Maternal Diabetes and Intrapartum Fetal Electrocardiogram

OBJECTIVE

 Fetal electrocardiogram (ECG) ST changes are associated with fetal cardiac hypoxia. Our objective was to evaluate ST changes by maternal diabetic status and stage of labor.

METHODS

 This was a secondary analysis of a multicentered randomized-controlled trial in which laboring patients with singleton gestations underwent fetal ECG scalp electrode placement and were randomly assigned to masked or unmasked ST-segment readings. Our primary outcome was the frequency of fetal ECG tracings with ST changes by the stage of labor. ECG tracings were categorized into mutually exclusive groups (ST depression, ST elevation without ST depression, or no ST changes). We compared participants with DM, gestational diabetes mellitus (GDM), and no DM.

RESULTS

 Of the 5,436 eligible individuals in the first stage of labor (95 with pregestational DM and 370 with GDM), 4,427 progressed to the second stage. ST depression occurred more frequently in the first stage of labor in participants with pregestational DM (15%, adjusted odds ratio [aOR] 2.20, 95% confidence interval [CI] 1.14-4.24) and with GDM (9.5%, aOR 1.51, 95% CI 1.02-2.25) as compared with participants without DM (5.7%). The frequency of ST elevation was similar in participants with pregestational DM (33%, aOR 0.79, 95% CI 0.48-1.30) and GDM (33.2%, aOR 0.91, 95% CI 0.71-1.17) as compared with those without DM (34.2%). In the second stage, ST depression did not occur in participants with pregestational DM (0%) and occurred more frequently in participants with GDM (3.5%, aOR 2.01, 95% CI 1.02-3.98) as compared with those without DM (2.0%). ST elevation occurred more frequently in participants with pregestational DM (30%, aOR 1.81, 95% CI 1.02-3.22) but not with GDM (19.0%, aOR 1.06, 95% CI 0.77-1.47) as compared with those without DM (17.8%).

CONCLUSION

 ST changes in fetal ECG occur more frequently in fetuses of diabetic mothers during labor.

CLINICALTRIALS

gov number, NCT01131260.

PRECIS

 ST changes in fetal ECG, a marker of fetal cardiac hypoxia, occur more frequently in fetuses of diabetic parturients.

KEY POINTS

· Fetal hypertrophic cardiomyopathy (HCM) and cardiac dysfunction occur frequently among fetuses of diabetic patients.. · Fetal ECG changes such as ST elevation and depression reflect cardiac hypoxia.. · Fetuses of diabetic patients demonstrate a higher prevalence of fetal ECG tracings with ST changes..

First trimester identification of fetal sex by ultrasound

PURPOSE

The hypothesis was fetal sex determination by ultrasound at 11-14 weeks' gestation has sufficient accuracy to be clinically relevant.

METHODS

Fetal sex assessment by transabdominal ultrasound was performed in 567 fetuses at 11-14 weeks' gestation (CRL: 45-84 mm). A mid-sagittal view of the genital region was obtained. The angle of the genital tubercle to a horizontal line through the lumbosacral skin surface was measured. The fetus was assigned male sex if the angle was > 30°, and female sex if the genital tubercle was parallel or convergent (< 10°). At an intermediate angle of 10-30°, the sex was not assigned. The results were divided into three categories based on gestational age: 11 + 2 to 12 + 1, 12 + 2 to 13 + 1, and 13 + 2 to 14 + 1 weeks' gestation. To establish its accuracy, the first trimester fetal sex determination was compared to fetal sex determined on a mid-second trimester ultrasound.

RESULTS

Sex assignment was successful in 534/683 (78%) of the cases. The overall accuracy of fetal sex assignment across all gestational ages studied was 94.4%. It was 88.3%, 94.7%, and 98.6% at 11 + 2 to 12 + 1, 12 + 2 to 13 + 1, and 13 + 2 to 14 + 1 weeks' gestation, respectively.

CONCLUSION

Prenatal sex assignment at the time of first trimester ultrasound screening has a high accuracy rate. The accuracy improved with increasing gestational age, which suggests that if clinically important decisions, such as chorionic villus sampling, are to be made based on fetal sex, they should be delayed until the latter part of the first trimester.

Benefits and harms of perioperative high fraction inspired oxygen for surgical site infection prevention: a protocol for a systematic review and meta-analysis of individual patient data of randomised controlled trials

INTRODUCTION

The use of high fraction of inspired oxygen (FiO2) intraoperatively for the prevention of surgical site infection (SSI) remains controversial. Promising results of early randomised controlled trials (RCT) have been replicated with varying success and subsequent meta-analysis are equivocal. Recent advancements in perioperative care, including the increased use of laparoscopic surgery and pneumoperitoneum and shifts in fluid and temperature management, can affect peripheral oxygen delivery and may explain the inconsistency in reproducibility. However, the published data provides insufficient detail on the participant level to test these hypotheses. The purpose of this individual participant data meta-analysis is to assess the described benefits and harms of intraoperative high FiO2compared with regular (0.21-0.40) FiO2 and its potential effect modifiers.

METHODS AND ANALYSIS

Two reviewers will search medical databases and online trial registries, including MEDLINE, Embase, CENTRAL, CINAHL, ClinicalTrials.gov and WHO regional databases, for randomised and quasi-RCT comparing the effect of intraoperative high FiO2 (0.60-1.00) to regular FiO2 (0.21-0.40) on SSI within 90 days after surgery in adult patients. Secondary outcome will be all-cause mortality within the longest available follow-up. Investigators of the identified trials will be invited to collaborate. Data will be analysed with the one-step approach using the generalised linear mixed model framework and the statistical model appropriate for the type of outcome being analysed (logistic and cox regression, respectively), with a random treatment effect term to account for the clustering of patients within studies. The bias will be assessed using the Cochrane risk-of-bias tool for randomised trials V.2 and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluation methodology. Prespecified subgroup analyses include use of mechanical ventilation, nitrous oxide, preoperative antibiotic prophylaxis, temperature (<35°C), fluid supplementation (<15 mL/kg/hour) and procedure duration (>2.5 hour).

ETHICS AND DISSEMINATION

Ethics approval is not required. Investigators will deidentify individual participant data before it is shared. The results will be submitted to a peer-review journal.

PROSPERO REGISTRATION NUMBER

CRD42018090261.

