Pregnancy outcomes and factors affecting the clinical effects of emergency cerclage in twin pregnancies with cervical dilation and prolapsed membranes.

OBJECTIVE: To determine the effect of mid-trimester emergency cerclage in women with twin pregnancies with cervical dilation and prolapsed membranes, and to identify risk factors predicting spontaneous preterm birth (sPTB) before 28 weeks, after cerclage. METHODS: Retrospective analysis of twin gestations with cervical dilation and prolapsed membranes treated with emergency cerclage or expectant management (2015-2020). The primary outcomes were the rate of sPTB before 28 weeks and the gestational latency. Multiple logistic regression analysis was used to determine the factors associated with sPTB before 28 weeks, after cerclage. RESULTS: Ninety-seven women were included, cerclage (n = 58) or no cerclage (n = 39). Cerclage placement was associated with significantly lower incidence of sPTB before 28 weeks of pregnancy (34.5% vs 82.1%) and prolongation of the gestational latency (46.71 ± 27.52 vs 10.95 ± 11.71 days). Positive cervical culture (odds ratio [OR] 10.69, 95% confidence interval [CI] 1.82-62.95), pregnancy duration at diagnosis less than 22 weeks (OR 9.42; 95% CI 1.69-52.69) and cervical dilation at least 4 cm (OR 7.92; 95% CI 1.40-44.71) were found to be independent risk factors for sPTB before 28 weeks, after cerclage. CONCLUSION: Emergency cerclage in women with twin pregnancies with cervical dilation and prolapsed membranes was associated with an overall 40% decrease in sPTB before 28 weeks and a prolongation of latency by 5 weeks. The strongest predictor of sPTB before 28 weeks after cerclage was a positive cervical culture.

Placenta accreta spectrum disorder trends in the context of the universal two-child policy in China and the risk of hysterectomy.

OBJECTIVE: To identify both the trends in placenta accreta spectrum (PAS) disorders in the context of the universal two-child policy in China and risk factors for hysterectomy. METHODS: The present retrospective analysis included confirmed PAS disorders during cesarean delivery at a tertiary hospital in Changsha, Hunan, China, from January 1, 2007, to December 31, 2016. Multivariable logistic regression was used to estimate the risk of hysterectomy. RESULTS: During the 10-year study period, the overall incidence of cesarean delivery was 51.6% (13 530/26 214) and that of PAS disorders was 1.2% (302/26 214). The PAS rate increased from 0.1% (5/4617) in 2007-2008 to 2.1% (133/6351) in 2015-2016, alongside a rise in elective repeat cesarean delivery from 5.0% (106/2124) to 38.4% (1385/3603). Previous cesarean delivery greatly increased the likelihood of PAS disorders (odds ratio [OR] 97.4; P<0.001). Invasive depth (OR 92.0; P<0.001), inter-cesarean interval less than 36 months (OR 7.0; P=0.002), rural residence (OR 5.3; P=0.018), and advanced maternal age (OR 3.0; P=0.045) were independent risk factors for hysterectomy among women with PAS disorders. CONCLUSION: The increasing incidence of elective repeat cesarean delivery combined with a high overall rate of cesarean delivery implies a high prevalence of PAS disorders within the context of the universal two-child policy in China. The main predictor of hysterectomy was invasive depth.

Preoperative infrarenal abdominal aorta balloon catheter occlusion combined with Bakri tamponade reduced maternal morbidity of placenta increta/percreta.

