Volume 42, Issue 3

Placental chorioangioma is the most common benign non-trophoblastic tumor of the placenta. It is derived from primitive chorionic mesenchyme and is typically vascular. Placenta chorioangiomas occur in approximately 1% of pregnancies. Most placental chorioangiomas are small and are not clinically important. However, those measuring more than 4–5 cm in diameter may be associated with maternal and fetal complications. Early diagnosis, close prenatal surveillance and appropriate intervention may prevent severe complications and perinatal mortality caused by chorioangioma. Here we review the incidence, prenatal diagnosis, complications, the pathophysiological mechanisms of maternal and fetal complications, and the therapeutic possibilities in pregnancies complicated by placental chorioangiomas.

Aim: To evaluate if transvaginal cervical length measurement in the second-trimester scan is an effective screening test for preterm delivery. Methods: We performed a search in Medline and, for each selected article, information was extracted regarding the performance of the test in terms of sensitivity, specificity, positive, and negative likelihood ratios, in low-risk, high-risk, and multiple gestations. We also evaluated the performance of the combined test (more than one sonographic marker). Results: A positive relationship was established between short cervix and preterm delivery in all articles. The majority of studies presented high specificity and positive likelihood ratio, while sensitivity and negative likelihood ratio were variable and globally poor. Better values of accuracy were found in high-risk and multiple gestations and, in all studied subgroups, for preterm delivery at lower gestational ages. Conclusions: We conclude that a short cervix is predictive of preterm delivery and can identify women that may benefit from preventive and therapeutic measures, however, a negative result is not always reassuring.

Introduction: Factor XI deficiency is predominantly found in the Ashkenazi Jewish population with a prevalence of 9%, but also seen in other ethnicities. Little information is available on obstetric anesthesia management in women with Factor XI deficiency. Therefore, we undertook a study to evaluate obstetric, anesthetic and perinatal outcomes in parturients with Factor XI deficiency. Methods: A retrospective study was conducted with chart reviews from 1996 to 2011 resulted in 74 women with Factor XI level deficiency. We compared anesthetic and obstetric management in parturients with low (≤30%) level of Factor XI to those with higher levels. Results: Ninety-one pregnancy outcomes were reviewed in these 74 women with Factor XI deficiency. Forty-three women had levels ≤30% in 46 labors while 31 women had levels >30% in 45 labors. Women with low levels of Factor XI were significantly more likely to receive FFP and less likely to receive neuroaxial anesthesia. There were no anesthetic complications and no difference in mode of delivery or neonatal outcomes. Discussion: This study is the first step in building a national database for anesthetic cases and outcomes of parturients with Factor XI deficiency. Further efforts must be made to provide safe analgesia for these women.

Objectives: Inferior vena cava compression syndrome (VCCS) is a serious complication of supine fetal magnetic resonance imaging (MRI) examinations, particularly during late gestation. This morphologic study correlated the occurrence of VCCS with the grade of inferior vena cava (IVC) compression. Materials and methods: There were 56 fetal MRI in the supine position [median gestational weeks (GW) 27+4] and 16 fetal MRI in the lateral position (median GW 30+6) retrospectively analyzed. The grade of maternal IVC compression was determined by the maximal anterior-posterior diameter (DAP) at the level of L4/L5. Fetal head position and right-sided uterus volume were analyzed. Clinical VCCS-related symptoms during fetal MRI were assessed. Results: A noncompressed IVC was present in 1.8% (n=1) and a DAP of 5 to <10 mm in 33.3% (n=19) and 1 to <5 mm in 64.9% (n=36). The DAP was independent of fetal head position (P=0.99) and showed no significant correlation with gestational age (r=0.33). IVC compression increased with right-sided uterus volume (r=–0.328; P=0.014). There was a significant difference in DAP in the lateral position compared with the supine position (P<0.001). Clinical assessment revealed no symptoms of VCCS in any woman. Conclusions: The presented data support the concept of physiologic compensation for significantly reduced venous backflow in the supine position during the second and third trimesters of pregnancy.

