Can pelvic floor dysfunction after vaginal birth be prevented?

INTRODUCTION AND HYPOTHESIS: Significant breakthroughs in our understanding of pelvic floor dysfunction have occurred in the past two decades. The next step is to translate this understanding into effective preventative and early intervention strategies to minimize maternal morbidity from vaginal birth. We have learned enough to chart a course toward prevention. METHODS: This article outlines some major advances in understanding the pathophysiology of pelvic floor dysfunction and suggests strategies for future prevention research. RESULTS: Vaginal birth is the primary risk factor for the development of pelvic floor disorders and this is compounded by forceps use. Age, race, and genetics are also risk factors. Steps to prevent or minimize the development of pelvic floor problems include moderating forceps use and utilizing risk assessment tools to offer cesarean delivery to those at greatest risk. CONCLUSION: These actions would represent one giant step forward in advancing the practice of obstetrics into the modern age of personalized medicine.

Adverse pregnancy outcomes among women with prior spontaneous or induced abortions.

OBJECTIVE: The aim of the article is to determine whether prior spontaneous abortion (SAB) or induced abortion (IAB), or the interpregnancy interval are associated with subsequent adverse pregnancy outcomes in nulliparous women. METHODS: We performed a secondary analysis of data collected from nulliparous women enrolled in a completed trial of vitamins C and E or placebo for preeclampsia prevention. Adjusted odds ratios (ORs) for maternal and fetal outcomes were determined for nulliparous women with prior SABs and IABs as compared with primigravid participants. RESULTS: Compared with primigravidas, women with one prior SAB were at increased risk for perinatal death (adj. OR, 1.5; 95% CI, 1.1-2.3) in subsequent pregnancies. Two or more SABs were associated with an increased risk for spontaneous preterm birth (PTB) (adj. OR, 2.6, 95% CI, 1.7-4.0), preterm premature rupture of membranes (PROM) (adj. OR, 2.9; 95% CI, 1.6-5.3), and perinatal death (adj. OR, 2.8; 95% CI, 1.5-5.3). Women with one previous IAB had higher rates of spontaneous PTB (adj. OR, 1.4; 95% CI, 1.0-1.9) and preterm PROM (OR, 2.0; 95% CI, 1.4-3.0). An interpregnancy interval less than 6 months after SAB was not associated with adverse outcomes. CONCLUSION: Nulliparous women with a history of SAB or IAB, especially multiple SABs, are at increased risk for adverse pregnancy outcomes.

Large-scale annotation dataset for fetal head biometry in ultrasound images.

This dataset features a collection of 3832 high-resolution ultrasound images, each with dimensions of 959×661 pixels, focused on Fetal heads. The images highlight specific anatomical regions: the brain, cavum septum pellucidum (CSP), and lateral ventricles (LV). The dataset was assembled under the Creative Commons Attribution 4.0 International license, using previously anonymized and de-identified images to maintain ethical standards. Each image is complemented by a CSV file detailing pixel size in millimeters (mm). For enhanced compatibility and usability, the dataset is available in 11 universally accepted formats, including Cityscapes, YOLO, CVAT, Datumaro, COCO, TFRecord, PASCAL, LabelMe, Segmentation mask, OpenImage, and ICDAR. This broad range of formats ensures adaptability for various computer vision tasks, such as classification, segmentation, and object detection. It is also compatible with multiple medical imaging software and deep learning frameworks. The reliability of the annotations is verified through a two-step validation process involving a Senior Attending Physician and a Radiologic Technologist. The Intraclass Correlation Coefficients (ICC) and Jaccard similarity indices (JS) are utilized to quantify inter-rater agreement. The dataset exhibits high annotation reliability, with ICC values averaging at 0.859 and 0.889, and JS values at 0.855 and 0.857 in two iterative rounds of annotation. This dataset is designed to be an invaluable resource for ongoing and future research projects in medical imaging and computer vision. It is particularly suited for applications in prenatal diagnostics, clinical diagnosis, and computer-assisted interventions. Its detailed annotations, broad compatibility, and ethical compliance make it a highly reusable and adaptable tool for the development of algorithms aimed at improving maternal and Fetal health.

Can statins reduce the inflammatory response associated with preterm birth in an animal model?