BACKGROUND: Placenta increta/percreta is an increasingly common and life-threatening obstetric complication. It poses a management challenge to clinicians. The present study aimed to evaluate efficacy and safety of preoperative placement of infrarenal abdominal aorta balloon catheter (IAABC) alone or combined with Bakri tamponade for the management of cases with placenta increta/percreta. METHODS: We retrospectively analyzed all cases with placenta increta/percreta at a tertiary referral teaching hospital in China between the year 2014 and 2017. Statistical analysis considered the individual subgroups: IAABC placed group and control group (without IAABC), and compared their maternal-fetal outcomes. RESULTS: The study covered 86 cases with placenta increta. For cases in the IAABC placed group (n = 48), significant reductions were noted in maternal morbidity including estimated blood loss (EBL), EBL ≥ 2000 mL, blood products transfusions, postpartum hemorrhage, operative time, intensive care unit admission, and postoperative days (P < .05 for all). The overall rate of hysterectomy was much lower (4.2%vs 23.7%, P = .018), compared with those in the control group (n = 38). Furthermore, in the IAABC placed group, hysterectomy was avoided in a further 17 cases combined with Bakri tamponade. In the control group, 10 cases were successful in preserving uterus by Bakri tamponade. Four cases failed and needed reoperation (3 uterine arterial embolism, 1 hysterectomy). There were no differences in fetal outcomes between the 2 groups. Eighteen cases were diagnosed with placenta percreta. Almost all the cases (17/18) inevitably underwent caesarean hysterectomy. Only 1 case was treated with a combination of IAABC and Bakri tamponade, and successfully reserved uterus. No differences were observed in any other outcomes, except for a significant less mean operative time (P = .017) in cases with IAABC placed (n = 10), compared with those without IAABC (n = 8). Only 1 case had a femoral artery thrombosis directly related to IAABC placement and recovered after conservative treatment. There was no maternal or neonatal death in this study. CONCLUSION: Prophylactic insertion of IAABC alone or combined with Bakri tamponade should be safe and effective in controlling intraoperative bleeding due to placenta increta, thus hysterectomy could be avoided. It seems to be less beneficial to women with placenta percreta. Bakri tamponade can be a good choice in the management of placenta increta/percreta before more aggressive surgeries.

Increased hepatic peroxisome proliferator-activated receptor coactivator-1α expression precedes the development of insulin resistance in offspring of rats from severe hyperglycemic mothers.

BACKGROUND: Prenatal hyperglycaemia may increase metabolic syndrome susceptibility of the offspring. An underlying component of the development of these morbidities is hepatic gluconeogenic molecular dysfunction. We hypothesized that maternal hyperglycaemia will influence her offsprings hepatic peroxisome proliferator-activated receptor coactivator-1α (PGC-1α) expression, a key regulator of glucose production in hepatocytes. METHOD: We established maternal hyperglycaemia by streptozotocin injection to induce the maternal hyperglycaemic Wistar rat model. Offspring from the severe hyperglycemia group (SDO) and control group (CO) were monitored until 180 days after birth. Blood pressure, lipid metabolism indicators and insulin resistance (IR) were measured. Hepatic PGC-1α expression was analyzed by reverse transcription polymerase chain reaction and Western blotting. mRNA expression of two key enzymes in gluconeogenesis, glucose-6-phosphatase (G-6-Pase) and phosphoenolpyruvate carboxykinase (PEPCK), were analyzed and compared. RESULTS: In the SDO group, PGC-1α expression at protein and mRNA levels were increased, so were expression of G-6-Pase and PEPCK (P < 0.05). The above effects were seen prior to the onset of IR. CONCLUSION: The hepatic gluconeogenic molecular dysfunction may contribute to the metabolic morbidities experienced by this population.

[Effects of severe hyperglycaemia in pregnancy and early overfeeding on islet development and insulin resistance].

