Placental maternal vascular malperfusion and adverse pregnancy outcomes in gestational diabetes mellitus

IntroductionMaternal vascular malperfusion (MVM) lesions represent hypoxic-ischemic damage to the placenta, and they are associated with adverse pregnancy outcomes. Women with gestational diabetes (GDM) are at increased risk for pregnancy complications, so we set out to characterize the prevalence and clinical correlates of MVM lesions in this cohort.MethodsThis was a retrospective cohort study of 1187/1374 (86.4%) women with GDM delivered between 2009 and 2012 who had placental pathology available. Placental lesions of all types were tabulated and grouped into constructs of related entities. MVM lesions specifically included villous infarcts, decidual vasculopathy, increased syncytial knots, perivillous fibrin, and fibrin deposition. We compared maternal characteristics between women with and without MVM lesions, and we also assessed the impact of these lesions on birth weight, preterm birth, and pre-eclampsia using multivariable logistic regression analysis.ResultsMVM lesions were the most common placental lesion type in women with GDM (n = 362, 30.5%). Excess gestational weight gain was independently associated with MVM lesions (aOR 1.42, 95% CI 1.06–1.91, p = 0.02) after adjusting for maternal characteristics. MVM lesions were associated with lower birth weight (−90.3 g, 95% CI -148.0 to −32.7, p = 0.002), as well as a 2-fold increased risk for delivery of a small for gestational age infant (10.8 vs 5.9%, p = 0.01) in overweight and obese women. MVM lesions were also associated with increased risk for preterm birth <34 weeks (adjusted OR 2.36, 95% CI 1.31–4.23, p = 0.004) and hypertensive disorders of pregnancy (HDP; adjusted OR 1.58, 95% CI 1.13–2.22, p = 0.02).DiscussionPlacental maternal vascular malperfusion lesions may be one pathway linking excess gestational weight gain to adverse pregnancy outcomes in women with GDM, and future studies are needed to identify metabolic factors that may explain this association.     

Placental growth factor as a marker of fetal growth restriction caused by placental dysfunction

IntroductionDiscriminating between placentally-mediated fetal growth restriction and constitutionally-small fetuses is a challenge in obstetric practice. Placental growth factor (PlGF), measurable in the maternal circulation, may have this discriminatory capacity.MethodsPlasma PlGF was measured in women presenting with suspected fetal growth restriction (FGR; ultrasound fetal abdominal circumference <10th percentile for gestational age) at sites in Canada, New Zealand and the United Kingdom. When available, placenta tissue underwent histopathological examination for lesions indicating placental dysfunction, blinded to PlGF and clinical outcome. Lesions were evaluated according to pre-specified severity criteria and an overall severity grade was assigned (0–3, absent to severe). Low PlGF (concentration <5th percentile for gestational age) to identify placental FGR (severity grade ≥ 2) was assessed and compared with routine parameters for fetal assessment. For all cases, the relationship between PlGF and the sampling-to-delivery interval was determined.ResultsLow PlGF identified placental FGR with an area under the receiver-operator characteristic curve of 0.96 [95% CI 0.93–0.98], 98.2% [95% CI 90.5–99.9] sensitivity and 75.1% [95% CI 67.6–81.7] specificity. Negative and positive predictive values were 99.2% [95% CI 95.4–99.9] and 58.5% [95% CI 47.9–68.6], respectively. Low PlGF outperformed gestational age, abdominal circumference and umbilical artery resistance index in predicting placental FGR. Very low PlGF (<12 pg/mL) was associated with shorter sampling-to-delivery intervals than normal PlGF (13 vs. 29.5 days, P < 0.0001).DiscussionLow PlGF identifies small fetuses with significant underlying placental pathology and is a promising tool for antenatal discrimination of FGR from fetuses who are constitutionally-small.     

Placental abnormalities differ between small for gestational age fetuses in dichorionic twin and singleton pregnancies

