Protein C global assay evaluation in naturally conceived vs. assisted reproduction-achieved twin pregnancies: a prospective longitudinal study.

PURPOSE: Protein C global assay tests the global function of the protein C pathway, the most clinically significant anticoagulant pathway in humans. The objective of this study is to assess the difference in protein C global assay levels, throughout twin gestation, in naturally conceiving and ART-treated women. METHODS: This is a prospective cohort longitudinal study of pregnant women with twin gestation. Protein C Global evaluation was performed on frozen blood samples. Ninety-eight women with twin pregnancy, thirty-eight naturally conceived and sixty following ART, were evaluated on four occasions: during the first, second, and third trimesters, and 6 weeks or later after delivery (baseline). RESULTS: Protein C global assay levels were lower throughout pregnancy as compared to basal levels in both the naturally conceived and ART-conceived groups. However, protein C global assay levels were similar between the ART-conceived and naturally conceived twin pregnancies in all three trimesters. Perinatal complications were associated with decreased protein C global assay levels during the third trimester, although no difference was encountered between naturally conceived and ART-complicated twin pregnancies. CONCLUSION: While protein C global assay levels drop during twin pregnancy, there is no difference between ART-conceived and naturally conceived gestations. Decreased levels of protein C global assay during the third trimester were similarly associated with perinatal complications in both groups. Our results imply that twin pregnancy of itself is a more dominant factor for perinatal complications as compared to other factors, such as subfertility or the exposure to ART per se.

The Impact of Prenatal Depression in Patients of High Risk Pregnancy Clinic on Obstetric Outcomes.

Prenatal depression is common and has been associated with risky maternal behavior, postpartum depression, and atypical child development. Still, its association with adverse perinatal outcomes is complex. The aim of our study was to look for this potential association in our region. The medical charts of women who were treated at our High-Risk Pregnancy Clinic and gave birth at our hospital were reviewed. The Edinburgh Postnatal Depression Scale (EPDS) was used to discover prenatal depression. Patients who reported past or current mental illness were excluded. We enrolled 202 women at a mean age of 32.81. Twin pregnancy was the most common reason for referral to the clinic (17.3%). The mean EPDS score was 4.63 (±4.66), with 15.3% scoring 10 or more. A significant correlation was found between the EPDS score and intrapartum fetal heart rate abnormalities, as well as with low birth weight. There were significant associations between the EPDS score and the maternal status of genetic disorder carrier, and the number of previous pregnancies, miscarriages, and elective termination of pregnancy. This study demonstrates a significant impact of the maternal psychological state on the obstetric outcome. In addition, we observed a significant association between maternal obstetric history, genetic data, and the risk of prenatal depression. Our study shows that completing the EPDS questionnaire is a very important part of the pregnancy follow-up, as it illuminates risk factors for prenatal depression and adverse perinatal outcomes.

A homozygous TTN gene variant associated with lethal congenital contracture syndrome.

Pathogenic variants in the TTN gene have been reported to cause various cardiomyopathies and a range of skeletal muscle diseases, collectively known as titinopathies. We evaluated a consanguineous family multiple members affected with a lethal congenital contracture syndrome. Using exome sequencing, we identified a homozygous c.36122delC (p. P12041Lfs*20) variant in exon 167 in the fetal IC isoform of TTN. The finding expands the phenotypes that can be caused by pathogenic variants TTN, which should be considered in lethal congenital contracture syndromes, arthrogryposis multiplex congenita, congenital myopathies, and hydrops fetalis.

The effect of oral probiotics on glycemic control of women with gestational diabetes mellitus-a multicenter, randomized, double-blind, placebo-controlled trial.

