Volume 35, Issue 2

Spontaneous preterm labor leading to preterm birth is a major cause of perinatal mortality and morbidity worldwide. The etiology of spontaneous preterm labor is multifactoral but there is overwhelming evidence to implicate infection in up to 40% of cases. Historically, this infective link has focused on the associations between abnormal genital tract flora in pregnancy (diagnosed by the presence of bacterial vaginosis) and preterm birth. Recently, another condition related to abnormal flora (periodontal disease) has been linked with preterm birth. There are microbiological similarities between the oral cavity and the female genital tract giving rise to a possible common pathophysiology. This review records the interrelationship between periodontal disease, bacterial vaginosis, and preterm birth. We postulate on the mechanism linking the three conditions, particularly through microbiology and gene-environmental interactions. Periodontal disease and bacterial vaginosis may be risk factors in their own rights or may be interrelated. We speculate on whether periodontitisis a marker for an immune hyperresponse to abnormal flora which in the oral cavity results in periodontitis and in the case of bacterial vaginosis might result in preterm birth. We also postulate on the riskof preterm birth by periodontitis alone, bacterial vaginosis alone, or both.

Objective: Some authors suggest a glucose challenge test (GCT) threshold of 150 mg/dL in Asian gravidas. The impact of such a policy on outcomes is unknown. Study Design: A retrospective cohort of 1705 Asian gravidas. Subjects (n=95) had a GCT of 140–150 mg/dL and underwent a 3-h glucose tolerance test (GTT). Matched controls (n=190) had a GCT of <140 mg/dL. Birthweight was the primary outcome and the secondary outcomes were cesarean delivery (CD) rate and macrosomia. Results: Eight subjects (11.9%) had gestational diabetes mellitus (GDM); none had GTT fasting values of >90 mg/dL. Mean birthweight was 3282 g in the subjects and 3238 g in the controls (P=0.39). There were no significant differences in the secondary outcomes. Conclusion: Compared with controls, study patients did not deliver significantly larger infants. However, raising the GCT threshold would have missed 8 subjects (11.9%) with GDM. Raising the GCT threshold to 150 mg/dL in Asian gravidas may unacceptably lower the sensitivity of the screening test.

Objective: To estimate the maternal puerperal morbidity in elective and emergent cesareans in twins. Study design: We evaluated postpartum complications among patients who underwent elective cesarean birth for twin pregnancy. This group was compared to matched singletons and to emergent cesareans in twins. Results: During the period September 1994–March 2006 there were 299 (47.4%) elective and 80 (12.7%) emergent cesarean sections in twin pregnancies, for a total of 379 (60.1%) cesarean births for both twins. Controls included 299 cases of elective cesareans in singletons. The comparison between elective and emergent cesareans and between elective cesareans in twins and in singletons found no significant differences in postpartum fever, scar infection, and postpartum hemorrhage. Venous thromboembolism occurred in two twin pregnancies, one in the elective and one in the emergent cesarean group. Postpartum hysterectomy was required in a singleton pregnancy following an elective cesarean birth. Conclusion: At present, no data exist to show a disadvantage for a planned cesarean birth for twins.

Objectives: There is no mandatory folic acid fortification of food in Finland. We investigated the effects of mineral water fortified with folic acid, vitamins B6, B12, D and calcium on serum and erythrocyte folate concentrations, serum vitamin B12 and plasma homocysteine concentrations in pregnancy. Design: A randomized, controlled, double-blind, parallel-group intervention study. Methods: Seventy-four pregnant women were recruited from two health care units. The study began at the eleventh week with a two-week run-in period, followed by an eight-week intervention period. The diet was monitored by food records. During the intervention, subjects consumed 1000 mL/day fortified or normal mineral water. The pregnancies were monitored carefully. Results: The folate intake was 255 μg/day in the study group and 274 μg/day in the controls. Serum folate concentrations increased in the study group by 10.3 nmol/L and decreased in the controls by 2.7 nmol/L (P<0.05) during the study. The erythrocyte folate concentrations increased in the study group by 360.9 nmol/L and in the controls by 195.6 nmol/L (P=0.004) and serum homocysteine concentrations fell by 1.1 μmol/L and by 0.3 μmol/L, respectively (P<0.05). Conclusions: Finnish pregnant women have low dietary folate intake. Fortified mineral water improved folate status and reduced plasma homocysteine concentrations in the pregnant subjects.

Objective: To study the transfer of parenteral iron sucrose into maternal milk in the postpartum period. Study design: Ten healthy lactating mothers with functional iron deficiency 2–3 days after delivery received 100 mg intravenous iron sucrose and were observed together with a control group (n=5) without iron treatment during four days. Milk samples were taken before the treatment and every day afterwards. Results: Mean milk iron levels at baseline were 0.43 and 0.46 mg/kg in the treatment and control group and decreased until the end of observation in both groups by 0.11 mg/kg. No significant difference between the groups was found on any study day as well as in the mean change from baseline over all four days. Conclusion: We could not show transfer of iron-sucorose into maternal milk for the given dosage. Since parenteral iron sucrose is widely used in obstetrics, the results provide information about safety of parenteral iron sucrose in the lactation period. The findings are also in agreement with other reports on active biological mammary gland regulation of milk iron concentration.

