Cervical Dilatation Curves of Spontaneous Deliveries in Pregnant Japanese Females

Background: Although cervical dilatation curves are crucial for appropriate management of labor progression, abnormal labor progression and obstetric interventions were included in previous and widely-used cervical dilatation curves. We aimed to describe the cervical dilatation curves of normal labor progression in pregnant Japanese females without abnormal labor progression and obstetric interventions. Methods: We completed retrospective obstetric record reviews on 3172 pregnant Japanese females (parity = 0, n = 1047; parity = 1, n = 1083; parity ≥ 2, n = 1042), aged 20 to 39 years old at delivery, with pregravid body mass indices of less than 30. All patients underwent spontaneous deliveries with term, singleton, cephalic and live newborns of appropriate-for-gestational age birthweight, without adverse neonatal outcomes. We characterized labor progression patterns by examining the relationship between elapsed times from the full dilatation and cervical dilatation stages, and labor durations by examining the distribution of time intervals from one cervical dilatation stage, to the next, and ultimately to the full dilatation. Results: Fastest cervical changes occurred at 6 cm (primiparas) and 5 cm (multiparas) of dilatation. The 95%tile of labor progression took over 3 hours to progress from 6 cm to 7 cm (primiparas), and over 2 hours to progress from 5 cm to 6 cm (multiparas). The 5%tile of traverse time to the full dilatation, during the active phase, was less than 1 hour (primiparas) and 0.5 hours (multiparas). At the end of the active phase, no deceleration phase was observed. Conclusions: Active labor may not start until 5 cm of dilatation. At the beginning of the active phase, cervical dilatation was slower than previously described. These results may reduce opportunities for obstetric interventions during labor progression.

Urinary protein-to-creatinine ratio in pregnant women after dipstick testing: prospective observational study

Background

The dipstick test is widely used as a primary screening test for detection of significant proteinuria in pregnancy (SPIP). However, it often shows a false positive test result. This study was performed to determine which pregnant women should be recommended to undergo determination of urinary protein-to-creatinine ratio (mg/mg, P/Cr test) after dipstick test for confirmation of SPIP.

Methods

This was a multicenter, prospective, and observational study of 2212 urine specimens from 1033 pregnant women who underwent simultaneous dipstick and P/Cr tests in the same spot urine samples at least once. SPIP was defined as P/Cr > 0.27. Preeclampsia was diagnosed in women with both hypertension and SPIP.

Results

Preeclampsia, hypertension alone, and SPIP alone developed in 202 (20 %), 73 (7.1 %), and 120 (12 %) women, respectively. Creatinine concentration [Cr] varied greatly, ranging from 8.1 to 831 mg/dL in the 2212 urine samples. Rate of positive dipstick test results increased with increasing [Cr], while SPIP prevalence rate was lower in urine samples with higher [Cr], yielding higher false positive rates in samples with higher [Cr]. Postpartum urine samples had significantly lower [Cr] compared to those obtained antepartum (60 [8.7–297] vs. 100 [10–401] mg/dL, respectively). At the first P/Cr test among women with similar dipstick test results, the risk of having SPIP was consistently and significantly higher for hypertensive women than for normotensive women at any dipstick test result: 18 % (14/77) vs. 3.2 % (8/251), 47 % (26/55) vs. 8.7 % (37/425), 91 % (82/90) vs. 59 % (44/75) for negative/equivocal, 1+, and ≥ 2+ test results, respectively. The risk of SPIP was 16 % (9/55) for normotensive women when two successive antenatal urine samples showed a dipstick test result of 1 + .

Conclusions

For prediction of SPIP, the dipstick test was more likely to show a false positive result in concentrated urine samples with higher [Cr]. Hypertensive women with ≥ 1+ as well as normotensive women with ≥ 2+ on dipstick test should be advised to undergo the P/Cr test.

Consecutive cervical length measurements as a predictor of preterm cesarean section in complete placenta previa

BACKGROUND

To evaluate whether consecutive cervical length measurements can predict preterm cesarean section in women with complete placenta previa.

METHODS

Seventy-one women with complete placenta previa were retrospectively categorized into women who delivered preterm due to massive hemorrhage (the preterm cesarean section group, n = 28) and those delivered at term (the control group, n = 43). Maternal characteristics, delivery outcomes, and cervical lengths serially measured at least every 2 weeks from 24 weeks' gestation until delivery were compared. The relationship between cervical length and preterm cesarean section was analyzed.

