Richard P. Porreco

Amniotic fluid infection, inflammation, and colonization in preterm labor with intact membranes

OBJECTIVE The purpose of this study was to compare intraamniotic inflammation vs microbial invasion of the amniotic cavity (MIAC) as predictors of adverse outcome in preterm labor with intact membranes. STUDY DESIGN Interleukin-6 (IL-6) was measured in prospectively collected amniotic fluid from 305 women with preterm labor. MIAC was defined by amniotic fluid culture and/or detection of microbial 16S ribosomal DNA. Cases were categorized into 5 groups: infection (MIAC; IL-6, ≥11.3 ng/mL); severe inflammation (no MIAC; IL-6, ≥11.3 ng/mL); mild inflammation (no MIAC; IL-6, 2.6-11.2 ng/mL); colonization (MIAC; IL-6, <2.6 ng/mL); negative (no MIAC; IL-6, <2.6 ng/mL). RESULTS The infection (n = 27) and severe inflammation (n = 36) groups had similar latency (median, <1 day and 2 days, respectively) and similar rates of composite perinatal morbidity and mortality (81% and 72%, respectively). The colonization (n = 4) and negative (n = 195) groups had similar outcomes (median latency, 23.5 and 25 days; composite morbidity and mortality rates, 21% and 25%, respectively). The mild inflammation (n = 47) groups had outcomes that were intermediate to the severe inflammation and negative groups (median latency, 7 days; composite morbidity and mortality rates, 53%). In logistic regression adjusting for gestational age at enrollment, IL-6 ≥11.3 and 2.6-11.2 ng/mL, but not MIAC, were associated significantly with composite morbidity and mortality rates (odds ratio [OR], 4.9; 95% confidence interval [CI], 2.2-11.2, OR, 3.1; 95% CI, 1.5-6.4, and OR, 1.8; 95% CI, 0.6-5.5, respectively). CONCLUSION We confirmed previous reports that intraamniotic inflammation is associated with adverse perinatal outcomes whether or not intraamniotic microbes are detected. Colonization without inflammation appears relatively benign. Intraamniotic inflammation is not simply present or absent but also has degrees of severity that correlate with adverse outcomes. We propose the designation amniotic inflammatory response syndrome to denote the adverse outcomes that are associated with intraamniotic inflammation.

The cesarean birth epidemic: Trends, causes, and solutions

Abstract We should anticipate a continued slow fall in cesarean birth rates over time as initiatives for health care improvement help us focus on strategies to avoid interference in the normal process of labor and vaginal birth. (Am J Obstet Gynecol 1996;175:369-74.)

The safety of inhaled β-agonist bronchodilators during pregnancy

Abstract To assess the safety of inhaled β-agonist bronchodilators during pregnancy, perinatal outcomes in 259 prospectively managed women with asthma using these medications during pregnancy were compared to perinatal outcomes in 101 concurrently followed pregnant subjects with asthma not using inhaled bronchodilators and to perinatal outcomes in 295 concurrently followed pregnant control subjects without asthma. No significant differences between women with asthma using inhaled bronchodilators and subjects not receiving inhaled bronchodilators were found in the following parameters: perinatal mortality, congenital malformations, preterm births, low birth weight infants, mean birth weight, small for gestational age or low ponderal index infants, Apgar scores, labor/delivery complications, or postpartum bleeding. Increased incidences of maternal chronic and pregnancy-induced hypertension and transient tachypnea of the neonate were observed in the pregnancies of subjects with asthma using regular inhaled bronchodilators compared to control subjects, but a logistic regression analysis within the sample of subjects with asthma did not significantly associate the use of inhaled bronchodilators with these outcomes. In the light of the known substantial perinatal risks of severe, uncontrolled asthma and the relatively sparse evidence of human gestational safety for alternative asthma medications, these data support the use of inhaled β-agonist bronchodilators as part of the management of asthma during pregnancy.

