Showing papers in "Journal of Perinatal Medicine in 2014"

A “multi-hit” model of neonatal white matter injury: cumulative contributions of chronic placental inflammation, acute fetal inflammation and postnatal inflammatory events

Abstract: OBJECTIVE We sought to determine whether cumulative evidence of perinatal inflammation was associated with increased risk in a "multi-hit" model of neonatal white matter injury (WMI). METHODS This retrospective cohort study included very preterm (gestational ages at delivery <32 weeks) live-born singleton neonates delivered at Hutzel Women's Hospital, Detroit, MI, from 2006 to 2011. Four pathologists blinded to clinical diagnoses and outcomes performed histological examinations according to standardized protocols. Neurosonography was obtained per routine clinical care. The primary indicator of WMI was ventriculomegaly (VE). Neonatal inflammation-initiating illnesses included bacteremia, surgical necrotizing enterocolitis, other infections, and those requiring mechanical ventilation. RESULTS A total of 425 live-born singleton neonates delivered before the 32nd week of gestation were included. Newborns delivered of pregnancies affected by chronic chorioamnionitis who had histologic evidence of an acute fetal inflammatory response were at increased risk of VE, unlike those without funisitis, relative to referent newborns without either condition, adjusting for gestational age [odds ratio (OR) 4.7; 95% confidence interval (CI) 1.4-15.8 vs. OR 1.3; 95% CI 0.7-2.6]. Similarly, newborns with funisitis who developed neonatal inflammation-initiating illness were at increased risk of VE, unlike those who did not develop such illness, compared to the referent group without either condition [OR 3.6 (95% CI 1.5-8.3) vs. OR 1.7 (95% CI 0.5-5.5)]. The greater the number of these three types of inflammation documented, the higher the risk of VE (P<0.0001). CONCLUSION Chronic placental inflammation, acute fetal inflammation, and neonatal inflammation-initiating illness seem to interact in contributing risk information and/or directly damaging the developing brain of newborns delivered very preterm.

Cervical strain determined by ultrasound elastography and its association with spontaneous preterm delivery

Abstract: Objective: To determine if there is an association between cervical strain, evaluated using ultrasound elastography, and spontaneous preterm delivery (sPTD) 25 th centile [endocervical: odds ratio (OR) 0.2; 95% confidence interval (CI), 0.03–0.96; entire cervix: OR 0.17; 95% CI, 0.03– 0.9]. Additional adjustment for gestational age, race, smoking status, parity, maternal age, pre-pregnancy body mass index, and previous preterm delivery did not appreciably alter the magnitude or statistical significance of these associations. Strain values obtained from the external cervical os and from the sagittal view were not associated with sPTD. Conclusion: Low strain values in the internal cervical os were associated with a significantly lower risk of spontaneous preterm delivery < 37 weeks of gestation.

Risk factors for unfavorable pregnancy outcome in women with adverse childhood experiences.

Abstract: Aims: To explore the association between childhood sexual abuse (CSA), physical abuse, as well as other adverse childhood experiences (ACE), and different obstetrical risk factors/behaviors. Methods: In this cohort study, obstetrical risk factors and perinatal outcome in 85 women exposed to CSA were compared to 170 matched unexposed women. CSA, physical abuse, and ACE were explored by face-to-face interviews and by questionnaire. Data on perinatal outcome were extracted from medical charts. Fisher’s exact, χ2-test, and multiple logistic regression were used for statistical analysis. Results: During pregnancy women with CSA experiences were significantly more often smoking (31.7%/9.4%; P<0.0001), had partners abusing drugs (10.6%/1.2%; P<0.0005), experienced physical (16.5%/0; P<0.0001), sexual (12.9%/0; P<0.0001), and emotional abuse (44.7%/1.7%; P<0.0001), reported depression (24.7%/1.8%; P<0.0001), and suicidal ideation (10.6%/0; P<0.0001) than women without CSA experiences. Differences in risk factors were more often correlated with physical than with sexual abuse during childhood. The probability for premature delivery was associated with CSA, physical abuse and ACE as well as with several of the risk factors investigated. Conclusion: Women with CSA, physical, and ACE present with a variety of abuse-associated obstetrical risk factors and an increased risk for premature delivery. Therefore, all types of abusive and other ACE should be considered in prenatal care.

Cesarean section and placental disorders in subsequent pregnancies--a meta-analysis.

