OBJECTIVE: A recent European randomized trial - Tracheal Occlusion To Accelerate Lung Growth - demonstrated that fetoscopic endoluminal tracheal occlusion (FETO) is associated with increased postnatal survival among infants with severe congenital diaphragmatic hernia (CDH). However, this differs in middle-income countries such as Brazil, where abortion is illegal and neonatal intensive care is inadequate. This study evaluated the effects of FETO on improving the survival of infants with moderate-to-severe CDH in isolated and non-isolated cases.
METHODS: This retrospective cohort study selected 49 fetuses with CDH, a normal karyotype, and a lung-to-head ratio (LHR) of <1 from a single national referral center for fetal surgery in São Paulo, Brazil, between January 2016 and November 2019. FETO was performed between 26 and 29 weeks of gestation. The primary outcomes were infant survival until discharge from the neonatal intensive care unit and survival until six months of age.
RESULTS: Forty-six women with singleton fetuses having severe CDH underwent prenatal intervention with FETO. Infant survival rates until discharge and at six months of age were both 38 %. The observed-to-expected LHR increased by 25 % after FETO in neonates who survived until discharge. Spontaneous intrauterine death occurred in four growth-restricted fetuses after FETO. Preterm birth in <37 weeks and preterm rupture of membranes in <34 weeks occurred in 56.5 % (26) and 26 % (12) cases, respectively.
CONCLUSIONS: FETO may increase neonatal survival in fetuses with severe CDH, particularly in countries with limited neonatal intensive care.

Because selective termination for discordant dichorionic twin anomalies carries a risk of pregnancy loss, deferring the procedure until the third trimester can be considered in settings where it is legal.
To determine whether perinatal outcomes were more favorable following deferred rather than immediate selective termination.
A French multicenter retrospective study from 2012 to 2023 on dichorionic twin pregnancies with selective termination for fetal conditions, which were diagnosed before 24 weeks gestation. Pregnancies with additional risk factors for late miscarriage were excluded. We defined 2 groups according to the intention to perform selective termination within 2 weeks after the diagnosis of the severe fetal anomaly was established (immediate selective termination) or to wait until the third trimester (deferred selective termination). The primary outcome was perinatal survival at 28 days of life. Secondary outcomes were pregnancy losses before 24 weeks gestation and preterm delivery.
Of 390 pregnancies, 258 were in the immediate selective termination group and 132 in the deferred selective termination group. Baseline characteristics were similar in both groups. Overall survival of the healthy co-twin was 93.8% (242/258) in the immediate selective termination group vs 100% (132/132) in the deferred selective termination group (P<.01). Preterm birth <37 weeks gestation was lower in the immediate than in the deferred selective termination group (66.7% vs 20.2%; P<.01); preterm birth <28 weeks gestation and <32 weeks gestation did not differ significantly (respectively 1.7% vs 0.8%; P=.66 and 8.26% vs 11.4%; P=.36). In the deferred selective termination group, an emergency procedure was performed in 11.3% (15/132) because of threatened preterm labor, of which 3.7% (5/132) for imminent delivery.
Overall survival after selective termination was high regardless of the gestational age at which the procedure was performed. Postponing selective termination until the third trimester seems to improve survival, whereas immediate selective termination reduces the risk of preterm delivery. Furthermore, deferred selective termination requires an expert center capable of performing the selective termination procedure on an emergency basis if required.

OBJECTIVE: To study the maternal and perinatal outcomes in women with severe pre-eclampsia before 28 weeks of pregnancy.
METHODS: A descriptive study from a tertiary care center. All consecutive women with severe pre-eclampsia withonset before 28 weeks of pregnancy were included. The details were collected in a predesigned structured proforma prospectively.
RESULTS: The study cohort included 145 women with a mean maternal age of 26.97 ± 5.36 years (range 19-47 years). The mean duration of prolongation of pregnancy was 13.04 ± 10.57 days (range 1-51 days). A total of 29.7% (n = 43) of women had at least one major adverse maternal outcome, and the most common was HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome (n = 24,16.6%), followed by eclampsia (n = 12,8.3%). The stillbirth rate was high (n = 103,68.7%), and most occurred in the antepartum period. Of 47 (31.3%) neonates born alive, only eight (17.02%;8/47) survived up to 28 days of life. Fetal growth restriction with Doppler abnormalities and neonatal sepsis were the most common reasons for perinatal mortality.
CONCLUSIONS: Expectant management should not be considered routinely when the onset of severe pre-eclampsia is before 25+6 weeks of pregnancy. Between 26 and 27+6 weeks it can be offered under close monitoring and the perinatal survival depends on the neonatal services available in their facility.

