Montse Palacio

Association of HIV infection with spontaneous and iatrogenic preterm delivery: effect of HAART.

Objectives:To assess the association between HIV infection and both spontaneous and iatrogenic preterm delivery (PTD), and to explore the impact of HAART on both entities. Methods:A matched retrospective cohort study was carried out on 517 HIV-infected pregnant women who consecutively attended a university referral hospital between 1986 and 2010. Two controls were assigned for each case. They were matched by ethnicity, smoking, maternal age and educational level. Exclusion criteria were multiple pregnancy and active injection drug use (IDU). PTD was defined as delivery less than 37.0 weeks. Spontaneous PTD included preterm premature rupture of membranes. Iatrogenic delivery was considered if medically indicated. Factors associated with PTD among HIV-infected women were analyzed by logistic regression. Results:A total of 1557 pregnant women were analyzed (519 HIV-infected and 1038 noninfected). The incidence of PTD was 19.7% in HIV-infected women and 8.5% in controls [odds ratio (OR) 2.6; 95% CI 1.9–3.6]. There was a significantly higher incidence of both spontaneous [adjusted OR (AOR) 2.1; 95% confidence interval (CI) 1.5–3.0] and iatrogenic prematurity (AOR 3.2; 95% CI 1.8–5.7). Iatrogenic PTD was significantly associated with the use of HAART during the second half of pregnancy, whereas spontaneous PTD was not related to HAART. Conclusion:There is a significant association of HIV infection with PTD, both spontaneous and iatrogenic PTD. HAART use was predominantly associated with iatrogenic PTD.

Clinical and inflammatory markers in amniotic fluid as predictors of adverse outcomes in preterm premature rupture of membranes.

OBJECTIVE We sought to evaluate gestational age, cervical length, amniotic fluid interleukin (IL)-6, and selected proteomic biomarkers as independent predictors of adverse outcome in preterm premature rupture of membranes (PPROM). STUDY DESIGN This was a prospective cohort study of 65 consecutive women with PPROM (20.0-34.6 weeks). Gestational age, cervical length, amniotic fluid IL-6, and proteomic biomarkers (calgranulins A and C, and neutrophil defensins 1 and 2) were evaluated at diagnosis. The predictive value for intraamniotic infection and neonatal composite morbidity was calculated by logistic regression. RESULTS Proteomic biomarkers were independent predictors of intraamniotic infection (odds ratio, 22.1; P=.011) and neonatal composite morbidity (odds ratio, 17.6; P=.02). With the exception of a trend between gestational age and neonatal morbidity (P=.054), none of the other parameters were independent predictors of outcome measures. CONCLUSION Selected proteomic biomarkers were the only independent predictors of adverse outcomes in PPROM. Contrary to what is reported in preterm labor with intact membranes, gestational age, cervical length, and IL-6 were not.

Predictive value of combined amniotic fluid proteomic biomarkers and interleukin-6 in preterm labor with intact membranes

OBJECTIVE To assess proteomic biomarkers and interleukin-6 alone or in combination to predict intraamniotic infection, preterm birth, and neonatal morbidity in preterm labor with intact membranes. STUDY DESIGN Amniotic fluid interleukin-6 and selected proteomic biomarkers were assayed from 86 patients with preterm labor and intact membranes (22-36 weeks). The predictive value of each marker alone or in combination was evaluated for intraamniotic infection, preterm birth, and neonatal composite morbidity. RESULTS Both interleukin-6 (odds ratio, 19.5; P = .012) and proteomic biomarkers (odds ratio, 25.2; P = .001) were statistically independent predictors of intraamniotic infection with sensitivity, positive predictive value, and false-positive rates of 25%, 17.6%, and 20% when 1 marker was present and of 75%, 75%, and 4.3% when both were detected. Their combination did not improve prediction of preterm birth or neonatal morbidity. CONCLUSION The combined use of proteomic biomarkers and interleukin-6 to predict intraamniotic infection shows better accuracy than when used alone.

Visual analysis of antepartum fetal heart rate tracings: inter- and intra-observer agreement and impact of knowledge of neonatal outcome

Abstract Objective: To evaluate the inter- and intra-observer agreement of visual analysis of fetal heart rate tracing and to evaluate the bias introduced by knowledge of perinatal outcome in this interpretation. Methods: One hundred tracings were independently analyzed by four observers. In a second study period, two observers re-analysed the 100 tracings in order to evaluate intra-observer agreement. The other two observers re-analyzed the tracings, which were labelled with fictitious perinatal outcome to evaluate the impact of this information on reliability. Agreement was analyzed by means of the proportion of agreement for qualitative parameters and the inter- and intra-class correlation coefficient for quantitative data. Results: Poor agreement was found for quantitative variability, low variability category and number of decelerations. Moderate agreement was observed for baseline, normal variability category and number of accelerations. Fetal heart rate variability and number of accelerations and decelerations were found to be significantly influenced by clinical information of perinatal outcome. Biased observers showed lower reliability than unbiased ones. Conclusion: Visual assessment of fetal heart rate tracings is unreliable due to low rates of agreement between and within observers. Only qualitative classification such as normal baseline and normal variability showed good agreement. Knowledge of clinical information introduces subjectivity to the visual analysis, leading to a negative impact on reliability.