ObjectiveTwin fetuses grow slower during the third trimester compared with singletons. However, the extent to which the relative smallness of twins is the result of placenta-mediated factors similar to those associated with fetal growth restriction in singletons remains unclear. Our aim was to address this question by comparing placental findings between small for gestational age (SGA) twins and SGA singletons.MethodsRetrospective cohort study of all SGA non-anomalous newborns from singleton and dichorionic twin pregnancies in a single tertiary referral center between 2002 and 2015. SGA was defined as birth weight <10th percentile for gestational age according to sex-specific national reference charts. Placental findings were compared between SGA twins and SGA singletons and were classified into lesions associated with maternal vascular malperfusion, fetal vascular malperfusion, placental hemorrhage and chronic villitis.ResultsA total of 532 SGA twins and 954 SGA singletons met the inclusion criteria. SGA twins had a higher mean placental weight (371 ± 103 g vs. 319 ± 107, p < 0.001) and a lower fetal-placental ratio (6.0 ± 2.5 vs. 6.7 ± 3.2, p < 0.001) compared with SGA singletons. Compared with SGA singletons, SGA twins were less likely to have any placental pathology (aOR 0.37, 95%-CI 0.29–0.46), hypercoiled cord (aOR 0.45, 95%-CI 0.33–0.61), placental weight<10th% (aOR 0.13, 95%-CI 0.08–0.20), maternal vascular malperfusion pathology (aOR 0.24, 95%-CI 0.18–0.30) and fetal vascular malperfusion pathology (aOR 0.62, 95%-CI 0.48–0.82). By contrast, SGA twins had higher odds of a marginal or velamentous cord insertion compared with SGA singletons (aOR 13.82, 95%-CI 10.44–18.30). Similar significant associations were observed in subgroups of SGA fetuses with a birth weight below the 5th and 3rd percentile for gestational age.ConclusionsOur findings illustrate that the mechanisms underlying reduced fetal growth in dichorionic twins differ from those involved in singletons, and may provide support to the hypothesis that smallness in dichorionic twins may be more benign than in singletons.     

Placental location and newborn weight

ObjectivePrevious studies suggest that placental location may affect fetal growth and the risks of preterm birth and preeclampsia. We studied the association between placental location and newborn weight.MethodsWe conducted a retrospective cohort study of 796 consecutive singleton births in women who delivered at ≥ 37 weeks’ gestation between July and October 2009. We evaluated placental location at the time of the second trimester prenatal ultrasound at 16 to 24 weeks’ gestation. Placental location was classified as lateral or central/fundal. We assessed the difference in newborn weight according to placental location and the incidence of small for gestational age birth weight < 10th percentile and pregnancy-induced hypertension. Using logistic regression analysis, odds ratios were adjusted for maternal age, world region of birth, gravidity, parity, maternal weight, history of hypertension or diabetes, current smoking or illicit drug use, and infant sex.ResultsAmong women with lateral versus central/fundal placentas, the respective mean (SD) birth weights were 3298 (550) g and 3352 (579) g (mean difference 54 g, 95% CI 53 to 161; P = 0.32). Relative to central/fundal location, laterally located placentas had an adjusted OR of 0.81 (95% CI 0.42 to 1.54) for SGA and 0.62 (95% CI 0.18 to 2.10) for preeclampsia/gestational hypertension.ConclusionPlacental location was not associated with differences in newborn weight or other perinatal outcomes.     

Placental Growth Factor and Soluble,Fms-Like Tyrosine Kinase-1 in Preeclampsia: A Case-Cohort (PEARL) Study

ObjectivePreeclampsia is associated with a higher maternal blood levels of soluble fms-like tyrosine kinase-1 (sFlt-1) and lower levels of placental growth factor (PlGF) that appear before clinical onset. We aimed to estimate the normal progression of these biomarkers in normal pregnancies and in those affected by preeclampsia.MethodsWe conducted a case-cohort study including low-risk nulliparous women recruited at 11–13 weeks gestation (cohort) and women with preeclampsia (cases). Maternal blood was collected at different points during pregnancy including at the time of diagnosis of preeclampsia for cases. Maternal serum PlGF and sFlt-1 concentrations and the sFlt-1/PlGF ratio were measured using B•R•A•H•M•S plus KRYPTOR automated assays and were compared between patients in both groups matched for gestational age. Cases were stratified as early- (≤34 weeks), intermediate- (35–37 weeks) and late-onset (>37 weeks) preeclampsia.ResultsThe cohort consisted of 45 women whose results were compared with those of 31 women who developed preeclampsia, diagnosed at a median gestational age of 32 weeks (range 25–38 weeks). We observed that sFlt-1, PlGF and their ratio fluctuated during pregnancy in both groups, with a significant correlation with gestational age after 28 weeks (P < 0.05). We observed a significant difference between cases and controls, with a median ratio 100 times higher in early preeclampsia (P < 0.001), 13 times higher in intermediate preeclampsia (P < 0.001), but no significant difference between groups in late-onset preeclampsia with matched controls.ConclusionPlGF, sFlt-1, and their ratio may be useful in the prediction and diagnosis of early- and intermediate-onset preeclampsia but are not useful for late-onset preeclampsia.     

