Clinical characteristics of preeclampsia in twin versus singleton pregnancies.

OBJECTIVE: We aimed to compare features of preeclampsia between twin and singleton pregnancies. METHODS: In this retrospective case-control study, women with twin pregnancies who were diagnosed with preeclampsia were matched to singleton pregnancies controls. RESULTS: Ninety-four women with twin gestation diagnosed with preeclampsia were compared to singleton pregnancies with preeclampsia. Twin pregnancies were diagnosed at an earlier mean gestational age (33.23 ± 7.32 vs 35.93 ± 3.52 weeks, p = .001), and had an earlier gestational age at delivery (35.05 ± 2.28 vs 36.31 ± 3.25 weeks, p = .002) in comparison to singleton pregnancies. Mean systolic blood pressure at diagnosis was lower (147.22 ± 14.62 vs 152.7 ± 15.22 mmHg, p = .013), and the rate of thrombocytopenia <100,000 platelets/microliter, (17.02% vs 7.45%, p = .045) was higher in the twin preeclampsia group. A subanalysis for diagnosis prior to 34 weeks of gestation revealed that the rate of chronic hypertension was lower (3.03% vs 26.32%, p = .020), and the gestational age at delivery was higher (32.83 ± 2.16 weeks vs 31.02 ± 2.49, p = .008) among the twin preeclampsia group. In the prior to 34 weeks gestation preeclampsia subanalysis, less women in the twin group were hospitalized due to maternal indications (hypertension, ominous signs for PE, disturbed laboratory tests and suspicion for intra-hepatic cholestasis of pregnancies) in comparison to the singleton preeclampsia group (63.64% vs 89.47%, p = .028), while non-maternal/fetal indications (active labor, premature rupture of membranes, cervical dynamics, latent phase or gastroenteritis) for hospitalization were more common in the twin preeclampsia group (30.30% vs 0.00%). CONCLUSION: Preeclampsia in women with twin pregnancies is diagnosed at an earlier gestational age with lower level of hypertension and a higher rate of thrombocytopenia in comparison to singleton pregnancies.

Fetal gender and umbilical cord characteristics at birth.

OBJECTIVE: To determine fetal gender on umbilical cord parameters. METHODS: Umbilical cords were prospectively collected from uncomplicated, singleton, term pregnancies, which ended either by elective cesarean section or spontaneous vaginal delivery. Data regarding obstetrical history and pregnancy outcome were collected. Various cord parameters were examined including, length, number of coils, umbilical cord index (UCI), which demonstrate the ratio between number of coils and cord length, site of placental insertion, direction of coiling and the presence of true knots. RESULTS: Overall, 154 umbilical cords were collected, of them 84 from male and 70 from female newborns. No differences were found regarding obstetrical history parameters or pregnancy outcome between the groups. The umbilical coiling index was significantly higher in female compared to male newborns (0.183 coils/cm versus 0.157 coils/cm, p=.006) due to higher number of cord coils (12.25 ± 5.31 vs. 10.17 ± 3.96, p=.007), with no difference in cord length (66.48 vs. 64.61 cm, p=.372). These differences remained statistically significant even after correction for gravidity, parity and gestational age using multiple linear regression analysis. CONCLUSION: Female newborns having higher umbilical cord index, compared to male as a result of more coils, with no length dissimilarity.

The effect of maternal sleep-disordered breathing on the infant's neurodevelopment.

OBJECTIVE: We sought to examine the effect of maternal sleep-disordered breathing (SDB) on infant general movements (GMs) and neurodevelopment. STUDY DESIGN: Pregnant women with uncomplicated full-term pregnancies and their offspring were prospectively recruited from a community and hospital low-risk obstetric surveillance. All participants completed a sleep questionnaire on second trimester and underwent ambulatory sleep evaluation (WatchPAT; Itamar Medical, Caesarea, Israel). They were categorized as SDB (apnea hypopnea index>5) and controls. Infant GMs were assessed in the first 48 hours and at 8-11 and 14-16 weeks of age. At 12 months of age the Infant Developmental Inventory and the Brief Infant Sleep Questionnaire were administered. RESULTS: In all, 74 women and their full-term infants were studied. Eighteen (24%) women had SDB. Mean birthweight was 3347.1±423.9 g. Median Apgar score at 5 minutes was 10 (range, 8-10). In adjusted comparisons, no differences were found between infants born to mothers with SDB and controls in GM scores in all 3 evaluations. Low social developmental score was detected at 12 months in 64% of infants born to SDB mothers compared to 25% of infants born to controls (adjusted P=.036; odds ratio, 16.7). Infant snoring was reported by 41.7% of mothers with SDB compared to 7.5% of controls (P=.004). CONCLUSION: Our preliminary results suggest that maternal SDB during pregnancy has no adverse effect on neonatal and infant neuromotor development but may affect social development at 1 year.

The role of C-reactive protein measurement as a diagnostic aid in early pregnancy.

