[Characterization of children born to mothers with Graves' disease]

INTRODUCTION

Neonatal hyperthyroidism is a disease that can cause mortality and sequelae. To date, there is no clinical series of cases that allows us to know the local reality of this condition.

OBJECTIVE

to charac terize the children of mothers with Graves' disease (GD) from a clinical and biochemical point of view.

SUBJECTS AND METHOD

A prospective follow-up of all newborns (NB) of mothers with history of GD was performed in two public hospitals in Santiago, during 5 years. Clinical and laboratory variables of mother-child pairs and thyroid-stimulating hormone receptor antibodies (TRAbs) le vels were analyzed looking for associations between these variables and the development of neonatal hyperthyroidism.

RESULTS

Seventy-six mother-child pairs were included (0.2% of all deliveries). Five neonates (6.6%) presented biochemical hyperthyroidism, and 3 of them developed clinical disease and required treatment. All 5 NBs who developed hyperthyroidism had mothers with positive or indeterminate TRAbs. No child of TRAbs-negative mothers developed the disease. TRAbs could be determined in only 65% of the mothers and 72% of the NBs. There was a significant correlation bet ween maternal TRAbs titers (p < 0.03), neonatal TRAbs titers (p < 0.008), and neonatal TSH between days 2-6 (p < 0.006), with the subsequent development of hyperthyroidism. All cases of neonatal hyperthyroidism were transient. There was no mortality in our series.

CONCLUSIONS

This is the first national case series of children of mothers with GD. Maternal and neonatal TRAbs and TSH between days 2-6 of life were predictors of neonatal hyperthyroidism.

Clinical chorioamnionitis at term X: microbiology, clinical signs, placental pathology, and neonatal bacteremia - implications for clinical care

OBJECTIVES

Clinical chorioamnionitis at term is considered the most common infection-related diagnosis in labor and delivery units worldwide. The syndrome affects 5-12% of all term pregnancies and is a leading cause of maternal morbidity and mortality as well as neonatal death and sepsis. The objectives of this study were to determine the (1) amniotic fluid microbiology using cultivation and molecular microbiologic techniques; (2) diagnostic accuracy of the clinical criteria used to identify patients with intra-amniotic infection; (3) relationship between acute inflammatory lesions of the placenta (maternal and fetal inflammatory responses) and amniotic fluid microbiology and inflammatory markers; and (4) frequency of neonatal bacteremia.

METHODS

This retrospective cross-sectional study included 43 women with the diagnosis of clinical chorioamnionitis at term. The presence of microorganisms in the amniotic cavity was determined through the analysis of amniotic fluid samples by cultivation for aerobes, anaerobes, and genital mycoplasmas. A broad-range polymerase chain reaction coupled with electrospray ionization mass spectrometry was also used to detect bacteria, select viruses, and fungi. Intra-amniotic inflammation was defined as an elevated amniotic fluid interleukin-6 (IL-6) concentration ≥2.6 ng/mL.

RESULTS

(1) Intra-amniotic infection (defined as the combination of microorganisms detected in amniotic fluid and an elevated IL-6 concentration) was present in 63% (27/43) of cases; (2) the most common microorganisms found in the amniotic fluid samples were Ureaplasma species, followed by Gardnerella vaginalis; (3) sterile intra-amniotic inflammation (elevated IL-6 in amniotic fluid but without detectable microorganisms) was present in 5% (2/43) of cases; (4) 26% of patients with the diagnosis of clinical chorioamnionitis had no evidence of intra-amniotic infection or intra-amniotic inflammation; (5) intra-amniotic infection was more common when the membranes were ruptured than when they were intact (78% [21/27] vs. 38% [6/16]; p=0.01); (6) the traditional criteria for the diagnosis of clinical chorioamnionitis had poor diagnostic performance in identifying proven intra-amniotic infection (overall accuracy, 40-58%); (7) neonatal bacteremia was diagnosed in 4.9% (2/41) of cases; and (8) a fetal inflammatory response defined as the presence of severe acute funisitis was observed in 33% (9/27) of cases.

CONCLUSIONS

Clinical chorioamnionitis at term, a syndrome that can result from intra-amniotic infection, was diagnosed in approximately 63% of cases and sterile intra-amniotic inflammation in 5% of cases. However, a substantial number of patients had no evidence of intra-amniotic infection or intra-amniotic inflammation. Evidence of the fetal inflammatory response syndrome was frequently present, but microorganisms were detected in only 4.9% of cases based on cultures of aerobic and anaerobic bacteria in neonatal blood.

Effects of Maternal Subclinical Hypothyroidism in Early Pregnancy Diagnosed by Different Criteria on Adverse Perinatal Outcomes in Chinese Women With Negative TPOAb

Aims: To compare the effects of maternal subclinical hypothyroidism (SCH) diagnosed by the 2011 or 2017 "Guidelines of the American Thyroid Association (ATA) for the diagnosis and management of thyroid disease during pregnancy and the postpartum" during the first trimester on adverse pregnancy outcomes in thyroid peroxidase antibody (TPOAb)-negative pregnant women. Methods: There were 1,556 Chinese singleton pregnant women with negative TPOAb diagnosed with either SCH or euthyroidism who were investigated, and the prevalence and risk of obstetric outcomes were compared between the two groups using 2011 and 2017 ATA standards, respectively. The effects of a mildly elevated thyroid-stimulating hormone (TSH) concentration on adverse pregnancy outcomes were evaluated by binary logistic regression. Results: Maternal SCH identified by the 2011 ATA guidelines correlated with higher rates and risks of pregnancy-induced hypertension (PIH), preeclampsia, and low-birth-weight infants, while maternal SCH diagnosed by the 2017 ATA guidelines was more likely to develop PIH, preeclampsia, cesarean delivery, preterm delivery, placenta previa, and total adverse maternal and neonatal outcomes. Moreover, a mildly elevated TSH level was significantly associated with PIH after adjustment for confounding factors. Conclusions: Compared with the 2011 ATA guidelines, the 2017 ATA guidelines could be more applicable to Chinese pregnant women to screen the effects of SCH on the majority of adverse pregnancy outcomes.

Blood parameters in fetuses infected with cytomegalovirus according to the severity of brain damage and trimester of pregnancy at cordocentesis

BACKGROUND AND OBJECTIVE

Cytomegalovirus (CMV) remains a major cause of congenital infection and disease. During pregnancy, symptomatic cases can be detected through ultrasound (US) features, nevertheless, prognostic assessment is difficult. The aim of this study was to assess the predictive value of specific blood parameters in CMV infected fetuses.

STUDY DESIGN

Twenty-eight CMV-infected fetuses in which a cordocentesis had been performed were included. Fetuses were considered severely or mildly affected according to prenatal US/MRI brain damage. Fetal blood parameters were assessed for the prediction of severe brain abnormalities, and compared according to the trimester of pregnancy. Logistic regression and receiver operating curve analysis were performed.

RESULTS

Thrombocytopenia (≤100,000/mm³; p:0.03) and high levels of gamma-glutamyl transpeptidase (GGT) (≥151 IU/L; p:0.02) signaled severity. For the prediction of brain damage, GGT levels ≥ 183 UI/l achieved 71% sensitivity, 83% specificity (AUC: 0.78), and OR of 2.05 (95% CI: 1.22-3.43) per 100 IU/l increase, adjusted for gestational age. However, thrombocytopenia (91% vs 50%; p: 0.04), β₂ microglobulin >10.4 mg/l (60% vs 0% p: 0.03), CMV-DNA >50,000 copies/ml (80% vs 25%; p: 0.02), and positive IgM (70% vs 17%; p: 0.04) were observed significantly more often in severely damaged fetuses sampled ≤28 weeks than thereafter.

CONCLUSION

In CMV infected fetuses, thrombocytopenia and high levels of GGT are associated with severe US/MRI brain abnormalities. Nevertheless, among severely affected fetuses, blood parameters, with exception of GGT, change according to gestational age. Fetal blood could be less predictive of brain damage in the third trimester.

Performance of semiconductor sequencing platform for non-invasive prenatal genetic screening for fetal aneuploidy: results from a multicenter prospective cohort study in a clinical setting

OBJECTIVE

To validate and evaluate the performance metrics of the high-throughput semiconductor sequencing platform, Ion Proton®, in non-invasive prenatal genetic screening (NIPS) for common fetal aneuploidies in a clinical setting.

METHODS

This prospective cohort study included 2505 pregnant women from eight academic genetics laboratories (695 high risk for trisomy 21 (risk ≥ 1/250) pregnancies in a validation study, and 1810 such pregnancies, without ultrasound anomalies, in a real-life NIPS clinical setting). Outcome was available for all cases in the validation cohort and for 521 in the clinical cohort. Cell-free DNA from plasma samples was sequenced using the Ion Proton sequencer, and sequencing data were analyzed using the open-access software, WISECONDOR. Performance metrics for detection of trisomies 21, 18 and 13 were calculated based on either fetal karyotype result or clinical data collected at birth. We also evaluated the failure rate and compared three methods of fetal fraction quantification (RASSF1A assay, and DEFRAG and SANEFALCON software).

