Incarceration histories of homeless veterans and progression through a national supported housing program.

There is increasing concern that adults with a past history of incarceration are at particular disadvantage in exiting homelessness. Supported housing with case management has emerged as the leading service model for assisting homeless adults; however there has been limited examination of the success of adults with past history of incarceration in obtaining housing within this paradigm. Data were examined on 14,557 veterans who entered a national supported housing program for homeless veterans, the Housing and Urban Development-Veterans Affairs Supportive Housing program (HUD-VASH) during 2008 and 2009, to identify characteristics associated with a history of incarceration and to evaluate whether those with a history of incarceration are less likely to obtain housing and/or more likely to experience delays in the housing attainment process. Veterans who reported no past incarceration were compared with veterans with short incarceration histories (≤ 1 year) and those with long incarceration histories (>1 year). A majority of participants reported history of incarceration; 43 % reported short incarceration histories and 22 % reported long incarceration histories. After adjusting for baseline characteristics and site, history of incarceration did not appear to impede therapeutic alliance, progression through the housing process or obtaining housing. Within a national supported housing program, veterans with a history of incarceration were just as successful at obtaining housing in similar time frames when compared to veterans without any past incarceration. Supported housing programs, like HUD-VASH, appear to be able to overcome impediments faced by formerly incarcerated homeless veterans and therefore should be considered a a good model for housing assistance programs.

Pathophysiology and medical management of systemic hypertension and pre-eclampsia in pregnancy.

Hypertension in pregnancy includes a group of distinct disorders that require special consideration in both prevention and pharmacological treatment. In recent years, there have been few advances regarding the pathophysiology and prevention of pre-eclampsia, however there have been some promising studies regarding possible modes of screening women for preeclampsia before clinical signs and symptoms are apparent. The recommendations for first-line drug therapy for the hypertensive complications of pre-eclampsia, and the recommendations for pharmacological treatment of women with chronic hypertension antedating pregnancy, have changed little primarily because first-line medications have the advantage of having had more extensive research experience. Recent clinical trials have demonstrated the efficacy and safety of various second-line drugs for the hypertensive disorders of pregnancy; whether these therapies can eventually replace the standard recommended medications will require more extensive long-term investigation.

Reference values of amniotic fluid neuron-specific enolase.

OBJECTIVE: Enolase is a dimeric cytoplasmic enzyme whose double gamma isoenzyme, neuron-specific enolase, is predominantly found in neuronal and neuroendocrine tissues. Cell injury causes its release into the blood and cerebrospinal fluid (CSF). Neuron-specific enolase has been measured in the serum and CSF of adults and full-term asphyxiated neonates as a marker of neurological injury. We recently observed an elevation of neuron-specific enolase in the amniotic fluid of women whose neonates subsequently developed intraventricular hemorrhage or periventricular leukomalacia. The purpose of our study was to establish reference values of neuron-specific enolase in the amniotic fluid as a function of gestational age. METHODS: A total of 110 amniotic fluid samples, obtained primarily for genetic studies (16-20 weeks, n = 22), for evaluation of preterm labor (21-35 weeks, n = 66) and for fetal lung maturity studies (36-40 weeks, n = 22), were analyzed for neuron-specific enolase. Samples were from women who subsequently delivered term neonates with normal neurological examinations or who delivered preterm neonates with normal neurosonograms up to the 7th day of life. Descriptive statistics and non-parametric correlations were used for analysis. RESULTS: There was no correlation between gestational age and concentration of neuron-specific enolase (Spearman's r = 0.059, p = 0.63). The overall mean neuron-specific enolase value was 2.5 +/- 1.39 microg/l. The highest value obtained was 6 microgl. Of the 110 women, 105 (95.5%) had neuron-specific enolase values of less than 5 microg/l, while five (4.5%) had values ranging from 5 to 6 microg/l. CONCLUSIONS: The amniotic fluid level of neuron-specific enolase does not change as a function of gestational age. These stable levels may have utility in the evaluation of cases with fetal neurological injury.

Sonographically estimated fetal weight percentile as a predictor of preterm delivery.

