Volume 41, Issue 4

Background: The Edinburgh Postnatal Depression Scale (EPDS) is a widely used instrument for screening for postpartum depression, but it might also detect anxiety symptoms. Objective: To investigate the factor structure of the EPDS administered immediately after delivery and to understand which factors predict a high EPDS score 3 months later. Methods: A cohort of 594 Italian mothers delivering a healthy baby at Versilia Hospital completed the EPDS at two points in time: 2 days after delivery (T 0 ) and 3 months later (T 1 ) by telephone interview. Results: EPDS scores were higher at T 0 than at T 1 . Overall, 15.7% of women at 2 days postpartum and 7.6% at 3 months later reported a score >9. The factor analysis of EPDS at T 0 indicated a three-factor structure: “depression” (items 7–10), “anxiety” (items 3–6) and “anhedonia” (items 1–2). Anxious symptoms were quantitatively more important than depressive ones (mean 3.9 vs. 1.2) but tended to spontaneously ameliorate at T1, whereas total EPDS score at T1 was better predicted by depressive symptoms at T 0 (discriminative ability 0.75 vs. 0.68). Conclusions: This study suggests that EPDS subscales immediately after delivery help understand the spectrum of maternal postpartum psychological problems. Anxious symptoms immediately after delivery are frequent but transient, linked probably to maternity blues or atypical depression, whereas the presence of depressive symptomatology at T 0 suggests higher risk of later depressive disorders.

Aims: To test if an isolated finding of low-normal amniotic fluid index (AFI) in the early third trimester in low-risk patients is associated with adverse perinatal outcomes. Methods: Retrospective cohort study with uncomplicated singleton pregnancies that had ultrasound studies between 28.0 and 31.9 weeks’ gestation. Two cohorts with AFI 8.0–11.9 cm (low-normal, LN) and AFI 12.0–19.9 cm (mid-normal, MN) were compared. Results: Patients with LN-AFI (n=99) were more likely to have early (<34 weeks) and late (<37 weeks) preterm birth (PTB) (relative risk 4.2 and 2.4, respectively) and a small for gestational age (SGA) infant (relative risk 1.8) than MN-AFI (n=834), corresponding to a higher NICU admission rate (relative risk 2.5). The risk of “spontaneous” PTB (preterm labor and rupture of membranes) did not differ between the cohorts, whereas the risk of “indicated” PTB (maternal or fetal indications) was significantly increased in LN-AFI. The incidence of abnormal antepartum testing, stillbirth, preeclampsia, placental abruption, fetal intolerance to labor, emergency cesarean delivery, umbilical artery pH <7.0, Apgar scores <7 at 5 min, and neonatal death was not increased in patients with LN-AFI. Conclusion: Low-normal AFI in the early third trimester increases the risk for subsequent delivery of an SGA infant and indicated PTB.

Aim: To investigate the characteristics of twin pregnancies and their mode of delivery over a 30-year period, in order to define the current trends in clinical practice regarding twin deliveries and the factors that influence these practices. Materials and methods: A retrospective study of twin deliveries at ≥24 weeks of gestation between January 1 st , 1981 and December 31, 2010. Data concerning number of twin deliveries, mode of delivery, maternal age, use of ART techniques, parity, gestational age at delivery, birth weight and Apgar scores were collected from labor ward records. Results: Over the years there has been a statistically significant increase in the number of twin deliveries, twins after IVF, cesarean section rate, maternal age, nulliparity and a statistically significant reduction in term deliveries, mean birth weight and assisted vaginal deliveries. Maternal age, gestational age, parity and conception after IVF are factors related to the risk of performing a cesarean section. Conclusions: Despite the lack of adequate scientific evidence concerning the optimal route of delivery in twin pregnancies it seems that over time cesarean section has become the standard of care in most of twin pregnancies. Changes in the demographic characteristics contribute among other factors to this practice.

