Volume 47, Issue 8

Complications of preterm birth (PTB) are the global leading cause of death in children younger than 5 years of age. Almost 15 million children are born prematurely in the world each year. Increasing evidence suggests that labor and delivery have many hallmarks of an inflammatory reaction, where complement activation has an active participation. As one of the most important components of inflammation, the role of complement during labor and PTB is becoming an attractive research target. The complement components C1q and C5b-9 are deposited on fetal membranes and release inflammatory mediators that contribute to uterine contractions, cervical ripening, cell chemotaxis, metalloproteinases production, membrane awaking and rupture, and it participates as a co-adjuvant in the onset and progress of labor. This article reviews a basic description of the complement system, its role in preterm birth and current concepts regarding its contribution in novel therapy strategies and new biomarkers.

Objective To assess post-partum inflammation for patients delivering prior to 34 6/7 weeks by birth etiology. Methods This was an observational study of early preterm birth (PTB) occurring between 20 0/7 and 34 6/7 weeks of gestation. Serum C-reactive protein (CRP) levels were measured 1 month post-partum. CRP measurements were compared by birth etiology. Results A total of 399 women were analyzed. Distribution of birth etiology was 35% (n = 138) preterm labor (PTL), 28% (n = 115) preterm premature rupture of membranes (pPROM), and 37% (n = 141) indicated preterm birth (IPTB). Serum CRP varied by birth etiology (P = 0.036). Women with pPROM had elevated median CRP levels compared to women with PTL (P = 0.037). IPTB demonstrated elevated CRP levels when compared to PTL (P = 0.019). Pre-eclamptic/eclamptic subjects exhibited increased median CRP levels compared to PTL (P = 0.04). Conclusion Post-partum inflammation varies by birth etiology. Such variation may serve as identification of subjects whose future pregnancies and, ultimately, overall health status may benefit from inter-pregnancy interventions aimed at reducing inflammatory-associated risk factors.

Background The aim of this study was to compare transabdominal and transcervical chorionic villus sampling (CVS) as well as amniocentesis (AC) with respect to their rates of premature delivery and fetal growth restriction. Methods We retrospectively evaluated the mentioned procedures of invasive prenatal testing performed in a single center between 2001 and 2016. Seven hundred and ninety-nine cases of AC and 719 cases of CVS were included, of which 400 were performed transvaginally. Only singleton pregnancies with a normal karyotype and delivery after 24 + 0 weeks of gestation were included. Fetal growth restriction was defined as birth weight below the 10 th percentile. Premature delivery was defined as delivery before 37 + 0 weeks of gestation. Data were compared to a control group without an invasive procedure. Results The frequency of premature delivery was 8.5% after transabdominal CVS, 6.3% after transcervical CVS and 10.5% after AC as compared to 10.8% in the control group. The frequency of fetal growth restriction was 8.2% after transabdominal CVS 6.8% after transcervical CVS and 8.4% after AC as compared to 9.7% in the control group. Conclusion Our study supports that the three different methods of invasive prenatal testing do not lead to a higher risk of either premature delivery or fetal growth restriction when compared to controls. We found no difference in risk profile among the three techniques.

Objectives To investigate the correlation between transperineal (TP) and transvaginal (TV) ultrasonography in the measurement of cervical length (CL) in the third trimester of pregnancy. Methods In this prospective study, CL measurements were conducted in women between 31 and 34 weeks of gestation by both the TP and TV approaches. A comparison of the measurements was made between the two techniques. The Pearson correlation coefficient, the paired samples t -test and Bland-Altman plot were used. Results In total, 240 women participated in the study. The CL was successfully measured transvaginally in all cases and transperineally in 229 (95.4%) of the cases. The mean TV CL was 32.8 ± 8.2 mm and the mean TP CL was 32.5 ± 8.1 mm. In the 229 cases with paired measurements, the Pearson correlation coefficient was 0.964. No significant differences in mean CL were identified between the two methods ( t  = 1.805; P = 0.072). In the Bland-Altman plot, the difference between the paired means was 0.26 mm and the 95% tolerance interval for any given paired observation (TV CL–TP CL) was −4.05 to 4.57 mm. Conclusion The findings of this study suggest that at 31–34 weeks of gestation the cervix can be visualized adequately by both the TV and TP sonography in about 95% of cases. The TP CL measurements demonstrate a close correlation with the TV measurements. TP ultrasound is a feasible alternative, especially in cases where the use of the vaginal transducer should be minimized or is not acceptable by women.

