Faculty Bibliography

OBJECTIVE: We propose a novel amniotic fluid inflammatory score from a comprehensive cytokine analysis of patients with mid-trimester short cervix. STUDY DESIGN: Amniotic fluid from singleton gestations (n = 44) with a cervical length of /=34 weeks). Mediators that reached statistical significance were included in the amniotic fluid inflammatory score. Patients were assigned 1 point for each significant mediator if their level was in the upper quartile. The amniotic fluid inflammatory score was determined, and its relationship to other clinical characteristics was examined. RESULTS: Fourteen mediators met the criteria. A score of >/=8 was predictive of delivery at <34 weeks' gestation (sensitivity, 87.0%; specificity, 100%; positive predictive value, 100%; negative predictive value, 87.5%). Twenty patients had a high inflammatory score (>/=8); 24 patients had a low score. All patients with a high inflammatory score delivered at <30 weeks' gestation. CONCLUSION: The amniotic fluid inflammatory score is related to delivery outcome and clinical characteristics.

OBJECTIVE:Preeclampsia, small for gestational age (SGA) and placental abruption - conditions that constitute the syndrome of "ischemic placental disease" (IPD) - may portend different clinical manifestations of a common underlying pathophysiology. We examined if (i) preeclampsia, SGA and abruption share similar risk profiles; and (ii) if there are any differences in these profiles between patients with IPD that delivered at term and preterm gestations. STUDY DESIGN/METHODS:We utilized data from the US Collaborative Perinatal Project, a multicenter, prospective cohort study (1959-1966), restricted to women that delivered singleton births at ≥ 20 weeks (n=47,495.) We compared risk factors between women with and without IPD as well as preeclampsia, SGA and abruption. RESULTS:A strong overlap in risk factors for all 3 conditions was evident. Socio-economic class, income, age, parity, education, race, BMI, marital status, and history of preterm birth were different between preterm and term gestations in women with IPD. Although rates of preeclampsia only, SGA only and preeclampsia with SGA were similar between term and preterm birth, rates of other conditions were higher at preterm gestations, with abruption being the driving condition behind these associations. CONCLUSIONS:The similar risk profiles for preeclampsia, SGA, and abruption provide compelling evidence to suggest that these conditions may share common pathophysiological mechanisms-ischemic placental disease. Greater homogeneity in risk profiles within preterm than term births suggests that IPD may be a syndrome that has strong underpinnings at preterm gestations.

OBJECTIVE:We sought to examine the extent to which a temporal increase in preterm cesarean delivery is associated with gestational age-specific changes in perinatal survival in preterm gestations. STUDY DESIGN/METHODS:We utilized data on singleton births in the United States (1990 through 2004) delivered between 24-36 weeks' gestation. Associations between changes in cesarean delivery at preterm gestations and trends in the risk of preterm stillbirth, and neonatal and perinatal mortality were estimated before and after adjustments for a variety of potential confounders. RESULTS:From 1990 through 2004, cesarean delivery rates increased by 50.6%, 40.7%, and 35.8% at 24-27, 28-33, and 34-36 weeks, respectively. The largest incremental effect of cesarean was associated with a reduction in stillbirths by 5.8%, 14.2%, and 23.1% at 24-27, 28-33, and 34-36 weeks, respectively, leading to an 11.4%, 4.9%, and 0.6% reduction in perinatal deaths at 24-27, 28-33, and 34-36 weeks, respectively. CONCLUSION/CONCLUSIONS:Increasing rates of preterm cesarean were associated with improved perinatal survival. This association was evident largely because of dramatic incremental declines in stillbirths.

OBJECTIVE:To examine the association between electronic fetal heart rate monitoring and neonatal and infant mortality, as well as neonatal morbidity. STUDY DESIGN/METHODS:We used the United States 2004 linked birth and infant death data. Multivariable log-binomial regression models were fitted to estimate risk ratio for association between electronic fetal heart rate monitoring and mortality, while adjusting for potential confounders. RESULTS:In 2004, 89% of singleton pregnancies had electronic fetal heart rate monitoring. Electronic fetal heart rate monitoring was associated with significantly lower infant mortality (adjusted relative risk, 0.75); this was mainly driven by the lower risk of early neonatal mortality (adjusted relative risk, 0.50). In low-risk pregnancies, electronic fetal heart rate monitoring was associated with decreased risk for Apgar scores <4 at 5 minutes (relative risk, 0.54); in high-risk pregnancies, with decreased risk of neonatal seizures (relative risk, 0.65). CONCLUSION/CONCLUSIONS:In the United States, the use of electronic fetal heart rate monitoring was associated with a substantial decrease in early neonatal mortality and morbidity that lowered infant mortality.

In the second half of the twentieth century, true antepartum fetal assessment became possible, mainly due to the advent of real-time ultrasound. Initially, the most widely used form of antepartum fetal assessment was electronic fetal heart rate monitoring, through the nonstress test or the oxytocin-induced contraction stress test. It was soon realized, however, that these forms of monitoring had significant limitations. The biophysical profile allows a more thorough evaluation of fetal well-being and has the potential to significantly reduce the false-positive rate of the nonstress test/contraction stress test.

OBJECTIVE:Preeclampsia, small for gestational age (SGA), and abruption are considered ischemic placental diseases (IPD), and are major contributors to both maternal and fetal morbidity and mortality. Although the placenta is considered a fetal organ, these conditions can present clinically with either maternal or fetal manifestations, but their relationship to preterm births is largely unexplored. METHODS:We designed a population-based study to assess the origins of IPD. IPD was classified as maternal (preeclampsia only), fetal (SGA only), or both (abruption only, preeclampsia with either SGA or abruption, or all 3). The study was based on 90,500 women that delivered singleton live births at 22-44 weeks gestation. RESULTS:Among 77,275 term births with IPD, 23.2% presented as maternal disease only, 68.9% as fetal disease, and 7.9% as both. In contrast, among 12,906 preterm births with IPD, the proportions were roughly equal (maternal 32.9%, fetal 36.5%, and both 30.6%). Among spontaneous preterm births with IPD, a greater proportion had a fetal presentation (43.0%), whereas among indicated preterm births with IPD, a greater proportion (43.4%) had both maternal and fetal presentations. CONCLUSIONS:IPD at preterm gestations is more likely to involve both the mother and fetus than at term. The differing clinical presentations by gestational age suggest different pathways between term and preterm births. This may reflect heterogeneous processes for IPD at early vs. late gestations, regardless of the effects of differing gestational age thresholds for interventions.