Impact of Medicaid expansion on pregnancy outcomes among women with gestational diabetes.

INTRODUCTION: The Affordable Care Act (ACA) aims to broaden health care access and significantly impacts obstetric practices. Yet, its effect on maternal and neonatal outcomes among women with gestational diabetes across diverse demographics is underexplored. OBJECTIVE: This study examines the impact of the implementation of the ACA on maternal and neonatal health in Maryland with ACA implementation and Georgia without ACA implementation. METHODOLOGY: We used data from the Maryland State Inpatient Database and US Vital Statistics System to assess the ACA's influence on maternal and neonatal outcomes in Maryland, with Georgia serving as a nonexpansion control state. Outcomes compared include cesarean section (CS) rates, low Apgar scores, neonatal intensive care unit (NICU) admissions, and assisted ventilation 7 h postdelivery. We adjusted for factors including women's age, race, insurance type, preexisting conditions, prior CS, prepregnancy obesity, weight gain during pregnancy, birth weight, labor events, and antenatal practices. RESULTS: The study included 52 479 women: 55.8% from Georgia and 44.2% from Maryland. Post-ACA, CS rates were 45.1% in Maryland versus 48.2% in Georgia (P = 0.000). Maryland demonstrated better outcomes, including lower rates of low Agar scores (odds ratio [OR], 0.74 [95% confidence interval (CI), 0.63-0.86]), assisted ventilation (OR, 0.79 [95% CI, 0.71-0.82]), and NICU admissions (OR, 0.76 [95% CI, 0.71-0.82]), but no significant change in CS rates (OR, 0.96 [95% CI, 0.92-1.01]). CONCLUSION: After ACA implementation, Maryland showed improved maternal and neonatal outcomes compared with Georgia, a nonexpansion state.

The association between community-level economic deprivation and incidences of emergency department visits on account of attempted suicides in Maryland.

Background: Suicide is a major cause of mortality in the United States, accounting for 14.5 deaths per 100,000 population. Many emergency department (ED) visits in the United States are due to attempted suicides. Suicide attempts predict subsequent completed suicides. Socioeconomic factors, such as community-level socioeconomic deprivation, significantly affect many traditional risk factors for attempted suicides and suicides. Aim: To determine the association between community-level socioeconomic deprivation and ED visits for attempted suicide in Maryland. Methods: A retrospective analysis of attempted suicides in the Maryland State Emergency Department Database from January 2018 to December 2020. Community-level socioeconomic deprivation was measured using the Distress Community Index (DCI). Multivariate regression analyses were conducted to identify the association between DCI and attempted suicides/self-harm. Results: There were 3,564,987 ED visits reported in the study period, with DCI data available for 3,236,568 ED visits; 86.8% were younger than 45 years, 64.8% were females, and 54.6% non-Hispanic Whites. Over the study period, the proportion of ED visits due to attempted suicide was 0.3%. In the multivariate logistic regression, compared to prosperous zones, those in comfortable (OR = 0.80, 95% CI: 0.73-0.88, p < 0.01), Mid-Tier (OR = 0.76, 95%CI:0.67-0.86, p < 0.01), At-Risk (OR = 0.77; 95%CI: 0.65-0.92, p < 0.01) and Distressed zones (OR = 0.53; 95% CI:0.42-0.66, p < 0.01) were less likely to visit the ED for attempted suicide. Conclusion: Prosperous communities had the highest rate of attempted suicides, with the risk of attempted suicide increasing as individuals move from the least prosperous to more prosperous areas.

Investigating the origin of the fetal gut and placenta microbiome in twins.

