Pregnancy-associated Complications Research Articles

Ectopic pregnancy morbidity and mortality in low-income women, 2004–2008

Does the risk of adverse outcomes at the time of ectopic pregnancy vary by race/ethnicity among women receiving Medicaid, the public health insurance program for low-income people in the USA? Among Medicaid beneficiaries with ectopic pregnancy, 11% experienced at least one complication, and women from all racial/ethnic minority groups were significantly more likely than whites to experience complications. In this population of Medicaid recipients, African American women are significantly more likely than whites to experience ectopic pregnancy, but the risk of adverse outcomes has not previously been assessed. We conducted a cross-sectional observational study of all women (n = 19 135 106) ages 15-44 enrolled in Medicaid for any amount of time during 2004-2008 who lived in one of the following 14 US states: Arizona; California; Colorado; Florida; Illinois; Indiana; Iowa; Louisiana; Massachusetts; Michigan; Minnesota; Mississippi; New York; and Texas. We analyzed Medicaid claims records for inpatient and outpatient encounters and identified ectopic pregnancies with a principal diagnosis code for ectopic pregnancy from 2004-2008. We calculated the ectopic pregnancy complication rate as the number of ectopic pregnancies with at least one complication (blood transfusion, hysterectomy, any sterilization, or length-of-stay (LOS) > 2 days) divided by the total number of ectopic pregnancies. We used Poisson regression to assess the risk of ectopic pregnancy complication by race/ethnicity. Secondary outcomes were each individual complication, and ectopic pregnancy-related death. We calculated the ectopic pregnancy mortality ratio as the number of deaths divided by live births. Ectopic pregnancy-associated complications occurred in 11% of cases. Controlling for age and state, the risk of any complication was significantly higher among women who were black (incidence risk ratio [IRR] 1.47, 95% CI 1.43-1.53, P < 0.0001), Hispanic (IRR 1.16, 95% CI 1.12-1.21, P < 0.0001), Asian (IRR 1.34, 95% CI 1.24-1.45, P < 0.0001), American Indian/Alaskan Native (IRR 1.34 95% CI 1.16-1.55, P < 0.0001), and Native Hawaiian/Pacific Islander (IRR 1.61, 95% CI 1.39-1.87, P < 0.0001) compared with white women. The ectopic pregnancy mortality ratio was 0.48 per 100 000 live births, similar to that reported in previous US surveillance. This is a secondary analysis of insurance claims. Among women at higher baseline risk of pregnancy complications due to their economic status, women from racial/ethnic minority groups face an additional risk of ectopic pregnancy adverse outcomes compared with whites. Systematic changes to reduce racial disparities are an essential part of improving maternal health in the USA. The Eunice Kennedy Shriver National Institute of Child Health and Human Development (1 K08 HD060663 to D.B.S.). The authors report no conflict of interest. Not applicable.

Cavernous hemangiomatous polyp of uterus: A report of case and review of literature

Cavernous hemangiomatous polyp of uterus is a rare vascular malformation of the uterus. Common sites of malformation in uterine wall include serosa, myometrium, and endometrium and most common presentation is diffuse involvement of uterus. Patients usually present with obstetric and gynecological complications ranging from menorrhagia, intermenstrual bleeding, infertility, and pregnancy-associated complications which includes maternal and fetal demise due to excessive bleeding. Uterine hemangiomas occur at all age groups without preponderance in any decades and are classified into congenital and acquired. Congenital hemangiomas may be associated with hereditary diseases whereas acquired hemangiomas are thought to be associated with both physical changes and hormone alterations.

Guía de práctica clínica para la prevención, detección temprana y tratamiento de las complicaciones del embarazo, parto y puerperio: sección 3. Infecciones en el embarazo: ruptura prematura de membranas (RPM)