OBJECTIVE: To evaluate the association between relative growth restriction and preterm birth. STUDY METHODS: Pregnant women referred for sonographic fetal weight assessments between 24 and 34 weeks of gestation were studied for gestational age at delivery. If a patient underwent more than one study, only the last one was considered. Patients with delivery induced iatrogenically or with abnormal growth patterns due to known pathology, such as maternal diabetes or fetal congenital anomaly, were excluded. A gestational age of 37 weeks or less was considered preterm and a gestational age of more than 37 weeks at delivery was considered term. Fetal weight estimation was obtained by Hadlock's formula based on biparietal diameter, femur length, and head and abdominal circumferences. The estimated fetal weight percentile was computed according to William's tables. Mean gestational age and incidence of preterm delivery for each fetal weight percentile between 1 and 100, at increments of 10, were calculated. The mean estimated fetal weight percentile, biparietal diameter, femur length, head circumferences and abdominal circumferences of preterm and term patients were compared. RESULTS: Among the 419 patients who met the inclusion criteria, duration of gestation was significantly shorter in fetuses with low estimated fetal weight percentile. The risk of preterm birth was 49% in fetuses of less than the 40th birth-weight percentile compared with a risk of 20% in fetuses of more than the 40th birth-weight percentile, representing a relative risk of 2.3. Individual fetal measurements indicate a head-sparing effect in the preterm group. CONCLUSION: Sonographically estimated fetal weight percentile measured between 24 and 34 weeks' gestation may be used as an additional and individually pertinent predictor of preterm birth.

Antenatal steroids and neonatal periventricular leukomalacia.

OBJECTIVE: To evaluate the effect of antenatal steroid treatment on the development of neonatal periventricular leukomalacia. METHODS: This retrospective cohort study included 1161 neonates with gestational ages of 24-34 weeks and birth weights of 500-1750 g, divided into two groups on the basis of antenatal steroid treatment. Neonatal neurosonograms were done on days 3 and 7 of life and labeled normal or abnormal. The abnormal outcomes evaluated were periventricular leukomalacia or intraventricular hemorrhage, periventricular leukomalacia with intraventricular hemorrhage, and isolated periventricular leukomalacia. The group treated with antenatal steroids was compared with the untreated group for these outcomes. RESULTS: Antenatal steroids were associated with significantly less periventricular leukomalacia or intraventricular hemorrhage (23% versus 31%, P =.005), periventricular leukomalacia with intraventricular hemorrhage (5% versus 11%, P =.001), and isolated periventricular leukomalacia (3% versus 7%, P =.009). Logistic regression analysis of antenatal steroid treatment, controlling for confounding maternal and neonatal characteristics, indicated that neonates treated with antenatal steroids had a 56% lower likelihood of periventricular leukomalacia with intraventricular hemorrhage (adjusted odds ratio [OR] 0.44, 95% confidence interval [CI] 0.25, 0.77) and a 58% lower likelihood of isolated periventricular leukomalacia (adjusted OR 0.42, 95% CI 0.20, 0.88). CONCLUSION: Antenatal steroid treatment was associated with over 50% reduction in the incidence of periventricular leukomalacia in preterm neonates. Increased use of antenatal steroid therapy might improve long-term neonatal neurologic outcomes.

Histologic chorioamnionitis, antenatal steroids, and perinatal outcomes.

