Reference values for pulsatility index of fetal anterior and posterior cerebral arteries in prolonged pregnancy.

OBJECTIVE: To establish consistent normal reference values for fetal anterior cerebral artery (ACA) and posterior cerebral artery (PCA) pulsatility index (PI) in prolonged pregnancy. METHODS: This prospective cross-sectional observational study included singleton normal prolonged pregnancies into two study groups according to the gestational age: from 40 + 0 to 40 + 6 and from 41 + 0 to 41 + 6 weeks. The PI was assessed in both anatomical segments of ACA (ACA-S1 and ACA-S2) and of PCA (PCA-S1 and PCA-S2) with color Doppler imaging and pulsed Doppler examination, and reference centiles charts were generated. PI values from the two investigated segments of each vessel were also compared. RESULTS: Data were obtained in 771 patients: n = 448 in the 40 + 0 and 40 + 6 weeks group, and n = 323 in the 41 + 0 and 41 + 6 weeks group. A moderate decrease in PI was observed as pregnancy progressed. No differences in PI values were found between the two anatomical segments of ACA and PCA. CONCLUSION: This study provides Doppler reference values for the fetal ACA and PCA PI. It also shows that Doppler examination could be performed indifferently in one of the two anatomical segments of these arteries.

Middle cerebral artery Doppler pulsatility index as a predictor of intrapartum meconium release in prolonged pregnancies.

OBJECTIVES: The aim of this study was to asses the correlation of middle cerebral artery pulsatility index (MCA-PI) and perinatal outcomes in prolonged pregnancies. STUDY DESIGN: This was a prospective study of all consecutive pregnant women beyond 41 weeks' gestation attending for obstetric surveillance during a two years period. We evaluated the predictive value of MCA-PI lower than the 5th percentile (

Fetal cerebral and cardiac hemodynamics in postdate pregnancy.

Objective: We aimed to determine the fetal cerebro-placental Doppler indices and modified myocardial performance index (Mod-myocardial performance index (MPI)) in this homogenous group of postdated pregnancies. Methods: A total of 92 singleton pregnant women were included in this prospective study. The study involved three groups; full term control (Group 1, n = 42, 39 0/7 to 40 6/7 week' gestation), late term (Group 2, n = 34, 41 0/7 to 41 6/7 week' gestation) and post term (Group 3, n = 16, ≥ 42 0/7 weeks' gestation). Each participant underwent a Doppler assessment of the fetal umbilical artery (UA), middle cerebral artery (MCA), Mod-MPI. We determined the correlation of the Doppler indices and mod-MPI in patients with unfavorable outcome. Results: MCA pulcatility indices (PI), cerebroplacental ratio (CPR) values were significantly higher in the control group than those in the late-term and post-term groups (Group 1: 1.63 ± 0.3, Group 2: 1.27 ± 0.51, Group 3: 1.13 ± 0.22, respectively, p < .001). The Mod-MPI was significantly higher in the late-term and post-term groups than in the control group (Group 1:0.38 ± 0.1, Group 2: 0.59 ± 0.09, Group 3: 0.60 ± 0.08, respectively, p < .001. MCA PI and CPR were only significantly lower in patients with unfavorable outcome). The threshold value for CPR levels for predicting unfavorable outcome in postdate pregnancies was calculated as 1.11 (area under curve [AUC] 0.762, confidence interval [CI] 0.575-0.95) with 72.7% sensitivity and 71.8% specificity. Conclusions: Fetal Mod-MPI does not differ in postdate pregnancies with favorable and unfavorable outcome. The monitorization of fetal well-being with CPR may help to clinicians to select patient for expectant management in postdate pregnancies.

Orthopedic Conditions of the Premature and Dysmature Foal.

Incomplete ossification of the cuboidal bones is a common finding in premature and dysmature foals, and possibly in foals with hypothyroidism. Radiographs of the carpus and tarsus should be performed in any high-risk foal to obtain a diagnosis. Goals of treatment include limiting weight bearing and exercise. The prognosis is guarded depending on the degree of incomplete ossification.

