Invasive diagnostic procedures and risk of hypertensive disorders in pregnancy.

OBJECTIVE: To determine whether the risk of hypertensive complications differs among low-risk women who undergo prenatal diagnosis via chorionic villus sampling (CVS) and amniocentesis. METHODS: In a retrospective study, data were analyzed from women who underwent prenatal diagnosis by CVS or amniocentesis at Alexandra Maternity Hospital, Athens, Greece, between 1998 and 2011. All women had either transabdominal CVS at 10-13 weeks of pregnancy with a 20-gauge needle, or amniocentesis at 17-21 weeks with a 22-gauge needle, both under direct ultrasound guidance. Only women who had cytogenetically normal pregnancies and delivered at the study hospital were included. The main outcome measure was the development of hypertensive complications. RESULTS: Overall, 3243 women who underwent CVS and 6875 woman who underwent amniocentesis met the inclusion criteria, and their outcomes were analyzed. In total, 237 women (2.3%) developed hypertensive disorders during their pregnancy. The incidence of pre-eclampsia (2.4% vs. 0.8%) and total hypertensive disorders (3.8% vs. 1.7%) was significantly higher (P<0.001) in the CVS group than in the amniocentesis group. CONCLUSION: Women who underwent CVS had a significantly higher risk of developing hypertensive disorders in comparison to those who underwent amniocentesis. This finding warrants further investigation via a well-designed prospective randomized trial.

Induction of labor versus expectant management for pregnancies beyond 41 weeks.

OBJECTIVE: To compare the outcome following labor induction at 41 + 1 weeks of gestation and after expectant management and selective induction at 42 completed weeks. METHOD: A retrospective analysis of post-term pregnancies in a 2-year period. In the induction group, women at 41 + 1 weeks of gestation received 3 mg prostaglandin E2 (dinoprostone) in the posterior fornix, repeating the dose 6 h later. Women with a Bishop score >6 had artificial rupture of the membranes. In the expectant management group, women at more than 41 weeks gestation were checked every 2 days in the hospital. In case of abnormalities either in the fetal heart rate evaluation or in the biophysical profile, labor was induced. Labor was also induced in all cases that pregnancy exceeded 42 + 1 gestational weeks. RESULTS: A total of 438 women who met the inclusion criteria were included in the study. In all, 211 comprised the induction group, while the expectant management group consisted of 227 women. The cesarean delivery rate in the induction group was 36.5% compared to 34.4% in the expectant management group, whereas the operative vaginal delivery rate was 11.4 and 9.2% in the two groups, respectively. The vast majority of women in the expectant management group (74%) had a spontaneous onset of labor. CONCLUSION: The perinatal outcome does not differ following a policy of routine labor induction in comparison to expectant management in pregnancies beyond 41 weeks.

Preterm birth trends in Greece, 1980-2008: a rising concern.

OBJECTIVE: To identify preterm birth trends in Greece. DESIGN: Retrospective epidemiological study. SETTING: Women giving birth in Greece from 1980 to 2008. POPULATION: Live births beyond the 24th gestational week. METHODS: Data acquisition from the Hellenic Vital Statistics records. Statistical analysis of preterm birth rate among neonates estimated for each year. MAIN OUTCOME MEASURES: Total number of births and preterm births, as well as rate of preterm birth by gestational week. Stillbirth rates by gestational age. RESULTS: 3 218 463 births occurred during the period under study, 151 594 (4.7%) of which were preterm. A steep rise in preterm births was noted during the final years of the study, reaching 9.6% in 2008. This was mainly due to the "late preterm" sub-group (34(+0) -36(+6) gestational weeks). The rates of stillbirth fell in a constant way regardless of the maturity index. CONCLUSIONS: Although preterm birth etiology is multifactorial, the selective rise in the "late preterm" group possibly was due to an increase in medical reasons necessitating a preterm delivery, changes in obstetric practice, or both. Further studies are needed to estimate the precise effect of each contributing factor.

Optimum mode of delivery in gestations complicated by preterm premature rupture of the membranes.

