Spontaneous Version of Fetal Presentation in Twin Pregnancies During Third Trimester: Longitudinal Assessment.

Little is known about longitudinal changes of the first twin presentation in twin gestations. This is a retrospective cohort study including 411 women who were admitted consecutively and delivered live-born twins at 36 weeks of gestation or more. Longitudinal assessment of the first twin presentation was conducted during gestation and at birth in all cases. Gestational age at antenatal assessment was divided into two intervals: early-third trimester (28-31 weeks) and mid-third trimester (32-35 weeks). Fetal presentation was categorized as vertex or non-vertex. We analyzed change of fetal presentation between antepartum intervals and birth. First twin presentation at early-third trimester had the same presentation at birth in 87.6% (360/411) of the study population. In this 'no change' group, vertex presentation was seen in 95.6% (283/296) and non-vertex was seen in 67.0% (77/115) of cases. In total, 96.1% (395/411) of the study population maintained their presentation between mid-third trimester and birth. Vertex presentation was seen in 98.4% (310/315) and non-vertex was seen in 88.5% (85/96) of cases. When comparing vertex with non-vertex, vertex presentation during third trimester was a more reliable predictor of presentation at birth (p < .001). The only factor that contributed significantly to spontaneous version of the first twin during mid-third trimester and birth was a lower birth weight of the first twin compared with the second twin. In conclusion, first twin presentation with vertex during third trimester is not likely to change into non-vertex at birth. We concluded that vertex presentation in twin gestations at early- and mid-third trimester is very predictable. In contrast, a non-vertex first twin presentation is relatively unstable.

Successful full-term delivery after out-of-hospital cardiac arrest during the second trimester of pregnancy: a case report.

Out-of-hospital cardiac arrest in pregnancy is extremely rare. In this case report, a 43-year-old female patient at 24.0 weeks of gestation collapsed outside her home after cardiac arrest. The paramedics performed cardiopulmonary resuscitation with defibrillation for ventricular fibrillation. Spontaneous circulation was achieved after 19 minutes. The fetus was stable during postarrest care. The patient exhibited high blood pressure with seizure-like symptoms for 2 days afterwards, which resolved with magnesium sulfate. She gradually recovered and returned to her daily activities while on treatment with beta blockers for cardiomyopathy and premature ventricular contractions until delivery. At 37.2 weeks of gestation, she underwent elective Cesarean section under spinal anesthesia. The baby weighed 2.55 kg and did not present with any complications. Here, we report a case of successful full-term delivery in a patient who underwent cardiopulmonary resuscitation for sudden cardiac arrest during the second trimester of pregnancy.

Hemoperitoneum: a complication of loop electrosurgical excision procedure.

Loop electrosurgical excision procedure (LEEP) is commonly performed for the management of cervical intraepithelial neoplasia. Although LEEP is considered to be a relatively simple procedure, several unexpected complications have been reported in the literature. Herein, we report a case of hemoperitoneum caused by uterine perforation following LEEP. Blood collection in pelvic cavity and two small defects of the uterus were confirmed by diagnostic laparoscopy. The defects were sutured and the patient recovered well after the operation.

Gastric type mucinous endocervical adenocarcinoma of the uterine cervix: very rare and interesting case.

Gastric type mucinous endocervical adenocarcinomas of the uterine cervix (GAC) are a newly classified mucinous subtype with morphologically in 2014, WHO. They have a much more aggressiveness and show unusual metastatic patterns compared to usual type endocervical adenocarcinoma. They tend to present at higher stage and even in stage I, they have worse survival. Therefore, differential diagnosis of GAC from the usual type of endocervical adenocarcinoma is very important because they are related to a significant risk of recurrence and decreased 5-year disease-specific survival. Besides, GACs are mostly not associated with human papillomavirus (HPV) infection and p16 immunohistochemistry is also typically negative in GAC that is HPV-unassociated tumor. We report a very rare and interesting case of stage IB1 GAC with negative HPV DNA and p16.

