Invasive Fetal Monitoring Research Articles

Perinatal transmission of hepatitis C virus: an update.

Infection with hepatitis C virus (HCV) is a major health problem worldwide. A large proportion of perinatal HCV infections are silent and may present later in adulthood with long-term complications. HCV has no effective immune prophylaxis and hence appropriate follow-up of all infants born to HCV-infected mothers is necessary. Universal antenatal screening for HCV is largely debatable. Intrauterine and partum transmission of HCV are both possible and higher rates are associated with a high maternal serum viral load (> 106 copies per milliliter), concomitant HIV infection, prolonged or difficult delivery, and invasive fetal monitoring during delivery. Infection during pregnancy and infancy needs to be investigated more in order to design management strategies for perinatal transmission of HCV most effectively. The recently approved new-generation, oral, direct-acting antiviral drugs may open a new era in HCV therapy for pregnant women and infected infants if proved to be safe during conception and infancy.

TNF-α And IL-8 As Prognostic Markers of Birth Outcome in Overweight and Non-Overweight Pregnant Women

Summary Introduction. Overweight has become a major risk factor for various diseases. Compared with normal weight overweight pregnant women have an increased risk of various complications in childbirth - invasive fetal monitoring, perineal ruptures, operative vaginal deliveries, cesarean sections, increased gestational age at delivery, and increased maternal length of stay are present. Both pregnancy and childbirth is a conditions significantly affected by the the immune system. However, this relationship and the possibility of its practical use is still not fully explored. Aim of the study. Our aim is to determine whether overweight have the same impact on obstetrical outcome as obesity, explore changes of Interleukin-8 (IL-8) and Tumor Necrosis Factor-alpha (TNF-α) levels in the first and second trimester of pregnancy, compare these changes in normal weight pregnant women and pregnant women with overweight, to clarify their relationship to pregnancy outcome and to determine whether these cytokines have the potential to serve as biomarkers for prediction of labor complications. Material and methods. This was a prospective, longitudinal study were we enrolled 55 pregnant women in their first antenatal visit. Blood samples were taken at different weeks of pregnancy. TNF-α and IL-8 concentrations were measured by Luminex xMAP technology (Luminex Corporation). Statistical analysis was performed using LibreOffice Calc, the Fisher exact test, Ttest, Spearman’s rank correlation coefficient and a non-parametric Mann-Whitney-Wilcoxon test. For all statistical analyses, p<0.05 was considered statistically significant. Results. Labor dysfunction and cesarean section were more frequently observed in women with high BMI. In cases of vaginal delivery ruptures were more often for patients in high BMI group but the difference is small. Although average birth weight was slightly lower in normal BMI group, the difference is not statistically significant (p=0.13). Male gender babies were more often for women with high BMI, but statistical difference is not significant (p=0.15). Comparing the levels of TNF-α and IL-8 in different weeks of pregnancy no statistically significant difference between the study groups was found. There was no strong tendencies in dynamics in TNF-α and IL-8 levels in differend first and second trimester weeks of pregnancy. No statistically significant differences in levels of TNF- α and IL-8 depending on the fetal macrosomia were observed, but IL-8 level correlated with labour dysfunction and mode of delivery. Conclusions. Overweight is a risk factor for labor dysfunction and probability of CS. TNF-α and IL-8 levels in early pregnancy does not differ in women with and without elevated BMI. In first and second trimesters of pregnancy no dynamics in TNF-α and IL-8 levels in maternal serum is observed. IL-8 level in the second trimester is correlated with labour dysfunction and increased cesarean section risk. This is an important finding, but its clinical value still requires further research.

A profile of body mass index in a large rural Victorian obstetric cohort

To report on the prevalence and implications of overweight and obesity in a rural maternity cohort. A retrospective 6-2013 cohort of 6138 pregnancies managed in a rural Victorian maternity service from 1 January 2005 to 31 December 2010. Maternal body mass index (BMI), prevalence of overweight and obesity, prevalence of pregnancy complications and their association with BMI class. A total of 65.6% of all women were overweight or obese. Only 32.7% of the women were of normal/healthy weight; 1.6% were underweight, 33.0% were overweight, 18.6% were obese class I, 8.3% obese class II and 5.7% were obese class III. Increased BMI was associated with increased rates of induction of labour, gestational diabetes mellitus, pregnancy-induced hypertension, operative vaginal deliveries, caesarean sections, invasive fetal monitoring, increased gestational age at delivery, increased birth weight, and increased maternal length of stay (P < 0.01 for all). Analysed separately, 60.5% of first-time mothers were overweight or obese. Almost two-thirds of this rural maternity cohort were overweight or obese; twice the level reported from metropolitan centres and higher than other Australian reports. The associations with complications are similar to those reported previously. This high rate of maternal overweight and obesity may have implications for rural maternity funding, outcomes and perinatal mortality rates.

