Spyros Mesogitis

Placental pathology in women with gestational diabetes

Background. The aim of this study was to investigate pathologic differences of the placenta in pregnancies complicated by gestational diabetes compared to non‐diabetic pregnancies. Methods. Forty singleton pregnancies complicated by gestational diabetes were recruited and compared to 40 consecutive normal pregnancies. A pathologist, blinded to all clinical data, reviewed all histological samples of the placentas. The histological assessment was carried out with regard to the following aspects: fetal vessel thrombosis, villous immaturity, chorangiosis, presence of nucleated fetal red blood cells (NFRBCs), ischemia, infarction, presence of hydropic or avascular villi, lymphohistiocytic villitis and villous fibrinoid necrosis. Results. The presence of degenerative lesions such as fibrinoid necrosis and vascular lesions like chorangiosis was apparent, mainly in the diabetes group. Villous immaturity and the presence of NFRBC as an indication of chronic fetal hypoxia were significantly increased in the placentas of women with diabetes compared with the control group. Fetal/placental weight ratio was significantly lower in the diabetic group. Conclusion. Histological abnormalities were observed more frequently in the diabetic placentas compared to the controls. These findings support the hypothesis that impaired placental function is one of the main reasons for the increased frequency of fetal complications in diabetic pregnancies.

Amniotic fluid interleukin-6 and tumor necrosis factor-α at mid-trimester genetic amniocentesis: Relationship to intra-amniotic microbial invasion and preterm delivery

OBJECTIVE To determine the value of amniotic fluid interleukin-6 (AF IL-6) and tumor necrosis factor-alpha (AF TNF-alpha) in the diagnosis of microbial invasion of the amniotic cavity and in the prediction of preterm delivery (PTD). STUDY DESIGN Following amniocentesis, a sample of amniotic fluid was sent for aerobic and anaerobic bacterial cultures along with Ureaplasma urealyticum culture and it was also assessed for IL-6 and TNF-alpha. RESULTS Forty-eight women who delivered preterm (<37 weeks) were matched with 96 controls. The AF IL-6 and TNF-alpha concentrations of women with spontaneous PTD were significantly higher than those who delivered at term (IL-6: 176.3 pg/ml [130.6-208.6] vs. 52.3 pg/ml [37.2-92.3]; TNF-alpha: 8.8 pg/ml [7.2-10.7] vs. 5.5 pg/ml [5.0-6.3]). AF IL-6 and TNF-alpha concentrations of >99.3 pg/ml and of >6.6 pg/ml respectively, had a sensitivity of 89.6% and 81.3% and a specificity of 80.3% and 79.2% for the prediction of spontaneous PTD. Moreover, AF IL-6 and TNF-alpha concentrations of >99.3 pg/ml and of 6.3 pg/ml respectively, had a sensitivity of 91.9% and 78.4% and a specificity of 73.8% and 70.1% for the prediction of a positive AF culture. CONCLUSIONS Elevated mid-trimester concentrations of AF IL-6, or/and of TNF-alpha can identify women at risk for intra-amniotic infection and for spontaneous PTD.

Bacterial Vaginosis and Group B Streptococcal Colonization and Preterm Delivery in a Low-Risk Population

Objective: To evaluate the relationship between bacterial vaginosis (BV) and group B streptococcal (GBS) colonization in the 2nd trimester of pregnancy and preterm delivery. Methods: 1,197 pregnant women between 22 and 25 weeks’ gestation had a high vaginal swab for assessment of BV and GBS. Exclusion criteria were: previous preterm delivery, or mid-trimester abortion or termination of pregnancy, multiple gestation, oligo- or polyhydramnios, placenta previa, fetal abnormalities, uterine malformations, cervical incompetence, cervical cerclage, or receipt of an antibiotic effective against BV or GBS following the screening. All women had no risk factors for preterm delivery. The primary outcome measure in this analysis was spontaneous preterm delivery before 37 weeks’ gestation. Results: The preterm delivery rate was 8.7%, while the maternal BV and GBS colonization rates were 7.9 and 12.5%, respectively. Following adjustment for potential confounders BV was associated with an increased risk of preterm delivery (RR 2.19; CI: 1.21–3.98) (p = 0.01). On the contrary, GBS colonization was found to have a negative correlation with preterm birth (RR 0.43; 95% CI: 0.19–1.00). Conclusions: Although BV is a risk factor for preterm delivery, GBS colonization in the 2nd trimester of pregnancy has an inverse correlation with preterm delivery.

