Identification of bacteriophages in the vagina of pregnant women: a descriptive study.

OBJECTIVE: To determine the presence and identity of extracellular bacteriophage (phage) families, genera and species in the vagina of pregnant women. DESIGN: Descriptive, observational cohort study. SETTING: São Paulo, Brazil. POPULATION: Pregnant women at 21-24 weeks' gestation. METHODS: Vaginal samples from 107 women whose vaginal microbiome and pregnancy outcomes were previously determined were analysed for phages by metagenomic sequencing. MAIN OUTCOME MEASURES: Identification of phage families, genera and species. RESULTS: Phages were detected in 96 (89.7%) of the samples. Six different phage families were identified: Siphoviridae in 69.2%, Myoviridae in 49.5%, Microviridae in 37.4%, Podoviridae in 20.6%, Herelleviridae in 10.3% and Inviridae in 1.9% of the women. Four different phage families were present in 14 women (13.1%), three families in 20 women (18.7%), two families in 31 women (29.1%) and one family in 31 women (29.1%). The most common phage species detected were Bacillus phages in 48 (43.6%), Escherichia phages in 45 (40.9%), Staphylococcus phages in 40 (36.4%), Gokushovirus in 33 (30.0%) and Lactobacillus phages in 29 (26.4%) women. In a preliminary exploratory analysis, there were no associations between a particular phage family, the number of phage families present in the vagina or any particular phage species and either gestational age at delivery or the bacterial community state type present in the vagina. CONCLUSIONS: Multiple phages are present in the vagina of most mid-trimester pregnant women. TWEETABLE ABSTRACT: Bacteriophages are present in the vagina of most pregnant women.

Perinatal outcomes after open fetal surgery for myelomeningocele repair: a retrospective cohort study.

OBJECTIVE: Describe outcomes of open fetal surgery for myelomeningocele (MMC) repair in two Brazilian hospitals and the impact of surgical experience on outcome. DESIGN: Retrospective cohort study. SETTING: Sao Paulo, Brazil. POPULATION: 237 pregnant women carrying a fetus with an open spinal defect. METHODS: Surgical details, and maternal and fetal outcomes collected from all patients. MAIN OUTCOME MEASURES: Analysis of surgical and perinatal outcome parameters. RESULTS: Total surgical time was 119 ± 7.6 minutes. Preterm labour occurred in 24.2%, premature rupture of membranes in 26.7%, placental abruption in 0.8%, need for a blood transfusion at delivery in 2.1%, and dehiscence at the repair site in 2.5%. Reversal of hindbrain herniation at birth occurred in 71.4%. There were no maternal deaths or severe maternal morbidities. The failure rate with the patient anaesthetised was 0.42% and perinatal mortality was 2.1% (three intrauterine demises and two neonatal deaths). Comparing results from our study in the first 3 years with the last 3 years demonstrated improvement in the total surgical time (121.2 ± 6.4 versus 118.5 ± 8.2 minutes, P = 0.005) and an increase in reversal of hindbrain herniation at birth (64.0 versus 77.1%, P = 0.042). CONCLUSION: Our open fetal surgical approach for MMC was effective and results were comparable to past studies. Improvements in surgical performance and perinatal outcome increased as the surgical team became more familiar with the procedure. FUNDING: The study was funded solely by institutional funds. TWEETABLE ABSTRACT: Brazilian experience of in utero open surgery for myelomeningocele repair.

Amniotic fluid lactic acid and matrix metalloproteinase-8 levels at the time of fetal surgery for a spine defect: association with subsequent preterm prelabour rupture of membranes.

