Eliezer Burstein

Cerebral palsy and fetal inflammatory response syndrome : a review

Abstract Cerebral palsy (CP) is the most common cause of severe physical disability in childhood. The precise etiological factor for the development of the majority of cases of CP has not been identified, however, prematurity is considered to be the leading identifiable risk factor. During the last decade, intrauterine infection/inflamation has been identified as the most common cause of preterm delivery and neonatal complications. When microorganisms or their products gain access to the fetus they stimulate the production of cytokines and a systemic response termed FIRS (Fetal Inflammatory Response Syndrome). Subsequently, FIRS was implicated as a cause of fetal or neonatal injury that leads to CP and chronic lung disease. Several authors found an increase in the risk for CP in infants born to mothers with clinical chorioamnionitis, especially in preterm neonates. A relationship between CP and intra-amniotic inflammation was demonstrated, intrauterine infection may lead to activation of the cytokine network which in turn can cause white matter brain damage and preterm delivery, as well as the future development of CP. This white matter insult is identified clinically as periventricular leucomalacia (PVL) which is associated with the subsequent development of impaired neurological outcomes of variable severity including CP.

Anemia during pregnancy and treatment with intravenous iron: review of the literature.

Anemia, the decrease of the hemoglobin concentration with a consequent decrease in the hematocrit level, is a common disorder complicating pregnancies and is mostly due to iron deficiency. The increase of iron requirements, plasma volume, and the poor intake of iron constitute the principal causes of this deficiency. The present review summarizes the current literature regarding anemia during pregnancy and the parenteral iron therapy options.

Pregnancy Outcome Among Obese Women: A Prospective Study

We investigated pregnancy outcome among obese women using a prospective cohort study comparing consecutive deliveries of obese and nonobese patients. Stratified analysis, using the Mantel-Haenszel technique, was done to assess the association between obesity and the risk for cesarean delivery (CD) while controlling for confounding variables. Complete data were abstracted for 376 women, of whom 21% ( N = 79) were obese. CD rate was significantly higher among obese women (32.9% versus 18.9%; P = 0.006). Maternal obesity was associated with multiparity (odds ratio [OR] 2.97, 95% confidence interval [CI] 1.27 to 6.97; P = 0.012), fertility treatments (OR 11.3, 95% CI 2.84 to 44.89; P = 0.001), insulin-treated gestational diabetes (OR 24.55, 95% CI 2.28 to 264.08; P = 0.008), and hydramnios (OR 20.46, 95% CI 2.17 to 192.89; P = 0.008). When controlling for possible confounders, the association between maternal obesity and CD remained significant (weighted OR 2.2, 95% CI 1.2 to 4.1; P = 0.018). No significant differences were noted between the groups regarding neonatal complications. Both first and second stages of labor were longer in obese women. Obesity is a risk factor for developing gestational hypertension, insulin-treated gestational diabetes, and hydramnios. Moreover, maternal obesity is an independent risk factor for CD. Additional independent risk factors for CD were fertility treatments, insulin-treated gestational diabetes, and hydramnios. However, neonatal outcome of obese women is comparable to women with normal prepregnancy body mass index.

Maternal and neonatal outcome following cerebrovascular accidents during pregnancy

Objective. To assess the clinical characteristics of maternal and neonatal outcome among women with cerebrovascular accidents (CVA) during pregnancy. Methods. Our computerized database was used to identify patients with CVA during pregnancy and puerperium from January 1988 to March 2004. Their medical records were identified and reviewed. Results. There were 16 cases of CVA among 173 803 deliveries, giving a risk of almost one case per 10 000 pregnant women. Out of 16 patients, 14 (88%) had a stroke and the remaining two cases were diagnosed with venous thrombosis. Of those 14 cases, nine (64%) had ischemic strokes and five (36%) had hemorrhagic strokes. Ten of the CVAs occurred antepartum, two intrapartum and four postpartum. Hypertensive disorders were diagnosed in 75% (12/16) of the patients. Out of these 12 patients with hypertension, 9 (75%) suffered from preeclampsia. One woman had a history of chronic hypertension. Smoking was associated with 63% (10/16) of the cases. There were two maternal deaths, both in women who had hemorrhagic strokes, and both in the first half of the study (1994 and 1996). Nine out of 16 women (56%), were delivered within 48 hours of the CVA including 7 (78%) antepartum, and two (22%) intrapartum. Cesarean deliveries were performed in 11/16 women (69%) including 8/10 with CVAs occurring antepartum, 1/2 intrapartum and 2/4 postpartum. One case of neonatal mortality was identified in a patient who was delivered at 24 gestational weeks. Conclusions. (1) Hypertensive disorders and smoking were the most important factors associated with CVA during pregnancy. (2) Maternal mortality was high among patients with CVA during pregnancy. (3) Neonatal outcome was considered generally good in cases of CVA.

