Volume 36, Issue 6

Severe peripartum hemorrhage (PPH) contributes to maternal morbidity and mortality and is one of the most frequent emergencies in obstetrics, occurring at a prevalence of 0.5–5.0%. Detection of antepartum risk factors is essential in order to implement preventive measures. Proper training of obstetric staff and publication of recommendations and guidelines can effectively reduce the frequency of PPH and its resulting morbidity and mortality. Therefore, an interdisciplinary expert committee was formed, with members from Germany, Austria, and Switzerland, to summarize recent scientific findings. An up-to-date presentation of the importance of embolization and of the diagnosis of coagulopathy in PPH is provided. Furthermore, the committee recommends changes in the management of PPH including new surgical options and the off-label use of recombinant factor VIIa.

Aims: To determine whether sonographic measurement of cervical length predicts intra-amniotic infection and impending preterm delivery (within 7 days of amniocentesis) in women with preterm labor and intact membranes, and to compare the predictability with that of amniotic fluid (AF) white blood cell (WBC) count. Methods: Transvaginal ultrasonographic assessment of cervical length was performed immediately after amniocentesis in 67 consecutive women with preterm labor. AF obtained by amniocentesis was cultured for aerobic and anaerobic bacteria and for Mycoplasmas , and WBC count was determined. Results: Patients with a positive AF culture had a significantly shorter median cervical length, higher median AF WBC count, and lower median gestational age at delivery than did those with a negative AF culture. Multivariate analysis indicated that only the AF WBC count bears a significant relationship with the presence of intra-amniotic infection, whereas only cervical length correlates with impending preterm delivery. Conclusions: Transvaginal sonographic measurements of cervical length are a valuable method for predicting intra-amniotic infection as well as impending preterm delivery in women with preterm labor. However, in comparison with AF WBC, cervical length is less predictive for intra-amniotic infection, whereas cervical length demonstrates better predictability of impending preterm delivery.

Objective: Visfatin, a novel adipokine originally discovered as a pre-B-cell colony enhancing factor, is expressed by amniotic epithelium, cytotrophoblast, and decidua and is over-expressed when fetal membranes are exposed to mechanical stress and/or pro-inflammatory stimuli. Visfatin expression by fetal membranes is dramatically up-regulated after normal spontaneous labor. The aims of this study were to determine if visfatin is detectable in amniotic fluid (AF) and whether its concentration changes with gestational age, spontaneous labor, preterm prelabor rupture of membranes (preterm PROM) and in the presence of microbial invasion of the amniotic cavity (MIAC). Methods: In this cross-sectional study, visfatin concentration in AF was determined in patients in the following groups: 1) mid-trimester (n=75); 2) term not in labor (n=27); 3) term in spontaneous labor (n=51); 4) patients with preterm labor with intact membranes (PTL) without MIAC who delivered at term (n=35); 5) patients with PTL without MIAC who delivered preterm (n=52); 6) patients with PTL with MIAC (n=25); 7) women with preterm PROM without MIAC (n=26); and 8) women with preterm PROM with MIAC (n=26). Non-parametric statistics were used for analysis. Results: 1) The median AF concentration of visfatin was significantly higher in patients at term than in mid-trimester; 2) Among women with PTL who delivered preterm, the median visfatin concentration was significantly higher in patients with MIAC than those without MIAC; 3) Similarly, patients with PTL and MIAC had a higher median AF visfatin concentration than those with PTL who delivered at term; 4) Among women with preterm PROM, the median AF visfatin concentration was significantly higher in patients with MIAC than those without MIAC. Conclusions: 1) Visfatin is a physiologic constituent of AF; 2) The concentration of AF visfatin increases with advancing gestational age; 3) AF visfatin concentration is elevated in patients with MIAC, regardless of the membrane status, suggesting that visfatin participates in the host response against infection.

Aims : The purpose of this study was to determine if a bedside test, the MMP-8 PTD Check™, can be of value in the antenatal identification of funisitis. This test can be performed in 15 min without any laboratory equipment. Methods : The relationship between the presence or absence of funisitis and the results of an MMP-8 PTD Check™ was examined in 139 patients who delivered preterm singleton neonates (gestational age <35 weeks) within 72 h of amniocentesis. Amniotic fluid (AF) was cultured for aerobic and anaerobic bacteria and for genital mycoplasmas. AF was analyzed for white blood cell (WBC) count, interleukin-6 (IL-6) and an MMP-8 PTD Check™. The IL-6 concentration was also determined in umbilical cord plasma collected at birth. Funisitis was diagnosed in the presence of neutrophil infiltration into the umbilical vessel walls or Wharton's jelly. Results : 1) Funisitis was present in 27% (38/139) of cases; 2) A positive MMP-8 PTD Check™ had a sensitivity of 97% (37/38), a specificity of 63% (64/101), a positive predictive value of 50% (37/74) and a negative predictive value of 99% (64/65) in the identification of funisitis; 3) Among cases without funisitis, patients with a positive MMP-8 PTD Check™ had a significantly higher median AF IL-6 concentration, AF WBC count, and umbilical cord plasma IL-6 concentration at birth than those with a negative MMP-8 PTD Check™ (P<0.05 for each). Conclusions : The MMP-8 PTD Check™ is a rapid, simple and sensitive bedside test which allows assessment of the risk of funisitis.