OBJECTIVE: In utero fetal surgery to correct incomplete closure of the spinal cord lessens the extent of permanent damage but is associated with preterm prelabour rupture of membranes (PPROM). We determined whether compounds in amniotic fluid collected at the time of surgery predicted subsequent development of PPROM. DESIGN: Prospective study. SETTING: Hospitals in Sao Paulo, Brazil. POPULATION: Twenty-four consecutive pregnant women at 24-26 weeks of gestation seen between February and October 2017 with a singleton pregnancy underwent in utero surgery to correct an open spinal defect in their fetus. METHODS: Amniotic fluid was tested for lactic acid, matrix metalloproteinase 2 (MMP-2), MMP-8, MMP-9 and interleukin-6 (IL-6) by enzyme-linked immunosorbent assay. Clinical data were collected after completion of all laboratory studies. MAIN OUTCOME MEASURE: Amniotic fluid concentration of compounds in women with or without PPROM. RESULTS: Preterm prelabour rupture of membranes occurred in seven (29.2%) women. There were no differences in maternal age, gravidity, parity, race, history of caesarean sections or fetal gender between women with or without PPROM. Length of surgery, days of wound healing and length of hospital stay were also indistinguishable. The median concentrations of MMP-8 (1.7 versus 0.6 ng/ml; P = 0.0041) and lactic acid (7.1 versus 5.9 mm; P = 0.0181) were higher in women with PPROM. The amniotic fluid MMP-8 level was also negatively correlated with gestational age at delivery (Spearman r = -0.4217, P = 0.0319). CONCLUSION: Differences in susceptibility to develop PPROM are present before fetal surgery. An increase in anaerobic glycolysis, evidenced by the intra-amniotic lactic acid level, may enhance MMP-8 production and weaken maternal and fetal membranes. TWEETABLE ABSTRACT: Matrix metalloproteinase-8 and lactic acid in amniotic fluid predict preterm prelabour rupture of membranes.

Effects of cervical cerclage on cervical length and the impact of changes in cervical length on pregnancy prognosis.

OBJECTIVE: To identify any cervix-related morphological and functional marker that can be correlated with pregnancy prognosis in patients who have undergone cerclage for cervical incompetence. DESIGN: An observational and prospective study. SETTING: Department of Obstetrics, Paulista School of Medicine - Federal University of São Paulo (UNIFESP-EPM). METHODS: Patients with cervical incompetence who underwent cervical cerclage using a modified version of the McDonald procedure during or before the 22nd week of pregnancy. The patients were examined by transvaginal ultrasound in the preoperative period, the immediate postoperative period, and between 20 and 24 weeks, 24 weeks + 1 day and 28 weeks, and 28 weeks + 1 day and 32 weeks. Cervical length and the presence of funneling were evaluated during all examinations. Changes in cervical length, presence or absence of funneling, percent increase or decrease in cervical length, and cervical length of less than established values (.

Application of fluorescence in situ hybridization (FISH) as a tool to aid cytogenetics in 1,409 fetal samples.

AIM: To evaluate the technical application of fluorescence in situ hybridization (FISH) as a support to classical cytogenetic in numerical chromosomal aneuploidies studies in samples of amniotic fluid, chorionic villus, and fetal loss. MATERIALS AND METHODS: The authois performed cytogenetic analyses in 1,409 patients (678 amniocentesis, 512 chorionic villus samples, and 219 spontaneous abortions) during one year. FISH molecular study aided traditional cytogenetic in 90 cases. These cases were indicated based on the diagnostic hypothesis of each patient or when no cellular growth was obtained. The authors standardized the FISH in discoloured slides. RESULTS: They had 85% positive FISH in amniotic fluid, 70% in chorionic villus, and 90% in abortion material using 13, 18, 21 X and Y centromeric probes. It showed 12% of altered FISH in amniotic fluid (100% trisomies), 10% in chorionic'villus (50% trisomy and 50% X - monosomy), and 22% in abortion material (50% trisomy, 25% X-monosomy, and 25% triploidy). FISH and cytogenetic analysis confirmed the results. CONCLUSION: This technique revolutionized clinical and research applications of cytogenetics. In this particular paper, FISH was a valuable and reliable technique to promptly identify rapid detection of aneuploidies in interphase cells, metaphase spread and paraffin-embedded samples. It is hoped that, in the future, the economic viability of array CGH and FISH, with the decreasing cost of testing and their genomics advantages can be incorporated as routine and customized in the approach of prenatal diagnosis.

Assessment of fetomaternal hemorrhage by Kleihauer-Betke test, flow cytometry and α-fetoprotein after invasive obstetric procedures.

