Faculty Bibliography

PURPOSE OF REVIEW/OBJECTIVE:Fetal growth restriction is a complicated perinatal condition, with multiple causes. It shares common pathophysiologies with other important disorders, such as preeclampsia and abruption. As a group, these conditions associated with ischemic placental disease are responsible for a large percentage of indicated preterm births. The ability to accurately predict, diagnose and manage these pregnancies has significant and far-reaching implications, including potential effects on long-term adult health. RECENT FINDINGS/RESULTS:Placental ischemia is the most common cause of fetal growth restriction. Alterations in placental development are being linked to various angiogenic mediators, which may be of future use in early risk-determination. Until then, the use of ultrasound to accurately diagnose fetal growth restriction and time delivery is the mainstay of management. Research in this area has revealed some commonalities in the deterioration of the growth restricted fetus, but has also indicated that not every affected fetus will follow the same progression in Doppler and other wellbeing parameters. Most importantly, gestational age at delivery is consistently being documented as a critical factor in perinatal morbidity and mortality. SUMMARY/CONCLUSIONS:Fetal growth restriction is a late manifestation of early abnormal placental development. Once abnormal Doppler velocimetry is present, surveillance and timing of delivery should be based on the antepartum test results and on the gestational age.

OBJECTIVE:We examined recurrence of preterm birth in twin pregnancy in the presence of a previous singleton preterm pregnancy, and assessed if these recurrence risks differed for medically indicated and spontaneous preterm birth. METHODS:A retrospective cohort study was designed using the maternally-linked data of women who delivered a first singleton live birth followed by a twin birth in the second pregnancy (n = 2329) in Missouri (1989--97). We examined preterm birth recurrence at <37 in the second twin pregnancy among women with a prior singleton preterm birth. Recurrence risks were based on hazard ratios (HR) and 95% confidence intervals (CI) estimated from Cox proportional hazards models after adjusting for potential confounders. RESULTS:Preterm birth rates in the second twin pregnancy were 69.0% and 49.9% among women who had a previous preterm and term singleton birth, respectively (HR 1.8, 95% CI 1.6-2.1). The preterm birth rate in the second pregnancy was about 95% when the first singleton pregnancy ended at <30 weeks. Women delivering preterm following a medical intervention in the first pregnancy had increased recurrence for both spontaneous (HR 1.4, 95% CI 1.1-2.0) and indicated (HR 2.4, 95% CI 1.8-3.2) preterm birth; similarly among women with a prior spontaneous preterm birth, hazard ratios were 1.8 (95% CI 1.5-2.1) and 1.6 (95% CI 1.3-1.9), for spontaneous and indicated preterm birth in the second twin pregnancy, respectively. CONCLUSIONS:Women with a singleton preterm birth carry increased risk of preterm birth in the subsequent twin pregnancy. A history of a singleton preterm birth has an independent and additive contribution to risk of preterm birth in the subsequent twin gestation.

BACKGROUND:Hereditary hemorrhagic telangiectasia (HHT) is a condition characterized by multiple telangiectases and arteriovenous malformations. Women with HHT may develop life-threatening complications in pregnancy. In particular, death from pulmonary hemorrhage has been reported. Consequently, these women are often advised not to conceive or to terminate their pregnancies. CASE/METHODS:We report a case of conservative management of HHT in pregnancy with a good outcome. CONCLUSION/CONCLUSIONS:This case demonstrates that in carefully selected cases, women with HHT who are managed conservatively may have good pregnancy outcomes. A diagnosis of HHT alone is not reason to advise women against pregnancy, nor should these women routinely be advised to undergo pregnancy termination.

Preterm birth complicates over 500,000 births annually, affecting 12.5% of pregnancies in the United States. Much of the temporal increase in preterm birth (<37 weeks) over the past decade is largely driven by a concurrent temporal increase in medically indicated preterm birth. Maternal and fetal indications that prompt an intervention at preterm gestational ages include preeclampsia, intrauterine growth restriction, and placental abruption-conditions that constitute "ischemic placental disease." Ischemic placental disease is implicated in over one of every two indicated preterm births compared with less than one in five births at term. Comprehensive evaluation of risk factors, with careful consideration of heterogeneity in the syndrome of medically indicated preterm birth and ischemic placental disease may provide important clues to predict and consequently prevent preterm birth.