Labor and delivery in a patient with hemophilia B

Hemophilia B is a rare X-linked disorder that may cause dramatic bleeding. Women account for only 3.2% of those clinically affected. The X-linked inheritance frequently delays the diagnosis in women and may expose the patient to an increased risk of adverse events. There is limited experience with these patients during labor and delivery. A 28-year-old primiparous woman with hemophilia B (bleeding phenotype) delivered a male infant by an unplanned cesarean delivery under general anesthesia following treatment with factor IX and normalization of her coagulation parameters, guided by thromboelastography. Postpartum vaginal bleeding required transfusion of two units of packed red blood cells. Factor IX supplementation continued for one week. Once diagnosed with hemophilia B, a multidisciplinary approach and advanced antenatal planning can increase the likelihood of a safe delivery. Neuraxial approaches and cesarean delivery are recommended only after normalization of the coagulation profile. The male fetus of a hemophilia A or B patient requires special attention. Operative vaginal delivery and invasive fetal monitoring should be avoided. Thromboelastography is an excellent technique to assess parturients with bleeding disorders or peripartum hemorrhage and may be underused.

Postpartum Endometritis Leading to Decidual Abscess

Postpartum Endometritis (PPE) is one of the common causes of postpartum fever. PPE leading to decidual abscess has not been reported previously in the literature. Risk factors for PPE range from invasive fetal monitoring to maternal diabetes mellitus and anemia. Our patient had several risk factors for the development of PPE. Commonly PPE is a polymicrobial infection but in our case it was monobacterial. Ultrasonography, tissue histopathology and culture sensitivity are helpful in diagnosing PPE, as well as tailoring the antimicrobial therapy. PPE is a common etiology for postpartum fever and acute infection of decidua which may progress and lead to decidual abscess formation. Endometritis can be monobacterial from the genital tract organisms. Uterine curettage and endometrial tissue culture and sensitivity will guide in tailoring the antimicrobial therapy.

Early Intravenous Immunoglobulin (IVIG) Therapy and Non Invasive Fetal Monitoring in Rh Alloimmunization (AI) and Pregnancy

High titer (HT), ≥1:32, anti-E, anti-c and anti-D Rh antibodies can cause hemolytic disease of the newborn (HDN). Maternal IVIG therapy may reduce need for intrauterine and exchange transfusions in HDN. Minimal data exists regarding optimal timing of therapy initiation, dose and frequency and fetal outcomes. Late administration of IVIG therapy beyond gestational age of 16 weeks have not been shown to improve fetal outcome. We describe the clinical course of 3 pregnant women with Rh AI. Two women with high titer Rh AI were treated with early IVIG dose of 1 gm/kg/week. A third woman with low titer Rh AI did not receive IVIG. Fetal status was monitored non-invasively with weekly Fetal Doppler ultrasound measurement of peak systolic velocity (PSV) of the middle cerebral artery (MCA). Patient 1 was a 38 year old Caucasian female with high anti- D (> 1:500) and history of HDN; second baby required 3 exchange transfusions and third baby required 3 intrauterine transfusions during pregnancy and 2 exchange transfusions post delivery. IVIG weekly infusion was started on week 11. Amniocentesis done at week 21 showed that baby was Rh(D) positive and the Kleihauer-Bethke test was negative. Serial fetal MCA PSV done weekly till labor induction did not show evidence of significant fetal anemia. The IVIG infusions were completed on 33rd week and the patient delivered healthy baby by cesarean section on the 35th week. The baby did not receive any intra uterine or exchange transfusions.Patient 2 was a 37 year old caucasian woman with anti-c AI. The patient's husband is c antigen positive and she had seroconversion during her third pregnancy which manifested as positive antibody screen in a routine type and screen with her third delivery which was uneventful. She subsequently had a miscarriage of her fourth pregnancy at 9 weeks. Her peak anti –c titer was 1: 128. She received IVIG infusion from week 11 to week 33 with stable anti-c titer of 1: 64. Serial MCA PSV assesments did not reveal significant fetal anemia. She had a normal vaginal delivery on week 34 with a healthy baby not requiring any exchange transfusions. Patient 3 was a 41 year old caucasian woman with low titer anti-E AI (1:8). No IVIG was administered as her titers remained low during her pregnancy course. Her titers were monitored every 2 weeks; peak antibody titer was 1:8. Fetal anemia was ruled out with Serial MCA PSV assesments. She delivered a healthy baby by Ceserean section at 38 weeks, 4 days.Patient 1Patient 2Patient3Gravid statusG4 P2103G5 P3013G8, P4034Blood groupA-A+O+Antibody identificationAnti DAnti cAnti EH/o documented HDNYesNoNoNumber of doses of IVIG2323NAAge of Gestation IVIG started10 weeks11 weeksNACumulative dose of IVIG1580 gms1750 gmsNAPeak antibody titer10481288Serial Fetal Peak MCA velocityNormalNormalNormalIntra uterine/Exchange transfusionsnoneNoneNonePregnancy outcomenormal fetusnormal fetusnormal fetusIVIG adverse effectsHeadache, fatigueNoneN/APatient 1Weeks of gestationAnti D TiterIVIG –Cumulative No. of dosesMCA PSV (cm/s) MoM= Multiples of Median91:512121:10481171:5127201:5121021 (0.83 MoM)211:5121128 (1.04 MoM)221:5121221.3 (0.76 MoM)231:5121328.1 (0.96 MoM)241:5121422 (0.71 MoM)251:5121525 (0.77 MoM)261:5121632 (0.95 MoM)271:5121728 (0.79 MoM)281:5121835 (0.94 MoM)301:5122045 (1.11 MoM)321:5122261 (1.37 MoM)331:5122351.9 (1.1 MoM)Patient 2Weeks of gestationAnti c TiterIVIG – Cumulative number of dosesMCA PSV (cm/s) MoM= Multiples of Median111:1281141:644201:6410221:641122.3 (0.79 MoM)241:641323.7 (0.77 MoM)251:641422.7 (0.70 MoM)261:641530.1 (0.89 MoM)271:641634.3 (0.97 MoM)291:641837.9 (0.98 MoM)301:641933.3 (0.82 MoM)311:642027.9 (0.65 MoM)321:642128 (0.62 MoM)331:642259 (1.26 MoM)341:642335 (0.71 MoM)Patient 3Weeks of gestationAnti E TiterIVIG - Cumulative No. of dosesMCA PSV (cm/s) MoM= Multiples of Median121:80191:80261:80281:8040.6 (1.07 MoM)291:4039.7 (1.02 MoM)321:4042 (0.94 MoM341:4055 (1.12 MoM)Median – 1.29 MoM = No fetal anemia1.29 – 1.5 MoM = Mild anemia>1.5 MoM = Severe anemiaConclusion- Early initiation of weekly IVIg therapy at dose of 1 gm/kg at gestational age of 10 to 11 weeks in high titer (≥ 1:32) maternal Rh AI is well tolerated and can eliminate the need for invasive fetal monitoring, intrauterine transfusion and exchange transfusion.

