Volume 33, Issue 5

Objective: To assess pre-labor attitudes and post-labor experiences of the use of vacuum extraction during delivery. To seek associations between traumatic labor experience and personal preparation, physiology of labor and treatment during labor. Methods: A total of 205 women filled in a questionnaire within five days of vacuum extraction delivery. The questionnaire was designed to distinguish the group of women having experienced their labor as traumatic from those not having such an experience. The association between explanatory variables grouped as background factors, physiological factors of labor and treatment-related factors in relation to traumatic experience status was studied by bivariate analysis by the chi-square test or Student's t -test. Logistic regression analysis was carried out to examine simultaneous effects of factors. In the first phase, each of the previously chosen groups was analyzed separately, and in the second, all risk factors thus emerging as significant were entered into the final model. Results: Forty-two women (20%) regarded their childbirth experience as traumatic. Of the background factors, insufficient pre-labor training and a pre-labor desire for extra strong pain relief during the coming labor were significantly more common in the traumatic birth group. Of the physiological factors of labor, unsatisfactory pain relief and a difficult third stage of labor were associated with a traumatic birth experience. The treatment-related factors showed mutual correlation and were strongly associated with birth experience. After logistic regression analysis only four independent risk factors emerged as significant: insufficient support immediately after delivery, the experience of being poorly listened to during labor, insufficient doctor's support during the first stage of labor, and pre-labor training classes considered insufficient. Conclusions: Treatment-related factors were the most powerful predictors of an adverse birth experience after vacuum extraction delivery, exceeding those related to labor physiology. Thus, the role of treatment and care before, during and after vacuum extraction is emphasized.

Objective : To examine whether the recommended weight gain during the first 24 weeks reduces the frequency of SGA triplets. Study design : We used data collected by the Women's Health Division of Matria Healthcare, Inc (Marietta, GA). We studied the frequency of SGA triplets (birth weight <10 th percentile by triplet standards) by weight gain, parity, and pregravid BMI category. Adequate weight gain was defined as >16.2 kg at 24 weeks and BMI categories were defined as underweight (<19.8), normal (19.8–26), and obese (BMI>26). Results : We studied 2890 triplet sets. Adequate weight gain reduces the frequency of SGA triplets, irrespective of pregravid BMI category and parity, except for obese nulliparous women. However, the reduced frequency of SGA infants was significant only in underweight nulli-paras (OR 0.3, 95% CI 0.1, 0.9). Conclusion : Higher pregravid BMI and parity seem to reduce the occurrence of SGA triplets. However, lean mothers, especially nulliparas, may be the most important target population for nutritional intervention in triplet pregnancies.

Objective: To evaluate clinical risk factors, cervical fetal fibronectin (fFN), cervical length, and mean gray value assessment in predicting of preterm delivery (PTD) in patients with signs and/or symptoms of preterm labor (PTL). Study design: One hundred and seventeen women with PTL between 24 and 34 weeks of gestation were included. Cervical swabs were tested for fFN using the rapid fFN assay. When 2-dimensional transvaginal ultrasound measurement of cervical length was completed, a region of interest (ROI) of constant size was defined in the midsection of the posterior wall, and the tissue-specific gray scale was determined. The end point were PTDs at <34 and <37 weeks of gestation. Results: In univariate analysis, the three strongest predictors of spontaneous preterm birth <34 weeks were positive fFN (relative risk [RR] 8.9; 95% confidence interval [CI] 2.6–30.1), cervical length ≤2.5 cm (RR 6.9; 95% CI 1.6–29.7), and a low mean gray value of ≤5.97 (RR 7.9; 95% CI 2.3–27.2). Predictors significantly associated with spontaneous PTD at less than 37 weeks of gestation included previous PTD in multiparas (RR 3.9; 95% CI 1.6–9.5), positive fFN (RR 7.6; 95% CI 3.8–15.3), cervical length ≤2.5 cm (RR 2.6; 95% CI 1.4–5.1) and a low gray scale value of ≤6.54 (RR 4.5; 95% CI 2.3–8.9). In the final regression models used to predict spontaneous PTD <34 weeks and <37 weeks of gestation, both a positive fetal fibronectin (odds ratio [OR] 13.4; 95% CI, 2.5–72.1, P=0.003 vs. OR, 17.3; 95% CI 4.9–61.8, P<0.001) and a low gray scale value (OR 6.3 95% CI 1.3–29.4, P=0.02 vs. OR, 7.1; 95% CI 2–25.2, P=0.003) remained powerful predictors. The RRs of spontaneous PTD <37 weeks has been analyzed by a combination of these significant parameters. Low mean gray value ≤6.54 and negative fFN had a 10.3-fold (95% CI 2–74.5) increased risk of spontaneous preterm birth at <37 weeks. Combination of positive fFN and normal gray level (>6.54), had a higher increase risk of PTD (RR 18.1; 95% CI 4.4–76.7). When both factors were positive, the RR increases to 24.8 (95% CI 6.2–98.7). Conclusions : Combined use of rapid fFN and cervical gray value analysis improves the diagnostic efficiency and allows identification of women at risk for preterm delivery and in need for further prophylactic/therapeutic intervention.