A study of 82 normal and 60 compromised pregnant women who were identified by uterine artery Doppler flow waveform systolic/diastolic ratio >95th percentile (increased peripheral resistance) was carried out to examine the elastic properties of the maternal abdominal aorta (AA). An aortic stiffness index (SI) was measured between 18 and 40 weeks at four-weekly intervals with a phase-locked loop ultrasound technique to estimate the aortic systolic and diastolic diameters and their correlation with blood pressure. In the normal group, the aortic systolic and diastolic diameters, as well as the SI, increased with the maternal age. In the compromised group, aortic diameter and blood pressure were normal, but the SI during the early second trimester was increased. Twenty-two women from the compromised group with an SI above the 95th percentile for their age had a significantly higher prevalence of preeclampsia in comparison with women with a normal SI (P<0.001). The aortic SI was significantly higher in severe than in mild preeclampsia. This study demonstrates that stiffness of the AA is increased in pregnant women with preeclampsia and that a progressive increase of the SI in serial studies is associated with severity of the disease. Aberrant hemodynamic adaptation in preeclampsia seems to include increased stiffness of the larger artery besides high resistance in small peripheral arteries.

Aim: To evaluate the efficacy and safety of oral misoprostol for labor induction in women with term premature rupture of membranes (PROM) and an unfavorable cervix. Methods: We randomized 130 women with PROM of ≤4 h to either oral misoprostol, 50 μg, or a placebo given every 4 h for up to three doses. Intravenous oxytocin was initiated if active labor did not begin within 12 h. Results: Sixty-four women received oral misoprostol and 66 received placebo. The PROM-to-delivery interval was shorter with misoprostol than with placebo (13.7±5.8 vs. 20.3±6.8 h, respectively, P<0.05). Misoprostol significantly reduced the need for oxytocin (28.1 vs. 72.7%, P<0.001) and antibiotics (25 vs. 69.7%, P<0.001). No significant differences in cesarean section or hyperstimulation rate were noted. Conclusion: Oral misoprostol given to women with unfavorable cervix soon after term PROM significantly reduces the induction-to-delivery time and the need for oxytocin and antibiotics.

Objective: To establish reference values for the sonographic cross-sectional area of the umbilical cord during gestation and to correlate them with fetal anthropometric parameters. Methods: A cross-sectional study was performed involving 312 normal pregnant women at gestational ages 24–39 weeks. Measurement of the cross-sectional area of umbilical cord was performed on a plane adjacent to the insertion of the cord into fetal abdomen. The following anthropometric parameters were calculated: biparietal diameter, head circumference, abdominal circumference and femur length. A polynomial regression analysis identified the curves that were better adjusted to the average and standard deviation according to gestational age. Spearman correlation was used to evaluate the correlation of the cross-sectional area of umbilical cord with fetal anthropometric parameters. Results: A statistically significant correlation was observed between the cord cross-sectional area and gestational age (r=0.376, P<0.001, CI 95%[0.276; 0.467]). Conclusions: The reference values of the cross-sectional area of umbilical cord increased according to gestational age until the 33 rd  week and are related to parameters of fetal growth.

Aims: To evaluate the effect of antenatal betamethasone and ritodrine in third trimester low risk singleton pregnancies by Doppler technology. Subjects and methods: Eighty-four third trimester pregnant women who received a full course of betamethasone and delivering uneventfully were recruited. The Doppler examination included the assessment of the pulsatility index (PI) of the umbilical artery (UA PI) and the middle cerebral artery (MCA PI) prior to treatment (baseline), and 48, 72 and 96 h after the second dose of betamethasone. Results: No significant difference was found in UA PI and UA/MCA values following betamethasone therapy. In contrast, MCA PI decreased significantly 48 h from the last injection of betamethasone in the whole study group (P<0.001), and returned to basal values at 96 h. We also found that MCA PI was reduced significantly at 48 h in the subgroup under tocolysis (n=41) and in the subgroup not receiving tocolysis (n=43). We compared MCA PI values for both subgroups in the four timings, and found a non-significant difference comparing baseline and 96 h values. However, when comparing MCA PI values after 48 and 72 h, significantly lower differences in PI values in both subgroups were found. Conclusion: In low risk pregnancies, betamethasone therapy in the third trimester is related to a significant but transient reduction of MCA PI, which is more pronounced during tocolytic therapy. Although the physiological basis of this effect is currently unclear, it could be related to the local regulation of intracerebral blood flow.

