Is meconium passage a risk factor for maternal infection in term pregnancies?

OBJECTIVE:To study the association between meconium and maternal infection. METHODS:This was a retrospective cohort study of 678 pregnant women. All term deliveries during a 31-month period with meconium passage were included. Each meconium delivery was matched with a consecutive delivery without meconium at the same gestational age. RESULTS: The overall infection rate was 16%, with 13% of the infections directly related to the pregnancy, labor, and delivery. The endometritis rate was 5%, with 7.1% and 3% in the meconium and no-meconium group, respectively. The chorioamnionitis rate was 8.3%, with 9.5% in the meconium and 7.1% in the no-meconium group. Factors found to be associated with overall obstetric infections had the following odds ratios (ORs) and 95% confidence intervals (CIs): meconium (OR 1.8, 95% CI 1.1, 2.8), internal monitoring (OR 3.4, 95% CI 1.9, 5.9), amnioinfusion (OR 2.0, 95% CI 1.3, 3.3), number of vaginal exams (OR 4.5, 95% CI 2.8, 7.1), length of labor (OR 2.8, 95% CI 1.8, 4.4), and cesarean (OR 3.1, 95% CI 1.9, 5.1). Logistic regression analyses revealed the following ORs and 95% CIs: 1) for endometritis-cesarean (OR 4.2, 95% CI 1.9, 8.9), internal monitoring (OR 2.5, 95% CI 1.1, 5.9), and meconium (OR 2.5, 95% CI 1.1, 5.5), and 2) for chorioamnionitis-length of labor greater than 10 hours (OR 2.7, 95% CI 1.4, 5.6), number of vaginal exams greater than seven (OR 3.4, 95% CI 1.7, 6.6), and use of internal monitors (OR 2.5, 95% CI 1.2, 5.3). CONCLUSION: Meconium passage increases the risk of postpartum endometritis but not chorioamnionitis. Length of labor, internal monitoring, and number of vaginal exams are risk factors for chorioamnionitis.     

Could alterations in maternal plasma visfatin concentration participate in the phenotype definition of preeclampsia and SGA?

Objective.?Women with preeclampsia and those who delivered a small-for-gestational-age (SGA) neonate share several mechanisms of disease, including chronic uteroplacental ischemia and failure of physiologic transformation of the spiral arteries. However, the clinical manifestation of these obstetrical syndromes is remarkably different. It has been proposed that an altered maternal metabolic state, as well as a unique circulating cytokines milieu, predispose women to develop either preeclampsia or SGA. Compelling evidence suggests that adipose tissue orchestrates both metabolic pathways and immunological responses via the production of adipokines. Visfatin is a novel adipocytokine with metabolic and immunomodulating properties. The objective of this study was to determine whether preeclampsia and SGA are associated with alterations in maternal circulating visfatin concentrations.

Methods.?This cross-sectional study included pregnant women in the following groups: (1) normal pregnancy (n?=?158); (2) patients with preeclampsia (n?=?43) of which 32 had an AGA and 11 had an SGA neonate; (3) patients without preeclampsia who delivered an SGA neonate (n?=?55). Maternal plasma visfatin concentrations were measured by ELISA. Nonparametric tests and multiple linear regression analysis were used.

Results.?(1) Women who delivered an SGA neonate had a higher median maternal plasma visfatin concentration than those with a normal pregnancy (20.0?ng/ml, interquartile range: 17.2–24.6 vs. 15.2?ng/ml, 12.1–19.2, respectively; P?<?0.001) and than those with preeclampsia (14.5?ng/ml, 12.5–18.7; P?<?0.001); (2) the median maternal plasma visfatin concentration did not differ significantly between patients with preeclampsia and those with a normal pregnancy (P?=?0.8); (3) among patients with preeclampsia, there was no significant difference in the median maternal plasma visfatin concentration between those with or without an SGA neonate (P?=?0.5); (4) in a linear regression model, delivery of an SGA neonate and pregestational body mass index were independently associated with increased visfatin concentration after adjustment for confounding factors (maternal age, smoking, gestational age at blood collection and the presence of preeclampsia or SGA).

