Boris Furman

Increased production of tumor necrosis factor-α TNF-α by IUGR human placentae

Objective: To evaluate the effect of pathological placental conditions such as intrauterine growth restriction (IUGR) or exposure to angiotensin II (AII) on TNF-a secretion in the vasculature of isolated human placental cotyledons. Study design: Isolated placental cotyledons from 10 normal and four intrauterine growth restricted fetuses were dually perfused. Perfusate samples from the fetal circulation were collected every 30 min during 120 min. TNF-a levels in the fetal–placental perfusate were evaluated using specific 29 24 commercial ELISA kits. In three additional normal placentae, bolus injections of angiotensin II (10 –10 mol / l) were given into the fetal–placental circulation and perfusate samples were collected. Statistical significance of difference TNF-a levels between different conditions was determined by analysis of variance (ANOVA) and paired t-test. Results: TNF-a levels were significantly higher in the perfusate of IUGR placentae as compared with normal placentae after 120 min of perfusion (mean 4106121 vs. 39614 pg/ml, P 5 0.005). There was a significant dose-dependent increase in TNF-a levels in the placental perfusate after a bolus injection of AII 66 29 25 pg /ml with AII 10 mol / l vs. 97 pg/ml with AII 10 mol / l (P 5 0.004), respectively. Conclusions: Placental pathology related to condition IUGR might induce the secretion of proinflammatory cytokines such as TNF-a, which may enhance the vasoconstriction of the fetal placental vascular bed. uf6d9 2001 Elsevier Science Ireland Ltd. All rights reserved.

Clinical significance and outcome of preterm prelabor rupture of membranes: population-based study

OBJECTIVEnTo evaluate maternal characteristics and neonatal and maternal birth outcome in cases of prelabor rupture of membranes (PPROM) in a non-selected parturient population.nnnSTUDY DESIGNnThe study population consisted of 5660 singleton preterm births (24-36 weeks gestation) occurring between 1988 and 1997 at the Soroka University Medical Center in Israel. Parturients with no prenatal care were excluded from the study. A cross-sectional study was designed between two groups. The study group consisted of patients with PPROM (n=968) and the comparison group consisted of patients without PPROM (n=4692). The data were analyzed by SPSS package. Information was obtained using a computerized database based on detailed obstetrical records. Logistic regression was used to assess the contribution of different risk factors to PPROM.nnnRESULTSnPPROM was associated with a significantly lower gestational age (24-32 weeks) and birth weight (<2500 g) than those with intact membranes. The rates of chorioamnionitis and urinary infection were found significantly higher in the PPROM group compared with women without PPROM (16.5 vs. 2.7%; 5.1 vs. 3.3%, respectively) (P<0.001). The rate of endometritis and bacteremia in the postpartum period were significantly higher in women with PPROM compared with controls 2.8 vs. 1.4%, (P=0.003) and 9.4 vs. 5%, (P=0.001), respectively. Total perinatal mortality rates were significantly higher in the group without PPROM 10.5 vs. 7.2% (P=0.01), however, rates of postpartum death were higher in the PPROM group 5.5 vs. 4% (P<0.01). When adjusted for recognized risk factors using logistic regression analysis, infection of amniotic fluid (OR=6.6) and genito-urinary tract infection (OR=1.64) remained the independent risk factors associated with PPROM.nnnCONCLUSIONSnInfectious morbidity in patients with preterm prelabor rupture of membranes and preterm delivery remained an important risk factor for obstetrical and neonatal complications.

Maternal and perinatal outcome of patients with preterm labor and meconium-stained amniotic fluid

Objective To determine the clinical significance of meconium-stained amniotic fluid (AF) observed at amniocentesis in patients with preterm labor. Methods A nested case-control study was constructed based on the color of AF during amniocentesis. Forty-five women admitted with preterm labor and meconium-stained AF were matched for gestational age at admission and compared with 135 women with preterm labor and clear AF. All AF samples were cultured for aerobic and anaerobic bacteria and mycoplasma. Results The rates of positive AF cultures for microorganisms, overall preterm birth (before 36 weeks), preternt birth before 32 weeks, and clinical chorioamnionitis were all significantly higher in patients with meconium-stained AF than in those with clear AF (positive AF cultures, 38 versus 11%, P < .001; preterm delivery before 36 weeks, 73 versus 41%, P < .001; preterm delivery before 32 weeks, 51 versus 17%, P < .001; and clinical chorioamnionitis, 22 versus 6%, P = .003). In contrast, no significant differences were observed between groups with respect to maternal age, gravidity, parity, abruptio placentae, placenta previa, fetal distress, cesarean rate, or puerperal morbidity. Conclusion Patients with preterm labor and meconiumstained AF had higher rates of microbial invasion of the amniotic cavity, clinical chorioamnionitis, and premature deliveries than those with clear AF.