Intrapartum Fetal Electrocardiogram in Small- and Large-for-Gestational Age Fetuses

OBJECTIVE

This study aimed to evaluate whether intrapartum fetal electrocardiogram (ECG) tracings with ST-elevation or depression occur more frequently in each stage of labor in small-for-gestational age (SGA) or large-for-gestational age (LGA), as compared with appropriate-for-gestational age (AGA) fetuses.

STUDY DESIGN

We conducted a secondary analysis of a large, multicenter trial in which laboring patients underwent fetal ECG waveform-analysis. We excluded participants with diabetes mellitus and major fetal anomalies. Birth weight was categorized as SGA (<10th percentile), LGA (>90th percentile), or AGA (10-90th percentile) by using a gender and race/ethnicity specific nomogram. In adjusted analyses, the frequency of ECG tracings with ST-depression or ST-elevation without depression was compared according to birthweight categories and labor stage.

RESULTS

Our study included 4,971 laboring patients in the first stage and 4,074 in the second stage. During the first stage of labor, there were no differences in the frequency of ST-depression in SGA fetuses compared with AGA fetuses (6.7 vs. 5.5%; adjusted odds ratio [aOR]: 1.41, 95% confidence interval [CI]: 0.93-2.13), or in ST-elevation without depression (35.8 vs. 34.1%; aOR: 1.17, 95% CI: 0.94-1.46). During the second stage, there were no differences in the frequency of ST-depression in SGA fetuses compared with AGA fetuses (1.6 vs. 2.0%; aOR: 0.69, 95% CI: 0.27-1.73), or in ST-elevation without depression (16.2 vs. 18.1%; aOR: 0.90, 95% CI: 0.67-1.22). During the first stage of labor, there were no differences in the frequency of ST-depression in LGA fetuses compared with AGA fetuses (6.3 vs. 5.5%; aOR: 0.97, 95% CI: 0.60-1.57), or in ST-elevation without depression (33.1 vs. 34.1%; aOR: 0.80, 95% CI: 0.62-1.03); during the second stage of labor, the frequency of ST-depression in LGA compared with AGA fetuses (2.5 vs. 2.0%, aOR: 1.36, 95% CI: 0.61-3.03), and in ST-elevation without depression (15.5 vs. 18.1%; aOR: 0.83, 95% CI: 0.58-1.18) were similar as well.

CONCLUSION

The frequency of intrapartum fetal ECG tracings with ST-events is similar among SGA, AGA, and LGA fetuses.

KEY POINTS

· SGA and LGA neonates are at increased risk of cardiac dysfunction.. · Fetal ECG has been used to evaluate fetal response to hypoxia.. · Fetal ST-elevation and ST-depression occur during hypoxia.. · Frequency of intrapartum ST-events is similar among SGA, AGA and LGA fetuses..

Evaluating Progestogens for Preventing Preterm birth International Collaborative (EPPPIC): meta-analysis of individual participant data from randomised controlled trials

BACKGROUND

Preterm birth is a global health priority. Using a progestogen during high-risk pregnancy could reduce preterm birth and adverse neonatal outcomes.

METHODS

We did a systematic review of randomised trials comparing vaginal progesterone, intramuscular 17-hydroxyprogesterone caproate (17-OHPC), or oral progesterone with control, or with each other, in asymptomatic women at risk of preterm birth. We identified published and unpublished trials that completed primary data collection before July 30, 2016, (12 months before data collection began), by searching MEDLINE, Embase, CINAHL, the Maternity and Infant Care Database, and relevant trial registers between inception and July 30, 2019. Trials of progestogen to prevent early miscarriage or immediately-threatened preterm birth were excluded. Individual participant data were requested from investigators of eligible trials. Outcomes included preterm birth, early preterm birth, and mid-trimester birth. Adverse neonatal sequelae associated with early births were assessed using a composite of serious neonatal complications, and individually. Adverse maternal outcomes were investigated as a composite and individually. Individual participant data were checked and risk of bias assessed independently by two researchers. Primary meta-analyses used one-stage generalised linear mixed models that incorporated random effects to allow for heterogeneity across trials. This meta-analysis is registered with PROSPERO, CRD42017068299.

FINDINGS

Initial searches identified 47 eligible trials. Individual participant data were available for 30 of these trials. An additional trial was later included in a targeted update. Data were therefore available from a total of 31 trials (11 644 women and 16185 offspring). Trials in singleton pregnancies included mostly women with previous spontaneous preterm birth or short cervix. Preterm birth before 34 weeks was reduced in such women who received vaginal progesterone (nine trials, 3769 women; relative risk [RR] 0·78, 95% CI 0·68-0·90), 17-OHPC (five trials, 3053 women; 0·83, 0·68-1·01), and oral progesterone (two trials, 181 women; 0·60, 0·40-0·90). Results for other birth and neonatal outcomes were consistently favourable, but less certain. A possible increase in maternal complications was suggested, but this was uncertain. We identified no consistent evidence of treatment interaction with any participant characteristics examined, although analyses within subpopulations questioned efficacy in women who did not have a short cervix. Trials in multifetal pregnancies mostly included women without additional risk factors. For twins, vaginal progesterone did not reduce preterm birth before 34 weeks (eight trials, 2046 women: RR 1·01, 95% CI 0·84-1·20) nor did 17-OHPC for twins or triplets (eight trials, 2253 women: 1·04, 0·92-1·18). Preterm premature rupture of membranes was increased with 17-OHPC exposure in multifetal gestations (rupture <34 weeks RR 1·59, 95% CI 1·15-2·22), but we found no consistent evidence of benefit or harm for other outcomes with either vaginal progesterone or 17-OHPC.

INTERPRETATION

Vaginal progesterone and 17-OHPC both reduced birth before 34 weeks' gestation in high-risk singleton pregnancies. Given increased underlying risk, absolute risk reduction is greater for women with a short cervix, hence treatment might be most useful for these women. Evidence for oral progesterone is insufficient to support its use. Shared decision making with woman with high-risk singleton pregnancies should discuss an individual's risk, potential benefits, harms and practicalities of intervention. Treatment of unselected multifetal pregnancies with a progestogen is not supported by the evidence.

FUNDING

Patient-Centered Outcomes Research Institute.

