Albert Franco

Amniotic fluid infection, inflammation, and colonization in preterm labor with intact membranes

OBJECTIVE The purpose of this study was to compare intraamniotic inflammation vs microbial invasion of the amniotic cavity (MIAC) as predictors of adverse outcome in preterm labor with intact membranes. STUDY DESIGN Interleukin-6 (IL-6) was measured in prospectively collected amniotic fluid from 305 women with preterm labor. MIAC was defined by amniotic fluid culture and/or detection of microbial 16S ribosomal DNA. Cases were categorized into 5 groups: infection (MIAC; IL-6, ≥11.3 ng/mL); severe inflammation (no MIAC; IL-6, ≥11.3 ng/mL); mild inflammation (no MIAC; IL-6, 2.6-11.2 ng/mL); colonization (MIAC; IL-6, <2.6 ng/mL); negative (no MIAC; IL-6, <2.6 ng/mL). RESULTS The infection (n = 27) and severe inflammation (n = 36) groups had similar latency (median, <1 day and 2 days, respectively) and similar rates of composite perinatal morbidity and mortality (81% and 72%, respectively). The colonization (n = 4) and negative (n = 195) groups had similar outcomes (median latency, 23.5 and 25 days; composite morbidity and mortality rates, 21% and 25%, respectively). The mild inflammation (n = 47) groups had outcomes that were intermediate to the severe inflammation and negative groups (median latency, 7 days; composite morbidity and mortality rates, 53%). In logistic regression adjusting for gestational age at enrollment, IL-6 ≥11.3 and 2.6-11.2 ng/mL, but not MIAC, were associated significantly with composite morbidity and mortality rates (odds ratio [OR], 4.9; 95% confidence interval [CI], 2.2-11.2, OR, 3.1; 95% CI, 1.5-6.4, and OR, 1.8; 95% CI, 0.6-5.5, respectively). CONCLUSION We confirmed previous reports that intraamniotic inflammation is associated with adverse perinatal outcomes whether or not intraamniotic microbes are detected. Colonization without inflammation appears relatively benign. Intraamniotic inflammation is not simply present or absent but also has degrees of severity that correlate with adverse outcomes. We propose the designation amniotic inflammatory response syndrome to denote the adverse outcomes that are associated with intraamniotic inflammation.

Depressive symptoms are associated with elevated serum proinflammatory cytokines among pregnant women

Psychosocial stress and depressive symptoms are associated with increased risk of negative perinatal outcomes including preterm delivery and gestational hypertension. Inflammation is a likely mechanism by which distress may promote these outcomes. It is well-established that stress and depressive symptoms are associated with elevated serum inflammatory markers in nonpregnant populations. However, the immune system exhibits significant changes during pregnancy. Thus, the extent to which these findings extend to pregnancy is largely unknown. The current study examined associations among perceived stress, depressive symptoms, and serum inflammatory markers in a sample of 60 pregnant women. Fifty seven percent were African-American, 82% had completed high school or less education, and 63% reported an annual family income below

Depressive symptoms predict exaggerated inflammatory responses to an in vivo immune challenge among pregnant women.

15,000. Participants completed the Perceived Stress Scale (PSS) and the Center for Epidemiologic Studies Depression Scale (CES-D). Serum levels of interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) were determined using high sensitivity immunoassays. Regression analyses demonstrated that after controlling for pre-pregnancy Body Mass Index (BMI), higher scores on the CES-D were related to significantly higher levels of IL-6 (beta=.23, p=.05) and marginally higher TNF-alpha (beta=.24, p=.06). Perceived stress was not significantly related to serum levels of IL-6 or TNF-alpha. In sum, these results indicate that depressive symptoms are associated with higher levels of maternal serum inflammatory markers during pregnancy. These data are consistent with the contention that depressive symptoms may contribute to negative perinatal outcomes via inflammatory pathways.