OBJECTIVE: The objective of the study was to determine the effect of statins on lipopolysaccharide (LPS)-induced inflammatory response in a mouse model of preterm birth (PTB). STUDY DESIGN: Day 15 CD1 mice were randomly allocated to intraperitoneal LPS injection (100 µg) or control. Mice in the LPS group were pretreated, 16 and 2 hours prior, with pravastatin (10 µg/g), simvastatin (10 µg/g), or vehicle control. Animals were sacrificed 6 hours after LPS. Cytokine messenger ribonucleic acid (mRNA) expression in the uterus and cervix, and concentrations in the maternal serum and amniotic fluid (AF) were determined. RESULTS: Pravastatin reduced interleukin (IL)-1ß and IL-6 mRNA expression in the uterus and cervix, respectively, and serum IL-1ß and granulocyte-macrophage colony-stimulating factor (GM-CSF) concentrations. Simvastatin reduced IL-1ß and IL-6 mRNA expressions in the uterus, IL-6 and tumor necrosis factor alpha (TNF-α) in the cervix, and IL-1ß, IL-2, IL-12p70, IL-13, TNF-α, GM-CSF, and interferon-γ concentrations in the serum and IL-6 in AF. CONCLUSION: Statins reduce the LPS-induced inflammatory responses in a mouse model of PTB.

Sex-specific effects of nicotine exposure on developmental programming of blood pressure and vascular reactivity in the C57Bl/6J mouse.

OBJECTIVE: The objective of the study was to determine whether perinatal nicotine exposure adversely affects cardiovascular health in adulthood. STUDY DESIGN: C57Bl/6J female mice were randomized to 200 µg/mL nicotine in 2% saccharin or 2% saccharin alone from 2 weeks before breeding until weaning. Offspring weight, vital signs, and carotid artery vascular reactivity were studied. A second cohort was subjected to shaker stress on day 4 of 7 days. Selected mediators of vascular tone were evaluated by molecular studies. Student t or Mann-Whitney U test was performed for statistical analysis (significance: P < .05). RESULTS: Nicotine-exposed compared with control female offspring had significantly elevated mean blood pressure under normal and stress conditions. Nicotine females lacked heart rate elevation after stress. Nicotine males had higher mean heart rate and a blunted contractile response to phenylephrine compared with controls, without an increase in blood pressure. CONCLUSION: Perinatal nicotine exposure has an impact on the developmental programming of future cardiovascular health, with adverse effects more evident in female offspring.

Ensemble Transfer Learning for Fetal Head Analysis: From Segmentation to Gestational Age and Weight Prediction.

Ultrasound is one of the most commonly used imaging methodologies in obstetrics to monitor the growth of a fetus during the gestation period. Specifically, ultrasound images are routinely utilized to gather fetal information, including body measurements, anatomy structure, fetal movements, and pregnancy complications. Recent developments in artificial intelligence and computer vision provide new methods for the automated analysis of medical images in many domains, including ultrasound images. We present a full end-to-end framework for segmenting, measuring, and estimating fetal gestational age and weight based on two-dimensional ultrasound images of the fetal head. Our segmentation framework is based on the following components: (i) eight segmentation architectures (UNet, UNet Plus, Attention UNet, UNet 3+, TransUNet, FPN, LinkNet, and Deeplabv3) were fine-tuned using lightweight network EffientNetB0, and (ii) a weighted voting method for building an optimized ensemble transfer learning model (ETLM). On top of that, ETLM was used to segment the fetal head and to perform analytic and accurate measurements of circumference and seven other values of the fetal head, which we incorporated into a multiple regression model for predicting the week of gestational age and the estimated fetal weight (EFW). We finally validated the regression model by comparing our result with expert physician and longitudinal references. We evaluated the performance of our framework on the public domain dataset HC18: we obtained 98.53% mean intersection over union (mIoU) as the segmentation accuracy, overcoming the state-of-the-art methods; as measurement accuracy, we obtained a 1.87 mm mean absolute difference (MAD). Finally we obtained a 0.03% mean square error (MSE) in predicting the week of gestational age and 0.05% MSE in predicting EFW.

Analysis of risk factors progression of preterm delivery using electronic health records.