RESULTS

Results from both cohorts were consistent and their gestational age was not significantly different so their data were combined to increase the sample size for analysis. Sensitivities and specificities, respectively, were as follows: for trisomy 21, 98.3% (95% CI, 93.5-99.7%) and 99.9% (95% CI, 99.4-100%); for trisomy 18, 96.7% (95% CI, 80.9-99.8%) and 100% (95% CI, 99.6-100%); and for trisomy 13, 94.1% (95% CI, 69.2-99.7%) and 100% (95% CI, 99.6-100%). Our failure rate was 1.2% initially and as low as 0.6% after retesting some of the failed samples. Fetal fraction estimation by the RASSF1A assay was consistent with DEFRAG results, and both were adequate for routine diagnosis.

CONCLUSIONS

We describe one of the largest studies evaluating Ion Proton-based NIPS and the first clinical study reporting pregnancy outcome in a large series of patients. This platform is highly efficient in detecting the three most common trisomies. Our protocol is robust and can be implemented easily in any medical genetics laboratory. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Molecular characteristics of thalassemia and hemoglobin variants in prenatal diagnosis program in northern Thailand

Molecular analysis of globin genes is an essential process for prenatal diagnosis (PND) of severe thalassemia. This study aimed to describe the molecular characteristics of thalassemia and hemoglobin (Hb) variants in PND program in northern Thailand. The type and frequency of globin gene mutations from 1290 couples at risk of fetal severe thalassemia diseases that were tested at Thalassemia Laboratory at Chiang Mai University from 2012 to 2017 were retrospectively reviewed. The PND program detected 444 (34.4%), 196 (15.2%) and 642 (49.8%) couples at risk of fetal Hb Bart's hydrops fetalis, beta-thalassemia major (BTM) and beta-thalassemia/Hb E disease, respectively. Coinheritance of more than one type of thalassemia was common and eight (0.6%) couples were at risk of two types of severe thalassemia. There were two types of alpha⁰-thalassemia; 893 (99.7%) Southeast Asian and 3 (0.3%) Thai deletions. Twenty beta-globin gene mutations were found with 94.3% of beta⁰-thalassemia. The codon 41/42 (- TTCT), codon 17 (A>T), IVS-I-1 (G>T) and codon 71/72 (+ A) comprised 90% of beta-thalassemia mutations. The study shows a high percentage of couples at risk of fetal Hb Bart's hydrops fetalis and BTM. The percentage of beta⁰-thalassemia is higher than those seen in other regions of Thailand.

Maternal concentrations of human chorionic gonadotropin (hCG) and risk for cerebral palsy (CP) in the child. A case control study

BACKGROUND

Intrauterine conditions may be important in the development of cerebral palsy in the child. The hormone, human chorionic gonadotropin (hCG), is synthesized in the placenta, and hCG plays an important role in placental angiogenesis and development. Thus, maternal hCG concentrations may be an indicator of placental function and thereby the intrauterine environment for the offspring. We studied the associations of maternal concentrations of hCG during pregnancy with cerebral palsy in the child.

METHODS

We performed a case-control study nested within a cohort of 29,948 pregnancies in Norway during 1992-1994. Cases were all women within the cohort who gave birth to a singleton child with cerebral palsy diagnosed before five years of age (n = 63). Controls were a random sample of women with a singleton child without cerebral palsy (n = 182).

RESULTS

The adjusted odds ratio (OR) for cerebral palsyin the child was 0.78 (95% CI: 0.55-1.10) per log-transformed unit of maternal hCG in the 1 st trimester, and the OR was 1.42 (95% CI: 0.94-2.16) in the 2nd trimester. Thus, women who did not have high hCG concentrations in the 1 st trimester and low hCG concentrations in the 2nd trimester, had increased risk for giving birth to a child with cerebral palsy. Adjustments were made for pregnancy week of serum sampling, maternal age and parity.

CONCLUSIONS

The abnormal hCG concentrations in pregnancies with cerebral palsy in the offspring, could suggest placental factors as causes of cerebral palsy.

A metabolomics-based approach for non-invasive screening of fetal central nervous system anomalies

BACKGROUND

Central nervous system anomalies represent a wide range of congenital birth defects, with an incidence of approximately 1% of all births. They are currently diagnosed using ultrasound evaluation. However, there is strong need for a more accurate and less operator-dependent screening method.

OBJECTIVES

To perform a characterization of maternal serum in order to build a metabolomic fingerprint resulting from congenital anomalies of the central nervous system.

METHODS

This is a case-control pilot study. Metabolomic profiles were obtained from serum of 168 mothers (98 controls and 70 cases), using gas chromatography coupled to mass spectrometry. Nine machine learning and classification models were built and optimized. An ensemble model was built based on results from the individual models. All samples were randomly divided into two groups. One was used as training set, the other one for diagnostic performance assessment.

RESULTS

Ensemble machine learning model correctly classified all cases and controls. Propanoic, lactic, gluconic, benzoic, oxalic, 2-hydroxy-3-methylbutyric, acetic, lauric, myristic and stearic acid and myo-inositol and mannose were selected as the most relevant metabolites in class separation.

CONCLUSION

The metabolomic signature of second trimester maternal serum from pregnancies affected by a fetal central nervous system anomaly is quantifiably different from that of a normal pregnancy. Maternal serum metabolomics is therefore a promising tool for the accurate and sensitive screening of such congenital defects. Moreover, the details of the most relevant metabolites and their respective biochemical pathways allow better understanding of the overall pathophysiology of affected pregnancies.

Longitudinal serum and urine steroid metabolite profiling in a 46,XY infant with prenatally identified POR deficiency

Although POR deficiency (PORD) is assumed to be accompanied by excessive placental androgen accumulation and enhanced adrenal and testicular androgen production via the backdoor pathway as well as compromised testicular androgen production via the frontdoor pathway, there is no direct evidence for the flux of excessive placental androgens into the fetal circulation and for the production of dihydrotestosterone (DHT) via the backdoor pathway. We examined longitudinal serum and urine steroid metabolite profiles in a 46,XY infant with PORD who was prenatally identified because of the progressive fetal masculinization and maternal virilization from the mid-gestation and the presence of fetal radio-humeral synostosis and was confirmed to have compound heterozygous mutations of POR (p.Q201X and p.R457H). The results showed (1) markedly and inappropriately elevated serum androstenedione and testosterone (T) values at birth, (2) a markedly increased serum DHT value with a normal DHT/T ratio at birth, (3) transient elevation of serum T and DHT values accompanied by a normal DHT/T ratio and concomitant elevations of intermediate steroid metabolites on both the frontdoor and backdoor pathways at 30 days of age, and (4) persistent PORD-compatible urine steroid profiles. Although the data obtained from a single infantile patient are too premature to be generalized, they imply: (1) the transfer of excessive placental androgens into the fetal as well as the maternal circulations from the mid-gestation, (2) lack of a clinically discernible amount of DHT production via the adrenal backdoor pathway around birth, and (3) the activation of both the frontdoor and backdoor pathways in the testis around the mini-puberty, with no production of a clinically discernible amount of DHT via the testicular backdoor pathway.

Non-invasive fetal RHD genotyping for RhD negative women stratified into RHD gene deletion or variant groups: comparative accuracy using two blood collection tube types

Non-invasive fetal RHD genotyping in Australia to reduce anti-D usage will need to accommodate both prolonged sample transport times and a diverse population demographic harbouring a range of RHD blood group gene variants. We compared RHD genotyping accuracy using two blood sample collection tube types for RhD negative women stratified into deleted RHD gene haplotype and RHD gene variant cohorts. Maternal blood samples were collected into EDTA and cell-free (cf)DNA stabilising (BCT) tubes from two sites, one interstate. Automated DNA extraction and polymerase chain reaction (PCR) were used to amplify RHD exons 5 and 10 and CCR5. Automated analysis flagged maternal RHD variants, which were classified by genotyping. Time between sample collection and processing ranged from 2.9 to 187.5 hours. cfDNA levels increased with time for EDTA (range 0.03-138 ng/μL) but not BCT samples (0.01-3.24 ng/μL). For the 'deleted' cohort (n=647) all fetal RHD genotyping outcomes were concordant, excepting for one unexplained false negative EDTA sample. Matched against cord RhD serology, negative predictive values using BCT and EDTA tubes were 100% and 99.6%, respectively. Positive predictive values were 99.7% for both types. Overall 37.2% of subjects carried an RhD negative baby. The 'variant' cohort (n=15) included one novel RHD and eight hybrid or African pseudogene variants. Review for fetal RHD specific signals, based on one exon, showed three EDTA samples discordant to BCT, attributed to high maternal cfDNA levels arising from prolonged transport times. For the deleted haplotype cohort, fetal RHD genotyping accuracy was comparable for samples collected in EDTA and BCT tubes despite higher cfDNA levels in the EDTA tubes. Capacity to predict fetal RHD genotype for maternal carriers of hybrid or pseudogene RHD variants requires stringent control of cfDNA levels. We conclude that fetal RHD genotyping is feasible in the Australian environment to avoid unnecessary anti-D immunoglobulin prophylaxis.

