Abstract: Fully understanding the determinants and sequelae of fetal growth requires a continuous measure of birth weight adjusted for gestational age. Published United States reference data, however, provide estimates only of the median and lowest and highest 5th and 10th percentiles for birth weight at each gestational age. The purpose of our analysis was to create more continuous reference measures of birth weight for gestational age for use in epidemiologic analyses. We used data from the most recent nationwide United States Natality datasets to generate multiple reference percentiles of birth weight at each completed week of gestation from 22 through 44 weeks. Gestational age was determined from last menstrual period. We analyzed data from 6,690,717 singleton infants with recorded birth weight and sex born to United States resident mothers in 1999 and 2000. Birth weight rose with greater gestational age, with increasing slopes during the third trimester and a leveling off beyond 40 weeks. Boys had higher birth weights than girls, later born children higher weights than firstborns, and infants born to non-Hispanic white mothers higher birth weights than those born to non-Hispanic black mothers. These results correspond well with previously published estimates reporting limited percentiles. Our method provides comprehensive reference values of birth weight at 22 through 44 completed weeks of gestation, derived from broadly based nationwide data. Other approaches require assumptions of normality or of a functional relationship between gestational age and birth weight, which may not be appropriate. These data should prove useful for researchers investigating the predictors and outcomes of altered fetal growth.

Abstract: Objectives: To evaluate: (1) the associations between maternal psychological stress, distress and low birth weight (LBW), prematurity and intrauterine growth retardation (IUGR); (2) the interactions between maternal stress, distress and smoking, alcohol and coffee intake; (3) the prevalences of stress and distress in pregnancy. Design: Longitudinal cohort study. Setting: Jundiai city, Sao Paulo state, Brazil. Subjects: A total of 865 pregnant women who attended antenatal care between September 1997 and August 2000. Methods: Measures of stress and distress were obtained, by interview, three times in pregnancy: at a gestational age (GA) lower than 16 weeks, from 20 to 26 weeks and from 30 to 36 weeks. Stress was investigated by the perceived stress scale, PSS, and distress by both the general health questionnaire, GHQ, and the State Trait Anxiety inventories, STAI. The outcomes were: LBW (birth weight <2500 g), prematurity (gestational age (GA) at birth <37 weeks) and IUGR (birth weight for GA ≤10th percentile of William's curve). The associations between the outcomes and the psychological measures were assessed in multiple logistic regression models. Results: Maternal distress was associated with LBW (RR=1.97, P=0.019) and prematurity (RR=2.32, P=0.015), respectively. There was an interaction between distress and smoking in the second interview (P=0.05). The prevalences of stress and distress in the different interviews of pregnancy varied from 22.1 to 52.9%. Conclusions: The present study has confirmed that distress is associated with both birthweight and GA. Further research is needed to evaluate the effectiveness of psychological interventions that can improve maternal and foetal well-being. Sponsorship: Fundacao de Amparo a Pesquisa do Estado de Sao Paulo - FAPESP (grant no. 1998/00321-0).

Abstract: Background Experimental and clinical data suggest that fetal endoscopic tracheal occlusion to induce lung growth may improve the outcome of severe congenital diaphragmatic hernia. We performed a randomized, controlled trial comparing fetal tracheal occlusion with standard postnatal care. Methods Women carrying fetuses that were between 22 and 27 weeks of gestation and that had severe, left-sided congenital diaphragmatic hernia (liver herniation and a lung-to-head ratio below 1.4), with no other detectable anomalies, were randomly assigned to fetal endoscopic tracheal occlusion or standard care. The primary outcome was survival at the age of 90 days; the secondary outcomes were measures of maternal and neonatal morbidity. Results Of 28 women who met the entry criteria, 24 agreed to randomization. Enrollment was stopped after 24 patients had been enrolled because of the unexpectedly high survival rate with standard care and the conclusion of the data safety monitoring board that further recruitment would no...