OBJECTIVES: To provide evidence about the preferable mode of delivery, vaginal (VD) or caesarean section (CS), in PPROM. METHODS: A retrospective study of 190 cases. Survival analysis was used to identify statistically significant differences in mortality rates. RESULTS: A total of 126 pregnancies were included in our study. Mean gestational age of rupture was 28(+0) weeks (min = 15, max = 36(+4), sd = 5.796). Mean birth age was 30(+0) weeks (min = 15, max = 37(+2), sd = 5.353). CS was performed in 55 cases (43.7%), VD in 71 cases (56.3%). Data analysis showed that, regardless of presentation, there was a statistically significant benefit on survival in favor of the CS in births below 30 gestational weeks (n = 39, nCS = 18, nND = 21, χ(2) = 7.946, p = 0.005). Hazard ratio estimation set the critical gestational age at 28 weeks. For vaginal deliveries, breech presentation was associated with inferior survival outcome compared to vertex (nTotal = 71; nVertex = 63, nBreech = 8, χ(2) = 13.012, p < 0.001.Also in breech presentation, VD survival outcome was inferior to CS (nTotal = 9; nVD = 6, nCS = 3, χ(2) = 5.145, p < 0.05). CONCLUSIONS: According to our results, in cases of PPROM, CS was beneficial below 28 weeks and in breech presentation below 30 weeks.

The effect on the fetal pituitary-adrenal axis of dexamethasone administration early in the second trimester of pregnancy.

OBJECTIVE: To evaluate the effect of a single dose of dexamethasone to pregnant women at early second trimester on the fetal pituitary-adrenal axis. METHODS: Thirty-eight women between 13 and 15 weeks' gestation were included in the study. Blood was taken from the mothers and their fetuses for the evaluation of plasma ACTH, cortisol, and free cortisol levels before and after treatment with a single dose of 1 mg of dexamethasone orally at 11 p.m. the night before the termination of pregnancy. RESULTS: The mean plasma ACTH was significantly lower following dexamethasone administration (8.5 ± 5.1 vs. 18.4 ± 10.9 pg/ml). Similarly, plasma cortisol was significantly lower after dexamethasone treatment (208.3: ± 168.7 vs. 772.7 ± 206.1 nmol/l), as well as plasma free cortisol levels (2.6 ± 0.0 vs. 6.1 ± 6.1 nmol/l). Mean plasma ACTH levels were not significantly different in the fetuses after dexamethasone treatment (33.6 ± 22.7 vs. 42.5 ± 21.9 pg/ml). Moreover, mean fetal plasma cortisol was not different before and after treatment (108.2 ± 27.2 vs. 94.3 ± 47.2 nmol/l), as well as the mean free cortisol levels (7.7 ± 5.2 vs. 7.0 ± 4.3 nmol/l). CONCLUSIONS: A single dose of 1 mg of dexamethasone to the mother early in the second trimester of pregnancy does not result in a significant suppression of the fetal pituitary axis.

The role of cervical length measurement at 11-14 weeks for the prediction of preterm delivery.

OBJECTIVE: To determine whether cervical length (CL) measurement at 11?14 weeks is predictive of preterm delivery (PTD). METHODS: This was a prospective study of a low-risk population of 1113 women, who underwent CL measurement at 11-14 weeks. Mean CL was calculated for deliveries at >37, <37 and <34 weeks. Cut-off limits of 27 mm and 30 mm were used to examine the predictive value of CL. RESULTS: Mean +/- SD CL for the entire study population was 40.6 +/- 5.5 mm. CL was analyzed for term and PTD (<37 weeks) and further analyzed for deliveries at 34-37 and <34 weeks. Mean CL was 38.9 +/- 5.5 mm for PTD and 40.8 +/- 5.5 mm for deliveries >37 weeks (p=0.001). Receiver operating characteristic analysis showed small predictive value of CL for PTD <37 weeks (sensitivity = 63.3% and specificity = 51.1%, area under the curve (AUC)=0.60, 95% CI: 0.54-0.66) (p=0.001) and did not show any predictive value for PTD <35 weeks (AUC=0.55, 95% CI: 0.43-0.67, p=0.355) or PTD <32 weeks (AUC=0.51, 95% CI: 0.30-0.74, p=0.851). CONCLUSION: CL at 11-14 weeks does not appear to be predictive of PTD. Statistical analysis of CL did not show any predictive value for PTD <35 weeks, or <32 weeks and although it showed a predictive value for PTD at <37 weeks, the sensitivity was very low.

