2023年 · 第05卷第04期

An autopsy is performed with the primary objective of finding the definitive cause of death (COD). Historically, it was done to know more about the anatomical details and pathological findings of the diseases. Extremely preterm (EP) infants are infants born at less than 28 weeks of gestation.¹According to the World Health Organization, more than 90% of EP babies born in low-income countries die within the first few days of life compared with less than 10% of EP babies in high-income settings.²In addition to the high mortality, the EP infants had poor neurodevelopmental outcome.³Among the causes of in-hospital mortality, necrotizing enterocolitis (NEC), respiratory distress syndrome, intraventricular hemorrhage (IVH), infections, and gastrointestinal causes are among the top.⁴Autopsy (postmortem) of preterm infants can provide vital information about the COD and the accuracy of antemortem clinical diagnosis. In the preterm infant, because clinical manifestations are often nonspecific, diagnostic errors like unintentionally delayed, wrong, or missed diagnoses could occur. An autopsy could help in these scenarios. It has been reported that frequently classical autopsies have revised the initial diagnosis.^5,6However, conventional autopsy might have religious, social, and cultural reservations. Additionally, with technological advancement, an alternative could be offered to families.

This study aimed to reach a consensus among obstetric experts on the prevention and treatment of preterm single births in China.

Based on the scoping literature review and the 2014 edition of preterm birth of Clinical Diagnosis and Treatment guidelines, we generated the Delphi survey statements with five evaluation dimensions, including the definition of preterm birth, exclusion of risk factors for preterm birth, prevention, and prediction of preterm birth, treatment of preterm birth, and evaluation of intervention outcomes of preterm birth. Obstetric experts from the Obstetrics and Gynecology Branch of the Chinese Medical Association formed the expert group for this survey. All the obstetric experts participated two-round modified Delphi survey via an anonymous online survey and an online panel. Mean scores, rank sum, full score ratio, and the lowest score ratio were calculated to reflect the concentration of expert opinions. The coefficient of variation and Kendall W coefficient were used to reflect the expert opinion coordination degree of the survey statement.

The expert response rate for both rounds of surveys was 100% (41/41). Experts reached an agreement on 36 statements in five dimensions of preterm birth prevention and treatment in the first round of the survey and reached a consensus on the remaining 13 statements in the second round. A total of 49 statements (mean scores ≥3, full score ratio ≥20%, coefficient of variation ≤0.3) were explicitly included in this guideline to form recommendations, while the remaining three clinical issues that did not reach a consensus require further determination based on evidence quality. The Kendall W coefficient in the two rounds of the Delphi survey were 0.20 (P < 0.001) and 0.29 (P < 0.001).

The five dimensions and 49 statements, agreed upon through a two-round Delphi study, determined the recommended statements to be included in the updated guidelines for the prevention and treatment of preterm birth in China. The defined lower limit is set at ≥28 gestational weeks; however, an update has been made to the definition of premature birth, specifying that "with the consent of the mother and her family, treatment is not abandoned for viable infants ≥26 gestational weeks."

This study focused on the prediction of preterm birth (PTB). It aimed to identify the transcriptomic signature essential for the occurrence of PTB and evaluate its predictive value in early, mid, and late pregnancy and in women with threatened preterm labor (TPTL).

Blood transcriptome data of pregnant women were obtained from the Gene Expression Omnibus database. The activity of biological signatures was assessed using gene set enrichment analysis and single-sample gene set enrichment analysis. The correlation among molecules in the interleukin 6 (IL6) signature and between IL6 signaling activity and the gestational week of delivery and latent period were evaluated by Pearson correlation analysis. The effects of molecules associated with the IL6 signature were fitted using logistic regression analysis; the predictive value of both the IL6 signature and IL6 alone were evaluated using receiver operating characteristic curves and pregnancy maintenance probability was assessed using Kaplan-Meier analysis. Differential analysis was performed using the DEseq2 and limma algorithms.

