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American Journal of Obstetrics &... Aug 2020To evaluate reported outcomes of published studies on the diagnosis and management of vasa previa in pregnancy. (Review)
Review
OBJECTIVE
To evaluate reported outcomes of published studies on the diagnosis and management of vasa previa in pregnancy.
MATERIALS AND METHODS
Databases such as MEDLINE, Embase, Cochrane, PubMed, and ClinicalTrials.gov were searched up to March 2018 for all published studies on vasa previa using combinations of the following medical subject headings and key words: vasa previa, placenta previa, low-lying placenta, succenturiate lobe or placenta, bilobed or bilobate placenta, and velamentous insertion. All original human research that described maternal, obstetric, placental, fetal or neonatal outcomes relating to pregnancies with vasa previa were included for analysis. Title and abstract screening and data extraction was conducted independently and in duplicate by 2 reviewers for all studies until total agreement for eligibility was achieved. Data extraction was also conducted in duplicate in approximately 50% of studies reviewed.
RESULTS
A total of 160 published studies (1004 pregnancies) were included. There was a wide range of reported outcomes, many of which were sparingly reported. The most commonly reported maternal outcomes included mode of delivery, presence of antepartum hemorrhage, time of diagnosis, and rupture of membranes. The presence of known risk factors for vasa previa such as a low-lying placenta, succenturiate or bilobed placenta, and (velamentous) cord insertion was incorrectly reported as "outcomes" in many studies. The most commonly reported fetal/neonatal outcomes included fetal heart rate, gestational age at delivery, birthweight, Apgar score, presence of neonatal anemia, cord blood gas measurements, need for blood transfusion, and death. Of note, only 3 studies reported outcomes related to life impact, maternal social and emotional functioning, perceived delivery of care, or resource utilization.
CONCLUSION
Despite the profound effect the diagnosis of vasa previa has on pregnant women, families, and healthcare systems, studies on vasa previa seldom report outcomes related to life impact and resource utilization. There is a need for the development of a core outcome set-a minimum standard set of outcomes deemed important by pregnant women and other stakeholders involved in their care-to standardize outcome reporting in future studies on vasa previa.
Topics: Female; Gestational Age; Humans; Infant, Newborn; Patient Reported Outcome Measures; Placenta; Placenta Previa; Pregnancy; Vasa Previa
PubMed: 33345867
DOI: 10.1016/j.ajogmf.2020.100116 -
Obstetrics and Gynecology Sep 2023To determine the causes and potential preventability of perinatal deaths in prenatally identified cases of vasa previa.
OBJECTIVE
To determine the causes and potential preventability of perinatal deaths in prenatally identified cases of vasa previa.
DATA SOURCES
Reports of prenatally identified cases of vasa previa published in the English language literature since 2000 were identified in Medline and ClinicalTrials.gov with the search terms "vasa previa," "abnormal cord insertion," "velamentous cord," "marginal cord," "bilobed placenta," and "succenturiate lobe."
METHODS OF STUDY SELECTION
All cases from the above search with an antenatally diagnosed vasa previa present at delivery in singleton or twin gestations with perinatal mortality information were included.
TABULATION, INTEGRATION, AND RESULTS
Cases meeting inclusion criteria were manually abstracted, and multiple antenatal, intrapartum, and outcome variables were recorded. Deaths and cases requiring neonatal transfusion were analyzed in relation to plurality, routine hospitalization, and cervical length monitoring. A total of 1,109 prenatally diagnosed cases (1,000 singletons, 109 twins) were identified with a perinatal mortality rate attributable to vasa previa of 1.1% (95% CI 0.6-1.9%). All perinatal deaths occurred with unscheduled deliveries. The perinatal mortality rate in twin pregnancies was markedly higher than that in singleton pregnancies (9.2% vs 0.2%, P <.001), accounting for 80% of overall mortality despite encompassing only 9.8% of births. Compared with individuals with singleton pregnancies, those with twin pregnancies are more likely to undergo unscheduled delivery (56.4% vs 35.1%, P =.01) despite delivering 2 weeks earlier (33.2 weeks vs 35.1 weeks, P =.006). An institutional policy of routine hospitalization is associated with a reduced need for neonatal transfusion (0.9% vs 6.0%, P <.001) and a reduction in the perinatal mortality rate in twin pregnancies (0% vs 25%, P =.002) but not in singleton pregnancies (0% vs 0.5%, P =.31).
