Tehran University Medical Journal

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The present research is a quasi-experimental prospective study to determine usefulness of stripping the fetal memberanes at term for preventing of postterm pregnancy. 212 pregnant women with firm gestational dates entered the study, 112 underwent stripping of the membranes and 100 controls did not. The difference between the number of patients who advanced beyond term (>290 days) was statistically significant between groups (P<0.01). The mode of delivery and neonatal APGAR score were similar in both groups.

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Acute amniotic fluid infection has emerged as a possible cause of many heretofore unexplained preterm births. Our purpose was to determine the effect of ampicillin in the prolongation of pregnancies receiving tocolysis for preterm labor. A blinded, placebo-controlled, randomized trial was conducted to study ampicillin in women hospitalized for preterm labor between 24 and 37 weeks' gestation. A total of 60 patients with intact membranes and without chorioamnionitis who were receiving magnesium sulfate were screened. Thirty women with preterm labor received ampicillin, and 30 received placebos. The primary end point was prolongation of gestation. There was no difference in age of delivery (37.6±9.7 days vs 36.08±3.9 days, P=0.085) and no difference in retardation of delivery (4.7±3.1 vs 4.1±2.1, P=0.39). The mean degree of preterm delivery were 0.62±1.93 and 1.8±3.3 weeks in ampicillin and placebo groups, respectively (not significant, P>0.1). Conclusions: Ampicillin had no effect on interval to delivery or duration of pregnancy in women treated for preterm labor. So rotine clinical use of ampicillin during tocolysis should not be recommended.

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There are now several tests available that can assess fetal status. A series of 164 cases of high risk pregnancies were studied in order to assess predictive value of a nonstress test. The majority (36%) of patients complained about postdate pregnancy. A nonreactive test was identified in 24 of the patients (14.6%). Fetal distress, low Apgar score in 1 and 10 minutes after birth and mean of Apgar score in 5 minutes, cesarean section due to fetal distress, congenital anomalies, need of neonatal care, IUGR, abnormal presentation and perinatal death were much more common in the group of pregnancies with a nonreactive NST than in the group with reactive test. The difference was statistically significant. A reactive test was found to be a good predictor of the healthy fetus. Negative predictive value and specifity of the test were found 80% and 91.9%, respectively. The nonreactive test could identify a population at risk but it was not helpful as a stand alone modality in decision making, because of the low sensitivity and positive predictive value rates (33.3% and 58%).

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Estimating fetal weight in utero, for better management of pregnancy and appropriate timing of delivery especially in high-risk pregnancies is necessary. Our purpose to evaluate a simple method in estimating fetal weight in Iranian pregnant patients and also to compare was with a previous western study. This study was carried out in Arash hospital, Tehran university of medical sciences in 1996-99. In a descriptive-analytic study that was done prospectively on 464 pregnant patients, ultrasonic measurement of biparietal diameter (BPD), mean abdominal diameter (MAD), and femur length (FL) performed close to delivery was conducted. Birth weight also was identified. Statistical analysis was done using multiple linear regression on the data and also student's T-test for comparison. Mean birth weight was 2320 gr. The outcome of linear regression analysis was the following model: Weight (gr)=95.8×FL (cm)+25×MAD (cm)-15.6×BPD (cm)-4632.1. The effect of all parameters were statistically significant (P<0.02). A fetal weight estimating table was also developed. T-test analysis showed a significant difference (P<0.05) in some final ranks of table (Weight estimations>4000 gr) in comparison with the Rose and Mc callum study. Our study showed that ultrasound using the sum of BPD, MAD and FL is a precise method in fetal weight estimation. Application of other biometric measurements may be needed for better elucidation especially in small and large for gestational age fetuses.

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Background: The preeclampsia/eclampsia is one of the most serious condition peculiar to pregnancy, which defined as occurrence of hypertension, proteinuria in pregnancy and convulsion in eclamptic women. There are major risk for eclamptic and pre eclamptic women due to maternal and fetal complications.

