Individualized norms of optimal fetal growth: fetal growth potential

OBJECTIVE: To demonstrate that individualized optimal fetal growth norms, accounting for physiologic and pathologic determinants of fetal growth, better identify normal and abnormal outcomes of pregnancy than existing methods. METHODS: In a prospective cohort of 38,033 singleton pregnancies, we identified 9,818 women with a completely normal outcome of pregnancy and characterized the physiologic factors affecting birth weight using multivariable regression. We used those physiologic factors to individually predict optimal growth trajectory and its variation, growth potential, for each fetus in the entire cohort. By comparing actual birth weight with growth potential, population, ultrasound, and customized norms, we calculated for each fetus achieved percentiles, by each norm. We then compared proportions of pregnancies classified as normally grown, between 10th and 90th percentile, or aberrantly grown, outside this interval, by growth potential and traditional norms, in 14,229 complicated pregnancies, 1,518 pregnancies with diabetes or hypertensive disorders, and 1,347 pregnancies with neonatal complications. RESULTS: Nineteen physiologic factors, associated with maternal characteristics and early placental function, were identified. Growth potential norms correctly classified significantly more pregnancies than population, ultrasound, or customized norms in complicated pregnancies (26.4% compared with 18.3%, 18.7%, 22.8%, respectively, all P<.05), pregnancies with diabetes or hypertensive disorders (37.3% compared with 23.0%, 28.0%, 34.0%, respectively, all P<.05) and neonatal complications (33.3% compared with 19.7%, 24.9%, 29.8%, respectively, all P<.05). CONCLUSION: Growth potential norms based on the physiologic determinants of birth weight are a better discriminator of aberrations of fetal growth than traditional norms. LEVEL OF EVIDENCE: II.     

The value of two-step operative laparoscopy with interval pituitary suppression in the treatment of infertility caused by severe endometriosis

PURPOSE OF REVIEW: To appraise a new approach to laparoscopic surgery for infertility caused by advanced endometriosis. RECENT FINDINGS: Endometriosis is a common systemic and local disease with altered peritoneal function, which requires both systemic and local treatment. Medication alone cannot improve infertility, and laparoscopic treatment, particularly in severe endometriosis, has a high recurrence rate and is often limited by technical difficulties. Novel treatment strategies have therefore to be sought, especially in women who do not want in-vitro fertilization as a first option, either because they suffer from pain in addition to infertility or want to enhance their fertility over many cycles. SUMMARY: Two-step operative laparoscopy with interval pituitary suppression by means of gonadotrophin-releasing hormone analogues reduces the extent of endometriosis, as classified by the American Fertility Association, and appears to be a promising method of achieving optimal cytoreduction and facilitating complicated surgery in severe endometriosis, while protecting the ovary from unnecessary trauma. A large-scale well-designed study is needed to confirm that this treatment leads to improved pregnancy rates.     

Angiogenesis in implantation

Problem Implantation failure and early pregnancy loss are common following natural conceptions and they are particularly important clinical hurdles to overcome following assisted reproduction attempts. The importance of adequate vascular development and maintenance during implantation has recently become a major focus of investigation. Materials and methods Review of current published literature was undertaken to summerize the cells and cell products that regulate tissue vascularity during implantation. Results Vascular development at the maternal fetal interface can be regulated by a number of different cell types; two principal candidates are trophoblast and natural killer cells. A wide range of soluble factors, some with well established angiogenic functions as well as other more novel factors, can contribute to vascular development and maintenance at the maternal–fetal interface. Conclusions Robust vascular development occurs during implantation and early placentation of normal pregnancies. Studies to define the extent and mechanisms by which defects in vascularity contribute to human implantation failure and early miscarriage need to be undertaken. Vascular development during implantation is mediated by numerous cell types and cell products and aberrant vascularity likely contributes to implantation failure and early pregnancy loss.     

Decision-making after ultrasound diagnosis of fetal abnormality

During the last few decades, the use of ultrasonography for the detection of fetal abnormalities has become widespread in many industrialised countries. This resulted in a shift in timing of the diagnosis of congenital abnormalities in infants from the neonatal period to the prenatal period. This has major implications for both clinicians and the couples involved. In case of ultrasound diagnosis of fetal anomaly, there are several options for the obstetric management, ranging from standard care to non-aggressive care and termination of pregnancy. This essay explores the context of both clinical and parental decision making after ultrasound diagnosis of fetal abnormality, with emphasis on the Dutch situation. While normal findings at ultrasound examination have strong beneficial psychological effects on the pregnant woman and her partner, the couple is often ill prepared for bad news about the health of their unborn child in the case of abnormal findings. This is, in particular, true in settings where ultrasonography for the detection of fetal abnormalities is offered as an integral part of antenatal care without appropriate counselling. An important question is to what extent the couple should be supported in decision making when a fetal abnormality is diagnosed. In this context, the parental perception of having a choice varies markedly. When parents consider end-of-life decisions, they experience both ambivalent and emotional feelings. On the one hand, they are committed to their pregnancy, while on the other hand, they want to protect their child, themselves and the family from the burden of severe disability. These complex parental reactions have implications for the counselling strategy.

Verhandlungen Ärztlicher Gesellschaften

Ohne Zusammenfassung     

Metabolism of 1-nitropyrene by cultured rabbit alveolar macrophages and respiratory tract tissues

The metabolism of 1-nitro[14C]pyrene (14C-1-NP; 8.1 microM) was studied in cultured (20 hr) rabbit alveolar macrophages, lung tissue, and tracheal tissue. Metabolites from the incubation medium and from the macrophages and respiratory tract tissues were extracted and then analyzed and quantified by high-pressure liquid chromatography. The following metabolites were detected in the lung and tracheal tissue incubation medium: 1-nitropyrene-4,5-dihydrodiol, N-acetyl-1-aminopyrene, 1-aminopyrene, and 10-hydroxy-1-nitropyrene. Nitropyrene phenols (4-, 5-, 6-, 8- or 9-hydroxy-1-nitropyrene) and 3-hydroxy-1-nitropyrene were only detected in the lung and tracheal tissue and not in the incubation medium for these tissues. Minor amounts of 1-aminopyrene and 10-hydroxy-1-nitropyrene were detected in the macrophage incubation medium, and only minute quantities of 1-nitropyrene-4,5-dihydrodiol, 1-aminopyrene, and 10-hydroxy-1-nitropyrene were detected in macrophages. The total percentage of 1-NP metabolism was significantly greater in the lung and tracheal tissue (28.0 and 23.0% of the recovered 14C, respectively) than in the alveolar macrophages (6.3% of the recovered 14C). The tracheal tissue was found to have the highest activity both in 1-NP metabolism and intracellular metabolite concentration. A major portion of the 1-NP metabolites produced was released into the incubation medium. The majority of the metabolites produced by tracheal and lung tissue, 70 and 84%, respectively, were ethyl acetate extractable. The metabolites retained within the cells or tissues were also predominantly ethyl acetate extractable rather than water soluble (83% for the macrophages and trachea, 95% for the lung tissue). The metabolite profiles obtained demonstrate that metabolism by both nitro reduction and ring oxidation occurs in respiratory tissue, and a degree of tissue specificity in the formation of metabolites exists. Ring oxidation was demonstrated in the lung and tracheal tissue, but very little occurred in the macrophages.