A Novel Partogram for Stages 1 and 2 of Labor Based on Fetal Head Station Measured by Ultrasound: A Prospective Multicenter Cohort Study

OBJECTIVE

This study was aimed to describe continuous labor curves, including second stage, based on fetal head station.

STUDY DESIGN

We performed a prospective multicenter cohort study. The inclusion criteria were women with singleton uncomplicated cephalic term pregnancies in labor, who delivered vaginally. We used a device that combines ultrasound imaging with position-tracking technology to monitor the head station noninvasively throughout labor. We collected data on demographics, labor parameters, and delivery and neonatal outcomes.

RESULTS

A total of 613 women delivered vaginally, 327 (53.3%) were nulliparous, while 286 (46.7%) were multiparous. Time to delivery (TTD) diminished progressively with descent of the fetal head. When the head is engaged, the labor curve of multiparous women demonstrated a more prominent downward shift in curve as compared with nulliparous women. When comparing multipara and nullipara at engagement level, the median TTD was 1 and 1.62 hours, respectively. In 95% of women with unengaged head during the second stage, TTD of nulliparous and multiparous women were less than 3.8 and 3 hours, respectively.

CONCLUSION

While current labor curves end at full dilatation, the described curves were developed throughout stages 1 and 2 of labor. The TTD, according to the station curves, shows an acceleration of labor, once passed the engagement level, especially in multiparous women.

Are we preventing the primary cesarean delivery at the second stage of labor following ACOG-SMFM new guidelines? Retrospective cohort study

OBJECTIVE

In 2014, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine (SMFM) published an Obstetric Care Consensus for safe prevention of primary cesarean delivery. We aimed to assess whether these guidelines decreased the primary CD rate during the second stage of labor, in our department.

DESIGN, SETTING, AND POPULATION

A retrospective cohort study of all women reaching the second stage of labor, at term, in a single university-affiliated medical center between2010 and 2017.

METHODS

We compared maternal and neonatal outcomes over three year's periods:-pre-guidelines (2010-2013) vs. 2nd period - post-guidelines (2014-2017).

THE MAIN OUTCOME MEASURES

CD rate at 2ndstage of labor.

RESULTS

The study included 11,464 women. The CD rate in the 2nd stage of labor has increased significantly from 4% to 5.9% in the post-guidelines period (OR 1.48, 95% CI 1.16-1.89, p = .001). After a sub-analysis of specific subgroups, and adjustment for confounders, the increase was solely observed in nulliparous women (aOR 1.418, 95% CI 1.067-1.885, p = .016). Furthermore, increased odds for vaginal operative delivery were observed in the multiparous women in the post-guidelines period (2.7% vs. 4.1%, p = .046).

CONCLUSIONS

The implementation of the new ACOG and SMFM guidelines was not associated with a change in the CD rate performed at the 2nd stage of labor in the whole study population. However, there was a rise in the CD rate performed at the 2nd stage in nulliparous women. Furthermore, there was an increase in operative deliveries in the whole study population, especially in multiparous women, without an apparent increase in other immediate adverse neonatal or maternal outcomes.

Is it time to abandon episiotomy use? A randomized controlled trial (EPITRIAL)

INTRODUCTION AND HYPOTHESIS

The objective of this trial was to evaluate whether avoidance of episiotomy can decrease the risk of advanced perineal tears.

METHODS

In this randomized (1:1) parallel-group superiority trial, primiparous women underwent randomization into "avoidance of episiotomy" (the study group in which episiotomy was allowed only in cases of fetal distress) or "standard care." The primary outcome was the incidence of advanced (3rd- and 4th-degree) perineal tears.

RESULTS

The participants were randomized into "standard care" (n = 337) vs. "no episiotomy" (n = 339) groups, not differing in any demographic or obstetric characteristics. Episiotomy rates were significantly lower in the study group (19.6%) compared with the standard care group (29.8%, p = 0.004). Five (1.5%) advanced tears were diagnosed in the study group vs. ten = 3.0% in the controls, yielding an odds ratio of 0.50 (95% CI 0.17-1.50) in favor of the "no episiotomy" group (p = 0.296). No differences were noted in any secondary outcomes. By per protocol analysis (omitting cases in which episiotomy was performed for indications other than fetal distress in the study group), a trend to decreased risk of advanced tears in the study group was noted (p = 0.0956). By per protocol analyses, no severe tears were noted in the 53 vacuum deliveries in the study group vs. 4/65 (6.2%) tears in the controls (p = 0.126).

CONCLUSIONS

Since decreased use of episiotomy was not associated with higher rates of severe tears or any other adverse outcomes, we believe this procedure can be avoided in spontaneous as well as vacuum-assisted deliveries. Trial registration no. NCT02356237.

Induction of labor versus expectant management among women with macrosomic neonates: a retrospective study

