Significance of highly phosphorylated insulin-like growth factor binding protein-1 and cervical length for prediction of preterm delivery in twin pregnancies

BACKGROUND A twin pregnancy can carry greater risks than singleton pregnancies.About 60 in 100 twin pregnancies result in spontaneous birth before 37 wk,which is associated with several complications in the premature babies.Clinical detection of biomarkers may help to predict the possibility of premature birth so that corresponding interventions can be given to the pregnant women in a timely manner,in order to reduce the risk of preterm birth and improve the outcomes of the newborn infants.AIM To explore the clinical value of transvaginal ultrasound measurement of cervical length combined with insulin-like growth factor binding protein-1(IGFBP-1)hyperphosphorylation in cervical secretions as predictors of preterm delivery in twin pregnancies.METHODS A total of 254 pregnant women with twin pregnancies,who were admitted to Hainan General Hospital and underwent maternity examination,were selected as the study subjects from January 2015 to December 2018.All participants received transvaginal ultrasound measurement of cervical length and phosphorylated IGFBP-1(phIGFBP-1)test between 24 and 34 wk gestation.The pregnancy outcomes were analyzed.RESULTS Of the women with a positive phIGFBP-1 test result,preterm birth rate was higher in those with a cervical length≤25 mm than those with a cervical length>25 mm(all P<0.05).Similarly,in women with a negative phIGFBP-1 test result,preterm birth rate was higher in those with a cervical length≤25 mm than those with a cervical length>25 mm(all P<0.05).The sensitivity,specificity,and positive and negative predictive values of the phIGFBP-1 test combined with the cervical length test were 95.71%,91.21%,95.12%and 92.22%,respectively,for the prediction of preterm birth.CONCLUSION Cervical length combined with phIGFBP-1 tests is of value for the prediction of outcomes of preterm delivery in twin pregnancies.

Risk Factors for Preterm Delivery in Asymptomatic Singleton Pregnant Women with a Sonographic Short Cervix

Objectives: Although an asymptomatic short cervix is a risk factor for spontaneous preterm birth (SPTB), the risk factors for SPTB among those with short cervix remain unknown. We herein investigated risk factors for preterm delivery (PTD) at <34 weeks of gestation in pregnant women with a short cervix. Methods: This was a retrospective study. Seventy-three asymptomatic pregnant women with a sonographic short cervix (excluding visible bulging fetal membranes) were selected, and the relationship between clinical or biochemical risk factors and preterm delivery (PTD) at <34 weeks was examined. Results: Thirteen cases (17.8%) had PTD at <34 weeks. A univariate analysis showed that a history of SPTD, gestational weeks on admission, cervical length, cervical mucus interleukin (CM-IL)-8 and amniotic fluid interleukin (AF-IL)-8 in PTD at <34 weeks significantly differed from those in delivery at ≥34 weeks (p < 0.05, respectively). A multiple logistic regression analysis identified CM-IL-8 ≥ 803.5 ng/mL [21.3 (3.0 - 260), p = 0.002] and cervical length ≤15 mm [17.1 (1.9 - 517), p = 0.008] as independent risk factors for PTD at <34 weeks. Conclusions: Evaluation for cervical inflammation may be necessary for appropriate treatment strategies in asymptomatic pregnant women with a short cervix. Cervical inflammation warrants further study.

Pregnancy outcomes and risk factors for low birth weight and preterm delivery among HIV-infected pregnant women in Guangxi, China