Local Application of Methotrexate for Ectopic Pregnancy with a Percutaneous Puncturing Technique

Management of ectopic pregnancy remains traditionally surgical. Early detection of unruptured ectopic pregnancies, using both ultrasound techniques and β-human chorionic gonadotropin (β-hCG) assays, allows a more conservative treatment. Twenty-six tubal pregnancies, which were managed with local methotrexate (MTX) injection, are presented. A single dose of 10–12.5 mg of MTX was percutaneously injected into the gestational sac under abdominal sonographic control. Complete resolution was obtained in all our patients. Four of them required a second percutaneous administration 4 days after the first one. Negligible serum β-hCG levels (<10 mIU/ml) were reached within 42 days after treatment. No systemic side effects were observed. Local administration of MTX under abdominal sonographic control seems to be an effective alternative for the treatment of ectopic pregnancy. The main potential advantages of the method are (1) a greater antitrophoblastic effect; (2) a shorter treatment period; (3) reduced dosage, and (4) absence of side effects.

Invasive techniques for fetal diagnosis in multiple pregnancy

During a 12‐year period, a variety of fetal diagnostic techniques were performed in 112 twin, 3 triplet and 1 quintuplet pregnancies, respectively. Tissues sampled included amniotic fluid, fetal blood and chorionic villi. Two spontaneous abortions occurred and one case of twins was stillborn. Four selective feticides were performed in twins for specific indications and four healthy surviving infants were delivered. It is concluded that fetal diagnosis in multiple pregnancy is safe and accurate without significant perinatal morbidity and mortality.

Sonographic Findings and Surgical Management of a Uterine Rupture Associated With the Use of Misoprostol During Second-Trimester Abortion

Misoprostol, a synthetic analogue of prostaglandin E 1 , is gaining popularity for use in second-trimester pregnancy termination worldwide, and several studies have reported excellent results with its use in the second trimester of pregnancy. 1 , 2 In women with previous cesarean delivery, the use of prostaglandins for labor induction during the second or third trimester is considered dangerous because of the risk of uterine rupture. 3 , 4 The incidence of this complication after misoprostol administration in women with a scarred uterus in the second trimester is unknown. In a retrospective study examining whether a previous cesarean delivery carries a higher risk of complications in women who undergo pregnancy termination with misoprostol, no increased risk of uterine rupture was found. 5 In this report, we describe a case of uterine rupture during a second-trimester pregnancy termination with misoprostol in a woman with a previous cesarean delivery. Apart from the clinical symptoms, the diagnosis was based on the sonographic findings that prompted surgical intervention.

Pregnancy in Gaucher disease.

An 18-year old woman with type I Gaucher disease and two uncomplicated pregnancies is described. Although she experienced one miscarriage and pregnancy was associated with exaggeration of the clinical symptoms, leading to the diagnosis of the disorder, both her 2nd and 3rd pregnancies were uneventful and deterioration of her clinical situation was not observed. The issue of criteria for risk assessment in pregnancy of type I Gaucher disease patients is addressed.

The effect of the mode of delivery on the maternal-neonatal erythrocyte membrane acetylcholinesterase activity.

