A novel extended prophylactic antibiotic regimen in preterm pre-labor rupture of membranes: A randomized trial.

OBJECTIVES: Prophylactic antibiotic use in preterm pre-labor rupture of membranes (PPROM) is associated with a significant reduction in intra-amniotic infection and improved neonatal outcome. However, data is insufficient to determine the optimal antibiotic regimen. Considering the rise in Escherichia coli and Klebsiella pneumonia early-onset sepsis rate and the emergence of ampicillin resistance, our aim is to compare the efficiency of two antibiotic regimens in prolonging pregnancy and reducing infectious morbidity. DESIGN: This multicenter randomized unblinded controlled prospective trial compared two antibiotic prophylactic protocols in PPROM: ampicillin + roxithromycin vs. cefuroxime + roxithromycin in 84 women with PPROM, from 12/2015-12/2019. RESULTS: The median latency period was significantly longer (p = 0.039) in the cefuroxime + roxithromycin group (4.63 [0.59-50.18] days) than in the ampicillin + roxithromycin group (2.3 [0.15-58.3] days). Neonatal admission to neonatal intensive care unit rate, hospitalization length, neonatal respiratory distress syndrome, neonatal fever, and need for respiratory support or mechanical ventilation, were similar between the groups. K. pneumonia cultures were significantly more frequent in the ampicillin + roxithromycin group. None of the cultures were group B Streptococcus positive. CONCLUSIONS: To prolong latency period and reduce gram-negative early-onset sepsis, cefuroxime + roxithromycin is recommended as the first-line protocol in PPROM. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02819570.

Microvesicles of women with gestational hypertension and preeclampsia affect human trophoblast fate and endothelial function.

Microvesicles shedding from cell membrane affect inflammation, apoptosis, and angiogenesis. We hypothesize that microvesicles of women with gestational vascular complications reflect pathophysiological state of the patients and affect their endothelial and trophoblast cell function. Microvesicles of healthy pregnant women, women with gestational hypertension, mild, or severe preeclampsia/toxemia, were characterized, and their effects on early-stage or term trophoblasts and endothelial cells were evaluated using apoptosis, migration, and tube formation assays. Patient subgroups differed significantly only in proteinuria levels, therefore their microvesicles were assessed as 1 group, demonstrating higher levels of inflammatory and angiogenic proteins compared with those of healthy pregnant women. In endothelial cells, microvesicles of healthy pregnant women reduced caspase 3/7 activity, increased migration, and induced tube formation. These processes were suppressed by microvesicles of women with gestational vascular complications. In early-stage trophoblasts, microvesicles of healthy pregnant women decreased apoptosis compared with untreated cells (6±5% versus 13.8±5.8%; P<0.001) and caspase 3/7 activity and induced higher migration (39.7±10.1 versus 20.3±8.3 mm2; P<0.001). This effect was mediated through extracellular signal-regulated kinase pathway. Conversely, microvesicles of women with gestational vascular complications increased term trophoblast apoptosis compared with cells exposed to microvesicles of healthy pregnant women (15.1±3.3% versus 6.5±2.1%; P<0.001) and inhibited early-stage trophoblasts migration (21.4±18.5 versus 39.7±10.1 mm2; P<0.001). In conclusion, microvesicle content and effects on endothelial and trophoblast cells vary according to the physiological/pathological state of a pregnant woman. Microvesicles seem to play a pivotal role in the course of pregnancy, which could potentially result in gestational vascular complications.

Pregnancy course and outcome in women traveling to developing countries.