Circulatory IL6 signaling activity increased significantly in cases with preterm labor than in those with term pregnancies (normalized enrichment score (NES) = 1.857, P = 0.001). The IL6 signature (on which IL6 signaling is based) was subsequently considered as the candidate biomarker for PTB. The area under the curve (AUC) values for PTB prediction (using the IL6 signature) in early, mid, and late pregnancy were 0.810, 0.695, and 0.779, respectively; these values were considerably higher than those for IL6 alone. In addition, the pregnancy curves of women with abnormal IL6 signature differed significantly from those with normal signature. In pregnant women who eventually had preterm deliveries, circulatory IL6 signaling activity was lower in early pregnancy (NES = -1.420, P = 0.031) and higher than normal in mid (NES = 1.671, P = 0.002) and late pregnancy (NES = 2.350, P < 0.001). In women with TPTL, the AUC values for PTB prediction (or PTB within 7 days and 48 hours) using the IL6 signature were 0.761, 0.829, and 0.836, respectively; the up-regulation of IL6 signaling activity and its correlation with the gestational week of delivery (r = -0.260, P = 0.001) and latency period (r = -0.203, P = 0.012) were more significant than in other women.

Our findings suggest that the IL6 signature may predict PTB, even in early pregnancy (although the predictive power is relatively weak in mid pregnancy) and is particularly effective in symptomatic women. These findings may contribute to the development of an effective predictive and monitoring system for PTB, thereby reducing maternal and fetal risk.

Preterm delivery is a major global health problem associated with increased neonatal morbidity and mortality. To develop effective strategies to reduce preterm birth, it is important to address the causes of and risk factors for this condition. Maternal metabolism plays a crucial role in pregnancy outcomes, as it affects the availability of nutrients, energy, and other essential factors required for fetal development and growth. Several aspects of maternal metabolism can potentially contribute to the risk of preterm delivery. Severe energy deficiency as observed in women suffering from eating disorders can affect the hypothalamic-pituitary-gonadal axis resulting in amenorrhea and infertility, suggesting that maintaining a minimum maternal weight is essential to uphold a functional reproductive system, thus ensuring a successful pregnancy. Maternal undernutrition as observed in past famine and observations and animal studies may affect fetal growth and trigger an early activation of the parturition pathway leading to preterm delivery. A correlation exists between maternal size and gestation duration. Obesity is associated with a higher likelihood of medically indicated preterm birth. Low maternal body mass index and low gestational weight gain during pregnancy have been associated with preterm birth, potentially due to fetal-maternal metabolic imbalance; however, the exact mechanism remains to be determined, thus emphasizing the importance of appropriate weight management before and during pregnancy. Addressing metabolic-related risk factors for preterm delivery requires a comprehensive approach to reduce the burden of preterm delivery and improve neonatal outcomes. This review aims to explore various aspects of fetal-maternal metabolic imbalance that could potentially contribute to preterm birth. By doing so, we suggest a novel and comprehensive approach that sheds light on the intricate connection between fetal-maternal imbalance and the susceptibility to preterm birth.

In 2019, preterm births (PTB) accounted for approximately 0.66 million deaths globally. PTB is also associated with a significantly higher risk of mortality and long-term complications for newborns. Long-term studies associated several factors, including disruption of immune tolerance and inflammation, with PTB. However, the pathogenesis of PTB remains unclear. Gonadal steroid hormones are critical for pregnancy maintenance and regulation of immune and inflammatory responses. However, it is not clear how unbalanced gonadal steroid hormones, such as imbalanced estrogen/androgen or estrogen/progesterone contribute to PTB. In this review, we discuss how gonadal steroid hormones mediate dysfunction in immune tolerance and inflammatory responses, which are known to promote the occurrence of PTB, and provide insight into PTB prediction.

Preterm birth is the leading cause of mortality and morbidity in newborns and children under 5 years-of-age. In order to improve the survival rate and quality of preterm infants, there is critical need to identify the specific mechanisms underlying the initiation of labor. Pregnancy represents a period of constant interactive dialog between mother and fetus. A disturbance in the pattern of maternal-fetal communication can induce physiological or pathological labor. Although a number of studies have investigated the contributions of maternal factors to the initiation of labor, the concept that fetal organ development and maternal adaptation are coordinated has emerged over recent years, thus emphasizing that factors of fetal origin may serve as hormonal signals for the initiation of labor. In this review, we summarize and discuss several specific mechanisms by which factors of fetal origin may influence parturition during term or preterm labor, including the specific regulation of fetal organs, including the lungs and accessory organs during pregnancy. Future research may focus on the specific pathways by which signals from the fetal lungs and other fetal organs interact with the maternal system to initiate eventual labor.

