Practice bulletins No. 139: premature rupture of membranes

Relationship between increased maternal serum free human chorionic gonadotropin levels in the second trimester and adverse pregnancy outcomes: a retrospective cohort study

BACKGROUND

A retrospective cohort study was conducted to collect the data of pregnant women who received hospital delivery in Hangzhou Women's Hospital from January 2018 to December 2020, and who participated in the second trimester (15-20+6 weeks) of free beta human chorionic gonadotropin (free β-hCG). And the study was conducted to explore the relationship between maternal serum free β-hCG and adverse pregnancy outcomes (APO).

METHODS

We retrospectively analyzed the clinical data of 1,978 women in the elevated maternal serum free β-hCG group (free β-hCG ≥ 2.50 multiples of the median, MoM) and 20,767 women in the normal group (0.25 MoM ≤ free β-hCG < 2.50 MoM) from a total of 22,745 singleton pregnancies, and modified Poisson regression analysis was used to calculate risk ratios (RRs) and 95% confidence intervals (CI) of the two groups.

RESULTS

The gravidity and parity in the elevated free β-hCG group were lower, and the differences between the groups were statistically significant (all, P < 0.05). The risks of polyhydramnios, preeclampsia, and hyperlipidemia, were increased in women with elevated free β-hCG levels (RRs: 1.996, 95% CI: 1.322-3.014; 1.469, 95% CI: 1.130-1.911 and 1.257, 95% CI: 1.029-1.535, respectively, all P < 0.05), intrauterine growth restriction (IUGR) and female infants were also likely to happen (RRs = 1.641, 95% CI: 1.103-2.443 and 1.101, 95% CI: 1.011-1.198, both P < 0.05). Additionally, there was an association between elevated AFP and free β-hCG levels in second-trimester (RR = 1.211, 95% CI: 1.121-1.307, P < 0.001).

CONCLUSIONS

APOs, such as polyhydramnios, preeclampsia, and hyperlipidemia, were increased risks of elevated free β-hCG levels, IUGR and female infants were also likely to happen. Furthermore, there was an association between elevated AFP levels and elevated free β-hCG levels in second-trimester. We recommend prenatal monitoring according to the elevated maternal serum free β-hCG level and the occurrence of APO.

Incidence and management of premature rupture of membranes in Victoria, Australia: A retrospective cohort study of 636 590 births between 2009 and 2017

BACKGROUND

Premature rupture of membranes (PROM) is a complication affecting 7-12% of pregnancies in which fetal chorioamniotic membranes rupture before labour begins. Preterm PROM (PPROM) (ie <37 weeks gestation) precedes one-third of preterm births, exposing the fetus to increased morbidity from placental abruption, respiratory distress syndrome and sepsis.

AIM

To analyse trends in the incidence and mode of birth in preterm and term PROM in Victoria, Australia between 2009 and 2017.

MATERIALS AND METHODS

This retrospective population-based cohort study included all singleton pregnancies from 2009 to 2017. We examined women with PROM (both <37 weeks (PPROM) and at term). Management was assessed in three categories: (a) expectant management; (b) induction of labour (IOL); and (c) elective caesarean section (elCS). A multinomial logistic regression model was used to adjust for confounders influencing the choice of management.

RESULTS

Of 636 590 singleton pregnancies, 52 669 (8.3%) births with PROM at term (42 439; 6.7%) or PPROM (10 230; 1.6%) were identified. Of these, the majority were managed expectantly (n = 22 726; 43.1%), or with IOL (25 931; 49.2%). While elCS represented only 7.6% of these cases (n = 4012), its use rose consistently from 2009 to 2017 for PROM at term and PPROM alike. For women with PPROM at 34-36 weeks the odds of elCS increased by 5% annually (adjusted odds ratio (aOR) 1.05; 95% CI 1.02-1.08) and 2% for IOL (aOR 1.02; 95% CI 1.00-1.05) vs expectant management.

CONCLUSIONS

The use of elCS and IOL in PPROM is rising in Victoria, particularly between 34 and 36 completed weeks of pregnancy. Research is needed to determine the drivers for this increase.

Perinatal factors and early neonatal outcomes of abnormal birthweight infants in Hangzhou, China, 2015-2021: a retrospective cohort study

BACKGROUND

This study aimed to investigate the perinatal factors and early neonatal outcomes of abnormal birth weight (ABW) in Hangzhou, China from 2015 to 2021.

METHODS

A retrospective cohort study was designed to analyse the data of 76 847 newborns, in which the case groups included 3042 cases of low birth weight (LBW) and 2941 cases of fetal macrosomia (MAC), and 70 864 cases of normal weight were as the reference group.

RESULTS

The incidence of LBW and MAC was 3.96% and 3.83% in Hangzhou, China from 2015 to 2021. Prematurity (<37 weeks), multiple births, hospitalisation >7 days, fetal anomalies, caesarean section, pregnancy complications, maternal coinfection with pathogens and summer births would be correlated with the incidence of LBW (ORs=43.50, 7.60, 2.09, 1.89, 1.57, 1.28, 1.19 and 1.18, all p<0.05). Factors such as post-term pregnancy (>41 weeks), scarred uterus, anterior vaginal incision and gravidity ≥2 were correlated with decreased incidence of LBW, with ORs of 0.05, 0.54, 0.65 and 0.80. Moreover, caesarean delivery, post-term pregnancy (> 41 weeks), parity ≥1, lateral vaginal incision, gravidity ≥2, hospitalisation >7 days, winter births and pregnancy complications also have association with the incidence of MAC (ORs=3.92, 2.73, 2.19, 1.87, 1.22, 1.20, 1.17 and 1.13, all p<0.05) while prematurity (<37 weeks), scarred uterus and anterior vaginal incision have close association with decreased incidence of MAC, with ORs of 0.07, 0.21 and 0.74 (all p<0.05).

CONCLUSION

There was a trend of yearly increase in ABW in Hangzhou, China from 2015 to 2021. Several neonatal and maternal-related variables such as caesarean section, pregnancy complications and hospitalisation >7 days are associated with the odds of LBW and MAC, however, factors such as pregnancy with scarred uterus relate to the decrease of ABW. Close monitoring and intervention during pregnancy are essential to reduce the occurrence of ABW.

Perinatal characteristics and pregnancy outcomes of advanced maternal age women with gestational diabetes mellitus: A retrospective cohort study

Background and Aims

The prevalence of gestational diabetes mellitus (GDM) continues to increase, and the phenomenon of women giving birth at an older age is becoming more common worldwide. Less is known abouts the impact of GDM combined with advanced maternal age (AMA) on pregnancy outcomes. To explore the impact of AMA complicated with GDM on pregnancy outcomes.

Methods

This study included 34,602 pregnancies between 2018 and 2020 in Hangzhou, China. The pregnant women were divided into four groups according to advanced age (≥35 years) and GDM as follows: AMA women without GDM (non-AGDM) group (n = 2614), young pregnant women with GDM (YGDM) group (n = 4016), AMA women with GDM (AGDM) group (n = 850), and young pregnant women without GDM (non-YGDM) group (n = 27,122). Univariate analysis was carried out by Mann-Whitney U test or Pearson's χ 2 test. Multivariate logistic regression analysis was used to investigate the effect of AMA and GDM on pregnancy outcomes.

Results

Multivariate logistic regression analysis showed that in the comparison against non-YGDM garoup, the ORs of fetal chromosome abnormality, parity, urgent cesarean section, gravidity, scheduled cesarean section, body mass index (BMI) ≥30 kg/m2, pre-eclampsia, thrombocytopenia, hyperlipidemia, BMI 25-29.9 kg/m2, blood urea nitrogen, fasting blood glucose, and creatinine in AGDM group were 16.044, 4.284, 3.530, 3.284, 3.257, 2.049, 1.935, 1.898, 1.690, 1.471, 1.304, 1.216, and 1.026 (all p < 0.05).

Conclusions

The prevalence of pregnant women with AGDM was 2.46% in Hang Zhou, China. The increasing gravidity of AMA women was related to a greater risk of GDM. The AGDM group associated with a greater risks of chromosomal abnormality in offspring and cesarean section, especially urgent cesarean section.

Correlation between elevated maternal serum alpha-fetoprotein and ischemic placental disease: a retrospective cohort study

BACKGROUND

To evaluate the correlation between elevated maternal serum alpha-fetoprotein (AFP) in the second trimester and ischemic placental disease (IPD).

METHODS

A retrospective cohort study was conducted to analyze the data of 22,574 pregnant women who delivered in the Department of Obstetrics at Hangzhou Women's Hospital from 2018 to 2020, and were screened for maternal serum AFP and free beta-human chorionic gonadotropin (free β-hCG) in the second trimester. The pregnant women were divided into two groups: elevated maternal serum AFP group (n = 334, 1.48%); and normal group (n = 22,240, 98.52%). Mann-Whitney U-test or Chi-square test was used for continuous or categorical data. Modified Poisson regression analysis was used to calculate the relative risk (RR) and 95% confidence interval (CI) of the two groups.

RESULTS

The AFP MoM and free β-hCG MoM in the elevated maternal serum AFP group were higher than the normal group (2.25 vs. 0.98, 1.38 vs. 1.04) and the differences were all statistically significant (all P < .001). Placenta previa, hepatitis B virus carrying status of pregnant women, premature rupture of membranes (PROM), advanced maternal age (≥35 years), increased free β-hCG MoM, female infants, and low birth weight (RR: 2.722, 2.247, 1.769, 1.766, 1.272, 0.624, 2.554 respectively) were the risk factors for adverse maternal pregnancy outcomes in the elevated maternal serum AFP group.

CONCLUSIONS

Maternal serum AFP levels during the second trimester can monitor IPD, such as IUGR, PROM, and placenta previa. Maternal women with high serum AFP levels are more likely to deliver male fetuses and low birth weight infants. Finally, the maternal age (≥35 years) and hepatitis B carriers also increased maternal serum AFP significantly.

