Can adverse neonatal outcome be predicted in late preterm or term fetal growth restriction?

OBJECTIVE: To identify independent predictors of adverse neonatal outcome in cases of fetal growth restriction (FGR) at > or = 34 weeks. METHODS: From a cohort of 481 FGR cases delivered at > or = 34 weeks, demographic and obstetric variables, fetal biometry and Doppler indices of the uterine, umbilical and fetal middle cerebral arteries available within 2 weeks of delivery, were related to adverse neonatal outcome, defined as admission to the neonatal intensive care unit for indications other than low birth weight alone. RESULTS: Logistic regression analysis showed that gestational age (GA) at delivery (odds ratio (OR) = 0.59; 95% CI, 0.50-0.70), abdominal circumference (AC) centile (OR = 0.69; 95% CI, 0.59-0.81) and umbilical artery (UA) pulsatility index (PI) centile (OR = 1.02; 95% CI, 1.01-1.04) significantly correlated with adverse neonatal outcome. From this model we calculated a score of adverse neonatal outcome expressed by the formula: (UA-PI centile/3) - (10 x AC centile) + (10 x (40 - GA at delivery in weeks)). Receiver-operating characteristics curve analysis demonstrated that a score of > or = 25 optimally predicted adverse neonatal outcome (sensitivity of 75%, false-positive rate of 18%). Beyond 37.5 weeks, gestational age no longer had an independent impact on outcome. CONCLUSIONS: In late preterm or term FGR, GA at delivery is the most important predictor of adverse neonatal outcome. At > 37.5 weeks, delivery may be the best option to minimize adverse outcome in all FGR cases. At 34-37 weeks, a score based on GA at delivery, UA-PI centile and AC centile optimally predicts adverse neonatal outcome.

A new splicing site mutation of the ABCB4 gene in intrahepatic cholestasis of pregnancy with raised serum gamma-GT.

BACKGROUND: Intrahepatic cholestasis of pregnancy is a liver disorder with a multifactorial etiology characterized by maternal pruritus, abnormal liver function tests and increased fetal risk. The main biochemical finding is the increase in total serum bile acid concentrations. In a subgroup of women, the serum gamma-glutamyl transpeptidase level is also increased. There is evidence that dysfunction of the ABCB4 gene might play a role in intrahepatic cholestasis of pregnancy development. AIM: To investigate the role of the ABCB4 gene in Italian women with intrahepatic cholestasis of pregnancy and raised gamma-glutamyl transpeptidase by, analyzing the complete coding sequence and mRNA splicing products. METHODS: Among 299 women with intrahepatic cholestasis of pregnancy, 10 showing raised gamma-glutamyl transpeptidase were enrolled in this study. DNA and RNA were extracted from peripheral blood mononuclear cells using standard procedures. The 27 coding exons and the promoter region were amplified by polymerase chain reaction and analyzed by sequencing. Reverse transcript-polymerase chain reaction analysis of ABCB4 mRNA and cDNA analysis were also performed. RESULTS: A novel splicing mutation that causes a truncated protein of 249 amino acid was identified in a woman who had the highest serum levels of gamma-glutamyl transpeptidase, alkaline phosphatase, bile acids, and the highest pruritus score. We identified also one already described p.R590Q mutation in a woman who had significantly higher serum levels of alkaline phosphatase, aspartate, and alanine aminotransferase. CONCLUSIONS: Our study demonstrates that splicing mutations in the ABCB4 gene can cause ICP in women with high gamma-glutamyl transpeptidase and thus a complete analysis of coding sequence and cDNA products is required.

[Treatment of maternal hyperthyroidism and fetal goiter]. / Trattamento dell'ipertiroidismo materno e gozzo fetale.

A fetal goitre is a potentially dangerous phenomenon because of mechanical obstruction and possible fetal thyroid function disorders. During pregnancy women with a history of Graves' disease under treatment with propylthiouracil (PTU) have an increased risk for fetal goitre. In this report a patient with Graves' disease diagnosed in early pregnancy and treated with PTU which resulted in a fetal goitre is described. The fetal thyroid status, investigated by percutaneous fetal umbilical cord blood sampling, was normal and the reduction of PTU dosage was sufficient to decrease goitre volume.

Hepatitis C virus infection is associated with a higher incidence of cholestasis of pregnancy.

