Xavier Pombar

A new method to assess fetal head descent in labor with transperineal ultrasound

To assess the feasibility and reproducibility of measuring fetal head station and descent during labor using transperineal ultrasound (TPU) imaging, to compare the evaluation of fetal station through digital examinations with concurrent TPU assessments, and to assess its utility in distinguishing patients whose pregnancy will result in spontaneous vaginal delivery from those who will require operative vaginal delivery or Cesarean section for failure to progress.

A comparison between acoustic output indices in 2D and 3D/4D ultrasound in obstetrics.

Three‐dimensional (3D) ultrasound is gaining popularity in prenatal diagnosis. While there are no studies regarding the safety of 3D ultrasound, it is now widely performed in non‐medical facilities, for non‐diagnostic purposes. The present study was aimed at comparing the acoustic output, as expressed by thermal index (TI) and mechanical index (MI), of conventional two‐dimensional (2D) and 3D/4D ultrasound during pregnancy.

Evaluating rapid diagnostic tests of intra-amniotic infection: Gram stain, amniotic fluid glucose level, and amniotic fluid to serum glucose level ratio ☆ ☆☆ ★

OBJECTIVE The aim of the study was to compare the diagnostic utility of the Gram stain, the amniotic fluid glucose level, and the ratio of amniotic fluid glucose level to serum glucose level in detecting intra-amniotic infection. STUDY DESIGN We conducted a prospective study of 127 patients with preterm labor and 26 patients with preterm premature rupture of the membranes (153 total). All patients underwent amniocentesis to diagnose intra-amniotic infection. The diagnostic criterion for intra-amniotic infection was a positive amniotic fluid culture result. RESULTS The Gram stain is 80% sensitive and 91% specific when a positive is considered the presence of white blood cells or bacteria. Amniotic fluid glucose level and the ratio of amniotic fluid glucose level to serum glucose level are significantly lower when amniotic fluid culture results are positive, but as diagnostic tests they are inferior to the Gram stain. Logistic regression models that combine predictors yield superior accuracy with respect to individual tests. The most accurate combination was amniotic fluid glucose level and Gram stain with white blood cells or bacteria. Although the number of patients with preterm premature rupture of the membranes was small in this study (n = 26), analysis of our data suggests that the diagnostic performance levels of these tests were similar when used in patients with preterm labor and intact membranes and in patients with premature rupture of the membranes. CONCLUSIONS The amniotic fluid glucose level and the ratio of amniotic fluid to serum glucose level have equivalent diagnostic utility and are inferior to the Gram stain. The combination of Gram stain with amniotic fluid glucose level is superior to any individual test.

Development of an Ultrasonic Method to Detect Cervical Remodeling in Vivo in Full-Term Pregnant Women

The objective of this study was to determine whether estimates of ultrasonic attenuation could detect changes in the cervix associated with medically induced cervical remodeling. Thirty-six full-term pregnant women underwent two transvaginal ultrasonic examinations separated in time by 12 h to determine cervical attenuation, cervical length and changes thereof. Ultrasonic attenuation and cervical length data were acquired from a zone (Zonare Medical Systems, Mountain View, CA, USA) ultrasound system using a 5-9 MHz endovaginal probe. Cervical attenuation and cervical length significantly decreased in the 12 h between the pre-cervical ripening time point and 12 h later. The mean cervical attenuation was 1.1 ± 0.4 dB/cm-MHz before cervical ripening agents were used and 0.8 ± 0.4 dB/cm-MHz 12 h later (p < 0.0001). The mean cervical length also decreased from 3.1 ± 0.9 cm before the cervical ripening was administered to 2.0 ± 1.1 cm 12 h later (p < 0.0001). Cervical attenuation and cervical length detected changes in cervical remodeling 12 h after cervical ripening administration.

Longitudinal Survey of Microbiota in Hospitalized Preterm Very-Low-Birth-Weight Infants.

