Cervical elastography during pregnancy: clinical perspectives

Uterine cervix is a part of the uterus responsible for maintaining pregnancy till term. As long as the cervix remains long and firm and its internal orifice (os) is closed, it can withstand enlargement of the uterine contents and resultant growing pressure. Mechanical properties of the cervix change during pregnancy; the cervix ripens prior to delivery, then effaces and dilates with contractions of the uterus. Ripening of the cervix can be assessed using the Bishop score and ultrasonographically determined length of the cervical canal and internal os. Consistency is one of the cervical properties that change during the course of the maturation process. Until recently, cervical consistency has been assessed only manually, but in 2007, the first report on elastographic imaging of the cervix during pregnancy has been published. Elastography presents the ability of a tissue to deform under pressure. The softer the tissue, the easier it changes its shape. Different methods of elastography are used - static, when tissue displacement in response to manual compression or physiological movements of vessels is measured, or dynamic, when the speed of shear wave propagation is determined. Irrespective of the method, elastography provides information on the internal os stiffness; this parameter, impossible for manual assessment, was shown to correlate with pregnancy outcome and is a strong predictor of preterm delivery or successful labor induction. Although elastography seems to be a highly promising diagnostic option, still no consensus has been reached regarding an optimal method for uterine cervix assessment, and virtually all previous studies of various elastographic methods produced highly satisfactory results. Future studies need to identify the most promising and objective elastographic method which may serve as a novel tool for pregnancy management, preventing adverse events, such as preterm delivery and unsuccessful labor induction.

Recommendations for Fetal Echocardiography in Twin Pregnancy in 2016

Progress in the fields of fetal cardiology and fetal surgery have been seen not only in singleton pregnancies but also in multiple pregnancies. Proper interpretation of prenatal echocardiography is critical to clinical decision making, family counseling and perinatal management for obstetricians, maternal fetal medicine specialists, neonatologists and pediatric cardiologists. Fetal echocardiography is one of the most challenging and time-consuming prenatal examinations to perform, especially in multiple gestations. Performing just the basic fetal exam in twin gestations may take an hour or more. Thus, it is not practical to perform this exam in all cases of multiple gestations. Therefore our review and recommendations are related to fetal echocardiography in twin gestation.

[Estimation of fetal middle cerebral artery peak systolic velocity at 18-39 weeks of gestation in Polish population]

OBJECTIVES

The aim of this paper was to establish normal values of fetal middle cerebral artery peak systolic velocity (MCA-PSV) between 18-39 weeks' gestation in the Polish population and to compare the results with values published by other authors, for different populations seeking the discrepancies between them.

MATERIAL AND METHODS

280 healthy pregnant women from the Polish population underwent ultrasound examination. The cross-sectional data were obtained based on the measurements of fetal middle cerebral artery peak systolic velocity A chart of normal MCA-PSV values as a function of the gestational age was constructed.

RESULTS

Normal ranges for MCA-PSV in the Polish population were established. The results were compared with values published by other authors, for different populations.

CONCLUSIONS

The use of MCA-PSV measurements has proven itself to be a reliable method in diagnosis of fetal anemia. Differences in normal values of MCA-PSV in the Polish population compared with other nations have been observed.

[Analysis of pregnancy, labor and neonatal course in babies with prenatally-diagnosed complete atrioventricular heart block]

INTRODUCTION

Complete heart block (third-degree atrioventricular block) is a defect of the conduction system of the heart, in which the impulse generated in the sinoatrial node does not propagate to the ventricles, and thus the latter contract independently of the atria. A third-degree atrioventricular block can be either congenital or acquired. In 60-70% of the cases, the congenital heart block results from destruction of the conduction system of the fetal heart by anti-Ro/SSA and anti-La/SSB antibodies present in maternal serum. The antibodies are synthesized in the course of autoimmune maternal conditions, most often systemic lupus erythematosus or rarer rheumatoid arthritis, dermatomyositis or Sjögren's syndrome. The complete block can occur as an isolated defect or be associated with structural anomalies of the fetal heart.

MATERIAL AND METHODS

A total of five patients whose fetuses were diagnosed with the third-degree atrioventricular block have been hospitalized at the Department of Obstetrics, Medical University of Gdansk between 2012 and 2014.

RESULTS

We present the data of the five patients, hospitalized at the Department of Obstetrics, Medical University of Gdansk, whose fetuses were diagnosed prenatally with the complete heart block. The cases differ in terms of etiology clinical outcome, and postnatal treatment. All data are presented in Table I.