Background: The macrosomic fetus predisposes a variety of adverse maternal and perinatal outcomes. Although older studies have shown no benefit in inducing women of suspected macrosomic fetuses, more updated studies show different information.Objectives: The aim of our study was to compare induction of labor versus expectant management among women with macrosomic neonates weighing more than 4000 g at term (between 37°^/7 and 41^6/7 weeks' gestation).Study design: This was a retrospective cohort study of all live-born singleton pregnancies with macrosomic newborns who were delivered at our institution between 1 January 2000 and 1 June 2015. We compared the outcomes of induction of labor, at each gestational age (GA), between 37 and 41 weeks (study group) with ongoing pregnancy. The primary outcome was cesarean section (CS) rate. Secondary outcomes were composite maternal and neonatal outcome and birth injuries.Results: Overall, out of 3095 patients with macrosomic newborns who were included in the study, 795 women (25.7%) underwent induction of labor. The cesarean section rate was not found to be significantly different between the groups at all gestational ages, nor was the vaginal delivery rate. After adjusting for confounders, induction of labor at 40 and 41 weeks' gestation was associated with composite maternal outcome (adjusted odds ratio (aOR) 1.6, 95% confidence interval (CI): 1.3-2.1; aOR 1.7, 95% CI: 1.3-2.2, respectively) and composite neonatal outcome (aOR 1.6, 95% CI: 1.1-2.4; aOR 1.8, 95% CI: 1.1-2.9). Induction of labor at 40 weeks' gestation was also associated with increased risk of birth injuries (aOR 2.9, 95% CI: 1.4-6).Conclusions: Compared with ongoing pregnancy, induction of labor of women with macrosomic neonates between 37 and 41 weeks of gestation does not reduce the CS rate, nor does it increase the vaginal delivery rate. Moreover, induction of labor of those women beyond 39 weeks' gestation is associated with composite adverse maternal/neonatal outcome, specifically birth injuries.

When should pregnancies that extended beyond term be induced?. J Matern Fetal Neonatal Med 2016;30:219-223. [PMID: 27002548 DOI: 10.3109/14767058.2016.1169520]

OBJECTIVE

To compare maternal and neonatal outcomes associated with a policy for induction of labor at ≥ 41 versus at ≥42 weeks'.

STUDY DESIGN

Retrospective cohort study of a 2 years' period before and after policy change from induction of labor at ≥ 42 gestational weeks' versus ≥41 gestational weeks.

RESULTS

During the 41-policy period (N = 968), the induction rate was higher, 60% versus 40% (p < 0.0001) while the cesarean delivery (CD) rate was lower, 15% versus 19.4% (p = 0.0135). Moreover, among women that were induced, the rate of CD was lower during the 41-policy period, 19% versus 27% (p = 0.0067). No significant differences in maternal or neonatal outcomes were noted. There was one case of intrauterine fetal death at 41 + 4 weeks during the 42-policy period.

CONCLUSION

As a policy for induction of labor at ≥ 41 reduces the rate of CD without any adverse maternal or neonatal outcomes, such a policy seems to be superior to a policy for induction at ≥ 42 weeks.

Prospective multicenter study of ultrasound-based measurements of fetal head station and position throughout labor

OBJECTIVES

To assess the relationship between fetal head position and head station during labor, as measured using an ultrasound-based system, and the occurrence of occiput posterior (OP) position at delivery.

METHODS

This was an international prospective observational study including women who delivered between January 2009 and September 2013 in four centers: one in Brooklyn, NY, USA; one in Haifa, Israel; and two in Paris, France. We used an ultrasound-based system (LaborPro) to monitor fetal head station and position non-invasively throughout labor. We collected data on demographics, labor parameters and outcome.

RESULTS

A total of 595 women were included. In 563 (94.6%) women, fetal head position at delivery was occiput anterior (OA), in 31 (5.2%) it was OP and in one (0.2%) it was occiput transverse. In 89% of pregnancies with intrapartum OP when fetal head station was above -2, the head position turned to OA at delivery; the equivalent figures were 74% and 63% OA at delivery when intrapartum OP was diagnosed at head stations of -2 to < 0, and 0 and below, respectively. Cesarean delivery was performed in 35% of pregnancies with fetal head in OP position at delivery, as opposed to 10% of those with non-OP position at delivery. On retrospective analysis, all deliveries in OP were already in OP at station -2 and below.

CONCLUSIONS

In this first assessment of fetal head position at delivery according to fetal head position at various station levels, our data show that 100% of OP positions at delivery were already in OP position at station -2 and below. We did not observe rotation from a non-OP to an OP position from station -2 and below. Nearly two-thirds of fetuses in OP at station 0 and below will rotate to an OA position for delivery.

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

AIM

Evaluation of placental protein 13 (PP13) and risk factors (RFs) as markers for predicting preeclampsia (PE) and use of aspirin for PE prevention.

MATERIALS AND METHODS

First-trimester pregnancy screening was based on having PP13 level ≤0.4 multiple of the median (MoM) and/or at least one major risk factor (RF) for PE. Management was by routine care or combined with daily treatment with 75 mg aspirin between 14 and 35 weeks of gestation.

RESULTS

Of 820 deliveries, 63 women developed PE (7.7%). Median PP13 levels was 0.2MoM in the PE group compared with 0.83MoM among unaffected and 1.0MoM in unaffected not treated with aspirin (P<0.0001). Low PP13 was a better predictor for PE versus major RFs, particularly for young nuliparous. Combining low PP13 with RFs increased prediction accuracy. Mean arterial pressure (not included in the initial prediction), could add to prediction accuracy when combined with low PP13 and RFs. PE prevention by aspirin was most effective when the risk was determined by low PP13 alone, less effective for combining low PP13 with RFs, and ineffective when determined by RFs alone.

CONCLUSION

When PE risk is determined by low first trimester PP13 or by combined low PP13 and RFs, prevention with aspirin is warranted.

Does cesarean section before the scheduled date increase the risk of neonatal morbidity?

BACKGROUND

Previous studies led to the recommendation to schedule planned elective cesarean deliveries at or after 39 weeks of gestation and not before 38 weeks. The question is whether this practice is appropriate in face of possible risks to the newborn should the pregnancy have to be ended by cesarean section before the scheduled date.