PURPOSE: The aim of this study was to evaluate the passage of fetal red blood cells to the maternal circulation, after invasive obstetric procedures, through the Kleihauer-Betke test, flow cytometry and by measurement of maternal serum alpha-fetoprotein level. METHODS: This prospective descriptive study with patients submitted to amniocentesis, cordocentesis, chorionic villus sampling (CVS), amnioreduction and ventriculoamniotic shunt was performed for karyotype analysis, treatment of hydrocephalus and polyhydramnios and to assess fetal lung maturity. Maternal blood samples were collected before and 60 minutes after the invasive obstetric procedure to search for fetal erythrocytes using the Kleihauer-Betke test, flow cytometry and serum alpha-fetoprotein measurement. RESULTS: Ten invasive obstetric procedures were performed. The mean age of the patients was 29.2 years and the mean gestational age was 29.6 weeks. The procedures were: five amniocenteses, two cordocenteses, one CVS, one ventriculo-amniotic shunt and one amnioreduction with cephalocentesis. The indications for the procedures were: karyotype analysis in five patients, fetal lung maturity assessment in two patients, amnioreduction in one patient, fetal hydrocephalus shunt in one patient and polyhydramnios related to hydranencephaly in one patient. Regarding the path of puncture, three procedures were accomplished through the placenta and seven apart from it. All punctures were successful at the first attempt. There was no significant increase of fetal erythrocyte quantity in maternal blood samples using the Kleihauer-Betke test. After cordocentesis, a significant increase of fetal erythrocytes was detected by flow cytometry and serum alpha-fetoprotein measurement. CONCLUSION: Invasive obstetric procedures during prenatal care are safe when performed by experienced professionals using adequate techniques, with minimal chance of passage of fetal erythrocytes from the fetal compartment.

Interruption of a study of cervical ripening with isosorbide mononitrate due to adverse effects.

PURPOSE OF INVESTIGATION: The objective of this study was to evaluate cervix length and the presence of cervical gland area (CGA) in ultrasounds performed before and after the administration of vaginal isosorbide mononitrate (IMN) for cervical ripening. METHODS: We performed an observational, descriptive, and longitudinal study of pregnant patients indicated for labor induction and with a Modified Bishop Score (MBS) lower than six. For cervical ripening, 40 mg of vaginal IMN was administered at 0, 16, and 24 hours after the initiation of cervix preparation. RESULTS: After enrolling 11 patients, the study had to be discontinued due to adverse effects. Three patients requested that they be withdrawn. Headaches were reported by all patients. Nausea, dizziness, dyspnea, and vomiting were also reported. The average cervical lengths at 0, 16, 24 and 36 hours were 27.6, 27.7, 25.9, and 23.0 mm, respectively. CGA disappeared in one of seven patients. CONCLUSIONS: The use of IMN appears to increase the MBS, slightly reducing cervical length without altering the appearance of CGA. Considering the importance of maternal wellbeing during labor, the routine use of IMN cannot be recommended for cervical ripening in the third trimester due to the frequency and intensity of side-effects.

Diagnosis of ovarian metastasis from gestational trophoblastic neoplasia by 3D power Doppler ultrasound and dynamic contrast-enhanced magnetic resonance imaging: case report.

Choriocarcinoma is a highly malignant disease of trophoblastic cells, which affects young women in the reproductive years. The main sites of metastasis from choriocarcinoma are lung, vagina, liver, gastrointestinal tract and kidneys, and the involvement of the ovaries is extremely rare. The diagnosis of ovarian metastasis is made mainly by two-dimensional ultrasonography (2DUS) with color Doppler, which shows a large vessel in the center of the mass. The three-dimensional power Doppler ultrasound (3D power Doppler) and dynamic contrast-enhanced magnetic resonance imaging (MRI) are new diagnostic modalities not yet published in literature. We report a case of metastatic choriocarcinoma with left ovary involvement in a 48-year-old woman with history of molar pregnancy and irregular follow-up of this disease. We emphasize the main findings by 2DUS with color Doppler, 3D power Doppler and dynamic contrast-enhanced MRI. 3D power Doppler is able to improve the assessment of anatomical relationships of vessels with the ovarian mass, while the resonance angiography allows us to evaluate the anatomic relations of the mass and adjacent structures, as well as the iliac vessels. The 3D power Doppler and dynamic contrast-enhanced MRI are promising methods in the evaluation of metastasis arising from gestational trophoblastic tumors.

PP098. Lipidic fingerprinting in women with early-onset preeclampsia: A first look.

