Outcomes of pregnancy and delivery in women with cardiac disease compared to matched healthy controls.

OBJECTIVE: We compared pregnancy and delivery outcomes between women with cardiac disease versus matched healthy controls. The primary outcome was the frequency of unplanned cesarean delivery. METHODS: In this single-center retrospective case-control study, women with cardiac disease were identified and matched (1:2 ratio, according to maternal age, parity, number of prior cesareans, gestational age, delivery onset and fetal presentation) to healthy controls who delivered within the same year. Outcomes were frequency of unplanned cesarean delivery, complications during pregnancy and postpartum course, intensive care unit (ICU) admissions, and length of hospitalization. RESULTS: One hundred and twelve women with cardiac disease (exposed group, 225 deliveries) were identified and matched with 450 healthy women (controls, 2003-2014). The cohort comprised of 103 women (204 deliveries) with acquired heart disease (valve disease [n = 69], arrhythmia [n = 31], 3 with cardiomyopathy and peri/myocarditis, and 9 women (21 deliveries) with congenital heart disease. The frequency of unplanned cesarean was 14 (7.9%) for the exposed group as compared with 12 (3.4%) in controls with an odds ratio of 2.33 (95% CI = 1.0.2-5.32, p = .045). This difference was accentuated in a sub-group of women with severe cardiac disease (15% vs. 4.2% in matched control group, p = .028). Seventy-one (31.6%) exposed women exhibited obstetric and cardiovascular complications during pregnancy as compared with 65 (14.4%) controls, p < .001. Twenty-five (13.9%) exposed women experienced postpartum complications versus 26 (7.5%) in the control group (p = .019). Maternal ICU admission occurred in 13 (7.3%) of the exposed group as compared with only 2 (0.6%) in controls (p < .001). CONCLUSIONS: Women with a background cardiac condition, particularly those with severe disease, are at a higher risk for an unplanned cesarean delivery and other peripartum complications as compared with matched healthy controls.

History-indicated cervical cerclage in management of twin pregnancy.

OBJECTIVE: Cervical cerclage, when performed in twin gestation, has been reported to be associated with poor outcome. However, the role of first-trimester history-indicated cerclage among women with a twin pregnancy and a history of preterm birth has not been evaluated. The aim of this study was to assess pregnancy outcomes among women with a twin pregnancy who underwent first-trimester history-indicated cervical cerclage compared with outcomes in those managed expectantly. METHODS: This was a retrospective matched case-control study. The study group comprised all women with a twin pregnancy who had undergone first-trimester history-indicated cerclage during the period 2006 to 2017 at Hadassah-Hebrew University Medical Center. A control group of women with a twin pregnancy who were managed expectantly was established by matching age, history of spontaneous preterm birth (20-36 weeks' gestation) and year of delivery. Pregnancy and delivery characteristics and neonatal outcomes were compared between the two groups. RESULTS: Data from 82 women with a twin gestation were analyzed, of whom 41 underwent first-trimester history-indicated cerclage and 41 were matched controls who were managed expectantly. Gestational age at delivery was higher in the cerclage group than in those managed expectantly (median 35 vs 30 weeks; P < 0.0001). Rates of spontaneous preterm birth before 24 weeks (2.4% vs 19.5%; odds ratio (OR), 0.10 (95% CI, 0.01-0.87); P = 0.03), before 28 weeks (12.2% vs 34.1%; OR, 0.27 (95% CI, 0.09-0.84); P = 0.03), before 32 weeks (22.0% vs 56.1%; OR, 0.22 (95% CI, 0.08-0.58); P = 0.003) and before 34 weeks (34.1% vs 82.9%; OR, 0.11 (95% CI, 0.04-0.30); P < 0.0001) were significantly lower in the cerclage group than in the control group. Median birth weight was higher in the cerclage group (2072 g vs 1750 g; P = 0.003), with lower rates of low birth weight (< 2500 g) (65.0% vs 89.4%; P = 0.001) and very low birth weight (< 1500 g) (21.3% vs 37.9%; P = 0.03) than in the group managed expectantly. Rates were also lower in the cerclage group for stillbirth, admission to the neonatal intensive care unit, respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, sepsis, neonatal mortality and composite adverse neonatal outcome. CONCLUSIONS: History-indicated cerclage performed in the first trimester, as compared with expectant management, in women with a twin pregnancy had an overall positive effect on pregnancy and neonatal outcomes. These findings suggest the need for adequate randomized trials on cerclage placement in this subset of women. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

The risk of overt diabetes mellitus among women with gestational diabetes: a population-based study.