Aims: Fetal behavioral states can be distinguished by biomagnetic recordings. We performed a longitudinal and a cross-sectional study to address the question whether the distribution of fetal behavioral states changes during the daytime. Methods: For the longitudinal study, 32 magnetocardiographic recordings were performed on a singleton pregnancy on a weekly basis. On each examination day, two recordings were performed at different times between 25 and 40 weeks of gestation. For the cross-sectional study, fetal magnetocardiograms (fMCG) were recorded in a group of 32 singleton pregnancies matched for gestational age and daytime to the longitudinal study. The recordings were separated into two gestational age groups (less and more than 32 weeks). Fetal behavioral states were extracted from actocardiograms generated from MCG. Results: No significant differences in fetal behavioral state distribution were found between morning and afternoon recordings in either the longitudinal or the cross-sectional study. Conclusion: This is the first magnetographic approach to show that daytime does not influence the distribution of fetal behavioral states in standardized recordings of 30 min length. This result implies that fetal magnetography recordings at normal daytimes can be combined without a bias and future recordings can be conducted independently of daytime as long as the varying behavioral states are generally taken into account during analysis.

Objective: The aim of the present study was to determine specific obstetrical and neonatal complications associated with diet-treated gestational diabetes (DTGD) and medically treated gestational diabetes (MTGD). Methods: This is a prospective cohort study of women followed in the Robert Debré Hospital (France, Paris) and who have given birth between 1 January, 2004, and 19 November, 2010. Clinical, biological, maternal and neonatal data were reported in the maternity database. Associations between obstetrical and neonatal complications and gestational diabetes were evaluated by estimating odd ratios (ORs) and their 95% CIs, using a logistic regression model. Results: 16,244 pregnancies were included in the study. 1515 (9.3%) women had gestational diabetes: 1108 (7.3%) had DTGD, 243 (1.7%) had MTGD. After full adjustment, MTGD was associated with an increased risk of nonscheduled cesarean (OR nonscheduled =2.3; 95% CI: 1.6–3.3; P<0.001) while DTGD was not (OR nonscheduled =1.0; 95% CI: 0.8–1.3; P<0.96). Clinical macrosomia was positively associated with DTGD (OR=2; 95% CI: 1.7–2.4; P<0.0001) or MTGD (OR=2.9; 95% CI: 2.1–3.9; P<0.0001). Conclusion: This study confirms that macrosomia is the main complication of DTGD. By contrast, DTGD was not associated with neonatal hypoglycemia and cesarean, while these complications were associated with MTGD.

Objective: To correlate placental pathologic lesions, as defined by the Society for Pediatric Pathology, to the severity of the ratio of the pulsatility Doppler index (PI) of the fetal middle cerebral artery to that of the umbilical artery (cerebroplacental ratio, CPR). Study design: A cohort-study of 176 singleton pregnancies complicated by fetal growth restriction (FGR). Results: The mean values of gestational age, birth weight and CPR of the entire cohort were 33.9±3.6 weeks, 1552±561 g, and 1.33±0.68, respectively. In ordered logistic regression analysis, after adjustment for potential confounders, muscularised arteries (Odds Ratio [OR]=3.14; 95% confidence intervals [CI]=1.58–6.28, P=0.001), mural hypertrophy (OR=2.35; 95% CI=1.26–4.4, P=0.008), immature intermediate trophoblast (OR=2.0; 95% CI=1.07–3.71, P=0.03) and maternal vascular underperfusion (OR=2.32; 95% CI=1.25–4.23, P=0.007) were the only parameters associated with severity of CPR. Conclusions: The correlation between placental histological findings indicating maternal underperfusion and placental occlusion suggest that forced centralization of fetal circulation in FGR could be at least partially attributable to the hemodynamic consequences of increased placental vascular resistance.

