ABSTRACT Background Eclampsia, an enigmatic multisystem complication of pregnancy, is commonly defined as new onset of grand mal seizure activity and /or unexplained coma during pregnancy or postpartum. Eclampsia is associated with maternal deaths ranging from, 1.8% in developed to 14% in developing countries respectively. The worldwide incidence of delayed postpartum eclampsia is on an increasing trend , now at 16-18% ,of all eclamptic seizures. Objective To study the clinical findings and morbidity, associated with postpartum eclampsia and its correlation with neuroimaging- in our institute- SRIHER, CHENNAI. Materials and methods This is a retrospective study from a period of June 2016- June 2021 , in SRIHER, Chennai. Case records of all patients with postpartum eclampsia were analysed. Results A total of 35 patients who satisfied the inclusion criteria were studied, out of which 55% of patients were diagnosed with hypertension or preeclampsia antenatally, and 45% presented as atypical eclampsia. In our institution, Postpartum eclampsia commonly occurred in the age group of 26-30 years of age (51.4%) ; was common after LSCS (71.4%) ; most commonly occurred immediate postpartum (42.8%), Most common prodromal symptom was headache (77%), followed by blurring of vision (37%). Most common MRI finding was PRES (69%). 17% patients required ICU care. There was no mortality associated with postpartum eclampsia in the study period. Conclusion This study emphasises that a high index of suspicion and a multidisciplinary approach effectively reduces mortality and morbidity associated with postpartum eclampsia. Neuroimaging is of robust help in the diagnosis and management.

Objective: To assess the outcome of pregnancy after appendectomy, the mode of surgery used, appendectomy rates and complications. Design: A prospective cohort study of pregnant women undergoing appendectomy. Setting: All appendectomies at South Stockholm General Hospital, December 2015 to February 2021. Population: Pregnant women undergoing appendectomy. Methods: Data on preoperative imaging, surgical method, intraoperative findings, microscopic findings, hospital stay, pregnancy, and 30-day complications were prospectively recorded in a local appendectomy register. Results: During the study period, 50 pregnant women underwent appendectomy of 38 199 women giving birth. During the same period 793 non-pregnant women underwent appendectomy and served as controls. No differences in preterm delivery (4.5% vs. 5.6%), small-for-gestational age (2.3% vs. 6.2%), or mode of delivery (cesarean delivery 18.2% vs. 20.4%) were observed between pregnant women with or without appendectomy. There were no cases of perforated appendix in the second half of pregnancy. However, women with gestational age > 20 weeks more frequently had an innocent appendix compared to those operated < 20 gestational weeks (4/11 vs. 2/39, p = 0.005). Laparoscopic surgery was used in 92% of appendectomies < 20 weeks gestation. The appendectomy rate was three times lower during the second half of pregnancy. Conclusion: Appendicitis in pregnancy is not a threat as long as surgery is conducted as soon as possible. Although a low threshold for surgery may increase the risk of finding an innocent appendix, this is outweighed by the lower risk for perforation and serious adverse events such as fetal loss or preterm delivery.

Background- Abdominal pregnancy remains a diagnostic and management challenge Objective- Highlighting diagnostic and management dilemmas in secondary abdominal pregnancy Search strategy- MEDLINE, EMBASE, PubMed and Web of Science searched from 1930-2021. Selection criteria- Articles on secondary abdominal pregnancies Data collection and analysis- An illustrative case report of a woman at 13 weeks gestation referred from a primary health centre with vague abdominal pain. Imaging confirmed secondary abdominal pregnancy with hemoperitoneum. Emergency laparotomy revealed significant hemoperitoneum, a live floating fetus in the abdominal cavity and placental attachment to the left cornu and fallopian tube which were removed and cornual repair performed. Recovery was uneventful. We reviewed the literature on secondary abdominal pregnancies, early and advanced from 1930-2021 and summarised management and outcomes of 314 such cases. Main Results- Among the 314 cases reviewed, 295 cases (93.9%) were surgically managed and 19 (6%) required hysterectomy. Post-surgery methotrexate was given in 9 cases (2.9%). Following primary methotrexate administration in 18 patients, 10 required surgery (55.5%). Complete placental removal was achieved in 264 cases (84%), partial in 27 (8.6%) and left in situ in 16 (5.1%). Seventy-four cases (23.6%) required blood transfusion. There were 15 maternal deaths (4.8%). Twenty-seven fetuses (8.6%) were live born, 6 (1.9%) were neonatal deaths and 46 (14.6%) were fetal demise. Conclusion- Maternal mortality and morbidity is of serious concern in abdominal pregnancies requiring a high index of suspicion and management expertise. Funding- None Keywords- abdominal pregnancy, primary peritoneal pregnancy, secondary abdominal pregnancy, hepatic pregnancy, omental pregnancy, diaphragmatic pregnancy.

