Thaddeus Waters

Longitudinal modulation of immune system cytokine profile during pregnancy.

OBJECTIVEnTo characterize immune modulation as expressed by cytokine assays at three time-points in human pregnancy.nnnSTUDY DESIGNnThis is a prospective, longitudinal study of a broad panel of cytokine expression during singleton pregnancies resulting in an uncomplicated, full-term, live births. Peripheral blood was obtained at 8-14, 18-22, and 28-32 weeks gestation. Six cytokines - IFN-γ, IL-4, TNF-α, IL-1β, IL-6, and IL-10 - were measured in supernatants obtained from whole blood stimulations with PHA or LPS and were compared to unstimulated controls. Samples were processed by Luminex-100 MAP®. We used Generalized Linear Models (GLM) to evaluate cytokine trajectories.nnnRESULTSnComplete data were obtained for 45 uncomplicated pregnancies. Overall, peripheral blood WBCs demonstrated dampened cytokine responses. However, over the course of pregnancy, we found enhanced counter-regulatory cytokine expression (e.g., shown by increased IL-10).nnnCONCLUSIONnThe overall decrease in pro-inflammatory cytokines and increase in counter-regulatory cytokines as uncomplicated pregnancy progresses supports the evolving concepts of immunoregulation for the maintenance of a viable pregnancy.

The management of preterm premature rupture of the membranes near the limit of fetal viability

Preterm premature rupture of the membranes near the limit of fetal viability is an uncommon complication of pregnancy, affecting approximately 4 in 1000 gravidas. However, maternal, fetal, and neonatal complications resulting from this condition are significant and include chorioamnionitis, pulmonary hypoplasia, restriction deformities, fetal loss, and complications of extreme prematurity among surviving infants. In this article, we review the literature regarding pregnancy outcomes after preterm premature rupture of the membranes near the limit of viability, and the data on traditional and nontraditional interventions to improve outcomes. An approach to patients who present with preterm premature rupture of the membranes near the limit of viability will be proposed.

Preterm PROM: prediction, prevention, principles.

Preterm premature rupture of the membranes remains difficult to predict accurately. The majority of those suffering preterm premature rupture of the membrane lack risk factors that might lead to preventative treatments. Its management is centered on an evaluation of the risks and benefits of attempted pregnancy prolongation compared with expeditious delivery. An understanding of the gestational age specific risks for newborn morbidity and mortality is essential to estimate the potential benefits of conservative management. Once the diagnosis of membrane rupture remote from term is made, conservative management to reduce neonatal complications is generally attempted while maintaining vigilance for complications such as infection, umbilical cord compression, or abruption. Concurrent antibiotic therapy and antenatal corticosteroid treatment are typically administered to prolong pregnancy, prevent infection, and reduce gestational age dependent morbidities. Near and at term, particularly if fetal pulmonary maturity has been confirmed, the patient is generally best served by expeditious delivery.

Neonatal Body Composition According to the Revised Institute of Medicine Recommendations for Maternal Weight Gain

BACKGROUNDnIn 2009, the Institute of Medicine (IOM) released revised pregnancy weight gain guidelines. There are limited data regarding the effect of maternal weight gain on newborn adiposity.nnnOBJECTIVEnThe aim of this study was to estimate neonatal fat mass, lean body mass, and percentage body fat according to current Institute of Medicine (IOM) pregnancy weight gain guidelines.nnnDESIGNnThis is a secondary analysis of a prospective observational cohort study of neonates delivered at least 36 wk gestation and evaluated for fat mass, lean body mass, and percentage body fat. Women with abnormal glucose tolerance testing and other known medical disorders or pregnancies with known fetal anomalies were excluded. Pregravid body mass index (BMI) was categorized as normal weight (<25 kg/m2), overweight (25-30 kg/m2), or obese (>30 kg/m2). Maternal weight gain was quantified as less than, equal to, or greater than current IOM guidelines. Newborn body composition measurements were compared according to weight gain and BMI categories.nnnRESULTSnA total of 439 maternal-newborn pairs were evaluated; 19.8% (n=87) of women gained less than IOM guidelines; 31.9% (n=140), equal to IOM guidelines; and 48.3% (n=212), greater than IOM guidelines. Significant differences for each component of body composition were found when evaluated by IOM weight gain categories (all ANOVA, P<0.001). When controlling for pregravid BMI, only weight gain for women who were of normal weight before pregnancy remained significant.nnnCONCLUSIONnMaternal weight gain during pregnancy is a significant contributor to newborn body composition, particularly for women who are of normal weight before pregnancy.

Impact of timing of antenatal corticosteroid exposure on neonatal outcomes

Objective. To evaluate morbidities among neonates with a history of remote antenatal corticosteroid (ACS) exposure compared to those with recent exposure. Study Design. This is a retrospective-cohort study of neonates born at 30–33 6/7 weeks gestational age. The primary outcome was newborn respiratory distress syndrome (RDS) defined by the persistent need for oxygen at 24 h of life. Maternal chart review established timing of ACS exposure. Data were stratified by the time interval of ACS administration to delivery: none or <48 h (Incomplete/Unexposed), 48 h to 7 days (Recent) and >7 days (Remote). Perinatal outcomes were compared between groups. Resuts. Five hundred and twenty-four infants were included: 273 Incomplete/Unexposed, 120 Recent and 131 with Remote ACS exposure. RDS was significantly less frequent with Recent vs. Remote exposure (RR: 1.73 [1.01–3.02]p = 0.04). This finding persisted in a logistic regression model. Conclusions. Infants delivering more than 1 week after ACS exposure have a higher frequency of RDS than those who deliver within 1 week.

Longitudinal trajectory of bacterial vaginosis during pregnancy

OBJECTIVEnThis study was undertaken to characterize the course of bacterial vaginosis in pregnancy and to discern the bacterial morphotypes responsible for infection.nnnSTUDY DESIGNnVaginal secretions were obtained in each trimester of pregnancy and were evaluated for bacterial vaginosis by Gram stain, categorized as normal or any of the following: Lactobacillus deficient, Gardnerella, Bacteroides, or Mobiluncus positive and by Nugent score. Results were evaluated for trends of bacterial vaginosis and Gram stain over pregnancy.nnnRESULTSnOne hundred forty-eight women were evaluated. Seventy-one women (48%) were bacterial vaginosis negative in all trimesters, compared with 14 (9.4%) who were positive throughout pregnancy. Among the 14 women who remained bacterial vaginosis positive, Gram stain findings were Gardnerella+Bacteroides+Lactobacillus, with approximately 50% harboring Mobiluncus. Few women become bacterial vaginosis positive as pregnancy progressed (6.1%). With each increasing week of pregnancy, the risk of becoming bacterial vaginosis positive decreased (0.93: 0.91-0.95; P < .001).nnnCONCLUSIONnIn this population, the majority of pregnant women trend toward bacterial vaginosis negative status. Few women are bacterial vaginosis positive across their pregnancy.