BACKGROUND: Preterm deliveries have many negative health implications on both mother and child. Identifying the population level factors that increase the risk of preterm deliveries is an important step in the direction of mitigating the impact and reducing the frequency of occurrence of preterm deliveries. The purpose of this work is to identify preterm delivery risk factors and their progression throughout the pregnancy from a large collection of Electronic Health Records (EHR). RESULTS: The study cohort includes about 60,000 deliveries in the USA with the complete medical history from EHR for diagnoses, medications and procedures. We propose a temporal analysis of risk factors by estimating and comparing risk ratios and variable importance at different time points prior to the delivery event. We selected the following time points before delivery: 0, 12 and 24 week(s) of gestation. We did so by conducting a retrospective cohort study of patient history for a selected set of mothers who delivered preterm and a control group of mothers that delivered full-term. We analyzed the extracted data using logistic regression and random forests models. The results of our analyses showed that the highest risk ratio and variable importance corresponds to history of previous preterm delivery. Other risk factors were identified, some of which are consistent with those that are reported in the literature, others need further investigation. CONCLUSIONS: The comparative analysis of the risk factors at different time points showed that risk factors in the early pregnancy related to patient history and chronic condition, while the risk factors in late pregnancy are specific to the current pregnancy. Our analysis unifies several previously reported studies on preterm risk factors. It also gives important insights on the changes of risk factors in the course of pregnancy. The code used for data analysis will be made available on github.

A Conceptual Framework for Fetus Head Analysis Based on Ultrasound Images.

Ultrasound images are the most used imaging methodologies in obstetrics to monitor the growth of a fetus during the gestation period. In particular, the obstetrician uses fetus head images to monitor the growth state and identify essential features such as Gestational age (GA), estimated fetus weight (EFW), and brain anatomical structures. However, this work requires an expert obstetrician, and it is time-consuming and costly. Therefore, we proposed an automatic framework by adopting a hybrid approach that combines three components i) automatic segmentation to segment the region of interest (ROI) in the fetus head, ii) measurement extraction to measure the segmented ROI, and iii) anomaly and features detection to predict fetus GA, EFW, and abnormality status.

Toward deep observation: A systematic survey on artificial intelligence techniques to monitor fetus via ultrasound images.

Several reviews have been conducted regarding artificial intelligence (AI) techniques to improve pregnancy outcomes. But they are not focusing on ultrasound images. This survey aims to explore how AI can assist with fetal growth monitoring via ultrasound image. We reported our findings using the guidelines for PRISMA. We conducted a comprehensive search of eight bibliographic databases. Out of 1269 studies 107 are included. We found that 2D ultrasound images were more popular (88) than 3D and 4D ultrasound images (19). Classification is the most used method (42), followed by segmentation (31), classification integrated with segmentation (16) and other miscellaneous methods such as object-detection, regression, and reinforcement learning (18). The most common areas that gained traction within the pregnancy domain were the fetus head (43), fetus body (31), fetus heart (13), fetus abdomen (10), and the fetus face (10). This survey will promote the development of improved AI models for fetal clinical applications.

The effect of the postnatal environment on altered fetal programming of adult vascular function in mice that lack endothelial nitric oxide synthase.

OBJECTIVE: The purpose of this study was to investigate vascular reactivity in heterozygous and homozygous offspring with a genetic predisposition for hypertension after postnatal cross-fostering to mothers with the opposite genetic inheritance of the NOS3 knockout allele. STUDY DESIGN: Homozygous NOS3 knockout (C57BL/6J-NOS3(-/-KO)) and wild-type mice (NOS3(+/+WT)) were bred to obtain heterozygous litters with a paternally derived (NOS3(+/-pat)) or maternally derived (NOS3(+/-mat)) knockout allele. After delivery, heterozygous and homozygous litters were cross-fostered to a mother with the opposite NOS3 gene status. Carotid arteries were placed in a wire myograph for isometric tension recording with the use of contractile and relaxant agents. Statistical analysis with 1-way analysis of variance and Neuman-Keuls post-hoc testing was performed. RESULTS: Increased sensitivity to phenylephrine and absent relaxation to acetylcholine in NOS3(+/-mat) was reversed with cross-fostering, and vasorelaxation to isoproterenol was increased. Contraction to calcium was increased in the cross-fostered paternally derived and wild-type litters. CONCLUSION: Postnatal interventions may alter the adult vascular profile favorably that is the result of an abnormal intrauterine environment.

Adipose Tissue Insulin Resistance in Gestational Diabetes.

