•Placental insufficiency is emerging as a contributor to spontaneous preterm birth.•Thrombin may be involved in mechanisms leading to spontaneous preterm birth.•PAPP-A and PlGF may prove useful in ...the prediction in spontaneous preterm birth.
Preterm Birth (delivery before 37 weeks of gestation) is the leading cause of childhood mortality and is also associated with significant morbidity both in the neonatal period and beyond. The aetiology of spontaneous preterm birth is unclear and likely multifactorial incorporating factors such as infection/inflammation and cervical injury. Placental insufficiency is emerging as an additional contributor to spontaneous preterm delivery; however, the mechanisms by which this occurs are not fully understood. Serum biomarkers and imaging techniques have been investigated as potential predictors of placental insufficiency, however none have yet been found to have a sufficient predictive value. This review examines the evidence for the role of the placenta in preterm birth, preterm prelabour rupture of the membranes and abruption as well as highlighting areas where further research is required.
Abstract Objective Treatment modalities to reduce the incidence of preterm birth are currently limited. Cerclage, is a common and established intervention in most obstetrics units worldwide, however, ...many questions regarding its efficacy, with respect to pregnancy outcomes remain unanswered. This study aims to investigate whether an antenatal placed cerclage affects the subsequent mode of delivery in women at high risk of preterm birth who labour. Study Design A retrospective case controlled study was performed at St Thomas’s Hospital London. Women who had undergone cervical cerclage were identified using a pre-existing database (n = 152). Cases were excluded where a C-section had been performed prior to labour (n = 26), datasets were incomplete (n = 5) or a rescue cerclage was performed (n = 2). Remaining cases were categorised into those who had: history indicated (n = 68) or ultrasound indicated (n = 51) cerclage. Control cases were obtained from the same database who also laboured but had not undergone cerclage, matched according to gestational age at delivery and parity (n = 114). Demographic details and outcome data were recorded. Groups were compared using Chi Squared analysis for discrete variables and t-test for continuous variables using IBM SPSS Statistics version 22. Results There was no statistical difference in the emergency C-section rate between history indicated and ultrasound indicated cerclage, or between patients who received cerclage and those who had not (p = 0.592). The emergency C-section rate for each group was: history indicated, 25%, ultrasound indicated 18% and no cerclage 18%. Conclusions Women at risk of preterm birth have high rates of emergency C-section despite the fact that the majority were multiparous. However, they can be reassured that cervical cerclage does not increase this risk.
Intergenerational transmission of marital functioning was examined in a sample of 60 newlywed couples by collecting (a) retrospective reports of conflict and divorce in spouses' families of origin, ...(b) data on demographic variables and interactional processes likely to increase risk for adverse marital outcomes, and (c) couples' actual 4-year marital outcomes. The association between wives' parental divorce and marital outcome was mediated by their verbal and physical aggression. The association between negativity in husbands' family of origin and marital outcome was mediated by dyadic expressions of negative affect. Demographic variables did not operate as mediators. Negative interpersonal processes appear to be a vehicle by which experiences in the family of origin are carried forward into the next generation of relationships.
