Spontaneous Mid-trimester Abortion Research Articles

Evidence that antibiotic administration is effective in the treatment of a subset of patients with intra-amniotic infection/inflammation presenting with cervical insufficiency

Cervical insufficiency is a risk factor for spontaneous midtrimester abortion or early preterm birth. Intra-amniotic infection has been reported in 8-52% of such patients and intra-amniotic inflammation in 81%. Some professional organizations have recommended perioperative antibiotic treatment when emergency cervical cerclage is performed. The use of prophylactic antibiotics is predicated largely on the basis that they reduce the rate of complications during the course of vaginal surgery. However, it is possible that antibiotic administration can also eradicate intra-amniotic infection/inflammation and improve pregnancy outcome. To describe the outcome of antibiotic treatment in patients with cervical insufficiency and intra-amniotic infection/inflammation. The study population consisted of 22 women who met the following criteria: (1) singleton pregnancy; (2) painless cervical dilatation of >1 cm between 16.0 and 27.9 weeks of gestation; (3) intact membranes and absence of uterine contractions; (4) transabdominal amniocentesis performed for the evaluation of the microbiologic and inflammatory status of the amniotic cavity; (5) presence of intra-amniotic infection/inflammation; and (6) antibiotic treatment (regimen consisted of ceftriaxone, clarithromycin, and metronidazole). Amniotic fluid was cultured for aerobic and anaerobic bacteria and genital mycoplasmas, and polymerase chain reaction for Ureaplasma spp. was performed. Intra-amniotic infection was defined as a positive amniotic fluid culture for microorganisms or a positive polymerase chain reaction for Ureaplasma spp., and intra-amniotic inflammation was suspected when there was an elevated amniotic fluid white blood cell count (≥19 cells/mm3) or a positive rapid test for metalloproteinase-8 (sensitivity 10 ng/mL). For the purpose of this study, the "gold standard" for diagnosis of intra-amniotic inflammation was an elevated interleukin-6 concentration (>2.6 ng/mL) using an enzyme-linked immunosorbent assay. The results of amniotic fluid interleukin-6 were not available to managing clinicians. Follow-up amniocentesis was routinely offered to monitor the microbiologic and inflammatory status of the amniotic cavity and fetal lung maturity. Treatment success was defined as resolution of intra-amniotic infection/inflammation or delivery ≥34 weeks of gestation. Of 22 patients with cervical insufficiency and intra-amniotic infection/inflammation, 3 (14%) had microorganisms in the amniotic fluid. Of the 22 patients, 6 (27%) delivered within 1 week of amniocentesis and the remaining 16 (73%) delivered more than 1 week after the diagnostic procedure. Among these, 12 had a repeat amniocentesis to assess the microbial and inflammatory status of the amniotic cavity; in 75% (9/12), there was objective evidence of resolution of intra-amniotic inflammation or intra-amniotic infection demonstrated by analysis of amniotic fluid at the time of the repeat amniocentesis. Of the 4 patients who did not have a follow-up amniocentesis, all delivered ≥34 weeks, 2 of them at term; thus, treatment success occurred in 59% (13/22) of cases. In patients with cervical insufficiency and intra-amniotic infection/inflammation, administration of antibiotics (ceftriaxone, clarithromycin, and metronidazole) was followed by resolution of the intra-amniotic inflammatory process or intra-amniotic infection in 75% of patients and was associated with treatment success in about 60% of cases.

Chronic Uterine Inversion Following Mid-Trimester Abortion.

Uterine inversion during the postpartum period is a relatively rare but serious complication. It occurs as acute, chronic and subacute forms depending on time interval from delivery. In terms of onset of the inversion, acute describes the event occurring before cervical ring contraction. If the cervical ring has contracted, a subacute inversion has occurred. The inversion is classified as chronic if 4 weeks have elapsed after the event. Severe postpartum hemorrhage and shock result from the uterine inversion. If unrecognized, this obstetric emergency could cause serious morbidity or death. The reported incidence of uterine inversion varies considerably in the literature. Treatment options for this obstetric complication also vary from patient to patient and depend upon surgeon’s familiarity with the procedure. Available options for correcting an inversion are hydrostatic as well as manual and surgical reposition with or without pharmacological agents (uterine relaxants). Here is a case report of complete chronic uterine inversion following spontaneous mid-trimester abortion.

