Eran Weiner

The placental component and obstetric outcome in severe preeclampsia with and without HELLP syndrome

OBJECTIVEnWe aimed to compare obstetric outcome and placental-histopathology in pregnancies complicated by preeclampsia with severe features with and without HELLP syndrome.nnnMETHODSnLabor, maternal characteristics, neonatal outcome and placental histopathology of pregnancies complicated with severe preeclampsia during 2008-2015 were reviewed. Results were compared between those without signs of HELLP syndrome (severe preeclampsia group) and those with concomitant HELLP syndrome (HELLP group). Placental lesions were classified to maternal vascular lesions consistent with malperfusion, fetal vascular lesions consistent with fetal thrombo-occlusive disease, and inflammatory lesions. Small-for-gestational-age (SGA) was defined as birth-weight ≤10th% and ≤5th%. Composite adverse neonatal outcome was defined as one or more early neonatal complications.nnnRESULTSnCompared to the severe preeclampsia group (nxa0=xa0223), the HELLP group (nxa0=xa064) was characterized by earlier gestational-age, 34.1xa0±xa02.7 vs. 35.3xa0±xa03.4 weeks, pxa0=xa00.010, higher rates of multiple pregnancies (pxa0=xa00.024), and thrombophilia (pxa0=xa00.028). Placentas in the HELLP group had higher rates of vascular and villous lesions consistent with maternal malperfusion (pxa0=xa00.023, pxa0=xa00.037 respectively). By multivariate logistic regression analysis models, vascular and villous lesions of maternal malperfusion were independently associated with HELLP syndrome (aOR 1.9, aOR 1.8, respectively). SGA was also more common in the HELLP group, both below the 10th percentile (pxa0=xa00.044) and the 5th percentile (pxa0=xa00.016). Composite adverse neonatal outcome did not differ between the groups.nnnCONCLUSIONnSevere preeclampsia and HELLP syndrome have similar placental histopathologic findings. However, HELLP syndrome is associated with higher rates of placental maternal vascular supply lesions and SGA suggesting that the two clinical presentations share a common etiopathogenesis, with higher placental dysfunction in HELLP syndrome.

Intraoperative findings, placental assessment and neonatal outcome in emergent cesarean deliveries for non-reassuring fetal heart rate

OBJECTIVEnTo correlate between intraoperative findings, placental histopathology and neonatal outcome in emergent cesarean deliveries (ECD) for non-reassuring fetal heart rate (NRFHR).nnnSTUDY DESIGNnData on ECD for NRFHR were reviewed for labor, documented intraoperative findings, neonatal outcome parameters and placental histopathology reports. Results were compared between those with and without intraoperative findings. Placental lesions were classified to those related to maternal underperfusion or fetal thrombo-occlusive disease, and those related to maternal (MIR) and fetal (FIR) inflammatory responses. Neonatal outcome consisted of low Apgar score (≤7 at 5 min), cord blood pH<7.0, and evidence of respiratory distress, necrotizing enterocolitis, sepsis, transfusion, ventilation, seizure, hypoxic-ischemic encephalopathy, phototherapy, or death.nnnRESULTSnIntraoperative findings were observed in 49.5% of 543 women, mostly cord complications (77%). Placental lesions were more common in those without intraoperative findings as compared to those with intraoperative findings: placental lesions related to maternal under-perfusion, vascular lesions, 9.1% vs. 4.1%, p=0.024, and villous changes, 39.2% vs. 30.7%, p=0.047, lesions consistent with fetal thrombo-occlusive disease, 13.6% vs. 7.4%, p=0.024, and inflammatory lesions, MIR and FIR, p=0.033, p=0.001, respectively. By using multivariate logistic regression analysis, adverse neonatal outcome was found to be dependent on maternal age, gestational age, preeclampsia placental weight <10th%, and MIR.nnnCONCLUSIONnNRFHR necessitating ECD may originate from different underlying mechanisms. In about half, the insult is probably acute and can be identified intraoperatively. In the remaining half, underlying placental compromise may be involved.

The role of placental histopathological lesions in predicting recurrence of preeclampsia

We aimed to study the role of placental pathology in the prediction of preeclampsia (PE) recurrence.

