Maternal Injury Research Articles

Возможности снижения родового травматизма у женщин из группы высокого риска по возникновению травм мягких родовых путей

Возможности снижения родового травматизма у женщин из группы высокого риска по возникновению травм мягких родовых путей

National Initiatives to Improve Systems for Postpartum Care.

Purpose To showcase several current national initiatives that focus on reducing maternal mortality and severe maternal morbidity and promote postpartum health and wellness for all women. Description Maternal injuries and deaths are a serious public health concern with tremendous impact on families, communities, and healthcare providers. Over the past two decades, it has become apparent that the timing of serious maternal complications has shifted, with more than half of deaths occurring in the immediate postpartum period up to 1year following birth. Many of these reported deaths could have been prevented, and the number of "near misses" of maternal morbidity cases continues to grow exponentially. In addition, postpartum women experience substantial unmet health needs, compromising their wellbeing. Assessment The American College of Obstetricians and Gynecologists and the Association of Women's Health, Obstetric, and Neonatal Nurses have thoroughly assessed the significance of the rising trends in maternal morbidity/mortality and are leading efforts to reduce these rates and improve overall health and wellbeing for all women during the postpartum period. Conclusion Developing national initiatives to improve postpartum health are vital to increasing the effectiveness of postpartum discharge education, and improving the participation in and the quality of postpartum care. Hopefully, evidence-based practice and widespread dissemination of these efforts will lead to a reduction in preventable post-birth maternal morbidity and mortality.

Melatonin modulates neonatal brain inflammation through endoplasmic reticulum stress, autophagy, and miR-34a/silent information regulator 1 pathway.

Maternal infection/inflammation represents one of the most important factors involved in the etiology of brain injury in newborns. We investigated the modulating effect of prenatal melatonin on the neonatal brain inflammation process resulting from maternal intraperitoneal (i.p.) lipopolysaccharide (LPS) injections. LPS (300μg/kg) was administered to pregnant rats at gestational days 19 and 20. Melatonin (5mg/kg) was administered i.p. at the same time as LPS. Melatonin counteracted the LPS sensitization to a second ibotenate-induced excitotoxic insult performed on postnatal day (PND) 4. As melatonin succeeded in reducing microglial activation in neonatal brain at PND1, pathways previously implicated in brain inflammation regulation, such as endoplasmic reticulum (ER) stress, autophagy and silent information regulator 1 (SIRT1), a melatonin target, were assessed at the same time-point in our experimental groups. Results showed that maternal LPS administrations resulted in an increase in CHOP and Hsp70 protein expression and eIF2α phosphorylation, indicative of activation of the unfolded protein response consequent to ER stress, and a slighter decrease in the autophagy process, determined by reduced lipidated LC3 and increased p62 expression. LPS-induced inflammation also reduced brain SIRT1 expression and affected the expression of miR-34a, miR146a, and miR-126. All these effects were blocked by melatonin. Cleaved-caspase-3 apoptosis pathway did not seem to be implicated in the noxious effect of LPS on the PND1 brain. We conclude that melatonin is effective in reducing maternal LPS-induced neonatal inflammation and related brain injury. Its role as a prophylactic/therapeutic drug deserves to be investigated by clinical studies.

Restricted episiotomy use and maternal and neonatal injuries: a retrospective cohort study.

There is relatively little information on episiotomies in the context of restricted episiotomy use. This study sought to examine maternal and neonatal injuries with restricted episiotomy use. We performed a retrospective database analysis of vaginal deliveries at a tertiary care maternity hospital from June 2010 to June 2015. Maternal injuries (third- or fourth-degree lacerations) and neonatal injuries (birth trauma) were identified through the International Classification of Diseases, Ninth Revision, codes. Vaginal deliveries were classified as spontaneous, vacuum-assisted, or forceps-assisted. The associations between episiotomy and maternal and neonatal injuries were examined with stratification by parity, type of vaginal delivery, and type of episiotomy (midline or mediolateral). Adjusted-odds' ratios were calculated for maternal and neonatal injuries using a multiple logistic regression model to adjust for potential confounders. 22,800 deliveries occurred during the study interval involving 23,016 neonates. The episiotomy rate was 6.7% overall and 22.9% in operative vaginal deliveries. Episiotomies, both midline and mediolateral, were associated with increased risks of maternal and neonatal injuries regardless of parity (p<0.0001). Upon stratification by the type of delivery, the association with maternal injury remained only for spontaneous vaginal deliveries (p<0.0001). Adjusted-odds' ratios demonstrated a continued association between episiotomy and maternal [aOR 1.67 (1.39-2.05)] and neonatal injuries [aOR 1.43 (1.17-1.73)]. Episiotomy continues to be associated with increased third- and fourth-degree lacerations with restricted use, particularly in spontaneous vaginal deliveries.

