Intrahepatic cholestasis of pregnancy and timing of delivery

Objective: We examined the morbidities from delivery at earlier gestational ages versus intrauterine fetal demise (IUFD) for women with intrahepatic cholestasis of pregnancy (ICP) to determine the optimal gestational age for delivery.

Methods: A decision-analytic model was created to compare delivery at 35 through 38 weeks gestation for different delivery strategies: (1) empiric steroids; (2) steroids if fetal lung maturity (FLM) negative; (3) wait a week and retest if FLM negative; or (4) deliver immediately. Literature review identified 18 studies that estimated IUFD in ICP; we used the mean rate, 1.74%, and assumed a uniform distribution from 34 to 40 weeks gestation. Large cohort data was used to calculate neonatal morbidity rates at each gestational age. Maternal and neonatal quality-adjusted life years (QALYs) were combined. Univariate sensitivity and Monte Carlo analyses were performed to test for robustness.

Results: Immediate delivery at 36 weeks without FLM testing and steroid administration was the optimal strategy as compared to delivery at 36 weeks with steroids (+47 QALYs) and as compared to immediate delivery at 35 weeks (+210 QALYs). Our results were robust up to a 30% increase in the rate of IUFD.

Conclusion: Immediate delivery at 36 weeks in women with ICP is the optimal delivery strategy.     

Velamentous cord insertion: is it associated with adverse perinatal outcomes?

Introduction: Velamentous cord insertion (VCI) can be identified on prenatal ultrasound with an incidence of around 1%. We set out to examine the association between VCI and perinatal outcomes.

Methods: This was a retrospective cohort study of 482?812 pregnancies using the California vital statistics birth cohort dataset linked with patient discharge dataset from 2006 during which 2327 (0.48%) were complicated by VCI. Outcomes examined included intrauterine fetal demise (IUFD), small for gestational age (SGA), preterm delivery, manual removal of the placenta and cesarean delivery. Statistical analysis was performed using Chi squared tests and multivariable logistic regression analyses.

Results: Pregnancies with VCI, compared to those without, were associated with an increased risk of IUFD (2.6% versus 0.28%, p?=?0.001), SGA (16.93% versus 10.17%, p?=?0.001), preterm delivery <37 weeks (12.5% versus 9.10%, p?=?0.001), manual removal of placenta (14.47% versus 0.76%, p?=?0.01) and postpartum hemorrhage (6.66% versus 2.88%, p?=?0.001). Adjusting for confounders, the adjusted odds of IUFD were more than nine times in pregnancies with VCI (aOR 9.56; 95% CI 6.76–13.5) than those without.

Discussion: VCI is associated with an increased risk of adverse perinatal outcomes such as IUFD, SGA, preterm delivery <37 weeks, need for manual removal of placenta and post-partum hemorrhage. Routine identification of the placental cord insertion site should be considered. Close surveillance of these pregnancies should be undertaken. Future research should focus on the optimal management including the gestational age for delivery of these pregnancies.     

The influence of psychological factors on postpartum weight retention 12 months post-birth

Background

During the first postpartum year 20% of women retain excessive weight from pregnancy (postpartum weight retention; PPWR), which predicts long-term overweight/obesity.

Objective

The aim of this study was to explore the associations between psychological factors (depression, anxiety and stress symptoms and body attitudes) in late gestation and at 12-months postpartum with PPWR one-year post-birth.

Methods

Pregnant women (N = 176) completed questionnaires in early–mid pregnancy (Time 1; mean (SD) = 16.97 (1.35) weeks), late pregnancy (Time 2; mean (SD) = 33.33 (2.05) weeks), and one year postpartum (Time 3; mean (SD) = 53.12 (3.34) weeks). Women provided demographic characteristics, height and pre-pregnancy weight at Time 1. At Times 2 and 3, weight, depressive, anxiety and stress symptoms and body attitudes (salience of weight and shape, attractiveness, feeling fat, and strength and fitness) were assessed in addition to physiological, socio-contextual and lifestyle factors. Gestational weight gain and PPWR were calculated. Hierarchical linear regression models were conducted to explore variance in 12-month PPWR.