Current status of organochlorine pesticides (OCPs) and polychlorinated biphenyls (PCBs) exposure among mothers and their babies of Korea-CHECK cohort study.

Despite the global ban, organochlorine pesticides (OCPs) and polychlorinated biphenyls (PCBs) have been a persistent and significant environmental health issue worldwide. Prenatal exposure to these persistent organic pollutants (POPs) has been identified as a major route of exposure among developing fetuses and newborn infants. Among Children's Health and Environmental Health of Korea (CHECK) cohort population, pregnant females (n=148) and their matching newborn infants (n=117) recruited from four cities of Korea in 2011 were investigated. The blood serum and cord blood serum were sampled at delivery, and measured for 19 OCPs and 19 PCBs. In addition, a questionnaire regarding demographic characteristics, and dietary habits were conducted. The most frequently detected POPs in both maternal blood and cord blood were p,p'-dichlorodiphenyl dichloroethylene (DDE) (99% detection in maternal, and 98% in cord blood serum) and PCB153 (95% in maternal, 74% in cord blood serum). The levels of dichlorodiphenyl trichloroethanes (DDTs) in both maternal (average 82.5ng/g lw) and cord blood serum (average 77.5ng/g lw) were comparable to or greater than those reported in Japan about a decade ago. Approximately two thirds of the pregnant women and newborn infants showed the p,p'-DDE concentrations exceeding the biological equivalent (BE) corresponding to 10-6 excess cancer risk. In addition, less chlorinated PCBs were detected higher in both maternal and cord serum. Less chlorinated PCBs also showed greater transplacental ratio. Dairy consumption among the subjects was positively associated, and tea consumption was negatively associated with serum levels of several POPs. Our results show that the exposure to legacy POPs, especially DDTs, among pregnant women and newborn infants is still prevailing, thus warrants measures for exposure mitigation among these vulnerable populations.

A rapid matrix metalloproteinase-8 bedside test for the detection of intraamniotic inflammation in women with preterm premature rupture of membranes.

OBJECTIVE: To examine whether the MMP-8 PTD Check (SK Pharma Co, Ltd, Kyunggi-do, Korea), a rapid bedside test that can be performed in 15 minutes, is of value in the identification of intraamniotic infection and/or inflammation and in the assessment of the likelihood of adverse pregnancy outcome in patients with preterm premature rupture of membranes (PPROM). STUDY DESIGN: Amniotic fluid was retrieved by transabdominal amniocentesis in 141 women with PPROM (<35 weeks' gestation). Fluid was cultured for aerobic and anaerobic bacteria and genital mycoplasmas; the remaining amniotic fluid was stored. The stored amniotic fluid was analyzed for interleukin-6 and MMP-8 PTD Check test. Intraamniotic infection/inflammation was defined as a positive amniotic fluid culture and/or elevated amniotic fluid interleukin-6 concentration (>2.6 ng/mL). Nonparametric and survival analysis were used. RESULTS: The prevalence of intraamniotic infection/inflammation was 43% (60/141 women) and that of proven amniotic fluid infection was 18% (25/141 women). Patients with a positive MMP-8 PTD Check test result had a significantly higher rate of intraamniotic infection/inflammation (77% [54/70 women] vs 9% [6/71 women]; P < .001); proven amniotic fluid infection (33% [23/70 women] vs 3% [2/71 women]; P < .001), and adverse outcome than those with a negative MMP-8 PTD Check test result. Adverse outcome included shorter interval to delivery and higher rate of preterm delivery, histologic chorioamnionitis, funisitis, low Apgar scores, and significant neonatal morbidity. A positive MMP-8 PTD Check test result had a sensitivity of 90%, a specificity of 80%, a positive predictive value of 77%, and a negative predictive value of 92% in the identification of intraamniotic infection/inflammation, and was an independent predictor of interval to delivery (hazards ratio, 3.7; 95% CI, 2.4-5.9) and significant neonatal morbidity (odds ratio, 3.1; 95% CI, 1.2-7.9). CONCLUSION: The MMP-8 PTD Check test is a rapid, simple, and sensitive bedside test to detect intraamniotic infection/inflammation and to predict adverse outcome that includes short latency, chorioamnionitis, and significant neonatal morbidity in patients with PPROM. The results of this study bring the rapid detection of intraamniotic infection/inflammation to the bedside in clinical obstetrics.