Antenatal Betamethasone for Women at Risk for Late Preterm Delivery

BACKGROUND

Infants who are born at 34 to 36 weeks of gestation (late preterm) are at greater risk for adverse respiratory and other outcomes than those born at 37 weeks of gestation or later. It is not known whether betamethasone administered to women at risk for late preterm delivery decreases the risks of neonatal morbidities.

METHODS

We conducted a multicenter, randomized trial involving women with a singleton pregnancy at 34 weeks 0 days to 36 weeks 5 days of gestation who were at high risk for delivery during the late preterm period (up to 36 weeks 6 days). The participants were assigned to receive two injections of betamethasone or matching placebo 24 hours apart. The primary outcome was a neonatal composite of treatment in the first 72 hours (the use of continuous positive airway pressure or high-flow nasal cannula for at least 2 hours, supplemental oxygen with a fraction of inspired oxygen of at least 0.30 for at least 4 hours, extracorporeal membrane oxygenation, or mechanical ventilation) or stillbirth or neonatal death within 72 hours after delivery.

RESULTS

The primary outcome occurred in 165 of 1427 infants (11.6%) in the betamethasone group and 202 of 1400 (14.4%) in the placebo group (relative risk in the betamethasone group, 0.80; 95% confidence interval [CI], 0.66 to 0.97; P=0.02). Severe respiratory complications, transient tachypnea of the newborn, surfactant use, and bronchopulmonary dysplasia also occurred significantly less frequently in the betamethasone group. There were no significant between-group differences in the incidence of chorioamnionitis or neonatal sepsis. Neonatal hypoglycemia was more common in the betamethasone group than in the placebo group (24.0% vs. 15.0%; relative risk, 1.60; 95% CI, 1.37 to 1.87; P<0.001).

CONCLUSIONS

Administration of betamethasone to women at risk for late preterm delivery significantly reduced the rate of neonatal respiratory complications. (Funded by the National Heart, Lung, and Blood Institute and the Eunice Kennedy Shriver National Institute of Child Health and Human Development; ClinicalTrials.gov number, NCT01222247.).

Transvaginal cervical length scans to prevent prematurity in twins: a randomized controlled trial

BACKGROUND

Twin pregnancies are associated with an increased risk of perinatal morbidity and mortality primarily due to spontaneous preterm deliveries. The mean gestational age for delivery is 35.3 weeks and twins account for 23% of preterm births <32 weeks. A number of strategies have been proposed to prevent preterm deliveries: tocolytics, bed rest, hospitalization, home uterine activity monitoring, cerclage, and most recently, progesterone. Unfortunately, none have proven effective. Recent metaanalyses and reviews suggest that transvaginal cervical length (TVCL) ultrasound in the second trimester is a powerful predictor of preterm birth among asymptomatic women. Indeed, TVCL has the highest positive and negative predictive values for determining the risk of spontaneous preterm delivery in twin pregnancies. It follows that TVCL assessment may allow identification of a subset of twin pregnancies that re better candidates for interventions intended to prevent prematurity.

OBJECTIVE

We sought to determine whether use of TVCL prolongs gestation in twin pregnancies.

STUDY DESIGN

This is a multicenter, randomized, controlled trial of 125 dichorionic or monochorionic/diamniotic twin pregnancies without prior preterm birth <28 weeks. The study group (n = 63) had TVCL and digital exams monthly from 16-28 weeks and were managed with a standard algorithm for activity restriction and cerclage. The control group (n = 62) had monthly digital cervical examinations but no routine TVCL ultrasound examinations. The primary outcome was gestational age at delivery. Secondary outcomes included percentage of deliveries <35 weeks, and maternal and neonatal outcomes.

RESULTS

The mean gestational age at delivery was 35.7 weeks (95% confidence interval [CI], 35.2-36.2) among those managed with TVCL and 35.5 weeks (95% CI, 34.7-36.4) among the control patients. The Kaplan-Meier estimates of deliveries <38 weeks were not significantly different between groups. This was true whether we compared curves with a log-rank test (P = .67), Breslow test (P = .67), or Tarone-Ware test (P = .64). The percentage of deliveries <35 0/7 weeks did not differ: 27.4% for subjects managed with routine TVCL and 28.6% for control subjects (relative risk, 0.96; 95% CI, 0.60-1.54). Our study had an 80% power to detect a 12-day difference in the gestational age at delivery with 95% confidence.

CONCLUSION

The overall mean length of gestation and the percentage of women delivering <35 weeks did not differ between twin gestations managed with TVCL and digital exams monthly from 16-28 weeks with a standard algorithm for activity restriction and cerclage and controls who had monthly digital cervical examinations but no routine TVCL. Routine second-trimester transvaginal ultrasound assessment of cervical length is not associated with improved outcomes when incorporated into the standard management of otherwise low-risk twin pregnancies.

A Randomized Trial of Intrapartum Fetal ECG ST-Segment Analysis

BACKGROUND

It is unclear whether using fetal electrocardiographic (ECG) ST-segment analysis as an adjunct to conventional intrapartum electronic fetal heart-rate monitoring modifies intrapartum and neonatal outcomes.

METHODS

We performed a multicenter trial in which women with a singleton fetus who were attempting vaginal delivery at more than 36 weeks of gestation and who had cervical dilation of 2 to 7 cm were randomly assigned to "open" or "masked" monitoring with fetal ST-segment analysis. The masked system functioned as a normal fetal heart-rate monitor. The open system displayed additional information for use when uncertain fetal heart-rate patterns were detected. The primary outcome was a composite of intrapartum fetal death, neonatal death, an Apgar score of 3 or less at 5 minutes, neonatal seizure, an umbilical-artery blood pH of 7.05 or less with a base deficit of 12 mmol per liter or more, intubation for ventilation at delivery, or neonatal encephalopathy.

RESULTS

A total of 11,108 patients underwent randomization; 5532 were assigned to the open group, and 5576 to the masked group. The primary outcome occurred in 52 fetuses or neonates of women in the open group (0.9%) and 40 fetuses or neonates of women in the masked group (0.7%) (relative risk, 1.31; 95% confidence interval, 0.87 to 1.98; P=0.20). Among the individual components of the primary outcome, only the frequency of a 5-minute Apgar score of 3 or less differed significantly between neonates of women in the open group and those in the masked group (0.3% vs. 0.1%, P=0.02). There were no significant between-group differences in the rate of cesarean delivery (16.9% and 16.2%, respectively; P=0.30) or any operative delivery (22.8% and 22.0%, respectively; P=0.31). Adverse events were rare and occurred with similar frequency in the two groups.