Obstetric and neonatal outcome following minor trauma in pregnancy. Is hospitalization warranted

OBJECTIVEnTo evaluate if hospitalization of pregnant women, involved in minor trauma, for 24h of surveillance, is warranted.nnnSTUDY DESIGNnThe medical files of pregnant women involved in minor trauma, during 2009-2014, at 22-42 gestational weeks, were reviewed. Minor trauma was defined as an injury severity score <3, no immediate complains, normal ultrasound evaluation, reactive non-stress test, and no regular contractions. Patients were divided into those who, according to our departmental protocol, were hospitalized for 24h observation (hospitalized group), and those who refused to be hospitalized, (non-hospitalized group). Pregnancy, delivery and neonatal outcomes were compared between the groups.nnnRESULTSnIncluded in the study were 946 minor trauma patients that met the inclusion criteria. Gestational age (GA) at the trauma event was lower in the non-hospitalized group (n=331) compared to the hospitalized group (n=615), 29.1 vs. 30.8 weeks, p<0.001, respectively. There were no between-groups differences in the rate of preterm birth, vaginal bleeding, GA at delivery, or cesarean delivery. There were no cases of placental abruption or intrauterine fetal death in both groups. Neonatal outcome did not differ between the groups.nnnCONCLUSIONnMinor trauma during pregnancy, with normal initial assessment, is not associated with adverse pregnancy outcomes. Therefore, routine hospitalization is probably not warranted.

The placental factor in spontaneous preterm birth in twin vs. singleton pregnancies

OBJECTIVEnThe association between infection and inflammatory response in singleton preterm birth (PTB) is well established, yet, less is known about PTB in twins. We aimed to compare the placental component and pregnancy outcome in pregnancies complicated with PTB of singletons vs. twin deliveries. We hypothesized that due to different underlying mechanisms, placental inflammatory lesions will be more prevalent in placentas derived from singleton pregnancies than twins.nnnSTUDY DESIGNnLabor characteristics, neonatal outcome and placental histopathology reports of spontaneous PTB at 24-336/7 weeks, from 1/2008-12/2015, were reviewed.nnnRESULTSnwere compared between dichorionic-diamniotic twin deliveries (twins group) and singleton deliveries (singleton group) matched for gestational age. Excluded from the study medically indicated deliveries, due to preeclampsia or fetal growth restriction, and monochorionic twins. Placental lesions were classified to maternal vascular supply lesions, fetal vascular supply lesions, and maternal (MIR) and fetal (FIR) inflammatory responses. Composite neonatal outcome was defined as one or more of early complications: respiratory distress, necrotizing enterocolitis, sepsis, blood transfusion, ventilation, seizures, intra-ventricular hemorrhage, hypoglycemia, phototherapy, or death.nnnRESULTSnThe twins group (n=72) was characterized by higher maternal BMI (p=0.009), and higher rates of assisted reproductive techniques (56.2% vs. 17.8%, p<0.001) and cesarean deliveries (75.3% vs. 32.8%, p<0.001) as compared to the singleton group (n=72). Placentas from the singleton group were characterized by higher rate of MIR, 58.9% vs. 19.2%, (p<0.001), FIR, 31.5% vs. 3.4%, (p<0.001), retro-placental hemorrhage, 26% vs. 8.9% (p<0.001), and vascular lesions related to maternal malperfusion, 28.8% vs. 9.6%, (p<0.001), as compared to placentas from the twins group. Higher rate of neonatal sepsis was observed in the singleton group as compared to the twins group, 24.7% vs. 4.1%, p<0.001, respectively. By logistic regression analyses retro-placental hemorrhage, placental maternal vascular malperfusion lesions, MIR, FIR and neonatal sepsis were found to be independently associated with singleton PTB: aOR 3.4, 95% CI 2.1-6.9, p<0.001, aOR=3.1, 95% CI 1.8-7.2, p<0.001, aOR=2.9, 95% CI 1.4-7.8, p<0.001, aOR=4.9, 95% CI 2.3-6.9, p<0.001, and aOR=4.8, 95% CI 2.3-6.7, p<0.001 respectively.nnnCONCLUSIONnPlacentas from singleton PTBs are characterized by higher rate of inflammatory and malperfusion lesions. The lack of these findings in twins PTBs suggests different factors that participate in the development of preterm birth in twins, such as over-distension of the uterus and up regulation of oxytocin receptors.