Intraoperative Ultrasound Guidance During Curettage After Second-Trimester Delivery is Associated With a Higher Rate of Complications

ObjectiveThe use of intraoperative ultrasound guidance for second-trimester elective dilation and curettage reduces the incidence of uterine perforation. However, the role of intraoperative ultrasound guidance during curettage following second-trimester delivery has not been evaluated. We aim to evaluate the effect of intraoperative ultrasound guidance during curettage following second-trimester delivery.MethodsWe conducted a retrospective cohort study that included patients who had a second-trimester delivery at up to 23^6/7 weeks gestation and underwent uterine curettage after the fetus was delivered.ResultsOverall, 273 patients were included. Of them, 194 (71%) underwent curettage without intraoperative ultrasound guidance, while 79 (29%) underwent the procedure utilizing intraoperative ultrasound guidance. The overall rate of a composite adverse outcome was higher among those undergoing curettage under intraoperative ultrasound guidance compared with no ultrasound guidance (31 [39.2%] vs. 40 [20.6%]; OR 2.4; 95% CI 1.4–4.4, P = 0.002). Placental morbidity (10 [12.6%] vs. 11 [5.6%]; OR 1.9; 95% CI 1.01–5.9, P = 0.04) and infectious complications (6 [7.5%] vs. 5 [2.5%]; OR 3.1; 95% CI 1.01–10.4, P = 0.05) were more frequent among those undergoing curettage with intraoperative ultrasound guidance. In a multivariate logistic regression analysis, intraoperative ultrasound guidance was the only independent factor positively associated with the occurrence of an adverse outcome (adjusted OR 1.93; 95% CI 1.1–3.4, P = 0.02). Procedure time was longer when ultrasound guidance was used (9:52 vs. 6:58 min:s; P < 0.001).ConclusionIntraoperative ultrasound guidance during curettage after second-trimester delivery is associated with a higher complication rate than no guidance.     

Endometriosis and assisted reproductive techniques independently related to mother–child morbidities: a French longitudinal national study

Research questionDoes endometriosis increase obstetric and neonatal complications, and does assisted reproductive technology (ART) cause additional risk of maternal or fetal morbidity?DesignA nationwide cohort study (2013–2018) comparing maternal and perinatal morbidities in three groups of single pregnancies: spontaneous pregnancies without endometriosis; spontaneous pregnancies with endometriosis; and ART pregnancies in women with endometriosis.ResultsMean maternal ages were 30.0 (SD = 5.3), 31.7 (SD = 4.8) and 33.1 years (SD = 4.0), for spontaneous conceptions, spontaneous conceptions with endometriosis and ART pregnancies with endometriosis groups, respectively (P < 0.0001). Comparison of spontaneous conceptions with endometriosis and spontaneous conceptions: endometriosis independently increased the risk of venous thrombosis (adjusted OR [aOR] 1.51, P < 0.001), pre-eclampsia (aOR 1.29, P < 0.001), placenta previa (aOR 2.62, P < 0.001), placental abruption (aOR 1.54, P < 0.001), premature birth (aOR 1.37, P < 0.001), small for gestational age (aOR 1.05, P < 0.001) and malformations (aOR 1.06, P = 0.049). Comparison of ART pregnancies with endometriosis and spontaneous conceptions with endometriosis: ART increased the risk of placenta previa (aOR 2.43, 95% CI 2.10 to 2.82, P < 0.001), premature birth (aOR 1.42, 95% CI 1.29 to 1.55, P < 0.001) and small for gestational age (aOR 1.18, 95% CI 1.10 to 1.27, P < 0.001), independently from the effect of endometriosis. Risk of pre-eclampsia, placental abruption or congenital malformations was not increased with ART.ConclusionEndometriosis is an independent risk factor for mother and child morbidities. Maternal morbidity and perinatal morbidity were significantly increased by ART in addition to endometriosis; however, some perinatal and maternal morbidity risks were increasingly linked to pathologies related to infertility.     

The differences in placental pathology and neonatal outcome in singleton vs. twin gestation complicated by small for gestational age

Objective

We aimed to compare placental histopathology and neonatal outcome between dichorionic diamniotic (DCDA) twins and singleton pregnancies complicated by small for gestational age (SGA).

Methods

Medical files and placental pathology reports from all deliveries between 2008 and 2017 of SGA neonates, (birthweight?<?10th percentile), were reviewed. Comparison was made between singleton pregnancies complicated with SGA (singletons SGA group) and DCDA twin pregnancies (Twins SGA group), in which only one of the neonates was SGA. Placental diameters were compared between the groups. Placental lesions were classified into maternal and fetal vascular malperfusion lesions (MVM and FVM), maternal (MIR) and fetal (FIR) inflammatory responses, and chronic villitis. Neonatal outcome parameters included composite of early neonatal complications.

