Proangiogenic Macrophage Development in Human Prenatal Stage:A Key Element in Maternal-Fetal Medicine Puzzle

Introduction Macrophages,a major immune cell type constituting the human innate immune system,are involved in various physiological processes,such as tissue development,remodeling,homeostasis,and repair,crucial for maintaining normal growth and development of embryos/fetuses.1-3 Influenced by their cellular origin and specific tissue environments,macrophages exhibit a diverse range of phenotypes.

Chinese Population Reference Curves for Ultrasound-Measured Amniotic Fluid Deepest Vertical Pocket in Dichorionic Twin Pregnancies,and Their Associations With Pregnancy Outcomes

Objective:To establish the Chinese population's amniotic fluid deepest vertical pocket(DVP)reference curves for dichorionic twin pregnancies and to investigate DVP links with adverse perinatal outcomes.Methods:This retrospective cohort study,conducted at Peking University Third Hospital from August 2011 to December 2020,used data from 375 women aged 20 to 45 years who had dichorionic twin pregnancies that were confirmed through first-trimester ultrasound.After exclusions,reference curves were developed using 318 women with 3,299 DVP scans,and the data analyzed included maternal demographics,pregnancy outcomes,ultrasound measurements,and neonatal information.DVPs were assessed via ultrasound at regular intervals and grouped by gestational age(GA)for analyses.Linear mixed models were used to create amniotic fluid reference curves.Associations between abnormalities and adverse perinatal outcomes were examined using Chi-squared or Fisher's exact tests.Logistic regression provided both crude and adjusted odds ratios,adjusting for pre-pregnancy weight,age,ethnicity,parity,and conception mode.Significance was set at P<0.05 with 95%confidence intervals(CI),and the analyses were conducted using SPSS ver.26.0(IBM Corp.,Armonk,NY)and SAS ver.9.4(SAS Institute Inc.,Cary,NC,USA)software.Results:DVP increased from the first trimester to a maximum at 26 weeks(95%confidence interval(CI),2.7–8.3 cm for twin 1 and 2.8–7.9 cm for twin 2)and then decreased gradually toward term.Differences between twins 1 and 2 were significant after 26 weeks(95%CI for twin 1:5.3,5.5;95%CI for twin 2:4.4,4.5;P<0.010).Polyhydramnios of twin 1 increased the risk of large for GA.Oligohydramnios of twin 1 increased the risk of small for GA.Polyhydramnios of twin 2 increased the risk of small for GA,premature birth,and neonatal complications.Oligohydramnios of twin 2 increased the risk of preeclampsia,hypertensive disorder complicating pregnancy,and premature rupture of membranes.Conclusion:Reference curves for twin amniotic fluid volumes vary by GA and differ between twins,with potential implications for pregnancy outcomes.

Intrauterine Treatment of Monochorionic Triamniotic Triplet Pregnancy with Twin Reverse Arterial Perfusion Sequence

To editor:This study reports a pregnant woman who was naturally conceived with monochorionic triamniotic(MCTA)combined with twin reversed arterial perfusion(TRAP).An ultrasound revealed that one of the fetuses had a cardiac malformation,and a connection between the umbilical arteries was suspected.To reduce the acardiac fetus,radiofrequency ablation was performed at 17+3 weeks of pregnancy.At 36+4 weeks,two healthy infants were delivered via elective cesarean section.Postoperative examination revealed a direct connection between the umbilical arteries,with the placental perfusion acting as a direct pump.It is essential to identify the intrauterine status of the blood-supplying infant and vascular connections in order to achieve successful outcomes in pregnancies with complications,such as edema and heart failure.The studies involving human participants were reviewed and approved by Human Research Ethics Committee of Tianjin Central Hospital of Obstetrics and Gynecology.The patient provided her written informed consent to participate in this study.

