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Background: Major depressive disorder and the use of serotonin reuptake inhibitors (SRIs) in pregnancy have been associated with preterm birth. Studies that have attempted to separate effects of illness from treatment have been inconclusive. We sought to explore the separate effects of SRI use and major depressive episodes in pregnancy on risk of preterm birth.Methods: We conducted a prospective cohort study of 2793 pregnant women, oversampled for a recent episode of major depression or use of an SRI. We extracted data on birth outcomes from hospital charts and used binary logistic regression to model preterm birth (<37 weeks' gestation). We used ordered logistic regression to model early (<34 weeks' gestation) or late (34-36 weeks) preterm birth, and we used nominal logistic regression to model preterm birth antecedents (spontaneous preterm labor/preterm premature rupture of membranes/preterm for medical indications/term).Results: Use of an SRI, both with (odds ratio = 2.1 [95% confidence interval = 1.0-4.6]) and without (1.6 [1.0-2.5]) a major depressive episode, was associated with preterm birth. A major depressive episode without SRI use (1.2 [0.68-2.1]) had no clear effect on preterm birth risk. None of these exposures was associated with early preterm birth. Use of SRIs in pregnancy was associated with increases in spontaneous but not medically indicated preterm birth.Conclusions: SRI use increased risk of preterm birth. Although the effect of a major depressive episode alone was unclear, symptomatic women undergoing antidepressant treatment had elevated risk. [ABSTRACT FROM AUTHOR]

Uterine fibroids (leiomyomas) are common in reproductive age women. Most women with fibroids have uneventful pregnancies. The most common complication is painful degeneration. Are fibroids associated with adverse pregnancy outcomes? If so, can we predict which fibroids are most likely to cause complications? And is there anything that can be done to prevent these complications, such as performing a myomectomy before pregnancy? Here we review the published literature looking at the impact of uterine fibroids on adverse pregnancy events, such as miscarriage, preterm labor, placental abruption, fetal growth restriction, and fetal malpresentation. A series of clinical recommendations for the management of pregnancy in women with uterine fibroids are included.

Purpose: Early life processes, through influence on fetal stem cells, affect postnatal and adult health outcomes. This study examines the effects of physical activity before and during pregnancy on stem cell counts in umbilical cord blood., Methods: We isolated mononuclear cells from umbilical cord blood samples from 373 singleton full-term pregnancies and quantified hematopoietic (CD34(+), CD34(+)CD38(-), and CD34(+) c-kit(+)), endothelial (CD34(+)CD133(+), CD34(+)CD133(+)VEGFR2(+), CD34(+)VEGFR2(+), and CD133(+)VEGFR2(+)), and putative breast (EpCAM(+), EpCAM(+)CD49f(+), EpCAM(+)CD49f(+)CD117(+), CD49f(+)CD24(+), CD24(+)CD29(+), and CD24(+)CD29(+)CD49f(+)) stem/progenitor cell subpopulations by flow cytometry. Information on physical activities before and during pregnancy was obtained from questionnaires. Weekly energy expenditure was estimated based on metabolic equivalent task values., Results: Prepregnancy vigorous exercise was associated positively with levels of endothelial CD34(+)CD133(+), CD34(+)CD133(+)VEGFR2(+), CD34(+)VEGFR2(+), and CD133(+)VEGFR2(+ )progenitor cell populations (P = 0.02, P = 0.01, P = 0.001, and P = 0.003, respectively); positive associations were observed in samples from the first births and those from the second or later births. Prepregnancy moderate and light exercises and light exercise during the first trimester were not significantly associated with any stem/progenitor cell population. Light exercise during the second trimester was positively associated with CD34(+)VEGFR2(+) endothelial progenitor cells (P = 0.03). In addition, levels of EpCAM(+)CD49f(+) and CD49f(+)CD24(+) breast stem cells were significantly lower among pregnant women who engaged in vigorous/moderate exercise during pregnancy (P = 0.05 and P = 0.02, respectively)., Conclusions: Vigorous exercise before pregnancy increases the number of endothelial progenitor cells in umbilical cord blood and thus could potentially enhance endothelial function and improve cardiovascular fitness in the offspring. Findings of lower levels of putative breast stem cell subpopulations could have implications on exercise and breast cancer prevention. Prenatal effects of exercise on fetal stem cells warrant further studies.

The timely onset of labor and birth is an important determinant of perinatal outcome. Prolonged (postterm) pregnancy--defined as delivery at or beyond 42 weeks' gestation--complicates 10% of all gestations and is associated with increased risks to both fetus (stillbirth, macrosomia, birth injury, meconium aspiration syndrome) and mother (cesarean delivery, severe perineal injury, postpartum hemorrhage). The risk of routine induction of labor (failed induction leading to cesarean delivery) in the era of cervical ripening is lower than previously reported. For these reasons, the authors favor a policy of routine induction of labor for low-risk pregnancies at 41 weeks' gestation.