Aims: Several case reports show a negative impact of childhood sexual abuse (CSA) on prenatal care. The study aimed to systematically investigate this association in a larger study group. Methods: CSA was investigated by face-to-face interviews and by a modified questionnaire developed by Wyatt. All study participants completed a self-administered questionnaire designed to investigate the consequences of CSA on prenatal care during adulthood. Data from 85 women after CSA were compared to those of 170 matched women without such experiences. Results: Women exposed to CSA had fewer than five prenatal consultations more often than unexposed women (26%/7%; P<0.0001). Of the 85 women with a positive history for CSA, 9.4% had been asked for such antecedents, 36.5% had intense memories on original abuse situations during pregnancy, 56.6% mentioned specific consequences of CSA on prenatal care and 61.2% were satisfied with obstetrical support. Exposed women (62.4%) felt significantly less prepared for labor than unexposed women (75.9%) (P<0.0001). Conclusions: CSA experiences are associated with impaired prenatal care. These results underscore the compelling need to improve prenatal care in women exposed to CSA through better education of obstetricians regarding the effects of CSA and in their ability to provide empathetic professional support.

Aim: To evaluate maternal and cord blood serum adropin concentrations in pregnant women with gestational diabetes mellitus (GDM). Study design: Twenty pregnant women with GDM and 20 gestational age-matched healthy pregnant women participated in the study. Maternal serum and cord blood adropin levels were assessed using an enzyme immunosorbent assay, at the time of birth. The relation of maternal serum and cord blood adropin levels with metabolic parameters were also assessed. Results: The mean maternal and cord serum adropin in the GDM group were significantly lower than those of the control women (P=0.01 and P<0.001, respectively). Maternal serum adropin levels did not correlate with either fetal serum adropin levels or maternal metabolic values. Conclusion: The data suggest that low adropin levels may contribute to the underlying pathogenesis of GDM.

Objective: To evaluate whether maternal ethnicity affects perinatal mortality by week of gestation from 39 weeks onwards. Study design: In this cohort study, we used data from the nationwide Netherlands Perinatal Registry from 1999 until 2008. All singleton infants born between 39 +0 and 42 +6 weeks of gestation without congenital anomalies were included. We used crude and multivariate logistic regression analyses with white Europeans as the reference to calculate the adjusted odds ratios (aOR) of South Asian, African and Mediterranean women. The main outcome measure was perinatal mortality (antepartum and intrapartum/neonatal mortality within 7 days after birth). Results: We studied 1,092,255 singleton deliveries. Perinatal mortality occurred in 2315 infants (2.1‰). There was interaction between gestational age and ethnicity (P<0.0001). In week 40 (40 +0 –40 +6 ) South Asian (aOR 1.9; 95% CI 1.1–3.4) and Mediterranean (aOR 1.3; 95% CI 1.04–1.7) women had an increased risk of perinatal mortality. The perinatal mortality risk became greater in week 41 for South Asian (aOR 4.5 95% CI 2.8–7.2), African (aOR 2.2; 95%CI 1.4–3.4) and Mediterranean (aOR 2.2; 95% CI 1.8–2.9) women, especially among small for gestational age infants. Conclusion: With increasing gestational age beyond 39 weeks, perinatal mortality risk increases more strongly among South Asian, African and Mediterranean women compared to European whites.

