Successful multidisciplinary team management of placenta accreta spectrum disorder: A referral center model in a middle-income country.

OBJECTIVE: The aim of the study was to evaluate the outcomes of placenta accreta spectrum (PAS) disorder managed by a multidisciplinary care team (MCT) compared with a conventional care team (CCT) in a PAS referral center in Thailand. METHODS: This retrospective single-center cohort study analyzed PAS management outcomes in the PSU PAS Center between January 2010 and December 2022. The incidence of hemorrhage ≥3500 mL and the composite maternal and neonatal outcomes of PAS were compared before and after the introduction of an MCT in 2016. RESULTS: Of 227 PAS cases, 219 (96.5%) had pathological confirmation. There were 52 (22.9%) cases of placenta accreta, 119 (52.4%) cases of placenta increta, and 56 (24.7%) cases of placenta percreta. The incidence of estimated blood loss (EBL) ≥3500 mL decreased from 61.8% to 34.3% (P < 0.001) after the establishment of the MCT. The median EBL decreased from 4000 (IQR: 2600,7250) mL to 2250 (1300, 4750) mL (P < 0.001). EBL reduction was statistically significant in the accreta and increta groups (P < 0.001). Red blood cell transfusions decreased from five (3, 9) to two (1, 6) units (P < 0.001) per patient. The length of maternal hospital stays and ICU admissions were statistically shorter when PAS was managed by an MCT (P < 0.001). The length of newborn hospital and ICU stays decreased significantly (P < 0.001). CONCLUSION: The incidence of massive postpartum hemorrhage and a composite of maternal and neonatal morbidities in pregnant women with PAS disorder improved significantly after the establishment of an MCT to manage PAS in a middle-income country setting.

Reliability of the sonographic evaluation for cervical length and elastography with pelvic parameters in term pregnancy by experienced operators with varying levels of experience.

OBJECTIVE: To assess the reliability of sonographic measurements of six cervical and pelvic parameters by three sonographers with varying levels of experience. METHODS: A cross-sectional study was conducted in pregnant women with a gestational age of ≥39 weeks. Each pregnant woman was examined by two sonographers with different levels of experience. Six parameters were measured: cervical length (CL), cervical strain elastography (extrinsic type), posterior cervical angle (PCA), fetal head-to-perineum distance (FHPD), fetal head-to-pubic symphysis distance (FHSD), and angle of progression (AOP). Intra- and interobserver reliabilities were assessed using the intraclass correlation coefficient with a 95% confidence interval. Pearson pairwise correlation coefficients were used to analyze the correlation between the parameter values. RESULTS: In all, 66 pregnant women were enrolled in this study. We found excellent intraobserver reliability for measurements of CL, PCA, FHPD, FHSD, and AOP and good-to-excellent intraobserver reliability for cervical strain values in the cross-sectional view of the endocervix in the internal os area and cross-sectional view of the entire cervix in the internal os area. Interobserver reliability was excellent for all pelvic parameters, except for the FHPD. Strain values were moderate to excellent in the area of the internal os. A significant negative correlation between CL and strain values at the internal os was observed. CONCLUSIONS: Pelvic parameters, except for FHPD, have excellent intra- and interobserver reliabilities. The high reproducibility of CL and cervical strain elastography at the internal os level, with a negative correlation between these two parameters, may play an important role in predicting successful induction of labor.

A predictive model for successfully inducing active labor among pregnant women: Combining cervical status assessment and clinical characteristics.

