A systematic review of early intrauterine intervention at 12 + 0 to 16 + 6 weeks in twin reversed arterial perfusion sequence

There is some evidence that in twin reversed arterial perfusion sequence, intervention at early gestational age could prevent a spontaneous death of the pump twin, achieving a better global survival.

OBJECTIVE

To review the perinatal outcomes of early intervention in pregnancies complicated by twin reversed arterial perfusion (TRAP) sequence.

STUDY DESIGN

A comprehensive search from inception to December 2022 was conducted on databases including MEDLINE, EMBASE, Cochrane Library and LILACS. All studies that reported intervention in twin or triplet pregnancy complicated with TRAP sequence at 12 + 0 to 16 + 6 weeks of gestation were eligible. A descriptive and bivariate analysis was performed.

RESULTS

Out of the 222 full-text articles, 44 studies reporting 108 cases of early intervention in TRAP sequence were included. A successful procedure was achieved in 105 (95.5 %) interventions: 89 (94.7 %) among twin pregnancies and 16(100 %) among triplet pregnancies. An overall livebirth rate was achieved in 75 patients (70.8 %): intrafetal laser group 55 (73.3 %), radiofrequency 10 (76.9 %) and endoscopic laser 3 (75.0 %). The median gestational age at delivery was 38 + 0 (37 + 4 - 39 + 4) weeks. The median treatment-delivery interval was 23 + 2 (IQR, 21 + 0-25 + 6) weeks. The most frequent adverse outcomes reported were preterm labor in 7 (13.7 %) patients. There were no severe adverse maternal outcomes.

CONCLUSION

Early intervention with intrafetal laser and radiofrequency in TRAP sequence achieves a livebirth rate of the pump twin of about 75 %.

Development of a Mobile Health Application Based on a Mixed Prenatal Care in the Context of COVID-19 Pandemic

OBJECTIVE

 We describe the development and structure of a novel mobile application in a mixed model of prenatal care, in the context of the COVID-19 pandemic. Furthermore, we assess the acceptability of this mobile app in a cohort of patients.

METHODS

 First, we introduced a mixed model of prenatal care; second, we developed a comprehensive, computer-based clinical record to support our system. Lastly, we built a novel mobile app as a tool for prenatal care. We used Flutter Software version 2.2 to build the app for Android and iOS smartphones. A cross-sectional study was carried out to assess the acceptability of the app.

RESULTS

 A mobile app was also built with the main attribute of being connected in real-time with the computer-based clinical records. The app screens detail information about activities programmed and developed in the prenatal care according to gestational age. A downloadable maternity book is available and some screens show warning signs and symptoms of pregnancy. The acceptability assessment was mostly rated positively regarding the characteristics of the mobile app, by 50 patients.

CONCLUSION

 This novel mobile app was developed as a tool among pregnant patients to increase the information available about their pregnancies in the provision of a mixed model of prenatal care in the context of the COVID-19 pandemic. It was fully customized to the needs of our users following the local protocols. The introduction of this novel mobile app was highly accepted by the patients.

Maternal Perinatal Telemonitoring in the Context of the Coronavirus Disease 2019 Pandemic in a Tertiary Health Center in Peru

OBJECTIVE

This study aimed to describe the characteristics of a telemonitoring program that was rapidly implemented in our institution as a response to the coronavirus disease 2019 (COVID-19) pandemic, as well as the maternal and perinatal outcomes of women who attended this program.

STUDY

DESIGN: Retrospective study of patients via phone-call telemonitoring during the peak period of the COVID-19 pandemic (May 2020-August 2020). Maternal and perinatal outcomes were collected and described. Health providers' satisfaction with the telemonitoring program was assessed via an email survey.

RESULTS

Twenty-three (69.7%) health providers answered the survey. The mean age was 64.5 years, 91.3% were OB/GYN (obstetrician-gynecologist) doctors, and 95% agreed that telemonitoring is an adequate method to provide health care when in-person visits are difficult. The 78.7% of scheduled telemonitoring consultations were finally completed. We performed 2,181 telemonitoring consultations for 616 pregnant women and 544 telemonitoring consultations for puerperal women. Other medical specialties offering telemonitoring included gynecology, reproductive health, family planning, cardiology, endocrinology, and following up with patients with reactive serology to severe respiratory syndrome coronavirus 2 (SARS-CoV-2). The majority of the population attending our telemonitoring program were categorized as the lowest strata, i.e., III and IV, according to the Human Development Index, and approximately 42% were deemed as high-risk pregnant women. Additionally, we reported the perinatal outcomes of 424 (63%) pregnant women, the most relevant finding being that approximately 53% of them had cesarean sections.