Psychological Symptoms and Social Functioning Following Repair of Obstetric Fistula in a Low-Income Setting.

Objectives Obstetric fistula is a maternal injury that causes uncontrollable leaking of urine or stool, and most women who develop it live in poverty in low-income countries. Obstetric fistula is associated with high rates of stigma and psychological morbidity, but there is uncertainty about the impact of surgical treatment on psychological outcomes. The objective of this exploratory study was to examine changes in psychological symptoms following surgical fistula repair, discharge and reintegration home. Methods Women admitted for surgical repair of obstetric fistula were recruited from a Tanzanian hospital serving a rural catchment area. Psychological symptoms and social functioning were assessed prior to surgery. Approximately 3months after discharge, a data collector visited the patients' homes to repeat psychosocial measures and assess self-reported incontinence. Baseline to follow-up differences were measured with paired t tests controlling for multiple comparisons. Associations between psychological outcomes and leaking were assessed with t tests and Pearson correlations. Results Participants (N=28) had been living with fistula for an average of 11years. Baseline psychological distress was high, and decreased significantly at follow-up. Participants who self-reported continued incontinence at follow-up endorsed significantly higher PTSD and depression symptoms than those who reported being cured, and severity of leaking was associated with psychological distress. Conclusions Fistula patients experience improvements in mental health at 3months after discharge, but these improvements are curtailed when women experience residual leaking. Given the rate of stress incontinence following surgery, it is important to prepare fistula patients for the possibility of incomplete cure and help them develop appropriate coping strategies.

Maternal collapse: Challenging the four-minute rule

IntroductionThe current approach to, cardiopulmonary resuscitation of pregnant women in the third trimester has been to adhere to the “four-minute rule”: If pulses have not returned within 4min of the start of resuscitation, perform a cesarean birth so that birth occurs in the next minute. This investigation sought to re-examine the evidence for the four-minute rule. MethodsA literature review focused on perimortem cesarean birth was performed using the same key words that were used in formulating the “four-minute rule.” Maternal and neonatal injury free survival rates as a function of arrest to birth intervals were determined, as well as actual incision to birth intervals. ResultsBoth maternal and neonatal injury free survival rates diminished steadily as the time interval from maternal arrest to birth increased. There was no evidence for any specific survival threshold at 4min. Skin incision to birth intervals of 1min occurred in only 10% of women. ConclusionOnce a decision to deliver is made, care providers should proceed directly to Cesarean birth during maternal cardiac arrest in the third trimester rather than waiting for 4min for restoration of the maternal pulse. Birth within 1min from the start of the incision is uncommon in these circumstances.

Shoulder dystocia: prediction and management.

Shoulder dystocia is a complication of vaginal delivery and the primary factor associated with brachial plexus injury. In this review, we discuss the risk factors for shoulder dystocia and propose a framework for the prediction and prevention of the complication. A recommended approach to management when shoulder dystocia occurs is outlined, with review of the maneuvers used to relieve the obstruction with minimal risk of fetal and maternal injury.

Injury patterns and health outcomes among pregnant women seeking emergency medical care in Kumasi, Ghana: Challenges and opportunities to improve care.