OBJECTIVES

To compare the outcomes of newborn infants who were delivered on their scheduled day by elective cesarean section versus those who required delivery earlier.

METHODS

This single-center retrospective study was based on medical records covering a period of 18 months. We compared the neonatal outcomes of 272 infants delivered by elective cesarean section as scheduled (at 38.8 +/- 0.8 weeks gestation)and 44 infants who had to be delivered earlier than planned j(at 37.9 +/- 1.1 weeks).

RESULTS

We found no morbidity directly related to delivery by cesarean section before the scheduled date. There were no significant differences in the need for resuscitation after delivery. Although more of the infants who were delivered early were admitted to intensive care and overall stayed longer in the hospital (5.8 +/- 7.3 vs. 3.9 +/- 0.8 days, P < 0.02), their more severe respiratory illness and subsequent longer hospitalization was the result of their younger gestational age. Transient tachypnea of the newborn was associated with younger gestational age at delivery in both groups.

CONCLUSIONS

We suggest continuing with the current recommendation to postpone elective cesarean singleton deliveries beyond 38-39 weeks of gestation whenever possible.

The effect of timing of maternal tetanus, diphtheria, and acellular pertussis (Tdap) immunization during pregnancy on newborn pertussis antibody levels - a prospective study

BACKGROUND

The Centers for Disease Control and Prevention recommend Tdap immunization during pregnancy, preferably at 27-36 weeks.

AIM

To ascertain whether there is a preferential period of maternal Tdap immunization during pregnancy that provides the highest concentration of pertussis-specific antibodies to the newborn.

METHODS

This prospective study measured pertussis-specific antibodies in paired maternal-cord sera of women immunized with Tdap after the 20th week of their pregnancy (n=61).

RESULTS

The geometric mean concentrations (GMCs) of Immunoglobulin G (IgG) to pertussis toxin (PT) were higher in the newborns' cord sera when women were immunized at 27-30(+6) weeks (n=21) compared with 31-36 weeks (n=30) and >36 weeks (n=7), 46.04 international units/milliliter (IU/mL) (95% CI, 24.29-87.30) vs. 8.69IU/mL (95% CI, 3.66-20.63) and 21.12IU/mL (95% CI, 7.93-56.22), p<0.02, respectively. The umbilical cord GMCs of IgG to filamentous hemagglutinin (FHA) were higher in the newborns' cord sera when women were immunized at 27-30(+6) weeks compared with 31-36 weeks and >36 weeks, 225.86IU/mL (95% CI, 182.34-279.76) vs. 178.31IU/mL (95% CI, 134.59-237.03) and 138.03IU/mL (95% CI, 97.61-195.16), p<0.02, respectively.

CONCLUSIONS

Immunization of pregnant women with Tdap between 27-30(+6) weeks was associated with the highest umbilical cord GMCs of IgG to PT and FHA compared with immunization beyond 31 weeks gestation. Further research should be conducted to reaffirm these finding in order to promote an optimal pertussis controlling policy.

The induction of breast milk pertussis specific antibodies following gestational tetanus-diphtheria-acellular pertussis vaccination

BACKGROUND

Center for Disease Control and Prevention recommends vaccination of pregnant women with tetanus-diphtheria-acellular pertussis (Tdap).

AIM

To measure pertussis specific antibodies, total protein and their ratio in breast milk following gestational Tdap vaccination.

METHODS

Women who received Tdap after the 20th week of pregnancy were recruited and unvaccinated women served as controls. Breast milk total protein, immunoglobulin A (IgA) to pertussis toxin (PT), filamentous hemagglutinin (FHA) and immunoglobulin G (IgG) to PT, FHA and pertactin (PRN) were measured. To overcome the dilution that occurs in the transition from colostrum to mature breast milk, we calculated pertussis specific antibody to total protein ratio.

RESULTS

Pertussis specific IgA was the predominant pertussis immunoglobulin in the colostrum of Tdap vaccinated women with the geometric mean concentrations (GMCs) of IgA to FHA higher than for IgA to PT, 24.12 ELISA units/milliliter (EU/mL) vs. 8.18EU/mL, respectively, p<0.004. There were differences between the vaccinated women and controls in the GMCs of IgA to FHA and IgG to PRN in the colostrum, 24.12EU/mL vs. 6.52EU/mL, p=0.01 and 2.46EU/mL vs. <0.6EU/mL, p=0.03, respectively. The GMCs of total protein showed significant decline over 8 weeks in the vaccinated women and controls, p<0.004. Among vaccinated women, there was significant decline in the GMCs of IgA to PT and FHA over 8 weeks, p<0.001. The geometric mean ratio of IgA to FHA to total protein also declined significantly over 8 weeks in the vaccinated women, p<0.01, demonstrating a true decrease, however, pertussis IgA was measurable at 8 weeks.

CONCLUSIONS

Select colostrum pertussis antibody levels were significantly higher among women vaccinated with Tdap during pregnancy compared with unvaccinated women. Among vaccinated women, maximal levels of pertussis specific IgA were in the colostrum but still detected at 8 weeks. Lactation may augment infant's protection against pertussis.

The role of the carbohydrate recognition domain of placental protein 13 (PP13) in pregnancy evaluated with recombinant PP13 and the DelT221 PP13 variant

INTRODUCTION

Placental protein 13 (PP13), a placenta specific protein, is reduced in the first trimester of pregnancy in women who subsequently develop preeclampsia. A naturally occurring PP13 deletion of thymidine at position 221 (DelT221 or truncated variant) is associated with increased frequency of severe preeclampsia. In this study we compared the full length (wildtype) PP13 and the truncated variant.