Abstract: BACKGROUND Despite an increase in the number of cesarean deliveries conducted worldwide, meta-analyses on the long-term effect of cesarean section (CS) on subsequent placental disorders are sparse. OBJECTIVE To examine the association between CS and three major types of placental disorders (placental abruption, placenta previa, and placenta accreta with its variants increta/percreta) in subsequent pregnancies. SEARCH STRATEGY We followed the MOOSE consensus statement for meta-analyses of observational studies and searched the PubMed database for observational studies published between January 1990 and July 2011 for examining the association between CS and placental disorders in subsequent pregnancies, without focusing on the effect of increasing number of CSs. SELECTION CRITERIA We included studies which provided adjusted measures of association for multiparous singleton-pregnant women with one of the three outcomes and information about prior mode of delivery. DATA COLLECTION AND ANALYSIS Five cohort and 11 case-control studies met the inclusion criteria for this meta-analysis. We combined the results of the included cohort and case-control studies as no significant heterogeneity was found across the studies. MAIN RESULTS The calculated summary odds ratio was 1.47 (95% confidence interval, CI: 1.44-1.51) for placenta previa, 1.96 (95% CI: 1.41-2.74) for placenta accreta, and 1.38 (95% CI: 1.35-1.41) for placental abruption. CONCLUSION In this meta-analysis, cesarean delivery appeared as a consistently reported risk factor for all three major forms of placental disorders in subsequent pregnancies.

The importance of repeated measurements of the sFlt-1/PlGF ratio for the prediction of preeclampsia and intrauterine growth restriction.

Abstract: AIMS The sFlt-1/PlGF ratio has been evaluated as a diagnostic marker for preeclampsia (PE). The aim of this study was to explore the use of the sFlt-1/PlGF ratio as an aid in prediction for PE. METHODS 150 patients with a high risk for PE were enrolled in this prospective study. Groups were compared according to the pregnancy outcome: controls (n=114), intrauterine growth restriction (IUGR) (n=14) and PE (n=22) with subclassification early PE<34 weeks (n=6). Measurements of sFlt-1 and PlGF were performed on the automated Elecsys system. Statistical comparison of the sFlt-1/PlGF ratio in different outcome groups and a mixed model analysis using random intercept models were performed. RESULTS The sFlt-1/PlGF ratio was significantly higher in pregnancies complicated by PE up to 4 weeks before clinical diagnosis compared to controls (106.7 ± 47.7 vs. 21.0 ± 4.1; P=0.02). Levels of the sFlt-1/PlGF ratio were higher throughout pregnancy in women with IUGR compared to PE/control patients (intercept 1.57 vs. 1.30/0.67; P<0.05). The slope for the sFlt-1/PlGF ratio was significantly higher in PE and IUGR pregnancies compared to controls, indicating that a steep increase of the sFlt-1/PlGF ratio correlates with pathologic pregnancy outcomes. CONCLUSION The sFlt-1/PlGF ratio can identify pathologic pregnancy outcomes such as IUGR and PE before clinical diagnosis. Repeated measurements are necessary to assess the dynamics in serum values. The time-dependent slope of the sFlt-1/PlGF ratio is predictive for future pregnancy outcome and risk of developing preeclampsia.

Effect of depth on shear-wave elastography estimated in the internal and external cervical os during pregnancy

Abstract: Aim To investigate the effect of depth on cervical shear-wave elastography. Methods Shear-wave elastography was applied to estimate the velocity of propagation of the acoustic force impulse (shear wave) in the cervix of 154 pregnant women at 11-36 weeks of gestation. Shear-wave speed (SWS) was evaluated in cross-sectional views of the internal and external cervical os in five regions of interest: anterior, posterior, lateral right, lateral left, and endocervix. Distance from the center of the ultrasound (US) transducer to the center of each region of interest was registered. Results In all regions, SWS decreased significantly with gestational age (P=0.006). In the internal os, SWS was similar among the anterior, posterior, and lateral regions and lower in the endocervix. In the external os, the endocervix and anterior regions showed similar SWS values, lower than those from the posterior and lateral regions. In the endocervix, these differences remained significant after adjustment for depth, gestational age, and cervical length. SWS estimations in all regions of the internal os were higher than those of the external os, suggesting denser tissue. Conclusion Depth from the US probe to different regions in the cervix did not significantly affect the SWS estimations.

Sickle cell disease and pregnancy outcomes: population-based study on 8.8 million births.

Abstract: Objective To estimate the prevalence of sickle cell disease (SCD) in pregnancy, and to measure risk factors, morbidity, and mortality among women with SCD with and without crisis at the time of birth. Methods We conducted a population-based, retrospective cohort study on all births in the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) from 1999 to 2008. Births to SCD with and without crisis were identified using ICD-9 codes. Adjusted effects of risk factors and outcomes were estimated using logistic regression analyses. Effect of hemoglobin variants among women with SCD was analyzed as a predictor of crisis. Results There were 4262 births to women with SCD for an overall prevalence of 4.83 per 10,000 deliveries. 28.5% of women with SCD developed crisis at the time of delivery. The maternal mortality rate was 1.6 per 1000 deliveries in women with SCD, compared to 0.1 per 1000 in women without SCD. Pregnant women with SCD had a higher risk of developing preeclampsia, eclampsia, venous thromboembolism, cardiomyopathy, intrauterine fetal demise, and intrauterine growth restriction. Cesarean delivery rates were higher in women with SCD. Among the 1898 SCD women with identified hemoglobin variants, homozygous SS was the greatest risk factor for sickle cell crisis, accounting for 89.8% of all women who developed crisis. Conclusion Pregnant women with SCD have a high risk of morbidity and mortality. Developing acute sickle cell crisis worsened perinatal outcomes.