IntroductionIn high-income countries, injury is the most common cause of non-obstetric death among pregnant women. However, the injury risk during pregnancy has not been well characterized for many developing countries including Ghana. Our study described maternal and fetal outcomes after injury at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, and identified associations between the prevalence of poor outcomes and maternal risk factors.MethodsWe conducted a cross-sectional study to identify pregnant women treated for injury over a 12-month period at KATH in Kumasi, Ghana. Descriptive statistics were used to characterize the population. We identified the association between poor outcomes and maternal risk factors using multivariable Poisson regression.ResultsThere were 134 women with documented pregnancy who sought emergency care for injury (1.1% of all injured women). The leading injury mechanisms were motor vehicle collision (23%), poisoning (21%), and fall (19%). Assault was implicated in 3% of the injuries. Eleven women (8%) died from their injuries. The prevalence of poor fetal outcomes: fetal death, distress or premature birth, was high (61.9%). One in four infants was delivered prematurely following maternal injury. After adjusting for maternal and injury characteristics, poor fetal outcomes were associated with pedestrian injury (adjusted prevalence ratio (aPR) 2.5, 95% CI 1.5–4.6), and injury to the thoraco-abdominal region (aPR 2.1, 95% CI 1.4–3.3).ConclusionsInjury is an important cause of maternal morbidity and poor fetal outcomes. Poisoning, often in an attempt to terminate pregnancy, was a common occurrence among pregnant women treated for injury in Kumasi. Future work should address modifiable risk factors related to traffic safety, prevention of intimate partner violence, and prevention of unintended pregnancies.

Sexual Problems During Pregnancy and After Delivery Among Women With and Without Anxiety and Depressive Disorders Prior to Pregnancy: A Prospective-Longitudinal Study.

Few prospective-longitudinal studies have examined the course of sexual problems during pregnancy and after delivery in women with and without anxiety and depressive disorders prior to pregnancy as well as with and without maternal birth injuries. To prospectively investigate associations of anxiety and depressive disorders prior to pregnancy and maternal birth injuries with sexual problems during the peripartum period. The Maternal Anxiety in Relation to Infant Development Study is a prospective-longitudinal study of 306 women enrolled during early pregnancy and repeatedly assessed in seven waves during the peripartum period. Anxiety and depressive disorders prior to pregnancy were assessed in early pregnancy (T1) using the Composite International Diagnostic Interview for Women. Maternal birth injuries were assessed by questionnaire shortly after delivery (T4). Sexual problems during pregnancy (T2) as well as 4 months (T6) and 16 months (T7) postpartum were measured using the German version of the Massachusetts General Hospital Sexual Function Questionnaire. Impairment of sexual interest, arousal, orgasm, lubrication, and overall sexual satisfaction at T2, T6, and T7. Rates of sexual problems generally increased from T2 to T6 and decreased from T6 to T7. Compared with women without anxiety and depressive disorders, those with comorbid anxiety and depressive disorders prior to pregnancy more often specified impairment of overall sexual satisfaction at T2 (odds ratio [OR] = 2.0) and T7 (OR = 2.1). In contrast, sexual problems were not pronounced in those with pure anxiety or pure depressive disorders, and women with pure anxiety disorders often reported even less impairment of sexual interest at T7 (OR = 0.5). Compared with women without birth injury, those with vaginal birth injury more often reported impairment of sexual interest (OR = 1.8) and lubrication (OR = 2.3) at T6. Findings suggest that especially women with comorbid anxiety and depression and vaginal birth injury are at increased risk for sexual problems during pregnancy and after delivery and thus might benefit from targeted early interventions.

A review of prerequisites for vacuum extraction: Appropriate position of the fetal head for vacuum extraction from a forceps delivery perspective

As the frequency of forceps delivery has lowered in recent years, the use of vacuum extraction has become the technique of choice for forced delivery due to its technical ease and low risk for maternal injury. However, the success rate of vaginal births by vacuum extraction is lower than for forceps delivery and the risk for fetal injury is higher, which has led to an overall increase in legal cases concerning vacuum extraction. Prerequisites for vacuum extraction are based on those for forceps delivery according to the American College of Obstetricians and Gynecologists (ACOG) guidelines, wherein delivery is performed for fetal head positions at station +0 or lower. In Japan, forceps delivery is contraindicated when the fetal head is higher than at station +2, while in the United States (US), mid forceps delivery, defined by a fetal head position higher than station +2, is only occasionally performed due to the technical difficulty of the method. Forceps delivery is usually indicated for a fetal head position at station +2 or lower, with an injury rate that is lower than for vacuum extraction. Consequently, as vacuum extraction has a weaker pulling power than forceps, it is a theoretical contradiction that vacuum extraction is being performed at fetal head heights for which forceps delivery is not recommended. Therefore, we propose that vacuum extraction ought to be performed only in cases in which the fetal head height is at least at station +2 or lower to improve the success rate of vaginal births and reduce the complications to mother and fetus from vacuum extraction.