A document by Richard Stein, written on Authorea.

Objective: To investigate reliable biomarkers for predicting histological chorioamnionitis (HCA). Design: In this retrospective study, PPROM mothers were treated with a course of dexamethasone. Blood tests for serum indictors were conducted continuously after first injection. Setting: One Shanghai hospital Population: PPROM mothers before 34 0/7 weeks of gestation Methods: Data were compared by General Linear Model analysis. The diagnostic accuracy in predicting HCA were evaluated with ROC curve. Main Outcome Measures: The response of infectious indictors to dexamethasone treatment; the diagnostic accuracy for CRP and PCT in predicting HCA. Results： We found 98 HCA women (62.42%) and 59 CON women (37.58%) in 157 PPROM mothers. WBC and neutrophil significantly increased 24 hours after the first injection in both groups, followed by a decrease at 72 hours post first injection (P<0.05). No significances were found between two groups in WBC, neutrophil and lymphocyte. Both CRP and PCT were significantly higher in the HCA group after first injection. PCT had both high specificity and sensitivity, especially at the baseline (cutoff, 0.031 ng/ml). Furthermore, the positive predictive values (PPV) of PCT were respectively 0.946 and 0.960 at 48 (cutoff, 0.049 ng/ml) and 72 (cutoff, 0.051 ng/ml) hours, which were better than the corresponding PPV of CRP. Conclusion: The response of WBC, neutrophil and lymphocyte to dexamethasone could be differentiated from uterine infection; PCT could be a reliable biomarker for early diagnosis of HCA. Funding: Shanghai Municipal Commission of Health and Family Planning (GWIV-26, 202040128); Pudong Commission of Health and Family Planning (PW2019D-13).

Objective: To investigate the association between transaminase elevation during the first trimester and early pregnancy loss (EPL) in patients with recurrent spontaneous abortion (RSA). Further, the contributing risk factors for transaminase elevation in early pregnancy in RSA patients were analyzed Design: Cross-sectional study Setting: China Population: RSA patients during the first trimester Methods: Patients were divided into EPL group and N-EPL group as well as transaminase-elevated group (TE group) and transaminase-normal group (TN group). The relationship between transaminase level and EPL and the risk factors of elevated transaminase were investigated via student’s t test, Pearson chi-square test and logistic regression analyses. Main outcome measure: The association between transaminase elevation and EPL and the risk factors for elevated transaminase. Results: Higher serum transaminase levels were observed in EPL group than in the N-EPL group (p <0.05). Comparing with TN group, EPL is more common in TE group (p =0.018). There is still a correlation between elevated transaminases and EPL in RSA patients after adjusting for covariates (AST: OR, 1.018; 95% CI, 1.007-1.029; p, 0.001; ALT: OR, 1.006; 95%CI, 1.001-1.011; p, 0.018). The higher the transaminases, the greater the likelihood of EPL (p <0.05). Multivariate regression analysis found that the use of IVIG was an independent risk factor for elevated transaminase in RSA patients (OR, 0.374; 95% CI, 0.162-0.864; p =0.021). Conclusion: Serum transaminase levels are significantly correlated with RSA early pregnancy loss. Moreover, medication use is significantly correlated with transaminase elevation in the first trimester in RSA patients, especially IVIG.

