Band 34, Heft 5

Non-selective multifetal pregnancy reduction is carried out to reduce healthy higher order multiple fetuses to one or two fetuses. No studies exist to show any benefit of this practice and a Cochrane review, as well as investigators in the field, have not found any justification for such practice. From a medical point of view, this non evidence-based practice is not following good clinical practice. Any practice that transfers more than one or two embryos, for instance due to commercial interests, should be abandoned by the international medical community because multifetal pregnancies can, to a large extent, be avoided by transferring only one or a maximum of two fertilized eggs by in vitro fertilization. Further, ovarian stimulating programs should strictly adhere to protocols aiming at mono-ovulation.

Preterm birth is defined as delivery at <37 completed weeks of pregnancy (World Health Organization). Spontaneous preterm birth (SPB) includes preterm labor, preterm spontaneous rupture of membranes, preterm premature rupture of membranes (PPROM) and cervical weakness; it does not include indicated preterm delivery for maternal or fetal conditions. Early SPB (<32 weeks' gestation) is associated with an increased higher perinatal mortality rate, inversely proportional to gestational age. The pathophysiologic events that trigger SPB are largely unknown but include decidual hemorrhage (abruption), mechanical factors (uterine overdistention or cervical incompetence), and hormonal changes (perhaps mediated by fetal or maternal stress). In addition, several cervicovaginal infections have been associated with preterm labor. SPB is also the leading cause of long-term morbidity, including neurodevelopmental handicap, cerebral palsy, seizure disorders, blindness, deafness and non-neurological disorders, such as bronchopulmonary dysplasia and retinopathy of prematurity. Delaying delivery may reduce the rate of long-term morbidity by facilitating the maturation of developing organs and systems. The benefits of administration of antepartum glucocorticosteroids to reduce the incidence and severity of respiratory distress syndrome may be exploited by delay. Delay may also permit transfer of the fetus in utero to a center with neonatal intensive care unit facilities. There is considerable variation in the way that spontaneous preterm labor (SPTL) is diagnosed, managed and treated internationally. The development of clinical guidelines requires an evidence-based approach to improve outcome and allow more efficient use of resources. With recent advances in our understanding of the etiology and mechanisms of SPTL and the availability of safer, more specific tocolytics, it was felt that guidelines should be developed to achieve, if possible, an European consensus in patient diagnosis, management and treatment.

Aims: Previous studies suggested that head circumference (HC) predicts the date of confinement better than the biparietal diameter (BPD). The present study aimed to prospectively test this assumption. Methods: A prospective study including 4179 consecutive women attending the second trimester routine ultrasound examination at 17–20 weeks of gestation. Outer-outer BPD and HC were determined as the average of three repeated measurements. Twins were excluded. Time of delivery was noted, the differences between this and the predicted date of delivery calculated with HC and BPD (based on a pregnancy duration of 282 days), and the two methods were compared using Wilcoxon signed rank test. Results: For the entire group, the median differences between actual and predicted delivery with HC and BPD were 0.9 and 1.2 days, respectively. For deliveries with a spontaneous onset of labor (n=3336) the corresponding differences were 0.9 and 1.4 days. The difference between the HC and BPD methods was significant (P<0.0001). In the group of spontaneous onset of labor, there were 05.6% post-term pregnancies (≥296 days) according to HC and 5.7% according to BPD. Conclusion: Provided that the expected pregnancy duration was 282 days, both HC and BPD predicted spontaneous birth with a mean accuracy of one day, HC being significantly better than BPD.