Angiotensinogen G(-6)A polymorphism is associated with the elevation of blood pressure in the hypertensive disorders of pregnancy.

The objective of the present study was to determine whether angiotensinogen G(-6)A polymorphism is associated with the elevation of blood pressure (BP) in the hypertensive disorders of pregnancy in Korean population. The subjects included 201 cases with the hypertensive disorders of pregnancy and 160 healthy controls. The medical records of subjects were reviewed. Cases were classified into the four subtypes (transient hypertension, preeclampsia, chronic hypertension, and preeclampsia superimposed on chronic hypertension) by the diagnostic criteria suggested by the National High Blood Pressure Education Program Working Group. Cases were also divided into the high and low BP group by the elevation of BP (diastolic BP greater than or equal to 110 mmHg). Maternal angiotensinogen G(-6)A polymorphism was determined by restriction fragment length polymorphism. Frequencies of AA genotype were significantly higher in the high than in the low BP group in the preeclampsia, superimposed preeclampsia, and the combined group (N = 201), suggesting that the angiotensinogen G(-6)A allele was significantly associated with the elevation of BP in the hypertensive disorders of pregnancy among South Korean women. The present findings imply that the elevation of BP can serve as an endophenotype for a spectrum of hypertensive conditions in pregnancy.

Funisitis in term pregnancy is associated with microbial invasion of the amniotic cavity and intra-amniotic inflammation.

OBJECTIVE: Funisitis is the histologic counterpart of the fetal inflammatory response syndrome, which is a multisystemic disorder associated with impending preterm delivery and adverse neonatal outcome. The purpose of this study was to examine the relationship between funisitis and the microbiologic status of amniotic fluid (AF) and AF white blood cell (WBC) count in patients at term. METHODS: The relationship between the presence of funisitis, AF culture, and AF WBC count was examined in 832 consecutive patients who delivered a term neonate within 72 hours of amniocentesis. AF was cultured for aerobic and anaerobic bacteria, as well as for mycoplasmas. Funisitis was diagnosed in the presence of neutrophil infiltration into the umbilical vessel walls or Wharton's jelly. AF WBC count was analyzed in a hemocytometer chamber. Nonparametric statistics were used for data analysis. RESULTS: Funisitis was present in 4% (30/832) of cases. A positive AF culture was more common in cases with funisitis than in those without funisitis (17% vs. 5%; p < 0.05). Patients with funisitis had a significantly higher median AF WBC count than those without funisitis (median >1000 cells/mm3 vs. median 2 cells/mm3; p < 0.001). The frequency of funisitis and of a positive AF culture was 1% in women without labor and with intact membranes and the frequencies and the median AF WBC count increased in the presence of labor or rupture of membranes. CONCLUSION: Funisitis is present in 4% of women at term and is associated with microbial invasion of the amniotic cavity (MIAC) and inflammation as reflected by increased AF WBC count.

Fetal plasma cortisol and dehydroepiandrosterone sulfate concentrations in pregnancy and term parturition.