BACKGROUND: The issue of travel to developing countries during pregnancy has not been sufficiently studied. The aim of this study is to investigate the rate, course, and outcome of pregnancies in women who traveled to developing countries while pregnant, or became pregnant during such travel. METHODS: Women visiting two major travel clinics in Israel for consultation within the years 2004 to 2009, who were pregnant or declared an intention of becoming pregnant during travel were contacted. This was followed by a telephone interview by an obstetrician with those women who were actually pregnant. Background characteristics, morbidity during travel, and pregnancy course and outcome were collected. RESULTS: Overall 52,430 travelers' records had been screened. Of these, we identified 49 women who were pregnant during their trip, but 3 declined participation. Of the remaining 46 women, 33 were pregnant at departure, and 13 conceived during travel. The incidence of pregnancy during travel was thus 0.93/1000 travelers. Thirty-three women traveled to East Asia, 8 to South and Central America, 5 to Africa. More than two thirds of women received pretravel vaccinations. Adherence to the World Health Organization recommendations regarding food and drink was high (87%) and travelers' diarrhea occurred in only 11% of women. Five of 22 women traveling to malarious areas had taken antimalarial prophylaxis. Six women required medical therapy during travel. Pregnancy outcome was not different from the normal population except for an unusually low rate of preterm delivery. CONCLUSIONS: In this cohort, travel to developing countries was not associated with adverse pregnancy outcome. Larger studies are needed to support these findings.

Adrenalectomy for adrenocortical adenoma causing Cushing's syndrome in pregnancy: a case report and review of literature.

We present a case of adrenocorticotropic hormone (ACTH)-independent Cushing's syndrome diagnosed in a patient in the third trimester of her pregnancy, with an adrenal mass observed on imaging studies. Laparoscopic adrenalectomy was performed successfully at 32 weeks. To the best of our knowledge, this is the latest gestational age at which laparoscopic adrenalectomy has been reported. We present the various considerations for determining the surgical approach and the optimal timing for surgery. Adrenalectomy during pregnancy for the treatment of Cushing's syndrome caused by adrenocortical adenoma has been reported in 23 patients in the English-language medical literature to date and seems safe and beneficial. According to the data, surgical treatment has led to a reduction in perinatal mortality and maternal morbidity rates, but has not affected the occurrence of preterm birth and intrauterine growth restriction. The best outcome can be achieved by a multidisciplinary approach, with a team comprising a maternal-fetal medicine specialist, an endocrinologist and a surgeon. The timing of surgery and the surgical approach need to be determined according to the surgeon's expertise, the severity of the condition, the patient's preferences, and gestational age. Laparoscopy may prove to be the preferred surgical approach. The small number of cases precludes providing evidence-based recommendations.

Oral naproxen versus oral tramadol for analgesia after cesarean delivery.

OBJECTIVE: To compare the efficacies of oral naproxen and oral tramadol for pain relief after cesarean delivery, and to evaluate administration at fixed intervals versus on request. METHODS: In a prospective study, 120 women were randomized into 4 groups receiving either oral naproxen or oral tramadol at fixed intervals or on request. Pain was assessed at 6, 12, 24, and 48hours after delivery, and adverse effects, mobility, breastfeeding, and the need for additional drugs for breakthrough pain were recorded. RESULTS: No difference in pain scores was observed at 6, 12, 24, or 48hours among the 4 groups, between the 2 drugs, or between the 2 methods of administration. Women randomized to receive oral tramadol requested additional drugs for breakthrough pain more frequently. In addition, adverse effects were twice as common in the tramadol group as in the naproxen group, and more women in the tramadol group abandoned the study. CONCLUSION: Although similar in terms of pain scores, oral naproxen might be more effective than oral tramadol for pain relief after cesarean delivery. Naproxen seemed to have a better adverse-effects profile, and therefore might be more suitable for mothers. Administration at fixed intervals might be more efficacious than administration on request.

Haptoglobin phenotype in women with preeclampsia.

