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Intrapartum transperineal ultrasound is considered useful in judging fetal head descent; however, the inability to detect ischial spines on ultrasound images has been a drawback to its legitimacy. The current study aimed to determine the anatomical location of ischial spines, which can be directly applied to intrapartum transperineal ultrasound images. Based on magnetic resonance imaging (MRI) of 67 pregnant women at 33+2 [31+6-34+0] weeks gestation (median [interquartile range: IQR]), we calculated the angle between the pubic symphysis and the midpoint of ischial spines (midline symphysis-ischial spine angle; mSIA), which is theoretically equivalent to the angle of progression at fetal head station 0 on ITU, by determining spatial coordinates of pelvic landmarks and utilizing spatial vector analysis. Furthermore, we measured symphysis-ischial spine distance (SID), defined as the distance between the vertical plane passing the lower edge of the pubic symphysis and the plane that passes the ischial spines. As a result, mSIA was 109.6° [105.1–114.0] and SID 26.4 mm [19.8–30.7] (median, [IQR]). There was no correlation between mSIA or SID and maternal characteristics, including physique. We established a novel method to measure the components of the pelvic anatomy by analyzing the three-dimensional coordinates of MRI data and identified the anatomical location of ischial spines which can be applied to ultrasound images. Our results provide valuable evidence to enhance the reliability of intrapartum transperineal ultrasound in assessing fetal head descent by considering the location of ischial spines.

Objective We experienced a case of 22q11.2 deletion syndrome (22qDS), with severe polyhydramnios, and dysphagia, which prompted us to review prognosis in neonates with 22qDS, with a focus on dysphagia. Case report A patient was referred to our hospital at 35 gestational weeks because of polyhydramnios. After amniotic fluid reduction, labor was induced at 38 weeks. The neonate had serious dysphagia, and 22qDS was diagnosed postnatally by fluorescent in situ hybridization analysis. This prompted a retrospective analysis of 9 cases with 22qDS experienced in our facility. Three out of these nine cases showed polyhydramnios, and had severe dysphagia postnatally. In total, 4 cases had dysphagia, while mortality was observed in 2 of these 4 cases. Additionally, 5 cases without dysphagia had normal development and no major complications. Conclusion Polyhydramnios associated with postnatal dysphagia might be a risk factor related to short-term prognostic outcomes in newborns with 22qDS.

Objective: Additional risk factors for preterm delivery in pregnant women with cervical shortening are not fully understood; however, mid-trimester cervical shortening is accepted as a risk factor for preterm delivery. This study aimed to identify risk factors associated with subsequent preterm delivery among patients with short cervix detected after late mid-trimester. Materials and methods: This was a retrospective study of medical data from a single perinatal tertiary facility. We identified 134 asymptomatic women with singleton pregnancies where cervical shortening (≤25 mm) was detected during routine universal screening at 22–33 weeks. Statistical analyses were conducted to identify causal relationships between the incidence of preterm delivery and known risk factors for preterm delivery. Results: Incidence of preterm delivery was 27.6% (37/134) and preterm premature rupture of membrane was preceded in 46.0% (17/37) of the women with preterm delivery. Using logistic regression analysis, we identified uterine contractions [aOR 4.25, 95% confidence intervals (CI):1.68–12.1] and increased C-reactive protein (CRP) and increased white blood cell (WBC) in blood test (CRP: aOR 3.45, 95% CI:1.50–9.71; WBC: aOR 1.28, 95% CI: 1.08–1.55) as risk factors which significantly increased the risk of preterm delivery among women diagnosed with short cervix. Preterm delivery occurred in 91% of women positive for both uterine contractions and CRP >0.5 mg/dl. Conclusions: Uterine contraction and elevated CRP were additional risk factors for preterm delivery among women with short cervix. These results might be clinically useful to evaluate subsequent risk for preterm delivery in asymptomatic pregnant women presenting with short cervix in mid-pregnancy. Keywords: Preterm labor, Cervical length, Inflammation, Pregnancy

