Mid-trimester Pregnancy Research Articles

Reproductive outcome following midtrimester pregnancy loss

The aim was to analyse reproductive outcome in pregnancy subsequent to a previous midtrimester pregnancy loss.This was a retrospective case note review over a 4 year period. Patients who had...

Infection and fetal loss in the mid‐second trimester of pregnancy

Chorioamnionitis is a common cause of second trimester pregnancy loss, usually due to ascending infection. This study investigates the prevalence and bacteriology of chorioamnionitis in cases of spontaneous pregnancy loss in previable gestations (16-22 weeks). Fetal losses between 16- and 22-week gestation were identified from the institutional database over a three-year period. Cases with an autopsy were identified, pathology reports reviewed, and maternal features noted (clinical symptoms, blood count and vaginal culture results). Second trimester medical termination for fetal abnormality during the same time period served as controls for the confounding influence of labour. A total of 101 cases of spontaneous non-anomalous non-macerated fetal losses and 103 control cases of induced loss for fetal anomaly were identified. Median gestation of cases was 19 weeks (interquartile range (IQR) 17, 21) and of controls was 20 weeks (IQR 19, 21). Maternal white cell count was higher in cases (median 13.6 IQR 10.8, 16.6) than in controls (9.9 IQR 7.6, 11.5) (P < 0.01). Seventy-eight (77.2%) of 101 cases and no controls had histological chorioamnionitis. A fetal reaction was identified in 48.7% of cases with chorioamnionitis, and the frequency of fetal reaction increased as gestation advanced (5.3% at 16-week gestation vs 33.3% at 22-week gestation). In cases with chorioamnionitis 36/76 (47.4%) were culture positive, whereas 4/25 (16%) without chorioamnionitis were culture positive. In otherwise normal fetuses, chorioamnionitis is a common finding in mid-trimester pregnancy loss. Routine culture methods have a low sensitivity for isolation of the causative micro-organisms. This inflammatory process seems to predate the onset of labour and appears a primary mechanism in the aetiology of such losses.

The effect of multimedia teaching in early and mid trimester pregnant woman school

Objective We changed the teaching model of our pregnant woman school to improve related knowledge accepted by pregnant woman in early and mid trimester of pregnancy communicate better and deeply between medical care personnel and pregnant woman reduce pregnant diseases and teratism rate.Method Using multimedia teaching in pregnant woman lesson and Comparing the difference between multimedia teaching and conventional instruction through taking back general health questionnaire.Results Test Volume 12 projects of which nine awareness rate increased to varying degrees. The rate in quickening had raised from 91.24% in 2006 to 97.8% in 2007 and in monitoring fetal growth from 50.85% in 2006 to 73.45% in 2007.Conclusions Using multimedia teaching could improve the status of pregnant woman awareness in early and mid trimester of pregnancy Key words: Pregnant woman school; Multimedia; Health education; Status of awareness

The Diagnosis Of The Spontaneous Dupture In Mid Drimester Of Pregnancy

Objective To analyze the mechanism of the spontaneous rupture of an gravid uterus in mid trimester of pregnancy, so as to reduce the damage of the expectant mother. Methods The study retrospectively analyzed 6 cases of the rupture of the uterus treated in my hospital recently, and mainly discussed the related reasons, diagnosis and treatment. Results All the six cases had entorrhagia differently, and need blood transfusion overall, five of them developed to hemorrhagic but all the fetus were dead inevitably. In the operations, we discovered four cases had placenta hominis. Conclusion The reasons of rupture may be resulted of scar uterus,uterine malformation, hypoplasia of uterus, placenta percreta, et al. B-ultrasonography associated with abdominal paracentesis can help final diagnosis significantly. Key words: The rupture of the uterus; Diagnosis; Operation; B-ultrasonography

