Fetal loss following second trimester amniocentesis. Who is at greater risk? How to counsel pregnant women?

OBJECTIVE: The purpose of this retrospective observational cohort study was to determine the impact of certain risk factors on fetal loss, after mid-trimester amniocentesis. MATERIAL AND METHODS: Six thousand seven-hundred and fifty-two (6752) consecutive amniocenteses with known pregnancy outcome performed during a 7-year period (2004-2010) were included in this study. Different maternal-, fetal- and procedure-related factors were evaluated in this study. RESULTS: During this 7-year period, 6752 cases who underwent amniocentesis, with complete data available were evaluated for the outcome and risk factors mentioned. Total fetal loss rate (FLR) up to the 24th week was 1.19%. Risk factors associated with increased risk of fetal loss after amniocentesis were maternal age (OR:2.0), vaginal spotting (OR:2.2) and serious bleeding (OR:3.5) during pregnancy, history of 2nd trimester termination of pregnancy (OR:4.0), history of more than three spontaneous (OR:3.0) or surgical first trimester abortions (OR:2.1), fibromas (OR:3.0) and stained amniotic fluid (OR:6.1). CONCLUSIONS: Amniocentesis is a safe-invasive procedure for prenatal diagnosis with total FLR of 1.19% in our institution during the study period. The present study has emphasized the significance of certain risk factors for adverse outcome and therefore the need to individualize the risk.

Risk for fetal loss and prematurity after 12,413 second trimester amniocenteses in a single center.

OBJECTIVES: The purpose of this retrospective controlled study is to estimate the risk for fetal loss and preterm delivery attributed to second trimester amniocentesis from a single tertiary center. METHODS: The study group consists of 12,413 singleton pregnancies with consecutive amniocenteses, performed in a single tertiary center during a 15-year period (1996-2010) with known pregnancy outcome. The control group consisted of 6993 pregnancies with negative second trimester screening for aneuploidies during the same period who did not have any invasive test. The two groups were compared in terms of fetal loss rate up to 24 weeks and premature deliveries. RESULTS: Total fetal loss up to 24 weeks in the study group, excluding terminations of pregnancy, was estimated at 1.25% (1.05%-1.45%, confidence interval [CI]: 95%). In the control group the loss rate was 0.65% giving a procedure related fetal loss rate of 0.6% which was not found to be a statistically significant difference. Delivery before the 28th, 32nd, 34th, and 37th week in the study group was reported in 0.2%, 0.8%, 1.2% and 8.1% respectively, and it was not statistically different from controls. CONCLUSION: The present study has shown that the risk of miscarriage that can be attributed to amniocentesis in our institution is 0.6%, and this is not statistically significant when compared with cases without any invasive procedure during pregnancy. Similarly, the risk for preterm labor was not statistically significant when compared with controls.

Bidirectional communication between neural and cardiac cells in human amniotic fluid.

OBJECTIVE: To evaluate whether amniotic fluid cells contain cardiomyocyte- and neuron-like cells. STUDY DESIGN: In this experimental study, cells from human amniotic fluid samples were analyzed for mRNA expression of microtubule-associated protein 2 (MAP-2), vimentin and oxytocin (OT) receptor via RT-PCR. Immunocytochemistry was also performed with MAP-2, OT receptor, vimentin and troponin I antibodies. RESULTS: In all samples, MAP-2, vimentin and mRNA expression were detectable. OT receptor was also detectable. The cells showed strong immunoreactivity for molecular markers of neurogenic cells including MAP-2 and vimentin. The cells also showed strong immunoreactivity for molecular markers of cardiac muscle such as troponin I and for OT receptors. This report also shows that atosiban (an OT antagonist) added to culture medium of amniotic fluid cells did not induce neurogenic and cardiomyogenic differentiation. CONCLUSIONS: The observed concurrent development of cardiomyocyte- and neuron-like cells suggests that amniotic fluid contains progenitor cells and there is bidirectional communication between both cell types.

Oxytocin receptor- and Oct-4-expressing cells in human amniotic fluid.

BACKGROUND/AIMS: The present clinical and molecular study aimed at investigating the presence of the genes encoding oxytocin receptor (OT-R) and Oct-4 in human amniotic fluid cells. METHODS: Amniotic fluid samples were obtained from amniocentesis. Cells from human amniotic fluid samples were analyzed for mRNA expression of OT-R and Oct-4 via reverse transcription-polymerase chain reaction (RT-PCR). Immunocytochemistry was also performed with OT-R and Oct-4 antibodies. RESULTS: RT-PCR from 10 independent amniocentesis samples demonstrated the expression of OT-R and Oct-4 mRNA. The cells also showed strong immunoreactivity for molecular markers of OT-R and Oct-4. CONCLUSION: OT-R and Oct-4 are expressed in human amniotic fluid cells. The role of oxytocin in the physiology and pathophysiology of amniotic fluid cells remains to be settled.

Deleted in Azoospermia-Like (DAZL) gene-expressing cells in human amniotic fluid: a new source for germ cells research?