CONCLUSION

Telemonitoring is an adequate method of continuing the provision of prenatal care when in-person visits are difficult in situations such as the COVID-19 pandemic. Telemonitoring is feasible even in institutions with no or little experience in telemedicine. The perinatal outcomes in women with telemonitoring seem to be similar to that in the general population.

KEY POINTS

· Telemonitoring for prenatal care is feasible even in low-income countries and in a critical scenario.. · OB/GYN doctors agreed with that telemonitoring is an adequate method to provide prenatal care.. · Maternal and perinatal outcomes are similar in women attending a telemonitoring program..

Prediction of neonatal survival according to lung-to-head ratio in fetuses with right congenital diaphragmatic hernia (CDH): A multicentre study from the Latin American CDH Study Group registry

OBJECTIVE

To evaluate survival outcomes of fetuses with right sided congenital diaphragmatic hernia (CDH) treated in Latin American centres and to assess the utility of left lung area to predict neonatal survival.

METHODS

A retrospective cohort including isolated right sided CDH cases managed expectantly during pregnancy in six tertiary centers from five Latin American countries. The utility of the observed/expected lung-to-head ratio (O/E-LHR) in predicting neonatal survival was assessed, and the best cut-off to predict prognosis was automatically selected by decision tree analysis.

RESULTS

A total of 99 right sided CDH cases were recruited, 58 isolated fetuses were selected at a median gestational age of 26.2 weeks, showing an overall survival rate of 26.2%. A linear trend was observed between survival and the O/E-LHR, showing that at higher O/E-LHR, the greater probability of survival (r = 0.56, p < 0.001). O/E-LHR discriminates two groups with different survival outcomes: fetuses with an O/E-LHR ≥65% showed a significantly higher survival rate than those with an O/E-LHR <65% (81.8% vs. 15.6%, p < 0.01).

CONCLUSIONS

Overall survival rate in right sided CDH is lower in Latin American countries. The severity category of pulmonary hypoplasia should be classified according to lung area and the survival rate in such population.

Severe fetal anaemia caused by congenital cytomegalovirus infection

A 22-year-old pregnant woman was referred to our fetal medicine unit due to severe fetal growth restriction at 26 weeks of gestation. An extensive detailed ultrasound revealed signs of bilateral periventricular hyperechogenicity, suggesting fetal infection potentially due to cytomegalovirus (CMV). Doppler ultrasound showed a high peak systolic velocity in the middle cerebral artery. Percutaneous umbilical cord blood sampling confirmed fetal CMV infection and severe fetal anaemia. We present this case to highlight the importance of fetal anaemia, which can be fatal regardless of whether it is associated with generalised oedema or hydrops fetalis.

Open intrauterine repair of spina bifida aperta: Historical aspects, current availability, and clinical outcomes from the Latin American Spina Bifida Consortium

OBJECTIVE

To determine the historical aspects, current availability, and clinical outcomes of open intrauterine repair of spina bifida aperta (IRSBA) in Spanish-speaking Latin American countries.

METHODS

Cases were collected from centers with at least 2 years of experience and a minimum of 10 open IRSBA interventions by December 2020. Clinical variables were compared to the results of the Management of Myelomeningocele Study (MOMS) trial.

RESULTS

Clinical experience with 314 cases from seven centers was reviewed. Most cases (n = 189, 60.2%) were performed between 24 and 25.9 weeks' gestation. Delivery at less than 30 weeks' gestation occurred in 36 cases (11.5%) and the overall perinatal mortality rate was 5.4% (17 of 314). The rate of maternal complications was low, including the need for blood transfusion (n = 3, 0.9%) and dehiscence or a thin uterine scar (n = 4, 1.3%). No cases of maternal death were recorded. Fifteen neonates required additional surgical repair of the spinal defect (4.8%) and 63 of 167 infants (37.7%) required a cerebrospinal fluid diversion procedure. Only two of the seven centers reported preliminary experience with fetoscopic IRSBA.