Addressing a broken drug pipeline for preterm birth: why early preterm birth is an orphan disease

Preterm birth remains one of the most urgent unresolved medical problems in obstetrics, yet only 2 therapeutics for preventing preterm birth have ever been approved by the United States Food and Drug Administration, and neither remains on the market. The recent withdrawal of 17-hydroxyprogesterone caproate (17-OHPC, Makena) marks a new but familiar era for obstetrics with no Food and Drug Administration-approved pharmaceuticals to address preterm birth. The lack of pharmaceuticals reflects a broad and ineffective pipeline hindered by extensive regulatory hurdles, soaring costs of performing drug research, and concerns regarding adverse effects among a particularly vulnerable population. The pharmaceutical industry has historically limited investments in research for diseases with similarly small markets, such as cystic fibrosis, given their rarity and diminished projected financial return. The Orphan Drug Act, however, incentivizes drug development for "orphan diseases", defined as affecting <200,000 people in the United States annually. Although the total number of preterm births in the United States exceeds this threshold annually, the early subset of preterm birth (<34 weeks' gestation) would qualify, which is predominantly caused by inflammation and infection. The scientific rationale for classifying preterm birth into early and late subsets is strong given that their etiologies differ, and therapeutics that may be efficacious for one subset may not work for the other. For example, antiinflammatory therapeutics would be expected to be highly effective for early but not late preterm birth. A robust therapeutic pipeline of antiinflammatory drugs already exists, which could be used to target spontaneous early preterm birth, in combination with antibiotics shown to sterilize the amniotic cavity. New applications for therapeutics targeting spontaneous early preterm birth could categorize as orphan disease drugs, which could revitalize the preterm birth therapeutic pipeline. Herein, we describe why drugs targeting early preterm birth should qualify for orphan status, which may increase pharmaceutical interest for this vitally important obstetrical condition.

Comparison of Perinatal Outcomes Between Syrian Refugees and Turkish Women in the Middle Anatolia Region of Turkey

OBJECTIVE

To compare the results of perinatal outcomes between Syrian refugees and Turkish women between 2016 and 2020.

METHODS

The birth results of 17,997 participants (Syrian refugees: 3579 and Turkish women: 14,418) who delivered in the Labor Department of our hospital between January 2016 and December 2020 were retrospectively analyzed.

RESULTS

Maternal age was younger (24.73 ± 6.08 vs. 27.4 ± 5.91 years, p < 0.001) and adolescent pregnancy rate was higher (19.4% vs. 5.6%, p < 0.001) in Syrian refuges than in Turkish women. Bishop scores on admission (4.6 ± 1.6 vs. 4.4 ± 1.1, p < 0.001), birth weight (3088.19 ± 575.32 g vs. 3109.76 ± 540.89 g, p = 0.044), low birth weight (11.3% vs. 9.7%, p = 0.004), and the rate of primary cesarean deliveries (10.1% vs. 15.8%, p < 0.001) were also statistically different. Additionally, the rates of anemia (65.9% vs. 29.2%, p < 0.001), preeclampsia (1.4% vs. 2.7%, p < 0.001), stillbirth (1.3% vs. 0.6%, p < 0.001), preterm premature rupture of membranes (2.7% vs. 1.9%, p = 0.002), and obstetric complications were different between the groups.

CONCLUSIONS

This study showed that inadequate antenatal care, communication and language barrier problems in Syrian refugees caused some adverse perinatal outcomes. All birth data of Syrian refugees must be disclosed by the Ministry of Health to confirm the accuracy of our data.

Incidence, temporal trends and risk factors of puerperal infection in Mainland China: a meta-analysis of epidemiological studies from recent decade (2010-2020)

BACKGROUND

Puerperal infection (PI) is a severe threat to maternal health. The incidence and risk of PI should be accurately quantified and conveyed for prior decision-making. This study aims to assess the quality of the published literature on the epidemiology of PI, and synthesize them to identify the temporal trends and risk factors of PI occurring in Mainland China.

METHODS

This review was registered in PROSPERO (CRD42021267399). Putting a time frame on 2010 to March 2022, we searched Cochrane library, Embase, Google Scholar, MEDLINE, Web of Science, China biology medicine, China national knowledge infrastructure and Chinese medical current contents, and performed a meta-analysis and meta-regression to pool the incidence of PI and the effects of risk factors on PI.

RESULTS

A total of 49 eligible studies with 133,938 participants from 17 provinces were included. The pooled incidence of PI was 4.95% (95%CIs, 4.46-5.43), and there was a statistical association between the incidence of PI following caesarean section and the median year of data collection. Gestational hypertension (OR = 2.14), Gestational diabetes mellitus (OR = 1.82), primipara (OR = 0.81), genital tract inflammation (OR = 2.51), anemia during pregnancy (OR = 2.28), caesarean section (OR = 2.03), episiotomy (OR = 2.64), premature rupture of membrane (OR = 2.54), prolonged labor (OR = 1.32), placenta remnant (OR = 2.59) and postpartum hemorrhage (OR = 2.43) have significant association with PI.

CONCLUSIONS

Maternal infection remains a crucial complication during puerperium in Mainland China, which showed a nationwide temporal rising following caesarean section in the past decade. The opportunity to prevent unnecessary PI exists in several simple but necessary measures and it's urgent for clinicians and policymakers to focus joint efforts on promoting the bundle of evidence-based practices.

Impact of extending criteria for home care management in Preterm Prelabor Rupture of Membranes

BACKGROUND

Preterm prelabor rupture of membranes (PPROM) is a frequent obstetrical condition with risks of maternal and neonatal morbidity and mortality. Home hospitalization (HH) management is an alternative to conventional hospitalization (CH) which remains controversial, and there has been little study of eligibility criteria.

OBJECTIVE

To study obstetrical and perinatal outcomes of PPROM between 24 and 34 gestational weeks in patients discharged to homecare after 4 days, based on a policy of expanded discharge criteria.

STUDY DESIGN AND SETTING

Retrospective before-and-after study over 10 years in a single French level III perinatal center. In period A (2009-2013), discharge criteria were restrictive and in period B (2015-2019), more extended discharge criteria were adopted. The primary outcome was the incidence of confirmed early-onset neonatal sepsis (EOS).

RESULTS

The proportion of patients discharged to home hospitalization increased from 28/170 (16.5) in period A to 39/114 (34.2) in period B (p < 0.01). Regarding the primary outcome, no statistically significant difference in EOS rates was observed between periods (11/153 (7.1) vs 5/110 (4.5), p = 0.37). The incidence of a composite outcome combining severe perinatal complications (intrauterine fetal demise, placental abruption and cord prolapse) did not significantly increase during period B (7/170 (4.1) vs 4/114 (2.7), p = 0.37). There was no significant difference between the periods for chorioamniotitis (9.41% in period A and 11.4% in period B, p = 0.58).

CONCLUSION

Severe maternal or neonatal complications rates did not increase when criteria for home hospitalization were expanded. Larger, prospective studies are needed to confirm the results of such a strategy.

Effect of maternal age and body mass index on induction of labor with oral misoprostol for premature rupture of membrane at term: A retrospective cross-sectional study

The aim of this study was to evaluate the effect of maternal age and body mass index (BMI) on induction of labor with oral misoprostol for premature rupture of membrane (PROM) at term. We have conducted retrospective cross-sectional study, including only term (37 weeks or more of gestation) PROM in healthy nulliparous women with a negative vaginal-rectal swab for group B streptococcus, a single cephalic fetus with normal birthweight, and uneventful pregnancy that were induced after 24 h from PROM. Ninety-one patients were included. According to the multivariate logistic regression, age and BMI odds ratio (OR) for induction success were 0.795 and 0.857, respectively. The study population was divided into two groups based on age (<35 and ≥35 years) and obesity (BMI <30 and ≥30). Older women reported a higher induction failure rate (p < 0.001); longer time to cervical dilation of 6 cm (p = 0.03) and delivery (p < 0.001). Obese women reported a higher induction failure rate (p = 0.01); number of misoprostol doses (p = 0.03), longer time of induction (p = 0.03) to cervical dilatation of 6 cm (p < 0.001), and delivery (p < 0.001); and higher cesarean section (p = 0.012) and episiotomy rate (p = 0.007). In conclusion, maternal age and BMI are two of the main factors that influence oral misoprostol efficacy and affect the failure of induction rate in term PROM.

Control of lupus activity during pregnancy via the engagement of IgG sialylation: novel crosstalk between IgG sialylation and pDC functions

Immunoglobulin (IgG) glycosylation affects the effector functions of IgG in a myriad of biological processes and has been closely associated with numerous autoimmune diseases, including systemic lupus erythematosus (SLE), thus underlining the pathogenic role of glycosylation aberration in autoimmunity. This study aims to explore the relationship between IgG sialylation patterns and lupus pregnancy. Relative to that in serum samples from the control cohort, IgG sialylation level was aberrantly downregulated in serum samples from the SLE cohort at four stages (from preconception to the third trimester of pregnancy) and was significantly associated with lupus activity and fetal loss during lupus pregnancy. The type I interferon signature of pregnant patients with SLE was negatively correlated with the level of IgG sialylation. The lack of sialylation dampened the ability of IgG to suppress the functions of plasmacytoid dendritic cells (pDCs). RNA-seq analysis further revealed that the expression of genes associated with the spleen tyrosine kinase (SYK) signaling pathway significantly differed between IgG- and deSia-IgG-treated pDCs. This finding was confirmed by the attenuation of the ability to phosphorylate SYK and BLNK in deSia-IgG. Finally, the coculture of pDCs isolated from pregnant patients with SLE with IgG/deSia-IgG demonstrated the sialylation-dependent anti-inflammatory function of IgG. Our findings suggested that IgG influences lupus activity through regulating pDCs function via the modulation of the SYK pathway in a sialic acid-dependent manner.

Optimal timing of labor induction after prelabor rupture of membranes at term: a secondary analysis of the TERMPROM study

BACKGROUND

In the case of prelabor rupture of membranes at term, the risk for neonatal and maternal infectious morbidity increases progressively with time from prelabor rupture of membranes. Although most studies identified a benefit associated with early induction within the first 24 hours following term prelabor rupture of membranes, there is currently no precise data regarding how early should induction be scheduled.

OBJECTIVE

This study aimed to identify the optimal timing of labor induction among women with term prelabor rupture of membranes by comparing the maternal and neonatal outcomes associated with labor induction with those of expectant management at any given 1-hour interval following prelabor rupture of membranes.