&lt;p&gt;Objetivo: realizar recomendaciones para la atención del embarazo con ruptura prematura de membranas como parte integral de la Guía de Práctica Clínica (GPC) para la prevención, detección temprana y tratamiento de las complicaciones del embarazo en Colombia.&lt;/p&gt;&lt;p&gt;Materiales y métodos:el grupo desarrollador de la Guía (GDG) elaboró esta GPC durante 2011-2012, acorde con la Guía Metodológica para la elaboración de Guías de Atención Integral en el Sistema General de Seguridad Social en Salud Colombiano, basándose en la evidencia científica disponible y sumando la participación activa de grupos de pacientes, sociedades científicas y grupos de interés. En particular, la evidencia de esta sección fue adaptada de la GPC “Preterm prelabour rupture of membranes” (Royal Collegue of Obstetrics and Gynecology-2006) y actualizada por medio de procedimientos sistemáticos, tanto para la búsqueda y valoración de la evidencia como para la generación de recomendaciones. El nivel de evidencia y la fuerza de las recomendaciones fueron expresadas por medio del sistema del Scottish Intercollegiate Guidelines Network (SIGN).&lt;/p&gt;&lt;p&gt;Resultados: se presentan las recomendaciones para la atención de los embarazos con ruptura prematura de membranas. Estas incluyen cambios en la conducta del personal de salud y las instituciones para aumentar la probabilidad de obtener un resultado materno fetal exitoso en las gestaciones con esta complicación.&lt;/p&gt;&lt;p&gt;Conclusiones: se presenta una versión resumida de las recomendaciones y evidencia de esta sección, que se espera sea adoptada por los profesionales de salud encargados de la atención del embarazo en el país para disminuir la morbilidad y mortalidad asociada a la gestación.&lt;/p&gt;

Abstract 11940: Aortic Complications Associated With Pregnancy in Marfan Syndrome: The NHLBI GenTAC Registry

Background: Definition of pregnancy risk in women with Marfan syndrome (MFS) has been confounded by ascertainment bias, lack of imaging data, small sample size, and inclusion of women without a known MFS diagnosis before a pregnancy complication. To lessen these limitations, we analyzed MFS women participating in the large GenTAC Registry. Results: Among 184 women in whom pregnancy information was available, 94 women (51%) had a total of 227 pregnancies (average 2.5, range 1-6). Compared to MFS women who never became pregnant, those with pregnancies were older at time of MFS diagnosis (27 vs. 13 years, p&lt;0.0001) and at time of GenTAC enrollment (47 vs. 37 years, p&lt;0.0001). When comparing ever-pregnant to never-pregnant women with MFS at the time of registry entry, higher historical rates of aortic dissection and prophylactic proximal aortic surgery were observed (24/94 [25.5%] vs. 13/90 [14.4%], p=0.068 and 15/94 [16.0%] vs. 4/90 [4.4%], p=0.014; respectively). Among the 94 MFS women with pregnancies, 10 (10.6%) experienced a pregnancy-related aortic complication (4 Type A and 3 Type B dissections, one coronary artery dissection, and 2 with significant [≥3 mm] aortic growth, 1 of whom required post-partum prophylactic surgery). Four of the aortic dissections, including all 3 Type B, and the coronary dissection occurred in the post-partum period. Only 3 of 7 women (43%) with an aortic dissection related to pregnancy were aware of their MFS diagnosis before pregnancy. Women with and without pregnancy-associated aortic complications did not differ in phenotypic features. The rate of aortic dissection was higher during pregnancy + post-partum period (3.5 per 100 person-years vs. 0.8 per 100 person-years, odds ratio 4.6 [95% confidence interval 2.1-10.1], p=0.0002). Conclusions: Pregnancy in MFS is associated with an increased risk of aortic dissection, both Types A and B, particularly in the immediate post-partum period, and more frequent prophylactic surgery. Lack of knowledge of underlying MFS diagnosis before aortic dissection is a major contributing factor. These findings underscore the need for early diagnosis, pre-pregnancy risk counselling, and multi-disciplinary peri-partum management.

Inflammation and preterm birth.

Preterm birth is the leading cause of neonatal morbidity and mortality. Although the underlying causes of pregnancy-associated complication are numerous, it is well established that infection and inflammation represent a highly significant risk factor in preterm birth. However, despite the clinical and public health significance, infectious agents, molecular trigger(s), and immune pathways underlying the pathogenesis of preterm birth remain underdefined and represent a major gap in knowledge. Here, we provide an overview of recent clinical and animal model data focused on the interplay between infection-driven inflammation and induction of preterm birth. Furthermore, here, we highlight the critical gaps in knowledge that warrant future investigations into the interplay between immune responses and induction of preterm birth.

