Faculty Bibliography

OBJECTIVE:Pregnant women with pyelonephritis are at higher risk for significant morbidty than nonpregnant women with pyelonephritis. The risk from pregnancy may continue into the postpartum period. Many of the physiologic and hormonal changes that occur during pregnancy persist after delivery. The objective of this study was to compare maternal morbidity in postpartum and antepartum pyelonephritis. METHODS:A retrospective cohort analysis included all pregnant and postpartum women hospitalized for pyelonephritis at a single tertiary care hospital between January 2004 and June 2007. The postpartum period was defined as up to 6 weeks from delivery. The primary outcome measure was maternal morbidity measured by length of hospitalization. RESULTS:256 cases of antepartum pyelonephritis and 23 cases of postpartum pyelonephritis were included in the analysis. Women in both groups were admitted for a mean of 4 days (p = 0.3). Women who were diagnosed in the postpartum period were more likely to be febrile (91.3% vs. 51.7%, p = 0.0001) and had a higher temperature on presentation (102.9°F vs. 99.1°F p < 0.0001). DISCUSSION/CONCLUSIONS:Pyelonephritis was equally morbid in the postpartum and antepartum periods. Postpartum pyelonephritis may warrant the same close inpatient observation as antepartum pyelonephritis.

In this study, we sought to assess how essential activation of toll-like receptor 4 (TLR-4) is to fetal brain injury from intrauterine inflammation. Both wild-type and TLR-4 mutant fetal central nervous system cells were exposed to inflammation using lipopolysaccharide in vivo or in vitro. Inflammation could not induce neuronal injury in the absence of glial cells, in either wild-type or TLR-4 mutant neurons. However, injured neurons could induce injury in other neurons regardless of TLR-4 competency. Our results indicate that initiation of neuronal injury is a TLR-4-dependent event, while propagation is a TLR-4-independent event.

OBJECTIVE:The purpose of this study was to investigate whether magnesium sulfate (MgSO(4)) prevents fetal brain injury in inflammation-associated preterm birth (PTB). STUDY DESIGN/METHODS:In a mouse model of PTB, mice exposed to lipopolysaccharide (LPS) or normal saline (NS) by intrauterine injection were randomized to intraperitoneal treatment with MgSO(4) or NS [corrected]. From the 4 treatment groups (NS + NS; LPS + NS; LPS + MgSO(4); and NS + MgSO(4)), fetal brains were collected for quantitative polymerase chain reaction studies and primary neuronal cultures. Messenger RNA expression of cytokines, cell death, and markers of neuronal and glial differentiation were assessed. Immunocytochemistry and confocal microscopy were performed. RESULTS:There was no difference between the LPS + NS and LPS + MgSO(4) groups in the expression of proinflammatory cytokines, cell death markers, and markers of prooligodendrocyte and astrocyte development (P > .05 for all). Neuronal cultures from the LPS + NS group demonstrated morphologic changes; this neuronal injury was prevented by MgSO(4) (P < .001). CONCLUSION/CONCLUSIONS:Amelioration of neuronal injury in inflammation-associated PTB may be a key mechanism by which MgSO(4) prevents cerebral palsy.

BACKGROUND:Systemic lupus erythematosis (SLE) is a multisystemic autoimmune connective tissue disorder that presents with a wide range of clinical manifestations including renal involvement. Routine prenatal care includes assessment of renal function. CASE/METHODS:A 29-year-old nullipara presented at 17 weeks with fever, vomiting, and costovertebral angle tenderness 1 week after being treated for a presumed urinary tract infection. On presentation, new-onset hypertension was noted. Inpatient evaluation established a diagnosis of SLE with lupus nephritis. The pregnancy ended with intrauterine fetal demise. CONCLUSION/CONCLUSIONS:SLE is a disease with complex and protean clinical manifestations. It should appear on the differential when more common disease processes are ruled out. Routine prenatal care can detect otherwise silent and undiagnosed renal disease, and with early intervention improve prognosis.