Breastfeeding is natural but not always easy: intervention for common medical problems of breastfeeding mothers – a review of the scientific evidence

Abstract: Natural processes do not always function perfectly. In breastfeeding, problems are encountered in up to 80% of mother-infant dyads. Altogether, in Western societies, the difficulties reduce the breastfeeding rate within the first months drastically. To deal with the problems of breastfeeding efficiently requires a profound understanding of its physiology, as well as of its psychological and social determinants. This review focuses on the current knowledge of breastfeeding physiology, only touching the psychosocial factors, which are included in the promotion strategies. Subsequently, it scrutinizes definitions, incidences, prevention, and treatment of breastfeeding problems faced most frequently by nursing mothers and their consultants. Not all measures used in counseling mothers and not all treatments for the most common medical problems withstand a careful evaluation on the basis of current scientific data. However, applying proven prevention strategies will significantly improve the well being of mothers and their infants, and may contribute to an affective attitude that increases the success, frequency, and duration of breastfeeding.

Placental chorioangioma: literature review.

Abstract: Placental chorioangioma is the most common benign non-trophoblastic tumor of the placenta. It is derived from primitive chorionic mesenchyme and is typically vascular. Placenta chorioangiomas occur in approximately 1% of pregnancies. Most placental chorioangiomas are small and are not clinically important. However, those measuring more than 4-5 cm in diameter may be associated with maternal and fetal complications. Early diagnosis, close prenatal surveillance and appropriate intervention may prevent severe complications and perinatal mortality caused by chorioangioma. Here we review the incidence, prenatal diagnosis, complications, the pathophysiological mechanisms of maternal and fetal complications, and the therapeutic possibilities in pregnancies complicated by placental chorioangiomas.

Hysteroscopic and laparoscopic management of uterine defects on previous cesarean delivery scars

Abstract: OBJECTIVE To examine the treatment of previous cesarean delivery scar defect after cesarean delivery and the feasibility of laparoscopic uterine repair or hysteroscopic scar excision. STUDY DESIGN A retrospective clinical study that took place from June 2009 to March 2013 and included 41 women who had previously had cesarean deliveries. RESULTS Seventeen women underwent a laparoscopic approach for the repair of scar diverticula, and 24 women underwent a hysteroscopic resection of fibrotic tissue overhanging underneath the diverticula. Most women remained free of symptoms over a 3- to 16-month follow-up and 6 women became pregnant without pregnancy complications. CONCLUSION Women with a history of cesarean delivery combined with irregular perimenstrual bleeding should undergo combined hysteroscopy and ultrasound examination to detect latent scar defects. In diagnosed cases, in those who desired future pregnancies and had a residual myometrial thickness of <3.5 mm or a defect that accounted for ≥50% of the anterior uterine wall, laparoscopic surgical repair was performed with good postoperative anatomic outcomes. Women with residual myometrial thickness of ≥3.5 mm or a defect that accounted for <50% of the anterior uterine wall were treated with hysteroscopic surgery and had a relief of symptoms.

Evaluation of a novel placental alpha microglobulin-1 (PAMG-1) test to predict spontaneous preterm delivery.

Abstract: Objective The PartoSure time-to-delivery (TTD) test (AmniSure International, Boston, MA, USA) is a newly available bedside test for the prediction of time to spontaneous preterm delivery via the detection of placental alpha microglobulin-1. The objective of this study was to determine the efficacy of the test in predicting imminent delivery in 7 or 14 days from the time of testing. Methods The study population consisted of 101 consecutively recruited pregnant women with singleton pregnancies between 20+0 and 36+6 weeks of gestation with symptoms of preterm labor, clinically intact amniotic membranes, and minimal cervical dilatation (≤3 cm). The PartoSure TTD test was performed on these patients and the test-to-spontaneous-delivery interval was calculated. Results The PartoSure TTD test predicted spontaneous preterm delivery within 7 days with 90.0% sensitivity, 93.8% specificity, 97.4% negative predictive value (NPV), and 78.3% positive predictive value (PPV). The test predicted spontaneous preterm delivery within 14 days with 80% sensitivity, 96.1% specificity, 93.6% NPV, and 87.0% PPV. Conclusion A positive PartoSure TTD test in patients presenting with symptoms of preterm labor, intact membranes, and minimal cervical dilatation (≤3 cm) indicated spontaneous preterm delivery will occur within 7 days with a high degree of accuracy. A negative result indicated that spontaneous preterm delivery within 14 days is highly unlikely.

