Umbilical Cord Biometry and Fetal Abdominal Skinfold Assessment as Potential Biomarkers for Fetal Macrosomia in a Gestational Diabetes Romanian Cohort.

Backgroundand Objectives: Gestational diabetes mellitus (GDM) is a pregnancy-associated pathology commonly resulting in macrosomic fetuses, a known culprit of obstetric complications. We aimed to evaluate the potential of umbilical cord biometry and fetal abdominal skinfold assessment as screening tools for fetal macrosomia in gestational diabetes mellitus pregnant women. Materials and methods: This was a prospective case−control study conducted on pregnant patients presenting at 24−28 weeks of gestation in a tertiary-level maternity hospital in Northern Romania. Fetal biometry, fetal weight estimation, umbilical cord area and circumference, areas of the umbilical vein and arteries, Wharton jelly (WJ) area and abdominal fold thickness measurements were performed. Results: A total of 51 patients were enrolled in the study, 26 patients in the GDM group and 25 patients in the non-GDM group. There was no evidence in favor of umbilical cord area and WJ amount assessments as predictors of fetal macrosomia (p > 0.05). However, there was a statistically significant difference in the abdominal skinfold measurement during the second trimester between macrosomic and normal-weight newborns in the GDM patient group (p = 0.016). The second-trimester abdominal circumference was statistically significantly correlated with fetal macrosomia at term in the GDM patient group with a p value of 0.003, as well as when considering the global prevalence of macrosomia in the studied populations, 0.001, when considering both populations. Conclusions: The measurements of cord and WJ could not be established as predictors of fetal macrosomia in our study populations, nor differentiate between pregnancies with and without GDM. Abdominal skinfold measurement and abdominal circumference measured during the second trimester may be important markers of fetal metabolic status in pregnancies complicated by GDM.

Third trimester intrauterine fetal death: proposal for the assessment of the chronology of umbilical cord and placental thrombosis.

The timing of umbilical cord and placental thrombosis in the third trimester intrauterine fetal death (TT-IUFD) may be fundamental for medico-legal purposes, when it undergoes medical litigation due to the absence of risk factors. Authors apply to human TT-IUFD cases a protocol, which includes histochemistry and immunohistochemistry (IHC) for the assessment of thrombi's chronology. A total of 35 thrombi of umbilical cord and/or placenta were assessed: 2 in umbilical artery, 6 in umbilical vein, 15 in insertion, 10 in chorionic vessels, 1 in fetal renal vein, 1 in fetal brachiocephalic vein. Thrombi's features were evaluated with hematoxylin-eosin, Picro-Mallory, Von Kossa, Perls, and immunohistochemistry for CD15, CD68, CD31, CD61, and Smooth Muscle Actin. The estimation of the age of the thrombi was established by applying neutrophils/macrophages ratio taking into consideration, according to literature, the presence of hemosiderophagi, calcium deposition, and angiogenesis. To estimate an approximate age of fresh thrombi (< 1 day), a non-linear regression model was tested. Results were compared to maternal risk factors, fetal time of death estimated at autopsy, mechanism, and cause of death. Our study confirms that the maternal risk factors for fetal intrauterine death and the pathologies of the cord, followed by those of the placental parenchyma, are the conditions that are most frequently associated with the presence of thrombi. Results obtained with histological stainings document that the neutrophile/macrophage ratio is a useful tool for determining placental thrombi's age. Age estimation of thrombi on the first day is very challenging; therefore, the study presented suggests the N/M ratio as a parameter to be used, together with others, i.e., hemosiderophagi, calcium deposition, and angiogenesis, for thrombi's age determination, and hypothesizes that its usefulness regards particularly the first days when all other parameters are negative.

Development of clinical sign-based scoring system for assessment of omphalitis in neonatal calves.

Omphalitis contributes significantly to morbidity and mortality in neonatal calves. Diagnosis of omphalitis is based on the local signs of inflammation-pain, swelling, local heat and purulent discharge. An abattoir trial identified an optimal, sign-based, scoring system for diagnosis of omphalitis. A sample of 187 calves aged between 7 and 15 days old were clinically examined for signs of umbilical inflammation and compared with postmortem examination of navels. On postmortem findings, 64 calves (34.2 per cent) had omphalitis. In the examined omphalitis cases, the most commonly affected umbilical structure was the urachus (78.1 per cent). Multivariable logistic regression revealed that thickening of the umbilical stump over 1.3 cm (P<0.001), discharge (P<0.001), raised local temperature (P=0.003) and the presence of umbilical hernia (P=0.024) were correlated and positive predictors of omphalitis. Discharge from the umbilical stump was associated with intra-abdominal inflammation (P=0.004). Assigning weights based on the multivariable logistic regression coefficients, a clinical scoring algorithm was developed. The cumulative score ranged from 0 to 9. Using this scoring system, calves were categorised as positive if their total score was ≥2. This scoring method had a sensitivity of 85.9 per cent, specificity of 74.8 per cent and correctly classified 78.6 per cent of all calves.

