Labour and delivery: a clinician's perspective on a biomechanics problem

Inflammatory Changes and Composition of Collagen during Cervical Ripening in Cows

Dystocia and stillbirths in cows pose a high risk of loss of both dams and fetuses, thereby resulting in high economic losses. One of the causes of these problems is birth canal abnormalities. Thus, to prevent these occurrences, it is necessary to understand the mechanisms underlying cervical ripening. Although physiological inflammatory responses and changes in collagen composition have been reported in humans and mice, related information is scarce for cows. We observed inflammatory changes and changes in the collagen composition in the cervix from late pregnancy to parturition to clarify some of the physiological changes associated with cervical ripening during normal calving in cows. Cervical mucus and tissue samples were collected from 41 Japanese Black cows at 200, 230, and 260 days of gestation and at 7-day intervals thereafter until parturition. The percentage of polymorphonuclear neutrophils (PMN%) in the mucus was calculated, and interleukin (IL)-8 concentration was determined by enzyme-linked immunosorbent assay. Blood samples were collected from the jugular vein, and leukocyte counts were determined. Picrosirius red-stained cervical tissue specimens were observed under a polarizing microscope, and the percentage of type I and type III collagen areas in the cervical tissue were calculated. The PMN% in cervical mucus was lowest at 200 days gestation (12−13 weeks before delivery), significantly increased 5 weeks before (21.7 ± 0.04), and was highest 1 week before calving (50.9 ± 0.04). IL-8 levels were increased at 295 days compared with those at 200 days of pregnancy (p < 0.05). No significant changes were observed in the white blood cell counts. The percentage of type I collagen in the cervical tissue reached a maximum (91.4 ± 0.02%) on day 200, significantly decreased after 274 days (3 weeks before calving), and continued to decrease thereafter until the week of parturition. There was no significant change in type III collagen levels. The results suggest that cervical ripening progresses when PMNs begin to infiltrate the cervix at around 260 days of gestation (5−4 weeks before parturition), IL-8, which increases at the end of pregnancy, mobilizes PMNs, and enhances inflammation, and that type I collagen changes are useful as an indicator of cervical ripening.

Magnetic resonance imaging of the supra-cervical fetal membrane detects an increased risk of prelabor rupture of membranes

OBJECTIVE

In 10% of term deliveries and 40% of preterm deliveries, the fetal membrane (FM) ruptures before labor. However, the ability to predict these cases of premature rupture of membranes (PROM) and preterm premature rupture of membranes (PPROM) is very limited. In this paper, our objective was to determine whether a prediction method based on T2 weighted magnetic resonance imaging (MRI) of the supra-cervical FM could predict PROM and PPROM.

METHODS

This prospective cohort study enrolled 77 women between the 28th and 37th weeks of gestation. Two indicators of fetal membrane defects, including prolapsed depth >5 mm and signal abnormalities, are investigated for our prediction. Fisher's exact test was used to determine whether prolapsed depth >5 mm and/or signal abnormalities were associated with PROM and PPROM. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated for prolapsed depth >5 mm, signal abnormalities, and the combination of prolapsed depth >5 mm and signal abnormalities.

RESULT

Among 12 women with PROM (5 preterm and 7 term, prior to labor onset), 9 had membrane prolapse >5 mm and 5 had FM signal abnormalities. Among 65 women with rupture of membranes at term, 2 had membrane prolapse >5 mm and 1 had signal abnormalities. By Fisher's exact test both indicators, membrane prolapse >5 mm and signal abnormalities, were associated with PROM (P<0.001, P<0.001) and PPROM (P=0.001, P<0.001). Additionally, membrane prolapse >5 mm, signal abnormalities, and the combination of the two indicators all demonstrated high specificity for predicting PROM (96.9%, 98.5%, and 100%, respectively) and PPROM (90.3%, 97.2%, and 100%, respectively).

CONCLUSION

MRI can distinguish the supra-cervical fetal membrane in vivo and may be able to identify women at high risk of PPROM.

Longitudinal ultrasonic dimensions and parametric solid models of the gravid uterus and cervix

Tissue mechanics is central to pregnancy, during which maternal anatomic structures undergo continuous remodeling to serve a dual function to first protect the fetus in utero while it develops and then facilitate its passage out. In this study of normal pregnancy using biomechanical solid modeling, we used standard clinical ultrasound images to obtain measurements of structural dimensions of the gravid uterus and cervix throughout gestation. 2-dimensional ultrasound images were acquired from the uterus and cervix in 30 pregnant subjects in supine and standing positions at four time points during pregnancy (8-14, 14-16, 22-24, and 32-34 weeks). Offline, three observers independently measured from the images of multiple anatomic regions. Statistical analysis was performed to evaluate inter-observer variance, as well as effect of gestational age, gravity, and parity on maternal geometry. A parametric solid model developed in the Solidworks computer aided design (CAD) software was used to convert ultrasonic measurements to a 3-dimensional solid computer model, from which estimates of uterine and cervical volumes were made. This parametric model was compared against previous 3-dimensional solid models derived from magnetic resonance frequency images in pregnancy. In brief, we found several anatomic measurements easily derived from standard clinical imaging are reproducible and reliable, and provide sufficient information to allow biomechanical solid modeling. This structural dataset is the first, to our knowledge, to provide key variables to enable future computational calculations of tissue stress and stretch in pregnancy, making it possible to characterize the biomechanical milieu of normal pregnancy. This vital dataset will be the foundation to understand how the uterus and cervix malfunction in pregnancy leading to adverse perinatal outcomes.

Bioengineering in women's health, volume 2: pregnancy—from implantation to parturition

This special issue of Interface Focus is the second of two sets of articles on the topic of bioengineering in women's health. This second issue in the series focuses on pregnancy, a dynamic time in a women's life that involves dramatic physiologic changes within a relatively small timeframe. Pregnancy demands endurance and resilience of one's body and represents a critical component of women's health research. The health of an individual leading up to, during and after pregnancy is paramount for reproductive health and the lifelong health of offspring. The articles in this issue explore physiological events that support reproduction spanning from embryo implantation, through gestation, to delivery and parturition. Specifically, the articles highlight essential developments in placenta, fetal membranes, cervix, pelvic floor and anthropometry research. The featured bioengineering disciplines deployed to study such complex biological processes are diverse, with articles detailing the latest advancements in computational modelling at various biological length-scales, biomaterial design, material modelling, non-invasive diagnostic techniques, microfluidic devices and experimental mechanics. This second issue continues the first in this series, on the physiology of the non-pregnant woman.