Decidual-tissue-resident memory T cells protect against nonprimary human cytomegalovirus infection at the maternal-fetal interface.

Congenital cytomegalovirus (cCMV) is the most common intrauterine infection, leading to infant neurodevelopmental disabilities. An improved knowledge of correlates of protection against cCMV is needed to guide prevention strategies. Here, we employ an ex vivo model of human CMV (HCMV) infection in decidual tissues of women with and without preconception immunity against CMV, recapitulating nonprimary vs. primary infection at the authentic maternofetal transmission site. We show that decidual tissues of women with preconception immunity against CMV exhibit intrinsic resistance to HCMV, mounting a rapid activation of tissue-resident memory CD8+ and CD4+ T cells upon HCMV reinfection. We further reveal the role of HCMV-specific decidual-tissue-resident CD8+ T cells in local protection against nonprimary HCMV infection. The findings could inform the development of a vaccine against cCMV and provide insights for further studies of the integrity of immune defense against HCMV and other pathogens at the human maternal-fetal interface.

Myocardial Function in Fetuses with Congenital Cytomegalovirus Infection.

INTRODUCTION: The objective of this study was to investigate myocardial deformation of left (LV) and right ventricle (RV) using 2-dimensional speckle-tracking echocardiography (2D-STE) in fetuses with and without congenital cytomegalovirus (CMV) infection. METHODS: This was a prospective single-center study. Vertical transmission was defined by a positive CMV polymerase chain reaction (PCR) test on the amniotic fluid or on the neonate's urine. Fetuses were divided into group 1 and group 2 if CMV-PCR was positive or negative, respectively. LV and RV global longitudinal strain (GLS) values were obtained and adjusted for gestational age by calculating Z-scores. Univariate analysis was carried out to compare cardiac indices between group 1 and group 2. RESULTS: Fetuses from group 1 (n = 11) had a significantly lower LV myocardial shortening than those from group 2 (n = 32). GLS was -20.7 ± 5.2% and -26.3 ± 4.1%, respectively (p = 0.001). Similarly, GLS Z-score was lower (0.02 ± 0.72) in group 1 than in group 2 (-0.80 ± 0.59) (p = 0.001). Similarly, RV GLS Z-score was significantly impaired in group 1 compared to group 2 (-0.44 ± 1.03 vs. -1.04 ± 0.71, p = 0.041). CONCLUSION: Fetuses with congenital CMV showed subclinical biventricular myocardial dysfunction. Further studies are needed to confirm the potential role of 2D-STE in identifying fetuses with congenital CMV at risk of postnatal cardiovascular morbidities.

Against medical advice for induction of labor due to post-term pregnancies - the impact on pregnancy outcome.

OBJECTIVE: To determine the impact of deciding against medical advice and refusing labor induction in post-term pregnancies on pregnancy outcome. METHODS: Maternal and neonatal outcomes of women who refused induction of labor due to post term pregnancy (study group) were retrospectively compared to a control group of women who agreed labor induction (1:2 ratio) in a university-affiliated tertiary single medical center. RESULTS: A total of 83 women who refused labor induction were identified and compared to 166 womenwho consented to labor induction. Women who refused labor induction had higher rates of cesarean deliveries (21.7 vs. 10.2% p = .04), longer post-delivery hospitalization (2.9 vs. 2.4 days p < .05) and more advanced gestational age at delivery (41 + 6 vs. 41 + 4 days, p < .05). No significant differences were found in the rate of operative vaginal deliveries, need for antibiotics treatment or blood transfusion between the studied groups. Adverse neonatal outcomes among women who refused labor induction were significantly higher with higher rates of meconium (44.6 vs. 15.7%, p < .01), admission to NICU (9.6 vs. 5%, p < .01) and need for mechanical ventilation (4.8 vs. 0.6%, p < .01). CONCLUSION: Refusing induction of labor due to post- term pregnancy is associated with higher rate of adverse maternal and neonatal outcomes, with a significant higher risk for cesarean section.

Intrapartum cesarean delivery and the risk of perinatal complications in women with and without a single prior cesarean delivery.