Tei index for prenatal diagnosis of acute fetal hypoxia due to intermittent umbilical cord occlusion in an animal model.

OBJECTIVE: To study the effectiveness of the pulsatility index for veins of ductus venosus (DV-PIV) and the Tei index in a prospective assessment of fetal hypoxic-ischemic brain damage in a near-term ovine fetus model with intermittent umbilical cord occlusion (UCO). METHODS: Twelve fetal sheep were studied with umbilical cord occlusion performed in the experimental group animals by complete inflation of an occluder cuff for 90 s, every 30 min for approximately 2.5 h. Fetal arterial blood was sampled at 5 min before the first umbilical cord occlusions, approximately 60 s of the first umbilical cord occlusions, and 3 min after each occlusion for blood gas, pH, neuron-specific enolase (NSE) and S100B. Doppler measurements and Doppler echocardiographic examinations were performed 5 min before the first umbilical cord occlusions and 3 min after each successive occlusion. RESULTS: In experimental group animals, UCO caused a large decline in arterial PaO(2) (to approximately 7.70 mmHg, p < 0.01), a modest decline in pH (to approximately 7.24, p < 0.01), and a modest rise in PaCO(2) (to approximately 53.31 mmHg, p < 0.01), with a return more or less to baseline after occluder release. and there was significant change as compared with the control animals (all p < 0.01) with cumulative changes in responses to repetitive cord occlusions. The DV-PIV waveforms, right ventricle (RV) and LV Tei indices, the serum levels of NSE and S100B increased with cord occlusions (all p < 0.05), and were significantly higher than the control animals (all p < 0.05) with a cumulative changes in responses to repetitive cord occlusions. RV and LV Tei indices were significantly correlated with PaO(2) (r = - 0.684, p < 0.01 and r = - 0.725, p < 0.01), PaCO(2) (r = 0.682, p < 0.01 and r = 0.780, p < 0.01), pH (r = - 0.538, p < 0.01 and r = - 0.681, p < 0.01), NSE (r = 0.653, p < 0.01 and r = 0.687, p < 0.01), and S100B (r = 0.606, p < 0.01 and r = 0.640, p < 0.01). Significant but weaker correlations were also present between DV-PIV and the parameters considered. CONCLUSION: Umbilical cord occlusion during the latter part of the pregnancy, enough to cause significant hypoxemia and acidosis, results in a significant increase of DV-PIV, RV and LV Tei indices, and the serum levels of NSE and S100B. There was a strong correlation between the RV and LV Tei indices and blood gas, pH, and NSE, S100B with hypoxia. Therefore, the Tei index might be an easy and useful quantitative parameter for assessing fetal hypoxic ischemia.

Avaliação do cordão umbilical pelo ultra-som tridimensional / Evaluation of umbilical cord by three-dimensional ultrasound

O cordão umbilical é uma estrutura de fundamental importância na vida intra-uterina ao manter conexão vascular entre feto e placenta. As patologias que acometem o cordão umbilical são responsáveis por altos índices de morbidade e mortalidade perinatais, sendo de extrema importância a sua detecção pré-natal. A ultra-sonografia bidimensional com o auxílio do Doppler colorido é utilizada rotineiramente no pré-natal na tentativa de diagnosticar as patologias funiculares, entretanto, em certas ocasiões o diagnóstico é impreciso e questionável. O surgimento da ultra-sonografia tridimensional nos modos multiplanar, reconstrução de superfície e Doppler colorido e de amplitude ao demonstrar a imagem nos três planos ortogonais facilita a visualização das relações espaciais do cordão umbilical. Com o maior desenvolvimento tecnológico da metodologia tridimensional espera-se maior fidedignidade no diagnóstico das patologias funiculares, principalmente nos casos nas quais a avaliação bidimensional é questionável

Development of clinical sign based algorithms for community based assessment of omphalitis.