Conclusion.?(1) Patients with SGA, but not those with preeclampsia, had a higher maternal plasma visfatin concentration than those with a normal pregnancy; (2) this finding suggests differential involvement of visfatin in SGA and preeclampsia; (3) we propose that changes in circulating maternal visfatin concentration may be implicated in the phenotypic definitions and distinction of preeclampsia and SGA.     

Does hospitalization prevent preterm delivery in the patient with a short cervix?

This study considers whether admission to the hospital of a patient diagnosed with a short cervix delayed delivery, prevented preterm delivery, and/or decreased the rate of change in the cervical length (CL) on follow-up measurements. The design was a retrospective cohort study of women carrying singleton pregnancies with cervical lengths 相似文献   

Prevention of cervical cancer in Africa: a daunting task?

Africa has a high estimated incidence of cervical cancer, thus requiring the development of an effective prevention strategy. Cytology-based screening is beyond the capacity of many African countries, hence the need for alternatives. Visual inspection of the cervix after application of 3-5% acetic acid (VIA) is a promising screening test, with similar sensitivity to that of cytology but lower specificity. The same accounts for other VIA methods using magnification devices, visual inspection after the application of Lugol's iodine, or human papilloma virus (HPV) DNA testing, all proposed alternatives to cervical cancer prevention screening tests. Vaccination against HPV is the most promising strategy for the prevention of cervical cancer, but a wider variety of HPV types than currently being investigated must be considered for the development of the multivalent vaccine preparations required in Africa. Other considerations in developing an effective prevention programme include full public sector investment and achieving acceptability of a vaccine against a sexually transmitted infection targeted for adolescents. Unfortunately, however, if HPV vaccines are developed the initial impact of prophylactic vaccines will be delayed for many years. Alternative strategies should, therefore, be promoted in parallel. There are several approaches to cervical cancer prevention and their evaluation should be comprehensive and coordinated to achieve short and long-term public health benefits in different programme settings.     

Is there a role for DHEA supplementation in women with diminished ovarian reserve?

Purpose

Poor ovarian reserve and poor ovarian response presents a challenge to IVF centers. Dehydroepiandrosterone (DHEA) supplementation is increasingly being used by many IVF centers around the world in poor responders despite the lack of convincing data. We therefore examined the rationale for the use of DHEA in poor responders, address the relevant studies, present new data, and address its potential mechanisms of action.

Methods

All published articles on the role of DHEA in infertile women from 1990 to April 2013 were reviewed.

Results

Several studies have suggested an improvement in pregnancy rates with the use of DHEA. Potential mechanisms include improved follicular steroidogenesis, increased IGF-1, acting as a pre-hormone for follicular testosterone, reducing aneuploidy, and increasing AMH and antral follicle count. While the role of DHEA is intriguing, evidence-based recommendations are lacking.

Conclusions

While nearly 25 % of IVF programs use DHEA currently, large randomized prospective trials are sorely needed. Until (and if) such trials are conducted, DHEA may be of benefit in suitable, well informed, and consented women with diminished ovarian reserve.     

Trial of labor in patients with a previous cesarean section: does maternal age influence the outcome?

OBJECTIVE: This study was undertaken to evaluate the effect of maternal age on the rate of vaginal delivery and the rate of uterine rupture in patients undergoing a trial of labor (TOL) after a prior cesarean delivery. STUDY DESIGN: A cohort study of all women with a live singleton fetus undergoing a TOL after a previous low-transverse cesarean delivery was performed between 1988 and 2002 in a tertiary care center. Patients were divided into 3 groups according to maternal age: less than 30 years old, 30 to 34 years old, and 35 years or older. Women with no prior vaginal delivery and with at least 1 prior vaginal delivery were analyzed separately. The rate of vaginal delivery and the rate of symptomatic uterine rupture were calculated. Multivariate logistic regression analyses were performed to adjust for potential confounding variables. RESULTS: Of the 2493 patients who met the study criteria, there were 1750 women without a prior vaginal delivery (659, 721, and 370, respectively) and 743 women with a prior vaginal delivery (199, 327, and 217, respectively). The rate of uterine rupture was comparable between the groups (2.0%, 1.1%, 1.4%, P=.404 and 0%, 0.3%, 0.9%, P=.312). Successful vaginal delivery was inversely related to maternal age (71.9%, 70.7%, 65.1%, P=.063, and 91.5%, 91.1%, 82.9%, P=.005). After adjusting for confounding variables, maternal age equal to or greater than 35 years old was associated with a lower rate of successful vaginal delivery in patients without prior vaginal delivery (odds ratio [OR] 0.73, 95% CI: 0.56-0.94), and in patients with a prior vaginal delivery (OR: 0.47, 95% CI: 0.29-0.74). CONCLUSION: Patients who are 35 years or older are more prone to have a failed TOL after a prior cesarean delivery.     