OBJECTIVE: To investigate the values of C-reactive protein (CRP) in early pregnancy for detection of any abnormality of the conceptus and especially the condition of extra-uterine pregnancy (EUP). STUDY DESIGN: In this prospective observational study, we established reference values for CRP in early pregnancy. Next, we tested whether a single, wide-range CRP measurement could serve as a diagnostic tool for abnormal first trimester pregnancy by comparing CRP levels in three different pregnancy statuses: viable intrauterine pregnancy (Group A), EUP (Group B) and delayed abortion (Group C). RESULTS: CRP levels were significantly higher in normal pregnancy (Group A) compared to abnormal pregnancy (Group B+C and Group B alone). CRP level was influenced only by the pregnancy status (normal, EUP or delayed abortion) and not by age, BMI, hematocrit or gravidity. The multiple logistic regression model (adjusted for age, gravidity, gestational age, hematocrit and BMI) revealed CRP as being a predictor for normal intrauterine pregnancy. CONCLUSION: This study examined the association between CRP levels and abnormal first trimester pregnancies. Our results support single CRP measurement as a diagnostic tool in early pregnancy.

Severe pregnancy complications are associated with elevated factor VIII plasma activity.

The objective of this study is to investigate the prevalence of elevated factor VIII activity among women with severe complications of pregnancy. The study group included 49 patients with a previous history of pregnancy complications: severe preeclampsia (n = 9); intrauterine fetal death (IUFD) (n = 9); severe intrauterine fetal growth restriction (IUGR) (n = 12); IUGR and preeclampsia (n = 7); preeclampsia and placental abruption (n = 2); IUFD and IUGR (n = 5); and abruptio placenta (n = 5). The control group included 49 healthy women who had had at least one normal pregnancy. Seventeen women of the study group (34.6%) had elevated factor VIII activity compared to one woman (2.1%) in the control group (P < 0.05). The mean level of factor VIII was 159 ± 52% and 88 ± 17.4% of normal activity (mean  ±  SD, t-test, P < 0.05). Importantly, 10 women of the study group (20.4%) had only elevated factor VIII activity with no other known thrombophilia compared to one woman (2.1%) in the control group (P < 0.05). Elevated plasma activity of factor VIII might be a risk factor for severe pregnancy complications.

Neonatal outcome of preterm discordant twins.

OBJECTIVE: To estimate the influence of fetal growth restriction (FGR) on neonatal morbidity and mortality among premature discordant twin neonates. STUDY DESIGN: Our medical records (2002-2007) of preterm twins born at 24-37 weeks' gestation were reviewed. Significant discordance was defined as >15% difference in birth weight. Small for gestational age (SGA) was defined as birth weight <10(th) percentile, and appropriate for gestational age (AGA) was between the 10(th) and 90(th) percentile, according to a twin and sex-adjusted gestational age nomogram. The SGA/AGA group comprised of one SGA twin and its AGA pair (30 pairs). Another group of non-SGA discordant twins was also evaluated (n=40 pairs, AGA/AGA). The morbidity and mortality rates were compared between the groups. RESULTS: Of the selected outcome variables, the only ones in which the incidence was significantly lower for SGA neonates than their AGA pairs were respiratory distress syndrome (5 vs. 11, P=0.014), apnea (1 vs. 9, P=0.004) and the need for respiratory support (5 vs. 14, P=0.002). Anemia, erythropoietin therapy and hyperbilirubinemia were significantly higher in the SGA twin. All selected outcome variables had similar rates within the AGA/AGA pairs. CONCLUSION: FGR among premature discordant twin pairs is associated with significantly lower rates of respiratory morbidity and higher anemia and erythropoietin therapy rates. Overall morbidity is similar for discordant non-FGR twin pairs.

Maternal snoring during pregnancy is associated with enhanced fetal erythropoiesis--a preliminary study.

OBJECTIVE AND BACKGROUND: Snoring is common among pregnant women and early reports suggest that it may bear a risk to the fetus. Increased fetal erythropoiesis manifested by elevated circulating nucleated red blood cells (nRBCs) has been found in complicated pregnancies involving fetal hypoxia. Both erythropoietin (EPO) and interleukin-6 (IL-6) mediate elevation of circulating nRBCs. The intermittent hypoxia and systemic inflammation elicited by sleep-disordered breathing (SDB) could affect fetal erythropoiesis during pregnancy. We hypothesized that maternal snoring will result in increased levels of fetal circulating nRBCs via increased concentrations of EPO, IL-6, or both. METHODS: Women of singleton uncomplicated full-term pregnancies were recruited during labor and completed a designated questionnaire. Umbilical cord blood was collected immediately after birth and analyzed for nRBCs, plasma EPO and plasma IL-6 concentrations. Newborn data were retrieved from medical records. RESULTS: One hundred and twenty-two women were recruited. Thirty-nine percent of women reported habitual snoring during pregnancy. Cord blood levels of circulating nRBCs, EPO and IL-6 were significantly elevated in habitual snorers compared with non-snorers (p = 0.03, 0.005 and 0.01; respectively). No differences in maternal characteristics or newborn crude outcomes were found. CONCLUSIONS: Maternal snoring during pregnancy is associated with enhanced fetal erythropoiesis manifested by increased cord blood levels of nRBCs, EPO and IL-6. This provides preliminary evidence that maternal snoring is associated with subtle alterations in markers of fetal well being.