OBJECTIVE: To determine maternal and neonatal complications associated with an intrapartum cesarean delivery (CD) with and without a history of a previous CD. METHODS: A retrospective cohort study of all women who underwent an unplanned intrapartum CD following a trial of labor in a university-affiliated tertiary hospital, between 2009 and 2016. Perinatal outcomes of women with and without a history of a previous CD were compared. Composite adverse maternal outcome included one or more of the following: postpartum hemorrhage, need for blood transfusion, or cesarean hysterectomy. Composite adverse neonatal outcome included one or more of the following: 5-min Apgar score <7, neonatal seizure, need for intubation, meconium-aspiration-syndrome, or hypoxic-ischemic encephalopathy. RESULTS: During the study period, 42 275 women attempted vaginal delivery. Of them, 2229 (5.3%) women underwent an unplanned intrapartum CD and met inclusion criteria: 337 (15.1%) with (study group) and 1892 (84.9%) without (control group) a previous CD. Women without a previous CD were younger and were characterized by higher rates of nulliparity and induction of labor compared with women with a previous CD. Other demographic and obstetrical characteristics did not differ between the groups. Indications for CD were also comparable between the groups. Uterine rupture complicated 2.3% of trials of labor among women with a previous CD. Adverse maternal (2.7% vs 2.9%, P = 1.0) and neonatal (3.9% vs 4.3%, P = 0.88) outcomes were comparable between the groups. After adjusting for potential confounders, a previous CD was not associated independently with adverse maternal outcomes (adjusted odds ratio [aOR] 0.86, 95% confidence interval [CI] 0.31-2.38; P = 0.78) or neonatal outcomes (aOR 0.79, 95% CI 0.36-1.75; P = 0.56). CONCLUSION: Our study provides evidence that perinatal outcomes of intrapartum CD delivery among women with a previous CD do not differ from those in women without a previous CD. These findings might improve the consultation and informed decision-making process for couples considering a trial of labor after CD.

The diagnostic accuracy of ultrasound in the diagnosis of acute appendicitis in pregnancy.

Objective: Clinically suspected appendicitis is the most common nonobstetric surgical problem encountered in pregnancy. The diagnosis of appendicitis is hampered by equivocal symptoms during pregnancy. Ultrasonography (US) remains, as a rule, the imaging test of choice for the diagnosis of clinically suspected appendicitis during pregnancy and other imaging tools such as computed tomography (CT) or magnetic resonance imaging (MRI) are usually avoided. We evaluated the accuracy of US in the diagnosis of appendicitis during pregnancy.Methods: The clinical and sonographic findings of all pregnant women (n = 90), who underwent appendectomy between January 2005 and December 2017 at our institution, were retrospectively reviewed, analyzed, and compared to the clinical and sonographic findings similarly obtained for a control group of nonpregnant women matched for age and date of surgery (±6 months). The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of ultrasonic findings were calculated and compared between groups as well as within the three pregnancy trimesters.Results: The mean age of the patients was 31.3 ± 0.4. Right lower quadrant pain was present in almost all patients (99%). The sole imaging modality used in our study cohort was US. Among nonpregnant controls, CT scan was primarily used on more occasions (53.3%) compared to US (45.6%). Nonpregnant women underwent significantly more laparoscopies compared to pregnant women (83.3 versus 45.6%, p < .001). The rate of negative appendectomy was higher in pregnant women (31.1 versus 10%, p = .002). Among pregnant women operated there was a higher rate of inconclusive or negative imaging (43.3 versus 11.1%, p < .001). The rate of perforated appendix at surgery was similar in both groups (6.7 and 4.4%, respectively, p = .75).Conclusions: Ultrasonography (US) is of mediocre accuracy for the diagnosis of acute appendicitis in pregnant patients beyond the first trimester of pregnancy. Thirty percent of pregnant women with suspected appendicitis are futilely operated. Given the low yield of US, a second-line imaging should be considered in cases of inconclusive US before surgery.

Maternal cardiovascular hemodynamics in normotensive versus preeclamptic pregnancies: a prospective longitudinal study using a noninvasive cardiac system (NICaS™).

BACKGROUND: Preeclampsia is among the most common medical complications of pregnancy. The clinical utility of invasive hemodynamic monitoring in preeclampsia (e.g., Swan-Ganz catheter) is controversial. Thoracic impedance cardiography (TIC) and Doppler echocardiography are noninvasive techniques but they both have important limitations. NICaS™ (NI Medical, PetachTikva, Israel) is a noninvasive cardiac system for determining cardiac output (CO) that utilizes regional impedance cardiography (RIC) by noninvasively measuring the impedance signal in the periphery. It outperformed any other impedance cardiographic technology and was twice as accurate as TIC. METHODS: We used the NICaS™ system to compare the hemodynamic parameters of women with severe preeclampsia (PET group, n = 17) to a cohort of healthy normotensive pregnant women with a singleton pregnancy at term (control group, n = 62) (1/2015-6/2015). Heart rate (HR), stroke volume (SV), CO, total peripheral resistance (TPR) and mean arterial pressure (MAP) were measured 15-30 min before CS initiation, immediately after administering spinal anesthesia, immediately after delivery of the fetus and placenta, at the abdominal fascia closure and within 24-36 and 48-72 h postpartum. RESULTS: The COs before and during the CS were significantly higher in the control group compared to the PET group (P < .05), but reached equivalent values within 24-36 h postpartum. CO peaked at delivery of the newborn and the placenta and started to decline afterwards in both groups. The MAP and TPR values were significantly higher in the PET group at all points of assessment except at 48-72 h postpartum when it was still significantly higher for MAP while the TPR only exhibited a higher trend but not statistically significant. The NICaS™ device noninvasively demonstrated low CO and high TPR profiles in the PET group compared to controls. CONCLUSIONS: The immediate postpartum period is accompanied by the most dramatic hemodynamic changes and fluid shifts, during which the parturient should be closely monitored. The NICaS™ device may help the clinician to customize the most optimal management for individual parturients. Our findings require validation by further studies on larger samples.