Background Six provinces in China accounted for 70%-80% of all reported HIV/AIDS cases in the country in 2009 and five provinces accounted for 78% of all reported mother-to-child transmission （MTCT） of HIV cases. Because Guangxi belonged to both groups, the Prevention of Mother-to-Child Transmission （PMTCT） Plus program was established there to understand better low birth weight （LBW） and preterm delivery （PD） birth outcomes and their associated risk factors better. Methods Pregnancy outcomes were examined among HIV-infected pregnant women who enrolled in the PMTCT Plus program from June 2006 to February 2009 in Guangxi, China. Multivariate Logistic regression analysis was used to explore the risk factors associated with LBW （〈2500 g） and PD （gestational age 〈37 weeks）. Results The prevalence of LBW and PD among 194 HIV-positive mothers was 19.6% （38/194） and 9.8% （19/194）, respectively. Multivariate Logistic regression analysis showed that CD4 cell count 〈100 cell/IJI （multivariate-adjusted odds ratio （AOR） 5.52; 95% Cl 1.11-25.55） and CD4 cell count 100-199 cells/IJI （AOR3.40; 95% Cl 1.03-11.25, compared to CD4 cell count 〉350 cells/IJI）, gestational age 〈37 weeks （AOR 4.38; 95% Cl 1.29-14.82, compared to 〉37 weeks）, maternal weight 〈45 kg （AOR 5.64; 95% Cl 1.09-29.07） and maternal weight 45-54 kg （AOR 3.55; 95% CI 1.31-9.60, compared to 〉55 kg） at enrollment, and H IV RNA 〉100 000 copies/ml at enrollment （AOR 4.22; 95% CI 1.24-14.32） and 20 000-99 999 （AOR 2.77; 95% Cl 1.01-7.77, compared to 〈20 000 copies/ml） were associated with a higher risk of LBW. For PD, only maternal injection drug use as the route of HIV transmission （AOR 5.30; 95% Cl 1.33-21.14, compared to those infected with HIV through sexual transmission） was significantly associated with a higher risk of PD. Conclusions Lower CD4 cell count and higher HIV RNA viral load at enrollment were associated with LBW. Optimal antenatal care, including earlier antenatal screening and HIV diagnosis, is critical to earlier PMTCT prophylaxis and/or HIV treatment to prevent transmission of HIV to the infant and also to prevent LBW pregnancy outcomes.

Previable Premature Rupture of Membranes in Dichorionic Diamniotic Twin Gestation, Loss of Leading Twin, Emergency Cervical Cerclage and Ceaserean Delivery at Term

Introduction: Multiple pregnancies have a higher risk of premature delivery and a weakened cervix has been associated with it. In most cases, emergency cerclage has proved to be beneficial as the birth of the first twin is usually followed by the unavoidable delivery of the second twin and most fetus dies shortly after delivery. Studies have noted that delayed delivery of the second fetus in a twin pregnancy is an effective management choice and the use of cervical cerclage after the first delivery is associated with a longer inter-delivery interval. We present a case of previable premature rupture of membrane of a dichorionic diamniotic twin gestation leading to the loss of the leading twin and subsequently having emergency cervical cerclage for the second twin and caesarean delivery at term. Case Presentation: She was a case of a 29 years old, G6P1+4 with 1 living child at a gestational age of 17 weeks plus 5 days who initially was diagnosed with dichorionic diamniotic twin gestation following an early ultrasound but presented with a history of bleeding and passage of liquor per vaginam. Ultrasound done on admission showed cervical funneling and a stable state of the second twin. She subsequently had emergency cervical cerclage after stabilization on account of previable premature rupture of membrane of a dichorionic diamniotic twin gestation with the loss of the leading twin. A repeat ultrasound done prior to discharge showed closed cervical os and a good state of the fetus. She then had elective caesarean delivery at term with a good feto-maternal outcome. Conclusion: Emergency cervical cerclage should be part of the options of management after stabilization in cases of previable premature rupture of membrane in a dichorionic or multichoronic gestation so as to save the viable once.

A Case-Control Study on Leisure Time Physical Activity (LTPA) during the Last Three Months of Pregnancy and Foetal Outcomes in Italy