A Clinical Observation Report on Prenatal Management and Postnatal Treatment of Congenital Granular Cell Epulis

Introduction Congenital granular cell epulis(CGCE)is a rare,benign tumor that manifests on the mucosal surface of the alveolar ridge in newborns.It was initially described by Neumann in 1871 and has been referred to by various names such as congenital epulis,congenital epulis of the newborn,and congenital granular cell tumor.1 Documentation on larger tumors is limited and reported diameters vary.2 Diagnosis necessitates histological examination and immunohistochemical staining,typically revealing negative immunoreactivity for S-100 and cluster of differentiation 68(CD68).3,4 This article presents a case of CGCE with weakly positive S-100 and CD68 staining,alongside a relatively large size.Additionally,it conducts a literature review on diverse aspects,encompassing multidisciplinary prenatal diagnosis,antenatal management,choice of delivery mode during childbirth,and postnatal treatment,with the objective of augmenting clinicians’comprehension of the ailment.The study adhered to the guidelines of the Declaration of Helsinki and obtained informed consent from the patient and approval from the medical ethics committee of Chongqing Health Center for Women and Children.

Basic Research Advances in China on Embryo Implantation,Placentation,and Parturition

This review aimed to summarize the major progress in maternal-fetal medicine achieved by Chinese scientists in recent years.PubMed was systematically searched from January 2020 to November 2023.Publications that reported the progress in embryo implantation,placentation,and parturition made by Chinese scientists in the last 3 years were selected.The milestone events during gestation,embryo implantation,endometrial decidualization,placentation,and parturition are pivotal to a successful pregnancy.Embryo implantation requires intricate interactions between implantation-competent blastocysts and receptive endometrium.To adapt to pregnancy,endometrial stromal cells transform into specialized decidual cells,which occur spontaneously under the influence of ovarian hormones in humans but require the presence of embryos in mice.With embryonic development,the placenta forms to support fetal growth until parturition.The maternal-fetal interface is composed of diverse cell types,including endometrial decidual cells,placental trophoblast cells,endothelial cells,and various immune cells,a sophisticated interplay among which contributes to the maintenance of pregnancy.Near term,the uterus transitions from quiescence to contractility,in preparation for delivery.Disruptions to these events lead to pregnancy-related disorders such as repeated implantation failure,recurrent pregnancy loss,preeclampsia,fetal growth restriction,preterm birth,and infertility.In recent years,Chinese scientists have made prominent achievements in basic research on the aforementioned pregnancy events.Chinese scientists have made remarkable contributions to reproductive biology and maternal-fetal medicine research in recent years,highlighting future research directions in this field.

Pregnancy Complicated With a Giant Pancreatic Tumor and Decompensation of Liver Cirrhosis:A Case Report and Literature Review

Pregnancy with solid pseudopapillary tumor of the pancreas(SPTP)is rare.Because pregnancy hormones may cause tumor progression,the management and treatment of SPTP need to balance the safety of pregnant women and fetuses with surgical treatment.We reported a case of a giant pancreatic tumor diagnosed during pregnancy that was considered to be SPTP.Examinations also showed hepatitis B virus infection and severe decompensation of liver cirrhosis.Medical termination of pregnancy was performed.The patient has lived with the tumor until now without surgery.We retrieved the published case reports,summarized the clinical characteristics of pregnancy with SPTP,and explored its management during the perinatal period.Most patients with SPTP have a good prognosis with good maternal and fetal outcomes,and it is important to choose an appropriate treatment method and timing.However,pregnancy combined with decompensated liver cirrhosis needs to be terminated in a timely manner because of its high-risk status.

Maternal Group B Streptococcus Infection Correlates Inversely With Preeclampsia in Pregnant African American Women