CONCLUSION
Routine hospitalization and earlier delivery of twins may result in a reduction in the perinatal mortality rate. A smaller benefit from routine admission of individuals with singleton pregnancies cannot be excluded. There is currently insufficient evidence to recommend the routine use of cervical length measurements to guide clinical management.
Topics: Infant, Newborn; Pregnancy; Female; Humans; Vasa Previa; Perinatal Death; Perinatal Mortality; Retrospective Studies; Prenatal Diagnosis; Pregnancy, Twin; Ultrasonography, Prenatal
PubMed: 37535966
DOI: 10.1097/AOG.0000000000005296 -
BJOG : An International Journal of... Jul 2016Vasa praevia (VP) is a rare phenomenon that is assumed to increase the risk of severe complications, including fetal death. Critical data on its incidence are lacking,... (Review)
Review
BACKGROUND
Vasa praevia (VP) is a rare phenomenon that is assumed to increase the risk of severe complications, including fetal death. Critical data on its incidence are lacking, so there is no rational basis for prenatal screening.
OBJECTIVES
To review the literature on the incidence and risk indicators for VP.
SEARCH STRATEGY
We searched OVID MEDLINE, OVID EMBASE, the Cochrane Library and PubMed for case-control and cohort studies on incidence and risk indicators for VP.
SELECTION CRITERIA
Two reviewers selected studies and scored their methodological quality.
DATA COLLECTION AND ANALYSIS
We calculated the mean incidence of VP. We constructed 2 × 2 tables cross-classifying potential risk indicators against the incidence of VP to calculate common odds ratios and 95% confidence intervals, using the Mantel-Haenszel method.
MAIN RESULTS
We included 13 studies (two prospective cohort studies, ten retrospective cohort studies and one case-control study) reporting on 569 410 patients with 325 cases of VP. Based on ten included cohort studies providing information on the incidence, the mean incidence of VP was 0.60 per 1000 pregnancies. We identified five different risk indicators and markers for VP: second-trimester placenta praevia, conception by assisted reproductive technologies, a bilobed or succenturiate placenta, umbilical cord insertion in the lower third part of the uterus at first-trimester ultrasound and velamentous cord insertion. Almost 83% of the cases of VP had one or more risk indicators.
AUTHORS' CONCLUSIONS
In view of the low incidence, screening for VP in an unselected population is not advised. Targeted screening of women with one or more risk indicators as a part of routine mid-gestation scanning should be considered.
TWEETABLE ABSTRACT
Vasa praevia is more common in placenta praevia, conception by ART, velamentous cord insertion and bilobed placenta.
Topics: Female; Humans; Odds Ratio; Placenta; Placenta Previa; Pregnancy; Pregnancy Trimester, First; Pregnancy Trimester, Second; Reproductive Techniques, Assisted; Risk; Risk Assessment; Ultrasonography, Prenatal; Umbilical Cord; Vasa Previa
PubMed: 26694639
DOI: 10.1111/1471-0528.13829 -
American Journal of Obstetrics and... Jun 2017Twin pregnancies are at higher risks of velamentous cord insertion and vasa previa. In vitro fertilization is an additional risk factor of abnormal cord insertion and... (Review)
Review
BACKGROUND
Twin pregnancies are at higher risks of velamentous cord insertion and vasa previa. In vitro fertilization is an additional risk factor of abnormal cord insertion and thus the incidence of vasa previa is likely to increase over the next decades.