OBJECTIVE: It is widely accepted that the microbiota is critical for human well-being; however, the origin of microbiota in the newborn is not well understood. In this study, we hypothesized that within a maternal-twin dyad (MTD) the meconium microbiome will be similar to the placenta microbiome and the meconium microbiome of within MTD will be similar to one another. METHODS: Prospectively, meconium (proxy for fetal gut), placenta and maternal buccal, skin, vaginal, stool samples were collected from a cohort of MTDs at time of delivery hospitalization. We performed gene sequencing using the V4 region of 16S rRNA with rigorous negative controls. Alpha and beta diversity indices were computed to characterize the microbial community of MTD samples. A p value of <.05 was considered significant. RESULTS: From 17 MTD, 87/132 samples were successfully sequenced. The alpha diversity of the microbiome collected from all the body sites were different (p ≤ .001). The meconium samples when compared to other samples in the MTD microbial community were different (p = .009) and the Bray-Curtis dissimilarity was greater than 0.95 for all of the comparisons (beta diversity). The MTD within-twin placenta microbiome samples were also different, confirmed by Bray-Curtis pairwise dissimilarity distance, 0.83. CONCLUSION: The fetal gut microbiome is different from placenta and maternal buccal, skin, vaginal and stool microbiome. We clearly identified a distinct placenta microbiome. Furthermore, placentas in the same MTD have distinct microbiomes, suggesting that fetal gut and placenta origin is complex and remains unclear.

Prenatal Diagnosis of Congenital Cataract: Sonographic Features and Perinatal Outcome in 41 Cases.

PURPOSE: To describe the prenatal ultrasonographic characteristics and perinatal outcomes of congenital cataract. MATERIALS AND METHODS: We analyzed congenital cataract diagnosed prenatally at four referral centers between August 2004 and February 2019. The diagnosis was confirmed by postnatal ophthalmologic evaluation of liveborn infants or autopsy for terminated cases. Maternal demographics, genetic testing results, prenatal ultrasound images, and perinatal outcomes were abstracted. RESULTS: Total of 41 cases of congenital cataract diagnosed prenatally among 788 751 women undergoing anatomic survey. Based on the sonographic characteristics, 16/41 (39.0 %) had a dense echogenic structure, 15/41 (36.6 %) had a hyperechogenic spot and 10/41 (24.4 %) had the "double ring" sign. 17/41 (41.5 %) were isolated, and 24/41 (58.5 %) had associated intraocular and extraocular findings. Microphthalmia, cardiac abnormalities, and central nervous system abnormalities were the most common associated abnormalities. Regarding potential etiology, 6 cases had a known family history of congenital cataract, 4 cases had confirmed congenital rubella infection, and 2 cases had aneuploidy. 31/41 (75.6 %) elected termination and 10/41 (24.4 %) elected to continue their pregnancy. Among the 10 cases, one case died, one case was lost to follow-up, and the remaining 8 cases were referred for ophthalmologist follow-up and postnatal surgery. CONCLUSION: Once fetal cataracts are detected, a detailed fetal anatomy survey to rule out associated abnormalities and a workup to identify the potential etiology are recommended. Prenatal diagnosis of congenital cataracts provides vital information for counseling and subsequent management.

Fetal Open and Closed Spina Bifida on a Routine Scan at 11 Weeks to 13 Weeks 6 Days.

OBJECTIVES: This study aimed to determine the sensitivity of a first-trimester routine scan in detecting spina bifida (SB) and evaluating the first-trimester intracranial signs. METHODS: This retrospective study was a review of a prospectively collected database. All cases of SB diagnosed in a tertiary center from 2008 to 2015 were identified. The ultrasound images and medical records were reviewed. All cases of SB diagnosed prenatally were confirmed at birth or autopsy. RESULTS: A total of 24 cases of SB were diagnosed from 53,349 pregnancy cases. Except for 10 cases with a body stalk anomaly, craniorachischisis, or iniencephaly, 7 cases with open spina bifida (OSB) and 7 cases with closed spina bifida (CSB) were analyzed. The first-trimester detection rates were 100% (7 of 7) for OSB and 28.5% (2 of 7) for CSB. Eight cases were highly suspected of SB in the first trimester because of an abnormal appearance of the posterior brain; 3 were false-positive cases. Two isolated cases of OSB had first-trimester intracranial signs. An obliterated cisterna magna (CM) showed the highest sensitivity for OSB but low specificity. Two cases of OSB had no discernible landmark of intracranial translucency and the CM, and 4 showed normal intracranial translucency with an obliterated CM. All CSB cases were coupled with a normal hind brain except for 2 cases. CONCLUSIONS: A first-trimester routine scan has high sensitivity in screening for OSB. The CM may be the most sensitive intracranial sign.

Congenital abnormalities of the aortic arch: revisiting the 1964 Stewart classification.

