Acute and chronic respiratory diseases in pregnancy: associations with spontaneous premature rupture of membranes

Management, Utilization, and Outcomes of Preterm Labor in an Integrated Health Care System

OBJECTIVE

 Fetal fibronectin (fFN) testing and transvaginal ultrasound (TVUS) are diagnostic tools used to predict impending spontaneous preterm birth (sPTB) among women presenting with preterm labor (PTL). We evaluated the association between fFN testing or TVUS cervical length (CL) measurement in predicting sPTB, respiratory distress syndrome (RDS), neonatal intensive care unit (NICU) admission, and sPTB-related costs.

STUDY DESIGN

 We conducted a retrospective cohort study using data from the Kaiser Permanente Southern California electronic health system (January 1, 2009-December 31, 2020) using diagnostic and procedure codes, along with a natural language processing algorithm to identify pregnancies with PTL evaluations. PTL evaluation was defined as having fFN and/or TVUS assessment. Outcomes were ascertained using diagnostic, procedural, and diagnosis-related group codes. Multivariable logistic regression assessed the association between fFN and/or TVUS results and perinatal outcomes.

RESULTS

 Compared with those without PTL evaluations, those with positive fFN tests had higher adjusted odds ratio (adj.OR) for sPTB (2.95, 95% confidence interval [CI]: 2.64, 3.29), RDS (2.34, 95% CI: 2.03, 2.69), and NICU admission (2.24, 95% CI: 2.01, 2.50). In contrast, those who tested negative had lower odds for sPTB (adj.OR: 0.75, 95% CI: 0.70, 0.79), RDS (adj.OR: 0.67, 95% CI: 0.61, 0.73), and NICU admission (adj.OR: 0.74, 95% CI: 0.70, 0.79). Among those with positive fFN results, the odds of sPTB was inversely associated with CL. Health care costs for mothers and neonates were lowest for those with fFN testing only.

CONCLUSION

 This study demonstrates that positive fFN results were associated with an increased odds of sPTB, RDS, and NICU admission and the association with sPTB was inversely proportional to CL. Additionally, negative fFN results were associated with decreased odds of sPTB, RDS, and NICU admissions. fFN testing may predict these and other sPTB-related adverse outcomes hence its utility should be explored further. Moreover, fFN testing has some cost savings over TVUS.

KEY POINTS

· Patients with positive fFN tests had higher odds of sPTB, RDS, and NICU admission.. · Inverse relationship between sPTB and CL among those with positive fFN tests was observed.. · Health care costs for mothers and neonates were lowest for those with fFN testing only..

Safety of the Seasonal Influenza Vaccine in 2 Successive Pregnancies

Importance

Although influenza vaccination has been found to be safe in pregnancy, few studies have assessed repeated influenza vaccination over successive pregnancies, including 2 vaccinations in a year, in terms of adverse perinatal outcomes.

Objective

To examine the association of seasonal influenza vaccination across successive pregnancies with adverse perinatal outcomes and whether the association varies by interpregnancy interval (IPI) and vaccine type (quadrivalent or trivalent).

Design, Setting, and Participants

This retrospective cohort study included individuals with at least 2 successive singleton live-birth pregnancies between January 1, 2004, and December 31, 2018. Data were collected from the Vaccine Safety Datalink, a collaboration between the Centers for Disease Control and Prevention and integrated health care organizations. Data analysis was performed between January 8, 2021, and July 17, 2024.

Exposures

Influenza vaccination was identified using vaccine administration codes. The vaccinated cohort consisted of people who received influenza vaccines during the influenza season (August 1 through April 30) in 2 successive pregnancies. The comparator cohort consisted of people identified as unvaccinated during both pregnancies.

Main Outcomes and Measures

Main outcomes were risk of preeclampsia or eclampsia, placental abruption, fever, preterm birth, preterm premature rupture of membranes, chorioamnionitis, and small for gestational age among individuals with and without vaccination in both pregnancies. Adjusted relative risks (RRs) from Poisson regression were used to assess the magnitude of associations. The associations with adverse outcomes by IPI and vaccine type were evaluated.

Results

Of 82 055 people with 2 singleton pregnancies between 2004 and 2018, 44 879 (54.7%) had influenza vaccination in successive pregnancies. Mean (SD) age at the start of the second pregnancy was 32.2 (4.6) years for vaccinated individuals and 31.2 (5.0) years for unvaccinated individuals. Compared with individuals not vaccinated in both pregnancies, vaccination in successive pregnancies was not associated with increased risk of preeclampsia or eclampsia (adjusted RR, 1.10; 95% CI, 0.99-1.21), placental abruption (adjusted RR, 1.01; 95% CI, 0.84-1.21), fever (adjusted RR, 0.87; 95% CI, 0.47-1.59), preterm birth (adjusted RR, 0.83; 95% CI, 0.78-0.89), preterm premature rupture of membranes (RR, 1.00; 95% CI, 0.94-1.06), chorioamnionitis (adjusted RR, 1.03; 95% CI, 0.90-1.18), or small for gestational age birth (adjusted RR, 0.99; 95% CI, 0.93-1.05). IPI and vaccine type did not modify the observed associations.

