National Heart Lung and Blood Institute grants T32HL007525 and R01HL133113.
Exposure to intrauterine inflammation (IUI) is associated with short- and long-term adverse perinatal outcomes. However, little data exist on utilizing placenta to prognosticate fetal injury in this scenario. Our study aimed to utilize imaging modalities to evaluate mechanisms contributing to placental injury following IUI exposure and correlated it to concomitant fetal brain injury. CD1 pregnant dams underwent laparotomies and received intrauterine injections of either lipopolysaccharide (LPS; a model of IUI) or phosphate-buffered saline (PBS). In utero ultrasound Doppler velocimetry of uterine and umbilical arteries and magnetic resonance imaging (MRI) of placental volumes with confirmatory immunohistochemical (vimentin) and histochemistry (fibrin) analyses were performed. ELISA for thrombosis markers, fibrinogen and fibrin was performed to analyze thrombi in placenta. Fetal brain immunohistochemistry was performed to detect microglial activation (ionized calcium-binding adaptor molecule 1, Iba1). On ultrasound, LPS group demonstrated elevated resistance indices, pulsatility indices and a greater occurrence of absent end-diastolic flow in the umbilical and uterine arteries. In the fetus, there was an increased cardiac Tei indices in the LPS group. MRI revealed decreased volume of placenta in the LPS group associated with placental thinning and placental endothelial damage on immunohistochemistry. Decreased fibrinogen content and more thrombi staining in placenta exposed to maternal LPS indicated the hypercoagulability. Furthermore, the expression of Iba1was significantly associated with placental thickness (r = -0.7890, Pearson correlation coefficient). Our data indicate that IUI can trigger events leading to maternal placental malperfusion and fetal vessel resistance, as well as predispose the developing fetus to cardiac dysfunction and brain damage. Furthermore, our data suggest that prenatal ultrasound can be a real-time clinical tool for assessing fetal risk for adverse neurologic outcomes following the potential IUI exposure.
To evaluate the impact of a preemptive case review process for all scheduled inductions up to 41 3/7 weeks of gestation on overall induction and primary cesarean delivery (CD) rates and other maternal and neonatal outcomes. STUDY DESIGN: Retrospective cohort study conducted at a single, academic, tertiary care center over a 6-year period from 2006-2012, 3 years before and after the implementation in 2009 of a formal peerreview process for all scheduled labor inductions. Inductions were classified as "medically indicated" or "nonmedically indicated" based on contemporary ACOG criteria and consensus panel opinion. Exclusion criteria included multiple gestations, prior CD or myomectomy, fetal malpresentation, or suspected abnormal placentation. Abstracted data included demographics, indication(s) for induction, gestational age at delivery, mode of delivery, and maternal and neonatal outcomes. RESULTS: During the study period, 13,753 deliveries occurred at our institution; 8,147 (59.2%) met study inclusion criteria. Labor was induced in 1,579 (19.4%) deliveries; the overall induction rate decreased from the pre-to the post-intervention period (21.0% versus 18.5%, p¼0.01) (Table). Nonmedically indicated induction rates also decreased significantly (2.9% versus 0.6%, p<0.001). Maternal wound infection and venous thromboembolism (VTE) rates were significantly lower in the post-intervention period (2.3% versus 1.1%, p<0.001; 0.4% versus 0.2%, p¼0.04, respectively), but there was no difference in rates of postpartum hemorrhage, chorioamnionitis, endomyometritis, or blood transfusion. No difference was observed in either the primary CD rate (14.4% versus 15.8%, p¼0.12) or neonatal outcomes including 5-minute APGAR <7, NICU admission, or stillbirth. CONCLUSION: Implementation of a case review process was associated with reduced overall and nonmedically indicated induction rates but did not affect primary CD rates or neonatal outcomes. Reductions in VTE and wound infection rates were likely attributable to concurrent practice changes. A less restrictive approach to induction between 39 and 41 weeks of gestation may be appropriate.
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