Characteristics of amniotic fluid derived stem cells with trisomy 21

목적: 다운증후군의 신경계 결함에 관련된 양수유래 줄기세포의 표지자를 정상과 비교 분석하였다. 연구 방법: 임신 중기에 산전 진단을 위해 시행한 양수천자를 통해 채취된 4개 표본의 양수세포는 염색체검사에서 2개는 21번 삼염색체로 확인되었고 다른 2개는 정상이었다. 두 단계로 이루어진 양수유래 줄기세포 배양을 통해 얻어진 줄기세포들을 분석하였다. 형태학 관찰, 염색체검사, 역전사효소 중합반응 및 Western blot 분석을 시행하였다. 결과: 양수유래 줄기세포는 계대배양에서 높은 증식력을 보였으며 대부분 섬유아세포와 같은 방추상의 단핵세포로 관찰되었으며 드물게 원형의 단핵세포들도 있었다. 줄기세포의 염색체검사에서는 양수의 염색체검사와 동일하게 다운증후군 두 개의 표본은 21 삼염색체증 (47,XX,+21)이었고 정상 임신의 양수유래 줄기세포도 염색체검사 결과는 정상 (46,XX)이었다. 다운 증후군과 관련된 것으로 알려진 단백 분석에서는 S100β는 다운증후군에서 정상보다 증가되어 나타났으며 COL6A1은 정상에서는 발현되었으나 다운증후군에서는 발현되지 않았다. Insulin like growth factor binding protein-1의 발현은 정상과 다운증후군 모두에서 차이가 없었다. 줄기세포 표지자 유전자인 Oct4, nanog, SOX2는 모두 발현되었다. 반면에, c-Kit의 발현은 정상에서는 나타났으나 다운증후군에서는 검출되지 않았다. 신경세포 표지자인 NSE는 모두 발현되었으나, microtubule associated protein 2와 glial fibrillary acidic protein는 다운증후군에서 발현되지 않았다. 세포자멸사 (apoptosis)와 관련된 Bcl-2 gene family 단백에 대한 분석에서는 Bcl-XL은 다운증후군에서 정상보다 증가되어 발현되었으며 Bcl-2, Bid 단백 발현은 정상과 다운증후군에서 차이가 없었다. Bax는 다운증후군에서 감소되었다. 결론: 양수유래 줄기세포는 조직 공학과 세포치료에 탁월한 재료가 될 것이다. 다운증후군의 양수유래 줄기세포의 분자생물학적 특성에 대한 분석은 앞으로의 연구를 위한 기초를 제공할 것이다.

Prediction and prevention of preterm birth after cervical conization

Prediction and prevention of preterm birth after cervical conization

521: One of every four patients with an asymptomatic short cervix (15mm) has subclinical intra-amniotic inflammation: implications for patient counseling and management

The clinical management of a patient with a sonographic short cervix is a common obstetrical challenge. A fraction of patients with a short cervix have evidence of intra-amniotic inflammation (Kiefer, AJOG, 2009); however, the outcome of these patients has not been characterized. The purpose of this study was to determine the frequency and clinical significance of intra-amniotic inflammation in asymptomatic women in the mid-trimester of pregnancy with a sonographic short cervix.

Cancer and pregnancy: parallels in growth, invasion, and immune modulation and implications for cancer therapeutic agents.

Many proliferative, invasive, and immune tolerance mechanisms that support normal human pregnancy are also exploited by malignancies to establish a nutrient supply and evade or edit the host immune response. In addition to the shared capacity for invading through normal tissues, both cancer cells and cells of the developing placenta create a microenvironment supportive of both immunologic privilege and angiogenesis. Systemic alterations in immunity are also detectable, particularly with respect to a helper T cell type 2 polarization evident in advanced cancers and midtrimester pregnancy. This review summarizes the similarities between growth and immune privilege in cancer and pregnancy and identifies areas for further investigation. Our PubMed search strategy included combinations of terms such as immune tolerance, pregnancy, cancer, cytokines, angiogenesis, and invasion. We did not place any restrictions on publication dates. The knowledge gained from analyzing similarities and differences between the physiologic state of pregnancy and the pathologic state of cancer could lead to identification of new potential targets for cancer therapeutic agents.

