G. Clerici

Maternal risk factors for preterm birth: a country-based population analysis

OBJECTIVE The aim of this study was to identify maternal risk factors for spontaneous preterm birth (PTB) compared to delivery at term, in order to recognize high risk women and to provide a global overview of the Italian situation. STUDY DESIGN A multicenter, observational and retrospective, cross-sectional study was designed. The study population comprised 7634 women recruited in 9 different University Maternity Hospitals in Italy. The main criteria for inclusion were: women having had vaginal preterm or term spontaneous delivery in each participating centre during the study period. The records related to deliveries occurring between April and December 2008. A multivariable logistic regression was employed to identify independent predictors of spontaneous preterm birth. Odds ratios (ORs) and 95% confidence intervals (95% CI) were reported with two-tailed probability (p) values. Statistical calculations were carried out using SAS version 9.1. A two-tailed p-value of 0.05 was used to define statistical significant results. RESULTS A significant increased risk of PTB was found in women with BMI>25 (OR=1.662; 95% CI=1.033-2.676; p-value=0.0365) and in women employed in heavy work (OR=1.947; 95% CI=1.182-3.207; p-value=0.0089). Moreover there was a significant association between PTB and previous reproductive history. In fact a history of previous abortion (OR=1.954; 95% CI=1.162-3.285; p-value=0.0116) or previous cesarean section (OR=2.904; 95% CI=1.066-7.910; p-value=0.0371) was positively correlated to the increased risk of PTB and an important statistically significant association was calculated between PTB and previous pre-term delivery (OR=3.412; 95% CI=1.342-8.676; p-value=0.0099). All the other covariates examined as potential risk factors for PTB were not found to be statistically significantly related (p-value>0.05). CONCLUSIONS The present study, applied to a substantial sample of Italian population, demonstrates that there are peculiar risk factors for spontaneous PTB in the Italian population examined. It shows an association between preterm delivery and certain maternal factors as: BMI, employment, previous abortions, previous PTBs and previous cesarean section.

Early ultrasonographic diagnosis and laparoscopic treatment of abdominal pregnancy.

An early, pre-operative, ultrasonographic diagnosis of an abdominal pregnancy was made and successfully treated by laparoscopy in an asymptomatic woman with a 8-weeks abdominal pregnancy. The early, ultrasonographic diagnosis allowed an easy, mini-invasive, endoscopic treatment of the potentially life threatening pregnancy.

Oxidative stress in pathological pregnancies

Oxidative stress (OS) plays a role in pregnancy at risk of pre-eclampsia, diabetes and premature labour. We measured three markers of OS: total antioxidant capacity (TAC), thiolyte capacity and pro-oxidant capacity in 45 women: 15 normal pregnancies, 17 pathological pregnancies (pre-eclampsia and pregestational diabetes) and 13 delivered pre-term. Plasma TAC (μmol/ml) values in patients with pathological pregnancies (235.67 ± 70.08) (p1 = 0.0086) and pre-term labour (243.51 ± 50.52) (p2 = 0.0479) were significantly reduced as compared with the controls (306.78 ± 70.08). Thiolyte capacity (μmol/ml) in the pathological pregnancies (326.03 ± 78.24) (p3 = 0.0029) and in pre-term labour (335.94 ± 76.63) (p4 = 0.0084) groups were significantly reduced compared with the control group (417.48 ± 39.76) (p < 0.05). Pro-oxidant capacity (mg/100 ml) in the pathological pregnancies (94.11 ± 26.13) (p5 = 0.00034) and in pre-term labour (87.18 ± 20.28) (p6 = 0.00044) groups were significantly higher compared with the controls (60.27 ± 6.33). Elevated OS values were seen in pathological pregnancies. This supports the important role of OS in diseases in pregnancy, particularly pre-eclampsia, diabetes and pre-term birth.

Use of tocolytics: what is the benefit of gaining 48 hours for the fetus?

Preterm birth remains one of the serious problems in perinatal medicine and is associated with an increased risk of neonatal complications and long‐term morbidity. Although each day that delivery is delayed between 22 and 28 weeks of gestation increases survival by 3%, since most spontaneous preterm labour occurs between 28 and 34 weeks of gestation, this is of secondary concern; the primary goal of delay is to improve the function of certain systems in the fetus and to balance the risks of a hostile intrauterine environment with the complications of extrauterine preterm life. Although there is a lack of definitive evidence that tocolytic drugs improve outcome following spontaneous preterm labour and preterm birth, there is ample evidence that tocolysis delays delivery for long enough to permit administration of a complete course of antepartum glucocorticoids and to facilitate in utero transfer to a tertiary care unit where neonatal care will be optimal. Both these measures have been associated with improved outcomes; antepartum glucocorticoids reduce the incidence of respiratory distress syndrome, intraventricular haemorrhage, periventricular leucomalacia and necrotising enterocolitis, and in utero transfer is associated with decreased morbidity and mortality and less hospital‐based intervention compared with postnatal transportation. Consequently, women who are more likely to benefit from tocolysis are those at early gestational ages, those needing transfer to a hospital that can provide neonatal intensive care and those who have not yet received a full course of antepartum glucocorticosteroids. In these cases, delaying labour for at least 48 hours with drugs such as atosiban should be considered, since it offers clear advantages for the fetus.