Noninvasive prenatal screening for fetal trisomies 21, 18, 13 and the common sex chromosome aneuploidies from maternal blood using massively parallel genomic sequencing of DNA

OBJECTIVE The objective of this study was to validate the clinical performance of massively parallel genomic sequencing of cell-free deoxyribonucleic acid contained in specimens from pregnant women at high risk for fetal aneuploidy to test fetuses for trisomies 21, 18, and 13; fetal sex; and the common sex chromosome aneuploidies (45, X; 47, XXX; 47, XXY; 47, XYY). STUDY DESIGN This was a prospective multicenter observational study of pregnant women at high risk for fetal aneuploidy who had made the decision to pursue invasive testing for prenatal diagnosis. Massively parallel single-read multiplexed sequencing of cell-free deoxyribonucleic acid was performed in maternal blood for aneuploidy detection. Data analysis was completed using sequence reads unique to the chromosomes of interest. RESULTS A total of 3430 patients were analyzed for demographic characteristics and medical history. There were 137 fetuses with trisomy 21, 39 with trisomy 18, and 16 with trisomy 13 for a prevalence rate of the common autosomal trisomies of 5.8%. There were no false-negative results for trisomy 21, 3 for trisomy 18, and 2 for trisomy 13; all 3 false-positive results were for trisomy 21. The positive predictive values for trisomies 18 and 13 were 100% and 97.9% for trisomy 21. A total of 8.6% of the pregnancies were 21 weeks or beyond; there were no aneuploid fetuses in this group. All 15 of the common sex chromosome aneuploidies in this population were identified, although there were 11 false-positive results for 45,X. Taken together, the positive predictive value for the sex chromosome aneuploidies was 48.4% and the negative predictive value was 100%. CONCLUSION Our prospective study demonstrates that noninvasive prenatal analysis of cell-free deoxyribonucleic acid from maternal plasma is an accurate advanced screening test with extremely high sensitivity and specificity for trisomy 21 (>99%) but with less sensitivity for trisomies 18 and 13. Despite high sensitivity, there was modest positive predictive value for the small number of common sex chromosome aneuploidies because of their very low prevalence rate.

GYNECOLOGIC MALIGNANCIES IN IMMUNOSUPPRESSED ORGAN HOMO-GRAFT RECIPIENTS

Immunosuppressed organ homograft recipients have a 5 to 69% incidence of de novo malignancies at some time after transplantation. Gynecologic cancers were encountered in 21 of 224 patients (9%) with these tumors. The predominant lesion was carcinoma of the cervix (18 cases), of which 16 were intraepithelial and 2 were invasive. Gynecologic malignancies have also been encountered in non-transplant patients who were treated with immunosuppressive agents or cancer chemotherapy. All such individuals require gynecologic examination before commencement of treatment and at regular intervals thereafter so that malignancies may be diagnosed at an early stage and treated effectively. Most neoplasms respond well to conventional cancer therapy, but high-grade malignancies may necessitate reduction or cessation of immunosuppressive therapy as well.

The changing specter of uterine rupture

OBJECTIVE The objective of the study was to review all patient records discharged with codes for uterine rupture in 2006 in Hospital Corporation of America hospitals. STUDY DESIGN All patient charts were distributed to a committee of perinatologists and general obstetricians. Case report forms were analyzed for variables of interest to determine validity of coding and quality of care. RESULTS Of 69 cases identified, only 41 were true ruptures. Twenty patients had previous cesareans, and in 9 of these patients, concurrent use of oxytocics was documented. Among the 21 patients without previous cesareans, 7 had previous uterine surgery, and oxytocics were documented in 12 of the remaining 14 patients. Standard of care violations were identified in 10 of 41 true rupture cases. CONCLUSION Epidemiological data on uterine rupture based on hospital discharge codes without concurrent chart review may be invalid. Patients with previous cesareans represent only half of true uterine ruptures in contemporary practice.