Steroid profiling for congenital adrenal hyperplasia by tandem mass spectrometry as a second-tier test reduces follow-up burdens in a tertiary care hospital: a retrospective and prospective evaluation.

Abstract: Background Newborn screening for congenital adrenal hyperplasia (CAH) based on measuring 17-hydroxyprogesterone (17-OHP) by immunoassay generates a number of false-positive results, especially in preterm neonates. We applied steroid profiling by using liquid chromatography-tandem mass spectrometry (LC-MS/MS) as a second-tier test in newborns with positive CAH screening and evaluated its clinical utility in a tertiary care hospital setting. Methods By performing a 4-year retrospective data review, we were able to test 121 dried blood spots from newborns with positive CAH screening for 17-OHP, androstenedione and cortisol levels by LC-MS/MS. We prospectively evaluated the clinical utility of steroid profiling after the implementation of steroid profiling as a second-tier test in our routine clinical practice. During the 2-year prospective study period, 104 cases with positive initial screening by FIA were tested by LC-MS/MS. Clinical and laboratory follow-up were performed for at least 6 months. Results The preterm neonates accounted for 50.7% (76/150) and 70.4% (88/125) of screening-positive cases in retrospective and prospective cohorts, respectively. By applying steroid profiling as a second-tier test for positive CAH screening, we eliminated all false-positive results and decreased the median follow-up time from 75 to 8 days. Conclusions Our data showed that steroid profiling reduced the burden of follow-up exams by improving the positive predictive value of the CAH screening program. The use of steroid profiling as a second-tier test for positive CAH screening will improve clinical practice particularly in a tertiary care hospital setting where positive CAH screening from preterm neonates is frequently encountered.

Balloon tamponade for the management of postpartum uterine hemorrhage

Abstract: Objective To evaluate the use of the Bakri balloon in postpartum hemorrhage (PPH) resistant to medical treatment. Methods The Bakri balloon was applied to 45 women with PPH after failure of initial management. Bilateral internal iliac artery ligation (BIIAL) and hysterectomy were performed if necessary. Results The Bakri balloon was applied in 45 women; an additional BIIAL was required in nine women. The mean inflation volume of the Bakri balloon was 571±264 mL (range: 240-1300 mL). Hemostasis was achieved in 34 (75.5%) women with the Bakri balloon alone, and in six women with an additional BIIAL. The Bakri balloon was effective with additional procedures overall in 40 of 45 (88.8%) women. In 34 women with uterine atony, the Bakri balloon was successful alone in 27 (79.4%) and with an additional BIIAL in 30 (88.2%) women. An inflation volume of >500 mL was necessary in 18 women with uterine atony. Conclusion The Bakri balloon may be performed as a first line of treatment for PPH resistant to uterotonic agents, and can be used not only in tertiary centers but also in limited-resource centers. The inflation volume of the Bakri balloon should be adjusted according to the type of PPH; a volume exceeding 500 mL may be necessary in uterine atony.

Silent chorioamnionitis and associated pregnancy outcomes: a review of clinical data gathered over a 16-year period.

Abstract: OBJECTIVE To assess neonatal outcomes and associated findings in pregnant women identified after delivery as having had underlying subclinical chorioamnionitis by either histology or bacterial culture. METHODS In 16 years, 8974 clinical, histological, and bacterial culture data were obtained retrospectively. RESULTS Placental histology was analyzed in 4237 pregnancies (2785 term and 1452 preterm) and 4737 amniotic cavity cultures were obtained during 5446 cesarean deliveries (3268 term and 1469 preterm). Histological results and bacterial cultures were both available in 1270 of the preterm deliveries. Histology revealed inflammation, suggestive of infection, in 13.6% of placentas. Subclinical acute chorioamnionic inflammation was confirmed in 142 out of 2785 term pregnancies (5.1%) and in 436 out of 1452 preterm pregnancies (30.0%, P<0.001). Bacteriological culture of the intrauterine cavity was obtained from the lower uterine segment of the uterus during cesarean section. A positive culture was found in 19.9% of all cases (941/4737), this proportion was significantly higher in preterm deliveries (343/1273, 26.9%) than in term (17.3%, P<0.001). The lower the birth-weight or gestational age, the higher the frequency of silent infections in the uterine cavity. CONCLUSIONS Our study findings support the association between intra-amniotic infections and preterm delivery.