STUDY DESIGN

This was a secondary analysis of data from the TERMPROM trial, an international, multicenter, randomized clinical trial on immediate delivery vs expectant management of women with prelaor rupture of membranes at term (≥37+0/7 weeks' gestation). We considered all participants as a single cohort of women with term prelabor rupture of membranes, irrespective of the original randomized study group allocation. For each given 1-hour time interval within the first 36 hours following prelabor rupture of membranes, we compared the outcomes of subjects for whom labor induction was initiated during this interval with those of subjects managed expectantly at the same time interval. The primary neonatal outcome was a composite of neonatal infection and admission to the neonatal intensive care unit. The primary maternal outcomes included maternal infection (clinical chorioamnionitis or postpartum fever) and cesarean delivery.

RESULTS

Of the 4742 subjects who met the study criteria, 2622 underwent labor induction, and 2120 experienced a spontaneous onset of labor. The rates of the neonatal composite outcome, neonatal admission to intensive care unit, and maternal infection increased progressively with time after prelabor rupture of membranes. The risk for these outcomes was lower among women who underwent induction when compared with those managed expectantly within the first 15 to 20 hours after prelabor rupture of membranes without affecting the risk for cesarean delivery. In addition, women who underwent labor induction within the first 30 to 36 hours had a shorter prelabor rupture of membranes to delivery time and a shorter total maternal hospital stay when compared with those managed expectantly at the same time interval. Among women managed expectantly, less than two-thirds (64%; 1365/2120) experienced a spontaneous onset of labor within the first 24 hours following prelabor rupture of membranes.

CONCLUSION

These findings suggest that immediate labor induction seems to be the optimal management strategy to minimize neonatal and maternal morbidity in the setting of prelabor rupture of membranes at term gestations. In cases for which immediate induction is not feasible, labor induction remains the preferred option over expectant management if performed within the first 15 to 20 hours after prelabor rupture of membranes.

The impact of intrahepatic cholestasis on pregnancy outcomes: a retrospective cohort study

BACKGROUND

This study analyzed the pregnancy outcomes of patients with intrahepatic cholestasis of pregnancy (ICP) in Hangzhou, China.

METHODS

Cases of pregnant women monitored by antepartum testing at Hangzhou Women's Hospital from January 2018 to December 2020 were reviewed. Subjects were classified into two groups according to whether they had ICP: 688 cases of ICP were assigned to an exposure group while 38,556 cases of non-ICP were assigned to a non-exposed group. Univariate analysis was performed on qualitative or quantitative data using the Chi-Squared test or Mann-Whitney U test, and the adjusted odds ratio (aOR) and 95% confidence interval (CI) of the two groups of related variables were calculated by multivariate binary logistic regression analysis.

RESULTS

The incidence rate of ICP was 1.75%. Pregnant women with hepatitis B virus were correlated with ICP. Hepatitis B carriers (aOR = 3.873), preeclampsia (PE, aOR = 3.712), thrombocytopenia (aOR = 1.992), gestational hypertension (GH, aOR = 1.627), hyperlipidemia (aOR = 1.602) and gestational diabetes mellitus (GDM, aOR = 1.265) were all risk factors for ICP. In contrast, Body Mass Index (BMI) ≥ 30 kg/m² (aOR = 0.446), 25 m² < maternal BMI < 29.9 kg/m² (aOR = 0.699) and parity ≥ 1 (aOR = 0.722) were protective factors for ICP. Pregnant women in the ICP group had an increased risk of gestation days < 259 days (aOR = 4.574) and cesarean delivery (aOR = 1.930) after ICP, and a decreased risk of longer gestational days (aOR = 0.105), premature rupture of membranes (aOR = 0.384) and fetal macrosomia (aOR = 0.551).

CONCLUSIONS

By analyzing a Chinese population with ICP, we identified that pregnant women who are hepatitis B carriers or with PE, thrombocytopenia, GH, hyperlipidemia, and GDM are at higher risk of ICP. Moreover, ICP is associated with adverse pregnancy outcomes; in particular, ICP may increase the incidence of shorter gestational days and non-vaginal delivery methods such as cesarean section but reduce the incidence of premature rupture of membranes and fetal macrosomia.

[Perinatal risk factors for the occurrence of singleton apparently stillborn infants]

OBJECTIVES

To identify the perinatal risk factors for the occurrence of singleton apparently stillborn infants.

METHODS

This was a case-control study. A total of 154 singleton neonates with gestational age ≥28 weeks and Apgar score of 0-1 who were subsequently successfully resuscitated in the Obstetrics and Gynecology Hospital of Fudan University from January 2006 to December 2015 were enrolled as the case group (apparently stillborn group). A total of 616 singleton infants born from January 2006 to December 2015 (1-minute Apgar score >1) were randomly selected in a 1:4 ratio as the control group. Univariate analysis and multivariate logistic regression were used to analyze the perinatal risk factors for the occurrence of apparently stillborn infants.

RESULTS

The gestational age and birth weight in the apparently stillborn group were significantly lower than those in the control group (P<0.05). The incidences of fetal hydrops, cord prolapse, grade III meconium-stained amniotic fluid, placental abruption, breech presentation, severe pre-eclampsia, maternal general anesthesia at delivery, abnormal antenatal fetal heart monitoring and decreased fetal movement were significantly higher in the apparently stillborn group than those in the control group (P<0.05). The multivariate logistic analysis showed that the mother had general anesthesia at delivery (OR=34.520), decreased antenatal fetal movement (OR=28.168),placental abruption (OR=15.641), grade III meconium-stained amniotic fluid (OR=6.365), abnormal antenatal fetal heart monitoring (OR=5.739), and breech presentation (OR=2.614) were risk factors for the occurrence of apparently stillborn infants (P<0.05), while higher gestational age was a protective factor (OR=0.686, P<0.05).

CONCLUSIONS

Attention needs to be paid to mothers with abnormal prenatal fetal heart monitoring, decreased fetal movement, preterm labor, placental abruption, breech presentation, grade III meconium-stained amniotic fluid, and general anesthesia. Preparations for resuscitation should be done to rescue apparently stillborn infants.

Determinants for perinatal adverse outcomes among pregnant women with preterm premature rupture of membrane: A prospective cohort study

Background

One of the most critical functions of the fetal membranes is to remain intact until the onset of labor to maintain the protective intrauterine fluid environment. In most pregnancies, spontaneous rupture usually occurs near the end of the first stage of labor. Preterm premature membrane rupture (PROM) occurs when the fetal membrane ruptures before 37 weeks of pregnancy, and it contributes to adverse maternal, fetal, and neonatal outcomes. Therefore, this study aimed to determine the association of determinant factors with adverse perinatal outcomes.

Methods

A prospective cohort study was conducted on pregnant women with preterm premature membrane rupture (n = 160) attending the teaching hospitals at Addis Ababa University. Socio-demographic and obstetric risk factors with adverse perinatal outcomes include the 5th minute Apgar score, neonatal intensive care unit (NICU) admission, early-onset neonatal sepsis (EONS), respiratory distress syndrome (RDS), perinatal mortality, Chorioamnionitis, and placental abruption were assessed. SPSS version 24, t-test, χ ² test, and logistic regression analysis were used. P-values <0.25 in the bivariate and p < 0.05 in the multiple logistic regression were considered statistically significant.

Results

The preterm (PROM) rate was 2.2% with perinatal mortality rate of 206/1,000. Gestational age (GA) at delivery was the determinate for low Apgar score at the 5th minute (AOR: 7.23; 95% CI, 1.10, 47.6; p = 0.04). Unable to use steroid (AOR: 8.23; 95% CI, 1.83, 37.0; p = 0.000), GA at membrane rupture (AOR: 4.61; 95% CI, 1.98, 31.8; p = 0.000) and delivery (AOR: 4.32; 95% CI, 1.99, 30.9; p = 0.000) were determinates for NICU admission. EONS was significantly affected by GA at membrane rupture (AOR: 5.9; 95% CI, 1.01, 37.0; p = 0.04). Placental abruption was significantly affected by GA at delivery (AOR: 7.52; 95% CI, 1.15, 48.96; p = 0.04).

Conclusion

GA at membrane rupture and delivery was the most critical predictors of adverse perinatal outcomes. Local guidelines on the approach and preterm PROM outcome management need to be prepared.

Non-invasive prediction of histologic chorioamnionitis using maternal serum markers in women with preterm prelabour rupture of membranes

PROBLEM

This study aimed to evaluate and compare the predictive accuracy of serum markers for histological chorioamnionitis (HCA) among women with preterm prelabour rupture of membranes (PPROM), and to develop a nomogram prediction model to minimize the damage of the disease.

METHOD OF STUDY

This case-control study included 153 pregnant women with PPROM with a gestational age of 20⁺⁰ ∼ 36⁺⁶ weeks. The subjects were assigned into two groups: PPROM with and without HCA. According to the results of Logistic regression analysis, the predictive equation and nomogram were generated using key parameters, and the discrimination and consistency of the model were evaluated by receiver operating characteristic (ROC) curves and calibration curves.

RESULTS

From 153 subjects with PPROM, 77 developed HCA. Compared with the PPROM without HCA group, the CRP, PCT and NLR were significantly higher in HCA group (P<0.001), and the CRP had the highest predictive value. The area under the curve (AUC) of the prediction model was 0.873, and the sensitivity and specificity of predicting HCA were 68.8% and 92.1%, respectively. And the calibration curves fitted well with the realistic situation.

CONCLUSION

Maternal serum CRP and NLR could be used as predictive biomarkers for HCA in women with PPROM, while PCT needs to be further explored due to its slightly lower predictive value. Our serum markers and gestational age at PPROM could be used as a non-invasive and convenient method to predict HCA in women with PPROM. This article is protected by copyright. All rights reserved.

Estimated time to emergence of secondary intra-amniotic infection or inflammation since the onset of the preterm premature rupture of membranes

OBJECTIVE

Prematurity is the most important prognostic factor for infants born following preterm premature rupture of membranes (PPROM). Therefore, when PPROM occurs between 22 and 33 weeks of gestation, prolonging pregnancy is recommended. Determination of management strategies requires screening for the presence of intra-amniotic infection or inflammation at the time of PPROM diagnosis. If intra-amniotic infection/inflammation is not detected, it is important to monitor the patient to diagnose any new infection/inflammation. We examined the period from PPROM to secondary intra-amniotic infection/inflammation and associated factors.