RESULTS

Cervical length gradually decreased with advancing gestational age. After 26 weeks' gestation, this decrease was significantly more rapid in the preterm cesarean section group. Cervical length before cesarean section in the preterm cesarean section group was significantly shorter than that in the control group. Just before cesarean section, 71.4% of the preterm cesarean section group presented with cervical lengths of ≤35 mm, whereas only 34.9% of the control group had cervical lengths of ≤35 mm (odds ratio 4.67, 95% confidence interval 1.66-13.10, p = 0.006).

CONCLUSIONS

In women with complete placenta previa, decrease in cervical length to ≤35 mm was associated with increased risk of preterm cesarean section due to massive hemorrhage.

Neonatal small-for-gestational age status as a favorable factor for the complete vaginal delivery of both fetuses in Japanese dichorionic twins

AIM

In singletons, neonatal small-for-gestational age (SGA) status is an unfavorable postpartum outcome leading to cesarean section (CS) and increasing the possibility of maternal operative complications. Perinatal characteristics of SGA newborns in dichorionic (DC) twins were investigated for the prognostic impact on their mothers.

METHODS

A retrospective study was performed from 2004 to 2009 on 329 DC twins with two live births. Neonates were classified as SGA if they weighed less than the 10th percentile at birth according to Japanese singleton norms. Statistical differences between DC twins delivering appropriate-for-gestational age (AGA)/AGA pairs (control group) and AGA/SGA, SGA/AGA or SGA/SGA pairs (the first/second twins) were analyzed.

RESULTS

The median (range) of the gestational ages at delivery for AGA/AGA, AGA/SGA, SGA/AGA and SGA/SGA pairs were 37.1 (27.1-40.3), 37.2 (29.0-40.9), 37.1 (28.1-40.7) and 37.3 (33.3-40.4) weeks, and the complete vaginal delivery rates of both fetuses were 66.2% (43/65), 84.8% (28/33), 82.4% (14/17) and 70.0% (7/10), respectively. Compared with AGA/AGA pairs, AGA/SGA pairs showed a higher incidence of spontaneous vaginal births of both fetuses (31.3% [26/83] vs 19.9% [37/186], OR 1.84, 95% CI 1.45-4.73) and a lower incidence of emergent CS (25.3% [21/83] vs 38.7% [72/186], OR 0.53, 95% CI 0.30-0.95).

CONCLUSION

The relatively small size of SGA fetuses allows both fetuses to remain inside the uterus for a longer time and to easily pass through the maternal parturient canal for complete vaginal delivery. Neonatal SGA status is a favorable factor for avoiding operative complications of CS and optimizing maternal perinatal outcomes.

A case of tumor lysis syndrome following chemotherapy for a uterine epithelioid leiomyosarcoma with focal rhabdomyosarcomatous differentiation

Tumor lysis syndrome (TLS) is a potential complication characterized by hyperuricemia, hyperphosphatemia, hyperkalemia and hypocalcemia due to massive necrosis of malignant cells after cytotoxic therapy. This fatal complication occurs frequently in tumors with hematological malignancies, such as acute lymphoblastic leukemia and Burkitt's lymphoma, and in other tumors with high proliferative rates and tumor burdens. TLS is rarely associated with the treatment of solid tumors. Herein, we report a case of TLS following the initial administration of effective chemotherapy for an epithelioid leiomyosarcoma with focal rhabdomyosarcomatous differentiation of the uterus.

Is a red umbilical cord a sign of umbilical venous congestion?: a case report

Postnatal examination of fetal appendages is important because this information may help predict perinatal outcome. We present a case of a red streak along the entire umbilical vein after a cesarean section due to non-reassuring fetal status. The pathological findings revealed an umbilical cord with dilated vascular changes and mild funisitis. Because the dilated change was intense in the umbilical vein, the red streak of the umbilical cord was caused by venous congestion. Moreover, we considered that the umbilical venous congestion was due to increased resistance in the fetal intra-abdominal umbilical vein, which was associated with the non-reassuring fetal status.

Maternal risk factors for small-for-gestational age newborns in Japanese dichorionic twins

AIM

To investigate the maternal risk factors for small-for-gestational age (SGA) newborns in Japanese dichorionic (DC) twins.

METHODS

A retrospective study was conducted from 2003 to 2008 on 340 DC twin pregnancies resulting in two live births. Newborns were classified as SGA if their birth weight was below the 10th percentile according to Japanese singleton norms. Statistical differences were evaluated between pregnancies resulting in appropriate-for-gestational age (AGA) pairs and those resulting in at least one SGA neonate.

