The role of placental alpha microglobulin-1 amnisure in determining the status of the fetal membranes; its association with preterm birth. Traditions traditions .

The integrity of the fetal amnion-chorion is an imperative for the preservation of a normal pregnancy in the human. The diagnosis of the status of the fetal membranes has traditionally been reduced to either intact or ruptured. In the last decades, evidence has accumulated demonstrating that this clinical approach may well be an over simplification. Practically, all maternal organs experienced physiologic or eventually pathologic changes during the length of the gestational period. We propose that the fetal membranes are also significantly impacted by those changes. The accurate, specific, simplified and low-cost diagnosis of the status of the fetal membranes is of critical importance for the assessment of risk to the pregnancy followed by efficient and prompt treatment. The presence of placental alpha macroglobulin-1 in the vagina specifically indicates a disruption in the integrity of the fetal membranes and may indirectly mean increased risk for preterm birth. Further research to properly characterize this marker and its importance in the care of pregnant woman at risk for preterm birth is strongly recommended.

Facing the noncommunicable disease (NCD) global epidemic--the battle of prevention starts in utero--the FIGO challenge.

Noncommunicable diseases (NCDs) are responsible for 36 million deaths every year. Of this death toll, nearly 80% (29 million) occur in low- and median-income countries. More than 9 million deaths attributed to NCDs occur in people under 60 years of age. National economies are suffering considerable losses due to premature death or disability to work resulting from heart disease, stroke, and diabetes. The knowledge that in utero and in early childhood certain processes can affect the risk of developing NCDs provides an opportunity to enforce interventions during this critical time, when they may have the greatest effect. Using appropriate protocols, the health-care provider can educate mothers about the risks of certain nutritional and environmental exposures and integrate health promotion on the agenda, as part of the social and economic development. All this could motivate a substantial reduction in the risk of NCDs. Current and future health challenges demand new and changing competencies that should form the basis for education, training, and workforce planning. The International Federation of Gynaecology and Obstetrics (FIGO) is aware of that responsibility and has joined hands with other agencies and organizations that make a considerable effort in providing appropriate prenatal care programs to prevent and treat most of the common preconditioning factors, especially in low-income countries.

ß-hCG and prediction of therapeutic success in ectopic pregnancies treated with methotrexate, results from a prospective observational study.

OBJECTIVE: To evaluate the diagnostic accuracy of different beta-human chorionic gonadotrophin (ß-hCG) levels measurement, for predicting success of medical treatment in cases diagnosed as tubal ectopic pregnancy (TEP). DESIGN: Five-year prospective observational study. SETTING: Prenatal Diagnosis Unit, Vall d'Hebron University Hospital - Barcelona. PATIENTS: TEP cases fulfilling criteria for medical treatment with Methotrexate. INTERVENTIONS: ß-hCG levels were measured on d 0, 4 and 7 of treatment. Results were compared by non-parametrical tests. A ROC curve was plotted to define cut-off points. Diagnostic accuracy of the different measurements was evaluated. MAIN OUTCOME MEASURE: Failure of treatment defined as need for surgical treatment or persistence of high ß-HCG levels despite treatment. RESULTS: 126 women were diagnosed as TEP, eligible for medical treatment. There were no differences in parity, age, previous TEP, or adnexal mass size. Success rate was 88%. ß-HCG decreased significantly more, between days 0-7 and 4-7, in the successful cases. LR for success prediction was 6.2 and 7.8 for ß-HCG levels at days 4 and 7 respectively, 4.02 and 2.47 for decrement between days 0-7 (25%) and 4-7 (20%), respectively. CONCLUSION: ß-hCG cutoff values have a potential for predicting a successful medical treatment of TEP.

The prevalence of congenital varicella syndrome after a maternal infection, but before 20 weeks of pregnancy: a prospective cohort study.