MATERIALS AND METHODS

This retrospective study was conducted at a single facility. We examined 26 patients who experienced PPROM between 26 and 33 weeks of gestation and were negative for intra-amniotic infection/inflammation at the time of diagnosis and underwent serial amniocentesis. Antibiotic therapy comprising ampicillin, amoxicillin, and clarithromycin for 7 days was started after the first amniocentesis. The period from PPROM to secondary intra-amniotic infection/inflammation was analyzed using a Kaplan-Meier survival curve. The onset of intra-amniotic infection/inflammation was considered as the time at which amniotic fluid bacterial culture results became positive, the time when amniotic fluid Interleukin (IL)-6 increased beyond 2.6 ng/mL, or the day of delivery if histological chorioamnionitis was observed in the delivered placenta. Patients were treated as censored if no intra-amniotic infection/inflammation could be confirmed in the amniotic fluid and delivered placenta.

RESULTS

The median time from PPROM to secondary intra-amniotic infection/inflammation was 18 days. Six patients developed intra-amniotic infection/inflammation, while 13 patients without intra-amniotic infections/inflammation delivered fewer than 7 days after PPROM. No confounding factors at the time of PPROM diagnosis were associated with the time from PPROM until secondary intra-amniotic infection/inflammation.

CONCLUSIONS

The time between PPROM and onset of secondary intra-amniotic infection/inflammation appears prolonged. Treatments other than antimicrobial agents may need to be added to prolong pregnancy.

Hemodynamic assessment in patients with preterm premature rupture of the membranes (pPROM)

OBJECTIVE

The aim of this study was to assess the hemodynamic differences in women with pPROM versus physiological pregnancies.

STUDY DESIGN

This was a prospective case control study of 15 patients with pPROM and 45 controls. Patients and controls were submitted at enrollment to a non-invasive hemodynamic evaluation with UltraSonic Cardiac Output Monitor (USCOM), and to blood tests to check white blood cells count and C-reactive protein (CRP) levels. We followed pPROM patients until delivery noting fetal/neonatal and maternal unfavorable outcomes (maternal fever, APGAR 1' and 5'< 7, stillbirth).

RESULTS

Patients with pPROM showed higher values of cardiac output (9.1 ± 2.3 vs 7.1 ± 0.85, p < 0.01), lower systemic vascular resistances (792.1 ± 162 vs 1006.2 ± 110.7, p < 0.01), higher minute distance (32.3 ± 7.8 vs 25 ± 2.8, p < 0.01), lower Potential to Kinetic Energy Ratio (16.5 ± 5.3 vs 22.4 ± 6.8, p < 0.01), higher heart rate (97.5 ± 15.4 vs 82.4 ± 12, p < 0.01) and higher oxygen delivery (1313.2 ± 325.8 vs 1080.7 ± 151.8, p < 0.01) vs. controls. Six out of 15 pPROM patients had an unfavorable outcome. There were no significant differences in CRP levels and WBC count at admission in the two pPROM subgroups, whereas maternal hemodynamics was characterized by lower SVR (718 ± 72 vs 863 ± 123, p = 0.02) in subsequently complicated patients.

CONCLUSIONS

Maternal hemodynamics is altered in pPROM patients, with a lower Systemic Vascular Resistance and higher Cardiac Output vs. controls. This hyperdynamic circulation appears to anticipates the changes of serum markers of inflammation (CRP, WBC count) and seems to be more pronounced at admission in pPROM patients developing unfavorable outcomes.

Maternal hepatitis B surface antigen Carrier Status and Pregnancy Outcome: A Retrospective Cohort Study

To investigate the effect of maternal hepatitis B surface antigen (HBsAg) carrier status during pregnancy on pregnancy outcomes in a population of patients in Hangzhou, China. A retrospective cohort study was conducted to analyse data from 20 753 pregnant women who delivered at Hangzhou Women's Hospital between January 2015 and March 2020. Of these, 18 693 were normal pregnant women (the non-exposed group) and 735 were HBsAg carriers (the exposed group). We then analysed by binary multivariate logistic regression to determine the association between maternal HBsAg-positive and adverse pregnancy outcomes. The prevalence of HBsAg carriers was 3.78% and the odds ratio (OR) for maternal age in the exposed group was 1.081. Pregnant women who are HBsAg-positive in Hangzhou, China, are at higher risk of a range of adverse pregnancy outcomes, including intrahepatic cholestasis of pregnancy (ICP) (adjusted OR (aOR) 3.169), low birth weight (aOR 2.337), thrombocytopenia (aOR 2.226), fallopian cysts (aOR 1.610), caesarean scar pregnancy (aOR 1.283), foetal distress (aOR 1.414). Therefore, the obstetricians should pay particular attention to ICP, low birth weight, thrombocytopenia, fallopian cysts, caesarean scar, foetal distress in HBsAg-positive pregnant women.

Development of standard definitions and grading for Maternal and Fetal Adverse Event Terminology

OBJECTIVE

Adverse event (AE) monitoring is central to assessing therapeutic safety. The lack of a comprehensive framework to define and grade maternal and fetal AEs in pregnancy trials severely limits understanding risks in pregnant women. We created AE terminology to improve safety monitoring for developing pregnancy drugs, devices and interventions.

METHOD

Existing severity grading for pregnant AEs and definitions/indicators of 'severe' and 'life-threatening' conditions relevant to maternal and fetal clinical trials were identified through a literature search. An international multidisciplinary group identified and filled gaps in definitions and severity grading using Medical Dictionary for Regulatory Activities (MedDRA) terms and severity grading criteria based on Common Terminology Criteria for Adverse Event (CTCAE) generic structure. The draft criteria underwent two rounds of a modified Delphi process with international fetal therapy, obstetric, neonatal, industry experts, patients and patient representatives.

RESULTS

Fetal AEs were defined as being diagnosable in utero with potential to harm the fetus, and were integrated into MedDRA. AE severity was graded independently for the pregnant woman and her fetus. Maternal (n = 12) and fetal (n = 19) AE definitions and severity grading criteria were developed and ratified by consensus.

CONCLUSIONS

This Maternal and Fetal AE Terminology version 1.0 allows systematic consistent AE assessment in pregnancy trials to improve safety.

Risk Factors for Intrapartum Cesarean Section Delivery in Low-risk Multiparous Women Following at Least a Prior Vaginal Birth (Robson Classification 3 and 4)

OBJECTIVE

 The aim of the present study was to evaluate the risk factors for cesarean section (C-section) in low-risk multiparous women with a history of vaginal birth.

METHODS

 The present retrospective study included low-risk multiparous women with a history of vaginal birth who gave birth at between 37 and 42 gestational weeks. The subjects were divided into 2 groups according to the mode of delivery, as C-section Group and vaginal delivery Group. Risk factors for C-section such as demographic characteristics, ultrasonographic measurements, smoking, weight gain during pregnancy (WGDP), interval time between prior birth, history of macrosomic birth, and cervical dilatation at the admission to the hospital were obtained from the charts of the patients. Obstetric and neonatal outcomes were compared between groups.

RESULTS

 The most common C-section indications were fetal distress and macrosomia (33.9% [n = 77 and 20.7% [n = 47] respectively). A bivariate correlation analysis demonstrated that mothers aged > 30 years old (odds ratio [OR]: 2.09; 95% confidence interval [CI]: 1.30-3.34; p = 0.002), parity >1 (OR: 1.81; 95%CI: 1.18-2.71; p = 0.006), fetal abdominal circumference (FAC) measurement > 360 mm (OR: 34.20; 95%CI: 8.04-145.56; p < 0.001)) and < 345 mm (OR: 3.06; 95%CI: 1.88-5; p < 0.001), presence of large for gestational age (LGA) fetus (OR: 5.09; 95%CI: 1.35-19.21; p = 0.016), premature rupture of membranes (PROM) (OR: 1.52; 95%CI: 1-2.33; p = 0.041), and cervical dilatation < 5cm at admission (OR: 2.12; 95%CI: 1.34-3.34; p = 0.001) were associated with the group requiring a C-section.

CONCLUSION

 This is the first study evaluating the risk factors for C-section in low-risk multiparous women with a history of vaginal birth according to the Robson classification 3 and 4. Fetal distress and suspected fetal macrosomia constituted most of the C-section indications.

Effects of histone H4 hyperacetylation on inhibiting MMP2 and MMP9 in human amniotic epithelial cells and in premature rupture of fetal membranes

Histone modification is closely associated with several diseases. The aim of the current study was to investigate the associations among histone acetylation, matrix metalloproteinases (MMPs) and premature rupture of membranes (PROM) during pregnancy. A total of 180 puerperants were divided into three groups: i) Preterm-PROM (PPROM), ii) term-PROM (TPROM) and iii) full-term labor (FTL). Enzyme-linked immunosorbent assay (ELISA) kits and western blotting were used to determine the protein concentrations of MMP2, MMP9, histone deacetylase (HDAC)1, HDAC2 and HDAC6, and the protein levels of histone H4 lysine (H4K)5 and H4K8 acetylation, respectively, in three types of fetal membranes. Additionally, human amniotic epithelial cells were used to determine the effects of the HDAC inhibitors droxinostat and chidamide on cell viability, histone acetylation and the levels of MMP2, MMP9, HDAC1, HDAC2 and HDAC6 in vitro, using the Cell Counting Kit-8 assay, western blotting and ELISA, respectively. Furthermore, the effects of droxinostat and chidamide on the invasion and migration abilities of human amniotic epithelial cells were investigated using transwell assays. In fetal membranes, the activities of MMP2 and MMP9 increased in PPROM, but decreased in TPROM. Further, the expression of HDAC1 was decreased and histone hyperacetylation was increased in both PPROM and TRPOM. In vitro experiments revealed that 5 µM droxinostat and 0.5 µM chidamide selectively decreased the level of HDAC and induced acetylation of H4K5 and H4K8. Additionally, the aforementioned HDAC inhibitors reduced human amniotic epithelial cell viability, invasion and migration, and decreased the expression levels of MMP2 and MMP9. The current study revealed a high expression level of MMP2 and MMP9 in PPROM compared with TPROM and FL tissue, which was in accordance with previously published studies. Furthermore, the in vitro tests performed in the current study revealed the effect of histone H4 hyperacetylation on inhibiting MMP2 and MMP9 levels in vitro was similar to that observed in TPROM. The results obtained in the current study may be used as a theoretical guide for clinical treatment of premature rupture of membranes.

Risk Factors and Safety Analyses for Intrapartum Fever in Pregnant Women Receiving Epidural Analgesia During Labor

Background

We aimed to explore the factors leading to epidural-related maternal fever and the influence of intrapartum fever on neonates.