Abstract Objective To utilise combined diffusion‐relaxation MRI techniques to interrogate antenatal changes in the placenta prior to extreme preterm birth among both women with PPROM and membranes ...intact, and compare this to a control group who subsequently delivered at term. Design Observational study. Setting Tertiary Obstetric Unit, London, UK. Population Cases: pregnant women who subsequently spontaneously delivered a singleton pregnancy prior to 32 weeks' gestation without any other obstetric complications. Controls: pregnant women who delivered an uncomplicated pregnancy at term. Methods All women consented to an MRI examination. A combined diffusion‐relaxation MRI of the placenta was undertaken and analysed using fractional anisotropy, a combined T2*‐apparent diffusion coefficient model and a combined T2*‐intravoxel incoherent motion model, in order to provide a detailed placental phenotype associated with preterm birth. Subgroup analyses based on whether women in the case group had PPROM or intact membranes at time of scan, and on latency to delivery were performed. Main Outcome Measures Fractional anisotropy, apparent diffusion coefficients and T2* placental values, from two models including a combined T2*‐IVIM model separating fast‐ and slow‐flowing (perfusing and diffusing) compartments. Results This study included 23 women who delivered preterm and 52 women who delivered at term. Placental T2* was lower in the T2*‐apparent diffusion coefficient model ( p < 0.001) and in the fast‐ and slow‐flowing compartments ( p = 0.001 and p < 0.001) of the T2*‐IVIM model. This reached a higher level of significance in the preterm prelabour rupture of the membranes group than in the membranes intact group. There was a reduced perfusion fraction among the cases with impending delivery. Conclusions Placental diffusion‐relaxation reveals significant changes in the placenta prior to preterm birth with greater effect noted in cases of preterm prelabour rupture of the membranes. Application of this technique may allow clinically valuable interrogation of histopathological changes before preterm birth. In turn, this could facilitate more accurate antenatal prediction of preterm chorioamnionitis and so aid decisions around the safest time of delivery. Furthermore, this technique provides a research tool to improve understanding of the pathological mechanisms associated with preterm birth in vivo.
The development of placenta and fetal brain are intricately linked. Placental insufficiency is related to poor neonatal outcomes with impacts on neurodevelopment. This study sought to investigate ...whether simultaneous fast assessment of placental and fetal brain oxygenation using MRI T2* relaxometry can play a complementary role to US and Doppler US.
This study is a retrospective case-control study with uncomplicated pregnancies (n = 99) and cases with placental insufficiency (PI) (n = 49). Participants underwent placental and fetal brain MRI and contemporaneous ultrasound imaging, resulting in quantitative assessment including a combined MRI score called Cerebro-placental-T2*-Ratio (CPTR). This was assessed in comparison with US-derived Cerebro-Placental-Ratio (CPR), placental histopathology, assessed using the Amsterdam criteria 1, and delivery details.
Pplacental and fetal brain T2* decreased with increasing gestational age in both low and high risk pregnancies and were corrected for gestational-age alsosignificantly decreased in PI. Both CPR and CPTR score were significantly correlated with gestational age at delivery for the entire cohort. CPTR was, however, also correlated independently with gestational age at delivery in the PI cohort. It furthermore showed a correlation to birth-weight-centile in healthy controls.
This study indicates that MR analysis of the placenta and brain may play a complementary role in the investigation of fetal development. The additional correlation to birth-weight-centile in controls may suggest a role in the determination of placental health even in healthy controls. To our knowledge, this is the first study assessing quantitatively both placental and fetal brain development over gestation in a large cohort of low and high risk pregnancies. Future larger prospective studies will include additional cohorts.
•Quantitative functional (T2*) MRI data from fetal brain & placenta in <1min.•The MRI Cerebro-Placental-T2*-Ratio (CPTR) is proposed & analysed.•Normative quantitative functional & structural MRI trends in a control cohort were obtained.•CPTR is correlated with birth weight centile in all and GA at delivery in controls.
To review systematically the quality, readability and credibility of English language webpages offering patient information on fetal growth restriction.
A systematic review of patient information was ...undertaken on Google with location services and browser history disabled. Websites from the first page were included providing they gave at least 300 words of health information on fetal growth restriction aimed at patients. Validated assessment of readability, credibility and quality were undertaken. An accuracy assessment was performed based on international guidance. Characteristics were tabulated.
Thirty-one websites including 30 different texts were included. No pages had a reading age of 11 years or less, none were credible, and only one was of high quality. Median accuracy rating was 9/24.
Patients cannot rely on Google as a source of information on fetal growth restriction. As well as being difficult to read, information tends to be low quality, low accuracy and not credible. Healthcare professionals must consider how to enable access to high-quality patient information and give time for discussion of information patients have found: failure to do so may disenfranchise patients.