CONCLUSIONS

Clinical experience and outcomes were within the expected results reported by the MOMS trial. There is still very limited experience with fetoscopic IRSBA in this part of the world.

Maternal clinical characteristics and perinatal outcomes among pregnant women with coronavirus disease 2019. A systematic review

OBJECTIVE

To describe the maternal clinical characteristics, maternal and perinatal outcomes in COVID-19-positive pregnant women.

METHODS

Articles in all languages on the SARS-CoV-2 infection in pregnant women were sought from MEDLINE, EMBASE, Cochrane Library and LILACS; China National Knowledge Infrastructure Database (CNKI), Chinese Science and Technology Periodical Database (VIP) and Wan Fang Data between December 1, 2019 and April 27, 2020. Bulletins and national reports were also searched.

RESULTS

From 12,168 retrieved articles, 143 were selected for full-text assessment; 33 for descriptive analyses, and 4 case-controls for meta-analysis. In 322 infected pregnant women, aged 20-45 years, the most frequent maternal comorbidity was obesity (24.2%). Forty-two (28.4%) were asymptomatic at admission. Cough (n = 148,59.7%) and fever (n = 147,59.3%) were the most prevalent symptoms. In the meta-analysis, fever (OR: 0.13,95% CI 0.05 to 0.36) and cough (0.26,95% CI 0.11 to 0.59) were lower in pregnant women with COVID-19 than non-pregnant women with COVID-19.195 (60.6%) delivered, and 125 (38.8%) remained pregnant during the study. Cesarean was reported in 99 (50.8%) women and vaginal delivery in 64 (32.8%). The main adverse obstetric outcome was premature birth (n = 37,18.9%). Thirty patients (10.3%) with COVID-19-related complications required intensive care, one (0.3%) died. SARS-CoV-2 was absent in breast milk, amniotic fluid, placenta or umbilical cord blood.

CONCLUSIONS

The maternal clinical characteristics of COVID-19-positive pregnant include frequently fever and cough; however significantly less frequently than non-pregnant women with COVID-19. Iatrogenic preterm birth is the main adverse obstetric outcome. Current data does not support vertical transmission in the third trimester.

EXIT (ex utero intrapartum treatment) surgery for the management of fetal airway obstruction: A systematic review of the literature

PURPOSE

To provide a comprehensive overview of the perinatal and maternal outcomes of fetuses undergoing EXIT surgery for the management of fetal airway obstruction secondary to cervical or oral tumors.

METHODS

A comprehensive search from inception to September 2018 was conducted on databases including MEDLINE, EMBASE, Cochrane Library and LILACS. All studies that reported an EXIT surgery in singleton were considered eligible. A descriptive analysis was performed.

RESULTS

Out of the 250 full-text study reports, 120 articles reporting 235 cases of EXIT surgery were included. EXIT surgery was performed at 35.1 weeks of gestation on average. The most frequent diagnosis was teratoma (46.4%, n = 109/235). There were 13 adverse maternal events, and the most frequent one was postpartum hemorrhage (4.7%, n = 11/235). No maternal death was reported. Fetal and neonatal death occurred in 17% (40/235) of the cases. There were 29 adverse fetal events (12.2%), and the most frequent one was the failure of intubation or tracheostomy (3.4%, n = 8/235).

CONCLUSION

EXIT surgery could be considered for the management of an oral or cervical tumor that's highly suspicious of blocking the fetal airway. This systematic review reports that EXIT surgery poses substantial risks of maternal and fetal adverse events, including neonatal death.

LEVEL OF EVIDENCE

IV case series with no comparison group.

Short Femur in the Second Trimester Scan Is Related to Maternal Preeclampsia and Small for Gestational Age Newborns

OBJECTIVE

To determine the contribution of short femur diaphysis length (FDL) at 19-22 weeks of gestation in the prediction of adverse pregnancy outcomes.

