Alex Fong

Intrauterine growth restriction caused by underlying congenital cytomegalovirus infection

BACKGROUND Human cytomegalovirus (HCMV) is the major viral etiology of congenital infection and birth defects. Fetal transmission is high (30%-40%) in primary maternal infection, and symptomatic babies have permanent neurological, hearing, and vision defects. Recurrent infection is infrequently transmitted (2%) and largely asymptomatic. Congenital infection is also associated with intrauterine growth restriction (IUGR). METHODS To investigate possible underlying HCMV infection in cases of idiopathic IUGR, we studied maternal and cord sera and placentas from 19 pregnancies. Anti-HCMV antibodies, hypoxia-related factors, and cmvIL-10 were measured in sera. Placental biopsy specimens were examined for viral DNA, expression of infected cell proteins, and pathology. RESULTS Among 7 IUGR cases, we identified 2 primary and 3 recurrent HCMV infections. Virus replicated in glandular epithelium and lymphatic endothelium in the decidua, cytotrophoblasts, and smooth muscle cells in blood vessels of floating villi and the chorion. Large fibrinoids with avascular villi, edema, and inflammation were significantly increased. Detection of viral proteins in the amniotic epithelium indicated transmission in 2 cases of IUGR with primary infection and 3 asymptomatic recurrent infections. CONCLUSIONS Congenital HCMV infection impairs placental development and functions and should be considered as an underlying cause of IUGR, regardless of virus transmission to the fetus.

Clinical morbidities, trends, and demographics of eclampsia: a population-based study

OBJECTIVE We sought to identify trends, demographics, and prepregnancy and peripartum morbidities of eclampsia in California. STUDY DESIGN We identified cases of eclampsia by International Classification of Diseases, Ninth Revision code using California health discharge data from 2001 through 2007. Cases with missing race/ethnicity as well as age <15 years or >55 years were excluded. Among the remaining cases, patients with eclampsia (n = 1888) were compared against those without (n = 2,768,983). Adjustments were performed for potential confounding variables using logistic regression. Significance was set at P < .05. RESULTS The incidence of eclampsia decreased over time, from 8.0 cases per 10,000 deliveries in 2001, to 5.6 cases per 10,000 deliveries in 2007 (P < .001). There was a bimodal distribution in age-related risk, with the highest risks at the extremes of age. Non-Hispanic blacks were associated with the highest risk of eclampsia while Asians had the lowest risk. Several antepartum morbidities had increased associations with eclampsia, including preexisting cardiac disease (adjusted odds ratio [OR], 6.84; 95% confidence interval [CI], 5.40-8.66), lupus erythematosus (adjusted OR, 3.68; 95% CI, 1.53-8.86), and twin gestations (adjusted OR, 3.28; 95% CI, 2.70-3.99). Peripartum complications increased in eclampsia included cerebrovascular hemorrhage/disorders (adjusted OR, 112.15; 95% CI, 77.47-162.35), peripartum cardiomyopathy (adjusted OR, 12.88; 95% CI, 6.08-27.25), amniotic fluid embolism (adjusted OR, 11.94; 95% CI, 3.63-39.21), and venous thromboembolism (adjusted OR, 10.71; 95% CI, 5.14-22.32). CONCLUSION This large population database confirms that there is a decline in eclampsia over time. However, there are extremely morbid complications associated with eclampsia, emphasizing the need for its close monitoring and prevention.

Pre-gestational versus gestational diabetes: A population based study on clinical and demographic differences

AIMS To assess the clinical and demographic differences in patients with pre-gestational diabetes mellitus (PGDM) compared to those with gestational diabetes (GDM). METHODS Using the 2001-2007 California Health Discharge Database, we identified 22,331 cases of PGDM and 147,097 cases of GDM via ICD-9-CM codes after excluding cases which were missing race or age data or with extremes of age. Data analyzed included demographics, pre-existing medical conditions, antepartum complications, and intrapartum complications. Logistic regression was used to adjust for potential confounders. RESULTS Both PGDM and GDM incidences increased during the study period. Advancing age was associated with increased prevalence of both diseases. Although Asians were found to have the highest prevalence of GDM, they, along with Caucasians, were found have the lowest prevalence of PGDM. Conditions with increased frequency in PGDM versus GDM included chronic hypertension, renal disease, thyroid dysfunction, fetal CNS malformation, fetal demise, pyelonephritis, and eclampsia. Subjects with PGDM were more likely than those with GDM to have a shoulder dystocia, failed induction of labor, or undergo cesarean delivery. CONCLUSIONS We have demonstrated clinical morbidities and demographic factors which differ in patients with PGDM compared to patients with GDM. Our findings suggest PGDM to be associated with significantly higher morbidity when compared to GDM. Our findings also suggest that races with the highest tendency for GDM during pregnancy may not necessarily have the highest tendency for PGDM outside of pregnancy.