Glycosaminoglycans are found in extracellular matrix and on the cell surface in the form of proteoglycans. There is evidence that these molecules regulate biological processes, including cell survival, migration and angiogenesis. Preeclampsia is a common pregnancy disorder associated with insufficient placental development. This study aimed to determine the concentrations of glycosaminoglycans and the proteoglycan syndecan-1 within villous trophoblast and to investigate changes associated with preeclampsia. Seventy-five placental samples collected from third trimester singleton pregnancies were divided into term placentas following labour onset, gestational age-matched placentas prior to labour onset and preterm placentas. Preterm placentas were divided into three gestational age-matched groups, spontaneous preterm labour, preterm premature rupture of membranes (PPROM) and preterm preeclampsia. Sulphated glycosaminoglycan (sGAG) concentrations in placental extracts were quantified using a modified 1,9-dimethylmethylene blue assay. Syndecan-1 expression was localised using immunohistochemistry and concentrations in placental extracts determined by immunoassay. Preterm placentas had significantly lower sGAG concentrations compared to term tissues and concentrations were significantly lower in preeclampsia compared to spontaneous preterm labour (medians 5.80 and 10.0 μg/mg protein respectively, P<0.05). Syndecan-1 expression was localised to syncytiotrophoblast and median concentrations were lower in preeclampsia compared to PPROM material (preeclampsia median = 41.7, PPROM 74.4 ng/mg tissue) but not significantly different to concentrations in spontaneous preterm labour. Multivariate analysis revealed that decreased sGAG and syndecan-1 in preeclampsia were independent of labour, gestational age and birthweight centile. These findings may provide insights into a role for these molecules in the pathophysiology of preeclampsia.

In obstetrical practice, the best prevention strategy for pregnant women aged >35 years without known thrombosis risk factors who underwent elective caesarean delivery (CD) is controversial. We performed an observational-longitudinal cohort study on pregnant women aged >35 years who delivered at term by elective caesarean section after a physiological single pregnancy to evaluate the role of maternal age in the decision-making process of whether or not to perform low-molecular-weight heparin (LMWH) prophylaxis during the post-partum period after elective CD in healthy women with unknown inherited thrombophilia status. During the 6 post-partum weeks, we followed two groups: GROUP-A (349 women treated for 7 days with low-molecular-weight heparin) and GROUP-B (180 women not treated with LMWH treatment). The outcomes were as follows: onset of thromboembolic events during the post-partum period; non-obstetrical-linked maternal haemorrhage; blood transfusion; re-laparotomy; detection of a surgical site haematoma; length of hospitalisation; and treatment suspension because of decreased platelet count. Except for the parity number, the two groups were homogeneous with regard to general features. In both the groups, we reported no cases of thromboembolic events during the follow-up period. Maternal haemorrhage requiring transfusion occurred in 16 women in GROUP-A and none in GROUP-B. Among the GROUP-A women, 11 demonstrated a surgical site haematoma and 4 required re-laparotomy. No cases of treatment suspension were reported. Pneumatic compression stockings represent a better, low cost and safe way to prevent post-partum venous thromboembolic episodes after elective caesarean section in an unscreened population. Pharmacological prophylaxis after elective caesarean section should be performed only in case of clear and known adjunctive risk factors, independent of maternal age.

Aim: To evaluate values and variability of T/QRS ratios between 28 and 42 weeks’ gestation in term and post-term pregnancies using non-invasive methods with electrodes placed over the maternal abdomen. Methods: Fetal electrocardiograms were recorded from 657 women with singleton pregnancies. Recorded signals were analyzed by KOMPOREL software from ITAM (Zabrze, Poland) and the T/QRS ratios were automatically calculated. The analyses were performed in subgroups according to gestational age. The T/QRS ratio variables were calculated; one-way analysis of variance (ANOVA test) and linear regression were carried out. Results: The T/QRS ratio was successfully measured in 95.4% (n=627) of patients during 30 min recordings. Values of T/QRS ratio variables changed during pregnancy. The mean T/QRS ratio ranged between 0.134 in the 41 st gestational week and 0.178 in the 35 th gestational week. Mean minimal and maximum values of the T/QRS ratio ranged between 0.02 and 0.29 [x=0.09; standard deviation (SD)=0.05] and 0.08 and 0.5 (x=0.27; SD=0.1), respectively. The highest values occurred in pre-term and post-term pregnancies. Conclusions: Measurement of the T/QRS ratio is one of the techniques used for non-invasive fetal distress assessment that can be used in antepartum fetal monitoring. Values of T/QRS ratio variables changed during pregnancy from higher in pre-term pregnancies, lower in the peripartum period and rose again in post-term pregnancies. The study provides more insight into the values of T/QRS ratios during pregnancy; however, additional research is required.

