Bernard Canzoneri

The Chorion Layer of Fetal Membranes Is Prematurely Destroyed in Women With Preterm Premature Rupture of the Membranes

Preterm premature rupture of the membranes (PPROM) is an important etiology of preterm birth and source of significant neonatal morbidity. We propose that PPROM occurs in the setting of long-standing altered tissue remodeling, which creates a vulnerable environment for the fetal membranes and pregnancy. We tested the hypothesis that PPROM is the result of tissue remodeling in the fetal membranes, specifically the chorion, and this weakening of the chorion compromises the protection provided to the amnion. The purpose of this study was to quantify thickness and apoptosis in the choriodecidua of fetal membranes in patients with PPROM, preterm labor (PTL), preterm no labor (PTNL), and women with term labor (TERM). We conducted a retrospective evaluation of fetal membrane samples from 86 placentas. Immunohistochemistry was performed using a cytokeratin antibody, and mean chorion cellular thickness was compared between each clinical group. To evaluate chorion apoptosis, fetal membranes from patients with PPROM, PTL, and TERM were stained with the M30 antibody, and the degree of cellular apoptosis was determined. Statistical analysis was performed using analysis of variance with corrections for multiple comparisons. The chorion cellular layer was thinner in patients with PPROM compared to patients with PTNL and TERM (62, 140, and 169 µm, respectively, P < .0001), though not significantly different from PTL (95 µm, P > .05). The percentage of apoptotic cells within the chorion among the patients with PPROM was greater compared to PTL and TERM (24.2%, 13.1%, and 8.4%, respectively, P < .001). The chorion cellular layer is thinner and demonstrates increased apoptosis in PPROM compared to patients with PTL, PTNL, and TERM, suggesting differential remodeling between clinical phenotypes.

Cervical ripening with foley balloon plus fixed versus incremental low-dose oxytocin: a randomized controlled trial

Objective: To evaluate cervical ripening with foley balloon combined with a fixed vs. incremental low-dose oxytocin infusion. Methods: Women presenting for term labor induction were randomized to fixed low-dose or standard incremental low-dose oxytocin infusion following foley balloon placement. The primary outcome was time from foley balloon placement to delivery. Results: Among 116 subjects, there was no difference in median time to delivery among subjects receiving fixed low-dose vs. standard incremental low-dose oxytocin during induction of labor with a foley balloon (23.7 vs. 19.2 hours). There were no differences between the two groups in median time to foley bulb extrusion, active labor and second stage of labor or incidence of uterine tachysystole, fetal heart rate abnormalities, mode of delivery or maternal hemorrhage. Conclusions: There is no difference in median time to delivery in women undergoing cervical ripening with a foley balloon combined with a fixed low-dose or standard incremental low-dose oxytocin.

Maternal serum interleukin-6 levels predict impending funisitis in preterm premature rupture of membranes after completion of antibiotics.

Objective: To determine if maternal serum interleukin-6 (IL-6) levels remain predictive of funisitis after completion of antibiotic administration in preterm premature rupture of membranes (PPROM). Methods: A secondary analysis of a prospective cohort study. Daily blood samples obtained from PPROM subjects were analyzed for IL-6 by enzyme-linked immunosorbent assay. Subjects (N = 39) delivered >7days post admission and were divided into those with and without funisitis. Data were analyzed using Mann–Whitney U test. Results: Maternal serum IL-6 levels obtained 24–48 hours and 48–72 hours before delivery are elevated in PPROM subjects with funisitis compared to those without funisitis (6.3 vs. 2.7 pg/ml, P < 0.03; 6.1 vs. 1.7 pg/ml, P < 0.02). Receiver operator characteristic curve revealed an IL-6 level of 1.98 pg/ml had sensitivity of 86.7%, specificity of 46.7%, positive predictive value of 61.9% and negative predictive value of 77.8%. Conclusion: This data suggests that maternal serum IL-6 levels continue to be predictive of PPROM subjects destined to develop funisitis after completion of antibiotics.

ORIGINAL ARTICLE: Maternal Circulating TNF-α Levels are Highly Correlated with IL-10 Levels, but not IL-6 and IL-8 Levels, in Women with Pre-Eclampsia

Problem  Several lines of evidence have shown that maternal cytokine levels of tumor necrosis factor‐α (TNF‐α), interleukin (IL)‐6, IL‐8, and IL‐10 were altered in women with pre‐eclampsia (PE) compared to those from normal pregnancies. In this study, we determined whether these cytokine levels are correlated before and after delivery in patients with PE.

P39.08: Cervicovaginal fistula presenting during spontaneous abortion

myxo-fibroblastic proliferation. There was focal chorangiosis with intervening normal placental mesenchyme. The fetal chorionic plate vessels were massively dilated, tortuous and congested. There was a 3-vessel umbilical cord with furcated marginal cord insertion. Immunohistochemical studies of the abnormal myxoid villi showed minimal staining for smooth muscle actin and positive p57KIP2 protein staining. This is only the third case of PMD with normal fetus where the p57KIP2 protein staining was used in the diagnosis. The p57KIP2 gene is paternally imprinted and maternally expressed. The presence of this protein indicates a functional maternal allele. This case supports the utility of p57KIP2 protein staining in distinguishing this disorder from molar pregnancy. In our case elevated free beta-hCG level was detected in the first trimester before placental abnormalities were visualized on ultrasound.

P39.09: Severe adenomyosis requiring cesarean hysterectomy

Case report: A 36 year-old gravida 13, para 0-1-12-0, with a history of cervical incompetence presented at 14 weeks’ gestation for a prophylactic Shirodkar cerclage. The most recent delivery occurred at 22 weeks after a failed prophylactic McDonald cerclage placed at 14 weeks and subsequent rescue McDonald cerclage placed at 20 weeks. At presentation she gave a two-day history of cramping and spotting. Because of the concern for spontaneous abortion, the prophylactic cerclage procedure was postponed and she was referred for ultrasound follow-up three days later. A transvaginal ultrasound revealed the external cervical os as closed and the amniotic sac appeared to be protruding through the posterior wall of the cervix (Figure 1). Bimanual and vaginal speculum exam verified that the amniotic sac was protruding through a defect in the posterior wall of the cervix into the vaginal vault through a defect most likely related to prior laceration. The pregnancy was interrupted by an uncomplicated dilatation and evacuation. Follow-up assessment of her endometrial cavity by saline infusion sonohysterograhy was normal. She later desired to proceed with prophylactic abdominal cerclage placement, which was performed without difficulty. Conclusions: This case demonstrates a cervicovaginal fistula occurring in a woman with cervical incompetence with prior failed cervical cerclage. The ultrasound findings suggest a need for a high index of suspicion for identifying cervicovaginal fistula in a woman with a prior cervical cerclage.

P38.03: Prenatal diagnosis of an obstructing enterogenous cyst

(pyloric atresia), genetic and dermatology services diagnosis was Junctional Epidermolysis Bullosa, skin biopsy was taken, working on identifying the mutation to offer the family PGD. Junctional epidermolysis bullosa: A blistering skin condition inherited in an autosomal recessive manner, due to mutation of a gene that normally promotes the formation of anchoring filaments (thread-like fibers) or hemidesmosomes (complex structures composed of many proteins). Junctional epidermolysis bullosa (JEB) is usually severe. In the most serious forms, large, ulcerated blisters on the face, trunk, and legs can be life-threatening due to complicated infections and loss of body fluid that leads to severe dehydration.