Aim: To determine any association between history of mothers with myasthenia gravis (MG) and the occurrence of neonatal myasthenia gravis (NMG). Methods: The prospective study involved pregnant women with MG and their newborns delivered in our center throughout the nine-year period. The study included 16 newborns with NMG and 33 healthy newborns without symptoms of NMG. Their outcome was evaluated in relation to the duration of the illness (<5, 5–10, >10 years) and maternal therapy (no therapy, mestinon, corticosteroid, or combination of the two). Results: The duration of maternal illness and type of therapy were not predictive of neonatal outcomes (P=0.159, and P=0.578, respectively). Conclusion: The duration of illness and therapy of women with MG do not correlate with manifestation of NMG and do not predict which pregnancies would result in an affected child. Because of possible severe, unpredictable, and life threatening NMG, these births should be carried out in a tertiary birth center.

Objective: To reconfirm that a low-lying placenta, with placental edge-internal os distance of 0–4 cm, is a risk factor for blood loss during delivery, and to determine whether blood loss differs between edge-os distance of ≤2 cm vs. >2 cm. Methods: We compared total blood loss between 73 singleton pregnant women with edge-os distance of 0–4.0 cm vs. controls. We also compared total blood loss between pregnant women with distance of 0–2.0 cm (lower) vs. 2.1–4.0 cm (higher). Results: Total blood loss was significantly greater in women with placental edge-os distance of ≤4 cm than controls in both delivery modes. The lower group showed a significantly higher incidence of excessive hemorrhage during vaginal delivery (60 vs. 19%, P=0.046) and bled more (median 1240 vs. 860 mL, P=0.059) than the higher group. Although this did not reach statistical significance, the lower group more frequently bled antepartum, required emergent cesarean section, and delivered abdominally. Regression analysis showed no association between the amount of blood loss and the edge-os distance in both delivery modes. Conclusion: Pregnant women with edge-os distance of 2.1–4.0 cm are of highest level of concern as are women with 0–2.0 cm distance.

Objective : There is limited evidence supporting the effectiveness of history-indicated cerclage in preventing spontaneous pregnancy loss or preterm birth. This study was undertaken to estimate the practice patterns of maternal-fetal medicine specialists in regards to history-indicated cerclage. Methods : We performed a mail-based survey of all SMFM specialists in the US. Subjects were asked whether they would recommend a history-indicated cerclage at 12–14 weeks in a patient whose prior pregnancy was her first pregnancy and ended in a spontaneous, painless loss at 19 weeks with no identifiable cause. Results : A total of 827 (46%) of SMFM members responded of which 75% would recommend a history-indicated cerclage for this patient. Twenty-one percent would not recommend one, but would place one if desired by the patient. Only 4% would not place a history-indicated cerclage in this scenario. A total of 71% believed a history-indicated cerclage was associated with moderate or significant benefit, and 89% believed it involved minimal or no risk. Female gender, non-academic practice, practicing in the southern region and greater interval since residency training were all independently associated with the recommendation for a history-indicated cerclage. Conclusions : Despite limited level-I evidence supporting its use, a history-indicated cerclage is recommended by most maternal-fetal medicine specialists.

Objective: To investigate the prevalence of detectable jugular lymphatic sacs in a setting for first trimester screening for Down syndrome, and to evaluate the influence of jugular lymphatic sacs on the screening performance for chromosomal abnormalities. Methods: A prospective single center study (Erasmus University Medical Center, Rotterdam, The Netherlands) over a period of one year (January 2003–February 2004). First trimester nuchal translucency measurement was performed in a study population of 415 fetuses. Additionally, the transversal plane with the spine and mandible was visualized to verify the presence of jugular lymphatic sacs. The jugular lymphatic sacs were measured anterior-posterior. The association between nuchal translucency and jugular lymphatic sacs was tested. Results: Follow-up was complete in 406 cases (97.8%). Jugular lymphatic sacs could be visualized in 98 out of 415 (23.5%). The nuchal translucency thickness and the mean of the left and right jugular lymphatic sac were significantly correlated. Conclusion: The sonographic visualization of jugular lymphatic sacs significantly predicts chromosomal abnormalities, although nuchal translucency is a better predictor. Nuchal translucency and jugular lymphatic sacs are strongly correlated and therefore not applicable in a combination test.