The association between Leisure Time Physical Activity (LTPA) during pregnancy and foetal outcomes has been extensively investigated. However, epidemiological studies specifically referred to LPTA in the last months of pregnancy are scarce. We evaluated the association between LPTA and the risk of both preterm delivery and small for gestational age (SGA) during the last three months of pregnancy in Italy. A nationwide case-control study was performed in nine Italian cities. A total of 299 preterm delivery, 364 SGA and 855 controls were enrolled in the study. A self-administered questionnaire was used to assess socio-demographic variables, medical and reproductive history, life-style habits and LTPA referred to the last three months of pregnancy. Univariate and multivariate regression analyses were performed in order to estimate Odds ratios and 95% CI. LTPA during the last three months of pregnancy decreases the risk of preterm delivery (adjusted OR = 0.56;95% CI 0.39 - 0.79). Among the different types of physical activity, walking, the most frequently referred activity, appears significantly protective against preterm delivery (adjusted OR = 0.53;95% CI 0.36 - 0.81). Moreover, a small protective effect of walking was evidenced against SGA (adjusted OR = 0.72;95% CI 0.51 - 1.00). In conclusion, a mild physical activity such as walking in the last three months of pregnancy seems to reduce the risk of preterm delivery and, at a lesser extent, of SGA, confirming the beneficial effects of physical activity along the whole pregnancy.

Antenatal corticosteroids in COVID-19 perspective

The aim of this manuscript is to discuss the practice of antenatal corticosteroids administration for fetal maturation in severe acute respiratory syndrome coronavirus 2 positive pregnant women.Recent high-quality evidence supports the use of dexamethasone in the treatment of hospitalized patients with coronavirus disease 2019(COVID-19).Randomized disease outcome data have identified an association between disease stage and treatment outcome.In contrast to patients with more severe forms who benefit from dexamethasone,patients with mild disease do not appear to improve and may even be harmed by this treatment.Therefore,indiscriminate usage of fluorinated corticosteroids for fetal maturation,regardless of disease trajectory,is unadvisable.Obstetrical care needs to be adjusted during the COVID-19 pandemic with careful attention paid to candidate selection and risk stratification.

Are Fetuses Affected by Gastroschisis Benefited from Prenatal Maternal Corticosteroid Use and Early Parturition?

Introduction: Gastroschisis (G) is a congenital defect of the abdominal walls through which intestinal herniation and permanent exposure to amniotic liquid (AL) and its components are developed at the end of gestation. G affects mostly fetuses from young mothers under 25 - 29 years old, but it occurs more often in fetuses of mothers’ ages between 12 - 15 years old. Some authors assert that it is not the low weight, nor the low gestational age that influences mortality. In addition to morphological alterations, histological alterations are characterized by disorganization, distribution and the degree of ganglia maturity and myenteric plexuses. The literature describes parturition anticipation of G disease carriers to minimize damages to intestinal loops. There are studies suggesting corticosteroids at the end of gestation in order to avoid morphological and histological damages to the intestinal loop. Objective: Identify if live newborn infants delivery anticipation, that is, gestational date less than 37 weeks and prenatal maternal use of corticosteroid were benefited from early enteral diet, namely, less than 10 post-surgery days. Material and Method: From 33 newborns researched in the period from 2010 to 2014;28 newborns full records were included in the study with 15.2% mortality rate. These newborns were divided in 3 groups according to maternal age: 6 newborns from mothers’ age between 16 - 20 years old (Group 1);14 newborns from mothers’ age between 21 - 25 years old (Group 2) and 8 newborns from mothers’ age between 26 - 29 years old (Group 3). Gestational age at birth and prenatal maternal usage of corticosteroid and beginning oral feeding were assessed. Results: From 28 newborns, 19 mothers ingested prenatal corticosteroid and 16 newborns received the first enteric diet 10 days before and 3 days later. The mothers of the other 9 newborns were not treated with corticosteroid;only 3 newborns were fed before 10 days and 6 were fed later (p = 0.0016). Regarding gestational age, 17 newborns were born before 37 weeks and their 1st enteral diet was offered before 10 days. From the 11 newborns born after 37 weeks, only 4 received the 1st enteral diet before 10 days (p = 0.015). Conclusion: Newborn infants born with gestational age below 37 weeks, whose mothers received prenatal corticosteroid, were benefited with the first enteral diet before 10 postoperative days.