Objective: The aim of this study was to investigate the relationship between the concentration of selected proinflammatory cytokines (IL-1α, IL-1β, IL-6 and IL-8) in cervicovaginal fluid, as measured in midgestation, and the risk of early-onset neonatal infection (EONI) . Method: Cervicovaginal fluids were obtained from a cohort of 114 pregnant women at 22 to 34 weeks' gestation. The samples were analyzed for the concentrations of selected proinflammatory cytokines using standard enzyme-linked immunosorbent assay technique (ELISA). Lower genital tract microbiology was diagnosed using Gram stain method according to Spiegel's criteria and by culture. Results: Mean gestational age at the time of sampling was 29.0 weeks. Mean time between sampling and delivery was 9.3 (SD 4.7) weeks. Bacterial vaginosis (BV) was diagnosed in 27.2% of subjects and M. hominis and U. urealyticum in 22.8% and 26.3%, respectively. Out of 114 women examined, 20 (17.5%) delivered newborns with EONI. Median cervicovaginal concentrations of IL-1α, IL-1β, IL-6 and IL-8 did not differ between women who delivered newborns with EONI as compared to women who delivered newborns without EONI. Women with pathological lower genital tract microflora and low IL-8 concentration (below 25 th percentile) during pregnancy presented a significant risk of delivering newborns with EONI (OR=4.9; 95% CI, 1.1–22.8). Subjects with pathological lower genital tract microflora and a low concentration of more than one cytokine had the highest risk of delivering a newborn with EONI, OR=16.2, 95% CI, 1.1–234.0. Conclusions: Cytokine measurement in cervicovaginal fluid in early gestation could be useful for predicting subsequent EONI only among pregnant women with lower genital tract infection. Maternal genital tract immune hyporesponsiveness as represented by low concentrations of proinflammatory cytokines may create a permissive environment for ascending infection and may lead to subsequent EONI.

In an effort to better define preeclamptic women at risk of eclampsia, we examined the predictive value of maternal demographic characteristics and admission maternal laboratory values for the risk of subsequent development of eclampsia in preeclamptic women, who were not receiving magnesium sulfate during hospitalization. The decision to use magnesium sulfate prophylaxis was at the discretion of the treating physician. Preeclamptic women admitted throughout a 3-year period and treated with a protocol exempting magnesium sulfate therapy were retrospectively included (n=497). Maternal data at admission were recorded and analyzed. Eight women developed an eclamptic seizure during subsequent hospital follow-up. Logistic regression models were used to assess the independent predictive role of each variable on the development of eclampsia. Lower serum fibrinogen values, increased leukocyte counts, and increased diastolic blood pressure at admission were independent predictors of a subsequent in-hospital eclamptic seizure. An initial diastolic blood pressure ≥120 mm Hg, blood leukocyte count >16,000/μL, and serum fibrinogen value <450 mg/dL were associated with a 25.4-, 7.1-, and 26.6-fold increased risk of eclampsia, respectively. We conclude that marked leukocytosis and diastolic blood pressure increment might precede the development of eclampsia. Serum fibrinogen concentrations >450 mg/dL seem to be protective for eclampsia. The association between inflammation and eclampsia merits further investigation.

Aim: To compare the efficacy of the ursodeoxycholic acid (UDCA) and S-adenosyl-L-methionine (SAMe) monotherapy with their combined effect on intrahepatic cholestasis of pregnancy (ICP). Patients and methods: We studied singleton pregnancies at <36 weeks with a moderate or severe form of ICP between January 1999 and March 2004. Patients were randomized to either oral UDCA 3×250 mg daily or 500 mg SAMe twice daily in slow running infusion for twelve days followed by oral administration of 500 mg twice daily until delivery. Intensive hematological, biochemical and fetal monitoring were carried out. Results: Of the 78 women enrolled, 25 received SAMe monotherapy, 26 received UDCA, and 27 received combined therapy. Groups were initially comparable in terms of gestational age, duration of therapy, parity and biochemical characteristics. All therapies improved the pruritus. The combined therapy and the monotherapy with UDCA (later) led to improving of the serum concentrations of bile acids and transaminases compared with SAMe monotherapy (P<0.01). Combined therapy led to a faster decrease of serum concentrations of bile acids and transaminases compared with UDCA monotherapy (borderline significance). Gestational ages were similar in all groups. No adverse effects were noted on the fetuses or neonates with either therapy. Conclusions: UDCA is an effective drug in the treatment of ICP, and combined with SAMe, has probably a synergistic effect on biochemical parameters. This mode of treatment seems more effective but the effect of the successful treatment on the fetus is unclear. Therefore, the ante- and intrapartum monitoring of the fetus should be part of the management of severe forms of ICP. The project is supported by IGA MZ CR (No. NH/7376-3)