Aim: To investigate the possible roles of selected single nucleotide gene polymorphisms (SNPs) of the activin A receptor type 2A ( ACVR2A ) gene in the pathogenesis of preeclampsia. Methods: Ninety-four patients with preeclampsia and 166 healthy pregnant women were included in this study. Genomic DNA was extracted from venous blood and were stored at −80°C before the analysis. Selected ACVR2A SNPs (rs10497025, rs1128919, rs13430086) were determined in an ABI 7900 HT Real-Time PCR instrument. Results: For all three SNPs, no statistically significant difference was found between preeclampsia and control groups in terms of genotype and allele frequencies. In the late preeclampsia group, with regard to the rs1128919 SNP, the frequency of GG genotype was found to be significantly lower (P=0.02). Although the frequency of “A” allele was found to be higher (P=0.05; OR=1.54), and the “G” allele was found to be lower (P=0.05; OR=0.65), the results did not reach statistical significance in late preeclamptic patients. For the rs1128919 SNP, the frequency of the AA genotype was found to be significantly higher in both mild (P=0.004) and severe (P=0.0001) preeclampsia groups, whereas the frequency of GG genotype was found to be significantly lower (P=0.008, and P=0.0001, respectively). For the rs13430086 SNP, while the frequency of the AA genotype was found to be significantly lower in both mild (P=0.02) and severe (P=0.0001) preeclamptic patients, the frequency of TT genotype was found to be significantly higher in only severe preeclampsia group (P=0.0001). Conclusion: ACVR2A gene polymorphisms may play a role in the development of preeclampsia.

Aim: To define a better cut-off value of the renal pelvis anteroposterior diameter (RPAPD) to predict persistent or progressive pyelectasis during pregnancy. Methods: We retrospectively reviewed 8873 women whose fetal RPAPD was measured. Midtrimester pyelectasis was defined as a RPAPD of ≥4 mm. Persistent/progressive pyelectasis was defined as a RPAPD of ≥10 mm before delivery. A RPAPD cut-off value to predict a persistent/progressive pyelectasis was determined by receiver operating characteristic curve analysis. Results: Among 249 isolated cases of pyelectasis, persistent/progressive pyelectasis was found in 6.9% before delivery. The midtrimester RPAPD cut-off value that best predicted persistent/progressive pyelectasis before delivery was ≥6 mm with sensitivity, specificity, positive and negative predictive values of 64.3%, 88.7%, 30.0%, and 97.1%, respectively. Conclusions: Although most cases of midtrimester fetal pyelectasis regress to normal during pregnancy, those with a RPAPD of ≥6 mm in the midtrimester are at higher risk for persistent or progressive pyelectasis.

Autophagy is an intracellular process that maintains homeostasis by the removal of damaged organelles and proteins. A single nucleotide polymorphism (SNP) in the autophagy-related 16-like 1 ( ATG16L1 ) gene results in decreased autophagy. We evaluated whether the ATG16L1 polymorphism influenced the time to delivery during labor induction in pregnant women with an unfavorable cervix. DNA from 69 women with an unfavorable cervix who required labor induction due to post-term (>294 days) (n=26), oligohydramnios (n=17), hypertension or pre-eclampsia (n=10), abnormal fetal heart rate (n=8), diabetes (n=3) or other reasons (n=5) was tested by gene amplification and endonuclease digestion for a SNP in ATG16L1 (rs2241880). The mean hours (SD) from induction to delivery was 20.8 (9.7) for women who were A,A homozygotes, 19.2 (8.8) for A,G heterozygotes and 14.3 (6.6) for homozygote carriers of the G,G variant (P=0.03 A,A vs. G,G, P=0.04 A,A/A,G vs. G,G). The G,G prevalence was 24.4% and 4.2% for those who delivered in ≤24 and >24 h, respectively (P=0.04). There was no difference in genotype distribution by indication for induction. A decreased genetic capacity for autophagy may be beneficial in women with an unfavorable cervix whose labor has to be induced.

Aims: The objective of this study was to examine the impact of one trial (the HYPITAT trial) on management of gestational hypertension. Study design: This is a retrospective cohort study of 5077 patients delivered at our institution from 7/1/2008 to 6/15/2011. “Pre-HYPITAT” was defined as 7/1/2008–9/30/2009 and “Post-HYPITAT” as 10/1/2009–6/15/2011. The primary outcome is the rate of delivery intervention for gestational hypertension. Secondary maternal and neonatal outcomes were analyzed in patients with gestational hypertension only. Statistical analyses included the χ 2 -test, Fisher’s exact test, and the two-sample t -test. Results: The rate of delivery intervention Pre-HYPITAT was 1.9%, compared to 4% Post-HYPITAT (P<0.001). There was no significant change in secondary outcomes. Conclusion: There was a statistically significant increase in delivery intervention for gestational hypertension at our institution after the publication of the HYPITAT trial. There was no significant change in immediate maternal or neonatal outcomes for patients with gestational hypertension.