Fetal Exposure to High Maternal Thyroid Hormone Levels Causes Central Resistance to Thyroid Hormone in Adult Humans and Mice

Context

Fetuses exposed to the high thyroid hormone (TH) levels of mothers with resistance to thyroid hormone beta (RTH-β), due to mutations in the THRB gene, have low birth weight and suppressed TSH.

Objective

Determine if such exposure to high TH levels in embryonic life has a long-term effect into adulthood.

Design

Observations in humans with a parallel design on animals to obtain a preliminary information regarding mechanism.

Setting

University research centers.

Patients or other participants

Humans and mice with no RTH-β exposed during intrauterine life to high TH levels from mothers who were euthyroid due to RTH-β. Controls were humans and mice of the same genotype but born to fathers with RTH-β and mothers without RTH-β and thus, with normal serum TH levels.

Interventions

TSH responses to stimulation with thyrotropin-releasing hormone (TRH) during adult life in humans and male mice before and after treatment with triiodothyronine (T3). We also measured gene expression in anterior pituitaries, hypothalami, and cerebral cortices of mice.

Results

Adult humans and mice without RTH-β, exposed to high maternal TH in utero, showed persistent central resistance to TH, as evidenced by reduced responses of serum TSH to TRH when treated with T3. In mice, anterior pituitary TSH-β and deiodinase 3 (D3) mRNAs, but not hypothalamic and cerebral cortex D3, were increased.

Conclusions

Adult humans and mice without RTH-β exposed in utero to high maternal TH levels have persistent central resistance to TH. This is likely mediated by the increased expression of D3 in the anterior pituitary, enhancing local T3 degradation.

Noninvasive detection of F8 int22h-related inversions and sequence variants in maternal plasma of hemophilia carriers

Direct detection of F8 and F9 sequence variants in maternal plasma of hemophilia carriers has been demonstrated by microfluidics digital PCR. Noninvasive prenatal assessment of the most clinically relevant group of sequence variants among patients with hemophilia, namely, those involving int22h-related inversions disrupting the F8 gene, poses additional challenges because of its molecular complexity. We investigated the use of droplet digital PCR (ddPCR) and targeted massively parallel sequencing (MPS) for maternal plasma DNA analysis to noninvasively determine fetal mutational status in pregnancies at risk for hemophilia. We designed family-specific ddPCR assays to detect causative sequence variants scattered across the F8 and F9 genes. A haplotype-based approach coupled with targeted MPS was applied to deduce fetal genotype by capturing a 7.6-Mb region spanning the F8 gene in carriers with int22h-related inversions. The ddPCR analysis correctly determined fetal hemophilia status in 15 at-risk pregnancies in samples obtained from 8 to 42 weeks of gestation. There were 3 unclassified samples, but no misclassification. Detailed fetal haplotype maps of the F8 gene region involving int22h-related inversions obtained through targeted MPS enabled correct diagnoses of fetal mutational status in 3 hemophilia families. Our data suggest it is feasible to apply targeted MPS to interrogate maternally inherited F8 int22h-related inversions, whereas ddPCR represents an affordable approach for the identification of F8 and F9 sequence variants in maternal plasma. These advancements may bring benefits for the pregnancy management for carriers of hemophilia sequence variants; in particular, the common F8 int22h-related inversions, associated with the most severe clinical phenotype.

Sequential fetal serum β2-microglobulin to predict postnatal renal function in bilateral or low urinary tract obstruction

OBJECTIVE

Fetal serum β2-microglobulin has been shown to predict postnatal renal outcome in cases of fetal obstructive uropathy. We assessed the value of serial measurements of fetal serum β2-microglobulin in the prediction of postnatal renal outcome.

METHODS

We retrospectively studied renal outcome in 42 fetuses with bilateral or low urinary tract obstruction that had fetal blood sampling on at least two occasions to assay serum levels of β2-microglobulin. Amniotic fluid volume at the time of each sampling was recorded. We classified renal outcome as either favorable (when postnatal renal function was normal) or adverse (when postnatal chronic renal failure occurred or when renal dysplasia at autopsy was noted). A β2-microglobulin cut-off of 5 mg/L and amniotic fluid index of 5 cm were used to predict postnatal renal outcome.

RESULTS

Renal outcome was adverse in 28 cases and favorable in 14. In 12 (28.6%) cases, fetal serum β2-microglobulin concentration differed between the first and last measurement. Prediction of postnatal renal outcome was correct in 11 of these cases based on the last β2-microglobulin measurement. The sensitivity of β2-microglobulin in predicting renal outcome was significantly higher (P = 0.005) when using the last rather than the first measurement (96.4% vs 64.3%), with similar specificity for both measurements (85.7% vs 78.6%, non-significant). The sensitivity of amniotic fluid volume was also significantly higher (P = 0.005) when using the last rather than the first measurement (75.0% vs 35.7%), with similar specificity for both measurements (64.3% vs 71.4%, non-significant).

CONCLUSION

Sequential measurement of serum β2-microglobulin, performed for adverse ultrasound findings, such as renal parenchymal abnormality or decreasing amniotic fluid volume, predicts postnatal renal outcome more accurately than does a single assay. This may be due to possible worsening of renal injury with increasing duration of urinary tract obstruction. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Cohort study on maternal cytomegalovirus seroprevalence and prevalence and clinical manifestations of congenital infection in China

Congenital cytomegalovirus (CMV) infection is the leading viral cause of birth defects and developmental disabilities in developed countries. However, CMV seroprevalence and burden of congenital CMV infection are not well defined in China.Cohort of newborns from 5 birthing hospitals in 2 counties of Shandong Province, China, were enrolled from March 2011 to August 2013. Dried blood spots (DBS) and saliva were collected within 4 days after birth for IgG testing for maternal seroprevalence and real-time PCR testing for congenital CMV infection, respectively.Among 5020 newborns tested for CMV IgG, 4827 were seropositive, resulting in CMV maternal seroprevalence of 96.2% (95% confidence interval [CI]:95.6%-96.7%). Of the 10,933 newborns screened for congenital CMV infection, 75 had CMV detected, resulting in an overall prevalence of 0.7% (95% CI: 0.5%-0.9%), with prevalences of 0.4% (14/3995), 0.6% (66/10,857), and 0.7% (52/7761) for DBS, wet saliva, and dried saliva specimens screened, respectively. Prevalence of congenital CMV infection decreased with increasing maternal age (0.9%, 0.6%, and 0.3% among newborns delivered from mothers aged 16-25, 26-35, and >35 years, respectively; P = 0.03), and was higher among preterm infants than full term infants (1.3% vs 0.6%, P = 0.04), infants with intrauterine growth restriction (IUGR) than those without (1.8% vs 0.7%, P = 0.03), and twins or triplets than singleton pregnancies (2.8% vs 0.7%, P = 0.04). None of the 75 newborns exhibited symptomatic congenital CMV infection, and there was no difference in clinical characteristics and newborn hearing screening results between infants with and without congenital CMV infection at birth.Congenital CMV infection prevalence was lower and the clinical manifestations were milder in this relatively developed region of China compared to populations from other countries with similarly high maternal seroprevalence. Follow-up on children with congenital CMV infection will clarify the burden of disabilities from congenital CMV infection in China.

Weight-related and analytical maternal factors in gestational diabetes to predict birth weight and cord markers of diabetic fetopathy

OBJECTIVE

The objective was to determine the value of clinical and analytical maternal factors to predict birth weight and umbilical cord biochemical markers of diabetic fetopathy.

METHODS

Prospective evaluation of gestational diabetes pregnancies (n = 50). Maternal weight-related clinical and analytical factors were collected during pregnancy. After birth, an umbilical cord sample was taken.

RESULTS

Univariate linear regression analysis showed relationship between maternal weight, glycated hemoglobin (HbA1c) and insulin-like growth factor 1 (IGF1) with birth weight percentile. A significant association was found between maternal weight and cord insulin and C-peptide. Maternal HbA1c, leptin and insulin during pregnancy showed a positive linear association to cord leptin, insulin and C-peptide. In multivariate analysis models, final maternal BMI showed an independent positive association with cord C-peptide.

