Does increasing body mass index affect cerclage efficacy?

OBJECTIVE

To study the relationship between body mass index (BMI) and gestational age (GA) at delivery in patients with cervical insufficiency (CI) undergoing cerclage.

STUDY DESIGN

We accessed a database of patients with singleton gestations undergoing cerclage (N=168) for a well-characterized history of CI, shortened cervix <2.5 cm with a history of prior preterm delivery or prolapse of membranes through the external os. Univariate and multivariate logistic regression analysis were performed to compare obstetrical outcomes between obese and normal-weight patients.

RESULT

Prior preterm delivery <35 weeks in obese vs normal-weight patients was significantly higher (44% vs 9%), odds ratio=6.9 (95% CI: 2.5, 18.5), with lower mean GA at delivery (32.6±7.0 vs 37.2±3.4 weeks, P<0.001). After controlling for confounders, BMI remained significantly predictive of prematurity (coefficient: -0.12, adjusted R (2)=0.24), such that every additional 1 unit of BMI was associated with a 1-day reduction in GA at delivery (P=0.03).

CONCLUSION

An inverse correlation exists between BMI and GA at delivery in patients with CI receiving cerclage. The findings are unexpected given the protective effect of obesity on spontaneous preterm delivery.

IMRTSIB and Concurrent CT for LAHNC: Toxicity and Quality of Life

Objective: Evaluate the acute toxicity of postoperative radiotherapy with intensity modulated simultaneous integrated boost (IMRT-SIB) and the impact of this treatment on quality of life for patients with head and neck cancer locally advanced (LAHNC).

Method: A total of 21 patients with histologically confirmed LAHNC received, from July 2008 to August 2010, postoperative IMRT-SIB and concurrent Cisplatin 100mg/m2 every 3 weeks. Quality of life was evaluated in 13 patients with M.D. Anderson Dysphagia Inventory, Karnofsky Performance Status, Performance Status Scale for Head & Neck Cancer, and EORTC H&N35.

Results: Median follow-up was 10 months (range, 2-30 months). Acute mucositis ≥ G2 occurred in 18 patients. Acute reactions ≥ G2 on salivary glands in 15 patients. Acute reaction ≥ G3 appeared in 4 patients on mucosae and in 5 on pharynx. At time of analysis 18 patients were free from locoregional recurrence.

Conclusion: IMRT-SIB and concurrent cisplatin is feasible and well tolerated in LAHNC and is not correlated with a decrease in healthy functioning, global health status, or subjective evaluation of level of illness.

Forestier disease: single-center surgical experience and brief literature review

OBJECTIVES

We describe the experience of our otolaryngology department in the treatment of Forestier disease, particularly regarding the diagnostic process, surgical treatment, and postoperative outcomes.

METHODS

The charts of 12 patients who underwent surgical treatment of Forestier disease between January 1, 2003, and January 1, 2009, were analyzed. All patients were subjected to clinical, radiologic, and endoscopic evaluation that confirmed the presence of cervical osteophytes. All patients were treated by a right-sided prevascular transcervical approach to remove cervical osteophytes. A literature review on Forestier disease was also carried out.

RESULTS

One case of immediate postoperative hemorrhage was reported. During the postoperative follow-up, ranging from 1 to 5 years, all patients underwent cervical radiography and fiberoptic laryngoscopy that confirmed no evidence of recurrence, and all patients remained asymptomatic.

CONCLUSIONS

A prevascular transcervical right-sided approach seems to be an effective treatment for surgical removal of hyperostosis in Forestier disease, with an acceptable rate of complications and recurrence.

Can adverse neonatal outcome be predicted in late preterm or term fetal growth restriction?

OBJECTIVE

To identify independent predictors of adverse neonatal outcome in cases of fetal growth restriction (FGR) at > or = 34 weeks.

METHODS

From a cohort of 481 FGR cases delivered at > or = 34 weeks, demographic and obstetric variables, fetal biometry and Doppler indices of the uterine, umbilical and fetal middle cerebral arteries available within 2 weeks of delivery, were related to adverse neonatal outcome, defined as admission to the neonatal intensive care unit for indications other than low birth weight alone.

RESULTS

Logistic regression analysis showed that gestational age (GA) at delivery (odds ratio (OR) = 0.59; 95% CI, 0.50-0.70), abdominal circumference (AC) centile (OR = 0.69; 95% CI, 0.59-0.81) and umbilical artery (UA) pulsatility index (PI) centile (OR = 1.02; 95% CI, 1.01-1.04) significantly correlated with adverse neonatal outcome. From this model we calculated a score of adverse neonatal outcome expressed by the formula: (UA-PI centile/3) - (10 x AC centile) + (10 x (40 - GA at delivery in weeks)). Receiver-operating characteristics curve analysis demonstrated that a score of > or = 25 optimally predicted adverse neonatal outcome (sensitivity of 75%, false-positive rate of 18%). Beyond 37.5 weeks, gestational age no longer had an independent impact on outcome.

CONCLUSIONS

In late preterm or term FGR, GA at delivery is the most important predictor of adverse neonatal outcome. At > 37.5 weeks, delivery may be the best option to minimize adverse outcome in all FGR cases. At 34-37 weeks, a score based on GA at delivery, UA-PI centile and AC centile optimally predicts adverse neonatal outcome.

Serial assessment of amniotic fluid index in uncomplicated term pregnancies: prognostic value of amniotic fluid reduction

OBJECTIVE

Assessment of amniotic fluid volume in association with a non-stress test is a commonly used method to monitor fetal well-being in high-risk pregnancies. The aims of our study were to determine whether oligohydramnios and the trend in amniotic fluid volume have prognostic significance in low-risk pregnancies between 40.0 and 41.6 weeks' gestation.