Maternal depression and risk of injuries in children aged 0–4 years: a population-based cohort study

BackgroundThe association between maternal depression and childhood injuries is underexplored, with existing studies relying on maternal reporting of injury occurrences. We aimed to assess the association between the incidence of three common childhood injuries and exposure to maternal antenatal depression, postnatal depression, or both. MethodsUsing a cohort of 209 418 mother–child pairs who had linked data from the Clinical Practice Research Datalink and Hospital Episode Statistics for 1997–2014, we estimated incidence of poisonings, fractures, and burns per 10 000 person-years from birth to the child's fifth birthday, stratified by whether the mother had antenatal depression, postnatal depression, or both. One child was randomly selected per mother to prevent clustering. Using Poisson regression, we estimated incidence rate ratios (IRRs), adjusted for maternal age at delivery, socioeconomic status, number of older siblings, and number of children aged 0–4 years in the household. The study was approved by the Independent Scientific Advisory Committee for the Medicines and Healthcare products Regulatory Agency in February, 2014. FindingsCrude injury rates were higher for each injury type among children whose mothers had antenatal depression, postnatal depression, or both. Poisoning incidence per 10 000 person-years was 59·6 (95% CI 48·7–72·8) for children of mothers with antenatal depression, 64·4 (57·4–72·2) for children of mothers with postnatal depression, and 74·2 (63·2–87·1) for children of mothers with both, compared with 36·3 (34·8–37·8) for those unexposed to either antenatal or postnatal depression. Similar patterns were seen for fractures and burns. After adjustment, IRRs remained significant for poisonings and burns, with the greatest risk for children whose mothers had both antenatal and postnatal depression (poisonings 1·94, 95% CI 1·63–2·32; burns 1·32, 1·13–1·55). However, there was no significant association between fractures and perinatal depression. InterpretationAntenatal and postnatal depression were associated with a higher risk of child poisonings and burns, suggesting that maternal depression could be a modifiable risk factor for these types of injury. By using routinely collected health data we only identified women who sought medical attention for depression, and were unable to adjust for other variables such as child behaviour. Differences in the ascertainment of injury events between mothers with and without perinatal depression could lead to an overestimation of injury risk. Further work could include assessing certain injuries (eg, long-bone fractures) for which ascertainment is likely to be almost complete. FundingRB is funded by the National Institute for Health Research (NIHR) School for Primary Care Research and the University of Nottingham.