CONCLUSIONS

Maternal weight-related and analytical parameters show diagnostic value to birth weight and cord markers.

The fetal glucose steal: an underappreciated phenomenon in diabetic pregnancy

Adverse neonatal outcomes continue to be high for mothers with type 1 and type 2 diabetes, and are far from eliminated in mothers with gestational diabetes mellitus. This is often despite seemingly satisfactory glycaemic control in the latter half of pregnancy. Here we argue that this could be a consequence of the early establishment of fetal hyperinsulinaemia, a driver that exaggerates the fetal glucose steal. Essentially, fetal hyperinsulinaemia, through its effect on lowering fetal glycaemia, will increase the glucose concentration gradient across the placenta and consequently the glucose flux to the fetus. While the steepness of this gradient and glucose flux will be greatest at times when maternal hyperglycaemia and fetal hyperinsulinaemia coexist, fetal hyperinsulinaemia will favour a persistently high glucose flux even at times when maternal blood glucose is normal. The obvious implication is that glycaemic control needs to be optimised very early in pregnancy to prevent the establishment of fetal hyperinsulinaemia, further supporting the need for pre-pregnancy planning and early establishment of maternal glycaemic control. An exaggerated glucose steal by a hyperinsulinaemic fetus could also attenuate maternal glucose levels during an OGTT, providing an explanation for why some mothers with fetuses with all the characteristics of diabetic fetopathy have 'normal' glucose tolerance.

[THE CONTENT OF SOME ESSENTIAL MICRONUTRIENTS IN INFANTS WITH LOW BIRTH WEIGHT WITH INTRAUTERINE HERPES INFECTION]

To study the comparative aspect of the content of certain essential trace elements in the blood serum of infants with low birth weight, identify the clinical signs of deficiency. The study involved 127 infants, of which 69 constituted the main group and 58 infants constituted the comparison group. All newborns were identified haematological and biochemical blood tests, some Essential micronutrients (copper, selenium, zinc). Laboratory diagnosis of microelement composition of blood was determined by mass spectrometry with inductively coupled argon plasma (ICP-MS). The analysis of some essential trace elements was diagnosed copper and selenium deficiency in all newborns. Mean while neonatal treatment group indicators selenium, copper are lower, than similar nutrients infants in the control group. The zinc content in both groups mostly within the normal parameters. Thus, the level of essential micronutrients (copper, selenium) in the blood serum of newborn infants in the study group and the control group was below the reference value, indicating that insufficient intake data trace in the fetus located in the mother's womb.

RECOMMENDATIONS

1. In the diagnosis of various diseases in newborns with low birth weight should take into account the level of serum essential micronutrients (copper, selenium). 2. In the appointment of the underlying disease treatment in these infants need to be borne in mind also correct micronutrient deficiencies.

[SOME CLINICAL AND IMMUNOLOGICAL ASPECTS OF PRETERM BIRTH]

Aim - to make a comparative assessment of the cytokines level in women with preterm labor with chronic infection and without it in order to determine the risk of implementation of intrauterine infection in their preterm infants. There was prospective investigation of 141 pregnant and their 141 premature infants with different gestation terms. There was identify cytokines levels in mother's blood with immune enzyme analysis method due implementation of intrauterine infection in compare with control group. It wasinterconnection ofinfection pathology withgestation terms, it lead to preterm labor. Prematurity which cause by mothers chronic infection, lead to heavier, extended period of bacterial infection in premature infants. It was increasing of cytokines levels IL-1β, IL-6, and TNF-α of mother's blood during implementation of intrauterine infection in premature infants. Multiparous pregnant, adverse outcomes of previous pregnancies in anamnesis, high frequency carrier of bacterial infection were risk factors for preterm labor among explored pregnant women. To study cytokine profile among the explored pregnant women from main group showed a pattern in increasing of level IL-1β, IL- 6 and TNF-α serum during pregnancy , indicating the course of pregnancy and can be used as a nonspecific marker for early diagnosis of preterm birth and implementing infection in premature . The level of IL-2 did not have a diagnostic value.

Significance of C-reactive protein in predicting fetal inflammatory response syndrome

OBJECTIVES

The aim of the study was to identify and evaluate a possible correlation between C-reactive protein (CRP) concentration in maternal blood and the risk of developing fetal inflammatory syndrome (FIRS).

MATERIAL AND METHODS

The study included 158 infants born at 22-34 weeks of gestation and their mothers. Umbilical cord blood cytokines were evaluated in immunoassay tests and maternal blood was tested for CRP concentration.

RESULTS

The period of gestation was significantly shorter in the FIRS group as compared to the control group (29.5 ± 3.1 vs. 32.2 ± 2.4 weeks, p < 0.001). Gestational age was ≤ 30 weeks for 53.8% of the newborns in the FIRS group and 15.8% of the newborns in the control group (p < 0.001). Maternal CRP before, during and after labor was significantly higher in the FIRS group as compared to the control group (p < 0.001). Our study investigated the correlation between CRP in maternal blood and IL-6 concentration during the entire perinatal period (p < 0.001).

CONCLUSION

CRP concentration in the FIRS group was significantly higher than in controls before, during, and after labor. Thus, it seems safe to conclude that changing concentration of inflammatory factors in maternal blood are closely related to FIRS. Elevated CRP in maternal blood might signify a progressing intrauterine infection and herald the development of FIRS.

Middle cerebral artery peak systolic velocity to predict fetal hemoglobin levels in twin anemia-polycythemia sequence

OBJECTIVE

To evaluate the diagnostic accuracy of middle cerebral artery peak systolic velocity (MCA-PSV) Doppler measurements in prediction of hemoglobin levels in twin anemia-polycythemia sequence (TAPS).

METHODS

This study involved a consecutive cohort comprising monochorionic twin pregnancies complicated by TAPS managed at three European fetal medicine centers between 2005 and 2013. The accuracy of MCA-PSV, measured immediately prior to fetal hemoglobin (Hb) measurement by fetal or cord blood sampling, for prediction of anemia and polycythemia was assessed using 2 × 2 tables.

RESULTS

A total of 116 measurements (74 recorded in donors and 42 in recipients) from 43 twin pregnancies complicated by TAPS were available for analysis. MCA-PSV multiples of the median (MoM) values correlated well with Hb levels (r = - 0.86; P < 0.001). The sensitivity of MCA-PSV ≥ 1.5 MoM to predict severe anemia (Hb deficit > 5 SD below the mean) in TAPS donors was 94% (95% CI, 85-98%); specificity was 74% (95% CI, 62-83%); positive and negative predictive values were 76% (95% CI, 65-85%) and 94% (95% CI, 83-98%), respectively. The sensitivity of MCA-PSV ≤ 1.0 MoM to predict polycythemia (Hb level > 5 SD above the mean) in TAPS recipients was 97% (95% CI, 87-99%); specificity was 96% (95% CI, 89-99%); positive and negative predictive values were 93% (95% CI, 81-97%) and 99% (95% CI, 93-100%), respectively.

CONCLUSION

MCA-PSV measurement has high diagnostic accuracy for predicting abnormal Hb levels in fetuses with TAPS.

Prediction of small-for-gestational-age neonates: screening by maternal biochemical markers at 30-34 weeks

OBJECTIVE

To investigate the potential value of serum placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1), pregnancy-associated plasma protein-A (PAPP-A), free β-human chorionic gonadotropin (β-hCG) and α-fetoprotein (AFP) at 30-34 weeks' gestation in the prediction of delivery of small-for-gestational-age (SGA) neonates, in the absence of pre-eclampsia (PE).

METHODS

This was a screening study in singleton pregnancies at 30-34 weeks' gestation, including 490 that delivered SGA neonates and 9360 cases that were unaffected by SGA, PE or gestational hypertension (normal outcome). Multivariable logistic regression analysis was used to determine if screening by serum PlGF, sFlt-1, PAPP-A, free β-hCG and AFP, individually or in combination, improved the prediction of SGA neonates provided by screening with maternal characteristics and medical history (maternal factors), and estimated fetal weight (EFW) from fetal head circumference, abdominal circumference and femur length.

RESULTS

Compared to the normal group, the mean log10 multiples of the median (MoM) values of PlGF and AFP were significantly lower and the mean log10 MoM values of sFlt-1 and free β-hCG were significantly higher in the SGA group with a birth weight < 5(th) percentile (SGA < 5(th)) delivering < 5 weeks following assessment. The best model for prediction of SGA was provided by a combination of maternal factors, EFW and serum PlGF. Such combined screening, predicted, at a 10% false-positive rate, 85%, 93% and 92% of SGA neonates delivering < 5 weeks following assessment with birth weight < 10(th), < 5(th) and < 3(rd) percentiles, respectively; the respective detection rates of combined screening for SGA neonates delivering ≥ 5 weeks following assessment were 57%, 64% and 71%.

