Mid-trimester Pregnancy Research Articles

Viral invasion of the amniotic cavity (VIAC) in the midtrimester of pregnancy

Introduction: The prevalence of viral infections in the amniotic fluid (AF) has not yet been ascertained. The aim of this study was to determine the prevalence of specific viral nucleic acids in the AF and its relationship to pregnancy outcome. Study design: From a cohort of 847 consecutive women undergoing midtrimester amniocentesis, 729 cases were included in this study after exclusion of documented fetal anomalies, chromosomal abnormalities, unavailability of AF specimens and clinical outcomes. AF specimens were tested by quantitative real-time PCR for the presence of genome sequences of the following viruses: adenoviruses, herpes simplex virus (HSV), varicella zoster virus (VZV), human herpesvirus 6 (HHV6), human cytomegalovirus (HCMV), Epstein-Barr virus (EBV), parvovirus B19 and enteroviruses. Viral nucleic acid testing was also performed in maternal blood and cord blood in the population of women in whom AF was positive for viruses and in a control group of 29 women with AF negative for viral nucleic acids. The relationship between the presence of viruses and pregnancy and neonatal outcome was examined. The correlation between the presence of nucleic acids of viruses in the AF and the concentration of the cytokine interleukin-6 (IL-6) and the T cell chemokine CXCL-10 (or IP-10) in AF and maternal blood were analyzed. Results: Viral genome sequences were found in 16 of 729 (2.2%) AF samples. HHV6 was the most commonly detected virus (7 cases, 1.0%), followed by HCMV (6 cases, 0.8%), parvovirus B19 (2 cases, 0.3%) and EBV (1 case, 0.1%), while HSV, VZV, enteroviruses and adenoviruses were not found in this cohort. Corresponding viral DNA was also detected in maternal blood of six out of seven women with HHV6-positive AF and in the umbilical cord plasma, which was available in one case. In contrast, viral DNA was not detected in maternal blood of women with AF positive for parvovirus B19, HCMV, EBV or of women with AF negative for viruses. HHV6 genome copy number in AF and maternal blood was consistent with genomic integration of viral DNA and genetic infection in all women. There was no significant difference in the AF concentration of IL-6 and IP-10 between patients with and without VIAC. However, for HCMV, there was a significant relationship between viral copy number and IP-10 concentration in maternal blood and AF. The group of women with AF positive for viral DNA delivered at term healthy neonates without complications in 14 out of 16 cases. In one case of HHV6 infection in the AF, the patient developed gestational hypertension at term, and in another case of HHV6 infection in the AF, the patient delivered at 33 weeks after preterm premature rupture of membranes (PPROM). Conclusion: Viral nucleic acids are detectable in 2.2% of AF samples obtained from asymptomatic women in the midtrimester. HHV6 was the most frequently detected virus in AF. Adenoviruses were not detected. Vertical transmission of HHV6 was demonstrated in one case.

Clinical value of fetal echocardiography at early and mid trimester of pregnancy in diagnosis for congenital

Fetal congenital heart disease can be identified reliably by prenatal echocardiography.A sequential segmental approach is critical for correct evaluation of the cardiac malformation.The outcome of the patients with congenital heart disease is poor and a multidisciplinary is needed to the parental counseling and perinatal management planning.It is of great significance for reducing rate of birth defect. Key words: Echocardiography; Fetus; Congenital heart disease

A comparison of SphygmoCor and Vicorder devices for measuring aortic pulse wave velocity in pregnancy

BackgroundAortic pulse wave velocity (aPWV) has been found to be increased in preeclampsia when compared to normal pregnancy. Preeclampsia is associated with increased risk of later cardiovascular disease and, as such, study of the aortic stiffness in pregnancy, and its hypertensive disorders, is important to the understanding the underlying vascular changes. We compared two different techniques to measure aPWV in the mid-trimester of pregnancy. Methods58 women were recruited from the obstetric ultrasound clinic, mean (±SD) age 33 (±6) years and gestation 27 (±1) weeks. Aortic PWV was measured using SphygmoCor and Vicorder devices. ResultsWe found that both devices provided similar aPWV values with no significant difference between devices: mean difference (±SD), 0.1 (±0.9)m/s, p = 0.4. We found good correlation between devices (r = 0.6, p < 0.001). Good intra-observer variability was observed for both SphygmoCor and Vicorder devices, coefficients of variation 5.69% and 2.67%, respectively. ConclusionsThe SphygmoCor and Vicorder devices produce similar readings for aPWV in the second trimester of pregnancy, with good intra-observer variability. Due to its simpler technique the Vicorder device may be more suited to the clinical setting, particularly in advanced pregnancy or obesity.