The Safety of Cannabis Use in Pregnancy

Based on self-reported surveys conducted by the Substance Abuse and Mental Health Services Administration, cannabis use in pregnant females has increased over the years. Despite the increasing trend, the relationship between cannabis use and fetal outcomes is not fully understood. This review paper evaluates the literature investigating the short-term and long-term fetal outcomes resulting from cannabis use during pregnancy. Additionally, the risk of chronic marijuana use leading to cannabis hyperemesis syndrome has been highlighted in this paper using conclusions compiled from several case studies. Several studies linked delayed mental growth and reduced cognitive function with prenatal cannabis use, but the literature was limited to lower-quality observational studies and could not establish causality. One systematic review investigated short-term outcomes of low birth rates and preterm deliveries, where marijuana use in conjunction with tobacco use was associated with more preterm deliveries. Another study found that six-year-old patients exposed to cannabis prenatally were more likely to score lower in different categories on the Stanford-Binet scale test, which measures intelligence. The exposure in the first, second, or third trimester was associated with lower composite or subcategory scores such as verbal reasoning or short-term memory. Despite these results, the studies evaluated had limitations. They could not establish a clear relationship between cannabis use and fetal outcomes, but the literature showed a similar pattern of health, social and economic inequities among the populations who self-reported cannabis and substance use and non-users. Current organization guidelines advise against the use of cannabis use during pregnancy due to mixed and limited literature. However, they emphasize the importance of the clinician in the public health efforts of education and resource-distribution in addressing these inequities.

Immune cells in term and preterm labor

Labor resembles an inflammatory response that includes secretion of cytokines/chemokines by resident and infiltrating immune cells into reproductive tissues and the maternal/fetal interface. Untimely activation of these inflammatory pathways leads to preterm labor, which can result in preterm birth. Preterm birth is a major determinant of neonatal mortality and morbidity; therefore, the elucidation of the process of labor at a cellular and molecular level is essential for understanding the pathophysiology of preterm labor. Here, we summarize the role of innate and adaptive immune cells in the physiological or pathological activation of labor. We review published literature regarding the role of innate and adaptive immune cells in the cervix, myometrium, fetal membranes, decidua and the fetus in late pregnancy and labor at term and preterm. Accumulating evidence suggests that innate immune cells （neutrophils, macrophages and mast cells） mediate the process of labor by releasing pro-inflammatory factors such as cytokines, chemokines and matrix metalloproteinases. Adaptive immune cells （T-cell subsets and B cells） participate in the maintenance of fetomaternal tolerance during pregnancy, and an alteration in their function or abundance may lead to labor at term or preterm. Also, immune cells that bridge the innate and adaptive immune systems （natural killer T （NKT） cells and dendritic cells （DCs）） seem to participate in the pathophysiology of preterm labor. In conclusion, a balance between innate and adaptive immune cells is required in order to sustain pregnancy; an alteration of this balance will lead to labor at term or preterm.

Role of Cervical Cerclage and Vaginal Progesterone in the Treatment of Cervical Incompetence with/without Preterm Birth History