Laparoscopic Adnexal Surgery in the Mid-Trimester of Pregnancy: Usage of Harmonic Scalpel and Left Upper Quadrant Approach

Laparoscopic Adnexal Surgery in the Mid-Trimester of Pregnancy: Usage of Harmonic Scalpel and Left Upper Quadrant Approach

Amniotic Fluid Index Accuracy in Mid-Trimester

Objective: The aim of this trial was to evaluate the correlation between amniotic fluid index (AFI) and the real amniotic volume in mid-trimester pregnancies. Methods: Eight women with mid-trimester anhydramnios pregnancies were included. Patients gave their informed consent. Those with premature rupture of membranes were excluded. Amnioinfusion was performed by instilling up to 400 ml of saline solution in 100 ml aliquots. With the patient in supine position, the AFI was determined by the sum of measurements of the deepest vertical pools in each of the 4 quadrants of the maternal uterus, evaluating the AFI after every 100 ml of infused solution. Statistical analysis was performed by analysis of variance, determination coefficient, linear correlation and t test. Results: We realized 29 AFI measurements after amnioinfusions of 100, 200, 300 and 400 ml of saline solution. The AFI ranges that corresponded to the infused volume were: after 100 ml = 5–11 cm (median 6.5 cm); after 200 ml = 9–12.7 cm (median 10.3 cm); after 300 ml = 10–17 cm (median 13.5 cm), and after 400 ml = 12–16 cm (median 15 cm). The correlation between the AFI and the volume infused was r = 0.81 (p < 0.0001), the variance was r² = 0.65, suggesting that 65% of the variation in AFI measurements is directly accounted for by the amniotic fluid volume and 35% of the AFI measurements is accounted for by factors other than amniotic volume. Conclusions: We obtained a strong correlation between AFI and amnioinfusion volume (median of 6.5, 10.3, 13.5 and 15 cm after amniotic infusion of 100, 200, 300 and 400 ml of saline solution, respectively). The variance (0.65) suggests that 35% of AFI measurements is accounted for by factors other than amniotic fluid volume.

Entero-utero-vaginal fistula: a rare complication of unsafe abortion

Background: Pregnancy whether wanted or not poses significant risks for women especially in developing countries with wide spread ignorance, poverty and limited facilities. Unsafe abortion exposes them to increased morbidity and mortality. Aim: To report a case of entero-utero-vaginal fistula in a teenager following unsafe abortion. Setting: University of Port Harcourt Teaching Hospital , Port Harcourt. Case report: A 17-year-old secondary school girl who terminated a mid trimester pregnancy with unskilled health providers is presented. Her uterus and a loop of small bowel were perforated leading to leakage of faeces through the uterus and vagina. She had a laparotomy for the repair of the perforated uterus and resection and end-to-end anastomosis of the damaged small bowel. She was discharged in a satisfactory state but with enormous social and financial post abortion care. Conclusion: This case highlights the need for continued emphasis on preventing unsafe abortion, abstinence, contraceptive services and access to safe abortion. Key words: Unsafe abortion, Entero-utero-vaginal fistula

TERMINATION OF PREGNANCY

O b j e c t i v e : To compare the efficacy of vaginal misoprostal with that of sublingual misoprostol in 2n d trimester of pregnancyby comparing the induction-expulsion interval between two groups of patients induced with vaginal and sublingual misoprostol. S t u dyd e s i g n : Interventional, quasi experimental study. Settings: Obstetrics &amp; Gynaecology Unit 1, Sir Ganga Ram Hospital, Lahore. Durationof s t u d y : Thirteen months from October 2006 to November 2007. S u b j e c t s a n d M e t h o d s : Sixty women at 12-26 weeks of gestation whichwere selected for termination of pregnancy were assigned into two groups. Thirty women received sublingual misoprostol and thirty womenreceived vaginal misoprostol. Dosage regimen was tablet Misoprostol 200fjg 4 hours apart till expulsion of fetus (maximum 5 doses). Mainoutcome measures were: 1. Induction-expulsion intervals 2. Maternal side effects 3. Fever 4. Nausea/vomiting 5.Diarrhea. R e s u l t s : Meaninduction-expulsion interval in vaginal group was 11.8±8.3 hours and in the sublingual group was 12.8±8.5 hours. Percentage of completeexpulsion was 53.3% in both groups. Cases of failed induction in vaginal group were 10% and in sublingual group were 13.3%. One case(3.3%) of fever and two cases (6.6%) of vomiting were observed in sublingual group and one case (3.3%) of vomiting was observed invaginal group. C o n c l u s i o n : Both routes appear to be equally efficacious for mid trimester pregnancy termination, without significant sideeffects.