BACKGROUND: Gestational diabetes mellitus (GDM) is a metabolic disorder characterized by insulin resistance (IR) and altered glucose-lipid metabolism. We propose that ectonucleotide pyrophosphate phosphodiesterase-1 (ENPP1), a protein known to induce adipocyte IR, is a determinant of GDM. Our objective was to study ENPP1 expression in adipose tissue (AT) of obese pregnant women with or without GDM, as well as glucose tolerance in pregnant transgenic (Tg) mice with AT-specific overexpression of human ENPP1. METHODS: AT biopsies and blood were collected from body mass index-matched obese pregnant women non-GDM (n = 6), GDM (n = 7), and nonpregnant controls (n = 6) undergoing cesarian section or elective surgeries, respectively. We measured the following: (1) Expression of key molecules involved in insulin signaling and glucose-lipid metabolism in AT; (2) Plasma glucose and insulin levels and calculation of homeostasis model assessment of IR (HOMA-IR); (3) Intraperitoneal glucose tolerance test in AtENPP1 Tg pregnant mice. RESULTS: We found that: (1) Obese GDM patients have higher AT ENPP1 expression than obese non-GDM patients, or controls (P = 0.01-ANOVA). (2) ENPP1 expression level correlated negatively with glucose transporter 4 (GLUT4) and positively with insulin receptor substrate-1 (IRS-1) serine phosphorylation, and to other adipocyte functional proteins involved in glucose and lipid metabolism (P < 0.05 each), (3) AT ENPP1 expression levels were positively correlated with HOMA-IR (P = 0.01-ANOVA). (4) Pregnant AT ENPP1 Tg mice showed higher plasma glucose than wild type animals (P = 0.046-t test on area under curve [AUC]glucose). CONCLUSIONS: Our results provide evidence of a causative link between ENPP1 and alterations in insulin signaling, glucose uptake, and lipid metabolism in subcutaneous abdominal AT of GDM, which may mediate IR and hyperglycemia in GDM.

Effect of tocolytics on interleukin-8 production by human amniotic and decidual cells.

Preterm labor is associated with the release of various cytokines that play an important role in its pathophysiology. In preterm labor, tocolytics are used to inhibit uterine contractions and prolong gestation. We tested the hypothesis that tocolytics alter endotoxin-induced interleukin (IL-8) production from amniotic and decidual cells in vitro. Amniotic and decidual cells were isolated from patients undergoing elective repeat cesarean section at term. Cells were grown in tissue culture flasks. Cells were subsequently incubated with 100 ng/ml of endotoxin in 24 well plates in the presence of increasing concentrations of magnesium sulfate, nifedipine and terbutaline. After 24 h, IL-8 levels in each well were measured by ELISA. Endotoxin caused a significant elevation in IL-8 production in both amniotic and decidual cells. Magnesium sulfate dose dependently inhibited the endotoxin-stimulated IL-8 production in both decidual and amniotic cells. However, nifedipine and terbutaline did not significantly affect IL-8 production in either cell type. In conclusion, magnesium sulfate differentially suppresses endotoxin-stimulated IL-8 production in amniotic and decidual cells in vitro. The cellular mechanisms of this suppression and its clinical relevance in the setting of preterm labor merit further investigation.

Amniotic Sac Herniation Through a Prior Cornual Scar in The Third Trimester.

Introduction Uterine rupture occurs in less than 0.1% of pregnancies. This complication can be detrimental to mother and fetus if not detected and managed in a timely manner. We report an unusual presentation of uterine scar rupture that was diagnosed on ultrasound in a completely stable patient with reassuring fetal status. Case Report A 24-year-old Gravida 5, Para 3 with history of cornual resection for ectopic pregnancy and two previous uterine ruptures presented at 30 weeks' gestation with worsening abdominal pain. Ultrasound identified herniation of the amniotic sac with fetal parts. The patient underwent cesarean delivery and cornual defect repair. Conclusion Close observation and early delivery remain vital to the patient's management.

Should second trimester ultrasound be routine for all pregnancies?

Ultrasound use has become ubiquitous in pregnancy. We review the evidence regarding the benefits of routine ultrasound use during pregnancy. Routine ultrasound use before 24 weeks improves detection of undiagnosed twins, reduces postdates inductions, and allows detection of fetal anomalies before birth. Wide variations exist in the sensitivity of ultrasound in detecting fetal anomalies. These may be related to equipment, training, and maternal characteristics, such as obesity. Standards have been developed for the performance of routine fetal ultrasonography in the second trimester. The benefits of routine first trimester ultrasound in the diagnosis of structural fetal anomalies or of routine ultrasonography after 24 weeks are not proven. As ultrasound technology improves and obstetrical care changes, new uses of routine ultrasonography may emerge.