INTRODUCTION: preeclampsia is characterized by intense inflammatory response and an anti-angiogenic state. Maternal obesity has been considered to have important impact on the genesis of preeclampsia as lipotoxicity leads to maternal endothelial dysfunction and chronic inflammation. Here we investigate the plasma lipid profile of preeclamptic women. OBJECTIVES: identify possible lipid biomarkers for preeclampsia. METHODS: this study included 8 pregnant women with early-onset preeclampsia (before 34weeks gestation) and 8 normal pregnant women. Each patient in the preeclampsia group was matched to a patient in the control group according to gestational age at the time of sample collection. All patients in the control group were followed until term and had normal outcomes. To investigate the lipid profile, lipids were extracted from plasma samples using the Bligh-Dyer protocol and the extracts were subjected to MALDI-TOF Mass Spectrometry. Data matrix was exported for partial least squares discriminant analysis. All the variables analysed were sorted by a score number named Variable Importance in the Projection. The major discriminant variables were selected and underwent to Mann-Whitney U test. RESULTS: a total of 1290 ions were initially identified during lipidomic assessment. Twelve m/z signals were highlighted as the most important lipids for the discrimination of patients with preeclampsia. The identification of these differential lipids was carried out through Lipid Database Search. The main classes identified were Glycerophosphocholines [GP01], Glycerophosphoserines [GP03], Glycerophosphoglycerols [GP04], Glycosyldiradylglycerols [GL05] and Glycerophosphates [GP10]. CONCLUSION: Our results suggest that some lipid species may be potential biomarkers for early-onset preeclampsia.

Three-dimensional power Doppler placental vascularisation indices in early pregnancy: a pilot study.

The objective of our study was to assess 1st trimester placental vascularisation using three-dimensional (3D) power Doppler vascular indices. A cross-sectional study was used involving 41 normal pregnancies from 7 to 10 + 6 weeks. Placental volume was obtained using the 30° virtual organ computer-aided analysis (VOCAL) method. The mean, median, standard deviation (SD), minimum and maximum values were calculated for three vascular indices: the VI, vascularisation index; the FI, flow index and the VFI, vascularisation and flow index. Pearson's correlation coefficient (r) was used to assess the correlation between vascular indices and crown-rump length (CRL). Our results showed mean (± SD) values ranged from 8.66 ± 12.04 to 15.34 ± 13.89 for the VI, from 63.83 ± 43.61 to 109.22 ± 33.87 for the FI and from 9.52 ± 13.86 to 20.59 ± 22.97 for the VFI. There was no correlation between CRL and VI (r = 0.073, p = 0.630) nor VFI (r = 0.147 and p = 0.037); there was a weak correlation between CRL and FI (r = 0.332, p = 0.037). It was concluded that the FI was the only 3D power Doppler vascular index that was correlated with CRL between 7 and 10 + 6 weeks' gestation.

Doppler velocimetry of the uterine, umbilical and fetal middle cerebral arteries in pregnant women undergoing tocolysis with oral nifedipine.

OBJECTIVES: To evaluate Doppler velocimetry (resistance index (RI) and peak systolic velocity (PSV)) in the maternal-fetal circulation before and 5 and 24 h after tocolysis with oral nifedipine. METHODS: This was a prospective, observational, analytic cohort study performed in 47 pregnant women undergoing nifedipine tocolysis, each subject acting as her own control. Doppler assessment of uterine, umbilical and fetal middle cerebral (MCA) arteries was performed before and 5 and 24 h after an initial 20-mg sublingual dose, which was repeated twice at 20-min intervals if contractions failed to diminish. The maintenance dose consisted of 20 mg orally every 6 h for 24 h up to a total of 100-120 mg nifedipine. We analyzed whether there was a time effect and compared values at the different time-points. RESULTS: The MCA-RI had decreased significantly after 24 h of tocolysis (0 h = 0.85; 5 h = 0.85; 24 h = 0.81; P = 0.001), with no differences in uterine or umbilical arteries or in the MCA to umbilical artery ratio. The MCA-PSV had reduced significantly after 5 h (0 h = 41.5 cm/s; 5 h = 34.7 cm/s; P = 0.001), returning close to baseline levels between 5 and 24 h. The PSV increased significantly between 5 and 24 h in the right uterine artery (5 h = 55.1 cm/s; 24 h = 65.0 cm/s; P = 0.037) and in the umbilical artery (5 h = 28.4 cm/s; 24 h = 33.1 cm/s; P = 0.038). CONCLUSIONS: Nifedipine tocolysis is associated with a reduction in RI in the MCA but not in the uterine or umbilical arteries, a reduction in PSV in the MCA after 5 h but returning to baseline within 24 h, and an increase in PSV between 5 and 24 h in the umbilical and right uterine arteries.

Evaluation of placental volume at 7-10+6 weeks of pregnancy by 3D-sonography.