Objective: To develop a predictive model for successfully inducing active labor by using a combination of cervical status and maternal and fetal characteristics. Study design: A retrospective cohort study was conducted among pregnant women who underwent labor induction between January 2015 and December 2019. Successfully inducing active labor was defined as achieving a cervical dilation > 4 cm within 10 h after adequate uterine contractions. The medical data were extracted from the hospital database; statistical analyses were performed using a logistic regression model to identify the predictors associated with the successful induction of labor. The receiver operating characteristic (ROC) curve and area under the curve (AUC) were used to assess the accuracy of the model. Results: In total, 1448 pregnant women were enrolled; 960 (66.3 %) achieved successful induction of active labor. Multivariate analysis revealed that maternal age, parity, body mass index, oligohydramnios, premature rupture of membranes, fetal sex, dilation, station, and consistency were significant factors associated with successful labor induction. The ROC curve of the logistic regression model had an AUC of 0.7736. For the validated score system to predict the probability of success, we found that a total score > 60 has a 73.0 % (95 % CI 59.0-83.5) probability of successful induction of labor into the active phase stage within 10 h. Conclusions: The predictive model for successfully achieving active labor using the combination of cervical status and maternal and fetal characteristics had good predictive ability.

Effective training program for antenatal diagnosis of placenta accreta spectrum disorder.

OBJECTIVE: To develop and evaluate a training program for diagnosing placenta accreta spectrum (PAS) disorder in obstetrics/gynecology and radiology residents. METHODS: This single-center prospective study was based on 177 ultrasound images of pathologically confirmed PAS extracted from 534 cases of placenta previa suspicious for PAS. First- to third-year residents were evaluated before training to assess experience and ability to diagnose PAS. They attended a principal lecture followed by weekly self-study exercises over 5 weeks. Post-course tests evaluated the efficacy of the training program for improving diagnosis of PAS after the program. RESULTS: Twenty-three (38.3%) obstetrics/gynecology and 37 (61.7%) radiology residents were trained. Before the training program, 98.3% reported minimal experience and 100% low confidence to correctly diagnose PAS. During the program, the overall accuracy of all participants in diagnosing PAS increased from 71.3% before to 95.2% after training (P < 0.001). Regression analyses showed that ability to diagnose PAS increased 2.52-fold (P < 0.001) following the program. The retention of knowledge at 1, 3, and 6 months posttest was 84.7%, 87.5%, and 87.7%, respectively. CONCLUSION: An antenatal diagnosis of PAS training program can be effective as a residency training program, considering the globally rising cesarean delivery rates.

Preoperative sonographic sliding sign for prediction of intra-abdominal adhesions before repeat cesarean delivery.

OBJECTIVE: To evaluate the usefulness of the uterine sliding sign for predicting intra-abdominal adhesions in women undergoing repeat cesarean section (CS) and the association of the sliding sign with other operative and neonatal outcomes. METHODS: A prospective cohort study was conducted among pregnant women with at least one previous CS. Transabdominal ultrasonography was performed and classified as a positive or negative sliding sign. Surgeons blinded to the sonographic results assessed intra-abdominal adhesions. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated. Operative and neonatal outcomes of the positive and negative sliding sign groups were compared. Factors associated with intraoperative adhesions were also analyzed. RESULTS: A total of 380 women were recruited. The sensitivity and specificity of the uterine sliding sign to detect moderate-to-thick adhesions were 60.6% and 91.9%, respectively. A negative sliding sign was significantly associated with a higher incidence of adhesions, longer skin-to-delivery time, longer total operative time, and lower 5-min APGAR score in newborns. A negative sliding sign and history of two or more previous CS were significant predictors of moderate-to-thick adhesions. CONCLUSION: The uterine sliding sign is an independent predictor of intraoperative adhesions, with acceptable sensitivity and high specificity and negative predictive value.

Two-dimensional ultrasound signs as predictive markers of massive peri-operative blood loss in placenta previa suspicious for placenta accreta spectrum (PAS) disorder.