Background: Injury to reproductive organs including the uterus is a known complication of ionizing radiation, but the risks to the mother and fetus during subsequent pregnancies are not well defined., Case: A young woman with a remote history of whole body irradiation for childhood leukemia had uterine rupture at 17 weeks' gestation. Pathologic examination of the supracervical hysterectomy specimen revealed a posterior-fundal placenta percreta with a diffusely thinned myometrium (1-6 mm). The clinicopathologic findings were consistent with prior radiation injury., Conclusion: Uterine irradiation may predispose to abnormal placentation and uterine rupture in a subsequent pregnancy.

Objective: To determine the neonatal outcome in accurately dated 23-week deliveries., Methods: We reviewed the records of consecutive births between 23 0/7 and 23 6/7 weeks at Brigham & Women's Hospital, Boston, Massachusetts, from January 1995 to December 1999. Women were excluded if they presented for elective termination or had known fetal death or poor dating criteria. Neonatal records were abstracted for mortality and short-term morbidity, including the respiratory distress syndrome (RDS), intraventricular hemorrhage, chronic lung disease, necrotizing enterocolitis, periventricular leukomalacia, and retinopathy of prematurity. Survival was defined as discharge from neonatal intensive care., Results: Thirty-three singleton pregnancies met criteria for inclusion, 11 of whom survived to discharge (survival rate 0.33; 95% CI 0.18, 0.52). More advanced gestational age was associated with increased likelihood of survival: 0 of 12 at 23 0/7 to 23 2/7 weeks, 4 of 10 at 23 3/7 to 23 4/7 weeks, and 7 of 11 at 23 5/7 to 23 6/7 weeks (P =.02). All 11 survivors developed RDS and chronic lung disease. One of 11 survivors had necrotizing enterocolitis, and 2 of 11 had severe retinopathy of prematurity. One survivor had periventricular leukomalacia on head ultrasonography, compared with 7 of the nonsurvivors who had head ultrasonography (P =.03). One survivor developed severe intraventricular hemorrhage (grade 3 or 4) compared with 8 of the 12 at-risk nonsurvivors who had head ultrasonography (P =.01)., Conclusion: About one third of infants delivered at 23 weeks' gestation survived to be discharged from neonatal intensive care. More advanced gestational age was associated with increased likelihood of survival. No neonates survived free of substantial morbidity.

Post-term pregnancy (longer than 42 weeks or 294 days) occurs in approximately 10% of all singleton gestations. The adverse outcomes of post-term pregnancy include a substantial increase in perinatal mortality and morbidity. ACOG currently recommends induction of labor for low-risk pregnancy during the 43rd week of gestation. However, that recommendation dates from 1989. Recent reports mandate reconsideration of the management of post-term pregnancy, including reinterpretation of the statistical risk of stillbirth in post-term pregnancies using ongoing (undelivered) rather than delivered pregnancies as the denominator, which shows a far higher risk to post-term fetuses than believed. Recent data also suggest that the risk of cesarean delivery after induction of labor at term is lower than reported, possibly because of improvements in methods for cervical ripening. Those findings provide rationale for earlier labor induction in low-risk pregnancies.

Background: Syringes were developed for injection, not aspiration. We describe an adapter that attaches to a standard syringe and aspirates by advancement rather than withdrawal., Technique: The adapter consists of a syringe barrel extension and an attachable finger grip. The adapter attached to a standard syringe allows aspiration by advancement rather than withdrawal, with the same hand motion used as with injection., Experience: In a comparison of timed in vitro fluid aspiration by 10 practitioners, mean times for aspiration of 15 mL were 32.4 seconds (range 24-45) with standard technique and 25.3 seconds (range 24-30) with the adapted syringe (P < .003, paired t test). Thirteen of 14 physicians who used the adapted syringe in vivo reported that much less effort was required, and one physician reported that a little less effort was required. Overall, eight practitioners reported that the adapted syringe made amniocentesis much easier and six found no difference between the two devices., Conclusion: This adapter converts a standard syringe to one permitting aspiration by advancement rather than withdrawal. Practitioner feedback was positive with regard to ease of use, degree of effort, and overall satisfaction.

Background: Cortical blindness is a complication of severe preeclampsia, but it is unclear whether it results from cerebral vasospasm and ischemic injury or vasogenic (hydrostatic) edema due to increased capillary permeability., Case: Reversible cortical blindness in a 33-year-old gravida 2, para 1, with severe postpartum preeclampsia after evacuation of a partial molar pregnancy at 19 weeks' gestation is presented. Initial neuroimaging studies showed hyperperfusion on head single-photon-emission computed tomography scan, which corresponded with lesions found on head computed tomography and magnetic resonance imaging scans. Follow-up neuroimaging studies 2 weeks later, by which time the patient's visual acuity had returned to normal, showed complete resolution of radiologic abnormalities., Conclusion: Neuroimaging studies in a woman with severe postpartum preeclampsia complicated by reversible cortical blindness showed that blindness resulted from vasogenic (hydrostatic) cerebral edema and not cerebral vasospasm.

