Cemiplimab for advanced cutaneous squamous cell carcinoma in kidney transplant recipients

Background

Kidney transplant recipients (KTR) are at increased risk of cancer due to chronic immunosuppression. Non-melanoma skin cancer has an excess risk of approximately 250 times higher than the general population. Moreover, in solid organ transplant recipients (SOTR) these cancers have a more aggressive behavior, with an increased risk of metastasis and death. Cemiplimab, a human monoclonal IgG4 antibody against programmed cell death (PD-1) has shown considerable clinical activity in metastatic and locally advanced cutaneous squamous cell carcinoma (cSCC) in patients for whom no widely accepted standard of care exists. Cemiplimab has therefore been approved since 2018 for the treatment of advanced cSCC. However, data regarding the use of cemiplimab in SOTR and particularly in KTR are scarce and based on published case reports and small case series. In this study, we report on the real-life outcome of cemiplimab use in a Belgian cohort of seven KTR suffering from advanced cSCC.

Objective

To report on the overall response rate (ORR) and safety of cemiplimab in KTR in Belgium.

Results

Seven patients suffering from advanced cSCC, treated with cemiplimab, between 2018 and 2022, in Belgium were identified. Three patients were on corticosteroid monotherapy, one patient on tacrolimus monotherapy and three patients were on at least 2 immunosuppressants at start of cemiplimab. The ORR was 42.8%, stable disease was seen in 14.3% and progressive disease was found in 42.8% of the patients, respectively. The median administered number of cycles was 12, interquartile range (IQR) 25-75 [3.5 - 13.5]. All patients were treated with surgery before administration of cemiplimab, 71.4% received additional radiotherapy and only 1 patient was treated with chemotherapy prior to receiving cemiplimab. Biopsy-proven acute renal allograft rejection was observed in one patient, who eventually lost his graft function but showed a complete tumor response to treatment. Low grade skin toxicity was seen in one patient of the cohort.

Conclusion

The present case series shows that the use of cemiplimab in KTR with advanced cSCC who failed to respond to previous surgery, chemo - and/or radiotherapy treatment is associated with an ORR of 42.8% with minimal risk of graft rejection (14.3%) and good tolerance.

The Belgian Obstetric Surveillance System to monitor severe maternal morbidity

BACKGROUND

In 2011 the Belgian Obstetric Surveillance System (B.OSS) was set up to monitor severe maternal morbidity in Belgium.

AIM

The aim of B.OSS is to get an accurate picture of the obstetric complications under investigation and secondly, to improve the quality and safety of obstetric care in Belgium by practical recommendations based on the results.

METHODOLOGY

Data are obtained through prospective active collection of cases by a monthly call according to the principle of nothing-to-report, along with data collection forms that confirm the diagnosis and gather detailed information. Data-collection occurs web-based since August 2013 through www.b-oss.be.

RESULTS

B.OSS achieves excellent participation rates and response rates. The results of the first registration round are gradually brought out by means of scientific publications and presentations, biennial reports, newsletters and the website. The international comparison of results within the International Network of Obstetric Survey Systems (INOSS) gives important added value. No alternative mandatory data sources are appropriate to check for underreporting.

CONCLUSIONS

B.OSS is successful in monitoring severe maternal morbidity thanks to the willingness of the Belgian OB-GYNs. The results of the first studies suggest the need to develop nationally adopted guidelines. Furthermore, the results invite to critically evaluate the current organisation of obstetric health care in Belgium. B.OSS aims to monitor the impact on patient safety in future surveys, when guidelines and recommendations are put into practice.

A nationwide population-based cohort study of peripartum hysterectomy and arterial embolisation in Belgium: results from the Belgian Obstetric Surveillance System

OBJECTIVES

To assess the prevalence of major obstetric haemorrhage managed with peripartum hysterectomy and/or interventional radiology (IR) in Belgium. To describe women characteristics, the circumstances in which the interventions took place, the management of the obstetric haemorrhage, the outcome and additional morbidity of these women.

DESIGN

Nationwide population-based prospective cohort study.

SETTING

Emergency obstetric care. Participation of 97% of maternities covering 98.6% of deliveries in Belgium.

PARTICIPANTS

All women who underwent peripartum hysterectomy and/or IR procedures in Belgium between January 2012 and December 2013.

RESULTS

We obtained data on 166 women who underwent peripartum hysterectomy (n=84) and/or IR procedures (n=102), corresponding to 1 in 3030 women undergoing a peripartum hysterectomy and another 1 in 3030 women being managed by IR, thereby preserving the uterus. Seventeen women underwent hysterectomy following IR and three women needed further IR despite hysterectomy. Abnormal placentation and/or uterine atony were the reported causes of haemorrhage in 83.7%. Abnormally invasive placenta was not detected antenatally in 34% of cases. The interventions were planned in 15 women. Three women were transferred antenatally and 17 women postnatally to a hospital with emergency IR service. Urgent peripartum hysterectomy was averted in 72% of the women who were transferred, with no significant difference in need for transfusion. IR procedures were able to stop the bleeding in 87.8% of the attempts. Disseminated intravascular coagulation secondary to major haemorrhage was reported in 32 women (19%).

CONCLUSION

The prevalence in Belgium of major obstetric haemorrhage requiring peripartum hysterectomy and/or IR is estimated at 6.6 (95% CI 5.7 to 7.7) per 10 000 deliveries. Increased clinician awareness of the risk factors of abnormal placentation could further improve the management and outcome of major obstetric haemorrhage. A case-by-case in-depth analysis is necessary to reveal whether the hysterectomies and arterial embolisations performed in this study were appropriate or preventable.