OBJECTIVE: To determine the perinatal effects of histologic chorioamnionitis on preterm neonates and the effectiveness of antenatal steroids in the presence of histologic chorioamnionitis. METHODS: We studied neonates at our institution who weighed 1750 g or less at birth from January 1990 through December 1997. The population was stratified primarily by presence of histologic chorioamnionitis and secondarily by exposure to antenatal steroids. Subgroups were compared by various perinatal outcomes and confounding variables. Student t test, chi(2), Fisher exact test, and logistic regression were used for analysis. RESULTS: Among 1260 neonates entered, the placentas of 527 had evidence of histologic chorioamnionitis and 733 did not. Those with histologic chorioamnionitis had a lower mean gestational age, lower birth weight, and higher rate of major neonatal morbidities than those without it. After adjusting for confounding variables, histologic chorioamnionitis independently associated with lower gestational age, lower birth weight, and neonatal death. Among neonates exposed to antenatal steroids who had histologic chorioamnionitis, there was a significantly lower incidence of low Apgar scores (18% compared with 33.5%, P <.001), respiratory distress syndrome (RDS) (39.6% compared with 55.9%, P <.001), intraventricular hemorrhage and periventricular leukomalacia (21.9% compared with 36.9%, P <.001), major brain lesions (7.7% compared with 18.4%, P <.001), patent ductus arteriosus (14.8% compared with 23.7%, P =.018), and neonatal death (8.3% compared with 16.2%, P =.02), with no increase in rate of proven neonatal sepsis (18.3% compared with 14%, P =.24). CONCLUSION: Histologic chorioamnionitis increases major perinatal morbidity through its association with preterm birth and is independently associated with neonatal death. In the presence of histologic chorioamnionitis, antenatal steroids significantly decreased the incidence of RDS, intraventricular hemorrhage and periventricular leukomalacia, major brain lesions, and neonatal mortality, without increasing neonatal sepsis.

Placenta accreta and methotrexate therapy: three case reports.

Placenta accreta is a complication that is rising in incidence. The reported experience of methotrexate treatment in the conservative management of placenta accreta is scant. Three cases of placenta accreta managed with methotrexate are presented. Case 1: A woman had an antenatal diagnosis of placenta percreta. A successful manual placental removal occurred on post-cesarean day 16. Case 2: A woman had retention of a placenta accreta after a term vaginal delivery. Successful dilation and curettage were performed on postpartum day 37. Case 3: A woman had an antenatal diagnosis of placenta previa-percreta with bladder invasion. A simple hysterectomy was performed on post-cesarean day 46. Conservative management and methotrexate treatment resulted in uterine preservation in two of our three patients; however, this treatment did not prevent significant delayed hemorrhage. In view of the rapid resolution of vascular invasion of the bladder, methotrexate may have an important role in the management of placenta percreta with bladder invasion. The utility of methotrexate treatment with the conservative management of placenta accreta requires further evaluation.

Amniocentesis for selection before rescue cerclage.

OBJECTIVE: To determine whether diagnostic amniocentesis should be part of evaluations of women under consideration for rescue cerclage. METHODS: We reviewed the obstetric records of 25 candidates for rescue cerclage seen between June 30, 1995, and July 1, 1997. Rescue cerclage was defined as a procedure on a cervix with an internal os dilated at least 2 cm and 50% effaced, with membranes visible at the external os. Transabdominal amniocentesis was offered as part of the preoperative evaluation, and amniotic fluid (AF) was sent for glucose and lactate dehydrogenase level determinations, Gram staining, and culture for aerobic and anaerobic bacteria. Placentas were examined for histopathologic evidence of inflammation. The women were divided into three groups. Eleven women had rescue cerclage after amniocentesis, seven had rescue cerclage after declining amniocentesis, and seven had amniocentesis but were treated conservatively because of AF markers of infection. Analysis of variance and chi(2) statistics were used. RESULTS: The group that had rescue cerclage after amniocentesis had a significantly longer mean admission-to-delivery interval, higher mean gestational age at delivery, higher mean birth weight, and higher neonatal survival rate than did the group that had rescue cerclage without amniocentesis and the group that had no cerclage after amniocentesis (P <.001). CONCLUSION: Amniocentesis before rescue cerclage placement identified women with subclinical chorioamnionitis who would not benefit from cerclage.

Reduced risk of low weight births among indigent women receiving care from nurse-midwives.