Results

Overall, models explained 26–39% variance in PPWR. Gestational weight gain in late pregnancy and low attractiveness at 12 months postpartum were the only variables associated significantly with 12-month PPWR.

Conclusion

While psychological factors did not appear to be important direct contributors to PPWR at 12 months, the overall contribution of all variables suggests that such factors may be implicated in a small and incremental way. Exploration of the interactions between variables will help unpack potential mechanisms of the development of PPWR at 12 months post-birth.     

The fetal outcomes of pregnancies of systemic lupus erythematosus patients in northern Israel

Objective: To assess the fetal outcomes of pregnancies of systemic lupus erythrematosus (SLE) patients in northern Israel.

Methods: A retrospective cohort study was conducted. The association between demographic characteristics, disease-related variables and adverse pregnancy outcome was assessed.

Results: Data were collected regarding 59 pregnancies of 35 SLE patients; 77.1% were Jewish patients and 22.8% Arab. None of the patients suffered from a major organ flare during pregnancy. There was no difference in the frequency of the different lupus manifestations across the two ethnic groups. The mean birth week of all pregnancies followed was 31.8 weeks. An adverse pregnancy outcome had occurred in 35.6% of the pregnancies. Intrauterine growth restriction was observed in 13.5% of the pregnancies. Antiphospholipid antibodies (APLA) positivity, past major organ involvement and a younger age at conception were associated with an adverse pregnancy outcome; however, ethnicity was not associated.

Discussion: The pregnancy outcomes of our cohort are similar to those previously published, worse than the general population. Ethnicity did not affect the fetal outcome.     

Polycystic ovary syndrome and low-grade inflammation with special reference to YKL-40

Objective: To evaluate the plasma level of YKL-40 in a Danish polycystic ovary syndrome (PCOS) population and to investigate whether YKL-40 is associated with CVD risk factors such as waist circumference, body mass index (BMI), insulin resistance (IR), fasting glucose, fasting insulin, blood lipids and CRP.

Design: Cross-sectional study.

Setting: Gynecological clinics at three Danish University Hospitals.

Patients: One hundred seventy-one premenopausal women with PCOS recruited consecutively from April 2010 to February 2012. PCOS was diagnosed according to the Rotterdam criteria.

Main outcome measures: Plasma level of YKL-40 in four phenotypes of PCOS defined by BMI and IR.

Results: No statistically significant difference was observed in the plasma level of YKL-40 across the four BMI/IR-phenotypes. Positive associations were observed between YKL-40 and BMI, total and free testosterone, triglycerides, and CRP. Total and free testosterone were independent predictors of YKL-40.

Conclusion: YKL-40, the marker of low-grade inflammation is not increased in women with PCOS.     

Low molecular weight heparin treatment and impact of inherited thrombophilia type in pregnancies with previous adverse outcome

Objective: To assess the impact of low molecular weight heparin (LMWH) treatment in 50 pregnancies of women with inherited thrombophilia and adverse pregnancy outcome (APO) in previous untreated pregnancies. The impact of “Conventional” (FVL, PT, AT, PC, PS) and “Novel” (MTHFR, PAI-1, ACE) thrombophilias on APO was investigated.

Methods: The primary outcomes (PO) were: early and late pregnancy loss (EPL, LPL), preterm birth (PTB) or term birth (TB) compared to the last untreated pregnancies of the same women. Secondary outcomes (SO) were APO in LMWH treated and last untreated pregnancies ended with birth. PO and SO were compared in relation to the thrombophilia type.

Results: LMWH decreased EPL and LPL rate and improved TB rate compared with last untreated pregnancies (p?<?0.001). There were less PTB (p?=?0.019) and no cases of intrauterine fetal death (IUFD) (p?=?0.0019) in LWMH-treated pregnancies. The division to Conventional and Novel thrombophilias showed: (a) difference between pregnancy losses and birth rate (p?=?0.0069) and (b) no difference in the prevalence of APO in untreated pregnancies ended with birth.

Conclusions: LMWH treatment improves pregnancy outcome in women with inherited thrombophilia and APO in previous pregnancies. Novel thrombophilias have the equal impact on the pregnancy outcome compared to the Conventional thrombophilias.     

