Volume 42, Issue 5

Aim: To investigate the effect of depth on cervical shear-wave elastography. Methods: Shear-wave elastography was applied to estimate the velocity of propagation of the acoustic force impulse (shear wave) in the cervix of 154 pregnant women at 11–36 weeks of gestation. Shear-wave speed (SWS) was evaluated in cross-sectional views of the internal and external cervical os in five regions of interest: anterior, posterior, lateral right, lateral left, and endocervix. Distance from the center of the ultrasound (US) transducer to the center of each region of interest was registered. Results: In all regions, SWS decreased significantly with gestational age (P=0.006). In the internal os, SWS was similar among the anterior, posterior, and lateral regions and lower in the endocervix. In the external os, the endocervix and anterior regions showed similar SWS values, lower than those from the posterior and lateral regions. In the endocervix, these differences remained significant after adjustment for depth, gestational age, and cervical length. SWS estimations in all regions of the internal os were higher than those of the external os, suggesting denser tissue. Conclusion: Depth from the US probe to different regions in the cervix did not significantly affect the SWS estimations.

Objective: To examine concordance among results obtained in measurement process of first-trimester placental volume using 3D ultrasound and eXtended Imaging Virtual Organ Computed-aided AnaLysis (XI-VOCAL ® , 3DXITM, Medison, Seoul, Korea) image analysis by three different operators. Methods: Twenty first-trimester normal pregnancy cases were selected for placental volume measuring using a Medison SA 8000 Live Prime ® (Medison, Seoul, Korea) with a convex volumetric multifrequency abdominal probe. Images were processed and studied independently by three operators with different grade of training. Each operator obtained 50 slices per case. Thus, this study is based on 1000 measurements that have generated four different sets of placental volume determinations based on 5, 10, 15, and 20 slices, respectively. Results of measurement process were analyzed using reliability coefficients. Results: There was a good degree of concordance in the placental length values obtained by all operators and not depend from the number of cuts measured [intraclass correlation coefficient (ICC)=0.734]. However, the number of cuts is important to obtain a placental volume with more accuracy. Reliability coefficients were low when determining placental volume adjusted to placental length (ICC=0.293), but combined results of the two operators that were trained in the same way showed higher coefficients of reliability (ICC=0.682), and therefore, greater concordance when comparing with the operator that was not trained in the same way. Conclusion: Higher coefficients of reliability guarantee high grades of concordance in the results among operators when measuring placental volumes independently, however, contouring process introduces high variability. Training in how to best use the image analysis software effectively assists in getting higher coefficients of reliability.

Objective: Acute pancreatitis is a rare condition in pregnancy. The aim of this study is to compare associated conditions, treatments and complications of pancreatitis in pregnant and age-matched non-pregnant controls. Methods: We carried out a population-based retrospective cohort study using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS) from 2003 to 2010. A cohort of pregnant women with acute pancreatitis was created and compared to a created age-matched cohort of non-pregnant women with acute pancreatitis at a 1:4 ratio. Comparisons of associated conditions, treatment types, and complications were carried out using unconditional logistic regression. Results: We identified 7725 cases of acute pancreatitis in pregnancy. As compared to non-pregnant controls, pancreatitis in pregnancy was more likely to be associated with cholelithiasis and less likely with hyperlipidemia and alcohol abuse. Pancreatitis in pregnancy was more likely to be treated with parenteral nutrition and less likely to undergo endoscopic sphincterotomy. As compared to non-pregnant controls, pregnant women with pancreatitis were less likely to have pancreatic pseudocysts/hemorrhage/necrosis, generalized peritonitis, adult respiratory distress syndrome, disseminated intravascular coagulation, and death. Conclusion: Pancreatitis in pregnancy is predominantly caused by cholelithiasis, and unlike in the non-pregnant state, usually has a milder course.

Background: Despite an increase in the number of cesarean deliveries conducted worldwide, meta-analyses on the long-term effect of cesarean section (CS) on subsequent placental disorders are sparse. Objective: To examine the association between CS and three major types of placental disorders (placental abruption, placenta previa, and placenta accreta with its variants increta/percreta) in subsequent pregnancies. Search strategy: We followed the MOOSE consensus statement for meta-analyses of observational studies and searched the PubMed database for observational studies published between January 1990 and July 2011 for examining the association between CS and placental disorders in subsequent pregnancies, without focusing on the effect of increasing number of CSs. Selection criteria: We included studies which provided adjusted measures of association for multiparous singleton-pregnant women with one of the three outcomes and information about prior mode of delivery. Data collection and analysis: Five cohort and 11 case-control studies met the inclusion criteria for this meta-analysis. We combined the results of the included cohort and case-control studies as no significant heterogeneity was found across the studies. Main results: The calculated summary odds ratio was 1.47 (95% confidence interval, CI: 1.44–1.51) for placenta previa, 1.96 (95% CI: 1.41–2.74) for placenta accreta, and 1.38 (95% CI: 1.35–1.41) for placental abruption. Conclusion: In this meta-analysis, cesarean delivery appeared as a consistently reported risk factor for all three major forms of placental disorders in subsequent pregnancies.