The traditional classification of congenital aortic arch abnormalities was described by James Stewart and colleagues in 1964. Since that time, advances in diagnostic imaging technology have led to better delineation of the vasculature anatomy and the identification of previously unrecognized and unclassified anomalies. In this manuscript, we review the existing literature and propose a series of modifications to the original Stewart classification of congenital aortic arch abnormalities to incorporate this new knowledge. In brief, we propose the following modifications: (1) In Group I, we further divide subgroup B into left arch atretic and right arch atretic; (2) In Group II, we add three more subgroups, including aberrant right innominate artery, "isolated" right innominate artery (RIA), "isolated" right carotid artery with aberrant right subclavian artery; (3) In Groups I, II, and III, we add a subgroup of absence of both ductus arteriosus; and (4) In Group IV, we add three subgroups, including circumflex retro-esophageal aorta arch, persistent V aortic arch, and anomalous origin of pulmonary artery from ascending aorta.

Progesterone Inhibits Apoptosis in Fetal Membranes by Altering Expression of Both Pro- and Antiapoptotic Proteins.

OBJECTIVE: Progesterone supplementation prevents preterm birth (PTB) in some high-risk women, but its mechanism of action is unknown. One-third of PTB is associated with preterm premature rupture of membranes (PPROMs). We have previously shown that progesterone inhibits basal and Tumor Necrosis Factor (TNF) α-induced apoptosis in an explant model of human fetal membranes. This study investigates the molecular mechanisms responsible for progesterone-mediated inhibition of apoptosis in fetal membranes. METHODS: Human fetal membranes were collected at elective cesarean at term (no labor, no infection; n = 6), washed, and pretreated with/without progesterone (125 ng/mL) for 24 hours. Thereafter, membranes were treated with/without TNFα (50 ng/mL) and/or progesterone for 48 hours, harvested, and homogenized. Apoptosis was determined by evaluating caspase-3, -8, and -9 activities. Expression of pro- BH3 interacting domain death against, Bc1-2 associated X protein (BID, BAX) and antiapoptotic proteins (X-linked inhibitor of apoptosis protein [XIAP], Bcl-2, FLICE inhibitory protein [FLIP]) were measured by Western blot. RESULTS: TNFα increased apoptosis (measured by caspase-3, -8, and -9 activities) in fetal membranes, and this effect was abrogated by progesterone. Under basal conditions, progesterone suppressed expression of the proapoptotic protein, BID, by 0.45 (0.14)-fold, and increased expression of the antiapoptotic proteins, Bcl-2 and XIAP; no change was seen in BAX or FLIP. In contrast, TNFα increased BID expression by 5.15 (2.92)-fold, which was prevented by pretreatment with progesterone. CONCLUSIONS: Progesterone inhibits apoptosis in fetal membranes by suppressing expression of the proapoptotic protein, BID (for both basal and TNFα-induced apoptosis), and upregulating expression of the antiapoptotic proteins, XIAP and Bcl-2 (under basal conditions only). These data provide a mechanism by which progesterone supplementation may prevent PPROM and PTB in some women at high risk.

Monochorionic-Triamniotic Triplet Pregnancy Complicated by Twin Reversed Arterial Perfusion Sequence: Case Report and Literature Review.

Background Monochorionic-triamniotic pregnancies are rare and fraught with complications. Case A case of monochorionic-triamniotic triplet pregnancy complicated by twin reversed arterial perfusion (TRAP) sequence is presented. The patient declined termination or selective fetal reduction. Triplet C was acardiac. At 24 weeks, triplet B developed polyhydramnios. At 30 weeks, polyhydramnios was seen in all three amniotic sacs, but without signs of fetal hydrops and with normal Doppler velocimetry measurements in the umbilical artery, middle cerebral artery, and ductus arteriosus of triplets A and B. At 32 2/7 weeks, the patient presented with preterm premature rupture of membranes and preterm labor. Two live male infants were delivered by cesarean delivery weighing 1,350 and 1,390 g, respectively; the acardiac fetus weighed 1,460 g. Pathology examination revealed a single placenta weighing1,250 g, with evidence of direct vascular connections between triplets A and C as well as between triplets A and B. Conclusion Monochorionic-triamniotic triplet pregnancy with TRAP sequence is rare. Although the risk of complications is high, such pregnancies can be managed conservatively in select cases.

Etiology and Perinatal Outcome of Nonimmune Hydrops Fetalis in Southern China.