CONCLUSIONS

We emphasize the role of appropriate pregnancy management and careful monitoring of the fetal condition. From obstetrical perspective, it is important to monitor the condition of fetuses with the third-degree atrioventricular block ultrasonographically and echocardiographically; in turn, cardiotocography is less useful in this setting. Therefore, a non-reactive cardiotocographic tracing should not constitute an indication for a preterm delivery. An affected fetus should be delivered in a tertiary center for perinatal care that cooperates with a pediatric cardiology center. An efficient program for cardologic prenatal care and close cooperation between obstetricians, neonatologists, pediatric cardiologists, and cardiac surgeons constitute the key to a successful outcome.

A Proposed Molecular Mechanism of High-Dose Vitamin D3 Supplementation in Prevention and Treatment of Preeclampsia

A randomized prospective clinical study performed on a group of 74 pregnant women (43 presenting with severe preeclampsia) proved that urinary levels of 15-F(2t)-isoprostane were significantly higher in preeclamptic patients relative to the control (3.05 vs. 2.00 ng/mg creatinine). Surprisingly enough, plasma levels of 25-hydroxyvitamin D3 in both study groups were below the clinical reference range with no significant difference between the groups. In vitro study performed on isolated placental mitochondria and placental cell line showed that suicidal self-oxidation of cytochrome P450scc may lead to structural disintegration of heme, potentially contributing to enhancement of oxidative stress phenomena in the course of preeclampsia. As placental cytochrome P450scc pleiotropic activity is implicated in the metabolism of free radical mediated arachidonic acid derivatives as well as multiple Vitamin D3 hydroxylations and progesterone synthesis, we propose that Vitamin D3 might act as a competitive inhibitor of placental cytochrome P450scc preventing the production of lipid peroxides or excess progesterone synthesis, both of which may contribute to the etiopathogenesis of preeclampsia. The proposed molecular mechanism is in accord with the preliminary clinical observations on the surprisingly high efficacy of high-dose Vitamin D3 supplementation in prevention and treatment of preeclampsia.

Temperament and the mother-infant dyad: associations with breastfeeding and formula feeding with a bottle

Breastfeeding supports the formation of an emotional bond between mothers and their children. The feeding method is associated with both the child's temperament and the mother's perception of herself and the child. Therefore, the present study focuses on the feeding method, mothers' reaction during feeding, and infants' temperament traits. Ninety-eight mothers with children aged 3 to 5 months participated in the study. Children were assessed with the Children Development Scale (A. Matczak et al., 2007) to measure their temperament. Mothers completed the Mother and Baby Scale (D. Wolke & I. St James-Roberts, 1987, as cited in T.B. Brazelton & K. Nugent, 1995), which measures mothers' evaluation of their children's behaviors during feeding and their overall experiences with their children's care. The results show that breastfed newborns, as compared to bottle-fed newborns, demonstrate higher vigor, which includes activity and the intensity of reaction. Bottle-fed children demonstrate higher regularity than do breastfed children. Mothers who bottle-feed their children perceive themselves to be less confident in the feeding domain than do mothers who breastfeed. Our results indicate that children's temperament might be an important factor in the decision regarding the feeding method. The study supports the idea of promoting knowledge of children's behaviors during feeding among mothers even before their children are born, such as during antenatal classes.

Effect of nitrosative stress on extracellular nucleotide metabolism in endothelial cells

Mechanisms of free radical injury involve chemical modification of proteins, lipid derivatives and nucleic acids and consequent loss of its function. However, specific targets and exact sequence of events has not been fully clarified. We determined whether extracellular enzymes that are involved in adenosine formation such as ecto-5'nucleotidase (e5N) and removal such as extracellular form of adenosine deaminase (eADA) could be affected by peroxynitrite. We used intact cell assay system that involves exposure of cultured HMEC-1 cells to substrates followed by HPLC analysis of conversion of substrates into products. We found that e5N and ADA activities decreased by 20-40% after incubation for 20 or 60 minutes with 30 μM peroxynitrite. Decrease of cellular ATP and NAD was also observed. We conclude that besides other cytotoxic effects modification of extracellular enzymes of nucleotide metabolism could be important target for free radical injury.

Comparison of fetal myocardial contractility before and after laser photocoagulation of communicating vessels in twin-to-twin transfusion syndrome

OBJECTIVES

To evaluate changes in myocardial contractility that occur after selective laser photocoagulation of communicating vessels (SLPCV) in fetuses from pregnancies complicated with twin-to-twin transfusion syndrome (TTTS).

