Neurological outcomes by mode of delivery for fetuses with open neural tube defects: a systematic review and meta-analysis.

BACKGROUND: Controversy exists regarding the optimal mode of delivery for fetuses with open neural tube defects. OBJECTIVE: To compare neurological outcomes among infants with open neural tube defects who underwent vaginal compared with caesarean delivery. SEARCH STRATEGY: Electronic databases MEDLINE, EMBASE, Scopus, and Clinicaltrials.gov were searched from inception to November 2017. SELECTION CRITERIA: Eligible studies included observational or randomised studies comparing vaginal and caesarean delivery in pregnancies with fetal open neural tube defects who did not undergo prenatal repair. DATA COLLECTION AND ANALYSIS: Two reviewers independently reviewed abstracts and full-text articles. Outcomes were compared between vaginal and caesarean delivery and prelabour caesarean versus exposure to labour. The primary outcome was motor-anatomic level difference. Secondary outcomes included shunt requirement, sac disruption, meningitis, and ambulation at 2 years. Meta-analysis was performed and mean difference or odds ratios with 95% CI were calculated. MAIN RESULTS: Of 201 abstracts identified in the primary search, nine studies (672 women) met the eligibility criteria. Comparing vaginal and caesarean delivery, there was no significant difference in motor-anatomic level difference (mean difference -0.10, 95% CI -0.58 to 0.38; I2  = 57%). The vaginal delivery group was less likely to require a shunt or have sac disruption [odds ratio (OR) 0.37, 95% CI 0.14-0.95 and OR 0.46, 95% CI 0.23-0.90, respectively]. Comparisons by prelabour caesarean versus exposure to labour showed no significant difference in motor-anatomic level difference (OR 1.29, 95% CI 0.63-3.21) or ambulation at 2 years (OR 2.13, 95% CI 0.35-13.12). CONCLUSION: Caesarean delivery was not associated with improved neurological outcomes among fetuses with open neural tube defects. TWEETABLE ABSTRACT: Available evidence does not support routine caesarean delivery for fetuses with open neural tube defects.

Potential biochemical events associated with initiation of labor.

Much of our understanding and knowledge of human parturition has been blurred by conjecture and extrapolation. The limited available data on human parturition reflect the inability to directly experiment with pregnant human subjects. In spite of this obvious impediment and the scarcity of longitudinal data on fundamental physiological changes in human pregnancy, recent reports have generated a better understanding of the synchronous activities leading to labor. The purpose of this review was to organize, in an evidence-based format, the current understanding of maternal physiologic phenomena leading from uterine quiescence to uterine labor activity. Recent discoveries have prompted a revision of pre-existing classical theories on the initiation of parturition, such as the progesterone block theory or the prostaglandins stimulation of the uterotonic action of oxytocin. The presence in the circulation of extrahypothalamic corticotrophin-releasing hormone (CRH) produced by the placenta and myometrium is an inciting unique feature of primate pregnancy and a promising field for research. The concept of anatomical regionalization in labor promotion, including the cervical physiological inflammatory reaction, is also discussed in the review, especially in support of the strong link between inflammatory activation and onset of preterm labor. Understanding the intimate chain of events leading to parturition is critical, and elucidating the interplay of signals and processes that initiate normal labor may help us to understand the abnormal variant, spontaneous preterm labor, and devise efficacious interventions against it.

Corticosteroids for the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP): what evidence?

The fundamental premise that has governed the proposal relative to the use of corticosteroids for the purpose of disease modification in Hemolysis, Elevated Liver Enzymes, and Low Platelets (HELLP) syndrome was that pre-eclampsia is a condition characterized by an inappropriate maternal systemic inflammatory response and possibly immune-mediated impairment in maternal-fetal communication, while corticosteroids have the capacity to exercise anti-inflammatory and immunosuppressive effects. The present article reviews the evidence behind this proposal, concluding that corticosteroids administration, either antepartum or postpartum, does not improve the outcome of pregnancies affected by HELLP syndrome. The risks associated with such an approach, especially in fetuses manifesting growth restriction and absent end-diastolic flow, are also discussed. The literature published in English between 1990 and 2006 was searched for papers dealing with corticosteroids treatment for disease modification in pre-eclampsia and HELLP syndrome, using a combination of keywords including ''HELLP syndrome '', ''pre-eclampsia'', ''corticosteroids'', and ''maternal and fetal outcomes''. The MEDLINE bibliographic database yielded 9 studies relevant to this topic, including one retrospective analysis, 7 randomized trials, and one meta-analysis. Until more convincing data become available, corticosteroids for disease modification in women with HELLP syndrome should not be used outside the setting of an approved investigational protocol.

More or less CHAOS: case report and literature review suggesting the existence of a distinct subtype of congenital high airway obstruction syndrome.