Erythrocyte membrane AChE, Na(+), K(+)-ATPase and Mg(2+) ATPase activities in mothers and their premature neonates in relation to the mode of delivery.

AIM: To investigate erythrocyte membrane AChE, Na(+), K(+)-ATPase and Mg(2+)-ATPase activities in mothers and their full-term or premature newborns in relation to the mode of delivery. METHODS: Blood was obtained from mothers pre- and post-delivery and the umbilical cord (CB) of their full-term newborns: Group A1 (n = 16) born with vaginal delivery (VD), Group B1 (n = 14) full-terms with scheduled cesarean section (CS), Group A2 (n = 12) prematures with VD, Group B2 (n = 14) prematures with CS. Total Antioxidant Status (TAS) and common laboratory tests were measured with routine methods, and the membrane enzyme activities spectrophotometrically. RESULTS: TAS was reduced in mothers post VD and in the CB whereas remained unaltered in CS mothers and their newborns. AChE and Na(+), K(+)-ATPase were increased in mothers post VD. AChE was lower in the CB of prematures than that of full-terms independently of the mode of delivery. Na(+), K(+)-ATPase activity was increased in the groups of mothers post VD and decreased in prematures. The enzyme was higher in prematures with CS than that with VD. Mg(2+)-ATPase activity was unchanged. CONCLUSION: The increased maternal AChE and Na(+), K(+)-ATPase activities may be due to the low TAS determined post VD, whereas their decreased activities in prematures to their immaturity.

Gitelman syndrome-associated severe hypokalemia and hypomagnesemia: case report and review of the literature.

We report a case of a woman with Gitelman syndrome who presented to our hospital mainly due to hyperemesis. Following her admission, intravenous potassium and magnesium supplementation was commenced to counter the observed hypokalemia and hypomagnesemia. Hyperemesis receded and although serum potassium remained low, she became asymptomatic. Oral potassium and magnesium supplementation was administered throughout pregnancy and biweekly ion level measurements were scheduled. Despite the intensive replacement, ion levels remained constantly low. She delivered at 38 weeks with an elective caesarean section because of a breech presentation, a healthy female baby weighing 3350 g. Neonatal electrolyte profile was normal.

Amniotic fluid interleukin-6 and tumor necrosis factor-alpha at mid-trimester genetic amniocentesis: relationship to intra-amniotic microbial invasion and preterm delivery.

OBJECTIVE: To determine the value of amniotic fluid interleukin-6 (AF IL-6) and tumor necrosis factor-alpha (AF TNF-alpha) in the diagnosis of microbial invasion of the amniotic cavity and in the prediction of preterm delivery (PTD). STUDY DESIGN: Following amniocentesis, a sample of amniotic fluid was sent for aerobic and anaerobic bacterial cultures along with Ureaplasma urealyticum culture and it was also assessed for IL-6 and TNF-alpha. RESULTS: Forty-eight women who delivered preterm (<37 weeks) were matched with 96 controls. The AF IL-6 and TNF-alpha concentrations of women with spontaneous PTD were significantly higher than those who delivered at term (IL-6: 176.3 pg/ml [130.6-208.6] vs. 52.3 pg/ml [37.2-92.3]; TNF-alpha: 8.8 pg/ml [7.2-10.7] vs. 5.5 pg/ml [5.0-6.3]). AF IL-6 and TNF-alpha concentrations of >99.3 pg/ml and of >6.6 pg/ml respectively, had a sensitivity of 89.6% and 81.3% and a specificity of 80.3% and 79.2% for the prediction of spontaneous PTD. Moreover, AF IL-6 and TNF-alpha concentrations of >99.3 pg/ml and of 6.3 pg/ml respectively, had a sensitivity of 91.9% and 78.4% and a specificity of 73.8% and 70.1% for the prediction of a positive AF culture. CONCLUSIONS: Elevated mid-trimester concentrations of AF IL-6, or/and of TNF-alpha can identify women at risk for intra-amniotic infection and for spontaneous PTD.

