ObjectiveTo determine accurate estimates of risks of maternal and neonatal complications in pregnancies with fetal macrosomia by performing a systematic review of the literature and meta-analysis.Methods A search of MEDLINE, EMBASE, CINAHL and The Cochrane Library was performed to identify relevant studies reporting on maternal and/or neonatal complications in pregnancies with macrosomia having a birth weight (BW) > 4000 g and/or those with birth weight > 4500 g. Prospective and retrospective cohort and population-based studies that provided data regarding both cases and controls were included. Maternal outcomes assessed were emergency Cesarean section (CS), postpartum hemorrhage (PPH) and obstetric anal sphincter injury (OASIS). Neonatal outcomes assessed were shoulder dystocia, obstetric brachial plexus injury (OBPI) and birth fractures. Meta-analysis using a random-effects model was used to estimate weighted pooled estimates of summary statistics (odds ratio (OR) and 95% CI) for each complication, according to birth weight. Heterogeneity between studies was estimated using Cochran's Q, I 2 statistic and funnel plots.Results Seventeen studies reporting data on maternal and/or neonatal complications in pregnancy with macrosomia were included. In pregnancies with macrosomia having a BW > 4000 g, there was an increased risk of the maternal complications: emergency CS, PPH and OASIS, which had OR (95% CI) Complicaciones maternas y neonatales de la macrosomía fetal: revisión sistemática y metaanálisis RESUMEN Objetivo Determinar estimaciones precisas de los riesgos de complicaciones maternas y neonatales en embarazos con macrosomía fetal mediante la realización de una revisión sistemática de la literatura y un metaanálisis.Métodos Se realizó una búsqueda en MEDLINE, EMBASE, CINAHL y The Cochrane Library para identificar estudios relevantes que informaron sobre complicaciones maternas y/o neonatales en embarazos con macrosomía con un peso al nacer (PN) >4000 g y/o aquellos con un peso al nacer >4500 g. Se incluyeron estudios de cohortes prospectivos y retrospectivos y estudios basados en la población que proporcionaron datos con respecto a los casos y controles. Las medidas maternas de resultados evaluadas fueron la cesárea de urgencia (CU), la hemorragia posparto (HPP) y la lesión obstétrica del esfínter anal (LOEA). Los resultados neonatales evaluados fueron distocia de hombro, lesión obstétrica del plexo braquial (LOPB) y fracturas de nacimiento. Se utilizó un metaanálisis con un modelo de efectos aleatorios para estimar las estimaciones agrupadas ponderadas de los estadísticos resumen (razones de momios [RM] y IC del 95%) para cada complicación, según el peso al nacer. La heterogeneidad entre estudios se estimó mediante la prueba estadística Q de Cochran, la prueba estadística I 2 y gráficos de embudo.Resultados Se incluyeron 17 estudios que reportaron datos sobre las complicaciones maternas y/o neonatales en embarazos con macrosomía. En aquellos con un PN >4000 g, hubo un mayor riesgo de complicaciones maternas:...
CONTRIBUTION What are the novel findings of this work?This study has demonstrated the feasibility of introducing a two-stage screening program for diagnosis of vasa previa based on transvaginal sonography at 20-22 weeks' gestation for pregnancies with velamentous cord insertion at the routine 11-13-week scan and those with low-lying placenta at the routine 20-22-week scan. What are the clinical implications of this work?Accurate and effective prenatal diagnosis of pregnancies with vasa previa can be achieved by a two-stage screening protocol. Appropriate monitoring and delivery of such pregnancies can potentially reduce the overall rate of stillbirth by about 10%. ABSTRACTObjectives To examine the feasibility and effectiveness of a two-stage ultrasound screening strategy for detection of vasa previa and to estimate the potential impact of screening on prevention of stillbirth.Methods This was a retrospective study of data from prospective screening for vasa previa in singleton pregnancies, undertaken at the Fetal Medicine Unit at Medway Maritime Hospital, UK, between 2012 and 2018. Women booked for prenatal care and delivery in our hospital had routine ultrasound examinations at 11-13 and 20-22 weeks' gestation. Those with velamentous cord insertion at the inferior part of the placenta at the first-trimester scan and those with low-lying placenta at the second-trimester scan were classified as high-risk for vasa previa and had transvaginal sonography searching specifically for vasa previa, at the time of the 20-22-week scan. The management and outcome of cases with suspected vasa previa is described. We excluded cases of miscarriage or termination at < 24 weeks' gestation. ResultsThe study population of 26 830 singleton pregnancies included 21 (0.08%; 1 in 1278) with vasa previa. In all cases of vasa previa, the diagnosis was made at the 20-22-week scan and confirmed postnatally by gross and histological examination of the placenta. At the 11-13-week scan, cord insertion was classified as central in 25 071 (93.4%) cases, marginal in 1680 (6.3%), and velamentous in 79 (0.3%). In 16 (76.2%) of the 21 cases of vasa previa, cord insertion at the first-trimester scan was classified as velamentous at the inferior part of the placenta, in two cases (9.5%) as marginal and in three cases (14.3%) as central. The 21 cases of vasa previa were managed on an outpatient basis with serial scans for measurement of cervical length and elective Cesarean section at 34 weeks' gestation; all babies were liveborn but there was one neonatal death. In the study population, there were 83 stillbirths, none of which had evidence of vasa previa on postnatal examination. On the assumption that, if we had not diagnosed prenatally all 21 cases of vasa previa in our population, half of these cases would have resulted in stillbirth, then the potential impact of screening is prevention of 10.6% (10/94) of stillbirths.Conclusion A two-stage strategy of screening for vasa previa can be incorporated into routine clinical practice, and such a strategy...