Transcervical Foley’s catheter versus Cook balloon for cervical ripening in stillbirth with a scarred uterus: a randomized controlled trial

Objective: To compare the efficacy and safety of the use of transcervical Foley’s catheter versus Cook cervical ripening balloon in pregnant women with stillbirth, unfavorable cervix and scarred uterus.

Design: Randomized controlled study.

Setting: El Minia University Hospital, El Minia, Egypt.

Patients and methods: Two-hundred pregnant women with stillbirth, unfavorable cervix and scarred uterus were recruited into this study. They were randomized into two groups. In group I (n?=?100), cervical ripening was done using Foley’s catheter. In group II (n?=?100), cervical ripening was done using Cook cervical ripening balloon.

Main outcome measures: Balloon insertion to delivery interval, successful ripening rate, cesarean delivery rate, maternal adverse events and maternal satisfaction.

Results: Time from balloon insertion to expulsion and from balloon insertion to delivery was significantly shorter in Foley’s catheter group. However, the difference between the two groups regarding time from balloon insertion to active labor, time from balloon expulsion to delivery, cervical ripening, cesarean section, instrumental delivery, pain score, need for analgesia, hospital stay and maternal satisfaction was not statistically significant.

Conclusions: Foley’s catheter and Cook cervical ripening balloon are comparable regarding efficacy and safety profile when used to ripen the cervix in pregnant women with stillbirth, unfavorable cervix and scarred uterus. However, Foley’s catheter has a shorter induction to delivery interval and is relatively cheaper device.     

ß-hCG and prediction of therapeutic success in ectopic pregnancies treated with methotrexate,results from a prospective observational study

Objective: To evaluate the diagnostic accuracy of different beta-human chorionic gonadotrophin (ß-hCG) levels measurement, for predicting success of medical treatment in cases diagnosed as tubal ectopic pregnancy (TEP).

Design: Five-year prospective observational study.

Setting: Prenatal Diagnosis Unit, Vall d'Hebron University Hospital – Barcelona.

Patients: TEP cases fulfilling criteria for medical treatment with Methotrexate.

Interventions: ß-hCG levels were measured on d 0, 4 and 7 of treatment. Results were compared by non-parametrical tests. A ROC curve was plotted to define cut-off points. Diagnostic accuracy of the different measurements was evaluated.

Main outcome measure: Failure of treatment defined as need for surgical treatment or persistence of high ß-HCG levels despite treatment.

Results: 126 women were diagnosed as TEP, eligible for medical treatment. There were no differences in parity, age, previous TEP, or adnexal mass size. Success rate was 88%. ß-HCG decreased significantly more, between days 0–7 and 4–7, in the successful cases. LR for success prediction was 6.2 and 7.8 for ß-HCG levels at days 4 and 7 respectively, 4.02 and 2.47 for decrement between days 0–7 (25%) and 4–7 (20%), respectively.

Conclusion: ß-hCG cutoff values have a potential for predicting a successful medical treatment of TEP.     

Impact of amniotic fluid “sludge” on the risk of preterm delivery

Objective: To evaluate the impact of amniotic fluid “sludge” (AFS) on the risk of preterm delivery and to describe the effect of antibiotic treatment in that situation.

Methods: Case–control study including singleton pregnancies with or without AFS, between 15–32 weeks of gestation. Factors associated with preterm delivery before 32 weeks, 34 weeks and 37 weeks were evaluated with univariate and multivariate logistic regression. Since all women with AFS in this study were treated with antibiotics, a historical comparison was performed with similar patients with AFS found before 2007 and not treated with antibiotics.

Results: AFS was observed in 90/1220 patients (7.4%). AFS was associated with shorter cervical length, greater body mass index, cervical cerclage and preterm birth before 28 weeks. However, after adjustment, AFS did not remain associated with preterm delivery before 32 or 34 weeks. The historical comparison suggested that azithromycin could significantly reduce the risk of preterm delivery before 34 weeks (odds ratio: 0.2; 95% CI: 0.04–0.92).

Conclusions: AFS, treated with azithromycin, was associated with a higher risk of prematurity, but not independently after adjustment for cervical length and second trimester vaginal bleeding. Further studies need to evaluate the effect of antibiotics in pregnancies with AFS.     

