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The purpose of this study was to assess and compare knowledge, self-awareness, and accuracy of perceived risks and weight status among overweight and obese women.This study was a secondary analysis of a cross-sectional questionnaire study of overweight and obese pregnant women who sought a routine first-trimester screening ultrasound. Those with a pre-pregnancy body mass index (BMI) ≥25 kg/mA total of 169 participants (88 overweight; 81 obese) were included. Most participants believed their weight did not impact the ultrasound detection of a fetal malformation (92.1% overweight vs. 55.6% obese,Although more obese than overweight women associated excess weight with pregnancy complications, both groups underestimated the impact on their pregnancies. Targeted educational programs are needed to improve the risk perception of these populations prior to pregnancy with the goal of improving their weight statuses and pregnancy outcomes.

Objectives To determine the effect of gestational age at delivery on maternal and neonatal outcomes in preterm prelabor rupture of membranes (PPROM) and assess various predictors of neonatal and infant mortality in these pregnancies. Methods United States birth data from CDC-National Center for Health Statistics natality database for years 2004–2008 was used to identify singleton pregnancies with PPROM and delivery from 32 0/7 to 36 6/7 weeks. Controls were singletons at 37–40 weeks, without PPROM. Maternal and neonatal complications reported by all states were analyzed along with neonatal outcomes such as chorioamnionitis and hyaline membrane disease, reported by a subgroup of states. OR (95% CI) were calculated after adjusting for preeclampsia, diabetes, chronic hypertension, maternal race, and infant sex. Results There were 134,502 PPROM cases and similar number of controls. There was a significant decrease in need for prolonged ventilation, hyaline membrane disease, 5 min Apgar score Conclusions We provide population-based evidence showing a decrease in neonatal complications and death with advancing gestational age in PPROM. Gestational age at delivery in pregnancies with PPROM is the strongest predictor of mortality risk.

To estimate the impact of body mass index (BMI) categories on duration of the nonstress test (NST), and the need for additional tests of fetal wellbeing or interventions.We conducted a retrospective cohort study of women with singleton pregnancies who had an NST for the indications of severe obesity (BMI ≥40 kg/mThree hundred and fifty-one women underwent 1665 NSTs during the study period. After excluding women18 and50 years, gestational age30 weeks, fetal anomalies, and NSTs lasting longer than 60 min, the study population included 313 women and 1471 NSTs. The mean NST duration in minutes of the BMI ≥50 (32.2 ± 9.6) category was significantly longer than the NST duration of the other BMI categories (BMI30: 29.4 ± 8.3; BMI 30-39: 29.7 ± 8.9; BMI 40-49: 29.9 ± 8.3) (We found an increase in NST duration as the BMI increased. Women with severe obesity and a comorbidity were more likely to have a nonreactive NST and require a subsequent BPP. Of the 20 patients delivered due to NST surveillance, the most common indication for delivery was hypertension.

To determine the obstetrical outcomes of women delivered for the diagnosis of intrahepatic cholestasis of pregnancy (ICP).Retrospective study of singleton pregnancies diagnosed with ICP between 1 May 2014 and 31 December 2017. Population was analyzed based on bile acids: normal (10 µmol/L), mild (10 to 40 µmol/L), moderate-severe (40 µmol/L), and not obtained. Receiver operating characteristic curves established critical values for aspartate aminotransferase (AST) and alanine aminotransferase (ALT) to predict elevated bile acids. Statistical analyses included χBile acids were normal in 39 (45.9%) women, 30 (35.3%) had mild cholestasis, 10 (11.8%) had moderate-severe cholestasis and not obtained for six (7%) women. Gestational diabetes was more common in mild cholestasis (ICP should not be presumed in patients with pruritus. This practice may lead to early term delivery and associated complications.

Objectives To review our 25-year experience with a single umbilical artery and fetal echocardiography to estimate the need for this test in cases of an isolated single umbilical artery. Methods We conducted a retrospective review of 436 patients with a diagnosis of a single umbilical artery at our institution between 1990 and 2015. Two hundred eighty-eight women had both an anatomic survey and a fetal echocardiogram. Pregnancies with concurrent extracardiac anomalies or aneuploidy were excluded. The study population was divided into 3 groups based on cardiac views on the anatomic survey: normal, incomplete, and suspicious. Echocardiographic results were compared among the 3 groups. The primary outcome measure was the incidence of cardiac anomalies in the normal group at fetal echocardiography. The data were analyzed by the χ2 test or Fisher exact test. Results The mean maternal age ± SD of the group was 29.2 ± 6.2 years; 44.1% were primiparas. The mean gestational age at diagnosis was 22.6 ± 5.2 weeks, and the mean gestational age at fetal echocardiography was 25.1 ± 3.6 weeks. In the normal group, 99.1% (230 of 232) of women had a normal fetal echocardiogram; the 2 abnormal cases were ventricular septal defects. Normal echocardiograms were obtained in 81.8% (36 of 44) and 25.0% (3 of 12) of the “incomplete” and “suspicious” groups, respectively. Conclusions Fetuses with a single umbilical artery, in the absence of structural abnormalities, and with normal cardiac views at the time of the anatomic survey do not warrant an echocardiogram.

To determine if using a checklist of specific ultrasound image criteria to screen the fetal heart improves the cardiac exam completion rate, defined as the ability to classify the heart as normal or abnormal. This is a retrospective cohort study of patients with singleton pregnancies who underwent a fetal anatomy survey between 18 and 28 weeks' gestation. A checklist was used from 1 September 2015 to 31 March 2016 to categorize exams as complete-normal, complete-abnormal, or incomplete. Performance was compared with a 7-month period prior to checklist introduction (1 December 2014 to 30 June 2015). Checklist utilization improved the cardiac exam completion rate by 8.9%. With the checklist, 1083 of 1202 exams (90.1%) were completed compared to 987 of 1193 (82.7%) pre-checklist, P < .001. We did not detect a change in cases classified as abnormal and referred for echocardiography: 25 (2.1%) with the checklist and 16 (1.3%) pre-checklist, P = .16. We did not detect more congenital heart disease (CHD), 12 (1.0%) with checklist screening, 5 (0.4%) pre-checklist, P = .14. Critical CHD was not missed in either group. Using the checklist improved the cardiac exam completion rate. There was no change in congenital heart disease detection.