METHODS

The study included singleton pregnant women who underwent a routine anomaly scan at 19-22 weeks of gestation at the Virgen de la Arrixaca University Clinical Hospital (Murcia, Spain) between August 2011 and August 2012. Fetal biometry and Doppler ultrasound of uterine arteries were assessed as part of the anomaly scan, and the mean pulsatility index of both uterine arteries was recorded. Maternal obstetric characteristics, such as ethnicity, age, weight, parity, cigarette smoking, and medical history including hypertension and diabetes mellitus were collected from our database system.

RESULTS

A total of 6,366 women were included in the study after excluding cases with abnormal karyotype, major fetal abnormalities, or termination of pregnancy. There were 88 cases of preeclampsia (PE) (1.4%). Logistic regression was performed including maternal and fetal characteristics. Short FDL at 19-22 weeks was significantly associated with subsequent development of PE (OR = 0.89, 95% CI: 0.80-0.99, p = 0.025). The best model to predict PE from our sample included gestational age at scan, parity, maternal weight, chronic hypertension, mean pulsatility index in the uterine arteries, and FDL (AUC = 0.78, 95% CI: 0.71-0.84). Regarding small for gestational age (SGA) neonates, there were also significant differences in FDL and FDL <5th centile between the control group and SGA newborns below the 3rd, 5th, and 10th centile. In the groups of preterm births (delivery before 32, 34, and 37 weeks), there were no differences in FDL compared with the control group (term births).

DISCUSSION

Our results suggest that FDL at 19-22 weeks of gestation is an independent predictor of PE and SGA newborns.

External iliac artery Doppler assessment in the prediction of adverse pregnancy outcomes

PURPOSE

The purpose of this study is to investigate the potential role of the mean external iliac artery pulsatility index (EIA-PI) as a predictor of adverse obstetric outcomes such as preeclampsia, gestational hypertension and small for gestational age (SGA).

METHODS

In women attending for first trimester screening at 11 + 0-13 + 6 weeks of gestation, we recorded maternal characteristics and measured EIA mean PI and uterine artery mean PI. We compared EIA mean PI in those that developed preeclampsia (n = 84), gestational hypertension (n = 50) or small for gestational age (n = 444) with those unaffected (n = 3736). Regression analysis was used to first determine which of the factors among the maternal variables were significant predictors of EIA mean PI in the unaffected group and, second, to predict adverse pregnancy outcomes.

RESULTS

In the unaffected group, EIA mean PI increased with maternal age and decreased with mean blood pressure. Additionally, EIA mean PI was lower in cigarette smokers. Compared with the unaffected group, EIA mean PI was significantly lower in women who develop gestational hypertension or SGA below third centile.

CONCLUSION

EIA mean PI in the first trimester is decreased in women who develop gestational hypertension and in those complicated by SGA below third centile. More studies are needed to confirm these findings.

Uterine and umbilical artery Doppler at 28 weeks for predicting adverse pregnancy outcomes in women with abnormal uterine artery Doppler findings in the early second trimester

OBJECTIVE

The objective of this study was to determine the contribution of uterine (UtA) and umbilical arteries (UA) Doppler examination at 28 weeks to predict adverse pregnancy outcomes in women who had increased resistance in UtA in the early second trimester.

METHODS

Women with UtA mean pulsatility index (PI) above the 95th centile at 19-22 weeks of gestation were offered a growth scan including Doppler examination of UtA and UA at 28 weeks. Adverse pregnancy outcomes included small for gestational age (SGA), defined as birth weight below the tenth centile, preeclampsia (PE) and early-onset PE (PE before 34 weeks).

RESULTS

We studied 266 pregnant women with elevated PI in the UtAs in the second trimester and ultrasound reassessment at 28 weeks. UtA PI >95th centile at 28 weeks was associated with subsequent PE [odds ratio (OR): 10.0, 95% CI: 2.3-43.5], early-onset PE (OR: 57.7, 95% CI: 3.8-87.6) and SGA less than the tenth centile (OR: 5.5, 2.2-13.9). UA PI >95th centile at 28 weeks was not significantly associated with any adverse outcome.

CONCLUSIONS

In women with abnormal UtA Doppler in the early second trimester scan, persistence of elevated UtA PI, but not abnormal UA PI, is associated with adverse pregnancy outcomes including PE, early-onset PE and SGA. © 2014 John Wiley & Sons, Ltd.