Results

The twins SGA group (n?=?66) was characterized by a higher maternal age (p?=?0.011), lower gestational age at delivery (34.9?±?3.1 vs. 37.7?±?2.6 weeks, p?<?0.001), and a higher rate of preeclampsia (p?=?0.010), compared to the singletons SGA group (n?=?500). Adverse composite neonatal outcome was more common in the twins SGA group (p?<?0.001). Placental villous lesions related to MVM (p?<?0.001) and composite MVM lesions (p?=?0.04) were more common in the singletons SGA group. On multivariate logistic regression analysis, the singletons SGA group was independently associated with placental villous lesions (aOR 3.6, 95% CI 1.9–7.0, p?<?0.001) and placental MVM lesions (aOR 2.44, 95% CI 1.29–4.61, p?=?0.006).

Conclusion

Placentas from SGA singleton pregnancies have more MVM lesions as compared to placentas from SGA twin pregnancies, suggesting different mechanisms involved in abnormal fetal growth in singleton and twin gestations.

     

Is serum placental growth factor more effective as a biomarker in predicting early onset preeclampsia in early second trimester than in first trimester of pregnancy?

Purpose

To determine whether maternal serum placental growth factor (PlGF) is more effective as a biomarker in predicting the occurrence of early onset preeclampsia in first trimester or early second trimester of pregnancy.

Methods

A prospective cohort study was conducted on women with singleton pregnancies, screened from the antenatal clinic. Serum PlGF estimation was done at 11–14 weeks of gestation on 1,244 women and at 22–24 weeks of gestation on 1,206 women from the initial study population. A cut-off value of <228 pg/ml for serum PlGF at 11–14 weeks of gestation and <144 pg/ml for serum PlGF at 22–24 weeks of gestation were determined by receiver operating characteristic (ROC) curve analysis for identifying pregnant women at risk of developing early onset preeclampsia (<32 weeks of gestation). Univariate logistic regression analysis was used to analyze the association between serum PlGF < 228 pg/ml at 11–14 weeks of gestation and <144 pg/ml at 22–24 weeks of gestation with the occurrence of early onset preeclampsia and odds ratio (OR) was computed. P value < 0.05 was considered statistically significant in this study.

Results

Maternal serum PlGF <144 pg/ml at 22–24 weeks of gestation had a stronger association (OR 18.83; 95 % CI 12.08–22.24; p = 0.000) than serum PlGF <228 pg/ml at 11–14 weeks of gestation (OR 2.76; 95 % CI 1.29–3.94; p = 0.007) with the occurrence of early onset preeclampsia. The sensitivity and specificity of serum PlGF <144 pg/ml at 22–24 weeks of gestation (84 and 78, respectively) were much higher than those of serum PlGF <228 pg/ml at 11–14 weeks of gestation (58 and 66, respectively) in predicting early onset preeclampsia.

Conclusion

Maternal serum PlGF may be more effective as a biomarker in early second trimester than in first trimester of pregnancy, in predicting the occurrence of early onset preeclampsia.     

First trimester screening of serum soluble fms-like tyrosine kinase-1 and placental growth factor predicting hypertensive disorders of pregnancy

ObjectiveTo assess the accuracy of first trimester soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) in predicting pregnancy hypertension and pre-eclampsia; and compare with the accuracy of routinely collected maternal and clinical risk factors.Study designIn this population-based cohort study, serum sFlt-1 and PlGF levels were measured in first trimester in 2,681 women with singleton pregnancies in New South Wales, Australia.Main outcome measuresPrediction of pregnancy hypertension and pre-eclampsia.ResultsThere were 213 (7.9%) women with pregnancy hypertension, including 68 (2.5%) with pre-eclampsia. The area under the curve (AUC) for both sFlt-1 and PlGF was not different from chance, but combined was 0.55 (P = 0.005). Parity and previous diagnosed hypertension had better predictive accuracy than serum biomarkers (AUC = 0.64, P < 0.001) and the predictive accuracy for all maternal and clinical information was fair (AUC = 0.70, P < 0.001 for pregnancy hypertension and AUC = 0.74, P < 0.001 for pre-eclampsia). Adding sFlt-1 and PlGF to maternal risk factors did not improve the ability of the models to predict pregnancy hypertension or pre-eclampsia.ConclusionsMaternal first trimester serum concentrations of sFlt-1 and PlGF do not predict hypertensive disorders in pregnancy any better than routinely collected clinical and maternal risk factor information. Screening for sFlt-1 and PlGF levels in early pregnancy would not identify those pregnancies at-risk.     