Characterization of κ opioid receptors in the rabbit ear artery

Abstract Quantitative characterization of the κ opioid receptor in the rabbit ear artery was carried out using three κ-selective agonist compounds, dynorphin-(1–13), U-69593 and ethylketocyclazocine. Kinetic analysis was performed using the antagonist, MR 2266. Two other in vitro preparations were studied for comparison: the mouse was deferens and rabbit vas deferens. To avoid μ receptor action in the mouse was deferens the irreversible μ receptor antagonist, β-funaltrexamine, was used. It was demonstrated that, using the highly selective κ agonist compound U-69593, K e values for MR 2266 obtained in the three assay systems were not significantly different. These results suggest that κ receptors present in these three tissues share identical properties.

Temporal trends and morbidities of vacuum, forceps, and combined use of both

Abstract Objective: To assess trends over time of operative vaginal delivery and compare delivery-related morbidity between vacuum delivery, forceps delivery, or combined use of both in California. Methods: California ICD-9 discharge data from 2001 to 2007 were used to identify cases of forceps and vacuum delivery. Results: There was a decline in all operative delivery types (9.0% in 2001 to 7.6% in 2007), with the decline in the use of forceps most pronounced (7.26/1000 deliveries in 2001 to 3.85/1000 in 2007). Higher rates of third/fourth degree lacerations, postpartum hemorrhage, manual extraction of placenta, pelvic hematoma requiring evacuation, cervical laceration repair, and thromboembolic events were noted in forceps compared to vacuum deliveries. When both instruments were used, rates of third/fourth degree lacerations and postpartum hemorrhage were increased. Operative delivery failure was highest in combined use compared to forceps or vacuum alone. Conclusion: The incidence of operative vaginal delivery in California is declining, with decreasing use of forceps most notable. Several maternal morbidities are increased in forceps and combined deliveries compared to vacuum deliveries. There is a significantly higher risk of failure when two operative delivery methods are employed. These findings may be contributing to the declining willingness of providers to perform operative vaginal delivery.

Amniotic fluid embolism: antepartum, intrapartum and demographic factors

Abstract Objective: To describe the incidence, antepartum, intrapartum and postpartum risk factors, and mortality rate of amniotic fluid embolism (AFE). Methods: We used 2001–2007 California health discharge data to identify cases of AFE by ICD-9 codes. Results: Of 3 556 567 deliveries during the time period, we identified 182 cases of AFE, resulting in a population incidence of 5.1 in 100 000. Twenty-four of the cases resulted in death, giving a case fatality rate of 13.2%. Non-Hispanic blacks had a higher than 2-fold odds of developing AFE. AFE increased significantly with maternal age, most significantly after age 39. Cardiac disease had a nearly 70-fold higher association with AFE, cerebrovascular disorders had a 25-fold higher association, while conditions such as eclampsia, renal disease, placenta previa and polyhydramnios had nearly 7- to 13-fold higher associations. Classical cesarean delivery, abruption placentae, dilation and curettage, and amnioinfusion were all procedures highly associated with AFE. Conclusion: Several antepartum and peripartum conditions and procedures are associated with significantly higher risks of amniotic fluid embolism. This information may contribute to a better understanding of the pathophysiology of AFE and potentially help identify those at the highest risk of developing this morbid condition.

Intrahepatic Cholestasis of Pregnancy: The Effect of Bile Acids on Fetal Heart Rate Tracings