Abstract: Objective. To provide pediatric endocrinologists, general pediatricians, neonatologists, and primary care physicians with recommendations for the management of short children born small for gestational age (SGA). Methods. A 13-member independent panel of pediatric endocrinologists was convened to discuss relevant issues with respect to definition, diagnosis, and clinical management of short children born SGA. Panel members convened over a series of 3 meetings to thoroughly review, discuss, and come to consensus on the identification and treatment of short children who are born SGA. Conclusions. SGA is defined as birth weight and/or length at least 2 standard deviations (SDs) below the mean for gestational age (≤−2 SD). Accurate gestational dating and measurement of birth weight and length are crucial for identifying children who are born SGA. Comprehensive pregnancy, perinatal, and immediate postnatal data may help to confirm the diagnosis. Maternal, placental, and fetal causes of SGA should be sought, although the cause is often not clear. Most children who are SGA experience catch-up growth and achieve a height >2 SD below the mean; this catch-up process is usually completed by the time they are 2 years of age. A child who is SGA and older than 3 years and has persistent short stature (ie, remaining at least 2 SD below the mean for chronologic age) is not likely to catch up and should be referred to a pediatrician who has expertise in endocrinology. Bone age is not a reliable predictor of height potential in children who are SGA. Nevertheless, a standard evaluation for short stature should be performed. A diagnosis of SGA does not exclude growth hormone (GH) deficiency, and GH assessment should be performed if there is clinical suspicion or biochemical evidence of GH deficiency. At baseline, insulin-like growth factor-I, insulin-like growth factor binding protein-3, fasting insulin, glucose, and lipid levels as well as blood pressure should be measured, and all aspects of SGA—not just stature—should be addressed with parents. The objectives of GH therapy in short children who are SGA are catch-up growth in early childhood, maintenance of normal growth in childhood, and achievement of normal adult height. GH therapy is effective and safe in short children who are born SGA and should be considered in those older than 2 to 3 years. There is long-term experience of improved growth using a dosage range from 0.24 to 0.48 mg/kg/wk. Higher GH doses (0.48 mg/kg/wk [0.2 IU/kg/d]) are more effective for the short term. Whether the higher GH dose is more efficacious than the lower dose in terms of adult height results is not yet known. Only adult height results of randomized dose-response studies will give a definite answer. Monitoring is necessary to ensure safety of medication. Children should be monitored for changes in glucose homeostasis, lipids, and blood pressure during therapy. The frequency and intensity of monitoring will vary depending on risk factors such as family history, obesity, and puberty.

Abstract: Onset of the maternal-placental circulation was studied by Doppler ultrasonography in 65 pairs of age-matched normal and abnormal pregnancies In normal pregnancies intervillous blood flow increased with gestational age, being detected in 9 of 25 cases at 8 to 9 weeks but in 18 of 20 at 12 to 13 weeks (P = 0001) By contrast, in abnormal pregnancies flow was detected in nearly all cases (22 of 25) at 8 to 9 weeks (P < 0001) In addition, regional differences were observed between the groups Early flow was restricted to the peripheral regions of most normal placentas (P < 0001), whereas in missed miscarriages it was most common in central regions or throughout the placenta (P < 005 and P < 0001, respectively) Immunoreactivity for heat shock protein 70 and nitrotyrosine residues was greater in samples from peripheral than from central regions of normal placentas (P = 0028 and P = 0019, respectively), and from missed miscarriages compared to controls (P = 0005 and P = 0001, respectively) Our results indicate that oxidative damage to the trophoblast, induced by premature and widespread onset of the maternal placental circulation secondary to shallow trophoblast invasion, is a key factor in early pregnancy loss High oxygen concentrations in the periphery of normal early placentas may similarly induce local regression of the villi, leading to formation of the chorion laeve