Eating difficulties in children born late and moderately preterm at 2 y of age: a prospective population-based cohort study.

BACKGROUND: Very preterm (<32 wk of gestation) infants are at increased risk of eating difficulties compared with their term-born peers. Little is known about the impact of late and moderately preterm (LMPT; 32-36 wk of gestation) birth on eating difficulties in early childhood. OBJECTIVES: The aims were to assess the prevalence of eating difficulties in infants born LMPT at 2 y corrected age and to explore the impact of neonatal and neurodevelopmental factors. DESIGN: A geographic population-based cohort of 1130 LMPT and 1255 term-born controls was recruited at birth. The parents of 651 (59%) LMPT and 771 (62%) term-born infants completed questionnaires at 2 y corrected age to assess neurodevelopmental outcomes. Parents also completed a validated questionnaire to assess eating behaviors in 4 domains: refusal/picky eating, oral motor problems, oral hypersensitivity, and eating behavior problems. Infants with scores >90th percentile were classified with eating difficulties in each domain. Neonatal data were collected at discharge, and sociodemographic information was collected via maternal interview. Poisson regression was used to assess between-group differences in eating difficulties and to explore associations with neonatal factors and neurodevelopmental outcomes at 2 y of age. RESULTS: In unadjusted analyses, LMPT infants were at increased risk of refusal/picky eating (RR: 1.53; 95% CI: 1.03, 2.25) and oral motor problems (RR: 1.62; 95% CI: 1.06, 2.47). Prolonged nasogastric feeding >2 wk (RR: 1.87; 95% CI: 1.07, 3.25), behavior problems (RR: 2.95; 95% CI: 1.93, 4.52), and delayed social competence (RR: 2.28; 95% CI: 1.49, 3.48) were independently associated with eating difficulties in multivariable analyses. After adjustment for these factors, there was no excess of eating difficulties in LMPT infants. CONCLUSIONS: Infants born LMPT are at increased risk of oral motor and picky eating problems at 2 y corrected age. However, these are mediated by other neurobehavioral sequelae in this population. This trial was registered on the UK Clinical Research Network Portfolio at http://public.ukcrn.org.uk/search/ as UKCRN Study ID 7441.

Amniotic membrane sweeping.

Amniotic membrane sweeping or stripping is a safe and effective method of labor induction supported by national obstetrical organizations. While its use dates back to antiquity by both midwives and physicians there are still areas that need further research to define its role in induction of labor. A review of the literature reveals that amniotic membrane sweeping is a safe, effective, and inexpensive method of labor induction. It can be done in the outpatient setting with minimal risks so long as it is avoided in patients with contraindications. Amniotic membrane sweeping can be performed in Group B Streptococcus-positive women with studies showing no increase in untoward outcomes. However, there is no data in women infected with HIV or hepatitis.

Single indications of induction of labor with prostaglandins and risk of cesarean delivery: a retrospective cohort study.

AIM: To determine the risk of cesarean delivery after induction of labor with prostaglandins and to establish if this is influenced by a single indication of induction of labor or any intrinsic characteristic of the woman or labor. MATERIAL AND METHODS: A retrospective cohort study was carried out. Three hundred and twenty-four pregnant women who underwent pharmacological induction of labor with prostaglandins were divided into nine groups through indication of labor induction. Statistical analysis was assessed with the Kolmogorov-Smirnov test to assess the normal distribution of variables, Kruskal-Wallis test for comparisons of non-parametric continuous variables, univariate analysis to compare cesarean delivery rates and multivariate logistic regression. RESULTS: The risk of cesarean section was significantly higher only in prolonged pregnancy (OR = 1.98; 95% CI: 1.18-3.34). Elective induction was associated with the lowest risk of cesarean section (OR = 0.46; 95% CI: 0.26-0.81). Maternal age and was directly related (OR = 1.087; 95% CI: 1.016-1.164), while parity (OR = 0.123; 95% CI: 0.051-0.332), Bishop score (OR = 0.703; 95% CI: 0.571-0.884), and duration of labor (OR = 0.995; 95% CI: 0.993-0.998) were inversely correlated with cesarean delivery. CONCLUSION: Cesarean delivery rate is not significantly influenced by any indication of induction of labor with prostaglandins, except for prolonged pregnancy. Elective induction is associated with the lowest risk of cesarean section. Increasing maternal age, low parity, low Bishop score and low duration of labor are at higher risk of cesarean section.