Material/Methods

A retrospective analysis was performed on data from pregnant women who received epidural analgesia during labor. The primary aim was to determine the influence of epidural labor analgesia on the incidence of intrapartum fever in pregnant women. The secondary aim was to determine the influence of intrapartum fever on neonates.

Results

Logistic regression analysis showed that premature rupture of membranes (OR=2.008, 95% CI: 1.551–2.600), vaginal examination performed more than 6 times (OR=1.681, 95% CI: 1.286–2.197), long duration of labor (OR=1.090, 95% CI: 1.063–1.118), and long time from rupture of membranes to delivery (OR=1.048, 95% CI: 1.010–1.087) were all risk factors for intrapartum fever in pregnant women with epidural labor analgesia. Regarding the secondary research outcome, the incidence of intrapartum fever was significantly associated with the number of neonates with Apgar score of 10 delivered from pregnant women with epidural labor analgesia (P<0.05). There was no statistically significant difference in the transfer rate of newborns to the Neonatal Intensive Care Unit (NICU) (P>0.05).

Conclusions

Premature rupture of membranes, vaginal examination performed more than 6 times, long duration of labor, and long time from rupture of membranes to delivery are all factors raising the risk of fever during epidural labor analgesia. Although intrapartum fever in the mothers had a significant influence on the number of neonates with Apgar score of 10, it did not affect the outcome of neonates in terms of NICU transfer rate.

Are Syrian refugees at high risk for adverse pregnancy outcomes? A comparison study in a tertiary center in Turkey

OBJECTIVE

In this study, we aim to compare obstetric and perinatal outcomes between Turkish citizens and Syrian refugees who applied to a tertiary center in Izmir.

MATERIALS AND METHODS

Demographic characteristics, obstetric and neonatal outcomes of 8103 Syrian refugee pregnant women and 47 151 Turkish citizen pregnant women between January 2013 and December 2018 were retrospectively compared. Our primary aim was to compare the cesarean rates and obstetrical results between two groups and to decide antenatal care secondarily.

RESULTS

Syrian refugee pregnant women are statistically younger (p < 0.001), mean pregnancy duration and mean birth weight is statistically lower (p < 0.001 and p < 0.001, respectively). Adolescent pregnancy rates, preterm birth rates and anemia are statistically higher in refugee group (p < 0.001, p < 0.001, and p < 0.001, respectively). Primary cesarean section rates, combined and triple screening tests application rates, gestational diabetes screening rates are meaningfully lower in refugee group (p < 0.001, p < 0.001, p < 0.001, and p < 0.001, respectively).

CONCLUSION

Syrian refugees are at risk for inadequate antenatal care, adolescent pregnancy, and adverse pregnancy outcomes. Therefore, care should be given to these risks during pregnancy and childbirth to Syrian refugees.

The Associations of Genital Mycoplasmas with Female Infertility and Adverse Pregnancy Outcomes: a Systematic Review and Meta-analysis

The roles of genital mycoplasmas including Mycoplasma genitalium (M. genitalium), Mycoplasma hominis (M. hominis), Ureaplasma urealyticum (U. urealyticum), and Ureaplasma parvum (U. parvum) in reproductive diseases are equivocal. To investigate whether genital mycoplasmas are risk factors of female infertility and adverse pregnancy outcomes, we performed a systematic review and meta-analysis. Electronic databases were searched for related studies. A random-effects model or fixed-effects model was employed to generate forest plots. Pooled odd ratios (ORs) with 95% confidence intervals (CIs) were applied to measure the strength of associations. Meanwhile, heterogeneity was evaluated by H statistic and I² statistic, and publication bias was explored by funnel plots based on Egger's test and Begg's test. The search yielded 2054 relevant records, and 35 articles were ultimately included for meta-analysis. M. genitalium was a significant risk factor for female infertility (OR, 13.03 [95% CI, 3.46-48.98]) and preterm birth (PTB) (OR, 1.81 [95% CI, 1.17-2.80]), but not for spontaneous abortion (SA) (OR, 0.58 [95% CI, 0.25-1.35]). M. hominis can significantly increase the potential risk of female infertility (OR, 1.56 [95% CI, 1.02-2.38]), SA (OR, 9.14 [95% CI, 4.14-20.18]), stillbirth (OR, 3.98 [95% CI, 1.39-11.36]), and premature rupture of membranes (PROM) (OR, 1.79 [95% CI, 1.26-2.55]), but was not associated with PTB (OR, 1.29 [95% CI, 0.78-2.15]). U. urealyticum had no significant risk effect on female infertility (OR, 0.68 [95% CI, 0.42-1.11]). Coinfections of M. hominis and Ureaplasma were significantly associated with female infertility, SA, and stillbirth, but not with PROM. On the basis of current evidences, this meta-analysis supports that M. genitalium is a risk factor for female infertility and PTB; M. hominis is a potential risk factor for female infertility, SA, stillbirth, and PROM; U. urealyticum has no significant association with female infertility; and the relationship of U. parvum with female infertility and adverse pregnancy outcomes needs to be paid more attention to and remains to be further revealed.

Active Versus Expectant Management for Preterm Premature Rupture of Membranes at 34-36 Weeks of Gestation and the Associated Adverse Perinatal Outcomes

OBJECTIVE

 To compare the type of management (active versus expectant) for preterm premature rupture of membranes (PPROM) between 34 and 36 + 6 weeks of gestation and the associated adverse perinatal outcomes in 2 tertiary hospitals in the southeast of Brazil.

METHODS

 In the present retrospective cohort study, data were obtained by reviewing the medical records of patients admitted to two tertiary centers with different protocols for PPROM management. The participants were divided into two groups based on PPROM management: group I (active) and group II (expectant). For statistical analysis, the Student t-test, the chi-squared test, and binary logistic regression were used.

RESULTS

 Of the 118 participants included, 78 underwent active (group I) and 40 expectant management (group II). Compared with group II, group I had significantly lower mean amniotic fluid index (5.5 versus 11.3 cm, p = 0.002), polymerase chain reaction at admission (1.5 versus 5.2 mg/dl, p = 0.002), time of prophylactic antibiotics (5.4 versus 18.4 hours, p < 0.001), latency time (20.9 versus 33.6 hours, p = 0.001), and gestational age at delivery (36.5 versus 37.2 weeks, p = 0.025). There were no significant associations between the groups and the presence of adverse perinatal outcomes. Gestational age at diagnosis was the only significant predictor of adverse composite outcome (x² [1] = 3.1, p = 0.0001, R² Nagelkerke = 0.138).

CONCLUSION

 There was no association between active versus expectant management in pregnant women with PPROM between 34 and 36 + 6 weeks of gestation and adverse perinatal outcomes.

Platelet indices as a predictive marker in neonatal sepsis and respiratory distress in preterm prelabor rupture of membranes

Preterm Prelabor rupture of membranes (PPROM) accompanies 2-3% of all pregnancies and 1/3rd of all preterm deliveries leading to intraamniotic infection, postpartum infections, sepsis along with perinatal morbidity and mortality worldwide. Early diagnosis and treatment can prevent the complications of PPROM and improve mother and child health. The platelet indices (platelet count, Mean platelet volume, Plateletcrit and Immature platelet fraction) could be a useful predictive parameters in PPROM, as platelets are acute phase reactants and there parameters may vary with inflammation and increased platelet consumption/production. In the present study, Mean Platelet volume (MPV) levels showed significant increase in cases as compared to controls (10.47 ± 1.92 fl Vs 8.84 ± 1.30 fl; P < 0.004). Plateletcrit (PCT) levels were also significantly increased in cases with respect to controls (0.22 ± 0.10% Vs 0.18 ± 0.05%; P = 0.004). Immature platelet fraction (IPF) is significantly increased in cases than in control subjects (8.73 ± 6.67% Vs 4.43 ± 1.75%; P < 0.001). Also, Mean Platelet volume (MPV) levels were found to be significantly higher in subjects whose neonate had developed sepsis(11.39 ± 1.69 fl Vs 8.91 ± 1.31 fl; P < 0.001) and respiratory distress (10.62 ± 2.09 fl Vs 9.26 ± 1.56 fl; P = 0.003). Similarly, PCT was significantly higher in groups with positive neonatal sepsis (0.32 ± 0.74% Vs 0.19 ± 0.65%; P = 0.010) and with respiratory distress (0.24 ± 0.78% Vs 0.18 ± 0.59%; P < 0.001). Levels of IPF were also increased in positive neonatal sepsis group (10.11 ± 6.27% Vs 5.06 ± 4.07%; P < 0.001) and respiratory distress group (9.11 ± 6.38% Vs 5.54 ± 4.43%; P = 0.009). The findings suggest that maternal platelet parameters (MPV, PCT and IPF) can be utilized as evidence of early predictors of development of neonatal sepsis and respiratory distress and may be considered as a predictive markers for adverse neonatal outcome.

Perinatal outcomes in pregnancies complicated by type 1 diabetes mellitus

The aim of this study was to explore the risk of perinatal outcomes in pre-gestational type 1 diabetes mellitus (T1DM) compared to gestational diabetes mellitus (GDM) and pregnancy without diabetes and to examine the association of glycemic level of third-trimester gestation with perinatal outcomes in T1DM. We included 69 pre-gestational T1DM, 1398 cases of GDM, and 1304 control pregnancies and collected data regarding demographics, obstetric, and perinatal outcomes from the hospital discharge database. Relative to the pregnancies without diabetes, women with T1DM encountered increasing risk of polyhydramnios, preterm delivery, and cesarean section. These adverse outcomes were also common in GDM, although with relatively lower adjusted ORs. The weights of babies delivered by women with T1DM were more intend to be large for gestational age, as well as to be less than 2.5 kg relative to those without diabetes. Poorly controlled hemoglobin A1c in late pregnancy was significantly associated with an increased risk of preterm birth in T1DM (adjusted odds ratio 2.01, 95%confidence interval 1.1-3.6). Women with T1DM have considerably increased risks of adverse perinatal outcomes, which appear more prevalent than the perinatal outcomes in women with GDM. Thus, a specific routine is required for pregnancy in T1DM to improve the glycemic control and obstetric care.

Application of a Prediction Model Based on the Laboratory Index Score in Prelabor Rupture of Membranes with Histologic Chorioamnionitis During Late Pregnancy

Background

This study aimed to establish a prediction model based on the maternal laboratory index score (Lab-score) for histologic chorioamnionitis (HCA) in patients with prelabor rupture of membranes (PROM) during late pregnancy.