Materials and Methods: In a prospective study, preeclamptic and eclamptic patients who were visited at Shariati hospital were divided into two groups due to having proper prenatal care or not. Maternal and fetal complication were studied in that two group. Maternal variables were included: incidence of preterm labor, eclampsia, mode of delivery, long term hospitalization, need for ICU, need to antihypertensive drugs over postportum, insistence of hypertension up to 6 weeks, postpartum trombocytosis, incidence of cesarean section due to abruptio placenta and IUGR, elevation of serum creatinine, incidence of HELLP syndrome and death of mother fetal variables were included incidence of IUGR and IUFD, pre term delivery and for need NICU. Relationship of demographic characteristics such as maternal age, parity, educational level, mode of delivery, presence of underlying disease, and educational level of person who referred the patient were studied.

Results: These variables except of educational level, and referral level were there was statistically significant difference between incidence of all of variables, in exception of mode of delivery. That means incidence of complications is lower in group with adequate prenatal care. Conclusion: It seems that adequate pernatal care can reduce or obligate maternal and fetal complication in hypertensive disorders in pregnancy.

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Background: The purpose of this study was to compare electronic fetal heart rate monitoring (EFM) characteristics between Appropriate for Gestational Age (AGA ) and Small for Gestational Age (SGA) fetuses and to determine whether SGA fetuses have specific abnormalities.

Materials and Methods: Among children born from Apr 2002 to Mar 2003 in Arash hospital, we identified 300 singleton infants born after 36 weeks' gestation of uncomplicated pregnancies in whom second-trimester (24-27 weeks' gestation) EFM records were obtained. Individual components of fetal heart rate (FHR) pattern baseline rate, baseline FHR variability, presence of acceleration and periodic and episodic deceleration , and birth characteristics were compared between AGA and SGA infants or between pregnancies with or without second-trimester decelerations. Statistical analysis was performed using Student t, Chi square and Fisher exact test.

Results: Among 300 infants, 261 (87%) were AGA and 39 (13%) were SGA 65 had and 235 did not have second-trimester decelerations. Baseline FHR variability, second- trimester decelerations and intrapartum FHR decelerations were significantly higher in SGA fetuses than in AGA fetuses (P<0.05). Birth weight and gestational age were significantly lower in SGA fetuses than in AGA fetuses (P<0.05). There were no significant differences in baseline rate and acceleration ,maternal age and parity, Apgar score in 1 minute, meconium staining, mode of delivery, NICU admission, between SGA and AGA infants. Small for Gestational Age infants were more frequent in pregnancies with second-trimester decelerations compared with those without second-trimester deceleration (P<0.05). Baseline FHR variability in pregnancies with second-trimester decelerations was significantly higher than in pregnancies without second-trimester deceleration (P<0.05).

Conclusion: Periodic or episodic decelerations and increased FHR variability during late second-trimester EFM were associated with an increased risk of SGA infant

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Background: The presence of increased numbers of nucleated red blood cell (NRBC) in the umbilical cord blood has been associated with states of relative hypoxia. Nucleated red blood cell counts are a potentially useful tool in estimating the degree and timing of intrauterine hypoxia. This may have important implication in determining causality in case of compromised infant. Cord blood NRBC counts may be obtained noninvasively from an otherwise discarded specimen and analyzed by personnel on equipment readily available in most hospital laboratories. Since the aim of monitoring of fetal heart is early diagnosis of hypoxia, we studied the relationship between abnormal fetal heart rate with the number of nucleated red blood cells (NRBC) in the umbilical cord blood.

Methods: We performed this research at Hazrat Zeynab Hospital on 130 full-term newborns (65 cases of fetal distress and 65 normal cases) between July 2005 and July 2006. The NRBC counts of newborns with abnormal fetal heart rate were compared with those of normal newborns and correlations with other parameters including Apgar score, hemoglobin level, condition of newborns in the first 24 hours of the birth and birth weight.

Results: The mean NRBC count in the fetal distress group was 9.45 ± 8.75 and that of the normal group was 9.17 ± 8.76 per 100 white cells (p=0.89). The mean duration between diagnosis of fetal distress to birth was equal to 1.2± 0.77 hours. Furthermore, there was no meaningful correlation between number of NRBC and Apgar score, hemoglobin, birth weight and condition of newborns in the first 24 hours.

Conclusion: If the fetus is born a short time after the diagnosis of distress with no risk factors for hypoxia, the NRBC count for cord blood is not elevated.