Ferrous bisglycinate 25 mg iron is as effective as ferrous sulfate 50 mg iron in the prophylaxis of iron deficiency and anemia during pregnancy in a randomized trial

Abstract: OBJECTIVE To compare the effects of oral ferrous bisglycinate 25 mg iron/day vs ferrous sulfate 50 mg iron/day in the prevention of iron deficiency (ID) and iron deficiency anemia (IDA) in pregnant women DESIGN Randomized, double-blind, intention-to-treat study SETTING Antenatal care clinic SAMPLE 80 healthy ethnic Danish pregnant women METHODS Women were allocated to ferrous bisglycinate 25 mg elemental iron (Aminojern®) (n=40) or ferrous sulfate 50 mg elemental iron (n=40) from 15 to 19 weeks of gestation to delivery Hematological status (hemoglobin, red blood cell indices) and iron status (plasma iron, plasma transferrin, plasma transferrin saturation, plasma ferritin) were measured at 15-19 weeks (baseline), 27-28 weeks and 36-37 weeks of gestation MAIN OUTCOME MEASURES Occurrence of ID (ferritin <15 μg/L) and IDA (ferritin <12 μg/L and hemoglobin <110 g/L) RESULTS At inclusion, there were no significant differences between the bisglycinate and sulfate group concerning hematological status and iron status The frequencies of ID and IDA were low and not significantly different in the two iron groups The frequency of gastrointestinal complaints was lower in the bisglycinate than in the sulfate group (P=0001) Newborns weight was slightly higher in the bisglycinate vs the sulfate group (3601±517 g vs 3395±426 g, P=009) CONCLUSIONS In the prevention of ID and IDA, ferrous bisglycinate was not inferior to ferrous sulfate Ferrous bisglycinate in a low dose of 25 mg iron/day appears to be adequate to prevent IDA in more than 95% of Danish women during pregnancy and postpartum

The impact of perinatal death on obstetrics nurses: a longitudinal and cross-sectional examination.

Abstract: Mental health and well-being among obstetrics nurses after perinatal death are understudied. Beyond the normal strain imposed on obstetric nurses, exposure to perinatal death may add significant stress. Two studies were conducted on obstetrics nurses. In study 1, obstetrics nurses were measured longitudinally, at baseline (with no recent history of exposure to perinatal death in the past 3 months), and 3 months after (2 months after two consecutive events of perinatal death have occurred 1 month after baseline). In study 2, a cross-sectional study was conducted comparing obstetrics nurses with a history of perinatal death (nurses from study 1) to obstetrics nurses with no history of exposure to perinatal death in the past 6 months. The results of study 1 showed that obstetrics nurses showed a higher level of psychiatric symptoms [posttraumatic stress disorder (PTSD), depressive, and psychosomatic symptoms] at time 2 (after exposure to perinatal death) in comparison to time 1. The results of study 2 showed a higher level of psychiatric symptoms (PTSD, depressive, and psychosomatic symptoms) in the exposed group in comparison to the non-exposed group. The effect of exposure to perinatal death is severe and needs to be addressed by developing intervention and preparation programs to help obstetric nurses cope with this critical incident.

Risk factors for pregnancy-associated venous thromboembolism: a review.

Abstract: To critically evaluate current understanding of risk factors for pregnancy-associated venous thromboembolism (VTE) and to describe underlying molecular mechanisms.

Sonographic measurement of cervical length as a predictor of preterm delivery: a systematic review

Abstract: Aim To evaluate if transvaginal cervical length measurement in the second-trimester scan is an effective screening test for preterm delivery. Methods We performed a search in Medline and, for each selected article, information was extracted regarding the performance of the test in terms of sensitivity, specificity, positive, and negative likelihood ratios, in low-risk, high-risk, and multiple gestations. We also evaluated the performance of the combined test (more than one sonographic marker). Results A positive relationship was established between short cervix and preterm delivery in all articles. The majority of studies presented high specificity and positive likelihood ratio, while sensitivity and negative likelihood ratio were variable and globally poor. Better values of accuracy were found in high-risk and multiple gestations and, in all studied subgroups, for preterm delivery at lower gestational ages. Conclusions We conclude that a short cervix is predictive of preterm delivery and can identify women that may benefit from preventive and therapeutic measures, however, a negative result is not always reassuring.

Impact of sex on perinatal mortality and morbidity in twins

Abstract: Objective: Twin studies offer opportunities to investigate mechanisms underlying sex-associated differences in perinatal outcomes. The objective of the study was to investigate sex-related differences in perinatal complications. Study design: A cohort of 16,045 twin pregnancies 32,090 twins - was explored for obstetric complications, perinatal and infant mortality, and neonatal morbidities. Results: Twin pregnancies with a female fetus had an increased risk for preeclampsia, but otherwise there were no pregnancy complications associated with fetal sex. After birth, female-female twins had lower early neonatal and infant mortality, and lower risk for respiratory morbidities than male-male twins at all gestational ages. In unlike-sexed twin pairs, very preterm males had higher respiratory morbidity than females and, females were at higher risk for being growth restricted. Conclusion: Male-male twins have higher respiratory morbidity and neonatal mortality than female-female twins. In unliked-sexed twin pairs, the males seem to be protected by having a female co-twin.