The placental component and neonatal outcome in singleton vs. twin pregnancies complicated by gestational diabetes mellitus

OBJECTIVEnWe aimed to compare placental histopathological lesions and neonatal outcome in singleton vs. twin pregnancies complicated by gestational diabetes mellitus (GDM).nnnMETHODSnMaternal characteristics, neonatal outcomes, and placental histopathology reports of pregnancies complicated by GDM, between 1/2008-10/2016, were reviewed. Results were compared between singletons (singleton group) and dichorionic-diamniotic twins (twin group). Placental lesions were classified as placental weight abnormalities, maternal and fetal vascular malperfusion lesions (MVM, FVM), inflammatory lesions, and lesions associated with chronic villitis. LGA was defined as birth-weight ≥90th percentile. Composite adverse neonatal outcome was defined as one or more early neonatal complications.nnnRESULTSnCompared with the twin group (nu202f=u202f57), the singleton group (nu202f=u202f228) was characterized by higher gestational-age (38.6u202f±u202f0.9 vs. 35.1u202f±u202f1.8 weeks, pu202f<u202f0.001) and a higher rate of insulin treatment (32.9% vs. 17.5%, pu202f=u202f0.023). Placentas from the singleton group were characterized by higher rates of MVM lesions (54.4% vs. 30.7%, pu202f<u202f0.001), villitis of unknown etiology (VUE, 5.7% vs. 0.9%, pu202f=u202f0.040), villous immaturity (10.1% vs. 0.9%, pu202f=u202f0.001), and placental weight <10th percentile (16.7% vs. 8.8%, respectively, pu202f=u202f0.049). Using multivariable regression analysis, MVM (aORu202f=u202f2.2, 95% CIu202f=u202f1.6-4.1), VUE (aORu202f=u202f1.2, 95% CIu202f=u202f1.1-2.1), villous immaturity (aORu202f=u202f2.3, 95% CI 1.8-7.6), and placental weight <10th percentile (aORu202f=u202f1.1, 95% CIu202f=u202f1.02-1.6), were the only lesions associated with singleton pregnancies. Composite adverse neonatal outcome was more common in the twin group (54.3% vs. 14.0%, pu202f<u202f0.001) and it was associated only with lower GA (aORu202f=u202f3.7, 95% CI 2.1-7.3).nnnCONCLUSIONnHigher rate of placental weight <10th percentile, MVM lesions, villous immaturity, and VUE characterize GDM singleton pregnancy as compared to twins GDM gestation, suggesting different placental alterations in the diabetic environment.

Casting doubt on the value of assessing the cardiac index in pregnancy

Abstract Objectives: The objective of this study is to assess the reliability of the cardiac index (CI) in healthy pregnant women at term by investigating the correlation between the cardiac output (CO) and the body surface area (BSA) using a novel non-invasive cardiography technique (NICaS™). Methods: Sixty-one healthy, normotensive women with a singleton pregnancy at term (≥37 gestational weeks) participated in this prospective observational study between 1/2015 and 6/2015u2009L. Each woman was assessed for CO by the NICaS™, an impedance device that non-invasively measures the CO and its derivatives. The NICaS™ demonstrated a very good correlation with the gold standard Swan–Ganz catheter. BSA was determined by the Dubois nomogram. Results: The meanu2009±u2009standard deviation maternal age was 34.2u2009±u20095.3 years, mean height 166u2009±u20096u2009cm, and mean body mass index 23.9u2009±u20094.9u2009kg/m2. The mean gestational age was 38.8u2009±u20090.7 weeks. The correlation between the CO and the BSA was poor (Pearson ru2009=u20090.254, pu2009<u2009.005). Conclusions: The current study demonstrated poor correlation between the CO and the BSA in pregnant women, therefore, making the CI a non-reliable variable for assessing CO in pregnant women. We, therefore, suggest that the CO rather than the CI is the preferred parameter for hemodynamic measurements in this population.

Pregnancy outcomes after failed cervical ripening with prostaglandin E2 followed by Foley balloon catheter