CONCLUSION

Combined screening by maternal factors, EFW and serum PlGF at 30-34 weeks' gestation can identify a high proportion of pregnancies that subsequently deliver SGA neonates.

Placental histology in clinically unexpected severe fetal acidemia at term

BACKGROUND

Fetal acidemia at birth is defined as a newborn condition wherein the cord blood pH value is less than 7.0. It could represent an association with newborn brain damage; therefore, it is important to investigate which conditions precipitate its occurrence. No extensive placental analysis has been performed in cases of acidotic newborns delivered from low-risk pregnancies.

AIMS

To study placental characteristics in cases with severe fetal acidemia.

STUDY DESIGN

Retrospective case-control study.

SUBJECT

34 cases, 102 controls.

OUTCOME MEASURES

Umbilical artery pH was measured at delivery from a doubly clamped portion of the cord. Placental characteristics were compared between cases with severe fetal acidemia (cord pH at birth <7.0) and controls (normal pH at birth) in term low-risk pregnancies.

RESULTS

Macroscopic placental and umbilical cord characteristics were comparable in cases and controls whereas histological characteristics exhibited differences: diffuse villous edema, increased number of syncytial knots and villous branching abnormalities significantly affected cases more frequently than controls. Diffuse villous edema is related to fetal vascularization and associated with an increase of venous pressure; in our low-risk population, it is conceivable that these changes of fetal flow and pressure occurred in labor during the alteration of fetal heart rate. An increased number of syncytial knots and villous branching abnormalities have been previously associated with chronic placental hypoxic condition; in our low-risk population they could reflect a clinically undetectable hypoxic situation that acted during pregnancy reducing fetal resources to bear labor and delivery.

CONCLUSIONS

Placental histology provides useful information related to fetal acidemia in low-risk term pregnancy.

NON-INVASIVE MONITORING OF FOETAL ANAEMIA IN KELL SENSITIZED PREGNANCY

We report a case of Kell sensitized pregnancy with good neonatal outcome. Anti-K antibodies were detected in maternal serum in early pregnancy as a part of routine antibody screening test. The middle cerebral artery doppler monitoring and serial titers were carried out to screen for foetal anaemia. Despite of rising antibody titers, serial middle cerebral artery doppler was normal and did not showed foetal anaemia. The pregnancy was carried out till term and patient delivered at 37 weeks of pregnancy with no evidence of foetal anaemia. This case underlines the need of general screening on rare antibodies in all pregnant women and that non-invasive monitoring of foetal anaemia can be done with anti-k titers and middle cerebral artery Doppler.

First example of an FY*01 allele associated with weakened expression of Fya on red blood cells

Duffy antigens are important in immunohematology. the reference allele for the Duffy gene (FY) is FY*02, which encodes Fy(b). An A>G single nucleotide polymorphism (SNP) at coding nucleotide (c.) 125 in exon 2 defines the FY*01 allele, which encodes the antithetical Fy(a). A C>T SNP at c.265 in the FY*02 allele is associated with weakening of Fy(b) expression on red blood cells (R BCs) (called Fy(x)). until recently, this latter change had not been described on a FY*01 background allele. Phenotype-matched units were desired for a multi-transfused Vietnamese fetus with α-thalassemia. Genotyping of the fetus using a microarray assay that interrogates three SNPs (c.1-67, c.125, and c.265) in FY yielded indeterminate results for the predicted Duffy phenotype. Genomic sequencing of FY exon 2 showed that the fetal sample had one wild-type FY*01 allele and one new FY*01 allele with the c.265C>T SNP, which until recently had only been found on the FY*02 allele. Genotyping performed on samples from the proband's parents indicated that the father had the same FY genotype as the fetus. Flow cytometry, which has been previously demonstrated as a useful method to study antigen strength on cells, was used to determine if this new FY*01 allele was associated with reduced Fy(a) expression on the father's RBCs. Median fluorescence intensity of the father's RBCs (after incubation with anti-FY(a) and fluorescein-labeled anti-IgG) was similar to known FY*01 heterozygotes. and significantly weaker than known FY*01 homozygotes. In conclusion, the fetus and father both had one normal FY*01 allele and one new FY*01W.01, is associated with weakened expression of Fy(a) on RBCs.

Online detection of fetal acidemia during labour by testing synchronization of EEG and heart rate: a prospective study in fetal sheep

Severe fetal acidemia during labour can result in life-lasting neurological deficits, but the timely detection of this condition is often not possible. This is because the positive predictive value (PPV) of fetal heart rate (FHR) monitoring, the mainstay of fetal health surveillance during labour, to detect concerning fetal acidemia is around 50%. In fetal sheep model of human labour, we reported that severe fetal acidemia (pH<7.00) during repetitive umbilical cord occlusions (UCOs) is preceded ∼60 minutes by the synchronization of electroencephalogram (EEG) and FHR. However, EEG and FHR are cyclic and noisy, and although the synchronization might be visually evident, it is challenging to detect automatically, a necessary condition for bedside utility. Here we present and validate a novel non-parametric statistical method to detect fetal acidemia during labour by using EEG and FHR. The underlying algorithm handles non-stationary and noisy data by recording number of abnormal episodes in both EEG and FHR. A logistic regression is then deployed to test whether these episodes are significantly related to each other. We then apply the method in a prospective study of human labour using fetal sheep model (n = 20). Our results render a PPV of 68% for detecting impending severe fetal acidemia ∼60 min prior to pH drop to less than 7.00 with 100% negative predictive value. We conclude that this method has a great potential to improve PPV for detection of fetal acidemia when it is implemented at the bedside. We outline directions for further refinement of the algorithm that will be achieved by analyzing larger data sets acquired in prospective human pilot studies.

Treatment of alpha(0)-thalassemia (--(SEA)/--(SEA)) via serial fetal and post-natal transfusions: Can early fetal intervention improve outcomes?

OBJECTIVE AND IMPORTANCE

Homozygous Southeast Asian alpha-thalassemia mutation (--(SEA)/--(SEA)) results in deletion of all alpha-globin genes (alpha(0)-thalassemia). Since all alpha-globin chains are absent, hemoglobin F cannot be synthesized, and hemoglobin Bart's becomes the dominant fetal hemoglobin. Hemoglobin Bart's is a γ tetramer with a very high oxygen affinity, thus oxygen delivery to the tissues is poor. Clinical manifestations include severe fetal anemia, hydrops fetalis, fetal demise, and high risk of neurodevelopmental impairment in the rare survivors.

CLINICAL PRESENTATION

A 39-year-old Vietnamese woman presented to our center at 28 0/7 weeks' gestation with fetal alpha(0)-thalassemia (--(SEA)/--(SEA) type deletion) and ultrasound markers suggestive of severe fetal anemia.

INTERVENTION

The fetus was treated with four intrauterine transfusions followed by post-natal chronic transfusions. Formal neurodevelopmental testing (Battelle Developmental Inventory, Second Edition) was performed at 18 months of age, and the developmental quotient was 93 (32nd percentile) with all subdomains noted within normal limits, indicating overall intact neurodevelopment.

CONCLUSION

We posit that earlier diagnosis and fetal treatment, prior to clinical findings suggestive of fetal anemia, may improve long-term outcomes by enhancing oxygen delivery to the tissues of the developing fetus.

Fetal blood sampling in prenatal diagnosis of thalassemia at late pregnancy

Fetal blood sampling is a procedure that involves the drawing of a blood sample from the umbilical vein of the umbilical cord, which can be performed after 18 weeks gestation. Fetal blood sampling is a preferable method for prenatal diagnosis of thalassemia in second trimester or late pregnancy. Additionally, it is suggested to be performed in cases in which mosaicisms are identified by amniocentesis or chorionic villus sampling (CVS), areas where DNA analysis is not available, and when mutations of the parents are not known. Laboratory steps regarding prenatal diagnosis by fetal blood sampling were summarized, including the ensuring of fetal origin, determination of red blood cell parameters, fetal hemoglobin analysis, and finally fetal DNA analysis. The objective of this review is to present an overview of procedures in terms of benefits, laboratory interpretations, and some limitations.

Leukocytosis as a prognostic marker in the development of fetal inflammatory response syndrome

OBJECTIVE

To identify and evaluate the correlation between leukocyte count in maternal blood and the risk of developing fetal inflammatory response syndrome (FIRS).

PATIENTS AND METHODS

The study involved 158 infants born at 22 - 34 weeks of gestation and their mothers. Umbilical cord blood cytokines were evaluated in immunoassay tests and maternal blood was tested for the leukocyte formula.