OBJECTIVE
We sought to evaluate the role of ultrasound imaging in optimizing the management of twins diagnosed with vasa previa antenatally.
STUDY DESIGN
We searched our database for twin pregnancies diagnosed with vasa previa and managed antenatally using measurements of cervical length and performed a systematic review of articles that correlated prenatal diagnosis of vasa previa in twins and pregnancy outcome. PubMed and MEDLINE were searched for studies published from 1987 through October 20, 2016, using specific medical subject heading terms, key words, and their combination. The primary eligibility criteria were articles that correlated prenatal ultrasound imaging of vasa previa and pregnancy outcome in twins. The secondary eligibility criteria was the use of cervical length in the management of twin pregnancies diagnosed antenatally with vasa previa. Two authors independently assessed inclusion criteria, data extraction, and analysis. The final selection included 3 case report series, 9 retrospective cohort studies, and 1 retrospective case-control study of vasa previa diagnosed prenatally and confirmed at birth in twin pregnancies.
RESULTS
The search of our databases identified 6 cases of dichorionic-diamniotic twins and 1 case of monochorionic-diamniotic twins diagnosed prenatally with vasa previa between 22-29 weeks and managed using cervical length. Two cases were delivered by emergency because of rapid changes in cervical length in one and bleeding on placenta previa in the other at 33 and 30 weeks, respectively. The systematic review identified data on 56 cases. The incidence of twin pregnancies diagnosed antenatally with vasa previa in the cohort and case-control studies was 11.0%. Data on chorionicity were available in only 34 cases and cervical length measurements were used by only the authors of 2 case reports and 4 cohort studies. Velamentous cord insertion was the most common additional ultrasound findings in twins presenting with vasa previa in both our series and the systematic review.
CONCLUSION
Vasa previa is associated with specific prenatal and obstetric complications with different outcomes in singletons compared to twins. Data on the diagnosis and management of vasa previa in twin pregnancies are limited but there is enough evidence to warrant guidelines for targeted screening. To enable the development of efficient management protocols tailored to the need of individual cases, future studies of the screening, diagnosis, and management of vasa previa should be prospective and multicentric with detailed data on twins including chorionicity and use of cervical length.
Topics: Case-Control Studies; Cervix Uteri; Chorion; Cohort Studies; Diseases in Twins; Female; Gestational Age; Humans; MEDLINE; Pregnancy; Pregnancy Complications; Pregnancy Outcome; Pregnancy, Twin; Prenatal Diagnosis; Retrospective Studies; Ultrasonography, Prenatal; Vasa Previa
PubMed: 28153653
DOI: 10.1016/j.ajog.2017.01.029 -
Biomedicines Jul 2022Abnormal cord insertion (ACI) is associated with adverse obstetric outcomes; however, the relationship between ACI and assisted reproductive technology (ART) has not... (Review)
Review
Abnormal cord insertion (ACI) is associated with adverse obstetric outcomes; however, the relationship between ACI and assisted reproductive technology (ART) has not been examined in a meta-analysis. This study examines the association between ACI and ART, and delivery outcomes of women with ACI. A systematic review was conducted, and 16 studies (1990-2021) met the inclusion criteria. In the unadjusted pooled analysis ( = 10), ART was correlated with a higher rate of velamentous cord insertion (VCI) (odds ratio (OR) 2.14, 95% confidence interval (CI) 1.64-2.79), marginal cord insertion ( = 6; OR 1.58, 95%CI 1.26-1.99), and vasa previa ( = 1; OR 10.96, 95%CI 2.94-40.89). Nevertheless, the VCI rate was similar among the different ART types (blastocyst cleavage-stage transfer and frozen fresh embryo transfer). Regarding the cesarean delivery (CD) rate, women with VCI were more likely to have elective ( = 3; OR 1.13, 95%CI 1.04-1.22) and emergent CD ( = 5; OR 1.93, 95%CI 1.82-2.03). In conclusion, ART may be correlated with an increased prevalence of ACI. However, most studies could not exclude confounding factors; thus, further studies are warranted to characterize ART as a risk factor for ACI. In women with ACI, elective and emergent CD rates are high.