Interleukin-4, interleukin-10, and granulocyte-macrophage colony stimulating factor in second-trimester serum from women with preeclampsia ☆

Objective To evaluate the serum levels of interleukin-4, interleukin-10, and granulocyte-macrophage colony-stimulating factor at the moment of diagnosis and in early second-trimester serum from women with preeclampsia and from gestational age-matched controls. Methods Serum from 14 women with preeclampsia at the moment of diagnosis and 14 gestational age-matched controls was analyzed. In 10 cases and 10 controls, second-trimester serum also was studied. Cytokines were measured by specific enzyme-linked immunosorbent assay. Results Serum levels of granulocyte-macrophage colony-stimulating factor at the moment of diagnosis were detected less frequently (21 compared with 71%, P < .01) and in lower concentrations (0 pg/mL [range 0–56] compared with 55.5 pg/mL [range 0–105], P = .01) in women with preeclampsia as compared with controls. In second-trimester serum, granulocyte-macrophage colony-stimulating factor detection rates (20 and 70% respectively, P = .06) and concentrations (0 pg/mL [range 0–32] and 2.5 pg/mL [range 0–37], respectively, P = .08) were lower in the group of preeclampsia, but the differences do not reach statistical significance. Measurements regarding interleukin-4 and interleukin-10 were similar between both study groups. Conclusion Differences in granulocyte-macrophage colony-stimulating factor support the concept of the existence of an immunologic imbalance as part of the etiologic mechanisms leading to preeclampsia.

Intra-Amniotic Inflammatory Response in Subgroups of Women with Preterm Prelabor Rupture of the Membranes

Background To evaluate the influence of microbial invasion of the amniotic cavity (MIAC) and histological chorioamnionitis (HCA) on the magnitude of intra-amniotic inflammatory response in preterm prelabor rupture of membranes (PPROM). Methodology/Principal Finding A prospective cohort study was performed in 107 women with PPROM between 23.0 and 36.6 weeks of gestational age. Twenty-six proteins were assayed by multiple immunoassay in amniotic fluid. The policy for PPROM in Czech Republic is active, and 90% of the women were delivered within 96 hours of membrane rupture. Histopathological placental findings were evaluated based on the Salafia classification. Data were analyzed in four subgroups of population according to the presence of MIAC and/or HCA. Results were stratified by gestational age at PPROM (< or ≥34.0 weeks). The rates of MIAC and HCA were 44% and 57%, respectively. Regardless of gestational age at PPROM, intra-amniotic inflammatory response was higher when MIAC and HCA were both present. There were no differences in the intra-amniotic inflammatory response between women with MIAC or HCA alone and women without infection. Conclusion A higher intra-amniotic inflammatory response was identified when both HCA and MIAC were detected.

Systemic and local inflammatory response in women with preterm prelabor rupture of membranes.

Objective To evaluate the inflammatory pattern in maternal circulation, amniotic cavity, cervix and vagina from women with preterm prelabor rupture of membranes (PPROM) considering the occurrence of microbial invasion of the amniotic cavity (MIAC). Methodology A prospective study was performed in 58 women with PPROM before 34+0 weeks of gestational age. Twenty-six proteins were analyzed by a multiple immunoassay in samples of amniotic fluid, serum, cervix and vagina. Association of an inflammatory response in the invasive and non-invasive samples with MIAC was investigated. Results The rate of MIAC was 36.2% (21/58). Both amniotic fluid IL-6 and cervical C-reactive protein (CRP) showed to be independent predictors of MIAC. A cut-off level of cervical CRP≥1836 pg/mL showed a detection rate of 75%, false positive rate of 19% and positive and negative predictive values to predict MIAC of 67% and 87%, respectively. There were no independent biomarkers of MIAC either in the serum or vaginal compartment. Conclusion A cervical inflammatory response mediated by CRP was observed in PPROM women with MIAC. Evaluation of serum or vaginal samples did not add valuable information regarding the outcome evaluated.

Randomised trial of cervical cerclage, with and without occlusion, for the prevention of preterm birth in women suspected for cervical insufficiency.

To evaluate the effect of cerclage, with and without cervical occlusion.

Efficacy of Two Regimens of Misoprostol for Early Second-Trimester Pregnancy Termination

Objective: To compare the efficacy of a combined regimen of misoprostol with vaginal misoprostol for early 2nd-trimester pregnancy termination. Methods: This is a prospective study that includes 79 pregnant women who requested legal termination of 2nd-trimester pregnancy between 13 and 22 weeks. Two regimens of misoprostol were used. Group 1: 400 µg of oral plus 400 µg vaginal misoprostol every 8 h (combined regimen) and group 2: 400 µg of vaginal misoprostol every 3 h up to a maximum of five doses (vaginal regimen). Results: The induction-to-abortion interval was significantly longer in group 1 (25.5 ± 24.45 h) than in group 2 (15 ± 7.14 h) (p = 0.016). The abortion rate within 24 h in group 1 was of 56.8 vs. 85.7% in group 2 (p = 0.006). The hazard rate for vaginal delivery within 24 h was found to be 2.277-fold greater in the group with the combined therapy once controlled for plausible confounders. Conclusions: Our study suggests that oral misoprostol combined with vaginal misoprostol does not reduce the induction-to-abortion interval compared to an exclusively vaginal route when used for early 2nd-trimester pregnancy termination.

Timing of umbilical cord clamping: New thoughts on an old discussion

The optimal time to clamp the umbilical cord in preterm and full-term neonates after birth continues to be a matter of debate. A review of randomised controlled trials comparing the effects of early versus late cord clamping on maternal and infant outcomes was performed to assess data in favor of immediate or delayed clamping. Although there is no conclusive evidence, delayed cord clamping seems to be beneficial in preterm and full-term neonates without compromising the initial postpartum adaptation phase or affecting the mother in the short term. However, further randomised clinical studies are needed to confirm the benefits of delayed cord clamping.