Mercury exposure in pregnancy: a review.

Abstract: Mercury exposure in pregnancy has been associated with both pregnancy complications and developmental problems in infants Apart from industrial accidents and contaminated food, mercury exposure is likely to arise from predatory fish consumption, environmental contamination and dental amalgam restorations placed before or during pregnancy It would be prudent to recommend that pregnant women avoid these potential problems and minimize any risk The available literature indicates a linear relationship with mercury levels and IQ deficit, and therefore a safe limit of mercury cannot be calculated

Practical application of kangaroo mother care in preterm infants: clinical characteristics and safety of kangaroo mother care

Abstract: AIM To determine the clinical characteristics and safety of kangaroo mother care (KMC) according to the gestational age (GA) or postmenstrual age (PMA). METHODS We conducted a prospective clinical study in 31 infants between 25 and 32 weeks' GA. The subjects were categorized into two groups (25-28 weeks' and 29-32 weeks' GA groups) to compare the clinical characteristics associated with KMC. Heart rate, respiratory rate, oxygen saturation, blood pressure and body temperature (BT) were longitudinally assessed for 60 min with respect to the PMA group (29-32 weeks' and 33-36 weeks' PMA groups). RESULTS The authors analyzed 70 sessions with 31 infants (25-32 weeks' GA, birth weight 760-1740 g, 29-36 weeks' PMA). All infants had statistically significant higher temperatures during KMC than before KMC within clinically acceptable limits (P<0.001). We found a significantly lower variation of BT in the 25-28 weeks' GA group compared with the 29-32 weeks' GA group at 33-36 weeks' PMA, suggesting accelerated skin maturation in more premature infants (P<0.001). CONCLUSION Our intermittent KMC was a safe and feasible method for preterm infants. Notably, at the same PMA, preterm infants in the lower at-birth GA group showed an advanced maturation of thermoregulation compared with those in the higher GA group.

Clinical differences between early- and late-onset severe preeclampsia and analysis of predictors for perinatal outcome.

Abstract: AIMS: To analyze the clinical differences between early- and late-onset cases of severe preeclampsia and to evaluate parameters that could help to predict perinatal outcome. METHODS: Over a period of 6 years, all cases of severe preeclampsia (n=68) at our institution were included in a retrospective cohort analysis. Differences between early (<34 weeks, n=44) and late (≥34 weeks, n=24) onset of the disease were evaluated. Risk factors for low 5-min Apgar score (≤7), small-for-gestational-age (SGA) infants and neonatal acidosis (umbilical arterial pH <7.20) were identified and considered in a multiple logistic regression model. RESULTS: Early- and late-onset severe preeclampsia differed from each other remarkably. Perinatal outcome was unfavorable in early-onset disease and seemed to be mainly a result of premature delivery and development of fetal growth restriction. Abnormal uterine Doppler velocimetry increased the risk of low 5-min Apgar values [odds ratio (OR) 8.0, P=0.012] and preterm birth <34+0 weeks (OR 17.9, P<0.001). An increased resistance of the umbilical artery was associated with a higher risk for SGA birth weight (OR 4.9, P=0.010). CONCLUSION: Preeclampsia is a heterogeneous syndrome even if only severe cases were analyzed. Abnormal Doppler flow characteristics facilitated the identification of patients who were at increased risk for worse perinatal outcome.

Variations of blood cells in prediction of gestational diabetes mellitus

Abstract: OBJECTIVE This study aims to evaluate the value of increasing inflammation in predicting gestational diabetes mellitus (GDM). MATERIALS AND METHODS Subjects in this cross-sectional study included 302 GDM and 310 normal pregnancies before 20 weeks. Sociodemographic and pregnancy characteristics as well as blood parameters were acquired by maternal health booklet, medical records and laboratory information systems. Blood cell parameters were compared between the two groups by independent sample t-tests. Multivariate logistic regression, χ²-test, receiver operator characteristic curve (ROC), and Fisher's linear discriminant were performed to analyze the screening effects of variables in developing GDM. RESULTS Women with GDM had significantly higher neutrophil (NEU), lymphocyte (LYM), platelet (PLT) and erythrocyte (RBC) counts, and were positively correlated with GDM. NEU (odds ratios, OR, 1.22) and LYM (OR, 2.01) were independently associated with the development of GDM (P<0.001). The OR of the mean platelet volume (MPV) and mean cell volume (MCV) were 0.84 and 0.92, respectively (P<0.01 for both). The efficiency of Fisher's equations in correctly classifying cases of GDM from 4 to 20 weeks of gestation was 70.06%. CONCLUSIONS Maternal WBC, RBC, and PLT counts are important correlates of GDM. Increased volume of RBC and PLT might protect pregnant women from development of GDM.