Objective: To evaluate the risk of developing pulmonary edema in women exposed to nifedipine, magnesium sulfate (MgSO 4 ), or both in a preterm setting. Study design : We carried out a retrospective case-control study at a large tertiary care center from 2007 to 2012. Cases of pulmonary edema were age, and gestational age matched to controls at a ratio of 1 case to 4 controls. Logistic regression analysis was used to estimate the effect of nifedipine and/or MgSO 4 on the development of pulmonary edema while controlling for predetermined confounding variables. Stepwise logistic regression analysis was used to evaluate additional risk factors of pulmonary edema. Results: A total of 150 charts were reviewed (28 cases and 122 controls). Nifedipine did not increase the odds of developing pulmonary edema [adjusted odds ratio (OR)=1.22 (confidence interval (CI) 0.50, 3.01), P=0.67], whereas exposure to MgSO 4 , or both MgSO 4 and nifedipine, significantly increased the risk of developing pulmonary edema [adjusted OR=3.91 (CI 1.44, 10.65), P=0.008 and adjusted OR=4.75 (CI 1.15, 19.71), P=0.032, respectively]. In the stratified analysis, this association persisted even in nonpreeclamptic women [nifedipine: adjusted OR=0.91 (CI 0.33, 2.52), P=0.852; MgSO 4 : adjusted OR=3.51 (CI 1.26, 9.76), P=0.016; both: adjusted OR=3.39 (0.76, 15.07), P=0.108]. Other independent risk factors for pulmonary edema were multi-fetal pregnancy, azithromycin, and erythromycin administration. Conclusion: MgSO 4 treatment is strongly associated with the development of pulmonary edema when used either as a tocolytic agent or for seizure prophylaxis. In light of the availability of safer alternatives, MgSO 4 should be used for tocolysis only in cases whereby the benefits clearly outweigh the risks.

Aim: Evaluation of placental protein 13 (PP13) and risk factors (RFs) as markers for predicting preeclampsia (PE) and use of aspirin for PE prevention. Materials and methods: First-trimester pregnancy screening was based on having PP13 level ≤0.4 multiple of the median (MoM) and/or at least one major risk factor (RF) for PE. Management was by routine care or combined with daily treatment with 75 mg aspirin between 14 and 35 weeks of gestation. Results: Of 820 deliveries, 63 women developed PE (7.7%). Median PP13 levels was 0.2MoM in the PE group compared with 0.83MoM among unaffected and 1.0MoM in unaffected not treated with aspirin (P<0.0001). Low PP13 was a better predictor for PE versus major RFs, particularly for young nuliparous. Combining low PP13 with RFs increased prediction accuracy. Mean arterial pressure (not included in the initial prediction), could add to prediction accuracy when combined with low PP13 and RFs. PE prevention by aspirin was most effective when the risk was determined by low PP13 alone, less effective for combining low PP13 with RFs, and ineffective when determined by RFs alone. Conclusion: When PE risk is determined by low first trimester PP13 or by combined low PP13 and RFs, prevention with aspirin is warranted.

Aim: To compare the efficacy and safety of two misoprostol dosing regimens for induction of labour in primiparous (1P) and multiparous (>1P) women. Methods: Retrospective study of induction of labour using vaginal misoprostol 25 μg vs. 50 μg every 6 h in 942 women at a tertiary centre. The main outcome variables are induction-to-delivery interval, latency period duration, vaginal delivery within 24 h, and maternal and foetal safety outcome. Results: With the 50 μg regimen, induction-to-delivery intervals were significantly shorter: 18.4 h vs. 24.6 h (1P) and 14 h vs. 17.9 h (>1P), as was latency period duration (by 5.4 and 4 h, respectively). Vaginal delivery within 24 h was significantly more frequent, as were non-reassuring foetal heart rate (1P: 20% vs. 14%) and tachysystole (1P: 31% vs. 11%; >1P: 21% vs. 7%). No uterine rupture was reported. Neonatal outcomes were similar except for significantly more frequent infant referral to neonatal intensive care in the >1P group receiving the 50 μg regimen (11% vs. 4%). Conclusion: Vaginal misoprostol 25 μg seems to maintain efficacy with more acceptable maternal and neonatal safety. As induction of labour is an off-label use for misoprostol, safety should be prioritised with the lower dosage regimen despite the longer induction-to-delivery interval.