PubMed: 35885027
DOI: 10.3390/biomedicines10071722 -
European Journal of Obstetrics,... Feb 2024Vasa praevia is a serious pregnancy complication that is potentially life-threatening for the fetus. The possible benefits of prophylactic hospital admission of... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Vasa praevia is a serious pregnancy complication that is potentially life-threatening for the fetus. The possible benefits of prophylactic hospital admission of asymptomatic women diagnosed with vasa praevia antenatally remain unclear. This study aims to compare the pregnancy outcomes of inpatient versus outpatient management in women with a prenatal diagnosis of vasa praevia.
METHODS
A systematic search of four electronic databases was conducted and two reviewers independently screened studies for eligibility. The inclusion criteria incorporated studies with prenatally diagnosed vasa praevia, a distinction on whether women were managed as inpatients and/or outpatients and where perinatal mortality was recorded as an outcome. The primary outcome of the study was perinatal mortality with additional outcomes of perinatal morbidity, need for emergency caesarean and antenatal steroid administration. Reporting of the results followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines.
RESULTS
The search produced 2,300 studies with ten of these studies included in the qualitative synthesis and four included in the quantitative analysis. There was no significant difference in perinatal mortality (OR 1.12, 95 % CI 0.10-12.07, p = 0.93, I = 0 %) or morbidity between women managed as inpatients or outpatients. The prophylactic inpatient group had higher rates of earlier gestational delivery and antenatal corticosteroid administration (OR 10.78, 95 % CI 1.07-108.74, p = 0.04, I = 82 %), but lower rates of emergency caesareans (OR 0.35, 95 % CI 0.17-0.72, p = 0.004, I = 0 %).
CONCLUSION
There were no significant differences in perinatal mortality or morbidity rates observed between inpatient and outpatient management of asymptomatic women with antenatally diagnosed vasa praevia. However, outpatient management is associated with prolonged gestation, a decrease in antenatal corticosteroid administration, and higher odds of emergency caesarean. Outpatient management of prenatally diagnosed vasa praevia seems appropriate for carefully selected asymptomatic women.
Topics: Pregnancy; Female; Humans; Vasa Previa; Outpatients; Inpatients; Prenatal Diagnosis; Perinatal Death; Adrenal Cortex Hormones
PubMed: 38057179
DOI: 10.1016/j.ejogrb.2023.11.033 -
American Journal of Obstetrics and... Oct 2015We sought to evaluate the extent of the association between placental implantation abnormalities (PIA) and preterm delivery in singleton gestations. We conducted a... (Meta-Analysis)
Meta-Analysis Review
We sought to evaluate the extent of the association between placental implantation abnormalities (PIA) and preterm delivery in singleton gestations. We conducted a systematic review of English-language articles published from 1980 onward using PubMed, MEDLINE, EMBASE, CINAHL, LILACS, and Google Scholar, and by identifying studies cited in the references of published articles. Search terms were PIA defined as ≥ 1 of the following: placenta previa, placenta accreta, vasa previa, and velamentous cord insertion. Observational and experimental studies were included for review if data were available regarding any of the aforementioned PIA and regarding gestational age at delivery or preterm delivery. Case reports and case series were excluded. Studies were reviewed and data extracted. The primary outcome was gestational age at delivery or preterm delivery <37 weeks' gestation. Secondary outcomes included birthweight, 1- and 5-minute Apgar scores, neonatal intensive care unit (NICU) admission, neonatal and perinatal death, and small for gestational age. Of the 1421 studies identified, 79 met the defined criteria; 56 studies were descriptive and 23 were comparative. Based on the descriptive studies, the preterm delivery rates for low-lying/marginal placenta, placenta previa, placenta accreta, vasa previa, and velamentous cord insertion were 26.9%, 43.5%, 57.7%, 81.9%, and 37.5%, respectively. Based on the comparative studies using controls, there was decreased pregnancy duration for every PIA; more specifically, there was an increased risk for preterm delivery in patients with placenta previa (risk ratio [RR], 5.32; 95% confidence interval [CI], 4.39-6.45), vasa previa (RR, 3.36; 95% CI, 2.76-4.09), and velamentous cord insertion (RR, 1.95; 95% CI, 1.67-2.28). Risks of NICU admissions (RR, 4.09; 95% CI, 2.80-5.97), neonatal death (RR, 5.44; 95% CI, 3.03-9.78), and perinatal death (RR, 3.01; 95% CI, 1.41-6.43) were higher with placenta previa. Perinatal risks were also higher in patients with vasa previa (perinatal death rate RR, 4.52; 95% CI, 2.77-7.39) and velamentous cord insertion (NICU admissions [RR, 1.76; 95% CI, 1.68-1.84], small for gestational age [RR, 1.69; 95% CI, 1.56-1.82], and perinatal death [RR, 2.15; 95% CI, 1.84-2.52]). In singleton gestations, there is a strong association between PIA and preterm delivery resulting in significant perinatal morbidity and mortality.