OBJECTIVE: To examine if changes in fetal plasma concentrations of cortisol or dehydroepiandrosterone sulfate (DHEAS) levels are associated with human term parturition. METHODS: Umbilical cord plasma cortisol and DHEAS concentrations were measured in 374 singleton pregnancies that delivered at term in the following six groups: group 1, cordocentesis for clinical indications before 36 weeks of gestation (n = 93); group 2, cordocentesis for clinical indications after 36 weeks of gestation (n = 9); group 3, cord blood sampling after elective cesarean section (CS) at term without labor (n = 140); group 4, cord blood sampling after CS at term with early labor (cervical dilatation < or =3 cm, n = 18); group 5, cord blood sampling after CS at term with active labor (cervical dilatation 4 cm or greater, n = 26); group 6, cord blood sampling after vaginal delivery at term (n = 88). Corticosteroids were not administered before blood collection. RESULTS: (1) Fetal plasma cortisol remained unchanged until 36 weeks of gestation and increased thereafter to term; (2) active labor was associated with a significant increase in fetal plasma cortisol; (3) fetal plasma DHEAS increased at term gestation (>36 weeks) but did not increase during active labor; (4) the cortisol/DHEAS ratio (stress index) increased with advancing gestation and with active labor at term. CONCLUSIONS. Human parturition at term is associated with an increase in fetal plasma cortisol and in the cortisol/DHEAS ratio, but not in DHEAS.

Pregnancy outcomes in women with mechanical heart valves.

OBJECTIVE: To evaluate maternal complications and perinatal outcomes in women with mechanical heart valves treated with warfarin and heparin during pregnancy. STUDY DESIGN: A retrospective chart review was performed on 45 pregnancies in 28 women who were previously fitted with mechanical valve prostheses and treated between 1991 and 2005 at Seoul National University Hospital. Outcome parameters were maternal complications and perinatal outcomes. RESULTS: Overall, there were 27 live births (60%), 7 stillbirths (15.6%), 2 therapeutic terminations in the second trimester (4.4%), 9 first-trimester spontaneous abortions (20%) and 2 neonatal deaths after preterm delivery. After excluding 9 first-trimester spontaneous abortions and 3 pregnancies administered warfarin throughout pregnancy, there were significantly more live births among patients administered heparin only after a diagnosis of pregnancy than among those administered warfarin from the second trimester (11 of 11 vs. 13 of 22, p = 0.015). One patient with mitral valve thrombosis during heparinization in the first trimester received valve replacement surgery and then aborted. Late postpartum hemorrhage occurred in 1 patient. All stillbirths and therapeutic terminations occurred in women being administered warfarin. CONCLUSION: Warfarin use from the second trimester in combination anticoagulation regimens increases the risk of an adverse perinatal outcome.

C-reactive protein concentration in vaginal fluid as a marker for intra-amniotic inflammation/infection in preterm premature rupture of membranes.

OBJECTIVE: The purpose of this study was to determine whether C-reactive protein (CRP) concentrations in vaginal fluid can identify patients with intra-amniotic inflammation/infection (IAI) and predict adverse outcome in preterm premature rupture of membranes (PROM). METHODS: The study population consisted of 121 singleton pregnant women with preterm PROM (36 weeks of gestation) who had an amniocentesis and vaginal fluid collection. A Dacron polyester-tipped applicator was soaked with vaginal fluid for 10 seconds and diluted with 1 mL buffer solution. Amniotic fluid was cultured for aerobic and anaerobic bacteria, as well as mycoplasmas. Vaginal fluid CRP and amniotic fluid matrix metalloproteinase-8 (MMP-8) were determined by specific immunoassays. IAI was defined as an amniotic fluid MMP-8 concentration >23 ng/mL and/or a positive amniotic fluid culture. Nonparametric tests and survival techniques were used for statistical analysis. RESULTS: Patients with IAI had a significantly higher median vaginal fluid CRP concentration than those without IAI (median (range), 7.8 (0.1-1310.1) ng/mL vs. 1.0 (0.1-319.4) ng/mL, p < 0.005). The median amniotic fluid white blood cell (WBC) count was significantly higher in patients with a vaginal fluid CRP concentration of >10 ng/mL than in those with a lower concentration (median (range), 82.5 (0-8640) cells/mm3 vs. 2 (0->1000) cells/mm3, p < 0.001). Patients with vaginal fluid CRP concentration of >10 ng/mL had a significantly shorter sampling-to-delivery interval and higher rates of preterm delivery within five days, funisitis, and histologic chorioamnionitis than did those with a vaginal fluid CRP concentration below this cut-off. A vaginal fluid CRP cut-off of 10 ng/mL had a specificity of 89% and a sensitivity of 45% in the identification of IAI. CONCLUSION: An elevated CRP concentration in vaginal fluid collected by polyester-tipped applicator is a risk factor for intra-amniotic inflammation/infection and impending preterm delivery in preterm PROM.