Aims: To evaluate the cross-trimester multiple marker correlation and the minimum marker combination needed for detecting various chromosomal aneuploidies. Materials and methods: Parturient women with singleton pregnancies who underwent non-interventional sequential screening test and followed prospectively were recruited. They all underwent first trimester combined nuchal translucency (NT), pregnancy-associated plasma protein-A (PAPP-A), and free β-human chorionic gonadotrophin (f-βhCG), followed by second trimester measurement of unconjugated estriol (uE 3 ), human chorionic gonadotrophin (hCG) and alpha-fetoprotein (AFP). Pearson correlation was applied to compute any cross-trimester marker correlation and logistic regression analysis was used to determine the minimum marker combination for detecting various categories of chromosomal aneuploidies. Results: The current study included 552 normal and 43 chromosomal-affected pregnancies (24 Down's syndrome [DS], 7 Turner's syndrome, 8 Edward's syndrome, 4 Klinefelter syndrome and 5 triploidy) for which the results of both the screening tests and the pregnancy outcome were available. In the normal cases, a significant correlation was found between f-βhCG and hCG (r=0.52), as well as between PAPP-A and uE 3 (r=0.174). In DS pregnancies, the NT correlated with both hCG (r=0.45) and uE 3 (r=−0.39). In Turner's syndrome, uE 3 correlated both with PAPP-A (r=0.97) and f-βhCG (r=0.97). No other significant correlations were found. Furthermore, with the exception of f-βhCG and hCG in the unaffected cases, all other markers correlation appeared very weak. For detecting all the above categories of aneuploidies, the combination of NT, PAPP-A and uE 3 and the maternal age background risk were found adequate, with a 74% detection rate (DR) for a 5% false positive rate (FPR). For DS only, the combination of maternal age-related background risk and the combination of NT, PAPP-A, hCG and AFP yielded a 79% DR for a 5% FPR. Conclusions: The current study agrees with a previous report that, overall, there is no strong correlation between first and second trimester markers. The extension of the integrated test for detecting various categories of common chromosomal aneuploidies using NT, PAPP-A and uE 3 deserves further evaluation.

This study investigated the effects of arecoline, an active ingredient of the areca nut, on the tone of human umbilical arteries and veins and on the eNOS expression and cell proliferation of human umbilical vein endothelial cells (HUVECs). We found that arecoline relaxes the human umbilical artery and vein rings in a concentration-dependent manner; the higher the concentration of arecoline, the greater the relaxation of the rings. However, the relaxation decreases after the endothelium was removed or pretreated with L-NAME, a nitric oxide synthase inhibitor. Moreover, arecoline increases in a dose-dependent way the cGMP levels of human umbilical arteries and veins. In HUVECs, arecoline also increases the eNOS expression. Therefore, the relaxant effects of arecoline on the umbilical artery and vein rings were endothelium-dependent through the NO-cGMP systems. In addition, arecoline at higher doses (100–1000 μM) inhibits endothelial cell proliferation; the exposure toarecoline (100–1000 μM) for 24 and 48 h induces G2/M cell cycle arrest of HUVECs. Our results indicate that arecoline would decrease vascular tone, in part mediated by NO. Higher doses of arecoline inhibit endothelial cell growth, which suggest that long-term use or high doses of areca nut might induce endothelial dysfunction and associated diseases.