Face and brow presentation: independent risk factors.

Objectives. The objectives of this study were to determine clinical characteristics including pregnancy and delivery outcome, among patients with face/brow presentation, and to investigate independent risk factors for these malpresentations. Methods. This was a retrospective cohort study comparing all singleton pregnancies of patients with and without face/brow presentation. Deliveries occurred during the years 1988–2002 at the Soroka University Medical Center. Stratified analyses using a multiple logistic regression model were performed to control for confounders. Results. Two hundred and nineteen cases were included in the study out of 130,247 deliveries with vertex presentation, giving a prevalence for face/brow presentation of 0.17%. No significant difference was found with regard to maternal age and gravidity between the control and study groups, but the primiparity rate was lower in the study group (20.4% vs.14.6%, p = 0.034). There was a significantly higher rate of previous history of cesarean delivery (CD), polyhydramnios, non-progressive labor, and non-reassuring fetal heart rate in the study group, but the rate of hypertensive disorders was lower. The prevalence of congenital anomalies was higher in the study group than in the control group, 7.3% vs. 3.6%, respectively. Also the CD rate in the study group was 67.1% as compared to 8.6% in the control group (p < 0.001). In contrast, neonatal outcome was not different between groups, including Apgar scores and perinatal mortality (0.5% vs. 1.2%, p = NS). In a logistic regression analysis model for face/brow presentation, the independent risk factors were fetal malformations (OR = 2.0), polyhydramnios (OR = 2.77) and primiparity (OR = 0.65). Conclusion. Face/brow presentation was associated with several adverse pregnancy outcomes, although there was a favorable neonatal outcome. Independent risk factors for face/brow presentation were fetal malformations and polyhydramnios, but primiparity had a protective effect.

Fetal Echogenic Bowel at 17 Weeks’ Gestational Age as the Early and Only Sign of a Very Long Segment of Hirschsprung Disease

1125 To the Editor: We report a case of a 27-year-old woman evaluated in our gynecologic ultrasound ward at 17 weeks’ gestation because of echogenic bowel. Her medical history was negative for diseases, surgeries, allergies, and family diseases. Her obstetric history included 1 vaginal delivery at term and 1 spontaneous abortion at 6 weeks. During the early fetal anatomic scan with a 5MHz transducer, grade 3 echogenic bowel was detected (Figure 1). At 22 weeks, a late anatomic scan was performed, with no change in the abnormal findings (Figure 2). The patient’s evaluation included genetic amniocentesis, carrier status for cystic fibrosis, and serologic tests for TORCH (toxoplasmosis, other agents, rubella, cytomegalovirus, and herpes simplex), the results of which were all normal. At 33 weeks’ gestation, a follow-up sonographic examination showed small-bowel dilatation. At 38 weeks, the patient gave birth to a female neo nate weighing 3310 g with normal Apgar scores. The neonate underwent abdominal sonographic and radiographic examinations, which revealed dilated bowel loops consistent with bowel obstruction. She underwent surgery, which revealed an unused colon and dilated jejunum. A resection of the large bowel except 40 cm of ileum was performed by an ileostomy. An extremely enlarged colon (unused) was found (Figure 3). Severe cholinergic nerve fiber atrophy was seen. The smooth muscle was well preserved. The pathologic diagnosis was intestinal hypoplasia due to an absence of the myenteric plexus in the colon and small intestine. This case is unique as an early finding of echogenic bowel with the rare and severe form of Hirschsprung disease. Echogenic bowel is diagnosed in 0.2% to 1.4% of second-trimester sonographic examinations.1–3 This finding occurs as a normal variant but also has been associated with cystic fibrosis,1,4 chromosomal abnormalities,3,4 structural abnormalities, and in utero infection with cytomegalovirus and toxoplasmosis.5 This finding in women with elevated maternal serum α-fetoprotein levels during the second trimester might also be associated with an adverse pregnancy outcome due to uteroplacental insufficiency.6 Sonographic assessment of echogenic bowel is subjective, comparing the echogenicity with that of adjacent bone or liver and grading the bowel from 1 to 3.7,8 Sepulveda and Sebire9 reported a 34% rate of adverse perinatal outcomes among 10 studies that included 804 patients. Among those with bowel abnormalities, serial sonographic examinations should be performed during pregnancy follow-up to detect bowel obstruction. The variations in the sonographic appearances depend on the level of obstruction and whether the obstruction is complete or incomplete.10 Letters to the Editor