Meconium stained amniotic fluid in very low risk pregnancies at term gestation

OBJECTIVEnTo determine the prevalence and clinical significance of meconium stained amniotic fluid (MSAF) in a low risk population at term gestation and to investigate whether MSAF is a predictor for intrapartum and neonatal morbidity.nnnMETHODSnA very low risk population including 37 085 consecutive deliveries at term composed the study population. A cross-sectional study was conducted and two groups of patients were identified according to the presence (n=6164) or absence (n=30921) of meconium in the amniotic fluid at delivery and the outcomes of the two groups compared.nnnRESULTSnThe prevalence of MSAF was 16.6%. The incidence of cesarean section (5.6% vs 2.3% P<0.01), instrumental deliveries (3.2% vs 1.8% P<0.01), fetal distress (6.5% vs. 2.1% P<0.01), clinical chorioamnionitis (0.2% vs. 0.1% P<0.01), post-partum infection (0.5% vs. 0.2% P<0.01), 1-minute Apgar score <3 (1.9% vs. 1.1% P<0.01), small for gestational age (7.4% vs. 6.4% P<0.01). was significantly higher in the MSAF compared with the clear amniotic fluid group. Intrapartum and neonatal mortality in this low risk population was significantly higher in the MSAF group (1.7/1000) compared with women with clear AF (0.3/1000).nnnCONCLUSIONSnMSAF in a low risk population at term gestation is a predictor for adverse perinatal outcome and peripartum complications.

Comparison study between induced and spontaneous term and preterm births of small-for-gestational-age neonates

OBJECTIVEnTo compare perinatal and maternal outcome between induced and spontaneous small-for-gestational-age (SGA) neonates at term and preterm deliveries.nnnSTUDY DESIGNnA cross-sectional study was designed and two groups were identified at each gestational age: study group - SGA neonates born after induction of labor, comparison group - SGA neonates born after spontaneous onset of labor. SGA was decoded as birth weight below 10th percentile. The population consisted of 367 consecutive SGA singleton preterm neonates (24-36 weeks gestation) and 3921 term SGA neonates (37-42 weeks gestation) delivered between 1990 and 1997. Patients with antepartum death and congenital anomalies were excluded from this study.nnnRESULTSnThe prevalence of SGA neonates among preterm deliveries was significantly higher than among term deliveries (9.3 versus 6.1%, P<0.001). The rate of induction of labor among preterm SGA deliveries was significantly higher than term SGA deliveries (17.7 versus 13.4%, P=0.002). The rates hypertensive disorders, suspected IUGR, placental abruption, cesarean section, chorioamnionitis and endometritis were significantly higher among preterm SGA than in term SGA. A multiple logistic regression analysis demonstrated that suspected IUGR, severe PIH (but not mild PIH), chronic hypertension and placental abruption were independent risk factors for induction of labor among preterm SGA neonates. In addition to these factors, oligohydramnios was considered to be an independent risk factor only among term SGA. No significant differences were found in the mean birthweight and post-partum death rates between the induced and spontaneous preterm and term SGA. The incidence of Apgar score < 7 at 5 min was significantly lower only among induced term SGA.nnnCONCLUSIONSnInduction of labor in preterm SGA neonates is performed mainly due to maternal severe hypertension disorders. The indications for induction of labor among term SGA include maternal hypertensive disorders (mild or severe) as well as neonatal status, represented mainly by oligohydramnios. In addition, induction of labor in preterm or term SGA neonates does not change neonatal outcome. Moreover, since no evidence of improved neonatal outcome was demonstrated in either indicated group, preterm or term, the question of timing and indications for induction of labor should be discussed.

Congenital anomalies are an independent risk factor for neonatal morbidity and perinatal mortality in preterm birth.

