Autophagy in placentas from acidotic newborns: an immunohistochemical study of LC3 expression.

Autophagy is an inducible catabolic process activated during compromised conditions, such as hypoxia. Neonatal encephalopathy (NE) is a syndrome of disturbed neurological function. No absolute prognostic indicators are available at birth to identify neonates at high risk to develop NE. Immunohistochemical staining with LC3 antibody was performed on 40 placentas from uneventful term singleton pregnancies with umbilical artery pH ≤ 7.00 at birth; semi-quantitative analysis was carried-out to estimate autophagy level. 6/40 (15%) neonates developed NE. Placentas from newborns with NE exhibited a higher LC3 expression. Autophagy protein expression in placentas with severe acidosis is a potential marker for poor outcome.

Prognostic role of umbilical artery Doppler velocimetry in growth-restricted fetuses.

OBJECTIVE: To correlate umbilical artery Doppler velocimetry with perinatal outcome in a group of growth-restricted fetuses. DESIGN: The study was a retrospective analysis of 578 singleton pregnancies with diagnosis of intrauterine growth restriction (IUGR), delivered in a single obstetric unit, at the Spedali Civili, Brescia, Italy, a university and teaching hospital with 3500 deliveries a year and neonatal intensive care unit (NICU). METHODS: During 1991-99 we studied 578 pregnancies with a diagnosis of IUGR referred for Doppler velocimetry. From this population, four subsets were formed: normal umbilical artery pulsatility index (NUAPI; 334 fetuses); increased pulsatility index but with telediastolic flow (abnormal umbilical artery pulsatility index AUAPI; 137 fetuses); absent end-diastolic flow (AEDF; 70 fetuses); reverse telediastolic flow (RF; 37 fetuses). Fetal biometry, amniotic fluid and fetal-maternal Doppler velocimetry were evaluated in all patients, with biophysical profile and routine non-stress test, when indicated. The following outcomes were examined: mean gestational age at delivery, number of preterm deliveries (< 34 weeks), mean neonatal weight, Apgar score at 5 min < 7, prenatal and neonatal deaths (within the first 28 days of life), admission to the NICU and number of days spent after birth in hospital. Neonatal morbidity was analyzed, including respiratory distress syndrome (RDS), intraventricular hemorrhage (IVH, grade 2-3), necrotizing enterocolitis (NEC) and retinopathy of prematurity. Long-term neurological follow-up is still ongoing and will not be presented in this paper. RESULTS: Out of 578 fetuses with IUGR, 547 were born alive. There were 26 neonatal deaths. The mean gestational age at delivery was 35.6 +/- 4 weeks and mean birth weight 1844 +/- 612 g. There were 28 intrauterine deaths and three elective terminations of pregnancy. A total of 60 cases (11%) were complicated by RDS, 13 cases (2.4%) by retinopathy of prematurity, IVH was present in nine cases (1.6%) and NEC in seven cases (1.3%). Total perinatal mortality was 9.8%; in the 26 cases of neonatal death, the mean week at delivery was 29.6 +/- 4 with a mean weight of 840 +/- 425 g. Patients with NUAPI had a mean week at delivery of 37 +/- 3, those with AUAPI delivered at 34 +/- 3.2, those with AEDF delivered at 31 +/- 3 and those with RF delivered at 29 +/- 2 weeks. In progressively worsening umbilical velocimetry, we observed an increase of incidence of low Apgar score. Days of admission to the NICU and incidence of perinatal mortality increased with the worsening of Doppler velocimetry. CONCLUSIONS: Our study underlines the existence of a strict correlation between umbilical Doppler velocimetry and an increased incidence of perinatal complications in IUGR fetuses.

Quantitative analysis of fetal DNA in maternal plasma in pathological conditions associated with placental abnormalities.

An increased fetal DNA concentration in maternal plasma has been observed in placental pathological conditions associated with hypertension and preeclampsia. To confirm these data, we performed real-time quantitative PCR on the SRY gene in a group of physiological and pathological male-bearing pregnancies. In 78 physiological pregnancies, fetal DNA concentration in maternal plasma was 20.7, 13.4, 23.6, and 74.8 genome-equivalents (g.e.)/mL during the first, second, and third trimesters and at term, respectively. In 10 preeclamptic women, fetal DNA concentration ranged from 59.3 to 615.2 g.e./mL (median: 332.9). In 7 women with preeclampsia and IUGR (intrauterine growth retardation), fetal DNA ranged from 96.5 to 859 g.e./mL (median: 146.8). In 4 women with IUGR and hypertension, fetal DNA ranged from 34 to 473.5 g.e./mL (median: 142.4). In 3 patients with IUGR, fetal DNA ranged from 168.6 to 519.7 g.e./mL (median: 308.1). In 2 patients with IUGR and HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, fetal DNA concentration ranged from 105 to 394.1 g.e./mL (median: 249.7). Four women who developed preeclampsia some weeks later showed fetal DNA levels within the physiological range. These data suggest that increased fetal DNA concentrations might represent a valuable marker of placental abnormalities and suggest that this rise may precede clinical manifestation of preeclampsia by only a few weeks.