AIMS: To determine the incidence of postpartum diabetes mellitus in the years following a diagnosis of gestational diabetes mellitus (GDM) and to determine whether the severity of GDM, represented by the magnitude of the deviation of diagnostic tests from the normal values or requirement for medications, is associated with the development of diabetes. METHODS: A retrospective cohort study was performed among 185 416 pregnant women who had glucose challenge test or 3 h oral glucose tolerance test (OGTT) in a large health maintenance organization in Israel. Subsequent diagnosis of diabetes was ascertained by using an automated patient registry. RESULTS: A total of 11 270 subjects were diagnosed with GDM, comprising 6.07% of the cohort. During a total follow-up period of 1 049 334 person-years there were 1067 (16.9 per 1000 person-years) and 1125 (1.1 per 1000 person-years) diagnoses of postpartum diabetes among GDM and non-GDM women, respectively. The cumulative risk of incident diabetes in GDM patients with up to 10 years of follow-up was 15.7%, compared with 1% among the non-GDM population. Gestational diabetes mellitus was associated with nearly an eightfold higher risk of postpartum diabetes after adjusting for important confounders, such as socioeconomic status and body mass index. Among women with a history of GDM, the number of abnormal OGTT values and use of insulin were associated with a substantially higher risk for developing diabetes. CONCLUSIONS: Three or four abnormal OGTT values and GDM requiring insulin or oral hypoglycaemic medications are important predictors of postpartum diabetes risk in women with a history of GDM.

Randomized controlled trial of external cephalic version in term multiparae with or without spinal analgesia.

BACKGROUND: Neuraxial analgesia significantly increases the success rate of external cephalic version (ECV) among nulliparae. The study objective was to compare ECV success among multiparae with and without spinal analgesia. METHODS: Prospective randomized controlled trial performed over a pre-defined 6 yr period in a tertiary referral delivery suite. Healthy multiparae at term requesting ECV for breech presentation, without fetal or uterine anomaly, were enrolled after written informed consent. Women were randomized to receive either spinal analgesia (bupivacaine 7.5 mg) or no analgesia before the ECV. The primary outcome was successful conversion from breech to vertex presentation, confirmed by ultrasound. Visual analogue pain score and adverse outcomes (complications of anaesthesia or ECV) were recorded. Statistical analysis was performed according to intention to treat using two-sided tests. RESULTS: Among 265 multiparae who underwent ECV, 65 consented to enrol, one subsequently refused ECV; therefore, data from 64 women were analysed. ECV was successful in 27 of 31 patients (87.1%) receiving spinal analgesia vs 19 of 33 (57.5%) with no analgesia (P=0.009; 95% CI of difference: 0.075-0.48). ECV with spinal analgesia reduced visual analogue pain score, mean (sd) 1.7 (2.4) vs 5.5 (2.9) without (P<0.0001). Maternal hypotension was seen after spinal analgesia in 10 of 31 (32%) (P=0.0003) and easily treated without adverse outcome. No complications were noted after the ECV. CONCLUSIONS: Administration of spinal analgesia significantly increased the rate of successful ECV among multiparae at term with increased patient comfort. The trial was registered at the National Institute of Health Trials Registry, NCT00119184, www.clinicaltrials.gov.

Walking reduces the post-void residual volume in parturients with epidural analgesia for labor: a randomized-controlled study.

