The Istanbul international consensus statement on the perinatal care of multiple pregnancy.

The purpose of this document is to expand the 1995 ISTS/COMBO Declaration of Rights which was initially produced to promote awareness of the special needs of multiple birth infants, children, and adults. It addresses the clinical and ethical dimensions of perinatal care of multiple pregnancy. The ad hoc committee was chaired by Isaac Blickstein. The following individuals were present (in alphabetical order): Birgit Arabin (Zwolle, Netherlands/Berlin, Germany), Isaac Blickstein (Rehovot, Israel), Frank A. Chervenak (NY, USA), Zehra Nese Kavak (Istanbul, Turkey), Louis G. Keith (Chicago, USA), Eric S. Shinwell (Rehovot, Israel) and Yves Ville (Paris, France). Secretary of the meeting was Alin Basgul (Istanbul, Turkey). This statement was endorsed by the International Society of Twin Studies (Ghent, Belgium, June, 2007) and by the World Association of Perinatal Medicine (Florence, Italy, September, 2007).

Drug utilization and teratogenicity risk categories during pregnancy.

A limited number of studies have investigated in detail the use of drugs during pregnancy. Researchers in the present study investigated the details of drug utilization in pregnant women during the month before pregnancy, at the time that they became aware of the pregnancy, and during the first trimester. Face-to-face interviews were conducted with 359 pregnant women who were admitted to the fetal medicine unit at a university hospital for diagnosis and follow-up. A questionnaire was used to document sociodemographic characteristics and details of drug use. Drugs were categorized according to the US Food and Drug Administration fetal risk classification. Mean maternal age was 29.9+/-5.1 y, and mean gestational age was 19.6+/-9.5 wk. Many of the pregnant women studied (46.6%) were university graduates, and most (61.9%) had a relatively high annual income. Mean gestational age when participants first learned of their pregnancy was 39.8+/-16.4 d. One hundred seventeen participants (32.6%) used drugs during the month before conception, 54 (15%) at the time when they learned of their pregnancy, 180 (50.1%) at the time of the interview, and 289 (80.5%) during the first trimester. The percentages of drugs in categories D and X used by these subjects were 14%, 13.5%, 2.9%, and 5.9%, respectively. Most of the drugs were hormones. The total rate of drug utilization was not high before and during the first trimester of pregnancy. A considerable number of women were using drugs from the D and X categories; however, these numbers decreased significantly when women learned of their pregnancies. Intake of folic acid, vitamins, and iron was very low during the preconception period and was not high enough during the first trimester; this suggests that particular attention should be paid to the use of beneficial "safe" drugs during the preconception and early pregnancy periods.

Spontaneous perforation of pyometra.

Pyometra is the accumulation of purulent material in the uterine cavity. Its reported incidence is 0.01-0.5% in gynecologic patients; however, as far as elderly patients are concerned, its incidence is 13.6% [3]. The most common cause of pyometra is malignant diseases of genital tract and the consequences of their treatment (radiotherapy). Other causes are benign tumors like leiomyoma, endometrial polyps, senile cervicitis, cervical occlusion after surgery, puerperal infections, and congenital cervical anomalies. Spontaneous rupture of the uterus is an extremely rare complication of pyometra. To our knowledge, only 21 cases of spontaneous perforation of pyometra have been reported in English literature since 1980. This paper reports an additional case of spontaneous uterine rupture.

Normal standards of fetal behavior assessed by four-dimensional sonography.

OBJECTIVE: In this prospective randomized study, fetal behavior was investigated in order to determine the standard parameters of fetal movements and facial expressions in all three trimesters of normal pregnancy. METHODS: Sixty-three pregnant women with singleton pregnancies in all trimesters were included in the investigation. Four-dimensional (4D) ultrasound was performed for each patient over a 30-minute period. Variables of maternal and fetal characteristics including gestational age, eight fetal movement patterns in the first trimester, and sixteen parameters of fetal movement and fetal facial expression patterns in the second and third trimesters were recorded for the construction of fetal neurological charts. RESULTS: In the first trimester, a tendency towards an increased frequency of fetal movement patterns with increasing gestational age was noticed. Only the startle movement pattern seemed to occur stagnantly during the first trimester (p > 0.05). At the beginning of the second trimester, the frequency of fetal movement patterns tended to increase. During the second and third trimester, multiple regression and polynomial regression revealed statistically significant changes in tongue expulsion (p < 0.05), smiling (p < 0.05), grimacing (p < 0.05), swallowing (p < 0.05), eye blinking (p < 0.01), head movements, and all hand to body contact movements (p < 0.01), except for head anteflexion (p > 0.05). There were no statistically significant changes during the second and third trimesters in mouthing, yawning, and sucking (p > 0.05). At the middle of the third trimester, the fetuses displayed decreasing or stagnant incidence of fetal facial expressions except for eye blinking, which showed increased frequency with increasing gestational age. A statistically significant correlation was found between all head movements and hand to body contact patterns during the second and third trimesters except for head anteflexion (r = -0.231; p > 0.05). CONCLUSIONS: The full range of quantitative fetal facial expressions and fetal movement patterns can be assessed successfully by 4D sonography. It is important to be able to assess normal fetal behavior throughout gestation to identify abnormal behavior before birth.