Midtrimester maternal plasma concentrations of angiopoietin 1, angiopoietin 2, and placental growth factor in pregnant women who subsequently develop preeclampsia.

OBJECTIVE: The aim of this study was to compare midtrimester maternal plasma concentrations of angiopoietin 1, angiopoietin 2, and placental growth factor between pregnant women who subsequently developed preeclampsia and those who did not. METHODS: Midtrimester maternal plasma was collected and stored at -70℃ when genetic amniocentesis was performed. Cases included 37 samples of individual who subsequently developed preeclampsia, and matched controls were from individuals who did not develop preeclampsia. Angiopoietin 1, angiopoietin 2, and placental growth factor concentrations were measured by the enzyme-linked immunosorbent assay method and were compared using the Mann-Whitney U-test. A P-value <0.05 was considered significant. RESULTS: In pregnant women who subsequently developed preeclampsia, midtrimester maternal plasma concentrations of angiopoietin 1 and angiopoietin 2 were significantly higher and placental growth factor concentrations were significantly lower than in women who did not develop preeclampsia (angiopoietin 1: 10.6 [3.1-19.7] vs. 7.8 [0.9-24.4] ng/mL, P=0.031; angiopoietin 2: 31.0 [4.7-81.2] vs. 18.4 [4.2-49.7] ng/mL, P<0.001; placental growth factor: 87.1 [14.2-774.3] vs. 148.8 [57.2-425.6] pg/mL, P<0.001). Within the case group who subsequently developed preeclampsia, the placental growth factor was significantly lower in those who had fetal growth restrictions than in those who did not (placental growth factor: 72.5 [14.2-774.3] vs. 140.9 [44.2-257.5] pg/mL, P=0.003). CONCLUSION: Midtrimester maternal plasma concentrations of angiopoietin 1, angiopoietin 2, and placental growth factor may be associated with the subsequent development of preeclampsia.

Comparison of fetal heart rate patterns using nonlinear dynamics in breech versus cephalic presentation at term.

BACKGROUND: It has been reported that breech fetuses have inferior neurological outcomes regardless of mode of delivery, raising the possibility that in utero neurological impairment is more frequent in breech fetuses, possibly contributing to malpresentation. AIMS: To assess differences between the cardiovascular autonomic nervous systems (ANSs) of breech and cephalic fetuses using nonlinear dynamic indices of fetal heart rate (FHR) variability. STUDY DESIGN AND SUBJECTS: This study included 86 fetuses with breech presentation and 173 fetuses with cephalic presentation, with no other maternal or fetal problems. We analyzed FHR variability and spectral indices as markers of ANS behavior. We used nonlinear dynamic indices to represent the complexity of heart rate regulation, as well as correlation dimension as a chaotic index of the cardiovascular control system. RESULTS: One of FHR parameters (Mean minute range) was significantly lower in breech than cephalic fetuses (p=0.0294). However, there were no other significant differences in any linear or nonlinear indices, nor in clinical outcomes, between breech and cephalic fetuses. CONCLUSION: Our data suggest that breech fetuses have neither more active ANS nor less active complexity control systems than do cephalic fetuses. This indicates that the neurologic maturation of breech fetuses is not inferior to cephalic ones. The practical implication of these findings is that the nervous system integrity of breech fetuses may not result directly in neonatal complications.

Prevalence and clinical features of arthralgia/arthritis in healthy pregnant women.