Role of cerebroplacental ratio for fetal assessment in prolonged pregnancy.

OBJECTIVE: The aim of this study was to assess the role of the cerebroplacental ratio (CPR), i.e. the ratio between the middle cerebral artery and umbilical artery pulsatility indices, in detecting fetal compromise in prolonged pregnancy. METHODS: Women attending a dedicated postdates clinic at 41 weeks' gestation were recruited for the study and CPR was calculated at 41+3 weeks. Induction of labor was offered at 42 weeks to those women still undelivered. Unfavorable outcome was defined as cord arterial pH < 7.15 with a base deficit of > 11 mM/L or operative delivery for abnormal intrapartum fetal electrocardiogram ST-segment analysis. The 5(th) centiles of the CPR, obtained from published reference ranges (0.90) and from our population (0.98), were used as lower cut-off values. RESULTS: Three hundred and twenty women who reached a gestational age of over 41 weeks were eligible for inclusion in the study. The median gestational age at delivery was 294 (range, 289-300) days. Unfavorable outcome was observed in 58/320 pregnancies. There was no significant difference in the proportion of unfavorable outcomes between the two groups defined using either CPR cut-off value (both P > 0.05). CONCLUSION: CPR is not predictive of unfavorable outcome in women with pregnancies lasting more than 41 weeks.

Fetal gender effects on induction of labor in postdate pregnancies.

OBJECTIVE: To determine delivery outcome in women undergoing induction of labor for postdate pregnancy in relation to fetal gender. STUDY DESIGN: A total of 365 nulliparous and 127 multiparous women carrying singleton postdate pregnancies with unfavorable cervix were enrolled. Clinical characteristics and delivery outcome were analyzed in relation to fetal gender. RESULTS: Women carrying male fetuses showed higher rate of caesarean section than those carrying females, in both nulliparous and multiparous women. Moreover, women carrying male fetuses presented more frequently with (i) interval between induction of labor and delivery >24 hours (P < .0002); (ii) augmentation of labor after cervical ripening (P < .0391); (iii) meconium-stained liquor (P< .0126); and (iv) higher neonatal weight (P < .0011) than those carrying females. CONCLUSION: Male fetuses are more likely to be associated with higher rates of cesarean section. In maternal fetal medicine, gender differences may add prognostic information on the delivery outcome in women induced for postdate pregnancy.

Poor spontaneous and oxytocin-stimulated contractility in human myometrium from postdates pregnancies.

Prolongation of pregnancy i.e. going more than 10 days over the estimated due date, complicates up to 10% of all pregnancies and is associated with increased risk to both mother and fetus. Despite the obvious need for contractions of the uterus to end pregnancy, there have been no studies directly examining the role of uterine smooth muscle, myometrium, in the aetiology of prolonged pregnancy. This study tested the hypothesis that the intrinsic contractile characteristics of myometrium taken from women with prolonged pregnancy (>41 weeks and 3 days) was reduced compared to those delivering at term (39-41 weeks). We recruited women undergoing Caesarean Section (CS) delivery either pre-labour (n = 27) or in labour (n = 66) at term or postdates. The contractile ability of the postdates myometrium, whether spontaneous or elicited by oxytocin or high-K solution, was significantly reduced compared to term myometrium. These differences remained when adjusted for parity and other maternal characteristics. The findings remained significant when expressed per cross sectional area. Histological examination revealed no differences between the two groups. The contractile differences were however related to intracellular Ca transients suggesting an effect of [Ca] on reduced force production in the postdates group. In summary, myometrium from prolonged pregnancies contracts poorly in vitro even when stimulated with oxytocin and in active labour. Responses to high K(+) and measurements of Ca suggest that alterations in excitation contraction coupling, rather than any histological changes of the myometrium, may underlie the differences between term and postdates myometrium. We show that postdates pregnancy is associated with poor myometrial activity and suggest that this may contribute to increased myometrial quiescence and hence, prolonged gestation.