Autophagy is essential for the maintenance of energy homeostasis and for survival during the neonatal starvation period. At birth, the trans-placental nutrient supply is suddenly interrupted, and neonates adapt to this adverse circumstance by activating autophagy. However, the mechanisms underlying the precise regulation of neonatal autophagy remain undefined. Here, we show that the destabilization of TP53 by the deubiquitylase ubiquitin-specific peptidase 10 (USP10) is essential for neonatal autophagy and survival. Usp10 deficiency results in decreased E3 ligase activity of MDM2 and accumulation of cytoplasmic TP53, which interferes with the conjugation of ATG12 and ATG5, the key autophagy-related genes, and ultimately inhibits autophagy in neonatal mice. Combined deletion of Tp53 and Usp10 recovers the nutrition supply and rescues the death phenotype of Usp10-deficient neonates. These findings reveal a role of the USP10-MDM2-TP53 axis in nutrient homeostasis and neonatal viability and provide insights into the long-perplexing mechanism by which cytoplasmic TP53 inhibits autophagy.

BACKGROUND: The classic mid-trimester preterm premature rupture of membranes (PPROM) is defined as a rupture of the fetal membranes prior to 28 weeks of gestation (WG) with oligo/anhydramnion; it complicates approximately 0.4-0.7% of all pregnancies and is associated with very high neonatal mortality and morbidity. Antibiotics have limited success to prevent bacterial growth, chorioamnionitis and fetal inflammation. The repetitive amnioinfusion does not work because fluid is lost immediately after the intervention. The continuous amnioinfusion through the transabdominal port system or catheter in patients with classic PPROM shows promise by flushing out the bacteria and inflammatory components from the amniotic cavity, replacing amniotic fluid and thus prolonging the PPROM-to-delivery interval.
OBJECTIVE: This multicenter trial aims to test the effect of continuous amnioinfusion on the neonatal survival without the typical major morbidities, such as severe bronchopulmonary dysplasia, intraventricular hemorrhage, cystic periventricular leukomalacia and necrotizing enterocolitis one year after the delivery.
METHODS: We plan to conduct a randomized multicenter trial with a two-arm parallel design. Randomization will be between 22/0 and 26/0 SSW. The control group: PPROM patients between 20/0 and 26/0 WG who will be treated with antibiotics and corticosteroids (from 22/0 SSW) in accordance with the guidelines of German Society of Obstetrics and Gynecology (standard PPROM therapy). In the interventional group, the standard PPROM therapy will be complemented with the Amnion Flush Method, with the amnioinfusion of Amnion Flush Solution through the intra-amnial catheter (up to 100 mL/h, 2400 mL/day).
METHODS: The study will include 68 patients with classic PPROM between 20/0 and 26/0 WG.
BACKGROUND: ClinicalTrials.gov ID: NCT04696003.
BACKGROUND: DRKS00024503, January 2021.

The success of maternal foraging strategies during the rearing period can greatly impact the physiology and survival of dependent offspring. Surprisingly though, little is known on the fitness consequences of foraging strategies during the foetal period. In this study, we characterized variation in maternal foraging strategy throughout pregnancy in a marine top predator (South American fur seal, Arctocephalus australis), and asked if these shifts predicted neonatal health and postnatal survival. We found that during early pregnancy all pregnant females belonged to a single, homogenized foraging niche without evident clusters. Intriguingly though, during late pregnancy, individual fur seal mothers diverged into two distinct foraging niches characterized by a benthic-nearshore and a pelagic-offshore strategy. Females that shifted towards the benthic-nearshore strategy gave birth to pups with greater body mass, higher plasmatic levels of glucose and lower levels of blood urea nitrogen. The pups born to these benthic females were eight times more likely to survive compared to females using the pelagic-offshore foraging strategy during late pregnancy. These survival effects were mediated primarily by the impact of foraging strategies on neonatal glucose independent of protein metabolic profile and body mass. Benthic-nearshore foraging strategies during late pregnancy potentially allow for the greater maternal transfer of glucose to the foetus, leading to higher chances of neonatal survival. These results call for a deeper understanding of the balance between resource acquisition and allocation provided by distinct foraging polymorphisms during critical life-history periods, and how this trade-off may be adaptive under certain environmental conditions.