Establishment of trimester-specific reference intervals for thyroid hormones in Korean pregnant women.

BackgroundEstablishment of trimester- and assay-specific reference intervals for every population is recommended. The aim of this study was to establish a trimester- and assay-specific reference interval for thyroid-stimulating hormone (TSH) and free thyroxine (FT4) in Korean pregnant women.MethodsFrom April 2012 to December 2012, 531 pregnant women receiving prenatal care and 238 age-matched, non-pregnant women were enrolled in this study. After excluding patients with pregnancy-associated complications or thyroid-specific autoantibody, 465 pregnant and 206 non-pregnant women were included. Non-parametric analysis (2.5-97.5th percentile) was performed to determine the reference interval. Levels of TSH and FT4 were determined by electrochemiluminescence immunoassay (Elecsys thyroid tests, Roche Diagnostics, Germany).ResultsThe TSH reference intervals were 0.01-4.10, 0.01-4.26, and 0.15-4.57 mIU/L for the first, second, and third trimester, respectively. From the first trimester to the third trimester, the median TSH levels showed a significantly increasing trend (P<0.0001). The FT4 reference intervals were 0.83-1.65, 0.71-1.22, and 0.65-1.13 ng/dL for the first, second, and third trimester, respectively, showing a significantly decreasing trend (P<0.0001).ConclusionsEstablishing trimester-specific reference intervals in pregnant women is essential for accurate assessment of thyroid function. Our population-specific and method-specific reference intervals will be useful for screening Korean pregnant women for thyroid disease.

The investigation of hereditary and acquired thrombophilia risk factors in the development of complications in pregnancy in Croatian women

Objectives: To investigate the genetic and acquired thrombophilic risk factors in pregnancy-associated complications and venous thromboembolism (VTE) and evaluate the association between particular thrombophilic risk factors and thromboembolic complications.Methods: In this study, pregnant women with pregnancy complications and VTE (N = 101) were the study group, and the control group were women with normal pregnancy (N = 102). All women underwent testing for factor V Leiden mutation (FVL), mutation of the coagulation factors II (FII20210), methylenetetrahydrofolate reductase (MTHFR), plasminogen activator inhibitor-1, antithrombin III (ATIII), protein C (PC) and protein S, lupus anticoagulant (LAC) antibodies, anticardiolipin antibodies and anti-beta-2-glycoprotein-1.Results: In this study group, mutations of the FVL was 15.8% (16/101), FII20210 5.9% (6/101) and the MTHFR at locus 677 was TT in 19.8% (20/101). Deficiency of ATIII and PC were rare: 3.0% and 1.0%, respectively. LAC were significantly higher in the study group than in the control group: 32.7% versus 3.9%; p < 0.0005. Pregnant women with VTE have been more frequent for FVL (41.7%; p < 0.005), PC deficiency (25.0%; p < 0.005) and LAC (33.3%; p < 0.005). Combination of FVL and MTHFR mutation was related to the risk of recurrent fetal death and habitual abortion.Conclusion: The inherited and the acquired thrombophilic risk factors were found to be up to 10 times more common in the study group than in the control group.

Pregnancy-Associated Severe Sepsis: Contemporary State and Future Challenges.

Pregnancy is associated with an increased risk of infection related to its associated mechanical and physiological changes. Sepsis remains among the top causes of maternal death worldwide and is associated with substantial maternal morbidity. However, there are sparse data on pregnancy-associated severe sepsis (PASS), related in part to infrequent reports, varying case definitions and methodological approach, small cohort size, and often limited focus on severe sepsis in selected phases of pregnancy outcomes. Available reports vary, but indicate that PASS is a rare but likely increasing complication, and it is more likely to develop with increased maternal age, among minority women, the poor, those lacking health insurance, those with chronic illness or pregnancy-associated complications, and following invasive procedures. Obstetric sites of infection are the most prevalent, but non-obstetric infections often underlie pregnancy-associated severe sepsis, though the source of infection is often not readily apparent during initial care. Women with PASS can have a rapidly fatal course and require heightened clinician vigilance for early diagnosis and timely effective intervention. Nevertheless, available reports raise concerns about prevalent substandard care of these patients, contributing to adverse outcomes. The case fatality of PASS appears lower than that in the general population with severe sepsis, while the long-term outcomes of survivors remain unknown.Electronic supplementary materialThe online version of this article (doi:10.1007/s40121-014-0037-7) contains supplementary material, which is available to authorized users.