STUDY OBJECTIVE: To examine the effect of a comprehensive prenatal and delivery programme administered by nurse-midwives on the risk of low weight births among indigent women. STUDY DESIGN: Historical prospective study. Birth outcomes among the cohort were compared with all county births during the same period, adjusting for maternal age and race. Results are expressed as relative risks with 95% confidence intervals. SETTING: An enhanced Medicaid funded pre-natal programme administered by nurse-midwives from 1992 to 1994 in Westchester County, New York. PARTICIPANTS: Indigent mothers (n = 1443), between the ages of 15 and 44, who were residents of Westchester County and indicated having Medicaid or no health care coverage. RESULTS: There were 1474 live births among cohort mothers. Mean (SD) gestational age was 39.4 (1.9) weeks. Less than 6% of births occurred before 37 weeks gestation. The mean birth weight of cohort infants was 3365.6 (518.6) g. Only 4.1% of the cohort births were less than 2500 g. Compared with all county births, the cohort showed a 41% reduction in the risk of low weight births (RRlbw = 0.59, 95% CI: 0.46 to 0.73, p < .001) and a 56% reduction when compared with county Medicaid births only (RR = 0.44, 95% CI: 0.34 to 0.57, p < .005) adjusting for maternal age and race. Larger reductions were found for very low weight births. CONCLUSIONS: Mothers need not be considered at high risk for adverse pregnancy outcomes based on their socioeconomic status alone. Moreover, a comprehensive prenatal programme administered by nurse-midwives may promote a reduction in adverse pregnancy outcomes among indigent mothers.

Alterations in relaxation to lactate and H(2)O(2) in human placental vessels from gestational diabetic pregnancies.

We determined whether alterations in the mechanism of relaxation to H(2)O(2) potentially contribute to the enhanced prostaglandin-mediated contractile response to H(2)O(2) and posthypoxic reoxygenation seen in human placental vessels of pregnancies with gestational diabetes mellitus (GDM). Isolated placental arteries and veins from GDM and uncomplicated full-term pregnancies were precontracted with prostaglandin F(2alpha) (PO(2) 35-38 Torr) and then exposed to lactate (1-10 mM), arachidonic acid (0.01-10 microM), nitroglycerin (1 nM-1 microM), forskolin (0.01-10 microM), or H(2)O(2) (1 microM-1 mM + 10 microM indomethacin). The rates of tissue H(2)O(2) metabolism by catalase and nitrite production were measured. The relaxation to lactate was reduced in GDM placental arteries and veins by 54-85 and 66-80%, and the relaxation to H(2)O(2) was inhibited by 80-94% in GDM placental veins compared with vessels from uncomplicated full-term pregnancies. H(2)O(2) caused only minimal relaxation of placental arteries. Responses to other relaxing agents were not altered in the GDM placental vessels. Diabetic vessels showed rates of nitrite production that were increased by 113-195% and rates of H(2)O(2) metabolism by catalase that were decreased by 44-61%. The loss of relaxation to H(2)O(2) and lactate (mediated via H(2)O(2)), perhaps as a result of the inhibition of catalase by nitric oxide, may explain the previously reported enhancement of prostaglandin-mediated contractile responses to H(2)O(2) and posthypoxic reoxygenation seen in GDM placental vessels.

Effectiveness of multidose antenatal steroids.

OBJECTIVE: To compare effectiveness between single and multiple courses of antenatal steroids in preterm births and determine adverse effects attributable to multiple courses. METHODS: We studied retrospectively the neonatal outcomes of infants who weighed 1750 g or less at birth between January 1990 and December 1997. Infants exposed to a single course were compared with those exposed to two or more courses of antenatal steroids, with respect to various perinatal outcome variables. RESULTS: Ninety-three neonates were exposed to two or more courses of antenatal steroids and 261 neonates had been given single courses. The mean (+/- standard deviation) gestational age (29.6 +/- 2.8 weeks compared with 28.7 +/- 2.7 weeks; P = .007) and birth weight (1252 +/- 321 g compared with 1159 +/- 339 g; P = .013) were significantly higher among neonates exposed to multiple courses. There were no significant differences between groups in perinatal outcomes; however, those exposed to multiple courses had a significantly lower rate of respiratory distress syndrome (RDS) (17 [18%] compared with 107 [41%]; P < or = .001) and surfactant use (40 [43%] compared with 149 [57%]; P = .02). Adjusting for confounding variables, multiple courses of steroids were significantly associated with a 65% reduction in the incidence of RDS (odds ratio 0.35; 95% confidence interval = 0.18, 0.70; P = .003). CONCLUSION: Compared with single courses, multiple courses of antenatal steroids reduced significantly the incidence of RDS with no apparent increase in neonatal sepsis or disturbances in fetal growth.