Late normalisation of uterine artery velocimetry in high risk pregnancy.

OBJECTIVE: To test whether late normalisation of abnormal uterine velocimetry is a favourable prognostic factor in high risk pregnancies. STUDY DESIGN: Uterine artery colour Doppler velocimetry was performed at 24, 28-30 and 32-34 weeks in 282 high risk pregnancies treated with low dose aspirin. RESULTS: 88 patients had abnormal waveforms at 24 weeks and 77 delivered after the second assessment at 28 weeks. Of these, 38 (49%) had a normalisation of Doppler indices by 34 weeks. Compared with the persistently abnormal Doppler group, these patients delivered fewer small for gestational age babies (5/38 versus 26/39; p=0.0001) and had less gestational hypertension without proteinuria (3/38 versus 15/39; p=0.004). No patients with preeclampsia or other severe complications of pregnancy were observed in the normalised group. CONCLUSIONS: Although abnormal uterine artery velocimetry at 24 weeks is predictive of adverse pregnancy outcome, nearly half have late normalisation of the Doppler indices and a better perinatal outcome. Persistently abnormal waveforms are related to the worst pregnancy outcome.

Glyceryl trinitrate and ritodrine in tocolysis: an international multicenter randomized study. GTN Preterm Labour Investigation Group.

OBJECTIVE: To compare the efficacy of transdermal glyceryl trinitrate and intravenous (IV) ritodrine as tocolytics. METHODS: Two hundred forty-five women with preterm labor and intact membranes between 24 and 36 weeks' gestation were randomized to transdermal glyceryl trinitrate or intravenous ritodrine. Treatment was continued until contractions stopped or a maximum of 7 days. Glyceryl trinitrate was administered as a 10- or 20-mg transdermal patch. Intravenous ritodrine was administered according to nationally available guidelines. The primary outcome was prolongation of gestation expressed as a percentage of the time from entry to 37 weeks. Secondary outcomes were proportion of women who delivered the same day, next day, or within 7 and 14 days of entry, and by 32, 34, and 37 weeks. Analysis was by intention to treat. RESULTS: Twelve women (5%) were lost to follow-up. Glyceryl trinitrate and ritodrine prolonged gestation by 74% of time to 37 weeks (difference glyceryl trinitrate-ritodrine 0%; 95% confidence interval (CI) -10%, +10%). There was no significant difference in the proportion of women receiving glyceryl trinitrate or ritodrine who delivered within the specified days from study entry or weeks of gestation; however, 42 women who received glyceryl trinitrate and 58 women who received ritodrine delivered by 37 weeks (difference -11%; 95% CI -24%, +2%). No serious maternal side effects were reported for ritodrine or glyceryl trinitrate. CONCLUSION: We found no overall difference between glyceryl trinitrate and ritodrine in the acute tocolysis of preterm labor but a suggested advantage of glyceryl trinitrate over ritodrine in reducing preterm delivery rate. The maternal side effect profile and treatment discontinuation rates were fewer for glyceryl trinitrate, suggesting it was a safer alternative to ritodrine.

[Ultrasonography of the uterine cervix in pregnancy. Curve of normality in a longitudinal and cross-sectional study]. / Studio ecografico del collo dell'utero in gravidanza. Curva di normalità in uno studio longitudinale e trasversale.