Maternal and umbilical cord copeptin levels in pregnancies complicated by fetal growth restriction

Objective: The aim of this study was to compare maternal and fetal serum copeptin concentrations in pregnancies complicated by isolated fetal growth restriction (FGR), and uncomplicated pregnancies, and to investigate relationships between copeptin levels and clinical parameters.

Methods: Maternal and fetal serum copeptin levels were measured in 21 women with pregnancies complicated by isolated FGR and 20 women with normal pregnancies (control group). Doppler assessment of the uterine and umbilical arteries was performed in each patient.

Results: Maternal serum copeptin levels were significantly higher in women with isolated FGR compared to controls (p?=?0.042). In addition, maternal copeptin levels were inversely correlated with the uterine artery pulsatility and resistance indices and positively correlated with neonatal birth weight. Umbilical vein copeptin levels were significantly increased in neonates with adverse outcomes (p?=?0.001).

Conclusions: Increased maternal copeptin concentration may reflect a response to stress, thus serving as a compensatory mechanism in pregnancies complicated by FGR.     

Impact of a prenatally diagnosed nuchal cord on obstetrical outcome in an unselected population

Objective: Evaluate the outcome of prenatally diagnosed nuchal cord.

Methods: A retrospective study on all cases of prenatally diagnosed nuchal cord. Study end points were gestational age at delivery, intrapartum fetal heart rate (FHR) abnormalities, mode of delivery, intrauterine fetal growth retardation (IUGR), intrauterine fetal demise (IUFD), and the rate of labor induction.

Results: This study included 44 cases; 86% were diagnosed at second trimester scan, confirmed by Color Doppler and 3D ultrasound. Mean gestational age at delivery was 39 weeks.18/44 cases (41%) underwent labor induction mostly as a result of parental anxiety. Primary cesarean rate was 34% (15/44), and 16% (7/44) had intrapartum FHR abnormalities with no impact for induction of labor. Instrumental vaginal delivery was used in 5 cases. IUGR was present in 7% (3/44), and none had IUFD. Nuchal cord was confirmed at birth in all cases. Correct prenatal diagnosis was in only one case of the 5/44 (11%) with multiple loops.

Conclusion: Prenatal diagnosis of nuchal cord is feasible with difficulty in determining multiple loops. Outcome is favorable, but parental anxiety is common and may increase induction rates, without leading to difference in cesarean rates or FHR abnormalities.     

Relevance of labor room fetal autopsy in increasing its acceptance

Background: Fetal autopsy is included in the basic protocol of investigating a perinatal death, parental refusal is the main reason for its low rate.

Aim: To increase acceptance of fetal autopsy and to provide better counselling to the couple regarding risk of recurrence in future pregnancies.

Materials and methods: All cases with antenatally diagnosed congenital anomaly resulting in stillbirth or termination before 20 weeks were offered fetal autopsy and it was performed in labor room itself by the fetal medicine specialist after consents. External and internal examination, photograph, infantogram and karyotyping were done, and relevant tissue was sent for histopathology. Correlation between the ultrasound and autopsy finding was done.

Results: Total 674 cases of antenatally detected major congenital anomaly were included in the study. Out of 403 cases of stillbirth and abortion, consent for autopsy was given in 312. Most common defect was cranio-vertebral defect followed by genitourinary anomaly. The autopsy finding correlated with USG findings fully in 63.5% cases, there were additional findings altering diagnosis in 24.7% cases, the diagnosis completely changed in 11.8% cases.

Conclusion: Autopsy if done in labor room increases its acceptance by the couple. Additional findings on autopsy helped in reaching at diagnosis and counseling accordingly.     

Birth outcomes of cases with conotruncal defects of heart – a population-based case-control study

Objective: The aim of this study was to evaluate the birth outcomes of cases with four types of conotruncal defects (CTDs), i.e. common truncus, transposition of great arteries, tetralogy of Fallot and double-outlet right ventricle.

Methods: Birth outcomes of 597 live-born cases with CTD and 38?151 population controls without any defects were compared in the population-based large dataset of the Hungarian Case-Control Surveillance of Congenital Abnormalities completed by socio-demographic variables of their mothers.