Objectives: To study the association between thickness of the umbilical cord at 11+0 to 14+6 gestational weeks and perinatal outcome. Methods: We studied 216 pregnant women between 11+0 and 14+6 weeks' gestation with singletons, intact membranes, normal volumes of amniotic fluid and a regular menstrual period. Patients with umbilical cord measurements below the 5 th centile were defined as thin umbilical cord group and those between the 5 th and 95 th or above 95 th centile were defined as non-lean umbilical cord group. Abortion or fetal demise, preeclampsia, mode of delivery, gestational age at delivery, birth weight, and 5-min Apgar scores were noted. Results: A statistically significant difference existed between the mean gestational age, mode of delivery, birth weight and adverse perinatal outcome of the two groups. The relative risk of the adverse perinatal outcome in lean umbilical cords was 6.92 (2.71–17.67; 95% CI). The umbilical cord thickness correlated with birth weight (P<0.05). Conclusions: Sonographic finding of a lean umbilical cord at 11+0 to 14+6 weeks' gestation should prompt the physician to strict monitoring of pregnancy.

Aims : Abdominal circumference (AC) assessment may be used as an index of abdominal visceral size, fetal fat store, and intrauterine nutrition. The aim of this study is to construct sex-specific references and smoothed percentiles for AC at birth in term and near-term Caucasian infants. Methods : AC was measured in 4542 singleton newborns (2323 males, 2219 females), at a gestational age ≥35 weeks. Smoothed percentiles for AC were constructed by sex and gestational age according to the LMS method. Results : Males had higher AC than females but differences were only statistically significant beyond 37 weeks. AC increased from 35 to 41 weeks in both sexes. Conclusions : Sex-specific references constructed for AC in term and near-term Caucasian newborns might be used, as other anthropometric parameters, in the assessment of nutritional status at birth.

Objective : To explore the ability of growth velocity and customized standards of fetal weight to predict adverse outcomes in small fetuses delivered at term. Methods : We evaluated a cohort of 86 consecutive singletons suspected to be small for gestational age during the third trimester (estimated fetal weight <10 th centile), who had normal umbilical artery Doppler and ultimately delivered at term. Conditional growth velocity and customized fetal growth were compared for the prediction of adverse outcome. Results : Overall, customized growth assessment showed better sensitivity than growth velocity assessment (57.1% vs. 42.9% for a 10 th centile cut-off) for the prediction of adverse outcome, but with comparable specificity. The odds of having an adverse outcome for women with a positive test compared with women with a negative test were 1.54 and 3.22 for the 10 th centile growth velocity and customized definitions, respectively. The area under the curve for the prediction of adverse outcome was larger for customized than for growth velocity standards (0.65 vs. 0.59), albeit without statistical significance. Conclusions : Our study suggests that customized growth assessment may have better accuracy in predicting adverse perinatal outcome than growth velocity in small fetuses with normal umbilical Doppler delivered at term.

Aims: To compare neonatal neurological morbidity associated with uterine rupture with morbidity associated with a non-reassuring fetal status. Methods: We conducted a retrospective cohort analysis. Twenty-one cases of term infants delivered after a symptomatic uterine rupture were analyzed and compared with a randomly selected group of 63 infants born after a non-reassuring fetal heart rate pattern. Results: Prevalence of uterine rupture was 0.058%. Maternal factors and infant general data were similar in both groups. Infants delivered after a uterine rupture had lower Apgar scores at 1 and 5 min, lower umbilical blood pH, and required more advanced resuscitation than infants delivered after a non-reassuring fetal status. Prevalence of hypoxic-ischemic encephalopathy in the uterine rupture group was 33%, compared with 5% in the other group (P<0.01, relative risk 3.7). Four infants in the uterine rupture group (19%) had moderate or severe encephalopathy; all of them had also multisystem dysfunction and an adverse outcome. No infant in the non-reassuring fetal status group showed moderate or severe encephalopathy. Conclusions: Uterine rupture is a considerable sentinel event that involves a high rate of early and late neurological morbidity in the newborn infant.

We report on an exceptional therapy with epidural anesthesia and tunnelling of the peridural catheter over a time period of 2–14 days in patients with threatening early preterm labor, intact membranes and vaginal engagement of the infants (4 singleton, 8 twin and 2 triplet pregnancies). A combination of bupivacaine (0.125%) and fentanyl (2 μg/mL) was used up to a maximum of 20 mL/h during the treatment period. Long-term follow-up of the infants was normal in 19/20 infants. The advantages, such as prolongation of pregnancy without maternal pain and disadvantages such as the risk of fetal and maternal infection and of sudden delivery are discussed. The online version of the Journal (see http://dx.doi.org/10.1515/jpm.2008.081_supp-1) allows video illustrations of a triplet pregnancy, in which the first triplet was born after one week of epidural anesthesia and the pregnancy continued under epidural anesthesia for the remaining two triplets staying with intact membranes in the vagina (delayed interval delivery) for six more days. The results of this pilot series suggest that prolongation of these pregnancies under epidural anesthesia might be an option in exceptional cases when viability is questionable or when corticosteroid therapy is desired before final delivery. Further evaluation of this strategy is needed but only in tertiary centers with 24-h presence of qualified obstetric and neonatal care and intensive surveillance.

No abstract available