OBJECTIVE: To evaluate certain two-dimensional (2D) ultrasound signs as predictors of massive peri-operative blood loss (PBL) in pregnant women with placenta previa suspicious of PAS disorder. MATERIALS AND METHODS: A single center retrospective study was done in pregnant women who had undergone prenatal diagnosis with 2D ultrasound grey scale and color Doppler using the EW-AIP (which has been changed to IS-PAS (International Society for the Placenta Accreta Spectrum)) criteria between January 2007 and May 2021. The patients were divided into 2 groups, non-massive hemorrhage with PBL ≤ 2500 mL and massive PBL >2500 mL. All PAS cases had pathological confirmation. Ultrasound signs and hemorrhagic outcomes were compared between the two groups. A PAS scoring system to predict massive PBL was constructed and a receiver operating characteristic (ROC) curve was calculated to evaluate the efficacy of the scoring system. RESULTS: Of 534 women, 146 (28.3%) had PBL > 2500 mL and 388 (71.7%) had PBL ≤ 2500 mL. In the massive PBL group, 101 (69.2%) were diagnosed as PAS and 45 (30.8%) as placenta previa alone. From 10 evaluated 2D ultrasound signs, 3 had the highest odds ratios (ORs) associated with massive PBL, 'focal exophytic mass' OR 8.17 (p = 0.024), 'placental bulge' OR 2.47 (p = 0.011), and 'placental lacunae feeder vessels' OR 2.38 (p = 0.01). When using the PAS scoring system, the AUC to predict massive PBL was 0.80 (95% CI, 0.76-0.85,). CONCLUSION: Our PAS scoring system based on 2-dimensional ultrasound signs combined with grey scale and color Doppler is useful to predict massive PBL and can help optimize pre-operative management in cases of previa suspicious of PAS.

Utility of fetal facial markers on a second trimester genetic sonogram in screening for Down syndrome in a high-risk Thai population.

BACKGROUND: To establish the reference ranges and evaluate the efficacy of the fetal facial sonomarkers prenasal thickness (PT), nasal bone length (NBL), PT/NBL ratio and NBL/PT ratio for Down syndrome screening in the second trimester of high-risk pregnancies using two-dimensional (2D) ultrasound. METHODS: A prospective study was done in Thai pregnant women at high risk for structural and chromosomal abnormalities between May 2018 and May 2019. The main exclusion criteria were any fetal anatomical anomaly detected on ultrasonography or postpartum examination, abnormal chromosome or syndrome other than Down syndrome. Ultrasounds were performed in 375 pregnant women at 14 to 22 weeks' gestation and the fetal facial parameters were analyzed. Down syndrome results were confirmed by karyotyping. The reference ranges of these facial ultrasound markers were constructed based on the data of our population. The Down syndrome screening performance using these facial ultrasound markers was evaluated. RESULTS: In total, 340 euploid fetuses and 11 fetuses with Down syndrome met the inclusion criteria. The PT, NBL, and PT/NBL ratios in the euploid fetuses gradually increased with gestation progression while the NBL/PT ratio gradually decreased between 14-22 weeks' gestation. The NBL, PT/NBL ratio, and NBL/PT ratio all had 100% sensitivity and PT had 91% sensitivity. These facial markers had 100% negative predictive value for Down syndrome screening in the second trimester. The Bland-Altman analysis showed the intra- and inter-observer variations of PT and NBL had high intraclass correlation coefficients (ICC) in both operators, with ICCs of 0.98 and 0.99 and inter-observer ICCs of 0.99 for both operators. CONCLUSION: The facial ultrasound markers are very useful for second trimester Down syndrome screening in our population. These facial ultrasound markers were easily identifiable and highly consistent either intra- or inter-operator by using widely-available 2D ultrasound. However, the reference ranges for these markers need to be constructed based on individual populations. TRIAL REGISTRATION: Registration number: REC 61-029-12-3. Date of registration: 18 May 2018.

Ethnic-specific reference range affects the efficacy of quadruple test as a universal screening for Down syndrome in a developing country.