Background Monocytes, after neutrophils, are the most abundant white blood cells found in the amniotic cavity of women with intra-amniotic inflammation/infection. However, the origin of such cells has not been fully investigated. Herein, we determined (1) the origin of amniotic fluid monocytes/macrophages from women with intra-amniotic inflammation/infection, (2) the relationship between the origin of amniotic fluid monocytes/macrophages and preterm or term delivery and (3) the localization of monocytes/macrophages in the placental tissues. Methods Amniotic fluid samples (n = 16) were collected from women with suspected intra-amniotic inflammation or infection. Amniotic fluid monocytes/macrophages were purified by fluorescence-activated cell sorting, and DNA fingerprinting was performed. Blinded placental histopathological evaluations were conducted. Immunohistochemistry was performed to detect CD14+ monocytes/macrophages in the placental tissues. Results DNA fingerprinting revealed that (1) 56.25% (9/16) of amniotic fluid samples had mostly fetal monocytes/macrophages, (2) 37.5% (6/16) had predominantly maternal monocytes/macrophages and (3) one sample (6.25% [1/16]) had a mixture of fetal and maternal monocytes/macrophages. (4) Most samples with predominantly fetal monocytes/macrophages were from women who delivered early preterm neonates (77.8% [7/9]), whereas all samples with mostly maternal monocytes/macrophages or a mixture of both were from women who delivered term or late preterm neonates (100% [7/7]). (5) Most of the women included in this study presented acute maternal and fetal inflammatory responses in the placenta (85.7% [12/14]). (6) Women who had mostly fetal monocytes/macrophages in amniotic fluid had abundant CD14+ cells in the umbilical cord and chorionic plate, whereas women with mostly maternal amniotic fluid monocytes/macrophages had abundant CD14+ cells in the chorioamniotic membranes. Conclusion Amniotic fluid monocytes/macrophages can be of either fetal or maternal origin, or a mixture of both, in women with intra-amniotic inflammation or infection. These immune cells could be derived from the fetal and maternal vasculature of the placenta.

Background Placental elasticity varies in different diseases. Our objective was to evaluate placental elasticity using point shear wave elastography (pSWE) in pregnancies with intrauterine growth restriction (IUGR). Methods A total of 66 pregnant women with IUGR and 81 healthy pregnant women were enrolled. Placental elasticity was measured using the transabdominal pSWE method. Ten measurements were made, and the mean was accepted as the mean placental elasticity value in each case. The results for IUGR pregnancies and controls were compared. Results The mean pSWE values were significantly higher in pregnancies with IUGR, which means that women with IUGR have stiffer placentas (P < 0.001). Furthermore, the pSWE values were significantly and positively correlated with Doppler indices and adverse perinatal outcomes. Conclusion The pregnancies with IUGR had stiffer placentas than the healthy controls. The utilization of pSWE for placental elasticity may be useful in the diagnosis and management of IUGR as a supplement to the existing ultrasonography methods.

Background When discussing termination of pregnancy (TOP) after the first trimester, the main foci are the ethics and psychological reasoning/consequences. In daily clinical practice, physicians are often faced with affected women querying the frequency of their condition(s) and decisions made by women in similar situations. The present study aimed to provide an overview of a representable number of such cases. Methods Cases of TOP beyond 14 + 0 weeks of gestation were collected between January 2000 and December 2017 in the Department of Obstetrics. Fetal and/or maternal medical causes leading to TOP were extracted and presented. Results A total of 1746 TOPs ≥14 + 0 weeks were performed. Reasons leading to TOP were subcategorized into 23 groups. The main medical diagnoses were trisomy 21 (15.5%), neurological malformations (11.0%), and cardiac and major vessel malformations (7.9%). There was no statistical difference concerning maternal age or gravida/para between the groups. The average gestational age (GA) was 21.0 weeks, varying between 16.2 and 24.2 weeks in the 23 subgroups, with an average of 23.6% per year of TOPs after viability. Conclusion An overview of the various causes of TOP and their frequency within a large dataset are shown here. According to data provided by the German Federal Statistical Office, the overall number of TOPs has declined over the past two decades; however, the number and percentage of TOPs beyond viability have increased continuously in Germany. Only early detection of maternal and fetal constitution can prevent a portion of TOP after viability.

Background Although cesarean sections at full dilatation are increasing, training in delivering a deeply impacted fetal head is lacking among obstetricians. The purpose of the study was to implement and evaluate a theoretical and simulation-based training program for this obstetrical emergency. Methods We developed a training program consisting of a theoretical introduction presenting a clinical algorithm, developed on the basis of the available literature, followed by a simulation session. We used the Kirkpatrick’s framework to evaluate the program. A questionnaire was distributed, directly before, immediately and 6 weeks after the training. Self-perceived competencies were evaluated on a 6-point Likert scale. Pre- and post-test differences in the Likert scale were measured with the Wilcoxon signed rank test. Additionally, the training sessions were video recorded and rated with a checklist in relation to how well the algorithm was followed. Results Eleven residents and eight senior physicians took part to the training. More than 40% of participants experienced a comparable situation after the course during clinical work. Their knowledge and self-perceived competencies improved immediately after the training program and 6 weeks later. Major improvements were seen in the awareness of the algorithm and in the confidence in performing the reverse breech extraction (14.3% of the participants felt confident with the maneuver in the pre-training assessment compared with 66.7% 6 week post-training). Conclusion Our theoretical and simulation-based training program was successful in improving knowledge and confidence of the participants in delivering a deeply impacted fetal head during a cesarean section performed at full dilation.

