Addition of Color Doppler Sonography for Detection of Amniotic Fluid Disturbances and Its Implications on Perinatal Outcomes.

OBJECTIVES: To determine whether color Doppler sonography increases the detection of pregnancies at risk for adverse outcomes. METHODS: Participants admitted to labor and delivery with the anticipation of a vaginal delivery underwent measurements of amniotic fluid volume (AFV) using amniotic fluid index (AFI) and single deepest pocket (SDP) techniques by grayscale followed by color Doppler sonography. Oligohydramnios was defined as an AFI of less than 5 cm or an SDP of less than 2 cm. Intrapartum and perinatal outcomes were compared between participants with a diagnosis of a low AFV by grayscale and color Doppler sonography. RESULTS: Over 42 months, 428 women were enrolled in the study. Color Doppler sonography resulted in lower AFV estimates (mean ± SD by the AFI, 10.7 ± 3.7 cm by grayscale sonography and 8.6 ± 3.6cm by color Doppler sonography; P < .0001). For the SDP, the mean AFVs were 4.6 ± 2.0 cm by grayscale sonography and 3.4 ± 1.4 cm by color Doppler sonography (P < .0001). The level of agreement between grayscale and color Doppler sonography in estimating the AFV was fair, with κ = 0.32 for the AFI and 0.28 for the SDP. Outcome measures of AFVs classified as low based on color Doppler sonography (normal by grayscale sonography) and those classified as low by grayscale sonography (low by color Doppler sonography) were compared. There was no difference in composite perinatal complications, mode of delivery, or composite neonatal complications. CONCLUSIONS: The use of color Doppler sonography leads to the overdiagnosis of low AFVs and does not appear to increase the detection of pregnancies destined for adverse intrapartum or perinatal outcomes.

Idiopathic polyhydramnios: persistence across gestation and impact on pregnancy outcomes.

PURPOSE: To investigate the likelihood of resolution of idiopathic polyhydramnios in pregnant women and compare outcomes between resolved and persistent cases. METHODS: One hundred and sixty-three women with idiopathic polyhydramnios who delivered at two medical centers during a 3 year period (January 2012-January 2015) were included in the study. Exclusion criteria included congenital fetal anomalies, maternal diabetes, isoimmunization, fetal infection, placental tumors or anomalies, and multiple gestation. Polyhydramnios was defined as SDP≥8cm or AFI≥24cm. Resolved cases were defined as those with AFI and/or SDP falling and remaining below 24cm and 8cm respectively. Pregnancy outcomes were compared between resolved and persistent cases. Two-sample t-test or Wilcoxon rank-sum test was used for continuous variables while chi-square test or Fisher's exact test was used for categorical measures. RESULTS: Resolution was noted in 61 of 163 (37%) patients. There were no differences in maternal age, gravidity or parity between resolved and persistent cases. Mean gestational age at diagnosis of polyhydramnios and overall mean AFI were significantly lower in the cases that resolved (29.7±4.5 weeks vs 33.4±4.1 weeks, p<0.0001; 23.3±3.5cm vs 25.8 23.3±4.0cm, p=0.0002). Similar to AFI measurements, mean SDP was also lower in cases with resolution (p=0.002). There was no difference in induction rates, mode of delivery, amnioinfusion rates, meconium staining of amniotic fluid and fetal heart rate abnormalities influencing intrapartum management between the two groups. Induction of labor for fetal indication and rupture of membranes were significantly more common in the persistent group. Cesarean delivery for abnormal lie and fetal distress did not differ between the groups. There was an increased risk of macrosomia (>4000g) and preterm delivery (<37 weeks) in the persistent group (p<0.05). CONCLUSIONS: Resolution rate was approximately 37% and more likely in cases diagnosed earlier in pregnancy and with lower mean amniotic fluid volume. Preterm delivery and macrosomia were more common in cases that persisted across gestation.

Discrepancy in Insulin Regulation between Gestational Diabetes Mellitus (GDM) Platelets and Placenta.

Earlier findings have identified the requirement of insulin signaling on maturation and the translocation of serotonin (5-HT) transporter, SERT to the plasma membrane of the trophoblast in placenta. Because of the defect on insulin receptor (IR) in the trophoblast of the gestational diabetes mellitus (GDM)-associated placenta, SERT is found entrapped in the cytoplasm of the GDM-trophoblast. SERT is encoded by the same gene expressed in trophoblast and platelets. Additionally, alteration in plasma 5-HT levels and the 5-HT uptake rates are associated with the aggregation rates of platelets. Therefore, here, we investigated a novel hypothesis that GDM-associated defects in platelet IR should change their 5-HT uptake rates, and this should be a leading factor for thrombosis in GDM maternal blood. The maternal blood and the placentas were obtained at the time of cesarean section from the GDM and non-diabetic subjects (n = 6 for each group), and the platelets and trophoblasts were isolated to determine the IR activity, surface level of SERT, and their 5-HT uptake rates.Interestingly, no significant differences were evident in IR tyrosine phosphorylation or the downstream elements, AKT and S6K in platelets and their aggregation rates in both groups. Furthermore, insulin stimulation up-regulated 5-HT uptake rates of GDM-platelets as it does in the control group. However, the phosphorylation of IR and the downstream elements were significantly lower in GDM-trophoblast and showed no response to the insulin stimulation while they showed 4-fold increase to insulin stimulation in control group. Similarly, the 5-HT uptake rates of GDM-trophoblast and the SERT expression on their surface were severalfold lower compared with control subjects. IR is expressed in all tissues, but it is not known if diabetes affects IR in all tissues equally. Here, for the first time, our findings with clinical samples show that in GDM-associated defect on IR is tissue type-dependent. While IR is impaired in GDM-placenta, it is unaffected in GDM-platelet.