Material/Methods

Sixty-nine cases of pregnant women with PROM were retrospectively analyzed. The general information and laboratory indicators were compared between the HCA (n=22) and non-HCA (n=47) groups. A multivariate logistic regression method was used to establish the prediction model. We plotted the receiver operating characteristic curve and calculated the area under the curve (AUC). The clinical effectiveness of each model was compared by decision curve analysis.

Results

Only C-reactive protein (CRP) in the laboratory index predicted HCA, but its diagnostic efficacy was not ideal (AUC=0.651). Then, we added CRP to the platelet/white blood cell count ratio and triglyceride level to construct the Lab-score. Based on the Lab-score, important clinical parameters, including body mass index, diastolic blood pressure, and preterm birth, were introduced to construct a complex joint prediction model. The AUC of this model was significantly larger than that of CRP (0.828 vs. 0.651, P=0.035), but not significantly different from that of Lab-score (0.828 vs. 0.724, P=0.120). Considering the purpose of HCA screening, the net benefit of the complex model was better than that of Lab-score and CRP.

Conclusions

The complex model based on Lab-score is useful in the clinical screening of high-risk populations with PROM and HCA during late pregnancy.

Term prelabor rupture of membranes: Foley catheter versus dinoprostone as ripening agent

INTRODUCTION

Term prelabor rupture of membranes (TPROM) occurs in approximately 8 % of pregnancies. This condition regularly requires medical intervention such as induction of labor. The actual data concerning cervical ripening in case of TPROM does not favor any of the available techniques. This is the first study comparing dinoprostone versus Foley catheter for cervical ripening in TPROM.

MATERIALS AND METHODS

We conducted a retrospective before-after study. We enrolled all the patients with confirmed TPROM after 37 weeks of gestation (WG) who required cervical ripening. Women were included if they had a singleton fetus in cephalic presentation, with unfavorable cervix (Bishop ≤ 6). Patients were excluded if they had a previous uterine surgery, a multiple pregnancy, contraindication to vaginal delivery, spontaneous labor or favorable cervix (Bishop > 6). During the first period (2015), the protocol of cervical ripening involved dinoprostone (prostaglandins E2) by vaginal administration (vaginal gel or pessary). During the second period (2016-2017), the protocol of cervical ripening involved Foley catheter (FC). The primary outcome was the rate of cesarean section.

RESULTS

Two hundred and thirty-eight patients were included for the analysis: 131 in the first period (dinoprostone group) and 107 in the second period (foley catheter group). There was no significant difference between the two groups regarding the mode of delivery (cesarean section: 206 % vs 13 %, p = 016). Concerning tolerance, the were no difference in the rates of postpartum hemorrhage, maternal per-partum fever and endometrisis. Neonatal outcomes were similar between the two groups. The induction to delivery interval was lower with dinoprostone (20,3 h versus 26,0 h, p = 0001). The mean duration of labor was also significantly different (6,9 h for dinoprostone group versus 8,7 h for FC group, p = 001).

CONCLUSION

Cervical ripening in case of TPROM after 37 W G with Foley catheter seems to be a safe technique with similar outcomes to prostaglandins regarding the mode of delivery.

Maternal inflammatory markers for chorioamnionitis in preterm prelabour rupture of membranes: a systematic review and meta-analysis of diagnostic test accuracy studies

BACKGROUND

There is no consensus on the role of inflammatory markers in identifying chorioamnionitis in preterm prelabour rupture of membranes (PPROM). We set out to evaluate the accuracy of maternal blood C-reactive protein (CRP), procalcitonin and interleukin 6 (IL6) in diagnosis of histological chorioamnionitis and/or funisitis (HCA/Funisitis) in PPROM.

METHODS

We searched MEDLINE, EMBASE and The Cochrane Library from inception to January 2020 for studies where maternal blood CRP, procalcitonin or IL6 was assessed against a reference standard of HCA/Funisitis in PPROM. The Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) tool was used to assess methodological quality. Hierarchical summary receiver operating characteristic (SROC) models were used to construct summary curves. Bivariate models were used to obtain summary estimates for studies with the same cut-off.

RESULTS

We included 23 studies reporting HCA/Funisitis in 902 of 1717 women, median prevalence 50% (inter-quartile range 38-57). Of these studies, 20 were prospective cohort design and 3 were retrospective cohort. Eleven studies reported the index test against a reference standard of HCA and/or funisitis, 10 reported HCA alone and 2 reported funisitis alone. Many studies had high risk of bias scores on the QUADAS-2 assessment but low concerns for applicability. Sensitivity and specificity for CRP ≥ 20 mg/L (5 studies, 252 participants) was 59% (95% CI 48-69) and 83% (95% CI 74-89) respectively. SROC curves are provided for each index test. At selected specificity of 80%, the sensitivities for CRP (all cut-offs, 17 studies, 1404 participants), PCT ( all cut-offs, 6 studies, 231 participants) and IL6 (all cut-offs, 5 studies, 299 participants) were 59%(95% CI 52-68), 56%(95% CI 50-69) and 52% (95% CI 50-86) respectively.

CONCLUSIONS

There is insufficient evidence to support use of CRP, procalcitonin or IL6 in maternal blood for diagnosis of HCA/Funisitis in PPROM. This review followed recommended methodology and data analytic methods that made the most of the data regardless of the different cut-offs used. However, the evidence is based on few studies with generally small sample sizes, poor-quality scores and substantial heterogeneity. There is a need for good-quality diagnostic accuracy studies to better assess the role of these biomarkers in PPROM.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42015023899, registered on 8 October 2015.

Maternal Serum Haptoglobin Levels as a Marker of Preterm Premature Rupture of Membranes

OBJECTIVE

We aimed to investigate the prognostic value of maternal serum haptoglobin levels in patients presenting with preterm premature rupture of fetal membranes (PPROM) during the second and the third trimesters of pregnancy.

METHODS

In this case control study, 60 patients were recruited (30 pregnant women with PPROM between 26-34 weeks of gestation and 30 healthy, gestational-age-matched pregnant women without PPROM). White blood cell count (WBC), interleukin 6 (IL-6), C-reactive protein (CRP), sedimentation rate, and haptoglobin levels were measured.

RESULTS

The mean age, gestational week, gravida, and parity of the 2 groups were statistically comparable (P>0.001). There was a statistically significant difference between the 2 groups in terms of haptoglobin values (p<0.001). The mean haptoglobin level was 115.5+33.1(mg/dl) in the PPROM group and 66.5+42.6 (mg/dl) in the control group. ROC curve analysis was performed to determine whether the level of haptoglobin alone could diagnose PPROM as an independent marker. It was shown that the level of 94.5 mg/dL for haptoglobin could indicate the diagnosis of PPROM with 80% sensitivity and specificity CONCLUSION: Maternal serum haptoglobin levels may be a diagnostic marker for suspected PPROM cases when membrane rupture diagnosis is not accurate based on physical examination and other diagnostic tests.

Balloon catheter use for cervical ripening in women with term pre-labor rupture of membranes: A 5-year cohort study

INTRODUCTION

To investigate the safety of balloon catheter for cervical ripening in women with term pre-labor rupture of membranes (PROM) and to compare the incidence of maternal and neonatal infections in women with PROM and women with intact membranes undergoing cervical ripening with a balloon catheter.

MATERIAL AND METHODS

This retrospective cohort study of 1923 women with term singleton pregnancy and an unfavorable cervix undergoing cervical ripening with a balloon catheter was conducted in Helsinki University Hospital between January 2014 and December 2018. For each case of PROM, two controls were assigned. The main outcome measures were the rates of maternal and neonatal infections. Statistical analyses were performed by SPSS.

RESULTS

In all, 641 (33.3%) women following PROM and 1282 (66.6%) women with intact amniotic membranes underwent labor induction. The rates of intrapartum infection (3.7% vs 7.7%; P = .001) and neonatal infection (1.7% vs 3.8%; P = .01) were not increased in women induced by balloon catheter following PROM. Intrapartum infections were associated with nulliparity (odds ratio [OR] 3.3, 95% confidence interval [CI] 1.6-6.5), history of previous cesarean section (OR 2.8, 95% CI 1.2-6.4), extended gestational age ≥41 weeks (OR 1.9, 95% CI 1.2-3.0) and an induction to delivery interval of 48 hours or more (OR 2.0, 95% CI 1.2-3.3). The risk of neonatal infection was associated with nulliparity (OR 3.3, 95% CI 1.4-8.0), gestational age ≥41 weeks (OR 1.9, 95% CI 1.09-3.36) and induction to delivery interval of 48 hours or more (OR 3.4, 95% CI 1.9-6.0).

CONCLUSIONS

Use of balloon catheter in women with term PROM appears safe and was not associated with increased maternal or neonatal infectious morbidity.

[Association between maternal age and adverse pregnancy outcome in twin pregnancy]

OBJECTIVE

To study the association between maternal age and adverse pregnancy outcome in twin pregnancy.

METHODS

The clinical data of 2 363 women with twin pregnancy from January 2006 to June 2016 were retrospectively reviewed. According to the age, the women were divided into six groups: <20 years (n=15), 20-24 years (n=158), 25-29 years (n=894), 30-34 years (n=936), 35-39 years (n=320), and ≥40 years group (n=40). The above groups were compared in terms of related baseline features and incidence rates of adverse pregnancy outcomes (preterm birth, birth defect, stillbirth in late pregnancy and small-for-gestational-age birth). A generalized estimating equation was used to investigate the risk of adverse pregnancy outcomes in different age groups.

RESULTS

After control for the factors including place of residence, primipara, pregnancy pattern, and gestational diseases, the incidence rates of very preterm birth and moderately preterm birth in the ≥40 years group were 2.60 and 1.99 times than those in the 25-29 years group respectively (P<0.05). The incidence rates of very preterm birth and late preterm birth in the 20-24 years group were 1.99 and 1.33 times than those in the 25-29 years group respectively (P<0.05). The incidence rates of stillbirth in late pregnancy in the <20 years group, the 20-24 years group, and the ≥40 years group were 9.10, 2.88 and 3.97 times than those in the 25-29 years group respectively (P<0.05). The incidence rates of small-for-gestational-age birth in the <20 years group and the 35-39 years group were 2.70 and 0.73 times than those in the 25-29 years group respectively (P<0.05).

