Vedran Stefanovic

Antenatal diagnosis of placenta accreta leads to reduced blood loss.

Objective. Placenta accreta is one of the most devastating pregnancy complications. We sought to compare outcomes between women with placenta accreta when diagnosed antenatally or intrapartum, and to define predictors of the antenatal diagnosis. Design. Retrospective case–control study. Setting. University teaching hospital. Population. Twenty‐four women with placenta accreta diagnosed antenatally and 20 women discovered intrapartum. Methods. Chart review of historical and delivery‐associated variables. Rates were compared between the groups. Main Outcome Measures. Placenta accreta diagnosed antenatally or intrapartum. Results. Women with antenatal diagnosis had a lower estimated blood loss of a median of 4500ml (range 100–15000ml) compared with 7800ml (range 2500–17000ml, p=0.012) and required fewer units of packed red blood cells transfused (median 7; range 0–27 compared with 13.5; range 4–31, p=0.026). Nineteen (79%) women diagnosed antenatally had balloon catheter occlusion carried out during the cesarean section. Five (21%) had the entire placenta left in situ. There was no difference in the rate of surgical complications or duration of hospitalization. The clinical diagnosis among women with antenatal diagnosis was more often placenta percreta (p=0.013). The risk factor profile of women with antenatal diagnosis of placenta accreta included higher gravidity (p=0.014) and parity (p<0.0001), history of cesarean section (p=0.004), and placenta previa in the current pregnancy (p<0.001). Conclusions. Antenatal diagnosis of placenta accreta may reduce peripartum blood loss and the need for blood transfusion. Women with antenatal diagnosis more often have placenta previa and history of previous cesarean section, and the clinical diagnosis is more often placenta percreta.

Use of Bakri balloon tamponade in the treatment of postpartum hemorrhage: a series of 50 cases from a tertiary teaching hospital

Objective. Massive postpartum hemorrhage (PPH) is one of the most serious complications during delivery. Hysterectomy is commonly performed when other conventional treatment attempts fail. Bakri balloon tamponade (BBT) is a novel conservative management option for PPH. Little is known of the effectiveness of this procedure. We report a large case series from a tertiary teaching hospital. Design. Retrospective case series (October 2008–June 2011). Setting. University teaching hospital. Population. Forty‐four women with massive PPH (blood loss >1000 mL) and six other women with expected high risk of PPH (blood loss <1000 mL) managed by BBT. Methods. Chart review. Main outcome measures. Achievement of definitive hemostasis by BBT among the study population. Results. Among the women treated with BBT, the cause of PPH was uterine atony (16%), cervical rupture (14%), vaginal rupture and/or paravaginal hematoma (22%), placenta previa (18%) and placental retention (30%). The overall success rate was 86%. Seven of the 50 patients needed additional procedures. Of the seven failures, supravaginal uterine amputation or hysterectomy was required in four cases and embolization of the uterine arteries in three cases. Conclusions. BBT is a simple, readily available, effective and safe procedure for the management of PPH in selective cases. BBT does not exclude the use of other procedures if necessary. Even if BBT failed, it may provide temporary tamponade and time to prepare for other interventions or transportation from local hospital to tertiary centre. We suggest that BBT should be included in the PPH protocol.

Proposal for standardized ultrasound descriptors of abnormally invasive placenta (AIP)

*The Nuffield Department of Obstetrics & Gynaecology, University of Oxford, Oxford, UK; †The Fetal Medicine Unit, John Radcliffe Hospital, Oxford, UK; ‡Department of Obstetrics and Division of Experimental Obstetrics, Study Group Perinatal Programming, Charité Campus Virchow, Berlin, Germany; §Department of Obstetrics and Gynecology, General Faculty Hospital, Charles University, Prague, Czech Republic; ¶Department of Obstetrics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark; **Centre Hospitalier Régional Universitaire de Nancy, Université de Lorraine, Nancy, France; ††Fetomaternal Medical Center, Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland; ‡‡Prenatal Zürich, Zürich, Switzerland; §§Medical Faculty, Heinrich Heine University, Düsseldorf, Germany; ¶¶University of Liège, CHR de la Citadelle, Liège, Belgium *Correspondence. (e-mail: sally.collins@obs-gyn.ox.ac.uk)