Effect of pregestational diabetes mellitus on first trimester placental characteristics: Three-dimensional placental volume and power Doppler indices

ObjectiveTo investigate whether pregestational diabetes mellitus (DM) induces changes in vascular placental development detectable at first trimester. MethodsThis was a prospective case–control study in 69 women with pregestational DM and 94 controls undergoing first-trimester combined screening for aneuploidies. Maternal characteristics, fetal nuchal translucency thickness, maternal serum pregnancy-associated plasma protein A (PAPP-A) and free β human chorionic gonadotrophin (β-hCG) were evaluated. Three-dimensional ultrasound was used to measure placental volume and three dimensional power Doppler (3D-PD) placental vascular indices including: vascularization index (VI), flow index (FI) and vascularization flow index (VFI). Pregnancy-associated hypertensive complications (PAHC) and perinatal outcomes were analyzed. The total group of diabetic women and the group of diabetic women without PAHC were compared separately with the control group. Results3D-PD placental vascular indexes were significantly lower in women with DM than in controls (VI p = 0.007, FI p = 0.003 and VFI p = 0.04). These differences remained on excluding cases with PAHC in the DM group. No differences were found in placental volumes between the DM group and controls. Serum PAPP-A levels were also lower in diabetic women (p < 0.02) and negatively correlated with the degree of maternal metabolic control at first trimester. ConclusionsPregestational DM induces demonstrable alterations in first trimester placental development, with significantly reduced placental vascularization indices and PAPP-A values. This effect is independent of the later development of PAHC.

Proteomics and Biological Systems: Application in Oxidative Stress, Nutrition and Prenatal Development

In biological systems, the genomic approach has emerged to provide a better understanding of the pathophysiological conditions leading to pregnancy-associated disorders and complications, thereby providing a perspective for improving prenatal development outcomes. Nevertheless, it is insufficient to accurately predict protein expression patterns and functions from quantitative messenger RNA [mRNA] due to post-transcriptional regulation mechanisms [mRNA export, surveillance, silencing and turnover] and post-translational modifications which can determine protein activity, localization, turnover and interactions with other proteins [1]. Therefore, investigations of steady-state mRNA expression can only partially predict protein abundances in mammalian cells [2]. In fact, mRNAs are less stable than proteins [3]. In addition, mRNAs are produced at a much lower rate than proteins [4].

Guía de Práctica Clínica para el abordaje de las complicaciones hipertensivas asociadas al embarazo

Objetivo: realizar recomendaciones para la atención de las complicaciones hipertensivas en el embarazo como parte integral de la “Guía de Práctica Clínica (GPC) para la prevención, detección temprana y tratamiento de las complicaciones del embarazo en Colombia”.Materiales y métodos: el grupo desarrollador de la Guía (GDG) elaboró esta GPC durante 2011-2012 acorde con la Guía Metodológica para la elaboración de Guías de Atención Integral en el Sistema General de Seguridad Social en Salud colombiano, basándose en la evidencia científica disponible y sumando la participación activa de grupos de pacientes, sociedades científicas y grupos de interés. En particular, la evidencia de esta sección fue adaptada de la GPC “Hypertension in pregnancy: the management of hypertensive disorders during pregnancy” (National Institute of Care and Health Excellence - NICE - 2010) y actualizada por medio de procedimientos sistemáticos, tanto para la búsqueda y valoración de la evidencia como para la generación de recomendaciones. El nivel de evidencia y la fuerza de las recomendaciones fueron expresados por medio del sistema del Scottish Intercollegiate Guidelines Network (SIGN).Resultados: se presentan las recomendaciones para la atención de las complicaciones hipertensivas en el embarazo. Estas incluyen cambios en la conducta del personal de salud y las instituciones para aumentar la probabilidad de obtener un resultado materno-fetal exitoso en las gestaciones con estas condiciones.Conclusiones: se presenta una versión resumida de las recomendaciones y evidencia para la atención de las complicaciones hipertensivas en el embarazo, la cual se espera sea adoptada por los profesionales de salud encargados de la atención del embarazo en el país para disminuir la morbilidad y mortalidad asociada a la gestación.