BACKGROUND: The post-void residual volume is higher among parturients who received epidural analgesia than those who received no or alternative analgesia. METHODS: This prospective, randomized, controlled, non-blinded study was performed in a tertiary referral center labor suite. The post-void residual volume was measured by a transabdominal ultrasound following a voiding attempt. Healthy parturients with low-dose epidural analgesia in active labor were randomized either to walk to the toilet or to use a bedpan for voiding. The primary outcome measure (post-void residual volume in labor) was compared between the study groups. RESULTS: The toilet group (n=34) and the bedpan group (n=28) demonstrated similar post-void residual volumes (212 +/- 100 vs. 168 +/- 93 ml, P=0.289). Twenty patients (59%) randomized to the toilet group were unable to walk and actually voided in a bedpan. A secondary analysis was performed analyzing the groups as treated. The post-void residual volume was significantly lower in the actual toilet group (n=14, 63 +/- 24 ml) vs. the bedpan group (n=48, 229 +/- 200 ml), P=0.0052. Thirteen (93%) women who walked to the toilet managed to void before the ultrasound measurement vs. 20/48 (42%) using the bedpan, P=0.001. Fewer women who managed to walk to the toilet required urinary bladder catheterization during the labor than women who used the bedpan (6/14, 43% vs. 36/48, 75%) P=0.028. CONCLUSION: Women who were randomized to walk to the bathroom with epidural analgesia and were able to do so during labor had a significantly reduced post-void residual volume and a reduced requirement for urinary catheterization.

Early diagnosis and treatment of atrioventricular block in the fetus exposed to maternal anti-SSA/Ro-SSB/La antibodies: a prospective, observational, fetal kinetocardiogram-based study.

BACKGROUND: A fetus exposed to maternal anti-SSA/Ro or anti-SSB/La antibodies (or both) may develop complete atrioventricular block (AVB), which results in high prenatal and postnatal morbidity and mortality. Until recently, only high-grade AVB could be diagnosed in utero. The tissue velocity-based fetal kinetocardiogram (FKCG) enables accurate measurement of AV conduction time and diagnosis of low-grade AVB. In the present multicenter observational study, we used FKCG to detect first-degree AVB in fetuses at risk. METHODS AND RESULTS: FKCG was performed in 70 fetuses of 56 mothers who were positive for anti-SSA/Ro and/or anti-SSB/La. Fetuses were monitored with weekly FKCG from 13 to 24 weeks' gestation, followed by monthly assessments until delivery in unaffected fetuses and weekly assessments in affected fetuses. AV conduction in 70 at-risk and 109 normal fetuses was compared. FKCG was obtained readily in all fetuses; 6 showed first-degree AVB (AV conduction time >2 z scores above normal mean) at 21 to 34 gestational weeks. Immediate maternal treatment with dexamethasone resulted in normalization of AV conduction in all affected fetuses within 3 to 14 days. AV conduction time in the remaining 64 untreated fetuses remained normal throughout gestation. The ECG PR interval immediately after birth was normal in all affected newborns. No child developed AVB or cardiomyopathy in the subsequent 1- to 6-year (median 4-year) follow-up. CONCLUSIONS: The present findings suggest that an FKCG can detect first-degree AVB in the fetus exposed to maternal anti-SSA/Ro or anti-SSB/La antibodies (or both). Dexamethasone given on detection was associated with normalized AV conduction in fetuses with first-degree AVB. No fetus in the present study developed complete prenatal or postnatal AVB.

Antepartum continuous epidural ropivacaine therapy reduces uterine artery vascular resistance in pre-eclampsia: a randomized, dose-ranging, placebo-controlled study.

BACKGROUND: No therapy is currently available to improve the reduced uteroplacental blood flow (UPBF) that characterizes pre-eclampsia. We hypothesized that sympathectomy induced by epidural local anaesthesia reduces uterine vascular resistance (which is inversely correlated with UPBF) in pre-eclampsia. METHODS: Ten pregnant women between 24 and 32 weeks of gestation with pre-eclampsia and uterine artery flow abnormalities were randomized to antepartum continuous epidural therapy (ACET) or control. ACET was initiated by a 5 day dose-ranging trial (ACET-1) of 0.04, 0.06, 0.08, and 0.1% ropivacaine and saline placebo, each at 10 ml h(-1) for 24 h. Doses were randomized and double-blind. Doppler ultrasound indices of vascular resistance were assessed at baseline and after each 24 h dosing period in both uterine arteries. Subsequently, these ACET patients were administered 0.1% ropivacaine until delivery (ACET-2), with one additional randomized double-blind placebo day. RESULTS: Five patients were randomized to ACET. In each patient, one uterine artery exhibited a dose-dependent reduction in vascular resistance (P=0.035), a response that returned to baseline following placebo (P<0.001). The contralateral uterine artery exhibited either increased vascular resistance or no change. In all cases, the uterine artery that responded to ACET had higher baseline resistance than its pair (P=0.043). Baseline right-left difference in resistance between paired uterine arteries was greatly diminished following ACET. Although ACET patients had a mean (sd) duration to delivery of 19 (9) days compared with control 2 (1) days (P=0.008), this should be interpreted with caution because of demographic differences between groups. CONCLUSIONS: ACET reduces uterine artery resistance in pre-eclampsia <32 weeks. Uteroplacental re-distribution is a novel observation and warrants further investigation.