Abstract: Objective. Intrauterine and neonatal growth failure of very low birth weight (VLBW; Design, Setting, Participants. A cohort of 103 male and 92 female VLBW infants who had a mean birth weight of 1189 g and mean gestational age of 29.8 weeks, were born from 1977 through 1979 and treated at Rainbow Babies and Children’s Hospital in Cleveland, Ohio, and were free of neurosensory impairment were followed prospectively from birth and compared with a population-based sample of 101 male and 107 female normal birth weight (NBW) controls selected at 8 years old. Maternal sociodemographic status and infant birth and neonatal data did not differ significantly between male and female VLBW subjects. However, male VLBW subjects had significantly higher rates of rehospitalization during infancy than female VLBW (39% vs 21%). At 20 years, their rates of chronic illness were similar (18% vs 24%). Main Outcome Measures. Weight and height z scores were computed at birth, 40 weeks, 8 and 20 months, and 8 and 20 years among the VLBW subjects, and at 8 and 20 years among the NBW controls. Body mass index (BMI) z scores were computed at 8 and 20 years. Among the VLBW subjects, gender-specific longitudinal growth measures were examined at birth, at the expected term date (40 weeks corrected age), and at 8 and 20 months, and 8 and 20 years of age. In addition, we compared the weight, height, and BMI of the VLBW and NBW controls at 8 and 20 years. Predictors of 20-year growth were examined via multivariate analyses. Results. Among the VLBW males, mean weight for age z scores at birth, 40 weeks, and 8 years were −0.7, −1.8, and −0.5; and height for age z scores were −1.2, −2.6, and −0.5, respectively. For VLBW females, mean weight for age z scores were −1.1, −2.0, and −0.2 and height for age z scores were −1.2, −2.4, and −0.2, respectively. At 8 years of age, VLBW males had a significantly lower mean weight, height, and BMI than NBW controls, whereas VLBW females differed significantly from their NBW controls in mean weight and BMI but not in height. Catch-up growth in weight, height, and BMI occurred between 8 and 20 years among VLBW females but not among VLBW males who remained significantly smaller than their controls at 20 years old. At 20 years mean weight of VLBW males was 69 kg versus 80 kg for controls ( z score −0.4 vs +0.5); mean height was 174 cm versus 177 cm ( z score −0.4 vs +0.03) and mean BMI was 23 versus 26, respectively. For VLBW females, mean weight was 65 kg versus 68 kg for controls ( z score +0.3 vs +0.5), mean height was 162 versus 163 cm ( z score −0.3 vs −0.1) and mean BMI was 25 versus 25, respectively. Rates of obesity (BMI >30) for VLBW males were 7% compared with 15% for controls and for VLBW females 15% compared with 18% for controls. Age of menarche was 12.4 years for VLBW females and 12.3 years for controls. Nineteen (18%) male and 20 (22%) female VLBW subjects were born small for gestational age (SGA; weight less than −2 standard deviation for gestational age). At 20 years, significantly more SGA than appropriate for gestational age VLBW males remained subnormal (less than −2 standard deviation) in weight (32% vs 6%) and height (21% vs 4%), whereas rates of subnormal growth did not differ significantly between SGA and appropriate for gestational age females (weight 5% vs 1%, height 0% vs 7%). Predictor variables included in the multivariate analyses of 20-year growth attainment were maternal education and height, race, birth weight z score (a measure of intrauterine growth failure), neonatal hospital stay (a measure of neonatal illness), and chronic illness at 20 years. Twenty-year weight was predicted by black race and chronic illness among females. Twenty-year height was predicted by maternal height and birth weight z score among both males and females and by duration of neonatal hospital stay among males only. In a separate model, when we examined the effect of being SGA at birth instead of the effect of birth weight z score, SGA birth was predictive of 20-year height among males but not among females. Conclusions. VLBW females catch up in growth by 20 years of age whereas VLBW males remain significantly shorter and lighter than controls. Since catch-up growth may be associated with metabolic and cardiovascular risk later in life, these findings may have implications for the future adult health of VLBW survivors.