Coiling characteristics of umbilical cords in breech vs. vertex presentation.

OBJECTIVE: To compare selected umbilical cord parameters, especially cord coiling, between breech and vertex presentations. METHODS: We prospectively collected umbilical cords from uncomplicated breech and vertex obtained during elective term cesarean deliveries. We compared various cord parameters between the two groups as well as data regarding obstetric history and pregnancy outcome. RESULTS: We evaluated 55 umbilical cords from breech and 55 from vertex deliveries. Umbilical cord length (56.93 cm vs. 63.95 cm, P=0.05), number of coils (5.1+/-0.4 vs. 11.7+/-0.6, P<0.0001) and umbilical cord index (UCI) (0.09 coils/cm vs. 0.18 coils/cm, P<0.0001) were all significantly lower for breech presentations and remained significant following multivariate analysis. CONCLUSION: We document significant differences in umbilical coiling and the UCI between breech and vertex presentation. The precise reason for these differences is still unclear.

Reference values for strong ion difference--a novel tool for fetal metabolic assessment.

OBJECTIVES: The aim of this pilot study was to establish reference values for strong ion difference (SID) in umbilical cord blood and investigate the feasibility of evaluating fetal metabolism according to the comprehensive approach to acid-base abnormalities, based on Stewart's physiochemical theory. STUDY DESIGN: A prospective observational study. Women who underwent an elective cesarean section at term (n=40) were compared to women who completed a normal spontaneous delivery at term (n=40). The primary outcome was the establishment of normal values for SID in the umbilical cord vein. We also compared acid-base variables in the umbilical vein between the groups. RESULTS: The apparent SID in the umbilical vein was 34.61+/-3.92 mequiv./L after normal delivery and 35.98+/-2.56 mequiv./L after elective cesarean section (the effective SID is 37.43+/-1.93 and 38.29+/-2.38 mequiv./L, respectively). The pH values were similar in both groups, but the pCO(2) was significantly higher and the plasma principal weak acids (albumin and phosphate) were significantly lower after cesarean sections. CONCLUSIONS: SID enables a comprehensive approach to acid-base abnormalities in the neonate, making it a potential additional tool for evaluating fetal acid-base status.

Perinatal outcome in women with severe pregnancy complications and multiple thrombophilias.

Hypercoagulability leading to placental thrombosis has been implicated in severe pregnancy complications. We compared the perinatal outcome in women with severe preeclampsia, intrauterine growth retardation (IUGR) and severe abruptio placentae and multiple acquired and inherited thrombophilias (study group, n=22) to matched women with similar complications and single thrombophilia (control group, n=22). Gestational age at delivery and birth weight were significantly lower in the study group compared to the control group (p<0.01) and among the study women with severe preeclampsia and IUGR. Severe pregnancy complications may occur earlier during pregnancy and more seriously affect perinatal outcome in women with multiple thrombophilias.

Mid-trimester severe intrauterine growth restriction is associated with a high prevalence of thrombophilia.

OBJECTIVE: To investigate the association between severe mid-trimester IUGR, whose causes are unknown in most cases, and maternal thrombophilias. DESIGN: Case-control study. SETTING: Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, The Sackler Faculty of Medicine, Tel Aviv University. POPULATION: Twenty-six women with severe mid-trimester (22-26 weeks of gestation) IUGR (birthweight <3rd centile) and 52 matched multiparous women with normal pregnancies (controls). METHODS: After excluding pregnancies with vascular maternal disease, chromosomal and structural aberrations and cytomegalovirus infection, 26 women out of 35 with severe mid-trimester IUGR remained and composed the study group. Each was matched for age, ethnicity and smoking status with two healthy women who had normal pregnancies. All the women were tested for genetic and acquired thrombophilias at least eight weeks after delivery. MAIN OUTCOME MEASURES: Prevalence of maternal thrombophilias. RESULTS: The frequency of thrombophilias was 69% in the study group compared with 14% in the control group [odds ratio (OR) 4.5; 95% confidence interval (CI) 2.3-9, P < 0.001]. The frequencies of factor V Leiden mutation, prothrombin gene mutation and protein S deficiency were significantly increased in the study group compared with the control group. The frequency of multiple thrombophilias was 33% in the study group versus none among the controls. Of the 26 pregnancies with severe mid-trimester IUGR, 13 ended in intrauterine fetal death before 25 weeks of gestation: 10 of these women had thrombophilia. CONCLUSION: Women with mid-trimester severe IUGR have an increased prevalence of inherited and acquired thrombophilias.