OBJECTIVE: Study the effects of early overfeeding in the adult offspring of mother with severely hyperglycaemia in pregnancy to islet development and insulin resistance. METHODS: Thirty healthy female Wistar rats were mated with 10 male Wistar rats and the morning on which sperm were found in three different visual fields of the vaginal smear was designated pregnancy day 1. The pregnant rats were intraperitoneally administered with Streptozotocin (STZ, 50 mg/L) on 5th day of pregnancy, and blood glucose exceeded 20 mmol/L to induce severely gestational diabetes mellitus (SDM) model. The pregnant Wistar rats were assigned to two experimental groups: SDM (n = 16) and control (n = 8). Litter size reduction in the lactation period induced early postnatal overfeeding model. Offspring were divided into three groups according to the level of blood glucose in pregnancy and feeding patterns in lactation: (1) control group (CG): euglycemia in pregnancy, eight pups in lactation; (2) severely gestational diabetes mellitus-normal feeding (SDM-N): severely gestational diabetes mellitus, eight pups in lactation; (3) severely gestational diabetes mellitus-overfeeding (SDM-O): severely gestational diabetes mellitus, four pups lactation. At the end of the lactation period, all pups were fed standard laboratory chow adlibitum until the date of the experiments. Offspring body weight was measured weekly after ablactation. Serum insulin was measured by enzyme-linked immunosorbent assay (ELISA) and pancreatic islet morphology was analyzed by immunohistochemistry (IHC) in all three groups at 26 weeks of age. RESULTS: (1) Blood glucose of pregnant Wistar rats: SDM (28.3 ± 5.1) mmol/L was statistically higher than control (6.3 ± 1.4) mmol/L (P < 0.05). (2) Growth rates of body weight in 3-7 weeks and 3-9 weeks: SDM-N: (4.6 ± 1.3)% and (6.8 ± 2.5)%, SDM-O: (3.2 ± 0.7)% and (4.6 ± 1.2)%, CG: (2.9 ± 0.6)% and (4.1 ± 0.8)%. The growth rates of body weight in SDM-N and SDM-O were both significantly higher than those in CG (P < 0.05). (3) Body weight at 26 weeks: CG: (486 ± 132) g, SDM-N: (387 ± 115) g, SDM-O: (382 ± 122) g. There was no statistical difference among the three groups (P > 0.05). (4) Fasting plasma glucose (FPG), fasting insulin (FINS), homeostasis model of insulin resistance (HOMA-IR) and insulin sensitivity index (ISI): at 26 weeks, the SDM-offspring has normal FPG, but more insulin was needed to keep it normal. The insulin level of SDM-O [(12.6 ± 3.3) mU/L] was statistically higher than those of SDM-N [(10.9 ± 3.3) mU/L] and CG [(8.6 ± 0.8) mU/L] (P < 0.05). The ISI of SDM-O (0.020 ± 0.006) was significantly smaller than its HOMA-IR (2.40 ± 0.62, P < 0.05). (5) The morphological change of pancreatic islet: The islets of CG and SDM-N were round or ellipse and have clear boundary between endocrine and exocrine parts and the ß cells distributed equally. However, SDM-O islets were not of uniform size and most of islets were hyperplasia and hypertrophy. (6) Relative ß cell area of pancreas, ß-cell area and islet size: SDM-O: (1.81 ± 0.31)%, (57.1 ± 3.2)% and (39,067 ± 3308) µm(2); SDM-N:(1.34 ± 0.43)%, (60.9 ± 0.6)% and (30,570 ± 4824) µm(2); CG: (1.11 ± 0.26)%, (63.7 ± 2.7)% and (26,443 ± 4431) µm(2). SDM-O has significantly increasing ß-cell mass, hypertrophic islet size and slightly decreasing ß-cell percentage compared with other two groups (P < 0.05). CONCLUSIONS: The exposure of severely hyperglycemia in pregnancy induces low weight infant and postnatal catch-up growth leading to the possibility of insulin resistance (IR) in adult and early postnatal overfeeding will accelerate such course. Islet morphology of SDM-N has no significant change, indicating that maternal diabetes mainly affected ß-cell function but not islet morphological features. SDM overfeeding results in early impairment of islet morphology and function, indicating that the compensation ability of islets has already been impaired and the risk of further development of impaired glucose tolerance (IGT) and diabetes. In conclusion, the nutritional environment in early life (duration of pregnancy and lactation) participate in the metabolic programming in adulthood.