Background Fetal intra-abdominal cysts have an incidence of 1/500–1/1000 live births. Cysts can be physiologic or pathologic and can either spontaneously regress or require intervention and treatment. Cytomegalovirus (CMV) is the most common cause of congenital infection in the USA with an incidence of 0.2–2%. The risk of transmission is greatest with a primary maternal infection and the severity of fetal injury increases when transmission occurs in the first half of the pregnancy. An infectious etiology for a fetal intra-abdominal cyst has not been reported to the best of our knowledge. Case presentation A 31-year-old multigravida presented at 19 weeks’ gestation for an anatomical survey. The female fetus was noted to have a 2.4 × 2.0 × 3.1 cm echolucent cyst in the right side of the abdomen. Three weeks later, the cyst was not seen; however, there was free fluid and a few echogenic areas within the fetal abdomen. Maternal serum tested positive for CMV IgM and IgG titers, and the CMV IgG avidity test was 0.75, consistent with high avidity. At 27 weeks’ gestation, ascites remained and a pericardial effusion was noted. Amniocentesis resulted in >2,000,000 copies of CMV DNA by polymerase chain reaction (PCR) in the amniotic fluid. The patient underwent termination of the pregnancy at 29 weeks of gestation. Conclusion It would be important to consider an infectious etiology in the differential diagnosis of fetal intra-abdominal cysts as the outcome in the fetus with congenital CMV infection could be much different. Amniocentesis is considered the best option for the diagnosis of fetal congenital CMV infection if performed after 21 weeks’ gestation and more than 6 weeks from maternal infection.

To compare the ability of magnetic resonance imaging (MRI) and ultrasound (US) in the diagnosis of placenta accreta, to examine the success of various sonographic and MRI features to correctly predict invasive placenta, and to define a specific role for MRI in placenta accreta.After Institutional Review Board approval, a blinded retrospective review was undertaken of US and MRI findings from 45 patients who had an obstetrical US and placental MRI between August 2006 and January 2012. Correlation with clinical history and pathologic findings was performed.US and MRI had similar sensitivity, specificity and positive and negative predictive values for placenta accreta. The best predictors of invasion by US were loss of the myometrial mantle, increased intraplacental vascularity and loss of the bladder wall echogenicity. The best predictors of invasion by MRI were loss of retroplacental myometrial mantle, a heterogeneous placenta, and intraplacental hemorrhage. Body mass index (BMI) did not affect the ability to make a diagnosis by either US or MRI. MRI proved effective in better evaluation of a posterior placenta with suspicion of placenta accreta. There was modality disagreement in 11 of 45 cases and MRI was correct in 9 of these 11 cases, all true negative (TN) cases.MRI should be considered in any case with posterior placenta previa and suspicion of accreta, in any case with clinical suspicion for accreta and discordant US findings, and in any case in which percreta is suspected.

We present a case of a pregnant woman with chronic immune thrombocytopenic purpura and chronic hypertension who developed pre-eclampsia with severe features warranting delivery. Her overall clinical picture and liver enzymes improved in the immediate postpartum period, however, aggressively progressing thrombocytopenia posed a diagnostic dilemma to the interdisciplinary care team. After failing to respond to first-line therapies including high-dose corticosteroids and intravenous immunoglobulin, she was successfully managed with a trial of the thrombopoietin receptor agonist, Romiplostim.

Background Fetal lateral neck cysts are transient fluid accumulations that result from abnormal lymphatic formations. In the first trimester, fetal lateral neck cysts accompanied by an increased nuchal translucency have been associated with aneuploidy, single-gene disorders and other malformations. Highlights We describe a case in which a lateral neck cyst, which measured 6.7 × 4 × 6.2 mm, was detected by ultrasonography in the first trimester with the additional finding of increased nuchal translucency (3.7 mm; >95th percentile). No other abnormalities were detected at that time. Standard cell-free DNA screening resulted in no aneuploidy detected for chromosomes 21, 18, 13 and the sex chromosomes. The patient declined diagnostic testing with chorionic villus sampling. A repeat ultrasound at 16 weeks’ gestation demonstrated a normally grown fetus with persistence of the cyst, which measured 4.9 × 5 × 8.4 mm, as well as a pericardial effusion with a single outflow tract overriding the ventricular septum and vermian hypoplasia. The diagnosis of trisomy 9, 47,XX,+9, was made by amniocentesis and the patient opted for termination of the pregnancy. Conclusions This report illustrates the importance of identifying additional abnormalities in a fetus with lateral neck cysts, documenting the size of the cysts and obtaining diagnostic genetic testing.

To review our 25-year experience with a single umbilical artery and fetal echocardiography to estimate the need for this test in cases of an isolated single umbilical artery.We conducted a retrospective review of 436 patients with a diagnosis of a single umbilical artery at our institution between 1990 and 2015. Two hundred eighty-eight women had both an anatomic survey and a fetal echocardiogram. Pregnancies with concurrent extracardiac anomalies or aneuploidy were excluded. The study population was divided into 3 groups based on cardiac views on the anatomic survey: normal, incomplete, and suspicious. Echocardiographic results were compared among the 3 groups. The primary outcome measure was the incidence of cardiac anomalies in the normal group at fetal echocardiography. The data were analyzed by the χThe mean maternal age ± SD of the group was 29.2 ± 6.2 years; 44.1% were primiparas. The mean gestational age at diagnosis was 22.6 ± 5.2 weeks, and the mean gestational age at fetal echocardiography was 25.1 ± 3.6 weeks. In the normal group, 99.1% (230 of 232) of women had a normal fetal echocardiogram; the 2 abnormal cases were ventricular septal defects. Normal echocardiograms were obtained in 81.8% (36 of 44) and 25.0% (3 of 12) of the "incomplete" and "suspicious" groups, respectively.Fetuses with a single umbilical artery, in the absence of structural abnormalities, and with normal cardiac views at the time of the anatomic survey do not warrant an echocardiogram.