CONCLUSIONS

In twin pregnancy, pregnant women, aged <20 years, have a higher risk of smaller-for-gestational-age birth and stillbirth in late pregnancy, those aged ≥40 years have a higher risk of very preterm birth, moderately preterm birth and stillbirth in late pregnancy, and those aged 20-24 years have a higher risk of very preterm birth, late preterm birth and stillbirth in late pregnancy.

Effect of premature rupture of membranes on time to delivery and outcomes in full-term pregnancies with vaginal dinoprostone-induced labour

OBJECTIVE

The aim of this study was to assess the effect of premature rupture of membranes (PROM) in full-term pregnancies with dinoprostone-induced labour.

PATIENTS AND METHODS

This historical cohort study analysed 2166 full-term pregnancies with dinoprostone-induced labour between 1 August 2016 and 30 April 2018. A group that underwent induction of labour for PROM (PROM group) was compared to a group that underwent labour induction for other indications (no-PROM group). Time to delivery and perinatal outcome were compared between the two groups.

RESULTS

A total of 2166 pregnancies (662 PROM and 1504 no-PROM) were included. The two groups demonstrated no significant differences except in biparietal diameter and gestational age (P < 0.001). The caesarean section delivery rate in the PROM group was significantly lower than in the non-PROM group (26.89 vs. 33.58%, P < 0.0001). In the PROM group, the induction-to-delivery time was shorter (P < 0.0001) and the rates of vaginal birth within 24 h (P < 0.0001) and 48 h (P < 0.0001) were higher than those in the control group. The incidence rate of amniotic fluid contamination in the PROM group was significantly lower than that in the non-PROM group (19.18 vs. 25.20%, P = 0.002).

CONCLUSION

PROM significantly affects perinatal outcome in Chinese women who undergo dinoprostone-induced labour, especially the caesarean delivery rate and the induction-to-delivery time.

Is homecare management associated with longer latency in preterm premature rupture of membranes?

PURPOSE

According to national guidelines, conventional management of preterm premature rupture of membranes (PPROM) is hospitalization until induction. Outpatient management could be another option. Our objective was to compare latency period between patients managed in hospital versus outpatients.

METHODS

A retrospective before/after monocentric study that occured from 2002 to 2015. Were included all patients with PPROM prior to 35 weeks with homecare inclusion criteria. The primary outcome measure was to study length of latency period (delay between PPROM and delivery). Second outcome measures were maternal and perinatal morbidities and mortalities.

RESULTS

Among the 395 women included after PPROM, 191 were managed as outpatients and 204 in hospital. In the outpatient group, the length of latency period was longer than in the inpatient group [39 (IQR 20 to 66) versus 21 (IQR 13 to 42) days; p < 0.001]. Clinical chorioamnionitis was observed in 30 (15.7%) in outpatient group versus 49 (24.0%) in inpatient group (p = 0.039). Concerning neonatal outcome, there were less neonatal transfer (49.2% versus 77.2%, p < 0.001), less respiratory distress syndrome (29.4% versus 47.5%; p < 0.001), less neonatal sepsis (13.9% versus 22.1%; p = 0.037), less bronchodysplasia (2.7% versus 9.8%; p = 0.004), and less pulmonary arterial hypertension (4.8% versus 10.3%; p = 0.040) in the outpatient group than in the inpatient group.

CONCLUSION

Home management seems to be a safe option to hospitalization in selected patients with PPROM. However, a randomized study would be required to approve those results.

Establishment of reference intervals for maternal blood and umbilical cord blood procalcitonin in healthy Chinese women in late pregnancy

AIM

To establish reference intervals (RIs) for maternal blood and umbilical cord blood procalcitonin (PCT) in healthy Chinese women in late pregnancy.

METHODS

One hundred and twenty-seven healthy Chinese women in late pregnancy, including 70 vaginal deliveries and 57 cesarean section deliveries, were retrospectively analyzed. These pregnant women gave birth to 58 male infants and 69 female infants. Another 127 age-matched healthy women who were not pregnant were enrolled as the control group. PCT levels in maternal blood, umbilical cord blood and control blood were determined using electrochemiluminescence immunoassay. The RIs of PCT were defined using an intermediate 95% interval.

RESULTS

The RIs for maternal blood and umbilical cord blood PCT were 0.020-0.075 ng/mL and 0.020-0.159 ng/mL, respectively. The cord blood PCT level was not significantly different between different delivery methods (P > 0.05). In contrast, the umbilical cord blood PCT in female newborns was higher than that in male newborns (0.088 ± 0.046 ng/mL vs 0.072 ± 0.030 ng/mL, P < 0.05).

CONCLUSION

Maternal blood and umbilical cord blood PCT of Chinese women in late pregnancy have different RIs, and umbilical cord blood PCT level is affected by the gender of newborns.

Predictive value of procalcitonin, C-reactive protein, and white blood cells for chorioamnionitis among women with preterm premature rupture of membranes

OBJECTIVE

To determine the predictive value of procalcitonin, C-reactive protein (CRP), and white blood cells (WBC) for chorioamnionitis among women with preterm premature rupture of membranes (PPROM).

METHODS

A prospective cross-sectional study of all women with singleton pregnancy and PPROM admitted to a referral hospital in Shiraz, Iran, from 2016 to 2018. All women were hospitalized until delivery. The incidence of chorioamnionitis was recorded. Maternal serum CRP, procalcitonin, and WBC were measured on the day of admission and the day before termination of pregnancy. The diagnostic accuracy of each test was evaluated by receiver operator characteristic (ROC) curve analysis.

RESULTS

Overall, 75 women with PPROM were included in the study. After termination of pregnancy, 34 (45.3%) were diagnosed with clinical chorioamnionitis. Those with chorioamnionitis had significantly higher serum levels of CRP both on admission (P=0.004) and before termination of pregnancy (P<0.001). The area under the curve for last CRP was 0.78 (95% confidence interval, 0.57-0.84), indicating moderate accuracy. Procalcitonin and WBC had low accuracy to predict chorioamnionitis.

CONCLUSION

Among CRP, procalcitonin, and WBC, maternal serum CRP was found to be the most accurate predictor of chorioamnionitis among women with PPROM.

Can we predict preterm delivery in patients with premature rupture of membranes?

PURPOSE

To characterize the parameters that predict preterm delivery in patients with preterm, premature rupture of membranes.

METHODS

This retrospective cohort study included women diagnosed with preterm premature rupture of membranes at 24-34 weeks gestation. Demographics, medical history, laboratory tests, and delivery data were reviewed.

RESULTS

Among 258 patients with preterm, premature rupture of membranes during the study period, 141 (54.7%) met the inclusion criteria. Therefore, the final cohort included 141 (54.78%) women, among whom, 32 (22.7%) delivered within the first 24 h of ROM and 109 (77.3%) delivered after 24 h. Univariant analysis revealed that advanced gestational age at the time of preterm, premature rupture of membranes, larger cervical dilation and leukocyte count at admission had significant effects on the likelihood of labor within 24 h. Analysis of the differences between each patient at admission to 24 h before labor in heart rate, temperature (fever), leukocyte counts and amniotic fluid color revealed significant changes in heart rate (P < 0.001), leukocyte count (P < 0.001) and in amniotic fluid from clean to meconium or bloody (P < 0.001). There was no significant change in elevated temperature (P = 0.065).

CONCLUSIONS

Our findings indicate that minimal changes in heart rate, body temperature (fever), leukocyte count and amniotic fluid color, within normal ranges, appear 24 h before delivery, among women with preterm, premature rupture of membranes and prolonged latency period. Increased attention to these changes might enable better follow-up and timing of delivery for patients with preterm, premature rupture of membranes before 34 weeks gestation.

Diagnosis of Placental Position by Early First-Trimester Ultrasound: A Pilot Study

OBJECTIVE

Conventional wisdom is that placental location cannot be identified before 8 weeks' gestation when the placenta first becomes hyperechogenic on ultrasound. We sought to evaluate whether placental location could be reliably diagnosed between 5 and 6 weeks' gestation.

MATERIALS AND METHODS

This was a retrospective analysis of prospectively acquired data. Early placental location was diagnosed by evaluation of the embryonal and yolk sac position inside the gestational sac on transvaginal ultrasound. Placental position was described as anterior, posterior, fundal, or lateral. Early and mid-pregnancy placental locations were compared and coded as being the same, having migrated to an adjacent surface, or being on an opposite surface.

RESULTS

A total of 111 patients met study criteria, providing 141 placental locations, comprising 85 singleton and reduced pregnancies and 28 dichorionic twin pregnancies. The most common placental location was anterior in both singleton and twin/triplet pregnancies. Placental location at the mid-pregnancy ultrasound was consistent with early pregnancy location in 100% of cases, with 79.5% (112/141) being on the same surface and 20.5% (29/141) having expanded onto an adjacent surface. Placental location was not associated with pregnancy outcome, although our study may have been underpowered to detect a significant difference.

CONCLUSIONS

Placental location diagnosed at 5 to 6 weeks' gestation is consistent with the location on mid-pregnancy ultrasound. Excluding the presence of an ectopic, cornual, or cesarean section scar and uterine subseptation pregnancy in early first trimester would allow a more effective tailoring of pregnancy follow-up.

New antibiotic regimen for preterm premature rupture of membrane reduces the incidence of bronchopulmonary dysplasia

AIM

The optimal antibiotic regimen for preterm premature rupture of membrane (pPROM) is still unclear. This study aimed to determine the effects of ampicillin-sulbactam (SBT/ABPC) and azithromycin (AZM) on the incidence of bronchopulmonary dysplasia (BPD).

METHODS

This retrospective study included women with singleton gestations and a diagnosis of pPROM between 22 and 27 weeks of gestation. In patients presenting with a high risk of intra-amniotic infection between January 2011 and May 2013, piperacillin or cefmetazole + clindamycin (regimen 1 group; n = 11) was administered, whereas SBT/ABPC and AZM (regimen 2 group; n = 11) were administered in patients presenting a similar risk between June 2013 and May 2016.

RESULTS

The incidence of moderate or severe infant BPD in the regimen 2 group was significantly lower than that in the regimen 1 group, even when adjusted for gestational age at the time of rupture of membrane, with an odds ratio (95% confidence interval) of 0.02 (1.8 × 10^-5 -0.33). The incidence of BPD and total days on mechanical ventilation were significantly lower in the regimen 2 group than in the regimen 1 group. No significant differences were seen in other morbidities.