CONCLUSIONS

Fetal ECG ST-segment analysis used as an adjunct to conventional intrapartum electronic fetal heart-rate monitoring did not improve perinatal outcomes or decrease operative-delivery rates. (Funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and Neoventa Medical; ClinicalTrials.gov number, NCT01131260.).

Utility of near infrared spectroscopy for the screening of the growth restricted fetus

A myriad of factors have been linked to increased risk for intrauterine growth restriction and the associated complications; the majority of which are based on observational statistics of demographics, socioeconomics and patient history. Unfortunately, there is a paucity of factors available that can appropriately address the underlying anatomy and physiology responsible for intrauterine growth restriction. To this point, it becomes necessary to use data acquisition modalities capable of addressing both the etiology and pathology in an effort to improve clinical management strategies. Near-infrared spectroscopy, although not traditionally used in standard, clinical screening has proven valuable for risk assessment in a number of recent investigational studies. Simulations based on the current literature are presented to assess near infrared spectroscopy utility regarding the ability to distinguish between the normal fetus and the growth restricted fetus. Findings are presented for all simulated data as well as the equipment-specific data derived from the NIRO-100 system (Hamamatsu Photonics, Hamamatsu, Japan). Results suggest an overall sensitivity and specificity on the order of 62% and 58%, respectively, and NIRO-100 sensitivity and specificity on the order of 85% and 92%, respectively.

Wernicke's encephalopathy complicating pregnancy in a woman with neonatal necrotizing enterocolitis and resultant chronic malabsorption

Wernicke's encephalopathy (WE) is a metabolic disturbance resulting from severe thiamine deficiency classically described in malnourished alcoholics. Untreated, it can result in stupor, coma, and death. WE has previously been reported as a complication of pregnancy in women with hyperemesis gravidarum. We report a case of WE complicating pregnancy in a woman with chronic malabsorption secondary to premature birth and subsequent necrotizing enterocolitis (NEC). Our patient progressed through classic stages of WE before lapsing into a coma. She made a complete recovery after aggressive intravenous thiamine and nutritional support. This is the first report of WE in pregnancy secondary to NEC-related chronic malabsorption. We report this case to bring attention to a potential pregnancy complication affecting women with malabsorptive conditions.

Serial sonographic growth assessment in pregnancies complicated by an isolated single umbilical artery

Pregnancies complicated by an isolated single umbilical artery (SUA) are thought to be at increased risk for intrauterine growth restriction (IUGR). The management of these pregnancies often includes serial sonographic assessments of fetal growth. The goal of our study was to test the validity of this assertion. We conducted a longitudinal sonographic assessment of intrauterine fetal growth in pregnancies complicated by a SUA. We included pregnancies where fetal growth was assessed three or more times, and the presence of SUA was repeatedly demonstrated. Pregnancies with fetal anomalies and multiple gestations were excluded. IUGR was defined as an estimated fetal weight (EFW) < or = 10th percentile of the normal ranges established by Hadlock. Between January 1999 and December 2005, we identified 273 pregnancies with SUA, for an overall incidence of 0.48% within the total population of patients examined at our institution. One hundred and thirty-five pregnancies did not meet our inclusion criteria. Of the 138 we analyzed, four pregnancies (2.9%) were found to have EFW < or = 10th percentile. We concluded that the occurrence of IUGR in pregnancies complicated by an isolated SUA is not increased. Serial sonographic assessments of fetal growth do not appear to be indicated in the management of such pregnancies.

Cardiac axis in fetuses with abdominal wall defects

OBJECTIVES

To investigate whether fetal cardiac axis is affected by the presence of an abdominal wall defect (AWD) independent of congenital heart disease (CHD).

METHODS

Video ultrasound records from fetuses with AWDs identified from 1991-2004 were reviewed. Still images of the fetal cardiac four-chamber view were digitized and two independent examiners measured the cardiac axis. A cardiac axis of >65 degrees or <25 degrees was considered abnormal. Maternal charts were reviewed for fetal echocardiogram results and neonatal charts were reviewed for confirmation of CHD and type of AWD.

RESULTS

Of 17 fetuses with omphalocele and 42 fetuses with gastroschisis, 16 (27%) fetuses had an abnormal cardiac axis, while only seven (12%) had CHD. Fifty-nine percent of fetuses with omphalocele had an abnormal cardiac axis and 35% had CHD. Fourteen percent of fetuses with gastroschisis had an abnormal cardiac axis and 2% had CHD. Of 43 fetuses with a normal cardiac axis, only one had CHD.

CONCLUSIONS

Fetal cardiac axis is often affected by the presence of an AWD independent of CHD. A normal cardiac axis in fetuses with AWDs is an accurate predictor of the absence of CHD, the negative predictive value being 97.7%.

Vasospasm of the Nipple Presenting as Painful Lactation

BACKGROUND

Breast pain is a common complaint among lactating women. Vasospasm of the nipple should be considered in the differential diagnosis of breast pain, particularly when no other signs of infection or trauma are encountered. This report demonstrates a case of vasospasm successfully treated with nifedipine.

CASE

A 26-year-old breastfeeding multipara presented with intermittent episodes of extreme pain associated with blanching of the nipple. The pain subsided upon return of normal color to the nipple. She was able to continue breastfeeding after successful treatment with nifedipine.

CONCLUSION

Vasospasm of the nipple causes severe episodic breast pain and may lead to discontinuation of breastfeeding if not appropriately treated. This phenomenon is not well reported in the obstetric and gynecologic literature, although the obstetrician may be the first physician to evaluate a patient with symptoms. Patients with episodic nipple pain and pallor can be successfully treated with nifedipine.

Perinatal outcome associated with sonographically detected globular placenta

OBJECTIVE

To evaluate the association between the sonographic appearance of globular placenta and perinatal outcome.

STUDY DESIGN

We prospectively followed the pregnancy course and perinatal outcome in women with globular placentas (hyperechoic, thick and highly vascular placentas with edges that lack the typical "tapering" appearance) during routine sonographic study.