Pharmacologic approaches for the management of systemic hypertension in pregnancy.

Hypertension in pregnancy includes a group of distinct disorders that require special consideration in both prevention and pharmacologic treatment. In recent years, there have been few advances regarding the pathophysiology and prevention of preeclampsia, or in recommendations for first-line drug therapy of the hypertensive complications of preeclampsia. Similarly, the recommendations for pharmacologic treatment of women with chronic hypertension antedating pregnancy have changed little, primarily because first-line medications have the advantage of having been the subjects of extensive research experience. Recent clinical trials have demonstrated the efficacy and safety of various second-line drugs for treating hypertensive disorders of pregnancy; whether these therapies can eventually replace the standard recommended medications will require more extensive long-term investigation.

Effect of causing fetal cardiac asystole on second-trimester abortion.

OBJECTIVE: To compare second-trimester abortions with prostaglandin (PG) E2, with and without pretreatment-induced fetal death. METHODS: A retrospective chart review of all vaginal PG E2-induced abortions at Westchester Medical Center between January 1996 and April 1998 was done. Only women who sought terminations between 18 and 24 weeks' gestation by prostaglandin induction were included. These abortions were predominantly secondary to fetal structural and chromosomal anomalies. The study population was subdivided into groups based on the use of pretreatment cardiac puncture with potassium chloride. The groups were compared for maternal, fetal, and procedural characteristics. The chi2 test, Student t test, and Wilcoxon rank-sum test were used for analysis. RESULTS: There were no differences between the cardiac puncture and control groups when compared for various maternal and procedural characteristics, fetal weight, and the need for curettage for retained products of conception. However, the required median doses of PG E2 and the initiation to expulsion interval were significantly lower in the cardiac puncture group compared with the control group (2.0 doses compared with 3.0 doses, P<.001; 570 minutes compared with 890 minutes, P = .006). CONCLUSION: Pretreatment-induced fetal death significantly reduced the interval to expulsion and doses of PG E2 required for late second-trimester abortion.

Perinatal outcome of triplet gestation: does prophylactic cerclage make a difference?

OBJECTIVE: To compare the perinatal outcome of triplet gestations with and without prophylactic cerclage. METHODS: A retrospective chart review of all triplet gestations delivered between January 1988 and June 1997 was performed. Only women initiating prenatal care before 15 weeks gestation were included. The cerclage group was compared to the no-cerclage group for maternal and perinatal outcome variables. Student t-test, Chi-square, and Fisher's exact test were used for analysis. RESULTS: Twenty of the 59 (33.8%) sets of triplet gestations had prophylactic cerclage. There were no differences between groups when compared for maternal age, parity, preterm labor rate, gestational diabetes, anemia, antenatal steroid use, histologic chorioamnionitis, and postoperative endometritis. In addition, there were no differences in mean birth weight, Apgar scores, respiratory distress syndrome (RDS), intraventricular hemorrhage/periventricular leucomalacia (IVH/PVL), and neonatal mortality. Although the mean gestational age at delivery for the cerclage group (32.8+/-2.4 weeks) was not different from the no-cerclage group (31.5+/-3.6 weeks), the proportion of pregnancies delivered at 31 weeks or more, and at 32 weeks or more, was significantly higher in the cerclage group (90 vs. 62%, P = .02; 80 vs. 54%, P = .05), respectively. In addition, the incidence of extremely low birth weight (LBW) was significantly decreased in the cerclage compared with the no-cerclage group (1.7 vs. 15.4%, P = .005). CONCLUSIONS: Prophylactic cerclage decreased significantly the incidence of extremely LBW neonates in triplet pregnancies. The proportion of neonates delivered at 31 weeks or more, and at 32 weeks or more was higher in the cerclage group.

Maternal magnesium sulfate and the development of neonatal periventricular leucomalacia and intraventricular hemorrhage.