Androgen levels are associated with blood pressure in pregnant women after term.

OBJECTIVE: To assess possible associations between androgen, estrogen and insulin levels and blood pressure in pregnant women after term, compared with the effect of other well-known factors. DESIGN: Cross-sectional retrospective study. SETTING: University Hospital, Trondheim region. POPULATION: Four hundred and eighty-nine post-term women with uncomplicated pregnancies. METHODS: Blood pressure measurements and fasting serum samples drawn one week beyond the estimated day of delivery (defined as 41(+2) weeks). MAIN OUTCOME MEASURES: Blood pressure, maternal age, body mass index, parity, smoking habits and serum levels of dehydroepiandrosterone sulfate, androstendione, free testosterone index, estradiol, estriol, progesterone, 17-hydroxy-progesterone and insulin. RESULTS: In univariate linear regression analyses, body mass index, androstendione, free testosterone index and insulin were positively associated and parity was negatively associated with both systolic and diastolic blood pressure. In multivariate linear regression analyses, systolic blood pressure was positively associated with body mass index and free testosterone index, but negatively associated with parity and 17-hydroxy-progesterone levels, while diastolic blood pressure was positively associated with age and free testosterone index, but negatively associated with parity and 17-hydroxy-progesterone levels. CONCLUSION: Testosterone may increase blood pressure in pregnant women, while 17-hydroxy-progesterone may have the opposite effect.

[Correlations between placental morphological and functional parameters and neonatal status after normal full-term, prolonged pregnancy, and truly protracted pregnancy].

To solve the problem of differentiating protracted pregnancy, a special morphometric study was undertaken to examine three placental groups: 1) after normal full-term pregnancy (n = 35); 2) after prolonged pregnancy (n = 40); 3) after truly protracted pregnancy with partial or complete Clifford's syndrome (n = 30). A semiquantitative score (14 most important placental indicators), placenta and birth weights, Apgar scores, the infant's weight and height at the end of the first year of life were used so as to estimate the mild, moderate, and severe degree at 0.5, 1.5, and 3 points, respectively. One hundred and twenty-six possible pairs of structural and functional parameters were made up in all the groups. Pearson's correlation coefficient (r > 0.4) was applied to graphically display the pairs. Normal full-term pregnancy was characterized by few positive correlations mainly between the terminal villi and weight-height indices without associations with the Apgar scale. Prolonged pregnancy with the multiple placental tissue structural parameters along with organometric indices being involved was intermediate. The total scores permitted grades 1 and 2 chronic placental insufficiency (CPI) to be diagnosed in 27.5 and 2.5%, respectively. The severest form was truly protracted pregnancy that was distinguished by the maximum positive and negative correlations between all the parameters and the highest rate of diagnosis of CPI of grades 1 (45%) and 2 (15%). The findings strongly suggest that it is essential to identify prolonged and truly protracted pregnancy as important risk factors, by following up the infants for a year.

[When the expected date of delivery is overdue]. / Kun laskettu aika on ohi.

When pregnancy has continued past the expected date of delivery, the capacity of the placenta to transport oxygen and nutrients will decrease, whereby the condition of the fetus may be endangered with concomitantly increasing intrapartum problems. In addition, the mother's risk of complications of labor will increase, which is partly due to the increasing size of the child. The pregnancy is closely followed at the maternity and prenatal clinic, and induction of active labor will usually be conducted no later than two weeks after the expected date.

Is there any relation between development of persistent non-reassuring fetal heart rate pattern and acutely increased uterine artery vascular flow resistance during dinoprostone use in prolonged pregnancies?