Background：Preterm birth （PTB） is the leading cause of perinatal morbidity and mortality worldwide,and its prevention is an important health-care priority.The cervical incompetence is a well-known risk factor for PTB and its incidence is about 0.1-2.0%,while there is no ideal optimum treatment recommended currently.The cervical incompetence causes about 15% of habitual abortion in 16-28 weeks.This study aimed to evaluate the effectiveness and safety of cervical cerclage and vaginal progesterone in the treatment of cervical incompetence with/without PTB history.Methods：We retrospectively observed the pregnancy outcome of 198 patients diagnosed with cervical incompetence from January 2010 to October 2015 in Beijing Hospital.Among the 198 women involved,women who had at least one PTB before 32 weeks （including abortion in the second trimester attributed to the cervical competence） were assigned to the PTB history cohort,and others were assigned to the non-PTB history cohort.All women underwent cerclage placement （cervical cerclage group） or administrated with vaginal progesterone （vaginal progesterone group） until delivery.The outcomes of interest were the differences in gestational age at delivery,the rate of premature delivery,neonatal outcome,complications,and route of delivery between the two treatment groups.Results：Among the 198 patients with cervical incompetence,116 patients in PTB history cohort and 80 patients in non-PTB history cohort were included in the final analysis.In the PTB history cohort,cervical cerclage group had significantly longer cervical length at 2 weeks after the start of treatment （23.1 ± 4.6 mm vs.12.4 ± 9.1 mm,P =0.002）,higher proportion of delivery ≥37 weeks＇ gestation （63.4% vs.33.3%,P =0.008）,bigger median birth weight （2860 g vs.2250 g,P =0.031）,and lower proportion of neonates whose 1-min Apgar score 〈7 （5.9% vs.33.3%,P =0.005）,compared with vaginal progesterone group.No significant differences were found in other outcome measures between the two treatment groups.In the non-PTB history cohort,there were no significant differences in the maternal outcomes between cervical cerclage and vaginal progesterone groups,such as median gestational age at delivery （37.4 weeks vs.37.3 weeks,P =0.346） and proportion of delivery ≥37 weeks＇ gestation （55.9% vs.60.9%,P =0.569）.There were also no significant differences in the neonatal outcomes between the cervical cerclage and vaginal progesterone groups including the median birth weight （2750 g vs.2810 g,P =0.145）,perinatal mortality （5.9% vs.6.5%,P =0.908）,and 1-min Apgar scores （8.8% vs.8.7%,P =0.984）.Conclusions：Cervical cerclage showed more benefits in the maternal and neonatal outcomes than vaginal progesterone therapy for women with an asymptomatic short cervix and prior PTB history,while cervical cerclage and vaginal progesterone therapies showed similar effectiveness for women with an asymptomatic short cervix but without a history of PTB.

Cervical Length at 28-32 Weeks of Gestation Predicts Preterm Birth

Objective:To evaluate the ability of cervical length(CL)at 28-32 weeks of gestation to predict spontaneous preterm delivery and preterm premature rupture of membranes(PPROM).Methods:It was a retrospective cohort study that vaginal ultrasonography at approximately 28-32 weeks of gestation was performed in 14,953 women between 17-49 years old with singleton pregnancies who delivered after 28 weeks of gestation at the Peking University First Hospital from June 2008 to December 2012.The pregnancy outcomes were followed and the relationship between the CL and preterm delivery or PPROM was assessed.The relative risk was calculated to assess group differences in the likelihood of an event occurring.Results:The overall prevalence of preterm delivery was 5.7%(858/14,953);the incidence for therapeutic preterm delivery was 2.1%(318/14,953),for spontaneous preterm delivery was 0.9%(133/14,953),and for PPROM was 2.7%(407/14,953).Excluding the 318 women who had therapeutic preterm delivery,the relative risk of preterm delivery for women with a CL between 25 mm and<30 mm,between 15 mm and<25 mm,and<15 mm was 3.7,9.3,and 30.2,respectively.The sensitivity,specificity,and positive and negative predictive values of CL<25 mm at 28-32 weeks of gestation as the cut-off value for predicting preterm delivery were 19.8%,97.5%,23.4%,and 96.9%,respectively.For preterm delivery before 35 weeks of gestation,the sensitivity,specificity,and positive and negative predictive values of a CL<25 mm at 28-32 weeks of gestation as the cut-off value were 30.0%,97.2%,11.8%,and 99.1%,respectively.In addition,women with PPROM(n=407)had significantly shorter CL(31.9±7.4)mm at 28-32 weeks of gestation compared that of women without PPROM(34.0±8.3)mm.The incidence of PPROM in women with a CL£25 mm at 28-32 weeks of gestation(19.4%,79/407)was significantly lower than that for women with a CL>25 mm(80.6%,328/407,P<0.05).Conclusion:CL at 28-32 weeks of gestation can predict spontaneous preterm delivery,and is valuable for predicting PPROM.

