Volume 45, Issue 4 - Highlight: Antenatal Care

The relation between fertility and longevity has always been a subject of study and controversy. Indeed, life expectancy extension is found to be tied to late births. This conclusion can be drawn from social-observational studies like the Long Life Family Study in New England and the New England Centenarian Study on which was found that women whose last birth was after 40 years of age are more likely to live longer. Recently, a group in Israel published a review on animal and human studies that shed some understanding on the cellular mechanisms behind the association between pregnancy and tissue regeneration and repair. These studies shed some understanding to draw biological plausibility on the association between late pregnancy and life expectancy.

Objective: The objective of this study is to investigate the alterations caused by smoking on the features of fetal heart rate (FHR) tracings as well as to make a comparison between pregnant smokers and pregnant women with intrauterine growth restriction (IUGR). Study design: A number of established features derived from linear and nonlinear fields were employed to study the possible influence of maternal smoking on FHR tracings. Moreover, correlation and measures of complexity of the FHR were explored, in order to get closer to the core of information that the signal of FHR tracings conveys. Data included FHR tracings from 61 uncomplicated singleton pregnancies, 16 pregnant smoker cases, and 15 pregnancies of women with IUGR. Results: The analysis of FHR indicated that some parameters, such as mutual information (P=0.0025), multiscale entropy (P=0.01), and algorithmic complexity (P=0.024) appeared decreased in the group of pregnant smokers, while kurtosis (P=0.0011) increased. The comparison between pregnant smokers and pregnant women with IUGR indicated a reduction in Hjorth complexity (P=0.039) for the former. Conclusion: Smoking during pregnancy seems to induce differences in several linear and nonlinear indices in recordings of FHR tracings. This may be the consequence of an altered neurodevelopmental maturation possibly resulting from chronic fetal hypoxemia in cigarette-exposed fetuses.

Objective: To determine the levels of 8-isoprostane (8-IP) and 8-hydroxy-2′-deoxyguanosine (8-OHdG) in urine and in amniotic fluid (AF) of pregnant women and to assess the correlation between oxidative status in the maternal and fetal compartment in the second trimester of pregnancy. Methods: One hundred and forty-six women with singleton pregnancies, undergoing amniocentesis at the Department of Obstetrics and Gynaecology at the University Medical Centre Ljubljana, were prospectively enrolled. AF and maternal urine were collected in the second trimester of pregnancy. Paired urinary and AF 8-IP and 8-OHdG were measured and evaluated cross-sectionally. Results: 8-IP and 8-OHdG concentrations were higher in maternal urine compared to AF and the ratios were 47:1 and 50:1, respectively. AF 8-OHdG was very low and in 74% was below the limit of detection (LOD). We found a positive correlation between 8-IP in maternal and fetal compartment (ρ=0.217, P=0.008), which stayed unchanged also after adjustment for possible confounding factors. Conclusions: Oxidative damage to lipids and DNA is also a part of physiologic processes during healthy pregnancy. 8-IP and 8-OHdG are constantly present in urine and AF. A weak positive correlation between maternal and fetal unit suggests a weak reflection of fetal oxidative status in maternal urine in the mid-trimester.

Aim: Our objective was to measure the circulating levels of ischemia-modified albumin (IMA) among pregnant with hyperemesis gravidarum (HEG) and to compare their levels with age- and body mass index (BMI)-matched control pregnant women. Method: The pregnant subjects were classified into the HEG group diagnosed with HEG (n=45) and age- and BMI-matched control group without a diagnosis of HEG (n=45) during their pregnancies. Serum IMA, hemoglobin, hematocrit, white blood cells, platelet, fasting blood glucose, creatinine, lipid profile, aspartate aminotransferase (AST) urea, alanine aminotransferase (ALT), sodium, potassium and thyroid-stimulating hormone (TSH) levels of the groups were measured. Result: Serum hemoglobin, hematocrit, white blood cells, platelet, fasting blood glucose, creatinine, lipid profile, AST, urea, ALT, sodium, potassium and TSH levels of the groups were statistically similar. Serum IMA values were significantly higher in subjects with HEG compared to the subjects without HEG. Conclusions: We found that HEG was related to increased maternal serum IMA levels. HEG might be due to an ischemic intrauterine environment leading to elevated serum IMA concentrations.