Prediction of Fetal Growth Restriction by Analyzing the Messenger RNAs of Angiogenic Factor in the Plasma of Pregnant Women

OBJECTIVE

To predict the occurrence of fetal growth restriction (FGR) by analyzing messenger RNA (mRNA) expression levels of vascular endothelial growth factor receptor 1 (fms-like tyrosine kinase 1 [Flt-1]) in maternal blood.

STUDY DESIGN

Eleven women with FGR were matched with 88 controls. Plasma samples were obtained during each trimester. The Flt-1 mRNA expression levels were compared between groups. Predicted probabilities were calculated, and sensitivity-specificity (receiver-operating characteristic [ROC]) curves were assessed based on regression models for each trimester measurement and possible combinations of measurements.

RESULTS

The mRNA levels of the FGR group during all trimesters were significantly higher than those of the control group. The ROC curve of combined first and second trimester data yielded a detection rate of 60% at a 10% false-positive rate, with an area under curve of 0.79.

CONCLUSION

The Flt-1 mRNA expression in maternal blood can be used as a marker to predict the development of FGR, long before a clinical diagnosis is made.

Effects of maternal smoking on the placental expression of genes related to angiogenesis and apoptosis during the first trimester

OBJECTIVE

Maternal cigarette smoking is reportedly associated with miscarriage, fetal growth restriction and placental abruption, and is paradoxically associated with a decreased risk of developing preeclampsia. In the present study, we investigated the gene expression levels of villous tissues in early gestation. We compared the expression levels of the genes related to angiogenesis and apoptosis in the villous tissues obtained from smoking and non-smoking pregnant women.

MATERIALS AND METHODS

We collected villous tissue samples from 57 women requesting surgical termination due to non-medical reasons at 6-8 weeks of gestation. The maternal cigarette smoking status was evaluated by the level of serum cotinine and patients were divided into active smokers and non-smokers by the serum cotinine level. The placental levels of VEGFA, PGF, FLT1, HIF1A, TP53, BAX and BCL2 mRNA were quantified by real time PCR.

RESULTS

The gene expression level of PGF and HIF1A in the active smoker group was significantly higher than that in the non-smoker group. We did not observe any significant differences in the VEGFA or FLT1 expression between the groups. In active smoker group, the gene expression levels of TP53 and BAX were significantly higher than those in the non-smoker group. The ratio of BAX/BCL2 mRNA in the active smoker group was significantly higher than that in the non-smoker group.

CONCLUSIONS

Our findings revealed that smoking might affect the placenta during early pregnancy. Maternal cigarette smoking in early pregnancy may be associated with villus hypoxia, which may influence angiogenesis and apoptosis.

Umbilical artery Doppler at 19 to 22 weeks of gestation in the prediction of adverse pregnancy outcomes

OBJECTIVE

The aim of this study was to determine the clinical utility of Doppler assessment of the umbilical artery in the second trimester scan for predicting adverse pregnancy outcomes.

METHODS

Singleton pregnancies that had undergone routine anomaly scan at 19 to 22 weeks of gestation with umbilical and uterine artery Doppler measurements. Receiver operating characteristic curves were constructed to evaluate the ability of umbilical artery pulsatility index (PI) to predict small for gestational age and preeclampsia.

RESULTS

The final study population comprised 4565 singleton pregnancies. Multiple regression analysis showed significant independent contribution of umbilical artery PI in predicting SGA <10th and SGA <5th centiles (adjusted odds ratios of 2.51 and 3.51, respectively). By using a cutoff of umbilical artery PI >90th centile, the likelihood ratio of SGA <5th centile is 2.3 (95% CI: 1.7-3.0).

CONCLUSIONS

Umbilical artery PI at 19 to 22 weeks of gestation is significantly associated with SGA below the tenth and fifth centiles. A multivariate model combining umbilical and uterine artery Doppler measurements with additional maternal and sonographic characteristics may help predict small for gestational age, particularly those below the fifth centile.