The aim of the study was to establish normative data for placental volume (PV) at 7-10+6 weeks of gestation using three-dimensional ultrasound (3DUS). The cross-sectional study involved 70 healthy pregnancies between 7 and 11 weeks. The VOCAL (Virtual Organ Computer-aided Analysis) method with a 30 degrees rotation angle and six planes was used for volumetric calculations. Regression models were constructed to assess the correlation between PV and crown-rump length (CRL) adjusted by the determination coefficient (R2). The method proposed by Royston and Wright was used to establish the 2.5th; 10th; 50th; 90th and 97.5th percentiles (percentile=mean+KxSD). The intraclass correlation coefficient (ICC), Bland-Altman graphs and Student's paired t-tests were used to assess intra- and interobserver variability. PV ranged from 1.7 to 42.6 cm3, with a mean of 13.6cm3 (+/-9.4cm3). There was a strong correlation between PV and CRL; the exponential equation was the model that best expressed the correlation between them (R2=0.76). For CRL between 9 and 40 mm, the mean PV increased 10.5 times, while CRL increased only 4.4 times. Inter- and intraobserver correlation were excellent (ICC=0.979 and 0.971, respectively). Bland-Altman graphs indicated a good reproducibility with a mean intraobserver and interobserver difference of 0.2 cm3 (95% CI: -0.7-1.2cm3) and -0.2cm3 (95% CI: -1.3-0.9cm3), respectively. Reference limits were generated for first trimester PV assessed by 3DUS using the VOCAL method. There is a strong correlation between PV and CRL. Placental volume obtained through this method was highly reproducible.

Measurement of embryo volume at 7-10 weeks' gestation by 3D-sonography.

The embryo volume (EV) is an important parameter for the early diagnosis of growth disorders. The objective of this study was to establish normal data for EV at 7-10 weeks' gestation with three-dimensional ultrasonography (3DUS). A cross-sectional study involving 50 pregnancies was performed. An endocavitary volumetric transducer (3D5-8EK) was used for all measurements. The VOCAL (Virtual Organ Computer-aided AnaLysis) method with a 30 degrees rotation angle was used for volumetric calculations. To analyse the correlation between EV and gestational age (GA) and crown-rump length (CRL), regression models were constructed. The mean, standard deviation, median, minimum and maximum values were calculated for each gestational age. The intraclass correlation coefficient (ICC) was used to determine inter- and intraobserver reliability. There was a significant correlation between EV and GA and CRL (R(2) = 0.951 and R(2) = 0.880, respectively). The exponential equation was the model that best expressed the correlation between these variables: [EV = exp(0.9481 x GA-8.117)] and [EV = 0.0871 exp(0.1207 x CRL)]. The mean EV ranged from 0.23 cm(3) (95% CI 0.03-0.42) at 7 weeks to 3.91 cm(3) (95% CI 3.85-3.96) at 10 weeks. Inter- and intraobserver correlation were excellent (ICC = 0.993 and 0.999, respectively). Embryo volume assessed through 3DUS increased from 7 to 10 weeks. Reference limits were generated for first trimester EV using 3DUS.

Prediction of acidemia at birth by Doppler assessment of fetal cerebral transverse sinus in pregnancies with placental insufficiency.

OBJECTIVES: To evaluate the prediction of acidemia at birth using cerebral transverse sinus (CTS) Doppler velocimetry and to determine the best parameter and cut-off values for its prediction in pregnancies complicated with placental insufficiency. METHODS: This was a prospective cross-sectional study involving 69 pregnant women (26-40 weeks' gestation) with placental insufficiency managed in two Brazilian hospitals. Doppler assessment of the CTS was carried out in the last 24 h before delivery, and the peak ventricular systolic (S-wave) and diastolic (D-wave) velocities as well as the atrial systolic velocity (A-wave) were recorded and the pulsatility index for veins (PIV) was calculated. At birth, arterial and venous umbilical cord blood samples were collected to determine acid-base and pH status. A receiver-operating characteristics (ROC) curve was constructed for each Doppler parameter with birth acidemia as the dependent variable. Sensitivity, specificity, positive and negative predictive values, accuracy and false-positive and false-negative rates were calculated for the parameters considered to be good predictors of acidemia. RESULTS: The S, D and A peak velocities and the S/A ratio were not good predictors of acidemia at birth. The PIV and the (S - A)/S ratio were good predictors of acidemia (area under the ROC curve = 0.698 (P = 0.009) and 0.654 (P = 0.009), respectively). The cut-off values were PIV = 0.855 and (S - A)/S = 0.703). CONCLUSIONS: The PIV and the (S - A)/S ratio of the CTS were good predictors of acidemia at birth in this high-risk population with placental insufficiency.