Conclusions and Relevance

In this large cohort study of successive pregnancies, influenza vaccination was not associated with increased risk of adverse perinatal outcomes, irrespective of IPI and vaccine type. Findings support recommendations to vaccinate pregnant people or those who might be pregnant during the influenza season.

Association between SARS-CoV-2 Infection and Adverse Perinatal Outcomes in a Large Health Maintenance Organization

OBJECTIVE

This study aimed to examine whether severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection during pregnancy is associated with increased odds of perinatal complications and viral transmission to the infant.

STUDY DESIGN

A retrospective cohort study of women who delivered at Kaiser Permanente Southern California hospitals (April 6, 2020-February 28, 2021) was performed using data extracted from electronic health records (EHRs). During this time polymerize chain reaction (PCR)-based tests for SARS-CoV-2 was universally offered to all pregnant women at labor and delivery admission, as well as earlier in the pregnancy, if they were displaying symptoms consistent with SARS-CoV-2 infection or a possible exposure to the virus. Adjusted odds ratio (aOR) was used to estimate the strength of associations between positive test results and adverse perinatal outcomes.

RESULTS

Of 35,123 women with a singleton pregnancy, 2,203 (6%) tested positive for SARS-CoV-2 infection with 596 (27%) testing positive during the first or second trimester and 1,607 (73%) during the third trimester. Women testing positive were younger than those who tested negative (29.7 [5.4] vs. 31.1 [5.3] years; mean [standard deviation (SD)]; p < .001). The SARS-CoV-2 infection tended to increase the odds of an abnormal fetal heart rate pattern (aOR: 1.10; 95% confidence interval [CI]: 1.00, 1.21; p = 0.058), spontaneous preterm birth (aOR: 1.28; 95% CI: 1.03, 1.58; p = 0.024), congenital anomalies (aOR: 1.69; 95% CI: 1.15, 2.50; p = 0.008), and maternal intensive care unit admission at delivery (aOR: 7.44; 95% CI: 4.06, 13.62; p < 0.001) but not preeclampsia/eclampsia (aOR: 1.14; 95% CI: 0.98, 1.33; p = 0.080). Eighteen (0.8%) neonates of mothers who tested positive also had a positive SARS-CoV-2 test after 24 hours of birth, but all were asymptomatic during the neonatal period.

CONCLUSION

These findings suggest that prenatal SARS-CoV-2 infection increases the odds of some adverse perinatal outcomes. The likelihood of vertical transmission from the mother to the fetus was low (0.3%), suggesting that pregnancy complications resulting from SARS-CoV-2 infection pose more risk to the baby than transplacental viral transmission.

KEY POINTS

· SARS-CoV-2 infection is associated with increased odds of adverse perinatal outcomes.. · The odds of specific adverse outcomes were greater when a mother was infected earlier in pregnancy.. · The proportion of vertical transmission from mother to fetus was 0.3%.

Using Blood Gas Analysis and Capnography to Determine Oxygenation Status in Bottlenose Dolphins (Tursiops truncatus) Following the Deepwater Horizon Oil Spill

Following the Deepwater Horizon (DWH) oil spill in 2010, poor pulmonary health and reproductive failure in bottlenose dolphins (Tursiops truncatus) in the northern Gulf of Mexico were well-documented. One postulated etiology for the increased fetal distress syndrome and pneumonia found in affected perinatal dolphins was maternal hypoxia caused by lung disease. The objective of this study was to evaluate the utility of blood gas analysis and capnography in determining oxygenation status in bottlenose dolphins with and without pulmonary disease. Blood and breath samples were collected from 59 free-ranging dolphins in Barataria Bay, Louisiana (BB), during a capture-release health assessment program, and from 30 managed dolphins from the U.S. Navy Marine Mammal Program in San Diego, CA. The former was the oil-exposed cohort and the latter served as a control cohort with known health histories. Capnography and select blood gas parameters were compared based on the following factors: cohort, sex, age/length class, reproductive status, and severity of pulmonary disease. Animals with moderate-severe lung disease had higher bicarbonate concentrations (p = 0.005), pH (p < 0.001), TCO₂ (p = 0.012), and more positive base excess (p = 0.001) than animals with normal-mild disease. Capnography (ETCO₂) was found to have a weak positive correlation with blood PCO₂ (p = 0.020), with a mean difference of 5.02 mmHg (p < 0.001). Based on these findings, indirect oxygenation measures, including TCO₂, bicarbonate, and pH, show promise in establishing the oxygenation status in dolphins with and without pulmonary disease.