Cesarean Birth for Failed Progress in Labor

&NA; “Failure to progress” is the leading indication for primary cesarean section and has a major impact on the escalating cesarean birth rate in the United States. We investigated the labor and delivery records of nulliparous women at term with vertex presentations admitted to the clinic and private services of our hospital to determine the importance of different management strategies associated with operative deliveries. Birth weights and immediate neonatal outcome were identical between the clinic and private services. The cesarean birth rate on the clinic service was 5.2%, compared with 17.1% on the private service; 80% of the abdominal deliveries on the private service were for “failure to progress.” Epidural use rates were similar on both services and were associated with a 70% incidence of oxytocin augmentation. Once oxytocin augmentation became part of labor management, a 14‐fold increase in cesarean sections was observed for the private service, but oxytocin had no impact on the cesarean birth rate in the clinic service. The placement of an intrauterine pressure catheter and an approach to the use of oxytocin that might be characterized as “selective active management” were necessary to achieve efficient uterine action in a timely fashion, permitting a high likelihood of vaginal birth on the clinic service. (Obstet Gynecol 73:915, 1989)

The use of continuous insulin infusion for the peripartum management of pregnant diabetic women

Sixteen pregnant diabetic patients near term were maintained on a regimen of continuous insulin infusion during the peripartum period. Blood glucose remained in the range of 75 to 150 mg. per deciliter, with insulin infusion rates between 0.25 and 2.00 U. per hour. Following delivery the infusion was continued through the first postpartum day or until oral intake was tolerated and subcutaneous long-acting insulin could be given. Sliding scale regimens were unnecessary; insulin dosage for discharge was easily determined; and the metabolic care of these patients was greatly simplified. Neonatal hypoglycemia in the 17 infants delivered of these diabetic patients was not entirely eliminated despite euglycemia in the mothers.

Amniocentesis in the management of preterm premature rupture of the membranes: A retrospective cohort analysis

Objective. This retrospective analysis determined the utility of amniocentesis in the management of preterm premature rupture of the membranes (PPROM). Study design. Consecutive patients with PPROM were managed with and without amniocentesis. Both groups received antibiotics and corticosteroids; tocolytics were withheld. Patients were induced if clinical or amniotic fluid (AF) proven chorioamnionitis occurred or gestational age goals were reached. Primary endpoints were individual and composite neonatal morbidity (CNM). Results. One hundred forty-seven maternal patients were managed with amniocentesis (AC) and 146 were managed without amniocentesis (NAC). CNM was significantly reduced in the group managed with AC (OR 2.94, 95% CI 1.68–5.15, NAC vs. AC). NAC patients had similar rates of neonatal sepsis as well as CNM to those patients in the AC group with positive AF Gram stains and/or cultures. Conclusions. Patients with PPROM who are managed with AC have significantly less CNM than NAC patients.

Pregnancy Outcome Following Donor Embryo Replacement

OBJECTIVE To investigate the occurrence of adverse perinatal outcome among donor embryo pregnancies. STUDY DESIGN Thirty-five pregnancies following donor embryo replacement were delivered between 1990 and 1994. Thirty-two pregnancies following standard in vitro fertilization (IVF) in women of 34 years of age or older were delivered during the same time period. All pregnancies meeting study criteria and who conceived through the same assisted reproductive technology program were included. Patients electing multifetal pregnancy reduction in either group were excluded. RESULTS The patients were similar with regard to age and parity. There was no difference in the mean number of embryos transferred between the groups or between those conceiving singleton or multiple gestations. The occurrence of spontaneous abortion was 34% in the donor embryo group and 25% in the control IVF group. Of the continuing pregnancies, there was a trend toward more cesarean births in the donor embryo group, but it was not statistically significant. Birthweights and gestational ages also were not different between the groups. Preterm birth occurred in approximately one-third of the pregnancies in each group owing largely to the number of multiple gestations. The incidence of preeclampsia was 26% among donor embryo pregnancies and 29% among control group pregnancies. Adverse outcome defined as preterm birth with or without preeclampsia occurred in over one-third of the pregnancies in each group. CONCLUSION There is no increase in adverse perinatal outcome among donor embryo pregnancies compared to age-like control IVF pregnancies. Modest increases in the occurrence of adverse outcome among such pregnancies cannot be excluded by the data in the current report.