Volume 36, Issue 2

This review addresses the effect of prenatal long-chain polyunsaturated fatty acid (LCPUFA) status on neurodevelopmental outcome. It focuses on the major LPCUFA doxosahexaenoic acid (DHA; 22:6ω3) and arachidonic acid (AA; 20:4ω6). Due to enzymatic competition high DHA intake results in lower tissue levels of AA. LCPUFA accumulation in the brain starts early and increases during the third trimester. Initially brain AA-accretion exceeds DHA-accretion; after term age DHA-accretion surpasses AA-accretion. Animal studies indicated that early ω3-depletion results in poorer developmental outcome. They also showed that early ω3-supplementation had no effect on cognitive outcome, promotes visual development and impairs auditory and motor development. Only limited human data are available. Correlational studies suggest that neonatal AA status shows a positive relation with early neurodevelopmental outcome and that neonatal DHA status also might be correlated with improved outcome beyond infancy. Results of human intervention studies are equivocal: most studies were unable to demonstrate a positive effect of prenatal ω3-supplementation. It is concluded that only limited evidence exists to support the notion that prenatal ω3-supplementation favours developmental outcome. Caution is warranted for an unbalanced high DHA intake during the first two trimesters of pregnancy, i.e., DHA without additional AA supplementation.

Background: Raw cesarean section rates are often compared among institutions with different patient populations. The purpose of this study was to develop an easily reproducible mathematical model that allows comparisons of cesarean delivery rates across different patient populations and institutions. Study design: We first calculated three institution's cesarean delivery rates for each of ten groups of patients based on age and parity. The population based adjusted total cesarean delivery rate was then calculated for each institution based on the distribution of patients in the 2004 national birth data (n=4,097,029) but using the three institutions' individual cesarean delivery rates. Results: The adjusted for age and parity cesarean delivery rate was significantly lower from raw cesarean delivery rates in two of the three institutions (A: 28.2% adjusted vs. 36.5% raw; P=0; B: 28.2% adjusted vs. 30.4% raw, P=0.0411; C: 28.7% adjusted vs. 29.7% raw, NS) reflecting the older and more nulliparous patients in these two institutions. Conclusions: Our study confirms that raw cesarean delivery rate should not be used to compare quality of care within and among different institutions unless they are adjusted for different patient characteristics. We believe that using unadjusted cesarean delivery rates without appropriate adjustments in quality assurance and when comparing data with other institutions and the national rate is erroneous and misleading.

Aim: To determine whether high maternal hemoglobin (Hb) at first antenatal visit is associated with adverse pregnancy outcomes. Methods: A retrospective cohort study was conducted in 920 singleton pregnancies who started their antenatal booking in the first trimester (≤14 weeks' gestation). Women with first-visit high Hb levels (>125 g/L) were matched 1:1 with those who had normal Hb values (110–124 g/L) according to age group and parity. Adverse pregnancy outcomes including preeclampsia, gestational diabetes mellitus (GDM), preterm delivery, low birth weight (LBW), and small for gestational age (SGA) infants between both groups were compared. Results: Complete obstetric records of 426 and 448 women who had high and normal Hb levels, respectively, were studied. By uni- and multivariable analyses, women with high Hb levels had significantly higher rates of preeclampsia and GDM than those with normal Hb levels; their adjusted relative risks were 3.8 (95% confidence interval [CI]; 2.0, 7.1) and 3.3 (95% CI; 1.8, 6.0), respectively. Rates of preterm delivery, low birth weight, and small for gestational age infants between the two groups were not significantly different. Conclusion: Our findings suggest that high Hb in the first trimester is associated with subsequent preeclampsia and GDM.