Objective To estimate the risks of maternal and neonatal complications in pregnancies with macrosomia. Methods This was a retrospective cohort study conducted at a large maternity unit in the UK between January 2009 and December 2016. The incidence of maternal and neonatal complications in pregnancies with macrosomia, defined as birth weight (BW) > 4000 g, and in those with severe macrosomia, defined as BW > 4500 g, was compared with that in pregnancies with normal BW (2500-4000 g). Regression analysis was performed to determine odds ratios (ORs) for complications in macrosomic pregnancies compared to those with normal BW.
To derive accurate estimates of perinatal survival in pregnancies with and without a prenatal diagnosis of vasa praevia from a systematic review of literature and meta-analysis. Methods: A search of MEDLINE, EMBASE and CINHAL was performed to review relevant citations reporting perinatal outcomes in pregnancies with vasa praevia. We selected prospective and retrospective cohort and population studies that provided data regarding both women with and without prenatal diagnosis of vasa praevia. Meta-analysis using random effects model was used to derive weighted pooled estimates of perinatal survival [(95% confidence intervals (CI)]. Incidence rate difference (IRD) meta-analysis was used to estimate the significance of difference in pooled proportions. Heterogeneity between studies was estimated using Cochrane's Q and I 2 statistic. Results: There were 21 studies reporting pregnancy outcome in 683 pregnancies with a prenatal diagnosis of vasa praevia of which there were 3 stillbirths (1.01%; 95% CI: 0.40-1.87), 5 neonatal deaths (1.19%; 95% CI: 0.52-2.12), with 675 neonates who survived with a pooled estimate for perinatal survival of 98.6% (95%CI: 97.6-99.3). Data from seven studies including cases with and without prenatal diagnosis showed that the pooled perinatal survival in cases without prenatal diagnosis (61/118) was 72.1% (95%CI: 50.6-89.4), vs. 98.6% (95%CI: 96.7-99.7) in cases with a prenatal diagnosis (224/226). Therefore, the risk of perinatal death was 25-fold higher, if a prenatal diagnosis of vasa praevia was not made antenatally, compared to when it was (OR 25.39; 95% CI: 7.93-81.31). Similar to perinatal deaths, in pregnancies without a prenatal diagnosis, the risk of hypoxic morbidity is increased 50-fold compared to those with a prenatal diagnosis (36/61 without prenatal diagnosis vs. 5/224 with prenatal diagnosis; OR 50.09; 95% CI: 17.33-144.79); the intact perinatal survival in those without a prenatal diagnosis is significantly lower compared to when a prenatal diagnosis is made [28.1% (95%CI: 14.1-44.728.1%) vs. 96.7% (95%CI: 95%CI: 93.6-98.8) (IRD 73.4% (95%CI: 53.9-92.7), Z=-7.4066; p<0.001). Conclusion: Prenatal diagnosis of vasa praevia is associated with a high rate of perinatal survival whereas lack of such an antenatal diagnosis significantly increases the risk of perinatal death and handicap. Further research studies should be undertaken to investigate strategies for incorporating prenatal screening for vasa praevia in routine clinical practice.
(Abstracted from Ultrasound Obstet Gynecol 2019;54:308–318) Pregnancy involving fetal macrosomia (defined as birth weight >4000 g) has been associated with significant adverse outcomes to both mother and child. However, accurate estimates of these risks in the literature are limited, and guidelines are lacking from professional bodies.
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