Introduction: Bilirubin can enter the alveolar space where it could inactivate surfactant and act as an anti-oxidant agent. Objective: To assess the hypothesis that total serum bilirubin level (TSB) may affect the severity of respiratory distress syndrome (RDS) and the need of respiratory supports in preterm infants. Study design: We performed a retrospective study of 184 preterm infants with RDS, whose peak TSB had a median value of 194.8 μmol/L (=11.3 mg/dL). This value was used to stratify patients into two groups: neonates who developed low and high TSB (≤ or >194.8μmol/L, respectively). For each patient the highest values of inspired oxygen fraction (FiO 2 ), arterial to alveolar oxygen tension ratio (a/APO 2 ), oxygenation index (O.I.), ventilatory index (V.I.), and the need and duration of respiratory supports were recorded. Results: Seventy-five infants were included in the low TSB group and 74 were included in the high TSB group. The RDS severity and the need of respiratory supports were similar in both the groups. The first day of life TSB and peak TSB did not correlate with the highest values of FiO 2 and a/APO 2 , and the duration of mechanical ventilation. Conclusions: We did not find any correlation between TSB level and RDS severity. We speculate that this result is because the potential inhibiting effect of bilirubin on surfactant function is neutralized by the exogenous surfactant treatment, while its antioxidant effects do not provide appreciable benefits in the lung tissue.

Aims : The objective of the study was to examine the effect of ranitidine on the incidence of late onset sepsis. Methods : This study was based on information extracted from charts of 569 infants admitted to the neonatal intensive care unit (NICU) from July 2003 to July 2005. All infants admitted for seven or more days were included. Late-onset neonatal sepsis was defined as a positive blood culture with clinical signs of sepsis after seven days of life. Outcome measures included the use of ranitidine, type of infection and infectious agent, birth weight gestational age, and type of care in the NICU. Results : Of the 569 infants admitted, 53 (9.3%) were treated with ranitidine. Of 74 infants who developed late-onset sepsis, 23 infants received ranitidine and 51 did not. Infants receiving ranitidine were at 7-times greater risk of late-onset sepsis (OR 6.99; 95% CI: 3.78–12.94; P<0.0001). The birth weights and gestational ages of infants with sepsis receiving ranitidine and those not receiving ranitidine were comparable, P=0.59. Conclusion : The use of ranitidine in infants admitted to the NICU elevates the risk of late-onset sepsis. The pathological mechanisms need to be further studied. The safety of widespread use of ranitidine in neonates is controversial.

Outcome of all live births at 21–28 weeks' gestation (GA) and/or <1250 g birth weight (BW) over an eight-year period were reviewed and compared with other outcome data. Causes of mortality were ascertained for all deaths. Significant morbidities were reviewed among <25 weeks GA and/or <800 g survivors over a two-year period. NICU admissions log book, monthly morbidity-mortality reports, medical records and autopsy findings were used to obtain outcome data. A total of 23,046 infants were born alive during the study period, including 339 (1.47%) at 21–28 weeks or <1250 g. Eighty of the 339 (23.6%) died. Of these 80 deaths 32.5% were extremely immature, 15% died from RDS, 15% from infection, 10% from pulmonary hemorrhage and 8% had lethal malformations. Survival outcome in each weight group except <500 g were similar to that reported by the Pediatrix Medical Group (2003–04) and 2002 US National Vital Statistics. Of the extremely low gestational age infants, 79% survived to discharge, and among these, the incidence of serious neuro-morbidity, severe chronic lung disease or retinopathy of prematurity requiring treatment was 52%; 18.5% had more than one major morbidity.

Aims: To investigate the prevalence of H. pylori antigen in the stools of Norwegian neonates and small children. Methods: A total of 249 children aged 0 days–3 years were tested for the presence of H. pylori antigen in feces using the HpSA immunoassay. For verification purposes, a selection of samples were analyzed with PCR targeting the 16 S rDNA Helicobacter gene. Results: H. pylori antigen in stool was detected in 52% (36/69) of the neonates, in 15% (7/46) of infants aged 7 days–1 month, and in 5% (7/134) of children aged 1 month–3 years. In neonates, H. pylori antigen detection was significantly associated with mode of delivery: 59% (30/51) with uncomplicated vaginal births were HpSA positive compared to only 10% (1/10) of infants delivered by cesarean section (P=0.02). Positive PCR results were found in 35% (9/26) of HpSA positive samples. Sequencing of PCR products revealed 97–100% homology with gene sequences from both H. pylori and other Helicobacter species. Conclusions: The low H. pylori antigen detection rate in children >1 month of age is in accordance with previous prevalence studies from Western countries. The unexpected finding of a high H. pylori antigen detection rate in neonates suggests that transient colonization may occur in the neonatal period.

Objective: Obstetric complications may be an important factor in the development of schizophrenia. The aim of this study is to evaluate the role of these complications in the development of schizophrenia in adult life, with particular attention to the potential role of birth weight. Method: We carried out a case-control study, comprising schizophrenics and patients with diseases of the schizophrenia spectrum as cases, and their healthy male brothers as controls. Obstetric complications were assessed using the “Midwife Protocol” of Parnas et al. Results: The main result was that birth weight may be a risk factor for schizophrenia, as indicated by odds ratio analysis. The confidence intervals are very wide and, without compromising the clinical significance of the results, they give a limited indication of the real entity of the risk. Conclusions: The results contribute to understanding of the role played by a single complications.