Increased levels of cell-free human placental lactogen mRNA at 28-32 gestational weeks in plasma of pregnant women with placenta previa and invasive placenta

We compared the levels of cell-free human placental lactogen (hPL) messenger RNA (mRNA) in maternal plasma at 28 to 32 weeks of gestation between women with diagnosis of placenta previa or invasive placenta and women with an uneventful pregnancy. Sensitivity and specificity of hPL mRNA for the prediction of invasive placenta were further explored. Plasma hPL mRNA were quantified by real-time reverse-transcriptase polymerase chain reaction in women with placenta previa (n = 13), invasive placenta (n = 5), and normal pregnancies (n = 92). Median (range) hPL mRNA was significantly higher in women with placenta previa, 782 (10-2301) copies/mL of plasma, and in those with invasive placenta, 615 (522-2102) copies/mL of plasma, when compared to normal pregnancies, 90 (4-4407) copies/mL of plasma, P < .01 and P < .05, respectively. We found a sensitivity of 100% and a specificity of 61.5% for the prediction of invasive placenta among women with placenta previa. In conclusion, expression of hPL mRNA is increased in plasma of women with placenta previa and invasive placenta at 28 to 32 weeks of gestation.

¿Es útil la amniotomía de rutina en el trabajo de parto de inicio espontáneo? Una revisión de la literatura

La amniotomía de rutina o sistemática, practicada en gestantes con trabajo de parto de inicio espontáneo, se da en gran parte de hospitales del Perú y el mundo, documentándose su prevalencia hasta en 77%. Sin embargo, poco se conoce acerca de los beneficios y daños que puede ocasionar en el feto y en la madre. Se realizó una búsqueda de la literatura médica, con la finalidad de encontrar evidencia científica sólida que respalde o rechace esta práctica. Se llega a la conclusión que la amniotomía practicada sistemáticamente altera la evolución fisiológica del trabajo de parto, acortándolo hasta en 50 minutos en promedio; sin embargo, este acortamiento no tiene trascendencia clínica ni para el feto ni para la madre. Por el contrario, su práctica de rutina puede aumentar el número de partos disfuncionales y el puntaje Ápgar menor de siete a los cinco minutos.

Placental expression of microRNA-17 and -19b is down-regulated in early pregnancy loss

OBJECTIVE

First, to determine if microRNA-17 and -19b are expressed in villous samples at early stages of pregnancy. Second, to determine whether placental expressions of these microRNAs along with their main targets (PTEN, CREB-1, TGFβ-1 and TGFβ-RII) are altered in early pregnancy loss.

STUDY DESIGN

Expression levels of microRNAs and mRNA targets in villous samples from early pregnancy loss (n=11) and matched normal cases (n=20) by gestational age were determined by RT-PCR.

RESULTS

Both microRNA-17 and -19b were expressed in all cases of normal pregnancy. They were significantly down-regulated (relative ratios: 0.35 and 0.34 respectively) in early pregnancy loss. Their main target, PTEN mRNA, was significantly up-regulated in early pregnancy loss (relative ratio: 2.6, 95%CI: 0.2-29.8). TGF-β1, CREB-1 and TGFβ-RII were not significantly different between the two groups.

CONCLUSION

microRNA-17 and -19b are expressed in early stages of pregnancy. They are down-regulated in villous samples from early pregnancy loss. We suggest that these main members of the microRNA-17-92 cluster might be involved in placental invasion and its dysregulation might also be related to other conditions characterized by defective placentation.

La importancia de la ecografía a las 11+0 a 13+6 semanas de embarazo. Actualización

La evaluación ecográfica del primer trimestre (11+0 a 13+6 semanas) constituye actualmente una de las herramientas fundamentales en el manejo de toda paciente obstétrica. Es el mejor ejemplo de tamizaje en Obstetricia por medio del cálculo de riesgo de anormalidades cromosómicas y, sumado a ciertas características obstétricas y clínicas, se constituye en un potencial predictor de riesgo de las principales complicaciones obstétricas. Es nuestro objetivo presentar en forma resumida y simplificada los avances en este importante tópico de Medicina Fetal, con la finalidad de que sea reafirmada y asumida por todos los responsables del cuidado de la salud materno-fetal, incluyendo los padres.

Physiological changes in the pattern of placental gene expression early in the first trimester

OBJECTIVE

To assess the physiological changes in the placental expression pattern of a panel of genes related to angiogenesis and oxidative stress during the early part of the first trimester of pregnancy.

