Fetal premature excess vertebral linear calcification: a case series.

During embryogenesis, the vertebrae begin development during the 6th week of gestation via two lateral chondrification centers per segment. It was assumed that when disruptions occur in the process of somitogenesis during membranous vertebral body formation, chondrification and ossification will follow the anomalous membranous vertebral body scaffolding, resulting in an anomalous vertebral formation, such as a hemivertebra. Another hypothesis is that hemivertebra may result from anomalous distribution of intersegmental arteries of the vertebral column. There is no description in the medical literature of "excess linear calcifications" of part of the fetal vertebra, characterized by the presence of linear calcifications in the vertebrae of a developing fetus. In the first two trimesters of pregnancy, the fetal vertebrae usually show three calcified points in an axial section: the vertebral body and two transverse processes. Premature linear vertebral calcification was defined as an anterior or posterior echogenic connection between two of the points (Fig. 1). In this study, we describe seven cases of premature fetal linear vertebral calcification.

Interpregnancy interval after vacuum delivery and subsequent perinatal outcomes.

OBJECTIVE: To evaluate whether a short interpregnancy interval (IPI) after vacuum extraction (VE), poses similar perinatal risks in a subsequent pregnancy. METHODS: This was a retrospective, single-center cohort study between 2011 and 2021. Nulliparous women with term, singleton VE deliveries and with known pregnancy outcomes in their subsequent pregnancy were eligible for inclusion in the study. Each woman was allocated into one of two groups based on the IPI, <18 months and between 18 and 60 months. The primary outcome was the risk of spontaneous preterm birth (PTB) <37 weeks in the consecutive birth. RESULTS: We included 1094 pregnancies: 212 (19.4%) with IPI <18 months and 882 (80.6%) with IPI between 18 and 60 months following the previous VE delivery. The VE characteristics were comparable between the groups. Young maternal age was a risk factor for a short IPI (28.0 ± 4.8 vs 30.3 ± 4 years, P < 0.01). Spontaneous PTB <37 weeks was significantly higher in the IPI <18 months group with 18-60 months (7.1% vs 2.6%, P = 0.002). Polynomial regression analysis also confirmed a significantly increased risk of preterm birth <37 weeks (P < 0.01). Short IPI <18 months was also associated with an increase in the risk of low birthweight <2500 g (6.1% vs 2.8%, P = 0.02) and admission to the neonatal intensive care unit (6.1% vs 2.6%, P = 0.013). The incidence of recurrent VE, albeit significant (2.3% vs 4.9%, P = 0.049), was low in both groups. No differences were noted in any of the other secondary outcomes. CONCLUSION: Short IPI (<18 months) following term VE delivery is associated with higher neonatal risks, particularly PTB, in the subsequent pregnancy. These findings are particularly important when counseling women planning an optimal IPI.

Hypoxia Leads to Diminished Ovarian Reserve in an Age-Dependent Manner.

OBJECTIVES: Perinatal hypoxia causes premature activation and initiation of growth in dormant follicles, leading to diminished ovarian reserve. An indirect mechanism such as the release of stress-related hormones may influence ovarian follicle recruitment under hypoxic conditions. We wanted to determine whether hypoxic ovarian damage results from increased follicle growth and "burnout" or from increased apoptosis and whether this damage is age-dependent. DESIGN: Animal study was conducted. PARTICIPANTS/MATERIALS, SETTING, METHODS: Using adult 6-week-old (n = 8) and one-day-old newborn (n = 20) ICR (CD-1) female mice, ovarian follicular counts were conducted on H&E-stained sections. METHODS: Immunohistochemistry was performed on sections stained with Ki-67, anti-Caspase 3, and anti-FOXO3A. RESULTS: Exposure to hypoxia resulted in significantly reduced proportion of primordial follicles versus normoxia in both adult dams and newborn pups (3.17 ± 2.75 vs. 17.89 ± 4.4%; p = 0.004; 40.59 ± 14.88 vs. 81.92 ± 31.56%, p = 0.001, respectively), concomitant with increased growing-primary and secondary follicles, and more pronounced in adult dams versus newborn pups (6-fold vs. 2-fold, respectively). Ki67 staining revealed higher scores of cell proliferation in follicular granulosa cells after exposure to hypoxia than normoxia. However, Caspase 3 and Foxo3A staining did not show any differences in these markers of apoptosis in oocytes, granulosa cells, theca cells, or stromal cells when exposed to hypoxia versus normoxia. LIMITATIONS: The current study has several limitations; first, the sample size for each group is relatively small, which could limit the generalizability of the findings. Second, the study used an ex vivo culture system, which may not fully capture the complex interactions that occur in the whole animal. Third, the exposure to hypoxia only lasted for 3 h, which may not be long enough to observe all the potential effects. In addition, the study only analyzed specific markers of apoptosis in a few cell types, and other cell types or apoptotic pathways might be involved. Lastly, the study provides evidence for accelerated follicular activation and decreased ovarian reserve, but the underlying mechanisms are not fully explored. CONCLUSIONS: Direct tissue hypoxia led to premature activation and initiation of growth in dormant follicles leading to diminished ovarian reserve. Hypoxic damage is age-dependent, with adult ovaries more susceptible than newborn ovaries. These findings support the possibility of follicular "burn out" as a potential mechanism responsible for hypoxia-induced loss of ovarian reserve.