Monochorionic monoamniotic twins: neonatal outcome

OBJECTIVE Stress and depressive symptoms predict exaggerated inflammatory responses to a biological challenge in nonpregnant humans and animals. The extent to which these findings generalize to pregnancy is unknown because the immune system exhibits substantial changes to support pregnancy. Notably, inflammatory responses to infectious agents play a causal role in the development of gestational hypertension as well as risk for preterm birth. Thus, depressive symptoms may increase susceptibility to these outcomes via sensitization of inflammatory processes. The current study was designed to test the hypothesis that depressive symptoms would predict an exaggerated proinflammatory response to an in vivo antigen challenge, influenza virus vaccination, among pregnant women. METHOD Twenty-two pregnant women completed two study visits: baseline and 1week after receiving influenza virus vaccination. Depressive symptoms were measured with the Center for Epidemiologic Studies Depression Scale (CES-D) at baseline. Serum levels of macrophage migration inhibitory factor (MIF) were determined using a high sensitivity immunoassay at both study visits. OUTCOMES Analyses demonstrated that, as compared to those in the lowest tertile of CES-D scores, those in the highest tertile exhibited significantly higher levels of MIF 1week after influenza virus vaccination (p=.035). CONCLUSIONS Depressive symptoms predicted exaggerated MIF production following influenza virus vaccination during pregnancy. These data support the hypothesis that depressive symptoms are associated with sensitization of the inflammatory response during pregnancy. Thus, women with greater depressive symptoms may be more vulnerable to negative sequelae of infectious illness during pregnancy.

Monochorionic Diamniotic Infants Without Twin-to-Twin Transfusion Syndrome

Background:Monochorionic monoamniotic twins (MoMo) occur in one of 10 000 pregnancies. Cord entanglement, malformations, twin-to-twin transfusion syndrome (TTS) and prematurity are responsible for their high perinatal morbidity and mortality.Objective:To report our experience with 36 sets of MoMo twins (1990 to 2005) and to provide updated information for counseling.Methods:Chorionicity was determined by placental examination, gestational age and TTS clinically and by sonography. Intrauterine growth restriction (IUGR) was diagnosed with a twin-specific nomogram.Results:Cord entanglement was observed in 15 pregnancies, but only one twin with entanglement and a true knot, experienced related morbidity. Four of 71 live births were IUGR. Malformations were diagnosed prenatally (one hypoplastic left heart and one body stalk) and postnatally (one vertebral anomalies-anal atresia-tracheoesophageal fistula-renal defect (VATER) and two lung hypoplasias). Twin-to-twin transfusion syndrome affected three sets of twins. Five twin sets delivered before 31, 19 sets at 31 to 32 and 12 sets at 33 to 34 weeks. Six of 71 (8%) twins died (four malformations, one TTS and one 26 weeks premature). Head ultrasounds in 59 of 65 survivors showed two (3%) periventricular leukomalacia, five (9%) Grade I–II intraventricular hemorrhage and 52 (88%) normal.Conclusions:Monochorionic monoamniotic twins remain a group at risk for cord entanglement, congenital malformations, TTS and prematurity. Although their neonatal mortality and morbidity is high, outcomes for survival are better than anticipated.

Adverse pregnancy outcomes in women with nausea and vomiting of pregnancy

BACKGROUND:Monochorionic-diamniotic twins (MoDi) occur in 0.3% of all pregnancies. Twin-to-twin transfusion syndrome (TTS) that occurs in 20% of MoDi pregnancies is associated with high perinatal morbidity and mortality. MoDi twins without TTS are more frequent (80%) but have been scarcely reported.OBJECTIVE:To study perinatal morbidity and mortality of 74 MoDi twin sets without TTS and to compare it to that of 38 sets of MoDi twins with TTS.METHODS:Chorionicity was determined by gender and placental examination. Gestational age (GA) was set by sonography and pediatric examination. TTS was diagnosed clinically and by sonography, discordance was defined by twins birth weight difference ≥20%, and fetal growth restriction was determined by using a twin-specific nomogram.RESULTS:MoDi twin pregnancies without and with TTS were similar in demographics, live births, history of preeclampsia, fetal distress and cesarean delivery. They were different (p<0.01) in discordant pregnancies (36 and 79%), GA at delivery (32 and 29 weeks) intrauterine growth restriction (39 and 89%) and neonatal mortality (12 and 36%). Concordant (47 sets) and discordant (27 sets) MoDi twins without TTS were clinically similar.CONCLUSIONS:MoDi twins without TTS have high rates of birth weight discordance, fetal growth restriction, fetal distress, prematurity and cesarean delivery. Although their perinatal mortality is low, the reported occurrence and the short- and long-term impacts of fetal and neonatal morbidities warrants attention.