METHODS

Full length PP13 or its DelT221 variant were cloned, expressed and purified from E-Coli. Both variants were administrated into pregnant rats at day 8 of pregnancy for slow release (>5 days) through osmotic pumps and rat blood pressure was measured. Animals were sacrificed at day 15 or day 21 and their utero-placental vasculature was examined.

RESULTS

The DelT221 variant (11 kDA) lacked exon 4 and a part of exon 3, and is short of 2 amino acids involved in the carbohydrate (CRD) binding of the wildtype (18 kDA). Unlike the wildtype PP13, purification of DelT221 variant required special refolding. PP13 specific poly- clonal antibodies recognized both PP13 and DelT221 but PP13 specific monoclonal antibodies recognized only the wildtype, indicating the loss of major epitopes. Wildtype PP13 mRNA and its respective proteins were both lower in PE patients compared to normal pregnancies. The DelT221 mutant was not found in a large Caucasian cohort. Pregnant rats exposed to wildtype or DelT221 PP13 variants had significantly lower blood pressure compared to control. The wildtype but not the DelT221 mutant caused extensive vein expansion.

CONCLUSION

This study revealed the importance of PP13 in regulating blood pressure and expanding the utero-placental vasculature in pregnant rats. PP13 mutant lacking amino acids of the PP13 CRD domain fails to cause vein expansion but did reduce blood pressure. The study provides a basis for replenishing patients at risk for preeclampsia by the full length but not the truncated PP13.

Adrenalectomy for adrenocortical adenoma causing Cushing's syndrome in pregnancy: a case report and review of literature

We present a case of adrenocorticotropic hormone (ACTH)-independent Cushing's syndrome diagnosed in a patient in the third trimester of her pregnancy, with an adrenal mass observed on imaging studies. Laparoscopic adrenalectomy was performed successfully at 32 weeks. To the best of our knowledge, this is the latest gestational age at which laparoscopic adrenalectomy has been reported. We present the various considerations for determining the surgical approach and the optimal timing for surgery. Adrenalectomy during pregnancy for the treatment of Cushing's syndrome caused by adrenocortical adenoma has been reported in 23 patients in the English-language medical literature to date and seems safe and beneficial. According to the data, surgical treatment has led to a reduction in perinatal mortality and maternal morbidity rates, but has not affected the occurrence of preterm birth and intrauterine growth restriction. The best outcome can be achieved by a multidisciplinary approach, with a team comprising a maternal-fetal medicine specialist, an endocrinologist and a surgeon. The timing of surgery and the surgical approach need to be determined according to the surgeon's expertise, the severity of the condition, the patient's preferences, and gestational age. Laparoscopy may prove to be the preferred surgical approach. The small number of cases precludes providing evidence-based recommendations.

Placental protein 13 and decidual zones of necrosis: an immunologic diversion that may be linked to preeclampsia

We evaluated the role of placental protein 13 (PP13; galectin 13) in the process of trophoblast invasion and decidual necrosis. Immunohistochemical analysis for PP13, immune cells, human placental lactogen, cytokeratin, and apoptosis markers was performed on 20 elective pregnancy termination specimens between 6 and 15 weeks of gestation. Placental protein 13 was localized to syncytiotrophoblasts in the chorionic villi and to occasional multinucleated luminal trophoblasts within converted decidual spiral arterioles. Cytotrophoblasts, anchoring trophoblasts, and invasive trophoblasts did not stain for PP13. Extracellular PP13 aggregates were found around decidual veins associated with T-cell-, neutrophil- and macrophage-containing decidual zones of necrosis (ZONEs). We hypothesize that PP13 is secreted into the intervillus space, drains through the decidua basalis veins, and forms perivenous PP13 aggregates which attract and activate maternal immune cells. Thus, syncytiotrophoblast-derived PP13 may create a ZONE that facilitates trophoblast invasion and conversion of the maternal spiral arterioles.

PP13, maternal ABO blood groups and the risk assessment of pregnancy complications

BACKGROUND

Placental Protein 13 (PP13), an early biomarker of preeclampsia, is a placenta-specific galectin that binds beta-galactosides, building-blocks of ABO blood-group antigens, possibly affecting its bioavailability in blood.

METHODS AND FINDINGS

We studied PP13-binding to erythrocytes, maternal blood-group effect on serum PP13 and its performance as a predictor of preeclampsia and intrauterine growth restriction (IUGR). Datasets of maternal serum PP13 in Caucasian (n = 1078) and Hispanic (n = 242) women were analyzed according to blood groups. In vivo, in vitro and in silico PP13-binding to ABO blood-group antigens and erythrocytes were studied by PP13-immunostainings of placental tissue-microarrays, flow-cytometry of erythrocyte-bound PP13, and model-building of PP13--blood-group H antigen complex, respectively. Women with blood group AB had the lowest serum PP13 in the first trimester, while those with blood group B had the highest PP13 throughout pregnancy. In accordance, PP13-binding was the strongest to blood-group AB erythrocytes and weakest to blood-group B erythrocytes. PP13-staining of maternal and fetal erythrocytes was revealed, and a plausible molecular model of PP13 complexed with blood-group H antigen was built. Adjustment of PP13 MoMs to maternal ABO blood group improved the prediction accuracy of first trimester maternal serum PP13 MoMs for preeclampsia and IUGR.

CONCLUSIONS

ABO blood group can alter PP13-bioavailability in blood, and it may also be a key determinant for other lectins' bioavailability in the circulation. The adjustment of PP13 MoMs to ABO blood group improves the predictive accuracy of this test.