Second trimester amniocentesis in assisted conception versus spontaneously conceived twins.

OBJECTIVE: To compare the outcome of amniocentesis in twins conceived with assisted reproduction technology (ART) versus spontaneously conceived twins. DESIGN: Retrospective analysis of case records between 1993 and 2006. SETTING: University-affiliated tertiary center for fetal medicine. PATIENT(S): 167 ART twin pregnancies and 275 spontaneous twin pregnancies. INTERVENTION(S): Genetic amniocentesis. MAIN OUTCOME MEASURE(S): Comparison of pregnancy loss rate and perinatal outcome between the ART and spontaneous twin-pregnancy groups. RESULT(S): The fetal loss rate was similar between the two groups (4.2% vs. 4.0% in the ART twins and spontaneous twins, respectively), although the interval between amniocentesis to miscarriage was statistically significantly shorter in the ART twins than the spontaneous twins (6.2 and 20.1 days, respectively). In all cases, fetal loss refers to the loss of the entire pregnancy. The preterm delivery rate before 37 weeks was statistically significantly higher in the ART group (64.1%) compared with controls (49.5%). CONCLUSION(S): Amniocentesis in ART twins carries a fetal loss rate similar to spontaneous twins. However, ART twins have a statistically significantly increased risk of preterm delivery especially before 32 weeks' gestation.

Association between abnormal uterine artery Doppler flow velocimetry, risk of preeclampsia, and indices of arterial structure and function: a pilot study.

Preeclampsia increases the risk of future cardiovascular disease. The association between abnormal uterine artery Doppler flow velocimetry, risk of preeclampsia, and indices of arterial structure and function is investigated in this study. The carotid intima-media thickness of 34 pregnant women with normal uteroplacental flow was compared with 30 women with abnormal uterine artery Doppler analysis during the transvaginal assessment of the uterine arteries at the routine anomaly scan (20-23 weeks of gestation). Women with abnormal uterine artery Doppler results had a greater mean internal (but not common) carotid intima-media thickness (0.58 +/- 0.06 vs 0.53 +/- 0.08, respectively, P = .005) and risk of developing preeclampsia (6 of 30 vs 0 of 34 or 20% vs 0%, respectively, P = .0079) compared with those with normal uteroplacental flow. Women with abnormal uterine artery Doppler results may be at increased risk not only for developing subsequent preeclampsia but also for future cardiovascular disease.

The effect of the mode of delivery on the maternal-neonatal erythrocyte membrane acetylcholinesterase activity.

UNLABELLED: Free radical production and high catecholamine levels are implicated with the modulation of acetylcholinesterase (AChE) activity. OBJECTIVE: To investigate the effect of the mode of delivery on maternal-neonatal erythrocyte membrane AChE activity. SUBJECTS AND METHODS: Some women with normal pregnancy (N = 30) were divided into two groups: group A (N = 16) with normal labour and vaginal delivery and group B (N = 14) with scheduled Cesarean section, twenty non-pregnant women were the controls. Blood was obtained from controls and from mothers pre- vs post-delivery as well as from the umbilical cord (CB). Total antioxidant status (TAS), membrane AChE activities and catecholamine blood levels were measured with a commercial kit, spectrophotometrically and HPLC methods, respectively. RESULTS: TAS and catecholamine levels as well as membrane AChE activities were similar in the two groups of mothers pre-delivery and in controls. TAS levels were reduced whereas AChE activities and catecholamine levels were increased post-delivery in mothers of group A and unaltered in group B at the same times of study. AChE activity was similarly lower in the CB of neonates than those of their mothers pre-delivery. CONCLUSIONS: During a normal delivery process, the low TAS, the increased levels of catecholamines and the increased AChE activity, post-delivery, may be due to the increased stress due to the participation of uterus and skeletal muscles as during endurance exercise. The low AChE activity in newborns may be related to perinatal immaturity.

Placental pathology in women with gestational diabetes.