Gelsolin down-regulates lipopolysaccharide-induced intraamniotic tumor necrosis factor-α production in the midtrimester of pregnancy

The purpose of this study was to identify gelsolin in midtrimester amniotic fluid and evaluate its interaction with lipopolysaccharide (LPS). Supernatants from 40 midtrimester amniotic fluid samples were incubated with Escherichia coli LPS, and gelsolin binding was measured by enzyme-linked immunosorbent assay. Unfractionated aliquots of 25 of the fluids were cultured ex vivo for 24 hours in the presence of LPS and supernatants tested for tumor necrosis factor (TNF)-alpha and interleukin (IL)-10 production, and the influence of antigelsolin antibody was evaluated. Each amniotic fluid was positive for gelsolin that bound to LPS. LPS-induced TNF-alpha production was inversely proportional to the amniotic fluid concentrations of LPS-bound gelsolin (r = -0.5047; P = .006). Preincubation with monoclonal antibody to gelsolin led to an increase in LPS-induced TNF-alpha production (P = .01). There was no relationship between gelsolin and IL-10 production. Gelsolin is present in midtrimester amniotic fluid, binds to LPS, and inhibits the induction of TNF-alpha.

Management der drohenden Frühgeburt ohne vorzeitigen Blasensprung

The frequency of preterm birth has increased markedly during the past two decades. Preterm births are responsible for more than 75 % of all neonatal deaths. There is general agreement that expectative management is recommended between the 24th and 34th weeks of gestation to reduce neonatal morbidity and mortality. Tocolytic therapy with beta-agonists, atosiban or calcium channel blockers succeeds in prolonging pregnancy for at least 48 hours in 90 % of cases; however, sufficient data is not available to date which would confirm the efficacy of maintenance tocolysis. The primary aims of tocolytic therapy are to allow the administration of a complete course of antepartal glucocorticosteroids in order to achieve foetal lung maturation and to arrange in utero transfer to a specialised perinatal centre. There is good evidence suggesting that antenatal application of glucocorticosteroids, mainly betamethasone, leads to a significant reduction in neonatal morbidity and mortality. At present, repeat dose(s) of glucocorticosteroids cannot be recommended for routine practice. The prophylactic administration of antibiotics is not indicated in cases of threatened preterm labour without rupture of the membranes. Symptomatic bacterial infections, such as bacterial vaginosis, should be treated as early as possible during pregnancy. Commonly used strategies such as bed rest, hydration or sedation are not evidence-based measures. Cervical cerclage is still a matter of debate in the current literature. An elective cerclage should be offered to patients with a history of ≥ 3 unexplained midtrimester pregnancy losses or preterm deliveries. Midtrimester transvaginal ultrasonography to measure the cervical length is an effective way of identifying pregnant women at high risk for preterm birth. Therapeutic cerclage in patients with previous second trimester abortions/preterm birth(s) and presenting a cervical length < 2.5 cm significantly reduces the risk of later preterm birth and non-significantly the rate of perinatal mortality. Recent studies have confirmed the beneficial effect of progesterone to prevent recurrent preterm birth (vaginal progesterone 100 mg daily or 250 mg of 17-alpha-hydroxyprogesterone caproate weekly). The efficacy of prophylactic progesterone application in different high-risk populations is currently under investigation.

Protein Nitration in Placenta – Functional Significance

Crucial roles of the placenta are disrupted in early and mid-trimester pregnancy loss, preeclampsia, eclampsia and intrauterine growth restriction. The pathophysiology of these disorders includes a relative hypoxia of the placenta, ischemia/reperfusion injury, an inflammatory response and oxidative stress. Reactive oxygen species including nitric oxide (NO), carbon monoxide and superoxide have been shown to participate in trophoblast invasion, regulation of placental vascular reactivity and other events. Superoxide, which regulates expression of redox sensitive genes, has been implicated in up-regulation of transcription factors, antioxidant production, angiogenesis, proliferation and matrix remodeling. When superoxide and nitric oxide are present in abundance, their interaction yields peroxynitrite a potent pro-oxidant, but also alters levels of nitric oxide, which in turn affect physiological functions. The peroxynitrite anion is extremely unstable thus evidence of its formation in vivo has been indirect via the occurrence of nitrated moieties including nitrated lipids and nitrotyrosine residues in proteins. Formation of 3-nitrotyrosine (protein nitration) is a “molecular fingerprint” of peroxynitrite formation. Protein nitration has been widely reported in a number of pathological states associated with inflammation but is reported to occur in normal physiology and is thought of as a prevalent, functionally relevant post-translational modification of proteins. Nitration of proteins can give either no effect, a gain or a loss of function. Nitration of a range of placental proteins is found in normal pregnancy but increased in pathologic pregnancies. Evidence is presented for nitration of placental signal transduction enzymes and transporters. The targets and extent of nitration of enzymes, receptors, transporters and structural proteins may markedly influence placental cellular function in both physiologic and pathologic settings.