Does delayed vacuum-assisted delivery harbor greater maternal or neonatal complications?

OBJECTIVE: To compare maternal and fetal outcomes between early (<2 h) and delayed (>2 h) vacuum extraction (VE) deliveries. METHODS: We performed a retrospective cohort study in a single, university-affiliated medical center (2014-2021). We included term singleton pregnancies delivered by VE, allocated into one of two groups according to second stage duration: <2 h or >2 h. Primary outcome was maternal composite adverse outcome (included chorioamnionitis, 3-4 degree lacerations, and postpartum hemorrhage [PPH]). RESULTS: We included 2521 deliveries: 2261 (89.6%) with early VE and 260 (10.4%) with delayed VE. Study groups' characteristics were not different, except of parity. Maternal composite outcome almost reached a significance (P = 0.054) comparing between the groups. Comparing second stage length up to 2 h versus more, there was similar rate of advance maternal lacerations. However, extending the second stage to more than 3 h was associated with third degree lacerations compared to 2-3 h (9.8% vs 3%, P = 0.011). There were significantly more PPH events in the later VE group (P = 0.004), but the need for blood transfusions was similar. The rates of 5 min Apgar score ≤7 (P = 0.001) and umbilical artery pH <7.0 were significantly higher in group 2 compared with group 1. The effect was much more pronounced when second stage was >3 h. After conducting multiregression analysis, the results became insignificant. CONCLUSION: Our study suggests that VE performed in the late second stage of labor, up to 3 h, is safe as VE performed in the early stages regarding maternal and neonatal outcomes. Extra caution is needed with extended second stage to more than 3 h.

Pre-labour Rupture of Membranes at Term in Women With Gestational Diabetes and the Risk of Neonatal Hypoglycemia.

OBJECTIVES: The management for improving maternal and neonatal outcomes of women with gestational diabetes mellitus (GDM) arriving at the delivery ward with pre-labour rupture of membranes (PROM) has not been elucidated. We tested the hypothesis that prolonged PROM in women with GDM would result in higher rates of neonatal hypoglycemia. METHODS: We retrospectively enrolled women with diet or insulin-controlled GDM who presented with spontaneous clear PROM. Each woman was allocated into one of two groups based on the PROM-delivery time: <18 hours (group 1) and ≥18 hours (group 2). The primary outcome was the incidence of neonatal hypoglycemia, defined as glucose <40 mg/dL (2.2 mmol/L) within 24 hours of birth. RESULTS: We ultimately analyzed 631 cases of GDM (6.7%), 371 with PROM-delivery <18 hours, and 260 with PROM-delivery ≥18 hours. The incidence of neonatal hypoglycemia did not differ between the two groups, reaching 7.3%. Women in group 2 were at increased risk of both cesarean delivery (20% vs. 12.4%, P < 0.01) and maternal chorioamnionitis morbidity (6.5% vs. 1.3%, P < 0.001). CONCLUSIONS: In a sub-group of women with GDM, a PROM-delivery time ≥18 hours is not associated with higher rates of neonatal hypoglycemia, but higher rates of chorioamnionitis and cesarean delivery were noted. Therefore, we suggest consideration for early delivery when managing women with GDM and PROM.

Fetal Renal Duplicated Collecting System at 14-16 Weeks of Gestation.