Eculizumab treatment during pregnancy does not affect the complement system activity of the newborn

Eculizumab is a humanized IgG2/4 chimeric anti-complement C5 antibody used to treat patients with paroxysmal nocturnal hemoglobinuria (PNH) or atypical hemolytic uremic syndrome. The aim of this study was to evaluate whether or not the complement activity in newborns from pregnant women who receive eculizumab is impaired. A novel eculizumab-C5 complex (E-C5) specific assay was developed and revealed that two newborns carried only 6-7% of the E-C5 detected in their eculizumab-treated PNH mothers. Serum from the pregnant women completely lacked terminal complement pathway activity, whereas the complement activity in the serum of the newborns was completely normal. Data from the pregnant women and their newborns were compared with that of healthy age-matched female controls and healthy newborns, as well as a non-treated pregnant woman with PNH and her newborn. These all showed normal complement activity without detectable E-C5 complexes. Furthermore, absence of eculizumab or E-C5 in the newborn could not be explained by lack of eculizumab binding to the neonatal Fc receptor (FcRn), as eculizumab bound strongly to the receptor in vitro. In conclusion, despite binding to FcRn neither eculizumab nor E-C5 accumulates in fetal plasma, and eculizumab treatment during pregnancy does not impair the complement function in the newborn.

Amniotic Fluid Oxidative and Nitrosative Stress Biomarkers Correlate with Fetal Chronic Hypoxia in Diabetic Pregnancies

Background: In spite of improvement in obstetrical care, pregnancy in women with type 1 diabetes mellitus is associated with increased perinatal morbidity and mortality. Hyperglycemia during pregnancy causes excessive fetal growth and chronic fetal hypoxia as reflected in increased erythropoietin (EPO) levels in amniotic fluid (AF). Objectives: We hypothesized that the degree of fetal hypoxia would correlate with fetal oxidative and nitrosative stress as evidenced by the concentration of specific biomarkers in AF. Material and Methods: 19 pregnant women with type 1 or insulin-treated gestational diabetes mellitus were studied. AF samples were collected and processed for EPO, meta-tyrosine, nitro-tyrosine and 8-hydroxy-2-deoxiguanosine by chemiluminescent immunoassay and high-performance liquid chromatography coupled to tandem mass spectrometry methods, respectively. Results: The mean (SD) of the last HbA1c concentration before delivery was 7.7% (1.1). Median gestational age was 258 days (range 231–268). Birth weight was 3,868 ± 695 g with a z-score >2 SD in 47% of the cases. A significant correlation was found between the concentrations of AF EPO and meta-tyrosine/phenylalanine ratio (p < 0.001), nitro-tyrosine (p < 0.01) and 8-oxo-dG/2dG ratio (p < 0.001). Conclusions: We confirmed that fetuses of type 1 diabetes or insulin-treated gestational diabetes pregnancies experience chronic hypoxia as reflected by increased EPO concentrations in AF near term. Moreover, EPO levels significantly correlated with the concentration of oxidative and nitrosative stress biomarkers in AF. This pro-oxidant status may predispose newborn infants to poor postnatal adaptation and early neonatal complications.

High Prevalence of Sacrococcygeal Teratoma in Finland – A Nationwide Population‐Based Study

The birth prevalence of sacrococcygeal teratoma (SCT) has been reported to range from 1:27 000 to 1:40 000. We assessed the population‐based prevalence and clinical presentation of SCT over 22 years.

Increased nuchal translucency and pregnancy outcome: a retrospective study of 1063 consecutive singleton pregnancies in a single referral institution

The goals of this study are to assess pregnancy outcome with increased nuchal translucency (NT) and to determine the risk of adverse pregnancy outcome in relation to the degree of increased NT.