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Background: Tumor cells need food and oxygen supply for growth and division. Therefore one of the most promising areas of cancer therapy focuses on using agents that inhibit tumor angiogenesis. Inhibition of angiogenesis prevents cell growth, division and metastasis. Previous studies showed that plasminogen related Protein-B has an anti-tumor activity in mice. This protein has a high level of homology with preactivation Peptide (PAP) of human plasminogen. According to this high homology, antiangiogeneic activity of PAP was investigated in an in vitro angiogenesis model.

Methods: PAP encoding region of human plasminogen gene was isolated by Polymerase Chain Reaction and ‎cloned in pGEX-2T vector. This plasmid was expressed in Escherichia coli as a fusion protein (GST-PAP). ‎GST-PAP was expressed as inclusion body and purified by affinity chromatography on GSH-sepharose ‎resin after refolding. antiangiogenic effects of purified protein were surveyed with Matrigel assay‏.‏‎ ‎

Results: The GST-PAP was expressed and purified and its accuracy was confirmed by SDS-PAGE analysis ‎and immunoblotting. Microscopic studies showed that GST-PAP inhibited angiogenesis in Matrigel system ‎which is shown by shrinking the length of capillary like structures and a decrease in the number of tubule. ‎While applying concentarations of 25μg/ml of GST-PAP and concentrations above that, antiangiogenic ‎activity of GST-PAP was significant comparing to the controls. ‎

Conclusion: Finding shows that GST-PAP can inhibit network formation in Matrigel system. This findings ‎support the theory that PAP is a potent angiogenesis inhibitor.‎

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Background: The Biophysical Profile (BPP) is a noninvasive test that predicts the presence or absence of fetal asphyxia and, ultimately, the risk of fetal death in the antenatal period. Intervention on the basis of an abnormal biophysical profile result has been reported to yield a significant reduction in prenatal mortality, and an association exists between biophysical profile scoring and a decreased cerebral palsy rate in a given population. The BPP evaluates five characteristics: fetal movement, tone, breathing, heart reactivity, and amniotic fluid (AF) volume estimation. The purpose of study was to determine whether there are different degree of acidosis at which the biophysical activity (acute marker) are affected.

Methods: In a prospective study of 140 patients undergoing cesarean section before onset of labor, the fetal biophysical profile was performed 24h before the time of cesarean and was matched with cord arterial PH that was obtained from a cord segment (10-20cm) that was double clamped after delivery of newborn. (using cord arterial PH less than 7.20 for the diagnosis of acidosis).

Results: The fetal biophysical profile was found to have a significant relationship with umbilical blood PH. The sensitivity, specificity, positive predictive value, negative predictive value of fetal biophysical profile score were: 88.9%, 88.6%, 50%, 98.1%.

Conclusion: The first manifestations of fetal acidosis are nonreactive nonstress testing and fetal breathing loss in advanced acidemia fetal movements and fetal tone are compromised. A protocol of antepartum fetal evaluation is suggested based upon the individual biophysical components rather than the score alone.

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Background: Previous studies have suggested the presence of a relationship between the increase of NRBC and the duration and intensity of asphyxia. The purpose of this study was to evaluate the relationship of fetal heart rate pattern and the number of NRBC's in umbilical cord blood sample at birth.

Methods: We enrolled 322 pregnant women with healthy, term fetuses who referred to Mirza Kouchak Khan Hospital for pregnancy termination in 2005 in a case-control study. All patients underwent continuous FHR monitoring and based on their FHR pattern, they were divided into two groups with normal FHR pattern and at least one abnormality in FHR pattern (including absence of beat to beat variability absence of proper acceleration and early, late, variable and prolonged deceleration). Samples of umbilical cord blood were evaluated for NRBC count and pH immediately after birth. The variables were compared in these two groups.

Results: The mean NRBC count was significantly higher in patients with any kind of deceleration (late, variable, early or prolonged) in comparison with controls (respectively 11.88±4.406, 8.32±4.64, 10.58±5.366, and 4.11±4.913 vs. 0.93±1.790 in controls). Furthermore the mean NRBC count was significantly higher in patients with absence of acceleration or beat to beat variability (10.73±5.07 and 13.73±3.58 vs. 1.47±2.50). There was a negative correlation between 5^th minute Apgar score and umbilical cord blood sample with mean NRBC count of umbilical cord blood sample.