The role of progesterone in maternal and fetal medicine

Progesterone is an essential hormone in the process of reproduction. It has been extensively studied in the treatment of different gynecological pathologies, as a contraceptive and in assisted reproductive technologies. However, the use of progesterone in the pathophysiology of pregnancy remains controversial. Progesterone, and its synthetic form 17 α-hydroxyprogesterone caproate (17 OHP-C), offer an effective intervention when the continuation of pregnancy is at risk from immunological factors, luteinic and neuroendocrine deficiencies, and myometrial hypercontractility. Progesterone has been successfully used as prophylaxis in the prevention of spontaneous miscarriage, with treatment beginning from the first trimester of pregnancy. There is substantial evidence, too, to indicate that women with idiopathic recurrent miscarriage may benefit from the immunomodulatory properties of progesterone in early pregnancy. The use of progesterone and 17 OHP-C has been extensively studied in the prevention of preterm birth in a variety of settings. Transvaginal ultrasound measurement of cervical length in singleton pregnancies between 19 and 24 weeks’ gestation has been deemed the best way to identify women (approximately 2% of the pregnant population) who would benefit from prophylactic progesterone treatment for the prevention of spontaneous preterm birth. This paper reviews the evidence for the safety and efficacy of the use of progesterone in each of these indications.

Potential effects of chocolate on human pregnancy: a randomized controlled trial

Objective: This trial was undertaken to evaluate the effects of high-cocoa-content chocolate supplementation in pregnancy on several haematochemical and clinical parameters. The study had as reference population the pregnant women requesting an obstetric control at Outpatient Clinic of Obstetrics and Gynaecology of the S. Maria della Misericordia University Hospital, Perugia, Italy. Candidates who participated in this study were all Caucasian women aged 18–40 years, who had a single gestation pregnancy between 11th + 0 and 13th + 0 week gestational age. Methods: We conducted a single-center randomized controlled trial. The pregnant women selected were randomized into Group A, which received daily doses of 30 g of chocolate (70% cocoa), and Group B, which was free to increase their diet with other foods. Results: Ninety women were randomized. Significant difference was found between the two groups for diastolic blood pressure (p = 0.05), systolic (p < 0.0001) and levels of liver enzymes, with values lower in Group A than in Group B. Total cholesterol levels and weight gain in Group A did not increase more than in Group B. Conclusions: A modest daily intake of high-cocoa-content chocolate contributes to reduce blood pressure, glycemic and liver pattern during pregnancy without affecting the weight gain.

Delayed interval delivery of a second twin

We report a case of diamniotic dichorionic pregnancy at 21 weeks and 5 days of gestation with threatened preterm labor with cervical modification and protrusion into vagina of the amniotic sac of twin one. After 4 days there was a rupture of membrane of the protruding sac and delivery of the first twin. We decided to retain the other one to allow improvement in the outcome for the second twin. The patient was treated with tocolytics, antibiotics and continuously monitored. After 18 days there was increasing uterine contractility and we decided to perform the cesarean section and delivered the second twin.

Multiple True Umbilical Knots: A Silent Risk for Intrauterine Growth Restriction with Anomalous Hemodynamic Pattern

True knots of the umbilical cord can represent a serious complication for the fetus due to the possible alteration in the fetal circulation with consequent intrauterine growth restriction or fetal death. We report a case of 5 true umbilical cord knots associated with severe fetal growth restriction and an abnormal hemodynamic pattern. The Doppler examination showed a hemodynamic pattern characterized by an early alteration in the waveform profile in the fetal venous districts with normal impedance to flow values in both uterine and umbilical arteries. This normal profile of the umbilical arteries remained unchanged until the last stage of hemodynamic decompensation, while the profiles of the uterine arteries remained normal until delivery. This case report suggests that it is important to pay close attention to the evaluation of the fetal cord in situations in which the above described hemodynamic pattern is noted. Although the ultrasound diagnosis of true knots is extremely difficult, the presence of a true knot should always be suspected in the presence of an intrauterine growth restriction fetus when the venous district is altered before the fetal arterial districts after exclusion of other detectable reasons for growth restriction.

Iron deficiency anemia in pregnancy

Anemia is the most frequent derailment of physiology in the world throughout the life of a woman. It is a serious condition in countries that are industrialized and in countries with poor resources. The main purpose of this manuscript is to give the right concern of anemia in pregnancy. The most common causes of anemia are poor nutrition, iron deficiencies, micronutrients deficiencies including folic acid, vitamin A and vitamin B12, diseases like malaria, hookworm infestation and schistosomiasis, HIV infection and genetically inherited hemoglobinopathies such as thalassemia. Depending on the severity and duration of anemia and the stage of gestation, there could be different adverse effects including low birth weight and preterm delivery. Treatment of mild anemia prevents more severe forms of anemia, strictly associated with increased risk of fetal–maternal mortality and morbidity.

Flecainide treatment of fetal tachycardia and hydrops fetalis in a twin pregnancy

Fetal supraventricular tachycardia (SVT) is a rarecomplication of pregnancy leading, in some cases, tocardiac failure and intrauterine fetal death. Digoxin isa safe and successful treatment for SVT and can beconsideredas thefirst-linechoicein singletonand multiplepregnancies in which one of the fetuses presents withSVT