Evaluation of risk-factor-based screening for thyroid peroxidase antibody positivity in pregnancy.

OBJECTIVE: To determine whether risk-factor-based screening for thyroid dysfunction in pregnancy performs well for detecting thyroid peroxidase antibodies (TPOAb), a marker for autoimmune thyroid disease. STUDY DESIGN: We prospectively evaluated pregnant women for thyroid dysfunction using The Endocrine Society's eleven screening questions. Serum was analysed for TPOAb. RESULT: We enrolled 546 women. TPOAb positivity was higher in women with a personal (odds ratio (OR) = 8·0; 95% confidence interval (CI) = 1·7-37·4; P = 0·02) or family history of thyroid disease (OR = 2·7; 95% CI = 1·3-5·7; P = 0·02). There was no association between the number of positive responses and TPOAb positivity (P = 0·41). Risk-factor-based screening missed 18 women (33%) with TPOAb. CONCLUSION: One-third of women with TPOAb were missed by the case-finding method. A personal or family history of thyroid disease was most strongly associated with TPOAb positivity.

Bile acid concentration reference ranges in a pregnant Latina population.

OBJECTIVE: The total bile acid (TBA) concentration criterion for diagnosing intrahepatic cholestasis of pregnancy varies in the published literature. The purpose of this study was to establish pregnancy-specific reference ranges for the TBA concentration among Latina women. STUDY DESIGN: Self-identified Latina women (n = 211) over 18 years of age with a singleton pregnancy were recruited and had random serum samples drawn during the second and third trimesters. The total and fractionated bile acid concentrations were analyzed by liquid chromatography-tandem mass spectrometry (LC-MS/MS), and reference ranges were calculated. Laboratory-provided general reference ranges from a general population of adult men and nonpregnant women were used for comparison. RESULTS: The TBA reference range for our Latina pregnant population (<8.5 µmol/L) was markedly lower than the laboratory-provided reference range (4.5 to 19.2 µmol/L). CONCLUSION: These data suggest that the upper TBA concentration reference range in our Latina pregnant population is 8.5 µmol/L, based on LC-MS/MS measurements.

Familial aggregation of hyperemesis gravidarum.

OBJECTIVE: This study was undertaken to determine whether there is familial aggregation of hyperemesis gravidarum (HG), making it a disease amenable to genetic study. STUDY DESIGN: Cases with severe nausea and vomiting in a singleton pregnancy treated with intravenous hydration and unaffected friend controls completed a survey regarding family history. RESULTS: Sisters of women with HG have a significantly increased risk of having HG themselves (odds ratio, 17.3; P = .005). Cases have a significantly increased risk of having a mother with severe nausea and vomiting; 33% of cases reported an affected mother compared to 7.7% of controls (P < .0001). Cases reported a similar frequency of affected second-degree maternal and paternal relatives (18% maternal lineage, 23% paternal lineage). CONCLUSION: There is familial aggregation of HG. This study provides strong evidence for a genetic component to HG. Identification of the predisposing gene(s) may determine the cause of this poorly understood disease of pregnancy.

The mechanical PR interval in fetuses of women with intrahepatic cholestasis of pregnancy.

OBJECTIVE: The purpose of this study was to evaluate the fetal mechanical PR interval in intrahepatic cholestasis of pregnancy (ICP). STUDY DESIGN: Fetal echocardiography was performed for women with ICP and control subjects. Clinical characteristics, total bile acids, and liver profile tests were compared between groups. RESULTS: Fourteen women with ICP and 7 control subjects were enrolled. Total bile acids (28.3 vs 6.2 µmol/L; P < .001), aspartate aminotransferase (53 vs 23 IU/L; P = .002), alanine aminotransferase (63 vs 19 IU/L; P = .002), and the PR interval (124 vs 110 msec; P = .006) were significantly higher in fetuses with ICP than in control fetuses. On multivariable linear regression analysis, only the presence of ICP was associated significantly with an increase in the PR interval (95% confidence interval, 4-24 msec; P = .01). CONCLUSION: The fetal cardiac conduction system is altered in ICP. Further investigation is needed to determine whether fetal echocardiography can help to predict which fetuses are at risk for death that is associated with ICP.