Association between ultrasound-based assessment of fetal head station and clinically assessed cervical dilatation

OBJECTIVES

To describe the association between ultrasound-based determination of fetal head station and clinical assessment of cervical dilatation during active labor.

METHODS

From 427 women with singleton uncomplicated term pregnancies we obtained, during the active phase of labor, 907 pairs of measurements. Fetal head station and position were determined using the LaborPro system, based on position tracking and ultrasound imaging technology, and degree of cervical dilatation was determined by digital vaginal examination. The association between them was analyzed.

RESULTS

The overall correlation between cervical dilatation and fetal head station was 0.64 (P < 0.001). Complete dilatation was observed in 78% of women with fetal head engagement, and in all women with a fetal head station of + 1.5 or more.

CONCLUSIONS

There is good association between non-invasive ultrasound-based determination of fetal head station and clinically assessed cervical dilatation.

Placenta-bound and body fluid PP13 and its mRNA in normal pregnancy compared to preeclampsia, HELLP and preterm delivery

OBJECTIVES

To compare the distribution of placental protein 13 (PP13) in fetal and maternal blood and amnionic fluid and to correlate it with PP13 protein and mRNA in the placenta.

METHODS

Umbilical arterial serum, amnionic fluid, maternal venous serum and placental tissues were collected from normal outcome pregnancies (N = 63) (GA>37), early onset preeclampsia (PE) (N = 12, GA: 26-33), and HELLP syndrome (N = 5, GA: 27-29). Because PE and HELLP cases delivered preterm, cases of preterm delivery (PTD) (N = 6, GA: 31-36) served as additional control. PP13 was determined by ELISA, Western blot, and immunohistochemistry. PP13 mRNA was measured by PCR (RT-PCR). Continuous parameters were compared by t-test, P < 0.05 was considered significant.

RESULTS

In women with normal pregnancy outcome significantly higher PP13 levels were found in maternal serum compared to amnionic fluid and negligible amount was found in fetal serum. A similar pattern was identified in cases of PTD with concentrations similar to term control. In PE and HELLP cases PP13 levels in amnionic fluid level were more than twice compared to maternal serum (P < 0.001). Umbilical cord level was negligible in PE but high in HELLP corresponding to the much higher level of PP13 in this patient group compared to all others. In the placenta PP13 level in term controls was higher compared to PTD. In PE and HELLP (similar early delivery time as PTD) the level was significantly higher (P < 0.01) compared to PTD or term controls. PP13 mRNA levels in term control and PTD were similar while PP13 mRNA levels in PE and HELLP placentas were significantly lower compared to term controls or PTD or the two combined. Syncytiotrophoblast labeling appeared stronger in PE and HELLP compared to term controls and PTD.

CONCLUSIONS

In all cases but HELLP, PP13 in fetal blood is very low indicating that routing of PP13 to fetal blood is limited and that the fetus is unlikely to generate PP13. PP13 mRNA is lower in the third trimester at the time of disease while protein level accumulates and become higher creating an unparallel change in the level of the mRNA and the corresponding protein.

Placental and trophoblastic in vitro models to study preventive and therapeutic agents for preeclampsia

In the field of preeclampsia, enormous efforts are ongoing to identify biomarkers predicting the syndrome already in the first trimester of pregnancy. At the same time, there is the need for in vitro models to test such biomarkers prior to their use in clinical trials. In addition, in vitro models may accelerate the development and evaluation of the benefit of any putative therapeutics. Therefore, in vitro systems have been established to evaluate the release of biomarkers and measure the effect of putative therapeutics using placental villous explants as well as the choriocarcinoma cell line BeWo. For explants, a cryogenic method to freeze, transport and thaw villous explants was developed to use such tissues for a multi-site tissue culture evaluation. Here we focus on three out of many in vitro models that have been established for human placental trophoblast. (1) Choriocarcinoma cell lines such as BeWo, Jeg-3 and Jar cells (2) isolated primary trophoblast cells, and (2) villous explants from normal placentas delivered at term. Cell lines were used to assess the effect of differentiation and fusion on the expression and release of a preeclampsia marker (placental protein 13; PP13) and beta-hCG. Moreover, cell lines were used to study the effect of putative preeclampsia therapeutics such as vitamins C and E, heparin and aspirin on marker release and viability. Cryopreservation of villous explants enabled shipment to a remote laboratory and testing of parameters in different countries using explants from one and the same placenta. Recently published data make it tempting to speculate that the choriocarcinoma cell line BeWo as well as fresh and cryogenically stored placental villous explants may well serve as in vitro models to study preventive and therapeutic agents in the field of preeclampsia.

Cervical varices complicated by thrombosis in pregnancy

We present a case of a 36-year-old pregnant woman with varicose veins of the uterine cervix diagnosed during the second trimester. The cervical tissue was completely replaced with dilated venous plexus. Therapeutic decisions were further complicated by the presence of blood clots within the dilated vessels. Pregnancy proceeded uneventfully, no bleeding occurred and the patient underwent a planned Cesarean delivery. This is the first reported case in the medical literature where the rare phenomenon of cervical varices was accompanied by thrombosis.

Effects of calcium, magnesium, low-dose aspirin and low-molecular-weight heparin on the release of PP13 from placental explants

BACKGROUND

Preeclampsia is one of the leading causes for maternal and fetal morbidity. Attempts to prevent preeclampsia have already been made using low-dose aspirin, low-molecular-weight heparin (LMWH), and calcium supplementation. Magnesium sulphate is used at the time of disease to prevent eclampsia. Here we investigated the effect of these agents on PP13 release from placental explants.