Late Midtrimester Pregnancy, Advanced Bulky Cervical Cancer, Radiation Therapy, and Physician’s Moral Distress: A Management Dilemma

Background: Approximately 3% of cervical cancers are diagnosed during pregnancy, of which 75% are detected in early stages. The management may pose significant challenges because of the pregnant state. Case: We describe a case of rapidly progressing bulky cervical cancer complicating a late second trimester pregnancy. The case was successfully managed by induction of labor with misoprostol after induced fetal demise followed by radiation therapy with fetus in situ. Conclusion: In a late second trimester pregnancy complicated by rapidly progressing bulky cervical cancer, optimal outcome was achieved using a multidisciplinary approach. Fetal intra cardiac potassium chloride injection is helpful in the management of select cases.

A very rare presentation of miliary tuberculosis in mid-trimester pregnancy masquerading as sepsis and severe acute respiratory syndrome: Category: Clinical lesson

We report a rare presentation of miliary tuberculosis (TB) in an HIV-negative pregnant Bangladeshi woman masquerading as acute sepsis with rapid progression to respiratory failure and acute respiratory distress syndrome (ARDS) and subsequent acute renal failure (ARF). The absence of any typical systemic prodromal symptoms, the short duration of illness and initially normal chest x-ray (CXR) with rapidly evolving radiological changes made ascertainment of the diagnosis of TB infection difficult. Aggressive investigation including liver and bone marrow biopsy lead to diagnostic confirmation, appropriate therapy, and, despite foetal loss at 22 weeks gestation, to a successful outcome.

Abstracts: ASUM Annual Scientific Congress 2011

Abstracts: ASUM Annual Scientific Congress 2011

Preventing preterm birth with progesterone: costs and effects of screening low risk women with a singleton pregnancy for short cervical length, the Triple P study

BackgroundWomen with a short cervical length in mid-trimester pregnancy have a higher risk of preterm birth and therefore a higher rate of neonatal mortality and morbidity. Progesterone can potentially decrease the number of preterm births and lower neonatal mortality and morbidity. Previous studies showed good results of progesterone in women with either a history of preterm birth or a short cervix. However, it is unknown whether screening for a short cervix and subsequent treatment in mid trimester pregnancy is effective in low risk women.Methods/DesignWe plan a combined screen and treat study among women with a singleton pregnancy without a previous preterm birth. In these women, we will measure cervical length at the standard anomaly scan performed between 18 and 22 weeks. Women with cervical length ≤ 30 mm at two independent measurements will be randomly allocated to receive either vaginal progesterone tablets or placebo between 22 and 34 weeks. The primary outcome of this trial is adverse neonatal condition, defined as a composite outcome of neonatal mortality and severe morbidity. Secondary outcomes are time to delivery, preterm birth rate before 32, 34 and 37 weeks, days of admission in neonatal intensive care unit, maternal morbidity, maternal admission days for preterm labour and costs. We will assess growth, physical condition and neurodevelopmental outcome of the children at two years of age.DiscussionThis study will provide evidence for the usefulness and cost-effectiveness of screening for short cervical length at the 18-22 weeks and subsequent progesterone treatment among low risk women.Trial registrationNetherlands Trial Register (NTR): NTR207

Cerclage cervical en urgence au deuxième trimestre de la grossesse : expérience clermontoise

Objectives The objective of this study was to identify factors associated with favourable perinatal outcome after emergency cervical cerclage during mid-trimester of pregnancy. Patients and methods This is a retrospective study of all cases who underwent emergency cervical cerclage between 16 to 28 weeks of gestation (WG) over a period of 16 years in a University Hospital. Results Among the 32 cases, the postnatal survival rate (day 28) was 80%. Delivery occurred at a mean gestational age of 33.1 WG [18–41.3 WG] and after 37 WG in 39% of cases. The perinatal outcome was improved by absence of bleeding ( P = 0.01), unripened cervix ( P = 0.02), cervical dilatation below 2 cm ( P = 0.002), no protruding membranes ( P = 0.02) and more advanced gestational age at the procedure ( P = 0.005). When no uterine contraction and no maternal blood inflammation were observed at admission, an expectancy of 48 hours before the procedure did not improve significantly perinatal outcome (gestational age at birth and survival rate [ P = 0.1 and P = 0.3 respectively]). Discussion and conclusion Perinatal outcome after emergency cerclage depends on cervical status and gestational age at procedure. It is not influenced by an expectancy of 48 hours before intervention for patients with no uterine contraction and no maternal blood inflammation at admission.