Identifying risk factors for premature rupture of membranes in small for gestational age neonates: a population-based study

Objective. To determine the prevalence and risk factors for premature rupture of membranes (PROM) among pregnancies complicated with small for gestational age (SGA) neonates. Methods. A computerised database was used to identify deliveries of SGA neonates in pregnancies complicated with PROM between the years 1988 and 2002. Pregnancies with PROM and SGA neonates were compared to those with SGA and without PROM. Demographic, obstetric, clinical and labour characteristics were evaluated. Multiple logistic regression analysis was used to determine independent risk factors for PROM in pregnancies complicated by SGA. Statistical analysis was performed with SPSS package. Results. There were 120 982 deliveries included out of which 6074 (5.99%) presented with appropriate for gestational age (AGA) neonates and PROM. A total of 1077 delivered SGA infants complicated with PROM (5.5%). After adjustment for confounding variables, the following characteristics were significantly associated with PROM and SGA: Jewish ethnicity, parity and cervical incompetence. The following complications were associated with PROM and SGA: arrest of labour, fetal distress, failed induction, cesarean delivery, clinical chorioamnionitis and placenta accreta. No significant differences regarding low Apgar scores and perinatal mortality rates were noted. Conclusions. The risk of PROM among patients with SGA is lower than in AGA infants. Parity and cervical incompetence are risk factors for PROM among women who delivered SGA neonates. In this population there is a higher rate of arrest of labour, chorioamnionitis, fetal distress and cesarean delivery. Neonatal outcome and perinatal mortality are similar in both groups.

Early sonographic prenatal diagnosis of seizures

Fetal seizures are an unusual phenomenon. When diagnosed by ultrasonography, they are frequently associated with malformations and carry a poor prognosis. We describe first trimester seizures in two siblings with arthrogryposis multiplex congenita. In both cases, convulsions appeared before other sonographic signs of the disease. Review of the literature revealed 11 other cases of fetal seizures diagnosed by ultrasound, all later in gestation. Fetal seizures may be the first manifestation of defective neural and motor development. Therefore, in pregnancies at high risk for neuromuscular disease, early sonographic evaluation of fetal motility, in addition to the anatomical survey, is advised. Copyright

Placental angiopoietin-1 and angiopoietin-2 expression and correlation with birth weight in twins.

Objective. To study the expression of angiopoietin 1 (Ang1) and angiopoietin 2 (Ang2) in human placentas of dizygotic dichorionic twins in relation to fetal growth. Study design. Placentas from dizygotic-dichorionic twins (n = 14) obtained from normal uncomplicated pregnancies were collected immediately after delivery. A quantitative assessment of the placental expression of Ang1 and Ang2 was done using quantitative PCR. Birth weight and anthropometric parameters were measured. Statistical analysis was preformed. Results. Ang1 and Ang2 were expressed in the placentas. We found a significant positive correlation between birth weight and expression of both Ang1 and Ang2 (p < 0.009, p < 0.011, respectively). In addition, there was a significant positive correlation between skin fold, BMI and Ang1 expression (p < 0.0001 and p < 0.01, respectively). Conclusion. A positive correlation between twin birth weight and placental angiogenesis was found. We suggest that placental expression of Ang1 and Ang2 may have an important role in fetal growth in twin pregnancy.

P41.08: Abnormal uterine artery Doppler flow velocimetry detected after the 34th week does not affect pregnancies complicated by fetal growth restriction

artery PI, had increased risk for Cesarean section and lower birth weight, lower gestational age at delivery, lower apgar scores and higher need for neonatal intensive care. Uterine Doppler test have a positive prediction value of 58% to predict adverse perinatal outcome and therefore it could be useful to assess SGA fetus with normal umbilical Doppler. CPR at diagnosis of SGA was not useful to assess the subsequent adverse outcome.