Introduction In vitro studies on the structure of human fetal membranes have involved light or electron microscopy with fixation, dehydration, and staining. Recently, optical coherence tomography (OCT), an imaging technology, has provided high-resolution cross-sectional images of living biological tissues, with a penetration of 2–3 mm. We evaluated the use of this technology to examine the histologic features of human fetal membranes immediately after delivery. Methods Samples of fetal membranes of ten patients undergoing cesarean deliveries (four uncomplicated pregnancies, four with preeclampsia, and two with chorioamnionitis) and eight patients undergoing vaginal deliveries (six uncomplicated pregnancies and two with chorioamnionitis) were collected immediately after delivery. Samples were stretched across customized disks, rinsed, and analyzed using a time-domain OCT imaging system. Following OCT scanning, the samples were placed in formalin for histologic study. The OCT images were compared to histologic images of common human fetal membrane features. Results We were able to delineate the layers of the fetal membranes using bench-top time-domain OCT. The system was able to image histologic features of the fetal membranes, such as microscopic chorionic pseudocysts, ghost villi, meconium stained membranes, and chorioamnionitis. The OCT images corresponded with the histologic findings. Discussion This feasibility study demonstrates the potential of OCT technology for real-time assessment of human fetal membranes and may provide clinically useful information at delivery.

Objectives To determine whether intertwin discordant abdominal circumference, femur length, head circumference, and estimated fetal weight sonographic measurements in early second-trimester monochorionic diamniotic twins predict adverse obstetric and neonatal outcomes. Methods We conducted a multicenter retrospective cohort study involving 9 regional perinatal centers in the United States. We examined the records of all monochorionic diamniotic twin pregnancies with two live fetuses at the 16- to 18-week sonographic examination who had serial follow-up sonography until delivery. The intertwin discordance in abdominal circumference, femur length, head circumference, and estimated fetal weight was calculated as the difference between the two fetuses, expressed as a percentage of the larger using the 16- to 18-week sonographic measurements. An adverse composite obstetric outcome was defined as the occurrence of 1 or more of the following in either fetus: intrauterine growth restriction, twin-twin transfusion syndrome, intrauterine fetal death, abnormal growth discordance (≥20% difference), and very preterm birth at or before 28 weeks. An adverse composite neonatal outcome was defined as the occurrence of 1 or more of the following: respiratory distress syndrome, any stage of intraventricular hemorrhage, 5-minute Apgar score less than 7, necrotizing enterocolitis, culture-proven early-onset sepsis, and neonatal death. Receiver operating characteristic and logistic regression-with-generalized estimating equation analyses were constructed. Results Among the 177 monochorionic diamniotic twin pregnancies analyzed, intertwin abdominal circumference and estimated fetal weight discordances were only predictive of adverse composite obstetric outcomes (areas under the curve, 79% and 80%, respectively). Receiver operating characteristic curves showed that intertwin discordances in abdominal circumference, femur length, head circumference, and estimated fetal weight were not acceptable predictors of twin-twin transfusion syndrome or adverse neonatal outcomes. Conclusions In our cohort, only second-trimester abdominal circumference and estimated fetal weight discordances in monochorionic diamniotic twin pregnancies were predictive of adverse composite obstetric outcomes. Twin-twin transfusion syndrome and adverse neonatal outcomes were not predicted by any of the intertwin discordances measured.

Early recognition and timely treatment of an interstitial pregnancy is imperative to avoid the high morbidity and mortality of this type of ectopic pregnancy. We report a case of twin interstitial pregnancy that was initially missed on initial sonogram and was subsequently recognized at our institution by transvaginal sonography. The patient underwent open laparoscopic surgery with cornual wedge resection but suffered infundibulopelvic ligament hemorrhage and subsequently required ipsilateral salpingo-oophorectomy. She did well and was discharged home a day later.

Objectives The purpose of this study was to investigate whether discordant nuchal translucency and crown-rump length measurements in monochorionic diamniotic twins are predictive of adverse obstetric and neonatal outcomes. Methods We conducted a multicenter retrospective cohort study including all monochorionic diamniotic twin pregnancies with two live fetuses at the 11-week to 13-week 6-day sonographic examination who had serial follow-up sonography until delivery. Isolated nuchal translucency, crown-rump length, and combined discordances were correlated with adverse obstetric outcomes, individually and in composite, including the occurrence of 1 or more of the following in either fetus: intrauterine growth restriction (IUGR), twin-twin transfusion syndrome (TTTS), intrauterine fetal death (IUFD), growth discordance (≥20%), and preterm birth before 28 weeks' gestation. Correlations with adverse composite neonatal outcomes were also studied. A receiver operating characteristic curve analysis and a logistic regression analysis with a generalized estimating equation were conducted. Results Fifty-four of the 177 pregnancies included (31%) had an adverse composite obstetric outcome, with TTTS in 19 (11%), IUGR in 21 (12%), discordant growth in 14 (8%), IUFD in 14 (8%), and preterm birth before 28 weeks in 10 (6%). Of the 254 neonates included in the study, 69 (27%) were complicated by adverse composite neonatal outcomes, with respiratory distress syndrome being the most common (n = 59 [23%]). The areas under the curve for the combined discordances to predict composite obstetric and neonatal outcomes were 0.62 (95% confidence interval, 0.52–0.72), and 0.54 (95% confidence interval, 0.46–0.61), respectively. Conclusions In our population, nuchal translucency, crown-rump length, and combined discordances in monochorionic diamniotic twin pregnancies were not predictive of adverse composite obstetric and neonatal outcomes.