Background: Decreased postpartum rotational thromboelastometric parameters of coagulation (ROTEM ® ) and fibrinogen levels have been associated with postpartum hemorrhage (PPH). However, the predictive power of prepartum ROTEM ® parameters and fibrinogen levels (Fbg pre ) for PPH remains unknown. Methods: This prospective observational pilot study included 217 healthy pregnant women. Maximum clot firmness (FIBTEM-MCF), fibrinogen levels and standard coagulation parameters were measured upon admission to the delivery room for labor and within 1 h after vaginal delivery. Blood loss was measured with a calibrated collecting drape during the third stage of labor. PPH was defined as blood loss ≥500 mL. Predictors for bleeding were identified via receiver operating characteristic analyses and bivariate and multivariate regression analyses. Results: Women with and without PPH did not differ in median FIBTEM-MCF [23 mm (25 th percentile 20 mm, 75 th percentile 26 mm) vs. 23 mm (19 mm, 26 mm), respectively; P=0.710] or mean Fbg pre (4.57±0.77 g/L vs. 4.45±0.86 g/L, respectively; P=0.431). Blood loss and prepartum coagulation parameters were not correlated (FIBTEM-MCF, r s =−0.055, P=0.431; Fbg pre , r s =−0.017, P=0.810). The areas under the curves (predictive power for PPH) for FIBTEM-MCF and Fbg pre and were 0.52 (0.41–0.64, P=0.699) and 0.53 [95% confidence interval (95% CI) 0.40–0.65, P=0.644], respectively. Neither FIBTEM-MCF nor Fbg pre was associated with PPH. However, primiparity [odds ratio (OR) 4.27, 95% CI 1.32–13.80, P=0.015) and urgent cesarean section (2.77, 1.00–7.67, P=0.050) were independent predictors of PPH. Conclusions: ROTEM ® parameters, Fbg pre and postpartum blood loss were not associated, nor did these factors predict PPH. Sufficiently powered prospective studies are needed to confirm these results.

Objective: To determine whether there is an effect of prenatal supplementation with docosahexaenoic acid (DHA) on the concentration of polyunsaturated fatty acids (PUFAs) in the breast milk of Chinese lactating women. Methods: A total of 409 participants were recruited at the postpartum care center during their 1-month postpartum care. They were assigned to the supplement group or the control group according to whether or not DHA supplements were taken during pregnancy. Dietary intake was assessed with a food frequency questionnaire (FFQ). Breast milk samples were collected on 1 day between the 22 nd and 25 th day postpartum and levels of eight kinds of fatty acids in the breast milk were measured by gas chromatography. Results: DHA intake was divided into three levels (<57 mg/day, 57–185 mg/day and >185 mg/day). The concentration of DHA postpartum in the breast milk of the group receiving a DHA supplement >185 mg/day was significantly higher (P=0.003) compared to the control group. Conclusions: DHA intake >185 mg/day resulted in increased DHA concentrations in breast milk. This finding suggests that mothers with inadequate dietary intake of DHA should change their dietary habits to consume a diet rich in DHA or take sufficient DHA supplements to meet the average nutritional needs of infants.

Objective: To compare the efficacy and safety of intravenous ferric carboxymaltose (FCM) with first-line oral ferrous sulfate (FS) in pregnant women with iron deficiency anemia (IDA). Materials and methods: Pregnant women (n=252; gestational weeks 16–33) with IDA were randomized 1:1 to FCM (1000–1500 mg iron) or FS (200 mg iron/day) for 12 weeks. The primary objective was to compare efficacy; secondary objectives included safety and quality of life. Results: Hemoglobin (Hb) levels improved at comparable rates across both treatments; however, significantly more women achieved anemia correction with FCM vs. FS [Hb ≥11.0 g/dL; 84% vs. 70%; odds ratio (OR): 2.06, 95% confidence interval (CI): 1.07, 3.97; P=0.031] and within a shorter time frame (median 3.4 vs. 4.3 weeks). FCM treatment significantly improved vitality (P=0.025) and social functioning (P=0.049) prior to delivery. Treatment-related adverse events were experienced by 14 (FCM; 11%) and 19 (FS; 15%) women, with markedly higher rates of gastrointestinal disorders reported with FS (16 women) than with FCM (3 women). Newborn characteristics were similar across treatments. Conclusions: During late-stage pregnancy, FCM may be a more appropriate option than first-line oral iron for rapid and effective anemia correction, with additional benefits for vitality and social functioning.