Single Nucleotide Polymorphisms from CSF2, FLT1, TFPI and TLR9 Genes Are Associated with Prelabor Rupture of Membranes

A prelabor rupture of membranes (PROM) and its subtypes, preterm PROM (pPROM) and term PROM (tPROM), are associated with disturbances in the hemostatic system and angiogenesis. This study was designed to demonstrate the role of single nucleotide polymorphisms (SNPs), localized in CSF2 (rs25881), FLT1 (rs722503), TFPI (C-399T) and TLR9 (rs352140) genes, in PROM. A population of 360 women with singleton pregnancy consisted of 180 PROM cases and 180 healthy controls. A single-SNP analysis showed a similar distribution of genotypes in the studied polymorphisms between the PROM or the pPROM women and the healthy controls. Double-SNP TT variants for CSF2 and FLT1 polymorphisms, CC variants for TLR9 and TFPI SNPs, TTC for CSF2, FLT1 and TLR9 polymorphisms, TTT for FLT1, TLR9 and TFPI SNPs and CCCC and TTTC complex variants for all tested SNPs correlated with an increased risk of PROM after adjusting for APTT, PLT parameters and/or pregnancy disorders. The TCT variants for the CSF2, FLT1 and TLR9 SNPs and the CCTC for the CSF2, FLT1, TLR9 and TFPI polymorphisms correlated with a reduced risk of PROM when corrected by PLT and APTT, respectively. We concluded that the polymorphisms of genes, involved in hemostasis and angiogenesis, contributed to PROM.

Effect of preeclampsia and premature rupture of membrane on neonatal birth weight and length by gestational age: A retrospective study in China

Background:

Preeclampsia (PE) and premature rupture of membrane (PROM) are considered significant risk factors for lower neonatal birth weight and birth length. However, very limited studies have reported the impact of PE and PROM on neonatal birth weight and birth length by gestational week. Therefore, we aimed to determine the effect of PE and PROM on neonatal birth weight and length by gestational age.

Materials and Methods:

A total of 9707 singleton neonates were selected for this study. All the data were collected and documented in the obstetric register by the trained nurses in the Gynecology and Obstetrics Department.

Results:

The neonatal mean birth weights and birth lengths were statistically significantly (P < 0.05) lowered among preeclamptic mothers compared to mothers without PE throughout the gestational age. Statistically significantly (P < 0.05) lowered mean birth weights and birth lengths were found among neonates born to mothers with PROM than among neonates born to mothers without PROM by all gestational weeks except for 32 weeks and 36 weeks. Moreover, in a multiple linear regression model, PE and PROM were significantly negatively associated with neonatal birth weights and birth lengths by almost all gestational weeks (β <0, P < 0.05).

Conclusion:

We concluded that after adjustment for covariates and confounding factors, PE and PROM had a significantly negative association with neonatal birth weights and birth lengths by all gestational weeks.

Characteristics and Outcomes of 241 Births to Women With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection at Five New York City Medical Centers

OBJECTIVE

To describe the characteristics and birth outcomes of women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as community spread in New York City was detected in March 2020.

METHODS

We performed a prospective cohort study of pregnant women with laboratory-confirmed SARS-CoV-2 infection who gave birth from March 13 to April 12, 2020, identified at five New York City medical centers. Demographic and clinical data from delivery hospitalization records were collected, and follow-up was completed on April 20, 2020.

RESULTS

Among this cohort (241 women), using evolving criteria for testing, 61.4% of women were asymptomatic for coronavirus disease 2019 (COVID-19) at the time of admission. Throughout the delivery hospitalization, 26.5% of women met World Health Organization criteria for mild COVID-19, 26.1% for severe, and 5% for critical. Cesarean birth was the mode of delivery for 52.4% of women with severe and 91.7% with critical COVID-19. The singleton preterm birth rate was 14.6%. Admission to the intensive care unit was reported for 17 women (7.1%), and nine (3.7%) were intubated during their delivery hospitalization. There were no maternal deaths. Body mass index (BMI) 30 or higher was associated with COVID-19 severity (P=.001). Nearly all newborns tested negative for SARS-CoV-2 infection immediately after birth (97.5%).

CONCLUSION

During the first month of the SARS-CoV-2 outbreak in New York City and with evolving testing criteria, most women with laboratory-confirmed infection admitted for delivery did not have symptoms of COVID-19. Almost one third of women who were asymptomatic on admission became symptomatic during their delivery hospitalization. Obesity was associated with COVID-19 severity. Disease severity was associated with higher rates of cesarean and preterm birth.