(1) Background: To examine the incidence of the prenatal diagnosis of the renal double-collecting system (rDCS) and describe its clinical outcome and associated genetic abnormalities. (2) Methods: This retrospective study included women who attended the obstetric clinic for early fetal anatomic sonography with findings of a renal DCS. Diagnosis was conducted by an expert sonographer using defined criteria. (3) Results: In total, 29,268 women underwent early ultrasound anatomical screening at 14-16 weeks, and 383 cases of rDCS were diagnosed (prevalence: 1:76). Associated abnormalities were diagnosed in eleven pregnancies; four had chromosomal aberrations. No chromosomal abnormalities were reported in isolated cases. Ectopic uretrocele and dysplastic kidney were diagnosed in 6 (1.5%) and 5 (1.3%) fetuses, respectively. One girl was diagnosed with vesicoureteral reflux and recurrent UTIs, and two boys were diagnosed with undescended testis. The recurrence rate of rDCS was 8% in subsequent pregnancies. (4) Conclusions: In light of its benign nature, we speculate that isolated rDCS may be considered a benign anatomic variant, but a repeat examination in the third trimester is recommended to assess hydronephrosis.

The effects of inflammation and acidosis on placental blood vessels reactivity.

INTRODUCTION: Inflammation and acidosis are two stress stimuli that correspond to pathophysiological processes occurring in placental-mediated vascular disorders. We aimed to investigate the effects of these stimuli on placental chorionic blood vessels reactivity using the ex-vivo placental perfusion model. METHODS: Term placentas were obtained immediately after cesarean deliveries, and selected cotyledons were cannulated and dually perfused ex-vivo. Placentas were perfused with three different protocols: culture medium (M199-controls, n = 5), culture medium with lipopolysaccharide (inflammatory stimuli) (LPS,1 µg/ml, n = 7), and acidotic culture medium (M - 199, pH: 6.9-7, n = 6). Each perfusion experiment was maintained for 180 min. Fetal perfusion pressure was continuously measured. Measurements in response to angiotensin II (AT II) at the end of the perfusion were compared between the treatment groups, including amplitude of the contraction response, relaxation factor, time to maximal constriction and the area under the pressure curve (AUC). RESULTS: In response to ATII there was a significant difference in the amplitude of the contraction and the AUC between the treatment groups, (p = 0.049, p = 0.015, respectively). As compared with control perfused cotyledon, the inflammatory stimuli significantly increased the vasoconstriction response to ATII in fetal placental blood vessels, as expressed by increased AUC - median (IQR): 555 (235-1184) vs. 133 (118-207), respectively, p = 0.017. The time to maximal constriction and the relaxation factor did not differ between the groups. DISCUSSION: Inflammatory stimuli but not acidosis impact fetal-placental vasculature in response to ATII, suggesting that inflammation can compromise vascular function.

Placental disposition of cannabidiol: An ex vivo perfusion study.

OBJECTIVE: In the absence of safety data in humans, the use of cannabidiol (CBD) is not recommended during pregnancy. Yet >50% of pregnancies in women with epilepsy are unintended, making fetal exposure to CBD possible. As a small-molecule, highly lipid-soluble drug, CBD is likely to be distributed into the placenta and cross it. To estimate the placental distribution profile of CBD and its potential short-term placental effects, we conducted an ex vivo perfusion study in human placentas. METHODS: Placentas were obtained from healthy women undergoing cesarean deliveries. Selected cotyledons were cannulated and perfused for 180 min with a CBD-containing medium (250 ng/mL, .796 µmol·L-1 ; representative of a low therapeutic concentration; n = 8). CBD concentrations were determined at 180 min in the medium and placental tissue using liquid chromatography-tandem mass spectrometry. A customized gene panel array was used to analyze the expression of selected genes in the perfused placental cotyledons as well as in placentas perfused with 1000 ng/mL CBD (3.18 µmol·L-1 ; high therapeutic concentration; n = 8) and in those exposed to the vehicle. RESULTS: CBD was sequestered in the placental tissue, exhibiting significant variability across samples (median = 5342 ng/g tissue, range = 1066-9351 ng/g tissue). CBD concentrations in the fetal compartment were one fifth of those measured in the maternal compartment (median = 59 ng/mL, range = 48-72 ng/mL vs. 280 = ng/mL, range = 159-388 ng/mL, respectively; p < .01). Placental gene expression was not significantly altered by CBD. SIGNIFICANCE: The placenta acts as a depot compartment for CBD, slowing down its distribution to the fetus. This phenomenon might yield flatter but prolonged fetal CBD levels in vivo. The attenuated transplacental CBD transfer does not imply that its use by pregnant women is safe for the fetus. Only pregnancy registries and neurocognitive assessments would establish the risk of being antenatally exposed to CBD.