Improving the housing of pregnant sows by giving them more space and access to deep straw had positive effects on their welfare, influenced their maternal behavior and improved the survival of their offspring. The present study aimed at determining whether these effects were actually due to environmental enrichment and whether the provision of straw pellets and wood can partly mimic the effects of straw bedding during gestation. Three graded levels of enrichment were used, that were, collective conventional pens on slatted floor (C, n = 26), the same pens with manipulable wood materials and distribution of straw pellets after the meals (CE, n = 30), and larger pens on deep straw litter (E, n = 27). Sows were then housed in identical farrowing crates from 105 days of gestation until weaning. Decreased stereotypies, blood neutrophils, and salivary cortisol, and increased behavioral investigation indicated that health and welfare of sows during gestation were improved in the E environment compared with the C environment. The CE sows responded as C or E sows depending on the trait. Piglet mortality rate in the first 12 h after birth was lower in E and CE litters than in C litters, but enrichment level during gestation had only small effects on lactating sow behavior and milk composition postpartum. On days 2 and 3 of lactation, E sows interrupted less often their nursing sequences than C and CE sows. On day 2, milk from both E and CE sows contained more minerals than that from C sows. In one-day-old piglets, the expression levels of genes encoding toll-like receptors (TLR2, TLR4) and cytokines (interleukin-1, -6 and -10) in whole blood after 20-h culture, were greater in E piglets than in CE or C piglets. In conclusion, housing sows in an enriched environment during gestation improved early neonatal survival, probably via moderate and cumulative positive effects on sow behavior, milk composition, and offspring innate immune response. The gradation in the effects observed in C, CE and E housing environment reinforced the hypothesis of a causal relationship between maternal environmental enrichment, sow welfare and postnatal piglet traits.

UNASSIGNED: To determine perinatal outcomes and influence of amniotic fluid volume in pregnancies complicated by previable, preterm prelabor rupture of membranes (pPPROM).
UNASSIGNED: This was a historical cohort study from two tertiary-level maternity hospitals (January 1, 2009 to December 31, 2015). All pregnancies complicated by pPPROM were identified using ICD coding of discharge abstracts. Hospital charts were reviewed to collect maternal demographics, pregnancy and delivery events, and immediate postnatal outcomes (including survival). Post-processing review of stored ultrasound images was performed to evaluate the relationship between amniotic fluid volume and outcomes.
UNASSIGNED: A total of 113 pregnancies were eligible and 99 were included in the final analysis (74 with \"expectant management\" and 25 opting for elective termination). The median gestational age at pPPROM was 20+6 weeks [IQR 19+4 to 21+5]. For those choosing expectant management, the median latency between pPPROM and delivery was 7 days, median gestational at delivery was 23+1 weeks, and neonatal survival to discharge was 27.5% overall. There was a trend towards higher rates of pregnancy termination at one hospital (31.7%) compared to the other (15.4%), but no difference between sites with respect to latency, mode of delivery, or survival amongst those managed expectantly. There was a relationship between survival and gestational age at pPPROM (p<0.04), as well as initial amniotic fluid volume category: 52.6% of survivors had normal initial amniotic fluid volumes whereas the majority of previable losses had oligohydramnios and the majority of stillbirths had anhydramnios.
UNASSIGNED: After expectant management, more than one in four newborns following pPPROM survived to hospital discharge. While gestational age at rupture was most strongly correlated with survival, normal initial amniotic fluid volumes were mostly seen in survivors whereas stillbirths more frequently had anhydramnios. These findings will help to improve counseling and care of patients with pPPROM and in guiding long-term follow-up studies.