OBJECTIVE: To evaluate the efficacy of the quadruple test for potential use as a Thai national policy for Down syndrome (DS) screening and establish an accurate equation for risk estimation of Down syndrome based on gestational age, weight and the ethnic-specific reference range of our population. METHODS: A prospective study was conducted on singleton pregnancies at 14 to 21 weeks of gestation to evaluate the efficacy of quadruple DS screening using the automatically calculated Western European descent factor (WF) in our population and the impact of screening using a specific Thai ethnic factor as well as to establish an equation for the risk estimation of DS based on gestational age, weight and a local Thai ethnic factor to correct for the impact of ethnic factor on the screening efficacy. RESULTS: Of a total of 5,515 women, 12 cases of DS and 8 cases of other aneuploidies were found. The detection rate, false positive rate and specificity were 75.0%, 9.1% and 90.9%, respectively, by automatic calculation with the widely used WF; the screening efficacy was lower when used in Asian populations than in other studies. The best-fitted regression equation of serum quadruple screening of AFP, free ß-hCG, uE3 and inhibin A was established by adjustment for gestational age (GA) in days, maternal weight and our Thai-specific ethnic reference range which was created for this study. Calculations with our Thai-specific ethnic model gave a better detection rate of 83.3%, a false positive rate of 9.6% and specificity of 90.4%. CONCLUSION: The serum quadruple test had a lower detection rate than expected when the risk estimation was based on the WF reference range. The serum quadruple test using WF had significantly different levels when corrected with our ethnic-specific factor. Using our local ethnic specific model could increase the detection rate of DS screening in Thailand with a minimal increase in false positive rates. Our findings indicate that DS screening should be adjusted with an appropriate individual ethnic factor when used for national screening.

Fetal tricuspid regurgitation in second trimester of pregnancies at risk for fetal chromosomal defects.

PURPOSE: To determine the prevalence and screening performance for detection of Down syndrome of fetal tricuspid regurgitation in the second trimester of pregnancies at risk for fetal chromosomal defects. METHODS: A prospective study was carried out on pregnant women at risk for fetal chromosomal defects who had amniocentesis or cordocentesis for fetal karyotyping at 16 to 23 weeks' gestation, between February 2017 and January 2018. An assessment of the fetal tricuspid valve was conducted before any invasive procedure. Tricuspid regurgitation was defined as flow reversal for at least half of systole, with a maximum velocity of ≥100 cm/s. RESULTS: In the 486 cases studies, fetal tricuspid regurgitation was found in 21 (4.3%), and 10 fetuses had Down syndrome. The tricuspid regurgitation was found in 15 (3.2%) of the 462 euploid fetuses, in 5 (50%) of the Down syndrome fetuses, and in 1 (7.1%) of the fetuses with other chromosome abnormalities. Tricuspid regurgitation was found as an isolated marker in 2 of the 10 Down syndrome fetuses. The sensitivity, specificity, positive predictive value, and negative predictive value to screen for Down syndrome were 50%, 96.8%, 25%, and 98.9%, respectively. CONCLUSIONS: Tricuspid regurgitation showed a high prevalence in fetal Down syndrome at the gestational age of 16 to 23 weeks and was an isolated marker in 20% of them.

Validation of the Fetal Lamb Model of Spina Bifida.

A randomized trial demonstrated that fetal spina bifida (SB) repair is safe and effective yet invasive. New less invasive techniques are proposed but are not supported by adequate experimental studies. A validated animal model is needed to bridge the translational gap to the clinic and should mimic the human condition. Introducing a standardized method, we comprehensively and reliably characterize the SB phenotype in two lamb surgical models with and without myelotomy as compared to normal lambs. Hindbrain herniation measured on brain magnetic resonance imaging (MRI) was the primary outcome. Secondary outcomes included gross examination with cerebrospinal fluid (CSF) leakage test, neurological examination with locomotor assessment, whole-body MRI, motor and somatosensory evoked potentials; brain, spinal cord, hindlimb muscles, bladder and rectum histology and/or immunohistochemistry. We show that the myelotomy model best phenocopies the anatomy, etiopathophysiology and symptomatology of non-cystic SB. This encompasses hindbrain herniation, ventriculomegaly, posterior fossa anomalies, loss of brain neurons; lumbar CSF leakage, hindlimb somatosensory-motor deficit with absence of motor and somatosensory evoked potentials due to loss of spinal cord neurons, astroglial cells and myelin; urinary incontinence. This model obtains the highest validity score for SB animal models and is adequate to assess the efficacy of novel fetal therapies.