BACKGROUND: Gestational diabetes mellitus should be treated adequately to avoid maternal hyperglycemia-related complications. Previously, probiotic supplements were suggested to improve fasting blood glucose in women with gestational diabetes mellitus. However, a major limitation of previous studies was that preprandial and especially postprandial glucose values, which are important predictors of pregnancy outcomes, were not studied. OBJECTIVE: This study aimed to examine the effect of a mixture of probiotic strains on maternal glycemic parameters, particularly preprandial and postprandial glucose values and pregnancy outcomes among women with gestational diabetes mellitus. STUDY DESIGN: A multicenter prospective randomized, double-blind, placebo-controlled trial was conducted. Women newly diagnosed with gestational diabetes mellitus were randomly allocated into a research group, receiving 2 capsules of oral probiotic formula containing Bifidobacterium bifidum, B lactis, Lactobacillus acidophilus, L paracasei, L rhamnosus, and Streptococcus thermophilus (>6 × 109/capsule), and a control group, receiving a placebo (2 capsules/day) until delivery. Glycemic control was evaluated by daily glucose charts. After 2 weeks, pharmacotherapy was started in case of poor glycemic control. The primary outcomes were the rate of women requiring medications for glycemic control and mean daily glucose charts after 2 weeks of treatment with the study products. RESULTS: Forty-one and 44 women were analyzed in the treatment and placebo cohorts, respectively. Mean daily glucose during the first 2 weeks in the probiotics and placebo groups was 99.7±7.9 and 98.0±9.3 mg/dL, respectively (P=.35). The rate of women needing pharmacotherapy because of poor glycemic control after 2 weeks of treatment in the probiotics and placebo groups was 24 (59%) and 18 (41%), respectively (P=.10). Mean preprandial and postprandial glucose levels throughout the study period were similar between the groups (P>.05). There were no differences in maternal and neonatal outcomes, including birthweight and adverse effect profile between the groups. CONCLUSION: The oral probiotic product tested in this study did not affect glycemic control of women with gestational diabetes mellitus.

Vertical transmission and humoral immune response following maternal infection with SARS-CoV-2: a prospective multicenter cohort study.

OBJECTIVE: To explore maternal humoral immune responses to SARS-CoV-2 infection and the rate of vertical transmission. METHODS: A prospective cohort study was conducted at two university-affiliated medical centers in Israel. Women positive for SARS-CoV-2 reverse-transcription-polymerase-chain-reaction (RT-PCR) test during pregnancy were enrolled just prior to delivery. Levels of anti-SARS-CoV-2 spike-IgM, spike IgG, and nucleocapsid IgG were tested in maternal and cord blood at delivery, and neonatal nasopharyngeal swabs were subjected to PCR testing. The primary endpoint was the rate of vertical transmission, defined as either positive neonatal IgM or positive neonatal PCR. RESULTS: Among 72 women, 36 (50%), 39 (54%) and 30 (42%) were positive for anti-spike-IgM, anti-spike-IgG, and anti-nucleocapsid-IgG, respectively. Among 36 neonates in which nasopharyngeal swabs were taken, one neonate (3%, 95% confidence interval 0.1-15%) had a positive PCR result. IgM was not detected in cord blood. Seven neonates had positive IgG antibodies while their mothers were seronegative for the same IgG. Anti-nucleocapsid-IgG and anti-spike-IgG were detected in 25/30 (83%) and in 33/39 (85%) of neonates of seropositive mothers, respectively. According to the serology test results during delivery with respect to the time of SARS-CoV-2 infection, the highest rate of positive maternal serology tests was 8 to 12 weeks post-infection (89% anti-spike IgG, 78% anti-spike IgM, and 67% anti-nucleocapsid IgG). Thereafter, the rate of positive serology tests declined gradually; at 20 weeks post-infection, only anti-spike IgG was detected in 33 to 50%. DISCUSSION: The rate of vertical transmission of SARS-CoV-2 was at least 3% (95% confidence interval 0.1-15%). Vaccination should be considered no later than 3 months post-infection in pregnant women due to a decline in antibody levels.

Uterine rupture after previous low segment transverse cesarean is rarely catastrophic.