Objective Loeys-Dietz syndrome (LDS) is associated with a higher risk of aortic dissections (ADs) during pregnancy and postpartum. However, there is limited evidence about the perinatal management of LDS patients who have undergone prophylactic aortic root replacements (ARRs) before conception. Case report We present the case of a 28-year-old nulliparous pregnant woman with LDS with a pathogenic variant within exon 5 of TGFBR2 (c.1379G > T, p.[Arg460Leu]), who underwent an ARR at 20 years of age. Cardiac echocardiography did not show any significant changes in the aorta during pregnancy, and her blood pressure remained normal. She had a cesarean section at 37 weeks of gestation. She developed an acute Stanford type B AD extending from the aortic arch to the infrarenal aorta 8 days postpartum and underwent a total arch replacement. Conclusion This case report suggests that patients with LDS after prophylactic ARRs still possess a risk for Stanford type B ADs.

Objectives: To investigate the spontaneous outcomes of vascularized retained products of conception (RPOC) detected by ultrasonography after second-trimester abortion, and to identify the predictiv...

Pulmonary hypoplasia is a rare entity in a fetus with imperforate anus. The fetus was diagnosed with high-type imperforate anus with rectourethral fistula based on the dilated fetal bowel and the presence of bowel calcification at 19 weeks of gestation. As gestation advanced, fetal ultrasonography demonstrated development of pulmonary hypoplasia, progressive bowel dilation, and persistent oligohydramnios from 28 weeks of gestation despite a fluid-filled bladder without hydroureter or hydronephrosis. To prevent further worsening of pulmonary hypoplasia caused by thoracic compression due to bowel dilation and oligohydramnios, a male neonate was delivered by cesarean section at 32 weeks of gestation. The neonate showed respiratory failure requiring full respiratory support. Although a catheter did not pass through the urethra into the bladder at birth, cystourethrography revealed the patency of fistula and stenosed lower urinary tract. Prenatal and postnatal findings strongly suggested that the meconium in the colon might have passed into the urethra in the penis, resulting in the physical blockage of urine outflow to the amniotic space which leads urine flow from the bladder to the colon through the fistula, which resulted in subsequent oligohydramnios and bowel dilation. To the best of our knowledge, this is the first case report of a fetus with imperforate anus developing pulmonary hypoplasia possibly due to urethral obstruction.

Previous studies have reported that congenital heart diseases (CHDs) develop in patients with genetic and environmental predisposition. Compared to CHDs, the significance of hereditary factors in the pathogenesis of congenital venous system anomalies remains unclear. Additionally, reports describing the pathogenic relationship between venous system anomalies and increased nuchal translucency (NT) are few. We report sibling recurrence of congenital venous system anomalies. In the prenatal periods of both siblings, increased NT without aneuploidy was confirmed. In the first sibling, the absence of ductus venosus (ADV) and umbilical vein-coronary sinus anastomosis was detected using prenatal ultrasonography. In the second sibling, abnormality of the pulmonary vein was suspected prenatally, leading to a final diagnosis of infracardiac total anomalous pulmonary venous return (TAPVR). This is the first report of extracardiac venous anomaly-associated recurrence of increased NT among siblings. We conclude that a hereditary factor may be responsible for the development of ADV and TAPVR.

OBJECTIVE To investigate pregnancy outcomes, especially the risk of pregnancy-related aortic dissection (AD), in patients with Marfan syndrome (MFS) after prophylactic aortic root replacement (ARR). DESIGN Retrospective case series study. SETTING Tertiary perinatal care centre at a university hospital. POPULATION Pregnant women fulfilling the revised Ghent nosology (2010) criteria for MFS who were managed at our institute. METHODS The pregnancy outcomes of all patients with MFS managed at our institute between 1982 and September 2016 were reviewed retrospectively based on medical records. MAIN OUTCOME MEASURES Obstetrical management and complication including the incidence of AD throughout the peripartum period. RESULTS Among 22 patients (28 pregnancies) who had been managed as potential MFS or related disorders, 14 (17 pregnancies) fulfilled the revised Ghent nosology (2010) criteria for MFS and were enrolled in this study. Five patients (five pregnancies) had received ARR before conception: three (60%) developed type B aortic dissection [AD(B)] during the peripartum period, compared with only one of 10 patients (12 pregnancies) without ARR (P