Clinical Implications

HomeHypertensionVol. 66, No. 3Clinical Implications Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBClinical Implications Originally published1 Sep 2015https://doi.org/10.1161/HYPERTENSIONAHA.115.06168Hypertension. 2015;66:445Pravastatin Treatment for Preeclampsia (p 687)Preeclampsia is a serious complication affecting 5% to 8% of pregnancies. The preeclamptic placenta releases elevated soluble fms-like tyrosine kinase-1 and soluble endoglin into the maternal circulation, leading to widespread endothelial dysfunction and maternal organ injury. There is no medical treatment and preterm delivery is required to stop the disease from progressing. This can lead to perinatal death and disability arising from prematurity. There is an increasing momentum to consider pravastatin as a treatment for preeclampsia. However, most of the evidence supporting this concept has come from mice models. There has been little evidence generated in human tissues. In this issue of Hypertension, Brownfoot et al report studies showing pravastatin reduces key aspects of preeclampsia in primary human tissues. The group found pravastatin reduced soluble fms-like tyrosine kinase-1 and soluble endoglin secretion from preterm preeclamptic human placenta. This effect was mediated through the 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase cholesterol synthesis pathway. Using multiple endothelial dysfunction assays, Brownfoot et al showed that pravastatin reduced key aspects of vascular dysfunction. Finally, the team administered pravastatin to 4 women with preterm preeclampsia. Excitingly, there was some suggestion that the drug might have stabilized the disease in 3 of the participants (Figure). This work supports the contention that pravastatin may be a promising treatment for preeclampsia, but it should not be used until it has been tested in clinical trials.Download figureDownload PowerPointN-Terminal Pro-Brain Natriuretic Peptide Predicts Incident Atherosclerotic Cardiovascular Disease Beyond Ambulatory Blood Pressure (p 681)Improvement of risk prediction for atherosclerotic cardiovascular disease is needed. Both ambulatory blood pressure (ABP) and the biomarkers amino-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein and cystatin C improve risk prediction compared with traditional risk factors, but the additive value of the biomarkers has not been evaluated in relation to ABP. Skoglund et al investigated the predictive value of these biomarkers for incident atherosclerotic cardiovascular disease in a model including traditional risk factors in combination with ABP variables in 907 healthy elderly men from Uppsala, Sweden. The additive value of ABP to a traditional model already including one of these biomarkers was also tested. Results showed that ABP improved discrimination for incident atherosclerotic cardiovascular disease when compared with office BP in a traditional risk factor model and NT-proBNP further improved net reclassification when added to ABP models. ABP improved net reclassification when added to a traditional risk factor model that already included NT-proBNP. NT-proBNP and ABP are widely available and easy to use methods. The results from the study by Skoglund et al indicate that the combination of NT-proBNP and ABP can be used to improve risk prediction for incident atherosclerotic cardiovascular disease in elderly male patients. The application of these methods in tailoring treatment of patients with high blood pressure could be of benefit and may reduce the risk for incident cardiovascular disease.Blood Pressure Variability and Cerebral Small Vessel Disease (p 634)Besides blood pressure (BP) levels, BP variability has been independently associated with the risk of cardiovascular events, including stroke. Because hypertension is a major risk factor for cerebral small vessel disease (CSVD), which is a determinant for future stroke and dementia, it might be worthwhile to evaluate whether short-term BP variability relates to the presence of CSVD (Figure). In addition, the contribution of short-term BP variability metrics and BP levels to the diagnosis of CSVD in asymptomatic individuals is not known. In this issue of Hypertension, Filomena et al reported the results of a cohort study involving 487 asymptomatic individuals who underwent brain magnetic resonance imaging and 24-hour ambulatory BP monitoring. CSVD was identified in 18.9% of the participants and was based on the presence of lacunar infarcts and white matter hyperintensity grades. Among 20 different metrics of short-term BP variability, only 24-hour and nocturnal average real variability of systolic BP were independently associated with the presence of CSVD, together with increasing systolic BP levels at any period. When both systolic BP levels and average real variability were increased over 24 hours, the CSVD prevalence was the highest. Nonetheless, their addition to other clinical parameters related to CSVD, such as age, male sex, diabetes mellitus, or office BP, was associated with a small increase in discrimination of CSVD (5.3%), which was not clinically relevant.Download figureDownload PowerPoint Previous Back to top Next FiguresReferencesRelatedDetails September 2015Vol 66, Issue 3 Advertisement Article InformationMetrics © 2015 American Heart Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.115.06168 Originally publishedSeptember 1, 2015 PDF download Advertisement

Magnesium sulfate prevents maternal inflammation–induced impairment of learning ability and memory in rat offspring

Maternal chorioamnionitis is associated with newborn neurologic injury. Recent evidence suggests that maternal administration of magnesium sulphate (MG) may protect fetuses from white matter injury. Previously we demonstrated evidence by magnetic resonance imaging that MG may prevent maternal inflammation-induced gray matter injury of offspring. Thus, we sought to determine the potential of maternal inflammation to induce fetal neurological/behavioral deficits and assess whether maternal MG attenuates these effects. Pregnant rats at day 18 received injections of intraperitoneal lipopolysaccharide (LPS) or saline. Dams were treated with subcutaneous saline/MG (270 mg/kg followed by 27 mg/kg every 20 minutes) for 2 hours before and following LPS/saline injections. Pups were delivered spontaneously. At 1 and 3 months of age, 11-12 offspring of each group (saline, LPS, MG, LPS-MG) underwent a 2-way shuttle box avoidance testing. The shuttle box is divided in half and the animal moves between compartments to avoid an electric shock in response to an auditory stimulus. Control offspring demonstrated significantly improved learning and memory abilities from age 1 to 3 months. At 1 month, LPS-treated dams' offspring were similar to controls with no improvement in learning abilities at 3 months. MG treatment of LPS dams significantly improved offspring learning at 3 months, to equal or better than that of controls. LPS-stimulated inflammation during pregnancy impairs offspring learning ability and memory, which is ameliorated by maternal MG treatment. These results suggest that maternal MG therapy may prevent white and gray matter injuries associated with maternal infection/inflammation.

Motor vehicle collision-related accidents in pregnancy.