Objectives: The aim of the present study was to examine the changes in bacteria in hospitalized preterm infants during the first month of life. Methods: Rectal swabs were collected daily from 12 preterm infants. DNA was extracted from swabs from day of birth and weekly thereafter. Bacterial taxa were identified with next generation sequencing using universal bacterial primers targeted at the 16S ribosomal DNA on a 454 Roche titanium platform. Sequences were clustered into operational taxonomic units, and taxonomy was assigned against the Greengenes databank using Quantitative Insights Into Microbial Ecology version 1.4. Quantitative polymerase chain reaction was used to determine the abundance of Bifidobacterium spp. Functional assessment of the microbiome was performed with Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt). Results: Average birth weight and gestational age were 1055 g and 28 weeks, respectively. There were 6 to 35 different bacterial families identified in the day-of-birth samples, unrelated to the mode of delivery. Richness decreased through hospitalization (week 1, 16.9 ± 7.7 vs weeks 3–5, 10.7 ± 3.4, P < 0.001). The Shannon diversity index demonstrated the lowest diversity at birth, an increase at week 2, followed by a rapid decline at weeks 3 to 5, suggesting the development of a more uniform microbiota composition after 2 weeks of stay at a neonatal intensive care unit. Enterobacteriaceae, Staphylococcaceae, and Enterococcaceae constituted the majority of the bacterial families. Bifidobacterium spp were infrequently detected at extremely low levels. PICRUSt analysis revealed the enhancement of peroxisome, PPAR, and adipocytokine signaling; plant–pathogen interaction; and aminobenzoate degradation pathways in week 1 samples. Conclusions: Our results suggest that although preterm infants have individualized microbiota that are detectable at birth, the differences decrease during the neonatal intensive care unit hospitalization with increasing prominence of pathogenic microbiota.

OBSTETRIC CARE FOR RENAL ALLOGRAFT RECIPIENTS OR FOR WOMEN TREATED WITH HEMODIALYSIS OR PERITONEAL DIALYSIS DURING PREGNANCY

Pregnancies in women on dialysis and in women who have had renal transplant are no longer uncommon. Optimal obstetric outcomes require a multidisciplinary team approach, patient counseling, and clinicians who are knowledgeable and experienced in taking care of these patients. Counseling should begin before pregnancy, and all reproductive age women on dialysis and who have undergone renal transplant should receive family planning counseling. Preconceptional counseling should be provided to those patients who desire pregnancy. If the patient presents in early pregnancy, she should be informed about the maternal and fetal risks associated with her pregnancy. Prenatal care must include intensive surveillance for hypertension, preeclampsia, preterm labor, intrauterine growth restriction, anemia, infection, and renal allograft rejection. Aggressive treatment of complications is mandatory. There are limitations to our current knowledge about pregnancies in these patients. It is important for clinicians who provide care for these patients to be aware of these limitations when making obstetric management decisions. Cesarean section should be reserved for usual obstetric indications. Breast-feeding is not advised in patients taking cyclosporin or azathioprine. Transplant patients have unique gynecologic needs, so they should be encouraged to pursue follow-up gynecologic care after the pregnancy.

The use of therapeutic hypothermia in the management of amniotic fluid embolism

Background: Amniotic fluid embolism (AFE) is a rare peripartum obstetric emergency where patients seldom survive neurologically intact. The exact pathophysiology is not completely understood and treatment remains mainly supportive. Case: A 34-year-old African American woman gravida 1, para 0-0-0-0 at 38 weeks and four days induced for chronic hypertension with superimposed preeclampsia experienced an AFE during labour. Supportive treatment included early use of therapeutic hypothermia resulting in a normal neurological outcome. Conclusion: This case demonstrates the timely use of therapeutic hypothermia in a patient surviving an AFE and suffering no neurological sequelae. Therapeutic hypothermia should be considered in the supportive treatment of AFE.