Abstract: Objective To evaluate whether prenatal use of non-steroidal anti-inflammatory drugs (NSAIDs) is associated with increased risk of miscarriage. Design Population based cohort study. Prenatal use of NSAIDs, aspirin, and paracetamol (acetaminophen) ascertained by in-person interview. Setting Kaiser Permanente Medical Care Program, a healthcare delivery system, in the San Francisco area of the United States. Participants 1055 pregnant women recruited and interviewed immediately after their positive pregnancy test. Median gestational age at entry to the study was 40 days. Main outcome measures Pregnancy outcomes up to 20 weeks of gestation. Results 53 women (5%) reported prenatal NSAID use around conception or during pregnancy. After adjustment for potential confounders, prenatal NSAID use was associated with an 80% increased risk of miscarriage (adjusted hazard ratio 1.8 (95% confidence interval 1.0 to 3.2)). The association was stronger if the initial NSAID use was around the time of conception or if NSAID use lasted more than a week. Prenatal aspirin use was similarly associated with an increased risk of miscarriage. However, prenatal use of paracetamol, pharmacologically different from NSAIDs and aspirin, was not associated with increased risk of miscarriage regardless of timing and duration of use. Conclusion Prenatal use of NSAIDs and aspirin increased the risk of miscarriage. These findings need confirmation in studies designed specifically to examine the apparent association.

Abstract: Objective To determine whether a short interval between pregnancies is an independent risk factor for adverse obstetric outcome. Design Retrospective cohort study. Setting Scotland. Subjects 89 143 women having second births in 1992-8 who conceived within five years of their first birth. Main outcome measures Intrauterine growth restriction (birth weight less than the 5th centile for gestational age), extremely preterm birth (24-32 weeks), moderately preterm birth (33-36 weeks), and perinatal death. Results Women whose subsequent interpregnancy interval was less than six months were more likely than other women to have had a first birth complicated by intrauterine growth restriction (odds ratio 1.3, 95% confidence interval 1.1 to 1.5), extremely preterm birth (4.1, 3.2 to 5.3), moderately preterm birth (1.5, 1.3 to 1.7), or perinatal death (24.4, 18.9 to 31.5). They were also shorter, less likely to be married, and more likely to be aged less than 20 years at the time of the second birth, to smoke, and to live in an area of high socioeconomic deprivation. When the outcome of the second birth was analysed in relation to the preceding interpregnancy interval and the analysis confined to women whose first birth was a term live birth (n = 69 055), no significant association occurred (adjusted for age, marital status, height, socioeconomic deprivation, smoking, previous birth weight vigesimal, and previous caesarean delivery) between interpregnancy interval and intrauterine growth restriction or stillbirth. However, a short interpregnancy interval (< 6 months) was an independent risk factor for extremely preterm birth (adjusted odds ratio 2.2, 1.3 to 3.6), moderately preterm birth (1.6, 1.3 to 2.0), and neonatal death unrelated to congenital abnormality (3.6, 1.2 to 10.7). The adjusted attributable fractions for these associations were 6.1%, 3.9%, and 13.8%. The associations were very similar when the analysis was confined to married non-smokers aged 25 and above. Conclusions A short interpregnancy interval is an independent risk factor for preterm delivery and neonatal death in the second birth.