Aim: To determine the accuracy of 4D sonography in the assessment of embryonic and early fetal motor activity in the first trimester of normal pregnancy, in comparison to the 2D sonography. Methods: Fifty pregnant women between 6–14 weeks of gestation with singleton pregnancy were assigned for the investigation. Two dimensional and four dimensional recordings were displayed on the screen and recorded on the videotape during the 15 minutes observation period. Results: General body, head and limb movements recorded by 2D sonography were notable by 4D technique in the same gestational age. These movements were presented collectively with maximum, minimum, and median frequencies during 15 minutes observation period. Spearman rank order correlation reached statistical significance (P<0.05) between the frequencies of all observed movement patterns assessed by two different techniques. Several movement patterns, such as sideway bending, hiccup, breathing movements, mouth opening and facial movements could be observed only by 2D sonographic technique in this period of gestation. Conclusion: Presently, both 2D and 4D methods are required for the assessment of early fetal motor development and motor behavior. It is reasonable to expect that such technological improvement may provide some new information about the intrauterine motor activity and facilitate the prenatal detection of some neurological disorders.

In order to investigate the neuropathological effects on the developing rat brain after intrauterine infection, identification of glail fibrillary acidic protein (GFAP), 2′, 3′-cyclic nucleotide phosphodiesterase (CNPase), and neurofilament (NF) was observed. Escherichia coli ( E. coli ) was inoculated into uterine horn of pregnant rats when gestation was 70% complete (15 days) and the control group was inoculated with normal saline. Immunohistochemistry was used for evaluation of GFAP, CNPase, and NF expression in pup brains at postnatal day 7 (P7) and reverse transcriptase-PCR (RT-PCR) to analyze macrophage inflammatory protein-1 α mRNA (MIP-1 α mRNA), macrophage inflammatory protein-1 β mRNA (MIP-1β mRNA), the regulated upon activation normal T expressed and secreted chemokine mRNA (RANTES mRNA) and Eotaxin mRNA expression in pup brains at P1, P3 and P7. The numbers of GFAP-positive cells of the E. coli -treated group pups were marked increased in periventricular white matter and hippocampus at P7 compared with the control group but no significant different levels of GFAP expression in corpus callosum were found between two groups. The integrate density (ID) of CNPase-positive staining of the Escherichia coli -treated group pups were marked decreased in periventricular white matter and corpus callosum at P7 compared with the control group. The ID of NF-positive staining of the Escherichia coli -treated group pups were marked decreased in periventricular white matter at P7 compared with the control group and no significant different levels of NF expression in corpus callosum were found between two groups. The expression of MIP-1 α mRNA and MIP-1 β mRNA in brain of the E. coli -treated pup rat were higher than the control at P1, but the expression of MIP-1 α mRNA and MIP-1 β mRNA in brain of the pup rat at P3 and P7 had no significant difference between two groups. The alteration of expression of GFAP, CNPase, and NF in the brain of neonatal rats after intrauterine infection suggested that intrauterine infection could cause neonatal white matter damage. Moreover, the transient increase in expression of chemokine such as MIP-1 α, MIP-1 β in neonatal brain after intrauterine infection indicated that MIP-1 α, MIP-1 β may be a mechanism mediating between the neonatal white matter damage and the intrauterine infection.

Aim: To evaluate the positive predictive value of the midsagittal view of the fetal brain in recognizing the cause of ventriculomegaly diagnosed with traditional axial scan. Methods: Fifty-eight pregnant women, referred to our Center following a generic diagnosis of ventriculomegaly have been evaluated: 38 had marked and 20 had borderline ventriculomegaly. The fetal brain was scanned by the midsagittal view using a transabdominal probe in fetuses in breech presentation or transverse lie and a transvaginal probe in fetuses in cephalic presentation. The possible cause of ventriculomegaly was postulated by combining the findings of the corpus callosum/cavum septi pellucidi complex with those of the posterior fossa. The prenatal diagnoses were compared with the anatomical specimens of aborted fetuses or with postnatal neuroimaging. Results: The prenatal diagnoses were confirmed in 54/58 cases (PPV 93.1%). In the marked ventriculomegaly group, one case of partial agenesis of the corpus callosum was mistaken for a complete agenesis. In the group of borderline ventriculomegaly, two cases of partial agenesis of the corpus callosum were confused with a complete agenesis, while one case of suspected isolated ventriculomegaly was diagnosed after birth as partial agenesis of the corpus callosum. Conclusions: The sagittal scan of the fetal brain is a useful source of information and allows the contemporary view of both corpus callosum and posterior fossa, where various typical sonographic findings are present in ventriculomegaly.