Childhood Respiratory Morbidity after Late Preterm and Early Term Delivery: a Study of Medicaid Patients in South Carolina.

BACKGROUND: There is a growing body of research documenting an increased risk of neonatal morbidity for late preterm infants (LPI, 34(0/7) weeks to 36(6/7) weeks) and early term infants (ETI, 37(0/7) weeks to 38(6/7) weeks) compared with term infants (TI, 39(0/7) to 41(6/7) ); however, there has been little research on outcomes beyond the first year of life. In this study, we examined respiratory outcomes of LPI and ETI in early childhood. METHODS: South Carolina Medicaid claims data for maternal delivery and infant birth hospitalisations were linked to vital records data for the years 2000 through 2003. Medicaid claims for all infants were then followed until their fifth birthday or until a break in their eligibility. Infants born between 34(0/7) and 41(6/7) weeks were eligible. Infants with congenital anomaly, birthweight below 500 g or above 6000 g, and multiple births were excluded. We fit Cox proportional hazard models from which adjusted hazard ratio (HR) and 95% confidence interval (CI) were derived. RESULTS: A total of 3476 LPI, 12 398 ETI, and 25 975 term infants were included. Both LPI and ETI were associated with an increased risk for asthma (LPI: HR 1.24, 95% CI 1.10, 1.40; ETI: HR 1.12, 95% CI 1.06, 1.19), and bronchitis (LPI: HR 1.15, 95% CI 1.00, 1.34; ETI: HR 1.13, 95% CI 1.05, 1.2) at 3 to 5 years of age. CONCLUSIONS: Late preterm infants and early term infants are at increased risk for asthma and bronchitis.

Legionella Infection in Pregnancy: The Forgotten Pathogen in Septic Shock.

BACKGROUND: Of eight cases of Legionella infection in pregnancy reported over 35 years, there was one case of maternal septic shock with poor outcome, one recovery with good outcome, and six with poor outcome. CASE: A 30-year-old woman, gravida 2 para 1, at 28 weeks of gestation presented with a high fever, cough, nausea, and vomiting. She deteriorated despite treatment for presumed urosepsis, was transferred to the intensive care unit, and remained intubated for 10 days receiving cardiovascular support, antivirals, antifungals, and multiple wide-spectrum antibiotics. Legionella infection antigen testing was performed on hospital day 1 and returned as positive. Azithromycin, started before the testing results became available, was continued for 14 days. The patient recovered, and the pregnancy progressed uneventfully to term. CONCLUSION: Legionella infection should be considered with maternal deterioration despite broad-spectrum antibiotic coverage. A favorable outcome is possible with early diagnosis and treatment.

Patient Awareness of Untoward Effects of Smoking on Fetal and Maternal Well-being During Pregnancy: A Pilot Study.

INTRODUCTION: To identify knowledge gaps regarding adverse effects of smoking during pregnancy that could be targeted through antenatal education. METHODS: This was a cross-sectional survey of patients who presented for initial prenatal care from April 6, 2011, through May 25, 2011. Inclusion criteria included fluency in English and completion of at least 75% of the questionnaire. Survey included demographic information and 4 sections that assessed (1) general knowledge about the effects of smoking, (2) cancer risks associated with smoking, (3) maternal and fetal complications resulting from smoking, and (4) long-term effects of smoking on offspring. Participants were grouped as nonsmokers, former smokers, and current smokers. Data from each group were compared using analysis of variance with Tukey-Kramer post-hoc tests. RESULTS: There were 82 participants (54 nonsmokers, 17 former smokers, and 11 smokers). Self-perceived knowledge about the adverse effects of smoking was significantly less in smokers than in nonsmokers (P < 0.05). There was no statistical difference between the knowledge base of smokers when compared with nonsmokers and former smokers. Smokers seemed to be less aware of the long-term respiratory morbidity associated with maternal smoking in their offspring. There was an overall deficit in knowledge among all 3 groups of cancer risks associated with smoking other than lung cancer. CONCLUSIONS: Obstetrician-gynecologists should employ more aggressive approaches in the education of pregnant parturients about the known deleterious maternal and fetal effects of smoking, especially those risks related to cancers other than lung and long-term respiratory morbidity in their children.

Telemedicine in obstetrics.

Telemedicine lends itself to several obstetric applications and is of growing interest in developed and developing nations worldwide. In this article we review current trends and applications within obstetrics practice. We searched electronic databases, March 2010 to September 2012, for telemedicine use studies related to obstetrics. Thirty-four of 101 identified studies are the main focus of review. Other relevant studies published before March 2010 are included. Telemedicine plays an important role as an adjunct to delivery of health care to remote patients with inadequate medical access in this era of limited resources and emphasis on efficient use of those available resources.