Abstract: Objectives To identify the most effective, safe and cost-effective method of antenatal screening for Down's syndrome using nuchal translucency (NT), maternal serum and urine markers in the first and second trimesters of pregnancy, and maternal age in various combinations.Design A prospective study of women who booked for their antenatal care at about 8-14 weeks of gestation, with follow-up to identify pregnancies with Down's syndrome ascertained through second trimester screening or at birth.Setting Twenty-five maternity units (24 in the UK and one in Austria) offering second trimester Down's syndrome serum screening that agreed to collect observational data in the first trimester.Participants The results were based on 47,053 singleton pregnancies, including 101 pregnancies with Down's syndrome.Measurements and tests NT measurements were included if obtained between 9 and 13 weeks of pregnancy; serum and urine samples were also taken and stored. Another pair of serum and urine samples was collected in the second trimester and included if obtained between 14 and 20 weeks. Urine and serum samples from each affected pregnancy and five matched controls were tested for:Serum:alphafetoprotein (AFP)total human chorionic gonadotrophin (hCG)unconjugated oestriol (uE(3))pregnancy associated plasma protein A (PAPP-A)free beta-hCG.dimeric inhibin-A.Urine:invasive trophoblast antigen (ITA)beta-core fragmenttotal hCGfree beta-hCG.The matching criteria were gestation (using an ultrasound crown-rump length or biparietal diameter measurement), duration of storage, and centre. Screening performance of the individual markers and combinations of markers together with maternal age was assessed using standard methods. In addition pairs of first and second trimester serum samples from 600 controls were tested to secure a larger set in which screening performance could be determined using distribution parameters based on dates (time since first day of the last menstrual period).Main outcome measures The following were determined for different combinations of markers:efficacy (by assessing screening performance, focusing on the false-positive rate (FPR) for an 85% detection rate (DR))safety (focusing on the number of fetal losses due to amniocentesis (or chorionic villus sampling) in 100,000 women screened)cost-effectiveness (focusing on the cost of screening 100,000 women and the cost per Down's syndrome pregnancy diagnosed).Results Efficacy (screening performance) The false-positive rates for an 85% detection rate for the main screening tests are shown in the above table, in decreasing order of screening performance:With the serum integrated test, 10 weeks is the preferred time in pregnancy for the PAPP-A measurement. For the integrated test and the combined test, the timing of the measurement of the first trimester markers is less critical.Safety The lower false-positive rate with the integrated test compared with other tests means that at an 85% detection rate there would be nine diagnostic procedure-related unaffected fetal losses per 100,000 women screened compared with 44 using the combined test or 45 with the quadruple test.Cost-effectiveness Screening using the integrated test is less costly than might be expected because the extra screening costs tend to be offset by savings in the cost of diagnosis arising from the low false-positive rate. It was estimated that to achieve an 85% detection rate the cost to the UK NHS would be pound15,300 per Down's syndrome pregnancy detected. The corresponding cost using the second trimester quadruple test would be pound16,800 and using the first trimester combined test it would be pound19,000.Conclusions Implications for healthcare The results showed that screening performance in the first trimester of pregnancy was virtually the same as that in the second trimester, and in either it was much less effective than integrating screening measurements from both trimesters into a single test. In applying these results to screening practice several conclusions can be drawn. The following tests offer the most effective and safe method of screening:overall: the integrated testif an NT measurement is not available: the serum integrated testfor women who do not attend for antenatal care until the second trimester of pregnancy: the quadruple testfor women who choose to have a screening test in the first trimester: the combined test.At a constant detection rate, the cost-effectiveness of these four tests is broadly similar, any extra screening costs tending to be offset by fewer diagnostic costs. The evidence presented in this report does not support retaining the double test, the triple test, or NT measurements on their own (with or without maternal age) because each would lead to many more women having invasive diagnostic tests, without increasing the proportion of Down's syndrome pregnancies detected.