Labor induction in nulliparous women with an unfavorable cervix: double balloon catheter versus dinoprostone.

Abstract: OBJECTIVE We sought to compare the efficacy of the double-balloon catheter and dinoprostone for induction of labor among nulliparous women with an unfavorable cervix. STUDY DESIGN Nulliparous women with a Bishop score <6 were randomized to receive a 10-mg intra-vaginal dinoprostone insert or a double-balloon catheter. Primary outcome was time to delivery. Statistical analyses were performed by intention to treat using the chi-square, Fisher's exact, and Student's t-test, as appropriate. RESULTS The mean induction-to-delivery time was shorter in the double-balloon group as compared to the dinoprostone group (17.9±5.8 vs. 26.3±9.7 h) as was the time from induction to vaginal delivery (19.13±5 vs. 24.45±8.7 h, respectively). More women in the catheter group were delivered within 24 h compared to the dinoprostone group (87.1% vs. 47.4%). Approximately 50% of women in both groups delivered by cesarean section. CONCLUSION Induction of labor with the double-balloon catheter in nulliparous women with an unfavorable cervix is associated with a shorter time to delivery compared to dinoprostone.

Inactivation of high-risk human papillomaviruses by Holder pasteurization: implications for donor human milk banking.

Abstract: Aims Several studies have recently reported the detection of oncogenic human papillomaviruses (HPV) in human milk of a minority of lactating mothers. These findings raised safety concerns in the context of human donor milk banking given the potential risk of HPV transmission to recipient infants. The aim of this study was to investigate whether the Holder pasteurization, a procedure currently in use in human donor milk banks for milk pasteurization, completely inactivates high-risk and low-risk HPV. Methods HPV pseudoviruses (PsV) were generated, spiked into cell culture medium or donor human milk and subjected to thermal inactivation. HPV PsV infectivity and morphological integrity was analyzed by cell-based assay and by electron microscopy, respectively. Results The Holder pasteurization completely inactivated the infectivity of high-risk (types 16 and 18) and low-risk (type 6) HPV both in cell culture medium and in human milk causing PsV particle disassembly. Conclusions The results presented here indicate that the Holder pasteurization is an efficient procedure to inactivate high-risk and low-risk HPV thus preventing the potential risk of their transmission through human donor milk.

Neonatal serum magnesium concentrations are determined by total maternal dose of magnesium sulfate administered for neuroprotection

Abstract: BACKGROUND Antenatal magnesium in preterm labor for neuroprotection decreases the incidence of cerebral palsy. However, there are no guidelines on the dose and duration of magnesium infusion for neuroprotection. As increased neonatal serum magnesium concentrations may be related to higher risk of morbidity and mortality, the role of total amount of magnesium and maternal serum magnesium concentrations associated with safe neonatal serum magnesium concentrations is not known. METHODS A retrospective study was conducted on 289 mothers who received antenatal magnesium for neuroprotection as a loading dose of 4-6 g infused over 30 min, followed by a maintenance infusion of 1-2 g/h. Total magnesium dose infused to the mother and maternal serum magnesium concentrations were correlated with neonatal serum magnesium concentrations. RESULTS Of the 289 mothers, 192 mother/baby dyads had all three measurements (maternal total magnesium dose, and maternal and neonatal serum magnesium concentrations). Magnesium infusion was continued beyond 24 h in 60 mothers. Total maternal magnesium dose at 24 and 48 h of infusion correlated with neonatal serum magnesium concentrations (r=0.55, P<0.0001 and r=0.35, P<0.0001, respectively), but not with maternal serum magnesium concentrations (r=0.004, P=0.98 and r=0.14, P=0.21). However, there was no correlation between the maternal and neonatal serum magnesium concentrations (r=0.10, P=0.15). CONCLUSION Total dose of magnesium infused to the mother correlates with neonatal serum magnesium concentrations. To keep neonatal serum magnesium concentrations within a range that is effective for neuroprotection and safe for the neonates, the total dose received by the mother needs to be monitored and limited.

The relationship between gestational weight gain and fetal growth: time to take stock?

Abstract: The aim of this article is to review the current evidence on gestational weight gain (GWG). Maternal obesity has emerged as one of the great challenges in modern obstetrics as it is becoming increasingly common and is associated with increased maternal and fetal complications. There has been an upsurge of interest in GWG with an emphasis on the relationship between excessive GWG and increased fetal growth. Recent recommendations from the Institute of Medicine in the USA have revised downwards the weight gain recommendations in pregnancy for obese mothers. We believe that it is time to take stock again about the advice that pregnant women are given about GWG and their lifestyle before, during, and after pregnancy. The epidemiological links between excessive GWG and aberrant fetal growth are weak, particularly in obese women. There is little evidence that intervention studies decrease excessive GWG or improve intrauterine fetal growth. Indeed, there is a potential risk that inappropriate interventions during the course of pregnancy may lead to fetal malnutrition that may have adverse clinical consequences, both in the short- and long-term. It may be more appropriate to shift the focus of attention from monitoring maternal weight to increasing physical activity levels and improving nutritional intakes.

