Julio Mateus

Validation of the prediction model for success of vaginal birth after cesarean delivery

OBJECTIVE: To validate a previously developed vaginal birth after cesarean (VBAC) prediction model using a patient cohort different than that from which it was derived. METHODS: We performed a cohort study of all term pregnant women (January 2002–August 2007) with one prior low transverse cesarean delivery attempting a trial of labor. Variables used in the final prediction model (maternal age, prepregnancy body mass index, ethnicity, prior vaginal delivery, prior VBAC, and indication for prior cesarean delivery) were extracted from medical records and used to calculate an individual woman’s predicted VBAC success rate. These rates at the level of the study population then were partitioned into deciles and compared with the actual VBAC rates. RESULTS: Of 545 women who fit the inclusion criteria, 502 had complete data available. A total of 262 (52.2%) had VBAC. The predicted probability of VBAC, as calculated by the regression equation, was significantly higher in those who had a successful trial of labor (median 78.4%, interquartile range 62.1–88.2) than in those who did not (median 59.7%, interquartile range 50.8–75.3, P<.001). The predictive model had an area under the receiver operating characteristic of 0.70 (95% confidence interval 0.65–0.74, P<.001), which was similar to that originally described. The actual VBAC rates did not differ from the predicted rates when the predicted chance of success was less than 50%. Above a 50% predicted success, the achieved success rates were consistently 10–20% lower. CONCLUSION: The published nomogram is predictive of VBAC success. It may help pregnant women contemplating a trial of labor reach a more informed decision. LEVEL OF EVIDENCE: II

Pregnancy outcome after ultrasound diagnosis of fetal intra-abdominal umbilical vein varix

Fetal intra‐abdominal umbilical vein (FIUV) varix is a focal dilatation of the intra‐abdominal portion of the umbilical vein, which has been reported to be associated with intrauterine death and other anomalies. Our aim was to examine our experience with this diagnosis at a single tertiary‐care center and to correlate it with clinical outcome.

Endothelial growth factor therapy improves preeclampsia-like manifestations in a murine model induced by overexpression of sVEGFR-1

This study examines the effects of VEGF-121 therapy in an animal model of preeclampsia induced by overexpression of soluble VEGF receptor 1 (sVEGFR-1). At day 8 of gestation, CD-1 mice were implanted with subcutaneous osmotic pumps containing either VEGF-121 or vehicle and fitted with telemetric blood pressure (BP) catheters for continuous BP monitoring (days 8-18 of gestation). On day 9, the animals in the VEGF-121 group were randomly allocated for injection with adenovirus carrying sVEGFR-1 or the murine immunoglobulin G2α Fc fragment (mFc) as virus control (Adv-sVEGFR-1; Adv-mFc). Animals in the vehicle group were injected with Adv-sVEGFR-1. On day 18, mice were euthanized, placentas and pups weighted, carotid arteries isolated, and their responses studied in vitro using a wire myograph for isometric tension recording. In mice overexpressing sVEGFR-1, treatment with VEGF-121 significantly reduced BP from days 10 to 18 of gestation compared with that of vehicle. VEGF-sVEGFR-1 animals had significantly higher vasorelaxant response to sodium nitroprusside and significantly lower contractile response to the thromboxane agonist (U-46619) compared with that of the vehicle-sVEGFR-1 mice. Phenylephrine and acetylcholine responses did not significantly vary between the VEGF-sVEGFR-1 and the vehicle-sVEGFR-1 mice. Average pup weight was significantly lower in the vehicle-sVEGFR-1 group compared with the VEGF-sVEGFR-1 and VEGF-mFc groups. In conclusion, VEGF-121 therapy attenuates vascular dysfunction and diminishes intrauterine growth abnormality in an animal model of preeclampsia induced by overexpression of sVEGFR-1. Modulation of VEGF pathway turns into a promising therapeutic approach of preeclampsia.