Nationwide population-based cohort study of uterine rupture in Belgium: results from the Belgian Obstetric Surveillance System

OBJECTIVES

We aimed to assess the prevalence of uterine rupture in Belgium and to evaluate risk factors, management and outcomes for mother and child.

DESIGN

Nationwide population-based prospective cohort study.

SETTING

Emergency obstetric care. Participation of 97% of maternity units covering 98.6% of the deliveries in Belgium.

PARTICIPANTS

All women with uterine rupture in Belgium between January 2012 and December 2013. 8 women were excluded because data collection forms were not returned.

RESULTS

Data on 90 cases of confirmed uterine rupture were obtained, of which 73 had a previous Caesarean section (CS), representing an estimated prevalence of 3.6 (95% CI 2.9 to 4.4) per 10 000 deliveries overall and of 27 (95% CI 21 to 33) and 0.7 (95% CI 0.4 to 1.2) per 10 000 deliveries in women with and without previous CS, respectively. Rupture occurred during trial of labour after caesarean section (TOLAC) in 57 women (81.4%, 95% CI 68% to 88%), with a high rate of augmented (38.5%) and induced (29.8%) labour. All patients who underwent induction of labour had an unfavourable cervix at start of induction (Bishop Score ≤7 in 100%). Other uterine surgery was reported in the history of 22 cases (24%, 95% CI 17% to 34%), including 1 case of myomectomy, 3 cases of salpingectomy and 2 cases of hysteroscopic resection of a uterine septum. 14 cases ruptured in the absence of labour (15.6%, 95% CI 9.5% to 24.7%). No mothers died; 8 required hysterectomy (8.9%, 95% CI 4.6% to 16.6%). There were 10 perinatal deaths (perinatal mortality rate 117/1000 births, 95% CI 60 to 203) and perinatal asphyxia was observed in 29 infants (34.5%, 95% CI 25.2% to 45.1%).

CONCLUSIONS

The prevalence of uterine rupture in Belgium is similar to that in other Western countries. There is scope for improvement through the implementation of nationally adopted guidelines on TOLAC, to prevent use of unsafe procedures, and thereby reduce avoidable morbidity and mortality.

Impact of childhood trauma on postpartum depression: a prospective study

Studies on the impact of childhood trauma on postpartum depression show inconsistencies and methodological limitations. The present study examines the effect of childhood trauma on depression 12 and 24 weeks after childbirth, while controlling for history of depression, depression symptoms during pregnancy and type D personality. During the third trimester of pregnancy, 210 women completed self-report questionnaires assessing depression (current and/or past episodes), childhood trauma and type D personality, of whom 187 participated in the postpartum follow-up, with depression symptoms being reassessed at 12 and 24 weeks after delivery with three depression outcome measures. Eventually, 183 participants were retained for analysis. Results indicated no predictive value of childhood trauma on postpartum depression in the univariate analyses, nor after controlling for previous depression, depression symptoms during pregnancy and type D personality. However, past depression and depression symptoms during pregnancy did independently and convincingly predict postpartum depression, especially at 12 weeks and to a lesser extent at 24 weeks following childbirth. Overall, we found no significant association between childhood trauma and postpartum depression. Past depression and depression symptoms during pregnancy are more relevant factors to assess before childbirth.

Obstetric Admissions to the Intensive Care Unit in a Tertiary Hospital

AIMS

A better understanding of the characteristics of obstetric patients admitted to an intensive care unit (ICU) could guide where the focus of obstetric training and awareness should be directed at to reduce further maternal mortality and morbidity.

METHODS

We retrospectively assessed the charts of all women admitted during pregnancy or postpartum to a tertiary ICU over a 12-year period. We retrieved whether women were followed locally or referred from another hospital and whether the ICU admission was prophylactic or therapeutic.

RESULTS

There were 190 admissions in 183 women. One-hundred and four admissions were in referred women and 86 in women cared for locally. Seventy-eight admissions (41.1%) were for direct obstetric causes (primarily postpartum hemorrhage (n = 14), hypertensive disorders of pregnancy (n = 12) and peripartum cardiomyopathy (n = 10)). Indirect obstetric admissions (n = 89; 46.8%) were primarily for cardiopathies (n = 35) and pulmonary diseases (n = 18). Among non-obstetric admissions, trauma (n = 6; 26.1%) and neurologic tumors (n = 6; 26.1%) were the most common.

CONCLUSION

Pre-existing and acquired cardiopathies are the main reason for admission to an ICU in a developed country and have surpassed hypertensive disorders and hemorrhage. This should become a focus of obstetric care provider training.

Turning the pink cloud grey: dampening of positive affect predicts postpartum depressive symptoms

OBJECTIVE

Maladaptive response styles to negative affect have been shown to be associated with prospective (postpartum) depression. Whether maladaptive styles to positive affect are also critically involved is understudied, even though anhedonia (a correlate of low positive affectivity) is a cardinal symptom of depression. The present study is the first to investigate the predictive value of cognitive response styles to both negative (depressive rumination) and positive affect (dampening) for postpartum depressive symptoms.

METHODS

During the third trimester of pregnancy, 210 women completed self-report instruments assessing depression (symptom severity and current and/or past episodes) and scales gauging the presence of depressive rumination and dampening. Of these women, 187 were retained for postpartum follow-up, with depressive symptoms being reassessed at 12 (n=171) and 24 (n=176) weeks after delivery.

