Minoru Mitani

The importance of low blood urea nitrogen levels in pregnant patients undergoing hemodialysis to optimize birth weight and gestational age

Most published reports indicate that intensified hemodialysis results in better pregnancy outcomes. Here we studied clinical characteristics and the outcomes of 28 pregnant women receiving hemodialysis. We found an association between maternal blood data and birth weight, and gestational age and outcomes. There were 18 surviving infants who were followed up for one year. In the others there were 4 spontaneous abortions, 1 stillbirth, 3 neonatal deaths and 2 deaths after birth. Analysis of blood chemistry for 20 pregnancies from 12 weeks of gestation until delivery showed that the average hemoglobin level was significantly higher in the group that successfully delivered than in the unsuccessful group. There were significant negative relationships between the blood urea nitrogen (BUN) level and the birth weight or gestational age in the latter cohort. A birth weight equal to or greater than 1500 g or a gestational age equal to or exceeding 32 weeks corresponded to BUN levels of 48-49 mg/dl or less. Whether the low BUN is the direct cause of the improved outcome remains to be examined.

Clinical features of fetal growth restriction complicated later by preeclampsia

Objective:  To assess the maternal and perinatal outcome of preeclampsia with fetal growth restriction (FGR) and to assess the risk factors of FGR complicated later by preeclampsia.

Prediction of fetal acidemia in placental abruption

BackgroundTo determine the major predictive factors for fetal acidemia in placental abruption.MethodsA retrospective review of pregnancies with placental abruption was performed using a logistic regression model. Fetal acidemia was defined as a pH of less than 7.0 in umbilical artery. The severe abruption score, which was derived from a linear discriminant function, was calculated to determine the probability of fetal acidemia.ResultsFetal acidemia was seen in 43 survivors (43/222, 19%). A logistic regression model showed bradycardia (OR (odds ratio) 50.34, 95% CI 11.07 – 228.93), and late decelerations (OR 15.13, 3.05 – 74.97), but not abnormal ultrasonographic findings were to be associated with the occurrence of fetal acidemia. The severe abruption score was calculated for the occurrence of fetal acidemia, using 6 items including vaginal bleeding, gestational age, abdominal pain, abnormal ultrasonographic finding, late decelerations, and bradycardia.ConclusionsAn abnormal FHR pattern, especially bradycardia is the most significant risk factor in placental abruption predicting fetal acidemia, regardless of the presence of abnormal ultrasonographic findings or gestational age.

Survival Rate of Extremely Low Birth Weight Infants and Its Risk Factors: Case-Control Study in Japan

Aim. To clarify the effect of perinatal events on the survival of ELBW infants in Japan. Methods. 1,713 ELBW infants, from 92,630 live births in 2001 and 2002, born at 22–36 weeks of gestation were registered. Case was defined as death at discharge. The relevant variables were compared between the cases (n = 366) and the controls (n = 1,347). Results. The total survival rate was 78.6%. There was a significant difference between the survival rate in cesarean and vaginal delivery at 24–31 weeks of gestation. Cesarean delivery in infants with a birth weight >400 g was significantly advantageous to the survival rate of ELBW infants than vaginal delivery. The significant contributing factors were gestational age at delivery (OR: 0.97), Apgar score at 5 min (0.56), antenatal steroid (0.41), and birth weight (0.996). Nonvertex presentation (1.81), vaginal delivery (1.56), and placental abruption (2.50) were found to be significantly associated with neonatal death. Conclusions. Cesarean section might be advantageous for survival in ELBW infants over 24 gestational weeks or 400 grams of birth weight. Nonvertex presentation, vaginal delivery, and placental abruption could be significant risk factors for survival of ELBW infants.