Exploring the Use of Exchange Transfusion in the Surgical Management of Priapism in Sickle Cell Disease: A Population-Based Analysis

IntroductionPriapism is a urologic emergency that may require surgical intervention in cases refractory to supportive care. Exchange transfusion (ET) has been previously used to manage sickle cell disease (SCD), including in priapism; however, its utilization in the context of surgical intervention has not been well-established.AimTo explore the utilization of ET, as well as other patient and hospital-level factors, associated with surgical intervention for SCD-induced priapismMethodsUsing the National Inpatient Sample (2010–2015), males diagnosed with SCD and priapism were stratified by need for surgical intervention. Survey-weighted regression models were used to analyze the association of ET to surgical intervention. Furthermore, negative binomial regression and generalized linear models with logarithmic transformation were used to compare ET vs surgery to length of hospital stay (LOS) and total hospital charges, respectively.Main Outcome Measures: Predictors of surgical intervention among patients with SCD-related priapismResultsA weighted total of 8,087 hospitalizations were identified, with 1,782 (22%) receiving surgical intervention for priapism, 484 undergoing ET (6.0%), and 149 (1.8%) receiving combined therapy of both ET and surgery. On multivariable regression, pre-existing Elixhauser comorbidities (e.g. ≥2 Elixhauser: OR: 2.20; P < 0.001), other forms of insurance (OR: 2.12; P < 0.001), and ET (OR: 1.99; P = 0.009) had increased odds of undergoing surgical intervention. In contrast, Black race (OR: 0.45; P < 0.001) and other co-existing SCD complications (e.g. infectious complications OR: 0.52; P < 0.001) reduced such odds. Compared to supportive care alone, patients undergoing ET (adjusted IRR: 1.42; 95% CI: 1.10–1.83; P = 0.007) or combined therapy (adjusted IRR: 1.42; 95% CI: 111–1.82; P < 0.001) had a longer LOS vs. surgery alone (adjusted IRR: 0.85; 95% CI: 0.74–0.97; P = 0.017). Patients receiving ET (adjusted Ratio: 2.39; 95% CI: 1.52–3.76; P < 0.001) or combined therapy (adjusted Ratio: 4.42; 95% CI: 1.67–11.71; P = 0.003) had higher ratio of mean hospital charges compared with surgery alone (adjusted Ratio: 1.09; 95% CI: 0.69–1.72; P = 0.710).ConclusionsNumerous factors were associated with the need for surgical intervention, including the use of ET. Those receiving ET, as well as those with combined therapy, had a longer LOS and increased total hospital charges.Ha AS, Wallace BK, Miles C, et al. Exploring the Use of Exchange Transfusion in the Surgical Management of Priapism in Sickle Cell Disease: A Population-Based Analysis. J Sex Med 2021;18:1788–1796.     

Impact of maternal serum levels of Visfatin,AFP, PAPP-A,sFlt-1 and PlGF at 11–13 weeks gestation on small for gestational age births

Objective: Investigating potential value of maternal serum Visfatin, sFlt-1, PlGF, AFP, PAPP-A levels at first trimester for prediction of small for gestational age (SGA) at birth.

Methods: Measurements were performed in 20 SGA and 65 control cases. Logistic regression analysis adjusted for age and weeks of pregnancy at data collection was performed to estimate odds ratios (OR), 95% confidence intervals (95% CI) and p values separately for each potential predictor. A multiple regression model was used to assess the impact of all the promising predictors adjusted for each other. Receiver operating characteristic (ROC) analysis was used to indicate the ability to discriminate between SGA cases and controls.

Results: There was an association of serum PlGF levels (OR 0.53 per interquartile range [IQR] increase in PlGF; 95% CI 0.24–1.16), sFlt-1/PlGF ratio (OR 1.42 per IQR increase in sFlt-1/PlGF; 95% CI 1.03–1.96), serum Visfatin levels (OR 0.31 per IQR increase in Visfatin; 95% CI 0.10–0.95) and smoking (OR 4.24; 95% CI 1.10–16.37) with SGA at birth.

Conclusions: Associations between SGA and lower PlGF, Visfatin levels as well as increased sFlt-1/PlGF ratio and smoking status were detected which may contribute to predict SGA.     