A randomized comparative study on vaginal administration of acetic acid-moistened versus dry misoprostol for mid-trimester pregnancy termination

Absorption and effectiveness of vaginally administered misoprostol tablets may vary according to the medium in which it is placed. This study was directed to compare the outcomes of vaginal administrations of acetic acid-moistened misoprostol tablets with those of dry tablets for induction of second-trimester abortion. A randomized comparative trial where 322 women at 13-20 weeks gestation, requiring medical abortion, were randomly assigned to vaginal administration of either acetic acid-moistened or dry misoprostol tablets with a dose schedule of 400 μg three-hourly, up to a maximum five doses over 24 h. The same doses were repeated for another 24 h in nonresponders. Primary outcome measure was complete abortion rate at 24 and 48 h, and the secondary outcome measures were induction-abortion interval, failure rate and side effects. A difference of 15% in success rates at 24 h was used to calculate the sample size required with a power of 0.8 at the 5% significance level. No statistically significant differences in the complete abortion rates were observed at 24 h (70.95 vs. 68.71%, P = 0.675) and at 48 h (86.49 vs. 84.35%, P = 0.604) when both groups were compared. The difference in mean induction-abortion interval was also statistically insignificant between the groups (12.5 ± 1.6 vs. 12.8 ± 1.5 h, P = 0.97). Other outcome measures were also comparable in both groups. Moistening misoprostol tablets with 5% acetic acid before vaginal application creates no difference in outcomes when compared with those after the vaginal application of dry tablets for the termination of second-trimester pregnancy.

Controversial Ultrasound Findings in Mid-Trimester Pregnancy

ABSTRACT US equipment became more and more important for the practicing obstetricians, and the demands for practicing US as part of the antenatal care becomes sometimes routine in certain areas. A lot of US workshops are practiced trying to put the guidelines for using the US in this domain, and every now and then new markers and US signs are added that could have some significance in relation to the fetal outcome. Here a problem now exists, which is the gap between the ability to detect and the understanding of the significance of these findings, and this of course creates a great deal of improper counseling which leads to anxiety and confusions. The aim of my lecture is to shed some light on some controversial US signs, like echogenic bowel, renal pyelectasis, cardiac echogenic foci, choroid plexus cyst, club foot, polydactyly, single umbilical artery and mild ventriculomegaly. First I shall discuss the epidemiology–the pathophysiology, underlying risk for associated chromosomal anomalies and the most important is the significance of these signs, if present alone, so trying to suit out an evidence-based approach to their management and to provide the clinician with all the data that enables him to properly counsel the parents and eliminates the confusion created by the mere detection of these findings.

Association between gestational age and induction-to-abortion interval in mid-trimester pregnancy termination using misoprostol

Objective The study was aimed to evaluate the effectiveness, outcome, and pain intensity of the vaginal administration of misoprostol for the induction of abortion between 13 and 24 gestational weeks. Study design A retrospective study was conducted at our tertiary medical center from January 2006 to December 2009 on 122 consecutive women who underwent termination of pregnancy (TOP) in the mid-trimester. They were given 400 mcg of vaginal misoprostol every 6 h, up to four doses. The induction-to-abortion interval and the level of pain experienced during the process were assessed. Success was defined by the fetus being expelled within 48 h. Results Vaginal misoprostol was effective in 84% (98/122) of patients. The median duration of the induction-to-abortion interval was 16 (5–48) h. The induction-to-abortion interval was correlated with gestational age, while inversely correlated with parity. A correlation was also found between gestational age and pain intensity at 12 h from induction. Conclusion Misoprostol is safe and effective in mid-trimester abortion induction. The induction-to-abortion interval is shorter and abortion less painful with lower gestational age. Higher parity is also associated with shorter induction to abortion interval.