Aims: The purpose of this study was to compare the diagnostic performance of an immunoassay for placental alpha microglobulin-1 (PAMG-1) in vaginal fluid with the intra-amniotic instillation of indigo carmine for the diagnosis of membrane rupture in patients with an equivocal status. Methods: A prospective multi-site study was performed involving women reporting signs, symptoms, or complaints suggestive of rupture of membrane (ROM) between 21 and 42 weeks of gestation without obvious leakage of fluid from the cervical os during sterile speculum examination and without confirmation of ROM by traditional methods. Results: A total of 140 patients were recruited with a prevalence of ROM of 19.3%. The PAMG-1 test had a sensitivity of 100.0% [confidence interval (CI) 0.87–1.0], specificity of 99.1% [(CI) 0.95–0.99], positive predictive value of 96.3% [(CI) 0.82–0.99], negative predictive value of 100.0% [(CI) 0.97–1.0], and ± likelihood ratios of 74.6 [(CI) 20.31–274.51] and 0.0 [(CI) 0.00–0.98]. Conclusions: The PAMG-1 immunoassay in vaginal fluid yielded results that were comparable to those of the instillation of indigo carmine into the amniotic cavity; therefore, we propose that PAMG-1 is a sensitive and specific test to assess ROM in patients with an equivocal diagnosis based on simple tests. This finding prompts consideration for the use of the noninvasive PAMG-1 test in situations where the use of the invasive dye test is not practical.

Aims: To analyze the clinical differences between early- and late-onset cases of severe preeclampsia and to evaluate parameters that could help to predict perinatal outcome. Methods: Over a period of 6 years, all cases of severe preeclampsia (n=68) at our institution were included in a retrospective cohort analysis. Differences between early (<34 weeks, n=44) and late (≥34 weeks, n=24) onset of the disease were evaluated. Risk factors for low 5-min Apgar score (≤7), small-for-gestational-age (SGA) infants and neonatal acidosis (umbilical arterial pH <7.20) were identified and considered in a multiple logistic regression model. Results: Early- and late-onset severe preeclampsia differed from each other remarkably. Perinatal outcome was unfavorable in early-onset disease and seemed to be mainly a result of premature delivery and development of fetal growth restriction. Abnormal uterine Doppler velocimetry increased the risk of low 5-min Apgar values [odds ratio (OR) 8.0, P=0.012] and preterm birth <34+0 weeks (OR 17.9, P<0.001). An increased resistance of the umbilical artery was associated with a higher risk for SGA birth weight (OR 4.9, P=0.010). Conclusion: Preeclampsia is a heterogeneous syndrome even if only severe cases were analyzed. Abnormal Doppler flow characteristics facilitated the identification of patients who were at increased risk for worse perinatal outcome.

Aim: To analyze the role of maternal placental growth factor (PlGF) in the prediction of small for gestational age (SGA) birth weight in pregnancy complicated by type 1 diabetes mellitus (T1DM). Methods: A prospective observational study on 59 normotensive T1DM pregnant women, assessing maternal PlGF concentrations between the 10 th –14 th and 22 nd –25 th weeks of gestation. Results: Number of SGA vs. non-SGA newborns was 11 (18.6%) vs. 48 (81.4%), respectively. First trimester PlGF serum concentrations (pg/mL) were similar between SGA vs. non-SGA groups [data given as median (interquartile range)]: 65.5 (35.58–159.20) vs. 68.23 (11.59–150.03), respectively; P=0.44. A trend for lower PlGF concentrations was observed in the second trimester in the SGA vs. non-SGA group: 63.34 (12.79–119.16) vs. 116.75 (33.93–235.82); P=0.07. In the SGA group, PlGF concentrations did not differ between the first and the second trimester: 65.5 (35.58–159.20) vs. 63.34 (12.79–119.16), respectively; P=0.36. In the non-SGA group, PlGF concentrations were significantly higher at the gestational age of 22–25 weeks compared to 10–14 weeks [116.75 (33.93–235.82) vs. 68.23 (11.59–150.03); P=0.03). Conclusions: Decreased PlGF serum concentration in mid-pregnancy, as well as a lack of physiological increase in PlGF levels between early and mid-gestation, may precede development of SGA in women with T1DM.