Parkinson's disease (PD) is a degenerative disorder characterized by several motor symptoms including shaking, rigidity, slow movement and difficult walking, which has been associated to the death of nigro-striatal dopaminergic neurons. >90% of PD patients also present olfactory dysfunction. Although the molecular mechanisms responsible for this disease are not clear, hereditary PD is linked to mutations in specific genes, including the PTEN-induced putative kinase 1 (PINK1). In this work we provide for the first time a thorough temporal description of the behavioral effects induced by a mutation in the PINK1 gene in adult Drosophila, a previously described animal model for PD. Our data suggests that the motor deficits associated to PD are fully revealed only by the third week of age. However, olfactory dysfunction is detected as early as the first week of age. We also provide immunofluorescence and neurochemical data that let us propose for the first time the idea that compensatory changes occur in this Drosophila model for PD. These compensatory changes are associated to specific components of the dopaminergic system: the biosynthetic enzymes, Tyrosine hydroxylase and Dopa decarboxylase, and the Dopamine transporter, a plasma membrane protein involved in maintaining dopamine extracellular levels at physiologically relevant levels. Thus, our behavioral, immunofluorescence and neurochemical data help define for the first time presymptomatic and symptomatic phases in this PD animal model, and that compensatory changes occur in the dopaminergic neurons in the presymptomatic stage.

To estimate the effect of reference text in an electronic medical record (EMR) on the recommended use of preoperative antibiotics for cesarean deliveries.A retrospective cohort study of all cesarean deliveries at Stony Brook Hospital between May 2009 and June 2011, was performed. Reference text was added to the EMR in May 2010. The cesarean deliveries performed before (group 1) and after (group 2) the addition of the reference text were compared for the type and dose of antibiotic ordered preoperatively, as well as the patient's body mass index (BMI), drug allergies, and diagnosis of chorioamnionitis. Those with chorioamnionitis were excluded. The χ and t tests were performed to study differences between the groups.Of the 2,273 deliveries identified, 172 were excluded for chorioamnionitis or incomplete medical records. The women in group 1 had a higher BMI (33.3 ± 7.3 kg/m²) compared with the women in group 2 (32.6 ± 6.3 kg/m²; P=.005). Otherwise, there were no differences between the groups regarding maternal weight, penicillin allergy, or other antibiotics. There was a significant increase in the number of patients receiving the adequate (92.6% compared with 85.7%; P.005) and recommended (58.1% compared with 43.4%; P.005) antibiotics in group 2 when compared with group 1.Reference text included within the EMR that prompts physicians to select the recommended antibiotics significantly improves preoperative antibiotic use.

To determine whether smoking is an independent risk factor for wound dehiscence after cesarean delivery.In this case-control study, medical records were reviewed for all patients with wound dehiscence after cesarean delivery during a 7-month period. Wound dehiscence was defined as separation of wound edges requiring treatment. Three control patients without such complications were randomly selected for each case patient. Univariate associations were assessed using t test or Fisher's exact test; univariate odds ratios (OR) and 95% confidence intervals (CI) were calculated with logistic regression. Multivariate associations were assessed with logistic regression on variables with a univariate association significant at p ≤ 0.10.Of 597 cesarean deliveries, 30 cases (5 %) with wound dehiscence were identified. As individual variables, smoking (46.7 vs. 21.1%, p0.01, cases vs. controls), histological chorioamnionitis (27.6 vs. 6.7%, p0.01) and preoperative hematocrit (34.0 ± 3.2 vs. 35.4 ± 3.4, p0.05) were significantly associated with wound complications. In a multivariate logistic regression model, only smoking (OR 5.32; 95% CI 1.77-15.97, p0.01) and histological chorioamnionitis (OR 5.62; 95% CI 1.43-22.11, p0.01) were independently associated with wound dehiscence.Smoking and histological chorioamnionitis are independently associated with wound dehiscence after cesarean delivery.

Background The amount of free fluid that can normally be present in a pregnant patient is unknown. Evaluation of pelvic free fluid in a population of pregnant patients without early history of trauma would help determine what amount of free fluid should raise suspicion of intra-abdominal injury in those who have suffered trauma. Methods Patients presenting for routine obstetric ultrasound without an early history of trauma were offered participation in the study. Routine imaging of the cul de sac and ovaries was used for assessment of presence or absence of free fluid, with accompanying digitally recorded images. Depth of the fluid pocket was measured in millimeters. Results Six of 89 patients successfully scanned were found to have free fluid in to the cul de sac for an occurrence of 6.7%. Four patients had free fluid present during the first trimester with subsequent resolution by the late first trimester or early second trimester. Two of these patients had an identifiable cause for free fluid, one with right ovarian hyperstimulation and the second with idiopathic theca lutein cysts. Two patients had isolated free fluid appearing in the third trimester. Conclusions These results suggest that the presence of pelvic free fluid in pregnant patients without antecedent trauma is very low. After blunt abdominal trauma, the presence of free fluid in the pelvis of a pregnant patient may not be physiologic, especially if there is >2 mm to 4 mm, and there is no history of ovarian hyperstimulation syndrome or other known associations.

International audience; Tetanic electrical stimulation induces two separate calcium signals in rat skeletal myotubes, a fast one, dependent on Cav 1.1 or dihydropyridine receptors (DHPRs) and ryanodine receptors and related to contraction, and a slow signal, dependent on DHPR and inositol trisphosphate receptors (IP(3)Rs) and related to transcriptional events. We searched for slow calcium signals in adult muscle fibers using isolated adult flexor digitorum brevis fibers from 5-7-wk-old mice, loaded with fluo-3. When stimulated with trains of 0.3-ms pulses at various frequencies, cells responded with a fast calcium signal associated with muscle contraction, followed by a slower signal similar to one previously described in cultured myotubes. Nifedipine inhibited the slow signal more effectively than the fast one, suggesting a role for DHPR in its onset. The IP(3)R inhibitors Xestospongin B or C (5 µM) also inhibited it. The amplitude of post-tetanic calcium transients depends on both tetanus frequency and duration, having a maximum at 10-20 Hz. At this stimulation frequency, an increase of the slow isoform of troponin I mRNA was detected, while the fast isoform of this gene was inhibited. All three IP(3)R isoforms were present in adult muscle. IP(3)R-1 was differentially expressed in different types of muscle fibers, being higher in a subset of fast-type fibers. Interestingly, isolated fibers from the slow soleus muscle did not reveal the slow calcium signal induced by electrical stimulus. These results support the idea that IP(3)R-dependent slow calcium signals may be characteristic of distinct types of muscle fibers and may participate in the activation of specific transcriptional programs of slow and fast phenotype.