Providing direction improves function: Comparison of a radial pore-orientated acellular collagen scaffold to clinical alternatives in a surgically induced rabbit diaphragmatic tissue defect model.

Gore-Tex® is a widely used durable patch for repair of congenital diaphragmatic defects yet may result in complications. We compared Gore-Tex with a composite of a radial pore-orientated collagen scaffold (RP-Composite) and clinically used porcine small intestinal submucosa (SIS; Surgisis®) in a rabbit model for diaphragmatic hernia. The growing rabbit mimics the rapid rib cage growth and reherniation rates seen in children. We created and immediately repaired left hemidiaphragmatic defects in 6-week-old rabbits with Gore-Tex, SIS, and an RP-Composite scaffold. An additional group of rabbits had a sham operation. At 90 days, survivors more than doubled in weight. We observed few reherniations or eventrations in Gore-Tex (17%) and RP-Composite (22%) implanted animals. However, SIS failed in all rabbits. Maximum transdiaphragmatic pressure was lower in Gore-Tex (71%) than RP-Composite implanted animals (112%) or sham (134%). Gore-Tex repairs were less compliant than RP-Composite, which behaved as sham diaphragm (p < 0.01). RP-Composite induced less foreign body giant cell reaction than Gore-Tex (p < 0.05) with more collagen deposition (p < 0.001), although there was a tendency for the scaffold to calcify. Unlike Gore-Tex, the compliance of diaphragms reconstructed with RP-Composite scaffolds were comparable with native diaphragm, whereas reherniation rates and transdiaphragmatic pressure measurements were similar.

Comparison of transabdominal and transvaginal sonography in the diagnosis of placenta previa.

PURPOSE: To compare the accuracies of transabdominal sonography (TAS) and transvaginal sonography (TVS) in the diagnosis of placenta previa. METHODS: A prospective, cross-sectional study was conducted at a university hospital. Both TAS and TVS were performed on 81 pregnant women with a suspicion of placenta previa in the third trimester. The final diagnosis was confirmed at delivery. The agreement between the two ultrasound methods and the parameters of each method were calculated. RESULTS: Fifty-eight percent of the women had a placenta previa. The sensitivities of TAS and TVS were 86% (95% CI 78-94%) and 95% (95% CI 91-100%), respectively (p= 0.2). The specificity of both methods was 93% (95 CI 88-99%), and the overall accuracies of TAS and TVS were 89% (95% CI 82-96%) and 94% (95% CI 89-100%), respectively. When TAS was followed by TVS, 23% of the previous diagnoses were changed. The agreement between both methods was good (Kappa value = 0.7, 95%CI 0.55-0.86). CONCLUSIONS: For the diagnosis of placenta previa, TAS showed a high sensitivity and specificity, which were comparable to those of TVS.

Modulation of the Early Host Response to Electrospun Polylactic Acid Matrices by Mesenchymal Stem Cells from the Amniotic Fluid.

PURPOSE: The reconstruction of congenital diaphragmatic hernia or other congenital soft tissue defects often requires implants. These can be either degradable or permanent, each having their advantages. Whatever type is being used, the host response induced by implants plays a crucial role to determine the outcome. Macrophages are pivotal during implant remodeling; they are plastic and acquire in response to environmental stimuli either an inflammatory status and mediate subsequent fibrosis or a regulatory status and facilitate functional remodeling. Matrices engineered with mesenchymal stem cells (MSCs) have the capacity to modulate the host immune reaction. MSCs are believed to promote constructive remodeling of the implant through a regulatory macrophage response among others. Herein, we evaluate this potential of MSC derived from the amniotic fluid (AF-MSC), an interesting MSC type for neonatal reconstruction, on electrospun polylactic acid (PLA) scaffolds. METHODS: We seeded AF-MSC at a density of 1.105/cm2 on electrospun PLA matrices and determined cell viability. In vivo, we used cell-seeded or cell-free PLA matrices for subcutaneous implantation in immune competent rats. The host immune response was evaluated by histomorphometry at 14 days postoperatively. RESULTS: The PLA matrix supported adherence and proliferation of AF-MSC. Fourteen days after implantation, PLA matrices were well penetrated by inflammatory cells, new blood vessels, and collagen fibers. AF-MSC-seeded scaffolds were associated with a similar response yet with a decreased number of eosinophils, increased matrix degradation and collagen fiber deposition compared with controls. The amount of total macrophages and of M2-subtype was similar for all animals. CONCLUSION: Electrospun PLA matrices are a suitable substrate for short-term culture of AF-MSC. In rats, addition of AF-MSC to PLA matrices modulates the host response after subcutaneous implantation, yet without a difference in macrophage profile compared with control.