Conclusion: Any abnormality in FHR pattern is associated with a significant increase in mean NRBC count of umbilical cord blood sample. There is also a significant relationship between the 5^th minute Apgar score and umbilical cord blood sample pH, and mean NRBC count in umbilical cord blood sample.

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Background: True umbilical cord knot is one of the abnormalities of the umbilical cord. Active fetal movements create cord knotting. True umbilical cord knots are rare but may be associated with fetal distress and stillbirth. True umbilical cord knots are capable of impeding blood flow to the fetus.
Case presentation: A 26-year old primigravid woman was first treated for genital herpes simplex virus (HSV type 2) at 36 weeks of gestational age. She received oral acyclovir (400 mg three times daily for 10 days). At the gestational age of 38 weeks and 5 days, fetal activity decreased and NST was nonreactive. She was delivered by cesarean section and a true umbilical cord knot was found. Four years later, in her second pregnancy, another true knot was seen.
Conclusion: Excessively long umbilical cords are more likely to be associated with true knots. Genetics has an important role in determining cord length and occurrence of true knots.

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Background: Anemia at the time of birth may cause some problem like asphyxia, heart failure shock or even death in a neonate. Different etiologies can be considered for this problem. Parvovirus B19, as a viral organism, can cause hydrops fetalis and neonatal anemia and consequent complications. We present here a case of newborn infant with severe anemia who had human parvovirus B19 infection.
Case Presentation: A male newborn with gestational age of 36 week was born from a mother with poor prenatal care and history of contact with domestic animal. The neonate was very pale with Apgar score 2 at 1 min and received resuscitation, mechanical ventilation and repeated blood transfusion The hemoglobin level was significantly low. Analysis was made based on the clinical presentations. According to the case history, physical and laboratory findings, neonatal severe anemia induced by parvovirus B19 infection was suggested and Laboratory work up documented his infection with parovirus B19.
Conclusion: Parvovirus B19 (B19 virus) is the smallest single strand linear DNA virus in animal viruses, which is the only strain of parvovirus that is pathogenic in humans. Human parvovirus B19 may cross the placenta and result in fetal infection, morbidity and death. Parvovirus is an uncommon cause of neonatal anemia and hydrops fetalis so this etiology must be considered in differential diagnosis of anemia at birth.

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Background: Chorionic villus sampling refers to a procedure in which small samples of placenta are obtained for prenatal genetic diagnosis, generally in the first trimester of pregnancy in 11 weeks till 13 weeks+6 days. This procedure provides prenatal diagnosis in pregnancy. Amniocentesis is a technique for windrowing amniotic fluid from the uterine cavity using a needle via a trans abdominal approach. Amniocentesis and chorionic villus sampling are invasive prenatal procedure. Their complications are fetal loss vaginal bleeding, rupture of membrane chorioamnionitis and limb reduction. There are some probable predictors of fetal loss after chorionic villus sampling and amniocentesis including maternal age, gestational age, number of needle insertion, previous miscarriage, and placental location. The aim of this study was to compare procedure related complications of amniocentesis and chorionic villus sampling in a tertiary referral hospital in Iran.

Methods: This retrospective cohort study was done in pregnant women who were high risk in genetic screening tests. The pregnancy outcome of women who underwent amniocenthesis and chorionic villus sampling was assessed in Yas Women General Hospital (Mirza Kuchak Khan), Tehran, Iran, from 2001 to 2011. Group one, pregnant women who underwent amniocentesis, was compared with group two, pregnant women that underwent chorionic villus sampling. The statistical analyses were performed with SPSSv.20 using a significant level of α<0.05.

Results: There were no significant differences between the two groups in procedure related fetal loss before 24th weeks of pregnancy (1.1% in chorionic villus sampling group versus 0.6% in amniocentesis group, P=0.318). A significant relationship between the number of needle insertion in the chorionic villus sampling group and fetal loss before 24th weeks of pregnancy was seen P<0.028. There were no significant differences between the two groups in the occurrence of vaginal bleeding, rupture of membrane, pre-term birth, placenta location, low birth weight and very low birth weight. The risk of chorioamnionitis was higher in chorionic villus sampling group (P=0.019). No significant difference was observed between the liquid and bloody amniotic fluid and pregnancy complications.

Conclusion: There was no significant difference between the procedure related complications of amniocentesis and chorionic villus sampling.

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