BACKGROUND: The aim of this study was to investigate pathologic differences of the placenta in pregnancies complicated by gestational diabetes compared to non-diabetic pregnancies. METHODS: Forty singleton pregnancies complicated by gestational diabetes were recruited and compared to 40 consecutive normal pregnancies. A pathologist, blinded to all clinical data, reviewed all histological samples of the placentas. The histological assessment was carried out with regard to the following aspects: fetal vessel thrombosis, villous immaturity, chorangiosis, presence of nucleated fetal red blood cells (NFRBCs), ischemia, infarction, presence of hydropic or avascular villi, lymphohistiocytic villitis and villous fibrinoid necrosis. RESULTS: The presence of degenerative lesions such as fibrinoid necrosis and vascular lesions like chorangiosis was apparent, mainly in the diabetes group. Villous immaturity and the presence of NFRBC as an indication of chronic fetal hypoxia were significantly increased in the placentas of women with diabetes compared with the control group. Fetal/placental weight ratio was significantly lower in the diabetic group. CONCLUSION: Histological abnormalities were observed more frequently in the diabetic placentas compared to the controls. These findings support the hypothesis that impaired placental function is one of the main reasons for the increased frequency of fetal complications in diabetic pregnancies.

Maternal-neonatal erythrocyte membrane Na(+), K (+)-ATPase and Mg (2+)-ATPase activities in relation to the mode of delivery.

Free radical production and high catecholamine levels are implicated in the modulation of Na(+), K(+)-ATPase, and Mg(2+)-ATPase activities. The aim of this study was to investigate the effect of the mode of delivery on the above-mentioned enzyme activities in maternal-neonatal erythrocyte membrane. Women with normal pregnancy (N = 30) were divided into two groups: Group A (N = 16) with normal labor and vaginal delivery, and Group B (N = 14) with scheduled cesarean section; 20 non-pregnant women were the controls. Blood was obtained from controls and mothers, pre- versus post-delivery, and from the umbilical cord (CB). Total antioxidant status (TAS), membrane enzyme activities, and catecholamine blood levels were measured with a commercial kit, spectrophotometrically, and by HPLC methods, respectively. The results showed that: TAS levels, catecholamine, and the membrane enzyme activities were similar in the two groups of mothers pre-delivery, whereas both enzyme activities were lower than those of controls. TAS levels were reduced whereas Na(+), K(+)-ATPase activities (0.35 +/- 0.03 vs. 0.65 +/- 0.06 micromol Pi/h x mg protein, P < 0.001), and catecholamine levels were increased post-delivery in mothers of Group A and unaltered in Group B (0.38 +/- 0.02 vs. 0.40 +/- 0.03 micromol Pi/h x mg protein, P > 0.05), at the same times of study. Mg(2+)-ATPase activities remained unaltered in both groups of mothers and newborns. Na(+), K(+)-ATPase activity was similarly lower in the CB of neonates than those of their mothers, pre-delivery. Our results suggest that: (a) during a normal vaginal delivery process, the low TAS and the increased levels of catecholamines may increase Na(+), K(+)-ATPase activity, post-delivery; (b) the low enzyme activities evaluated in mothers pre-delivery may be due to the high estrogen levels and those in newborns due to perinatal immaturity.

Increasing the noninvasive management of rhesus isoimmunization.

OBJECTIVE: To determine the clinical outcome of isoimmunized pregnancies managed by middle cerebral artery peak systolic velocity (MCA-PSV) in an intention-to-treat study. METHOD: Rhesus isoimmunized pregnancies were managed with serial ultrasound and Doppler studies at 7-day intervals up to 34 weeks of gestation, between 2001 and 2005. Invasive diagnostic and therapeutic procedures were carried out when MCA-PSV was indicative of moderate or severe anemia. RESULTS: The overall sensitivity in detecting moderate to severe fetal anemia at less than 34 weeks was 100% (95% confidence interval, 54.1-100.0 L). Twenty-two cases were managed with MCA-PSV. Twelve cases needed fetal blood sampling and 6 cases needed intrauterine transfusion. Cordocentesis revealed a hematocrit of more than 26% in 6 fetuses. CONCLUSION: Management by MCA-PSV Doppler at weekly intervals is a highly sensitive method for detecting fetal anemia. It reduces the number of fetal blood samples needed and significantly lowers interventional procedures.

Management of pregnancy in adolescence complicated by acute lymphoblastic leukemia.