METHODS

The study included 51 pregnant women between 16 and 26 weeks of gestation who underwent SLPCV due to TTTS. Ultrasonography was performed before SLPCV and on postoperative day 1, 3(4) and 7. Fetal heart contractility in both fetuses was evaluated by determining the shortening fractions of the left and right ventricles (FS LV and FS RV), and the myocardial performance index (Tei-Index).

RESULTS

There was a significant increase in postoperative FS LV and FS RV in recipients (from 35.7% to 44%, P = 0.037 and from 27.6% to 32.9%, P = 0.021, respectively). Pre-operative Tei-Index values for both the left (0.55) and right ventricle (0.6) were above normal. The mean postoperative Tei-Index for the left ventricle decreased significantly to 0.49 (P = 0.011), while no significant change was observed in the right ventricle (0.57). No significant differences between pre- and postoperative FS and Tei-Index values were noted in the donors.

CONCLUSIONS

SLPCV is reflected by a significantly increased myocardial contractility in recipients.

Influence of place of residence on indications for genetic amniocentesis in the Pomeranian region of Poland before and after introduction of the Prenatal Screening Program in 2008

Background

The aim of the study was to analyze differences in the indications for amniocentesis in patients living in urban and rural areas before and after introduction of the Prenatal Screening Program by Polish National Health Insurance agency in the Pomeranian region in 2008.

Material/Methods

Indications for 2578 amniocenteses performed in the Department of Obstetrics of the Medical University of Gdansk between 1996 and 2010 were recorded.

Results

Advanced maternal age accounted for 69% of women in urban areas and 61% of women in rural areas being referred for amniocentesis (p<0.001). There was also a significant difference between locations in chromosomal abnormality in previous pregnancy, accounting for 4% of referrals for amniocentesis in urban areas compared with 7% of referrals in rural areas. In urban areas, advanced maternal age accounted for 73% of referrals between 1996–2007 compared with 60% of referrals for amniocentesis between 2008 and 2010 (p=0.004), and in rural areas it was 66% and 54%, respectively (p<0.001). Abnormal result of biochemical screening surprisingly accounted for 13% of referrals for amniocenteses between 1996–2007 in urban areas compared with 28% after 2008 (p<0.001). In rural areas this indication accounted for 12% referrals before 2008 and for 28% from 2008 onward (p<0.001).

Conclusions

The results of the study suggest that in both urban and rural areas there was a significant decrease in advanced maternal age as a reason for referral for amniocentesis, but a significant increase in abnormal results of biochemical screening as an indication for amniocentesis after 2008.

[Appendicitis and gall bladder diseases as acute abdominal conditions in pregnancy]

Appendicitis (APP) and gall bladder diseases (GBD) are the most frequent non-obstetric indications for urgent surgery among pregnant women. The aim was to present the diagnosis, treatment and potential complications of APP and symptomatic GBD. We searched the literature for APP and GBD during pregnancy and presented the results in the form of a review article. APP symptoms among pregnant women are comparable to these in the general population. Typical clinical symptoms are present in 50-75% of cases. Laboratory tests are useful for a differential diagnosis. The imaging of choice is an ultrasonography scan, but magnetic resonance is of the highest accuracy The final diagnosis is difficult. When the surgery is delayed, the risk of appendix perforation increases and thus complications are more frequent. GBD symptoms and signs are comparable to those in the general population. The best imaging is an ultrasonography scan, and laboratory tests are important in a jaundice differential diagnosis. In cases with symptomatic GBD, a delay in surgery is associated with an increased risk of complications (pancreatitis, abortion, intrauterine death). The treatment method of choice for APP and symptomatic GBD is surgery both laparotomy and laparoscopy (preferred), which are considered relatively safe, though laparoscopy compared to laparotomy for APP can be associated with a higher risk of abortion. Untreated or delayed APP and symptomatic GBD treatment during pregnancy increases the risk of complications, both for the woman and the fetus. Diagnosis is difficult and should be based on a multidisciplinary approach to the patient. Surgery by laparotomy or laparoscopy is relatively safe.

Demographic factors determining termination of pregnancy following the detection of lethal fetal malignancy

OBJECTIVE

To identify demographic and clinical variables differentiating pregnant Polish women who decided to terminate the pregnancy in the case of lethal fetal malformation from those who preferred to continue the pregnancy in such a situation.