To compare betamethasone with dexamethasone in terms of effectiveness in reducing perinatal morbidities and mortality among preterm infants.We enrolled 299 women at risk for preterm delivery in a double-blind, placebo-controlled, randomized trial of antenatal betamethasone compared with dexamethasone at Stony Brook University Hospital from August 2002 through July 2004. We excluded women with clinical chorioamnionitis, fetal structural and chromosomal abnormalities, prior antenatal steroid exposure, and steroid use for other indications. Statistical analysis was performed in accordance of the intention-to-treat principle.There were no significant differences between the groups with regard to baseline characteristics. The rate of respiratory distress syndrome, need for vasopressor therapy, necrotizing enterocolitis, retinopathy of prematurity, patent ductus arteriosus, neonatal sepsis, and neonatal mortality were not significant different between the groups. However, the rates of intraventricular hemorrhage (6 of 105 [5.7%] compared with 17 of 100 [17.0%], relative risk [RR] 2.97, 95% confidence interval [CI] 1.22-7.24, P=.02) and any brain lesion (7 of 105 [6.7%] compared with 18 of 100 [18.0%], RR 2.7, 95% CI 1.18-6.19, P=.02) were significantly lower in neonates exposed to dexamethasone compared with betamethasone. The absolute risk reduction in the rate of intraventricular hemorrhage was 11.3 % ( 95% CI 2.7-11.9%), and the number needed to treat was 9 (95% CI 5-37) in favor of dexamethasone.Betamethasone and dexamethasone are comparable in reducing the rate of most major neonatal morbidities and mortality in preterm neonates. However, dexamethasone seems to be more effective in reducing the rate of intraventricular hemorrhage compared with betamethasone.

To evaluate effects of endometrial ablation on the staging and treatment planning of postablation endometrial cancer. After authorization from the institutional review board, we performed a retrospective chart review of patients with a history of endometrial ablation and a subsequent diagnosis of endometrial cancer from July 2006 to December 2013. The information obtained included patient's age at time of cancer diagnosis, pre-ablation endometrial biopsy histology, dilation and curettage histology at time of ablation, endometrial biopsy-to-ablation interval, ablation-to-hysterectomy interval, final pathologic diagnosis, Federation Internationale de Gynecologie et d'Obstetrique (FIGO) staging, and treatment recommendations for adjuvant therapy. The histopathology was examined by a gynecologic pathologist. The National Comprehensive Cancer Network guidelines were applied to determine need for adjuvant therapy. Six of 490 (1.2%) patients with endometrial cancer were identified to have an antecedent ablation. Mean patient age was 48.2 years (range: 40-53). The time interval from office pre-ablation endometrial sampling to ablation ranged from 1 to 17 months. Four patients (67%) had an undetected endometrial cancer at the time of ablation, despite having benign pre-ablation histology. Following surgical staging, 4 patients (67%) had no evidence of residual carcinoma, and 2 (33%) had evidence of endometrial adenocarcinoma grades 1 to 2. There was no evidence of myometrial invasion in all cases, and a FIGO stage of IA was assigned. No adjuvant therapies were indicated. There have been no documented cancer recurrences, with a follow-up range from 16 to 52 months (average 30.2). Endometrial ablation artifact does not appear to hinder evaluation and treatment planning in the presence of endometrial cancer.

The choice of therapy for fetal growth restriction (FGR) depends on the nature of the insult that led to the development of FGR. Many etiologic factors are either not amenable to therapy or fetal growth has not been improved by treatments that benefit the mother. Many therapeutic approaches have been used to improve fetal condition. None of the approaches have been of value in a consistent manner. We present the numerous approaches, and their rationale for their use, that have been tried to treat the growth impaired fetus. The evidence from the randomized clinical trials is summarized and their conclusions given.

To compare the amniotic fluid (AF) concentration of pro-inflammatory cytokines between women with preterm labor and intact membranes that delivered within 7 days, with those that delivered after 7 days of the amniocentesis according to the result of the AF culture.Fifty-two women with preterm labor and intact membranes between 21 and 35 weeks of gestation were included in the study. Transabdominal amniocentesis was performed to rule out intra-amniotic infection, and AF concentrations of interleukin-1alpha (IL-1alpha), interleukin-1beta (IL-1beta), interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor (TNF) were determined with sensitive and specific enzyme-linked immunosorbent assays. Amniotic fluid was cultured for aerobic and anaerobic bacteria, Ureaplasma urealyticum, and Mycoplasma hominis. Exclusion criteria included preterm premature rupture of membranes, vaginal bleeding, multiple gestations, uterine anomalies, fetal congenital anomalies, ominous fetal heart rate tracings and fetal deaths. Proportions were compared using chi2 or Fisher's exact test. Receiver operator characteristic (ROC) curve analysis was performed for each cytokine for the prediction of delivery within 7 days.Sixty-two percent (32/52) of women delivered within 7 days and 38% (20/52) delivered after 7 days of amniocentesis. All women that delivered after 7 days of the procedure had negative AF cultures. In contrast, 28% (9/32) of women that delivered within 7 days had positive AF cultures and 72% (23/32) had negative AF cultures. Women that delivered within 7 days regardless of AF cultures had a lower birth weight and a shorter amniocentesis-to-delivery interval than those that delivered after 7 days of amniocentesis. Among women that delivered within 7 days, those with positive AF cultures had a lower gestational age at delivery and a higher frequency of histologic chorioamnionitis than those with negative AF cultures. The AF concentrations of all cytokines were significantly higher in women that delivered within 7 days with positive AF cultures than in those with negative AF cultures. Similarly, the AF concentrations of IL-1alpha, IL-6, and IL-8 were significantly higher in women that delivered within 7 days than those that delivered after 7 days of the amniocentesis, regardless of the AF culture results. Diagnostic indexes were calculated for all cytokines using critical values derived from ROC curve analysis for the prediction of delivery within 7 days.Women with preterm labor and intact membranes that delivered within 7 days had higher AF concentrations of pro-inflammatory cytokines than those who delivered after 7 days of the amniocentesis regardless of the AF culture results.