Aims: To evaluate the intra-operator reliability of tissue Doppler imaging-based quantitative cervical elastography in at-term pregnancies. Methods: Three series of two cycles of manual gentle compression-relaxation of the cervix were performed by one gynecologist in 11 consecutive at-term pregnancies through the vaginal probe. The compression movements should be sufficient to obtain the maximal compression of the anterior portion of the cervical tissue, until the posterior portion begins to be dislocated. Strain values were assessed on the entire thickness of the anterior cervical lip. The influence of strain type (Lagrangian vs. natural) and the extent of compression exerted (difference among the two cycles of compression-relaxation) were evaluated. Results: Strain measurement was influenced by the extent of compression, as well as by the strain type. The strain measured during the cycle with larger cervical compression, using the natural strain preset, showed a superior reliability [mean strain among patients: 0.68±0.18; mean of differences among three measures: 0.07±0.06; intraclass correlation coefficient (ICC) consistency: 0.90]. The strain measured using the Lagrangian strain preset showed overall a low reliability (ICC consistency: 0.04). Conclusions: Quantitative cervical elastography performed in at-term pregnancies, under standardized conditions, has a high reliability.

Objective: The objective of this study was to determine whether maternal residential proximity to a nuclear reactor is associated with prevalence of certain birth defects. Study design: The New York State Vital Statistics and Congenital Malformations Registry data (1992–2001) were analyzed for five Hudson Valley counties in a 20-mile radius from the Indian Point nuclear reactor (Buchanan, NY, USA). Four zones of 5-mile increments were used to categorize proximity to the reactor. Data included congenital anomalies, low birth weight, and prematurity. Result: Over the 10-year period, 702 malformations in 666 children were identified from a birth population of 328,124, yielding a regional rate of 2.1 major malformations per 1000 births. The prevalence of defects, low birth weight, and prematurity were not related to proximity to the nuclear power plant. Conclusion: These data did not substantiate an association between maternal proximity to the reactor and certain birth defects and provide baseline data for comparison in the event of a nuclear accident.

Objectives: To evaluate the fetal magnetic resonance imaging findings of lymphangiomas. Methods: The magnetic resonance scans of eight fetuses with lymphangiomas were evaluated. Magnetic resonance evaluation included: number; size; signal intensities of the lesions; thickness of the septae; configuration of the margins; presence of blood breakdown products; change in size or signal intensity (in four patients with multiple examinations); exact expansion of the lesions to the adjacent anatomical structures; and concomitant pathological findings. Results were compared with postpartum clinical assessment and imaging in seven patients and with autopsy in one patient. Results: Two retroperitoneal, three thoracic, and three cervical lymphangiomas (diameters between 3.3 and 15.6 cm) were included. All lesions consisted of macrocysts, and additional microcystic parts were found in three lymphangiomas. Blood breakdown products were found in one lesion. Agreement with postpartum imaging was excellent. One patient received intrauterine drainage for chylothorax, and one pregnancy was terminated. Conclusions: Fetal lymphangiomas display the same magnetic resonance imaging features as postnatal lymphangiomas. Intrauterine magnetic resonance characterization of lymphangiomas provides the exact delineation, detection of associated and/or concomitant pathologies, and differential diagnosis among other cystic pathologies. Patient management may be altered with respect to the type and/or time of treatment, and with regard to the continuation or termination of pregnancy.