Pathology findings in preterm placentas of women with autoantibodies: a case–control study

Objective: To evaluate the placental histopathology findings in women with systemic lupus erythematosus or antiphospholipid syndrome delivered preterm. Methods: We performed a case-control study comparing clinical outcomes and placental histopathology of 18 consecutive singleton pregnancies with systemic lupus erythematosus (n = 9) or antiphospholipid syndrome (n = 9) delivered between 24 and 37 weeks, and 54 controls matched for gestational age and type of preterm delivery (spontaneous or indicated). Placental examinations were performed by a single pathologist, and placental lesions were grouped into four categories: uteroplacental vascular pathology and related villous lesions; coagulation-related damage; chronic inflammation; and acute inflammatory lesions. Statistical analysis included the Mantel-Haenzsel or Fisher's exact test, and logistic regression, with a value of p < 0.05 or an odds ratio (OR) with 95% confidence intervals (CI) not inclusive of unity considered significant. Results: Lupus anticoagulant was positive in ten out of 18 cases and medium or high positive IgG anticardiolipin antibodies in seven out of 18. Antenatal treatment included corticosteroids (n = 9), low-dose aspirin (n = 15) and heparin (n = 8). Rates of necrotizing enterocolitis (33% vs. 0%, p < 0.001) and of perinatal mortality (33% vs. 9%, p = 0.02) were significantly different between cases and controls, and rates of birth weight < 10th centile approached statistical significance. Uteroplacental vascular lesions (OR 3.7, 95% CI 1.1, 11.7) and coagulation-related damage (OR 16.8, 95% CI 3.9, 72.6) were significantly more common among cases than controls, and rates of chronic inflammatory lesions approached significance. Conclusions: Cases of systemic lupus erythematosus and antiphospholipid syndrome delivered preterm are associated with a significant increase in placental vascular and coagulation-related lesions, which are reflected clinically by higher rates of perinatal mortality, necrotizing enterocolitis, and small-for-gestational age neonates.     

Second trimester placental location as a predictor of an adverse pregnancy outcome.

OBJECTIVE: To determine if the second trimester placental location is associated with perinatal outcomes. MATERIALS AND METHODS: Observational study of placental location and the subsequent risk of an adverse pregnancy outcome. Placental location was divided into three categories, low, high lateral and high fundal. RESULTS: There were 3336 pregnancies analyzed in this study. Low implantation sites had a greater risk of preterm labor (odds ratio (OR) 1.70, 95% confidence interval (CI) 1.38 to 2.90, P<0.001), preterm delivery (OR 1.86, 95% CI 1.36 to 2.54, P<0.001), fewer fetuses with macrosomia (OR 0.56, 95% CI 0.38 to 0.83, P=0.010) and reduced risk of postpartum hemorrhage (OR 0.56, 95% CI 0.46 to 0.95, P=0.026). High lateral implantations had a greater risk of low 1-min (OR 1.80, 95% CI 1.11 to 2.93, P=0.017) and 5-min (OR 3.49, 95% CI 1.46 to 8.36, P=0.005) Apgar scores. CONCLUSIONS: Low placental implantation was associated with an increased risk of preterm labor, preterm delivery and a reduced risk of postpartum hemorrhage, and of a macrosomic fetus. High lateral implantation was associated with low Apgar scores.     

The effect of adenomyosis types on clinical outcomes of IVF embryo transfer after ultra-long GnRH agonist protocol

Research questionWhat is the effect of adenomyosis types on IVF and embryo transfer (IVF-ET) after ultra-long gonadotrophin-releasing hormone (GnRH) agonist protocol?DesignPatients who underwent the first cycle of IVF-ET with ultra-long GnRH agonist protocol were included in this retrospective cohort study. They were divided into three groups: (A) 428 patients with diffuse adenomyosis; (B) 718 patients with focal adenomyosis; and (C) 519 patients with tubal infertility. Reproduction outcomes were analysed.ResultsLogistic regression analysis revealed that, compared with focal adenomyosis and tubal infertility, diffuse adenomyosis was negatively associated with clinical pregnancy and live birth (clinical pregnancy: A versus B: OR 0.708, 95% CI 0.539 to 0.931, P = 0.013; A versus C: OR 0.663, 95% CI 0.489 to 0.899, P = 0.008; live birth: A versus B: OR 0.530, 95% CI 0.385 to 0.730, P < 0.001; A versus C: OR 0.441, 95% CI 0.313 to 0.623, P < 0.001), but positively associated with miscarriage (A versus B: OR 1.727, 95% CI 1.056 to 2.825, P = 0.029; A versus C: OR 2.549, 95% CI 1.278 to 5.082, P = 0.008). Compared with patients with tubal infertility, focal adenomyosis was also a risk factor for miscarriage (B versus C: OR 1.825, 95% CI 1.112 to 2.995, P = 0.017).ConclusionsCompared with patients with focal adenomyosis or tubal infertility, the reproduction outcomes of IVF-ET in patients with diffuse adenomyosis seems to be worse.     