The effect of barusiban, a selective oxytocin antagonist, in threatened preterm labor at late gestational age: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: The objective of the study was to compare barusiban with placebo in threatened preterm labor. STUDY DESIGN: This was a randomized, double-blind, placebo-controlled, multicenter study. One hundred sixty-three women at 34-35 weeks plus 6 days, and with 6 or more contractions of 30 seconds duration during 30 minutes, cervical length 15 mm or less, and cervical dilatation > 1 and < 4 cm were randomized to a single intravenous bolus of barusiban (0.3, 1, 3, or 10 mg) or placebo. The primary endpoint was percentage of women who did not deliver within 48 hours. RESULTS: None of the barusiban doses reduced the number of uterine contractions compared with placebo. There was no significant difference in the percentage of women who did not deliver within 48 hours (72% placebo and 65-88% barusiban groups; P = .21-.84). Barusiban was not associated with an adverse safety profile in the woman, fetus, neonate, or infant. CONCLUSION: An intravenous bolus of barusiban was no more effective than placebo in stopping preterm labor in pregnant women at late gestational age.

Alteration of secretory leukocyte protease inhibitor in human myometrium during labor.

OBJECTIVE: Secretory leukocyte protease inhibitor (SLPI) has been shown to have antimicrobial and antiinflammatory properties. The aim of this study was to verify its expression in human myometrium. STUDY DESIGN: Myometrium was obtained at time of cesarean delivery with (n = 9) or without (n = 11) labor. Expression of SLPI was detected using real-time polymerase chain reaction, enzyme-linked immunosorbent assay, and immunohistochemistry. SLPI expression relative to nuclear factor-kappaB p65 subunit was compared between subjects. SLPI response to inflammatory mediators was studied in myometrial explants. RESULTS: SLPI was predominantly localized in the nuclei of myocytes and colocalized with CD68(+) macrophages. The nuclear immunoreactivity of SLPI was increased after the onset of labor and was associated with increased nuclear translocation of nuclear factor-kappaB p65 subunit. Treatment with lipopolysaccharide, interleukin-1beta, or tumor necrosis factor-alpha increased SLPI messenger RNA and protein concentrations slightly in myometrium explants. CONCLUSION: SLPI was expressed in human myometrium and increased after the onset of labor.

Are patients with twin-twin transfusion syndrome and a very short cervix candidates for laser surgery?

OBJECTIVES: The purpose of this study was to determine the relationship between cervical length (CL) and perinatal outcomes in cases of twin-twin transfusion syndrome (TTTS) treated with laser surgery and to assess whether patients with a very short cervix (0.5-1.9 cm) are appropriate candidates for laser surgery. METHODS: All women who underwent laser surgery for TTTS from March 2006 to April 2008 at the study institution were evaluated consecutively. Patients were grouped according to pre-operative CL: greater than 2.5, 2 to 2.5, and 0.5 to 1.9 cm. The gestational age at delivery, latency from laser surgery to delivery, and 30-day neonatal survival were documented prospectively and compared among these groups. RESULTS: The 99 women in the study population were grouped by CL: greater than 2.5 cm (n = 76), 2 to 2.5 cm (n = 13), and 0.5 to 1.9 cm (n = 10). For these groups, the median gestational ages at delivery were 34, 32.29, and 31.86 weeks, respectively (P = .411). The median latencies from laser surgery to delivery were 12.79, 11, and 11.07 weeks (P = .424). The frequency rates of at least 1 surviving twin were 69 of 76 (91%), 13 of 13 (100%), and 8 of 10 (80%) (P = .254). Finally, dual survivors were observed in 54 of 76 (71%), 12 of 13 (92%), and 5 of 10 (50%) (P = .08). CONCLUSIONS: In cases of TTTS complicated by a very short cervix (0.5-1.9 cm), treatment with laser surgery resulted in perinatal outcomes that were sufficiently favorable to justify the surgery, suggesting that these patients should not be excluded from undergoing laser surgery for TTTS.