Results: There was a male excess in cases with CTD (56.8%) with the same mean gestational age (39.4 versus 39.4 weeks) and preterm birth rate (8.2 versus 9.2%), but their mean birth weight was smaller (3077 versus 3276?g) with a high rate of low birthweight (14.6 versus 5.7%) compared to the birth outcomes of population controls. These data indicate intrauterine growth restriction of fetuses affected with transposition of great arteries, tetralogy of Fallot and double-outlet right ventricle particularly in females, while there were a shorter mean gestational age and smaller mean birth weigh in cases with common truncus.

Conclusions: In general CTD, except common truncus, had no effect for gestational age but associated with a high risk for intrauterine fetal growth restriction particularly in female cases.     

Concurrence of gestational diabetes and pre-gravid obesity (“diabesity”) in twin gestations

Objective: To assess the effect of the concurrence of gestational diabetes mellitus (GDM) and pre-gravid obesity in twin gestations (“diabesity”).

Methods: We compared perinatal outcomes of twin gestation in mothers with GDM and pre-gravid obesity (1.7%), mothers with GDM but with normal BMI (6.2%), and obese mothers without GDM (7.0%).

Results: Twin pregnancies with “diabesity” were associated with significantly higher incidence of stillbirth (OR = 6.4; 95%CI = 1.4, 33.4) and existing chronic hypertension (OR = 4.2; 95%CI = 1.2, 14.8) than in GDM pregnancies without obesity, and with births at 33–36 weeks as compared with the other groups. Otherwise, the comparisons showed remarkable similar results in terms of gestational age, birth weight, preeclampsia, cesarean section rate, and fetal-neonatal outcomes.

Conclusion: It appears that diabesity has a relatively minor effect in twins. If this will be confirmed by other studies, it would be important to elucidate how twins ameliorate the adverse outcomes of diabesity.     

Increased human leukocyte antigen-G expression at the maternal–fetal interface is associated with preterm birth

Objective: The maternal–fetal interface must modulate immune function to allow tolerance of fetal cells while still reacting to pathogens to suppress infection. Human leukocyte antigen-G (HLA-G) is a class Ib major histocompatibility complex protein involved in maternal–fetal tolerance. We posited that alterations in placental HLA-G expression predispose women to preterm birth. The aim of this study was to compare HLA-G expression in the maternal–fetal interface of term versus preterm human placentas.

Methods: We performed a cross-sectional study of specimens from the basal plate of the human placenta from women enrolled in a tissue specimen and clinical data consortium. Immunohistochemistry with digital microscopic analysis was used to quantify HLA-G protein expression in the basal plate from preterm and term placentas.

Results: Preterm birth <37 weeks occurred in 29.5% of 149 singleton pregnancies. HLA-G-positive cells occupied one-third of the basal plates, and the HLA-G-positive area was increased by 14% in placentas from preterm births than in those from term births (32.1% in term placentas versus 36.6% in preterm placentas).

Conclusion: Although HLA-G is required for maternal tolerance of the semi-allogeneic fetus, higher levels of HLA-G expression at the maternal–fetal interface is associated with preterm birth.     

Prenatal diagnosis of fetal right and left congenital ventricular aneurysms

Aim: To describe the ultrasonographic appearance of fetal ventricular aneurysm.

Methods: Ultrasound characteristics of two cases of prenatally diagnosed fetal ventricular aneurysm were reviewed.

Results: There was one case of left ventricular aneurysm diagnosed by prenatal ultrasound at 38 weeks of gestation. Another case of fetal right ventricular aneurysm was diagnosed prenatally at 36 weeks of gestation. Both the babies expired in the immediate post-natal period.

Conclusion: Congenital ventricular aneurysm is a rare cardiac malformation characterized by protrusion or out pouching of a portion of the ventricular wall. It is important to differentiate an aneurysm from diverticulum, as the latter has favorable prognosis. The aneurysms are usually large and have broad-based communication with the ventricular cavity in contrast to diverticuli, which are small and connected by a narrow base.     

Type-2 diabetes mellitus: does prenatal care affect outcomes?