OBJECTIVE: The cornerstone of concerns over trial of labor after cesarean (TOLAC) is the risk of uterine rupture. The purpose of this study was to document the rate of uterine rupture during TOLAC and to delineate its severity and consequences. MATERIALS AND METHODS: We retrospectively collected the data on vaginal and cesarean deliveries after a previous cesarean section with specific emphasis on uterine rupture and dehiscence in our center from 2006 through 2013. RESULTS: 22,670 deliveries were registered, with 18.2% rate of cesarean section. 2890 women had a single cesarean scar; of them 1206 delivered vaginally and 194 were re-operated during unsuccessful TOLAC. Seven cases of uterine rupture and 16 cases of dehiscence were recorded. There were no maternal, intrapartum or neonatal deaths, and no cesarean hysterectomy. There was one re-laparotomy, one ICU admission, and one blood transfusion; one neonate was admitted to NICU. TOLAC was successful in 86.1% of cases. CONCLUSIONS: Cautious selection and close monitoring of candidates are the cornerstones of successful management of TOLAC. Readily available facilities for emergency cesarean delivery and concerted obstetrical team can save the mother and child from catastrophic complications.

Early and short follicular gonadotropin-releasing hormone antagonist supplementation improves the meiotic status and competence of retrieved oocytes in in vitro fertilization-embryo transfer cycles.

OBJECTIVE: To investigate whether early and short follicular administration of GnRH antagonist using the flexible protocol has the potential to improve IVF-ET clinical results. DESIGN: Prospective, controlled, randomized study. SETTING: University-affiliated assisted reproductive technology unit. PATIENT(S): Fifty-three consecutive infertile women were enrolled to the study and control groups. INTERVENTION(S): Both groups were treated with recombinant FSH and the flexible GnRH antagonist protocol. Women in the study group were additionally supplemented with three injections of GnRH antagonist (0.25 mg/d on days 1, 2, and 3 of the menstrual cycle). MAIN OUTCOME MEASURE(S): Hormonal milieu, oocyte meiotic status, competence for normal fertilization, cleavage, and clinical pregnancy rate. RESULT(S): Both groups had comparable baseline characteristics. The duration of recombinant FSH treatment was significantly longer in the study group as compared with the control group (10.9+/-3.1 and 9.7+/-1.3 days, respectively). The number of follicles>or=14 mm and E2 level on the day of hCG administration, number of retrieved oocytes, and endometrial thickness were similar between the two groups. However, the fertilization rate was significantly higher in the study as compared with the control group (85%+/-16% and 69%+/-24%, respectively). Moreover, the cumulative rate of mature first polar body oocytes was significantly higher in the study group as compared with the control group (93% and 85%, respectively). Concomitantly, day-3 FSH and LH levels after initiation of treatment were significantly lower in the study as compared with the control group (6.1+/-2.4 mIU/mL vs. 7.2+/-1.9 mIU/mL and 2.4+/-1.6 mIU/mL vs. 5.6+/-2.7 mIU/mL, respectively). CONCLUSION(S): Early and short follicular GnRH antagonist supplementation using flexible GnRH antagonist treatment improves the meiotic status and competence of retrieved oocytes. It seems that early and short pituitary shutdown has the potential to improve clinical results in IVF-ET GnRH antagonist cycles.

Abdominal compartment syndrome after laparoscopic salpingectomy for ectopic pregnancy.

Abdominal compartment syndrome is a consequence of increased intraabdominal pressure. It can be triggered by inflammation, hemorrhage, chemical peritonitis, or prolonged insufflations during laparoscopy. It is a well-known phenomenon for intensive care specialists, but gynecologists are relatively unfamiliar with its occurrence. A woman with heterotopic pregnancy underwent urgent laparoscopy because of abdominal hemorrhage. The postoperative course was complicated by abdominal pain, ascites, bowel dysfunction, and renal failure, which resolved rapidly after catheterization and paracentesis. In this case, abdominal compartment syndrome developed after unremarkable laparoscopy, and appeared to be triggered by change of progesterone formulation. Decompression by paracentesis was lifesaving, and led to rapid resolution of the symptoms.