Perinatal inflammation induces sex-related differences in cardiovascular morbidities in mice

Sex-related differences in cardiovascular health and disease have been identified, with males having a higher incidence of cardiovascular events but females more likely to develop arrhythmias. Adverse fetal environments are now accepted as a cause for the development of cardiovascular diseases in adulthood, but sex-related differences in response to adverse fetal environments have not been extensively explored. The combination of both in utero and postnatal exposure to inflammation is highly relevant for the infant that is born preterm or has clinical complications at birth or in early postnatal life. We have previously observed cardiac contractile deficiencies and dysregulation of Ca2+-handling proteins in our model of maternal lipopolysaccharide (LPS) and neonatal hyperoxia exposures (LPS/O2). This investigation tested the hypothesis that there are sex-related differences in the adult pathologies after exposure to perinatal inflammation. Using pressure-volume assessments, males exposed to LPS/O2 had more pronounced contractile deficiencies than similarly exposed females, but females tended to have long PR intervals. While both sexes demonstrated decreases in α-myosin heavy chain and connexin 43 after LPS/O2 exposure compared with saline/room air controls, females indicated aberrant increases in microRNA 208a, microRNA 208b, and desmin expression. Our study supports our hypothesis that early life exposure to inflammation results in sex-dependent deficits in cardiovascular function. NEW & NOTEWORTHY Sex-specific differences in cardiovascular disease are recognized, but the mechanisms and origins are not well understood. Adverse maternal environments can influence cardiac development and later cardiovascular disease. This study identifies sex-dependent differences in cardiac disease associated with perinatal inflammation.

Obstetric medical care in the United States of America

The current models of obstetric medical care utilized in the United States, how those models fit in with the overall care system, and ways to increase the role of obstetric internists will be reviewed.

The primary microbial pathogens associated with premature rupture of the membranes in China: a systematic review

To describe the spectrum of pathogens isolated from Chinese women experiencing premature rupture of the membranes (PROM) and those of their neonates, in order to provide effective management of PROM. We searched Ovid Medline, Chinese Biomedical Literature Database, China National Knowledge Infrastructure, and VIP Database for Chinese Technical Periodicals up to April 2012. The quality of studies was assessed utilizing the Strengthening the Reporting of Observational Studies in Epidemiology Statement. Among the included 36 studies, 11 (30.55%) were deemed to be at Level A, 12 (33.33%) at Level B, three (8.33%) at Level C, and 10 (27.78%) at Level D. Staphylococcus and Escherichia coli were the two primary microorganisms isolated from women with PROM and their infants. Subgroup analysis showed the distribution of microorganisms from the six regions of China varied. Staphylococcus bacteria were resistant to penicillins, except oxacillin, but more sensitive to first- and second-generation cephalosporins. Escherichia were sensitive to first- and second-generation cephalosporins and were more sensitive to aztreonam than cephalosporins. The main pathogens derived from women with PROM and their newborns were Staphylococcus and E. coli, which differs from the pathogens in Western countries. Hence, one might infer that the pathogens involved in PROM should be defined in each region to maximize antibiotic effectiveness. In addition, randomized controlled studies are needed to compare prophylactic use of antibiotics versus use of antibiotics after a positive culture for newborn infants with a history of PROM.

Maternal β-hemolytic streptococcal pharyngeal exposure and colonization in pregnancy

Objectives. To report the pharyngeal colonization rate of β-hemolytic streptococci and changes in the value of antistreptolysin O (ASO) and anti-DNase B serology titers during pregnancy. Methods. Healthy pregnant women were recruited and blood was drawn in each trimester. The upper limit of normal (ULN) values for ASO and anti-DNase B was calculated for each trimester. Throat swabs were collected for culture and positive cultures were further assessed for the identification of serogroup of the isolated β-hemolytic streptococcus. Results. Out of a total of 126 pregnant women, 34.1% had positive throat cultures. Group C and group G strains were isolated in 18.2% of throat cultures while group F was detected in 13.5% of cases. The rate of colonization with GAS was 1.6%. There was an overall drop in ASO titer during pregnancy while anti-DNase B titers remained relatively unchanged. ULN values of 164^IU, 157^IU, and 156^IU were calculated for ASO at the first, second, and third trimesters, respectively. Based on the ULN values, 28.6% of patients had recent streptococcal exposure. Conclusions. These results show that pregnant women act as a reservoir for spreading potentially immunogenic (groups C and G) and disease producing (group F) virulent strains of streptococci.