STUDY DESIGN

Cross-sectional study.

RESULTS

The group of women who decided to abort contained a higher fraction of multiparas than the group of patients who chose to continue their pregnancies, and was characterized by significantly lower mean gestational age at diagnosis of lethal fetal malformation. The only demographic variable approaching statistical significance was the presence of siblings, which was significantly more frequent amongst women who decided to terminate the pregnancy.

CONCLUSIONS

As the decision-making process on pregnancy termination is multimodal, pregnant women require particular support in the case of detecting lethal malformation in their fetuses.

Evolution of the indications for genetic amniocentesis after the introduction of the prenatal screening program by the national health insurance in Poland

OBJECTIVE

In 2008, the Prenatal Screening Program was introduced by the National Health Insurance in the Pomeranian region of Poland. As of then, biochemical and ultrasound screening was offered to women eligible for amniocentesis according to the earlier policy. The aim of the study was to investigate the evolution of the indications for amniocentesis after the introduction of the Program.

MATERIAL AND METHODS

In total, 2579 women referred for amniocentesis to the Department of Obstetrics, Medical University of Gdansk, were included in the study They were divided into two groups: 1705 women referred between 1996 and 2007 (group A) and 874 women referred between 2008 and 2010 (group B). Indications for amniocentesis were compared between the groups.

RESULTS

A significant difference in the indications for amniocentesis was found between the groups (Kruskal-Wallis test; p < 0.001). Maternal age, fetal malformation in the previous pregnancy and anxiety were less frequent in group B (p < 0.0001, p = 0.0008 and p = 0.0156, respectively). In contrast, a higher frequency of positive biochemical screening and abnormal ultrasound results as indications for amniocentesis was found in group B (p < 0.0001 and p = 0.0008, respectively).

CONCLUSIONS

The introduction of the Prenatal Screening Program by the National Health Insurance shifted the proportion of indications for amniocentesis from maternal age to positive results in biochemical and ultrasound screenings, and increased the number of invasive testing. Further observation of the trend and its influence on the detection rate is imperative to confirm that the proposed Program is adequate and does not require adjustments.

[Intestinal obstruction during pregnancy]

This is a review of literature concerning intestinal obstruction in pregnant women. Approximately 50-90% and 30% of pregnant women, respectively suffer from nausea and vomiting, mostly during the first trimester. There is also increased risk of constipation. During the perioperative period, the administration of tocolytics should be considered only in women showing symptoms of a threatening premature delivery. Intensive hydration should be ordered to sustain uterine blood flow. The incidence of intestinal obstruction during pregnancy is estimated at 1:1500-1:66431 pregnancies and is diagnosed in II and III trimester in most cases. However, it can also occur in the I trimester (6%) or puerperium. Symptoms of intestinal obstruction in pregnancy include: abdominal pains (98%), vomiting (82%), constipation (30%). Abdominal tenderness on palpation is found in 71% and abnormal peristalsis in 55% of cases. The most common imaging examination in the diagnosis of intestinal obstruction is the abdominal X-ray. However ionizing radiation may have a harmful effect on the fetus, especially during the first trimester. X-ray is positive for intestinal obstruction in 82% of pregnant women. Ultrasonography and magnetic resonance imaging are considered safe and applicable during pregnancy. Intestinal obstruction in pregnant women is mostly caused by: adhesions (54.6%), intestinal torsion (25%), colorectal carcinoma (3.7%), hernia (1.4%), appendicitis (0.5%) and others (10%). Adhesive obstruction occurs more frequently in advanced pregnancy (6% - I trimester 28% - II trimester; 45% - III trimester 21% - puerperium). Treatment should begin with conservative procedures. Surgical treatment may be necessary in cases where the pain turns from recurrent into continuous, with tachycardia, pyrexia and a positive Blumberg sign. If symptoms of fetal anoxia are observed, a C-section should be carried out before surgical intervention. The extent of surgical intervention depends on the intraoperative evaluation. Intestinal torsion during pregnancy mostly occurs in the sigmoid colon and cecum. Small bowel torsion secondary to adhesions is diagnosed in 42% of pregnant women with intestinal obstruction. The risk of intestinal torsion is higher in the 16-20 and 32-36 weeks of pregnancy and during puerperium. Intestinal torsion results in vessel occlusion which induces more severe symptoms and makes urgent surgical intervention necessary. The overall prognosis is poor--during II and III trimester the fetal mortality rate reaches 36% and 64%, respectively while the risk of maternal death is 6%. Acute intestinal pseudoobstruction can be diagnosed during puerperium, especially following a C-section. Diagnosis is made on the basis of radiological confirmation of colon distension at the cecum as > 9cm, lack of air in the sigmoid colon and rectum, exclusion of mechanical obstruction. In most cases, the treatment is based on easing intestine gas evacuation and administering neostigmine. The authors point out the need for multi-specialty cooperation in the diagnostic-therapeutic process of pregnant women suspected with intestinal obstruction, since any delay in making a correct diagnosis increases the risk of severe complications, both for the woman and the fetus.