OBJECTIVEnTo determine whether congenital anomalies are associated with a high rate of neonatal morbidity in preterm birth.nnnSTUDY DESIGNn312 singletons (22-36 wk) with congenital anomalies that were delivered preterm were compared with a random sample of 936 preterm singleton without congenital anomalies. Data was obtained using the computerized birth discharge records. Statistical analysis included univariate and multivariate logistic regression analyses.nnnRESULTSnThree thousand five hundred and seventy-eight (3578) women with preterm births met the inclusion criteria (singleton with prenatal care). The prevalence of congenital anomalies in the study population was 8.7% (312/3578). Gestational age at delivery was significantly lower in the congenital anomaly group compared with the control (32.0+/-3.7 SD vs. 34.4+/-2.7 SD; p<0.001). The following pregnancy complications were higher in the group with congenital anomalies than in those without anomalies: severe pregnancy induced hypertension (PIH), hydramnions, oligohydramnion, intrauterine growth restriction (IUGR), fetal distress, cesarean section, malpresentation and mal position, abruption placenta, meconium stained amniotic fluid, 1 min Apgar score (<2), 5 min Apgar score (<7). Perinatal mortality rates in 28-32 wk and 33-36 wk were significantly higher in the group with congenital anomalies than in the control group. Neonatal morbidity data (necrotizing enterocolitis, respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, and sepsis) was available for 909 neonates (239 with congenital anomalies and 670 without congenital anomalies). After adjusting for gestational age, the presence of congenital anomalies remained strongly associated with neonatal morbidity (having one or more of the above mentioned conditions) (adjusted OR: 5.3, 95% CI 3.4-9.2). When adjusting for other confounding variables, congenital anomalies were strongly associated with neonatal morbidity (OR: 6.44, 95% CI 3.94-10.51), and perinatal mortality (OR: 3.08, 95% CI 2.04-4.65). In terms of attributable fraction in our population of preterm births, the proportion of neonatal morbidity and the proportion of perinatal mortality attributable to congenital malformation is 32% and 15%, respectively.nnnCONCLUSIONnCongenital anomalies in preterm birth are associated with a higher rate of pregnancy complications and are an independent risk factor for neonatal morbidity and perinatal mortality.

Breech presentation is a risk factor for intrapartum and neonatal death in preterm delivery.

OBJECTIVESnTo determine the prevalence of malpresentation among preterm births and to evaluate the clinical significance of malpresentation as a predictor of neonatal complications in preterm delivery.nnnSTUDY DESIGNnA cross-sectional study was conducted comparing 692 nonvertex preterm deliveries of singleton births (24-36 weeks) to 4685 vertex preterm deliveries. Women with gestational age less than 24 weeks and birthweight <500 g were excluded from the study.nnnRESULTSnThe study population included 5377 women who met the inclusion criteria. The prevalence of malpresentation was 12.8% (692/5377); 73% in the breech presentation, 22% in the transverse lie, and 5% in other positions. The mean gestational age at birth was significantly lower in the nonvertex group (32.4+/- 3.5 vs. 34.2+/-2.6; P<0.0001). Higher rates of perinatal mortality (23.1% vs. 10.1%; P<0.0001) were observed in the nonvertex group when compared with vertex births, as well as other complications such as oligohydroamnion (9.2% vs. 3.2%; P<0.0001); small-for-gestational-age; (10.5% vs. 5.9%; P<0.001); congenital anomalies (11% vs. 5.9%; P<0.001); placental abruption (8.7% vs. 4. 1%; P<0.0001); placenta previa (6.8% vs. 2.5%; P<0.0001); premature rupture of membranes (25.4% vs. 16.6%; P<0.0001); chorioamnionitis (7.9% vs. 2.9%; P<0.001); prolapse of cord (2.3% vs. 0.6%; P<0.0001) and cesarean section rate (63.9% vs. 19.1%; P<0.0001). Neonatal mortality was found to be higher for breech presentation, odds ratio (OR)=4 (confidence interval [CI]=2.76-4; P<0.0001), transverse lie, OR=2.1 (1.1-4.12; P<0.02) and for other malpositions, OR=7.3 (2. 72-20; P<0.0001). After multivariate adjustment for birthweight, cesarean section, placental pathology and chorioamnionitis, a strong association remained between the presence of breech presentation and neonatal mortality, with an adjusted OR of 2.2 (CI=1.36-3.63; P<0.01). The adjusted OR for the two other groups of malpresentation was not statistically significant.nnnCONCLUSIONnBreech presentation in preterm delivery is an independent risk factor for neonatal mortality after simultaneous adjustment for birthweight, chorioamnionitis and placental pathology. Cesarean section was found to have a protective effect on neonatal mortality rates.