Smoking and respiratory conditions in pregnancy: associations with adverse pregnancy outcomes

OBJECTIVES

Acute and chronic respiratory conditions affect a large segment of pregnant women. The purpose of the current study was to examine the concomitant effects of respiratory conditions and smoking during pregnancy on gestational age, birth weight, fetal distress, infant mortality, premature rupture of membranes, placenta abruption, and mode of delivery.

METHODS

This study used data (n = 1,064,969) from the North Carolina linked birth/infant death files from 1999 to 2007. Logistic regression was used to compute odds ratios and 95% confidence intervals (CIs) in assessing risk of adverse pregnancy outcomes.

RESULTS

We found that women with respiratory conditions/smoking status were significantly more likely than nonsmokers with no respiratory conditions to have a low-birth-weight infant, an infant with fetal distress, and experience preterm birth and an infant's death. Adjusted odds ratios also revealed that smokers with respiratory conditions were 2.37 (95% CI 1.69-3.32) times more likely than women with no respiratory conditions/nonsmoking status to have placenta abruption and 2.20 (95% CI 1.85-2.61) times more likely to have premature rupture of membranes. Regardless of smoking status, women with respiratory conditions were less likely to have a vaginal delivery.

CONCLUSIONS

These findings underscore the need for clinical and public health programs to educate women, particularly those with respiratory diseases, of the immense array of adverse outcomes that may occur as a consequence of active maternal smoking during gestation. It is important for interventions to target mothers with respiratory conditions early on to ensure favorable birth outcomes.

Pneumonia and pregnancy outcomes: a nationwide population-based study

Objective

Using 2 nationwide population-based datasets, this study aimed to assess the risk of adverse pregnancy outcomes, including low birthweight (LBW), preterm birth, small for gestational age (SGA), cesarean section (CS), lower Apgar score, and preeclampsia/eclampsia, between women with and without pneumonia.

Study Design

This study included 1462 women who had been hospitalized with pneumonia during pregnancy and used 7310 matched women without pneumonia as a comparison group.

Results

Compared to women without pneumonia, conditional logistic regression analyses showed that the adjusted odds ratios for LBW, preterm birth, SGA, CS, Apgar scores <7 at 5 minutes, and preeclampsia/eclampsia in women with pneumonia were 1.73 (95% confidence interval [CI], 1.41–2.12), 1.71 (95% CI, 1.42–2.05), 1.35 (95% CI, 1.17–1.56), 1.77 (95% CI, 1.58–1.98), 3.86 (95% CI, 1.64–9.06), and 3.05 (95% CI, 2.01–4.63), respectively.

Conclusion

Women with pneumonia during pregnancy had significantly higher risk of LBW, preterm birth, SGA, low Apgar scores infants, CS, and preeclampsia/eclampsia, compared to unaffected women.

Prenatal inflammation exacerbates hyperoxia-induced functional and structural changes in adult mice

Maternally derived inflammatory mediators, such as IL-6 and IL-8, contribute to preterm delivery, low birth weight, and respiratory insufficiency, which are routinely treated with oxygen. Premature infants are at risk for developing adult-onset cardiac, metabolic, and pulmonary diseases. Long-term pulmonary consequences of perinatal inflammation are unclear. We tested the hypothesis that a hostile perinatal environment induces profibrotic pathways resulting in pulmonary fibrosis, including persistently altered lung structure and function. Pregnant C3H/HeN mice injected with LPS or saline on embryonic day 16. Offspring were placed in room air (RA) or 85% O(2) for 14 days and then returned to RA. Pulmonary function tests, microCTs, molecular and histological analyses were performed between embryonic day 18 and 8 wk. Alveolarization was most compromised in LPS/O(2)-exposed offspring. Collagen staining and protein levels were increased, and static compliance was decreased only in LPS/O(2)-exposed mice. Three-dimensional microCT reconstruction and quantification revealed increased tissue densities only in LPS/O(2) mice. Diffuse interstitial fibrosis was associated with decreased micro-RNA-29, increased transforming growth factor-β expression, and phosphorylation of Smad2 during embryonic or early fetal lung development. Systemic maternal LPS administration in combination with neonatal hyperoxic exposure induces activation of profibrotic pathways, impaired alveolarization, and diminished lung function that are associated with prenatal and postnatal suppression of miR-29 expression.

Systemic maternal inflammation and neonatal hyperoxia induces remodeling and left ventricular dysfunction in mice

AIMS

The impact of the neonatal environment on the development of adult cardiovascular disease is poorly understood. Systemic maternal inflammation is linked to growth retardation, preterm birth, and maturation deficits in the developing fetus. Often preterm or small-for-gestational age infants require medical interventions such as oxygen therapy. The long-term pathological consequences of medical interventions on an immature physiology remain unknown. In the present study, we hypothesized that systemic maternal inflammation and neonatal hyperoxia exposure compromise cardiac structure, resulting in LV dysfunction during adulthood.