OBJECTIVE:We sought to compare maternal and neonatal morbidity as well as obstetric outcomes associated with pyelonephritis in pregnancy during the first compared to the second/third trimester. STUDY DESIGN/METHODS:A retrospective cohort analysis was performed of all pregnant women admitted to a single tertiary care hospital between January 2004 and June 2007 with pyelonephritis. The primary outcome was length of hospitalization. The study had 80% power to detect a 1-day difference in length of stay. RESULTS:In all, 219 cases of acute pyelonephritis were identified: 23 diagnosed in the first trimester and 196 in the second/third trimester. Women were hospitalized for a median of 4 days in both the first (range, 2-7) and second/third (range, 2-9; P = .6) trimesters. Neonatal and obstetric outcomes were not statistically significant. CONCLUSION/CONCLUSIONS:Maternal morbidity and obstetric outcomes do not differ between first- and second-/third-trimester pyelonephritis. First-trimester pyelonephritis should be aggressively treated to prevent adverse outcomes.

OBJECTIVE:To examine serum markers measured in the second trimester to identify women who subsequently develop preeclampsia. METHODS:Clinically defined preeclampsia was confirmed in 45 women who had provided a serum sample as part of Down syndrome screening. Preeclampsia was categorized as mild or severe, as well as early (<32 weeks) or late onset. Each case was matched with five controls based on gestational age and date of serum collection. Stored sera were retrieved and tested for inhibin A, soluble vascular endothelial growth factor receptor 1 (sVEGF R1), placental growth factor (PlGF), and endoglin. Results were converted to multiples of the median (MoM) and compared in case and control pregnancies. Univariate analysis was used to identify the strongest markers, which were then used in a multivariate model. RESULTS:Inhibin A, PlGF, and endoglin were consistently associated with preeclampsia, especially for early onset disease. A multivariate model using the three markers could identify 50% of the pregnancies with early onset preeclampsia with a 2% false positive rate. CONCLUSION/CONCLUSIONS:The levels of inhibin A, PlGF, and endoglin in the second trimester can be combined using a predictive model to provide individualized risk estimates for early onset preeclampsia.

OBJECTIVE:To evaluate interval fetal growth and compare the incidence of small-for-gestational age (SGA) newborns between fetuses with an isolated single umbilical artery and those with a 3-vessel umbilical cord. METHODS:A retrospective, case-controlled study in which 84 singleton pregnancies with an isolated single umbilical artery were compared with 3-vessel umbilical cord fetuses as the control group. RESULTS:There was no statistical difference between the groups in maternal demographic data, except for ethnicity and neonatal outcomes, respectively. The mean newborn birth weight was similar between the isolated single umbilical artery and the control groups, 3,268 +/- 596 g and 3,274 +/- 627 g, respectively. The prevalence of SGA newborns was 7.1% (6 of 84) in the isolated single umbilical artery group and 4.8% (4 of 84) in the control group. An ultrasound examination demonstrated fetal growth restriction in 50% of cases (3 of 6) in the isolated single umbilical artery group and in 25% of subjects (1 of 4) in the control group, respectively. CONCLUSION/CONCLUSIONS:Fetuses with an isolated single umbilical artery are at similar risk for SGA compared with fetuses with 3-vessel umbilical cords. It appears that antepartum serial ultrasound examination does not provide more information for interval fetal growth assessment in fetuses with an isolated single umbilical artery.

Delays between speech production and hearing, delayed auditory feedback (DAF), reduce speech and reading rates. Smoking cessation in heavy smokers causes subjective reports of difficulty in concentration, decrements in cognitive performance, and EEG changes. The purpose of the present study was to determine if tobacco cessation disrupts linguistic processing as modeled by the DAF paradigm. Smokers (n = 14) were tested on 3 d of ad libitum smoking and 3 d no smoking. At each session, they read a word list (24 words) and a story (about 57 words) with and without delay (220 msec). The delay significantly decreased reading speed of the story from 3.4 to 2.9 words per second (wps) and of list from 2.1 to 1.7 wps. However, tobacco cessation had no significant effect on reading speed and no interaction with DAF. Although tobacco withdrawal slows performance on cognitive tasks, linguistic processing modeled by DAF is preserved. DAF may prove useful for the study of other drug classes and drug withdrawal states.