Secretory leukocyte protease inhibitor (SLPI) and progranulin (PGRN) are secretory proteins with an anti-inflammatory property. Their involvement in cervical remodeling in pregnant uterus is not yet elucidated. Thus, this study aimed to explore the significance of SLPI and PGRN in the maintenance of pregnancy by investigating the factors associated with their expression levels at the cervix. Concentrations of SLPI and PGRN proteins were measured in cervical mucus samples collected from asymptomatic pregnant women at 24-26 weeks of gestation (n = 166). The concentrations of those molecules were analyzed with clinical parameters related to risk for preterm delivery (PD). In pregnant mice, we evaluated the effect of lipopolysaccharide-induced inflammation and progesterone effect modulation on cervical mRNA expression of SLPI and PGRN. The cervical PGRN level was significantly lower in women with short cervix (

To evaluate the potential impact of adenomyosis on the pregnancy outcomes by retrospectively investigating adenomyosis-complicated pregnancy cases.We performed a retrospective case-control study. Forty-nine singleton pregnancy cases complicated with adenomyosis were included in this study. The controls (n = 245) were singleton pregnant women without adenomyosis and were frequency matched to adenomyosis cases by age, parity, and the need for assisted reproductive technology for this conception. The incidence of obstetrical complications and delivery and neonatal outcomes were examined.Patients in the adenomyosis group were significantly more likely to have a second trimester miscarriage (12.2% versus 1.2%, odds ratio (OR): 11.2, 95% confidence interval (95% CI): 2.2-71.2), preeclampsia (18.3% versus 1.2%, OR: 21.0, 95% CI: 4.8-124.5), placental malposition (14.2% versus 3.2%, OR: 4.9, 95% CI: 1.4-16.3), and preterm delivery (24.4% versus 9.3%, OR: 3.1, 95% CI: 1.2-7.2), compared with the control group.Adenomyosis was associated not only with an increased incidence of preterm delivery, as previously reported, but also with an increased risk of second trimester miscarriage, preeclampsia, and placental malposition, which could lead to poor perinatal outcomes.