METHODS

Placentas harvested after C-section of term or preterm control and preeclampsia cases or first trimester terminations were used to obtain explants. Explants were incubated for 24h with/without respective agents, harvested, weighed and subjected to PP13 determination in the culture medium and the explant. LDH was used to determine viability. Dose response curves were obtained for each drug. P < 0.05 was considered significant.

RESULTS

Exposure to magnesium (0.7-7g/day) slightly decreased PP13 release from controls, and slightly increased it in preeclampsia and first trimester termination. Calcium (0. 3-6g/day) showed a tendency to decrease the release in control and preeclampsia, whereas in first trimester release was increased in a bell-shaped manner. Aspirin (0-250 mg/day) tended to decrease the release in controls but increased it in a bell-shaped manner in first trimester and preeclampsia. LMWH showed no effect from 0 to 80 mg/day in controls but tended to decrease PP13 release in preeclampsia and first trimester.

CONCLUSION

This data might point to a beneficial effect of aspirin and calcium supplementation in the first trimester of pregnancy and aspirin at the time of disease, although the interaction with the maternal system still needs to be elucidated.

Haptoglobin phenotype in women with preeclampsia

In pre-eclampsia, poor placentation causes both oxidative and endoplasmic reticulum stress of the placenta. The anti-oxidative protein Haptoglobin has three phenotypes: 1-1, 1-2, and 2-2. Haptoglobin 1-1 is a more potent antioxidant. Our objective was to determine whether haptoglobin 1-1 was less common in women with preeclampsia which is a disease with an oxidatives-stress component, compared to the healthy population. Haptoglobin phenotype was compared in 240 healthy and 120 preeclamptic gravida in a case-control study. Statistical analysis was performed using Chi square test. The prevalence of haptoglobin 1-1 was 13% among healthy women and 6% among preeclamptic women (P=0.049). Secondary analysis was also performed. The prevalence of haptoglobin 1-1 is higher in healthy compared to preeclamptic subjects, a finding compatible with a protective role. Haptoglobin 1-1 might have a protective role in preeclampsia. Further work is needed with more Hp 1-1 subjects before we can conclude on the possible use of Haptoglobin phenotype to assess the risk of preeclampsia.

How reliable is the determination of cervical dilation? Comparison of vaginal examination with spatial position-tracking ruler

OBJECTIVE

The purpose of this study was to evaluate the accuracy of clinical measurement of cervical dilation with a position-tracking system during vaginal examination.

STUDY DESIGN

This prospective study that was conducted in Poissy, France, Brooklyn, NY, and Haifa, Israel, included 333 measurements that were performed in 188 women with term singleton vertex uncomplicated pregnancies during the active stage of labor. Ninety measurements with clinical diagnosis of full dilation were excluded from analysis. Measurements were performed with a sensor attached to the midwife's index fingertip and a position-tracking system that was based on a low magnetic field. Evaluations were done when cervical examinations were clinically indicated.

RESULTS

Results were similar in all centers. Mean error was 10.2 +/- 8.4 mm and ranged from 7.5 +/- 7.3 mm, when cervical dilation was > 8 cm, to 12.5 +/- 8.7 mm when cervical dilation was between 6.1 and 8 cm.

CONCLUSION

This first evaluation of cervical assessment accuracy during vaginal examination with a position-tracking system shows limited precision.

Determination of fetal head station and position during labor: a new technique that combines ultrasound and a position-tracking system

OBJECTIVE

The purpose of this study was to compare the ultrasound-based LaborPro (Trig Medical Ltd, Yokneam, Israel) system determination of fetal head station and position with routine vaginal examination.

STUDY DESIGN

This prospective study, which was conducted in 3 centers included 311 measurements that were performed in 166 singleton term pregnancies during the active phase of vertex, uncomplicated labor. Ultrasound-based position-tracking system calculations of fetal head station and position were compared with routine vaginal examination measurements.

RESULTS

Comparison of vaginal examination with the system head station results revealed a mean absolute difference of 5.5 +/- 6.1 mm (n = 311). Vaginal examination head-position evaluation, within a 45 degrees interval, complied with the system in 35 of 87 cases (40.2%).

CONCLUSION

Our data show that an ultrasound-based system can determine fetal head station and position during labor, when compared with vaginal examination, and requires minimal ultrasound skills. The limits of vaginal examination assessment of the head position are in agreement with published data.

Determination of the solubility and size distribution of radioactive aerosols in the uranium processing plant at NRCN

Inhalation is the main route of internal exposure to radioactive aerosols in the nuclear industry. To assess the radiation dose from the intake of these aerosols, it is necessary to know their physical (aerodynamic diameter distribution) and chemical (dissolution rate in extracellular lung fluid) characteristics. Air samples were taken from the uranium processing plant at the Nuclear Research Center, Negev. Measurements of aerodynamic diameter distribution using a cascade impactor indicated an average activity median aerodynamic diameter value close to 5 microm, in accordance with the recent recommended values of International Commission on Radiological Protection (ICRP) model. Solubility profiles of these aerosols were determined by performing in vitro solubility tests over 100 d in a simultant solution of the extracellular fluid. The tests indicated that the uranium aerosols should be assigned to an absorption between Types M and S (as defined by the ICRP Publication 66 model).