Objective: To determine whether certain rheumatic diseases will affect the fetal thymus diameter when compared to uncomplicated singleton pregnancies. Additionally, we created a reference chart for fetal thymus size in healthy singleton pregnancies from 19 to 37 weeks of gestation. Methods: Sonographic fetal thymus size was retrospectively evaluated in 190 healthy pregnant women, and 84 pregnancies of mothers suffering from systemic lupus erythematosus, antiphospholipid syndrome (APS), or Sjögren’s syndrome between 19 and 37 weeks of gestation. These fetuses were matched one-to-one for gestational age with control fetuses. The thymic-thoracic ratio (TT-ratio) was defined as the quotient of the anteroposterior thymic and the intrathoracic mediastinal diameter. Results: Rheumatic diseases often affect pregnancy outcome, especially in case of primary APS. The TT ratio of fetuses of mothers suffering from rheumatic disease was equal to controls (P=0.807). Conclusions: Ours is the first study to assess the correlation of fetal thymus size in high-risk pregnancies with rheumatic diseases in comparison to controls. Women with rheumatic diseases deal with pregnancy complications more frequently than controls. Our data suggest that maternal rheumatic diseases do not affect the fetal thymus size.

This article traces the decline of milk from a heavenly elixir to a tradeable food. Early cultures regarded milk not as a simple nutrient, but a living fluid. Heroes and gods were believed to have been nurtured by animals after being abandoned. Character traits were assumed to be transmitted by milk; infantile diseases were attributed to “bad milk”, whereas “good milk” was used as a remedy. With chemical methods developed at the end of the 18 th century, it became known that human milk was higher in sugar and lower in protein than cow’s milk. During the 19 th century, “scientific” feeding emerged that meant modifying cow’s milk to imitate the proportion of nutrients in human milk. In Boston from 1893, Rotch initiated the “percentage” method, requiring a physician’s prescription. In Paris from 1894, Budin sterilized bottled infant milk. In Berlin in 1898, Rubner measured oxygen and energy uptake by calorimetry, prompting feeding by calories, and Czerny introduced regulated feeding by the clock. These activities ignored the emotional dimension of infant nutrition and the anti-infective properties of human milk. They may have also enhanced the decline in breastfeeding, which reached an all-time low in 1971. Milk’s demystification made artificial nutrition safer, but paved the way for commercially produced infant formula.

Aims: To assess placental transfer of antibodies to the child at birth and at 2 months of age. Materials and methods: For the quantification of anti-PT IgG antibodies, we used an indirect enzyme-linked immunosorbent assay standardized by The National Institute of Epidemiologic Diagnosis and Reference (InDRE). Samples were considered negative from 0 to 48 IU/mL, indeterminate from 49 to 93 IU/mL and positive at ≥94 IU/mL. We performed a cross-sectional assessment of anti-PT IgG antibody levels in the mother, umbilical cord, and child. Results: There was a higher concentration of IgG anti-TP in the umbilical cord (4.3%) and in the mother (1.4%), but a total absence was observed in the child (0%). Conclusion: The vulnerability of children to Bordetella pertussis shows the need to implement effective immunization strategies, whether actively, in the child, or passively through the mother, adolescents, and adults who are in contact with the child.

Aims: Dental personnel are exposed to mercury when using dental amalgam. This exposure constitutes a potential hazard to offspring of women working in dentistry. The present study examined increased mortality risk in offspring of mothers working in dentistry. Methods: Mortality was compared between sons of dental personnel and sons of nondental health-care personnel. Hazard ratios were calculated for three decades (1960s–1980s), when the magnitude of mercury exposure in dentistry was likely to have varied. Results: During the 1960s, there was a statistically significant increase in the risk of neonatal mortality for sons of dental nurses when compared with sons of assistant nurses: hazard ratio (HR) 1.82 (95% confidence interval, CI: 1.04–3.22). There was no increased risk in the subsequent decades, but a trend test demonstrated a consistent decrease in the risk over the three decades: HR for trend 0.63 (95% CI: 0.44–0.90). The raised mortality risk was limited to neonatal mortality. The comparison between dentists and physicians had insufficient statistical power. Conclusions: There is no increased mortality risk among sons of female dentists after the 1960s. Although the results should be interpreted with caution, they suggest a modestly raised risk of neonatal mortality, during the 1960s, when exposure to mercury was thought to be highest.