Objective: To assess whether maternal multiple sclerosis (MS) is associated with adverse pregnancy outcomes by determining the clinical course of disease during pregnancy and postpartum throughout a 10-year-period in a single tertiary center. Methods: We conducted a case-control study that included pregnancies with a definitive diagnosis of MS (n=43), matched with 100 healthy pregnant women with similar characteristics. Maternal and perinatal data were retrieved from hospital files. Groups were compared with the Mann-Whitney and χ 2 tests. Logistic regression models were constructed to determine independent effects. Results: Maternal demographic and baseline laboratory data were similar across the groups. Rates of preterm delivery, fetal growth restriction, preeclampsia, gestational diabetes, stillbirth, cesarean delivery, congenital malformation, and 5-min Apgar score were comparable (P>0.05 for all). General anesthesia during cesarean delivery (96% vs. 39%, P=0.002), urinary tract infection (UTI) (12% vs. 3%, P=0.04), low 1-min Apgar score (21% vs. 9%, P=0.04), and nonbreastfeeding (33% vs. 2%, P=0.001) were more frequent in women with MS. The low 1-min Apgar score and breastfeeding rates were independent of general anesthesia and UTI in regression models. Conclusion: MS during pregnancy was not associated with adverse maternal and perinatal outcomes except UTI, low 1-min Apgar scores, and decreased breastfeeding rates.

Aim: The present study aimed to determine the levels of total cholesterol, triglycerides (TG), low-density lipoproteins (LDL), high-density lipoproteins (HDL), and vitamins B1 and B2 in intrahepatic cholestasis of pregnancy (ICP) patients, and to evaluate if these were involved in the pathophysiology of the disease. Methods: The prospective randomized study included 35 pregnant patients who were admitted to the Gynecology and Obstetrics Polyclinic, Faculty of Medicine at Dicle University and who were diagnosed with ICP (Group 1), and 40 healthy pregnant women who were admitted in the same period and who had no systemic diseases that might complicate the pregnancy during the pregnancy follow-up (Group 2). Serum lipid levels and vitamins B1 and B2 were determined and compared, and statistical comparisons of the groups were made. Results: There was no difference between the TG levels of the two groups (P=0.631). Total cholesterol, LDL, HDL, and vitamin B1 and B2 levels were higher in Group 1 than in Group 2 (P=0.001, P=0.001, P=0.001, P=0.001, and P=0.032, respectively). Conclusions: Increased levels of vitamins B1 and B2 may indicate a need for increased energy metabolism at the fetus. So we believe that new studies are required, which will be supported by the placental analyses of the pyruvate and lactate levels in maternal blood at delivery and fetal cord blood in order to develop a better understanding on the fetal effects of energy metabolism.

Objective: The objective of our study was to evaluate the prevalence and clinical factors associated with hyponatremia in patients with preeclampsia. Study design: This is a descriptive study of all patients who delivered at our institution from 2013 to 2014. Patients with preeclampsia were identified from electronic medical records. Preeclampsia with and without severe features was defined using the criteria outlined in the American Congress of Obstetricians and Gynecologists Hypertension in Pregnancy guidelines. As sodium levels have been shown to be approximately 5 mEq/L lower in pregnancy, hyponatremia was defined as a sodium level <130 mEq/L. Results: We identified 332 pregnancies complicated by preeclampsia, including 277 singletons and 55 twins. Hyponatremia was noted in 32 (9.7%) patients. Preeclampsia with severe features was present in the majority of patients with hyponatremia, and hyponatremia was more common in those with preeclampsia with severe features compared to those without (P<0.001). Hyponatremia also occurred more frequently in twins (P=0.001) and in older women (P=0.017). Only one patient without hyponatremia had an eclamptic seizure. Conclusion: Hyponatremia is not uncommon in preeclampsia, and is even more common in those with preeclampsia with severe features and twin gestations. As women with preeclampsia are at risk for hyponatremia, serum sodium should be monitored, especially in women with preeclampsia with severe features or twin gestations.

Objective: To evaluate whether routine measurement of cervical length (CL) by transvaginal ultrasound (TVU) in twin pregnancies can enable identification of women who will give birth before 34 weeks and require antenatal corticosteroids (ACSs), and whether it can limit their administration to women who will give birth later. Study design: Retrospective comparative study in two tertiary referral centers in France. Women with twin gestations followed in two tertiary university hospital maternity units and who delivered from January 1, 2007 to December 31, 2009 were included. In one center, TVU was targeted to women with cases of suspected preterm labor, while the other center used it monthly for all twin pregnancies. The main outcome measure was the administration of a full course of ACS to twins delivered before 34 weeks. Results: Two hundred and seventy women were eligible in the “targeted use” group, and 296 women in the “routine use” group. The rate of administration of at least one full course of ACS for twins born before 34 weeks did not differ between the two groups (85.0% in the targeted use group and 90.0% in the routine use group, P=0.40), but the rate of such administration for those born after 34 weeks was lower in the targeted use group (25.7% vs. 81.2%, P<0.01). On adjusting for confounders using logistic regression modeling, no significant difference in ACS administration before 34 weeks was found between the two groups [adjusted odds ratio (aOR), 0.71, 95% confidence interval (CI), 0.39–1.30]. Conclusion: Routine monitoring performed every month of CL with TVU does not affect the rate of administration of ACS to twins born before 34 weeks, but is associated with a higher rate of such administration for those born later in the specific center of the study.