OBJECTIVE: To evaluate whether amniotic fluid cells contain a germ-like cell subpopulation. DESIGN: Experimental study. SETTING: University hospital. PATIENT(S): None. INTERVENTION(S): Cells from human amniotic fluid samples were analyzed for messenger RNA expression of Deleted in Azoospermia-Like gene (DAZL) and Oct-4 by reverse transcriptase polymerase chain reaction. DAZL and C-kit protein expression was assessed by flow cytometry. Immunocytochemistry also was performed to determine DAZL-, stage-specific embryonic antigen 4 (SSEA-4)-, and Oct-4-positive cells. MAIN OUTCOME MEASURE(S): DAZL gene expression in amniotic fluid cells. RESULT(S): Reverse transcriptase polymerase chain reaction, flow cytometric, and immunocytochemical analyses revealed that human amniotic fluid consists of a distinct cell population that expresses DAZL, C-kit, SSEA-4, and Oct-4. CONCLUSION(S): Our results suggest that human amniotic fluid represents a new source for the isolation of human DAZL-, C-kit-, SSEA-4-, and Oct-4-positive stem cells without raising the ethical issues associated with human embryonic research.

Management of cervical insufficiency and bulging fetal membranes.

OBJECTIVE: To evaluate the efficacy of emergency cerclage in cases with dilated cervix and protruding fetal membranes in a group of women considered at low risk for preterm delivery by their obstetric histories. METHODS: All cases of cervical dilatation and bulging membranes were detected through a transvaginal ultrasonographic screening for preterm delivery between 18 and 26 weeks during a 6-year study period. Twenty-nine women underwent an emergency cervical cerclage and composed the cerclage group, whereas 17 others refused and formed the bed rest group. All patients were given antibiotics and prophylactic tocolysis. RESULTS: The mean prolongation of pregnancy (8.8 weeks) and the mean birth weight (2,101 g) after cerclage placement differed significantly from those of the bed rest group (3.1 weeks and 739 g, respectively). Twenty-five of the 29 pregnancies in the cerclage group ended in live birth, compared with 7 of the 17 pregnancies in the bed rest group (P = .001) (relative risk [RR] 0.33, 95% confidence interval [CI] 0.11-0.98). Neonatal survival was 96% in the cerclage group and 57.1% in the bed rest group (P = .025) (RR 0.09, 95% CI 0.01-0.76). The preterm delivery rate less than 32 weeks was 31% and 94.1% in the cerclage and the bed rest groups, respectively (P < .001) (RR 0.33, 95% CI 0.19-0.57), whereas the admission to neonatal intensive care unit was 28% and 85.7% in the 2 groups, respectively, (P = .01) (RR 0.33, 95% CI 0.16-0.66). CONCLUSION: Emergency cervical cerclage can be accomplished safely in women with dilated cervix and bulging membranes. It can reduce preterm delivery before 32 weeks and improve neonatal survival compared with bed rest. LEVEL OF EVIDENCE: II-1.

Fetal intravascular transfusion for hydropic disease due to rhesus isoimmunization.

OBJECTIVE: To evaluate the management of hydropic fetuses, due to rhesus isoimmunization, with fetal intrauterine intravascular transfusions. MATERIAL AND METHODS: This is a retrospective analysis of 18 rhesus-negative pregnant women presenting at our hospital with fetal hydrops during a 7-year period. All cases were managed with serial intrauterine intravascular transfusions with the goal of delivery by cesarean section beyond 33 weeks of gestation. All patients received prophylactic ampicillin and ritodrine for 4 days after the procedure. RESULTS: There were 11 mildly and 7 severely hydropic fetuses. All fetuses with mild hydrops and 5 of the 7 with severe hydrops were delivered alive after 32 weeks of gestation in a good condition. Two fetuses both with severe hydrops died in utero, at 28 weeks of gestation. Intrauterine reversal of hydrops occurred in 90.9% of fetuses with mild hydrops and in 57.1% of severely hydropic fetuses. CONCLUSIONS: The survival rate for the hydropic fetuses in our study was 88.9% and it was associated with the severity of fetal hydrops.

Management of early viable cervical pregnancy.

OBJECTIVE: To evaluate conservative management of early viable cervical pregnancy. DESIGN: Prospective study. SETTING: A tertiary teaching hospital. POPULATION: All cases of cervical pregnancies with fetal cardiac activity presenting to our hospital over six years. METHODS: All cases were managed with trans-abdominal intra-amniotic injection of 25 mg of methotrexate under ultrasound guidance. Follow up sonographic examinations and serum beta-hCG measurements were performed every three days. Cervical curettage was performed after two follow up ultrasound examinations had shown a dead fetus and a regressing gestational sac as well as declining beta-hCG levels. Patients were managed as outpatients. MAIN OUTCOME MEASURES: Successful management and need for hospitalisation. RESULTS: Nine cases were encountered. Two required a second injection of methotrexate for persistent fetal cardiac activity and serum beta-hCG rise in the follow up examination. We did not observe any side effects and no patient required admission to the hospital. CONCLUSIONS: Intra-amniotic methotrexate injection and subsequent cervical curettage after one week is a successful alternative for the management of cervical pregnancies.

Prenatal diagnosis of atraumatic fetal subdural hematoma.

We present a case of atraumatic subdural hematoma diagnosed by ultrasound at 22 weeks. A hyperechogenic round mass was identified in the posterior fossa. Further investigation with fetal brain magnetic resonance imaging confirmed the diagnosis. After medical consultation, the parents opted for pregnancy termination. The pathology report confirmed the ultrasonographic and magnetic resonance imaging diagnosis.