OBJECTIVE: Neonatal periventricular leucomalacia and intraventricular hemorrhage are strong correlates of cerebral palsy. Our objective was to evaluate the effect of maternal magnesium sulfate exposure on the incidence and severity of periventricular leucomalacia and intraventricular hemorrhage in preterm neonates. METHODS: Nine hundred eighteen consecutive inborn neonates with birth weights from 500 to 1750 g were divided primarily into two groups on the basis of maternal exposure to magnesium sulfate. The groups were divided secondarily into two clinical groups, a physician-initiated group, which consisted of neonates delivered for maternal or fetal indications, and a preterm delivery group, which included neonates delivered as a result of preterm labor or preterm premature rupture of membranes. These clinical groups were stratified further into magnesium sulfate-exposed and -unexposed subgroups. Neonatal neurosonograms were performed on days 3 and 7 of life and described as normal or abnormal. Abnormal sonograms included any periventricular leucomalacia or intraventricular hemorrhage. Severe lesions included periventricular leucomalacia, periventricular leucomalacia with intraventricular hemorrhage, or grades 3 or 4 intraventricular hemorrhage. The magnesium sulfate groups and the clinical groups with their magnesium sulfate strata were compared for the incidence and severity of abnormal sonograms. They also were compared for maternal and neonatal characteristics. RESULTS: Maternal magnesium sulfate exposure was not associated with reduction in the incidence of abnormal sonograms when compared with the unexposed group (27% compared with 33%, P = .06). However, fewer severe lesions were observed in the exposed group (14% compared with 21%, P = .004). When clinical groups were examined, magnesium sulfate was not associated with a decrease in abnormal sonograms (adjusted odds ratio [OR] 1.09, 95% confidence interval [CI] 0.78, 1.52, P = .40) or severe lesions (adjusted OR 1.11, 95% CI 0.73, 1.68, P = .42). Logistic regression analyses of magnesium sulfate exposure within clinical groups controlling for the confounding effects of maternal and neonatal characteristics revealed no protective effect of magnesium sulfate exposure on the incidence of abnormal sonograms (adjusted OR 1.01, 95% CI 0.70, 1.44, P = .97) or severe lesions (adjusted OR 1.01, 95% CI 0.70, 1.74, P = .69). Within clinical groups, the preterm delivery group exhibited an increased risk for abnormal sonograms (adjusted OR 1.63, 95% CI 1.01, 2.67, P = .05) and severe lesions (adjusted OR 9.79, 95% CI 3.27, 29.29, P = .001) when compared with the physician-initiated delivery group, independent of maternal magnesium sulfate exposure. CONCLUSION: Maternal magnesium sulfate exposure had no protective effect on the incidence or severity of periventricular leucomalacia and intraventricular hemorrhage in preterm neonates. The prevalence of these lesions was correlated better with the clinical group of origin and indication for its use.

Effectiveness of antenatal steroids in obstetric subgroups.