METHODS AND RESULTS

Pregnant C3H/HeN mice were injected on embryonic day 16 (E16) with LPS (80 µg/kg; i.p.) or saline. Offspring were placed in room air (RA) or 85% O(2) for 14 days and subsequently maintained in RA. Cardiac echocardiography, cardiomyocyte contractility, and molecular analyses were performed. Echocardiography revealed persistent lower left ventricular fractional shortening with greater left ventricular end systolic diameter at 8 weeks in LPS/O(2) than in saline/RA mice. Isolated cardiomyocytes from LPS/O(2) mice had slower rates of contraction and relaxation, and a slower return to baseline length than cardiomyocytes isolated from saline/RA controls. α-/β-MHC ratio was increased and Connexin-43 levels decreased in LPS/O(2) mice at 8 weeks. Nox4 was reduced between day 3 and 14 and capillary density was lower at 8 weeks of life in LPS/O(2) mice.

CONCLUSION

These results demonstrate that systemic maternal inflammation combined with neonatal hyperoxia exposure induces alterations in cardiac structure and function leading to cardiac failure in adulthood and supports the importance of the intrauterine and neonatal milieu on adult health.

Maternal inflammation, growth retardation, and preterm birth: insights into adult cardiovascular disease

The "fetal origin of adult disease Hypothesis" originally described by Barker et al. identified the relationship between impaired in utero growth and adult cardiovascular disease risk and death. Since then, numerous clinical and experimental studies have confirmed that early developmental influences can lead to cardiovascular, pulmonary, metabolic, and psychological diseases during adulthood with and without alterations in birth weight. This so called "fetal programming" includes developmental disruption, immediate adaptation, or predictive adaptation and can lead to epigenetic changes affecting a specific organ or overall health. The intrauterine environment is dramatically impacted by the overall maternal health. Both premature birth or low birth weight can result from a variety of maternal conditions including undernutrition or dysnutrition, metabolic diseases, chronic maternal stresses induced by infections and inflammation, as well as hypercholesterolemia and smoking. Numerous animal studies have supported the importance of both maternal health and maternal environment on the long term outcomes of the offspring. With increasing rates of obesity and diabetes and survival of preterm infants born at early gestational ages, the need to elucidate mechanisms responsible for programming of adult cardiovascular disease is essential for the treatment of upcoming generations.

[Acute non-obstetrical diseases during pregnancy and role of the obstetrician]

The management of a pregnant woman with an acute non-obstetrical disease must be made in narrow collaboration with an obstetrician. This one must be warned from the beginning of the care of the patient. In a pregnant woman, any acute medical, surgical or traumatic non-obstetrical disease can have obstetrical consequences. The diagnostic and therapeutic management of an acute non-obstetrical disease can have iatrogenic consequences during pregnancy. The most often described risks are early pregnancy loss, intra-uterine fetal death, placenta abruption, direct fetal hurts, preterm labor, prematurity and its complications. Obstetrical complications can induce maternal and neonatal life-threatening risks. Simple and easily accessible examinations in emergency allow detecting the obstetrical consequences of an acute non-obstetrical disease. During the management of an acute non-obstetrical disease in a pregnant woman, the induced obstetrical consequence of the disease can require emergency action of the obstetrician in conditions associated with maternal life-threatening risk. During the management of an acute non-obstetrical disease in a pregnant woman, once the mother condition was stabilized, the obstetrician had to estimate the fetal consequences and to adapt his or her therapeutic attitude. He or she sets up the fetal and placental surveillance adapted to the obstetrical risks and decides on the duration of this surveillance.

Recurrence of preterm premature rupture of membranes in relation to interval between pregnancies

OBJECTIVE

The purpose of this study was to examine whether the recurrence risk of preterm premature rupture of membranes (PPROM) is modified by the interpregnancy interval (IPI).

STUDY DESIGN

We used the Missouri 1989-1997 longitudinally linked data to examine the recurrence risk of PPROM in women with first 2 (n = 150,929) and first 3 (n = 30,011) successive pregnancies. Race-specific recurrence risks were examined. Adjusted odds ratios (ORs) were used to estimate risks.

RESULTS

Risks of PPROM in the second pregnancy among women with and without previous PPROM were 5.7% and 2.3%, respectively, among white women (OR, 8.7; 95% confidence interval, 6.7-11.4) and 10.3% and 4.3%, respectively, among African American women (OR, 7.2; 95% confidence interval, 5.1-10.1). Short IPI was associated with increased risk for PPROM recurrence, with substantially higher risk for African American women than white women. However, long IPI was associated with increased recurrence among African American women.

CONCLUSION

Women with previous PPROM are at increased risk for recurrence, and a short IPI is associated with increased risk.