RESULTS

Regression analyses showed that higher levels of dampening of positive affect during pregnancy predicted higher levels of depressive symptoms at 12 and 24 weeks postpartum, irrespective of initial symptom severity, past history of depression and levels of rumination to negative affect. Prepartum trait levels of rumination, however, did not predict postpartum symptomatology when controlled for baseline symptoms and history of major depressive episode(s).

CONCLUSIONS

The results of this investigation suggest that the way women cognitively respond to positive affect contributes perhaps even more to the development of postpartum depression than maladaptive response styles to negative affect.

Analysis of Pregnancy Outcomes Using the New IADPSG Recommendation Compared with the Carpenter and Coustan Criteria in an Area with a Low Prevalence of Gestational Diabetes

Aims. This paper aims to evaluate characteristics and pregnancy outcomes in women prior classified normal by Carpenter and Coustan criteria (old criteria) and now gestational diabetes (GDM) by the IADPSG criteria. Methods. Retrospective analysis of 6727 pregnancies is used. Using the old criteria, 222 had GDM (old GDM). Using the IADPSG criteria, 382 had GDM of which 160 had a normal glucose tolerance with the old criteria (new GDM). We compared the new GDM group with the old GDM group and women with normal glucose tolerance with both criteria (NGT group, 6345). Results. New GDM women were younger (31.6 ± 4.7 versus 33.3 ± 7.2 years, P = 0.010) than old GDM women. Caesarean section was performed in 30.5% of new GDM, in 32.4% of old GDM (P = 0.706), and in 23.3% of NGT women (P = 0.001). Large for gestational age occurred in 10.8% of new GDM, in 13.8% of old GDM (P = 0.473), and in 9.0% of NGT women (P = 0.099). Shoulder dystocia occurred in 3.9% of new GDM, in 3.2% of old GDM (P = 0.736), and in 1.4% of NGT women (P = 0.007). Conclusion. Using the IADPSG criteria, more women are identified as having GDM, and these women carry an increased risk for adverse gestational outcome compared to women without GDM.

Gestational diabetes: overview of the new consensus screening strategy and diagnostic criteria

Gestational diabetes (GDM) is a frequent medical condition during pregnancy. GDM is associated with an increased risk of complications for both the mother and the baby during pregnancy and birth. Women with GDM also have an increased risk of developing type 2 diabetes later in life. Two large randomised intervention trials demonstrated improvement in perinatal outcomes in the group that received treatment of mild glucose intolerance during pregnancy. However, there is lack of international uniformity in the approach to ascertainment and diagnosis of GDM. The HAPO trial studied for the first time on a very large scale the relationship between glucose tolerance of the mother and the risk for complications for both mother and child. The 'International Association of Diabetes and Pregnancy Study Groups (IADPSG)' subsequently published a new consensus for a screening strategy and diagnosis of GDM which has now been adopted by the American Diabetes Association (ADA). This remains controversial as the American College of Obstetricians and Gynecologists (ACOG) advices to continue with the two-step screening strategy, while other associations have not yet reached a consensus. The discussion now focuses on two issues: an improved detection of pregestational diabetes and an improved detection of GDM. The new screening strategy and the more stringent diagnostic criteria for GDM will probably lead to an important increase in the prevalence of GDM in Belgium and might lead to logistical problems to organise an universal screening with the 2-hour 75 g oral glucose tolerance test (OGTT). We performed an audit on the current two-step screening strategy for GDM in the university hospital Leuven. Diagnosis of GDM seems sub-optimal as only two thirds of abnormal glucose challenge tests were appropriately followed by an OGTT. When the new criteria for GDM are used, the prevalence for GDM increases significantly from 3.3% to 5.7%. We feel that more data are necessary on the cost-effectiveness of an universal screening strategy using an OGTT with more stringent diagnostic criteria for GDM, especially in a population with a low background prevalence of GDM.

Physiologic variations of serum tumor markers in gynecological malignancies during pregnancy: a systematic review

BACKGROUND

Recent insights provide support for the treatment of cancer during pregnancy, a coincidence that poses both mother and fetus at risk. Our aim was to critically review studies on the physiologic variations during pregnancy, the most common tumor markers used in diagnosis and follow-up of gynecological cancers.

METHODS

We conducted a systematic review of six tumor markers during normal pregnancy: carbohydrate antigen (CA) 15-3 (breast cancer); squamous cell carcinoma antigen (cervical cancer); and CA 125, anti-Müllerian hormone, inhibin B and lactate dehydrogenase (ovarian cancer).

RESULTS

For CA 15-3, 3.3% to 20.0% of all measurements were above the cut-off (maximum 56 U/mL in the third trimester). Squamous cell carcinoma antigen values were above cut-off in 3.1% and 10.5% of the measurements (maximum 4.3 µg/L in the third trimester). Up to 35% of CA 125 levels were above cut-off: levels were highest in the first trimester, with a maximum value up to 550 U/mL. Inhibin B, anti-Müllerian hormone and lactate dehydrogenase levels were not elevated in maternal serum during normal pregnancy.

CONCLUSION

During normal pregnancy, tumor markers including CA 15.3, squamous cell carcinoma antigen and CA 125 can be elevated; inhibin B, anti-Müllerian hormone and lactate dehydrogenase levels remain below normal cut-off values. Knowledge of physiological variations during pregnancy can be clinically important when managing gynecological cancers in pregnant patients.