Objective: The transcatheter pelvic arterial embolization (TAE) is effective for postpartum hemorrhage (PPH). There has been a little information about the factors for ineffectiveness of TAE. The aim of this study was to determine factors associated with TAE failure for PPH. Study design: Fifty-five women who underwent TAE for intractable PPH were included. Clinical factors involving age, history of pregnancy, gestational weeks of delivery, mode of delivery, causes of PPH, complete blood count, blood loss volume, transfusion amount, shock index and disseminated intravascular coagulation (DIC) score were compared between TAE success group (n=48) and TAE failure group (n=7). Results: The uni- and multi-variate analyses revealed that advanced maternal age (OR 1.46, 95% CI 1.12–2.18) and retained placenta as a cause of PPH (15.48, 2.04–198.12) were found to be significant factors for TAE failure. Conclusion: The advanced age and retained placenta were independent factors associated with TAE failure for intractable PPH.

Objective: To examine the treatment of previous cesarean delivery scar defect after cesarean delivery and the feasibility of laparoscopic uterine repair or hysteroscopic scar excision. Study Design: A retrospective clinical study that took place from June 2009 to March 2013 and included 41 women who had previously had cesarean deliveries. Results: Seventeen women underwent a laparoscopic approach for the repair of scar diverticula, and 24 women underwent a hysteroscopic resection of fibrotic tissue overhanging underneath the diverticula. Most women remained free of symptoms over a 3- to 16-month follow-up and 6 women became pregnant without pregnancy complications. Conclusion: Women with a history of cesarean delivery combined with irregular perimenstrual bleeding should undergo combined hysteroscopy and ultrasound examination to detect latent scar defects. In diagnosed cases, in those who desired future pregnancies and had a residual myometrial thickness of <3.5 mm or a defect that accounted for ≥50% of the anterior uterine wall, laparoscopic surgical repair was performed with good postoperative anatomic outcomes. Women with residual myometrial thickness of ≥3.5 mm or a defect that accounted for <50% of the anterior uterine wall were treated with hysteroscopic surgery and had a relief of symptoms.

Objectives: Chemerin, a novel adipocytokine, has been implicated in major metabolic and inflammatory processes. Study aims were to determine whether circulating maternal chemerin concentration (1) differs between pregnant and non-pregnant women, (2) changes as a function of gestational age, and (3) correlates with maternal insulin resistance. In addition, we investigated which compartment, maternal, fetal or placental, is the source of chemerin in maternal circulation. Methods: The study included three groups: Non-pregnant (n=18), pregnant women in the first trimester (n=19) and pregnant women in the third trimester (n=33). Chemerin was measured in cord blood and in maternal serum samples taken before and after delivery. Chemerin mRNA expression was evaluated in fetal and human adult tissues. Results: Chemerin serum concentration was significantly higher in pregnant women in the third trimester than in non-pregnant and pregnant women in the first trimester. Chemerin concentration positively correlated with body mass index (BMI) and insulin resistance. Antenatal chemerin concentration was significantly lower than that during the postpartum period. Neonatal chemerin did not correlate with maternal one. Chemerin mRNA expression was abundant in fetal and adult liver and omental fat, but relatively low in placenta. Conclusions: Chemerin is increased during normal gestation and is associated with maternal BMI and insulin resistance. Maternal tissues, possibly liver and adipose tissue, contribute to the increased maternal chemerin concentration.