Motor vehicle accidents (MVA) are a major contributor of worldwide morbidity and mortality; however, relatively little is known about the incidence and consequences of traffic accidents on pregnant women. Our aim is to compare rates and outcomes of motor vehicle collision-related accidents in pregnant women. We conducted a population-based retrospective cohort study using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database from 2003 to 2011. The risk of different MVA and injuries were compared among pregnant and non-pregnant subjects using conditional logistic regression. We identified 5936 cases of collision-related MVA in pregnancy and age-matched them at a 1:10 ratio to 59,360 non-pregnant women with collision-related MVA. As compared to non-pregnant women, pregnant women who were admitted after an MVA suffered less severe injuries and consequently required fewer therapeutic interventions and a shorter hospital stay. Pregnant women who had a collision-related MVA were, however, at increased risk of requiring genitourinary surgery (odds ratio [OR], 1.45; 95% confidence interval [CI], 1.24-1.69). When restricted to women with a fracture, pregnant women were even more likely to require genitourinary surgery (OR, 2.93; 95%CI, 2.32-3.71) as well as require a blood transfusion (OR, 1.21; 95%CI, 1.01-1.44). Pregnant women admitted to hospital after a collision-related MVA tend to sustain less severe injuries compared to non-pregnant women. However, the influence of admissions for fetal monitoring, rather than maternal injury, could not be determined from our dataset. Pregnant women who experienced a collision-related MVA also required less surgical intervention, with the exception of genitourinary surgery, which may be indicative of more cesarean deliveries.

Effect of Lamaze breathing combined with perineal massage during labor on reducing maternal perineal laceration

Objective To explore the effect of Lamaze breathing combined withperineal massage during labor on reducing maternal perineal laceration. Methods A total of 400 cases of maternal vaginal deliveries in our hospital conditions, were randomly divided into experimental group and control group. The experimental group used Lamaze breathing and perineum massage combining method, the control group adopted conventional confinements, the two groups of mothers were compared with maternal perineal injury. Results The experimental group intact perineum rate was significantly better(P<0.05);and episiotomy rate, maternal II°laceration, theincidence of the second stage of labor and the postpartum 2h amount of bleeding and the rate of neonatal asphyxia in the experimental group was significantly lower than that in the control group(P<0.05). Conclusions The Lamaze breathing method combined with perineal massage wears method application can effectively reduce the rate of episiotomy, intact perineum rate, shorten the second stage of labor and reduce postpartum hemorrhage. Key words: Vaginal delivery; Lamaze breathing; Perineal massage; Episiotomy

Effects of Maternal Exposure to Cadmium Oxide Nanoparticles During Pregnancy on Maternal and Offspring Kidney Injury Markers Using a Murine Model

Nanoparticles (NP) are pervasive in many areas of modern life, with little known about their potential toxicities. One commercially important NP is cadmium oxide (CdO), which is used to synthesize other Cd-containing NP, such as quantum dots. Cadmium (Cd) is a well-known nephrotoxicant, but the nephrotoxic potential of CdO NP remains unknown, particularly when exposure occurs during pregnancy. Therefore, pregnant CD-1 mice were used to examine the effects of inhaled CdO NP (230 μg CdO NP/m3) on maternal and neonatal renal function by examining urinary creatinine and urinary biomarkers of kidney injury, including kidney injury molecule-1 (Kim-1) and neutrophil gelatinase-associated lipocalin (NGAL). Inhalation of CdO NP by dams produced a fivefold increase in urinary Kim-1 with no marked effect on urinary creatinine levels. Kim-1 mRNA expression peaked by gestational day (GD) 10.5, and NGAL expression increased from GD 10.5 to 17.5. In addition, histological analyses revealed proximal tubular pathology at GD 10.5. Neonatal Kim-1 mRNA expression rose between postnatal days (PND) 7 and 14, with mammary glands/milk being the apparent source of Cd for offspring. These studies demonstrate that, similar to what is seen with other Cd forms, Cd associated with inhaled CdO NP results in renal injury to both directly exposed dam and offspring. As commercial uses for nanotechnology continue to expand throughout the world, risks for unintentional exposure in the workplace increase. Given the large number of women in the industrial workforce, care needs to be taken to protect these already vulnerable populations.