RESULTS

The period of gestation was significantly shorter in the FIRS group compared to the control group (29.5±3.1 vs. 32.2±2.4 weeks, p<0.001). Gestational age was ≤30 weeks for 53.8% of the newborns in the FIRS group and 15.8% of the newborns in the control group (p<0.001). The number of leukocytes in maternal blood before and during labor was significantly higher in the FIRS group than in the control group (p=0.034 and 0.004, respectively). The study determined the correlation between the total leukocyte count in maternal blood and IL-6 concentration during labor (p=0.05) and tumor necrosis factor (TNF-α) concentration in umbilical cord blood before and during labor (p=0.02 and 0.007, respectively).

CONCLUSION

Leukocytosis in the FIRS group was significantly higher than in the control group before and during labor. According to our data, one of the possible indicators of intrauterine infection could be the number of leukocytes in maternal blood.

Review: advances in non-invasive prenatal diagnosis

The invasive procedures amniocentesis and chorionic villus sampling are routinely applied in pregnancies at risk for fetal genetic disorders and the results obtained are the gold standard for prenatal diagnosis. These procedures have an approximately 0.5-1% risk for fetal loss and are mainly used in cases at risk for fetal chromosomal abnormalities and single-gene disorders. Identification of cell-free fetal nucleic acids (DNA and RNA) in maternal plasma and the recognition that they represent a useful source of fetal genetic material for prenatal diagnosis has led to intensive efforts to develop non-invasive prenatal testing. This review summarizes recent developments in the field of non-invasive prenatal diagnosis through the use of cell-free fetal nucleic acids in maternal circulation during pregnancy and provides an overview of the possibilities for future clinical applications.

The effects of malaria and intermittent preventive treatment during pregnancy on fetal anemia in Malawi

BACKGROUND

Fetal anemia is common in malarious areas and is a risk factor for infant morbidity and mortality. Malaria during pregnancy may cause decreased cord hemoglobin (Hb) and fetal anemia among newborns. Intermittent preventive treatment during pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is protective against malaria but may also affect hematopoiesis and contribute to fetal anemia.

METHODS

Peripheral, placental, and cord blood were examined for malaria parasitemia and Hb concentration in a cross-section of 3848 mothers and infants delivered at Queen Elizabeth Central Hospital in Blantyre, Malawi between 1997 and 2006. Unconditional linear and logistic regressions were performed with multiple imputation for missing covariates to assess the associations between malaria, IPTp with SP, and fetal anemia.

RESULTS

The overall prevalence of fetal anemia was 7.9% (n = 304). Malaria parasitemia at delivery was associated with an adjusted decrease in cord Hb of -0.24 g/dL (95% confidence interval [CI], -.42 to -.05). The adjusted prevalence odds ratio for the effect of malaria on fetal anemia was 1.41 (95% CI, 1.05-1.90). Primigravidae who did not take IPTp had infants at highest risk for fetal anemia, and density of parasitemia was correlated with the decrease in cord Hb. There was no significant association between SP use and cord Hb or fetal anemia.

CONCLUSIONS

Malaria during pregnancy, but not IPTp, decreases cord Hb and is a risk factor for fetal anemia in Malawi. Intermittent preventive treatment during pregnancy with SP may continue to be safe and effective in preventing malaria during pregnancy and fetal anemia despite development of SP resistance.

[The characteristics of formation of antibodies to xeno- and endobiotics in women with inherent malformation of fetus]

The study revealed high levels of antibodies class A and G to benzopyrene and antibodies class G to estradiol and progesterone in women with pathology of fetus development. The most informative indicators of high risk of development of reproductive pathology are established The recommendations concerning the application of antibodies to benzopyrene, estradiol and progesterone in diagnostics of inherent malformations of fetus are provided.

Fetomaternal hemorrhage in the second trimester

AIMS

To investigate fetomaternal hemorrhage (FMH) rate and quantity in the second trimester of pregnancies with fetal anomalies and to assess the impact of invasive prenatal and termination procedures.

METHODS

Blood samples from women before termination of pregnancy were collected and analyzed by dual-color flow cytometry. Various clinical parameters were studied for their association with FMH.

RESULTS

In total, 67 women were recruited; pre- and post-termination pairs were collected for 31 women. HbF cells were present in 91.0% of specimens, in 29.9% the transfused blood volume was ≥4.2 mL. FMH ≥30 mL was found in 3.0%, and chronic FMH, defined as FMH ≥40% of fetoplacental blood volume in 7.5%. At the limit of quantification (0.1%) none of the clinical parameters was associated with the presence of HbF cells, nor was there a difference in HbF cell concentrations between pre- and post-termination blood samples.

CONCLUSIONS

Compared to normal term pregnancy, transfer of fetal red blood cells into the maternal circulation is increased in second-trimester pregnancies with fetal anomalies. FMH is not associated with invasive procedures or surgery performed in the context of termination. We hypothesize that the abnormal pregnancy itself, by means of an abnormal uteroplacental interface, is causing the increased transfer.

[The experience of the genetic laboratory in Varna on maternal serum screening for a six year period]

The aim of the presentation is to report the results of the Genetic laboratory in University hospital "St. Marina" Varna on second (15-19 gw) and first trimester (12-14 gw) maternal serum screening for common chromosome disorders, for the period 2005-2010. The test was performed on 10741 pregnant women from 8 regions of North-Eastern Bulgaria: 9743 women were screened in the second trimester (8251 at the age < 36 and 1492 at the age > 36) and 998 women - in the first trimester (827 at the age < 36 and 171 at the age > 36). The fluorimetric dual method was based on biochemical markers; software calculated risk as function of precise gestational age, maternal weight and age. The most common strategy was to combine the risk as determined from first and second trimester screening test in a sequential manner. High risk for a chromosome disorder (a risk above 1:250) was found by second trimester screening in 784 (8,04%): 488 (5,91%) <36 and 296 (19,83%) >36. The most recent first trimester screen test, which have been involved in the laboratory since April 2010 detected 7 (0,84%) and 23 (13,45%) women respectively to the age groups with increased risk for a chromosome disease. Additional ultrasonographic scan confirmed the biochemical risk for a serious Neural Tube/Abdomainal Wall defects in 5 out of 32 fetuses with increased risk for these defects; other 3 fetuses were detected to be involuntary miscarried as "missed abortion", 1 triploidy included. We comment on the sensitivity, limitations and the stepwise sequential testing way of achieving a high performance of screening for chromosome diseases based on preliminary information to pregnant women on different options for a contemporary approach for genetic prevention.

Rapid elimination of CO through the lungs: coming full circle 100 years on

At the start of the 20th century, CO poisoning was treated by administering a combination of CO(2) and O(2) (carbogen) to stimulate ventilation. This treatment was reported to be highly effective, even reversing the deep coma of severe CO poisoning before patients arrived at the hospital. The efficacy of carbogen in treating CO poisoning was initially attributed to the absorption of CO(2); however, it was eventually realized that the increase in pulmonary ventilation was the predominant factor accelerating clearance of CO from the blood. The inhaled CO(2) in the carbogen stimulated ventilation but prevented hypocapnia and the resulting reductions in cerebral blood flow. By then, however, carbogen treatment for CO poisoning had been abandoned in favour of hyperbaric O(2). Now, a half-century later, there is accumulating evidence that hyperbaric O(2) is not efficacious, most probably because of delays in initiating treatment. We now also know that increases in pulmonary ventilation with O(2)-enriched gas can clear CO from the blood as fast, or very nearly as fast, as hyperbaric O(2). Compared with hyperbaric O(2), the technology for accelerating pulmonary clearance of CO with hyperoxic gas is not only portable and inexpensive, but also may be far more effective because treatment can be initiated sooner. In addition, the technology can be distributed more widely, especially in developing countries where the prevalence of CO poisoning is highest. Finally, early pulmonary CO clearance does not delay or preclude any other treatment, including subsequent treatment with hyperbaric O(2).

The role of granulocyte colony-stimulating factor in the neutrophilia observed in the fetal inflammatory response syndrome

OBJECTIVES

Fetal neutrophilia is present in two-thirds of cases with the fetal inflammatory response syndrome (FIRS). The mechanisms responsible for this finding have not been elucidated. Granulocyte colony-stimulating factor (G-CSF) is the primary physiologic regulator of neutrophil production and plays a key role in the rapid generation and release of neutrophils in stressful conditions (i.e., infection). The objective of this study was to determine: 1) whether FIRS was associated with changes in fetal plasma G-CSF concentrations; and 2) if fetal plasma G-CSF concentrations correlated with fetal neutrophil counts, chorioamnionitis, neonatal morbidity/mortality and cordocentesis-to-delivery interval.

