Maternal One-carbon Metabolism during the Periconceptional Period and Human Foetal Brain Growth: A Systematic Review

The maternal environment during the periconceptional period influences foetal growth and development, in part, via epigenetic mechanisms moderated by one-carbon metabolic pathways. During embryonic development, one-carbon metabolism is involved in brain development and neural programming. Derangements in one-carbon metabolism increase (i) the short-term risk of embryonic neural tube-related defects and (ii) long-term childhood behaviour, cognition, and autism spectrum disorders. Here we investigate the association between maternal one-carbon metabolism and foetal and neonatal brain growth and development. Database searching resulted in 26 articles eligible for inclusion. Maternal vitamin B6, vitamin B12, homocysteine, and choline were not associated with foetal and/or neonatal head growth. First-trimester maternal plasma folate within the normal range (> 17 nmol/L) associated with increased foetal head size and head growth, and high erythrocyte folate (1538–1813 nmol/L) with increased cerebellar growth, whereas folate deficiency (< 7 nmol/L) associated with a reduced foetal brain volume. Preconceptional folic acid supplement use and specific dietary patterns (associated with increased B vitamins and low homocysteine) increased foetal head size. Although early pregnancy maternal folate appears to be the most independent predictor of foetal brain growth, there is insufficient data to confirm the link between maternal folate and offspring risks for neurodevelopmental diseases.

Maternal outcome of primigravida patient with term pregnancy with engaged versus unengaged foetal head at onset of labour

Background: The primigravida are a group at risk as their capacity of child bearing has never put to the test, “primigravida is a dark and untired horse". The potential for future child bearing is determined by outcome of first labour. Hence, if first pregnancy results in normal healthy child, patient is mentally better prepared for subsequent pregnancies. Foetal head is said to be engaged when its biparietal diameter, the greatest diameter in an occiput presentation, passes through the pelvic inlet. Unengagement of head in primigravida has long been considered a possible sign of cephalopelvic disproportion.Methods: The study had 220 primigravida of which 110 had unengaged head as study group and 110 engaged head as controls. Data collection was done and the course of labour in all the patients recorded on partograph and all the patients were studied in detail. Engagement of the head was defined on the basis of Second Pawlik’s grip and Crichton’s fifth’s formula.Results: Our study shows that higher age group had more number of cases with unengaged head. The patient with engaged head had higher number of vaginal delivery than study group with unengaged head. More number of LSCS i.e. about 39.1% in study group as compared to 21% of controls is statistically significant difference (p value 0.05).Conclusions: We can conclude that primigravida with unengaged foetal head at onset of labour may deliver vaginally with minimal maternal morbidity, if proper monitoring and maintenance of partogram is done.

Outcome of Primigravida with high foetal head at term or onset of labour

Objective: To determine the causes of high foetal head and their relative frequencies in primigravidae presenting at term and to determine the proportion of these patients undergoing lower segment caesarean section or vaginal delivery. Design: A descriptive study.Place and duration of study: The study was carried out at Mugda Medical College Hospital from March 2017 to June 2017.Materials and Methods: A total of 50 primigravidae patients presenting at term and having a single pregnancy were randomly selected. On the basis of history, Physical examination and abdominal ultrasonography, patients having a high foetal head were recognized and their causes documented.Results: Out of 50 primigravidae, with high foetal head there was foetal malpresentation 17(34%), Cephalopelvic disproportion 13(26%) , Foetal distress 12(24%). Lower segment caesarian section was the management of choice in more than half of the patients with high foetal head.Conclusions: Foetal malpresentation & Cephalopelvic disproportion were the major cause of high foetal head in this study and lower segment Caesarean section was the mode of delivery in more than half of the patients with high foetal head.J Dhaka Medical College, Vol. 26, No.2, October, 2017, Page 122-125

A prospective, randomized, cross sectional study of manual versus vacuum extraction of mobile head in caesarean section

Background: Considering the high rate of caesarean section, and the difficulty during delivery of the floating foetal head even by the most experienced obstetrician, the use of vacuum has been described. The present study was undertaken with the hypothesis that, vacuum assisted foetal head delivery during caesarean section is safe and effective without increasing maternal and neonatal complications. The outcomes enumerated by the limited literature available need to be evaluated before it is used routinely.Methods: A prospective, randomized, comparative, cross sectional Hospital based study was conducted at St. Philomena’s Hospital, Bangalore. Every woman randomized for the study received either conventional method or ventouse extraction of fetal head at cesarean section. 200 women were enrolled into the study with 100 in each arm. The primary outcome measures were percentage of successful extractions and I-D interval. The secondary outcome measures were, uterine incision extension, estimated blood loss, Apgar scores, neonatal hyperbilirubinemia and neonatal scalp or head injury.Results: Successful extraction was done in 89 % and 98 % cases in manual and vacuum extraction cases. (p =0.0184). U-D interval in the manual extraction group was 66.59±4.64 seconds and in the Vacuum extraction group it was 56.06±3.46 seconds (P<0.001). The mean pre-delivery hemoglobin levels in group I was 11.6±0.73 compared to 11.36±0.49 gm% in group II. The mean post-delivery hemoglobin levels in group I was 10.29±0.79 compared to 10.21±0.53 gm% in group II (p <0.001). The uterine incision extensions were significantly higher in manual extraction group, 18 of the 100 women (18 %), whereas only 2 of the 100 women in vacuum group had uterine extensions (p=0.0002).Conclusions: Authors conclude that the routine use of ventouse is safe and effective for mobile fetal head extraction at cesarean section.