Single vs.Recurrent Episodes of Preeclampsia-population-based Epidemiological and Clinical Characteristics

Objective:The aims of this study were to determine the differences between women with single vs.recurrent episodes of preeclampsia in term of:(1)the outcome of the first pregnancy affected by preeclampsia;and(2)the perinatal outcomes of subsequent pregnancies.Methods:This population based retrospective cohort study included all multiparous patients with a singleton gestation who delivered at Soroka University Medical Center(Beer Sheva,Israel)from January 1988 until December 2012,meeting the inclusion criteria,those who had fetuses with chromosomal or anatomical abnormalities were exclude.Our cohort included 213,558 deliveries that met the inclusion criteria,of them 208,017 had normotensive pregnancies and 5541 had preeclampsia.The latter group was further divided into those who had a single episode of preeclampsia followed by normotensive gestations(n=3879),and women who had recurrent preeclampsia(n=1662).We used parametric and non-parametric statistics as appropriate.Results:(1)Women with recurrent preeclampsia had an increased rate of early((130/1662)7.8%vs.(171/3879)4.4%,P<0.001)and late((268/1662)16.1%vs.(438/3879)11.3%,P<0.001)preterm deliveries than a single episode of preeclampsia;(2)of interest,the rate of chronic hypertension is higher in the first pregnancy of those with a single preeclampsia episode(P<0.001),while women with recurrent preeclampsia developed It in the subsequent gestations(P<0.001);(3)the rate of small for gestational age neonates in the index pregnancy was higher in those with recurrent rather than a single episode of preeclampsia(single episode 450/3879,11.6%,recurrent preeclampsia 244/1662,14.7%,P=0.002);(4)patients with recurrent disease had an increased rate of cesarean deliveries in the subsequent pregnancies(P<0.001);and(5)patients who developed severe preeclampsia in the subsequent gestations had lower mean birthweight(P<0.001),a higher rate of perinatal mortality(P<0.001),and a lower Apgar score at 1 and 5 minutes(P<0.001),than those who developed mild preeclampsia in subsequent pregnancies,those with a single episode of preeclampsia and the control group.Conclusion:Recurrent preeclampsia increases the rate of pregnancy complications in the following gestations.Early onset preeclampsia at the index pregnancy of women with recurrent preeclampsia,is associated with increased risk for severe preeclampsia,placental abruption and perinatal mortality in subsequent pregnancies.

Gastroschisis at the Leon University Hospital, Nicaragua

Objective::The prevalence of midline birth defects, such as gastroschisis, has increased worldwide, over the last few decades. This study aims to explore the prevalence, maternal epidemiological characteristics, and natural history of neonates affected by gastroschisis at the University Hospital of Leon city, Nicaragua.Methods:Data were collected from the birth defect surveillance system of the Hospital Oscar Danilo Rosales (HEODRA). The analysis included all pregnancies that had gastroschisis complications between January 1 and December 31, 2020. The prevalence of gastroschisis was calculated according to maternal age. The mothers were interviewed, and the clinical records of the newborns were reviewed.Results::Among the 4,460 deliveries included in this study, four cases of gastroschisis were identified, including three live births and one stillbirth. The gastroschisis rate was 8.9 per 10,000 live births (95% confidence interval [CI]: 0.18-17.8). The prevalence among mothers younger than 20 years and those older than 20 years was 26.4 (95% CI: -3.43 to 56.25) and 3.01 (95% CI: 2.89-8.90)/10,000 births, respectively. Mothers of gastroschisis-affected fetuses were of rural origin ( n = 3), had normal body mass indexes ( n = 3), were exposed to tobacco and wood smoke ( n = 2), and one was exposed to pesticides during the periconceptional period. Primary closure of the gastroschisis was performed on one patient, and complex gastroschisis for intestinal perforation was observed in another patient. The mean hospitalization duration was 33 days, and two patients were discharged alive. Conclusions::Gastroschisis was a significant birth defect among children delivered at HEODRA in 2020. Its prevalence in Nicaragua was higher than that in other countries in the region. All complicated pregnancies were young women with unplanned pregnancies, from rural areas, with exposure to secondhand smoke, and without vitamin supplements before or during the first trimester of pregnancy. Only 67% of infants survived after hospital discharge.