INTRODUCTION: Fetal death from intrahepatic cholestasis of pregnancy can be a sudden event and is not reliably predicted by findings on fetal heart rate tracing. Our objective is to assess whether there are differences in antenatal testing and delivery outcomes between patients with severe compared with mild intrahepatic cholestasis of pregnancy. METHODS: This is a retrospective analysis on 87 patients with intrahepatic cholestasis of pregnancy who underwent antenatal testing and subsequent delivery at a single institution. Patients with severe intrahepatic cholestasis of pregnancy were defined as having total bile acids levels greater than 40 IU/mL, whereas those with mild intrahepatic cholestasis of pregnancy had total bile acids of less than 40 IU/mL. The primary outcome was the presence of decelerations in antenatal testing. Secondary outcomes included birth weight, delivery route, meconium, and neonatal intensive care admission. Fishers exact, &khgr;2, and Mann-Whitney U tests were used as indicated. RESULTS: Eighty-seven patients were identified; 20 had severe intrahepatic cholestasis of pregnancy, whereas 67 had mild intrahepatic cholestasis of pregnancy. The severe group had significantly higher median total bile acids (P=.001), alkaline phosphatase (P=.006), and aspartate and alanine aminotransferase levels (P=.001; Table 1). There were no differences between the two groups in fetal heart rate at baseline or presence of decelerations. Patients with severe intrahepatic cholestasis of pregnancy were older (33 [26.5–36] compared with 27.7 [22.25–32] years, P=.024). Cesarean delivery rate, meconium, and neonatal intensive care unit admission were not different (Table 2). Table 1 Characteristics. Between Severe Intrahepatic Cholestasis of Pregnancy (Total Bile Acids 40 Micromoles/L or Greater) Compared With Mild Intrahepatic Cholestasis Of Pregnancy (Sheibani, p. 78-9S) Table 2 Outcomes Between Severe Intrahepatic Cholestasis of Pregnancy (Total Bile Acids 40 Micromoles/L or Greater) Compared With Mild Intrahepatic Cholestasis of Pregnancy (Sheibani, p. 78-9S) CONCLUSION: When compared with patients with mild intrahepatic cholestasis of pregnancy, those with severe intrahepatic cholestasis of pregnancy did not have a higher risk of fetal heart rate decelerations. This supports previous findings that fetal demise in the setting of intrahepatic cholestasis of pregnancy is a sudden event that can occur with previously normal antenatal testing.

A gut-wrenching feeling

A 44 year old G4P3 presents with massive hernia recurrence and bowel obstruction. Her symptoms resolve with conservative management, and she is delivered by cesarean section at term with herniorrhaphy performed 10 weeks postpartum.

Maternal and neonatal outcomes after antenatal corticosteroid administration for PPROM at 32 to 33 6/7 weeks gestational age*

Abstract Background: Preterm Premature Rupture of Membranes (PPROM) precedes many deliveries and experts agree with expectant management until 34 weeks gestation. However, there is controversy regarding the gestational age (GA) for administration of corticosteroids. Study design: We performed a retrospective cohort study in the University of California Fetal Consortium (UCfC). We searched available charts of singleton pregnancies with PPROM between 32 and 33 6/7 weeks GA. Outcomes from the groups were analyzed. Results: Of 191 women with PPROM at 32 to 33 6/7 weeks, 150 received corticosteroids. The median GA at admission was earlier for the exposed versus unexposed group (32 4/7 versus 33 0/7 weeks, respectively, p = 0.001). The mean GA at delivery in the exposed was 33 2/7 (32 0/7 to 35 0/7) weeks versus 33 5/7 (32 0/7 to 36 1/7) weeks in the unexposed (p = 0.001). There was no difference in chorioamnionitis or RDS. Conclusion: In women with PPROM at 32 to 33 6/7 weeks, our data suggests that corticosteroids are associated with similar outcomes despite earlier GA at delivery and no differences in major morbidities. A larger prospective study is needed to determine if the benefit of corticosteroids outweighs the potential risks in PPROM.

Declining VBAC Rates Despite Improved Delivery Outcomes Compared to Repeat Cesarean Delivery [20Q]

INTRODUCTION: To describe the incidence and sociodemographic features of vaginal birth after cesarean (VBAC) and to compare delivery-related outcomes of patients undergoing VBAC when compared to repeat cesarean delivery (RCD). METHODS: A retrospective cohort study was performed using California discharge data. All deliveries from 2001–2009 were analyzed. VBAC cases as well as other delivery-related morbidities were identified via ICD-9-CM code. Logistic regression was performed to adjust for potential confounders. RESULTS: Out of 663,700 women with prior cesarean delivery, 14.2% underwent VBAC. VBAC incidence decreased considerably during the time period, from a peak of 23.7% down to about 10.9%. Caucasians, those with government-funded insurance, and extremes of age had the lowest VBAC rates. VBAC rates were significantly lower in subjects with gestational diabetes, preeclampsia, eclampsia, multiple gestations, preterm delivery, and obesity. There were 234 total cases of uterine rupture identified in the cohort, comprising a uterine rupture rate of 3.5 in 10,000. VBAC, when compared to RCD, was associated with increase in some vaginal delivery related morbidity, such as manual placental extraction, third/fourth degree laceration, and postpartum hemorrhage. RCD, however, was associated with increased rates of postpartum endometritis and anesthesia-related complications, as well as severe morbidities such coagulopathy and hysterectomy. CONCLUSION: VBAC levels overall declined during the study period. Subjects with certain co-morbid conditions are less likely to undergo VBAC. Given the overall low uterine rupture rate of VBAC, and evidence of increased serious morbidity of repeat CD, initiatives should be undertaken to encourage providers to offer VBAC to their patients.