Objective To evaluate the association of a set (or the lack thereof) of pre-gravid maternal features with a better outcome in terms of gestational age and birth weight of twins. Methods Analysis of a Slovenian population-based cohort of all dichorionic twin pairs born at ≥22 weeks during an 11-year period from 2002 to 2013. The independent variables included tall stature (≥170 cm), multiparity, and normal pregravid body mass index (BMI). The outcome variables included gestational age and total twin birth weight. Results We studied 3232 dichorionic twins. Being “tall”, multiparous, and with a normal pregravid BMI was significantly associated with a higher total twin birth weight, more advanced gestational age, fewer sets with a total twin birth weight <3000 g, fewer births at ≤32 weeks, more pairs with a total twin birth weight >5000 g and more pairs born at ≥37 weeks. In contrast, women with the converse features had a significantly worse outcome. Being just multiparous was different only in the incidence of total twin birth weight >5000 g. Conclusion Maternal stature >170 cm, being multiparous, and having a normal pregravid BMI is association with improved outcomes in terms of gestational age and birth weight of twins.

Aim: The aim of this study was to investigate the involvement and immunophenotype of macrophages in acute chorioamnionitis (ACA) and chronic chorioamnionitis (CCA), marking amniotic fluid infection and anti-fetal rejection, respectively. Methods: Chorioamniotic membranes from (1) gestational age-matched cases without chorioamnionitis, (2) cases with ACA, and (3) cases with CCA were studied after immunohistochemical staining using antibodies against CD14, CD68, CD163, and DC-SIGN. Results: Macrophages increased prominently in the chorionic trophoblastic layer of both ACA and CCA cases in contrast to non-inflammatory cases. Macrophages in the decidua and the chorioamniotic membranes of ACA cases expressed CD14. Macrophages in the chorionic trophoblastic layer of CCA cases were characterized by CD68 positivity. DC-SIGN-positive cells were increased in the chorioamniotic mesodermal layer of CCA cases. Conclusions: Macrophages participate in the inflammatory response in ACA and CCA. The differential immunophenotypes of macrophages in the decidua and chorioamniotic membranes of ACA and CCA cases suggest their disease-specific and region-specific roles at the feto-maternal interface.

Objective: To compare longitudinal trends of cardiotocographic (CTG) parameters between small-for-gestational-age (SGA) and normal fetuses, from 24 to 41 weeks of pregnancy. Methods: A prospective cohort study was carried out in singleton pregnancies without fetal malformations. At least one CTG was performed in each of the following intervals: 24–26 weeks+6 days, 27–29 weeks+6 days, 30–32 weeks+6 days, 33–35 weeks+6 days, 36–38 weeks+6 days and ≥39 weeks. Tracings were analyzed using the Omniview-SisPorto ® 3.6 system. Cases with a normal pregnancy outcome, including a birthweight ≥10 th percentile for gestational age, were compared with two groups of SGA fetuses: with birthweight <10 th percentile (SGA<p10) and <3 rd percentile (SGA<p3; a subgroup of the latter). Generalized linear mixed-effects models were used for analysis. Results: A total of 176 fetuses (31 SGA) and 1256 tracings (207 from SGA fetuses) were evaluated. All CTG parameters changed significantly throughout pregnancy in the three groups, with a decreasing baseline and probability of decelerations, and an increasing average long-term variability (LTV), average short-term variability (STV) and accelerations. Baseline showed a more pronounced decrease (steeper slope) in SGA fetuses, being higher in these cases at earlier gestational ages and lower later in pregnancy. Average LTV was significantly lower in SGA<p3 fetuses, but a parallel increase occurred in all groups. There was a considerable inter-fetal variability within each group. Conclusion: A unique characterization of CTG trends throughout gestation in SGA fetuses was provided. A steeper descent of the baseline was reported for the first time. The findings raise the possibility of clinical application of computerized CTG analysis in screening and management of fetal growth restriction.