Transperineal versus transvaginal sonographic cervical length measurement in second‐ and third‐trimester pregnancies

To investigate the reliability of, and patient satisfaction with, transperineal cervical length measurement during the third trimester of pregnancy and to compare these with measurement during the mid-trimester, using transvaginal sonographic imaging of the cervix as a reference. Women attending an outpatient clinic for cervical length measurement before 29 weeks or after 35 weeks of gestation were examined by transvaginal and transperineal ultrasound and the results compared. Preference for either method was indicated by both sonographers and patients. Seventy-one patients participated in the study, 23 in the second and 48 in the third trimester of pregnancy. There was failure to obtain a clear image on transperineal ultrasound in 30% of mid-trimester pregnancies, and in 19% of third-trimester cases. Elevation of the patient's hips improved the image in five out of 10 women in whom the scan was repeated following a postural change. Transvaginal cervical length measurements could be obtained in all cases. There was a strong correlation between transvaginal and transperineal measured cervical length (Pearson's correlation coefficient = 0.85). Sonographers preferred transvaginal images of the cervix irrespective of whether they were obtained in the second or third trimester. Transperineal ultrasound was judged as not or mildly painful by most women, but transvaginal ultrasound was preferred. Transvaginal ultrasound is the least painful, most feasible, and probably most accurate method with which to measure cervical length in the third trimester of pregnancy. Transperineal ultrasound is a feasible alternative, although its application in clinical practice is restricted by the need for an experienced sonographer.

Uterine electrical activity and cervical shortening in the midtrimester of pregnancy

Objective: To determine whether a correlation exists between increased uterine electrical activity and cervical length (CL) in the midtrimester of pregnancy. Method: In this case-control study, 312 asymptomatic nulliparous women underwent both uterine electromyographic assessment and ultrasound CL measurement between the 16th and 23rd weeks of a singleton pregnancy. The outcome measure was the difference in ultrasound CL measurement between the women found to have uterine action potentials on electromyography and those who did not. Results: Action potentials were detected in 66 (21.1%) of the 312 women; and compared with the remainder of the study population, cervical length was significantly shorter in these women (35.7 ± 8.9 mm vs 38.8 ± 7.9 mm; P < 0.01 by the Mann-Whitney test). Conclusion: Ultrasound CL measurement in the midtrimester was significantly shorter in women with increased uterine electrical activity.

Inflammation in Pregnancy: Its Roles in Reproductive Physiology, Obstetrical Complications, and Fetal Injury

Fetal development and growth occur in a sterile amniotic cavity while first exposure to microorganisms happens at birth. However, at least 25% of all preterm births, the leading cause of perinatal morbidity and mortality worldwide, occur in mothers with microbial invasion of the amniotic cavity. Microbial attack of the fetus takes place in approximately 10% of pregnancies with intra-amniotic infection, and the human fetus is capable of deploying an inflammatory response (cellular and humoral) in the mid-trimester of pregnancy. The onset of premature labor in the context of infection is mediated by pro-inflammatory cytokines, such as interleukin (IL)-1beta and tumor necrosis factor alpha (TNF-alpha), as these cytokines are produced by intrauterine tissues in response to microbial products, can stimulate prostaglandin production, and induce labor in animals. Moreover, knockout experiments suggest that infection is less likely to lead to premature labor when the IL-1 and TNF signaling pathways are disrupted. A fetal inflammatory systemic response occurs in a fraction of fetuses exposed to microorganisms in utero, and is associated with the impending onset of labor as well as multisystem organ involvement. Neonates born with funisitis, the histologic marker of such inflammation, are at increased risk for neurologic handicap and cerebral palsy. Evidence has begun to accumulate that gene-environment interactions determine the likelihood of preterm labor and delivery and, probably, the risk of fetal injury. Fetal inflammation has emerged as a major mechanism of disease responsible for complications in the perinatal period (in utero and in the first 28 days of life), as well as in infancy. Moreover, reprogramming of the fetal immune response may predispose to diseases in adulthood.