Spontaneous rupture of capillary splenic hemangioma in mid trimester pregnancy: a rare entity

Spontaneous rupture of capillary splenic hemangioma in mid trimester pregnancy: a rare entity

Comparison of sublingual versus vaginal misoprostol for second-trimester pregnancy termination: A meta-analysis

The development of safe and effective techniques for second-trimester abortion (associated or not with fetal death) has become a major clinical challenge. To compare the efficacy and safety of sublingual versus vaginal misoprostol for mid-trimester pregnancy termination. We conducted a meta-analysis of published randomised controlled trials that compared sublingual and vaginal routes. Primary outcome measures were complete abortion rate at 24 and 48 h and induction-abortion interval, and the secondary outcome measures were side effects and patients' preference for the route. Pooled risk ratios were calculated for categorical variables, and continuous variables were compared by means of weighted mean differences. Both routes' efficacy was similar following 24 h of treatment (pooled RR 1.04, 95% CI 0.93-1.7). Successful induction percentage after 24 h was significantly higher in nulliparous women with vaginal misoprostol (pooled RR 0.78; 95% CI 0.71-0.87). The efficacy after 48 h was significantly greater with vaginal misoprostol in the general population (pooled RR 0.96; 95% CI 0.93-0.99) and in nulliparous women (pooled RR 0.89; 95% CI 0.86-0.95). The sublingual route shortened the induction-fetal expulsion interval (WMD -4.54, 95% CI -8.03 to -1.05) and was the route preferred among women. No statistically significant differences between treatment groups were observed for placental retention or for any side effect except for fever, which was more common in the vaginal group. Sublingual and vaginal misoprostol are safe and effective for mid-trimester pregnancy termination. The differences obtained between both routes probably do not have clinical consequences.

Perinatal Exposure to Environmental Phthalate and the Cognitive Development of 6-Month-Old Infants (MOCEH Study)

PP-31-073 Background/Aims: The relationship between the maternal urinary concentrations of phthalate metabolites during pregnancy and the children's intellectual development was explored. Methods: Mono-2-ethylhexyl phthalate (MEHHP) and mono (2-ethyl-5-oxohexyl) phthalate (MEOHP), both metabolites of di (2-ethylhexyl) phthalate (DEHP), and mono-n-butyl phthalate (MBP), a metabolite of dibutyl phthalate (DBP), were measured in urine samples of 236 mothers at first trimester and 470 mothers at mid trimester of pregnancy. The cognitive developmental status of the 6-month-old infants was assessed using Korean Bayley scales of Infant development-second edition. Results: The mean concentrations of MEHHP, MEOHP, and MBP were 12.6 μg/L (SD = 13.8, range: 0.25–97.9), 13.3 μg/L (SD = 17.8, range: 0.28–193.9), and 35.3 μg/L (SD = 66.1, range: 0.22–911.9), respectively, at first trimester and 15.4 μg/L (SD = 23.0, range: 0.25–262.7), 18.9 μg/L (SD = 29.7, range: 0.28–303.6), and 35.5 μg/L (SD = 56.9, range: 0.22–528.1), respectively, at mid trimester. After adjusting for demographic and developmental covariates, the cognitive quotient and motor quotient were negatively associated with DEHP metabolites, but not with DBP metabolites concentrations of mothers at first trimester. We also found a tendency for negative relationship between the cognitive quotient and motor quotient and DEHP metabolites, but not with DBP metabolites concentrations of mothers at mid trimester. After controlling for maternal IQ, the tendency for inverse relationship between the DEHP metabolites at mid trimester and the cognitive quotient and motor quotient was still observed. Conclusion: This study observed a tendency for an inverse relationship between phthalate metabolites in urine of mothers during pregnancy and the infant developmental quotient at 6 month of the offspring.

Prenatal diagnosis of lobar bronchial atresia

We report three cases of fetal lobar bronchial atresia referred to our Fetal Medicine Center during the mid-trimester of pregnancy over the last 15 years. Lobar bronchial atresia can mimic a main stem bronchial atresia on mid-trimester ultrasound examination as it induces extensive lobar enlargement, major mediastinal shift and eversion of the diaphragm. It was associated with severe pulmonary hypoplasia in all three cases, even though polyhydramnios and ascites were absent in two. Termination of pregnancy was performed at parental request after extensive counseling in each of the cases and necropsy confirmed one or two enlarged lung lobes leading to major compression of the remaining lobe(s) of the ipsilateral lung, the contralateral lung and the heart. No other anomalies were observed and the karyotype was normal in all cases.

High-dose oxytocin is not associated with maternal temperature elevation: a retrospective cohort study of mid-trimester pregnancy with intrauterine fetal demise

Background Maternal intrapartum fever has been associated with an increased incidence of neonatal morbidity. In this retrospective cohort study, we evaluated whether intravenous oxytocin has a fever-inducing effect. Oxytocin augments secretion of prostaglandins E 2 and F 2α which are inflammatory mediators known to elevate body temperature. Methods Between January 2005 and June 2008, 279 patients were admitted with mid-trimester fetal demise. Patients meeting inclusion criteria included 34 women who received a high-dose intravenous oxytocin regimen and 29 patients who delivered after spontaneous labor without the need for augmentation. Oral temperatures were measured on admission and at delivery. Results The median length of oxytocin infusion was 5.3 h. The calculated temperature change was −0.14°C in the oxytocin group and +0.12°C in the control group. These findings were confirmed in a model adjusted for patients’ white blood cell count and duration of labor. We did not observe an effect of analgesia type, epidural versus intravenous analgesia, on duration of labor. Conclusion Based on this comparative analysis of pregnant women who received high-doses of oxytocin, we found insufficient evidence to support that high-dose intravenous oxytocin elevates intrapartum maternal temperature.