RESULTS

Fourteen women were included. In 7 women the globular appearance of the placenta normalized spontaneously, and perinatal outcome was good. The other 7 experienced poor perinatal outcomes. There were no significant differences between the 2 groups. Among pregnancies in which the globular placental appearance persisted, 3 resulted in fetal demise; 3 women had severe intrauterine growth restriction and oligohydramnios and underwent cesarean deliveries at 26, 27 and 31 weeks, respectively; and 1 patient had premature preterm rupture of membranes and underwent a cesarean delivery due to placental abruption.

CONCLUSION

In half the pregnancies complicated by the sonographic appearance of a globular placenta, this shape spontaneously normalized, and the perinatal outcome was normal. However, when the globular appearance of the placenta persisted, the condition was associated with a poor perinatal outcome. Pregnancies complicated by a globular placenta should be followed closely.

Gender-related differences in fetal heart rate during first trimester

OBJECTIVE

Many expecting parents wish to ascertain fetal gender early in pregnancy. Our goal was to determine whether fetal heart rate (FHR) of males and females during the first trimester is significantly different.

MATERIALS AND METHODS

From November 1997 to February 2003 we enrolled pregnant women with singleton gestations who underwent obstetric sonography at less than 14 weeks of gestational age. Indications for the sonographic study included first-trimester bleeding, uncertain gestational dating, poor obstetrical history, and aneuploidy screening by nuchal translucency. The sonographic studies were performed by a single sonographer and reviewed by the first author. The FHR was determined by m-mode. All subjects underwent second-trimester sonography at 18.0-24.0 weeks' gestation by the same team, and fetal gender was recorded. Multiple gestations, miscarriages and pregnancies with uncertain fetal gender were excluded. Sonographically assigned fetal gender was confirmed at delivery.

RESULTS

Of the 966 first-trimester studies performed, 477 met the inclusion criteria. Of these, 244 (51%) were female and 233 (49%) were males. There were no statistical differences in mean maternal age, gravidity, parity, and mean gestational age at the time of the first study (9.0 +/- 2.3 weeks for female fetuses and 9.0 +/- 2.3 weeks for males, p = 0.7). The average female FHR was 151.7 +/- 22.7 bpm and male FHR was154.9 +/- 22.8 bpm (p = 0.13).

DISCUSSION

Contrary to beliefs commonly held by many pregnant women and their families, there are no significant differences between male and female FHR during the first trimester.

Comparison of Lamellar Body Counts Using Light Microscopy with Standard Coulter Counter Techniques to Assess Fetal Lung Maturity

OBJECTIVE

To determine if lamellar body counts determined using light microscopy and a manual hemochromocytometer correlate with counts made on standard electronic cell counters.

METHODS

Aliquots of amniotic fluid samples obtained by amniocentesis to assess fetal lung maturity were divided into two sterile tubes. One tube was sent immediately to be counted in a cell counter by standard technique and the other tube was stored at -70 degrees C until manual counting could be performed. Manual counts on the same samples were made on two different occasions. Intra-observer variability and correlation with the standard technique was determined. Pearson coefficient was calculated.

RESULTS

There were 11 specimen pairs. The intra-observer correlation was significant: intraclass correlation coefficient 0.95 (CI 0.84-0.99). There was significant correlation between the Coulter counter lamellar body counts and manual counts: intraclass correlation coefficients 0.88 (CI 0.62-0.97) and 0.92 (CI 0.73-0.98), respectively.

CONCLUSION

Lamellar body counts determined by light microscopy correlate well with results obtained for lamellar body counts using standard Coulter counter techniques. Results of this pilot study show that this experimental method of evaluating fetal lung maturity deserves further evaluation.

Neonatal Group B Streptococcus Sepsis After Negative Screen in a Patient Taking Oral Antibiotics

BACKGROUND

Group B streptococcus (GBS) is a leading cause of serious neonatal infection. Neonatal morbidity and mortality can be reduced by appropriate prenatal screening and intrapartum chemoprophylaxis.

CASE

A 20-year-old primigravida was treated with oral antibiotics at 35 weeks for a recurrent urinary tract infection. Her GBS screen following the antibiotic treatment showed a negative culture. The patient, therefore, did not receive intravenous antibiotics during her induction of labor for mild preeclampsia. The infant developed early onset neonatal GBS pneumonia and sepsis.

CONCLUSION

Oral antibiotics can cause a temporary negative culture in a GBS-colonized patient. Relying on a negative culture for management may not be appropriate in a patient treated with oral antibiotics. Additional studies are necessary to elucidate the effects of oral antibiotics on GBS.

The effect of a single course of antenatal corticosteroids on maternal adrenal function at term

OBJECTIVE

To determine if one course of antenatal corticosteroids at 32 weeks produces maternal adrenal suppression at term.

METHODS

The adrenocorticotropic hormone (ACTH) stimulation test was administered at 38 weeks to 11 pregnant women who had received a single course of antenatal betamethasone prior to 33 weeks and to six control subjects.

RESULTS

There was no difference in basal cortisol levels (mean+/-standard deviation) between the two groups: 41.6+/-6.9 microg/dl for controls versus 36.0+/-7.8 microg/dl for the steroid group, p=0.16. Peak cortisol levels at 45 min following ACTH stimulation were not different: 61.6+/-3.5 microg/dl for controls versus 55.0+/-2.6 microg/dl for the steroid group, p=0.16. The power of the study to detect a statistical difference in the observed peak cortisol levels was greater than 95%. None of the study subjects had laboratory criteria or clinical signs of adrenal suppression.

CONCLUSIONS

A single course of betamethasone for women at risk for preterm delivery does not produce adrenal insufficiency at term and stress dose steroids are not recommended.

Misoprostol Outpatient Cervical Ripening Without Subsequent Induction of Labor: A Randomized Trial

OBJECTIVE

To estimate the effect of outpatient administration of a single dose of vaginal misoprostol at term on the interval to delivery in women with unfavorable cervices.

METHODS

Randomized, double blind, placebo-controlled trial comparing a single 25-microg outpatient intravaginal dose of misoprostol to placebo in pregnant women with Bishop scores less than 9 at 40 weeks or greater. After placement of the study medication, subjects were permitted to go into spontaneous labor unless an indication for induction developed. Analysis was by intent to treat. The interval to delivery, defined as the time from medication placement to delivery, was compared by Student t test and by survival analysis with the log-rank test.