Objective:To determine whether an association exists between group B Streptococcus(GBS)colonization and preeclampsia among pregnant Black women.Methods:This retrospective cross-sectional study involved Black women who gave birth at State University of New York Downstate Hospital between January 2010 and December 2017.Data were collected from the Obstetric Department,including delivery date,time,mode of delivery,age of the mother,weeks of gestation at delivery,and antepartum complications.The GBS test results were originally determined using the eSwab transport system.Preeclampsia was defined based on the American College of Obstetricians and Gynecologists criteria for the periods 2010–2012 and 2013–2017.The primary outcome was whether GBS was associated with the outcome of preeclampsia in the population of Black women.Covariates,including smoking status,gestational age,parity,body mass index,maternal age,and presence of herpes simplex virus(HSV)and human immunodeficiency virus(HIV)were examined as potential confounders.Chi-squared test and logistic regression model were used,presenting odds ratios with 95%confidence intervals(P<0.050),analyzed with SAS on Demand for Academics(SAS Institute,Inc.,NY).Results:Among the 8,019 Black women included in this study,GBS-positive women(n=977)had a 53%reduction in the likelihood of being diagnosed with preeclampsia compared to GBS-negative women(adjusted odds ratio,0.47;95%confidence interval,0.32–0.70).We did not find evidence of differences in the distribution of smoking habits(P=0.783)or maternal age(P=0.107)between GBS-positive and GBS-negative women.However,the GBS-positive women tended to be less likely to have a preterm delivery(9.62%(94/977)vs.24.24%(1707/7042),P<0.001),less likely to be nulliparous(33.37%(326/977)vs.37.87%(2667/7042),P=0.006),and less likely to be obese(51.38%(502/977)vs.55.30%(3894/7042),P<0.001)compared with GBS-negative women.In contrast,GBS-positive women were more likely to have a comorbid infection than their counterparts:HSV(5.94%(58/977)vs.2.63%(185/7042),P<0.001)and HIV(1.54%(15/977)vs.0.82%(58/7042),P=0.028).Conclusion:We found a reduced likelihood of preeclampsia among women who were positive for GBS at delivery.Given the cross-sectional nature of our study,more research is needed to further explore this association.

The Impact of an Evidence-Based Bundle on Cesarean Section-Related Surgical Site Infections:A Randomized Clinical Trial

Objective:To compare the effectiveness of an evidence-based bundle in minimizing cesarean section(CS)-related surgical site infections(SSIs)with that of standard routine care.Methods:This was a single-center,parallel,and randomized clinical trial conducted at KAHER’s Dr.Prabhakar Kore Charitable Hospital,Belagavi,India,from January 2021 to December 31,2021.Three hundred twenty women undergoing CS delivery were selected and allocated into two groups(1:1)using simple randomization with fixed allocation.An evidence-based surgical bundle(a combination of more than three perioperative interventions)was used for the intervention group,whereas the control group received routine standard perioperative care.The primary outcome was the incidence of SSI(superficial,deep,and organ or space SSIs)within 6 weeks postpartum in both groups.Categorical and continuous data were analyzed using appropriate statistical tests with a significance threshold set at P<0.05.Results:In this study,16 and 17 participants each from the control and intervention groups,respectively,were lost to follow-up,resulting in a total of 144 and 143 study participants included in the respective groups.Twenty-eight(19.4%)and 14(9.8%)women developed SSI in the control and intervention groups,respectively(P=0.02).Methicillin-resistantStaphylococcus aureus was the most common cause of SSI in both groups(63.6%(7/11)and 100%(3/3)in the control and intervention groups,respectively).Conclusion:The use of the evidence-based bundle for CS-related SSI prevention effectively decreased the incidence of SSI by half compared to standard routine practice.Implementing the use of this bundle in routine perioperative care will reduce the cost of CS and improve health outcomes in CS.

First Trimester Preeclampsia Screening and Prevention:Perspective in Chinese Mainland

Preeclampsia(PE),a multisystem disorder in pregnancy,is one of the leading causes of perinatal morbidity and mortality that poses financial and physical burdens worldwide.Preterm PE with delivery at<37 weeks of gestation is associated with a higher risk of adverse maternal and perinatal outcomes than term PE with delivery at≥37 weeks of gestation.A myriad of first trimester screening models have been developed to identifying women at risk of preterm PE.In fact,the Fetal Medicine Foundation(FMF)first trimester prediction model has undergone successful internal and external validation.The FMF triple test enables the estimation of patient-specific risks,using Bayes theorem to combine maternal characteristics and medical history together with measurements of mean arterial pressure,uterine artery pulsatility index,and serum placental growth factor.Establishing a quality control process for regular monitoring and to ensure data standardization,reliability,and accuracy is key to maintaining optimal screening performance.The rate of preterm PE can be reduced by 62%by using the FMF prediction model,followed by the administration of low-dose aspirin.Recent evidence has also demonstrated that metformin has the potential for preventing PE in patients at high-risk of the disorder.In this article,we will summarize the existing literature on the different screening methods,different components of risk assessment,therapeutic interventions,and clinical implementation of the first trimester screening and prevention program for PE with specific considerations for Chinese mainland.