Microwave Ablation for Twin-Reversed Arterial Perfusion Sequence

Abstract Objective: To examine the influence of nausea and vomiting of pregnancy (NVP) on pregnancy outcomes. Methods: Outcomes were compared for primigravidas with a current singleton gestation enrolled at <20 weeks’ gestation in a maternity risk screening and education program (n = 81 486). Patient-reported maternal characteristics and pregnancy outcomes were compared for women with and without NVP and within the NVP group for those with and without poor weight gain. Results: 6.4% of women reported NVP as a pregnancy complication. Women reporting NVP were more likely to be younger, obese, single and smoke. They had higher rates of preterm delivery, pregnancy-induced hypertension and low birth weight <2500 g. Almost one-quarter of women with NVP had lower than recommended weight gain. Poor weight gain was associated with a higher incidence of adverse outcomes. Obesity, tobacco use and poor pregnancy weight gain independently increased the odds of an adverse outcome. Conclusion: NVP and subsequent poor weight gain may be associated with adverse pregnancy outcomes.

Antenatal sexually transmitted infection screening in private and indigent clinics in a community hospital system

INTRODUCTION: Twin-reversed arterial perfusion sequence is a rare complication of monochorionic twin pregnancies in which an acardiac twin is perfused through placental anastomoses by a pump twin. Untreated, this leads to cardiac failure and hydrops in the pump twin. Various techniques are used to treat twin-reversed arterial perfusion, including laser, bipolar cord coagulation, and radiofrequency ablation. We describe two cases in which twin-reversed arterial perfusion was treated using microwave ablation. METHODS: The first patient presented with twin-reversed arterial perfusion sequence at 23 weeks of gestation with worsening left ventricular function and increasing acardiac mass-to-pump twin ratio to 0.70. The second patient presented with monochorionic–diamniotic triplet gestation with twin-reversed arterial perfusion sequence at 16 weeks of gestation with increasing acardiac mass-to-pump twin ratio to 0.90. Both patients underwent microwave ablation with a 2.45-gigahertz microwave system using a 1.8-mm antenna. Microwave ablation was performed with successful coagulation of intratwin-reversed arterial perfusion vessels. RESULTS: In both cases, the patient and pump twin tolerated the procedure well and there was no subsequent blood flow to the acardiac twin. In the first patient, improvement in cardiac function and decreasing acardiac mass-to-pump twin ratio were noted and the patient went on to deliver at 25 3/7 weeks of gestation. In the second patient, the remaining mono–mono pair improved; however, they were subsequently noted to have cord entanglement. Unfortunately, the second patient experienced intrauterine fetal demise of remaining twins at 17 2/7 weeks of gestation. CONCLUSION: Microwave ablation is a superior energy source than monopolar radiofrequency for vessel and soft tissue coagulation. Microwave ablation can be used effectively in the treatment of twin-reversed arterial perfusion sequence.

1. Depressive symptoms predict inflammation during pregnancy

OBJECTIVE To determine whether clinics that serve indigent patients demonstrate equal compliance with sexually transmitted infection testing guidelines when compared with private clinics. STUDY DESIGN One hundred eighty-three women were divided into cohorts based on whether they received prenatal care at a private or indigent clinic. Timing of required antenatal sexually transmitted infection screening was collected for 8 tests and compliance scores were calculated. Primary outcome was average compliance score compared between clinic types. Secondary outcomes included disease-specific compliance and percent of perfect compliance at different office types. RESULTS Compliance was found to be different between clinic types (P = .023). Indigent clinics had the same median with slightly higher inner-quartile range than private clinics (7 [7-8], 7 [7-7]). Indigent clinics had higher mean compliance scores (7.1 vs 6.9) and a greater percentage of patients demonstrating perfect compliance (42% vs 14%, P < .001). CONCLUSION Clinics serving indigent patient populations had a higher compliance with required testing compared to private clinics. HIV testing in the third trimester remains the greatest need for improvement for all practice types.

Detection of microbial invasion of the amniotic cavity by analysis of cervicovaginal proteins in women with preterm labor and intact membranes

Depressive symptoms are associated with increased risk of negative perinatal outcomes including preterm delivery and gestational hypertension. Inflammation is a key potential mechanism by which depressive symptoms may influence such outcomes. The current study examined associations among psychosocial factors and serum inflammatory markers in 60 pregnant women who were primarily from lower socioeconomic backgrounds. Participants were 25 years old (SD = 5) and at 15 weeks (SD = 7.5) gestation on average. The sample included 33 African-American and 19 Caucasian women. Sixty-five percent reported an annual family income of less than