The authors prospectively investigated 155 pregnant women, without a history of rheumatic disease who visited the Department of Obstetrics and Gynecology for routine antenatal care, to evaluate the prevalences and clinical features of arthralgia and arthritis in healthy pregnant women. Mean of the 155 subjects' ages was 31.8 +/- 3.8 (years, +/-SD). Arthralgia was found in 26 (16.7%) and arthritis in 15 (9.6%) pregnant women. Arthralgia or arthritis developed in the third trimester (28-40 weeks of gestation), except in one case (16 weeks of gestation). Most commonly involved joints were the proximal interphalangeal (n = 19, 12.2%). Rheumatoid factor and antinuclear antibody were negative in patients with arthritis. Ten women (6.8%) had persistent arthralgia for over 6 weeks, post-delivery. Four of them were followed up at Rheumatology Clinic and were diagnosed as having spondyloarthropathy (1), or unspecified arthralgia (3). In conclusion, arthralgia is common during pregnancy and most frequent in proximal interphalangeal joints.

Relationship between twin-to-twin delivery interval and umbilical artery acid-base status in the second twin.

The purpose of this study was to determine the effect of twin-to-twin delivery interval on umbilical artery acid-base status of the second twin at birth. This was a retrospective cohort study of all live-born twins with measured acid-base status in umbilical arterial blood who were delivered after 34 weeks' gestation from June 2003 to February 2006. Twins with any maternal or fetal complications were excluded. Subjects were divided into two groups based on the mode of delivery of the first twin: normal cephalic vaginal deliveries (n=40) or cesarean deliveries (n=67). The inter-twin differences in umbilical arterial blood pH, PCO(2), PO(2), and base excess in twin newborns born vaginally were significantly greater than the corresponding differences in those born by cesarean section. A significant positive correlation was found between twin-to-twin delivery interval and inter-twin difference in umbilical arterial blood pH in twin newborns born vaginally. The umbilical arterial blood pH of the second twin was less than 7.0 in 14% (2/14) in cases delivered more than 20 min after the first twin. The umbilical arterial blood gas status of the second twin worsened with increasing twin-to-twin delivery interval, and pathologic fetal acidemia (pH<7.0) might develop in the second twin when the twin-to-twin delivery interval was greater than 20 min.

An elevated maternal plasma, but not amniotic fluid, soluble fms-like tyrosine kinase-1 (sFlt-1) at the time of mid-trimester genetic amniocentesis is a risk factor for preeclampsia.

OBJECTIVE: The purpose of this study was to determine if an elevated concentration of soluble fms-like tyrosine kinase-1(sFlt-1) in maternal plasma and amniotic fluid is a risk factor for the subsequent development of preeclampsia. STUDY DESIGN: A case-control study was conducted to compare mid-trimester concentrations of maternal plasma and amniotic fluid sFlt-1 in patients who developed preeclampsia with those who did not. The study included 32 cases with preeclampsia (18 cases: severe preeclampsia) and 128 matched controls with normal outcomes. Patients with an abnormal fetal karyotype or major anomaly, multiple pregnancies, chronic hypertension, diabetes, and renal disease were excluded. Soluble Flt-1 concentration was measured by specific immunoassay. Nonparametric techniques were used for statistical analysis. RESULTS: 1) The median maternal plasma, but not amniotic fluid, sFlt-1 concentration in patients who developed preeclampsia was significantly higher than in the control cases (maternal plasma: median 730 pg/mL, range 60-3375 pg/mL vs median 441 pg/mL, range 58-1959 pg/mL, P < .05; amniotic fluid: median 10,504 pg/mL, range 5253-38,023 pg/mL vs median 10,236 pg/mL, range 4326-87,684 pg/mL, P = .65). 2) The median plasma concentration of sFlt-1 was higher in cases of severe preeclampsia than in those with mild preeclampsia without reaching statistical significance (median 762 pg/mL, range 261-3309 pg/mL vs median 334 pg/mL, range 60-3375 pg/mL; P = .07). However, there was no significant difference in the median amniotic fluid sFlt-1 concentrations between patients with severe preeclampsia and those with mild preeclampsia (P = .45). 3) An elevated maternal plasma sFlt-1 concentration (higher than 700 pg/mL) is a risk factor for the development of preeclampsia (OR 3.9, 95% CI 1.7-8.6) and severe preeclampsia (OR 7.4, 95% CI 2.5-22.1) after genetic amniocentesis. 4) The median interval from amniocentesis to the diagnosis of preeclampsia in patients with maternal plasma sFlt-1 concentrations higher than 700 pg/mL was 117 days (range 19-154 days). CONCLUSION: An elevated concentration of sFlt-1 in maternal plasma at the time of mid-trimester amniocentesis is a risk factor for the subsequent development of preeclampsia.