Sexting and Young Adolescents: Associations with Sexual Abuse and Intimate Partner Violence

Study ObjectiveTo explore whether sexting by young adolescent girls and boys is associated with adverse life experiences including exploitative or violent sexual relationships.Design and SettingCross-sectional, anonymous survey of a convenience sample of minor adolescents younger than age 18 years recruited while waiting for care in clinics affiliated with a children's hospital in a low-resource, high-poverty, urban community.ParticipantsFive hundred fifty-five adolescents aged 14-17 years, 63% girls and 37% boys.Main Outcome MeasuresWe measured sexting by asking, “Have you ever sent a sexually suggestive or naked picture of yourself to another person through text or e-mail?” The survey also measured risk behaviors, sexual abuse, intimate partner violence (IPV), and arrest and included a validated depression scale.ResultsMean age was 15.6 ± 1.1 years; 59% were Hispanic, 28% were black; 44% of girls and 46% of boys ever had sex; 24% of girls and 20% of boys ever sent a sext. More girls than boys reported sexual abuse (16% vs 3%; P < .01), IPV victimization (15% vs 7%; P < .01), and depression (33% vs 17%; P < .01). More boys than girls reported arrest (15% vs 7%; P < .01). Independent associations with sexting for girls were: ever had sex (odds ratio [OR], 4.59; 95% confidence interval [CI], 2.29-9.19; P < .001); sexual abuse (OR, 3.81; 95% CI, 1.80-8.05; P < .001); IPV victim (OR, 2.72; 95% CI, 1.11-6.62; P < .05), and for boys: ever had sex (OR, 4.26; 95% CI, 1.47-12.32; P < .01); sexual abuse (OR, 38.48; 95% CI, 1.48-999.46; P < .05); IPV perpetration (OR, 16.73; 95% CI, 1.64-170.75; 95% CI, P < .05), as well as cannabis use, older age, other race, and arrest.ConclusionFor young adolescents, sexting is independently associated with exploitative and abusive sexual relationships including sexual abuse and IPV with similarities and differences in predictors of sexting for girls and boys.     

Placental expression of the angiogenic placental growth factor is stimulated by both aldosterone and simulated starvation

Aldosterone is an important factor supporting placental growth and fetal development. Recently, expression of placental growth factor (PlGF) has been observed in response to aldosterone exposure in different models of atherosclerosis. Thus, we hypothesized that aldosterone up-regulates growth-adaptive angiogenesis in pregnancy, via increased placental PlGF expression.We followed normotensive pregnant women (n = 24) throughout pregnancy and confirmed these results in a second independent first trimester cohort (n = 36). Urinary tetrahydroaldosterone was measured by gas chromatography-mass spectrometry and corrected for creatinine. Circulating PlGF concentrations were determined by ELISA. Additionally, cultured cell lines, adrenocortical H295R and choriocarcinoma BeWo cells, as well as primary human third trimester trophoblasts were tested in vitro. PlGF serum concentrations positively correlated with urinary tetrahydroaldosterone corrected for creatinine in these two independent cohorts. This observation was not due to PlGF, which did not induce aldosterone production in cultured H295R cells. On the other hand, PlGF expression was specifically enhanced by aldosterone in the presence of forskolin (p < 0.01) in trophoblasts. A pronounced stimulation of PlGF expression was observed with reduced glucose concentrations simulating starvation (p < 0.001).In conclusion, aldosterone stimulates placental PlGF production, enhancing its availability during human pregnancy, a response amplified by reduced glucose supply. Given the crucial role of PlGF in maintaining a healthy pregnancy, these data support a key role of aldosterone for a healthy pregnancy outcome.     

Maternal and Neonatal Outcomes in Pregnancies Complicated by Systemic Lupus Erythematosus: A Population-Based Study

ObjectiveTo determine maternal and neonatal outcomes in pregnancies complicated by systemic lupus erythematosus (SLE).MethodsIn a retrospective cohort study using the Nova Scotia Atlee Perinatal Database, 97 pregnancies in women with SLE, with 99 live births, were compared with 211 355 pregnancies in women without SLE and their 214 115 babies. All were delivered in Nova Scotia between 1988 and 2008.ResultsIn women with SLE, gestational age at birth and mean neonatal birth weight were lower (P < 0.001) than in women without SLE. On bivariate analysis, severe preeclampsia, Caesarean section, newborn resuscitation for > 3 minutes, respiratory distress syndrome, assisted ventilation, bronchopulmonary dysplasia, patent ductus arteriosus, mild to moderate intraventricular hemorrhage, retinopathy of prematurity, and congenital heart block in neonates were significantly more frequent in the women with SLE.Logistic regression analysis identified that having SLE increased the risks of Caesarean section (OR 1.8; 95% CI 1.1 to 2.8, P = 0.005), postpartum hemorrhage (OR 2.4; 95% CI 1.3 to 4.3, P = 0.003), need for blood transfusion (OR 6.9; 95% CI 2.7 to 17, P = 0.001), postpartum fever (OR 3.2; 95% CI 1.7 to 6.1, P = 0.032), small for gestational age babies (OR 1.7; 95% CI 1.005 to 2.9, P = 0.047), and gestational age ≤ 37 weeks (OR 2.1; 95% CI 1.3 to 3.4, P = 0.001). Neonatal death was not shown to be more common in women with SLE (RR 3.05; CI 0.43 to 21.44, P = 0.28).ConclusionMothers with SLE have an increased risk of Caesarean section, postpartum hemorrhage, and blood transfusion. They are more likely to deliver premature babies, smaller babies, and babies with congenital heart block.     