METHODS

Between January 1997 and December 2000, all uncomplicated gestations with a singleton non-anomalous fetus reaching 40.0 weeks' gestation underwent semi-weekly monitoring of amniotic fluid index (AFI) until delivery. Oligohydramnios was defined as an AFI of < or = 5 cm. Changes in AFI were expressed as centimeters per day, and were calculated as: [(last AFI before delivery minus first AFI at 40.0 weeks) / interval in days between the two scans]. Adverse outcome was considered the occurrence of 5-min Apgar score < 7; umbilical artery pH < 7.0; Cesarean section for fetal distress; or fetal death. Comparisons between the groups with favorable and adverse outcomes was performed with chi(2) or Fisher's exact test for categorical variables, and Student's t test for continuous variables. A two-tailed p value < 0.05 was considered significant.

RESULTS

A total of 3050 women met the study criteria, and underwent a median number of two (range 1-7) sonographic assessments of AFI after 40.0 weeks, with oligohydramnios detected in 341 women. In 1466 women at least two serial AFI determinations were obtained, allowing computation of an AFI trend. Gestations resulting in adverse perinatal outcome (n = 167, 5.5%) had a significantly higher rate of oligohydramnios (33/167, 19.8% vs. 308/2883, 10.7%, p = 0.001), but a similar rate of reduction in AFI ( -0.65 +/- 0.64 vs. - 0.66 +/- 0.66 cm/day; p = 0.85) than those with favorable outcome. The difference in rate of reduction of AFI between the two groups was not significant, even in the subset of gestations that developed oligohydramnios ( -1.08 +/- 0.87 vs. -1.26 +/- 0.89 cm/day; p = 0.27).

CONCLUSION

A sonographic diagnosis of oligohydramnios carries an increased risk of adverse perinatal outcome, even in low-risk pregnancies after 40 weeks. The trend in amniotic fluid volume reduction does not seem to have prognostic significance.

Auto-crosslinked hyaluronan gel injections in phonosurgery

Objectives: To evaluate the clinical performance of an auto-crosslinked gel obtained from hyaluronic acid (ACP-based gel) as an anti-adhesive agent and/or augmentative agent in vocal cord surgery for the treatment of vocal fold (VF) atrophy, sulcus vocalis, and postsurgery scarring as well as its tolerability at short- and long-term follow-up.

Study Design: This was a prospective multicenter trial conducted between 2007 and 2009.

Setting: Academic center.

Subjects and Methods: Inclusion criteria were patients with glottic gap due to previous endoscopic phonosurgery, VF scars, vocal cord atrophy, and sulcus vocalis. Forty patients who underwent endoscopic injection of hyaluronic acid under general anesthesia were enrolled. Two different injections sites were used: the thyroarytenoid muscle in cases of glottic gap for augmentative purposes, and the lamina propria for treatment of scars and sulcus vocalis. A voice-evaluation protocol was performed before surgery, at the first follow-up visit (3 mo), and at the final follow-up (12 mo).

Results: Follow-up data at three months were available for 38 patients, while data at 12 months follow-up were available for 27 patients. No side effects, hematoma, or infection and allergic reactions were reported in either the perioperative or postoperative period. Patients had statistically significant improvement in voice parameters compared with the baseline data at the first follow-up visit and at the 12-month follow-up.

Conclusion: ACP-based gel seems to be a new tool in the challenging treatment of VF scarring, functioning as both an anti-adhesive product and an augmentation agent. Improvements in all glottal parameters and in both objective and subjective evaluation of voice performance were observed.

Are ultrasonographic myoma characteristics associated with blood loss at delivery?

OBJECTIVES

The presence of myomas in pregnancy is associated with greater blood loss at delivery. The aim of this study was to evaluate whether the sonographic characteristics of myomas can predict blood loss at delivery in women with large myomas.

METHODS

Among women who underwent second-trimester ultrasound screening at our department between January 1996 and December 2004, 251 had at least one myoma with a mean diameter > or = 5 cm. Number of myomas (single vs. multiple), maximum diameter of the largest myoma, sum of the maximum diameter of each myoma, change in size of myomas between first and last scan, and location in relation to the placenta and to the presenting part of the fetus (above or below) were analyzed in relation to blood loss at delivery and severe postpartum hemorrhage (> or = 1000 mL).

RESULTS

Multivariate analysis showed that the presence of multiple myomas was the only parameter independently associated with amount of blood loss at delivery (P = 0.003). The association between the presence of multiple myomas and severe postpartum hemorrhage was of borderline significance for the statistical power of this study (P = 0.08).

CONCLUSIONS

In women with large myomas, the presence of multiple tumors is independently associated with heavier blood loss at delivery but not with postpartum hemorrhage of > or = 1000 mL.

Quality of life in patients treated with PDMS injection for swallowing disorders

Objective: To document the efficacy of polydimethylsiloxane (PDMS) injections in patients with swallowing disorders after partial supracricoid laryngectomy; to assess the importance of quality-of-life (QOL) outcome in oncologic patients.

Subjects and Methods: The study included 11 patients with swallowing disorders after partial laryngectomy and appropriate rehabilitation. They were treated with endoscopic injection of PDMS; QOL was investigated with four questionnaires (M.D. Anderson Dysphagia Inventory, Performance Status Scale for Head and Neck Cancer, Performance Karnofsky Scale, and Voice Handicap Index-10) before and after surgical treatment and further rehabilitation.

Results: A significant improvement in QOL of all 11 patients was seen after endoscopic injection. The impact of this treatment on the social life of patients was considerable.

Conclusion: Swallowing disorders and speech problems are quite common complications of partial laryngectomy. QOL in oncologic patients is a mandatory outcome measure. PDMS injection showed an improvement in the everyday life of selected patients.

Prenatal sonographic evaluation of male genitalia development

AIM

The aim of this study was to evaluate the sonographic development of normal fetal male genitalia.

METHODS

A longitudinal study was performed on 60 male fetuses. The development of penis, prepuce and presence of testes in scrotum were observed with a high resolution transabdominal ultrasonography between weeks 11 and 40.

RESULTS

The overall success of identifying correctly the fetal male gender increased with gestational age from 46% to 80%, and 96% at 12, 13 and 14 week, respectively. The number of the scans performed in relation to the gestational age from week 11 to week 14 improves the ability to assign the male gender and to report the penile length (P<0.05); the earliest observations of descend testis were at 24 weeks. The bilateral observation of testicular descend was at 31 weeks in 98% of fetuses.