Early enteral fat supplementation with microlipid® and fish oil in the treatment of two premature infants with short bowel

The infusion of Intralipid? is a main risk factor for parenteral nutrition-associated cholestasis in infants with short bowel syndrome. Early provision of enteral fat to reduce the use of Intralipid while providing adequate fat for the growth of infants with short bowel has not been reported. We present 2 cases of premature infants with short bowel who received early supplementation of enteral Microlipid? and fish oil. This approach allowed us to discontinue Intralipid shortly after initiating feedings. The infants tolerated Microlipid/fish oil well without adverse reactions, had appropriate weight gain and ostomy output. They underwent bowel reanastomosis 3 weeks after enteral feeding began, and were discharged on full oral feedings. In case 1, the infant did not develop parenteral nutrition-associated cholestasis; in case 2, cholestasis had developed before initiating feeds, but was not aggravated by enteral fat and was improving prior to discharge.     

Herpes simplex virus infection of the uterine cervix--relationship with a cervical factor?

OBJECTIVE: To determine the prevalence of genital herpes simplex virus (HSV) in women of reproductive age and to evaluate a potential relation of asymptomatic HSV shedding with a cervical factor. DESIGN: Prospective study. SETTING: Outpatient infertility clinic of a university hospital. PATIENT(S): Randomly chosen asymptomatic women (n = 1,262) with a median age of 30 years. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Prevalence of cervical HSV, cervical index parameters, and other variables of CM quality, including CM penetrability in vivo and in vitro. RESULT(S): The prevalence of HSV infection of the uterine cervix was 5.2% (identified with cell culture). There was a tendency toward increased viscosity of the CM in HSV-positive women, but no significant relation with the other variables of CM quality (amount, spinnbarkeit, ferning, cervical appearance, and cellularity of the CM), or with the summarized Insler score or the cervical index according to World Health Organization guidelines. Postcoital testing and the in vitro penetration test, using either partners' or donors' semen, showed that the penetrability of the CM did not differ significantly between women with and without cervical HSV shedding. Asymptomatic cervical HSV infection was not significantly associated with bacterial colonization of the lower genital tract, with leukocyte counts in cervical secretions, with the pH of the CM or the vaginal fluid, or with antisperm antibodies in the CM. CONCLUSION(S): The results suggest that in asymptomatic women under controlled endocrine conditions, cervical HSV infection is not a significant cause of impaired quality and penetrability of the CM.     

Stillbirth at term in women of advanced maternal age in the United States: when could the antenatal testing be initiated?

We sought to determine if advanced maternal age (AMA) is a risk factor for intrauterine fetal demise (IUFD). We used a U.S. Centers for Disease Control and Prevention database and analyzed outcomes in women 15 to 44 years of age with term singleton gestations. Cox proportional hazards models and Cochran-Mantel-Haenszel tests were used. Results were controlled for maternal race and smoking. After excluding congenital anomalies and medical complications, 6,239,399 singleton term deliveries were identified. When compared with women 25 to 29 years of age, the risk of IUFD increased with advancing age: 30 to 34 years, odds ratio [OR] = 1.24 (95% confidence interval [CI], 1.13 to 1.36); 35 to 39 years, OR = 1.45 (95% CI, 1.21 to 1.74), and 40 to 44 years, OR = 3.04 (95% CI, 1.58 to 5.86). The risk of IUFD for women 40 to 44 years of age at 39 weeks is comparable with that of 42 weeks in those 25 to 29 years of age. We concluded that AMA is an independent predictor of IUFD, and a strategy of antenatal testing in those > or = 40 years of age beginning at 38 weeks may be considered.     