Preterm Premature Rupture of Membranes: Clinical Outcomes of Late-Preterm Infants

Objective: To determine gestational age-specific neonatal outcomes of late preterm infants delivered as a consequence of premature rupture of membranes (PROM). Methods: Retrospective cohort study of infants born to women delivered electively due to preterm PROM between 340/7 and 366/7 weeks of gestation. Neonatal outcomes were compared between those delivered at 340/7 to 34 6/7 weeks, at 350/7 to 356/7 weeks, and at 36 0/7 to 366/7 weeks. Results: 192 infants were identified. The 340/7 to 346/7 week infants had significantly higher neonatal intensive care admission rate (72.5%) compared to those at 35 0/7 to 356/7 weeks (22.8%) and at 36 to 366/7 weeks (17.8%) (P < .05). Neonatal respiratory distress syndrome was significantly higher at 340/7 to 346/7 weeks (35.4%) compared with 350/7 to 356/7 week and 360/7 to 36 6/7 week infants (10.5% and 4.1%; P < .05). The longest hospitalization occurred in the 340/7 to 346/7 week infants (248.5 ± 20.0 hours). Conclusion: Substantial short-term morbidity occurred in late preterm infants. The greatest number of complications affected infants born at 340/7 to 346/7 weeks.

Sex-specific effects of nicotine exposure on developmental programming of blood pressure and vascular reactivity in the C57Bl/6J mouse.

OBJECTIVE The objective of the study was to determine whether perinatal nicotine exposure adversely affects cardiovascular health in adulthood. STUDY DESIGN C57Bl/6J female mice were randomized to 200 μg/mL nicotine in 2% saccharin or 2% saccharin alone from 2 weeks before breeding until weaning. Offspring weight, vital signs, and carotid artery vascular reactivity were studied. A second cohort was subjected to shaker stress on day 4 of 7 days. Selected mediators of vascular tone were evaluated by molecular studies. Student t or Mann-Whitney U test was performed for statistical analysis (significance: P < .05). RESULTS Nicotine-exposed compared with control female offspring had significantly elevated mean blood pressure under normal and stress conditions. Nicotine females lacked heart rate elevation after stress. Nicotine males had higher mean heart rate and a blunted contractile response to phenylephrine compared with controls, without an increase in blood pressure. CONCLUSION Perinatal nicotine exposure has an impact on the developmental programming of future cardiovascular health, with adverse effects more evident in female offspring.

No evidence for mutations in NLRP7 and KHDC3L in women with androgenetic hydatidiform moles

The objective of this study was to evaluate the mutational spectrum of NLRP7 and KHDC3L (C6orf221) in women with sporadic and recurrent androgenetic complete hydatidiform moles (AnCHM) and biparental hydatidiform moles (BiHM) to address the hypothesis that autosomal recessive mutations in these genes are only or primarily associated with BiHM.

Recognition and prevention of gastric injury during gynecologic laparoscopy.

BACKGROUND: Laparoscopy has become an essential tool for the gynecologist. Its use has dramatically increased, in part, because of technological advances, but also because of well-documented advantages over laparotomy in particular scenarios. Immediate recognition of a complication is essential for reducing morbidity and potential mortality. We report an inadvertent gastric injury during a diagnostic laparoscopy. CASE: A 36-year-old woman sustained a gastric perforation during the insertion of an umbilical 5-mm trocar. After the injury was recognized, the patient underwent exploratory laparotomy, and primary repair of the defect was performed. The patient had an uneventful postoperative recovery. CONCLUSION: Gastric injury is a rare complication of gynecologic laparoscopy. Identification of risk factors, the use of a nasogastric or orogastric tube to relieve any gastric dilatation before initiation of the procedure, and proper surgical technique may minimize such injuries.

Clinical Management of the Short Cervix

Cervical cerclage is associated with prolongation of gestation in singleton pregnancies with prior spontaneous preterm delivery and a short cervix on vaginal ultrasonography in the mid-trimester. Ultrasound screening of cervical length is not indicated in low-risk singleton pregnancies and in women with multiple gestations. 17α-Hydroxyprogesterone does not prevent preterm delivery in twin gestations with a short cervix. Cervical cerclage may cause detrimental effects in twin gestations. Vaginal pessary for the prevention of preterm birth in women with a short cervix is currently under active investigation.

225: Developmental programming of adult disease: the role of DNA methylation in genes responsible for antioxidant enzymes

gain, fetal weights, placental weights or number of pups between the RV and control groups. Treatment with RV had no significant effect on baseline myometrial contractility nor on contractility after indomethacin or nifedipine treatment. CONCLUSION: Unlike its effect on vascular smooth muscle, resveratrol does not seem to affect myometrial contractility nor potentiate the effect of tocolytics in pregnant mice.