between IGFBP4/SHBG ratio and gestational age at birth (p=0.017); AUC 0.60 (95% CI, 0.53-0.68). Including previous PTB (multiparous women) or prior miscarriage (primiparous women) improved performance (AUC 0.65 and 0.70, respectively, for PTB <37 and <34 weeks’ gestation). Optimal performance (AUC 0.74) was between 19-20 weeks’ gestation, for BMI >21kg/m 2 and age 20-35 years. Conclusions We have validated a novel serum biomarker for PTB risk stratification in a very different setting to the original study. Further research is required to determine appropriate ratio thresholds based on the prevalence of risk factors and the availability of resources and preventative therapies.

Objective: To evaluate the implementation of the London Measure of Unplanned Pregnancy (LMUP) in antenatal care. Design: Mixed methods evaluation of a pilot. Setting: Antenatal care at University College London Hospital and Homerton Hospital, England, 2019-2022. Population: Pregnant women attending antenatal care at one of the sites during the evaluation. Methods: Quantitative and psychometric analysis of anonymous data and qualitative analysis of interviews and focus groups with women and midwives, using a Framework Analysis. Main Outcome Measures: Acceptability of the inclusion of the LMUP, measured by completion rates and women’s and midwives opinions. Results: Completion of the LMUP at UCLH stabilised at around 70% and the LMUP performed as expected. Asking the LMUP at antenatal booking appointments is feasible and acceptable to women and midwives. Advantages of asking the LMUP, highlighted by participants, include providing additional support and personalising care. Midwives’ concerns about judgment were unsubstantiated; women with unplanned pregnancies valued such discussions. Conclusions: These findings support the implementation of the LMUP in routine antenatal care and show how it can provide valuable insights into the circumstances of women’s pregnancies. This can be used to help midwives personalise care, and potentially reduce adverse outcomes and subsequent unplanned pregnancy. Integration of the LMUP into the Maternity Services Data Set, will establish national data collection for a population-level measure of unplanned pregnancy, serving as a key outcome measure for sexual and reproductive health and enabling analysis of the prevalence, factors, and implications of unplanned pregnancies across subpopulations to inform implementation. Funding : NIHR PDF-2017-10-021

Objective This study aims to determine the incidence of episiotomy in Kasr Alainy OBGYN Hospital in Cairo, Egypt. Objectives include identifying factors influencing the incidence of episiotomy. Design This cross-sectional study was conducted between March 1, 2022 and June 30, 2022, to determine the incidence of episiotomy among vaginal deliveries in the hospital. Setting Data was collected from patient charts at Kasr Alainy OBGYN Hospital in Cairo, Egypt. Patient Sample The total number of patient charts inspected was 1731, of which 1545 met the inclusion criteria. Methods Data was manually collected from patient hospital records at the end of each day, and entered into a standardized data-collection form. The data collected was then statistically analyzed using SPSS. Main Outcome Measures The overall incidence of episiotomy was found to be 64%. Results The overall incidence of 64%, broken-down by gravidity, it was found that the incidence of episiotomy is 97% in primigravid patients, and 52% in multigravida patients. Several other associated factors were reviewed. Conclusions The incidence of episiotomy at Kasr Alainy OBGYN Hospital is greater than the WHO recommended rate. Further research is recommended to study the indications of episiotomy and collect information regarding how episiotomy affects patients’ perineal health and quality of life. This will aid in drawing evidence-based conclusions regarding the advantages and drawbacks of episiotomy, and how its incidence changes over time. Funding This research received no external funding. Keywords episiotomy; vaginal delivery; Egypt; Middle East; Africa; gravidity; maternal age; gestational age; cervical diameter; gestational weight

Objective: To compare the carbon footprint of caesarean and vaginal birth. Design: Life cycle assessment. Setting: Tertiary maternity units and home births in the UK and the Netherlands Methods: A life cycle assessment, including: equipment use, energy, analgesia, hospital stay, waste, sterilisation and laundry, was conducted using primary data combined with data from published sources. Main Outcome Measures: ‘Carbon footprint’ (in kgCO 2e) Results: Excluding analgesia, the carbon footprint of a caesarean birth in the UK was 31.21 kgCO 2e, compared with 12.47 kgCO 2e for vaginal birth in hospital and 7.63 kgCO 2e at home. In the Netherlands the carbon footprint of a caesarean was higher (32.96 kgCO 2e), but lower for vaginal birth in hospital and home (10.74 and 6.27 kgCO 2e respectively). Emissions associated with analgesia for vaginal birth were: 0.08 kgCO 2e (opioid analgesia), 0.75 kgCO 2e (remifentanil), 1.2 kgCO 2e (epidural) and 237.33 kgCO 2e (nitrous oxide with oxygen). Differences in analgesia use resulted in a lower average carbon footprint for vaginal birth in the Netherlands than the UK (11.64 vs. 193.26 kgCO 2e). Conclusion: The carbon footprint of a caesarean is higher than for vaginal birth if analgesia is excluded, but this is very sensitive to the analgesia used; use of nitrous oxide with oxygen multiplies the carbon footprint of vaginal birth 25-fold. Alternative methods of pain relief or nitrous oxide destruction systems would lead to a substantial improvement in carbon footprint. Although clinical need and maternal choice are paramount, protocols should consider the environmental impact of different choices.