Normalisation of spot urine samples to 24-h collection for assessment of exposure to uranium

For dose assessment of workers at Nuclear Research Center Negev exposed to natural uranium, spot urine samples are analysed and the results are normalised to 24-h urine excretion based on 'standard' man urine volume of 1.6 l d(-1). In the present work, the urine volume, uranium level and creatinine concentration were determined in two or three 24-h urine collections from 133 male workers (319 samples) and 33 female workers (88 samples). Three volunteers provided urine spot samples from each voiding during a 24-h period and a good correlation was found between the relative level of creatinine and uranium in spot samples collected from the same individual. The results show that normalisation of uranium concentration to creatinine in a spot sample represents the 24-h content of uranium better than normalisation to the standard volume and may be used to reduce the uncertainty of dose assessment based on spot samples.

Three-dimensional power Doppler in the evaluation of painful leiomyomas and focal uterine thickening in pregnancy

OBJECTIVE

To determine the usefulness of 3-dimensional (3D) power Doppler ultrasound in distinguishing painful leiomyomas from focal myometrial contractions or nonpainful leiomyomas in pregnancy.

METHODS

A 2D section of the area of interest in the uterine wall was first obtained in 29 patients to determine whether the pain originated from a myoma or a uterine contraction. Then, volume acquisition was activated and Doppler indices (vascularization index, flow index, and vascularization-flow index) were calculated for thickened and normal uterine wall.

RESULTS

Of 15 patients found to have uterine myomas, 11 had multiple tumors and 4 had single tumors. In the remaining 14 patients the painful uterine thickening proved to be a focal contraction. Painful segments of uterine thickening were associated with lower Doppler indices. Painful myomas were found to have significantly lower indices than normal uterine wall (P=0.008, 0.03, and 0.01 for VI, FI, and VFI, respectively, vs. 0.001, 0.003, and 0.01). However, the differences in indices between nonpainful myomas and uterine wall on the one hand, and nonpainful myomas and focal uterine contractions on the other, were not statistically significant.

CONCLUSION

Three-dimensional power Doppler ultrasound may be a sensitive and reliable tool for distinguishing painful uterine myomas from focal myometrial contractions and nonpainful myomas.

The outcome and cumulative morbidity associated with the second and third postcesarean delivery

The purpose of this study was to compare the outcome and cumulative morbidity among women who delivered twice after a cesarean delivery (CD), and who underwent in the second delivery either a trial of labor (TOL) or planned cesarean delivery (PCD). Eligible women (N = 399) were divided into two groups based on first post-CD: a TOL (n = 304) or PCD (n = 95). Women attempting a TOL were successful in 70 and 75% in the first and second post-CD, respectively. All participants undergoing a PCD subsequently had a third PCD. The overall morbidity was 8.4 and 5.3% among PCD and TOL groups, respectively ( P = 0.258). Women attempting a TOL after a previous CD had a 70 and 53% likelihood for at least one successful or two successful vaginal births in the two subsequent deliveries, respectively. No significant difference was documented between the groups regarding the cumulative morbidity.

Immediate versus delayed umbilical cord clamping in premature neonates born < 35 weeks: a prospective, randomized, controlled study

The purpose of this study was to test whether delayed versus immediate cord clamping would result in higher blood pressure (BP) and hematocrit (Hct), and to assess its clinical effects on the neonatal course in premature neonates (< 35 weeks). This was a prospective, masked, randomized, controlled study. Prior to delivery, 35 neonates were randomly assigned to immediate cord clamping (ICC) at 5 to 10 seconds, and a comparable group of 30 neonates were randomly assigned to delayed cord clamping (DCC) at 30 to 45 seconds. Intention-to-treat analyses revealed that the DCC group tended to have higher initial diastolic BP and higher Hct (especially in vaginally delivered neonates). Infants weighing < 1500 g with DCC tended to have higher mean BP, and needed less mechanical ventilation and surfactant compared with ICC neonates. Infants with DCC did not experience more polycythemia (Hct > 60%), but had a trend toward higher bilirubin levels with no differences in the phototherapy needs. DCC seems to be safe and may be beneficial when compared with ICC in premature neonates. However, the differences between the two methods were modest and the clinical relevance needs to be assessed further by larger studies and additional meta-analysis of randomized trials.

Ehlers-Danlos syndrome: insights on obstetric aspects

Ehlers-Danlos syndrome (EDS) is a heterogeneous group of connective tissue disorders characterized by joint hypermobility, skin hyperelasticity, tissue fragility, easy bruising, and poor healing of wounds. The clinical manifestations vary depending on the type of disease. The syndrome may be associated with a number of pregnancy and peripartum complications. Because of the multiorgan involvement and varied presentation of this disease, no uniform or routine obstetric and anesthetic recommendations can be made for the perinatal care of these patients. We present a review of the literature on EDS with emphasis on the obstetric, anesthetic, and perinatal consequences. We also report our experience with this syndrome: an uneventful term vaginal delivery in a 32-year-old woman diagnosed with hypermobility type of EDS.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to recall the potentially severe nature of Ehlers-Danlos Syndrome (EDS) in both pregnant and nonpregnant patients, summarize the wide range of signs and symptoms and its genetic inheritance, and explain the difficulty in recommending obstetric and anesthesia procedures to avoid complications.

An improved method for Organic Bound Tritium (OBT) determination in urine samples

The Organic Bound Tritium (OBT) amount in the body may induce changes in the evaluation of the internal exposure to tritium, due to its different retention time relative to HTO. OBT measurements for urine are not performed routinely, mainly because of the lengthy work needed in preparation of the samples, when using the standard oxygen combustion method. A simpler and more rapid method based on liquid scintillation counting (LSC) was employed, and an evaluation was performed to check its suitability for urine samples. The principle of the proposed method is based on subtracting the LSC counts of the water phase sample (HTO) from the total activity of the urine sample (OBT+HTO). A good correlation was found between the results obtained when applying the proposed direct method and the Gold standard method. The minimum detectable activity when using this method was determined.