Spontaneous preterm birth remains a significant problem in the United States despite intense research to decrease its prevalence. Strategies have been limited by inability to identify patients at risk for preterm birth, as the majority of patients do not have historical risk factors. The development of an assay to detect vaginal fetal fibronectin, along with the use of transvaginal ultrasonography to determine cervical length, has greatly increased our ability to identify those patients at highest risk. This article reviews the most significant studies on this topic, providing a context for suggested management algorithms for both symptomatic and asymptomatic patients at risk for spontaneous preterm birth.

OBJECTIVE:To examine whether acute and chronic respiratory diseases are associated with an increased risk of spontaneous premature rupture of the membranes (PROM). METHODS:We used the 1993-2004 National Hospital Discharge Survey data of singleton deliveries in the USA (N = 41 250 539). The International Classification of Diseases Ninth Revision was utilized to identify acute (acute upper respiratory diseases, viral/bacterial pneumonia, and acute bronchitis/bronchiolitis) and chronic (chronic bronchitis and asthma) respiratory conditions and spontaneous PROM. All analyses were adjusted for potential confounders. RESULTS:The incidence of PROM was 5%, and rates of acute and chronic respiratory conditions were 2.1 and 9.5 per 1000 pregnancies, respectively. Chronic bronchitis was associated with a reduced risk of PROM (RR 0.39, 95% CI 0.31, 0.48). Asthma was significantly associated with PROM at preterm (RR 1.15, 95% CI 1.14, 1.17) and term (RR 1.27, 95% CI 1.23, 1.30). Stratification by race showed that acute upper respiratory disease was associated with preterm PROM in whites (RR 1.90, 95% CI 1.71, 2.11) and blacks (RR 6.76, 95% CI 5.67, 8.07). Viral/bacterial pneumonia was associated with preterm PROM in blacks and term PROM in both races. Asthma was associated with term PROM in blacks but not whites. CONCLUSIONS:Acute respiratory diseases and asthma during pregnancy are associated with spontaneous PROM, with substantially stronger association among blacks than whites. We speculate that timely diagnosis and treatment, coupled with closely mentoring of pregnant women may help reduce the rate of PROM and associated complications.

OBJECTIVE:Most women in their first pregnancy are at 'unknown' risk for preterm birth. We hypothesized that such women may be at an increased risk for preterm birth in comparison to those with a prior term birth. METHODS:We used Missouri's maternally-linked data (1989-97), comprised of women delivering their first singleton live birth (N = 259 431) and women delivering their first two consecutive singleton live births (N = 154 810). We compared preterm birth (<37 weeks) rates among women with a previous term birth, women with no reproductive history (primiparous women), and in those with a previous preterm birth. Risks of spontaneous and medically indicated preterm birth were also examined after adjustments for confounders through multivariate log-binomial regression models. RESULTS:Preterm birth rates were 8.1%, 9.6%, and 23.3% among women with a previous term birth, among primiparous women, and among those with a previous preterm birth, respectively. In comparison to women with a prior term birth, risks of spontaneous preterm birth among primiparous women and among women with a prior preterm birth were 1.1-fold (95% confidence interval (CI) 1.0, 1.2) and 2.5-fold (95% CI 2.4, 2.6) higher, respectively. These risks were higher for medically indicated preterm birth among both primiparous women (RR 1.3, 95% CI 1.2, 1.4) and those with a prior preterm birth (RR 3.2, 95% CI 3.0, 3.5) than for spontaneous preterm births. CONCLUSIONS:Primiparous women are at increased risk of both medically indicated and spontaneous preterm birth. The findings suggest that studies on preterm birth should consider a risk assignment to include three groups: low-risk (prior term birth), intermediate risk (primiparity), and high-risk (prior preterm birth). This strategy will be informative for the identification of women with impending risk of delivering preterm, and complications associated with prematurity.