CONCLUSION

Development of male genitalia is easy evaluated through the pregnancy. This could be useful to early identify male genitalia abnormalities.

Pentraxin 3 in plasma and vaginal fluid in women with preterm delivery

OBJECTIVE To investigate the role of pentraxin 3 (PTX3), an acute-phase protein produced by cells of innate immunity in response to inflammatory signals, in spontaneous preterm delivery (PTD). DESIGN Cohort study. SETTING Department of Obstetrics and Gynecology of the University of Milano-Bicocca. POPULATION Forty-six pregnant women with preterm rupture of membranes (n=33) or preterm labour with intact membranes (n=13) delivering at <34 weeks of gestation and 34 women with uncomplicated pregnancies (control group). METHODS We compared plasma and vaginal PTX3 levels between study group and controls, and in women with versus women without clinical or histologic evidence of intrauterine infection using statistical analysis. MAIN OUTCOME MEASURES Peak PTX3 concentration. RESULTS Peak PTX3 concentration in plasma samples of study group was significantly higher than that in controls (1175, 0-9630 versus 650, 0-1450 pg/ml; P=0.0003) but not in vaginal swabs (1660, 0-6604 versus 457, 0-4649 pg/ml; P=0.386). PTX3 levels in plasma were significantly higher in women with placenta vasculopathy compared with that in women with no placental lesions (2910, 0-9630 versus 636, 0-5692 pg/ml; P=0.04). Peak plasma and vaginal PTX3 concentrations were not significantly different in women with versus women without intrauterine infection (1168, 0-7110 versus 845, 0-9630 pg/ml, P=0.34 and 1975, 471-6604 versus 1919, 0-4150 pg/ml, P=0.38, respectively). CONCLUSIONS Spontaneous PTD is associated with a significant increase of maternal plasma concentrations of PTX3. PTX3 seems to be a marker of placenta vasculopathy rather than intrauterine infection.

Voice therapy in pediatric functional dysphonia: a prospective study

OBJECTIVE

We evaluated the efficacy of voice therapy according to Borragan's method associated to S. Magnani's vocal counselling in functional dysphonia in children.

PATIENTS AND METHODS

We prospectively treated 16 patients with vocal fold nodules (10 males, 6 females). Age ranged from 6 to 11 years with a mean age of 9 years. We performed a full screening phoniatric evaluation. In addition psychological tests were carried out to investigate psychological background.

RESULTS

We lost three patients at follow-up; one patient received surgery, eight patients healed (43.75%), four improved (25%). There was no statistical difference in the analysis of electroacoustical parameters while MPT significatively raised after therapy.

CONCLUSION

If patients have motivation voice therapy could improve functional dysphonia in children. It is also important psychological background. Further studies on bigger populations with long-term follow-up are needed.

Endoscopic removal of ethmoido-sphenoidal foreign body with intracranial extension

We describe the case of a foreign body lodged into ethmoidal labyrinth and sphenoidal sinus with fracture of the clivus and consequent rhinoliquorrhea removed by an endoscopic technique. We performed a skull base plasty to close the rhino-liquoral fistula with resolution of the rhinoliquorrhea. There were no postoperative complications and there was a good therapeutic result at long-term follow-up.

Prenatal diagnosis of supernumerary ring chromosome 1: case report and review of the literature

A supernumerary ring chromosome was found on amniocentesis performed for advanced maternal age. A review of the literature found 34 reports of supernumerary ring chromosome I which are compared to our case.

The normal-weight snorer: polysomnographic study and correlation with upper airway morphological alterations

Obesity is recognized as playing an important role in causing snoring and in turning simple snoring into obstructive sleep apnea syndrome (OSAS). From our series of patients with sleep disturbances, we studied a group of 43 normal-weight snorers in whom we detected a significant number of OSAS episodes. An articulated diagnostic protocol was adopted, and Müller's maneuver was extensively applied. The resulting data were compared to data from a group of 43 obese patients from the same series. The major risk factor for developing OSAS in normal-weight snorers appears to be anatomic abnormalities, in particular, septal deviation and base of tongue hypertrophy. Soft palate hypertrophy alone is not enough, although in obese snorers it can produce a sleep disorder. The normal-weight snorer needs to be thoroughly investigated because of the significant risk of developing OSAS and for the detection of multiple concomitant sites of obstruction.

Gender differences in amniotic fluid cytokine levels

OBJECTIVE

Placental trophoblast invasion and amniotic fluid cytokine receptor levels have been reported to vary with fetal gender. We investigated whether fetal gender affects amniotic fluid levels of the inflammatory cytokines interleukin (IL)-6 and IL-10 and the pro-angiogenesis cytokine angiogenin.

METHODS

Specimens from singleton gestations undergoing mid-trimester amniocentesis for genetic indications were used. Inclusion criteria were (1) outcome information available, (2) no structural or chromosomal anomaly and (3) no conditions associated with preterm delivery. Amniotic fluid IL-6, IL-10 and angiogenin levels were measured by immunoassay. Statistical analysis included the Mann-Whitney U test and Fisher's exact test with p < 0.05 indicating significance.

RESULTS

A total of 74 samples were analyzed. Angiogenin levels were significantly lower in amniotic fluid samples from pregnancies with a male than with a female fetus (median (range): 22.2 (5.9-66.4) vs. 32.0 (11.4-159.2) ng/ml, p=0.007), in contrast to no differences in amniotic fluid IL-6 and IL-10 levels (p=0.4 and p=0.1, respectively). In pregnancies with male fetuses delivering preterm (< 37 weeks), angiogenin was also detected at lower levels (p=0.02). There were no gender differences with respect to race, nulliparity or maternal age.

CONCLUSION

Angiogenin levels, but not IL-6 or IL-10 levels, are significantly lower in second-trimester amniotic fluid of women with male compared with female fetuses, including those women delivering preterm.