Objective: We examined the effect of repetitive administration of acetylcholine receptor agonist (carbachol) on brain damage and microglial accumulation in three brain regions after hypoxia-ischemia (HI) in newborn rat. Study Design: Seven-day-old Wistar rats were divided into two groups, one receiving a 0.1 mg/kg dose of carbachol on days 7, 8 and 9 to examine the attenuating effect on brain damage with decreasing accumulation of microglia, and the other group receiving saline as a control. Rats were subjected to left carotid artery ligation followed by hypoxia. We evaluated brain damage and the number of microglias in three regions on days 10 and 14. Results: Brain tissue was better preserved in the carbachol group on days 10 and 14. Microglial accumulation in the cortex was strong and persisted from day 10s to 14 in the control. Conversely, the accumulation of microglias was attenuated in the hippocampus and white matter on day 14. Carbachol significantly reduced the number of microglias in the hippocampus and white matter on day 10 and in the cortex on days 10 and 14. Conclusion: The main area of late inflammation was the cortex. Repetitive administration of carbachol reduces early and late inflammation after HI in the developing brain.

Background: The objective of this study was to assess the ability of prenatal ultrasound to predict an unfavorable outcome and the need for postnatal surgery in cases of fetal hydronephrosis (HY). Methods: Antenatal HY was classified according to the renal pelvis anteroposterior (AP) diameter in the third trimester. Postnatal outcome was considered favorable in the presence of spontaneous resolution or postnatal diagnosis of HY <20 mm, and unfavorable in the presence of postnatal diagnosis of >20 mm HY or urinary tract pathologies. Results: Prenatal diagnosis of HY was made in 120 fetuses (for a total of 161 abnormal renal units). The rates of postnatal urinary tract pathology were 14, 27 and 53% for antenatal HY of ≤7, 8–15 and >15 mm, respectively. An AP diameter ≥7 mm in the third trimester had a sensitivity of 100% and a specificity of 23% to predict unfavorable outcome. A formula inclusive of AP diameter and presence or absence of urinary tract anomalies can predict the need for postnatal surgery. Conclusions: The majority of infants with congenital HY have a favorable postnatal outcome. Risk of unfavorable outcome increases with the degree of dilatation of the renal pelvis and the presence of urinary tract anomalies. An AP diameter ≥7 mm in the third trimester warrants postnatal follow-up.

Aim: To assess the burden of congenital and perinatal cytomegalovirus (CMV) disease among infants hospitalized in neonatal intensive care units (NICUs). Methods: CMV infection was defined as a report of positive CMV viral culture or polymerase chain reaction at any time since birth in an infant hospitalized in a NICU reporting to California Perinatal Quality Care Collaborative during 2005–2010. Results: One hundred and fifty-six (1.7 per 1000) infants were reported with CMV infection, representing an estimated 5% of the expected number of live births with symptomatic CMV disease. Prevalence was higher among infants with younger gestational ages and lower birth weights. Infants with CMV infection had significantly longer hospital stays and 14 (9%) died. Conclusions: Reported prevalence of CMV infection in NICUs represents a fraction of total expected disease burden from CMV in the newborn period, likely resulting from underdiagnosis and milder symptomatic cases that do not require NICU care. More complete ascertainment of infants with congenital CMV infection that would benefit from antiviral treatment may reduce the burden of CMV disease in this population.

Aims: The development of fetal heart rate (FHR) variability and acceleration, and their loss in the hypoxic brain damage and cerebral palsy (CP) is investigated. Methods: FHR, movements in physiologic sinusoidal FHR and fetal movements were studied by actocardiogram. Results: Periodic fetal respiratory movements evoked moderate FHR variation similar to medium variability. Small fetal movements provoked FHR variability, and large fetal movement burst developed the acceleration. The brain centers should be midbrain for variability and acceleration. FHR variability and acceleration develop by the reaction of fetal brain to fetal movements. As severe organic fetal brain damage could develop through fetal hypoxia in the loss of variability, early delivery before the loss of variability will prevent infantile CP. As the abnormal FHR would be developed by fetal brain damage in non-hypoxic fetal insults, early delivery before the loss of variability could also prevent the brain damage in viral and bacterial infections.