Is stabilization of disease a useful indicator for survival in second-line treatment of ovarian carcinoma pre-treated with Paclitaxel-Platinum?

OBJECTIVE: Recurrent ovarian carcinoma is considered an incurable disease and second-line chemotherapy is administered for extension of survival and palliation. The impact of continued antineoplastic treatment in patients with stable disease without a demonstrable response is uncertain. The aim of this analysis was to assess the value of a stabilization of the tumor size in second-line chemotherapy as an indicator of survival. METHODS: Retrospective, single-institution study of 487 consecutive patients with primary epithelial ovarian carcinoma. Inclusion criteria: (1) FIGO stage IC-IV epithelial ovarian carcinoma; (2) first-line chemotherapy with Paclitaxel and a Platinum-compound; (3) refractory, persistent, or recurrent disease diagnosed by imaging methods; and (4) intravenous second-line chemotherapy with single Topotecan or Paclitaxel-Carboplatin. Univariate and multivariate analyses of survival with the World Health Organization (WHO) tumor response parameter included as a time-dependent variable were performed. RESULTS: The response rates were (N = 100): complete response (CR) 27%, partial response (PR) 14%, stable disease (SD) 41% and progressive disease (PD) 18%. In a multivariate Cox regression analysis of survival, SD was found to be an independent prognostic factor for survival and the death hazard ratio was 0.37 (SD versus PD; 95% CI: 0.16-0.86; P = 0.02). There was no statistically significant difference in survival between patients with PR and SD (P = 0.09). CONCLUSION: In second-line chemotherapy of ovarian cancer, patients demonstrating SD have a survival benefit compared to patients with PD measured by the WHO tumor response criteria.     

Clinical application of maternal serum cytokine determination in premature rupture of membranes--interleukin-6, an early predictor of neonatal infection?

BACKGROUND: In cases of premature rupture of membranes (PROM), an early detection of fetal infection is necessary in order to weigh infectious complications against prematurity. As routine parameters (leukocytes, C-reactive protein (CRP), fever, and fetal tachycardia) lack satisfactory sensitivity and specificity, this study evaluates whether the determination of interleukin-6 (IL-6), interleukin-8 (IL-8) or soluble interleukin-2 receptor (IL-2R) in maternal serum could supplement or replace routine inflammation parameters. METHODS: In this prospective study results of clinical and laboratory parameters were investigated with respect to neonatal infection in 71 patients with PROM. IL-6, IL-8 and IL-2R were determined by enzyme immunoassays. RESULTS: Best specificity and sensitivity could be demonstrated for CRP and IL-6. Both elevation of CRP and IL-6 correlated significantly (p<0.01 and p<0.001, respectively) with the onset of neonatal infection. At a cutoff of 11 pg/ml, IL-6 reaches a sensitivity of 81% and a specificity of 76%; CRP a specificity of 76% (cutoff 1.2 mg/dl) and a sensitivity of 56%. In 4/16 (25%) cases developing neonatal infection, IL-6 increased earlier than CRP. IL-8 and IL-2R results showed a less significant correlation with fetal outcome. CONCLUSIONS: Determination of IL-6 in maternal serum can significantly contribute to an earlier detection of fetal infection in patients with PROM.     

Is treatment with vaginal pessaries an option in patients with a sonographically detected short cervix?