Regional anesthesia for pain at delivery in the presence of maternal thrombocytopenia is a clinical dilemma. We reviewed 10,369 obstetric cases (12 months) from our tertiery center. Generally, hemodilution of pregnancy does not result in thrombocyte counts of <150,000/mm 3 at delivery. A total of 166 births (1.6%) were recorded in women with thrombocytes <150,000/mm 3 at delivery. Parturients with >150,000/mm 3 at week 36 were separated post hoc (n=35; 21%) and the remaining parturients were divided as having <100,000/mm 3 (n=30; 18%) or 101,000–150,000/mm 3 (n=101; 60.5%). Epidural or spinal anesthesia was administered to 30% women with <100,000/mm 3 whereas 56% women with >101,000/mm 3 received these options (P=0.003). A total of 13.9% of parturients with trimester-long thrombocytopenia required blood products; 10/23 (43.5%) parturients undergoing cesarean section also required blood products (P=0.000). Four of six babies with Apgar scores of ≤7 at 1-min were born to women with platelets <100,000/mm 3 (P=0.009). There were no statistically significant differences in mean birth weights. Women with thrombocytes <150,000/mm 3 at birth but within the normal range at week 36 were more likely multiparas (P=0.001). We conclude that a difference in maternal and neonatal outcomes exists between mothers who were thrombocytopenic only at delivery compared to those with trimester-long thrombocytopenia, with the latter mothers and babies having more adverse events.

Objective : This study evaluated the association of maternal factors known to influence outcomes of triplets, different discordance levels (<25, 25.1–35, and >35%), and three types (according to the birth weight of the middle-sized triplet) of birth weight discordance in triplets. Methods : We used data collected by the Women's Health Division of Matria Healthcare, Inc. (Marietta, GA). We analyzed a cohort of 2706 triplet sets, to calculate the frequencies of different levels and types of birth weight discordance by maternal age, parity, weight, height, body mass index and weight gain at 24 weeks of gestation. Results : We found a positive association between maternal parity and birth weight discordance level but no clear association between the other maternal factors and the level of discordance as well as the type of discordance. However, a trend was seen whereby overweight women had a trend towards the low-skew (a set comprising one large and two small triplets) type of birth weight discordance and an opposite trend in underweight women. Conclusions : These results corroborate previous findings that nulliparity is associated with aberrant growth in triplet pregnancies.

Objective: To determine whether the obstetric gel shortens the second stage of labor and exerts a protective effect on the perineum. Method: A total of 251 nulliparous women with singleton low-risk pregnancies in vertex position at term were recruited. A total of 228 eligible women were randomly assigned to Group A, without obstetric gel use, or to Group B, obstetric gel use, i.e., intermittent application into the birth canal during vaginal examinations, starting at the early first stage of labor (prior to 4 cm dilation) and ending with delivery. Results : A total of 183 cases were analyzed. For vaginal deliveries without interventions, such as C-section, vaginal operative procedure or Kristeller maneuver, obstetric gel use significantly shortened the second stage of labor by 26 min (30%) (P=0.026), and significantly reduced perineal tears (P=0.024). First stage of labor and total labor duration were also shortened, but not significantly. Results did not show a significant change in secondary outcome parameters, such as intervention rates or maternal and newborn outcomes. No side effects were observed with obstetric gel use. Conclusion : Systematic vaginal application of obstetric gel showed a significant reduction in the second stage of labor and a significant increase in perineal integrity. Future studies should further investigate the effect on intervention rates and maternal and neonatal outcome parameters.

Background: Cord artery protein S-100 levels at birth are potential markers of brain damage after asphyxia. Our aim was to investigate if S-100 levels were elevated in neonates with indirect signs of asphyxia during birth. S-100 levels in cord blood were studied in relation to cardiotocography (CTG) and fetal electrocardiography (FECG) changes during birth and to acidemia in umbilical blood. Material and methods: This case-control study was performed in parallel to a large randomized controlled trial (RCT) studying FECG at birth. Protein S-100 samples were collected from 103 neonates at birth and related to the CTG and ECG changes during labor and to pH in umbilical blood. Results: Protein S-100 was significantly higher in neonates with umbilical artery blood pH≤7.05, compared to neonates with pH>7.05. Furthermore, neonates with preterminal CTG patterns showed increased S-100 levels compared to neonates with normal CTG. Neonates having significant CTG and ECG changes, leading to intervention according to clinical guidelines, showed significantly higher S-100 levels compared to neonates without such indication of intervention. Conclusion: A relation exists between S-100 in umbilical blood at birth, acidosis and pathological patterns in CTG and FECG during labor.