High prevalence of severe nausea and vomiting of pregnancy and hyperemesis gravidarum among relatives of affected individuals.

OBJECTIVE: The goal of this study was to determine the prevalence of severe nausea and vomiting of pregnancy/hyperemesis gravidarum among relatives of affected individuals. STUDY DESIGN: Family history data were obtained on 1224 self-reported cases of hyperemesis gravidarum. Cases completed an online survey administered by the Hyperemesis Education and Research Foundation between 2003 and 2006. RESULTS: Approximately 28% of cases reported their mother had severe nausea and vomiting or hyperemesis gravidarum while pregnant with them. Of the 721 sisters with a pregnancy history, 137 (19%) had hyperemesis gravidarum. Among the most severe cases, those requiring total parenteral nutrition or nasogastric feeding tube, the proportion of affected sisters was even higher, 49/198 (25%). Nine percent of cases reported having at least two affected relatives including sister(s), mother, grandmother, daughters, aunt(s), and cousin(s). CONCLUSION: There is a high prevalence of severe nausea and vomiting of pregnancy/hyperemesis gravidarum among relatives of hyperemesis gravidarum cases in this study population. Because the incidence of hyperemesis gravidarum is most commonly reported to be 0.5%, this study provides strong but preliminary evidence for a genetic component to extreme nausea and vomiting of pregnancy.

Posttraumatic stress symptoms following pregnancy complicated by hyperemesis gravidarum.

OBJECTIVE: Hyperemesis gravidarum (HG) can be accompanied by severe physical and emotional distress. Most studies have focused on the physical and psychological stress associated with this condition during the affected pregnancy. This study explores posttraumatic stress symptoms (PTSS) and negative life outcomes following HG pregnancies. METHODS: A total of 610 women (HG = 377 and control = 233) were recruited and completed an online survey. χ-square analyses were used to compare the HG and control groups on various life outcome variables. RESULTS: Eighteen percent of women with HG reported full criteria PTSS (n = 68). Negative life outcomes regarding financial and marital status, career, as well as psychological and physical well-being differed significantly for the HG groups compared to the control group (0.001 < p < 0.05). CONCLUSIONS: PTSS is common following HG pregnancies and is associated with negative life outcomes including inability to breastfeed, marital problems, financial problems, and inability of self care.

Late pregnancy complications can affect risk estimates of elective induction of labor.

OBJECTIVE: Multiple observational studies have emphasized the increased risk of elective induction versus spontaneous labor. We estimated the risks of elective induction before 39 weeks compared to expectant management. METHODS: Using a single institution's delivery data (1996-2004), we identified women with uncomplicated term gestations who underwent elective induction before 39 weeks (Early Induction Group). A comparison group of women eligible for elective induction before 39 weeks but who were managed expectantly was created by identifying the remaining deliveries ≥ 39 weeks and excluding women with "established" pregnancy complications such as diabetes or heart disease (Expectant Management Group), but retaining women with complications that may have developed while waiting, e.g. gestational hypertension or abruption. RESULTS: Pregnancies in the Early Induction Group were generally not at increased risk for morbidity when compared to the entire Expectant Management Group, in whom 49% developed pregnancy complications or went postdates. These pregnancies had poorer maternal and neonatal outcomes when compared to patients who remained uncomplicated with spontaneous labor onset, thus reducing the overall benefit of expectant management. CONCLUSIONS: Failure to account for the large proportion of women who develop late pregnancy complications can falsely elevate the estimated risk of elective induction prior to 39 weeks.

Evidence against a link between hyperemesis gravidarum and personality characteristics from an ethnically diverse sample of pregnant women: a pilot study.