Maternal morbidity following routine second trimester genetic amniocentesis.

Two cases of septic complications of routine second trimester amniocentesis are presented. The first case is a 37-year-old gravida suffering from ulcerative colitis who was admitted for amniocentesis in the 18th week of her third pregnancy. An uncomplicated transabdominal amniocentesis was performed using a sterile technique and ultrasound guidance. Twenty-eight hours later the patient had a septic abortion and sepsis. The second case is a 34-year-old gravida in the 24th week of her pregnancy who was admitted with amnionitis 10 h after an uncomplicated amniocentesis, and subsequently had a septic abortion. A high index of suspicion and rapid intervention were crucial in both cases.

Post-void residual volume in labor: a prospective study comparing parturients with and without epidural analgesia.

BACKGROUND: This prospective, non-randomized study compared post-void residual volume in laboring and postpartum women with or without epidural analgesia. METHODS: The study was conducted over 1 year with institutional review board approval. Parturients were recruited in early labor and self-selected to either the study (with epidural) or control (without epidural) group. Post-void residual volume was compared between groups, using transabdominal ultrasound during labor, and on postpartum day 1 and 2. Main outcome measure was intrapartum residual bladder volume. RESULTS: Thirty patients were recruited to each group. During labor, residual bladder volume was significantly larger in the epidural group compared with the non-epidural group [median (range)] 240 (12-640), ml vs. 45 (13-250) ml, respectively, P < 0.001], but was similar on postpartum day 1 and 2. Twenty-five (83%) women with epidural analgesia required bladder catheterization during labor vs. one (3.3%) without (P < 0.0001). CONCLUSION: The greater post-void residual volume and increased inability to void in parturients with epidurals suggests that epidural analgesia plays a role in intrapartum urinary retention.

Holy consent--a dilemma for medical staff when maternal consent is withheld for emergency caesarean section.

A parturient (grand multipara) developed arrested labour complicated by severe fetal heart rate decelerations. Senior physicians explained the need for a caesarean section, but she chose to deliver vaginally since rabbinical blessing could not be obtained. Forcing the mother to have a cesarean section without consent is considered "civil battery." The dilemma faced by medical staff and the implications of her refusal for the treating medical staff are described.

Caesarean section following the Fontan procedure: two different deliveries and different anaesthetic choices in the same patient.

The Fontan procedure is performed for patients with a hypoplastic right ventricle, and pregnancies following this palliative surgery are likely to increase. We present a parturient with the Fontan physiology who successfully underwent two consecutive caesarean deliveries; the first under general anaesthesia for emergency surgery and the second under regional anaesthesia for elective surgery. We suggest that pregnancy and delivery do not typically adversely affect maternal cardiac status in these patients. Attention must be paid, however, to fetal loss, prematurity, growth retardation and associated cardiac congenital malformations for which insufficient data exist in the literature in this patient population.

Fetal intracranial hemorrhage (fetal stroke): does grade matter?

