Differential impact of abnormal vaginal colonization on perinatal outcome and association with early-onset neonatal sepsis: preterm labor vs. preterm premature rupture of membrane.

OBJECTIVE: The purpose of this study was to check whether the impact of abnormal vaginal colonization on perinatal outcomes would be different in patients with preterm labor (PTL) and premature membrane rupture (PPROM). We also sought to determine the concordance rate of microorganisms isolated from the maternal vagina and neonatal blood in cases of early-onset neonatal sepsis (EONS) in PTL and PPROM. METHODS: This retrospective study included 996 singleton pregnancies who were admitted to the high risk care unit of our institution due to PTL (n = 519) or PPROM (n = 477) and underwent vaginal culture examination at admission between January 2005 and April 2019. Abnormal vaginal colonization was defined upon isolation of aerobic microorganisms. The maternal baseline characteristics, delivery, and neonatal outcomes were compared according to the presence or absence of abnormal vaginal flora, both in PTL and PPROM. RESULTS: The rate of abnormal vaginal colonization in PTL and PPROM was 17.0 and 21.4%, respectively. Both in PTL and PPROM, the gestational age at admission was lower in the abnormal vaginal colonization group (PTL, 27.2 ± 3.5 vs. 28.2 ± 3.5 weeks, p = .024; PPROM, 26.1 ± 5.3 vs. 27.5 ± 4.5 weeks, p = .007). Multivariable analysis demonstrated that the group with abnormal bacteria in PPROM but not in PTL had a significantly higher rate of EONS than the group without abnormal bacteria after adjustment for confounders including gestational age at admission (PPROM, odds ratio, OR [95% confidence interval, CI]: 4.172 [1.426-12.206]; PTL, OR [95% CI]: 0.661 [0.079-5.505]). Concordance analysis showed that the maternal vaginal bacteria colonization by Escherichia coli (5.9 vs. 0.5%, p = .033) and Staphylococcus aureus (14.3 vs. 0.2%, p = .032) in PPROM was significantly correlated with the microorganisms from the neonatal blood culture EONS cases. In PTL, no specific microorganisms showed concordance between maternal vaginal bacteria and microorganisms causing EONS. CONCLUSION: Our data showed that maternal vaginal colonization in PPROM, but not in PTL, is an independent risk factor for EONS.

Maternal pre-pregnancy body mass index and the risk for gestational diabetes mellitus in women with twin pregnancy in South Korea.

OBJECTIVE: To investigate the association between maternal pre-pregnancy body mass index (BMI) and the risk for gestational diabetes mellitus (GDM) in women with twin pregnancy in South Korea. MATERIALS AND METHODS: We performed a single-center, retrospective cohort study involving 1028 women with twin pregnancy from January 2006 to December 2018 in South Korea. Pregnancies with monoamnionic twins, twin-twin transfusion syndrome, fetal death in utero before 24 weeks, pre-gestational diabetes mellitus, and unknown BMI or GDM status were excluded. Subjects were grouped into four groups based on pre-pregnancy BMI: underweight (<18.5 kg/m2), normal (18.5-22.9 kg/m2), overweight (23.0-24.9 kg/m2), and obese (≥25.0 kg/m2). RESULTS: Among 1028 women who were included in the analysis, 169 (16.4%), 655 (63.7%), 111 (10.8%), and 93 (9.0%) women were underweight, normal, overweight, and obese, respectively, before pregnancy. The incidence of GDM was 8.9% in the total study population: 4.7%, 8.2%, 11.7%, and 17.2% in the underweight, normal, overweight, and obese group, respectively (p = 0.005). The incidence of GDM significantly increased according to the increase in pre-pregnancy BMI (p < 0.001). Women in the obese group were more likely to be affected by GDM compared to the normal group (adjusted odds ratio = 2.20, 95% confidence interval = 1.19-4.08) after controlling for maternal age, parity, type of conception, and chorionicity. CONCLUSION: In twin pregnancies in South Korea, the risk of GDM increased as maternal pre-pregnancy BMI increased and obese women before pregnancy were more likely to be affected by GDM.