Tissuepatch is biocompatible and seals iatrogenic membrane defects in a rabbit model.

OBJECTIVE: To evaluate novel sealing techniques for their biocompatibility and sealing capacity of iatrogenic fetal membrane defects in a pregnant rabbit model. METHOD: At day 23 of gestation (term = d31), a standardized fetoscopy was performed through a 14G cannula. The resulting fetal membrane defect was closed with condensed collagen, collagen with fibrinogen, Tissuepatch, Duraseal, or a conventional collagen plug (Lyostypt) as reference. At d30, the fetuses were harvested and full thickness fetal membrane samples were analyzed. The study consisted of 2 consecutive parts: (1) biocompatibility testing by fetal survival, apoptosis, and infiltration of polymorphonuclear cells in the membranes and (2) the efficacy to seal fetal membrane defects. RESULTS: Three sealants (collagen with fibrinogen, Duraseal, or Lyostypt) were associated with a higher fetal mortality compared to control unmanipulated littermates and hence were excluded from further analysis. Tissuepatch was biocompatible, and amniotic fluid levels were comparable to those of control untouched littermates. Compared to the condensed collagen, Tissuepatch was also easier in surgical handling and induced limited cell proliferation. CONCLUSION: Tissuepatch had the best biocompatibility and efficacy in sealing an iatrogenic fetal membrane defect in the pregnant rabbit compared to other readily available sealants.

Normative weight-adjusted models for the median levels of first trimester serum biomarkers for trisomy 21 screening in a specific ethnicity.

OBJECTIVE: To establish normative weight-adjusted models for the median levels of first trimester serum biomarkers for trisomy 21 screening in southern Thai women, and to compare these reference levels with Caucasian-specific and northern Thai models. METHODS: A cross-sectional study was conducted in 1,150 normal singleton pregnancy women to determine serum pregnancy-associated plasma protein-A (PAPP-A) and free ß-human chorionic gonadotropin (ß-hCG) concentrations in women from southern Thailand. The predicted median values were compared with published equations for Caucasians and northern Thai women. RESULTS: The best-fitting regression equations for the expected median serum levels of PAPP-A (mIU/L) and free ß- hCG (ng/mL) according to maternal weight (Wt in kg) and gestational age (GA in days) were: [Formula: see text] and [Formula: see text] Both equations were selected with a statistically significant contribution (p< 0.05). Compared with the Caucasian model, the median values of PAPP-A were higher and the median values of free ß-hCG were lower in the southern Thai women. And compared with the northern Thai models, the median values of both biomarkers were lower in southern Thai women. CONCLUSION: The study has successfully developed maternal-weight- and gestational-age-adjusted median normative models to convert the PAPP-A and free ß-hCG levels into their Multiple of Median equivalents in southern Thai women. These models confirmed ethnic differences.

A growing animal model for neonatal repair of large diaphragmatic defects to evaluate patch function and outcome.