Objectives: This study aimed to determine whether feeding Lactobacillus GG (LGG) at varying levels (10 8 to 10 10 cfu/day) would result in colonization, defined as ≥1,000 cfu of LGG per gram of stool in 3 of 5 samples collected during the feeding period. Methods: Infants received unsupplemented formula during a 7-day baseline, 1 of 4 formulas containing 0 (control), 10 8 (low), 10 9 (medium), or 10 10 (high) cfu of LGG per day during a 2-week test, and unsupplemented formula during a 2-week follow-up. Baseline, test, and follow-up stool samples were evaluated for levels of viable LGG. Results: During test, supplemented infants were colonized, compared with control (P < 0.05). Median stool counts of LGG (log 10 cfu/g) in colonized infants were 5.24 (low), 6.05 (medium), and 5.97 (high). LGG persisted in the stools for 7 to 14 days after discontinuing LGG. No differences were observed among groups in stool consistency, flatulence, fussiness, or adverse events. Conclusion: A 2-week oral administration of 10 8 to 10 10 cfu/day LGG was well tolerated; all levels successfully colonized the intestinal tract of healthy, term infants.

Background The Arnold-Chiari malformation type I is characterized by the prolapse of the cerebellar tonsils below the foramen magnum. There is a lack of literature on the management of a pregnancy in a woman affected by an Arnold-Chiari malformation. Case A young primipara with severe headaches underwent an elective primary cesarean delivery under general anesthesia successfully. Five years earlier, she had undergone neurosurgical resection for filum terminale syndrome shortly after her first pregnancy (term vaginal delivery) and decompression of a type I Arnold-Chiari malformation 4 months later. Conclusion Careful selection of anesthetic technique for the delivery of a woman with an Arnold-Chiari malformation is of paramount importance.

Objective To assess the effectiveness of an incomplete course of antenatal corticosteroids on perinatal morbidity and mortality. Methods We studied consecutive neonates born at 23–34 weeks’ gestation between January 1, 1998, and July 31, 2002. The study population was divided into a group exposed to one 12-mg dose of betamethasone before delivery and a non–corticosteroid-exposed group, which were compared for various perinatal outcome variables. The Student t test, χ2, Fisher exact tests, and logistic regression were used for analysis. Results One hundred twenty-five neonates (55.6%) were exposed to one 12-mg dose of betamethasone before delivery, whereas 104 neonates (45.4%) did not receive antenatal corticosteroids. Mean gestational age at delivery (28.4 ± 3.1 weeks versus 29.7 ± 3.5 weeks, P = .002) and birth weight (1189 ± 409 g versus 1289 ± 441 g, P = .07) were lower among the steroid-exposed group. Adjusting for gestational age, one dose of betamethasone was associated with significant reduction in the need for vasopressors (odds ratio [OR] 0.35; 95% confidence interval [CI] 0.14, 0.85; P = .02), the rate of intraventricular hemorrhage (OR 0.42; 95%CI 0.19, 0.92; P = .03), and neonatal death (OR 0.31; 95% CI 0.11, 0.86; P = .02). There were no differences between groups in the rate of clinical and histological chorioamnionitis, low Apgar scores, postnatal surfactant exposure, respiratory distress syndrome, bronchopulmonary dysplasia, necrotizing enterocolitis, patent ductus arteriosus, retinopathy of prematurity, and neonatal sepsis. Conclusion An incomplete course of antenatal corticosteroids is associated with reduction in the need for vasopressors, the rate of intraventricular hemorrhage, and neonatal death in preterm neonates.

To determine whether the fetal admission test is predictive of intrapartum complications.We studied the fetal heart rate tracings of women in spontaneous labor at 37-42 weeks' gestation from 1 November 2001 to 31 March 2002. The study population was subdivided based on reactivity defined asor = 15 beats/min foror = 15 s, reactivity redefined asor = 10 beats/min foror = 10 s, variability, presence of late and/or variable decelerations, and reassuring fetal admission test; and compared for various labor outcome variables. Student's t test, the chi2 test and Fisher's exact test were used for analysis.A total of 426 women met our inclusion criteria. There were no differences between groups when compared for maternal age, parity, gestational age, birth weight, labor analgesia and length of labor. Irrespective of the definition of reactivity, women with a non-reactive fetal admission test were more likely to be delivered by Cesarean section, to have fetal distress resulting in Cesarean section and to have a longer neonatal hospital stay. In addition, redefining reactivity improved the specificity, positive and negative predictive values, accuracy, relative risk and likelihood ratio with regard to development of fetal distress. Similar results were obtained when variability and decelerations were used as criteria for comparisons.The fetal admission test is useful in predicting the absence of intrapartum fetal distress irrespective of the criterion used for evaluation. Redefined reactivity appears to be most predictive of intrapartum fetal distress.

OBJECTIVES: To estimate the incidence, indications, risk factors, and complications associated with emergency peripartum hysterectomy at a community-based academic medical center. METHODS: We analyzed retrospectively 47 of 48 cases of emergency peripartum hysterectomy performed at Winthrop-University Hospital from 1991 to 1997. Emergency peripartum hysterectomy was defined as one performed for hemorrhage unresponsive to other treatment less than 24 hours after delivery. Fisher exact test, Wilcoxon rank sum test, and Cochran-Armitage exact trend test were used for analysis. RESULTS: There were 48 emergency peripartum hysterectomies among 34,241 deliveries for a rate of 1.4 per 1000. Most frequent indications were placenta accreta (48.9%, 12 with previa, 11 without previa), uterine atony (29.8%), previa without accreta (8.5%), and uterine laceration (4.3%). Placenta accreta was the most common indication in multiparous women (58.8%, 20 of 34), uterine atony the most common in primiparas (69.2%, nine of 13). Twenty-two of 23 (95.6%) women with placenta accreta had a previous cesarean delivery or curettage. The number of cesarean deliveries or curettages increased the risk of placenta accreta proportionally. Thirty-eight (80.9%) of the hysterectomies were subtotal. Postoperative febrile morbidity was 34%; other morbidity was 26.3%. CONCLUSION: Placenta accreta has become the most common indication for emergency peripartum hysterectomy.