Hourly Oral Misoprostol Administration for Terminating Midtrimester Pregnancies: A Pilot Study

This pilot study retrospectively evaluated the outcomes of medical induction of termination of midtrimester pregnancies with hourly oral misoprostol administration. Sixteen women with living fetuses, who had undergone pregnancy termination at 12-25 weeks of gestational age, were reviewed. The method of induction was hourly oral administration of misoprostol, given at doses of 200 μg/hr for the first 12 hours and 400 μg/hr after 12 hours until delivery. Data including the induction-to-delivery interval and total dosage of misoprostol were recorded and analyzed. All 16 women successfully underwent vaginal termination within 36 hours. The median induction-to-delivery interval was 12.0 hours (range, 6.3-30.9 hours), with 13 women (81.3%) undergoing vaginal delivery within 24 hours. The median total dosage of misoprostol was 2,600 μg. The most common side effect was diarrhea, which was easily relieved by medication. Our preliminary results show that oral administration of misoprostol at hourly intervals is a promising method for terminating midtrimester pregnancies.

Observation on the effect of three species of drug treatment on vulvovaginal candidiasis in the mid trimester of pregnancy

Objective To observe the clinical therapeutic effect of the treatment on vulvovaginal candidiasis (VVC) in the mid trimester of pregnancy with three species of drug (Clotrimazole,Macmirorcomplex, Baofukang Shuan). Methods 83 women diagnosed with VVC in the mid trimester of pregnancy were divided into three groups: Group A with 30 cases, treated with Clotrimazole for twice; Group B with 28 cases, treated with Macmirorcomplex for 6 days; Group C with 25 cases, treated with Baofukang Shuan for 8 days. Observed the clinical effect, the microbes therapeutic effect and the adverse effect of the treatment with three species of drug. Results (1)The clinical cure rate of Group A was 86.67% and the fungal negative rate was 93.33%. The clinical cure rate of Group B was 57.14% and the fungal negative rate was 75%. The clinical cure rate of Group C was 60% and the fungal negative rate was 40%. There were no adverse effect to be found in the three groups. (2) The clinical cure rate and curative rate of Group A were significantly higher than those of Group B and Group C( P＜0,05 ),but there were no difference in Group B and Group C ( P＞ 0.05 ). The V VC scores of the three groups were significantly descended compared with those of pretherapy ( P＜ 0.01 ), but there were no difference of the curative rate about microbes therapeutic effect in the three groups ( P＞ 0.05 ).Conclusion The three drugs for VVC in pregnancy are all effective and no serious adverse effect. Clotrimazole has better clinical therapeutic effect than Macmirorcomplex and Baofukang Shuan. Key words: The mid trimester of pregnancy; Vulvovaginal candidiasis(VVC); Clotrimazole; Macmirorcomplex; Baofukang Shuan

Association between placental mineral deposition, villous architecture and fetal aneuploidy

We retrospectively evaluated the relationship between fetal aneuploidy and placental mineral deposits and villous architecture in 2nd trimester placentas of mid-trimester pregnancy terminations for fetal anomaly. Study cases were aneuploid and matched with euploid controls. Six slides per case were histologically evaluated. Our findings showed significantly increased subtrophoblastic mineral depositions in aneuploidy placentas; also, villous architecture changes between study and control cases were significant for multifocal/extensive villous scalloping and syncytial budding. Our conclusion was that placental histological findings of extensive subtrophoblastic mineral deposition, multifocal/extensive villous scalloping and syncytial budding may suggest aneuploidy.

Unruptured Second Trimester Tubal Pregnancy-A Case Report

Ectopic pregnancy is a major health risk for women of reproductive age group and is a major cause of death in the first trimester. While most cases of tubal pregnancy will present in the first trimester, advanced tubal pregnancy is rare and may be associated with diagnostic difficulty. We present the case of a 30 year-old primigravida who had total salpingectomy for unruptured mid-trimester tubal pregnancy with favorable outcome at 20 weeks gestation.