BACKGROUND: Hyperemesis gravidarum (HG), a pregnancy-related condition marked by extreme nausea and vomiting, has been considered a psychosomatic illness associated with long-standing personality characteristics (e.g., hysteria). In this pilot study, we examined personality, somatic, and psychological variables with ethnically diverse samples of women with HG and women with typical levels of nausea and vomiting of pregnancy (NVP). METHODS: Personality (Minnesota Multiphasic Personality Index-2 [MMPI-2] and MMPI-2RF), somatic (MMPI-2RF), and psychological (Beck Depression Inventory-II [BDI-II] and NVP-related quality of life) variables collected during the first trimester of pregnancy were compared between 15 women with HG and 15 women with normal levels of NVP matched for age, education, marital status, insurance source, and race/ethnicity. A secondary analysis was performed comparing these variables among a group of 9 asymptomatic pregnant women to the HG and NVP groups. RESULTS: No significant differences were found between the HG and NVP groups on any personality, somatic, or psychological variables. Both groups had clinically significant elevations on the MMPI-2 hypochondriasis scale, which incorporates somatic symptoms. The NVP group had a clinically significant elevation on the MMPI-2RF gastrointestinal complaints scale. Both groups had significantly higher means on the MMPI-2 and MMPI-2RF scales than the asymptomatic group. Predominantly Spanish speakers appeared particularly vulnerable to psychological distress associated with somatic complaints. CONCLUSIONS: The results of this pilot study suggest that research with HG patients is feasible and that psychological distress expressed by women with HG and NVP may reflect reactions to somatic symptoms. No evidence was found to support an association between HG and personality characteristics. Recommendations for future research are provided, such as examining the potential benefits of translation services for Spanish-speaking HG patients.

Perinatal survival following preferential sequential selective laser surgery for twin-twin transfusion syndrome.

OBJECTIVE: To describe our experience with preferential use of sequential selective laser photocoagulation of communicating vessels (SQLPCV) in women with twin-twin transfusion syndrome (TTTS). METHODS: Women with TTTS received treatment using the SQLPCV technique whenever possible. SQLPCV mandates ablation of all donor-to-recipient arteriovenous communications first, in comparison to the standard non-sequential selective technique. RESULTS: Of 99 consecutive women treated, 64 received SQLPCV. Overall survival of one or both twins was 91% and dual survival was 72%. Higher dual survival rates (80 vs. 57%, p=0.0317) and donor survival rates (83 vs. 63%, p=0.0489) were noted in the SQLPCV group. Multivariable logistic regression demonstrated that the SQLPCV technique was highly associated with dual survivorship (OR=4.64 [1.57-13.74], p=0.0056), when controlling for gestational age at surgery, duration of laser treatment and number of anastomoses lasered. Neither Quintero stage, placental location, preoperative discordance prior to surgery, nor preoperative cervical length contributed to this equation. The SQLPCV technique was also associated with donor survivorship (OR=4.43 [1.44-13.67], p=0.0095), when controlling for the same covariates. CONCLUSION: Treatment of TTTS via SQLPCV technique was associated with higher dual survival and donor twin survival rates as compared to standard SLPCV.

Left atrial thrombosis in pregnant women with mitral stenosis and sinus rhythm.

OBJECTIVE: The purpose of this study was to describe pregnant patients with mitral stenosis who had intracardiac thrombosis in the absence of atrial fibrillation. STUDY DESIGN: We reviewed the clinical course of 3 pregnant women with severe mitral stenosis and normal sinus rhythm who had clinically significant intracardiac thrombosis. RESULTS: The first patient was examined at 21 weeks of gestation with embolic stroke that was the result of left atrial thrombus. A second patient was found to have a large left atrial thrombus that prevented the performance of balloon valvuloplasty. The third patient had left atrial clot that partially occluded the mitral valve orifice and led to the development of pulmonary edema that resulted in an emergent cesarean delivery and anoxic brain injury in the newborn infant. CONCLUSION: Pregnant patients with mitral stenosis in normal sinus rhythm can experience thromboembolic events that can be detrimental to both the mother and the fetus. Anticoagulation therefore should be strongly considered in this group.