BACKGROUND: The aim of the study was to establish a normality curve of cervical length variations during pregnancy in our pregnant women population, to be compared with pathological cases (risk of preterm labor and cervical incompetence). DESIGN: A prospective longitudinal and cross-sectional study in women with single pregnancy and without risk factors for preterm labor was carried on. SETTING: Obstetric and Gynecology Department, University of Brescia, Italy. POPULATION OR SAMPLE: One hundred and thirty-four pregnant women with single pregnancy, 112 cross-sectionally and 22 longitudinally followed, with labor at term, were selected. Sixty-eight were nulliparous, 66 pluriparous. Multiple pregnancy, previous placental and vaginal bleeding were excluded. METHODS: A transvaginal probe was used to assess uterine cervix and the patients were studied from the 12th to 41st gestational week. Statistical analysis was carried out by Student's "t"-test and Z-test. MEASURES: Cervical longitudinal diameter, internal uterine os and funneling were assessed. RESULTS: No statistically significant differences emerged in the curves with regard to nulliparous and pluriparous patients. The cut-off between normality and pathology, from the 24th to the 32nd gestational week (2ndSD), seems to correspond to a cervical length lower than 25 mm; a significant progressive decrement of the cervical longitudinal diameter begins from the 28th gestational week. CONCLUSIONS: These results allows the gathering of reference data about normality to compare with pathology (cervical incompetence and preterm delivery), which could be useful both for prevention and follow-up of these cases.

A randomized comparison of vaginal prostaglandin E2 with oxytocin plus amniotomy for induction of labour in women with intermediately ripe cervices.

OBJECTIVE: To compare the effects of oxytocin and amniotomy or vaginal prostaglandin E2 (PGE2) for induction of labour. STUDY DESIGN: We conducted a randomized clinical trial. Eligible for the trial were women with normal pregnancy, parity 0-3, with intact membranes, >40 weeks of gestation documented by ultrasound examination before 20 weeks gestation, observed in a network of 13 general and teaching hospitals in Italy. Inclusion criteria were cervical Bishop's score 5-7, less than six uterine contractions per hour, single pregnancy, cephalic presentation, no history of cesarean section and uterine surgery. Eligible women were randomly assigned by phone to oxytocin plus amniotomy (163 women) or vaginal PGE2 2 mg, two doses at 6-h intervals (157 women). RESULTS: Overall, 50 women (15.6%) delivered by cesarean section, 22 (13.5%) randomized to oxytocin, and 28 (17.8%) randomized to PGE2 (not significant). Twelve hours after randomization, induction had failed in 26 women of the 163 randomized to oxytocin plus amniotomy (21.6%) and 34 out of the 157 randomized to PGE2 (15.9%): the difference was not significant. Neonatal outcome was similar in the two groups. CONCLUSIONS: This study did not find marked differences in labour and neonatal outcome between women randomized to oxytocin plus amniotomy or vaginal PGE2. A shorter induction delivery interval in the group receiving amniotomy and oxytocin after PGE2 priming was observed.

Role of uterine artery Doppler investigation in pregnant women with chronic hypertension.

OBJECTIVE: To evaluate the role of uterine artery Doppler investigation in predicting perinatal outcome of patients with chronic hypertension. STUDY DESIGN: Uterine artery velocimetry was investigated at 24 weeks gestation in 78 chronic hypertensive pregnant women by means of color Doppler. The resistance index (RI) and the presence of a diastolic notch were recorded and related to the development of superimposed preeclampsia (SPE), pregnancy aggravated hypertension (PAH). and intrauterine growth retardation (IUGR). RESULTS: There were more pregnancy complications in the 25 patients with abnormal RI, compared with the 53 women with normal RI (SPE 12% vs. 0%, PAH 36% vs. 7% and IUGR 52% vs. 2%; P<0.01), and more in women with a bilateral diastolic notch compared with those without (SPE 23% vs. 0, PAH 54% vs. 4%, IUGR 85% vs. 2%; P<0.0001), while no differences were detected in those with only a unilateral notch, except for PAH (27% vs. 4%; P<0.01). CONCLUSION: Uterine artery Doppler velocimetry identifies a subgroup of chronic hypertensive patients with a high frequency of pregnancy complications.

[Streptococcus group B and pregnancy: the therapeutic role of topical intravaginal clindamycin]. / Streptococco di gruppo B e gravidanza: ruolo terapeutico della clindamicina topica intravaginale.