RESULTS

Thirty-three women were randomly assigned to receive misoprostol, and 35 were assigned to receive placebo. The mean interval to delivery was significantly less in the misoprostol group, 4.2 +/- 4.1 compared with 6.1 +/- 3.6 days, P =.04. The interval to delivery for only the nulliparous patients was significantly less in the misoprostol group, 4.2 +/- 4.0 compared with 7.2 +/- 3.7 days, P =.02. The survival curves for the interval to delivery were significantly different (P =.04 by log-rank test) with 4.1 days median interval to delivery for misoprostol compared with 9.2 days for placebo. There were no adverse outcomes in either group.

CONCLUSION

A single 25-microg outpatient intravaginal dose of misoprostol is effective in decreasing the interval to delivery in women with unfavorable cervices at term.

Maternal group B streptococcal (GBS) genital tract colonization at term in women who have asymptomatic GBS bacteriuria

Objective: To determine the rate of positive group B streptococcus (GBS) cultures at 35–37 weeks gestation in women who have first trimester asymptomatic GBS bacteriuria.

Methods: Pregnant women with asymptomatic first trimester GBS bacteriuria had genital cultures for GBS performed at 35–37 weeks gestational age. Serotyping was performed by the standard Lancefield capillary precipitin method.

Results: Fifty-three women with positive urine cultures had genital cultures performed at 35–37 weeks. Sixteen of the 53 (30.2%; 95% confidence interval: 18.4–44.3%) third trimester vaginal cultures were positive for GBS. Five of eight (63%) of the women with typable urine serotypes had the same typable serotype in the third trimester genital culture.

Conclusion: Genital tract cultures at 35–37 weeks for GBS correlate poorly with first trimester asymptomatic GBS bacteriuria. Recommendations for GBS prophylaxis in labor in women who have first trimester asymptomatic GBS bacteriuria should be investigated further and reconsidered.

Magnesium sulfate induces translocation of protein kinase C isoenzymes alpha and delta in myometrial cells from pregnant women

OBJECTIVES

The purpose of this study was to determine the effect of magnesium sulfate on protein kinase C (PKC) translocation in myometrial cells from pregnant women.

STUDY DESIGN

Myometrium was obtained at the time of cesarean delivery from women at term before labor. Cultured myometrial cells were treated with magnesium sulfate (3, 5, and 10 mmol/L), oxytocin (0.1 micromol/L), or 12-O-tetradecanoylphorbol-13-acetate (TPA, 0.1 micromol/L). The translocation of PKC isozymes alpha (calcium dependent) and delta (calcium independent) from cytosol to membrane fractions was assessed with use of Western blot analysis.

RESULTS

In unexposed control cells, the majority of PKC alpha and delta was located in the cytosol fraction. Exposure to magnesium sulfate for 60 minutes induced translocation of both PKC alpha and delta at concentrations as low as 5 and 3 mmol/L, respectively. The magnitude of magnesium sulfate induced translocation for PKC delta is similar to that seen after oxytocin or TPA exposure but less for PKC alpha. Exposure to oxytocin for 30 minutes and 60 minutes induced translocation of PKC alpha and delta, respectively. Exposure to TPA for 5 and 30 minutes induced translocation of PKC alpha and PKC delta, respectively. In calcium-free media, only TPA induced translocation of these two isoenzymes.

CONCLUSION

Magnesium sulfate stimulates PKC translocation in cultured myometrial cells from pregnant women. Magnesium sulfate and oxytocin require extracellular calcium to induce translocation of both PKC alpha and delta.

Effectiveness and infectious morbidity of outpatient cervical ripening with a Foley catheter

OBJECTIVE

To assess the effectiveness and infectious morbidity of outpatient cervical ripening with a Foley catheter.

STUDY DESIGN

Labor inductions utilizing a Foley catheter for cervical ripening from January 1994 to October 1999 were retrospectively reviewed. The inductions were divided into inpatient and outpatient groups. Vaginal delivery rates and infectious morbidity were compared between the 2 groups.

RESULTS

There were 315 inpatient and 300 outpatient cases. The observed differences in vaginal delivery rates and infectious morbidity were not clinically or statistically significant. However, there was insufficient power to exclude a type II error. The cost savings was $165,000, and there is the potential to save $750 per patient with this method.

CONCLUSION

Outpatient cervical ripening with a Foley catheter is clinically effective, does not result in excess infectious morbidity and is more cost effective as compared to inpatient cervical ripening.

Elective cesarean delivery for women with a previous anal sphincter rupture

OBJECTIVE

The purpose of this study was to evaluate elective cesarean delivery for women with a history of anal sphincter rupture.

STUDY DESIGN

The effectiveness of cesarean delivery in parous women with a previous anal sphincter rupture was determined by decision analysis. The outcomes were excess cesarean deliveries and morbidity and mortality rates per prevented case of anal incontinence.

RESULTS

We needed 2.3 cesarean deliveries to prevent one case of anal incontinence. A woman who chooses a cesarean delivery has a 11.3% risk of morbidity compared with a 4.2% risk for vaginal delivery (relative risk, 2.7; 95% CI, 2.6-2.8; P<.001). The relative risk for maternal death from a cesarean delivery is 2.6 (95% CI, 1.5-4.5; P<.001).

CONCLUSION

Continent women with a previous anal sphincter rupture who are delivered vaginally are at high risk for permanent anal incontinence. Cesarean delivery will prevent most cases of anal incontinence, although marginally increasing maternal risk. The increased risk may be justified by the potential benefits. Patients should be counseled on these risks and benefits.

Nasal bone hypoplasia in trisomy 21 at 15-22 weeks' gestation

OBJECTIVE

To investigate the potential value of ultrasound examination of the fetal profile for present/hypoplastic fetal nasal bone at 15-22 weeks' gestation as a marker for trisomy 21.

METHODS

This was an observational ultrasound study in 1046 singleton pregnancies undergoing amniocentesis for fetal karyotyping at 15-22 (median, 17) weeks' gestation. Immediately before amniocentesis the fetal profile was examined to determine if the nasal bone was present or hypoplastic (absent or shorter than 2.5 mm). The incidence of nasal hypoplasia in the trisomy 21 and the chromosomally normal fetuses was determined and the likelihood ratio for trisomy 21 for nasal hypoplasia was calculated.