Acceptance, reliability and confidence of diagnosis of fetal and neonatal virtuopsy compared with conventional autopsy: a prospective study

OBJECTIVES

To compare prospectively maternal acceptance of fetal and neonatal virtuopsy with that of conventional autopsy and to determine the confidence with which magnetic resonance (MR) virtuopsy can be used to diagnose normality/abnormality of various fetal anatomical structures.

METHODS

MR and/or computed tomography virtuopsy and conventional autopsy were offered to 96 women (102 fetuses/neonates) following termination of pregnancy (TOP), intrauterine fetal death (IUFD) or neonatal death. Multivariable logistic regression analysis was used to investigate the effect on maternal acceptance of virtuopsy and/or conventional autopsy of the age of the mother, gestational age at TOP or delivery after IUFD, order of pregnancy, parity, religion, type of caregiver obtaining consent and reason for death. When parents consented to both MR virtuopsy and conventional autopsy of fetuses ≥ 20 weeks of gestation or neonates, the confidence with which MR virtuopsy could be used to diagnose normality/abnormality of various anatomical structures was determined on a scale in which conventional autopsy was considered gold standard. On autopsy we classified fetuses/neonates as having either 'normal' or 'abnormal' anatomical structures; these groups were analyzed separately. At virtuopsy, we indicated confidence of diagnosis of normality/abnormality of every anatomical structure in each of these two groups defined at autopsy, using a scale from 0 (definitely abnormal) to 100 (definitely normal).

RESULTS

Of the 96 women, 99% (n = 95) consented to virtuopsy and 61.5% (n = 59) to both conventional autopsy and virtuopsy; i.e. 36 (37.5%) consented to virtuopsy alone. Maternal acceptance of conventional autopsy was independently positively related to singleton pregnancy, non-Moslem mother, earlier gestation at TOP or delivery afer IUFD and a maternal-fetal medicine specialist obtaining consent. Thirty-three fetuses ≥ 20 weeks of gestation had both conventional autopsy and MR virtuopsy, of which 19 had a full autopsy including the brain. In fetuses with normal anatomical structures at conventional autopsy, MR virtuopsy was associated with high diagnostic confidence (scores > 80) for the brain, skeleton, thoracic organs except the heart, abdominal organs except the pancreas, ureters, bladder and genitals. In fetuses with abnormal anatomical structures at autopsy, MR virtuopsy detected the anomalies with high confidence (scores < 20) for these same anatomical structures. However, in three cases, virtuopsy diagnosed brain anomalies additional to those observed at conventional autopsy.

CONCLUSION

MR virtuopsy is accepted by nearly all mothers while conventional autopsy is accepted by about two-thirds of mothers, in whom refusal depends mainly on factors over which we have no control. Although conventional autopsy remains the gold standard, the high acceptance of virtuopsy makes it an acceptable alternative when the former is declined.

Ultrasound Determination of Chorionicity in Twin Pregnancy: Accuracy and Operator Experience

To evaluate the accuracy of ultrasound in early detection of chorionicity and amnionicity in twin pregnancies and evaluate the role of operator-experience, a prospective follow up of 87 consecutive twin pregnancies was performed. Chorionicity and amnionicity were determined by 17 different observers, divided in 2 groups on the basis of their experience, using a composite of US markers at the first US examination confirming a viable intrauterine twin pregnancy. Accuracy of prediction was determined for both groups by comparison with postnatal pathology. From the 87 pregnancies examined at 10.1 (minimum 5.5 weeks, maximum 26.0) weeks of gestation, pathology was available in 82 cases and a correct prediction of chorionicity was made in all but two cases, both being diagnosed as monochorionic while dichorionic by observers belonging the more experienced group. No monochorionic pregnancy was missed and amnionicity was correctly diagnosed in all cases, including two monoamniotic twins. We conclude that use of a composite of ultrasound markers for early detection of chorionicity and amnionicity is reliable in a clinical setting where physicians with a variable degree of experience perform ultrasound examination.

Endovascular trophoblast and preeclampsia: A reassessment

Since the earliest report on impaired spiral artery remodelling in preeclamptic human pregnancies, numerous studies have been devoted to possible mechanisms of impaired trophoblast invasion. A better knowledge of early uteroplacental blood flow has provided a physiological context for the processes of spiral artery invasion and associated remodelling, revealing a closely timed relationship between increasing flow and early steps in vascular remodelling. Concerning the impaired trophoblast invasion in preeclampsia, it has also to be considered that impaired invasion not only concerns invasion depth per se, but also the extension of this deep invasion from the central towards the more lateral spiral arteries of the placental bed. Since also in preeclampsia the very central spiral arteries may be normally invaded, the existence of such spatial gradient provides a further dimension to the problem. A practical consequence is that frequently used rodent models, which show invasion of two or three spiral arteries only, may be less useful for studying this particular aspect of the disease. Amongst non-human primates, baboons and rhesus monkeys are 'shallow invaders', and only in some of the great apes deep trophoblast invasion and associated spiral artery remodelling occurs. A better knowledge of the evolutionary history of deep invasion and its possible selective benefit might ultimately improve our understanding of failed deep invasion and impaired spiral artery remodelling in preeclampsia.