The impact of extending the second stage of labor on repeat cesarean section and maternal and neonatal outcome.

OBJECTIVE: To evaluate the effects of extending the second stage of labor in women attempting a trial of labor after a cesarean section (TOLAC). METHOD: A retrospective cohort study comparing maternal and neonatal outcomes following TOLAC over two periods: period I whose prolonged second stage was considered 2 h, and period II whose prolonged second stage was considered 3 h. The primary outcome was repeat cesarean delivery (CD) rate. RESULTS: Incidence of repeat CD was significantly lower in period II (18.1% vs 29.7%, P < 0.001). Incidence of uterine rupture was significantly higher in period II (P < 0.001). Instrumental delivery rates were significantly higher in period II (26.2% vs 15.6%, odds ratio [OR] 1.67, 95% CI 1.21-3.56, P < 0.001). Rates of third- and fourth-degree perineal lacerations, chorioamnionitis, and length of hospital stay were similar between groups. Incidence of fetal acidemia was significantly higher in period II (1.5% vs 0.7%, OR 2.14, 95% CI 1.32-5.63, P < 0.001), and incidence of neonatal intensive care unit (NICU) admission was significantly higher (2.5% vs 1.6%, P = 0.004). CONCLUSION: Extension of the second stage of labor is associated with a decrease in repeat CD rate with a concomitant increase in instrumental delivery rates, uterine rupture, fetal acidemia, and NICU admissions. These findings may warrant further consideration of allowing a prolonged second stage in patients attempting TOLAC.

Intestine and brain TLR-4 modulation following N-acetyl-cysteine treatment in NEC rodent model.

Necrotizing enterocolitis (NEC) brain injury is mediated through Toll-like receptor 4 (TLR4) on the intestinal epithelium and brain microglia. Our aim was to determine whether postnatal and/or prenatal NAC can modify NEC associated intestinal and brain TLR4 expression and brain glutathione levels in a rat model of NEC. Newborn Sprague-Dawley rats were randomized into three groups: Control (n = 33); NEC (n = 32)-hypoxia and formula feeding; and NEC-NAC (n = 34)-received NAC (300 mg/kg IP) in addition to NEC conditions. Two additional groups included pups of dams treated once daily with NAC (300 mg/kg IV) for the last 3 days of pregnancy: NAC-NEC (n = 33) or NAC-NEC-NAC (n = 36) with additional postnatal NAC. Pups were sacrificed on the fifth day, and ileum and brains harvested for TLR-4 and glutathione protein levels. Brain and ileum TLR-4 protein levels were significantly increased in NEC offspring as compared to control (brain 2.5 ± 0.6 vs. 0.88 ± 0.12 U and ileum 0.24 ± 0.04 vs. 0.09 ± 0.01, p < 0.05). When NAC was administered only to dams (NAC-NEC) a significant decrease in TLR-4 levels was demonstrated in both offspring brain (1.53 ± 0.41 vs. 2.5 ± 0.6 U, p < 0.05) and ileum (0.12 ± 0.03 vs. 0.24 ± 0.04 U, p < 0.05) as compared to NEC. The same pattern was demonstrated when NAC was administered only or postnatally. The decrease in brain and ileum glutathione levels observed in NEC offspring was reversed with all NAC treatment groups. NAC reverses the increase in ileum and brain TLR-4 levels and the decrease in brain and ileum glutathione levels associated with NEC in a rat model, and thus may protect from NEC associated brain injury.

The optimal induction timing in prelabor rupture of membranes: a retrospective study.