OBJECTIVE: To determine the effectiveness of antenatal steroids in the reduction of neonatal morbidity and mortality in obstetric subgroups of preterm labor with intact membranes, preterm premature rupture of membranes (PROM), and pregnancy-associated hypertension. The secondary objective was to determine the effect of antenatal steroids in appropriate for gestational age (AGA) and growth-restricted neonates. METHODS: We studied the neonatal outcomes for all women who delivered infants weighing 1750 g or less at birth between January 1990 and July 1997 at our institution. The study population was divided primarily into three clinical groups: preterm labor with intact membranes, PROM, and pregnancy-associated hypertension. Secondarily, the total population was divided based on birth weight and gestational age into AGA and growth-restricted neonates. Within each obstetric subgroup, neonates exposed to antenatal steroids were compared with unexposed neonates for respiratory distress syndrome (RDS), intraventricular hemorrhage and periventricular leukomalacia, the incidence of major brain lesions, necrotizing enterocolitis, proved neonatal sepsis, patent ductus arteriosus, and neonatal death. The subgroups were also compared for gestational age at delivery, birth weight, birth weight percentile, Apgar scores, postnatal surfactant exposure, and clinical and histologic chorioamnionitis. Descriptive statistics, Student t test, chi2, Fisher exact test, and logistic regression were used for analysis. RESULTS: A total of 1148 neonates weighing 1750 g or less were delivered during the study period. There were 447 and 410 neonates delivered after preterm labor with intact membranes and PROM, respectively, and 245 neonates born to mothers with pregnancy-associated hypertension. Nine hundred twenty-eight neonates were AGA and the remaining 220 neonates were growth restricted. Antenatal steroids significantly decreased the incidence of RDS, the incidence and severity of intraventricular hemorrhage and periventricular leukomalacia, necrotizing enterocolitis, and neonatal mortality in preterm labor with intact membranes. In the presence of PROM, it significantly decreased the incidence and severity of intraventricular hemorrhage and periventricular leukomalacia and decreased neonatal mortality, with no apparent effect on the incidence of RDS. Antenatal steroids did not show any beneficial effect in pregnancy-associated hypertension and fetal growth restriction (FGR). Additionally, a significant increase was observed in the incidence of proved neonatal sepsis when antenatal steroids were used in pregnancy-associated hypertension. CONCLUSION: The effectiveness of antenatal steroids varies with the obstetric population studied. Antenatal steroids significantly decreased the incidence of major neonatal morbidity and mortality in the AGA preterm neonate delivered after preterm labor with intact membranes. Antenatal steroids did not show any benefit in cases of pregnancy associated with maternal hypertension or FGR. Its effect in the presence of PROM is limited to a significant reduction in the incidence and severity of intraventricular hemorrhage and periventricular leukomalacia and in neonatal death.

Elevated Amniotic Fluid Interleukin-6 as a Predictor of Neonatal Periventricular Leukomalacia and Intraventricular Hemorrhage.

> Objective: To investigate the relationship between amniotic fluid interleukin-6 levels and the development of periventricular leukomalacia and intraventricular hemorrhage in the preterm neonate and to compare the value of amniotic fluid interleukin-6 with amniotic fluid culture and histologic chorioamnionitis in the prediction of periventricular leukomalacia and intraventricular hemorrhage. Methods: 119 women, between 20 and 34 weeks gestation, in preterm labor with intact membranes, underwent transabdominal amniocentesis. Amniotic fluid was cultured for aerobic and anaerobic bacteria, Ureaplasma urealyticum and Mycoplasma hominis. Amniotic fluid interleukin-6 levels were determined by enzyme-linked immunosorbent assay. The placentas were examined for histopathologic evidence of inflammation. Where the birth weight was <2,000 g, transfontanelle cranial sonography was performed on the 3rd and 7th days of life for diagnosis of periventricular leukomalacia and intraventricular hemorrhage. Student's t test, the Mann-Whitney U test, likelihood ratio chi2, logistic regression, and receiver-operator characteristic curve were used for analysis. Results: 33 women were excluded from the analysis because they delivered at other institutions. The neonates of 33 women did not have sonography because they weighed >2,000 g at birth. Two neonates died before sonography was performed; four neonates who weighed <2,000 g at birth did not have sonography. In the definitive study group of 47 women, those with neonates who developed periventricular leukomalacia and intraventricular hemorrhage (n = 14) had higher median amniotic fluid interleukin-6 levels (42,795 pg/ml versus 8,020 pg/ml; P = 0.009), more positive amniotic fluid cultures (64% vesus 21%; P < 0.003), and a shorter median amniocentesis-to-delivery interval (16 h versus 24 h; P = 0.045) than women (n = 33) who delivered neonates without periventricular leukomalacia or intraventricular hemorrhage. The groups did not differ in gestational age at admission (P = 0.15), birth weight (P = 0.09), or histologic chorioamnionitis (P = 0.37). An amniotic fluid interleukin-6 level >/=20,000 pg/ml had a sensitivity of 71% and a specificity of 70% compared with a sensitivity of 69% and specificity of 79% for amniotic fluid culture, and a sensitivity of 71% and specificity of 42% for histologic chorioamnionitis in the prediction of periventricular leukomalacia and intraventricular hemorrhage. Women with amniotic fluid interleukin-6 levels >/=20,000 pg/ml (n = 20) had more neonates with periventricular leukomalacia or intraventricular hemorrhage than women with amniotic fluid interleukin-6 levels <20,000 pg/ml (n = 27) (50% versus 15%; P = 0.009). They also were of lower birth weight (P = 0.02), had more neonatal morbidity (P = 0.01), had more positive amniotic fluid cultures (P = 0.01), and more histologic chorioamnionitis (P = 0.02). Logistic regression analysis demonstrated that amniotic fluid interleukin-6 was an independent risk factor for the development of periventricular leukomalacia and intraventricular hemorrhage (odds ratio, 5.81; 95% confidence interval, 1.02-33.16; P = 0.05) after controlling for gestational age, birth weight, histologic chorioamnionitis, and amniotic fluid culture (odds ratio, 7.94; 95% confidence interval 1.22-51.77; P = 0.03). Conclusions: In women in preterm labor with intact membranes amniotic fluid interleukin-6 is useful in predicting neonatal periventricular leukomalacia and intraventricular hemorrhage.