OBJECTIVE: To determine if the severity of antenatally diagnosed hemorrhagic fetal brain insults and fetal stroke detected by ultrasound and magnetic resonance imaging (MRI) predicts postnatal neurodevelopmental prognosis. METHODS: The in-utero presentation and postnatal neurodevelopmental outcome of sonographically detected subdural hematoma or fetal stroke presenting as intraventricular hemorrhage (IVH) or intraparenchymal brain hemorrhage were investigated. RESULTS: Of 33 fetuses diagnosed with hemorrhagic brain lesions, 17 were electively terminated and two suffered intrauterine fetal demise. Thirteen were liveborn, seven by Cesarean delivery and six by spontaneous vaginal delivery. One case was lost to follow-up. Eight neonates had moderate to severe neurological deficit by a mean age of 35 (range, 6-96) months. One died at 2 months of age. These nine were diagnosed with Grade III-IV IVH in utero. Four neonates had normal neurological outcome by a mean age of 41 (range, 30-48) months; these four were diagnosed with subdural hematoma (n = 1) or Grade I-II IVH (n = 3) in utero. Fourteen cases were followed up with MRI, which confirmed ultrasound findings in 10 (71%) cases. In three (21%) cases MRI diagnosis was more accurate and the severity of grading was greater than that obtained on ultrasound imaging. Unilateral left hemispheric lesions were much more common than right-sided lesions (13 vs. 1, respectively). CONCLUSIONS: An antenatal sonographic diagnosis of fetal stroke with IVH Grade III-IV or with brain parenchymal involvement appears to be associated with poor neurological outcome. MRI may contribute to the accuracy of diagnosis, particularly in Grade II and III lesions. Left-sided unilateral lesions are more common than right-sided ones.

Suppression of inflammatory and fibrotic responses in allergic inflammation by the amniotic membrane stromal matrix.

BACKGROUND: The amniotic membrane (AM), which is the innermost layer of the placenta, was shown to possess anti-inflammatory and anti-fibrotic properties in various in vitro and clinical studies. PURPOSE: To evaluate the anti-fibrotic and anti-inflammatory effects of the AM matrix (AMM) on human conjunctival and lung fibroblasts in an in vitro system that tests fibrotic and inflammatory responses at the effector stages of allergic inflammation. METHODS: Human conjunctival or lung fibroblasts were seeded on plastic or on the stromal aspect of the AM, which was mounted on plastic inserts. Sonicates of human peripheral blood eosinophils activated with lipopolysaccharide (LPS), or human mast cell (HMC-1) leukaemia cell sonicates, were added to sub-confluent fibroblast monolayers. Proliferation of the sub-confluent fibroblasts was assessed using the [3H]-thymidine incorporation assay. The production of transforming growth factor (TGF)-beta1, granulocyte-macrophage colony-stimulating factor (GM-CSF) and IL-8 in conjunctival or lung fibroblasts was measured in conditioned media from these cultures by ELISA. RESULTS: After 4 days in culture, the [3H]-thymidine incorporation assay indicated a reduced proliferation of activated conjunctival and lung fibroblasts when cultured directly on the AMM. The production of both TGF-beta1 and IL-8 was significantly suppressed in activated conjunctival fibroblasts cultured on the AMM compared with those cultured on plastic, while the production of both TGF-beta1 and GM-CSF was decreased in human lung fibroblast cultured on the AMM. CONCLUSIONS: The AMM is capable of suppressing fibrotic responses in an in vitro system of effector stages of ocular allergic inflammation. These data may provide a basis for exploring matrix components in the AM for the treatment of allergic eye disease.

The correlation between sampling site and gene expression in the term human placenta.

Using oligonucleotide microarrays we recently identified a set of transcripts that were up-regulated in hypoxic human trophoblasts. To test the hypothesis that expression of hypoxia-related placental transcripts depends on sampling site we analyzed nine different sites from term human placentas (n=6), obtained after uncomplicated pregnancies. These sites spanned the placental center to the lateral border and the basal to the chorionic plate. Relative gene expression at each site, determined using quantitative PCR, was correlated with villous histology. The expression of vascular endothelial growth factor (VEGF) and connective tissue growth factor (CTGF), the cytoskeleton proteins lamininA3 and alpha-tubulin, and the signal transduction protein Rad was enhanced in the subchorionic lateral border compared to medial basal site (1.6-2.9 fold, p<0.05). In contrast, the expression of NDRG1, adipophilin and human placental lactogen was unchanged. Enhanced villous maturation, syncytial knots and fibrin deposits were more frequent in the subchorionic placental lateral border, and correlated with up-regulation of hypoxia-related transcripts (p<0.05). The association between sample site and expression level was not observed in placentas with marginal cord insertion. The expression of hypoxia-related genes in the term human placenta is dependent on sampling site within the placental disk, likely reflecting local differences in villous perfusion.