OBJECTIVE: Term prelabour rupture of membrane (PROM) occurs in 8% of term deliveries, but it is unclear when to initiate induction. Our objective was to assess the optimal timing of oxytocin induction in the management of term PROM in terms of maternal and neonatal outcomes. METHODS: A retrospective cohort study was performed at a single tertiary care center from 2010 to 2020. All singleton pregnancies with PROM beyond 37 weeks gestation, without regular uterine contractions, were included. Eligible women were divided into three groups according to the timing of oxytocin induction (≤12; 12-24; ≥24 h) following PROM. RESULTS: Of 9,443 women presented with the term PROM, 1676 were included. They were classified according to the timing of oxytocin induction initiation following PROM: 1,127 within 12 h; 285 within 12-24 h; 264 after 24 h. There were no significant differences in baseline demographic characteristics between groups. Women who presented at our emergency department were induced earlier delivered significantly sooner than those who received oxytocin later (45 vs. 28.2 vs. 23.2 h, respectively, p < .001. Maternal infection rate was similar and unrelated to oxytocin starting time. Induction at <12 h from PROM was associated with reduced rate of antibiotic administration compared with other timings (26.8% vs. 38.6% vs. 33.33%, respectively; p < .001), and the same was found for neonatal composite adverse outcomes (RR = 1.27, p = .0307). CONCLUSION: In term PROM, early induction (within 12 h of PROM) may be recommended to reduce the time-do-delivery interval and increase the delivery rate within 24 h. It may be of economic significance and improve women satisfaction. Furthermore, early induction may also improve neonatal outcomes, without worsening maternal outcomes.

Prenatal detection of gastrointestinal bubbles since early pregnancy: Clues to correct diagnosis.

OBJECTIVE: To characterize gastrointestinal bubbles detected since early pregnancy and to describe corresponding diagnoses. METHOD: A retrospective cohort review of all cases in which gastrointestinal bubbles were detected starting in early prenatal transvaginal scans at 14-17 weeks of gestation between the years 2007 and 2021. Sonographic features and data regarding associated anomalies, genetic abnormalities, and pregnancy outcome were evaluated. RESULTS: Bubbles were detected in 23 of 27 073 early scans and a total of 31 394 scans. Diagnosis was available in 22 cases. Transient bubbles were detected in 10 cases and represented normal peristalsis. Fixed double bubble was detected in nine cases. Double-walled double bubbles represented duodenal duplications (three cases) and esophageal duplications (two cases). Simple cysts represented duodenal atresia (three cases) and a pancreatic cyst (one case). A triple bubble represented duodenal obstruction from Ladd bands in one case. Quadribubble was detected in two cases and represented jejunal atresia. CONCLUSION: Prenatal detection of gastrointestinal bubbles can accurately diagnose physiological versus pathological upper gastrointestinal conditions. Transient bubbles are physiological. Fixed double bubbles might represent either duodenal atresia or esophageal/duodenal duplications when a double wall is demonstrated. Three or four bubbles might represent more distal intrinsic or extrinsic obstruction.

Continuous versus disrupted subcutaneous tissue closure in cesarean section: A retrospective cohort study.

OBJECTIVES: To compare rates of surgical-site infections following continuous, as compared with interrupted, subcutaneous tissue closure technique during cesarean delivery (CD). METHODS: A retrospective cohort study during 2008-2018. The study group included women who underwent either elective or emergent CD with continuous subcutaneous tissue closure, while the control group comprised those with interrupted subcutaneous tissue closure. We excluded women with suspected infectious morbidity before CD. The primary outcome was surgical-site infection (SSI) rate. RESULTS: The final analysis included 6281 women. We performed continuous subcutaneous tissue closure in 37.4% (1867/4988) of scheduled CD, and 45.8% (592/1293) of emergent CD. The rate of SSI was significantly lower following continuous than interrupted subcutaneous tissue closure, in both elective CD (2.7% versus 4.5%, respectively, P = 0.031) and emergent CD (3.2% versus 5.4%, respectively, P = 0.036) in nulliparous and multiparous women. Similarly, secondary outcomes such as re-admission rates, postoperative maternal fever, and need for antibiotic treatment were significantly lower following continuous subcutaneous closure. CONCLUSIONS: Continuous subcutaneous closure technique during CD yields a lower rate of surgical-site complications compared with the interrupted technique.

Postpartum cervical length as a predictor of subsequent preterm birth-novel insights on an old enigma.