Optimal thresholds of the lecithin/sphingomyelin ratio and lamellar body count for the prediction of the presence of phosphatidyl glycerol in diabetic women

OBJECTIVE

To assess the optimal thresholds of the lecithin/sphingomyelin (L/S) ratio and lamellar body count for the prediction of the presence of phosphatidyl glycerol (PG) in diabetic pregnant women.

METHODS

We accessed a database of clear amniotic fluid specimens obtained by transabdominal amniocentesis in diabetic women with singleton non-malformed fetuses. PG results were classified as 'absent' or 'present'. Receiver operating characteristic (ROC) curve analysis was constructed of different L/S ratios and lamellar body counts to identify the optimal threshold for prediction of the presence of PG. Sensitivity was defined as the rate of L/S ratio and lamellar body count above specific thresholds among cases with present PG. The false-positive rate was that of L/S ratios or lamellar body counts above specific thresholds among cases with absent PG. Statistical analysis included one-way analysis of variance with post-hoc analysis, with p < 0.05 considered significant.

RESULTS

A total of 76 consecutive women were included in the analysis, 74% (n = 56) using insulin and the remainder treated by diet alone. L/S and PG results were both available in 72 women. PG was reported as 'present' in 70% (51/73) of specimens. As expected, there was a significant relationship between L/S ratios and presence of PG (area under the curve = 0.932, p < 0.001). An L/S ratio of > or = 3.0 represented the optimal trade-off between sensitivity (68%) and false-positive rate (6%) in the prediction of present PG. Similarly, there was a significant relationship between lamellar body count values and presence of PG (area under the curve = 0.976, p < 0.001). A lamellar body count of > or = 50 000 represented the optimal trade-off between sensitivity (92%) and false-positive rate (0%) in the prediction of present PG.

CONCLUSION

In diabetic pregnant patients, the presence of PG in the amniotic fluid more closely corresponded to an L/S ratio of > or = 3.0 or to a lamellar body count of > or = 50,000.

Surgery of the nasal columella in external valve collapse

The authors describe and discuss their experience with the collapse of the external nasal valve, focusing on the role that surgery of the columella plays in solving this problem. Thirty-seven cases were treated. In all but I there had been a previous septorhinoplasty. Seven patients had concomitant internal valve collapse. A modified alarplasty associated with columelloplasty was adopted in the cases with severe collapse. When the reduction of the nostril opening was mild to moderate, the surgical strategy varied depending on the width of the columella base: alarplasty in cases with a narrow to normal columella, and columelloplasty in the presence of a wide columella base. The authors' philosophy tends to minimize intervention on the nasal valve areas. Their results demonstrate that when the collapse and its functional effect are not too severe, a good result can be achieved by working only on the columella, especially if its base is significantly wide.

Predictive value of transvaginal cervical length in triplet pregnancies for spontaneous preterm delivery at < or = 32 weeks

OBJECTIVE

To establish whether cervical length is a predictor of spontaneous preterm delivery at < or = 32 weeks in triplet pregnancies.

METHODS

This was a case-control study of all triplet pregnancies followed with more than three sonographic assessments of cervical length at 4-week intervals from 1995 to 2000. Cervical length in women delivered spontaneously at < or = 32 weeks (cases) was compared with that of the remaining women (controls). Statistical analysis included Fisher's exact test, chi2 test, one-way analysis of variance, logistic regression and receiver operating characteristic (ROC) curve to determine optimal cervical length thresholds for spontaneous preterm delivery at < or = 32 weeks.

RESULTS

Of the 58 women included in the study, 17 (29%) delivered spontaneously at < or = 32 weeks. The preterm delivery group had similar demographic and obstetric variables, but a higher rate of cerclage placement (65% vs 17%, p < 0.001) than controls. Mean +/- standard deviation cervical length was significantly shorter among cases than controls at 16-20.0 weeks (3.0 +/- 1.2 vs. 3.9 +/- 0.8 cm, p = 0.01), but not at 20.1-24.0 weeks (3.5 +/- 1.1 vs. 3.8 +/- 1.0 cm, p = 0.76). Logistic regression analysis determined that cervical length at 16-20 weeks had an odds ratio of 0.43 (95% CI = 0.23, 0.80) for the prediction of spontaneous preterm delivery at < or = 32 weeks. ROC curve analysis identified a cervical length of < or = 2.6 cm as the optimal threshold for the prediction of spontaneous preterm delivery at < or = 32 weeks (sensitivity 41%, specificity 92%).

CONCLUSIONS

In a population of triplet gestations with a 29% rate of preterm delivery, cervical length at 16-20.0 weeks, but not at 20.1-24.0 weeks, was inversely correlated with the probability of preterm delivery at < or = 32 weeks.

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

OBJECTIVE

To evaluate the placental histopathology findings in women with systemic lupus erythematosus or antiphospholipid syndrome delivered preterm.

METHODS

We performed a case-control study comparing clinical outcomes and placental histopathology of 18 consecutive singleton pregnancies with systemic lupus erythematosus (n = 9) or antiphospholipid syndrome (n = 9) delivered between 24 and 37 weeks, and 54 controls matched for gestational age and type of preterm delivery (spontaneous or indicated). Placental examinations were performed by a single pathologist, and placental lesions were grouped into four categories: uteroplacental vascular pathology and related villous lesions; coagulation-related damage; chronic inflammation; and acute inflammatory lesions. Statistical analysis included the Mantel-Haenzsel or Fisher's exact test, and logistic regression, with a value of p < 0.05 or an odds ratio (OR) with 95% confidence intervals (Cl) not inclusive of unity considered significant.

RESULTS

Lupus anticoagulant was positive in ten out of 18 cases and medium or high positive IgG anticardiolipin antibodies in seven out of 18. Antenatal treatment included corticosteroids (n = 9), low-dose aspirin (n = 15) and heparin (n = 8). Rates of necrotizing enterocolitis (33% vs. 0%, p < 0.001) and of perinatal mortality (33% vs. 9%, p = 0.02) were significantly different between cases and controls, and rates of birth weight < 10th centile approached statistical significance. Uteroplacental vascular lesions (OR 3.7, 95% CI 1.1, 11.7) and coagulation-related damage (OR 16.8, 95% CI 3.9, 72.6) were significantly more common among cases than controls, and rates of chronic inflammatory lesions approached significance.