Bladder Base Tenderness in the Etiology of Deep Dyspareunia

IntroductionBladder base tenderness can be present on pelvic exam in women with pelvic pain. However, its exact prevalence and clinical implications are not well understood.AimThe aim of this study was to determine whether bladder base tenderness is associated with specific symptoms or signs in women, particularly dyspareunia.MethodsRetrospective review of 189 consecutive women seen by a gynecologist in 2012 at a tertiary referral center for pelvic pain was conducted. Associations were tested between bladder base tenderness and variables on history/examination using bivariate analyses and multiple logistic regression.Main Outcome MeasureDeep dyspareunia and superficial dyspareunia (present/absent) were the main outcome measures.ResultsBladder base tenderness was present in 34% of pelvic pain patients (65/189), which was significantly greater than the prevalence of bladder base tenderness of 3% (1/32) in a control sample of women without pelvic pain (odds ratio [OR] = 16.3, 95% confidence interval [CI] 2.17–121.7, Fisher exact test, P < 0.001). For the pelvic pain patients, on bivariate analyses, bladder base tenderness was significantly associated with deep dyspareunia (P < 0.001), superficial dyspareunia (P < 0.001), bladder symptoms (P = 0.026), abdominal wall trigger point (P < 0.001), and pelvic floor tenderness (P < 0.001). In contrast, bladder base tenderness was similarly present in women with or without endometriosis. On logistic regression, bladder base tenderness was independently associated with only deep dyspareunia (OR = 6.40, 95% CI: 1.25–32.7, P = 0.011), abdominal wall trigger point (OR = 3.44, 95% CI: 1.01–11.7, P = 0.037), and pelvic floor tenderness (OR = 8.22, 95% CI: 3.27–20.7, P < 0.001).ConclusionsBladder base tenderness is present in one‐third of women with pelvic pain, and contributes specifically to the symptom of deep dyspareunia. Bladder base tenderness was also associated with the presence of an abdominal wall trigger point and with pelvic floor tenderness, suggesting a myofascial etiology and/or nervous system sensitization. Nourmoussavi M, Bodmer‐Roy S, Mui J, Mawji N, Williams C, Allaire C, and Yong PJ. Bladder base tenderness in the etiology of deep dyspareunia. J Sex Med 2014;11:3078–3084.     

A case–control study of placental lesions associated with pre-eclampsia

ObjectiveTo investigate gross and microscopic placental lesions associated with pre-eclampsia and to determine which lesions are most strongly linked to serious pregnancy complications.MethodsA retrospective case–control study of 173 placentas from women with pre-eclampsia and 173 placentas from healthy normotensive women was conducted.ResultsThe mean placental weight in the pre-eclampsia group was lower than that recorded for the control group (280 g vs 360 g; P < 0.001). Infarcts (65.9% vs 13.2%; P < 0.001) and placental abruption (P < 0.001) were most frequent among women with pre-eclampsia. Microscopic findings showed the following lesions to be associated with pre-eclampsia: hypermature villi, defined by absence of intermediate villi (72% vs 16%; P < 0.001), excessive syncytial knots (90% vs 9%; P < 0.001), decidual vasculopathy (51% vs 8%; P < 0.001), villous fibrosis (6% vs 0%; P < 0.001), erythroblastosis (11% vs 4%; P < 0.01), and avascular terminal villi (9% vs 3%; P < 0.05). Increased syncytial knots, infarcts, basal decidual vasculopathy, hypermature villi, and placental erythroblastosis were still associated with pre-eclampsia after logistic regression modeling.ConclusionPlacental lesions most strongly associated with pre-eclampsia were all causes or expressions of placental hypoxia or ischemia, which appears as the primary mechanism of pre-eclampsia.