BACKGROUND: Preterm birth poses one of the biggest challenge in modern obstetrics. Prediction of preterm birth has previously been based on patient history of preterm birth, short cervical length around midtrimester, and additional maternal risk factors. Little is known about cervical length and physiology during the postpartum period and any associations between postpartum cervical features and subsequent preterm birth. OBJECTIVE: This study aimed to determine the feasibility and utility of postpartum cervical length measurements in prediction of subsequent spontaneous preterm birth. STUDY DESIGN: This was a prospective cohort study in a single tertiary center, conducted during a 5-year period (2017-2021). We evaluated the mean postpartum cervical length in patients after both preterm birth and term deliveries at 4 time periods: 8, 24, and 48 hours, and 6 weeks postpartum, with follow-up in their subsequent pregnancies to evaluate gestational age at delivery. The mean postpartum cervical length in different populations stratified by gestational age at delivery was assessed in phase 1 of the study, and the gestational age at subsequent delivery was assessed in phase 2. RESULTS: A total of 1384 patients participated in phase 1. Mean postpartum cervical length was significantly shorter in the preterm birth (<34 weeks' gestation) group than in the term group at 8 hours (8.4±4.2 vs 22.3±3.5 mm; P<.0001), 24 hours (13.2±3.8 vs 33.2±3.1 mm; P<.0001), and 48 hours (17.9±4.4 vs 40.2±4.2 mm; P<.0001) postpartum. There was no significant difference in mean postpartum cervical length between the preterm birth group and the term group at 8, 24, and 48 hours postpartum. Cervical length was similar between the groups at 6 weeks postpartum. A total of 891 patients participated in phase 2. The area under the curve was higher for preterm birth screening based on a history of a short postpartum cervix alone than for a history of spontaneous preterm birth alone (0.66 [95% confidence interval, 0.63-0.69] vs 0.57 [95% confidence interval, 0.54-0.61]; P<.0001). Combining both a history of spontaneous preterm birth and a short postpartum cervix resulted in additional benefit, with an area under the curve of 0.74 (95% confidence interval, 0.73-0.84; P<.0001). CONCLUSION: Postpartum cervical length measurements may assist in detecting the group of patients at higher risk of subsequent spontaneous preterm birth. It may be beneficial to consider an increased follow-up regimen and earlier interventions in this group to reduce adverse perinatal outcomes.

Long-term effects of prophylactic MgSO4 in maternal immune activation rodent model at adolescence and adulthood.

The effects of MgSO4 as an anti-inflammatory agent in pregnant women have been investigated in the last few years. Infections can cause an inflammatory reaction involving the placenta membranes and amniotic cavity. They may have short-term effects on the mother and her fetuses, like preterm birth, cerebral palsy, and developmental delay. Despite the alleged advantages of MgSO4 as a neuroprotective agent in the preterm brain, the long-term molecular and behavioral function of MgSO4 has not been fully elucidated. Here, we investigated the long-term effect of antenatal MgSO4 , during late gestation, on offspring's behavior focusing on cognitive function, motor activity, and social cognition in adolescence and adulthood, and explored its influence on brain gene expression (e.g., ErbB signaling, pro-inflammatory, and dopaminergic markers) in adulthood. A significant abnormal exploratory behavior of offspring of MgSO4 -treated dams was found compared to the control group in both adolescence and adulthood. Furthermore, we found that adult females exposed to MgSO4 under inflammation displayed working and recognition memory impairment. A reduction in IL-6 expression was detected in the prefrontal cortex, and hippocampus specimens derived from LPS-Mg-treated group. In contrast, an imbalanced expression of dopamine 1 and 2 receptors was detected only in prefrontal cortex specimens. Besides, we found that MgSO4 ameliorated the overexpression of the Nrg1 and Erbb4 receptors induced by LPS in the hippocampus. Thus, MgSO4 treatment for preventing brain injuries can adversely affect offspring cognition behavior later in life, depending on the sex and age of the offspring.

Late preterm delivery has a distinctive second-stage duration and characteristics.