Intra- and interobserver agreement on cervical volume and flow indices during pregnancy using transvaginal 3-dimensional ultrasonography and Doppler angiography.

OBJECTIVES: To assess intra- and interobserver agreement in cervical volume and flow indices measurements. METHOD: We prospectively examined 126 patients by two seperate observers using transvaginal 3D gray-scale and power Doppler ultrasound. The two acquired volume datasets were analyzed using the VOCAL imaging program for assessing cervical volume, vascularization index (VI), flow index (FI), and vascularization flow index (VFI). Reproducibility of volume and vascularity measurement was assessed by calculating intraclass (intra-CC) and interclass (inter-CC) correlation coefficients (ICCs). RESULTS: Both intraobserver and interobserver cervical volume measurements were in perfect agreement with intra-CC values of 0.95, 0.96 for both examiners and with an inter-CC value of 0.95. Intraobserver agreement for VI, FI and VFI measurements were as good as the interobserver agreement for VI, and VFI measurements were adequate but less for FI measurements (inter-CC 0.67). Overall, volumetric data were more reliably acquirable than power Doppler measurements. CONCLUSIONS: 3D ultrasound gray-scale and power Doppler measurement of cervical volume and vascularization have acceptable intra- and interobserver variations and thus may be used in clinical research of cervical physiology and pathophysiology during pregnancy.

Predictive power of maternal serum and amniotic fluid CRP and PAPP-A concentrations at the time of genetic amniocentesis for the preterm delivery.

OBJECTIVE: To investigate whether maternal serum and amniotic fluid CRP and PAPP-A concentrations at the time of genetic amniocentesis are markers of preterm delivery. STUDY DESIGN: One hundred and forty-one pregnant women were included in this prospective study. Amniotic fluid and maternal serum CRP and PAPP-A concentrations were determined by using commercially available kits. Receiver-operating characteristic (ROC) analysis was performed to determine the efficacy of maternal serum and amniotic fluid CRP and PAPP-A levels in predicting women with preterm delivery. RESULTS: The prevalence of spontaneous preterm delivery before 37 weeks of gestation was 9.9%. ROC analysis revealed that amniotic fluid CRP level was the only parameter, which had a significant power in the prediction of preterm delivery. The optimum cut-off level was 0.65 mg/L. The sensitivity and specificity were 92.9% and 78.7%, respectively. CONCLUSION: The amniotic fluid CRP level has a high sensitivity and specificity in the prediction of preterm delivery and this may be helpful in predicting preterm delivery during genetic amniocentesis.

Antral follicle assessment after down-regulation may be a useful tool for predicting pregnancy loss in in vitro fertilization pregnancies.

Women with diminished ovarian reserve (OR) have a high rate of pregnancy loss. The relationship between hormonal OR tests and pregnancy loss has been studied previously, but, to our knowledge, that between the antral follicle count (AFC) and pregnancy loss has not. Therefore, we aimed to determine whether OR tests, including the AFC, can predict pregnancy loss in women achieving pregnancy by means of in vitro fertilization (IVF), and also to compare their predictive value. All women underwent a fresh cycle of intracytoplasmic sperm injection with a long protocol with mid-luteal start of the gonadotropin-releasing hormone analog, and antral follicles were counted on cycle day 3 following down-regulation. Pregnancy losses up to 12 gestational weeks (n=28) were compared with apparently healthy deliveries (n=34) in this retrospective analysis. Receiver operating characteristic analysis of consecutive pregnancies (n=71) was performed to analyze the optimum cut-off value for the significantly different OR tests. Women with a pregnancy loss had a lower AFC than those with healthy deliveries. Age and hormonal OR tests were comparable between groups. The optimum cut-off value for the AFC to predict pregnancy loss was 7.5. AFC may be a useful tool for predicting pregnancy loss in IVF pregnancies.

Exposure to low outdoor temperature in the midtrimester is associated with low birth weight.

BACKGROUND: Although seasonal variation of birth weight has been reported previously, contributing factors such as the meteorological factor and its specific period of exposure remain unclear. AIM: To investigate the effect of season on birth weight and to determine the meteorological factor and its specific period of exposure which can contribute to any seasonal variation in birth weight. METHODS: Retrospective analysis of 3333 singleton live births after 36 completed weeks of pregnancy. Maternal age, parity, route of delivery, sex and individual meteorological variables for the first, second, and third trimesters of each pregnancy were analysed using multiple regression analysis with the birth weight as the dependent variable. RESULTS: A seasonal pattern was observed with lowest birth weights in women who had their last menstrual periods in summer and autumn. Upon multiple regression analysis, sex, parity, mode of delivery, and the temperature which the mother was exposed to in the second trimester were the independent determinants of birth weight. CONCLUSION: Exposure to low outdoor ambient temperature in the midtrimester can be associated with low birth weight.