Amniotic fluid neuron-specific enolase: a role in predicting neonatal neurologic injury?

OBJECTIVE: To determine the relationship between amniotic fluid (AF) neuron-specific enolase and the development of neonatal intraventricular hemorrhage and periventricular leucomalacia. METHODS: Thirty-nine AF samples, obtained from women in preterm labor between 24 and 32 weeks' gestation, were analyzed for neuron-specific enolase. All women delivered preterm neonates who had neurosonograms on the 3rd and 7th days of life. The results of the neurosonograms were used to divide the study population first into normal and abnormal groups, then into normal, minor, and major brain lesion groups. The groups were compared for the median neuron-specific enolase, proportion with values of 6 microg/L or more, and other demographic characteristics. RESULTS: There were no differences between the groups' maternal and neonatal characteristics. However, the abnormal group had significantly higher median value of neuron-specific enolase than the normal group (9.5 microg/L and 2.0 microg/L, respectively; P < .001). The median neuron-specific enolase levels for the major, minor, and normal groups were 9.75 microg/L, 6.5 microg/L and 2.0 microg/L, respectively (P < .001). The optimum cutoff point, with a sensitivity of 89% and specificity of 100%, was 6 microg/L; 89% of the abnormals had values of 6 microg/L or more, compared with none of the normals (P < .001). The risk of developing intraventricular hemorrhage or periventricular leucomalacia was 11.5 times greater when AF neuron-specific enolase levels were 6 microg/L or more. CONCLUSION: Amniotic fluid neuron-specific enolase is a useful marker of neonatal neurologic injury.

Intra-amniotic pressure reduction in twin-twin transfusion syndrome.

OBJECTIVE: Our purpose was to measure intra-amniotic pressure before and after decompression amniocentesis in twin-twin transfusion syndrome. STUDY DESIGN: Intra-amniotic pressures were measured during decompression amniocentesis on 18 occasions in 5 pregnancies complicated by twin-twin transfusion syndrome. The intra-amniotic pressure was determined with a water manometer before and after removal of amniotic fluid. For comparison, intra-amniotic pressure was determined in 10 uncomplicated gestations. RESULTS: Initial intra-amniotic pressures in twin-twin transfusion gestations (mean, 17.2 +/- 5.2 cm H2O; range, 5.5 to 33.0 cm H2O) were higher than those of the uncomplicated gestations (mean, 8.4 +/- 3.3 cm H2O; range, 3.5 to 13.5 cm H2O; p < 0.002). Intra-amniotic pressures following therapeutic amniocentesis (mean, 10.9 +/- 5.1 cm H2O; range, 3.5 to 23.0 cm H2O) were not different from those of the uncomplicated gestations (p = 0.16). CONCLUSION: The intra-amniotic pressure in twin-twin transfusion gestations is higher than that of the uncomplicated gestation. Decompression amniocentesis reduces intra-amniotic pressure to that of the uncomplicated gestation.