Objective: To confirm previous known relationships between Fetal Inflammatory Response Syndrome (FIRS) and neonatal bronchopulmonary dysplasia (BPD) and to present information on previously unknown special relationships between inflammatory variables and BPD. Study design: At delivery, we obtained biological specimens including umbilical cord venous blood for plasma interleukin-6 levels, as well as placental histology and bacteriology. Among other neonatal outcomes, we collected prospective information on BPD. Results: Of 141 newborns in the study, 16 had BPD; 79% of these had antecedent FIRS, 27% of those without FIRS had BPD. By multivariable regression, only very low birth weight (adjusted [adj] odds ratio [OR] 32.0, 95% Confidence Interval [CI] 5.0 to positive infinity) and FIRS (adj OR 5.7, 95% CI 1.1 to 42.3) remained significant risk factors. Escherichia coli , perhaps due to its pyogenic nature (strongly elicits inflammatory responses), may have had a special relationship with BPD. Conclusions: In our data, FIRS and neonatal BPD are highly associated. It is possible that certain pyogenic bacteria in the chorioamnion space may be implicated more often than others. Condensation: Neonates having Fetal Inflammatory Response Syndrome at delivery may later develop BPD. Pyogenic bacteria, such as Escherichia coli , may be implicated more frequently.

Background: Endotracheal (ET) suctioning causes cardiovascular side effects and may impair cerebral hemodynamics. Subjectively, these effects are worse if patients are disconnected from the ventilator (open system suctioning, OSS) than if they remain connected to the ventilator during suctioning (closed system suctioning, CSS). It is uncertain whether the response to ET suctioning is similar in conventionally (CV) and high frequency (HF) ventilated patients. Objectives: To investigate if the mode of suctioning or of mechanical ventilation influences cerebral blood flow velocities (CBFVs) in extremely low birth weight (ELBW) infants. Methods: Transcranial Doppler sonography in the middle cerebral artery during OSS and CSS in CV and HF ventilated ELBW infants. Results: Forty-one measurements were performed in 19 infants within the first two weeks of life. Mean CBFVs decreased during suctioning from baseline 18.8 to 14.3 cm/s (−24%), increased thereafter to 24.7 cm/s (73%) and then returned to baseline (20.8 cm/s). Changes in CBFV were less pronounced in infants with higher baseline CBFVs. Heart rate decreased during ET suctioning and thereafter returned to baseline values. The alterations in CBFV and heart rate were both independent of the mode of ventilation or suctioning. Conclusions: The mode of suctioning or ventilation does not influence CBFVs in ELBW infants.

Objectives: To document pain expression characteristics in former preterm infants in the first year of life in whom systematic evaluation and treatment of pain was provided. Methods: Data on the Modified Behavioral Pain Scale (MBPS), Visual Analogue Scale (VAS, crying time and heart rate were collected during immunization. The effect of clinical characteristics {postconception and gestational age [PCA], surgery, ventilation, fentanyl, length of stay (LOS)} on bio-behavioral parameters was evaluated. Results: 121 procedures were recorded in 49 infants. GA was 28 (25–32) weeks. PCA was 60 (34–90) weeks. Median MBPS was 8 (2–10), median crying time 44 (0–112) s. Median pre-procedural heart rate was 144 (103–201) and increased to 184 (147–220) afterwards, resulting in a relative increase of 29 (5–99)%. Median VAS score was 7 (1–10). Significant correlations of PCA with pre-procedural heart rate (r=−0.36) and with relative increase in heart rate (r=0.33) were identified. A correlation of LOS on crying time (r=0.37) was observed. Conclusions: Correlations of PCA with pre-procedural and relative increase in heart rate reflect the maturational decrease in heart rate. LOS had an effect on pain expression, potentially reflecting the impact of cumulative ‘minor’ procedural pain.