Motor Vehicle Collision–Related Accidents in Pregnancy [310

INTRODUCTION: Motor vehicle accidents (MVAs) are a major contributor of worldwide morbidity and mortality; however, relatively little is known about the incidence and consequences of traffic accidents on pregnant women. Our aim is to compare rates and outcomes of motor vehicle collision-related accidents in pregnant women. METHODS: We conducted a population-based retrospective cohort study using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database from 2003 to 2011. The risk of different motor vehicle accidents and injuries were compared among pregnant and non-pregnant subjects using conditional logistic regression. RESULTS: We identified 5,936 cases of collision-related motor vehicle accidents in pregnancy and aged-matched them at a one-to-10 ratio to 59,360 nonpregnant women with collision-related motor vehicle accidents. As compared with nonpregnant women, pregnant women admitted after a motor vehicle accident suffered less severe injuries and consequently required fewer therapeutic interventions and a shorter hospital stay. Pregnant women who had a collision-related motor vehicle accident were however at increased risk of requiring genitourinary surgery (odds ratio [OR] 1.45, 95% confidence interval [CI] 1.24–1.69). When restricted to women with a fracture, pregnant women were even more likely to require genitourinary surgery (OR 2.93, 95% CI 2.32–3.71) as well as require a blood transfusion (OR 1.21, 95% CI 1.01–1.44). CONCLUSION: Pregnant women admitted to hospital after a collision-related motor vehicle accident tend to sustain less severe injuries compared with non-pregnant women. However, the influence of admissions for fetal monitoring, rather than maternal injury, cannot be determined from our dataset. Pregnant women who experienced a collision-related motor vehicle accident also require less surgical intervention, with the exception of genitourinary surgery, which may be indicative of more cesarean deliveries.

Clinical Implications

HomeHypertensionVol. 65, No. 4Clinical Implications Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBClinical Implications Originally published1 Apr 2015https://doi.org/10.1161/HYPERTENSIONAHA.115.05374Hypertension. 2015;65:697Renal Denervation and Atherosclerosis (page 758)Sympathetic nervous system overactivity is associated with a variety of cardiovascular diseases. Sympathetic innervation to specific organs may be particularly relevant. For example, renal sympathetic activity may play an important role in hypertension by regulating renin–angiotensin–aldosterone system activity, as well as other humoral factors. These downstream factors may also affect other vascular disease processes, such as atherosclerosis, independent of hypertension. In this issue of Hypertension, Wang et al report the effects of renal denervation (RDN) in a normotensive, atherosclerosis-prone mouse model. Despite absence of effects on blood pressure or total cholesterol, mice receiving bilateral RDN developed less atherosclerosis compared with mice receiving a sham operation (Figure). Atherosclerotic lesions in RDN mice also appeared more stable with increased smooth muscle cell content. Protection from atherosclerosis in the RDN group was associated with reduction of systemic factors implicated in the progression of atherosclerosis, including aldosterone, monocyte chemoattractant protein-1, and a marker of oxidative stress, 8-isoprostane. Further studies will be necessary to identify the precise causal mechanism(s) responsible for the apparent beneficial effects of RDN on progression of atherosclerosis, so that this pathway might be targeted in subjects at high risk for vascular disease. Complications of atherosclerosis (or surrogate end points) should also be studied if future clinical RDN trials in humans are performed.Download figureDownload PowerPointPreeclampsia Potentiates Future Vascular Injury (page 863)Download figureDownload PowerPointWomen who develop preeclampsia during pregnancy have an increased risk of cardiovascular disease later in life. Preeclampsia affects 5% of pregnancies, thereby exposing many women to increased cardiovascular risk for which there is no treatment aside from modification of traditional risk factors. The pervading explanation for this 2- to 4-fold increased cardiovascular risk is that preeclampsia identifies woman destined to develop cardiovascular disease. This is based on data revealing common risk factors for preeclampsia and cardiovascular disease. In this issue of Hypertension, Pruthi et al provide data supporting a novel emerging theory in which permanent vascular damage sustained during the preeclamptic episode contributes directly to cardiovascular disease pathogenesis. They demonstrate for the first time that mice exposed to experimental preeclampsia retain an enhanced response to vascular injury months after preeclampsia resolves. In their study, mice without preexisting cardiovascular risk factors were exposed to wire carotid injury 2 months after experimental preeclampsia. Preeclampsia-exposed mice developed increased vessel thickening and enhanced vascular cell proliferation and fibrosis after injury. Exploration of the mechanism for these persistent changes in the vasculature after preeclampsia has the potential to yield totally novel therapies to prevent this vascular damage during preeclampsia or to treat women after preeclampsia to avert the rapid progression to cardiovascular disease.Sofalcone Upregulates Heme Oxygenase-1 and Decreases Soluble fms–Like Tyrosine Kinase 1 (page 855)Preeclampsia complicates 3% to 8% of all pregnancies and is globally responsible for an estimated 60 000 maternal deaths annually and a far greater number of fetal losses. A therapeutic for preeclampsia could be a significant breakthrough, saving mothers and babies. Sadly, there is no such treatment. Solfacone is widely used as an antiulcer agent in Asia. In this issue of Hypertension, Onda et al report studies showing Solfacone has 3 different biological actions that raise the surprising possibility that it may be a treatment for preeclampsia. Preeclampsia is strongly associated with oxidative stress. The team reports Solfacone switches on a master transcription factor (Nrf2) that translocates to the nucleus and upregulates a raft of antioxidant genes. Secondly, the preeclamptic placenta produces elevated levels of soluble fms–like tyrosine kinase 1, which circulates widely, causing maternal endothelial dysfunction. Onda et al found Solfacone decreased soluble fms–like tyrosine kinase 1 secretion. Finally, circulating placental factors (including soluble fms–like tyrosine kinase 1) cause widespread endothelial dysfunction that leads to hypertension and multiple maternal organ injury. The team used several assays to show that Solfacone may protect blood vessels by decreasing endothelial dysfunction (Figure). Although there is little data on the safety of Solfacone in pregnancy, no links have been made with adverse pregnancy outcomes. Therefore, it is justifiable to proceed to clinical trials to treat women having severe preeclampsia with Solfacone where clinical options are limited.Download figureDownload PowerPoint Previous Back to top Next FiguresReferencesRelatedDetails April 2015Vol 65, Issue 4 Advertisement Article InformationMetrics © 2015 American Heart Association, Inc.https://doi.org/10.1161/HYPERTENSIONAHA.115.05374 Originally publishedApril 1, 2015 PDF download Advertisement