Placental lesions associated with acute atherosis

Objective: Acute atherosis is a lesion of the spiral arteries characterized by fibrinoid necrosis of the vessel wall, an accumulation of fat-containing macrophages, and a mononuclear perivascular infiltrate, which can be found in patients with preeclampsia, fetal death, small-for-gestational age, spontaneous preterm labor/premature prelabor rupture of membrane, and spontaneous mid-trimester abortion. This lesion is thought to decrease blood flow to the intervillous space which may lead to other vascular lesions of the placenta. The objective of this study was to test whether there is an association between acute atherosis and placental lesions that are consistent with maternal vascular underperfusion (MVU), amniotic fluid infection (AFI), fetal vascular thrombo-occlusive disease (FVTOD) or chronic inflammation.Material and methods: A retrospective cohort study of pregnant women who delivered between July 1998 and July 2014 at Hutzel Women’s Hospital/Detroit Medical Center was conducted examine 16 457 placentas. The frequency of placenta lesions (diagnosed using the criteria of the Perinatal Section of the Society for Pediatric Pathology) was compared between pregnancies with and without acute atherosis.Results: Among 16 457 women who were enrolled, 10.2% (1671/16 457) were excluded, leaving 14 786 women who contributed data for analysis. Among them, the prevalence of acute atherosis was 2.2% (326/14 786). Women with acute atherosis were more than six times as likely as those without to have placental lesions consistent with maternal underperfusion (adjusted odds ratio – aOR: 6.7; 95% CI 5.2–8.6). To a lesser degree, acute atherosis was also associated with greater risks of having either lesions consistent with FVTOD (aOR 1.7; 95% CI 1.2–2.3) or chronic chorioamnionitis (aOR 1.9; 95% CI 1.3–3), but not with other chronic inflammatory lesions, after adjusting for gestational age at delivery. In contrast, women with acute atherosis were 60% less likely to have lesions consistent with AFI, adjusting for gestational age at delivery (aOR 0.4; 95% CI 0.3–0.5).Conclusions: Acute atherosis is associated with increased risks of having placental lesions consistent with MVU, and to a lesser extent, chronic chorioamnionitis and those consistent with FVTOD.

Cervico-vaginal fistula and spontaneous mid-trimester abortion

An unusual complication of spontaneous second trimester abortion which was unaided by external agents is presented. We found no similar case in the literature.

Some Observations of Levels of Plasma Cholinesterase Activity Within an Obstetric Population

Summary An account of plasma cholinesterase activity in samples of maternal and cord blood is presented. It is confirmed that plasma exchange markedly reduces the level of activity in maternal blood, and that the level is further reduced during the first 3–4 postnatal days. A particularly marked decrease was found in those cases in which spontaneous mid-trimester abortion occurred. The level of activity in maternal blood (excluding mothers subjected to plasma exchange) at the time of delivery, was higher than that in cord blood in 61% of cases. In 23% of cases the level of activity was appreciably (0.05 units) higher in cord blood, and two-thirds of these cord samples contained the E2+ electrophoretic variant of plasma cholinesterase. The mean levels of activity in maternal and cord blood of Rhesus negative patients were significantly lower than those among Rhesus positive patients but there was no such distinction between Rhesus positive and Rhesus negative males and nonpregnant females. We encountered an incidence of 1:228 abnormal phenotypes in a series of 1593 mothers who underwent Caesarean section under a technique of general anaesthesia which included a suxamethonium infusion. However, probably only two of the seven patients would definitely be sensitive when not pregnant.

Some observations of levels of plasma cholinesterase activity within an obstetric population.

An account of plasma cholinesterase activity in samples of maternal and cord blood is presented. It is confirmed that plasma exchange markedly reduces the level of activity in maternal blood, and that the level is further reduced during the first 3-4 postnatal days. A particularly marked decrease was found in those cases in which spontaneous mid-trimester abortion occurred. The level of activity in maternal blood (excluding mothers subjected to plasma exchange) at the time of delivery, was higher than that in cord blood in 61% of cases. In 23% of cases the level of activity was appreciably (0.05 units) higher in cord blood, and two-thirds of these cord samples contained the E2+ electrophoretic variant of plasma cholinesterase. The mean levels of activity in maternal and cord blood of Rhesus negative patients were significantly lower than those among Rhesus positive patients but there was no such distinction between Rhesus positive and Rhesus negative males and nonpregnant females. We encountered an incidence of 1:228 abnormal phenotypes in a series of 1593 mothers who underwent Caesarean section under a technique of general anaesthesia which included a suxamethonium infusion. However, probably only two of the seven patients would definitely be sensitive when not pregnant.

Cervical resistance in patients with previous spontaneous mid-trimester abortion.

Summary. The Cervical Resistance Index (CRI) was measured in 20 patients with a history of previous spontaneous midtrimester abortion. The mean CRI was 2.44±0.78 in patients with a history suggestive of cervical incompetence and 4.91±0.41 in 102 patients who were parous women with normal menstrual cycles. This new procedure which is used in the non‐pregnant state provides an additional method for diagnosis of cervical incompetence.

Pregnancy following conization of the cervix: Complications related to cone size

A retrospective study of 88 pregnancies occurring in 77 patients after cervical conization was undertaken to compare pregnancy outcome with cone size. Cone specimens were divided into two groups. Those measuring less than 2 cm in height or less than 4 cc in volume were considered to be “small cones” and those greater than 2 cm in height or 4 cc in volume were regarded as “large cones”. The over-all normal term vaginal delivery rate was 46.6%, and was found to be inversely proportional to the size of the cone. The incidence of both spontaneous midtrimester abortion and prematurity increased in direct proportion to cone size. Cervical stenosis necessitating cesarean section was, however, noted to be a complication associated with small rather than large cones. It was concluded from this study that all postcone pregnancies should be regarded as high risk, preterm complications being particularly related to large cones.

Systemic Lupus Erythematosus Presenting as Post‐partum Chorea

A case of systemic lupus erythematosus (SLE) is reported in which chorea was the dominant clinical feature, and which presented following a spontaneous mid-trimester abortion. The diagnosis, natural history and management of this uncommon manifestation of CNS lupus is discussed, as well as the influence of pregnancy on disease activity in SLE.