The aim of this study was to describe the characteristics of cases of feline dystocia presenting to a university emergency service.
The medical records of queens presenting for dystocia between January 2009 and September 2020 were reviewed. Data collected included queen signalment, presenting complaints, treatments, and maternal and neonatal outcomes. Clinicopathologic data included serum ionized calcium concentration, blood glucose level, packed cell volume and total solids. Owing to the small sample size, descriptive statistics were used and data presented as median (range).
Thirty-five cases were reviewed. Dystocia was attributed to maternal factors in 69% (n = 24) and fetal factors in 31% (n = 11). Venous blood gas data from 19 queens in stage 2 labor revealed that no queens were hypocalcemic (median ionized calcium 5.4 mg/dl [range 4.9-5.8]) or hypoglycemic (median glucose 143 mg/dl [range 78-183]). Medical management was attempted in 21/35 queens. Successful medical management was achieved in 29% (n = 6/21). Thirteen queens underwent surgical management, six of these after failing medical management. Seven queens received no treatment. Fifteen queens were discharged and one queen was euthanized while still in labor. The remaining 19 queens delivered all fetuses with medical (n = 6) or surgical management (n = 13). Maternal survival was 94% (n = 33/35). A total of 136 kittens were born to all queens, with 58% (n = 79/136) born prior to initiation of treatment, 16% (n = 22/136) after medical management and 26% (n = 35/136) after surgical management. Overall neonatal survival to discharge was 66% (n = 90/136).
Feline dystocia is an emergent condition that can result in up to 34% neonatal mortality for kittens delivered via both medical and surgical means. Hypoglycemia and hypocalcemia were not precipitating causes of feline dystocia in this population.

Cesarean delivery is currently not recommended before 23 weeks\' gestation unless for maternal indications, even in the setting of malpresentation. These recommendations are based on a lack of evidence of improved neonatal outcomes and survival following cesarean delivery and the maternal risks associated with cesarean delivery at this early gestational age. However, as neonatal resuscitative measures and obstetrical interventions improve, studies evaluating the potential neonatal benefit of periviable cesarean delivery have reported inconsistent findings.
This study aimed to compare the survival rates at 1 year of life among resuscitated infants delivered by cesarean delivery with those delivered vaginally at 22 and 23 weeks of gestation.
We conducted a population-based cohort study of all resuscitated livebirths delivered between 22 0/7 and 23 6/7 weeks of gestational age in the United States between 2007 and 2013. The primary outcome was the rate of infant survival at 1 year of life for different routes of delivery (cesarean vs vaginal delivery) at both 22 and 23 weeks of gestation. The secondary outcome variables included infant survival rates for neonates who survived beyond 24 hours of life, neonatal survival, and the length of survival. A secondary analysis also included a comparison of the infant survival rates between the different routes of delivery cohorts stratified by fetal presentation, steroid exposure, and ventilation. Information about composite adverse maternal outcomes were limited to infants who were delivered between 2011 and 2013 (when these items were first reported) and were defined as a requirement for blood transfusion, an unplanned operating room procedure following delivery, unplanned hysterectomy, and intensive care unit admission; the composite adverse maternal outcomes were also compared between the different delivery route cohorts for deliveries occurring between 22 and 23 weeks of gestation. Multivariable logistic regression analysis was used to determine the association between cesarean delivery and infant survival and other neonatal and maternal outcomes.
Resuscitated infants delivered by cesarean delivery had higher rates of survival at 22 weeks (44.9 vs 23.0%; P<.001) and at 23 weeks (53.3 vs 43.4%; P<.001) of gestation regardless of fetal presentation. Multivariable logistic regression analysis demonstrated that infants who were delivered by cesarean delivery at 22 weeks (adjusted relative risk, 2.3; 95% confidence interval, 1.9-2.8) and 23 weeks (adjusted relative risk, 1.4; 95% confidence interval, 1.2-1.5) of gestation were more likely to survive than those delivered vaginally. When the cohort was limited to neonates who survived beyond the first 24 hours of life, vertex neonates born by cesarean delivery were not more likely to survive at 22 weeks (adjusted relative risk, 1.2; 95% confidence interval, 0.9-1.7) or 23 weeks (adjusted relative risk, 1.1; 95% confidence interval, 0.9-1.3) of gestation. An increased risk for composite adverse maternal outcomes (adjusted relative risk, 1.7; 95% confidence interval, 1.1-2.7) was associated with cesarean delivery at 22 to 23 weeks of gestation.
Cesarean delivery is associated with increased survival at 1 year of life among resuscitated, periviable infants born between 22 0/7 and 23 6/7 weeks of gestation, especially in the setting of nonvertex presentation. However, cesarean delivery is associated with increased maternal morbidity.