METHODS AND RESULTS

The expression of a selected panel of genes was quantified by reverse transcriptase-polymerase chain reaction in samples of villous trophoblasts obtained from women between 6 and 11 weeks of gestation undergoing elective artificial abortion. We found that the levels of messenger RNA (mRNA) expression of placental growth factor (PlGF), heme oxygenase 1(HO-1), and superoxide dismutase (SOD) increased significantly with gestational age (r = .37, P = .001; r = .24, P =.04; and r = .52, P < .001, respectively). Conversely, the mRNA expression level of fms-like tyrosine kinase 1 (FLT-1) decreased significantly (r = -.30, P = .009).

CONCLUSION

During the early part of the first trimester of pregnancy, the placental gene expression levels of PlGF, HO-1, and SOD increase with gestational age, whereas the expression of FLT-1 decreases. The alteration in this pattern of gene expression in early pregnancy may therefore play an important role in placenta-related disorders such as preeclampsia.

Estudio comparativo entre cesárea tipo Misgav Ladach y cesárea tipo Kerr

Introducción: La técnica de cesárea conocida como Misgav Ladach es una técnica minimalista y está siendo usada cada vez más en diferentes partes del mundo. Objetivos: Determinar los beneficios de la técnica Misgav Ladach, comparados con los de la cesárea clásica de Kerr. Diseño: Estudio retrospectivo, comparativo. Lugar: Hospital II EsSalud, Huamanga, Ayacucho. Participantes: Gestantes a término con feto único vivo, con indicación de cesárea. Intervenciones: Cesárea. Principales medidas de resultados: Tiempo operatorio, tiempo de extracción fetal, sangrado operatorio, uso de analgésico en el postoperatorio. Resultados: Los tiempos operatorios promedio fueron 25 vs. 38 minutos, según el empleo de la técnica Misgav-Ladach y Kerr, respectivamente. Los tiempos de extracción fetal fueron 79 vs. 139 segundos, con diferencia significativa. La media de hemoglobina fue de 1,2 g/dL en el grupo de casos y 1,47 g/dL en el grupo control, mostrando diferencia significativa. El grupo Misgav-Ladach requirió menor analgesia postoperatoria. No se alcanzó diferencia significativa en la morbilidad febril y en la necesidad de antibiótico terapia poscirugía. Conclusiones: La cesárea Misgav- Ladach parece mostrar mejores beneficios con respecto a la cesárea clásica, lo cual debe ser confirmado mediante estudios prospectivos aleatorios.

Perinatal outcomes after sonographic detection of isolated short femur in the second trimester

PURPOSE

To determine the association of fetal isolated short femur in the second-trimester ultrasound (US) examination with perinatal outcomes such as small-for-gestational age (SGA) and low-birth weight (LBW) neonates.

METHODS

This is a retrospective cohort study in fetuses routinely assessed by US examination at 18 to 24 weeks during 2006-2009. A fetal isolated short femur was defined as femur length below the 5th percentile and with no chromosomal or structural abnormalities. Fetuses with abdominal circumference below the 5th percentile at the time of US examination were excluded. Each case of short femur was matched with three controls according to gestational age at the time of the US examination.

RESULTS

Sixty-one fetuses met the inclusion criteria. Both the group of women carrying a fetus with isolated short femur and that of women carrying a fetus with normal femur length had similar general and obstetric characteristics. Women carrying a fetus with isolated short femur were significantly more likely to deliver a SGA neonate (19.7% versus 8.7%, p < 0.05) and a LBW neonate (19.7% versus 7.1%, p < 0.05) than women carrying a fetus with normal femur length. Logistic regression analysis found odds ratios for SGA and LBW of 2.6 (95% confidence interval, 1.1-5.9) and 2.9 (95% confidence interval, 1.2-7.1), respectively.

CONCLUSIONS

Isolated short femur in the second-trimester US examination is associated with a subsequent delivery of SGA and LBW neonates.

Perinatal outcomes associated with subsequent pregnancy among adolescent mothers in Peru

OBJECTIVE

To assess the perinatal outcomes of a subsequent pregnancy among adolescent mothers living in Peru.