Topics: Apgar Score; Birth Weight; Female; Gestational Age; Humans; Infant, Newborn; Infant, Small for Gestational Age; Intensive Care, Neonatal; Perinatal Death; Placenta Accreta; Placenta Diseases; Placenta Previa; Pregnancy; Premature Birth; Risk Factors; Vasa Previa
PubMed: 26428506
DOI: 10.1016/j.ajog.2015.05.058 -
American Journal of Obstetrics &... Feb 2023Velamentous cord insertion may be identified prenatally, but the clinical implications of this diagnosis remain controversial. This meta-analysis aimed to quantitatively... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
Velamentous cord insertion may be identified prenatally, but the clinical implications of this diagnosis remain controversial. This meta-analysis aimed to quantitatively summarize current data on the association of velamentous cord insertion and adverse perinatal outcomes.
DATA SOURCES
A systematic search was performed in MEDLINE, Scopus, and the Cochrane Library from inception until May 22, 2022 to identify eligible studies.
STUDY ELIGIBILITY CRITERIA
Observational studies including singleton pregnancies with velamentous cord insertion, either prenatally or postnatally identified, and comparing them with those with central/eccentric cord insertion were considered eligible.
METHODS
The quality of the studies was assessed with the Newcastle-Ottawa scale and the risk of bias with the Quality In Prognosis Studies (QUIPS) tool. The main outcome was small-for-gestational-age neonates. Heterogeneity of the studies was evaluated using a Q test and an I index. Analyses were performed using a random-effects model, with outcome data reported as relative risk or mean difference with 95% confidence interval.
RESULTS
In total, 9 cohort and 2 case-control studies, of which 4 had prenatal and 7 had postnatal velamentous cord insertion diagnosis, were included. The overall prevalence of velamentous cord insertion was estimated to be 1.4% among singleton pregnancies. Compared with the central/eccentric cord insertion control group, pregnancies with velamentous cord insertion were at higher risk of several adverse perinatal outcomes, namely small-for-gestational-age neonates (relative risk, 1.93; 95% confidence interval, 1.54-2.41), preeclampsia (relative risk, 1.85; 95% confidence interval, 1.01-3.39), pregnancy-induced hypertension (relative risk, 1.58; 95% confidence interval, 1.46-1.70), stillbirth (relative risk, 4.12; 95% confidence interval, 1.92-8.87), placental abruption (relative risk, 2.94; 95% confidence interval, 1.72-5.03), preterm delivery (relative risk, 2.14; 95% confidence interval, 1.73-2.65), emergency cesarean delivery (relative risk, 2.03; 95% confidence interval, 1.22-3.38), 1-minute Apgar score <7 (relative risk, 1.53; 95% confidence interval, 1.14-2.05), 5-minute Apgar score <7 (relative risk, 1.97; 95% confidence interval, 1.43-2.71), and neonatal intensive care unit admission (relative risk, 1.63; 95% confidence interval, 1.32-2.02). In a subgroup analysis, prenatally diagnosed velamentous cord insertion was associated with small-for-gestational-age neonates (relative risk, 1.66; 95% confidence interval, 1.19-2.32), stillbirth (relative risk, 4.78; 95% confidence interval, 1.42-16.08), and preterm delivery (relative risk, 2.69; 95% confidence interval, 2.01-3.60). In a sensitivity analysis of studies excluding cases with vasa previa, velamentous cord insertion was associated with an increased risk of small-for-gestational-age neonates (relative risk, 2.69; 95% confidence interval, 1.73-4.17), pregnancy-induced hypertension (relative risk, 1.94; 95% confidence interval, 1.24-3.01), and stillbirth (relative risk, 9.42; 95% confidence interval, 3.19-27.76), but not preterm delivery (relative risk, 1.92; 95% confidence interval, 0.82-4.54).