Clinical Management Guidelines for Intrahepatic Cholestasis of Pregnancy

Intrahepatic cholestasis of pregnancy(ICP)is a significant gestational complication in late pregnancy,potentially leading to severe perinatal complications such as intrauterine fetal demise and preterm birth.The Obstetrics Group of the Gynecology and Obstetrics Branch and the Perinatal Medicine Branch of the Chinese Medical Association organized a panel of domestic experts to deliberate and propose recommendations based on domestic and international guidelines,recent evidence-based medical evidence about key clinical issues including risk factors,clinical manifestations,perinatal outcomes,diagnosis,severity grading,maternal and fetal monitoring,treatment methods,timing,and methods of pregnancy termination,and postpartum follow-up for ICP,with the aim to guide its clinical diagnosis,treatment,and management.

Matrix Metalloproteinase-9 in the Etiopathogenesis of Placenta Accreta Spectrum:A Literature Review

The recent increase in placenta accreta spectrum has been correlated with a rise in the rate of cesarean sections.A recent study provides evidence that hampered wound healing results in cesarean scar defects that lead to a failure in the normal process of decidualization and deeper adherence of trophoblasts.Matrix metalloproteinase(MMP)is crucial in every step of wound healing as it alters the wound matrix,facilitating cell migration,as well as tissue remodeling.MMP-9 expression is higher in placental and decidual tissue in cases of placenta accreta.Based on these findings,assessment of MMP-9 expression can shed new light on the etiopathology of placenta accreta spectrum disorder and can be a potential diagnostic marker.

The Evolution of Management Strategies for Placenta Accreta Spectrum

To editor:The disorders associated with placenta accreta spectrum(PAS)are potentially severe obstetric complications that should be managed by expert centers with substantial re-sources to provide both preoperative and intraoperative as-sessments and then prearrange a multidisciplinary team with an appropriate delivery plan.Placenta accreta spectrum was first described in 1937 as“attempts to remove the pla-centa led to major postpartum hemorrhage that required emergency or secondary hysterectomy to control bleeding.”1 In 1966,Luke et al-classified this condition into placenta creta(or vera,adherenta),increta,and perceta based on the depth of placenta villi adhesion or invasion,as determined by pathological features.Although infrequent,there have been significant advances in the global evolution of the strat-egies used to manage PAS,especially over the last decade.

Wernicke-Korsakoff Syndrome From Hyperemesis Gravidarum

To editor:Wernicke encephalopathy(WE)is an acute neurological disorder caused by a deficiency of vitamin B1(thiamine),with a prevalence of 1.3%in autopsy studies.1 Eighty-four percent of patients with WE will develop Korsakoff syndrome,which is characterized by amnesia and confusion.2 Although WE is more common in alcoholics,it can also be caused by vomiting,malnourishment,and other situations.

Villous Capillary Malformation and Intermediate Trophoblast Invasiveness:Histopathologic Findings From Fetomaternal Hemorrhage with Gestational Choriocarcinoma

To editor:Fetomaternal hemorrhage(FMH)refers to the fetal blood transfection into the maternal circulation,usually involving a bleeding volume exceeding 30 ml.This phenomenon can promptly trigger a sinusoidal fetal heart rate pattern,posing a significant risk of life-threatening fetal anemia and even mortality1,2 Upon suspicion of FMH,immediate intervention is essential to prevent neonatal death,often leading to the insufficient recognition of placental examination in many published reports.However,an increasing number of FMH case reports have underscored the potential subsequent risk of choriocarcinoma.

Third-Trimester Spontaneous Uterine Rupture After Ultrasound-Guided High-Intensity Focused Ultrasound Therapy

To editor:Uterine rupture,despite its low incidence,is a severe obstetric complication that is associated with adverse maternal and neonatal outcomes.Previous uterine scarring is a known risk factor for uterine rupture.Uterine scars can form from hysterotomy after abdominal/hysteroscopic myomectomy,cesarean delivery,or hysteroscopic surgery.Over the past few decades,ultrasound-guided high-intensity focused ultrasound(USgHIFU)has emerged as a non-invasive therapeutic tool and has found wide application for the safe and effective management strategy of uterine fibroids and adenomyosis.