Comorbidities and Contraceptive Counseling Should Go Hand in Hand

Because maternal medical comorbidities portend pregnancy-associated complications, providing contraceptive counseling to women in suboptimal health is

Maternal and neonatal health outcomes following assisted reproduction

This study assessed the risk for maternal complications in women and neonatal outcomes in children conceived following assisted reproductive treatment as compared with spontaneously conception and also separately evaluated conventional IVF and intracytoplasmic sperm injection (ICSI). The prospective cohort included 1161 women with singleton pregnancies: 561 who conceived following assisted reproduction (223 following IVF and 338 following ICSI) and 600 who conceived spontaneously. No differences were observed in pregnancy complications (including spontaneous abortion, pregnancy-induced hypertension, gestational diabetes and Caesarean delivery) except for significantly increased risk for excess vaginal bleeding in assisted reproduction pregnancies (21.4% versus 12.9%; OR 1.67, 95% CI 1.18–2.37), which was prominent in women who reported polycystic ovary syndrome. Neonates born following assisted reproduction had increased risk for prematurity (10.6% versus 5.3%; OR 1.72, 95% CI 1.04–2.87), and IVF, but not ICSI, was associated with significantly increased risk for prematurity (OR 2.36, 95% CI 1.28–4.37) and low birthweight (OR 1.89, 95% CI 1.03–3.46). In conclusion, this study observed only an increased risk for excess vaginal bleeding as a pregnancy-associated complication in singleton pregnancies following assisted compared with spontaneous conception. However, singleton neonates born following IVF, but not ICSI, were at increased risk for prematurity.The current study evaluated the risk for maternal complications in women and outcomes of children conceived following assisted reproduction treatment as compared with spontaneously conceived pregnancies. In addition, conventional IVF and intracytoplasmic sperm injection (ICSI) were separately evaluated against spontaneously conceived pregnancies. The study cohort included 1161 women with singleton pregnancies: 561 who conceived following assisted reproduction (223 following IVF and 338 following ICSI) and 600 women who conceived spontaneously. No differences were observed in the risk for complications during pregnancy including spontaneous abortion, pregnancy-induced hypertension, gestational diabetes and Caesarean delivery, except for a significantly increased 1.6-fold risk for vaginal bleeding in assisted reproduction treatment. A 1.7-fold excess risk for prematurity was present in the assisted reproduction group. When the two assisted reproduction methods were compared separately with spontaneous conception, IVF cycles were associated with significantly increased risk for prematurity and low birthweight. However, no significantly increased risk was found in preterm birth or low birthweight following ICSI as compare to spontaneous conception. In conclusion, this study did not show increased risk of pregnancy-associated complications in singleton pregnancies following assisted reproduction compared with spontaneous pregnancies except for excess vaginal bleeding. However, singleton neonatals born following IVF, but not ICSI, were at increased risk for prematurity.

670: Obstructive sleep apnea in pregnancy: perinatal outcomes

were associated with increasing BMI. In the multivariate logistic regression, obese and morbidly obese women were 6 times more likely to develop hypertension, 4 times more likely to develop diabetes, and 2-4 times more likely to require a cesarean. Overweight women were at 1.5-1.8 times more likely to have these complications (Table). CONCLUSION: Pre-pregnancy increased BMI is a known risk factor for multiple pregnancy complications. Overweight and obese nulliparous patients may be at even higher risk than previously thought for significant complications such as hypertension, diabetes, and cesarean delivery. Effective interventions to reduce BMI before pregnancy, even in overweight women, are needed to decrease pregnancy-associated complications.