Association of adherence to guidelines for cervical cerclage with perinatal outcomes and placental inflammation in women with cervical length ≥2.0 cm.

OBJECTIVES: Cerclage operation is one of the most common obstetric controversies. The aim of this study was to compare the perinatal outcomes and placental inflammation of cerclage performed adherent and non-adherent to international guidelines. MATERIAL AND METHODS: This study included all consecutive women with singleton deliveries who underwent cerclage. According to the current American College of Obstetricians and Gynecologists (ACOG) guideline, we designated our study population into two groups: the adherent-to-guideline and non-adherent groups. Each group was categorized into two groups according to cervical length (CL) at the time of cerclage (<2.0 cm vs. ≥2.0 cm). We evaluated the reasons for cerclage, maternal characteristics, perioperative variables, pregnancy and neonatal outcomes, and placental inflammatory pathology according to the criteria proposed by the Society of Pediatric Pathology. RESULTS: Among 310 women with cerclage, we excluded patients (n = 21) with indicated preterm delivery (PTD), major fetal anomaly, fetal death in-utero, and missing information for reason of cerclage. We also excluded patients who underwent physical examination-indicated cerclage (n = 53) and with missing information of CL at the time of cerclage (n = 52). A total of 184 women were eventually analyzed. In women with CL < 2.0 cm, the non-adherent group showed similar PTD (<28 weeks, <34 weeks) and neonatal composite morbidity rates compared to the adherent-to-guideline group. However, in women with CL ≥ 2.0 cm, the non-adherent group manifested significantly higher PTD (<28 weeks; 16.7% vs. 4.4%, p = 0.04, <34 weeks; 23.8% vs. 5.8%, p = 0.006) and neonatal composite morbidity (20.5% vs. 5.9%, p = 0.028) rates than the adherent-to-guideline group despite similar perioperative variables and lower PTD history rates. The non-adherent group with CL ≥ 2 cm at the time of cerclage was also associated with severe histologic chorioamnionitis (p = 0.033). CONCLUSION: Cerclage performed beyond the current guidelines in pregnant women with CL ≥ 2.0 cm may confer an additional risk of perinatal complications in association with severe placental inflammation.

Degree of intrapartum fever and associated factors: Three group analysis of no fever, borderline and overt fever.

AIM: Previous studies analyzing intrapartum fever by dichotomization of fever just above 38.0°C or not may lead to overlook clinical significance of borderline fever. We aimed to investigate the maternal baseline and intrapartum characteristics, neonatal outcomes, and inflammatory placental pathology in relation to the degree of intrapartum fever by three group analysis. METHODS: We performed a retrospective analysis of consecutive singleton deliveries between 370/7 to 410/7 weeks divided into three groups based on the peak body temperature during labor: No fever (< 37.5°C), borderline fever (≥ 37.5°C and < 38.0°C), and overt fever (≥ 38.0°C). Maternal and intrapartum characteristics, neonatal outcomes, and inflammatory placental pathology were compared by trend analysis, intergroup difference analysis, and multivariable analysis. RESULTS: The degree of intrapartum fever was significantly associated with younger maternal age, nulliparity, longer duration of rupture of membrane, and epidural analgesia (p < 0.001). And the incidence of neonatal proven sepsis and mortality were not significantly different among the groups. The degree of intrapartum fever was associated with the stage of acute chorioamnionitis and funisitis (p < 0.001). Multivariate analysis revealed that the association with epidural analgesia was stronger in borderline fever than overt fever (adjusted odds ratio [95% confidence interval], borderline fever = 18.487 [11.447-29.857]; overt fever = 11.068 [4.874-25.133]) after controlling for maternal age, parity, induction or augmentation, duration of ROM, birth weight, and meconium staining. CONCLUSION: Our data support that both epidural analgesia and inflammation of the placenta may contribute to the development of intrapartum fever at term.

Umbilical cord arterial blood gas analysis in term singleton pregnancies: a retrospective analysis over 11 years.