RESULTS

All fetuses were successfully examined for the presence of the nasal bone. The nasal bone was hypoplastic in 21/34 (61.8%) fetuses with trisomy 21, in 12/982 (1.2%) chromosomally normal fetuses and in 1/30 (3.3%) fetuses with other chromosomal defects. In 3/21 (14.3%) trisomy 21 fetuses with nasal hypoplasia there were no other abnormal ultrasound findings. In the chromosomally normal group hypoplastic nasal bone was found in 0.5% of Caucasians and in 8.8% of Afro-Caribbeans. The likelihood ratio for trisomy 21 for hypoplastic nasal bone was 50.5 (95% CI 27.1-92.7) and for present nasal bone it was 0.38 (95% CI 0.24-0.56).

CONCLUSION

Nasal bone hypoplasia at the 15-22-week scan is associated with a high risk for trisomy 21 and it is a highly sensitive and specific marker for this chromosomal abnormality.

Cervicovaginal fetal fibronectin levels in women with preeclampsia

OBJECTIVE

To estimate the mean levels of fetal fibronectin in cervicovaginal secretions of women with preeclampsia and compare them with levels in normotensive controls.

METHODS

Cervicovaginal swabs were obtained before digital examination from women who presented to labor and delivery for evaluation of preeclampsia and compared with fetal fibronectin levels from a group of control subjects with a similar gestational age. Fetal fibronectin was assayed by a specific enzyme-linked immunoassay. A concentration greater than 50 ng/mL was considered a positive result.

RESULTS

Forty women with preeclampsia (17 mild and 23 severe) and 31 normotensive women were analyzed. The control group had 9.7% positive fetal fibronectins, whereas the preeclampsia group had 15% positive, P =.72, with 80% power to detect a 22% difference. The majority of the quantitative values in both groups were less than 20 ng/mL. There was not a significant difference between the two groups in quantitative cervicovaginal fetal fibronectin, P =.72, nor was there a difference between the women with severe preeclampsia and the controls, P = 1.0, or between the nulliparous women with preeclampsia versus the nulliparous controls, P =.3.

CONCLUSION

Fetal fibronectin is not elevated in cervicovaginal secretions of women with preeclampsia.

The effects of repeat doses of antenatal corticosteroids on maternal adrenal function

OBJECTIVE

The purpose of this study was to determine whether repeated doses of maternal corticosteroids suppress the maternal hypothalamic-pituitary-adrenal axis.

STUDY DESIGN

The low-dose corticotropin stimulation test (1.0 microg intravenously) was administered a median of 3 days after the last betamethasone dose to 18 pregnant women who had received at least 2 weekly courses of antenatal betamethasone and to 6 control subjects matched for gestational age who had not received antenatal corticosteroids.

RESULTS

The mean basal cortisol level was significantly depressed among women who had received betamethasone with respect to control subjects (1.9 +/- 1.5 vs 26.5 +/- 6.2 microg/dL; P <.001). The maternal cortisol level after corticotropin stimulation was significantly lower in all women who had received betamethasone (P <. 001). The mean time to attainment of peak cortisol level was significantly longer among women who had received betamethasone than among control subjects (37 +/- 6.8 vs 27.4 +/- 1.6 minutes; P <.001).

CONCLUSIONS

Repeated courses of betamethasone lead to barely detectable maternal basal cortisol levels and secondary adrenal insufficiency.

Effect of digital cervical examination on the expression of fetal fibronectin

OBJECTIVE

To determine whether oncofetal fibronectin (fFN) assays from symptomatic women are influenced by digital examination of the cervix.

STUDY DESIGN

Cervicovaginal fFN specimens were obtained from women at 22-34 weeks' gestational age with symptoms of preterm labor immediately prior to a digital examination of the cervix and two hours after. Fetal fibronectin was assayed by a specific enzyme-linked immunoassay. Results were reported as positive (> or = 50 ng/mL) or negative (< 50 ng/mL). Paired initial and repeat fFN results were compared for statistical difference, and the clinical outcomes were used to assess the accuracy of the initial and repeat results.

RESULTS

Fifty symptomatic women at an average gestational age of 29.3 +/- 2.0 weeks were enrolled. Eighty-six percent of the repeat fFN results remained unchanged after a digital examination, (P = .26, beta = .2). The predictive value of a negative fFN obtained after a digital examination was 97% for the absence of spontaneous preterm delivery in < 8 or < 15 days. Two of 16 initially positive results became negative after an examination, and one patient delivered two days later. Five of 34 initially negative fFN results became positive after an examination, and 5/5 delivered more than seven days later.

CONCLUSION

Digital examination of the cervix has an effect on fFN results. The routine use of fFN after a digital examination is not recommended.

Prostaglandin E2 cervical ripening without subsequent induction of labor

OBJECTIVE

To determine whether outpatient administration of intracervical prostaglandin (PG) E2 gel decreases the interval to delivery and duration of labor.

METHODS

A randomized, double-blind, placebo-controlled trial compared the intracervical placement of 0.5 mg PGE2 gel with placebo in 61 pregnant women at 38 weeks' or greater gestation with Bishop scores less than 9. Transvaginal cervical length, fetal fibronectin, and Bishop score were assessed before gel placement. Subjects were then allowed to go into spontaneous labor unless an indication for induction developed.

RESULTS

Thirty women were assigned to PGE2 and 31 to placebo. There were no significant demographic differences between the groups and there were no differences in cervical length, fetal fibronectin status, or Bishop scores. Fifteen women in the PGE2 group and five in the placebo group went into labor and delivered within the first 2 days after gel placement (P = .007). The median interval to delivery was significantly shorter in the PGE2 group, at 2.5 days, compared with placebo, at 7 days (P = .02). Nulliparas in the PGE2 group had a median interval to delivery of 2 days, compared with 7 days for nulliparas receiving placebo (P = .03). Active phases of labor were significantly shorter in the PGE2 group and for women with a negative fetal fibronectin test who received PGE2.

CONCLUSION

Outpatient administration of intracervical PGE2 gel shortened intervals to delivery and shortened labor.

Management of pregnancies complicated by anti-Kell isoimmunization

OBJECTIVE

To assess the efficacy of managing pregnancies complicated by anti-Kell isoimmunization using the methods developed for evaluating anti-Rh-D isoimmunization.