Obesity is associated with hyperinsulinemia and reduced insulin sensitivity, both risk factors for type 2 diabetes. However, it is not clear whether these risk factors occur as a result of obesity or whether they contribute to the development of obesity. The aims of this study were to determine whether baseline (first visit) or changes in insulin measures over time were associated with longitudinal changes in body fat mass during growth in children. The study group consisted of 137 children (83 Caucasian and 54 African American) with a mean age of 8.1 yr at baseline. The children returned for 3-6 annual visits for measurement of fasting insulin, insulin sensitivity (Si), and acute insulin response (AIR) from the tolbutamide-modified frequent sampling iv glucose tolerance test and for determination of body composition by dual energy x-ray absorptiometry. Data were analyzed using SAS Proc mixed growth models. Total fat mass increased with time by 15.6%/yr (P = 0.013), but the rate of increase was not significantly influenced by race, sex, or Tanner stage. However, fasting insulin (positive effect), Si (negative effect), and AIR (positive effect) were significantly associated with the rate of increase in fat mass. In conclusion, in this cohort of children, growth-related increases in body fat were significantly associated with increases in fasting insulin and AIR and decreases in Si.

HUANG, TERRY T.-K., MARIA S. JOHNSON, REINALDO FIGUEROA-COLON, JAMES H. DWYER, AND MICHAEL I. GORAN. Growth of visceral fat, subcutaneous abdominal fat, and total body fat in children. Obes Res. 2001;9:283‐289. Objective: To examine the patterns of growth of visceral fat, subcutaneous abdominal fat, and total body fat over a 3- to 5-year period in white and African American children. Research Methods and Procedures: Children (mean age: 8.1 6 1.6 years at baseline) were recruited from Birmingham, Alabama, and those with three or more repeated annual measurements were included in the analysis (N 5 138 children and 601 observations). Abdominal adipose tissue (visceral and subcutaneous) was measured using computed tomography. Total body fat and lean tissue mass were measured by DXA. Random growth curve modeling was performed to estimate growth rates of the different body fat compartments. Results: Visceral fat and total body fat both exhibited significant growth effects before and after adjusting for subcutaneous abdominal fat and lean tissue mass, respectively, and for gender, race, and baseline age (5.2 6 2.2 cm 2 /yr and 1.9 6 0.8 kg/yr, respectively). After adjusting for total body fat, the growth of subcutaneous abdominal fat was not significant. Whites showed a higher visceral fat growth than did African Americans (difference: 1.9 6 0.8 cm 2 /yr), but there was no ethnic difference for growth of subcutaneous abdominal fat or total body fat. There were no gender differences found for any of the growth rates. Discussion: Growth of visceral fat remained significant after adjusting for growth of subcutaneous abdominal fat, implying that the acquisition of the two abdominal fat compartments may involve different physiologic mechanisms. In contrast, growth of subcutaneous abdominal fat was explained by growth in total body fat, suggesting that subcutaneous fat may not be preferentially deposited in the abdominal area during this phase of growth. Finally, significantly higher growth of visceral fat in white compared with African American children is consistent with cross-sectional findings.

BACKGROUND Body composition and resting energy expenditure (REE) have not been examined longitudinally during puberty. OBJECTIVE The purpose of this longitudinal study was to examine the influence of pubertal maturation on REE relative to body composition in African American and white children. DESIGN The study included 92 white and 64 African American children (mean age at baseline: 8.3 and 7.9 y, respectively) from Birmingham, AL. The children had 2-5 annual measurements of fat mass (FM), lean mass (LM), and REE. The Tanner stages of the children ranged from 1 to 5. Mixed-model repeated-measures analyses were used to test the change in REE relative to body composition with increasing Tanner stage among ethnic and sex groups. RESULTS LM increased from Tanner stage 1 to subsequent stages. FM relative to LM decreased from Tanner stage 1 to stages 3, 4, and 5 but not from stage 1 to stage 2. The African American children had relatively higher limb LM and lower trunk LM than did the white children. REE declined with Tanner stage after adjustment for ethnicity, sex, FM, and LM. This decline was significant from Tanner stage 1 to stages 3, 4, and 5 but not to Tanner stage 2. After adjustment for age, Tanner stage, FM, and LM or LM distribution, REE was significantly higher in white than in African American children (by approximately 250 kJ/d). CONCLUSION In a large sample of children at various Tanner stages, we found an ethnic difference in REE after adjustment for age, Tanner stage, FM, and LM that was not explained by the difference in LM distribution.

Objective: To determine whether diagnostic amniocentesis should be part of evaluations of women under consideration for rescue cerclage. Methods: We reviewed the obstetric records of 25 candidates for rescue cerclage seen between June 30, 1995, and July 1, 1997. Rescue cerclage was defined as a procedure on a cervix with an internal os dilated at least 2 cm and 50% effaced, with membranes visible at the external os. Transabdominal amniocentesis was offered as part of the preoperative evaluation, and amniotic fluid (AF) was sent for glucose and lactate dehydrogenase level determinations, Gram staining, and culture for aerobic and anaerobic bacteria. Placentas were examined for histopathologic evidence of inflammation. The women were divided into three groups. Eleven women had rescue cerclage after amniocentesis, seven had rescue cerclage after declining amniocentesis, and seven had amniocentesis but were treated conservatively because of AF markers of infection. Analysis of variance and χ 2 statistics were used. Results: The group that had rescue cerclage after amniocentesis had a significantly longer mean admission-to-delivery interval, higher mean gestational age at delivery, higher mean birth weight, and higher neonatal survival rate than did the group that had rescue cerclage without amniocentesis and the group that had no cerclage after amniocentesis ( P Conclusion: Amniocentesis before rescue cerclage placement identified women with subclinical chorioamnionitis who would not benefit from cerclage.