Amniotic fluid tumor necrosis factor-alpha is a marker for the prediction of early-onset neonatal sepsis in preterm labor.

BACKGROUND: Our purpose was to determine whether amniotic fluid concentrations of tumor necrosis factor-alpha are of value in the prediction of early-onset neonatal sepsis (proven or suspected) in patients with preterm labor and intact membranes. METHODS: The relationship between amniotic fluid tumor necrosis factor-alpha concentrations and early-onset neonatal sepsis was examined in 59 consecutive patients with preterm labor and intact membranes who delivered preterm neonates within 72 h after transabdominal amniocentesis. Early-onset neonatal sepsis was defined either as the presence of a positive blood culture or as suspected sepsis within 72 h of delivery. Tumor necrosis factor-alpha was determined by enzyme-linked immunosorbent assays. RESULTS: Patients delivering neonates with early-onset neonatal sepsis had significantly higher median amniotic fluid TNF-alpha concentrations than patients delivering neonates without early-onset neonatal sepsis (p < 0.0005). An amniotic fluid tumor necrosis factor-alpha concentration > or =41 pg/ml had a sensitivity of 82% (23/29) and specificity of 79% (38/48) in the prediction of early-onset neonatal sepsis. Multiple logistic regression indicated that elevated amniotic fluid tumor necrosis factor-alpha (> or =41 pg/ml) was the only independent predictor of early-onset neonatal sepsis (odds ratio 12.9, 95% confidence interval 1.3-125.3, p=0.01) after correction for known confounding variables. CONCLUSIONS: (1) Amniotic fluid tumor necrosis factor-alpha is a marker for the prediction of early-onset neonatal sepsis in patients with preterm labor and intact membranes. (2) Amniotic fluid tumor necrosis factor-alpha is a better independent predictor of early-onset neonatal sepsis than placental histologic finding or amniotic fluid culture.

Chorionic plate vessels as an origin of amniotic fluid neutrophils.

The present study was conducted to investigate the potential anatomical source of amniotic fluid neutrophils. Microdissection of neutrophils from the chorioamnion of the fetal membranes and the amnion of the chorionic plates of 10 preterm placentas with acute chorioamnionitis was performed and the genotypes of the neutrophils were compared with those of the mother and fetus using polymerase chain reaction of nine autosomal STR loci. In separate analyses, we reviewed eight cases of fetal autopsies with increased amniotic fluid neutrophils for the presence of neutrophils in the alveoli, and also analyzed the relationship between the amniotic fluid white blood cell (WBC) count and the histological pattern of placental inflammation. The genotypes of all of the neutrophils found in the chorioamnion of the fetal membrane matched those of the mother (n = 10). The genotypes of neutrophils found in the chorionic plate were of mixed maternal and fetal origin (n = 4). In the autopsy series of the fetuses with amniotic fluid WBC (n = 8), only five cases showed neutrophils in the alveolar space, while all the placentas had chorioamnionitis. There was no significant difference in amniotic fluid WBC count between the cases with or without acute membranitis, while among the cases with placental inflammation, those with inflammation of the chorionic plate had a significantly higher amniotic fluid WBC count than both the membranitis-only cases (P < 0.001) and the membranitis and funisitis cases (P < 0.05). These results imply that fetal vasculature at the chorionic plate is the main source of amniotic fluid neutrophils, especially in the cases without funisitis.