Although pre-eclampsia affects 5–10% of pregnancies globally and is responsible for substantial maternal and perinatal morbidity and mortality, currently there is no cure other than delivery of the ...baby. Predictive screening tests based on clinical risk factors, with or without the addition of biomarkers and imaging, have been developed, but adoption into clinical practice is limited by suboptimal test performance. Once established pre-eclampsia is diagnosed, a woman is usually managed expectantly prior to 37weeks' gestation to reduce perinatal morbidity and mortality associated with iatrogenic prematurity until maternal or fetal triggers for delivery mean that risks of pregnancy prolongation outweigh the benefits. Associated fetal growth restriction is a common feature of pre-eclampsia, particularly with early-onset disease, and will influence decisions for delivery and subsequent neonatal course. Prematurity and fetal growth restriction both have potential short and long-term consequences for the infant and child.
Cervical cerclage is an intervention which when given to the right women can prevent preterm birth and second‐trimester fetal losses. A history‐indicated cerclage should be offered to women who have ...had three or more preterm deliveries and/or mid‐trimester losses. An ultrasound‐indicated cerclage should be offered to women with a cervical length <25 mm if they have had one or more spontaneous preterm birth and/or mid‐trimester loss. In high‐risk women who have not had a previous mid‐trimester loss or preterm birth, an ultrasound‐indicated cerclage does not have a clear benefit in women with a short cervix. However, for twins, the advantage seems more likely at shorter cervical lengths (<15 mm). In women who present with exposed membranes prolapsing through the cervical os, a rescue cerclage can be considered on an individual case basis, taking into account the high risk of infective morbidity to mother and baby. An abdominal cerclage can be offered in women who have had a failed cerclage (delivery before 28 weeks after a history or ultrasound‐indicated but not rescue cerclage). If preterm birth has not occurred, removal is considered at 36–37 weeks in women anticipating a vaginal delivery.
Synopsis
Cervical cerclage given to the right women can prevent preterm birth and second‐trimester fetal losses.
Demographic and relationship quality data were collected from 704 individuals recruited to participate in a randomized study of relationship enhancing interventions. Recruiting at bridal shows ...produced partners who were more satisfied, earlier in their relationships, and less likely to be parents, with a marginally higher proportion of Latino couples. Radio and television coverage produced more established couples with higher levels of relationship discord. Self-selection effects revealed that couples from demographic groups at greater risk for divorce (those who had not completed high school, those with children at marriage, and African American couples) were more likely to agree to participate. In contrast, imposing a set of common selection criteria served to exclude couples from demographic risk groups and selected for couples with higher marital quality. Implications for recruiting couples to participate in preventive interventions are outlined.
Objectives
To evaluate changes occurring in the fetal brain prior to very preterm delivery using MRI T2* relaxometry, an indirect assessment of tissue perfusion.
Method
Fetuses that subsequently ...delivered spontaneously <32 weeks gestation and a control cohort were identified from pre‐existing datasets. Participants had undergone a 3T MRI assessment including T2* relaxometry of the fetal brain using a 2D multi‐slice gradient echo single shot echo planar imaging sequence. T2* maps were generated, supratentorial brain tissue was manually segmented and mean T2* values were generated. Groups were compared using quadratic regression.
Results
Twenty five fetuses that subsequently delivered <32 weeks and 67 that delivered at term were included. Mean gestation at MRI was 24.5 weeks (SD 3.3) and 25.4 weeks (SD 3.1) and gestation at delivery 25.5 weeks (SD 3.4) and 39.7 weeks (SD 1.2) in the preterm and term cohorts respectively. Brain mean T2* values were significantly lower in fetuses that subsequently delivered before 32 weeks gestation (p < 0.001).
Conclusion
Alterations in brain maturation appear to occur prior to preterm delivery. Further work is required to explore these associations, but these findings suggest a potential window for therapeutic neuroprotective agents in fetuses at high risk of preterm delivery in the future.
Key points
What is already known on this topic?
Few studies have been conducted exploring brain development prior to preterm birth; however, a reduction in the cerebral cortex and extracerebrospinal fluid volumes and alterations in functional connectivity have been reported in fetuses that subsequently deliver preterm.
What does this study add to what is known?
Mean T2* relaxometry values are significantly lower in fetuses that subsequently deliver <32 weeks in comparison with fetuses that deliver at term, indicating that alterations in tissue perfusion may be occurring prior to preterm birth.
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