Causation of permanent brachial plexus injuries to the anterior arm after shoulder dystocia – Literature review

Not all neonatal brachial plexus injuries should be deemed the fault of the accoucheur. However, there is a small (<10%) subset of neonatal brachial plexus injuries that are related to excessive traction by the accoucheur: permanent injuries to the anterior arm after SD. The position regarding posterior injuries remains predominantly the same; if the injury is to the posterior shoulder, the injury is likely to have been caused by maternal propulsion against the sacral promontory before the foetal head is delivered, rather than excessive and inappropriate traction. However, there is no reliable evidence that a combination of maternal propulsion and diagnostic traction alone causes significant and permanent injury to the anterior shoulder after shoulder dystocia. This was recognised in Deith vs. Lanarkshire where the judge found: that where there is a severe injury to an anterior arm after SD, excessive traction is overwhelmingly likely to be the cause.

Foetal vascular lesion-Case report

Frequency and preciseness of prenatal detection of foetal tumours increases due to improvement of sophisticated imaging methods. As correct diagnosis impacts the course of care in utero, it is essentially to improve diagnostic workout in a case of detected foetal anomalies. Here we report the case of partly involuting congenital haemangioma of foetus, which antenataly caused foetal secondary cardiomegaly. Pregnant woman was referred to Riga Maternity Hospital with unexplained tumour on the surface of foetal head at 24+2 weeks of gestation. Ultrasound exam revealed tubular structure without solid components between calvarium and skin under the left ear with very rich vascularization. Magnetic Resonance Image demonstrated enhancing multi-cystic lobulated mass. Hypertrophic secondary cardiomegaly was present without any additional structural abnormality. The foetus remained stable until 36+4 weeks of gestation, when the size of tumour succeeded 85 mm × 46 mm. Haemangioma was confirmed after delivery as round raised and infiltrating vascular lesion. After birth MRI demonstrated its connection with a. carotis externa. Propranolol was recommended with continuing follow-up. At 2 years and 3 months of age the lesion decreased by size noticeably, but still persists. Accurate diagnosis lets obstetricians to optimize antenatal care by providing an opportunity for planning deliveries, preparing family and medical staff for appropriate postpartum therapy and management.

A Study of Outcome of Labour in Primigravida With High Head at Term

Objective: This prospective study was carried out to see the effect of engagement of foetal head at term in primigravidae women. Materials and Methods: The study was conducted in the Department of Obstetrics & Gynaecology, Sir Salimullah Medical College & Mitford Hospital (SSMC & MH), Dhaka from June, 2006 to December, 2006. The study included 1440 women who were admitted in the hospital during the above mentioned period. All women were examined to see the engagement of foetal head by the rule of 5 at or after 38 weeks pregnancy. Of them, 262(18.2%) presented with engagement of foetal head and 1178(81.8%) without foetal head engagement. Main outcome measure was the effect of engagement of foetal head at term in primigravidae women. Foeto-maternal outcomes were recorded by clinical observation. Result: No significant differences were found in terms of demographic and anthropometric characteristics (like age, height and weight) between primigravidaewomen who had engaged foetal head and women who did not have foetal head engaged (p = 0.969; p = 0.258 and p = 0.139). Three-quarters (74.96%) of the patients at presentation were in labour and the rest were not in labour. Duration of labour was significantly higher in non-engaged group compared to those who had foetal head engaged.The incidence of non-engagement of foetal head in nulliparous women at or after 38 weeks of pregnancy was 81.8%; but only 11.5% of them had cephalo-pelvic disproportion (CPD). The incidence of vaginal delivery in the non-engaged and engaged group was 36.9% and 66.1% respectively. Most of the patients underwent caesarean section due to foetal distress and indications other than CPD. Conclusion: The findings of the study suggest that the obstetricians should take a conservative attitude and a non-engaged foetal head at term in a primigravid woman should not by itself be an indication for caesarean section. Ibrahim Card Med J 2016; 6 (1&2): 62-66