Objective: To explore the characteristic lipid signature in placentas collected from normal pregnancies and those with mild and severe intrahepatic cholestasis of pregnancy (ICP). This research aims to clarify the pathogenesis and identify lipid biomarker for ICP through LC-MS/MS based lipidomic analysis. Design: Cross-sectional study, including normal pregnancy women and women with mild and severe ICP. Setting: Chengdu Women’s and Children’s Center Hospital. Population: Placenta samples collected from 30 normal pregnancy women and 30 mild and severe ICP women respectively. Women with normal pregnancy and ICP were recruit from April 2021 to July 2022 in Chengdu, China. Main outcome measures: Differentially expressed lipids. Results: Fourty-four lipids were differentially expressed both in mild and severe ICP placenta. The pathway analysis revealed these lipids are mainly enriched in glycerophospholipid metabolism and autophagy pathway. Weighted correlation network analysis (WGCNA) identified the correlation network module of lipids highly related to ICP. Using multiple logistic regression analysis, we identified three and four combined metabolites that had an area under receiver operating characteristic curves (AUC) ≥ 0.90. Conclusion: Our results systematically revealed the lipid signature in mild and severe ICP placenta. The results may provide new insight into the treatment and early prediction of ICP.

Objective To explore and characterise maternity healthcare professionals’ (MHCPs) experience and practice of informed decision-making (IDM), to inform policy, research and practice development. Design Qualitative focus group study. Setting Online with MHCPs from a single maternity unit in the Southwest of England. Population MHCPs who give information relating to clinical procedures and pregnancy care and are directly involved in decision-making conversations purposively sampled from a single National Health Service (NHS) Trust. Data collection: A semi-structured topic guide was used. Data Analysis: Reflexive thematic analysis . Results Twenty-four participants attended seven focus groups. Two themes were developed: contextualising decision-making and controversies in current decision-making. Contextual factors that influenced decision-making practices included lack of time, and challenges faced in intrapartum care. MHCPs reported variation in how they approach decision-making conversations and asked for more training on how to consistently achieve IDM. There were communication challenges with women/birthing people who do not speak English. Three controversies were explored in the controversies theme: the role of prior clinical experience, the validity of informed consent when women/birthing people were in pain and during emergencies, and instances where women/birthing people declined medical advice. Conclusions We found that MHCPs are committed to IDM but need better support to deliver it consistently. Structured processes including core information sets, communication skills training and the decision support aids may help to standardise the information and better support IDM.

COMMENTARY

OBJECTIVE: To sonographically characterize the cervical gland area (CGA) and determine if its evaluation at the time of cervical length (CL) screening can be useful for preterm birth (PTB) prediction. DESIGN: Pilot retrospective cohort study. SETTING: Academic medical center (NYU Langone Health Tisch Hospital). POPULATION: Singleton gestations with universal CL screening performed between 18 0/7 – 23 6/7 weeks with subsequent live neonate delivery. METHODS: Transvaginal ultrasound (TVUS) cervical images and clinical data were reviewed, comparing sonographically present and absent CGA groups. MAIN OUTCOME MEASURES: Spontaneous PTB <37 weeks and quantitative CGA measurements. RESULTS: The cohort of 772 patients demonstrated similar characteristics when stratified by absent and present CGA. Rates of PTB and absent CGA were 2.6% and 2.3%, respectively. Absent CGA was significantly associated with delivery <37, <34, and <32 weeks (p<0.001), but gland measurements did not correlate with gestational age at delivery. There was good agreement between reviewers for qualitative CGA (PABAK 0.89). Multiple logistic regression modeling demonstrated better performance of CL screening for PTB prediction with the addition of qualitative CGA evaluation (p<0.001). CONCLUSIONS: Qualitative evaluation of the CGA on mid-gestation TVUS may improve CL screening for PTB. Given the biologic activity of the cervical glands, optimal screening in populations with various risk profiles may warrant a multimodal approach that evaluates the mechanical and biological functions of the cervix.

Intervention bias refers to a systematic difference in management or variable exposure among subjects in studies, which can significantly influence outcomes.

Objective: The purpose of this study was to examine the association between the implementation of a mobile obstetric emergency system (MORES) and referral time for obstetric emergencies as well as maternal/newborn outcomes. Design: Pre/post intervention descriptive study. Setting: Liberia’s caesarean section (CS) coverage is about 5%, lower than 9-19% coverage associated with decreased maternal mortality. Delays in the referral process from a rural health facility (RHF) to a district hospital for comprehensive emergency obstetric and newborn care (CEmONC) services such as CS contribute to the high maternal mortality. Sample: Women with referral data from both RHFs (n=20) and hospitals (n=2) within Bong County, Liberia. Methods: A pre/post descriptive analysis was conducted on data collected from RHFs and two hospitals in Bong County, Liberia. Descriptive analysis and logistic regression models examined the relationship between the intervention’s implementation and mode of delivery, maternal outcome, newborn outcome, and transfer time from RHF to district hospital. Main outcome measures: Mode of delivery, maternal outcome, newborn outcome, and transfer time. Results: Women had higher odds of undergoing a CS at endline (OR: 1.86 95%; CI: 0.99- 3.46) compared to baseline. Additionally, newborns had lower odds of showing depressive symptoms (OR: 0.31; 95%CI: 0.14-0.68), defined as a non-vigorous newborn with poor respiratory effort, muscle tone or heart rate <100 beats per minute. Conclusion: MORES is a promising means to increase timely care seeking along the referral pathway which may enhance access to caesarean section as well as improved newborn outcomes in low- and middle-income countries.