Biovar diversity of Ureaplasma urealyticum in amniotic fluid: distribution, intrauterine inflammatory response and pregnancy outcomes.

OBJECTIVE: The objective of this study was to determine the distribution of two biovars of Ureaplasma urealyticum (parvo and T960) in human amniotic fluid and to examine whether the magnitude of the intrauterine inflammatory response and pregnancy outcomes are different between patients with microbial invasion of the amniotic cavity with "parvo biovar" and those with "T960 biovar". STUDY DESIGN: This cohort included 77 preterm singleton pregnancies (gestational age < 37 weeks) in whom U. urealyticum was detected from amniotic fluid using the polymerase chain reaction (PCR). Amniotic fluid was obtained by transabdominal amniocentesis. Amniotic fluid was cultured for aerobic and anaerobic bacteria as well as mycoplasmas. U. urealyticum was biotyped by PCR methods. Amniotic fluid inflammatory response was determined by amniotic fluid white blood cell count and interleukin-6 concentration. RESULTS: 1) The "parvo biovar" was detected in 82% (63/77) and "T960 biovar" was in 18% (14/77) of cases; 2) U. urealyticum was isolated by conventional culture method from amniotic fluid in 56% (35/63) of cases with positive for "parvo biovar" and in 50% (7/14) of cases with positive for "T960 biovar"; 3) There were no significant differences in the median gestational age at amniocentesis, gestational age at delivery, birth weight, amniotic fluid white blood cell count, amniotic fluid interleukin-6 concentration and the rates of clinical chorioamnionitis, histologic chorioamnionitis, funisitis and neonatal morbidity between patients in the two biovar groups. CONCLUSIONS: 1) The "parvo biovar" is more frequently isolated from amniotic fluid of preterm gestations than the "T960 biovar"; 2) Biovar diversity of U. urealyticum in amniotic fluid was not associated with different pregnancy outcome and magnitude of the intraamniotic inflammatory response.

Clinical significance of intra-amniotic inflammation in patients with preterm premature rupture of membranes.

OBJECTIVE: This study was conducted to determine the frequency and clinical significance of intra-amniotic inflammation in patients with preterm premature rupture of the membranes. STUDY DESIGN: Amniotic fluid was retrieved from 219 patients with preterm premature rupture of the membranes; the fluid was cultured for aerobic and anaerobic bacteria and mycoplasmas and assayed for neutrophil collagenase, which is also known as matrix metalloproteinase-8. Matrix metalloproteinase-8 was used because previous studies indicated that this was a sensitive and specific index of inflammation and that is correlated with the amniotic fluid white blood cell count. Intra-amniotic inflammation was defined as an elevated amniotic fluid matrix metalloproteinase-8 concentration (>23 ng/mL). Nonparametric and survival techniques were used for statistical analysis. RESULTS: The overall rate of intra-amniotic inflammation was 42% (93/219 samples); proven intra-amniotic infection was detected only in 23% (50/219 samples). Intra-amniotic inflammation with a negative amniotic fluid culture for micro-organisms was found in 23% (51/219 samples) and was as common as proven intra-amniotic infection. Pregnancy outcome was worse in patients with intra-amniotic inflammation and a negative culture than in those patients with a negative culture and without inflammation. There were no differences in the interval-to-delivery or rate of complications between patients with intra-amniotic inflammation and a negative culture and patients with proven amniotic fluid infection. CONCLUSION: We conclude that intra-amniotic inflammation, regardless of culture result, is present in 42% of patients with preterm premature rupture of the membranes and that it is a risk factor for impending preterm delivery and adverse outcome. We propose that intra-amniotic inflammation, rather than infection, be used to classify and treat patients with preterm premature rupture of the membranes.