Fetoscopic Laser Photocoagulation for Twin-Twin Transfusion Syndrome in a Dizygotic Monochorionic Twins

To editor:Monochorionicity was traditionally considered indicative of monozygosity.However,recent years have witnessed the emergence of several noteworthy instances of monochorionic dizygotic(MCDZ)twins in clinical practice.In 2000,Viëtor et al.1 documented the initial established case of MCDZ twins.Subsequent studies have further documented this unconventional twinning phenomenon.2,3 The recognized complications associated with monochorionic monozygotic pregnancies,including twin-twin transfusion syndrome(TTTS),twin anemia–polycythemia sequence(TAPS),selective intrauterine growth restriction(sIUGR),congenital malformations,and intrauterine fetal death,could also manifest in MCDZ pregnancies.4,5 In this correspondence,we presented an extremely rare case of TTTS in a dizygotic monochorionic diamniotic twin gestation successfully treated with fetoscopic laser photocoagulation.The patients’permission to publish was obtained.

The Impact of Regular Diet Recovery on Postoperative Rehabilitation After Elective Cesarean Section

Objective To determine the role of regular diet recovery after restoration of normal muscle strength of both lower extremities in promoting postoperative recovery in women undergoing elective cesarean section.Methods This was a prospective observational cohort study.Patients who underwent elective cesarean section at Xiangya Hospital,Central South University,from October 2022 to December 2022,were categorized into two groups based on the duration of postoperative fasting:the observation group resumed eating after regaining lower extremity muscle strength,while the control group adhered to traditional postoperative fasting guidelines,waiting 6 hours before eating.Primary outcomes included postoperative pain levels assessed by visual analog scale(VAS)pain scores and time to first flatus.Demographic characteristics,time to first lactation,hospital stay length,and patient satisfaction were also assessed.Statistical analysis was conducted using Student’s t test and Chi-squared test,with significance set at P<0.05.Results Out of a total of 300 patients,240 were included in the analysis,comprising 112 in the control group and 128 in the observation group.There were no significant differences in baseline demographic characteristics.The median values of the first flatus time and the first lactation time were 33.37±1.22 vs.18.06±6.34 hours(P=0.003)and 26.34±8.21 vs.7.05±1.26 hours(P=0.001)in the control and observation groups,respectively.The median hospital stay duration in the control and observation groups was 6.54±0.53 vs.4.84±0.18 days(P=0.000),respectively.Median postoperative VAS pain scores and patient satisfaction values were 8.57±0.11 vs.4.91±0.27(P=0.000)and 9.36±0.16 vs.9.72±0.08(P=0.005)in the control and observation groups,respectively.There were no statistically significant differences in other postoperative outcomes,such as intestinal obstruction,infection,and readmission within 42 days(P>0.05).Conclusion Food intake after restoration of lower extremity muscle strength improves first flatus,relieves postoperative pain,shortens hospital stay,and enhances satisfaction after elective cesarean section,without adverse effects.It is crucial for postoperative rehabilitation and should be encouraged.

Erratum to Clinical Management Guidelines for Intrahepatic Cholestasis of Pregnancy.Volume 6,Issue 1,Janurary 2024

In reference to Clinical question 5 in the original article publication,the authors suggest removing specific sections from the first and third paragraphs,as well as Recommendation 5-2,to avoid ambiguity.

Making Elimination of Perinatal Hepatitis B Infection a Reality:The Chinese Contribution

Chronic hepatitis B virus(HBV)infection,referred to the presence of hepatitis B surface antigen(HBsAg)over 6 months,is a serious health issue because of its severe sequelae such as cirrhosis and hepatocellular carcinoma.Prevention of mother-to-child transmission(MTCT)of HBV is most important to control hepatitis B because a vast majority of HBV acquisition in infancy will become chronic carriers.

Noninvasive Prenatal Testing Test Versus Chorionic Villus Sampling,Where Are We Now?

Introduction The discovery of cell-free fetal DNA(cff-DNA),also known as noninvasive prenatal testing(NIPT),by Lo et al.in 1997,1 has significantly changed the screening for common chromosomal abnormalities.Its widespread acceptance globally underscores its impact.NIPT analyzes fetal DNA originating from the apoptosis of the outer cytotrophoblast,the fetal hematopoietic system,and lysis of other fetal cells.The DNA fraction increases from 10%to 15%between 10 and 20 gestational weeks.Rapid cff-DNA clearance occurs in maternal circulation,spanning from 4 minutes to 2 weeks postpartum.