REINALDO FIGUEROA-COLON, GARY R. HUNTER, MATTHEW S. MAYO, RUBY A. ALDRIDGE, MICHAEL I. GORAN, and ROLAND L. WEINSIER. Reliability of treadmill measures and criteria to determine VO2max in prepubertal girls. Med. Sci. Sports Exerc., Vol. 32, No. 4, pp. 865–869, 2000.Purpose:The main objective of thi

Background Longitudinal studies in infants and children suggest that low total energy expenditure (EE) (TEE) and parental body composition are important predisposing factors to obesity. Objective The aim of this study was to examine potential predictors of changes in total or percentage body fat over 2.7 y in premenarcheal girls. Design We studied 47 normal-weight prepubertal girls aged 4.8-8.9 y in 3 visits. The girls' age, total and percentage body fat at baseline, sleep EE (SEE) and activity-related EE (AEE) adjusted for fat-free mass (FFM) and total body fat, mothers' and fathers' total and percentage body fat and FFM at baseline, and time to follow-up visits were measured; 24-h EE and SEE were measured by whole-room indirect calorimetry. AEE was calculated as TEE minus (SEE + 0.1 TEE), with the assumption that the thermic effect of food was 10% of TEE. The girls' body composition was measured at each visit and that of the parents was measured at the time of the girls' enrollment by using dual-energy X-ray absorptiometry. Results From baseline to the first (mean: 1.6 y) and the second (mean: 2.7 y) follow-up visits, the girls' mean (+/-SD) change in total fat adjusted for FFM was 1.2 +/- 2.7 and 3.3 +/- 4.0 kg, respectively, and the mean change in percentage body fat was -2.0 +/- 5.0% and -0. 8 +/- 5.9%, respectively. Fathers' total and percentage body fat were the main predictors of changes in the girls' total and percentage body fat. For the first follow-up visit, SEE, girls' age at baseline, and AEE were significant predictors of percentage body fat. Conclusion Fathers' total and percentage body fat were predictors of changes in body fat of premenarcheal girls during a 2. 7-y period.

Objective: To compare the perinatal outcome of triplet gestations with and without prophylactic cerclage.Methods: A retrospective chart review of all triplet gestations delivered between January 1988 and June 1997 was performed. Only women initiating prenatal care before 15 weeks gestation were included. Management guidelines for triplets were uniform with the exception of use of prophylactic cerclage placed at 14 +/- 1 weeks gestation. Hospitalization was reserved for maternal medical and obstetric conditions, or fetal indications. Tocolytics were initiated only for persistent uterine contractions with intact membranes. All deliveries were effected by cesarean section at 37 weeks or less for maternal or fetal indications. All neonates were cared for at our institution. The cerclage group was compared to the no cerclage group for gestational age at delivery and maternal and neonatal complications. Descriptive statistics, Student t test, and Mann-Whitney U test were used for analysis.Results: Fourteen of the 51 (27.4%) sets of triplets had cerclage. There were no differences between groups when compared for maternal age, length of hospital stay, preterm labor rate, steroid use, histologic or clinical chorioamnionitis, and postoperative complications. In addition, there were no differences in mean birth weight, Apgar scores, respiratory distress syndrome, intraventricular hemorrhage/periventricular leucomalacia, NICU stay, and neonatal mortality. Although the mean gestational age at delivery for the cerclage group (33.1 +/- 2.7 weeks) was not different from the no cerclage group (31.7 +/- 3.7 weeks), the proportion of pregnancies delivered at 31 weeks or more was significantly higher in the cerclage group (13/14 vs 23/37, P =.03).Conclusions: Prophylactic cerclage may influence the proportion of triplet gestations delivered at 31 weeks or more. Lack of differences in the other parameters may be reflective of the small sample size.

The purpose of this study was to determine the effects of strength training on fat distribution and its relationship to glucose tolerance in obese prepubertal girls.A strength training intervention study was designed in which the children exercised three times per week for 5 months. Twelve healthy, obese prepubertal girls (ages 7-10 yr,95th percentile weight for height) were enrolled in the study. Body composition was measured by dual-energy x-ray absorptiometry and computed tomography, and glucose tolerance was measured by a 3-h oral glucose tolerance test at baseline and after training.Significant increases in height, weight, fat-free mass, fat mass, and subcutaneous abdominal adipose tissue occurred after training (P0.05), whereas intra-abdominal adipose tissue (IAAT) remained stable (N = 11). Insulin area was highly correlated with IAAT before (r = 0.91) and after (r = 0.90) training (both P0.01, N = 9).In growing obese prepubertal girls undergoing a strength training program, IAAT remains unchanged, whereas subcutaneous abdominal fat and total body fat increased; insulin area is related to IAAT in these children.

Objective: To determine the relationship between amniotic fluid (AF) neuron-specific enolase and the development of neonatal intraventricular hemorrhage and periventricular leucomalacia. Methods: Thirty-nine AF samples, obtained from women in preterm labor between 24 and 32 weeks’ gestation, were analyzed for neuron-specific enolase. All women delivered preterm neonates who had neurosonograms on the 3rd and 7th days of life. The results of the neurosonograms were used to divide the study population first into normal and abnormal groups, then into normal, minor, and major brain lesion groups. The groups were compared for the median neuron-specific enolase, proportion with values of 6 μg/L or more, and other demographic characteristics. Results: There were no differences between the groups’ maternal and neonatal characteristics. However, the abnormal group had significantly higher median value of neuron-specific enolase than the normal group (9.5 μg/L and 2.0 μg/L, respectively; P < .001). The median neuron-specific enolase levels for the major, minor, and normal groups were 9.75 μg/L, 6.5 μg/L and 2.0 μg/L, respectively (P < .001). The optimum cutoff point, with a sensitivity of 89% and specificity of 100%, was 6 μg/L; 89% of the abnormals had values of 6 μg/L or more, compared with none of the normals (P < .001). The risk of developing intraventricular hemorrhage or periventricular leucomalacia was 11.5 times greater when AF neuron-specific enolase levels were 6 μg/L or more. Conclusion: Amniotic fluid neuron-specific enolase is a useful marker of neonatal neurologic injury.