BACKGROUND: Late preterm neonates born between 34.0 and 36.6 weeks' gestation are at increased risk for short- and long-term morbidity and mortality when compared with their term counterparts. Currently, no separate labor curve is available for late preterm births, and this group's optimal duration of the second stage of labor has never been defined separately. OBJECTIVE: This study aimed to compare the second stage duration between late preterm and term births. STUDY DESIGN: This was a retrospective study from May 2014 until May 2021. Eligible were women with a singleton pregnancy, vertex presentation, spontaneous or induced onset of labor, and those who delivered vaginally beyond 34.0 weeks of gestation. The primary outcome of our study was to compare and characterize the second stage of labor duration between late preterm and term births. RESULTS: We analyzed 962 late preterm and 9476 term vaginal deliveries. Women who delivered during the late preterm period were more likely to be multiparous (52.4% vs 45.2%; P<.001) and fewer required oxytocin during labor (41.2% vs 54.4%; P<.001) or used epidural analgesia (75.2% vs 83.6%; P<.001). The overall mean duration of the second stage of labor was significantly shorter in the late preterm period than at term (1.08±1.09 hours vs 1.49±1.22 hours; P<.001). This was even more pronounced for nulliparous women (1.05±1.00 hours vs 2.10±1.17 hours; P<.001). Among multiparous women, epidural use significantly affected the duration of the second stage of labor, and the second stage was relatively longer during the late preterm period than at term in this subgroup (1.16 vs 0.5 hours; P<.001). Using a multivariate Cox regression, variables such as maternal age (hazard ratio, 1.02; 95% confidence interval, 1.01-1.04), parity (hazard ratio, 4.11; 95% confidence interval, 3.65-4.63), preterm birth (hazard ratio, 2.08; 95% confidence interval, 1.4-3.10), and birthweight at delivery (hazard ratio, 1.15; 95% confidence interval, 1.01-1.30) shortened the second stage, whereas induction of labor (hazard ratio, 0.75; 95% confidence interval, 0.66-0.86) and epidural use (hazard ratio, 0.68; 95% confidence interval, 0.64-0.86) extended its total duration. Regardless of parity, lower rates of operative vaginal deliveries were observed in the late preterm period than at term (3.7% vs 15.5%; P<.001). This period was also associated with lower rates of third- and fourth-degree perineal lacerations (0.2% vs 2.2%; P<.001) but higher rates of chorioamnionitis (1.7% vs 0.1%; P<.001), Apgar score at 5 minutes <7 (1.0% vs 0.2%; P<.001), and admission to the neonatal intensive care unit (19.3% vs 1.0%; P<.001). CONCLUSION: Women who delivered vaginally during the late preterm period had a distinctive second-stage duration. Primarily, it was shown to be significantly shorter for nulliparous and multiparous women. Future studies should further clarify the optimal duration of this stage in relation to neonatal outcomes at such a vulnerable period.

Which part of cervical length is predictive of preterm birth in women with cerclage?

OBJECTIVE: To evaluate the predictive value of transvaginal ultrasonography measures: total cervical length (TCL), length to internal OS (LIO) and external OS (LEO) from the cerclage following cerclage placement, for spontaneous preterm birth (PTB). METHODS: A retrospective cohort at a single tertiary care center (2010-2020). Women with McDonald cerclage were evaluated during the 2nd and 3rd trimesters for cervical measurements: TCL, LIO, LEO. The primary outcome was PTB < 37 weeks. Demographic data, obstetric history, delivery information and serial cervical length measurements were collected. Subgroup analyses were performed to evaluate cervical length parameters (as described) and PTB rates prior to 34, 32 and 28 weeks of gestation. RESULTS: Of 66 women enrolled, 36.4% (n = 24) had PTB. There were no differences in the obstetrical history and demographic information (p > .05) nor indication for cerclage (p = .369). Cervical length measurements at 20-24 weeks demonstrated a shorter TCL & LIO (22.69 vs. 33.86 mm, p = .001; 9.25 vs. 15.9 mm, p = .0042; respectively) in the preterm group. The LEO was similar in both groups. This pattern was also shown in a subgroup analysis (PTB < 34, 32 and 28 weeks). CONCLUSION: Cervical length from internal OS to cerclage and total cervical length have a predictive value for PTB in women with a cervical cerclage, regardless of the indication for cerclage/previous pregnancy outcomes. Our data emphasize the importance of follow-up cervical length measurements of women with a cervical cerclage, and especially cervical length from internal OS to cerclage as those women may need additional care.

Magnesium sulphate neuroprotection mechanism is placental mediated by inhibition of inflammation, apoptosis and oxidative stress.