Objectives: The relative contributions of vitamin D status to pregnancy complications are not fully understood. We investigated the correlation between vitamin D status and pregnancy outcomes. Design: Prospective analysis of cases Setting: China Population or Sample: A total of 1766 pregnant women admitted to The Eighth Affiliated Hospital, Sun Yat-sen University and Guangdong Women and Children Hospital between January 2019 and December 2020. Methods: This prospective cohort study was performed on women who paid antennal visits during their whole gestation. Serum 25-hydroxyvitamin D [25(OH)D] concentrations were measured among women before 24 weeks of gestation. Associations between maternal vitamin D status, maternal characteristics, and pregnancy outcomes were assessed. The adjusted odds ratio (OR) for adverse pregnancy outcomes was calculated using the logistic regression analysis. Results: Among all the participants ,192(10.87%), 1023(57.93%) and 551(31.20%) were defined as vitamin D sufficiency, insufficiency, and deficiency, respectively. There was no significant difference in vitamin D between pregnant women with adverse pregnancy outcomes and those without adverse pregnancy outcome. Neither vitamin D deficiency nor insufficiency was associated with adverse pregnancy outcomes compared with vitamin D sufficiency. Risks of adverse outcomes were as follows: GDM (OR=0.72 95%CI 0.46-1.14; OR=0.86 95%CI 0.57-1.30), SGA (OR=1.38 95%CI 0.73-2.60; OR=1.28 95%CI 0.70-2.34), early preterm delivery (OR=0.59 95%CI 0.13-2.70; OR=0.84 95%CI 0.23-3.00), PE (OR=3.44 95%CI 0.43-27.52; OR=2.40 95%CI 0.31-18.50), and postpartum hemorrhage (OR=0.58 95%CI 0.33-1.03; OR=0.81 95%CI 0.49-1.35). Conclusions: Low vitamin D status may not be associated with adverse pregnancy outcomes. Vitamin D screening in all pregnant women seems not reasonable.

Commentary for manuscript BJOG 2022 Gurol-Urganci et al (10.1111/1471-0528.17193)

Background: Science integrity initiatives require specific recommendations for randomised clinical trials (RCT). Objective: To prepare a set of statements for RCT integrity through an international multi-stakeholder consensus. Methods: Following prospective registration (https://osf.io/bhncy, https://osf.io/3ursn), the consensus was developed via: multi-country multidisciplinary stakeholder group composition and engagement; evidence synthesis of 55 systematic reviews concerning RCT integrity; anonymised two-round modified Delphi survey with consensus threshold based on the average percent of majority opinions; and, a final consensus development meeting. Results: There were 30 stakeholders representing 14 countries from 5 continents including trialists, ethicists, methodologists, statisticians, consumer representative, industry representative, systematic reviewers, funding body panel members, regulatory experts, authors, journal editors, peer-reviewers and advisors for resolving integrity concerns. Delphi survey response rate was 86.7% (26/30 stakeholders). There were 111 statements (73 stakeholder-provided, 46 systematic review-generated, 8 supported by both) in the initial long list, with 8 additional statements provided during the consensus rounds. Through consensus the final set consolidated 81 statements (49 stakeholder-provided, 41 systematic review-generated, 9 supported by both). The entire RCT life cycle was covered by the set of statements including general aspects (n=6), design and approval (n=11), conduct and monitoring (n=19), reporting of protocols and findings (n=20), post-publication concerns (n=12), and future research and development (n=13). Conclusion: Implementation of this multi-stakeholder consensus statement is expected to enhance RCT integrity.

Background: The trustworthiness of randomised clinical trials (RCTs) is suffering a crisis of confidence. Objectives: We undertook an umbrella review of the research integrity literature concerning RCTs. Search strategy and selection criteria: Following prospective registration (https://osf.io/3ursn), two reviewers independently searched PubMed, Scopus, Cochrane Library and Google Scholar, without language or time restrictions until November 2021. We included systematic reviews covering any aspect of research integrity throughout the RCT lifecycle. Data collection and analysis: We assessed methodological quality using a modified AMSTAR-2 tool and collated the main findings. Main results: There were 55 relevant reviews summarising a total of 6001 studies (median per review 63; range 8-1106 studies). The overall quality of 53 (96.4%) reviews was critically low. Eight (14.6%) reviews focused on the general aspects of a RCT, 12 (21.8%) on the design and approval, 6 (10.9%) on the conduct and monitoring, 21 (38.2%) on the reporting of protocols and findings, one (1.8%) on post-publication concerns and 7 (12.7%) on future research and development. The integrity issues covered were varied, the most common being the importance of ethics (10/55, 18.2%) and transparency (10/55, 18.2%). Conclusions: Various research integrity issues covering RCT lifecycle, captured from mostly low-quality reviews, provided a broad overview emphasising the need for high level of ethical standards and professionalism. Many gaps in the RCT integrity landscape were also identified. There is a need to generate multistakeholder consensus to create specific RCT integrity standards.

