Tharwat Stewart Boulis

Omega-3 polyunsaturated fatty acids enhance cytokine production and oxidative stress in a mouse model of preterm labor

Abstract Objective: Omega-3 polyunsaturated fatty acid (ω-3 PUFA) supplementation during pregnancy remains controversial. We sought to examine the effects of ω-3 PUFA on inflammation and oxidative stress in vitro and in vivo using a model of preterm labor. Methods: In vivo. Female Swiss Webster mice were fed a normal diet or a 5% fish oil (FO) diet for 3 weeks then mated with normal-fed males. On gestational day 15, dams were injected with either saline (n=10 per group) or lipopolysaccharide (LPS, intrauterine) (n=10 per group). Maternal plasma, amniotic fluid, placentas, and uteri were collected 4 h later and assessed for cytokines; maternal plasma and amniotic fluids were analyzed for oxidative stress. In vitro. RAW264.7 mouse macrophage-like cells were treated with either: vehicle, H2O2, docosahexaenoic acid (DHA), or eicosapentaenoic acid (EPA) (0, 0.1–100 μM) and analyzed for oxidative stress. Results: In vivo. Administration of the 5% FO diet enhanced LPS-induced cytokines in the placenta (P<0.05–0.01) and increased tumor necrosis factor-α in the uterus (P<0.05) and amniotic fluid (P<0.01) when compared to LPS-treated normal-fed animals. Maternal plasma obtained from FO-fed dams showed higher LPS-induced oxidative stress than control-fed animals (P<0.035). However, no differences in oxidative stress were observed in the amniotic fluid. In vitro. Treatment of macrophage-like cells with ω-3 PUFA significantly and dose-dependently increased oxidative stress (P<0.001–0.0001). Conclusions: Supplementation with FO for prior to and during pregnancy significantly increased LPS-induced inflammation in the amniotic fluid, uterus, and placenta and significantly increased maternal systemic oxidative stress in vivo. Likewise, DHA and EPA induced oxidative stress in macrophage-like cells in vitro.

Is There an Association Between Placenta Previa and Serum Analytes

INTRODUCTION: The objective of this study was to evaluate the association between maternal serum analytes and placenta previa. METHODS: Chart review of deliveries from 2004 to 2012 with two comparison groups: placenta previa without accreta and a control group. Patients in the control group were randomly selected from deliveries without placenta previa. Patients with previa were confirmed by third-trimester ultrasonography. Exclusion criteria were placenta previa with pathology-confirmed accreta, multiple gestations, fetal anomalies, or growth restriction. Primary outcomes were maternal serum analytes in the first trimester: pregnancy-associated plasma protein A and free &bgr;-human chorionic gonadotropin (&bgr;-hCG), and second trimester: &agr;-fetoprotein), free &bgr;-hCG, unconjugated estriol, and inhibin. RESULTS: Twenty-six women with previa met inclusion criteria and 43 women in the control group. The groups did not differ with respect to maternal age, gravidity, or parity. Alpha-fetoprotein multiples of the median was significantly higher in women with previa cases than women in the control group (P<.005). Pregnancy-associated plasma protein A multiples of the median was higher (but was not statistically significant) in women with previa than in the women in the control group (P<.064). There were no differences between groups with respect to first-trimester free &bgr;-hCG, second-trimester free &bgr;-hCG, unconjugated estriol, or inhibin (Table 1). The following analytes were not available on all specimens: second-trimester free &bgr;-hCG, unconjugated estriol, and inhibin. Table 1 Comparison of Serum Analytes Between Placenta Previa Without Accreta Cases and Control Cases. CONCLUSIONS: In our women with placenta previa, maternal serum &agr;-fetoprotein was significantly higher than in women in the control group. We also observed higher levels of pregnancy-associated plasma protein A in women with previa but this did not reach statistical significance. Prospective studies are needed to confirm these findings and determine the relationship with pregnancy outcome.

Implementing an Obstetric Triage Acuity Tool in a High-Volume Obstetric Unit

INTRODUCTION: Our objective was to evaluate an obstetric triage acuity tool that we developed and implemented in January 2013. METHODS: A four-level triage acuity tool, Level 1 (most acute) to Level 4 (least acute), was developed to prioritize patients presenting for urgent care to the obstetric triage unit. Acuity scores, assigned by a triage nurse, dictated acceptable wait times for a medical screening examination (Level 1, 5 minutes; Level 2, 15 minutes; Level 3, 30 minutes; Level 4, 60 minutes). This was a prospective cohort study of all 2,228 urgent triage visits from March 1 to May 31, 2013. The validity of obstetric triage acuity tool was evaluated by comparing hospital admission rates across acuity levels to determine whether admission rates increased with increasing acuity level. Wait times from acuity score to medical screening examination and to final disposition were calculated and assessed by acuity level. RESULTS: Admission rates increased significantly across acuity levels from least acute to most acute; admission rates at Level 4, 3, 2, and 1 were respectively, 16%, 40%, 54%, and 84%, respectively (Table 1; P<.001). Goals for acceptable wait time for a medical screening examination were met for 89% of Level 1, 84% of Level 2, 91% of Level 3, and 94% of Level 4 visits. Table 1 Hospital Admission and Triage Evaluation Times Stratified by Acuity Level CONCLUSIONS: Increasing hospital admission rates across acuity levels supports the validity of obstetric triage acuity tool. Since implementing the obstetric triage acuity tool, most patients presenting for urgent care were seen for a medical screening examination within clinically acceptable wait times.

Triphasic umbilical artery waveform: association with severe fetal growth restriction, fetal demise, and extreme velamentous cord insertion

Abstract Extreme Doppler abnormalities of the umbilical artery such as absent or reversed end diastolic velocity are associated with adverse perinatal outcomes. We present a case of a triphasic umbilical artery waveform identified at 24 weeks. The fetus was severely growth restricted with an estimated fetal weight of 314 g. A week later, fetal demise occurred. Placental pathology revealed a placental weight of 83 g, an extensive maternal floor infarction, and an extreme velamentous cord insertion 7 cm from the edge of the placental disc, with vessels entering at opposite poles of the placental disc and a single anastomotic bridging vessel on the chorionic plate connecting these two vascular poles. A triphasic umbilical artery waveform may be associated with a premorbid state and severe placental vascular abnormality. We hypothesize that the third and positive component in late diastole is present due to forward flow across the communicating bridging vessel into the contralateral entering vessel.