Chorionic villous sampling: differences in patients' perspectives according to indication, ethnic group and religion

BACKGROUND

The decision to undergo prenatal testing may be influenced by ethnic or religious factors.

OBJECTIVES

To evaluate factors that might influence the decision of pregnant women to choose chorionic villous sampling for prenatal testing.

METHODS

The study group comprised 239 women referred for prenatal diagnosis who elected to undergo CVS. The data were analyzed according to indication, ethnic group and religion.

RESULTS

Among women undergoing CVS because of advanced maternal age and anxiety, we noted a significantly high proportion of unbalanced families, i.e., with three or more children of the same gender and deviated gender ratio. We found a significant excess of males among the Jewish families and a significant excess of females among the non-Jewish families. Jews were over-represented in the monogenic group while Christian Arabs were over-represented in the maternal age/anxiety group.

CONCLUSIONS

The proportion of women who chose CVS for prenatal diagnosis varied according to indication, ethnic group and religion. The data in this study indicate that CVS may have been utilized for balancing families with > or = 3 or more children of the same sex. Christian Arabs chose CVS more often than the other groups. Jewish women may have utilized CVS for family balancing of both sexes, while non-Jews may have utilized CVS for balancing families with > or = 3 daughters.

Maternal Complications Associated With Multiple Cesarean Deliveries

OBJECTIVE

The claim that a planned repeat cesarean delivery is safer than a trial of labor after cesarean may not be applicable to women who desire larger families. The aim of this study was to assess maternal complications after multiple cesarean deliveries.

METHODS

The records of women who underwent two or more planned cesarean deliveries between 2000 and 2005 were reviewed. We compared maternal complications occurring in 277 women after three or more cesarean deliveries (multiple-cesarean group) with those occurring in 491 women after second cesarean delivery (second-cesarean group).

RESULTS

Excessive blood loss (7.9% versus 3.3%; P < .005), difficult delivery of the neonate (5.1% versus 0.2%; P < .001), and dense adhesions (46.1% versus 25.6%; P < .001) were significantly more common in the multiple-cesarean group. Placenta accreta (1.4%) and hysterectomy (1.1%) were more common, but not significantly so, in the multiple-cesarean group. The proportion of women having any major complication was higher in the multiple-cesarean group, 8.7% versus 4.3% (P = .013), and increased with the delivery index number: 4.3%, 7.5%, and 12.5% for second, third, and fourth or more cesarean delivery, respectively (P for trend = .004).

CONCLUSION

Multiple cesarean deliveries are associated with more difficult surgery and increased blood loss compared with a second planned cesarean delivery. The risk of major complications increases with cesarean delivery number.

LEVEL OF EVIDENCE

II-2.

Instability of Doppler cerebral blood flow in monochorionic twins

OBJECTIVE

The purpose of this study was to evaluate Doppler flow velocity changes in cerebral vessels of monochorionic twins with twin-twin transfusion syndrome (TTTS).

METHODS

Repeated Doppler umbilical and cerebral blood flow studies were performed in 7 twin pairs with TTTS. Eight monochorionic twin pairs and 11 dichorionic twin pairs served as control groups. The following Doppler parameters were assessed: umbilical artery pulsatility index (PI), middle cerebral artery (MCA) PI, cerebroplacental ratio, delta PI between the umbilical artery and MCA, and peak systolic velocity (PSV) in the MCA.

RESULTS

Significant variations in PSV in the MCA and cerebral indices were found in the study group of monochorionic twins with TTTS. Periods of high PSV with low PI in the MCA were followed by lower PSV in the same fetus. Repeated measurements in the comparison groups were stable without significant variations. The delta cerebroplacental ratio was significantly higher in the study group (0.38 versus 0.09 and 0.19 in the comparison groups; P < .02).

CONCLUSIONS

Significant changes in Doppler flow velocity and indices suggest instability of cerebral blood flow with episodes of "hyperperfusion" in monochorionic twins with TTTS. Further studies are needed to elucidate the relationship of these transient changes to neurologic sequelae in the neonate.

Association between a functional dopamine D4 receptor promoter region polymorphism (-C521T) and pre-eclampsia: a family-based study

Although many candidate genes have been studied in pre-eclampsia (PE), the important class of catecholamine receptors that contribute to sympathetic tone and blood pressure regulation has yet to be investigated. We therefore examined the dopamine D4 receptor (DRD4) gene. We performed a prospective family-based study in 50 families (patient and both her parents) who were genotyped for three DRD4 promoter regions. These single-nucleotide polymorphisms (SNPs) were tested for association using family-based association test (FBAT) that also included two quantitative measures, aspartate aminotransferase [serum glutamic oxalacetic transaminase (SGOT)] and systolic blood pressure. SNPs were assayed using a commercially available SNAPSHOT kit and PCR products were analysed in an ABI 310 DNA analyser. A significant association (preferential transmission of the T allele from a heterozygous parent to affected mother) was observed between the -C521T SNP and PE (P = 0.019). Significant association was also observed between the -521T allele and two-dimensional measures of PE : GOT (P = 0.039) and systolic blood pressure (P = 0.036). The DRD4 promoter region -C521T SNP that reduces transcriptional efficiency of this gene is suggested to contribute to developing PE. Additionally, DRD4 -521 TT homozygosity may be a marker for severe PE.