STUDY DESIGN

Percutaneous umbilical cord blood sampling was performed in a population of patients with preterm labor (n=107). A fetal plasma interleukin-6 (IL-6) concentration >11 pg/mL was used to define FIRS. Cord blood G-CSF was measured by a sensitive and specific immunoassay. An absolute neutrophil count was determined and corrected for gestational age. Receiver operating characteristic (ROC) curve, survival analysis and Cox proportional hazard model were employed.

RESULTS

1) G-CSF was detected in all fetal blood samples; 2) fetuses with FIRS had a higher median fetal plasma G-CSF concentration than those without FIRS (P<0.001); 3) a fetal plasma G-CSF concentration ≥134 pg/mL (derived from an ROC curve) was associated with a shorter cordocentesis-to-delivery interval, a higher frequency of chorioamnionitis (clinical and histological), intra-amniotic infection, and composite neonatal morbidity/mortality than a fetal plasma concentration below this cut-off; and 4) a fetal plasma G-CSF concentration ≥134 pg/mL was associated with a shorter cordocentesis-to-delivery interval (hazard ratio 3.2; 95% confidence interval 1.8-5.8) after adjusting for confounders.

CONCLUSIONS

1) G-CSF concentrations are higher in the peripheral blood of fetuses with FIRS than in fetuses without FIRS; and 2) a subset of fetuses with FIRS with elevated fetal plasma G-CSF concentrations are associated with neutrophilia, a shorter procedure-to-delivery interval, chorio-amnionitis and increased perinatal morbidity and mortality.

DNA extraction from chorionic villi for prenatal diagnosis of foetal haemoglobin genotype

BACKGROUND

Extraction of DNA from the chorionic villi is the first major step in the molecular determination of foetal haemoglobin genotype. There are few reports on DNA extraction from the chorionic villi. A desired method should be simple to conduct, reliable and cost effective.

OBJECTIVE

The aim of the study was to demonstrate that boiling-based protocol for DNA extraction can be used for the prenatal determination of foetal haemoglobin genotype in a low resource setting.

METHODS

Chorionic villi obtained from 10 women in transabdominal procedures were treated with trypsin. Prepared solution 1, (0.5gm NaOH , 250mls distilled H20 at pH 8.0) was added to the sample and boiled. Finally prepared solution 2 (6.05gm TrisHCl and 250 mls of distilled H20 at pH 7.5) was added. Extracted DNA was amplified using PCR , run on gel electrophoresis and gel imager for determination of foetal genotype.

RESULTS

DNA was successfully extracted and foetal genotype determined in all cases. The mean wet weight of sample was 25 mg with twice aspirations in 50% of women. Foetal genotypes were AA in five, AS in four and SS in one. No case of repeat extraction on account of inability to obtain a genotype was reported.

CONCLUSION

Boiling-based method is a rapid and reliable way to extract DNA from the chorionic villi.

[Analysis and perinatal outcome after intravascular transfusion]

INTRODUCTION

the leading cause of fetal anemia is Rh isoimmunization. The timely diagnosis by ultrasound and intravascular transfusion improves the prognosis.

OBJECTIVE

to evaluate the increase in hemoglobin in the fetus and correlate the red cell transfusion volume with elevation of hemoglobin and perinatal outcome.

PATIENTS AND METHODS

prospective, case series study. We included 17 patients with fetal anemia detected by measuring the peak systolic velocity of middle cerebral artery and determination of fetal hemoglobin before and after cordocentesis. After confirmation of fetal anemia (Hb <10 g/dL), was held fetal transfusion with 50 mL/kg estimated fetal weight, with packed red blood cells type O Rh negative.

RESULTS

In 17 cases fetal anemia was diagnosed, of which 11 (64%) had Rh isoimmunization and 6 (36%) were not immune. The 17 cases received 27 intravascular transfusions, in 75% hemoglobin rose to 10 g/dL, 45% in the first transfusion, 25% in the second and 10% in the third transfusion. Fetal hemoglobin between before and after transfusion was 6.5 and 12.9 g/dl, respectively (p<0.001) and allowed to continue the pregnancy from 3 to 12 weeks from the first transfusion. There were 4 deaths (2 stillbirths and 2 neonatal), but only one was related to the procedure. the survival rate was 76%, mortality in the presence of hydrops was 30% and no deaths in patients without hydrops.

CONCLUSIONS

Mortality in fetal anemia was 23.6% and only one case was related to intravascular transfusion. In cases of survival to birth, pregnancy lasted >30 weeks gestation. Hemoglobin rose from 27 to 300% of the initial fetal hemoglobin. The presence of fetal hydrops significantly increases mortality.

[Clinical analysis of fetal death cases in intrahepatic cholestasis of pregnancy]

OBJECTIVE

To investigate the clinical features, critical laboratory parameters, and fetal monitoring methods in intrahepatic cholestasis of pregnancy (ICP).

METHODS

A retrospective analysis of 21 cases of ICP suffered with fetal death in Women's hospital, School of Medicine, Zhejiang University from January 1999 to December 2010 were discussed.

RESULTS

(1) The average age of ICP patients suffered with fetal death were (30.2 ± 4.6) years old. Among them, 4 cases were older than 35 years, six cases were multipara, one of them suffered stillbirth 2 year before. Twenty cases were singleton pregnancies and 1 case was twin pregnancy. (2) All 21 cases of fetal death occurred in the third trimester, 12 cases occurred before 37 weeks, 9 cases after 37 weeks.Nine cases were diagnosed by ultrasound in outpatient clinics, fetal heart beat disappeared in 9 patients after admission because of ICP, two disappeared after labor, one during anesthesia before emergent surgery. Perinatal mortality rate of ICP was 0.148% (21/14 184), and fetal death occurred from 29 to 41 weeks with an average gestational age of (33.8 ± 4.2) weeks. (3) Puritus occurred in all 21 cases while 11 of them had pruritus all over the body. Ten pregnant women felt the fetal movement decreased or disappeared before diagnosis of fetal death. The glycocholic acid levels increased in all of the 21 cases. Among them, glycocholic acid levels in 11 cases were (21.49 - 64.48) µmol/L, while in 10 cases were ≥ 64.48 µmol/L. Serum bile acid levels elevated in 16 cases which had been analyzed (the other 5 cases had not been checked), and the highest level reached 270 µmol/L. Serum alanine aminotransferase and aspartate aminotransferase were increased in 14 cases. Seven cases had their total bilirubin > 21 µmol/L, and 12 cases had their direct bilirubin levels significantly elevated. Among the 21 cases of ICP, 15 cases were in severe status, while the other 6 cases were mild. (4) Nine patients had no antepartum surveillance since fetal death were diagnosed before admission. The results of antepartum surveillance were as follows: 2 cases had nonreassuring nonstress test (NST), one had mild "V" type deceleration. Absence of diastolic flow in umbilical artery were found in 3 cases, and low fetal biophysical score was got in one case. (5) All 21 patients had vaginal delivery. Six of them delivered after natural contraction, and the remaining 14 cases delivered after oral intake of mifepristone and amniotic injection of ethacridine, or oxytocin induced labor within 48 hours, only one case delivered after additional dinoprostone suppositories. The appearance of fetus, placentas and membranes were normal, the lengths of umbilical cord were average. Four cases were found with cords binding the necks or the bodies. Eighteen cases had grade III amniotic fluid with meconium-stained, and 2 cases complicated by oligohydramnios. Ten cases had their fetuses and placentas examined by pathologist. Among them, one case had multiple malformations, no more obvious pathological abnormalities were found in other fetuses. Pathologic examination showed that fibrin deposited around chorion and deciduas basalis, large vessels accompanied by calcification, degeneration, hemorrhagic infarction, and increased focal syncytial nodules could be seen in all of the ten placentas.

CONCLUSIONS

Fetal death in pregnant women with ICP often occurs after the contractions, Severe ICP may be a key factor that involved in the occurrence of fetal death. Up to now, there is no valid indicators in fetal monitoring, which can predict fetal death. Extensive assessment of the severity and careful antepartum surveillance should be achieved before timely termination of pregnancy.

Antithyroid drug-induced fetal goitrous hypothyroidism

Maternal overtreatment with antithyroid drugs can induce fetal goitrous hypothyroidism. This condition can have a critical effect on pregnancy outcome, as well as on fetal growth and neurological development. The purpose of this Review is to clarify if and how fetal goitrous hypothyroidism can be prevented, and how to react when prevention has failed. Understanding the importance of pregnancy-related changes in maternal thyroid status when treating a pregnant woman is crucial to preventing fetal goitrous hypothyroidism. Maternal levels of free T(4) are the most consistent indication of maternal and fetal thyroid status. In patients with fetal goitrous hypothyroidism, intra-amniotic levothyroxine injections improve fetal outcome. The best way to avoid maternal overtreatment with antithyroid drugs is to monitor closely the maternal thyroid status, especially estimates of free T(4) levels.