Background: Insufficient oxygen supply is associated with the pathophysiology of fetal growth restriction (FGR). Although the erythrocyte (RBC) is the most abundant and only cell type to deliver oxygen, its function and regulatory mechanism in FGR remains unknown. Recently, adenosine uptake by equilibrative nucleoside transporter 1 (ENT1), a key adenosine transporter expressed in RBCs, was reported to be crucial for RBCs to deliver oxygen. We aimed to investigate the involvement of RBCs' oxygen delivering capacity in maintaining fetal growth by focusing on RBC ENT1. Methods and Results: The mating strategy was to delete ENT1 only on the maternal RBCs but not in the placentas or fetuses to assess the effect of maternal RBC ENT1 on fetal growth. Specifically, EpoR-Cre+ (EPO) female mouse was used as a control and Ent1f/f-EpoR-Cre+ (E1FE) female mouse as an experimental mouse and mated with WT male mouse. As a result, E1FE dams showed FGR phenotype with reduction of 12.9% in fetal weight compared to EPO group. The maternal RBCs showed decrease in p50 and 2,3-BPG in E1FE, indicating decreased oxygen delivery in E1FE RBCs. To determine the molecular basis underlying the FGR phenotype seen in EIFE dams, we conducted a metabolomics screening of the RBCs isolated from controls and EIFE dams. It showed that adenosine metabolism inside the RBCs is the most impacted pathway. Specifically, it showed decrease in adenosine, AMP, and hypoxanthine, but adenine, ADP, and ATP did not show any reduction, implicating that ENT1-mediated uptake of adenosine is largely converted to AMP. We then incubated either WT or ENT1 KO RBCs with isotopically 13C15N labeled adenosine and traced the metabolism of intracellular adenosine derived from labeled adenosine. Indeed, adenosine was rapidly phosphorylated to AMP upon uptake, and 13C15N labeled AMP levels were lower in the ENT1 KO RBCs compared to controls. These findings provide evidence that 1) the most affected metabolic pathway in the RBCs of EIFE dam is adenosine metabolism; 2) ENT1-mediated uptake of extracellular adenosine is largely converted to AMP but not ATP. We hypothesized that decreased AMP/ATP ratio underlies the reduced 2,3-BPG production by lowering AMPK activity and subsequently decreasing BPG mutase (BPGM) activity. We measured AMPK phosphorylation and BPGM activity in the RBCs from E1FE and EPO dams. Both AMPK and BPGM activity were decreased in RBCs of E1FE dams compared to controls. Thus, we conclude that i) adenosine derived from uptake via ENT1 is largely converted to AMP; ii) lack of maternal RBC ENT1 lowers AMP/ATP ratio and activity of AMPK and BPGM in maternal RBC. We conducted immunofluorescence staining to assess hypoxia in the placentas, and confirmed the increased expression of HIF-1α in the placentas from E1FE dams. To determine functional changes of these placentas, we conducted metabolomics profiling in both the placenta and maternal plasma. Of all the metabolites altered, amino acids (AA) were the most reduced metabolites in E1FE placentas. In contrast, AA were the most accumulated in maternal plasma. We then injected isotopically labelled 13C15N AA mix in both controls and EIFE dams 24 hours prior to sacrifice. 13C15N AA level was decreased in the placentas in EIFE compared to the controls, while it was accumulated in plasma of EIFE, indicating reduced AA transporter function in the placentas of EIFE. Finally, we performed real time PCR to quantify the mRNA of the known main transporters of AA in the mouse placenta. It showed reduction of LAT1 mRNA in E1FE placenta, where there was no difference in LAT2, SNAT1, or SNAT2. Western blot of the placenta lysates confirmed the expression of LAT1 was indeed reduced. To validate our mouse finding and determine if HIF-1α elevation directly induces LAT1 mRNA in humans, we treated cultured human trophoblast cell line (HTR-8/SVneo cells) with or without DMOG, a cell permeable prolyl-4-hydroxylase inhibitor. After confirming DMOG upregulated HIF-1α, we found stabilized HIF-1α induced LAT1 mRNA levels. Thus, we conclude that elevated HIF-1α underlies the reduction of LAT1 mRNA in cultured human trophoblasts. Conclusion: Our findings suggest that maternal RBCs' oxygen delivering capacity mediated by ENT1 is essential for maintaining adequate placental oxygenation to support fetal growth via AA transporter function. Strategies to improve RBCs' function to deliver oxygen may provide new therapeutic possibilities for FGR. Figure Disclosures No relevant conflicts of interest to declare.

Citation Iwasawa Y, Kawana K, Fujii T, Schust DJ, Nagamatsu T, Kawana Y, Sayama S, Miura S, Matsumoto J, Adachi K, Hyodo H, Yamashita T, Kozuma S, Taketani Y. A possible coagulation-independent mechanism for pregnancy loss involving β2glycoprotein 1-dependent antiphospholipid antibodies and CD1d. Am J Reprod Immunol 2012; 67: 54–65 Problem β2glycoprotein1 (β2GP1)-dependent antiphospholipid antibodies (aPL) increase the risk for recurrent pregnancy loss. We address whether anti-β2GP1 antibodies can interact with phosphatidylserine (PS)-bearing CD1d on trophoblast cells and induce local inflammation. Methods CD1d-bearing choriocarcinoma cells were used in flow cytometry and immunoprecipitation experiments. CD1d-mediated cytokine induction was assessed using antibody cross-linking. Cytokine production during co-culture of decidual lymphocytes with CD1d-bearing cells was also examined. Results Trophoblast surface-expressed CD1d forms a complex with PS-bound β2GP1. Anti-β2GP1 mAb cross-linking causes IL12p70 release from CD1d-bearing cells. IL12p70 release from CD1d-bearing trophoblast cells was also induced during co-culture with human decidual lymphocytes. The addition of anti-β2GP1 mAb to co-cultures resulted in a three-fold increase in IL12p70 secretion. IFNγ secretion from decidual lymphocytes was also induced during co-culture with anti-β2GP1 mAbs. Conclusions β2GP1-dependent IL12 release from CD1d-bearing trophoblast in the presence of aPL may link the antiphospholipid syndrome to pregnancy loss via an inflammatory mechanism.