OBJECTIVE: To evaluate the clinical and therapeutic efficacy of 2% clindamycin vaginal cream in pregnant women heavily colonized with group B streptococci (GBS). STUDY DESIGN: A prospective, clinical trial in which carriers of group B streptococci were randomized to receive topical intravaginal clindamycin or oral amoxicillin. PATIENTS: We randomized 105 pregnant women: 55 received 2% clindamycin vaginal cream (100 mg/day for 7 days) and 50 oral amoxicillin (2 g/day for 7 days). INTERVENTIONS: Patients were treated during pregnancy, none of them received intrapartum chemoprophylaxis. On the other hand, all the neonates, within 24 hours from delivery, were studied from the microbiological point of view, carrying out auricolar, nasal, oropharyngeal and umbilical cultures. RELIEFS: The eradication of the microorganism was evaluated by performing a vaginal culture after 6 weeks from the beginning of antibiotic therapy. RESULTS: The eradication rate of the microorganism was significantly higher in women treated with topical clindamycin compared with the group receiving oral amoxicillin (71% versus 36%; p < 0.05). The neonatal outcome was similar in the two groups in terms of gestational age at delivery and mean birthweight. None of the neonates was admitted to the neonatal intensive care unit and no cases of neonatal sepsis were recorded. CONCLUSIONS: From our experience we can conclude that, during pregnancy, a treatment with topical intravaginal clindamycin may be useful in the eradication of GBS.

Doppler velocimetry of the uterine arteries in nulliparous women.

The aim of this study was to evaluate the role of uterine artery Doppler velocimetry performed at 20 and 24 weeks gestation in predicting gestational hypertension and small-for-gestational age babies in a population of nulliparous women. Four hundred and fifty-six patients without risk factors for pregnancy complications and with fetuses free from structural abnormalities at ultrasonographic examination at 20 weeks gestation were considered in the study. During the routine 20 weeks ultrasound a continuous-wave Doppler examination of the uterine arteries was performed. The patients with abnormal uterine Resistance Index (RI) repeated the Doppler evaluation at 24 weeks by means of Colour Doppler equipment. Among the 419 women who completed the study an abnormal Doppler uterine arteries velocimetry was found in 8.6% of the patients. Pregnancy complications (gestational hypertension and/or small-for-gestational age babies) were observed in 56% of the patients presenting high uteroplacental RI versus 10% of those with normal uterine artery velocimetry (P = 0.0001). In the group of patients with an abnormal RI value, the presence of a diastolic notch in one or both of the uterine arteries identified a population of pregnant women at higher risk for pregnancy complications when compared with patients without notch (78% vs. 33%, P = 0.007). The knowledge of the uteroplacental resistance can help in identifying a subgroup of patients at higher risk of hypertensive disorders and small-for-gestational age babies that could benefit from prophylaxis with low dose aspirin.

Absent end-diastolic velocity in umbilical artery: risk of neonatal morbidity and brain damage.

OBJECTIVE: We conducted a cohort study in growth-retarded fetuses to establish if absent or reverse end-diastolic flow in the umbilical artery was associated with increased perinatal mortality and morbidity and neurologic damage at long-term follow-up. STUDY DESIGN: Thirty-one fetuses with intrauterine growth retardation and absent or reverse end-diastolic flow in the umbilical artery (study group) and 40 growth-retarded fetuses with detectable diastolic flow in the umbilical artery, divided into two control groups, were followed up with serial nonstress tests, Doppler flow studies, and biophysical profiles. Twenty newborns from the study group survived the perinatal period and were observed for a mean of 18 months (range 12 to 24 months). Their neurologic outcomes were compared with those of 26 neonates from the two control groups. RESULTS: Study group fetuses had a higher incidence of abnormal karyotype (9.7% vs 0%) and corrected perinatal mortality (26% vs 6% and 4%) and a greater risk of permanent neurologic sequelae (35% vs 0% and 12%) compared with the fetuses from the two control groups. CONCLUSIONS: Growth-retarded fetuses with absent or reverse end-diastolic flow in the umbilical artery not only have an increased fetal and neonatal mortality but also a higher incidence of long-term permanent neurologic damage when compared with growth-retarded fetuses with diastolic flow in the umbilical circulation.

Effects of maternal hyperoxygenation on ductus venosus flow velocity waveforms in normal third-trimester fetuses.

On the basis of the data obtained in sheep fetuses showing a high interdependence between umbilical vein oxygenation and ductus venosus flow, we investigated the effect of maternal hyperoxygenation on ductus venosus velocity waveforms in normal third-trimester human fetuses. Ductus venosus velocity waveforms were recorded by using color and pulsed Doppler ultrasonography before and after 15 min of maternal administration of humidified 60% oxygen. During maternal hyperoxygenation, there was a significant increase of both estimated peak velocities during systole, diastole and atrial contraction and the mean temporal velocity during the total cardiac cycle and systolic and diastolic portions. On the other hand, during maternal hyperoxygenation, no significant changes were found in fetal heart rate or in the ratios between peak velocities and mean temporal velocities during systole and diastole. These findings suggest a close relationship between fetal oxygenation and ductus venosus velocity waveforms that may be useful in monitoring fetal hypoxemia.