Abstract: Objectives To assess the benefits and risks of antenatal corticosteroid therapy for fetal maturation. Options To administer antenatal corticosteroids or not to women at risk of preterm birth. Outcomes Perinatal morbidity, including: respiratory distress syndrome, intraventricular hemorrhage, infection, adrenal suppression, somatic and brain growth; perinatal mortality; and maternal morbidity, including infection and adrenal suppression. Evidence MEDLINE and PubMed searches 1996 to August 2002 for English-language articles related to antenatal corticosteroid therapy for fetal maturation, the Cochrane Library, and national statements including that of the National Institutes of Health (NIH), the American College of Obstetricians and Gynecologists, and the Royal College of Obstetricians and Gynaecologists. Values The evidence obtained was reviewed and evaluated by the Maternal-Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and recommendations were made according to guidelines developed by the Canadian Task Force on the Periodic Health Exam. BENEFITS AND HARMS: A single course of corticosteroids reduces perinatal mortality, respiratory distress syndrome, and intraventricular hemorrhage. Information regarding repeat courses of corticosteroids is limited and conflicting, with many studies being retrospective and non-randomized. Some studies suggested a reduction in respiratory distress syndrome with repeat courses, but some found increased rates of neonatal and maternal infection; fetal, neonatal, and maternal adrenal suppression; decreased fetal or neonatal somatic and brain growth; and increased perinatal mortality. Recommendations The SOGC supports the recommendations of the NIH Consensus Development Panel: 1. All pregnant women between 24 and 34 weeks' gestation who are at risk of preterm delivery within 7 days should be considered candidates for antenatal treatment with a single course of corticosteroids. (I-A) 2. Treatment should consist of two 12 mg doses of betamethasone given IM 24 hours apart, or four 6 mg doses of dexamethasone given IM 12 hours apart (I-A). There is no proof of efficacy for any other regimen. 3. Because of insufficient scientific data from randomized clinical trials regarding efficacy and safety, repeat courses of corticosteroids should not be used routinely (II-2E) but be reserved for women participating in randomized controlled trials. Validation This Committee Opinion has been reviewed and approved by the Maternal-Fetal Medicine Committee of the SOGC and approved by SOGC Council.

Abstract: Aim Twelve years’ outcome analysis of pregnancies in women with Type 2 diabetes in a multiethnic geographically defined area. Methods Information about 182 women delivered between 1990 and 2002 was ascertained from a regional computerized database. The main outcome measures were rates of miscarriage, stillbirth, neonatal/postnatal deaths, congenital malformations, birth weight, mode of delivery, and neonatal unit care as well as maternal morbidities of polyhydramnios, postpartum haemorrhage, pregnancy-induced hypertension/pre-eclampsia. Results Among 182 singleton pregnancies, 161 (88%) resulted in a live outcome. There were 16 (8.8%) spontaneous miscarriages, two (1.2%) stillbirths, and three (1.6%) terminations. Congenital malformations occurred in 18 pregnancies (99/1000). There were two early and one late neonatal deaths and two further deaths in the postnatal period. Twenty-eight percent of infants were large for gestational age, with 15 (9.3%) greater than 4 kg. Fifty-three percent were delivered by caesarean section and 68 (37%) required admission to neonatal unit (NNU) care. Hypertension/pre-eclampsia was two times, polyhydramnios three times, and postpartum haemorrhage six times more common than in non-diabetic women. Conclusions Women with Type 2 diabetes have a less satisfactory pregnancy outcome compared with the general population. Infants have a two-fold greater risk of stillbirth, a 2.5-fold greater risk of a perinatal mortality, a 3.5-fold greater risk of death within the first month and a six-fold greater risk of death up to 1 year compared with regional/national figures. They have an 11 times greater risk of a congenital malformation. We need to develop better educational and screening strategies if we are to improve.

Abstract: Background: Inhaled corticosteroids are recommended as first-line therapy for pregnant women with moderate to severe asthma, although the effects on pregnancy outcome are uncertain. A low compliance with the recommendations might lead to inadequate control of asthma, which has been associated with adverse outcomes both for the mother and the infant. Objective: To investigate whether the reported use of inhaled budesonide (Pulmicort) during pregnancy influences birth outcome. Methods: Data were derived from the Swedish Medical Birth Register, which includes 99% of births in Sweden. During 1995 to 1998, 293,948 newborn infants were identified. Pregnancy outcomes were compared for mothers in Sweden reporting asthma medication usage with those reporting no asthma medication usage. Results: The 2968 mothers who reported use of inhaled budesonide during early pregnancy gave birth to infants of normal gestational age, birth weight, and length, with no increased rate of stillbirths or multiple births. The rate of caesarean births was higher among mothers who used asthma medication during their pregnancy than among the control group. Conclusions: The use of inhaled budesonide in Sweden is not linked with any clinically relevant effects associated with pregnancy outcome.