Objective This study aims to analyze the etiology and perinatal outcome of nonimmune hydrops fetalis (NIHF) in Southern China. Methods All cases with NIHF diagnosed antenatally from January 1, 2007 to December 31, 2014 were identified and analyzed. Results Total 482 cases of NIHF were identified during the study period. The most common cause of NIHF was hemoglobin (Hb) Bart's disease (61.8%), followed by chromosomal abnormalities (13.5%), idiopathic etiology (13.1%), cardiac abnormalities (6.4%), and others (5.2%). After 20 weeks' gestation, a total of 408 cases of NIHF presented, including Hb Bart's disease (279 cases), cardiac abnormalities (27 cases), and infection (7 cases). NIHF caused by chromosomal abnormalities mainly presented between 15 and 19 weeks' gestation. Of the 482 cases, 459 cases elected termination of pregnancy. The remaining 23 cases elected to continue their pregnancy. Among them, 14 (60.9%) resulted in intrauterine fetal death, 6 had neonatal death, 3 infants survived to 1 year of age. Of the three infants, one has cerebral palsy, and the remaining two are normal. Conclusions Hb Bart's disease is the most common cause of NIHF in Southern China. An effective prenatal screening and counseling program for thalassemia in this region may be the most effective way to lower the incidence NIHF.

Ultrasonographic Characteristics of Cortical Sulcus Development in the Human Fetus between 18 and 41 Weeks of Gestation.

BACKGROUND: Fetal brain development is a complicated process that continues throughout pregnancy. Fetal sulcus development has typical morphological features. Assessment of fetal sulcus development to understand the cortical maturation and development by prenatal ultrasound has become widespread. This study aimed to explore a reliable method to assess cortical sulcus and to describe the normal sonographic features of cortical sulcus development in the human fetus between 18 and 41 weeks of gestation. METHODS: A cross-sectional study was designed to examine the fetal cortical sulcus development at 18-41 weeks of gestation. Ultrasound was used to examine the insula, sylvian fissure (SF), parieto-occipital fissure (POF), and calcarine fissure (CF). Bland-Altman plots were used for assessing the concordance, and the intraclass correlation coefficient was used for assessing the reliability. RESULTS: SF images were successfully obtained in 100% of participants at 22 weeks of gestation, while the POF images and CF images could be obtained in 100% at 23 weeks of gestation and 24 weeks of gestation, respectively. The SF width, temporal lobe depth, POF depth, and the CF depth increased with the developed gestation. The width of uncovered insula and the POF angle decreased with the developed gestation. By 23 weeks of gestation, the insula was beginning to be covered. Moreover, it completed at 35 weeks of gestation. The intra- and inter-observer agreements showed consistent reproducibility. CONCLUSIONS: This study defined standard views of the fetal sulcus as well as the normal reference ranges of these sulcus measurements between 18 and 41 weeks of gestation. Such ultrasonographic measurements could be used to identify fetuses at risk of fetal neurological structural disorders.

Urine Protein/Creatinine Ratios during Labor: A Prospective Observational Study.

PURPOSE: To evaluate the utility of urine protein/creatinine ratio (uPCR) measurements among healthy parturients at term we performed a prospective cohort study at a community teaching hospital. METHODS: Serial urine samples were collected. Ninety-three women contributed 284 urine samples. uPCRs were determined. Multiple imputation and paired sampled analysis was performed when appropriate. RESULTS: Two-thirds (63/93) of women had at least one measured uPCR ≥ 0.3. One-third (31/93) had a uPCR ≥ 0.3 at admission, including 39.1% (9/23) of women not in labor. Median (IQR) uPCRs increased during labor and after delivery: latent phase/no labor, 0.15 (0.06-0.32); active phase, 0.29 (0.10-0.58); early postpartum, 0.45 (0.18-1.36) (all p < 0.04). Median uPCRs were significantly < 0.3 in the latent phase and significantly > 0.3 in the immediate postpartum period (p < 0.01). Women who labored before cesarean delivery had the highest early postpartum uPCRs: median (IQR) 1.16 (0.39-1.80). A negative urine dipstick protein result did not exclude uPCR ≥ 0.3. uPCRs were similar when compared by method of urine collection. CONCLUSION: uPCR ≥ 0.3 is common among healthy women with uncomplicated pregnancies at term. uPCR increases during labor and is not a reliable measure of pathologic proteinuria at term or during the peripartum period.