Changes in endovascular trophoblast invasion and spiral artery remodelling at term in a transgenic preeclamptic rat model

As a follow-up to our previous study which revealed a surprisingly deeper endovascular trophoblast (ET) invasion on day 18 in a transgenic preeclamptic (PE) rat model (hAngiotensinogen female symbol x hRenin male symbol) compared to non-PE controls, we examined further changes in ET invasion and associated spiral artery (SA) remodelling at term (day 21). PE transgenic rats and non-PE reversely mated (RM) transgenic rats were compared to normal SD rats (C). Sections were stained to visualize trophoblast, fibrinoid, vascular smooth muscle (VSM) and endothelium. SA were evaluated in three depth levels in the mesometrial triangle (MT) using the KS-400 image analysis system. In separate transgenic rats, Doppler ultrasound was performed in uterine arteries, and the resistance indices (RI) were calculated. Although for the whole MT differences in ET invasion were no longer significant between the PE and C, indicating a partial catching up in C rats, there was still significantly more ET in the deepest level in the PE group as compared to the C and RM groups. At the same time the SA walls in PE rats contained significantly more fibrinoid (versus RM and C) and VSM (versus C). In all SA cross-sections, re-endothelialisation was prominent, but significantly different between PE and C group. The Doppler results showed a significantly lower RI in the arcuate uterine artery of the PE group compared to the C group. There was no evidence of elimination of deeply invaded ET at term, previously considered as a possible mechanism for restriction of vascular remodelling in human PE. The differences in vascular remodelling, previously described on day 18 by histology and Doppler data, were maintained on day 21, but there was extensive endothelial repair in the three groups. Atherosis-like lesions were observed in the three groups, most frequently in the RM group, but were never associated with placental infarcts.

Maternal bariatric surgery: adverse outcomes in neonates

BACKGROUND

The obesity epidemic in developed countries has led to an increased prevalence of obese women of reproductive age. As maternal obesity has far-reaching consequences for both mother and child, the consensus is that weight loss before pregnancy will reduce obesity-related morbidity and mortality. Therefore, an increasing number of women become pregnant after undergoing obesity surgery.

RESULTS AND DISCUSSION

From the literature, data shows that perinatal outcome after bariatric surgery is generally considered as favourable for both mother and child. Only a few case reports highlight the possibility of side effects on the foetus and neonate. We report on five cases with severe intracranial bleeding, all possibly related to vitamin K deficiency following maternal bariatric surgery.

CONCLUSION

These reports indicate that careful nutritional follow-up during pregnancy after obesity surgery is mandatory, because nutritional deficiencies such as vitamin K deficiency can lead to life-threatening bleeding.

Trends in preterm births in Flanders, Belgium, from 1991 to 2002

Changes in the preterm birth rate have been attributed predominantly to increases in multiple pregnancies, associated with advanced maternal age and assisted reproduction, and to obstetric intervention. We examined their contribution to the frequencies of preterm (<37 weeks), very preterm (<32 weeks) and severely preterm (<28 weeks) birth among 700 383 singleton and twin births in Flanders from 1991 to 2002. We examined changes across four 3-year periods (triennia) with confidence interval [CI] analysis and yearly incremental rates using linear and logistic regression analyses. Over the 12 years, twin pregnancies increased from 1.5% to 2.0%, averaging 1.6% [95% CI 1.54, 1.66] in 1991-93 and 1.9% [95% CI 1.81, 1.94] in 2000-02 (P < 0.001). The proportion of women aged 35 years or more increased from 6.8% [95% CI 6.69, 6.92] in 1991-93 to 11.3% [95% CI 11.2, 11.5] in 2000-02 (P < 0.001) and those aged under 20 from 1.9% [95% CI 1.81, 1.93] to 2.3% [95% CI 2.26, 2.41] (P < 0.001). Assisted reproduction increased from 2.6% [95% CI 2.48, 2.62] to 4.2% [95% CI 4.11, 4.30] (P < 0.001) and obstetric intervention to end pregnancy from 36.2% [95% CI 36.0, 36.4] to 40.3% [95% CI 40.1, 40.6] (P < 0.001). These increases related to an annual increase of 0.23% in the preterm birth rate from 5.5% [95% CI 5.4, 5.6] in 1991-93 to 7.2% [95% CI 7.1, 7.3] in 2000-02 (P < 0.001). The proportions of very and severely preterm births also increased by nearly a third, but their contribution to the total preterm birth rate remained stable at 15% and 5%, respectively. Odds ratios for the increases per year were 1.035 [95% CI 1.032, 1.038] for preterm birth, 1.024 [95% CI 1.018, 1.031] for very preterm and 1.028 [95% CI 1.017, 1.040] for severely preterm births after adjusting for other changes in the population. Overall, the data show, first, marked increases in the frequency of known contributors to the preterm birth rate, including twin pregnancies, advanced maternal age, assisted reproduction and obstetric intervention. Second, the preterm birth rate further increased significantly within subgroups of women with one or more of these characteristics. Third, the preterm birth rate also rose, from 4.4% [95% CI 4.2, 4.5] in 1991-93 to 5.6% [95% CI 5.5, 5.8] in 2000-02 (P < 0.001), in women with none of these contributing factors. This indicates that changes in the frequency of these known predictors are insufficient to explain the steady increase in preterm, very preterm and severely preterm births over more than a decade.

Adverse drug reactions to tocolytic treatment for preterm labour: prospective cohort study

OBJECTIVE

To evaluate the incidence of serious maternal complications after the use of various tocolytic drugs for the treatment of preterm labour in routine clinical situations.

DESIGN

Prospective cohort study.

SETTING

28 hospitals in the Netherlands and Belgium.

PARTICIPANTS

1920 consecutive women treated with tocolytics for threatened preterm labour.

MAIN OUTCOME MEASURES

Maternal adverse events (those suspected of being causally related to treatment were considered adverse drug reactions) leading to cessation of treatment.