Objective To assess the perception, knowledge, and practices regarding maternal perception of fetal movements (FMs) among women and their healthcare providers in a low-resource setting. Design Qualitative study. Setting The maternity unit of Mnazi Mmoja Hospital, Zanzibar, Tanzania. Population Pregnant and postpartum women, and health providers. Methods Semi-structured interviews, questionnaires and focus group discussions were conducted with 45 Zanzibar women (18 antenatal, 28 postpartum) and 28 health providers. Main outcome measures Descriptive and thematic analyses were conducted to systematically extract subthemes within four main themes 1) knowledge/awareness, 2) behavior/practice, 3) barriers, and 4) improvements. Results Within the main themes it was found that 1) Women were instinctively aware of (ab)normal FM-patterns and healthcare providers had adequate knowledge about FMs. 2) Women often did not know how to monitor FMs or when to report concerns. There was inadequate assessment and management of (ab)normal FMs. 3) Women did not feel free to express concerns. Healthcare providers considered FM-awareness among women as low and unreliable; lack of staff, time and space for FM-education, and no protocol for FM-management. 4) Women and health providers recognized the need for education on assessment and management of (ab)normal FMs. Conclusion Women expressed FMs in an adequate way and perceived abnormalities of these movements better than assumed by health providers. There is a need for more evidence on the effect of improving knowledge and awareness of FMs in order to construct evidence-based guidelines for low resource settings.

Objective: To describe clinical and laboratory characteristics of term deliveries complicated by chorioamnionitis, and to assess their association with adverse neonatal outcomes. Design: Cross-sectional cohort study Setting: The study is based on data from the Swedish Pregnancy Register, enriched with clinical data extracted from medical charts. Population and Sample: A random sample of 500 term singleton deliveries in Stockholm County with registered diagnosis of chorioamnionitis in the Swedish Pregnancy Register between 2014 and 2020. Methods: Logistic regression was used to estimate odds ratios (OR) as a measurement of the association between clinical and laboratory characteristics and neonatal complications Main Outcome Measures: Neonatal infection and asphyxia-related complications. Results: Maternal fever, maternal and fetal tachycardia, and elevated inflammatory laboratory markers were frequent signs of chorioamnionitis. The prevalence of neonatal infection and asphyxia-related complications was 10 and 22%, respectively. First leukocyte count in the second tertile (OR 2.14 [95% CI 1.02-4.49]), maximum CRP level in the third tertile (OR 4.01 [95% Cl 1.66-9.68]), and positive cervical culture (OR 2.22 [95% Cl 1.10-4.48]) were associated with an increased risk of neonatal infection. Maximum level of CRP in the third tertile (OR 1.93 [95% Cl 1.09-3.41]), and fetal tachycardia (OR 1.63 [95% Cl 1.01-2.65]) were associated with increased risk of asphyxia-related complications. Conclusions: In addition to maternal intrapartum fever, maternal and fetal tachycardia, and elevated inflammatory laboratory markers were common signs of chorioamnionitis. Elevated inflammatory laboratory markers were associated with both neonatal infection and asphyxia-related complications, and fetal tachycardia was associated asphyxia-related complications.

Objective: Many women desire optimal pain management during labour and delivery. However, evidence on labour pain management in developing countries, is scarce. This study explores knowledge and perspectives of postnatal mothers and healthcare providers on pain management during labour and delivery. Design: A cross-sectional study. Setting: Maternal and Child clinics. Population or sample: Mothers and healthcare professionals. Main outcome measures: Labour Pain Survey. Results: Over 50% mothers reported severe to excruciatingly unbearable labour pain during recent labour. Age and education level were important predictors on pain relief information and preferences. Health professionals preferred third trimester to hold first discussion regarding preferences of labour pain relief, however not much support was received. Conclusions: This study highlights the need for health professionals in clinics and hospitals to equally provide informed choices on methods of labour pain relief and consider social media as a platform to educate expectant mothers regarding labour pain and its management.