Color Doppler Ultrasound was performed on 202 post-term pregnancies to detect the presence of a nuchal cord. A nuchal cord was diagnosed if the umbilical cord could be followed 360° around the fetal neck. The results were not disclosed to the managing obstetrician, midwife, and patient. The perinatal outcome was analyzed according to Apgar score, umbilical cord artery and vein pH and base excess (BE), perinatal death, cesarean section, operative delivery for fetal distress (ODFD) and admission to neonatal intensive care unit (NICU). A nuchal cord was detected in 69 patients (34.2%). The incidence was not affected by parity or reduced amniotic fluid volume. There was no statistically significant increased risk for 1- and 5-min Apgar scores <7, umbilical artery pH <7.1, umbilical vein pH <7.20, umbilical artery base excess <−11, umbilical vein base excess <−11, perinatal death, cesarean section, ODFD or admission to NICU. Nuchal cord in post-term pregnancies is not associated with an increased risk for signs of fetal distress and operative intervention during labor and delivery.

Aim: To evaluate the screening for trisomy 21 by maternal age and nuchal translucency in a low-risk population. Methods: Screening was performed in 7096 singleton pregnancies. The estimated risk for trisomy 21, the detection rate (DR), false positive rate (FPR) and the cut-off nuchal translucency thickness to obtain a 5% FPR were calculated. Results: The median maternal age was 28.6 years. The estimated risk for trisomy 21 was 1 in 300 or greater in 2.4% (171 of 7096) of all pregnancies and in 75% (9 of 12) of trisomy 21 pregnancies. The DR for all aneuploidies was 83.3%, and 75% for trisomy 21. The estimated FPR at risk 1 in 300 for the whole population in 2004 was 3.8%. It is predicted to remain below 4% at least until 2007; to achieve a 5% FPR in 2007 the risk limit 1 in 400 is proposed. Conclusions: Screening for trisomy 21 in a low-risk population in Slovenia gives comparable results to those in other countries. The only result that varies is the percentage of screen positive patients at the risk limit 1 in 300. We believe the risk limit should be specifically estimated for each country based on its population distribution of maternal age.

Aims: To determine the association of hypotonia and depression in neonates at or near term with metabolic acidemia at birth (umbilical arterial pH<7.0 and base excess <−12 mM). Methods: This case-control study identified 87 infants without chromosomal or congenital abnormalities born at a single university hospital between 7/91 and 10/04 with hypotonia at birth requiring resuscitation and admission to the neonatal intensive care unit that had a cord gas at delivery. Controls were the subsequent delivery with a cord gas matched by gestational age. Results: Cases and controls did not differ in gestational age (38.7±1.9, 38.6±1.9 weeks) or birth weight (3066±664, 3171±655 g, P=0.20). Cases were more likely to have a cord pH<7.0 [17 (20%) vs. 1 (1.1%), P=0.0001] and cord pH 7.0–7.1 [13 (14.9%) vs. 2 (2.3%), P=0.003]. Among the hypotonic infants, 31 (35.6%) also were depressed at birth with a 5-min Apgar <7. In the depressed subset of hypotonic neonates 14/31 (45%) had a pH<7.0. Of the 12 hypotonic neonates with seizures, 3 (25%) had pH<7.0. Multivariate analysis showed a significant association between neonatal hypotonia and hypoglycemia, umbilical arterial pH, and nucleated red blood cell count. Conclusions: Although metabolic acidemia is significantly associated with hypotonia at the time of birth, the majority of neonates with hypotonia and depression or seizures do not have objective evidence of asphyxia as measured by a cord gas at the time of delivery.