RESULTS

An independent panel evaluated the recorded adverse events, without knowledge of the type of tocolytic used. Of the 1920 women treated with tocolytics, 1327 received a single course of treatment (69.1%), 282 sequential courses (14.7%), and 311 combined courses (16.2%). Adverse drug reactions were categorised as serious or mild in 14 cases each. The overall incidence of serious adverse drug reaction was 0.7%. Compared with atosiban, the relative risk of an adverse drug reaction for single treatment with a beta adrenoceptor agonist was 22.0 (95% confidence interval 3.6 to 138.0) and for single treatment with a calcium antagonist was 12 (1.9 to 69). Multiple drug tocolysis led to five serious adverse drug reactions (1.6%). Multiple gestation, preterm rupture of membranes, and comorbidity were not independent risk factors for adverse drug reactions.

CONCLUSIONS

The use of beta adrenoceptor agonists or multiple tocolytics for preventing preterm birth is associated with a high incidence of serious adverse drug reactions. Indometacin and atosiban were the only drugs not associated with serious adverse drug reactions. A direct comparison of the effectiveness of nifedipine and atosiban in postponing preterm delivery is needed.

The use of Alamar Blue assay for quantitative analysis of viability, migration and invasion of choriocarcinoma cells

BACKGROUND

The current techniques for quantifying trophoblast viability, migration and invasion are mainly limited by the need to sacrifice the cells during the test procedure. In this study, the vital dye AB (AB) was used to quantify cell number and viability of BeWo and JEG-3 choriocarcinoma cells, as well as their migration and invasion through fibronectin-coated filters.

METHODS

AB was directly added to culture medium of incubated test and control cells. At various time intervals, the redox reaction, in which AB is reduced by the cells, was measured by absorbance readings at 540 and 630 nm. For cell migration and invasion, cells were cultured onto uncoated or fibronectin-coated inserts, respectively. AB reduction of migrated cells was normalized to that of control cells to calculate percentages of migration. This model was also tested in the presence of a reported inhibitor, transforming growth factor (TGF) beta.

RESULTS

The curve of %AB reduction versus cell number was linear, with intra- and inter-assay Coefficient of Variations of 1.88%and 2.94%, respectively. AB reduction increased with both seeding concentrations and incubation time with AB. TGFbeta treatment caused a modest decrease in AB reduction in both JEG-3 and BeWo cells. TGFbeta treatment also decreased migration in BeWo, but not in JEG-3, cells.

CONCLUSIONS

AB assay is a simple and reliable method for quantifying trophoblast viability, migration and invasion.

The Uterine Spiral Arteries In Human Pregnancy: Facts and Controversies

Uterine spiral arteries play a vital role in supplying nutrients to the placenta and fetus, and for this purpose they are remodelled into highly dilated vessels by the action of invading trophoblast (physiological change). Knowledge of the mechanisms of these changes is relevant for a better understanding of pre-eclampsia and other pregnancy complications which show incomplete spiral artery remodelling. Controversies still abound concerning different steps in these physiological changes, and several of these disagreements are highlighted in this review, thereby suggesting directions for further research. First, a better definition of the degree of decidua- versus trophoblast-associated remodelling may help to devise a more adequate terminology. Other contestable issues are the vascular plugging and its relation with oxygen, trophoblast invasion from the outside or the inside of the vessels (intravasation versus extravasation), the impact of haemodynamics on endovascular migration, the replacement of arterial components by trophoblast, maternal tissue repair mechanisms and the role of uterine natural killer (NK) cells. Several of these features may be disturbed in complicated pregnancies, including the early decidua-associated vascular remodelling, vascular plugging and haemodynamics. The hyperinflammatory condition of pre-eclampsia may be responsible for vasculopathies such as acute atherosis, although the overall impact of such lesions on placental function is far from clear. Several features of the human placental bed are mirrored by processes in other species with haemochorial placentation, and studying such models may help to illuminate poorly understood aspects of human placentation.

Urachal carcinoma during pregnancy

We report a case of Stage T4aN2M0 urachal carcinoma that was diagnosed early in pregnancy. Because positive pelvic lymph nodes and uterine involvement were present, surgical resection, including hysterectomy with termination of the pregnancy, and postoperative radiotherapy were performed. The treatment options, which largely depend on the duration of the pregnancy, the tumor stage, and the patient's desire to continue the pregnancy, are discussed.

In vivo analysis of trophoblast cell invasion in the human

In vivo analysis of trophoblast cell invasion is highly dependent on histological techniques, which are amply described in standard textbooks. The emphasis of this chapter therefore lies on material collection and interpretation of tissue sections, rather than on histological techniques per se. Proper identification of vascular structures on placental bed histological sections is important, the more because invading trophoblastic cells induce significant structural changes in uterine blood vessels, which may be disturbed in complicated pregnancies. Guidelines for distinguishing several vascular structures are provided, and different approaches for qualitative and quantitative assessment of spiral artery changes are discussed. The purpose of such studies is not only to obtain a better insight into mechanisms of trophoblast invasion and associated maternal tissue changes, but also to understand placental bed defects in various pregnancy complications.

Medico-legal approach to sexual assault victims: the Belgian situation

Clinical forensic medicine is a relatively new discipline in Belgium although (sexual) violence has been around for centuries. A brief overview of the Belgian legal system and the way it interacts with forensic medicine is presented, with special emphasis on the investigation of complainants of sexual violence. The epidemiology of sexual violence in Belgium is discussed together with the procedures that were developed by the government to standardise the medical examination of sexual assault victims.