Scalp hair diameter increases during pregnancy.

The hair diameter major-axis has been shown to decrease normally toward the scalp in individual fibres. In this report sharp increases, rather than decreases, of hair-shaft major-axis diameters during pregnancy are described. Mean major-axis hair diameters of 15-20 fibres from each of 12 pregnant and 13 nonpregnant women were measured from the scalp distally at regular 6-mm intervals. Sample diameters were normalized relative to putative times of conception or a distance from the scalp equivalent to full term pregnancy, for the pregnant and nonpregnant women, respectively, and averaged. Major-axis diameter increases toward the scalp in hair of pregnant women were found to start at the beginning of pregnancy with a slope measuring 0.58%/cm, which is highly significant (r = 0.99, P < 0.0001). Hair diameters of the nonpregnant women, on the other hand, decreased toward the scalp during analogous times to the pregnancy, with a slope measuring -0.66%/cm, also highly significant (r = -0.97, P < 0.0001), and in good agreement with previously published data. To our knowledge this is the first description of hair diameter increases during a normal physiological process.

Dexamethasone inhibits maturation, cytokine production and Fc epsilon RI expression of human cord blood-derived mast cells.

BACKGROUND: Mast cells are responsible for eliciting the early phase and for contributing to the development of the late phase of allergic reactions, through the release of cytokines and other inflammatory mediators. OBJECTIVE: To assess whether the glucocorticoid dexamethasone has a direct effect on mast cell progenitor maturation and on mature cord blood-derived mast cell properties. METHODS: Mast cells were obtained by culturing human umbilical cord blood mononuclear cells with stem cell factor, IL-6 and prostaglandin E2. Mast cell numbers were assessed by Toluidine Blue staining and immunocytochemistry of tryptase positive cells. The expression of Fc epsilon RI, CD49d and c-kit was assessed by flow cytometry. Histamine release was determined by a radioenzymatic assay. Cys-LT, GM-CSF and TNF-alpha production and release were determined by ELISA. RESULTS: Dexamethasone (10(-6) M-10(-9) M) time- and dose-dependently inhibited the maturation of the mast cell progenitors. Dexamethasone did not affect the basal expression of Fc epsilon RI, CD49d and c-kit, but it inhibited the IgE-dependent enhanced expression of Fc epsilon RI. Dexamethasone (10(-6) M-10(-9) M) had no significant effect on Fc epsilon RI-dependent histamine release or the synthesis and release of Cys-LT from the mature mast cells. However, pre-incubation of the mast cell cultures with dexamethasone for 1 h, prior to cross-linking of Fc epsilon RI, dose-dependently inhibited the production and secretion of both GM-CSF and TNF-alpha. CONCLUSIONS: From these in vitro data we propose that glucocorticosteroids are effective drugs in the management of allergic inflammation due to their capacity to inhibit mast cell development, IgE-dependent Fc epsilon RI expression and mast cell production of GM-CSF and TNF-alpha.

Is laparoscopic appendectomy safe in pregnant women?

BACKGROUND: Because of limited laboratory and clinical data, no accepted guidelines concerning the safety of laparoscopic appendectomy (LA) in pregnancy have been established yet. In this prospective study, we evaluated the safety and outcome of LA in pregnant women as compared with the same control group of pregnant women who underwent open appendectomy (OA) during the same period. METHODS: During the years 1996 to 1999, 11 consecutive pregnant women (mean age, 27 years; range 21-39 years; gestation age range, 7-34 weeks) who underwent LA were prospectively evaluated and compared with a matched group of 11 women (mean age, 30 years; range 18-42 years; gestation age range, 11-37 weeks) who underwent OA. The following parameters were analyzed: obstetric and gynecologic risk factors, length of procedure, perioperative complications, length of stay, and outcome of pregnancy. Both groups were well matched in age and risk factors for pregnancy loss. RESULTS: There was no significant difference in the length of procedure (60 vs. 46 min) and the complications rate (one in each group) between the LA and OA groups, respectively. There was no conversion in the LA group. The length of postoperative stay was shorter in the LA group (3.6 vs 5.2 days; p = 0.05). There was no fetal loss or other adverse outcome of pregnancy in either group, and all the women in both groups had normal full-term delivery. The infants' development was normal in both groups for a mean follow-up period of 30 months. CONCLUSIONS: According to this relatively small-scale study laparoscopic appendectomy in pregnant women may be as safe as open appendectomy. This procedure is technically feasible in all trimesters of pregnancy and associated with the same known benefits of laparoscopic surgery that nonpregnant patients experience.