METHODS

A large hospital-based retrospective cohort study was conducted to evaluate singleton births during a 9-year period (2001-2009). The study population was divided into 3 groups: adolescents aged 15-19 years who had 1 previous parturition (n=2074), nulliparous adolescents (n=20721), and multiparous adults aged 20-29 years (n=23 129).

RESULTS

No significant differences were found between multiparous adolescents and the 2 control groups with regard to preterm delivery, perinatal death, and 5-minute Apgar score below 7. Logistic regression analysis showed no significant differences in the rates of cesarean delivery or preterm birth before 34 or 37 weeks. After adjusting for confounding factors, low birth weight (LBW) and small for gestational age (SGA) were more likely to occur during a subsequent pregnancy among adolescent mothers than during the 1st pregnancy among nulliparous adolescents. The odds ratios were 1.38 (95% CI, 1.14-1.67) and 1.27 (95% CI, 1.02-1.56), respectively.

CONCLUSION

Multiparous adolescents are more likely to experience LBW or SGA than are nulliparous adolescents. No significant differences in other perinatal outcomes were found among the 3 study groups.

Prediction of spontaneous preterm delivery from maternal factors, obstetric history and placental perfusion and function at 11-13 weeks

OBJECTIVE

To develop a model for prediction of spontaneous delivery before 34 weeks based on maternal factors, placental perfusion and function at 11-13 weeks' gestation.

METHODS

Two groups of studies: first, screening study of maternal characteristics, serum pregnancy-associated plasma protein-A (PAPP-A), free β-human chorionic gonadotrophin (β-hCG) and uterine artery pulsatility index (PI). Second, case-control studies of maternal serum or plasma concentration of placental growth factor (PlGF), placental protein 13 (PP13), a disintegrin and metalloprotease 12 (ADAM12), inhibin-A and activin-A. Regression analysis was used to develop a model for the prediction of spontaneous early delivery.

RESULTS

Spontaneous early delivery occurred in 365 (1.1%) of the 34 025 pregnancies. A model based on maternal factors could detect 38.2% of the preterm deliveries in women with previous pregnancies at or beyond 16 weeks and 18.4% in those without, at a false positive rate (FPR) of 10%. In the preterm delivery group, compared with unaffected pregnancies there were no significant differences in the markers of placental perfusion or function, except for PAPP-A which was reduced.

CONCLUSIONS

Patient-specific risk of preterm delivery is provided by maternal factors and obstetric history. Placental perfusion and function at 11-13 weeks are not altered in pregnancies resulting in spontaneous early delivery.

Prenatal sonographic diagnosis of duplicated middle cerebral artery

We report a fetus scanned by color Doppler ultrasound at 37 weeks for suspicion of growth restriction with an extremely rare variation of duplicated middle cerebral artery. Three-dimensional color power Doppler and tomographic ultrasound imaging enhanced our incidental finding.

Fungal endocarditis: evidence in the world literature, 1965-1995

We analyzed 270 cases of fungal endocarditis (FE) that occurred over 30 years. Vascular lines, non-cardiac surgery, immunocompromise and injection drug abuse are increasing risk factors. Delayed or mistaken diagnosis (82% of patients), long duration of symptoms before hospitalization (mean +/- standard deviation, 32+/-39 days) and extracardiac manifestations were characteristic. From 1988 onwards, 72% of patients were diagnosed preoperatively, compared with 43% before 1988 (P=.0001). The fungi most commonly isolated were Candida albicans (24% of patients), non-albicans species of Candida (24%), Apergillus species (24%), and Histoplasma species (6%); recently-emerged fungi accounted for 25% of cases. The mortality rate was 72%. Survival rates were better among patients who received combined surgical-antifungal treatment, were infected with Candida, and had univalvular involvement. Improvement in the survival rate (from <20% before 1974 to 41% currently) coincided with the introduction of echocardiography and with improved diagnostic acumen. Fungal endocarditis recurs in 30% of survivors. It is recommended that fungal endocarditis be diagnosed early through heightened diagnostic acumen; that patients be treated with combined lipid-based amphotericin B and early surgery; and that patients be followed up for > or =4 years while on prophylactic antifungal therapy.