Pregnancy Outcomes in Women With Aortic Valve Substitutes

Young women who require aortic valve replacement need information on the potential cardiac and obstetric complications of pregnancy for the different valve substitutes available. We, therefore, assessed the pregnancy outcomes in women who had received an autograft, homograft, or mechanical valve in the aortic position. Women who were pregnant after surviving aortic valve replacement at our institution from 1987 to 2011 were included. Information on cardiac status and pregnancy outcome was obtained through the hospital medical records and by an extensive patient questionnaire. A total of 40 women experienced 67 pregnancies, of which 55 (82%) were completed pregnancies, 6 (9%) were miscarriages, and 6 (9%) were terminated. Of the 40 women, 18 (45%) had a pulmonary autograft, 13 (32%) a homograft, and 9 (23%) a mechanical valve. The mean age at the first pregnancy was 30.0 ± 5.7 years. No maternal mortality but 1 fetal death (1.8%) and 1 neonatal death (1.8%) occurred. Maternal cardiac complications developed in 13% and obstetric complications in 38% of the completed pregnancies. Heart failure (9%), arrhythmias (7%), hypertension-related disorders (7%), preterm delivery (24%), and small-for-gestational-age infants (15%) were most often encountered. Mechanical valve recipients had the greatest incidence of both cardiac and obstetric complications. In conclusion, pregnancy-associated complications after aortic valve replacement were common, and human tissue valves should be considered in the discussion for the optimal aortic valve substitute in a young woman. However, careful obstetric monitoring is mandatory.

Cerebral oxygen saturation evaluated by near‐infrared time‐resolved spectroscopy (TRS) in pregnant women during caesarean section – a promising new method of maternal monitoring

Time-resolved spectroscopy (TRS-20) measures tissue oxygen saturation (%) by evaluating the absolute concentrations of oxygenated, deoxygenated and total haemoglobin based on measurement of the transit time of individual photons through a tissue of interest. We measured tissue oxygen saturation in the prefrontal lobes of the brain by TRS-20 in eighteen pregnant women during caesarean section. In a case of placenta previa, massive bleeding immediately decreased cerebral oxygen saturation from 67·2% to 54·2%, but did not alter peripheral tissue oxygenation as measured by pulse oximetry. Four cases of pre-eclampsia revealed chronic changes in elevated base levels of cerebral oxygen saturation, though peripheral oxygen saturation was similar to that in normotensive pregnant women. Average cerebral oxygen saturation in the cases of pre-eclampsia before the introduction of anaesthesia was 73·6±4·4 (SD)% (n=4), significantly higher than in normotensive pregnant women, 67·2±4·3% (n=13, P<0·05). Z-scores of cerebral oxygen saturation prior to anaesthesia positively correlated with those of systolic or diastolic blood pressure. TRS-20 could detect acute as well as chronic changes in brain oxygen saturation in response to pregnancy-associated complications.

PP072. Features of intrarenal blood flow in patients with preeclampsia (PE)

The pregnancy-associated complication preeclampsia is a leading cause of maternal and fetal morbidity and mortality. The classical clinical manifestations of preeclampsia are elevated blood pressure and proteinuria due to renal damage. In severe cases of preeclampsia, the only effective treatment is delivery, irrespective of gestational age. To investigate renal perfusion in PE patients by ultrasound Doppler examination and to assess the possibility of strategy to identify renal blood flow changes to predict preeclampsia before the onset of disease. We studied 31 pregnant women of 21-46 years without renal disease: 19 PE (gr.1) and 12 volunteers (gr.2 ). PE was defined as a combination of proteinuria >0.3g/24h and blood pressure >140/90mmHg. We used Vivid7. We measured systolic (Vps), diastolic (Ved) velocities in renal and segmental arteries, and in at 5 pulse beats of interlobar and arcuate arteries. The resistance parameter (RI)=(Vps-Ved )/Vps. Table 1. The intrarenal blood flow in distal arteries. There was no difference in velocities and RI in renal and segmental arteries in both groups. We noted decrease of arterial and increase of the venous flow (color Doppler) of distal arteries in gr.1 seems to be a marker of renal ischaemia. All volunteers have the same parameters from signals of all pulse beats in one area - in arcuate and interlobar arteries. The RI in gr.1 varied in all distal arteries pulse beats in comparison with gr.2, where RI was identical. The "patchy" decreasing of RI suggests the presence of thromo-occlusive lesions leading to arteriovenous blood flow bypassing. The doppler ultrasonography may be used as a method of early diagnostic PE.

