Shimrit Yaniv Salem

Maternal “isolated” obesity and obstetric complications

Objective: To investigate pregnancy outcomes, particularly cesarean delivery (CD), among women with “isolated” obesity (i.e. without additional comorbidities). Study design: We conducted a retrospective population-based study between the years 1988–2010. The pregnancy outcomes of obese (prepregnancy BMI ≥30 kg/m2) and nonobese patients were compared. Patients with chronic hypertension, pregestational diabetes mellitus, other preexisting chronic morbidities, multiple gestations, age above 40 years, grand multiparity (above 5 deliveries), lack of prenatal care, and following fertility treatments were excluded from the analysis. Stratified analyses, using multiple logistic regression models, were performed to control for confounders. Results: During the study period, a total of 173,628 deliveries met the inclusion criteria; 1605 (0.9%) occurred in patients with “isolated” obesity. Higher rates of CD were found among patients with “isolated” obesity (30.7% vs. 12.3%; odds ration [OR] = 3.2; p < 0.001). When controlling for possible confounders, using a multivariable model with CD as the outcome variable, the association between “isolated” obesity and CD remained significant (adjusted OR = 2.6; p < 0.001). No significant differences were found in the risks of perinatal complications including perinatal mortality, shoulder dystocia, congenital malformations, and low 5-min Apgar score. Conclusion: “Isolated” obesity, although not a risk factor for adverse perinatal outcomes, is an independent risk factor for CD.

Passive fetal monitoring by adaptive wavelet denoising method

Fetal Heart Rate (FHR) monitoring is one of the most important fetal well being tests. Existing FHR monitoring methods are based on Doppler ultrasound technique, which has several disadvantages. Passive fetal monitoring by phonocardiography is an appropriate alternative; however, its implementation is a challenging task due to low energy of fetal heart sounds and multiple interference signals presence. In this paper, an advanced signal processing method for passive fetal monitoring based on adaptive wavelet denoising is presented. The methods performance is compared with Doppler ultrasound monitor. The results show 94-97.5% accuracy, including highly disturbed cases.

Lower circulation levels and activity of α-1 Antitrypsin in pregnant women with severe preeclampsia

Objective: α-1 antitrypsin (AAT) is an anti-protease, anti-inflammatory and tissue-protective molecule. Normal circulating levels are <3.5 mg/dl and rise during pregnancy. Although AAT deficiency is associated with several pregnancy and placental disorders, little is known regarding AAT levels and preeclampsia. Since unopposed inflammation might contribute to preeclampsia, we studied whether preeclampsia is associated with lower than normal levels and activity of AAT. Methods: In a prospective case-control study, we compared maternal serum AAT activity and levels between patients with severe preeclampsia (n = 23) and without preeclampsia (n = 18). Results: AAT levels were 1.91 ± 0.08-fold lower in the preeclampsia group compared to healthy group (3.854 ± 0.26 vs. 7.397 ± 0.34 mg/ml; p < 0.001), and correlated with protease inhibitory capacity (46.56 ± 2.08% vs. 67.08 ± 1.74%; p < 0.001). Conclusions: Our findings show association between lower AAT levels and severe preeclampsia during pregnancy. Further studies are required to identify the mechanism behind the association, and the possibility of safe AAT augmentation for individuals with insufficient circulating AAT.

Low levels of circulating alpha-1 antitrypsin are associated with spontaneous abortions

Abstract Objective: Alpha-1 antitrypsin (AAT), a circulating anti-inflammatory molecule, rises four- to sixfold during acute phase responses and during pregnancy. AAT deficiency is linked with various pregnancy complications. The aim of this study is to determine plasma concentrations and activity of AAT and serum cytokine levels in blood samples from women undergoing spontaneous abortions as compared with elective abortions. Methods: A prospective case–control study consisted of patients with sporadic abortions (n = 15), recurrent spontaneous abortions (n = 14) and healthy pregnancies going through elective terminations (n = 11). Circulating AAT and cytokine levels were determined before dilatation and curettage. Results: AAT levels were lower in both recurrent and sporadic spontaneous abortion groups compared with healthy pregnancies (1.421 ± 0.08, 1.569 ± 0.14 and 3.224 ± 0.45 mg/ml, respectively, p < 0.001). Reduced AAT levels correlated with elevated proinflammatory cytokines. Conclusions: AAT levels in patients with either sporadic or recurrent spontaneous abortions were lower than normal pregnancies, and were associated with an inflammatory profile. Future studies should examine larger cohort groups, effects of earlier time-points and the influence of antithrombotic therapy in such patients who are diagnosed with relatively low levels of circulating AAT, in an effort to improve pregnancy outcomes.