METHODS

We reviewed 156 anti-Kell-positive pregnancies seen from 1959 to 1995, which were managed with serial maternal titers, amniotic fluid deltaOD450 determination, and funipuncture. Data on maternal titers, paternal phenotypes, invasive fetal testing and therapies, and neonatal outcomes were collected and analyzed to determine whether severely affected pregnancies were identified in time for successful fetal and neonatal therapy.

RESULTS

Twenty-one fetuses were affected, eight with severe disease, and two fetuses in this group died. All of the severely affected fetuses were associated with maternal serum titers of at least 1:32. A critical titer of 1:32 was found to be 100% sensitive for identifying the affected pregnancies. The affected group had significantly higher amniotic fluid deltaOD450 values over the range of gestational ages than did the unaffected group (P < .001). The upper Liley curve was a specific discriminator for the diagnosis of affected fetuses, and the lower curve was specific for the diagnosis of unaffected or mild cases.

CONCLUSION

Fetal anemia due to anti-Kell isoimmunization might be due in part to erythropoietic suppression, but it is still largely a hemolytic process. The methods based on a hemolytic process, including use of a critical maternal serum titer of 1:32, serial amniotic fluid analyses when the titer was exceeded, and liberal use of funipuncture, were successful in identifying severely affected fetuses.

Group B streptococcal infections

Group B streptococcal infection is the most common cause of neonatal sepsis and is responsible for significant neonatal morbidity and mortality. Group B streptococcus is also the causative agent in 50,000 maternal infections per year. Approximately 30% of women have asymptomatic group B streptococcal colonization at some time during pregnancy, but the neonatal attack rate is only about 2 per 1,000 deliveries. Maternal and neonatal risk factors contribute to the rates of vertical transmission and symptomatic neonatal disease. Options that have been investigated for prevention of neonatal group B streptococcal disease include identification of at-risk pregnancies as well as antenatal, intrapartum, and neonatal treatment. The intrapartum treatment of women at risk for vertical transmission of group B streptococcus to their neonates unequivocally has been shown to decrease the rate of neonatal colonization. Practitioners should implement one of two strategies that incorporate intrapartum prophylaxis for prevention of perinatal group B disease.

Interleukin-1 alpha, epidermal growth factor, and transforming growth factor-beta exhibit differential kinetics on endothelin-1 synthesis in amnion cells

OBJECTIVE

To investigate the effects of three cytokines, interleukin-1 alpha (IL-1 alpha), epidermal growth factor (EGF), and transforming growth factor-beta (TGF-beta), on the regulation of endothelin-1 (ET-1) mRNA and protein production in human amnion cells.

METHODS

Human amnion cells were harvested from uncomplicated pregnancies undergoing elective cesarean delivery at term and grown in primary monolayer culture. Cells were treated with IL-1 alpha, EGF, and TGF-beta for dose-response and time course experiments. Northern analysis was used to determine ET-1 mRNA expression, and enzyme-linked immunosorbent assay was used for ET-1 peptide determination.

RESULTS

Interleukin-1 alpha, EGF, and TGF-beta induced the expression of ET-1 mRNA and protein in a dose- and time-dependent fashion. The kinetics of ET-1 mRNA production did not differ markedly with respect to the inducing cytokine, but the kinetics of ET-1 protein production was quite different. Interleukin-1 alpha and EGF stimulated a rapid increase in ET-1 that peaked by 24 hours, and the levels declined to just above the detection limit by 72 hours. In contrast, TGF-beta-stimulated cells showed modest ET-1 production at early times (4-24 hours) and then gradually increased and peaked at 72 hours.

CONCLUSIONS

Cytokines modulate the expression of ET-1 mRNA and its cognate protein in human amnion cells. The differential kinetics of ET-1 peptide expression in amnion cells suggests that ET metabolism as well as synthesis contribute to the net expression of endothelin in amnion.

The Potential for Ozone Depletion in the Arctic Polar Stratosphere

The nature of the Arctic polar stratosphere is observed to be similar in many respects to that of the Antarctic polar stratosphere, where an ozone hole has been identified. Most of the available chlorine (HCl and ClONO(2)) was converted by reactions on polar stratospheric clouds to reactive ClO and Cl(2)O(2) throughout the Arctic polar vortex before midwinter. Reactive nitrogen was converted to HNO(3), and some, with spatial inhomogeneity, fell out of the stratosphere. These chemical changes ensured characteristic ozone losses of 10 to 15% at altitudes inside the polar vortex where polar stratospheric clouds had occurred. These local losses can translate into 5 to 8% losses in the vertical column abundance of ozone. As the amount of stratospheric chlorine inevitably increases by 50% over the next two decades, ozone losses recognizable as an ozone hole may well appear.

Inhibition of recovery from potentially lethal radiation damage in A549 cells by the K+/H+ ionophore nigericin

A549 cells held for 4 hr in Hank's balanced salt solution, after 10 Gy irradiation, exhibit potentially lethal damage recovery (PLDR) which is dependent on extracellular pH (pHe). Recovery factors of 2.2 to 3.5 are observed when pHe is 6.40 to 7.30, but recovery factors of less than 1.0 are found when pHe is reduced to 6.20 or 6.00. The K+/H+ ionophore nigericin, when added to cells post-irradiation, inhibits PLDR in a pHe-dependent manner; it is increasingly more effective as pHe is reduced from 6.80 to 6.40. The presence of nigericin thus causes inhibition of PLDR at pHe's that normally promote recovery. The drug does not affect radiation response of A549 cells when present only during irradiation. Effects of low pHe buffer, with and without nigericin, on intracellular pH (pHi) and on ATP levels were examined in an effort to elucidate the mechanisms for inhibition of PLDR and enhancement of radiation response. Incubation of cells in pHe 6.00 buffer results in a slight decrease in pHi and does not induce a drop in ATP levels. In contrast, post-irradiation incubation of cells in pHe 6.40 buffer containing 2 microM nigericin causes an immediate and dramatic decrease in pHi, and a gradual loss of ATP to 30% of control levels by 4 hr. The data obtained so far suggest that a very slight lowering of pHi may influence post-irradiation holding recovery, and that the mechanisms by which pHe 6.00 buffer alone, or pHe 6.40 buffer containing nigericin, affect holding recovery are different.