The use of high-frequency oscillatory ventilation in a patient with H1N1 pneumonia

A 32-year-old multigravida was admitted at 33.9 weeks with respiratory distress. Community-acquired pneumonia was suspected and antimicrobial treatment initiated with ceftriaxone sodium and azithromycin. However, despite these therapies her respiratory status deteriorated. She was subsequently diagnosed with Swine-origin Influenza A (H1N1) Virus pneumonia and treated with oseltamivir. After failing conventional ventilation, high-frequency oscillatory ventilation (HFOV) was utilized. In pregnant patients who fail to respond to conventional ventilation techniques, HFOV should be considered.

Deficits in lung alveolarization and function after systemic maternal inflammation and neonatal hyperoxia exposure

Systemic maternal inflammation contributes to preterm birth and is associated with development of bronchopulmonary dysplasia (BPD). Infants with BPD exhibit decreased alveolarization, diffuse interstitial fibrosis with thickened alveolar septa, and impaired pulmonary function. We tested the hypothesis that systemic prenatal LPS administration to pregnant mice followed by postnatal hyperoxia exposure is associated with prolonged alterations in pulmonary structure and function after return to room air (RA) that are more severe than hyperoxia exposure alone. Timed-pregnant C3H/HeN mice were dosed with LPS (80 microg/kg) or saline on gestation day 16. Newborn pups were exposed to RA or 85% O2 for 14 days and then to RA for an additional 14 days. Data were collected and analyzed on postnatal days 14 and 28. The combination of prenatal LPS and postnatal hyperoxia exposure generated a phenotype with more inflammation (measured as no. of macrophages per high-power field) than either insult alone at day 28. The combined exposures were associated with a diffuse fibrotic response [measured as hydroxyproline content (microg)] but did not induce a more severe developmental arrest than hyperoxia alone. Pulmonary function tests indicated that hyperoxia, independent of maternal exposure, induced compliance decreases on day 14 that did not persist after RA recovery. Either treatment alone or combined induced an increase in resistance on day 14, but the increase persisted on day 28 only in pups receiving the combined treatment. In conclusion, the combination of systemic maternal inflammation and neonatal hyperoxia induced a prolonged phenotype of arrested alveolarization, diffuse fibrosis, and impaired lung mechanics that mimics human BPD. This new model should be useful in designing studies of specific mechanisms and interventions that could ultimately be utilized to define therapies to prevent BPD in premature infants.

CO and NO pulmonary diffusing capacity during pregnancy: Safety and diagnostic potential

This paper reviews the scientific evidence for the safety of carbon monoxide (CO) and nitric oxide (NO) inhalation to measure pulmonary diffusing capacity (DL(CO) and DL(NO)) in pregnant women and their fetuses. In eight earlier studies, 650 pregnant women had DL(CO) measurements performed at various times during pregnancy, with a minimum of two to four tests per session. Both pregnant subjects that were healthy and those with medical complications were tested. No study reported adverse maternal, fetal, or neonatal outcomes from the CO inhalation in association with measuring DL(CO). Eleven pregnant women, chiefly with pulmonary hypertension, and 1105 pre-term neonates, mostly with respiratory failure, were administered various dosages of NO (5-80ppm for 4 weeks continuously in pregnant women, and 1-20ppm for 15min to 3 weeks for the neonates). NO treatment was found to be an effective therapy for pregnant women with pulmonary hypertension. In neonates with respiratory failure and pulmonary hypertension, NO therapy improved oxygenation and survival and has been associated with only minor, transient adverse effects. In conclusion, maternal carboxyhemoglobin ([Hb(CO)]) levels can safely increase to 5% per testing session when the dose-exposure limit is 0.3% CO inhalation for <or=3min, and for NO, 80ppm for <or=3min. The risk of late fetal or neonatal death from increased Hb(CO) from diffusion testing is considerably less than the risk of death from all causes reported by the Centers for Disease Control, and is therefore considered "minimal risk".

The incidence rate of premature rupture of membranes and its influence on fetal-neonatal health: a report from mainland China

Premature rupture of membranes (PROM) is a common pregnancy complication and is associated with significant risks of fetal and neonatal morbidity and mortality. However, there is a lack of data concerning PROM in China. We investigated the incidence rate and analysed the influence of PROM on fetal and neonatal health. This used data from five specialist hospitals and one general hospital in mainland China. The total number of deliveries and the number of those complicated by PROM were recorded between January 2003 and December 2007. The time from initiation of PROM until delivery (latent period), the volume of amniotic fluid at delivery, fetal conditions and neonatal clinical conditions were recorded. The results suggest that the incidence of PROM was 19.53% and it could influence various aspects of the health of fetuses and neonates, including platelet parameters, erythrocyte parameters, neonatal jaundice and myocardial injury.