Long-term sequelae of abdominal cervical cerclage and a minimally invasive approach to resolution

Cervical incompetence is diagnosed in 0.1–1% of all pregnancies and in 8% of women with repeated mid-trimester pregnancy loss. This condition may be managed by the application of a suture around the cervix, placed vaginally, abdominally, or laparoscopically. The case histories of two patients are presented, both of whom had abdominal cervical cerclage applied via laparotomy 4 and 6 years previously. Counselling and decision making processes are discussed, and the operative reports of the successful laparoscopic total removal of the cervical sutures are described. Published cases of laparoscopic cerclage removal are rare; indeed only four cases have been recorded. Three of these involved the removal of the suture after a very short period of time (5–7 weeks) with one further report of a partial removal being achieved laparoscopically. We have described successful laparoscopic total removal of two abdominally placed cervical sutures that had been in-situ for a prolonged period of time. In a unit with skilled laparoscopic surgeons and high-risk obstetricians, the potential for laparoscopic insertion and removal of abdominal cervical sutures exists.

Evidence of the involvement of caspase-1 under physiologic and pathologic cellular stress during human pregnancy: A link between the inflammasome and parturition

Objective. Caspase-1 is a component of the NALP3 inflammasome, a cytosolic multiprotein complex that mediates the processing of pro-inflammatory caspases and cytokines. The inflammasome represents the first line of defense against cellular stress and is a crucial component of innate immunity. Caspase-1 is the enzyme responsible for the cleavage and activation of interleukin (IL)-1β, which is a potent pro-inflammatory cytokine, and plays a central role in the mechanisms leading to labor (preterm and term) particularly in the context of intrauterine infection/inflammation. In addition, caspase-1 cleaves IL-18 and IL-33. The objectives of this study were to determine whether there is a relationship between amniotic fluid concentrations of caspase-1 and gestational age, parturition (term and preterm), and intra-amniotic infection/inflammation (IAI).Study design. A cross-sectional study was conducted including 143 pregnant women in the following groups: (1) mid-trimester of pregnancy (n = 18); (2) term not in labor (n = 25); (3) term in labor (n = 28); (4) preterm labor (PTL) who delivered at term (n = 23); (5) PTL without IAI who delivered preterm (n = 32); (6) PTL with IAI who delivered preterm neonates (n = 17). Caspase-1 concentrations in amniotic fluid were determined by a specific and sensitive immunoassay. Non-parametric statistics were used for analysis.Results. (1) Caspase-1 was detected in amniotic fluid of women at term, but in none of the mid-trimester samples. (2) Patients in labor at term had a significantly higher median amniotic fluid concentration of caspase-1 than women at term not in labor (term in labor: 10.5 pg/mL, range 0.0–666.0 vs. term not in labor: 5.99 pg/mL, range 0.0–237.4; p < 0.05). (3) Among patients with spontaneous PTL, those with IAI (median 41.4 pg/mL, range 0.0–515.0) had a significantly higher median amniotic fluid caspase-1 concentration than those without IAI who delivered preterm (median 0.0 pg/mL, range 0.0–78.4) and than those who delivered at term (median 0.0 pg/mL, range 0.0–199.5); p < 0.001 for both comparisons.Conclusions. (1) The presence and concentration of caspase-1 in the amniotic fluid varies as a function of gestational age. (2) Women with spontaneous labor at term had a higher median caspase-1 amniotic fluid concentration than women at term without labor. This suggests that the inflammasome may be activated in spontaneous parturition at term. Since most women with labor do not have intra-amniotic infection, we propose that cellular stress during labor accounts for activation of the inflammasome. (3) Preterm labor associated with infection/inflammation was also associated with a high concentration of caspase-1, suggesting that infection may induce caspase-1 production and activation of the inflammasome. (4) The sequential activation of the inflammasome and caspase-1, leading to interleukin-1β processing and secretion, is a candidate pathway leading to the activation of the common pathway of parturition.