Aims: To report our neonatal management experience in patients who received a diagnosis of brainstem dysgenesis (BSD). Patients and methods: This study retrospectively reviewed the medical records of 15 neonates with BSD diagnosed between 1984 and 2011. Data on the perinatal period, physical examination, laboratory findings, and management by systems were systematically analyzed. Results: All cases were sporadic. Cocaine abuse and misoprostol use were recorded in two pregnancies. The reason for admission was prematurity (2 of 15), respiratory distress (8 of 15), gastroschisis (1 of 15), and abnormal neurological examination (4 of 15). Clinically, the most commonly affected cranial nerves were the 7 th (13 of 15), 9 th (11 of 15), 10 th (8 of 15), 5 th (7 of 15), 12 th (7 of 15), 6 th (3 of 15), 4 th (1 of 15), and 3 rd (1 of 15). Five patients required positive pressure ventilation during delivery room resuscitation, three had difficult airways, and two needed tracheostomy during admission. Most patients required nasogastric tube feeding shortly after birth, and four patients had a gastrostomy on discharge. Two patients died of respiratory and cardiac failure. Electromyography and nerve conduction velocity were used to exclude generalized neuromuscular disorders, and in conjunction with other neurophysiological and gastrointestinal tract studies, helped uncover the extent of brainstem involvement in most cases. Cranial magnetic resonance imaging supported the diagnosis in more than half of the patients. Conclusions: Early diagnosis of BSD is mainly clinical, difficult to establish unless suspected, and crucial to prevent complications. Neonatal care of patients with BSD requires a comprehensive approach that must take into consideration the etiological, anatomical, and pathogenic aspects contributing to the clinical manifestations of this disorder. Care should be provided by multidisciplinary teams, in which neonatologists, pediatric neurologists, nutritionists, physical therapists, and other professionals participate, depending on the associated morbidity in order to improve its management and prognosis.

Objective: To reduce the incidence of hypothermia (admission temperatures <36°C) in extremely low birth weight (ELBW) neonates using a multi-intervention quality improvement (QI) initiative. Study design: We conducted a multi-intervention QI initiative to reduce hypothermia (admission temperatures <36°C) among preterm ELBW (≤1000 g birth weight) neonates born at Hutzel Women’s Hospital. The QI project was conducted in three periods: period 1, traditional thermal care of drying and wrapping in towel; period 2, wrapping in plastic wrap without first drying; and period 3, periodic staff education, additional use of chemical warming mattress, and increase in operating room temperature from 20°C to 21°C. Statistical analysis included ANOVA, χ 2 , and logistic regression as appropriate. Results: In our cohort of 209 patients, baseline characteristics were comparable in the three periods except for a reduction in the need for surfactant doses in the 3 rd period. Temperature on admission to the neonatal intensive care unit was significantly higher, with a reduction in hypothermia in the 3 rd period. There was no patient with a temperature of ≥37.5°C. On logistic regression, with gestational age, 5-min Apgar score, and mode of delivery as covariates, time period 3 was significantly associated with a reduction in the incidence of hypothermia (P=0.02). Conclusion: A concerted QI approach improved admission temperature in ELBW neonates, with more neonates in the euthermic range, without increasing the risk for hyperthermia. Such an approach could be associated with improved outcomes in this population.

Objective: We report on the risk of miscarriage with high- and low-dosage periconceptional folic acid (FA) supplementation from a double-blind randomized clinical trial for prevention of orofacial cleft recurrence in Brazil. Methods: Women at risk of recurrence of orofacial clefts in their offspring were randomized into high (4 mg/day) and low (0.4 mg/day) doses of FA supplementation. The women received the study pills before pregnancy, and supplementation continued throughout the first trimester. Miscarriage rates were compared between the two FA groups and with the population rate. Results: A total of 268 pregnancies completed the study protocol, with 141 in the 4.0-mg group and 127 in the 0.4-mg group. The miscarriage rate was 14.2% in the low-dose FA group (0.4 mg/day) and 11.3% for the high-dose group (4 mg/day) (P=0.4877). These miscarriage rates are not significantly different from the miscarriage rate in the Brazilian population, estimated to be around 14% (P=0.311). Conclusions: These results indicate that high-dose FA does not increase miscarriage risk in this population and add further information to the literature on the safety of high FA supplementation for prevention of birth defect recurrence.