Objective To describe the scenario of academic tweeting and utilization of Twitter by editorial board members of the leading journal in obstetrics and gynecology. Methods The Twitter presence of an editorial board members of obstetrics and gynecology journal with an impact factor greater than 4 was determined. Details of their Twitter activity, year of graduation from medical school and gender were analyzed. Median SparkScore™, an online influence measure, of journals was compared to the highest impact factor journals in medicine ( New England Journal of Medicine , The Lancet , The British Medical Journal and Journal of the American Medical Association ). Results In the six highest impact factor journals in obstetrics and gynecology, 92 of 240 (38.3%) editorial board members had an active Twitter account. The Twitter presence of editorial members of Obstetrics and Gynecology was statistically less when compared to all other journals (P < 0.01). The median number of tweets in the last 24 h and 7 days were 0. Median SparkScore™ for the highest impact factor obstetrics and gynecology journals (24) were lower compared to the highest impact journals in medicine (66) (P = 0.03). Conclusion Editorial board members of the six highest impact factor journals in obstetrics and gynecology are not capitalizing on the dynamic nature of Twitter and its instant convenient access from our smartphones to further academia, when compared to specialties in medicine. There is a need for increased adoption of Twitter among physician leaders in the specialty.

Objective To evaluate our ability in classifying the fetal heart as normal or abnormal during the 1 st trimester scan through fetal cardiac examination and determining the best time for this examination. Methods This was a prospective study performed on 3240 pregnant women to examine the fetal heart. Four chambers view and ventricular outflow tracts were mainly examined during the scan. We used grayscale and color mapping in the diagnosis. Color Doppler was used if additional information was needed, and all patients were rescanned during the 2 nd trimester to confirm or negate our diagnosis. Results The cardiac findings were normal at both scans in 3108 pregnancies. The same cardiac abnormality was detected at both scans in 79 cases. In 36 cases there was false-positive diagnosis at the early scan; in 20 of these cases, there were mildly abnormal functional findings early in pregnancy with no abnormality found later. In 17 fetuses, there was discordance between the early and later diagnosis due to missed or incorrect diagnoses. The best time to do fetal heart examination during 1 st trimester is between 13 and 13 + 6 weeks. Conclusion A high degree of accuracy in the identification of congenital heart disease (CHD) can be achieved by a 1 st trimester fetal echocardiography.

Background This study aimed to investigate fetal cardiac functions by spectral tissue Doppler imaging (s-TDI) in pregnancies complicated with late-onset fetal growth restriction (LO-FGR) and small-for-gestational age (SGA). Methods Forty pregnancies complicated with late-onset FGR and 40 pregnancies complicated with SGA between the 34 th and 37 th weeks of gestation were enrolled in this study. Forty gestational age-matched pregnant women with no obstetrics complication were randomly selected as a control group. Small fetuses were classified as fetal growth restriction or SGA according to estimated fetal weight (EFW), umbilical artery pulsatility index (PI), cerebroplacental ratio (CPR) and uterine artery PI. s-TDI measurements were obtained at the right atrioventricular valve annulus. Results SGA and LO-FGR fetuses had significantly lower A′ and S′ values, and higher E′/A′ ratio than the control group (P < 0.001). In comparison to controls, significantly prolonged isovolumetric contraction time (ICT′) and isovolumetric relaxation time (IRT′) and, significantly shortened ejection time (ET′) were observed in fetuses with SGA and LO-FGR. Increased myocardial performance index (MPI′) values were also found in fetuses with SGA and LO-FGR compared to controls. Conclusion The signs of cardiac dysfunction were observed both in fetuses with SGA and LO-FGR. The fetal cardiac function assessment with s-TDI could be a valuable method in the diagnosis of true growth restricted fetuses and in the management of these fetuses.

Background Preterm newborns may be discharged when clinical conditions are stable. Several criteria for early discharge have been proposed in the literature. This study carried out the first quantitative comparison of their impact in terms of hospitalization savings, safety and costs. Methods This study was based on the clinical histories of 213 premature infants born in the Neonatal Intensive Care Unit of Padova University Hospital between 2013 and 2014. Seventeen early discharge criteria were drawn from the literature and retrospectively applied to these data, and computation of hospitalization savings, safety and costs implied by each criterion was carried out. Results Among the criteria considered, average gains ranged from 1.1 to 10.3 hospital days and between 0.3 and 1.1 fewer infections per discharged infant. Criteria that led to saving more hospital days had higher cost-effectiveness in terms of crisis and infection, and they spared infants from more infections. However, episodes of apnea and bradycardia were detected after the potential early discharge date for all criteria, with a mean number of episodes numbering between 0.3 and 1.4. Conclusion The results highlight a clear trade-off between days saved and health risks for infants, with potential consequences for health care costs.