OBJECTIVE: To describe the prevalence of congenital varicella syndrome (CVS) within the population of presumably infected pregnant women. METHODS: From 1993 to 2006, all women who presented vesicular rash or a suspicious contact were referred and evaluated in a special unit at our center. Those with residual immunity or were serologically negative were precluded from this study. Positive IgM cases underwent monthly ultrasound scans (US), fetal blood (FB) sampling (including IgM anti VZV and virus culture). Amniotic fluid sample for PCR was added to the diagnosis of positive IgM cases after 1997. RESULTS: A total of 276, of the 566 consulted women, tested positive for IgM anti VZV. Seventeen (6%) were excluded because of an unadvised termination of pregnancy and seven (2.55%) miscarried. Only seven (2.7%) were considered highly likely to have a VZV fetal infection. One case showed positive IgM in FB but developed normally. Another fetus showed positive PCR and infection was confirmed post TOP. Four cases that underwent TOP and histochemistry confirmed no more cases. Complete post-natal follow-up was carried out. The asymptomatic infected child grew healthy until the completion of screening tests when it reached 5 years old. CONCLUSION: The fetal infection rate in this cohort was 0.8%, but the best expected prevalence of CVS, according to our findings, should be 0.39% among infected women. This data should be considered and used during parental counselling.

Use of 3-dimensional sonography for prenatal evaluation and follow-up of fetal goitrous hypothyroidism.

OBJECTIVE: Fetal goitrous hypothyroidism is a rare and potentially lethal condition. Consequently, its early diagnosis and treatment improve prognosis. Thyroid hormone measurement in either fetal serum or amniotic fluid implies important risks. Here we present a fetal goiter and the follow-up procedure, both done by the traditional method and by using 3-dimensional power Doppler (3DPD) imaging and virtual organ computer-aided analysis (VOCAL). METHODS: A single well-documented case of fetal goiter was followed weekly from 22 weeks until delivery. Amniocentesis for thyrotropin (TSH) and free thyroxine (T(4)) measurement as well as levothyroxine injections were performed at every control. In addition to amniocentesis, every control involved a sonographic evaluation, which included standard measurements of the gland and the capture of volume image sets in gray scale and 3DPD. Volume calculation of the gland was done using VOCAL software. Vascularization of the gland was evaluated by the vascularization index (VI) included in the software. RESULTS: With treatment, TSH levels decreased progressively until normalization. Free T(4) levels increased toward the end of gestation. Sonographic measurements of the gland volume to estimated fetal weight ratio decreased across treatment as levels of TSH did. The VI clearly depicted the vascular regression of the goiter, decreasing throughout treatment in a consistent way until 24 hours before delivery. CONCLUSIONS: Gray scale and 3DPD evaluations of the thyroid gland have been validated under similar circumstances and might be reliable complements to the invasive methods used in the management of this fetal condition.

Guidelines for the management of spontaneous preterm labor.

Preterm birth is defined as delivery at <37 completed weeks of pregnancy (World Health Organization). Spontaneous preterm birth (SPB) includes preterm labor, preterm spontaneous rupture of membranes, preterm premature rupture of membranes (PPROM) and cervical weakness; it does not include indicated preterm delivery for maternal or fetal conditions. Early SPB (<32 weeks' gestation) is associated with an increased higher perinatal mortality rate, inversely proportional to gestational age. The pathophysiologic events that trigger SPB are largely unknown but include decidual hemorrhage (abruption), mechanical factors (uterine overdistention or cervical incompetence), and hormonal changes (perhaps mediated by fetal or maternal stress). In addition, several cervicovaginal infections have been associated with preterm labor. SPB is also the leading cause of long-term morbidity, including neurodevelopmental handicap, cerebral palsy, seizure disorders, blindness, deafness and non-neurological disorders, such as bronchopulmonary dysplasia and retinopathy of prematurity. Delaying delivery may reduce the rate of long-term morbidity by facilitating the maturation of developing organs and systems. The benefits of administration of antepartum glucocorticosteroids to reduce the incidence and severity of respiratory distress syndrome may be exploited by delay. Delay may also permit transfer of the fetus in utero to a center with neonatal intensive care unit facilities. There is considerable variation in the way that spontaneous preterm labor (SPTL) is diagnosed, managed and treated internationally. The development of clinical guidelines requires an evidence-based approach to improve outcome and allow more efficient use of resources. With recent advances in our understanding of the etiology and mechanisms of SPTL and the availability of safer, more specific tocolytics, it was felt that guidelines should be developed to achieve, if possible, an European consensus in patient diagnosis, management and treatment.