In pre-eclampsia, poor placentation causes both oxidative and endoplasmic reticulum stress of the placenta. The anti-oxidative protein Haptoglobin has three phenotypes: 1-1, 1-2, and 2-2. Haptoglobin 1-1 is a more potent antioxidant. Our objective was to determine whether haptoglobin 1-1 was less common in women with preeclampsia which is a disease with an oxidatives-stress component, compared to the healthy population. Haptoglobin phenotype was compared in 240 healthy and 120 preeclamptic gravida in a case-control study. Statistical analysis was performed using Chi square test. The prevalence of haptoglobin 1-1 was 13% among healthy women and 6% among preeclamptic women (P=0.049). Secondary analysis was also performed. The prevalence of haptoglobin 1-1 is higher in healthy compared to preeclamptic subjects, a finding compatible with a protective role. Haptoglobin 1-1 might have a protective role in preeclampsia. Further work is needed with more Hp 1-1 subjects before we can conclude on the possible use of Haptoglobin phenotype to assess the risk of preeclampsia.

Pregnancy exacerbating hepatopulmonary syndrome.

BACKGROUND: Hepatopulmonary syndrome is an uncommon complication of liver cirrhosis. The natural history of this condition and its optimal management during pregnancy are not yet known. CASE: We present the case of a 35-year-old woman with liver cirrhosis who developed severe dyspnea in the 25th week of gestation and was diagnosed as suffering from hepatopulmonary syndrome. She was managed conservatively until 35 weeks of gestation, when she was delivered by cesarean. CONCLUSION: The natural history, in this case, indicates that pregnancy may induce hepatopulmonary syndrome in an otherwise asymptomatic cirrhotic patient. Oxygen supplementation was the cornerstone of treatment and resulted in a favorable outcome.

Decidualization of ovarian endometriosis during pregnancy mimicking malignancy.

OBJECTIVE: The purpose of this series is to present deciduosis (the formation of extrauterine decidua) as one of the differential diagnoses of a malignant tumor during pregnancy. METHODS: Two cases are described in which pregnant patients had a pelvic tumor. The lesions, which were diagnosed in the early second trimester, consisted of complex masses with an extensive blood supply and had a sonographic appearance of a malignant tumor. The high suspicion for malignancy necessitated surgical intervention. RESULTS: During surgery, the lesions were observed to be of an ovarian origin with papillary excrescences covering their exterior. The lesions were excised and sent for histologic examination. The results showed a markedly decidualized endometriotic cyst in both cases. CONCLUSIONS: This phenomenon is a diagnostic challenge and should be considered in the differential diagnosis of a malignant mass during pregnancy.

Selenium concentrations in maternal and umbilical cord blood at 24-42 weeks of gestation: basis for optimization of selenium supplementation to premature infants.

BACKGROUND & AIMS: Selenium (Se) deficiency may have deleterious effects on premature infants. Umbilical cord (UC) Se concentrations presumably reflect fetal Se concentrations and represent reference values that should be achieved in premature infants. We aimed to establish reference data of Se serum concentrations in parturient women and their neonates across gestation. SUBJECTS AND METHODS: Parturient mothers and their newborn infants born after 24-42 weeks of gestation were enrolled. Only appropriate for gestational age (GA) singleton infants were included. Se serum concentrations were measured by atomic absorption spectrometry, in blood samples from parturient mothers and their infants (umbilical blood). Demographic, perinatal and labor data were obtained, and their correlations with umbilical Se serum concentrations, maternal Se serum concentrations, and the maternal-umbilical Se difference were examined. RESULTS: UC Se serum concentrations increased as gestation progressed (P<0.01). A statistically significant linear relationship was found between UC Se serum concentrations and GA (R=0.341, P<0.0001), birth weight (R=0.237, P=0.002), and 5-min Apgar score (R=0.202, P<0.01). Using multiple regression analysis, only GA was significantly associated with UC serum Se concentration (P=0.012). Maternal Se serum concentration were stable throughout gestation, and maternal-umbilical Se difference was negatively correlated with GA (R=-0.337, P<0.0001) and birth weight (R=-0.369, P<0.0001). CONCLUSIONS: UC Se serum concentration increases and the maternal-umbilical Se difference declines with gestation progression, probably reflecting fetal accretion of Se. With the current Se supplementation in premature infants, Se concentrations are lower than those measured in our study. We, therefore, suggest a two-fold increase or more in the recommended Se dosage.