Background A core outcome set could address inconsistent outcome reporting and improve evidence for stillbirth care research, which has been identified as an important research priority. Objectives To identify outcomes and outcome measurement instruments reported by studies evaluating interventions after the diagnosis of a stillbirth. Search strategy Amed, BNI, CINAHL, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, MEDLINE, PsycINFO, and WHO ICTRP from 1998 to August 2021. Selection criteria Randomised and non-randomised comparative or non-comparative studies reporting a stillbirth care intervention. Data collection and analysis Interventions, outcomes reported, definitions and outcome measurement tools were extracted. Main results 40 randomised and 200 non-randomised studies were included. 58 different interventions were reported, labour and birth care (52 studies), hospital bereavement care (28 studies), clinical investigations (116 studies), care in a multiple pregnancy (2 studies), psychosocial support (28 studies) and care in a subsequent pregnancy (14 studies). 391 unique outcomes were reported and organised into 14 outcome domains: labour and birth; postpartum; delivery of care; investigations; multiple pregnancy; mental health; emotional functioning; grief and bereavement; social functioning; relationship; whole person; subsequent pregnancy; subsequent children and siblings and economic. 242 outcome measurement instruments were used, with 0-22 tools per outcome. Conclusions Heterogeneity in outcome reporting, outcome definition and measurement tools in care after stillbirth exists. Considerable research gaps on specific intervention types in stillbirth care were identified. A core outcome set is needed to standardise outcome collection and reporting for stillbirth care research.

Background:Preterm labor is one of the most common pregnancy complications, and it can have catastrophic effects, including preterm birth and accompanying complications. This study’s objective is to compare the efficacy of Magnesium Sulfate and Indomethacin vs Magnesium Sulfate alone in avoiding preterm labor in pregnant women at Kosar Hospital in2019–2021. Methods:In this interventional study, which was conducted as a double-blind, randomized clinical trial on 200 pregnant women with gestational ages ranging from24to32weeks who were referred to Qazvin’s Kosar Hospital. Patients were divided into two equal groups and given magnesium sulfate and indomethacin (group A)or magnesium sulfate alone(group B).The data then was analyzed with SPSS statistical software and statistical tests. Results:According to the study’s findings, the average time interval between receiving the drug and childbirth in group A was774.71+505.91hours and in group B it was545.77+503.32hours,which was statistically significant (P0.05). Besides that, the mean gestational age at the time of pregnancy termination was35.30+250weeks in group A and35.03+2.65weeks in group B, which was not statistically significant (P>0.05).The type of intervention, on the other hand, had a significant relationship with the number of labors during the first 7 days after starting the drug (P >0.05). Conclusion:The results showed that magnesium sulfate and indomethacin were more effective than magnesium sulfate alone in inhibiting and delaying preterm labor.There were similarities in comparing the findings of our study with other studies. Keywords:Preterm labor,Magnesium Sulfate,Indomethacin Financial disclosures:None

Objectives: The aim of this study was to explore the associations of abdominal muscles thickness and inter-recti distance (IRD) at late pregnancy with birth-related outcomes and umbilical cord blood (CB) gas values. Design: cross-sectional study. Setting: Sport and Health University Research Institute Sample: One hundred and fifty-two pregnant women. Main outcome measures: The thickness of the abdominal muscles (transverse abdominis [TrA], internal [IO] and external obliques [EO]) and the IRD were measured by ultrasound at the 34th gestational week. Birth outcomes were collected from obstetric medical records. Umbilical CB gas concentrations were assessed after birth using a blood analyzer. Results: Greater TrA and IO thickness were associated with a higher venous CB PO2 value, both at muscular rest (respectively, p<0.01 and p<0.05) and during activation (both p<0.05). A greater activated TrA thickness was associated with a higher venous CB oxygen saturation (p<0.05). EO thickness at rest was positively related to arterial CB pH (p<0.05), and during activation to the 1-minute Apgar test (p<0.05). A greater IRD was associated with higher arterial (at rest p<0.01; during crunches p<0.05) and venous CB (at rest, p<0.05) PCO2 values, and with lower arterial CB PO2 (p<0.05), arterial CB oxygen saturation (at rest, p<0.05; during crunches p<0.01), and venous CB oxygen saturation (during crunches, p<0.05, and lower venous pH (p<0.05). Conclusion: Greater abdominal muscle thicknesses and a smaller IRD at late pregnancy are related to better umbilical CB gas values at birth. ClinicalTrials.gov Identifier: NCT02582567