Abstract Objective: To study pregnancy outcomes of cervical ripening with Foley catheter, in women who failed to respond to prostaglandin-E2 (PGE2). Methods: A retrospective cohort study of all patients with a singleton pregnancy, who underwent cervical ripening with vaginal PGE2, between 2013 and 2014, was performed. Patients who failed to respond to a total dose of 6–9 mg PGE2, defined as no change in Bishop score, underwent subsequent ripening with Foley catheter (non-responders group). Data were compared to patients who achieved sufficient response to a total dose of up to 9 mg PGE2 (responders group). Results: Compared with the responders group (nu2009=u2009813), patients in the non-responders group (nu2009=u200949) had higher rates of nulliparity (pu2009<u20090.001), pre-induction cervical dilation ≤1u2009cm (pu2009=u20090.004), pre-induction cervical effacementu2009≤50% (pu2009=u20090.01) and birth weight >4000u2009g (pu2009=u20090.02). A significantly higher cesarean delivery rate was observed in the non-responders group (51 versus 12.3%, pu2009<u20090.001). Failed ripening with PGE2 was found to be independently associated with cesarean delivery (aORu2009=u20095.11, 95% CIu2009=u20092.72–9.62). Conclusions: The need for an additional cervical ripening method after failure with PGE2 is associated with a very high risk of cesarean delivery. This is particularly significant in nulliparous women, women carrying large fetuses, and women presenting with a low Bishop score.

Placental Histopathology Differences and Neonatal Outcome in Dichorionic–Diamniotic as Compared to Monochorionic–Diamniotic Twin Pregnancies:

Objective: We aimed to compare the differences in placental histopathology lesions and pregnancy outcome in dichorionic–diamniotic (DCDA) versus uncomplicated monochorionic–diamniotic (MCDA) twin gestations. Study Design: Maternal characteristics, neonatal outcome, and placental histopathology reports of all twin deliveries between 24 and 41 weeks were reviewed. Excluded were pregnancies complicated by twin-to-twin transfusion syndrome, twin anemia–polycythemia sequence, selective intrauterine growth restriction, placenta previa, intrauterine fetal death, and malformation. Placental lesions were classified to maternal/fetal vascular malperfusion lesions. Umbilical cord abnormalities included hypo-/hypercoiling and abnormal insertion. Composite adverse neonatal outcome was defined as 1 or more early complications. Small for gestational age (SGA) was defined as birth weight ≤10th percentile. Results: The DCDA group (n = 362) was characterized by higher rates of assisted reproductive techniques (P < .001) and nulliparity (P = .03) as compared to the MCDA group (n = 65). Gestational age at delivery was similar between groups. Placental maternal vascular malperfusion lesions were more common in placentas from DCDA group (38.2% vs 23.1%; P = .016), while fetal vascular malperfusion lesions and abnormal cord insertion were more common in placentas from MCDA group (P = .027; P< .001). The SGA and composite adverse neonatal outcome were more common in the MCDA group (P = .031 and P = .038, respectively). By multivariate regression analysis, composite adverse neonatal outcome was found to be independently associated with the MCDA group, adjusted odds ratio (aOR) = 1.2, 95% confidence interval (CI) = 1.04 to 1.89, P = .041, and with placental fetal malperfusion lesions aOR = 1.3, 95% CI = 1.1 to 2.09, P = .038. Conclusion: Placental pathology differs between MCDA and DCDA twin pregnancies. Adverse neonatal outcome in uncomplicated MCDA twins, as compared to DCDA twins, could be related to increased placental fetal malperfusion lesions and abnormal cord insertion.

Can Placental Histopathology Lesions Predict Recurrence of Small for Gestational Age Neonates

Objective: To study the role of placental pathology in predicting the recurrence of delivery of small for gestational age (SGA) neonates. Methods: The medical records and placental pathological reports of normotensive women who gave birth at 24 to 42 weeks to neonates with birth weight (BW) <10th percentile were reviewed. Patients were divided according to their subsequent pregnancy into those who developed or did not develop recurrent SGA (BW < 10th percentile). The clinical and pathological characteristics of the index pregnancies were compared between the groups. A prediction model was generated for SGA recurrence. Results: The recurrent SGA group (n = 67) was characterized by a higher rate of placental weight <10th percentile (P = .01), and higher neonatal to placental weight ratio (P = .003), as compared to the nonrecurrent SGA group (n = 99). On multivariate logistic regression analysis, placental maternal and fetal vascular malperfusion lesions and higher neonatal to placental weight ratio were all independently associated with recurrent SGA. Birth weight <3rd percentile was the only clinical variable associated with recurrent SGA. A prediction model for recurrent SGA included the following independent risk factors: BW <3rd percentile, villous lesions of maternal vascular malperfusion, and neonatal to placental weight ratio. Conclusion: The presence of placental vascular malperfusion lesions and increased neonatal to placental weight ratio at index pregnancy are associated with recurrent SGA in subsequent pregnancy.