Community-acquired pneumonia in pregnancy

Community-acquired pneumonia is a common disease worldwide, with considerable morbidity and mortality. In the United States, pneumonia complicates 0.5 to 1.5 per 1,000 pregnancies. Physiologic adaptations in the respiratory and immunologic systems may increase susceptibility to pulmonary infections as well as alter their clinical course. Bacterial, viral and fungal pathogens all cause pneumonia in pregnancy, although the causative agent is identified in only 40-60% of cases. The most common single pathogen is Streptococcus pneumoniae, which is identified in 15-20% of community-acquired pneumonia cases in pregnancy. Recent recommendations by the Infectious Diseases Society of America and the American Thoracic Society on the management of community-acquired pneumonia address diagnostic techniques and management schemes for bacterial and viral pneumonias. These guidelines are discussed in the setting of the pregnant woman with community-acquired pneumonia.

Maternal exposure to endotoxin delays alveolarization during postnatal rat lung development

Maternal bacterial infections adversely affect lung development by crossing the placental barrier and infecting the developing fetus. The underlying mechanism negatively affecting pulmonary development remains unknown. Herein, we investigated whether a systemic maternal infection affects postnatal inflammation and alveolar development. Pregnant rats were injected with 2.5 mg/kg LPS on day 20 and 21 (term = 22 days). Postnatal (PN0-21) mRNA and protein expression of cytokines (IL-1beta, IL-6, IL-10, CXCL1/2, TNFalpha) and genes implicated in alveologenesis [tropoelastin, lysyl oxidase (LOX), lysyl oxidase-like (LOXL)1, tenascin-C (TNC), fibulin 5, vascular endothelial growth factor (VEGF-A), VEGF receptor (VEGFR)2, VEGFR1, platelet-derived growth factor (PDGF)A, PDGFB, and PDGFRalpha] were quantified by real-time PCR and beadlyte technology. Lung transcript and protein levels of IL-1beta, IL-6, and CXCL1/2 were significantly greater in LPS-exposed pups than those of control pups at PN0, 2, 6, 10, and 14. Bronchoalveolar lavage fluid (BALF) of LPS-exposed animals contained significantly more macrophages at PN2 and 14 than BALF of control pups. Morphometric analysis revealed that LPS-exposed animals had fewer and larger alveoli, fewer secondary septa, and decreased peripheral vessel density when compared with control pups. This morphological delay in alveolar development disappeared after PN14. Tropoelastin, LOXL1, VEGF, VEGFR2, and PDGFRalpha mRNA expression of LPS-exposed animals was significantly greater than those of control animals in PN2-14 lungs. TNC, LOX, fibulin 5, VEGFR1, PDGFA, and PDGFB expression was not affected by maternal LPS exposure. Together, the data demonstrate that maternal exposure to endotoxin results in a prolonged pulmonary inflammation postnatally, altered gene expression of molecules implicated in alveologenesis, and delayed morphological maturation of the lung.

Medical issues from preconception through delivery: a roadmap for the internist

The age of the pregnant population and the number of pregnant women with medical issues are increasing. It is widely recognized that internists have the unique opportunity to identify potential pregnancy issues and address them before a problem arises. Therefore, it's important that we become aware of how to approach these issues. In addition to addressing medical issues in a currently pregnant woman, doctors also have the opportunity to identify issues that occurred during a prior pregnancy, such as gestational diabetes, preeclampsia, or pregnancy loss, and to decrease the risk of complications in future pregnancies. The goal of this article is to provide a roadmap to practicing internists so they will incorporate pregnancy planning into their everyday care plans. The approach is similar to that used when performing a preoperative risk assessment: We want to optimize our patients medically for pregnancy.

Self-regulation and women with asthma

PURPOSE OF REVIEW

Recent research related to sex and gender role influences on asthma in women is summarized. Implications for enhancing women's self-regulation and ability to manage asthma effectively are discussed.

RECENT FINDINGS

Studies in the past year have indicated that asthma is a significant burden on women and emphasized the importance of control, especially during pregnancy. The significance of hormonal variation in symptoms and severity has been noted. An association between weight and asthma has been observed. Evidence suggests that hormonal changes contribute to the asthma prevalence shift from men to women in adolescence. One study showed positive results of focusing on sex-related and gender-related factors in self-regulation education for women. Recent findings imply that enhancing self-regulation and effective management of asthma in women requires attention to sex and gender role influences in clinical counseling and intervention research.

SUMMARY

Clinicians may help female patients with asthma by incorporating sex and gender role related considerations into their clinical consultations. Evidence-based asthma education interventions to assist women with their particular asthma management challenges are needed.