To investigate a possible relationship between hepatitis C virus infection and cholestasis of pregnancy, we identified all cases of cholestasis of pregnancy (145/16,271) and hepatitis C virus infection (63/16,271) between January 1992 and December 1997. Serologic screening was performed universally. The rate of cholestasis of pregnancy was greater in women whose hepatitis C virus antibodies were positive rather than negative [15.9% (10/63) vs 0.8% (135/16,208), P < 0.001]. Among women with cholestasis of pregnancy, mean (standard deviation) gestational age at onset of symptoms and at delivery was significantly lower among women whose hepatitis C virus antibodies were positive compared with negative women: 28.9 (3.2) vs 34.3 (3.5) weeks, P < 0.001 and 36.3 (0.9) vs 37.0 (1.6) weeks, P = 0.03, respectively. These findings suggest that early occurrence of cholestasis of pregnancy may be an indication for serologic testing for hepatitis C virus.

Do uterine leiomyomas influence pregnancy outcome?

To evaluate the clinical significance of the presence, location, size, and number of uterine leiomyomas in pregnancy, a retrospective cohort study in which pregnancy complications and outcome of pregnant women with uterine myomas was undertaken by routine second trimester ultrasound examination. The case group consisted of 183 consecutive women with uterine myomas detected and followed during the years 1983-1989; the control group was made up of all pregnancies diagnosed and followed at the obstetric clinic during the period 1985-1987. The incidences of preterm delivery (less than 37 weeks), preterm premature rupture of membranes, in utero growth retardation (less than 5th percentile), placental abruptio, placenta previa, postpartum hemorrhage (more than 500 cc), and retained placenta were not significantly increased in the group of women with myomas compared with the general population. However, cesarean sections were more common in women with myomas (23 vs 12%; P < 0.001). Within the group of women with myomas, the incidence of cesarean section was not different in cases with multiple rather than solitary myomas, but it was significantly higher in cases of lower uterine segment compared with fundal myomas (39 vs 18%; P < 0.01) and when the mean diameter of the myoma was greater than 5 cm (35 vs 17%; P = 0.01). Stepwise logistic regression analysis showed that both myoma location and size were independent predictors of the odds of cesarean section.

[Intrahepatic cholestasis in pregnancy: incidence, clinical course, complications]. / Colestasi intraepatica gravidica: incidenza, decorso, complicanze.

From January 1st, 1984 to December 31st, 1988 67 cases of cholestasis during pregnancy (frequency rate 0.7%) have been reviewed. In the 79% of the cases cholestasis arose after the 32nd week. Preterm deliveries were 19.5% and cesarean sections were 19.4%. Perinatal mortality was 30%. Pregnancy complicated by cholestasis is a high risk problem in obstetrics. An attempt to show a clinical management is exposed.

[Premature birth and perinatal mortality 1982-1988. I]. / Parto prematuro e mortalità perinatale 1982-88: Parte I.

The Authors analyzed the premature deliveries performed between 1982 and 1988 at the IV Clinica Ostetrica e Ginecologica of the University of Milan at the S. Gerardo Hospital, Monza, 1267 newborns out of 12507 were preterm. The rate was between 8.7 and 11.0% (average 9.8%). The early neonatal mortality is 10.6% (excluding malformed newborns, 8.3%), the late neonatal mortality is 12.7% (excluding malformed newborns, 9.8%). The early mortality is significantly lower starting from the 32nd week of pregnancy (35.4% vs 3.2%) and with a newborn's weight greater than 1500 grams (36.9 vs 3.2%). The early mortality is lower for females (8.4%) than for males (11.1%). In spite of other Authors, the early mortality is significantly higher than for AGA newborns (19.4 vs 7.9%). The causes of the early mortality are analyzed in detail.

[The sleep-wake rhythm of the fetus]. / Le rythme sommeil-veille du foetus.

Our work refers to a body of studies carried out by Sonargram observation, which allowed us to study fetal movements in real time. These fetuses were studied not only as parameters of correct neurobiological maturity but also from the psychological interest which looks for the beginning of thinking based on the question: When and how does the thought process begin in biological matter? The study comparing the movement of fetuses and new-born babies to psychoanalytical research (which have been described in other works) led us to formulate the following hypothesis: motor and sense experiences can only become "mental" after separation from the mother; it can only come about by birth which effectively forces a confrontation on biological grounds: it prepares the thinking process without yet having it. There is a debate between these positions and psychoanalytical schools of thought in which thinking could precede the birth of the human fetus; there might be a stage of sleep (REM) that corresponds to adult dreaming.