OBJECTIVE: Given that the large volume of data on cord arterial blood gas analysis (ABGA) have been rarely addressed in Korean population, we aimed to examine the incidence, associated factors, and neonatal outcomes in cases of low cord pH, and investigate the incidence of cerebral palsy (CP). METHODS: From data of all consecutive term singleton pregnancies delivered in our institution from 2006 to 2016 (n=15,701), cases with cord ABGA (n=14,221) available were included. We collected information on maternal clinical characteristics and delivery outcomes and also examined neonatal and infant outcomes, including neonatal intensive care unit (NICU) admission and CP, in cases with low cord pH, defined as a pH <7.1. RESULTS: Rates of low Apgar scores at 1 minute (<4) and 5 minutes (<7) were 0.6% (n=79) and 0.4% (n=58), respectively. Rates of cord pH <7.2, <7.1, and <7.0 were 7.1% (n=1,011), 1.1% (n=163), and 0.3% (n=38), respectively. Among cases with low cord pH, 30.1% (n=49/163) were admitted to the NICU and 11.0% (n=18/163) required ventilator support. Ultrasonography of the brain was performed in 28.8% (n=47/163), with abnormal findings observed in 27.7% (n=13/47). Among cases with low cord pH, 1.8% (n=3/163) were subsequently diagnosed with CP, including 2 cases of spastic CP and 1 of ataxic CP. CONCLUSION: Although low cord pH was a relatively frequent finding observed in 1 out of every 87 cases, hypoxic-ischemic encephalopathy-related CP was found in only 1 out of 7,111 term singleton deliveries over 11 years in our institution.

Pretreatment Lymph Node Metastasis as a Prognostic Significance in Cervical Cancer: Comparison between Disease Status.

PURPOSE: Lymph node metastasis (LNM) is the most significant prognostic factor in cervical cancer that was recently incorporated into the International Federation of Gynecology and Obstetrics (FIGO) staging system. This study was performed to evaluate whether the prognostic significance of LNM differs according to disease status. MATERIALS AND METHODS: Patients with FIGO stage IB or higher cervical cancer who had pretreatment computed tomography and/or magnetic resonance imaging studies as well as long-term follow-up were enrolled in this retrospective study. The hazard ratio (HR) of Cox regression was used to determine the prognostic significance of LNM. The HRs were compared between the different tumor groups (based on stage, histology, tumor size, primary treatment, age, parametrium involvement, and lymphovascular space invasion). RESULTS: A total of 970 patients treated between January 1999 and December 2007 were included. The pretreatment LNM had prognostic significance in patients with stage IB1/IIA (HR for progression-free survival 2.10, p=0.001; HR for overall survival 1.99, p=0.005). However, the significance gradually decreased or disappeared with advancing stages. Similarly, the prognostic significance of the pretreatment LNM decreased with advancing disease status, including old age, parametrial involvement or lymphovascular space involvement. In contrast, the tumor size was associated with the prognostic significance of LNM with advancing status. The significance of the clinical LNM did not reflect the significance of the clinical stage. In contrast, the tumor size, parametrial involvement, and significance of the pathologic LNM reflected the clinical stage. CONCLUSION: In patients with cervical cancer, pretreatment LNM on imaging has different clinical significance depending on the tumor status.

Sirolimus therapy for fetal cardiac rhabdomyoma in a pregnant woman with tuberous sclerosis.

Rhabdomyoma is the most common fetal cardiac tumor, and its development is related to tuberous sclerosis. Fetal cardiac rhabdomyomas often spontaneously regress in utero or after birth, but large tumors can cause hemodynamic obstruction. Sirolimus, a mammalian target of rapamycin (mTOR) inhibitor, has been used as an immunosuppressant after organ transplantation. The mTOR inhibitors are well-known to have anti-tumor activity, and they have been used for the treatment of patients with tuberous sclerosis. In the current case, fetal cardiac rhabdomyoma was completely resolved in utero during oral sirolimus treatment in the mother with tuberous sclerosis. This case shows that oral sirolimus therapy in pregnancy may be a treatment for multiple or large fetal cardiac rhabdomyomas.