Delayed childbearing

The proportion of women who are intentionally delaying pregnancy beyond the age of 35 years has increased greatly in the past few decades because of the clash between the optimal biological period for women to have children with obtaining additional education and building a career. This article highlights the effects of delayed childbearing on fertility and obstetric and perinatal outcome. Demographic studies indicate that fertility rates are falling in many countries, Europe being the continent with lowest total fertility rate. Female employment and childrearing can be combined when the reduction in work-family conflict is facilitated by state of policy intervention. It has been traditionally accepted that fertility is more related to the age of the female than the male partner but recent literature suggests trends that increased paternal age is also associated with lower fertility, an increase in pregnancy-associated complications and an increase in adverse outcome in the offspring. Delayed childbearing is rarely a conscious choice and women are unaware that, at present, with the exception of egg donation, assisted reproductive technology has no answer yet to age-related decline of female fertility. There is no evidence of a beneficial effect of preimplantation genetic screening for women of advanced maternal age. Concerning perinatal outcomes, apart from the known effects of advanced maternal age on common fetal and obstetric complications, recent evidence increasingly points toward an independent association between maternal (and paternal age) and cerebral palsy, neurocognitive and psychiatric disorders. The consequences of advancing maternal and paternal age are not only relevant for the risk of natural and assisted conception, but also for the outcome of pregnancy. Although the absolute rate of poor pregnancy outcomes may be low from an individual standpoint, the impact of delaying childbearing from a public health perspective cannot be overestimated and should be in the agenda of public health policies for the years to come.

Uterine Hemangioma: A Rare Pathologic Entity

Uterine hemangioma is a rare benign tumor usually presenting with menorrhagia or pregnancy-associated complications. Although the current literature identifies fewer than 50 cases, we in our institution identified 5 similar cases among 3700 patients undergoing total hysterectomy from January 2006 to December 2010. Adenomyosis was the most common preoperative diagnosis among our patients. Vaginal examination, uterine curettage specimens, ultrasonography, and hysterography are usually uninformative, and the definitive diagnosis relies on the final histologic examination. The differential diagnosis includes adenomatoid tumor, lymphangioma, and arteriovenous malformation. Uterine hemangiomas are classified into congenital and acquired. The former is believed to be associated with some hereditary diseases, while the latter is associated with both physical changes and hormone alteration, especially high estrogen level. The best treatment for hemangiomas is unclear. However, it is very important to obtain an accurate diagnosis to prevent overtreatment among reproductive-age women. The prognosis is excellent after hysterectomy.

Circulating MicroRNA miR-323-3p as a Biomarker of Ectopic Pregnancy

The use of serum human chorionic gonadotropin (hCG) and progesterone to identify patients with ectopic pregnancy (EP) has been shown to have poor clinical utility. Pregnancy-associated circulating microRNAs (miRNAs) have been proposed as potential biomarkers for the diagnosis of pregnancy-associated complications. This proof-of-concept study examined the diagnostic accuracy of various miRNAs to detect EP in an emergency department (ED) setting. This study was a retrospective case-control analysis of 89 women who presented to the ED with vaginal bleeding and/or abdominal pain/cramping and received a diagnosis of viable intrauterine pregnancy (VIP), spontaneous abortion (SA), or EP. Serum hCG and progesterone concentrations were measured by immunoassays. The serum concentrations of miRNAs miR-323-3p, miR-517a, miR-519d, and miR-525-3p were measured with TaqMan real-time PCR. Statistical analysis was performed to determine the clinical utility of these biomarkers, both as single markers and as multimarker panels for EP. Concentrations of serum hCG, progesterone, miR-517a, miR-519d, and miR-525-3p were significantly lower in EP and SA cases than in VIP cases (P < 0.01). In contrast, the concentration of miR-323-3p was significantly increased in EP cases, compared with SA and VIP cases (P < 0.01). As a single marker, miR-323-3p had the highest sensitivity of 37.0% (at a fixed specificity of 90%). In comparison, the combined panel of hCG, progesterone, and miR-323-3p yielded the highest sensitivity (77.8%, at a fixed specificity of 90%). A stepwise analysis that used hCG first, added progesterone, and then added miR-323-3p yielded a 96.3% sensitivity and a 72.6% specificity. Pregnancy-associated miRNAs, especially miR-323-3p, added substantial diagnostic accuracy to a panel including hCG and progesterone for the diagnosis of EP.