INTRODUCTION: Maternal inflammation may induce placental cytokine production resulting in fetal exposure, and development of neonatal neurologic injury. Maternal magnesium sulphate (MG) is used as neuroprotective in preventing white matter brain injury. We sought to determine whether maternal MG can prevent placental activation of inflammatory pathways associated with fetal injury. METHODS: Pregnant Sprague Dawley rats at gestational day 20 (E20) (n = 24) received injections of intraperitoneal lipopolysaccharide (LPS; 500 µg/kg) or saline (SAL) at time 0. Dams were randomized to treatment with subcutaneous saline or MG for 2 h prior to and 2 h following LPS/saline injections. Four hours following first injection rats were sacrificed. Placentas were collected from all treatment groups (LPS/SAL, LPS/MG, SAL/MG, SAL/SAL). Placental Caspase 3, NF-kB p65, neuronal nitric oxide synthase (phospho-nNos) interleukin (IL)-6 and tumor necrotic factor-α (TNF-α) protein levels were determined by western blot and compared. RESULTS: Maternal LPS at E20 significantly increased protein levels of placental caspase 3 (0.22 ± 0.01 vs. 0.12 ± 0.01 u), NFkB p65 (0.27 ± 0.01 vs. 0.10 ± 0.01 u), phospho-nNOS (0.20 ± 0.01 vs. 0.10 ± 0.01 u) as well as IL-6 and TNF-α compared to control. MG treatment to LPS dams significantly reduced all placental mediators to levels similar to SAL/SAL controls (p < 0.05). DISCUSSION: Maternal inflammation-induced fetal brain injury may be mediated via placental activation of inflammation, oxidative stress, and apoptotic pathways. The prevention of preterm brain injury could possibly intervene also via inhibition of one or more of these putative pathways.

Vaginal fluid index - The fifth amniotic pocket.

OBJECTIVE: The forebag is a pocket of amniotic fluid preceding the fetal presenting part. Herein we describe the feasibility of transvaginal measurements of the forebag and assess its correlation with the standard amniotic fluid index (AFI). METHODS: A prospective study was carried out between January 2019 and July 2020. Eligible cases were women with singletons, vertex presentation, and normal AFI at term. We assessed the implementation and acceptance of a novel process in the clinical practice setting. Feasibility was assessed by using transvaginal ultrasound to measure the three orthogonal planes of the forebag. The vaginal fluid index (VFI) was defined as the volume composite of the three orthogonal planes. Correlations of the forebag measurements with both AFI and maximal vertical pocket were then calculated. RESULTS: In total, 292 out of 305 (95.7%) women were enrolled. All participants completed both transabdominal and transvaginal ultrasound, of which the vaginal pocket was demonstrated in 266 (91.1%) cases. We found significant correlations, in both nulliparas and multiparas, between the vaginal pocket measurements and the VFI to both the AFI and maximal vertical pocket measurements (R = 0.38, P < 0.001; R = 0.3, P < 0.001, respectively). CONCLUSION: We introduced a new ultrasound variable, the VFI, with a high feasibility rate. This may provide invaluable information for future decision making around the time of delivery.

Vaginal Dinoprostone Insert versus Cervical Ripening Balloon for Term Induction of Labor in Obese Nulliparas-A Randomized Controlled Trial.

Data regarding the preferred induction method in women with obesity is scarce. The current study was aimed at comparing pharmacological and mechanical induction in this population. This prospective randomized controlled trial was conducted between 2016−2020, in nulliparas with a pre-pregnancy body mass index >30. Inclusion criteria were singleton-term pregnancies, bishop score < 5, and indication for induction. Patients were randomized to induction by a cervical ripening balloon (CRB) or a 10 mg vaginal dinoprostone insert. The primary outcome was delivery rate within 24 h. Secondary outcomes included time to delivery, cesarean section rate, maternal and neonatal outcomes, satisfaction, and anxiety. The study population comprised of 83 women in the CRB group and 81 in the dinoprostone group. There was a significant difference in delivery rates within 24 h and time to delivery between the dinoprostone and CRB groups (45% vs. 71%, p = 0.017 and 49.3 ± 6.8 h vs. 23.5 ± 5.9 h, p = 0.003, respectively). There were no differences in cesarean delivery rates or maternal and neonatal outcomes, though CRB induction was associated with a significantly lower rate of tachysystole. Induction with CRB was accompanied by higher satisfaction and lower anxiety. In summary, CRB induction is associated with shorter time to delivery, higher satisfaction, and lower anxiety compared to PGE2 in women with obesity, without compromising maternal or neonatal outcomes.