N-terminal pro-B-type natriuretic peptide: a potential marker of fetal heart failure in hemolytic disease

OBJECTIVES

The hemolysis of red blood cells due to isoimmunisation results in fetal anaemia and hypoxia leading to fetal heart failure. An assessment of N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a routine practice in adult heart failure. No studies on this marker have been reported in fetal heart failure. The aim of the current study was to investigate changes in fetal NT-proBNP serum concentrations before and after intrauterine transfusions and to assess its value as a marker of fetal heart failure.

DESIGN

Therapy of Rh immunisations was performed in 14 fetuses with 61 intrauterine transfusions. Hemoglobin concentration, red blood cells count, hematocrit and NT-proBNP concentrations were assessed in samples taken before and after each transfusion.

RESULTS

An increase in the concentrations of blood parameters was strongly correlated with a decrease in the concentration of NT-proBNP. NT-proBNP concentrations were the greatest with the smallest Hb (4.0-5.9 g/dl), hematocrit and red blood cell (RBC) concentrations, respectively. An increase in Hb concentration by 1mg/dl and the RBC count by 1M/µl resulted in a corresponding decrease in NT-proBNP concentration by 659.0 and 2 007.1 pg/ml, respectively. The NT-proBNP concentrations decreased significantly following 52 transfusions.

CONCLUSIONS

The fetal serum concentration of NT-proBNP appears to be a satisfactory marker for heart failure in fetuses inflicted with severe anaemia caused by hemolytic disease. Intrauterine therapy decreases the severity of anaemia and reduces the fetal heart failure index. There appears to be a strong inverse correlation between the pre-transfusion NT-proBNP concentration and morphological parameters.

Fetal risk assessment in pregnancies complicated by diabetes mellitus

BACKGROUND

Hypoglycemia and hyperglycemia can pose a number of serious risks to pregnant mothers with diabetes, but these risks are not always related to glucose concentrations directly. Previous studies have shown the utility of using mathematical transformation functions to create patient risk profiles that can then be used to analyze and predict adverse outcomes in individuals with diabetes. We propose a novel use of these functions to analyze the risks posed to the fetus in pregnancies complicated by diabetes.

METHODS

We retrospectively analyzed 71 h continuous glucose monitoring system (CGMS Gold, Medtronic Northridge, CA) third trimester tracings obtained during a normal pregnancy and in those complicated by gestational diabetes mellitus (GDM), type 2 diabetes mellitus (T2DM), and type 1 diabetes mellitus (T1DM). We then used a transformation function to calculate fetal and maternal risk in each case.

RESULTS

In the normal pregnancy (0.93), the risk was at a minimum. Along with mean glucose values, the risk increased in those cases where gestation was complicated by GDM (3.12), T2DM (7.85), and T1DM (16.94). In contrast, the original patient risk profile yielded a minimal value for the GDM tracings.

CONCLUSIONS

Total fetal risk increases from normal to GDM to T2DM to T1DM pregnancies. This new risk assignment better distinguishes the stages of fetal risk than the original method and therefore may be useful in future clinical trials and applications to predict risk for adverse outcomes in pregnancies complicated by diabetes.

[Impact of fetal urinary ascites on serum beta2 microglobuline in obstructive uropathies: a case report]

We report a posterior urethral valves case diagnosed at 33 week's gestation on a fetus presenting with anamnios and urinary ascites. In this fetus, the serum beta2 microglobuline rate was high, suggesting a very poor renal prognosis. At 1-year-old, the creatinine rate is nearly normal. In case of urinary ascites, the serum beta2 microglobuline rate could be improved in relation with the transperitoneal reabsorption of this protein.

Serum vitamin B12 and homocysteine levels in pregnant women with neural tube defect

OBJECTIVE

The aim of the study is to investigate the importance of serum vitamin B12 levels in pregnant women with foetal neural tube defect (NTD).

STUDY DESIGN

This study consists of 31 pregnant women having fetuses with NTD. The pregnant women in the study group were selected among cases with normal folate levels. Serum vitamin B12 levels were investigated. Additionally, complete blood count, serum iron level, iron binding capacity, ferritin, folate, free T(3), free T(4), thyroid stimulating hormone and plasma homocysteine levels were measured. Control group consisted of 32 pregnant women who did not have a history of NTD in previous pregnancies and did not have fetuses with NTD in present pregnancy. NTD was diagnosed between 14th and 20th gestational age. The mean gestational age of members of control group was the same as those of NTD group.

RESULTS

There was no statistically significant difference between pregnants with NTD and control group according to number of cases with vitamin B12 deficiency.

CONCLUSION

It seems that vitamin B12 deficiency does not play a causative role in the development of foetal NTD. Monitoring maternal homocystein levels might be important in understanding the aetiologies of foetal NTD.

Intracranial hemorrhage in alloimmune thrombocytopenia: stratified management to prevent recurrence in the subsequent affected fetus

OBJECTIVE

We sought to prevent intracranial hemorrhage (ICH) through antenatal management of alloimmune thrombocytopenia.

STUDY DESIGN

A total of 33 women (37 pregnancies) with alloimmune thrombocytopenia and ICH in a previous child were stratified according to the timing of the previous child's ICH: extremely high risk (HR) (n = 8) had ICH <28 weeks, very HR (n = 17) between 28-36 weeks, and HR (n = 12) in the perinatal period. Treatment was initiated at 12 weeks with intravenous immunoglobulin 1 or 2 g/kg/wk, and if the fetal platelet count by cordocentesis was <30,000/mL despite treatment, prednisone and/or more intravenous immunoglobulin were added.

RESULTS

Five of 37 fetuses suffered ICHs. Two ICHs had platelet counts >100,000/mL, and 1 was grade I. The other 2 ICHs were unequivocal treatment failures; both were grade III-IV and resulted in fetal demise.

CONCLUSION

These findings demonstrate the success of stratified treatment in these HR patients, which tailored interventions according to the timing of the sibling's ICH.

Homozygous alpha-thalassemia-1 presenting in a fetus without anemia

A fetus at risk for alpha-thalassemia presented with cardiomegaly without evidence of anemia. Invasive testing demonstrated the diagnosis of homozygous alpha-thalassemia-1 with a normal-range hemoglobin (Hb) level. We suggest that in the prenatal detection of homozygous alpha-thalassemia-1 by sonography, the diagnosis should always be confirmed with definitive methods such as fetal cord blood Hb analyses. This is important for genetic counseling and treatment for the affected fetus.

Role for serial prenatal anti-Vel quantitative serologic monitoring with 2-ME serum treatment during pregnancy: case report

Anti-Vel is an uncommon antibody to a high-prevalence antigen. Its clinical significance and management in the prenatal setting are not well characterized. We present a case that demonstrates the utility of serial prenatal anti-Vel quantitative serologic monitoring with 2-ME serum treatment during pregnancy. The patient is a 23-year-old Hispanic woman with history of prior pregnancy and prior transfusion who was discovered to have an antibody to the high-prevalence Vel antigen in the first trimester (week 7) of her second pregnancy. Interval measurements of the serologic antibody titers were performed during the next 26 weeks. The untreated serum (IgM and IgG) titer increased from a baseline of 4 to 16 during that interval, while the 2-ME (presumed IgG component) titer remained stable at 4. Responding to ultrasound findings suspicious for fetal anemia, the child was delivered without complications at 34 weeks' gestation. At birth, the DAT was negative and there was no evidence of HDN. Placed in the context of other similar reports, this case demonstrates the importance of separately reporting the IgG fraction (after either DTT treatment or 2-ME treatment) from the untreated (IgM and IgG) fraction and the importance of correlating the treated serum titer with potential clinical significance.

[Estimation of diagnostic value of the middle cerebral artery peak systolic velocity in prediction of fetal anemia in pregnancies complicated by alloimmunisation]

The use of the middle cerebral artery peak systolic velocity (PSV) for the noninvasive diagnosis of fetal anemia in pregnancies complicated by alloimmunisation has the potential to reduce the number of invasive procedures.

OBJECTIVES

The study was undertaken to determine the detection of fetal anemia by fetal middle cerebral artery peak systolic velocity (MCA PSV).

MATERIAL AND METHODS

31 fetuses with red cell alloimmunisation were evaluated with Doppler ultrasongraphy. On the basis of ROC (AUC) analysis the cutoff point of MoM=1.215 with the highest sensitivity and specificity was established. We examined the relation between MoM=1.215 and neonatal hemoglobin level and the maternal antibody titre in the indirect antiglobulin test. Sensitivity specificity positive and negative value and statistical significance were calculated.

CONCLUSIONS

Data reported to date suggest that a threshold of 1.215 multiples of the median can be used to better diagnostic of fetal anemia.