CONCLUSION
Velamentous cord insertion is associated with several adverse perinatal outcomes, including stillbirth, and these associations persist when only prenatally diagnosed cases are considered and when vasa previa cases are excluded. According to these findings, the exact pathophysiology should be further investigated and an effective prenatal monitoring plan should be developed.
Topics: Infant, Newborn; Pregnancy; Female; Humans; Vasa Previa; Pregnancy Outcome; Stillbirth; Hypertension, Pregnancy-Induced; Placenta; Premature Birth; Fetal Growth Retardation
PubMed: 36379439
DOI: 10.1016/j.ajogmf.2022.100812 -
Obstetrics and Gynecology Feb 2024
Topics: Female; Humans; Pregnancy; Perinatal Death; Perinatal Mortality; Prenatal Diagnosis; Vasa Previa
PubMed: 38237163
DOI: 10.1097/AOG.0000000000005486 -
British Journal of Sports Medicine Dec 2020Clinical guidelines recommend pregnant women without contraindication engage in regular physical activity. This is based on extensive evidence demonstrating the safety...
BACKGROUND
Clinical guidelines recommend pregnant women without contraindication engage in regular physical activity. This is based on extensive evidence demonstrating the safety and benefits of prenatal exercise. However, certain medical conditions or contraindications warrant a reduction, modification or cessation of activity due to potential health risks.
AIM
To review and evaluate the evidence related to medical disorders which may warrant contraindication to prenatal exercise.
METHODS
Online databases were searched up to 5 April 2019. Forty-four unique studies that reported data on our Population (pregnant women with contraindication to exercise), Intervention (subjective/objective measures of acute or chronic exercise), Comparator (not essential) and Outcomes (adverse maternal or fetal outcomes) were included in the review.
KEY FINDINGS
We found that the majority of medical conditions listed as contraindications were based on expert opinion; there is minimal empirical evidence to demonstrate harm of exercise and benefit of activity restriction. We identified 11 complications (eg, gestational hypertension, twin pregnancy) previously classified as contraindications where women may in fact benefit from regular prenatal physical activity with or without modifications. However, the evidence suggests that severe cardiorespiratory disease, placental abruption, vasa previa, uncontrolled type 1 diabetes, intrauterine growth restriction, active preterm labour, severe pre-eclampsia and cervical insufficiency are associated with strong potential for maternal/fetal harm and warrant classification as absolute contraindications.
CONCLUSION
Based on empirical evidence, we provide a call to re-evaluate clinical guidelines related to medical disorders that have previously been considered contraindications to prenatal exercise. Removing barriers to physical activity during pregnancy for women with certain medical conditions may in fact be beneficial for maternal-fetal health outcomes.
Topics: Contraindications; Exercise; Female; Humans; Practice Guidelines as Topic; Pregnancy; Pregnancy Complications; Prenatal Care
PubMed: 32513676
DOI: 10.1136/bjsports-2020-102042