RESULTS

The study population consisted of AGA/AGA (50.8%), AGA/SGA (37.0%) and SGA/SGA pairs (12.0%). Logistic regression analysis identified significant interrelations for SGA with maternal nulliparity (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.30-0.91), smoking (OR 3.25, 95% CI 1.09-9.66), assisted reproductive technology (OR 0.52, 95% CI 0.30-0.89), pregnancy-induced hypertension (OR 2.00, 95% CI 1.01-4.31), pregravid weight (kg) (unitary OR 0.94, 95% CI 0.91-0.97) and monthly weight gain (kg/month) (unitary OR 0.25, 95% CI 0.14-0.44). Bivariable receiver operating characteristic curves were generated for monthly weight gain (area under the curve [AUC] 0.626, cutoff 1.41 kg/month, P<0.001) and total weight gain (AUC 0.615, cutoff 14.0 kg, P<0.001).

CONCLUSION

Cigarette smoking and weight gain control are relatively modifiable factors for which interventional management is necessary to avoid perinatal problems arising from SGA pregnancy. Further studies are needed to investigate optimal nutrition, health guidance and subsequent weight gain control that lead to concrete improvement in maternal and infant prognoses.

Transition of cytomegalovirus seropositivity in Japanese puerperal women

AIM

To investigate the latest serological tendency of cytomegalovirus (CMV) in Japanese puerperal women and to estimate the sequential influence on child-bearing women in Japan.

METHODS

We studied 3966 puerperal women registered at a cord blood bank. Serum samples were obtained from umbilical cords at delivery and on the third day after delivery. CMV immunoglobulin G (IgG) and CMV immunoglobulin M (IgM) antibodies were determined using enzyme immunoassay kits. Scatter diagrams between seroprevalences and perinatal details were generated, and Pearson product-moment correlation coefficients (r) and coefficients of determination (R(2)) were calculated.

RESULTS

The overall CMV seroprevalence was 68.4% for the IgG antibody and 3.9% for the IgM antibody. IgM seroconversion had occurred separately in 0.28% of the cases without IgG seroconversion. Including outliers on scatter plots, linear decreasing trends were observed for IgG seropositivity with measurement year (r = -0.72, P < 0.05, R(2) = 51.8%) and maternal birth year (r = -0.43, P < 0.05, R(2) = 18.2%). There was a linear increasing tendency for IgG seroprevalence with maternal age (r = 0.46, P < 0.05, R(2) = 21.4%). Without the outlier, a linear decreasing tendency was found for IgM seropositivity (r = -0.85, P < 0.01, R(2) = 71.6%).

CONCLUSION

CMV seropositivity decreased with maternal youth in Japanese puerperal women. A possible contradiction was identified: decreasing tendencies in the seroprevalence of both IgG and IgM might coexist. We assume that actual CMV infections spread in a transient epidemic manner in which it may not be possible to observe a linear tendency and/or that the actual risk of maternal CMV infection might be decreasing.

Maternal obesity as a risk factor for very pre-term delivery in dichorionic twin pregnancies

We attempt here to identify the maternal characteristic factors most strongly associated with the increased risk of very pre-term delivery in dichorionic twin deliveries. Data were collected from 24 dichorionic twin pregnancies who were born at <32 weeks' gestation (very pre-term delivery) and 245 dichorionic twin pregnancies, who were born at 37-40 weeks' gestation as controls. Data included maternal age, height, body weight, body mass index (BMI), history of abortion, parity, maternal smoking, history of infertility therapy, such as in vitro fertilisation and/or embryo reduction, chronic hypertension and diabetes mellitus. Using logistic regression, the risk of very pre-term delivery was significantly increased among obese women (BMI >or=30 during prepregnancy; the adjusted odds ratio: 5.1, 95% confidence intervals: 1.2-21, p = 0.01). The current results indicate that maternal obesity is an independent risk factor for very pre-term delivery in dichorionic twin pregnancies.

A case of monochorionic-diamniotic twin pregnancy with polyhydramnios-polyhydramnios sequence

We present a case of monochorionic-diamniotic (MD) twin pregnancy with polyhydramnios-polyhydramnios sequence. A 20-year-old woman, gravida 1, para 0, was referred to our hospital at 31 weeks and 6 days' gestation for consultation about a high-risk pregnancy due to the presence of discordant fetal growth pattern (26% of fetal growth discordance) with polyhydramnios in MD twin pregnancy. Ultrasound examination at admission showed a maximal vertical pocket (MVP) of 11.4 cm in twin A and an MVP of 4.7 cm in twin B. At 33 weeks' gestation, the MVPs had increased to 22.2 cm and 10.2 cm, respectively. At 33 weeks and 2 days' gestation, Cesarean section was performed because of uncontrolled uterine contractions associated with polyhydramnios. Twin A was a female weighing 2,280 g, and twin B was a female weighing 1,782 g (22% growth discordance). The estimated amniotic fluid volumes of twins A and B were 5,000 and 1,000 mL, respectively.