Methicillin-Resistant Staphyloccocus aureus intracranial Epidural Abscess with Osteomyelitis During Pregnancy: A Case Report.

BACKGROUND: The incidence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) infection is increasing, and 0.5-4% of pregnant women are colonized. CASE: A 30-year-old pregnant woman at term presented with intractable headache 1 week after incision and drainage of a MRSA-positive axillary abscess. Imaging demonstrated a right-sided epidural abscess with midline shift and myositis of the overlying temporalis muscle. She underwent cesarean delivery followed by craniectomy of osteomyelitic bone and evacuation of the epidural abscess. CONCLUSION: Central nervous system abscess is rare but should be considered in patients with a history of MRSA infection and new neurologic signs or symptoms. Surgical evacuation and antibiotic therapy in combination with obstetrical care considering delivery timing based upon maternal stability and gestational age may produce excellent outcomes.

First-Trimester Echocardiographic Features and Perinatal Outcomes in Fetuses With Congenital Absence of the Aortic Valve.

OBJECTIVES: The purpose of this study was to describe the echocardiographic features and perinatal outcomes of congenital absence of the aortic valve diagnosed by first-trimester echocardiography. METHODS: This retrospective study assessed the feasibility of first-trimester echocardiography in detecting absence of the aortic valve. All cases of absence of the aortic valve diagnosed by first-trimester fetal echocardiography from January 2010 to December 2014 were identified at a single referral center using an established perinatal database. Demographic information, echocardiograms, perinatal outcomes, and autopsy reports were reviewed. Echocardiographic features were described. RESULTS: A total of 50,822 fetuses underwent first-trimester echocardiography during the study period. Ten cases of congenital absence of the aortic valve were diagnosed, for an overall incidence rate of 0.019%. The earliest gestational age at diagnosis was 11 weeks 6 days. The mean crown-lump length was 61.9 mm; mean gestational age was 12 weeks; and mean maternal body mass index ± SD was 21.2 ± 3.9 kg/m(2). Nine fetuses had increased nuchal translucency ranging from 2.4 to 12.4 mm (mean ± SD, 6.4 ± 3.6 mm). Color Doppler flow imaging revealed biphasic bidirectional flow in the ascending aorta and aortic arch and reversed flow in the ductus venosus during atrial systole in all cases. Reversed diastolic flow was present in the umbilical arteries and thoracic aorta. All cases had complex cardiac malformations as well as extracardiac abnormalities. CONCLUSIONS: Our study confirms that absence of the aortic valve is a rare cardiac defect that can be diagnosed by first-trimester fetal echocardiography. A "to-and-fro" flow pattern or biphasic bidirectional flow in the great arteries is a key echocardiographic feature in fetuses with absence of the aortic valve.

Routine screening for fetal limb abnormalities in the first trimester.

OBJECTIVE: We aim to determine the accuracy of first-trimester ultrasonography in detecting fetal limb abnormalities. METHODS: This is a retrospective study of all women undergoing fetal nuchal translucency (NT) assessment and detailed fetal anatomic survey in the first trimester at a single tertiary-care referral center in China. Fetal anatomy scans were repeated in the second trimester. Detection of fetal limb abnormalities was compared between first and second trimester anatomy scans and confirmed at delivery or at autopsy. RESULTS: Analyzed were 9438 fetuses from 9197 women (241 twin pairs). The incidence of fetal limb abnormalities was 0.38% (36/9438). Of these, 28 (77.8%) were diagnosed prenatally: 23 (63.9%) on first trimester scan and 5 (13.9%) on second trimester scan. Limb reduction defects (usually transverse limb deficiencies) were the most common limb defects identified in the first trimester (n = 12), followed by clubfoot (n = 4), skeletal dysplasia (n = 3), sirenomelia (n = 1), limb dysplasia (n = 1), malposition (n = 1), and syndactyly (n = 1). Nine fetuses with isolated limb abnormalities had normal NT, while 74.1% (20/27) of limb abnormalities that were associated with other abnormalities had increased NT. CONCLUSIONS: This study demonstrates that the majority of limb abnormalities detected prenatally [23/28 (82%)] can be identified in the first trimester, especially major limb defects; however, our numbers are small and still need larger cases for further investigation.

