Nicole P. Yost

A prospective observational study of domestic violence during pregnancy.

Objective: To assess whether women reporting domestic violence are at increased risk for adverse pregnancy outcomes. Methods: A screening questionnaire, previously validated for the identification of female victims of domestic violence, was offered to women presenting to our Labor and Delivery Unit. The survey prompted women to indicate whether her partner or family member physically hurt her, insulted or talked down to her, threatened her with harm, or screamed or cursed at her. The primary study outcome was to detect a 3-fold increase in low birth weight infants (≤ 2,500 g) in women reporting physical abuse, compared with those not reporting domestic violence. Results: A total of 16,041 women were approached to be interviewed. Of these, 949 (6%) women responded affirmatively to one or more of the survey questions, and another 94 (0.6%) declined to be interviewed. The incidence of low birth weight infants was significantly increased in women who reported verbal abuse, compared with the no-abuse group (7.6% versus 5.1%, respectively, P = .002). Physical abuse was associated with an increased risk of neonatal death (1.5% versus 0.2%, P = .004). Interestingly, women who declined to be interviewed had significantly increased rates of low birth weight infants (12.8% versus 5.1%, P < .001), preterm birth at 32 weeks of gestation or less (5.3% versus 1.2%, P = .002), placental abruptions (2.1% versus 0.2%, P < .001), and neonatal intensive care admissions (7.4% versus 2.2%, P = .008) when compared with women in the no-abuse group, respectively. Conclusion: Women who declined to be surveyed regarding domestic violence were at increased risk for adverse pregnancy outcome. Level of Evidence: II-2

Postpartum regression rates of antepartum cervical intraepithelial neoplasia II and III lesions.

OBJECTIVE To study the histologic regression and progression rates of cervical intraepithelial neoplasia (CIN) II and III after delivery and the effect the route of delivery has on the regression rates of CIN. METHODS Pregnant patients with satisfactory colposcopic examinations and biopsy-proven CIN II and III were identified. Delivery information and postpartum biopsy results were obtained by chart review. RESULTS Two hundred seventy-nine patients had antepartum biopsies of CIN II or CIN III. Of these, 126 women were excluded for the following reasons: lost to follow-up (75), human immunodeficiency virus positive (two), cesarean hysterectomy (four), and inadequate postpartum follow-up (45). This yielded a study group of 153 patients consisting of 82 with CIN II and 71 with CIN III. The regression rates were 68% and 70% among CIN II and CIN III patients (P = .78), respectively. Seven percent of patients with CIN II progressed to CIN III on postpartum evaluation. Twenty-five percent of those patients with CIN II and 30% of those with CIN III remained the same postpartum. No CIN lesions progressed to invasive carcinoma. There were no differences in regression rates or progression rates among the women who had vaginal deliveries (130), women who labored and then underwent cesarean (17), or women who proceeded to a cesarean without laboring (six). CONCLUSION We found similar high postpartum regression rates despite the route of delivery. We recommend conservative antepartum management with postpartum colposcopic evaluation regardless of route of delivery because we are unable to predict which of these lesions are more likely to regress.

Pitfalls in ultrasonic cervical length measurement for predicting preterm birth.

OBJECTIVE To describe the anatomic and technical difficulties encountered with transvaginal ultrasound imaging of the cervix in a consecutive series of women at risk for preterm delivery. METHODS Three groups of women had cervical ultrasound examinations: those with histories of preterm birth, those with incompetent cervices, and those admitted for preterm labor that did not progress. Standardized ultrasound examinations of the cervix involved measuring the length of the endocervical canal, funneling length, and internal os dilation with and without fundal pressure. RESULTS Sixty consecutive women had transvaginal ultrasound examinations for assessment of the cervix. Forty-six had histories of preterm birth, five had incompetent cervices, and nine had arrested preterm labor. Six types of problems arose, which can be divided into anatomic or technical considerations, with an overall frequency of 27% (95% confidence interval 16%, 40%). Anatomic pitfalls that hampered identification of the internal os included an undeveloped lower uterine segment (n = 5), a focal myometrial contraction (n = 1), rapid and spontaneous cervical change (n = 1), and an endocervical polyp (n = 1). Technical pitfalls included incorrect interpretation of internal os dilation because of vaginal probe orientation (n = 7) and artificial lengthening of the endocervical canal because of distortion of the cervix by the transducer (n = 1). CONCLUSION We caution those who perform cervical length examinations to be wary of falsely reassuring findings due to potential anatomic and technical pitfalls.

Estrogen and progesterone metabolism in the cervix during pregnancy and parturition.