Congenital obstruction of the upper airway (CHAOS) is a rare, usually lethal abnormality. A literature review of 36 prenatally diagnosed cases of CHAOS and the analysis of our own case suggest the existence of a distinct subtype of CHAOS, raising important implications for diagnosis and management. Serial fetal ultrasound examinations at 17-23 weeks' gestation showed hyperechoic and enlarged lungs, mediastinal shift, flattened diaphragm, polyhydramnios and apparently fluid-filled esophagus, findings interpreted as bilateral cystic adenomatoid malformation Type III. Ultrasound findings normalized around 32 weeks. The diagnosis of CHAOS was made after birth at term by direct laryngoscopy prompted by ventilatory difficulties and failed attempts at intubation. A pinhole opening posterior to the cricoid cartilage allowed the passage of an endotracheal tube. Based on observations in our case and those of five similar cases in the literature, we describe for the first time a subtype of CHAOS that is characterized by minor pharyngotracheal or laryngotracheal communications and associated with a less severe natural history and even resolution of ultrasound findings. In spite of this, a high index of awareness should be maintained because resolution of ultrasound findings does not necessarily indicate resolution of underlying pathology.

In vitro quantification of dexamethasone-induced surfactant protein B expression in human lung cells.

OBJECTIVE: To determine whether the effect of a single 48-h exposure to dexamethasone in human lung cells is limited to 7-8 days. STUDY DESIGN: We used the NCI-H441 cell line, in which stability can be maintained beyond 7 days. The outcome was the stimulatory effect of dexamethasone on surfactant protein B (SP-B) gene transcription as expressed by SP-B mRNA accumulation. The experiment was conducted five times, in parallel with control. SP-B mRNA was determined at baseline, 48 h after dexamethasone exposure, and at 48-h intervals thereafter, up to 14 days, by quantitative reverse transcription polymerase chain reaction. Comparisons were made by the Mann-Whitney test. RESULTS: In conditions of our experiment, the inductive profile of SP-B mRNA after exposure to dexamethasone demonstrated maximal stimulation at 48 h (13-fold over control). Subsequently, there was a decline in mRNA, with return to near control levels by day 8, suggesting reversibility of dexamethasone action. CONCLUSION: Our data support the view that the surfactant-inducing properties of corticosteroids are limited to 7-8 days.

Controversies in the use of antenatal steroids for fetal maturation.

After decades of caution and reticence, by the early 1990s, the use of antenatal corticosteroids was accepted as a pharmacologic intervention to reduce neonatal morbidity and mortality associated with prematurity. Many prospective studies yielded robust evidence to support the use of corticosteroids for fetal maturation. Their use is no longer disputed. Nevertheless, many unanswered questions remain regarding issues such as the ideal dose, drug form, regimen, or timing of treatment. This article explores many of the unanswered questions associated with antenatal corticosteroid use.

Antenatal corticosteroids in women with preterm premature rupture of the membranes.

The authors believe that the literature provides sufficient evidence that antenatal corticosteroid administration is beneficial and safe even in conditions of ruptured membranes. The evidence by now is remarkably robust and one can be reasonably confident regarding the benefits of antenatal corticosteroids in the setting of ruptured membranes. As recently stated by a group of investigators from New Zealand, including Liggins, the originator of this historical medical intervention (antepartum corticosteroids), the safety and efficacy of corticosteroids in conditions of ruptured membranes is beyond any doubt. It is time to accept this reality and to move on to other unresolved issues, like the optimal dose and corticosteroid preparation, the optimal timing of treatment, or the optimal exposure interval.

Blastocyst transfer in human in vitro fertilization. A solution to the multiple pregnancy epidemic.

Since the 1950s, the incidence of twin gestation has doubled and the incidence of triplets has increased approximately sevenfold in the United States. Of extreme concern is the fact that many of these multiple pregnancies are iatrogenic: 35% of twin gestations and 77% of higher-order pregnancies are the result of some form of infertility therapy. Anything that can be done to reduce the number of these multiple pregnancies would benefit our patients and society. Great hope is placed on emerging blastocyst technology, which has the potential of achieving higher pregnancy rates per embryo transfer while reducing the risk of multiple pregnancy. We present the evolution of the blastocyst transfer concept and the technical aspects involved. The article also outlines the experience with blastocyst culture and transfer at Brigham and Women's Hospital, Boston, and describes identifiers for application of blastocyst transfer. The number of eight-cell embryos on day 3 is an independent marker for the selection of patients who would benefit from transfer on day 5. With no eight-cell embryos on day 3, 0% and 33% pregnancies resulted from day 5 vs. day 3 transfers, suggesting that these cases would not benefit from day 5 transfer. When at least one eight-cell embryo is available, there is no difference in ongoing pregnancy rates between day 5 and day 3 transfers, but there is a significant decrease in multiple gestations with day 5 transfers.