CONCLUSIONS

Cases of systemic lupus erythematosus and antiphospholipid syndrome delivered preterm are associated with a significant increase in placental vascular and coagulation-related lesions, which are reflected clinically by higher rates of perinatal mortality, necrotizing enterocolitis, and small-for-gestational age neonates.

Congenital postauricular swelling in a child

First branchial cleft cysts develop as a result of incomplete fusion of the cleft between the first and second branchial arches. In 1972, Work introduced a modified classification of these anomalies that recognized the existence of two types. Type I lesions, which are extremely rare, present as a cystic mass posterior to the pinna and concha. Type II lesions represent a duplication of both the membranous and cartilaginous portions of the external ear canal. They are associated with fistulas in the concha or in the external ear canal. Clinical and surgical management is often difficult because these anomalies have a variable relationship to the facial nerves. We describe a rare localization of a type I first branchial cleft cyst in a child and the clinical management with successive surgical treatment.

Severe meconium aspiration syndrome is not caused by aspiration of meconium

Meconium aspiration syndrome can present clinically with different degrees of severity, ranging from a mild form of respiratory compromise to severe forms that may result in perinatal death despite mechanical ventilation or extracorporeal membrane oxygenation. However, advances in our knowledge concerning meconium aspiration syndrome have revealed that most cases of severe meconium aspiration syndrome are not in fact causally related to the aspiration of meconium but rather are caused by other pathologic processes occurring in utero, primarily chronic asphyxia and infection. Proper understanding of the causative processes underlying fetal or neonatal compromise in these cases is essential to direct future research into preventive or therapeutic treatments and for counseling of the parents of an affected child.

Randomized controlled trial of 50 and 100 mcg of misoprostol for induction of labor at term

To compare the safety and efficacy of two different regimens of misoprostol for labor induction at term, we conducted a randomized controlled trial on women presenting for induction of labor at > or =37 weeks' gestation. Eligible women were randomized to receive intravaginal misoprostol 50 microg every 4 h or 100 microg every 6 h until any of the following: 1) adequate contraction pattern (3 contractions/10 min); 2) dilatation >3 cm; 3) artificial rupture of membranes; or 4) signs of uterine hyperstimulation. Use of oxytocin during labor was at the discretion of the managing clinician. The main outcome variable considered for analysis was cesarean section rate. Secondary outcome measures were induction to delivery interval and neonatal outcome (Apgar scores, meconium staining, and umbilical artery pH). A total of 58 women were randomized to receive either misoprostol 100 microg (n=26) or 50 microg (n=32). The 100 and 50 microg groups had similar mean Bishop's scores at induction (4.0+/-2.3 vs 4.1+/-2.2, p=0.87), rates of nulliparity, use of epidural anesthesia, and oxytocin augmentation. The number of doses of misoprostol used was similar in the two groups (1.4+/-0.6 vs 1.8+/-1.2). The mean+/-standard deviation time to delivery (hours) (11.9+/-7.3 vs 14.3+/-9.6 h, p=0.30) and cesarean section rate (35% vs 19%, p=0.30, relative risk: 1.8, 95% confidence interval 0.7-5.4) were not different in the 100 vs 50 microg group. Power analysis demonstrated that 132 women would be required in each group to achieve statistical significance in the primary outcome measure (alpha=0.05, beta=0.80). Similarly, rates of 5-minute Apgar scores <7 (4% vs 3%, p=1.0), and of meconium passage (17% vs 25%, p=0.73) were not significantly different between the two groups.

Optimization of cytokine stability in stored amniotic fluid

OBJECTIVE

Many studies use stored amniotic fluid samples to assay cytokines and other proteins for outcome-based research; however, there is little information on the optimal methods of storage. The objective of our study was to evaluate cytokine stability in amniotic fluid stored at different temperatures both with and without a proteolytic enzyme inhibitor.

STUDY DESIGN

Patients undergoing midtrimester genetic amniocentesis for routine indications gave consent for the study. After the sample was centrifuged, the acellular portion of the sample was mixed to homogeneity and aliquoted in 0.5-mL increments and stored for 1 year at 4 degrees C, -20 degrees C, and -80 degrees C with and without the protease inhibitor aprotinin. Enzyme-linked immunoassays for angiogenin, interleukin-6, and vascular endothelial growth factor were performed simultaneously on each aliquot.

RESULTS

Thirty samples were assayed for each storage condition. Results were calculated as the percentage of its own sister aliquot stored at -80 degrees C without aprotinin. In all samples, there was a significant relation between storage temperature and cytokine levels, with the lowest levels found at 4 degrees C and the highest at -80 degrees C (angiogenin, P =.004; interleukin-6, P <.001; vascular endothelial growth factor, P =.02). The addition of aprotinin improved stability only for angiogenin at all temperatures (all P <.05).

CONCLUSIONS

Degradation of cytokines occurs when amniotic fluid samples are stored for prolonged periods at temperatures greater than -80 degrees C. The addition of a protease inhibitor helps stem the degradation of some cytokines.

Fetal seizures: case report and literature review

We report a case of fetal seizures secondary to lissencephaly. Among the 13 published cases of fetal seizures, including ours, diagnosed at a mean gestational age of 35.5 weeks (range 20-42), a fetal heart rate tracing was available in ten and showed a normal pattern in three, low variability in two and repetitive decelerations or bradycardia in five. The most common cause of fetal seizures was congenital anomalies (seven of 13), mainly of the central nervous system (six of seven). Outcome among the 11 liveborn neonates included death by 6 months of age in eight cases, and mental or motor delay in three.

Amniotic fluid index in the uncomplicated term pregnancy. Prediction of outcome

OBJECTIVE

To establish whether an association between oligohydramnios and pregnancy outcome is present in the uncomplicated term pregnancy.