Objective: To determine if prenatal care affects adverse perinatal outcomes in pregnant women with Type-2 diabetes mellitus (T2DM).

Study design: This was a retrospective cohort study of pregnant women with pregestational diabetes mellitus pregnancies in the state of California between 1997 and 2006, using vital statistics data linked to birth certificates. Women were stratified by time of presentation to care and we compared those who presented in the first trimester, third trimester, and those who had no prenatal care prior to delivery. Perinatal outcomes looked at included: preeclampsia, macrosomia, preterm delivery, cesarean delivery, and intrauterine fetal demise (IUFD). The two groups were compared with chi-squared testing to determine statistical significance.

Results: In women with pregestational diabetes those who presented at time of delivery had an 11.3% risk of IUFD compared to 0.9% in those who presented in the first trimester. There was also an increased rate of preterm birth in the late presentation cohort (29.4% at time of delivery versus 21.0% in the first trimester). After adjusting for possible confounding variables using logistic regression models, rates of IUFD and preterm delivery were still found to be statistically significant with adjusted odds ratios of 11.37 (95% CI: 6.10–21.16) and 1.55 (95% CI: 1.03–2.32), respectively. There were no differences in rates of macrosomia or preeclampsia between the three cohorts.

Conclusions: Treatment of T2DM throughout pregnancy leads to improved maternal and neonatal outcomes.     

Outcome of singleton preterm small for gestational age infants born to mothers with pregnancy-induced hypertension. A population-based study

Background: Pregnancy-induced hypertension (PIH) has been associated with a decreased risk of infant mortality in small for gestational age (SGA) preterm infants.

Objective: To evaluate the influence of PIH on mortality and major neonatal morbidities in singleton preterm SGA infants, in the presence and absence of acute pregnancy complications.

Methods: Population-based observational study of singleton SGA infants, born at 24 to 32 weeks gestation in the period 1995–2010 (n?=?2139). Multivariable logistic regression analyses were used to assess the independent effect of PIH on mortality and neonatal morbidities. Acute pregnancy complications comprised premature labor, premature rupture of membranes >6?h, antepartum hemorrhage and clinical chorioamnionitis.

Results: In the absence of pregnancy complications, the odds ratio (95% confidence interval) for mortality (0.77; 0.50–1.16), survival without severe neurological morbidity (1.14; 0.79–1.65) and survival without bronchopulmonary dysplasia (BPD) (0.85; 0.59–1.21) were similar in the PIH versus no-PIH groups. In the presence of pregnancy complications, mortality (0.76; 0.40–1.44), survival without severe neurological morbidity (1.16; 0.64–2.12) and survival without BPD (1.04; 0.58–1.86) were also similar in the PIH versus no-PIH groups.

Conclusions: PIH was not associated with improved outcome in preterm SGA infants, both in the presence and absence of acute pregnancy complications.     

Is there any relationship between adverse pregnancy outcome and first trimester nuchal translucency measurements in normal karyotype fetuses?

Aim: This study aims to research whether there is a relationship between first trimester nuchal translucency (NT) measurements and pregnancy complications such as gestational diabetes mellitus (GDM), gestational hypertension (GHT), intrauterine growth restriction (IUGR) and oligohydramnios.

Method: This study included 225 singleton pregnancies attending Canakkale Onsekiz Mart University Obstetrics and Gynecology clinic for all monitoring and examinations, and gave birth at our clinic between January 2011 and December 2012. Data sources were clinical records and the hospital's automation system, and the study was planned as retrospective cohort. NT measurement was made between 10 weeks 3 days and 13 weeks 6 days gestation. For data analysis, the chi-square, Mann–Whitney U test and Spearman correlation were used.

Results: Of pregnancies, in the study, 5 (2.2%) developed GDM, 6 (2.6%) developed GHT, 2 (0.89%) developed IUGR and 10 (4.4%) developed oligohydramnios. There was no correlation identified between NT measurements and development of GDM, GHT, IUGR and oligohydramnios.

Conclusion: There was no relationship found between first trimester NT measurements and complications that could develop in pregnancy. For the first time in the literature, NT and oligohydramnios were studied and no relationship was observed.