UNLABELLED Free radical production and high catecholamine levels are implicated with the modulation of acetylcholinesterase (AChE) activity. OBJECTIVE To investigate the effect of the mode of delivery on maternal-neonatal erythrocyte membrane AChE activity. SUBJECTS AND METHODS Some women with normal pregnancy (N = 30) were divided into two groups: group A (N = 16) with normal labour and vaginal delivery and group B (N = 14) with scheduled Cesarean section, twenty non-pregnant women were the controls. Blood was obtained from controls and from mothers pre- vs post-delivery as well as from the umbilical cord (CB). Total antioxidant status (TAS), membrane AChE activities and catecholamine blood levels were measured with a commercial kit, spectrophotometrically and HPLC methods, respectively. RESULTS TAS and catecholamine levels as well as membrane AChE activities were similar in the two groups of mothers pre-delivery and in controls. TAS levels were reduced whereas AChE activities and catecholamine levels were increased post-delivery in mothers of group A and unaltered in group B at the same times of study. AChE activity was similarly lower in the CB of neonates than those of their mothers pre-delivery. CONCLUSIONS During a normal delivery process, the low TAS, the increased levels of catecholamines and the increased AChE activity, post-delivery, may be due to the increased stress due to the participation of uterus and skeletal muscles as during endurance exercise. The low AChE activity in newborns may be related to perinatal immaturity.

Induction of labor versus expectant management for pregnancies beyond 41 weeks

Abstract Objective: To compare the outcome following labor induction at 41 + 1 weeks of gestation and after expectant management and selective induction at 42 completed weeks. Method: A retrospective analysis of post-term pregnancies in a 2-year period. In the induction group, women at 41 + 1 weeks of gestation received 3 mg prostaglandin E2 (dinoprostone) in the posterior fornix, repeating the dose 6 h later. Women with a Bishop score >6 had artificial rupture of the membranes. In the expectant management group, women at more than 41 weeks gestation were checked every 2 days in the hospital. In case of abnormalities either in the fetal heart rate evaluation or in the biophysical profile, labor was induced. Labor was also induced in all cases that pregnancy exceeded 42 + 1 gestational weeks. Results: A total of 438 women who met the inclusion criteria were included in the study. In all, 211 comprised the induction group, while the expectant management group consisted of 227 women. The cesarean delivery rate in the induction group was 36.5% compared to 34.4% in the expectant management group, whereas the operative vaginal delivery rate was 11.4 and 9.2% in the two groups, respectively. The vast majority of women in the expectant management group (74%) had a spontaneous onset of labor. Conclusion: The perinatal outcome does not differ following a policy of routine labor induction in comparison to expectant management in pregnancies beyond 41 weeks.

Optimum mode of delivery in gestations complicated by preterm premature rupture of the membranes

Objectives: To provide evidence about the preferable mode of delivery, vaginal (VD) or caesarean section (CS), in PPROM. Methods: A retrospective study of 190 cases. Survival analysis was used to identify statistically significant differences in mortality rates. Results: A total of 126 pregnancies were included in our study. Mean gestational age of rupture was 28+0 weeks (min = 15, max = 36+4, sd = 5.796). Mean birth age was 30+0 weeks (min = 15, max = 37+2, sd = 5.353). CS was performed in 55 cases (43.7%), VD in 71 cases (56.3%). Data analysis showed that, regardless of presentation, there was a statistically significant benefit on survival in favor of the CS in births below 30 gestational weeks (n = 39, nCS = 18, nND = 21, χ2 = 7.946, p = 0.005). Hazard ratio estimation set the critical gestational age at 28 weeks. For vaginal deliveries, breech presentation was associated with inferior survival outcome compared to vertex (nTotal = 71; nVertex = 63, nBreech = 8, χ2 = 13.012, p < 0.001.Also in breech presentation, VD survival outcome was inferior to CS (nTotal = 9; nVD = 6, nCS = 3, χ2 = 5.145, p < 0.05). Conclusions: According to our results, in cases of PPROM, CS was beneficial below 28 weeks and in breech presentation below 30 weeks.