OBJECTIVES: We aimed to develop a more representative model for neonatal congenital diaphragmatic hernia repair in a large animal model, by creating a large defect in a fast-growing pup, using functional pulmonary and diaphragmatic read outs. BACKGROUND: Grafts are increasingly used to repair congenital diaphragmatic hernia with the risk of local complications. Growing animal models have been used to test novel materials. METHODS: 6-week-old rabbits underwent fiberoptic intubation, left subcostal laparotomy and hemi-diaphragmatic excision (either nearly complete (n = 13) or 3*3cm (n = 9)) and primary closure (Gore-Tex patch). Survival was further increased by moving to laryngeal mask airway ventilation (n = 15). Sham operated animals were used as controls (n = 6). Survivors (90 days) underwent chest X-Ray (scoliosis), measurements of maximum transdiaphragmatic pressure and breathing pattern (tidal volume, Pdi). Rates of herniation, lung histology and right hemi-diaphragmatic fiber cross-sectional area was measured. RESULTS: Rabbits surviving 90 days doubled their weight. Only one (8%) with a complete defect survived to 90 days. In the 3*3cm defect group all survived to 48 hours, however seven (78%) died later (16-49 days) from respiratory failure secondary to tracheal stricture formation. Use of a laryngeal mask airway doubled 90-day survival, one pup displaying herniation (17%). Cobb angel measurements, breathing pattern, and lung histology were comparable to sham. Under exertion, sham animals increased their maximum transdiaphragmatic pressure 134% compared to a 71% increase in patched animals (p<0.05). Patched animals had a compensatory increase in their right hemi-diaphragmatic fiber cross-sectional area (p<0.0001). CONCLUSIONS: A primarily patched 3*3cm defect in growing rabbits, under laryngeal mask airway ventilation, enables adequate survival with normal lung function and reduced maximum transdiaphragmatic pressure compared to controls.

Thrombin Generation by Fetoscopic Trauma to the Fetal Membranes: An in vivo and in vitro Study.

OBJECTIVE: We first aimed to investigate in vivo thrombin generation induced by fetoscopy, and second we used term membrane explants for measurement of thrombin generation, thrombin receptor location and induction of selected matrix metalloproteinases (MMPs) in tissue culture. MATERIALS AND METHODS: In vivo study (37 cases): samples of amniotic fluid were taken at the beginning and end of fetoscopy (mean gestational age 26.7 weeks) and analyzed by ELISA for thrombin-antithrombin complexes. In vitro study: fetal membranes were put in culture and punctured for measurement of thrombin generation by calibrated automated thrombography and ELISA. Induction of MMP-9 and MMP-2 was analyzed by zymography. PAR-1 was localized by immunohistochemistry. RESULTS: No significant increase in thrombin-antithrombin was measured in amniotic fluid obtained during fetoscopy. In vitro, thrombin generation induced by needle trauma of membrane cultures is correlated to the amount of plasma. Activity of MMP-9 but not MMP-2 was elevated in cultured membranes but could not be inhibited by a thrombin inhibitor. On histology, the thrombin receptor PAR-1 was located in the chorion and decidua, but not in the amnion. DISCUSSION: Despite the influence of thrombin on punctured fetal membranes in vitro, the role of thrombin in iatrogenic preterm premature rupture of membranes is questionable.

Reducing Pain and Anxiety during Second Trimester Genetic Amniocentesis Using Aromatic Therapy: A Randomized Trial.

OBJECTIVE: To evaluate the benefit of aromatic therapy using menthol for decrease pain perception during amniocentesis. MATERIAL AND METHOD: A prospective randomized study was conducted to compare pain level between groups ofpregnant women who underwent amniocentesis with and without aromatic therapy using menthol. Visual analogue scale (VAS) was usedfor pain assessment. The participants were askedfor their anticipated pain and anxiety level and level ofpain before and immediately after the procedure. RESULTS: Three hundred seventeen pregnant women were recruited into the present study, 158 in the menthol group and 159 in the non-menthol group. Mean VAS score of the post-procedure pain and anxiety did not differ significantly between the two groups. Mean VAS score of the anticipated pain influenced the mean VAS score of the pre-procedure anxiety and post-procedure pain and anxiety irrespective of the group. Mean VAS score of the pre-procedure anxiety and post-procedure pain and anxiety increased about 0.3 cm for each 1 cm of increasing mean VAS score of anticipated pain. CONCLUSION: Aromatic therapy using menthol was not significantly effective in reducing pain and anxiety during second trimester genetic amniocentesis.