OBJECTIVE:The objective of the study was to examine whether the risk and indications for primary cesarean in the second pregnancy are influenced by changes in prepregnancy body mass index (BMI) between pregnancies. STUDY DESIGN/METHODS:We performed a cohort analysis using the Missouri maternally linked birth and infant death surveillance datasets (1989-1997), comprised of women with their first 2 consecutive live births (n = 113,789). BMI (kilograms per square meter) was categorized as underweight (less than 18.5 kg/m2), normal (18.5 to 24.9 kg/m2), overweight (25 to 29.9 kg/m2), and obese (30 kg/m2 or greater). Indications for primary cesarean were categorized as breech, dystocia, fetal distress, and others. Timing of primary cesarean was categorized as elective (prior to labor) and emergent (after initiation of labor). Adjusted odds ratio (OR) was used to quantify the associations between changes in prepregnancy BMI and indications for primary cesarean. RESULTS:The rate of primary cesarean in the second pregnancy was 9.2%. Compared with women with normal BMI in their first 2 pregnancies, women who increased their BMI between pregnancies had increased risk of primary cesarean for all indications. Women who remained obese or overweight in both pregnancies were at increased risk of primary cesarean following breech (OR 1.28 and 1.13, respectively); dystocia (OR 1.94 and 1.41, respectively); fetal distress (OR 1.43 and 1.26, respectively); others (OR 3.17 and 1.63, respectively); and elective (OR 2.31 and 1.43, respectively) and emergent (OR 1.66 and 1.30, respectively) cesarean section. Women who lowered their BMI from obese to overweight or overweight to normal between pregnancies had risks of primary cesarean comparable with those with normal BMI in both pregnancies. Any increase in BMI from underweight to overweight or obese between the first 2 pregnancies was associated with increased risk of primary cesarean (OR 1.20 to 3.04) in the second pregnancy. CONCLUSION/CONCLUSIONS:Increases in prepregnancy BMI between first 2 pregnancies from normal to obese is associated with increased risk of indications for primary cesarean. The association between being overweight or obese or increases in prepregnancy BMI between pregnancies and primary cesarean in the second pregnancy suggests that counseling women with regard to their high BMI may be beneficial.

INTRODUCTION/BACKGROUND:A 28-year old female presented with a non-radiating persistent left upper quadrant pain and tenderness for 5 weeks. METHODS:A preliminary CT scan displayed bony structures in the spleen. A delayed scanning subsequently showed the bones to have changed position, consistent with a life fetus. RESULTS:Ultrasound confirmed the CT findings, and ascertained the fetus to be consistent with 13 weeks of gestation. Laparoscopic splenectomy was performed and examination of the intact spleen confirmed a male fetus that was morphologically normal. CONCLUSION/CONCLUSIONS:This is the first report of fetal bony structures in the spleen associated with an advanced intra-splenic pregnancy.

PROBLEM/OBJECTIVE:Data regarding cervical interleukin 18 (IL-8) and IL-10 concentrations during pregnancy is limited. METHOD OF STUDY/METHODS:This was a cross sectional study of healthy pregnant women. Specimens were collected from the cervical os secretions. IL-8 and IL-10 levels were measured by using enzyme-linked immunosorbent assay. Median (range) cytokine concentrations were derived for each trimester and compared across trimesters. The relationship between gestational age and cytokine levels was assessed by regression analysis. The mean of the ratios of IL-8 to IL-10 was compared in each trimester using anova. RESULTS:The median (range) IL-8 concentrations in cervical secretions were in pg/mL: 1562 (1210-4100), 2460 (1047-4688), 3660 (1451-4748) (P < 0.0021); the median (range) IL-10 concentrations in cervical secretions were in pg/mL: 38.3 (6.8-227.9), 10.9 (0-263.3), 9.5 (0-35.6); the mean IL10/IL-8 x 100 (+/- standard deviation) concentrations were: 3.33 +/- 0.65, 1.47 +/- 0.41, 0.38 +/- 0.52 (P = 0.0035) during the first, second and third trimesters, respectively. CONCLUSION/CONCLUSIONS:The patterns of cervical IL-8 concentration is inversely related to gestational age, and the ratio of IL-10/IL-8 decreases with advancing gestation.