CONTEXT Experimental and clinical studies in a variety of nonprimate species demonstrate that progesterone withdrawal leads to changes in gene expression that initiate parturition at term. Mice deficient in 5alpha-reductase type I fail to undergo cervical ripening at term despite the timely onset of luteolysis and progesterone withdrawal in blood. OBJECTIVE Our objective was to test the hypothesis that estrogen and progesterone metabolism is regulated in cervical tissues during pregnancy, even in species in which parturition is not characterized by progesterone withdrawal in blood. DESIGN Estradiol and progesterone metabolism was quantified in intact cervical tissues from nonpregnant and pregnant women at term before or after labor. SETTING The study was conducted at a university hospital. PATIENTS Tissues were obtained from five nonpregnant and 21 pregnant women (nine before labor and 12 in labor). MAIN OUTCOME MEASURES Enzyme activity measurements, Northern blot analysis, quantitative real-time RT-PCR, and immunohistochemistry were used to quantify steroid hormone metabolizing enzymes in cervical and myometrial tissues. RESULTS During pregnancy, 17beta-hydroxysteroid dehydrogenase type 2 was induced in glandular epithelial cells to catalyze the conversion of estradiol to estrone and stroma-derived 20alpha-hydroxyprogesterone to progesterone. During parturition, 17beta-hydroxysteroid dehydrogenase type 2 was down-regulated in endocervical cells, thereby creating a microenvironment favorable for cervical ripening. CONCLUSIONS Together, the data indicate that cervical ripening during parturition involves localized regulation of estrogen and progesterone metabolism through a complex relationship between cervical epithelium and stroma, and that steroid hormone metabolism in cervical tissues from pregnant women is unique from that in mice.

Natural history of cervical funneling in women at high risk for spontaneous preterm birth

OBJECTIVE: To estimate the natural history of funneling in the second trimester by transvaginal ultrasonograms and whether funneling increases the risk of spontaneous birth. METHODS: Secondary analysis of a blinded, multi-center observational study of women with at least one prior spontaneous preterm birth at 16.0–31.9 weeks who subsequently carried singleton gestations. Cervical length, funneling (membrane prolapse greater than or equal to 5 mm), funnel shape, and dynamic changes were recorded at 16–18 weeks, and then every 2 weeks until 23.9 weeks. Managing obstetricians were blinded to the ultrasonography results. The primary outcome was gestational age at delivery. RESULTS: Five hundred ninety scans were performed in 183 women, of which 60 (33%) had funneling observed on at least one of the serial evaluations. These 60 women delivered at an earlier gestational age at delivery than the 123 women without funneling (31.7±7.9 weeks compared with 36.9±4.4 weeks; P<.001). In the 60 women with funneling on at least one evaluation, the progression over time of internal os cervical anatomy from a “T” to a “V” to a “U” shape was associated with earlier gestational age at delivery, whereas resolution of “V” shape funnels was associated with term delivery. Women with a shortened cervical length less than 25 mm (n=60) had a similar gestational age at birth with or without funneling (30.6±8.0 weeks compared with 31.9±6.6 weeks; P=.59). After controlling for the shortest observed cervical length, largest funnel percent was not a significant independent risk factor. CONCLUSION: The natural history of second-trimester funneling has significant variability and a significant association with earlier gestational age at delivery. As an independent finding, funneling does not add appreciably to the risk of early gestational age at delivery associated with a shortened cervical length. LEVEL OF EVIDENCE: II

Infection and preterm labor.

There are many conditions, such as non-white race, young maternal age, and uterine malformations, that have been associated with preterm birth that are not amenable to intervention. Maternal cervical and intrauterine infection and inflammation may have a primary causative role in a fraction of the cases of preterm birth and preterm rupture of membranes and may also interact adversely with a variety of maternal (shortened cervix, smoking) and fetal factors (polyhydramnios, multifetal gestation) to decrease the threshold to preterm birth. Further studies are needed to better-define the link between various maternal microbial colonizations and preterm delivery, with the possibility to establish new screening and treatment recommendations. Because of the innumerable causes of preterm birth, a new strategy of targeted treatment of cervical or vaginal infections may lead to only a modest reduction in the incidence of this devastating problem of modern obstetrics.

Acute fatty liver of pregnancy: clinical outcomes and expected duration of recovery

OBJECTIVE Our aim was to provide a description of clinical and laboratory finding: pregnancy outcomes in women with acute fatty liver of pregnancy (AFLP). We also characterize the duration of recovery of multiorgan system dysfunction that begins after delivery. STUDY DESIGN All women who were admitted to Parkland Hospital with AFLP were identified; their clinical and laboratory findings, pregnancy outcomes, and postpartum resolution of AFLP were reviewed. RESULTS Between 1975 and 2012, there were 51 women who were identified to have AFLP. The most common complaints were persistent nausea and vomiting (57%), hypertension (57%), and abdominal pain (53%). More than 90% of these women had at least 1 of these findings or combinations thereof. A combination of hepatic and renal dysfunction was nearly universal, but with variable severity. Procoagulant synthesis was impaired in more than three-fourths of the women, which served to intensify obstetric hemorrhage for which 50% of the 51 women received blood and component transfusions. The stillbirth rate was 120 of 1000 pregnancies, and there were 2 maternal deaths. Composite recovery times of various markers of hepatic and renal function indicated normalization of most laboratory values within 7-10 days after delivery. CONCLUSION The clinical features and laboratory findings of women with AFLP derive from the central pathologic process: liver failure. After delivery, clinical recovery typically is seen within 3-4 days; however, laboratory abnormalities can persist for much longer.