Aims: To examine whether coagulation-fibrinolysis in late pregnancy in women with twin pregnancies is more pronounced than in women with singleton pregnancies. Patients and methods: The plasma levels of D-dimer, fibrinogen/fibrin degradation products (FDP), and fibrinogen, the platelet count, and the antithrombin activity were assessed from 3 weeks before delivery until postpartum day 7 in 48 women (24 singleton and 24 twin pregnancies) without preeclampsia who underwent cesarean sections. Results: Women with singleton or twin pregnancies gave birth at 37.3±1.2 weeks or 35.2±1.4 weeks, respectively. Compared with singleton mothers, prenatal D-dimer and FDP levels were consistently and significantly higher among women with twin pregnancies. A significantly larger proportion of twin mothers exhibited prenatal levels of D-dimer >5.0 μg/mL, FDP >10.0 μg/mL, fibrinogen <420 mg/mL and antithrombin activity <70%. In addition, prenatal antithrombin activity in plasma was significantly lower. Conclusions: Coagulation-fibrinolysis is more enhanced in women with twin gestation than in women with singleton gestation.

Aims: This study examined whether analysis of fetal behavioral states by monitoring fetal heart rate and movement using an actocardiogram (ACG), could provide prognostic information related to fetal central nervous system (CNS) lesions. Methods : The ACG simultaneously records fetal heart rate (FHR) and fetal movement bursts composed of spikes of ultrasonic Doppler signals. Durations of FHR accelerations and fetal movement bursts were measured manually. Five actocardiographic indices were studied in 12 fetuses with CNS lesions and in 14 normal pregnancies of 28–38 weeks. Results: Severity of the fetal CNS lesions was estimated from the acceleration/burst (A/B) duration ratio, which correlated with the rank of the sonographic fetal functional test in cases with CNS lesions. Severity of a fetal lesion may also be estimated by the regression equation of the A/B duration ratio and behavioral ranking. Conclusion: The severity of fetal CNS lesions may be estimated by quantitative analysis of ACG usings the measurement of A/B duration ratio to provide a prognosis. An ACG may demonstrate a loss of CNS control in cases with severe brain damage.

Objective : To examine if the recommended weight gain of >680 g/week during the first 24 weeks of pregnancy decreases the frequency of adverse birth weight outcomes in triplet mothers with a normal pregravid BMI. Study design : Retrospective observational study of a large sample of triplet mothers with a normal (19.8–26) pregravid BMI. Adequate, average, and inadequate weight gains were defined as >680, 500–680, and <500 g/week. Outcome measures were the incidence of ≥1 SGA infant and total triplet birth weight <4500 g. Results : Of the 1166 triplet mothers, 208 (17.8%) gained >680 g/week during their pregnancy. This presumed adequate weight gain did not reduce the incidence of SGA triplets or that of total birth weight <4500 g, irrespective of parity. These adverse birth weight outcomes were 2 to 3.5 times lower among multiparous compared to nulliparous mothers. Conclusion : Early weight gain of >680 g/week in triplet mothers with a normal pre-pregnancy BMI is not associated with a decrease in the incidence of adverse outcomes. Weight gain recommendations in triplet pregnancies should be realistic and associated with a low risk-benefit ratio.