Objective To study the patterns of glycemic status in response to Antenatal corticosteroid administered to women with risk of preterm delivery between 24 weeks and 36 weeks 6 days of gestation in normoglycemic subjects and to evaluate if maternal characteristics predicted the development of hyperglycemia Design : longitudinal study Participants : 76 antenatal women, normoglycemic status between 24 weeks and 36 week 6 days of gestation Methods : Antenatal women who screened negative for Gestational Diabetes Mellitus by 75 gm GTT who received Injection Betamethasone for risk of preterm delivery . Fasting and Postprandial blood sugar levels were recorded from day 1 to 7 after steroid administration. Results Forty seven out of seventy six patients had hyperglycemia of varying severity. Among the risk factors associated with hyperglycemia, age>25 years, family history ofdiabetes and hypertension and BMI >25 have statistically significant association with hyperglycemia. was Conclusion : Antenatal corticosteroids have proven benefit in reducing neonatal mortality and morbidity hence should be definitely administered as benefit outweigh sideeffects .Hyperglycemia can occur even in normoglycemic women after antenatal corticosteroids. Testing of all antenatal patients who are at risk for development of hyperglycemia especially in age group more than 25years, BMI over 25, hypertensive patients, family history of diabetes is recommended after ACS . KEY WORDS : GLYCEMIC STATUS, ANTENATAL STEROIDS

Short birth pregnancy intervals have been associated with adverse maternal outcomes like anemia, pre-eclampsia, eclampsia, puerperal infection and maternal mortality and other morbidities. Fetal outcome is preterm birth, low birth weight, IUGR, fetal or neonatal death. Prevention of short birth pregnancy interval can be achieved by post-partum contraception.

Objective: Preeclampsia (PE) is a leading cause of morbidity and mortality in pregnancy. This observational study aims to determine associations between oral and placental microbiome in women with and without preeclampsia and periodontal disease (PD) and evaluate systemic immune responses in patients with and without PE and PD. Population: Fifty-four pregnant patients with and without PE and PD were recruited. The microbiome profiles of both oral subgingival region and placenta were characterized by V4 region of 16S rRNA gene sequencing. Systemic inflammation markers tumor necrosis factor-alpha (TNF-α), C-reactive protein (CRP), lipopolysaccharide binding protein (LBP), interleukins 6 & 8 (IL-6, IL-8) in blood were measured by ELISA. Results: PD significantly increased the risk of PE after adjustments for age, preterm delivery and smoking status (OR=2.26, 95% CI=1.14-4.48, p=0.024). A group of oral associated bacteria Veilonella, Fusobacterium, Haemophilus, Granulicatella, Streptococcus, Gemella and Neisseria in placenta had significantly higher prevalence in women with PE compared to women without PE (53.8% vs 19.0%, p=0.018), the highest prevalence in patients with both PE and PD (58.8%). Relative abundances of Haemophilus, Veillonella and Fusobacterium in oral samples were significantly higher in patient with PE than those without PE. Proinflammation cytokine analysis showed that PE patients with PD had higher blood IL-8 levels than PE patients without PD (p=0.028). Conclusion: Oral-like microbiome was identified in placenta more frequently in patients with PE than those without PE. Placental microbiome is associated with systemic inflammation. High abundances of Haemophilus in oral cavity is associated with increased risk of PE.

Objective Studies have shown that chronobiological factors may adversely affect glycemic control in patients with type 2 diabetes mellitus (T2DM). Our objective was to assess the association of chronobiological disorders with glycemic control and neonatal birthweight in women with GDM. Design A prospective observational study was conducted. Setting Israel Population 208 women aged 18-45 years with a singleton pregnancy who were randomly selected from among women undergoing follow-up for GDM at the Maternal-Fetal Medicine Unit of a tertiary medical center in 2016 and 2017. Methods Nutrition, sleep, and lifestyle patterns were assessed from onset of GDM until birth along with glycemic control and obstetrical outcomes. Data were collected by structured interview and from the medical files. Main outcome measures Maternal glycemic control and large for gestational age (LGA) neonate. Results Multivariate analyses on a cohort of 208 women revealed suboptimal glycemic control which was associated with a late breakfast (RR=2.26; 95% CI 1.09-4.67). Any 10-g increase in carbohydrate intake in the evening increased the risk 1.19 times for suboptimal glycemic control (RR=1.19; 95% CI 1.003-1.42), and 2.14 times for poor sleep quality (RR=2.14; 95% CI 1.04-4.41). The adjusted relative risk for birthweight above the 85th percentile was associated with excessive of 10-g increase of carbohydrate intake in the morning (RR=1.70; 95%CI 1.30-2.23) and in the evening (RR=1.39; 95% CI 1.16-1.67). Conclusions Chronobiological disorders are associated with suboptimal glycemic control and large-for-gestational-age newborn in women with GDM.