Severe hemolytic disease of fetus and newborn caused by red blood cell antibodies undetected at first-trimester screening (CME)

BACKGROUND: The objective was to determine clinical consequences of anti‐D and non‐D antibodies undetected at first‐trimester screening for infant or fetus.

Amniotic fluid S100B protein and erythropoietin in pregnancies at risk for fetal hypoxia

OBJECTIVE S100B protein is a biochemical marker for brain injury, and high serum S100B levels have been observed in newborns with birth asphyxia. We hypothesized that the concentration of amniotic fluid erythropoietin, which increases in chronic fetal hypoxia, correlates with amniotic fluid S100B concentration. STUDY DESIGN Amniotic fluid samples in 35 pregnancies at high risk for chronic fetal hypoxia were obtained at cesarean section or by amniocentesis done within a median of 2 days before delivery. S100B and erythropoietin concentrations were measured by chemiluminescent immunoassays. RESULTS A positive correlation existed between the concentrations of S100B and erythropoietin in the amniotic fluid (r=0.57, p<0.0001). Amniotic fluid S100B concentration was higher (70 ng/l; 33-469, n=17) (median; range) in pregnancies with elevated amniotic fluid erythropoietin (>or= 50 IU/l) than in pregnancies with normal erythropoietin (34 ng/l; 20-340, n=18) (p<0.0001, Mann-Whitney U-test). S100B predicted an elevated amniotic fluid erythropoietin concentration in the study population with the sensitivity of 94% and specificity of 83%. CONCLUSION A strong positive correlation exists between amniotic fluid S100B and erythropoietin concentrations in pregnancies at high risk for chronic fetal hypoxia. This suggests that chronic fetal hypoxia increases the intrauterine release of S100B.

Asphyxia, Neurologic Morbidity, and Perinatal Mortality in Early-Term and Postterm Birth.

BACKGROUND AND OBJECTIVES: Neonatal outcomes vary by gestational age. We evaluated the association of early-term, full-term, and postterm birth with asphyxia, neurologic morbidity, and perinatal mortality. METHODS: Our register-based study used retrospective data on 214 465 early-term (37+0–38+6 gestational weeks), 859 827 full-term (39+0–41+6), and 55 189 postterm (≥42+0) live-born singletons during 1989–2008 in Finland. Asphyxia parameters were umbilical cord pH and Apgar score at 1 and 5 minutes. Neurologic morbidity outcome measures were cerebral palsy (CP), epilepsy, intellectual disability, and sensorineural defects diagnosed by the age of 4 years. Newborns with major congenital anomalies were excluded from perinatal deaths. RESULTS: Multivariate analysis showed that, compared with full-term pregnancies, early-term birth increased the risk for low Apgar score (<4) at 1 and 5 minutes (odds ratio 1.03, 95% confidence interval 1.03–1.04 and 1.24, 1.04–1.49, respectively), CP (1.40, 1.27–1.55), epilepsy (1.14, 1.06–1.23), intellectual disability (1.39, 1.27–1.53), sensorineural defects (1.24, 1.17–1.31), and perinatal mortality (2.40, 2.14–2.69), but risk for low umbilical artery pH ≤7.10 was decreased (0.83, 0.79–0.87). Postterm birth increased the risk for low Apgar score (<4) at 1 minute (1.26, 1.26–1.26) and 5 minutes (1.80, 1.43–2.34), low umbilical artery pH ≤7.10 (1.26, 1.19–1.34), and intellectual disability (1.19, 1.00–1.43), whereas risks for CP (1.03, 0.84–1.26), epilepsy (1.00, 0.87–1.15), sensorineural defects (0.96, 0.86–1.07), and perinatal mortality (0.91, 0.69–1.22) were not increased. CONCLUSIONS: Early-term birth was associated with low Apgar score, increased neurologic morbidity, and perinatal mortality. Asphyxia and intellectual disability were more common among postterm births, but general neurologic morbidity and perinatal mortality were not increased.