Neoadjuvant chemotherapy followed by radical hysterectomy for invasive cervical cancer diagnosed during pregnancy: report of a case and review of the literature

Although cervical carcinoma is among the most frequently encountered malignancies during pregnancy, only four cases of neoadjuvant chemotherapy during pregnancy have been reported. A 28-year-old A0P1G2M0 was diagnosed at 15 weeks with stage Ib1 invasive squamous cervical cancer. Because she strongly desired the continuation of this pregnancy, after extensive counseling she was treated with 75 mg/m(2) cisplatin every 10 days starting at 17 weeks. After six cycles, clinically and radiologically stable disease with normalization of the squamous cell carcinoma tumor marker was obtained. An elective cesarean delivery followed by radical hysterectomy and lymphadenectomy was performed at 32 weeks gestation. The pathology report revealed a moderately differentiated squamous cell carcinoma of 3.5 cm, and all 33 lymph nodes were free of disease. Neonatal examination of the baby could not reveal any abnormalities, and this was confirmed at 6 months. The use of neoadjuvant chemotherapy enabled us to continue this pregnancy until the fetus was viable. Cisplatin did not influence the short-term outcome, but only a long-term follow-up will inform us on its safety during pregnancy.

Differential effects of inducers of syncytialization and apoptosis on BeWo and JEG-3 choriocarcinoma cells

BACKGROUND

The interactions of trophoblasts with the cytokine network at the fetomaternal interface determine the pathway the cell undertakes, e.g. proliferation, differentiation and apoptosis.

METHODS

We used cultures of fusigenic BeWo and non-fusigenic JEG-3 choriocarcinoma cells to study the effects of inducers of syncytialisation (forskolin) and apoptosis [tumour necrosis factor-alpha (TNFalpha)] on differentiation, viability, proliferation and apoptosis.

RESULTS

E-cadherin immunostaining showed that syncytium formation was confined to BeWo and not JEG-3 cells, while secretion of hCG was promoted by forskolin in both cell types implying a 'dissociation' between morphological and biochemical differentiation. Forskolin also had differential effects on cell viability (MTT reduction test) and proliferation (Ki67 immunostaining with MIB-1 monoclonal antibody), both decreasing in BeWo and increasing in JEG-3 cells. TNFalpha increased apoptosis (cytokeratin neo-epitope immunostaining with M30 monoclonal antibody) in both cell types, an effect which was blocked by epidermal growth factor selectively in JEG-3 cells.

CONCLUSION

Our results suggest that the differential responses of BeWo and JEG-3 cells to inducers of syncytialization and apoptosis might be related to their fusigenic capacity. Caution is needed when extrapolating results obtained by these models to normal trophoblast populations. However, we speculate that these models can help identify key factors involved in trophoblast differentiation at the placental bed.

Intrathecal Sufentanil and Fetal Heart Rate Abnormalities: A Double-Blind, Double Placebo-Controlled Trial Comparing Two Forms of Combined Spinal Epidural Analgesia with Epidural Analgesia in Labor

Combined spinal epidural analgesia (CSE) for labor pain relief has become increasingly popular. However, the effect of intrathecal sufentanil on the incidence of uterine hyperactivity and fetal heart rate (FHR) abnormalities remains controversial. We hypothesized that the use of intrathecal sufentanil in a dose of 7.5 microg is more likely to induce a nonreassuring FHR tracing than a small dose of spinal sufentanil combined with bupivacaine or epidural analgesia. Three-hundred parturients were randomized into three groups. In the first group, epidural analgesia was initiated with 12.5 mg of bupivacaine, 12.5 microg of epinephrine, and 7.5 microg of sufentanil in a volume of 10 mL (EPD group). In Group 2, initial intrathecal analgesia consisted of 2.5 mg of bupivacaine, 2.5 microg of epinephrine, and 1.5 microg of sufentanil (BSE group); in Group 3, spinal analgesia consisted of 7.5 microg of sufentanil (SUF group). Analgesia was maintained in all groups with patient-controlled epidural analgesia using bupivacaine 0.125%, 1.25 microg/mL of epinephrine, and 0.75 microg/mL of sufentanil (bolus, 4 mL; lockout, 15 min). Cardiotocography was monitored continuously 15 min before analgesia and for 60 min after the start of analgesia. The quality of analgesia, labor, and neonatal outcome and side effects were recorded. Twenty-four percent of patients in the SUF group developed FHR abnormalities (bradycardia or late decelerations) during the first hour after initiation of analgesia compared with 12% in the BSE group and 11% in the EPD group. Uterine hyperactivity occurred in 12% of parturients in the SUF group but in only 2% in the other groups. Onset of analgesia was more rapid in both CSE groups as compared with the EPD group. However, 29% of patients in the BSE group developed severe hypotension, requiring IV ephedrine (29% in the BSE group versus 7% and 12% in the EPD and SUF groups, respectively). All these differences reached statistical significance. The present data corroborate previous recommendations of caution when performing CSE using a large dose (7.5 microg or more) of spinal sufentanil because of the risk of uterine hyperactivity and FHR abnormalities.

IMPLICATIONS

Combined spinal epidural analgesia (CSE) produces pain relief during labor. Fetal heart rate changes after CSE using intrathecal sufentanil have been reported. We performed a randomized, blinded trial confirming that fetal heart rate changes are more frequent after CSE using 7.5 micro g of intrathecal sufentanil as compared with other forms of neuraxial labor analgesia.