Objective: To determine if epidural analgesia is associated with differences in rates of severe perineal trauma during vaginal deliveries., Methods: We studied 1942 consecutive, low-risk, term, vaginal deliveries in nulliparas, including spontaneous and induced labors, at a single institution from December 1994 to August 1995. The rate of third- and fourth-degree lacerations was compared for women who had and did not have epidural analgesia for labor-pain relief. Statistical significance was determined using chi2. Logistic regression analyses were used to evaluate associations while controlling for possible confounding variables., Results: Overall rates of third- and fourth-degree lacerations were 10.8% (n = 210) and 3.4% (n = 63), respectively. Epidural analgesia was given to 1376 (70.9%) women. Among women who had epidurals, 16.1% (221 of 1376) had severe perineal lacerations compared with 9.7% (n = 55) of the 566 women who did not have epidurals (P < .001; odds ratio [OR] 1.8, 95% confidence interval [CI] 1.3, 2.4). When controlling for birth weight, use of oxytocin, and maternal age in logistic regression analysis, epidural remained a significant predictor of severe perineal injury (OR 1.4, 95% CI 1.0, 2.0). Epidural use is consistently associated with increased operative vaginal deliveries and consequent episiotomies, so we constructed a logistic regression model to evaluate whether the higher rates of those procedures were responsible for the effect of epidurals on severe perineal traumas. With operative vaginal delivery and episiotomy in the model, epidural was no longer an independent predictor of perineal injury (OR 0.9, 95% CI 0.6, 1.3)., Conclusion: Epidural analgesia is associated with an increase in the rate of severe perineal trauma because of the more frequent use of operative vaginal delivery and episiotomy.

Objective: To examine the relationship between birth weight and brachial plexus injury and estimate the number of cesareans needed to reduce such injuries., Methods: All 80 neonatal records coded for brachial plexus injury from October 1985 to September 1993 at the Brigham and Women's Hospital in Boston, Massachusetts, were studied along with linked maternal files. Birth weight, method of delivery, presence or absence of shoulder dystocia, and any diagnosis of maternal gestational or nongestational diabetes were abstracted. Data for the group with brachial plexus injury were compared with data for live-born infants without this injury during the same period. The sensitivity and specificity of birth weight as a predictor of brachial plexus injury were calculated. Further, the number of cesarean deliveries necessary to prevent a single brachial plexus injury was estimated using various weight cutoffs (4000, 4500, and 5000 g) for elective cesarean delivery., Results: Among 77,616 consecutive deliveries, there were 80 brachial plexus injuries identified, for an incidence of 1.03 per 1000 live births. The incidence of brachial plexus injury increased with increasing birth weight, operative vaginal delivery, and the presence of glucose intolerance. In the group of women without diabetes, between 19 and 162 cesarean deliveries would have been necessary to prevent a single immediate brachial plexus injury. Among women with diabetes, between five and 48 additional cesareans would have been required., Conclusion: Although birth weight is a predictor of brachial plexus injury, the number of cesarean deliveries necessary to prevent a single injury is high at most birth weights. Because of the large number of cesarean deliveries needed to prevent a single brachial plexus injury in infants born to women without diabetes, it is difficult to recommend routine cesarean delivery for suspected macrosomia in these women.

Objective: To measure prostaglandin (PG) D2 output by human decidua at term and to identify the cell population(s) responsible for its production., Methods: Decidual cell suspensions were prepared enzymatically and the cells were labeled with either of two monoclonal antibodies: F10/89/4, which recognizes the leukocyte common antigen (CD45), or L243, which labels HLA-DR and is specific for macrophages in this tissue. Cells were sorted on a Coulter EPICS 541 flow cytometer. Prostaglandin levels were measured by radioimmunoassay., Results: Human decidua is an important intrauterine source of PGD2 at term. Twenty-nine percent (median) of decidual cells were CD45-positive and 12% were HLA-DR-positive; sorted cell populations were 95% pure. Prostaglandin D2 output (fmol/10(6) cells per 3 hours) by bone marrow-derived (CD45-positive) cells was significantly higher than that by non-bone marrow-derived cells: median 63 (range 35-67) versus 20 (13-21), respectively; HLA-DR-positive cells (macrophages) had the highest PGD2 production rate (186, range 97-288 fmol/10(6) cells per 3 hours). Under basal conditions, PGD2 production by unsorted term decidual cells was not influenced by labor., Conclusion: Bone marrow-derived cells (macrophages) are the major source of decidual PGD2 at term. Further studies are required to investigate the possible role of PG production by human decidual macrophages in the mechanism of term and/or preterm labor.