Long-term follow-up for organic dysfunction in breech - presenting children

Background

The authors performed a long term outcome analysis of minimal brain damage in children delivered in breech presentation, and related the results to the mode of delivery (vaginal or by cesarean section).

Material/Methods

In the Department of Obstetrics at the Medical University of Gdansk (Poland), 917 breech deliveries took place between 1981 and 1990. Excluding stillbirths and multiple pregnancies, 874 deliveries were analyzed. We received positive responses from 232 mothers, who provided us with considerable information about the children’s further development and problems that had arisen during their school years. All the respondents were contacted by telephone, and 83 of them agreed to visit our Department with their children to undergo a psychological examination – the following tests were performed: 1) the Bender-Kopitz Test (BKT), and 2) the Benton Visual Retention Test (BVRT).

Results

The mode of delivery for all groups and subgroups had no influence on the incidence of organic brain disorders in later childhood, assessed by the Benton Visual Retention test and by the Bender-Kopitz test.

Conclusions

Vaginal breech deliveries are safe in both primiparous and multiparous mothers.

[Malignant tumor of nasal cavity during pregnancy. Case report]

Malignant neoplasm of the head and neck is rare disease of pregnant woman. The most common localization of this tumors are larynx, thyroid, melanoma and lymphoma. Many diagnostic and therapeutic procedures (routinely used in patients with cancer) are contraindicated in the presence of pregnancy. The authors presents a case of a 28-year-old female with malignant tumor of nasal cavity during the 37 week of pregnancy. We performed caesarean section and radical surgery (lateral rhinotomy) with removing of the tumor. The histological examination result was: esthesioneuroblastoma. 5-weeks after surgery radiotherapy was realized. During the 6-year follow-up no recurrence was observed.

[Incidence of hereditary thrombophilia in women with pregnancy loss in multi-center studies in Poland]

AIM

The aim of this study was to estimate the prevalence of factor V Leiden and prothrombin gene G20210A mutation among women with pregnancy loss in Poland.

MATERIAL AND METHODS

we analyzed a group of 396 women (mean age of 30.4 (+/- 4.6) years), who experienced at least one pregnancy loss. Patients were recruited from 6 academic centers (Poznań, Białystok, Lublin, Wrocław Bydgoszcz, Gdańsk), and were divided into the following groups: 122 patients with 3 episodes of early recurrent pregnancy loss (group 1), 87 patients with late pregnancy loss (group 2) and 46 patients with intrauterine pregnancy loss (group 3). Patients who did not fulfill the above inclusion criteria were divided into additional groups. 50 healthy women (mean age of 29.2 (+/- 4.5) years), having at least one child, constituted the control group. Factor V Leiden mutation and prothrombin G20210A gene mutation were examined in all 396 women with pregnancy loss and 50 controls. For molecular analysis peripheral blood was tested. Genome DNA isolation from lymphocyte was performed with commercial assay QIAampDNA Blood Mini Kit.

RESULTS

Among 396 women with unexplained loss of at least one pregnancy 36 (9.1%) were carriers of inherited thrombophilia. Factor V Leiden mutation was present in 29 women (73%), prothrombin gene mutation G20210A in 6 (1.5%) and in 1 (0.3%) patient both mutations were detected. No coagulation defects were found in the control group. Factor V Leiden mutations was the most common disorder (21.7%) in patients with intrauterine demise and was significantly higher than in the group of women with early recurrent and late losses, p<0.011 and p<0,006 respectively The frequency of G20210 A prothrombin gene mutation did not differ substantially between the examined groups; the highest number (2.6%) was found in women with early and late pregnancy losses, and the lowest number (0.8%) was seen in women with early recurrent miscarriages.

CONCLUSION

Factor V Leiden screening should be performed, regardless of negative history of thrombosis, in patients who experienced intrauterine fetal demise or recurrent early miscarriages.