T cell activation in abnormal perinatal events

The aim of this study was to determine the percentage of CD45RO+ T cells in umbilical cord blood from neonates born at less than 37 weeks of gestation. Fifty‐nine patients were enrolled in this study, including 49 with preterm and 10 with term deliveries. Preterm deliveries were divided into two categories; spontaneous (Group A, n= 31) and indicated (Group B, n= 18). Perinatal infection was categorized as C‐CAM, H‐CAM and neonatal infection. The percentage of CD45RO+ T cells in the umbilical cord was assessed using flow cytometry. IL‐6 was measured using ELISA. In Group A, the percentage of CD45RO+ T cells and concentrations of IL‐6 in patients with perinatal infection (n= 18) were significantly higher than in those without perinatal infection (n= 13). A significant correlation between percentage of CD45RO+ T cells and IL‐6 concentrations was observed in the cord blood (r= 0.62, P= 0.001). In Group B, pink–tinged amniotic fluid was observed in seven cases. In these cases, an increase in the percentage of CD45RO+ T cells (>10%) was noted. In the cases without perinatal infection, which included all those delivered at term (n= 32), no correlation was observed between the percentage of CD45RO+ T cells and gestational age at delivery (r=−0.139, P= 0.448). We concluded that a high percentage of CD45RO+ cord blood T cells is observed not only in perinatal infection, but also in the presence of abnormal perinatal events such as maternal bleeding in preterm gestation.

Assessment of the Usefulness of Antithrombin-III in the Management of Disseminated Intravascular Coagulation in Obstetrically Ill Patients

Objective: The aim of this study was to analyze the antithrombin-III (AT-III) activity in the serum in relation to other laboratory findings, including the serum albumin, total protein (TP), and uric acid (UA), and to assess the recovery of the AT-III activity in the serum after its administration in obstetrically ill patients. Patients and Methods: The medical records of 27 patients who were diagnosed to have disseminated intravascular coagulation (DIC) based on the obstetric DIC scores were reviewed and the relationships between the activity of AT-III in the serum and other laboratory findings were evaluated. The effect of administration of AT-III on the recovery of AT-III activity in the serum was also evaluated. Results: All the patients survived without any sequelae. The mean obstetric DIC score was 11.1 ± 3.1 (range 8-19) and the mean blood loss during the first 24 hours was 3798 ± 3,435 mL (range 480-16 208 mL). There was a significant correlation between the serum AT-III activity before the treatment and the serum albumin (r = .67, P = .001) and TP (r = .59, P = .021), but not serum UA. Seven patients required over 3000 IU of AT-III concentrate to obtain an increase in the serum AT-III activity to over 70%. The UA level in this group was significantly higher than that in the remaining patients. Conclusion: The serum AT-III activity was correlated with the serum albumin level before the start of treatment. Therefore, measurement of the serum albumin level before and during treatment is helpful.

Ritodrine Should Be Carefully Administered during Antenatal Glucocorticoid Therapy Even in Nondiabetic Pregnancies

Aim. Antenatal glucocorticoid therapy (AGT) has been commonly used recently. However, this therapy has severe harmful effects such as maternal hyperglycemia. In Japan, ritodrine hydrochloride has been used as a tocolytic agent. In this study, we performed retrospective casecontrol study to clarify whether concomitant use of ritodrine and glucocorticoid was safe to pregnant women without diabetes mellitus. Methods. We reviewed the computerized records of pregnant women with pregestational diabetes (n = 9) and nondiabetes (n = 45) who gave birth at our hospital between 2002 and 2011. Cases and controls received AGT. Blood glucose after the therapy was analyzed, and additional volume of insulin was compared to that before the therapy. Results. From this study, 30 units of insulin were necessary when performing AGT in diabetic pregnant women. And also, an increase in blood glucose of 40 mg/dL was seen after the therapy even in nondiabetic pregnant women. Blood glucose increased significantly in the group that also received ritodrine, and it was shown that the number of pregnant women who might develop ketoacidosis might increase 11-fold. Conclusions. Ritodrine should be carefully administered during antenatal glucocorticoid therapy. It may be necessary to adequately monitor blood glucose, when performing the therapy, even in nondiabetic pregnant women.

Plasma antithrombin levels correlate with albumin and total protein in gestational hypertension and preeclampsia.