Perinatal outcome and peripartum complications in preterm singleton and twins deliveries: a comparative study

OBJECTIVEnMultiple pregnancy is one of the major risk factors for preterm births. The aim of the present study was to compare perinatal outcome and peripartum complications between twins and singletons, born preterm.nnnSTUDY DESIGNnThe study population consisted of preterm deliveries of 435 pairs of twins (870 neonates) and the comparison group included 4754 preterm deliveries of singletons, born in the same period (January 1, 1989-December 31, 1996). Exclusion criteria were lack of prenatal care and births following infertility treatments. The three steps in statistical analysis consisted of (1) degree of concordance between the twins; (2) comparison between each twin (I and II) to their singleton comparison groups using SPSS computer program; (3) stratified analysis to examine perinatal mortality rates at different gestational age groups.nnnRESULTSnThe prevalence of preterm deliveries was 7.9% (6192/77610). Perinatal mortality was lower in twins of both birth orders, however, it was statistically significant only when APD is considered. Mortality rates in all gestational age groups and for both twin groups were lower than that of singleton [OR=0.45 (0.26-0.75; 95% CI) for twin-I; OR=0.36 (0.21-0.59; 95% CI) for twin-II]. Compared to singletons, twin gestations had less congenital malformations. Twin gestation had statistically lower rates of preterm premature rupture of membranes, severe pregnancy induced hypertension, oligohydramnios, placenta previa, placental abruption and clinical chorioamnionitis [12.2 vs.17.3%, 2.5 vs. 6.3%, 2.3 vs. 4.7%, 0.9 vs. 2.9%, 1.8 vs. 5%, 1.8 vs. 5.2%, respectively (P<0.01)]. Mothers of twins had less diabetes mellitus class B-R, hydramnios and chronic hypertension than that of singleton (1.8 vs. 2.6%, 5.5 vs. 7.4%, 3.7 vs. 4.8%, respectively). Cesarean section rates were significantly higher in twins gestation. Mothers of twins tended to be older and of higher birth and gravidity order.nnnCONCLUSIONSnPerinatal mortality rates and peripartum complications were lower in twin compared to singleton gestations.

Twelve cases of placental chorioangioma. Pregnancy outcome and clinical significance.

Abstractu2008u2008Introduction:To determine perinatal complications and pregnancy outcome in12 women with chorioangioma of placenta. Study design:During the period between January 1986 and December 1997, 12 women with histologic diagnosis of chorioangioma of placenta who delivered in our institution were studied. Case-control study was designed. Sixty women with histologic examination of the placenta without chorioangioma were randomly identified as control group matched for maternal age and parity. Statistical analyses included t-test, Chi-square test and Fisher’s exact test when appropriate. Results:Nine cases (75%) were diagnosed postnatal. The mean gestational age was significantly lower and preterm delivery rate was significantly higher among the chorioangioma group (34 vs. 38.8 weeks P<0.0001; 66% vs. 10%; P <0.001 respectively). Conclusions:Chorioangioma of the placenta, in a high risk population, although small, is associated with significantly higher risk for preterm delivery. This emphasizes the need for pathologic examination of all placentas of patients with preterm delivery

Multiple pregnancies in women after renal transplantation: Case report that rises a management dilemma

OBJECTIVESnTo report the pregnancy outcome in women with multiple pregnancies after renal transplantation.nnnMATERIALS AND METHODSnWe report two cases of multiple pregnancies (triplets and twins) in renal allograft recipients and evaluate the pregnancy courses and maternal and fetal outcome of these patients.nnnRESULTSnAfter fetal reduction from triplet to twin pregnancy the first patient delivered healthy twin babies at 36 weeks gestation. Six months after delivery the woman is well with no signs of renal function impairment. Although the second patient did not meet the optimal criteria for consideration of pregnancy in renal transplant recipients, she delivered normal twin babies at 33 weeks gestation. Maternal complications during pregnancy included preeclampsia, mild deterioration of renal function tests, and secondary complications due to drug therapy that was resolved after delivery. No graft rejection episodes were noted in either case during pregnancy.nnnCONCLUSIONSnMultifetal gestation in renal allograft recipients represents a high-risk pregnancy that should be managed at a tertiary care institution. The overall outcome in properly consulted patients can be considered favorable. Based on our limited experience with two cases, we suggest reduction of triplets to a twin pregnancy which is consistent with the current literature data.