Objectives: To analyse the inter-observer and inter-artery reliability of the umbilical artery (UA) pulsatility index (PI) at different sampling sites. Methods: One hundred consecutive singleton pregnancies between 24 and 40 weeks were included. The PI was calculated by two independent operators from both umbilical arteries at the placental end, at a free-floating loop and at the perivesical segment. Reliability analyses were performed between observers and between arteries at each sampling site. Results: The mean percentage of PI difference between arteries was 15.2, 14.5 and 22% at the placental end, free-loop and perivesical site, respectively. The Intraclass correlation coefficients at each site were 0.51, 0.59 and 0.67, respectively. Whereas about 20% of cases showed a percentage of PI difference between arteries greater than 20% at free-loop and placental end sites, and at the perivesical site this figure was 45%. Conclusions: The perivesical sampling site for UA PI calculation is more reliable than at a free-floating loop, albeit without significance, and is significantly more reliable than at the placental end of the umbilical cord. Since discordances in PI between both arteries are more pronounced at the perivesical site, it seems mandatory to evaluate both arteries in this segment.

Our purpose was to evaluate the hemodynamic significance of fetal inferior vena cava (IVC) flow velocity waveform indices during fetal development in relation to the diameter pulse waveform. Doppler ultrasound and a phase locked loop echo tracking system were used to measure flow velocity waveform and diameter pulse waveform, respectively. Twenty-seven normal singleton pregnancies were examined from 20 weeks until term at 4-week intervals. The diameter pulse waveform consisted of four waves (A, X, V, and Y waves). The A value (end-diastolic diameter) was associated with the end-diastolic pressure, which causes reverse flow during right atrial contraction. In normal fetuses, a weight-related lower end-diastolic diameter suggested that the end-diastolic pressure was decreased. Except for a positive correlation between the percent reverse flow during atrial contraction and the A value per unit fetal weight, no correlations were found between diameter waveform indices and blood flow velocity waveform indices. The peak velocity index of the velocity waveform significantly correlated with the umbilical artery flow velocity waveform systolic/diastolic ratio. The fetal IVC velocity waveform indices did not yield unequivocal information as to changes in central venous pressure, for which purpose the diameter pulse waveform analysis would seem to be the only available method.

Background: Prevention of early-onset Group B Streptococcal (GBS) infection has been attempted by employing universal maternal screening for GBS, intrapartum chemoprophylaxis, and a single dose of penicillin given to neonates in the first hour of life. This strategy, however, does not seem to prevent the occurrence of late-onset neonatal group B streptococcal disease. Study design: We assessed early and late-onset GBS disease with the use of a before–after study designed to evaluate the implementation of intrapartum antimicrobial prophylaxis. Moreover, universal neonatal screening for colonization of GBS was carried out with swabs of the external ear canal. Newborns with GBS colonization received a preventive treatment with oral amoxicillin for 10 days. Results: Early-onset GBS infection decreased from 0.5‰ at baseline period to 0.19‰ at the study period. The incidence of late-onset GBS disease decreased from 1:1348 (0.74‰) to 1:20,710 (0.048‰). The overall cost for universal neonatal screening paid for by the Italian Health System in the study period was US$ 31,065 with an antibiotic prophylaxis cost of US$ 2,399. Conclusions: A combined strategy based on GBS culture screening and assessment of risk factors for perinatal GBS disease can significantly reduce the rate of both early and late-onset GBS infections.

Objective: Posterior urethral valves (PUV) are a common cause of lower urinary tract obstruction. Renal failure occurs in approximately one third of the cases. It is debated whether urinoma formation is a protective mechanism to reduce pressure-related impairment of renal function. The aim of our study was to determine if urinoma formation is able to preserve renal function on the side of the urinoma. Methods: Five male patients diagnosed with posterior urethral valves and uni- or bilateral urinoma formation were reviewed. Renal function was assessed by serum creatinine level at days 4–7 and at two months, in addition to dimercaptosuccinylacid (DMSA) scintigraphy at 4–6 weeks postnatal age. Results: Impaired renal function occurred unilaterally in four patients, two had bilateral urinoma formation, and the other two boys presented with unilateral urinoma, one with preserved renal function ipsilateral to the urinoma and the other on the contralateral side. Urinary ascites was detected in three patients, all underwent antenatal centesis. Conclusions: No association was found between renal function and urinoma formation in patients with PUV.