Objective: To assess the differences in clinical characteristics, management and outcome between the neonatal transfers and inborn neonates with pneumothorax. Methods: The records of 36 neonatal transfers (Group A) and 25 inborn (Group B) neonates with symptomatic pneumothorax were retrospectively analyzed. Results: In Group A, gestational age (36±2 vs. 31±4 weeks; P<0.01), birth weight (2720±537 vs. 1736±1028 g; P<0.01), exclusive oxygen-therapy before the event (47% vs. 20%; P<0.05) and tube thoracostomy (78% vs. 44%; P<0.05) were significantly higher than in Group B. The need of resuscitation at birth (19% vs. 44%; P<0.05), conventional mechanical ventilation (20% vs. 56%; P<0.05), presence of associated major congenital malformations (0% vs. 20%; P<0.01), length of hospital stay (9±6 vs. 32±32 days; P=0.01) and mortality (0% vs. 16%; P=0.01) were significantly lower in Group A than in Group B. Conclusions: Neonatal transfers and inborn neonates with pneumothorax have different clinical characteristics and outcome. This information could be useful for all persons involved in the interhospital care of perinatal patients.

Aims: Critical congenital cardiovascular malformations (CCVMs) require surgical correction during the first month of life, physical examination is unable to detect >50% of affected infants. An oximetry screening has been previously proposed. Our aim was to verify the usefulness and consistency of a pulse oximetry screening for early detection of CCVMs in a small size nursery. Methods: A single determination of SpO 2 was performed on 5292 consecutive apparently healthy newborns, discharged from nursery at a median age of 72 h during the period May 1, 2000 and November 30, 2004. Infants showing signs of congenital heart disease before the screening and those with a prenatal diagnosis were excluded. Cardiac ultrasound was performed on all infants with SpO 2 ≤95% at >24 h. The accuracy of the screening in identifying CCVMs was assessed by receiver-operating characteristic (ROC) curves analysis. Results: We found 2 (0.038%) true positives, 1 (0.019%) false negative, 1 (0.019%) false positive, and 5288 (99.92%) true negatives. Prevalence of critical CCVMs was 1 in 1764. Clinical follow-up showed no evidence of CCVMs in the negative cases. A pulse-oximetry cut-off value of ≤95% showed 66.7% sensitivity (95% CI: 11.6–94.5), 100% specificity (95% CI: 99.9–100.0), 50% positive predictive value, 100% negative predictive value and AUC of 0.833 (standard error: 0.145) (95% CI: 0.823 to 0.843) in identifying CCVMs. Conclusions: Our findings indicate that pulse oximetry is a non-invasive and specific screening tool for an early detection of CCVMs, and is easily applicable to a small size nursery.

We report a case of prelabor rupture of membranes at 20 weeks' gestation where a hydrogel sealant was applied to the cervical canal in order to maintain an adequate liquor volume in the second trimester. The use of this agent for the purpose of creating a cervical plug has not been reported to date.

Aims: Assuming the importance of estrogen in perinatal physiology, we tested the association of an estrogen receptor-alpha (ER-alpha) gene Pvull pP polymorphism with perinatal morbidity in premature infants. Methods: The ER-alpha Pp genotype was determined in 69 low-birth weight (LBW) boys and 72 LBW girls, 86 term boys and 81 term girls. The association between risk factors, genotype, gender and perinatal morbidity was tested with binary logistic regression analysis. Results : Boys carrying “p” allele were at lower risk for necrotizing enterocolitis (OR [95% Cl]: 0.24 [0.07–0.83]) and patent ductus arteriosus (OR [95% Cl]: 0.24 [0.05–0.97]). The carrier state of the “p” allele was associated with a 34-h shorter period of oxygen supplementation on average (P=0.0018). Boys with pp genotype were at greater risk for intraventricular hemorrhage (OR [95% Cl]: 4.39 [1.15–16.82]). No association between ER-alpha Pvull polymorphism and morbidity was present in girls. Conclusions: Since homozygocity for any Pvull alleles (i.e. having PP or pp genotype) increases the risk for at least one of the most common perinatal complications, it is likely that the heterozygous carrier state of Pvull genotypes has a protective effect, which is gender-dependent.