Posterior axilla sling traction for shoulder dystocia: case review and a new method of shoulder rotation with the sling

The purpose of this study was to report on all cases in which posterior axilla sling traction (PAST) has been used to deliver cases of intractable shoulder dystocia and to describe a new method of shoulder rotation with the sling. A record of all published and known cases was collected that included information on preliminary obstetric techniques that were used and how the PAST technique was performed. Maternal outcomes that included maternal injury and length of hospital stay and fetal outcomes, which included birthweight, Apgar scores, nerve injuries, fractures, hospital stay, and outcome, were documented. We have recorded 19 cases where PAST has been used. In 5 cases, the babies had died in utero. Ten were assisted deliveries. PAST was successful in 18 cases. In one case, it was partially successful because it enabled delivery of the posterior shoulder with digital axillary traction. The most commonly used material was suction tubing. Once the posterior shoulder was delivered, the shoulder dystocia was resolved in all cases. Time from insertion to delivery was <3 minutes when recorded. The birthweights of the infants varied from 3200-4800 g. Posterior arm humerus fractures occurred in 3 cases. There was one case of a permanent Erb's palsy and 4 cases of transient Erb's palsies. None were of the posterior arm. During this review, we found that, when direct delivery of the posterior shoulder was difficult because of very severe impaction, the sling could be used to rotate the shoulders easily through 180 degrees assisted by counter pressure on the back of the anterior shoulder. This new method was used in 5 cases and may reduce fetal trauma further during difficult shoulder delivery. This review confirms that PAST can be a lifesaving technique when all another techniques for shoulder dystocia fail. Advantages are that it is easy to use (even by someone who has not seen it used previously), that the sling material is readily available, and that it is inserted quickly with 2 fingers. This is the first report of its use to rotate the posterior shoulder to the anterior position for delivery.

A study of outlet forceps in modern era

Background: Aim of current study was to study the use of outlet forceps in modern obstetrics and find out its fetal and maternal outcomes. Methods: Observational study of 50 cases of outlet forceps application over a period of 3 years and our institution from June 2012 to May 2015. Results: Outlet forceps was more commonly used in primipara patient between 21-30 years in term babies in prolonged second stage of labor and in case of fetal and maternal distress with perineal infiltration of local analgesia with minimal NICU admissions of the babies and minimal maternal perineal injuries. Conclusions: Prophylactic use of forceps is a safe alternative to cut short the second stage of labor. Using outlet forceps the overall rates of maternal and perinatal morbidity and mortality are negligible and comparable to normal delivery.