Complete Chorioamniotic Membrane Separation

We present a patient who developed complete chorioamniotic membrane separation (CMS) in two consecutive pregnancies. The first pregnancy ended with an intrauterine fetal death at 25 weeks of gestation. The entire separated amniotic sac had twisted around the umbilical cord. In the subsequent pregnancy, a complete CMS was diagnosed at 34 weeks of gestation. In both pregnancies, the patient underwent an early 2nd-trimester genetic amniocentesis. A review of the literature shows that extensive CMS is associated with miscarriage, in utero fetal death, umbilical cord complications, and preterm delivery. Most reported cases occurred after invasive intrauterine procedures.

Optimisation of prenatal group B streptococcal screening

The purpose of the study presented here was to confirm the high yield of group B streptococci (GBS) on Granada medium for the detection of pregnant GBS carriers and to compare the results with those obtained using standard Columbia blood agar at two participating centers in Belgium. Culture results of the vaginorectal swabs obtained at the two centers were also compared. A total of 1,142 samples (838 in Leuven and 304 in Bonheiden) obtained from consecutive pregnant women were cultured onto both media. Of all GBS carriers 84.7% were detected on Columbia blood agar and 93.4% on Granada agar ( P<0.01, McNemar test). The addition of Granada agar was responsible for a 15% higher rate of detection of GBS carriers. As a result of this study, both participating hospitals will use a combination of Granada agar with Columbia blood agar for optimal GBS screening in the future.

Fetal assessment: do newer technologies offer better assessment and outcomes?

PURPOSE OF THE REVIEW

The present manuscript reviews recent data on fetal intrapartum surveillance with special attention to new technologies.

RECENT FINDINGS

Continuous fetal heart-rate monitoring, fetal blood sampling, intrapartum stimulation tests, fetal pulse oximetry and fetal electrocardiography will be reviewed.

SUMMARY

From the available data it appears that to date the analysis of the sinus tachycardia segment of the fetal electrocardiography used in conjunction with continuous fetal heart-rate monitoring is the method of choice.

Post dural puncture headache following combined spinal epidural or epidural anaesthesia in obstetric patients

A retrospective review of obstetric anaesthesia charts was performed for all parturients receiving regional anaesthesia over a 22-month period. The incidence of headache, post dural puncture headache (PDPH) and various other complications of regional anaesthesia that had been prospectively assessed were noted, as was the anaesthetic technique used (epidural or combined spinal epidural (CSE)). PDPH was rare (0.44%) and occurred with similar frequency in those managed with either epidural or CSE anaesthesia or analgesia. The pencil-point spinal needle gauge (27 or 29) did not influence the incidence of PDPH. Following a CSE technique, the epidural catheter more reliably produced effective analgesia/anaesthesia as compared with a standard epidural technique (1.49% versus 3.18% incidence of replaced catheters respectively). We conclude, based on the results of this retrospective review, that CSE is acceptable with respect to the occurrence of PDPH and that it is possible it is advantageous in relation to the correct placement of the epidural catheter

Ultrasound determination of chorionicity in twin pregnancy: accuracy and operator experience

To evaluate the accuracy of ultrasound in early detection of chorionicity and amnionicity in twin pregnancies and evaluate the role of operator-experience, a prospective follow up of 87 consecutive twin pregnancies was performed. Chorionicity and amnionicity were determined by 17 different observers, divided in 2 groups on the basis of their experience, using a composite of US markers at the first US examination confirming a viable intrauterine twin pregnancy. Accuracy of prediction was determined for both groups by comparison with postnatal pathology. From the 87 pregnancies examined at 10.1 (minimum 5.5 weeks, maximum 26.0) weeks of gestation, pathology was available in 82 cases and a correct prediction of chorionicity was made in all but two cases, both being diagnosed as monochorionic while dichorionic by observers belonging the more experienced group. No monochorionic pregnancy was missed and amnionicity was correctly diagnosed in all cases, including two monoamniotic twins. We conclude that use of a composite of ultrasound markers for early detection of chorionicity and amnionicity is reliable in a clinical setting where physicians with a variable degree of experience perform ultrasound examination.

Ruptured renal artery aneurysm during pregnancy: successful ex situ repair and autotransplantation

Rupture of a renal artery aneurysm during pregnancy is a rare event, with a high mortality rate for both mother and fetus. Until now, 25 cases have been reported in the English medical literature. Renal salvage with in situ repair of the renal artery has been documented in only four cases, and successful ex situ repair and autotransplantation in only one case. We report the case of a mother and fetus who both survived acute rupture of a renal artery aneurysm after treatment with ex situ repair and autotransplantation.

Control of error in randomized clinical trials

The randomized clinical trial is the method of choice for comparing the effects of alternative care options, both in its own right and as the cornerstone of systematic reviews of the subject. Errors in such trials, therefore, have major consequences for health care. This paper provides a brief introduction to the major sources of such errors, whether they be systematic or chance errors. It addresses selection bias, due to either biased entry in or biased exclusion from the trial, bias in assessing outcomes, and biases due to contamination or co-intervention. Random errors, including type I and type II errors, are discussed along with ways in which they can be minimized. Small clinical trials, in particular, provide a major problem not only by themselves, but also if they become incorporated in systematic reviews without appropriate consideration of the phenomenon of publication bias.

Malignant trophoblastic disease following a twin pregnancy consisting of a complete hydatiform mole and a normal fetus and placenta. A case report

We report an unusual pregnancy with a complete hydatiform mole coexisting with a normal fetus and placenta. This report stresses the importance of a correct diagnosis and the dilemmas the clinician is faced with when managing such a case. Malignant trophoblastic disease occurs in 55% of complete hydatiform mole and fetus. Two-thirds require combination chemotherapy.