STUDY DESIGN

Pregnancies with a singleton fetus in cephalic presentation at term (> or = 37 weeks), a reactive non-stress test and an antepartum amniotic fluid index performed within four days of delivery between January 1994 and September 1998 were identified. Excluded were those with any maternal or fetal complication or unavailable outcome information. The primary outcome measure was rate of operative vaginal or abdominal delivery for a nonreassuring fetal heart rate tracing. Statistical analysis included Fisher's exact test and one-way analysis of variance, with a two-tailed P < .05 considered significant.

RESULTS

Two hundred thirty-two women met the inclusion criteria; of them, 44 (19%) had an amniotic fluid index < or = 5 cm. There was no difference in the operative delivery rate for a nonreassuring fetal heart tracing between those with a normal amniotic fluid index > 5 cm vs. < or = 5 cm (39 [21%] vs. 5 [11%], P > .05). In addition, there were no differences between the two groups in rates of neonatal intensive care unit admissions or five-minute Apgar scores < 7. Patients with a normal amniotic fluid index had a significantly lower labor induction rate (96 [51%] vs. 42 [98%], P < .001) and higher rate of meconium-stained amniotic fluid (65 [35%] vs. 7 [16%], P = .01) than those with a low amniotic fluid index.

CONCLUSION

In the uncomplicated pregnancy at term, an amniotic fluid index < or = 5 cm increases the incidence of labor induction but does not appear to affect the rate of operative delivery for abnormal fetal heart rate tracings.

Antenatal Corticosteroids and Placental Histology in Preterm Birth

To assess the effects of antenatal corticosteroid use on placental histopathology, we have reviewed a database of 463 consecutive non-anomalous singleton liveborns delivered at less than 32 weeks between April 1988 and December 1994, of which 280 received one or more doses of corticosteroids for promotion of fetal lung maturation. Patients were grouped by the number of corticosteroid doses received (analyzed as none, 1, 2 and 3 or more doses). Clinical and demographic factors were recorded prospectively. Placental histopathology was reviewed blinded to clinical factors except gestational age, and 42 distinct placental lesions were examined and scored for severity. Data were analyzed by contingency tables, one-way analysis of variance, and linear regression analysis. Among clinical variables, univariate analysis showed that the number of corticosteroid doses was significantly related to presence of labour prior to delivery, pre-eclampsia, premature rupture of membranes and clinical suspicion or diagnosis of chorioamnionitis. Using linear regression analysis with these clinical variables as confounders, increased number of doses of antenatal corticosteroids was related to increased severity of villous fibrosis and stromal mineralization, and fewer villous infarcts.

Can a cyclo-oxygenase type-2 selective tocolytic agent avoid the fetal side effects of indomethacin?

We evaluated the efficacy and safety of nimesulide (100 mg orally twice daily for > 48 hours) in a pilot series of five women (two with twin pregnancies) at 24(+6) weeks (range 21(+3) - 27(+2)) in preterm labour which was unresponsive to intravenous ritodrine. Nimesulide therapy was continued for eight days (5-16) and was associated with a prolongation of pregnancy of 27 days (6-69). Oligohydramnios occurred in all seven fetuses after three to nine days of therapy, and in the five pregnancies that continued after discontinuation of nimesulide, it resolved within four days (2-7). None of the babies manifested permanent renal damage.

Levels of interleukin-6 in second-trimester amniotic fluid are not predictive of adverse neonatal outcome

OBJECTIVE

Elevation of interleukin (IL)-6 in the amniotic fluid (AF) during the second trimester is associated with increased risk of preterm deliver

Does exposure to magnesium sulfate in utero decrease the risk of necrotizing enterocolitis in premature infants?

BACKGROUND

The objective of this study is to assess whether antenatal exposure to magnesium sulfate may decrease the risk of necrotizing enterocolitis in preterm infants.

METHODS

We have compared the rate of magnesium sulfate exposure before birth among 23 consecutive infants diagnosed with necrotizing enterocolitis with that of 46 controls matched by gestational age at delivery and gender. Relevant obstetric and neonatal variables were compared between the two groups using chi-square and Fisher's exact test for categorical data, and one-way analysis of variance for continuous variables, with a two-tailed p-value <0.05 considered significant.

RESULTS

No significant differences were present between the two groups in mode of delivery (p=0.9), rate of Apgar score at five minutes below seven (p=0.4), prenatal exposure to indocin (p=0.5) or steroids (p=0.6), or neonatal administration of surfactant (p=0.1). Similar proportions of babies with necrotizing enterocolitis and controls were diagnosed with respiratory distress syndrome (p=0.5), intraventricular hemorrhage grades three or four (p=0.9), and sepsis (p=0.6). Babies with necrotizing enterocolitis had a significantly longer hospital stay (74.6+/-64.0 vs. 41.9+/-37.0 days, p=0.01) and intubation period (31.4+/-24.1 vs. 16.8+/-15.6 days, p=0.01) than controls. The rates of prenatal exposure to magnesium sulfate were similar in the necrotizing enterocolitis and control groups (30% vs. 39% respectively, p=0.4). Power analysis demonstrated that 385 babies would be required in each group to reach statistical significance (alpha=0.05, beta=80%).

CONCLUSION

In this retrospective case-control study, maternal administration of magnesium sulfate prior to delivery does not appear to confer a significant protective effect for the neonatal occurrence of necrotizing enterocolitis.

Role of amnioinfusion in the management of premature rupture of the membranes at <26 weeks' gestation

OBJECTIVE

We sought to evaluate whether serial amnioinfusions for persistent oligohydramnios can affect the perinatal and long-term outcomes in extreme cases of preterm premature rupture of membranes.