Relation of placental diagnosis in stillbirth to fetal maceration and gestational age at delivery.

Abstract: Aim To study the relation of retention of dead fetus resulting in its maceration and gestational age at delivery to placental diagnosis. Methods Some 75 clinicoplacental phenotypes have been retrospectively analyzed in 520 consecutive stillbirths, 329 macerated and 191 nonmacerated, and at three gestational age interval cohorts (330 second trimester, 102 preterm third trimester, and 88 term). Chi-square and clustering methods (Ward dendrograms and multidimensional scaling) were used for statistical analysis. Results Maternal diabetes mellitus, induction of labor, fetal growth restriction, various umbilical cord abnormalities, and placental clusters of sclerotic/hemosiderotic chorionic villi were more common in macerated stillbirths, while clinicoplacental signs and symptoms of ascending infection and placental abruption, i.e., retroplacental hematoma, premature rupture of membranes, and acute chorioamnionitis in nonmacerated stillbirths. Placental abnormalities were less common in the second trimester, other than the acute chorioamnionitis. Patterns of chronic hypoxic placental injury were common in preterm third trimester, while signs of in-utero hypoxia (abnormal cardiotocography, meconium, and histological erythroblastosis of fetal blood) in term pregnancy. In addition to classical statistics, the clustering analyses added new information to placental investigation of cause of stillbirth. Conclusions Macerated third trimester stillbirths have multifactorial etiology more likely than the second trimester stillbirths and the likely stasis-induced fetal thrombotic vasculopathy secondary to occult umbilical cord compromise should be sought in placental investigation in such cases. Nonmacerated stillbirths are associated with ascending infection and placental abruption.

Prediction of preeclampsia by placental protein 13 and background risk factors and its prevention by aspirin

Abstract: AIM: Evaluation of placental protein 13 (PP13) and risk factors (RFs) as markers for predicting preeclampsia (PE) and use of aspirin for PE prevention. MATERIALS AND METHODS: First-trimester pregnancy screening was based on having PP13 level ≤0.4 multiple of the median (MoM) and/or at least one major risk factor (RF) for PE. Management was by routine care or combined with daily treatment with 75 mg aspirin between 14 and 35 weeks of gestation. RESULTS: Of 820 deliveries, 63 women developed PE (7.7%). Median PP13 levels was 0.2MoM in the PE group compared with 0.83MoM among unaffected and 1.0MoM in unaffected not treated with aspirin (P<0.0001). Low PP13 was a better predictor for PE versus major RFs, particularly for young nuliparous. Combining low PP13 with RFs increased prediction accuracy. Mean arterial pressure (not included in the initial prediction), could add to prediction accuracy when combined with low PP13 and RFs. PE prevention by aspirin was most effective when the risk was determined by low PP13 alone, less effective for combining low PP13 with RFs, and ineffective when determined by RFs alone. CONCLUSION: When PE risk is determined by low first trimester PP13 or by combined low PP13 and RFs, prevention with aspirin is warranted.

Chemerin concentrations in maternal and fetal compartments: implications for metabolic adaptations to normal human pregnancy

Abstract: Objectives Chemerin, a novel adipocytokine, has been implicated in major metabolic and inflammatory processes. Study aims were to determine whether circulating maternal chemerin concentration (1) differs between pregnant and non-pregnant women, (2) changes as a function of gestational age, and (3) correlates with maternal insulin resistance. In addition, we investigated which compartment, maternal, fetal or placental, is the source of chemerin in maternal circulation. Methods The study included three groups: Non-pregnant (n=18), pregnant women in the first trimester (n=19) and pregnant women in the third trimester (n=33). Chemerin was measured in cord blood and in maternal serum samples taken before and after delivery. Chemerin mRNA expression was evaluated in fetal and human adult tissues. Results Chemerin serum concentration was significantly higher in pregnant women in the third trimester than in non-pregnant and pregnant women in the first trimester. Chemerin concentration positively correlated with body mass index (BMI) and insulin resistance. Antenatal chemerin concentration was significantly lower than that during the postpartum period. Neonatal chemerin did not correlate with maternal one. Chemerin mRNA expression was abundant in fetal and adult liver and omental fat, but relatively low in placenta. Conclusions Chemerin is increased during normal gestation and is associated with maternal BMI and insulin resistance. Maternal tissues, possibly liver and adipose tissue, contribute to the increased maternal chemerin concentration.