Morbid obesity and intra-partum care

SummaryObesity is a major health problem in the developed world and is beginning to have an impact on pregnancy (CEMACH ). We aimed to examine the differences in the intra-partum care of morbidly obese women compared with those of normal weight women. Intra-partum variables of labour monitoring as well as anaesthetic and neonatal variables were compared between 50 morbidly obese and 50 normal weight women. The morbidly obese group was observed to be significantly more prone to invasive fetal monitoring (27% vs 0%, p ≤ 0.001), difficult uterine contraction monitoring (30% vs 0%, p ≤ 0.001), more medical personnel involvement (22% vs 2%, p = 0.007). They were also found to be more likely to experience multiple epidural attempts (28% vs 0%, p<0.001), complications in labour (32% vs 6%, p < 0.001) and paediatric involvement (26% vs 3%, OR for 95% confidence interval is 1.5–20.8). There were no significant differences in the demographic variables, such as age, parity, gestational age and birth weight. Morbidly obese women are at significantly increased risk of complications during the intra-partum period, and require more intervention leading to increased morbidity and cost. Guidelines are needed for the intra-partum management of the morbidly obese pregnant woman to reduce the risk of morbidity and mortality.

Acute and chronic hepatitis: Working Group Report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition.

Acute and chronic hepatitis: Working Group Report of the First World Congress of Pediatric Gastroenterology, Hepatology, and Nutrition.

UK study of intrapartum care for low risk primigravidas: a survey of interventions.

STUDY OBJECTIVE: To determine the extent of intrapartum intervention received by primigravidas. DESIGN: Cross sectional survey of NHS hospitals in the UK. SETTING: One hundred and one randomly selected hospital...

Prophylactic Use of Cefazolin in Monitored Obstetric Patients Undergoing Cesarean Section

Prophylactic cefazolin was evaluated in high-risk obstetric patients who had invasive fetal monitoring and subsequent cesarean section. A three-dose regimen of either cefazolin or placebo was administered randomly in a double-blind manner to 93 patients, 48 receiving cefazolin and 45 placebo, with the first dose given when the cord was clamped. In the placebo group, 51% of the patients were treated for endomyometritis compared to 29% in the cefazolin group. The incidence of urinary tract and wound infections was similar in the 2 groups. One patient in the active drug group was diagnosed as having septic pelvic thrombophlebitis and received multiple antibiotics and heparin before she recovered. One patient in the placebo group required triple antibiotic therapy. Operation to control infection was not required in any patients and there were no maternal deaths. The cefazolin patients had fewer degree-hours of morbidity as calculated by the quantitative fever index (P less than 0.002). The perioperative use of cefazolin was efficacious in reducing the incidence of endomyometritis, but did not prevent serious postoperative pelvic infection.