OBJECTIVE To analyze the antithrombin-III (AT-III) activity in the plasma in relation to the serum albumin and total protein in preeclampsia and gestational hypertension. STUDY DESIGN The medical records of 139 patients who were diagnosed with gestational hypertension (n=33) and preeclampsia (n=106) were reviewed, and the relationships between the activity of AT-III and serum albumin or total protein were evaluated. MAIN OUTCOME MEASURES The plasma AT-III activity in gestational hypertension and preeclampsia was correlated with the serum albumin and TP levels. RESULTS There were significant correlations between AT-III activity and albumin in gestational hypertension (r=0.504, p=0.003) and preeclampsia (r=0.343, p=0.003). There were also significant correlations between AT-III activity and TP in gestational hypertension (r=0.619, p=0.001) and preeclampsia (r=0.366, p=0.001). Regression coefficients between AT-III and albumin and between AT-III and TP in gestational hypertension (23.7 and 14.0, respectively) were significantly steeper than those in preeclampsia (14.6 and 9.6, respectively). CONCLUSIONS The plasma AT-III activity in gestational hypertension and preeclampsia was correlated with the serum albumin and TP levels. This suggests that AT-III activity is more likely to decrease in gestational hypertension than in preeclampsia.

Umbilical artery pH may be a possible confounder for neonatal adverse outcomes in preterm infants exposed to antenatal magnesium

Objectives: To determine the normal range of ionized magnesium (IMg) levels in cord blood during preterm gestation and to investigate whether antenatal Mg administration affects neonatal intraventricular hemorrhage (IVH) or patent ductus arteriosus (PDA). Methods: In this retrospective case–control study, we reviewed 118 pregnant women with antenatal Mg administration and their infants after they gave birth at one tertiary care center between January 2006 and December 2010. Thirty-seven cases with IVH and/or PDA were compared to 81 controls by multiple logistic regression analysis. The normal range of IMg levels was determined by another 79 subjects without any tocolytic agents and possible confounders. Perinatal and neonatal characteristics were then compared between three groups divided by the IMg levels in cord serum. Results: The normal range of IMg levels in cord blood was determined to be 0.47 ± 0.07 mmol/L, regardless of gestational weeks. IMg level in cord serum could not be a risk factor for IVH or PDA. Elevation of IMg level in cord blood resulted in an increased incidence of IVH and a decreased incidence of PDA, but not significantly. IMg level in cord blood was inversely correlated with umbilical artery pH (p = 0.067). Conclusions: There was no significant relationship between the IMg levels in cord serum and neonatal IVH and PDA. Umbilical artery pH may be a possible confounder.

Risk factors associated with preterm delivery in women with cardiac disease

BACKGROUND The purpose of this study was to identify clinical characteristics of preterm delivery at less than 37 weeks of gestation (PD37G) and prenatal events associated with preterm delivery at less than 35 weeks of gestation (PD35G) in women with cardiac disease (WCD). METHODS A case-control study was conducted of 599 pregnancies in 479 single pregnant women with congenital or acquired cardiac lesions or cardiac arrhythmias. The relevant variables were compared between women who had PD35G (n=37) and the controls (n=562). Cardiac dysfunction was defined as the appearance of clinical symptoms of heart failure, abnormal electrocardiogram, or cardiac ultrasonography. RESULTS PD37G occurred in 77 cases (12.9%). The spontaneous and indicated preterm delivery was 26 (33.8%) and 51 (66.2%) cases, respectively. The presence of cardiac dysfunction [odds ratio (OR) 21.82, 95% confidence interval (CI) 8.3-57.49], New York Heart Association class II (OR 3.96, 95% CI 1.05-14.93), cardiomyopathy (OR 7.74, 95% CI 1.69-35.45) and pregnancy-induced hypertension (PIH) (OR 3.15, 95% CI 1.37-7.24) was significantly associated with an increased risk of PD35G. No maternal death was seen within one year after delivery. CONCLUSIONS Although pregnancy and delivery are generally safe in WCD, it is necessary to be aware of the risk factors of cardiac dysfunction, cardiomyopathy, and PIH from the aspect of PD35G.