STUDY DESIGN

All singleton pregnancies with preterm premature rupture of membranes at <26 weeks' gestation and lasting >4 days between January 1991 and June 1998 were included. Amniotic fluid volume was assessed as the maximum cord-free pocket with serial ultrasonographic examinations. Consenting women with persistent (>4 days) oligohydramnios (amniotic fluid </=2 cm) received serial transabdominal amnioinfusions to maintain an amniotic fluid pocket >2 cm. The pregnancy, neonatal, and long-term neurologic outcomes of the cases that spontaneously maintained a median amniotic fluid pocket >2 cm (amnioinfusion-not-necessary group) were compared with those of women with oligohydramnios who underwent amnioinfusion but continued to have a median amniotic fluid pocket after preterm premature rupture of membranes </=2 cm (persistent oligohydramnios group) and with those of women in whom oligohydramnios was alleviated by the procedure for at least 48 hours (successful amnioinfusion group). Statistical analysis included the Wilcoxon rank-sum test and the Fisher exact test, with a 2-tailed P <.05 considered significant.

RESULTS

Among the 49 women included in the study, 13 (26.5%) did not have oligohydramnios, the neonatal survival rate was 92%, and normal fetal lung development and neurologic outcome were achieved in all survivors. The remaining 36 women had oligohydramnios, and all underwent serial amnioinfusions, which successfully restored a median amniotic fluid pocket >2 cm for >/=48 hours in 11 (30%) patients. This successful amnioinfusion group was comparable with the persistent oligohydramnios group (n = 25) in gestational age at first amnioinfusion (median, 20.2 weeks; range, 16-25.6 weeks; vs median, 20.3 weeks; range, 16.5-24.2 weeks; P =.4), number of amnioinfusions (median, 3; range, 1-9; vs median, 3; range, 1-5; P =.4), and interval between amnioinfusions (median, 6 days; range, 4-14 days; vs median, 8 days; range, 6-43 days; P =. 1). However, patients in the persistent oligohydramnios group had a significantly shorter interval to delivery, lower neonatal survival (20%), and higher rates of pulmonary hypoplasia (62%) and abnormal neurologic outcomes (60%) than the patients in the groups in which amnioinfusion was not necessary or was successful (all P </=.01).

CONCLUSION

Pregnancies with preterm premature rupture of membranes-related oligohydramnios at <26 weeks' gestation in which serial amnioinfusions successfully alleviate oligohydramnios have a perinatal outcome that is significantly better than the outcome in those with persistent oligohydramnios and is comparable with gestations with preterm premature rupture of membranes in which oligohydramnios never develops.

Fertility after ectopic pregnancy. Effects of surgery and expectant management

OBJECTIVE

To evaluate the effects of different management strategies for ectopic pregnancy on fertility.

STUDY DESIGN

Retrospective cohort study of 180 consecutive patients who were diagnosed with ectopic pregnancy between September 1988 and December 1995. The fertility rate after ectopic pregnancy treated with surgery was compared with that after expectant treatment. Statistical analysis took into consideration the following confounding variables: history of sterility, infertility, ectopic pregnancy, use of intrauterine device, endometriosis, pelvic inflammatory disease or pelvic surgery prior to ectopic pregnancy, and type of therapy for ectopic pregnancy.

RESULTS

Of the 180 women enrolled in the study, 97 desired conception. The intrauterine conception rate was similar in those initially treated expectantly as in those allocated to primary surgery (63% [31/49] vs. 51% [19/37], P = .37). Successful completion of expectant management was associated with rates of subsequent intrauterine pregnancy similar to those of surgical treatment (including primary surgery and surgery after failure of expectant management) (65% [22/34] vs. 54% [28/52], P = .44). Women undergoing delayed surgery due to failure of expectant management had rates of subsequent intrauterine conception similar to those who underwent primary surgery (9/15 vs. 19/37, P = .79). Several anamnestic factors had a significant and adverse effect on reproductive outcome: history of infertility (P = .01), history of ectopic pregnancy (P = .02) and previous pelvic surgery (P = .001).

CONCLUSION

Expectant and surgical management of ectopic pregnancy had similar subsequent intrauterine conception rates, even when failure of expectant management led to secondary surgery. Gynecologic history can identify the subgroup of patients at higher risk of a poor reproductive outcome.

Magnesium sulfate therapy affects attention and working memory in patients undergoing preterm labor

OBJECTIVE

Patients commonly consent to undergoing invasive procedures while receiving magnesium sulfate therapy. This study evaluated the effects of magnesium sulfate on attention, comprehension, and memory in patients undergoing preterm labor.

STUDY DESIGN

Consenting patients were studied while receiving(study) and not receiving (control) intravenous magnesium sulfate tocolysis for preterm labor. Excluded were patients with possible preeclampsia, imminent delivery, sedative administration, or prior mental illness. Patient comprehension was assessed with the Boston Diagnostic Aphasia Examination. Level of attention and working memory were evaluated with the Paced Auditory Serial Addition Test. Verbal learning, short-term memory, and recognition were determined with the Hopkins Verbal Learning Test. Gross mental-neurologic deficits were evaluated with the Mini-Mental Status Examination. The tests were administered by the same examiner. Control testing was performed >24 hours after intravenous magnesium sulfate was discontinued. Magnesium levels were obtained at the time of testing. The primary outcome measure was the Paced Auditory Serial Addition Test score because of its ability to elicit subtle differences in attention capacity. Statistical analysis included the paired t test and the McNemar test.

RESULTS

Fifteen patients completed the study. Paced Auditory Serial Addition Test scores were significantly higher (ie, more errors were made) during magnesium sulfate therapy than periods without therapy (14 +/- 8 vs 7 +/- 7; P <.05). Comprehension (Boston Diagnostic Aphasia Examination score) was not different between the groups (P =.7). There was no difference in short-term memory (Hopkins Verbal Learning Test) or gross mental-neurologic deficits between the 2 groups (all P >.1).

CONCLUSIONS

Magnesium sulfate therapy appears to have an effect on attention and working memory but not on long-term memory or comprehension. The significant differences in Paced Auditory Serial Addition Test scores reveal deficits in information-processing ability in patients on a regimen of magnesium sulfate therapy.

Biophysical profile in predicting acute ascending infection in preterm rupture of membranes before 32 weeks

OBJECTIVE

To assess the performance of the biophysical profile (BPP) and its components within 24 hours of delivery in predicting histopathologic evidence of severe acute placental inflammation in women with premature rupture of membranes (PROM) before 32 weeks' gestation.