Abstract: Effects of high participation in the Infant Health and Development Program (IHDP), an 8-site randomized trial that targeted low-birth-weight (LBW) premature infants (N=1,082), were estimated Children in the treatment group were offered high-quality center-based care in their 2nd and 3rd years of life (full-day care, 50 weeks per year) High-dosage effects were estimated with a new methodology that found a matched comparison group within the follow-up group for those with high participation rates; these estimates were compared with traditional intention-to-treat (ITT) estimates At age 8, effects on the Wechsler Intelligence Scale for Children Full and Verbal scales for children who attended > 400 days ranged from 7 to 10 points For the heavier LBW infants (2,001-2,500 g), the effects were about 14 points for > 400 days; for the lighter LBW infants ( 350 days

Abstract: Severe complications might ensue when the placenta is implanted in the uterine scar left by a previous cesarean section. Both placenta previa and placenta accreta are encountered. It is estimated that an abnormally inserted placenta accounts for at least 50% of obstetric hysterectomies. The authors report 18 pregnancies implanted in an existing lower-segment cesarean section scar. These cases were encountered over 4 years, all of them in the first trimester. The population screened were women referred for transvaginal ultrasonography because of suspected early pregnancy complications. The diagnosis rested on an empty uterus; the presence of a gestational sac anteriorly at the level of the internal os covering the site of a previous lower-segment cesarean section scar and Doppler evidence of functional trophoblastic/placental circulation. Medically treated women had 25 mg methotrexate injected directly into the pregnancy through the transvaginal route guided by continuous ultrasound monitoring. They also received a single intravenous dose of 1.5 g cefuroxime and 500 mg metronidazole. Embryocide using potassium chloride was the initial step when embryonic cardiac activity was detected. Surgery consisted of suction curettage, also performed under ultrasound guidance. A saline-filled Foley catheter was used to control heavy intraoperative bleeding by compression. It was left in place for 12-24 hours. The estimated prevalence of cesarean scar pregnancy in this patient population was 1 in 1800. A majority of women had had multiple previous sections. Gestational age ranged from 4-23 weeks. Eight women were initially treated surgically, 7 medically, and 3 expectantly. Surgery succeeded in all cases, although 3 women had significant bleeding. There were no retained products of conception present after surgery in any case. Five of 7 women had a good outcome with medical management but 2 required surgery and blood transfusion. Expectant management succeeded in 1 of 3 cases. Seven women have attempted another pregnancy, and 5 of them went on to have normal singleton intrauterine pregnancies. Women treated in the first trimester for pregnancy in a cesarean section score do much better than those found.in late pregnancy to have placenta previa or placenta accreta. Expectant management seems to be unwarranted. When the patient agrees to be actively treated, local injection of methotrexate and transcervical aspiration are preferable to laparoscopy or laparotomy.

Abstract: Aim: To define growth outcomes of a geographically defined population of extremely preterm babies. Population: The EPICure study identified all surviving children in the United Kingdom and Ireland born at ⩽ 25 weeks 6 days gestation between March and December 1995. Of 308 survivors, 283 (92%) were evaluated at 30 months of age corrected for prematurity. Methods: Growth was measured as part of a medical and full neurodevelopmental assessment. Growth parameters were evaluated in relation to other 30 month outcomes and perinatal variables. Results: The children were smaller in each of the five growth measures compared with published population norms: mean (SD) standard deviation scores were −1.19 (1.32) for weight, −1.40 (1.37) for head circumference, −0.70 (1.19) for height, −1.00 (1.38) for body mass index, and −0.75 (0.95) for mid-upper arm circumference. Despite being of average size at birth, children were significantly lighter with smaller head circumferences at the expected date of delivery, compared with population norms, and only weight showed later catch up, by 0.5 SD. Poorer growth was found in children whose parents reported feeding problems and with longer duration of oxygen dependency, as a marker for neonatal respiratory illness. Although severe motor disability was associated with smaller head circumference, overall there was no relation between Bayley scores and head growth. Conclusions: Poor growth in early childhood is common in extremely preterm children, particularly when prolonged courses of systemic steroids have been given for chronic lung disease. Improving early growth must be a priority for clinical care.