Commentary

Abstract Objective: To determine the occurrence of sporadic and periodic accelerations during labour and odds ratio, OR, for acidaemia. Design: Case-control study. Setting: One regional and one university hospital. Sample: Cardiotocograms, CTGs, from 295 neonates with cord blood pH <7.05 born during the second stage of labour, 70 neonates with cord blood pH <7.10 born during the first stage and 731 controls with pH ≥7.15. Method: The last 30-60 minutes of CTG recordings before birth from 365 neonates born with acidaemia and from the corresponding stage in labour for 731 controls were scrutinized. Main outcome measures: Odds ratio with 95% confidence interval for acidaemia at birth. Results: During the first stage, sporadic accelerations were present in 16% of cases and 78% of controls; OR for acidaemia 0.05 (0.02-0.10). In the second stage the corresponding rates were 13% and 60%; OR 0.09 (0.06-0.14). Isolated periodic accelerations were infrequent. A weak negative association with acidaemia was found in the second stage; OR 0.51 (0.30-0.86), whereas it was not significant in the first stage; OR 0.24 (0.04-1.4). Less than two sporadic accelerations were associated with an increased risk of acidaemia despite normal fetal heart rate variability (5-25 beats per minute, OR 10.3 (7.2-14.8)). Conclusions: Sporadic accelerations indicate a very low probability of acidosis but are absent in 40% of fetuses with normal pH during a 30-60 minutes second stage recording. Tweetable abstract: Sporadic, but not periodic, accelerations indicate normal fetal pH. This should be a part of CTG guidelines.

Objective: We previously described a technique for repair of the myometrial defect at repeat Caesarean section which increases residual myometrial thickness thereby potentially reducing future niche-related complications. Here we describe how this technique can be modified for use for placenta accreta spectrum disorders. Design: Comparison of surgical performance of the modified technique with peripartum hysterectomy in women having repeat Caesarean delivery for placenta accreta Setting: A two year retrospective case control study at a tertiary unit in Singapore. Population: All women with placenta accreta spectrum disorder between December 2019 and October 2021. Methods: After delivery through the isthmocele women either underwent the modified technique which comprised uterine exteriorisation, systematic placental removal initiated from the posterior uterine wall, identification, mobilization and apposition of the boundaries of myometrial defects and repair or peripartum hysterectomy. Main Outcome Measures: Operating time, estimated blood loss and complication rate. Results: Ten women had Caesarean hysterectomy and ten had Caesarean section using the modified approach. Age and gestational age at delivery were similar for the two groups. Women in the modified technique group had had fewer prior Caesarean sections and had a lower body mass index. Operating time, estimated blood loss and need for transfusion were lower in the myometrial repair group but without statistical significance and there were no visceral injuries. There was one bladder injury in the hysterectomy group. Conclusion: The modified approach provides an effective alternative to peripartum hysterectomy with favourable surgical profile and allows uterine conservation with restoration of myometrial thickness.

Background Antenatal corticosteroids (ACS) are recommended in threatened preterm labour to improve short term neonatal outcome. Preclinical animal studies suggest detrimental effects of ACS exposure on offspring cardiac development; their effects in humans are unknown. Objectives To systematically review the human clinical literature to determine the effects of ACS on offspring cardiovascular function. Main results Twenty-six studies including 1921 patients were included, of which most were cohort studies of mixed quality. The type of ACS exposure, gestational age at exposure, dose and number of administrations varied widely. Offspring cardiovascular outcomes were assessed from one day to 36 years postnatally. The most commonly assessed parameter was arterial blood pressure (18 studies), followed by echocardiography (8 studies), heart rate (5 studies), electrocardiogram (ECG, 3 studies) and cardiac magnetic resonance imaging (MRI, 1 study). There were no clinically significant effects of ACS exposure on offspring blood pressure. However, there were insufficient studies assessing cardiac structure and function using echocardiography or cardiac MRI to be able to determine an effect. Conclusions Administration of ACS is not associated with long-term effects on blood pressure in exposed human offspring. The effects on cardiac structure and other measures of cardiac function were unclear due to the small number of studies, study heterogeneity and mixed quality. Given the emerging preclinical evidence of harm following ACS exposure, there is a need for further research to assess central cardiac function in human offspring exposed to ACS. Keywords: Antenatal corticosteroids, ACS, cardiovascular, offspring, blood pressure