CONCLUSION

In patients with pPROM between 22 and 27 weeks of gestation, the administration of SBT/ABPC and AZM may improve the perinatal outcomes.

RNA-Sequencing of Umbilical Cord Blood to Investigate Spontaneous Preterm Birth: A Pilot Study

Objective  To analyze the transcriptomic gene expression of umbilical cord blood leukocytes using RNA-sequencing from preterm birth (PTB) and term birth (TB). Study Design  Eight women with spontaneous PTB (sPTB) and eight women with unlabored TB were enrolled prospectively. The sPTB and TB cohorts were matched for maternal age, race, mode of delivery, and fetal sex. Cord blood RNA was extracted and a globin depletion protocol was applied, then sequenced on the Illumina HiSeq 4000. Raw read counts were analyzed with DESeq2 to test for gene expression differences between sPTB and TB. Results  148 genes had significant differential expression ( q  < 0.01). Cell cycle/metabolism gene expression was significantly higher and immune/inflammatory signaling gene expression significantly lower in the sPTB cohort compared with term. In African American (AA) infants, 18 genes specific to cell signaling, neutrophil activity, and major histocompatibility complex type 1 had lower expression in preterm compared with term cohort; the opposite pattern was seen in non-Hispanic Whites (NHWs). Conclusion  Compared with term, preterm fetuses have higher cell cycle/metabolism gene expression, suggesting metabolic focus on growth and development. Immune function gene expression in this pilot study is lower in the sPTB group compared with term and differs in AA compared with NHW infants.

Amniotic fluid index, single deepest pocket and transvaginal cervical length: Parameter of predictive delivery latency in preterm premature rupture of membranes

OBJECTIVE

Prediction of delivery latency complicated with preterm premature rupture of membrane (PPROM) is crucial for reducing maternal and neonatal complications. Therefore, we investigated the correlations between latency period and cut-off values of ultrasonographic parameters, ultimately predicting delivery latency.

MATERIALS AND METHODS

The retrospective study was performed on 121 PPROM patients enrolled between March 2010 and July 2015. Parameters including amniotic fluid index (AFI), single deepest pocket (SDP) and transvaginal cervical length (TVCL) were measured in 99 singleton pregnancies with PPROM. Latency was defined as the period from sonographic measurements to delivery day. The parameters were analyzed independently by Wilcoxon rank sum test and Fisher's exact test. Cut-off values were determined using a receiver operating characteristic (ROC) curve.

RESULTS

In delivery latency within 3 days, AFI and SDP were decreased with significantly shorter TVCL. AFI and SDP had the highest sensitivity (82.2%) and SDP combined with TVCL showed the highest specificity (75.9%) in area under curve (AUC) value. The predicted median latency period was less than 2 days within the cutoff value of parameter (AFI ≤ 7.72, SDP ≤ 3.2 and TVCL ≤ 1.69).

CONCLUSION

AFI and SDP combined with TVCL could be useful predictive parameters of the latency interval from PPROM to delivery.

Smoking Exposure in Early Pregnancy and Adverse Pregnancy Outcomes: Usefulness of Urinary Tobacco-Specific Nitrosamine Metabolite 4-(Methylnitrosamino)-1-(3-Pyridyl)-1-Butanol Levels

OBJECTIVES

The aim was to investigate the effect of -maternal smoking exposure assessed by urinary tobacco-specific nitrosamine metabolite 4-(methylnitrosamino)-1-(3-pyridyl)-a1-butanol (NNAL) with adverse pregnancy outcomes.

METHODS

A total of 251 pregnant women were recruited. Urinary cotinine and NNAL were measured. Participants' sociodemographics were obtained by questionnaire and pregnancy outcomes were collected by charts review after delivery.

RESULTS

The prevalence of smoking was 8.4% (21 of 249), 1.2% (3 of 241), and 3.7% (9 of 241) in pregnant women according to questionnaire, cotinine, and NNAL, respectively. As compared with questionnaire positivity and cotinine levels, women with positive NNAL were independent determinants for spontaneous abortion (adjusted OR 12.357, 95% CI 2.053-74.368), preterm birth (adjusted OR 22.239, 95% CI 3.737-132.357), and small for gestational age (adjusted OR 6.915, 95% CI 1.385-34.524).

CONCLUSIONS

Urinary NNAL might be a useful biomarker in detection of maternal smoking status in association with adverse pregnancy outcomes. Use of this marker in preconception and pregnancy counselling before planning pregnancy may allow prevention of several adverse pregnancy outcomes.

Magnesium sulfate differentially modulates fetal membrane inflammation in a time-dependent manner

PROBLEM

Chorioamnionitis and infection-associated inflammation are major causes of preterm birth. Magnesium sulfate (MgSO₄ ) is widely used in obstetrics as a tocolytic; however, its mechanism of action is unclear. This study sought to investigate how MgSO₄ modulates infection-associated inflammation in fetal membranes (FMs), and whether the response was time dependent.

METHOD OF STUDY

Human FM explants were treated with or without bacterial lipopolysaccharide (LPS); with or without MgSO₄ added either: 1 hour before LPS; at the same time as LPS; 1 hour post-LPS; or 2 hours post-LPS. Explants were also treated with or without viral dsRNA and LPS, alone or in combination; and MgSO₄ added 1 hour post-LPS After 24 hours, supernatants were measured for cytokines/chemokines; and tissue lysates measured for caspase-1 activity.

RESULTS

Lipopolysaccharide-induced FM inflammation by upregulating the secretion of a number of inflammatory cytokines/chemokines. Magnesium sulfate administered 1-hour post-LPS inhibited FM secretion of IL-1β, IL-6, G-CSF, RANTES, and TNFα. Magnesium sulfate administered 2 hours post-LPS augmented FM secretion of these factors as well as IL-8, IFNγ, VEGF, GROα and IP-10. Magnesium sulfate delivered 1- hour post-LPS inhibited LPS-induced caspase-1 activity, and inhibited the augmented IL-1β response triggered by combination viral dsRNA and LPS.

CONCLUSION

Magnesium sulfate differentially modulates LPS-induced FM inflammation in a time-dependent manner, in part through its modulation of caspase-1 activity. Thus, the timing of MgSO₄ administration may be critical in optimizing its anti-inflammatory effects in the clinical setting. MgSO₄ might also be useful at preventing FM inflammation triggered by a polymicrobial viral-bacterial infection.

Medically indicated late preterm delivery and its impact on perinatal morbidity and mortality: a retrospective population-based cohort study

Objective: In the last few decades, attention has been focused on morbidity and mortality associated with late preterm delivery (34-36 + 6/7 weeks), accounting for 60-70% of all preterm births. This study is aimed to determine (1) the prevalence of late preterm deliveries (spontaneous and medically indicated) in our population; and (2) the rate of neonatal morbidity and mortality as well as maternal complications associated with the different phenotypes of late preterm deliveries. Study design: This retrospective population-based cohort study, included 96,176 women who had 257,182 deliveries, occurred between 1988 and 2011, allocated into three groups: term (n = 242,286), spontaneous (n = 10,063), and medically indicated (n = 4833) late preterm deliveries. Results: (1) Medically indicated late preterm deliveries were associated with increased maternal morbidity, as well as neonatal morbidity and mortality, in comparison with other study groups (p < .01 for all comparisons); (2) medically indicated late preterm delivery was an independent risk factor for composite neonatal morbidity (low Apgar score at 5', seizures, asphyxia, acidosis) after adjustment for confounding factors (maternal age and ethnicity and neonatal gender) and stratification according to gestational age at delivery; and (3) the proportion of medically indicated late preterm deliveries affected the neonatal mortality rate. Below 35% of all late preterm deliveries, indicated late preterm birth were associated with a reduction in neonatal mortality; however, above this threshold medically indicated late preterm deliveries were associated with an increased risk for neonatal death. Conclusions: (1) Medically indicated late preterm deliveries were independently associated with adverse composite neonatal outcome; and (2) to benefit in term of neonatal outcome from the tool of medically indicated late preterm birth, their proportion should be kept below 35% of all late preterm deliveries, while exceeding this threshold increases the risk of neonatal mortality.

The impact of time of delivery on gestations complicated by preterm premature rupture of membranes: daytime versus nighttime

Background: Perinatal death, in particular intrapartum stillbirth and short-term neonatal death, as well as neonatal short-term and long-term morbidity have been associated with the time of day that the birth occurs. Indeed, evening and nighttime deliveries were associated with an increased risk of an adverse perinatal outcome when compared to similar daytime deliveries. Impact of shift change, as well as time of day delivery have been extensively studied in the context of maternal and neonatal complications of cesarean delivery, however, no studies were previously performed on timing of delivery and its effect on the outcome of pregnancies complicated by preterm premature rupture of membranes. Objective: Our objective was to compare obstetric, neonatal as well as long-term outcomes between women delivered in the daytime versus nighttime, in singleton gestations whose pregnancies were complicated by preterm premature rupture of membranes. Study design: This was a secondary analysis of a trial of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network "A Randomized Clinical Trial of the Beneficial Effects of Antenatal Magnesium Sulfate for the Prevention of Cerebral Palsy." For this analysis, the time of delivery was divided into the daytime, from 07:01 to 19:00, and the nighttime, from 19:01 to 07:00. Epidemiological, obstetric characteristics as well as neonatal and long-term outcomes were compared between deliveries occurring during the daytime versus the nighttime periods. Inclusion criteria consisted of singleton gestations diagnosed with preterm premature rupture of membranes (PPROM). Multifetal gestations and pregnancies with preterm labor without preterm premature rupture of membranes were excluded. Results: A total of 1752 patients met inclusion criteria, 881 delivering during the daytime, while 871 during the nighttime. There were no differences in demographic maternal variables. There were no differences in the number of patients receiving steroids and the doses of steroids. Antibiotic prophylaxis was also equal in both groups. Postpartum endometritis, chorioamnionitis, and the latency to delivery were also equivalent between both the groups. Cesarean delivery for distress was the only different outcome, more prevalent in daytime deliveries (157 (44.7%) versus 108 (35.9%) of the nighttime ones p = .02). Neonatal adverse outcomes as well as long-term outcomes were similar between the two groups. Conclusions: In the setting of delivery at a tertiary care center, and in the era of universal use of steroids, and latency antibiotics for the management of preterm premature of membranes, there is no marked difference in pregnancy, neonatal as well as long-term outcomes for infants delivered in the daytime versus nighttime.