Aims: Amniotic infection (AI) and preeclampsia (PE), which are commonly the reason for prematurity, inflict stress of different duration on immature fetuses. Whether chronic stress, as reflected by intrauterine growth retardation, influences the level of 17-OH progesterone (17-OHP), was not previously examined. Methods: We analyzed 17-OHP and TSH levels during neonatal screenings in the first hours of life of 90 premature infants born between 25 and 33 weeks of gestation in infants with AI (n=37) or with PE (n=53). Control of acute stress parameters was derived from umbilical arterial cord blood pH and base excess (BE). Results: Mean 17-OHP levels of infants born to mothers with PE were 85.7 nmol/L compared to 54.6 nmol/L (P<0.001) in AI infants. 17-OHP was even higher when intrauterine growth restriction was present (99.8 nmol/L). Antenatal steroids and mode of delivery did not significantly affect 17-OHP levels. Conclusions: Stress of relatively long duration, as in cases of PE, leads to a significant increase of 17-OHP level in preterm infants. The postnatal 17-OHP level may be considered as a measure for severity of intrauterine stress and might be used as an individualized indicator for earlier intensive care.

Objective: Severe hypoxia/ischemia is a major cause of neonatal cardiorespiratory dysfunction and mortality. We tested whether prenatal hypoxia preconditioning would augment hypoxic and hypercapnic ventilatory responses, and thereby reduce neonatal mortality. Methods: Pregnant rats at 19 days' gestation were exposed to six episodes of intermittent hypoxia (10-min of 15% O 2 followed by 10-min of normoxia/episode, PPC), or room air (CON) per day until delivery. The ventilatory responses to 1 min of 10% O 2 and 10% CO 2 , and 5 min of 5% O 2 were performed in anesthetized pups. The conscious pups were exposed to 5% O 2 for ∼105 min, and their mortality and dry/wet weight of the lung and brain were evaluated. Results: We found that augmented ventilatory responses to 1 min of 10% O 2 and 10% CO 2 were similar in the two groups (P>0.05). In contrast, 5 min of 5% O 2 initially caused a ventilatory peak response followed by a decline that was markedly diminished (35%, P=0.013) by PPC. PPC also significantly decreased neonatal mortality by 22% (P=0.044) as compared with CON. Conclusion: We conclude that prenatal hypoxia preconditioning reduces neonatal mortality apparently by improving the severe hypoxic ventilatory response.

Objective: To describe mortality and morbidity of neonates born at <26 weeks' gestation in a contemporary population-based cohort. Methods: We analyzed data of neonates born at <26 weeks between 1998 and 2003 in the Federal State of Hesse, Germany. Survival was calculated at 28 days and at discharge from hospital. Results: Out of a total of 800 births, 572 infants were liveborn. Among those admitted for neonatal intensive care, 62.3% survived until day 28. Among the neonates followed until death or discharge, 59.6% were discharged home. Logistic regression analyses showed the following variables to be associated with an increased risk of death: Twins (Odds Ratio (OR) 3.7; 95% Confidence Interval (CI) 1.34–10.26), multiple birth ≥3 (OR 8.14; CI 1.23–53.86), intraventricular hemorrhage (IVH) ≥grade III (OR 4.79; CI 1.89–12.14), clinical risk index for babies score >15 (OR 2.9; CI 1.09–7.76), and a gestational age ≤23 weeks (OR 5.34; CI 1.24–22.98). Among infants discharged home, bronchopulmonary dysplasia was diagnosed in 52.2%, IVH ≥grade III and/or periventricular leukomalacia in 15%, and severe retinopathy of prematurity in 29.8%. Conclusions: This study provides outcome data derived from a contemporary population-based cohort. Mortality and complication rates remain high.

Conception sometimes results in products that are not capable of developing into an embryo and fetus. This group, designated with the term gestational trophoblastic neoplasia, comprises the benign hydatidiform mole, the invasive mole (chorioadenoma destruens) and the frankly malignant variety, choriocarcinoma. Another type of atypical oocyte activation occurs in parthenogenesis. In the human, two types of tumors, dermoid cysts and teratomas, are believed to result from this process. We elucidate the generation of these abnormal growths and provide explanations as to why they cannot be regarded as human individuals or human beings. We argue that it is not the number of chromosomes that is required for a given form of human life to become a human being but rather the biparental origin of the chromosome set.