The role of doppler waveforms in the fetal main pulmonary artery in the prediction of neonatal respiratory distress syndrome.

OBJECTIVE: To describe changes in the Doppler waveforms of the fetal main pulmonary artery (MPA) throughout gestation and to assess their predictive value of neonatal respiratory distress syndrome (RDS). STUDY DESIGN: In the first phase of this study, we performed Doppler measurement of MPA acceleration time (AT), ejection time (ET), peak systolic velocity, end-diastolic velocity, mean velocity, pulsatility index, and resistance index in 288 healthy fetuses. In the second phase, we carried out these measurements in a prospective cohort of 52 pregnant women with impending preterm birth. RESULTS: In phase I, satisfactory fetal MPA Doppler recordings were collected in 284 of 288 (98.6%) normal fetuses. Significant and positive linear correlations were found between gestational age and AT, AT/ET ratio, peak systolic velocity, and mean velocity (p < 0.01), with the strongest correlations concerning AT (r = 0.898) and AT/ET ratio (r = 0.868). In phase II, satisfactory fetal MPA Doppler waveforms were obtained in 43 of 44 (97.7%) fetuses. Of these, 14 (32.6%) developed RDS and 29 did not. Using less than or equal to the fifth percentile as a gestational age-specific cutoff, AT alone could predict RDS with a sensitivity of 78.6% and a specificity of 89.7%. The AT/ET ratio could predict RDS with 71.4% sensitivity and 93.1% specificity. CONCLUSIONS: Fetal MPA Doppler velocimetry can reliably be obtained throughout gestation. AT and AT/ET ratios of the fetal MPA Doppler waveform may help identifying fetuses at risk of developing neonatal RDS.

Prenatal diagnosis and perinatal outcome of congenital dacryocystocele: a large case series.

OBJECTIVE: To describe the incidence, prenatal diagnosis, and perinatal outcome in fetuses with congenital dacryocystocele. METHODS: All cases of congenital dacryocystocele diagnosed by prenatal ultrasound were identified using an established perinatal database. Prenatal ultrasound images were reviewed, and perinatal outcome was abstracted from the medical records. The correlation between the cyst size, gestational age, and prenatal and neonatal outcome was analyzed. RESULTS: The overall incidence of fetal dacryocystocele was 0.016% (75/456,202). Fifty-three cases (70.7%) had unilateral, and 22 (29.3%) had bilateral lesions. Lesions were seen more commonly among female fetuses with a female : male ratio 1.48 : 1. The average diameter of cysts size was 6.9 ± 1.9 mm (3.3-11 mm). There was a direct correlation between cyst size and gestational age. Among the 75 cases, 8 were lost to follow-up, 3 underwent elective termination of pregnancy. 58 resolved spontaneously before birth, and 6 were confirmed at birth. Two developed neonatal infection requiring antibiotic treatment. All 6 cases confirmed at birth resolved without surgical resection. CONCLUSIONS: Congenital dacryocystocele can be diagnosed by prenatal ultrasound. Such lesions typically resolve spontaneously in utero or in the early neonatal period. Thus, it should be considered as a developmental variant rather than a structural birth defect.

Prenatal diagnosis of diastematomyelia: a case report and review of the literature.

Diastematomyelia is a rare congenital disorder in which the spinal cord is divided longitudinally for part of its length. It can be accurately identified in the prenatal period by detailed sonographic examination of the spine. We report a case of diastematomyelia localized to spinal levels T6-T9 diagnosed prenatally at 31 weeks' gestation and review the existing literature on the diagnosis and management of this condition during pregnancy.

Intra-amniotic infection upregulates neutrophil gelatinase-associated lipocalin (NGAL) expression at the maternal-fetal interface at term: implications for infection-related preterm birth.