Ultrasonographic prenatal diagnosis of microcephalic osteodysplastic primordial dwarfism types I/III.

Microcephalic osteodysplastic primordial dwarfism is a rare disease characterized by unique clinical appearance and specific radiographic findings, and distinctive brain abnormalities. We describe the prenatal diagnosis of two siblings with microcephalic osteodysplastic primordial dwarfism types I/III at 23 and 26 weeks of gestation, respectively. Early detection by sequential antenatal sonographic evaluation is important for counselling families known to be at risk of this rare disease.

Alloreactivity of umbilical cord blood mononuclear cells: specific hyporesponse to noninherited maternal antigens.

Earlier studies noted that patients who underwent cord blood (CB) transplantation had a lower incidence of graft-versus-host disease (GVHD) than those who underwent bone marrow transplantation (BMT). The premise that the immune reactivity of CB mononuclear cells (CB-MNC) to HLA mismatched combinations and to noninherited maternal antigens (NIMA) may be one of the factors involved in this phenomenon is still debatable. In this study we have attempted to evaluate the alloresponse and alloreactivity induced by CB-MNC by means of the standard mixed lymphocyte reaction test (SMLR) and the more sensitive, modified mixed lymphocyte reaction test (MMLR). Both techniques were used to test CB-MNC (n = 28) against HLA class II mismatched MNC from mothers (n = 26), fathers (n = 12), and unrelated individuals (n = 60) who served as controls. Alloresponse capabilities and stimulation capacities of CB-MNC in the SMLR were similar to those of control MNC: relative response (RR) = 73 vs. 65 and 58 vs. 65, respectively. Similar results were obtained in the MMLR. CB-MNC responded weakly to the maternal MNC in comparison with control MNC (RR = 47 vs. 73 [p = 0.0099]), while a stronger response was noted to the paternal than the maternal MNC (RR = 72 vs. 47 [p = 0.045]). Our results demonstrate that CB-MNC both respond to and induce alloresponse in HLA mismatched combinations. Moreover, the hyporesponse of CB-MNC to maternal cells that we observed suggests a form of tolerance to NIMA, which is probably due to the fetus's exposure to these antigens in its intrauterine life.

Significance of success rate of external cephalic versions and vaginal breech deliveries in counseling women with breech presentation at term.

OBJECTIVE: To appreciate the role of success rates of external cephalic versions and breech deliveries, in order to assess the risk reduction in women with breech presentation at term. STUDY DESIGN: We reviewed the patient files of all women with breech presentation whom had an attempt of external cephalic version (ECV) at term. Most of the ECVs were performed under intravenous ritodrine infusion. All women had a trial of labor (TOL) as long as they did not meet one or more of the exclusion criteria of vaginal delivery. Success rates of ECV and TOL were assessed, and statistical analysis was performed by using the student t-test for continuous data, and the Chi-square and Fisher's exact tests for categorical data. Statistically significant differences required a P value of <0.05. RESULTS: Of all women with breech presentation at term and not in labor, who had no contraindication for an ECV, 164 consented and were included in the study. The success rate of ECV was 30% (22/74) and 67% (60/90) for nulliparae and multiparae, respectively. Multiparity was the only significant positive predicting variable for ECV success (OR=4.73, 95% CI 4.19-5.27, P=0.00001). Of all the women that underwent a successful ECV, 18/22 primiparae (82%), and 52/60 multiparae (87%) had a vaginal delivery, compared to only 52% of the primiparae and 63% of the multiparae that reached labor with a breech presentation. There were no significant perinatal complications except for one case of mild placental abruption. In the primiparous women, ECV decreased the chance of cesarean delivery by only 9% (P=0.2), compared to a 16% decrease in the multiparae (P=0.019). CONCLUSIONS: When counseling women with breech presentation at term, complete information is needed for consent, and should take into account the success rate of ECVs and of vaginal breech deliveries in the specific center.