Extreme preterm infants (<28 weeks' gestation) often require positive pressure ventilation with oxygen during postnatal stabilization in the delivery room. To date, optimal inspired fraction of oxygen (FiO₂) still represents a conundrum in newborn care oscillating between higher (>60%) and lower (<30%) initial FiO₂. Recent evidence and meta-analyses have underscored the predictive value for survival and/or relevant clinical outcomes of the Apgar score and the achievement of arterial oxygen saturation measured by pulse oximetry ≥85% at 5 minutes after birth. New clinical trials comparing higher versus lower initial FiO₂ have been launched aiming to optimize postnatal stabilization of extreme preterm while avoiding adverse effects of hypoxemia or hyperoxemia.

The recent implementation of trauma-validated damage control strategies in severe postpartum hemorrhage proves the importance of interdisciplinary management in the obstetric patient. Massive hemorrhage control techniques and damage control surgery are clear examples of how learning from trauma can benefit the obstetric population. Currently, most obstetric programs do not include training in this type of interventions. Nevertheless, it has been shown that these interventions are useful in the management of severe postpartum hemorrhage. The aim of this article is to introduce the application of damage control surgery principles in the management of massive obstetric hemorrhage. We propose to include appropriate training and the implementation of damage control surgery in obstetric management protocols. The prompt application of damage control principles can be considered in patients with persistent hemodynamic instability despite control of the source of bleeding.

Broad ligament pregnancy is defined as gestation that grows in the space formed by anterior and posterior peritoneal folds of the broad ligament. We report a case of 30 years old lady admitted to our hospital with the diagnosis of gravida 2, para 1, live birth 1, with 24 weeks of gestation with low lying placenta with anhydramnios. She was taken up for lower segment cesarian section at 28 weeks gestation in view of low lying placenta with chorioamnionitis. The broad ligament pregnancy was diagnosed peroperatively after identifying the anatomical relationship of the pregnancy. Sac was excised and margins secured after extraction of the baby and placenta. Patient had an uneventful postoperative period. Broad ligament pregnancy may be missed in antenatal period but in cases of displaced cervix, early onset unexplained anhydramnios, and failed induction of labor, it may raise high suspicion. Laparotomy/laparoscopic management is the mainstay of management of broad ligament pregnancy.

Congenital diaphragmatic hernia consists of a defect in the embryonic development of the diaphragm that allows the passage of the abdominal viscera into the thoracic cavity, its diagnosis during pregnancy is quite rare. We present the case of a 31-year-old woman, with 23 weeks of gestation, who consulted for epigastric pain, nausea, and repetitive emetic episodes, without improvement with the medication provided. Due to the intense abdominal pain, a computed tomography of the abdomen and thorax was performed where the 28 mm defect was found at the left diaphragmatic level with protrusion of the gastric fundus to the thoracic cavity. She was taken to surgical management by laparoscopy with abdominal and thoracic approach, with a successful result and without maternal perinatal complications. Although the integrity of the diaphragmatic suture could be feared in relation to the increase in intraabdominal pressure due to uterine growth, the evolution of our patient and previous reports show that postoperative complications are not frequent. Successful vaginal delivery has even been described in some reports. Diaphragmatic hernias diagnosed during pregnancy are quite rare. We suggest that the optimal management of them during pregnancy is immediate surgical correction in case of persistent symptoms, more studies are needed to establish firm recommendations on the management of this pathology.

Anemia in pregnancy is a significant event that often requires treatment to prevent long term effects in the mother and the fetus. Many factors determine which iron preparation to use, including route and ease of administration, patient tolerability, safety, and cost. This case report summarizes two separate patient cases where sodium ferric gluconate complex was administered intravenously to pregnant women, resulting in fetal bradycardia and emergent cesarean procedures.

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