OBJECTIVE: Neutrophil gelatinase-associated lipocalin (NGAL) is a ubiquitous lipocalin that serves as a critical component of innate immunity and a transport shuttle for numerous substances (retinoids, arachidonic acid, prostaglandins, fatty acids, steroids, iron, and MMPs). Despite the well-documented association between intra-amniotic infection/inflammation (IAI) and preterm birth, NGAL expression in the uterus has not previously been examined. This study investigates NGAL expression at the maternal-fetal interface in vivo and in vitro. METHODS: Neutrophil gelatinase-associated lipocalin expression in term placenta with/without IAI was examined by immunohistochemistry. Trophoblast and decidual stromal cells were retrieved from elective cesarean, purified, and depleted of leukocytes. On days 1 (cytotrophoblast cells) and 4 (syncytiotrophoblast), cells were stimulated with/without interleukin 1ß (IL-1ß; 1 ng/mL), tumor necrosis factor α (TNF-α; 1 ng/mL), or lipopolysaccharide (LPS; 1 µg/mL). Neutrophil gelatinase-associated lipocalin messenger RNA (mRNA) and protein expression were measured by immunocytochemistry/Western blot and RT-qPCR, respectively. RESULTS: Under basal conditions, NGAL is expressed in trophoblast, but not decidua. Trophoblast NGAL is significantly upregulated in tissues with evidence of IAI vs controls. NGAL expression was increased after stimulation with all 3 pro-inflammatory mediators in day 1 (cytotrophoblast) but not day 4 cells (syncytiotrophoblast). IL-1ß and TNF-α (not LPS) upregulated NGAL gene expression in cytotrophoblast (not syncytiotrophoblast) cells. CONCLUSIONS: Intra-amniotic infection/inflammation is associated with increased expression of NGAL in trophoblast tissues in vivo. IL-1ß, TNF-α, and LPS stimulated NGAL in cytotrophoblast cells (not syncytiotrophoblast and decidua) in vitro. These data suggest that, in keeping with its role as a mediator of innate immunity, NGAL may have a central role to play in IAI-induced preterm birth.

Prenatal diagnosis of congenital vascular rings and slings: sonographic features and perinatal outcome in 81 consecutive cases.

OBJECTIVE: To describe the sonographic features and perinatal outcome of congenital vascular rings diagnosed prenatally at a single tertiary care institution. METHODS: All cases of congenital vascular rings diagnosed by prenatal ultrasound between July 2005 and December 2009 were identified at a single referral center using an established perinatal database. The diagnosis was confirmed by postnatal echocardiography for live-born infants or autopsy for terminated cases. RESULTS: The overall incidence of vascular ring during this 5-year period was 0.086% (81 cases among 94 321 women undergoing perinatal ultrasound examination). Forty-four cases had complete O-shaped (n = 3) or U-shaped (n = 41) vascular rings, and 37 cases had incomplete C-shaped vascular rings (vascular slings). The most common type of vascular ring seen in 50.6% (41/81) of cases was a right aortic arch with aberrant left subclavian artery. The second most common type was a left aortic arch with an aberrant right subclavian artery [39.5% (32/81)]. Chromosomal analysis was performed prenatally in 46 pregnancies, and six cases (13.0%) of fetal aneuploidy were identified. CONCLUSIONS: Congenital vascular rings can be diagnosed with prenatal ultrasound using the three-vessel trachea view and subsequent fetal echocardiography with particular attention to the relationship of the aortic arches, ductal arches, and the trachea.

Spontaneous rupture of the spleen: a rare but serious case of acute abdominal pain in pregnancy.

BACKGROUND: Spontaneous (non-traumatic) rupture of the spleen rarely occurs in the setting of a normal spleen, especially during pregnancy. OBJECTIVES: We report a case of spontaneous rupture of a normal spleen at 33.7 weeks gestation and review the literature with the aim of exploring the etiology, diagnosis, and management of this condition during pregnancy. CASE REPORT: A 30-year-old Chinese primigravida presented at 33.7 weeks gestation with acute onset of severe, constant left upper abdominal pain. She developed acute hypotension. Physical examination revealed diffuse abdominal tenderness with rebounding and guarding. An emergent cesarean delivery and abdominal exploration was performed. A non-viable male infant was delivered, and active bleeding was identified at the splenic hilum consistent with splenic rupture. A splenectomy was performed, and a consumptive coagulopathy was identified and treated. The patient had an uncomplicated postoperative course and was discharged home on postoperative day 15. CONCLUSION: Splenic rupture in pregnancy is a life-threatening complication. Early diagnosis and aggressive surgical intervention will allow for optimal maternal and perinatal outcome.