OBJECTIVE: To investigate the relation between changes in Doppler parameters of fetal and uterine arteries and development of persistent non-reassuring fetal heart rate (FHR) pattern during induction of labor with dinoprostone (Propess) in pregnancies at >or=41 weeks gestation. DESIGN: Prospective cohort study. SETTING: Etlik Zubeyde Hanim Women's Hospital, Turkey. SAMPLE: One hundred forty-one prolonged pregnancies. METHODS: Doppler parameters of umbilical, middle cerebral, and uterine arteries were measured before and 4-6 hours after dinoprostone application between uterine contractions. Non-reassuring FHR pattern and persistent non-reassuring FHR pattern criteria were defined based on NICE 2007 guidelines. Women with successful spontaneous vaginal delivery were recruited as a control group (n=108), while women who underwent cesarean delivery due to persistent non-reassuring FHR pattern were recruited as a study group (n=15). MAIN OUTCOME MEASURES: Prediction of non-reassuring FHR pattern with Doppler analysis of uterine and fetal arteries. RESULTS: After dinoprostone application there was significant enhancement in uterine artery resistance index (RI) in the study group compared to the control group (p=0.002). Receiver operating characteristics curve analysis identified a uterine artery RI increase value of 0.11 as the optimal threshold for prediction of persistent non-reassuring FHR pattern with 73.3% sensitivity and 69.4% specificity. Logistic regression analysis demonstrated that an increase in the uterine artery RI was predictive for persistent non-reassuring FHR pattern (odds ratio (OR) 4.97; 95% CI 1.5-16.8). CONCLUSION: Acute increase in uterine artery RI due to dinoprostone use may end with persistent non-reassuring FHR pattern in prolonged pregnancies. This may allow earlier prediction of persistent non-reassuring FHR pattern development and risk assessment.

Impaired leukocyte influx in cervix of postterm women not responding to prostaglandin priming.

BACKGROUND: Prolonged pregnancies are associated with increased rate of maternal and fetal complications. Post term women could be divided into at least two subgroups, one where parturition is possible to induce by prostaglandins and one where it is not. Our aim was to study parameters in cervical biopsies in women with spontaneous delivery at term (controls) and compare to those that are successfully induced post term (responders), and those that are not induced (non-responders), by local prostaglandin treatment. METHODS: Stromal parameters examined in this study were the accumulation of leukocytes (CD45, CD68), mRNAs and/or proteins for the extracellular matrix degrading enzymes (matrix metalloproteinase (MMP)-2, MMP-8 and MMP-9), their inhibitors (tissue inhibitor of MMP (TIMP)-1 and TIMP-2), interleukin-8 (IL-8), the platelet activating factor-receptor (PAF-R), syndecan-1 and estrogen binding receptors (estrogen receptor (ER)alpha, ERbeta and G-coupled protein receptor (GPR) 30) as well as the proliferation marker Ki-67. RESULTS: The influx of leukocytes as assessed by CD45 was strongest in the responders, thereafter in the controls and significantly lower in the non-responders. IL-8, PAF-R and MMP-9, all predominantly expressed in leukocytes, showed significantly reduced immunostaining in the group of non-responders, while ERalpha and GPR30 were more abundant in the non-responders, as compared to the controls. CONCLUSION: The impaired leukocyte influx, as reflected by the reduced number of CD45 positive cells as well as decreased immunostaining of IL-8, PAF-R and MMP-9 in the non-responders, could be one explanation of the failed ripening of the cervix in post term women. If the decreased leukocyte influx is a primary explanation to absent ripening or secondary, as a result of other factors, is yet to be established.

[Perinatal risk at term and post-term revisited]. / Période du terme: le risque périnatal revisité.

The aim of this review was to revisit the evaluation of risk of foetal and neonatal mortality at term. We analyse the meaning of term period and difficulty to determine the normal duration of the pregnancy. Specific complications associated with post term and the statistic approach of the perinatal risk are analysed, together with various mortality rates and especially the prospective risk introducing foetal term as a new concept. We study various aspect and evolution of non specific morbidity of the term period. An optimal decision for term management should involve pregnant women and the analysed parameters should be taken into consideration.