Effect of coitus on recurrent preterm birth.

OBJECTIVE: To estimate the impact of sexual behavior on the risk of recurrent spontaneous preterm birth at less than 37 weeks of gestation. METHODS: This is a secondary analysis of a multicenter, blinded observational study of endovaginal sonographic examinations performed at 16–18 weeks of gestation on 187 women with singleton gestations who were at high risk for recurrent spontaneous preterm birth (prior spontaneous preterm birth at < 32 weeks of gestation). At the time of enrollment, each woman was interviewed by a research nurse with regard to her sexual history. The patient was asked about the number of sexual partners in her lifetime, the number of sexual partners since the start of her pregnancy, and, on average, the frequency of intercourse per week in the preceding month. RESULTS: A total of 165 pregnancies were available for this analysis. The population incidence of spontaneous preterm birth at less than 37 weeks of gestation in the study pregnancy was 36%. An increasing number of sexual partners in a womans lifetime was associated with an increased risk of spontaneous preterm delivery (one partner 19%, 2–3 partners 29%, ≥ 4 partners 44%, P = .007), whereas the number of sexual partners since the start of pregnancy was not (P = .42). Women who reported infrequent sexual intercourse during early pregnancy had an incidence of recurrent spontaneous preterm birth of 28% compared with 38% in those women who reported some intercourse (P = .35). CONCLUSION: Self-reported coitus during early pregnancy was not associated with an increased risk of recurrent preterm delivery. There was an association between increasing number of sexual partners in a womans lifetime and recurrent preterm delivery. LEVEL OF EVIDENCE: II-2

Second-trimester cervical sonography: features other than cervical length to predict spontaneous preterm birth.

OBJECTIVE: To estimate whether cervical and lower uterine segment characteristics other than cervical length and funneling predict recurrent preterm birth. METHODS: We conducted a secondary analysis of a multicenter, blinded observational study of 181 women with singletons and prior spontaneous preterm births. Endovaginal ultrasonic examinations were performed at 2-week intervals between 16 0/7 weeks and 23 6/7 weeks of gestation. Cervical canal contour (straight/curved), cervical position (horizontal/vertical), posterior cervical width, lower uterine segment thickness, vascularity, endocervical canal dilation, with or without associated membrane prolapse and chorioamnion visible at the internal os, were systematically assessed. RESULTS: At the initial sonogram (16 0/7–18 6/7 weeks), membranes visible overlying the internal os (relative risk 1.9, confidence interval [CI] 1.2, 3.1) and canal dilation of 2–4 mm (relative risk 2.6, CI 1.4, 4.7) were significant predictors of spontaneous preterm birth of less than 35 weeks in univariate analyses. Only canal dilation remained statistically significant after controlling for cervical length (odds ratio 5.5, CI 1.1, 28.6). CONCLUSION: Endocervical canal dilation of 2–4 mm during second-trimester endovaginal sonography was associated with an increased risk of recurrent preterm delivery independent of cervical length. LEVEL OF EVIDENCE: II-2

Absence of the G1528C (E474Q) mutation in the α-subunit of the mitochondrial trifunctional protein in women with acute fatty liver of pregnancy

Acute fatty liver of pregnancy (AFLP) is a rare and dreaded complication of pregnancy, almost exclusively seen in the third trimester. The histopathologic features of AFLP closely resemble those seen in metabolic disorders characterized by deficiency of fatty acid oxidative enzymes. Several reports have established a strong association between AFLP in the mother and fetal deficiency of the enzyme long-chain l-3-hydroxyacyl-CoA dehydrogenase (LCHAD). However, these studies have an inevitable selection bias resulting from ascertainment through an affected infant, rather than an unselected population of patients with AFLP. We retrospectively examined a series of 10 women with pregnancies complicated by AFLP to determine the prevalence of the common LCHAD mutation (G1528C) in this population. The existing LCHAD primers, which produce a 640-bp amplicon (IJlst L, Ruiter JP, Hoovers JM, Jakobs ME, Wanders RJ:J Clin Invest 98:1028–1033, 1996), were modified to make them amenable to analysis of fragmented DNA obtained from microdissected formalin-fixed material. None of the patients were found to harbor the common G1528C mutation. It is likely that AFLP arising in the context of fetal LCHAD deficiency represents only one of the possible etiologies for this uncommon disorder, and the metabolic basis of AFLP is more heterogeneous than previously believed.