Maternal hemodynamics in late gestation and immediate postpartum in singletons vs. twin pregnancies.

PURPOSE: Differences in hemodynamic changes during a cesarean section (CS) between twin and singleton pregnancies are poorly defined. The Non-Invasive Cardiac System (NICaS) is an impedance device that measures cardiac output (CO) and its derivatives. We compared maternal cardiac parameters using NICaS™ in singleton and twins before and during delivery, as well at the early puerperium in healthy women undergoing CS at term. METHODS: This prospective longitudinal study included women with twin (n = 27) or singleton pregnancies (n = 62) whose hemodynamic parameters were assessed by NICaS before an elective CS, after spinal anesthesia, immediately after delivery, after fascia closure, and within 24-36 and 48-72 h postpartum. RESULTS: By 24-36 h postpartum, the mean arterial pressure and the total peripheral resistance equaled preoperative values in both groups. The CO increased throughout the CS and peaked immediately after delivery in the singleton group (P < 0.0001), after which it abruptly began to decline until reaching a nadir 24-36 h after delivery (P < 0.0001), while it remained steady throughout the CS and then dropped until 24-36 h after delivery in the twin group (P < 0.05). None of the studied parameters differed significantly between the groups for the 24-36 and 48-72 h postpartum measurements. CONCLUSIONS: Hemodynamic parameters immediately before, during and shortly after CS in singleton and twin pregnancies are equivalent. Further evaluations of the value of NICaS™ in assessing cardiovascular-related pregnancy complications are warranted.

Casting doubt on the value of assessing the cardiac index in pregnancy.

OBJECTIVES: The objective of this study is to assess the reliability of the cardiac index (CI) in healthy pregnant women at term by investigating the correlation between the cardiac output (CO) and the body surface area (BSA) using a novel non-invasive cardiography technique (NICaS™). METHODS: Sixty-one healthy, normotensive women with a singleton pregnancy at term (≥37 gestational weeks) participated in this prospective observational study between 1/2015 and 6/2015 L. Each woman was assessed for CO by the NICaS™, an impedance device that non-invasively measures the CO and its derivatives. The NICaS™ demonstrated a very good correlation with the gold standard Swan-Ganz catheter. BSA was determined by the Dubois nomogram. RESULTS: The mean ± standard deviation maternal age was 34.2 ± 5.3 years, mean height 166 ± 6 cm, and mean body mass index 23.9 ± 4.9 kg/m2. The mean gestational age was 38.8 ± 0.7 weeks. The correlation between the CO and the BSA was poor (Pearson r = 0.254, p < .005). CONCLUSIONS: The current study demonstrated poor correlation between the CO and the BSA in pregnant women, therefore, making the CI a non-reliable variable for assessing CO in pregnant women. We, therefore, suggest that the CO rather than the CI is the preferred parameter for hemodynamic measurements in this population.

Total bilateral salpingectomy versus partial bilateral salpingectomy for permanent sterilization during cesarean delivery.

PURPOSE: Sterilization via bilateral total salpingectomy is slowly replacing partial salpingectomy, as it is believed to decrease the incidence of ovarian cancer. Our objective was to compare short-term intra and post-operative complication rates of bilateral total salpingectomy versus partial salpingectomy performed during the course of a cesarean delivery. METHODS: A large series of tubal sterilizations during cesarean sections were studied in a single tertiary medical center between 1/2014 and 8/2016 before and after a policy change was made, switching from partial salpingectomy to total salpingectomy. Patients who underwent bilateral partial salpingectomy using the modified Pomeroy technique were compared with those who underwent total salpingectomy. Operative length, estimated blood loss, postpartum fever, wound infection, need for re-laparotomy, hospitalization length, and blood transfusions were compared. RESULTS: During the study period, 149 women met inclusion criteria. Fifty parturients underwent bilateral total salpingectomy and 99 underwent partial salpingectomy in the course of the cesarean section. Demographic, obstetrical, and surgical characteristics were similar in both groups. Mean cesarean section duration was comparable for partial salpingectomy and total salpingectomy (a median of 35 min in both groups, P = 0.92). Complications were rare in both groups with no significant differences in rates of postpartum fever, wound infection, re-laparotomy, hospitalization length, estimated blood loss, transfusions, and readmissions within 1-month postpartum. CONCLUSION: Rates of short-term complications are similar in patients undergoing bilateral partial salpingectomy and total salpingectomy during cesarean deliveries, making the latter a feasible alternative to the former.