BACKGROUND: In developing countries, newborn omphalitis contributes significantly to morbidity and mortality. Community based identification and management of omphalitis will require standardised clinical sign based definitions. OBJECTIVE: To identify optimal sign based algorithms to define omphalitis in the community and to evaluate the reliability and validity of cord assessments by non-specialist health workers for clinical signs of omphalitis. DESIGN: Within a trial of the impact of topical antiseptics on umbilical cord infection in rural Nepal, digital images of the umbilical cord were collected. Workers responsible for in-home examinations of the umbilical cord evaluated the images for signs of infection (pus, redness, swelling). Intraworker and interworker agreement was evaluated, and sensitivity and specificity compared with a physician generated gold standard ranking were estimated. RESULTS: Sensitivity and specificity of worker evaluations were high for pus (90% and 96% respectively) and moderate for redness (57% and 95% respectively). Swelling was the least reliably identified sign. Measures of observer agreement were similar to that previously recorded between experts evaluating subjective skin conditions. A composite definition for omphalitis that combined pus and redness without regard to swelling was the most sensitive and specific. CONCLUSIONS: Two sign based algorithms for defining omphalitis are recommended for use in the community. Focusing on redness extending to the skin around the base of the stump will identify cases of moderate and high severity. Requiring both the presence of pus and redness will result in a definition with very high specificity and moderate to high sensitivity.

The significance of the placenta in assessment of the newborn.

The placenta may harbor many diagnostic tools available for the care of ill neonates. Such tools enable fine-tuning of diagnoses or even the establishment of diagnoses not considered during the investigation and care of the newborn. For this reason, obstetricians, pediatricians, and pathologists should all be familiar with common placental diagnoses so that sharing of the available data among these specialists may, in many cases, provide supportive and diagnostic information critical to the management of the newborn.

Prenatal ultrasonographic morphologic assessment of the umbilical cord: a review. Part II.

Ultrasonographic assessment, although not always possible throughout the entire length of the umbilical cord, may assist in the diagnosis of congenital and functional anomalies of this structure. In such fashion, prenatal ultrasound may outline normal anatomy or alternatively depict various congenital abnormalities of the umbilical cord including: cysts; pseudocysts umbilical vein varix; persistent right umbilical vein; angiomyxomas; aneurysm (arterial or venous); single, hypoplastic or fused umbilical artery; hematomas (spontaneous or iatrogenic); velamentous insertion; vasa previa. The umbilical cord coiling index, an additional ultrasonographic morphologic feature, may identify patients at risk for adverse perinatal outcome. Conditions of potential fetal compromise due to umbilical cord compression including nuchal cords, true knots, occult prolapse, cord presentation, fetal grasping, and cord entanglement in monoamniotic twins, may be detected prenatally; and impaired umbilical flow can be confirmed with Doppler flow velocimetry. Ultrasound has been widely used to guide invasive diagnostic and therapeutic procedures involving access to umbilical circulation. We conclude that the review of current literature supports that precise prenatal ultrasonographic depiction of the morphology of the umbilical cord may enhance perinatal management.

Why all placentas should be examined by a pathologist in 1990.

Placental pathology is rarely a part of the training for either obstetrician or pathologist. As a result there has been confusion regarding the potential benefits of routine placental examination. These benefits include clarification of the causes of many adverse pregnancy outcomes, improvement of the risk assessment for future pregnancies, and ascertainment of newborn risk for long-term neurodevelopment sequelae. Information on placental abnormalities may reveal the presence of chronic fetal insults and allow their differentiation from acute (peripartum) stresses. Current methods of risk assessment fail to identify the majority of pregnancies that end in prematurity, stillbirth, growth retardation, or fetal distress. We suggest that placental pathology should be a routine component of obstetric-neonatal care.

Histologic chorioamnionitis and preterm delivery in different patient populations.

The placentas of 1843 deliveries were examined for the presence of histologic chorioamnionitis, which was classified as mild, moderate, or severe. Chorioamnionitis was present in 7.5% of patients who underwent cesarean before labor and in 18 and 32% of those delivering at term and preterm, respectively. Chorioamnionitis was severe in 74% of preterm but in only 15% of term deliveries. Premature rupture of membranes (PROM) was more frequent with preterm than with term delivery, with chorioamnionitis present in 42 and 15% of patients, respectively. Although chorioamnionitis was equally frequent in women with intact membranes delivering preterm and term, chorioamnionitis was severe in 63% of preterm and 14% of term deliveries (P less than .001). The frequency and severity of chorioamnionitis were related inversely to gestational age at preterm birth. Preterm delivery was more frequent in black than in white patients (19 versus 9%) and in indigent clinic versus private patients (13 versus 7.5%). However, there was no significant difference in frequency and severity of chorioamnionitis between black and white or between indigent clinic and private patients who delivered preterm. Among term births, chorioamnionitis was more often severe in black than in white patients. Chorioamnionitis in term deliveries was more frequent in clinic than in private patients; however, this was not true when only severe chorioamnionitis was considered. There were no differences in PROM between these patient populations. Thus, higher preterm birth rates in black and indigent clinic populations are not due to the more frequent occurrence of chorioamnionitis.