METHODS

We examined placentas from a series of consecutive, nonanomalous, live-born, singleton infants delivered before 32 weeks' gestation after PROM. In 166 cases, biophysical profiles (BPP) were done within 24 hours of birth. Histologic evidence of acute inflammation was assessed in the maternal (amnion) and fetal (chorionic and umbilical cord vessels) compartments, and scored on a severity scale of 0-4 by a single pathologist masked to clinical data. The presence and severity of acute inflammation was related to BPP results and its individual components.

RESULTS

The overall prevalence of severe acute inflammation, ie, a score of 3 or 4, was 59% (98 of 166). In 30 (18%) cases it was present in the amnion, in 49 (30%) cases in chorionic or umbilical cord vessels, and in 19 (11%) cases in maternal and fetal compartments. There was no association between abnormal BPP score and presence or absence of severe acute placental inflammation (48% versus 46%, P =.7). Our study had a 90% power to detect a 0.26 difference between them. When rates of abnormal BPP scores were compared in cases with different degrees of acute inflammation in the maternal, fetal, or both compartments, no association was found. When the individual components of the BPP were analyzed in relation to site and severity of acute inflammation, no association was detected.

CONCLUSION

We did not find evidence of a dose-response relationship between acute placental inflammation and BPP score or its individual components in cases of PROM with infants delivered before 32 weeks. Mediators other than infection might affect BPP in preterm PROM.

Successful outcome after antibiotic treatment of postamniocentesis membrane rupture and chorioamnionitis in multiple pregnancy

Postamniocentesis chorioamnionitis is usually managed with induction of labor to prevent maternal sepsis and related morbidity and mortality. We report a case of chorioamnionitis in a triplet pregnancy after midtrimester genetic amniocentesis, in which multiple antibiotic treatment (ampicillin 2 g i.v. loading dose followed by 1 g i.v. every 6 hr; clindamycin 900 mg i.v. every 8 hr; gentamicin 120 mg i.v. loading dose followed by 100 mg i.v. every 8 hrs; and erythromycin 500 mg i.v. every 6 hr) for 7 days and delivery of the presumably infected triplet A successfully reversed the clinical symptomatology, allowing prolongation of pregnancy until 26 weeks and survival of the remaining fetuses. At age 2 years, both infants are doing well and are meeting their developmental milestones. The viable outcome of this management strategy suggests that antibiotic treatment and expectancy may be an option in selected cases of postamniocentesis chorioamnionitis in multiple pregnancies.

Risk factors for neonatal intraventricular haemorrhage in spontaneous prematurity at 32 weeks gestation or less

In this study we aimed to establish which clinical and histopathological factors are associated with early-onset neonatal intraventricular haemorrhage (IVH) in non-iatrogenic preterm delivery before 32 weeks of gestation. We retrospectively reviewed all singleton pregnancies delivered before 32 weeks of gestation after spontaneous onset of preterm labour or preterm membrane rupture during the period January 1993 to June 1997. Clinical and histopathological data in cases with IVH diagnosed at neonatal cranial ultrasound within 72 h of birth (n = 17) were compared with those of neonates not experiencing this complication (non-IVH) (n = 54). Histological lesions analysed were those of acute inflammation and those on a uteroplacental vascular basis. Statistical methods included the Wilcoxon rank sum test, Fisher's exact test, and logistic regression analysis. A P<0.05 was considered significant.IVH and non-IVH groups were not significantly different in birthweight, gestational age at delivery, cord pH at birth, rates of 5-min Apgar score below 7, caesarean delivery, diagnosis of clinical chorioamnionitis or antenatal administration of steroids. Respiratory distress syndrome was more frequently diagnosed in the IVH than non-IVH group (64 per cent versus 33 per cent, P=0.02). Placental acute inflammatory or uteroplacental vascular lesions were present in 100 per cent of IVH neonates versus 22 per cent of non-IVH cases (P<0.001). Logistic regression analysis demonstrated that only respiratory distress syndrome (P = 0.04) and histological evidence of acute placental inflammation (P = 0.02) were significantly and independently associated with IVH. Histopathological evidence of acute inflammatory placental lesions is the best predictor of occurrence of neonatal IVH.

Isolated fetal choroid plexus cysts: role of ultrasonography in establishment of the risk of trisomy 18

OBJECTIVE

The significance of isolated choroid plexus cysts found by ultrasonographic scan during the second trimester as a marker for trisomy 18 is still debated. We analyzed our data and reviewed the series published in the English-language literature to calculate the likelihood ratio of trisomy 18 in the presence of isolated choroid plexus cysts; that is, the factor by which the individual risk of trisomy 18 is increased in the presence of isolated choroid plexus cysts.

STUDY DESIGN

Likelihood ratios were calculated as ratio of the sensitivity to the false-positive rate. Sensitivity was defined as the rate of isolated choroid plexus cysts detected at midgestation among fetuses with trisomy 18. False-positive rate was defined as the rate of choroid plexus cysts detected at midgestation in the population without trisomy 18. The sensitivities of all published series reporting rates of choroid plexus cysts at the time of the first ultrasonographic examination between 14 and 24 weeks' gestation in populations with trisomy 18 and in low-risk populations were included in the analysis. To these we added all cases of trisomy 18 diagnosed at our institution during the period January 1, 1988, through June 30, 1998, in which prenatal ultrasonographic examination was performed between 14 and 24 weeks' gestation.

RESULTS

The prevalence of second-trimester ultrasonographic detection of isolated choroid plexus cysts among fetuses with trisomy 18 was 6.7% (13/194), whereas that in the population without trisomy 18 was 0.9% (752/79,583). The likelihood ratio associated with isolated choroid plexus cysts was therefore 7.09 (95% confidence interval, 3.97-12.18).

CONCLUSION

The presence of isolated second-trimester choroid plexus cysts increases the base risk of trisomy 18 by a factor of 7.09. This likelihood ratio can be multiplied by the risk calculated according to maternal age to obtain the individual risk of trisomy 18 and thus permit more accurate counseling of the patient.