Fetal heart rate monitoring category 3 during the 2nd stage of labor is an independent predictor of fetal acidosis.

Abstract Objective: To determine whether fetal heart rate (FHR) monitoring categories during the 1st and 2nd stage of labor can predict arterial cord pH <7.2. Materials and methods: A case control study was conducted including 653 consecutive term deliveries (37 weeks gestation and above) that were divided according to fetal pH ≤ 7.2 (n = 315) and fetal pH > 7.2 (n = 338). Deliveries occurred during the year 2013 in tertiary medical center, where arterial cord pH is routinely taken after birth. Intrapartum FHR monitoring categorization was defined according to the ACOG committee guidelines by two obstetricians. Multivariable models were constructed to control for confounders. Results: Variable decelerations, late decelerations and bradycardia during the 1st and 2nd stages of labor were significantly higher in group of deliveries ended in cord pH < 7.2 compared with group of deliveries ended in cord pH > 7.2. A significant association was observed between category 2 and 3 during the 1st stage of labor and pH ≤ 7.2. However, while controlling for FHR category 3 at the 2nd stage of labor, 1st stage categorization lost its association with pH <7.2, and only category 3 during the 2nd stage were noted as an independent risk factor for acidosis. Conclusion: FHR monitoring category 3 during the 2nd stage of labor is an independent predictor of fetal acidosis as expressed by arterial cord pH < 7.2.

α1-Antitrypsin insufficiency is a possible contributor to preterm premature rupture of membranes

Objective: α1-Antitrypsin (AAT) is protective of tissue damage induced by enzymes of inflammatory cell source. Inflammatory cells are involved in preterm labor, preterm premature rupture of membrane (PPROM) and term premature rupture of membrane (PROM). The purpose of this research was to examine whether plasma concentration and activity of AAT differ between these manifestations. Methods: In a prospective case control study, blood samples were assayed for AAT concentration and activity in 71 individuals. AAT concentration and activity were measured by standard methods. Results: No significant differences were found between AAT levels (p = 0.497) and activity (p = 0.879) in preterm and term labor. AAT levels and activity in PPROM and PROM were not significantly different as well (p = 0.748 and p = 0.880, respectively). While 69 out of 71 patients displayed normal circulating levels of AAT, 2 PPROM patients out of 15 had abnormally low, previously undiagnosed,AAT concentrations, and had subsequently developed complications that were absent in the other groups. Conclusions: No statistically significant differences were demonstrated in the levels of AAT between patients with preterm and term labor, nor between preterm and term PROM. Yet, unexpectedly, patients that had marked AAT deficiency belonged exclusively to the PPROM group.

Diminished activity of circulating α1-antitrypsin is associated with pre-gestational isolated obesity.

Abstract Objective: To examine possible correlation between α1-antitrypsin (AAT) levels and activity in patients with and without obesity, after excluding complications such as gestational diabetes mellitus (GDM), during pregnancy. Study design: A prospective case–control study was conducted. AAT levels were determined by standard human AAT ELISA according to the manufacturers instructions. Elastase inhibition was determined by kinetic assay according to manufacturer recommendations. Assays were performed in duplicates and repeated twice for each sample in separate sessions. Patients with diabetes mellitus were excluded from the study. The Mann–Whitney U-test was performed in order to determine statistical differences between the groups, and AAT concentration and activity. Results: During the study period, 43 patients were recruited: 21 with isolated obesity and 22 non-obese parturients (control group). According to ELISA, AAT concentrations were mildly lower in obese women compared with non-obese women (8.31 ± 0.28 mg/ml versus 9.5 ± 0.37 mg/ml, p = 0.0155). However, the elastase inhibitory capacity was markedly lower in obese versus non-obese parturients (mean 27.33 ± 2.08 % versus 43.73 ± 3.1%, p < 0.001). Conclusions: Isolated obesity in pregnancy is associated with lower activity of AAT. These findings correlate with the reduced concentration and activity of AAT found in patients with GDM. Accordingly, it might suggest an inflammatory axis shared by obesity and the development of insulin resistance.