The management of the common acute lymphoblastic leukemia in pregnancy has been controversial. We report a case of a 16-year-old primigravida with acute lymphoblastic leukemia, first presented in pregnancy, which was treated with aggressive chemotherapy protocols. Full remission of the disease was achieved. The neonate was born at 32 weeks following a cesarean section. The woman remains in complete remission, continuing maintenance chemotherapy, 18 months following diagnosis. The offspring did not show any abnormality in physical examinations or laboratory tests and keeps growing normally 18 months after birth.

Screening for pre-eclampsia and small for gestational age fetuses at the 11-14 weeks scan by uterine artery Dopplers.

OBJECTIVE: To assess the role of uterine artery Doppler studies at 11-14 weeks in screening for pre-eclampsia (PET), small for gestational age (SGA) fetuses, and placental abruption. METHODS: Prospective study on 1,123 women presenting for routine ultrasound examination at 11-14 weeks for nuchal translucency measurement. Uterine artery blood flow was studied by transvaginal colour Doppler, the mean pulsatility index (PI) was calculated, and the presence of a diastolic notch was recorded. RESULTS: The mean, median and 95th centile of uterine artery PI were 1.71, 1.64 and 2.54, respectively. Bilateral notches were observed in 63.4%, and a unilateral notch in 18.4% of cases. The sensitivity of mean uterine artery PI>or=95th centile for PET, early onset severe PET necessitating delivery before 34 weeks, SGA

Emergency obstetric hysterectomy.

BACKGROUND: All cases of obstetric hysterectomies that were performed in our hospital during a seven-year study period were reviewed in order to evaluate the incidence, indications, risk factors, and complications associated with emergency obstetric hysterectomy. METHODS: Medical records of 45 patients who had undergone emergency hysterectomy were scrutinized and evaluated retrospectively. Maternal age, parity, gestational age, indication for hysterectomy, the type of operation performed, estimated blood loss, amount of blood transfused, complications, and hospitalization period were noted and evaluated. The main outcome measures were the factors associated with obstetric hysterectomy as well as the indications for the procedure. RESULTS: During the study period there were 32,338 deliveries and 9,601 of them (29.7%) were by cesarean section. In this period, 45 emergency hysterectomies were performed, with an incidence of 1 in 2,526 vaginal deliveries and 1 in 267 cesarean sections. All of them were due to massive postpartum hemorrhage. The most common underlying pathologies was placenta accreta (51.1%) and placenta previa (26.7%). There was no maternal mortality. CONCLUSIONS: Obstetric hysterectomy is a necessary life-saving procedure. Abnormal placentation is the leading cause of emergency hysterectomy when obstetric practice is characterized by a high cesarean section rate. Therefore, every attempt should be made to reduce the cesarean section rate by performing this procedure only for valid clinical indications.

Bacterial vaginosis and group B streptococcal colonization and preterm delivery in a low-risk population.

OBJECTIVE: To evaluate the relationship between bacterial vaginosis (BV) and group B streptococcal (GBS) colonization in the 2nd trimester of pregnancy and preterm delivery. METHODS: 1,197 pregnant women between 22 and 25 weeks' gestation had a high vaginal swab for assessment of BV and GBS. Exclusion criteria were: previous preterm delivery, or mid-trimester abortion or termination of pregnancy, multiple gestation, oligo- or polyhydramnios, placenta previa, fetal abnormalities, uterine malformations, cervical incompetence, cervical cerclage, or receipt of an antibiotic effective against BV or GBS following the screening. All women had no risk factors for preterm delivery. The primary outcome measure in this analysis was spontaneous preterm delivery before 37 weeks' gestation. RESULTS: The preterm delivery rate was 8.7%, while the maternal BV and GBS colonization rates were 7.9 and 12.5%, respectively. Following adjustment for potential confounders BV was associated with an increased risk of preterm delivery (RR 2.19; CI: 1.21-3.98) (p = 0.01). On the contrary, GBS colonization was found to have a negative correlation with preterm birth (RR 0.43; 95% CI: 0.19-1.00). CONCLUSIONS: Although BV is a risk factor for preterm delivery, GBS colonization in the 2nd trimester of pregnancy has an inverse correlation with preterm delivery.