OBJECTIVE: The purpose was to determine the effect of vaginal pessaries in patients at risk for spontaneous preterm birth (SPB). STUDY DESIGN: Transvaginal sonography (TVS) was longitudinally performed to measure cervical length (CL) in 258 singleton at risk for SPB and 282 twin pregnancies. Pairs with or without treatment were matched for gestational age and the CL at examination. RESULTS: In 4 singleton and 7 twin pregnancies the CL was < 15 mm before 24 weeks, the mean interval between pessary insertion and delivery was 13 + 2 and 12 + 5 weeks respectively. For the matched control analysis, 12 pairs with singleton and 23 pairs with twin pregnancies were compared. For singleton pregnancies, the mean interval between TVS and delivery was 99 (70-134) days in the treatment and 67 (2-130) days in the control group (p = 0.0184), the mean gestational age at delivery was 38 (36 + 6-41) and 33 + 4 (26-38) weeks respectively (p = 0.02). For twin pregnancies, the interval was 85 (43-129) days in the treatment and 67 (21-100) days in the control group (p = 0.001), gestational age at delivery was 35 + 6 (33-37 + 4) and 33 + 2 (24 + 4-37 + 2) respectively (p = 0.02). Within singleton pregnancies with pessary, there was no SPB < 36 weeks compared to 6/12 cases in the control group (p < 0.001). Within twin pregnancies, the rates were 8/23 cases with SPB < 36 weeks but none < 32 weeks, compared to 12/23 cases with SPB < 36 weeks and 7/23 cases < 32 weeks in the control group (p < 0.001). CONCLUSIONS: Insertion of a vaginal pessary may be a cost-effective preventive treatment in patients at risk for SPB. Prospective controlled trials are needed.     

Aromatase inhibitors--is it a new opportunity in the treatment of infertility?

Aromatase P-450 is a key enzyme in the production of estrogens, that is, the conversion of androstenedione and testosterone to estrone and estradiol. Aromatase is a good target for selective inhibition. New aromatase inhibitors provide a good opportunity for successful treatment during infertility management. They have a potential to replace clomiphene citrate (CC) as the first-line treatment for ovulation induction. Applying aromatase inhibitors during assisted reproduction followed: reducing the FSH dose needed to achieve optimum controlled ovarian hyperstimulation (COH); improving ovarian response to FSH in poor responders; terminating positive feedback loop and improving ovarian response to COH in infertile case with endometriosis; improving implantation rates in assisted reproduction technology (ART); reducing estrogen levels to reduce the risk of OHSS during COH.     

Preeclampsia – a risk factor for osteoporosis? Analysis of maternal Sclerostin levels and markers of bone turnover in patients with pre-eclampsia

Introduction: The role of preeclampsia (PE) in affecting bone metabolism could not be clarified in the past years. Recently Sclerostin, a new marker of bone metabolism which is known to have an inhibitory effect on bone formation causing osteoporosis, was discovered. Objective: To investigate serum levels of Sclerostin and markers of bone turnover in women with normotensive pregnancies and pregnancies complicated by PE. Methods: In this prospective study we enrolled 22 women with PE and 22 healthy pregnant women to observe serum levels of carboxyterminal propeptide of type I collagen (PICP), cross-linked carboxyl terminal telopeptide of the type I collagen (ICTP), calcium, phosphate, 25-hydroxyvitamin D and parathyroid hormone. In 16 preeclamptic and 16 healthy pregnant women, serum Sclerostin levels were analyzed. Results: Serum levels of Sclerostin (mean?±?standard deviation: healthy 10.5?±?8.1?pmol/l versus PE 11.5?±?9.4?pmol/l, p?=?0.768), ICTP (healthy 0.3?±?0.2?ng/ml versus PE 0.4?±?0.1?ng/ml, p?=?0.462), PICP (healthy 59.9?±?49.9?ng/ml versus PE 89.0?±?62.0?ng/ml, p?=?0.094), phosphate (healthy 1.1?±?0.2?mmol/l versus PE 1.2?±?0.4?mmol/l, p?=?0.162) and parathyroid hormone (healthy 26.9?±?14?pg/ml versus PE 35.3?±?17.6?pg/ml, p?=?0.08) showed no significant differences between the groups. Significantly lower serum calcium (healthy 2.3?±?0.1?mmol/l versus PE 2.2?±?0.2?mmol/l, p?p?Conclusion: Pregnancies complicated by PE show no signs of high bone turnover and may not lead to a higher risk of osteoporosis in later life.     

Conservative treatment of ectopic pregnancy with methotrexate in a nonoperable patient with Crohn’s disease

We present a case of conservative management using methotrexate for ectopic pregnancy in a nonoperable patient with complicated severe Crohns disease. This case demonstrates the successful use of methotrexate in an unusual situation in which laparoscopy or laparotomy could have further jeopardised the patients medical status.