Objective:Mid-trimester painless cervical dilation is associated with high rates of perinatal morbidity and mortality.'Rescue' cerclage is one option in managing these patients. We evaluated pregnancy outcomes of women in whom we placed Shirodkar cerclage.Study Design:We analyzed the pregnancy outcome of a retrospective cohort of women carrying singleton pregnancies who experienced late mid-trimester cervical dilation in whom we placed Shirodkar cerclage. Exclusion criteria were uterine contractions, bleeding, premature rupture of membranes and chorioamnionitis. Primary outcomes were gestational age at delivery, maternal, fetal and neonatal outcomes and surgical complications.Result:Between January 2003 and December 2005, 68 patients met our inclusion criteria. The average maternal age was 26.4+/-8.3 years and the mean gestational age at the time of surgery was 19.6+/-3.2 weeks. Seven women opted for expectant management and 5 more were followed up by their referring physicians; the 12 of them were used as a comparison group. Fifty-six women underwent placement of Shirodkar cerclage. We were unable to place a cerclage in three women (5.1%) and all three delivered before 23 weeks. Of the 56 women who had cerclage, 14 (23.7%) delivered at term, 20 (33.9%) delivered between 34 and 36.9 weeks, 13 (22%) between 30 and 33.9 weeks, 6 (10.2%) between 24 and 29.9 weeks and 3 (5.1%) before 24 weeks. Median time from diagnosis to delivery was longer in the cerclage group (9.1 weeks) than in the comparison group (3.3 weeks P<0.01).Conclusion:When pregnancies are complicated by late mid-trimester cervical dilation, placement of Shirodkar cerclage in appropriately selected patients has the potential to be a beneficial therapeutic option.Journal of Perinatology advance online publication, 22 January 2009; doi:10.1038/jp.2008.221.

Women with recurrent painless mid-trimester miscarriages are often diagnosed with cervical insufficiency. Presenting symptoms typically include vaginal pressure and minimal bleeding; when the cervix is examined, advanced dilatation is usually detected. Labour is short and the premature fetus is born alive. Women with this history were traditionally considered candidates for the placement of cervical cerclage. Recently, this practice has been called into question. Rather than routine placement of prophylactic cervical cerclage at 12 - 14 weeks, many patients are followed expectantly with serial sonographic assessments of cervical length. The goal of this update is to review the literature regarding management options of mid-trimester cervical dilatation.

OBJECTIVE: Many expecting parents wish to ascertain fetal gender early in pregnancy. Our goal was to determine whether fetal heart rate (FHR) of males and females during the first trimester is significantly different. MATERIALS AND METHODS: From November 1997 to February 2003 we enrolled pregnant women with singleton gestations who underwent obstetric sonography at less than 14 weeks of gestational age. Indications for the sonographic study included first-trimester bleeding, uncertain gestational dating, poor obstetrical history, and aneuploidy screening by nuchal translucency. The sonographic studies were performed by a single sonographer and reviewed by the first author. The FHR was determined by m-mode. All subjects underwent second-trimester sonography at 18.0-24.0 weeks' gestation by the same team, and fetal gender was recorded. Multiple gestations, miscarriages and pregnancies with uncertain fetal gender were excluded. Sonographically assigned fetal gender was confirmed at delivery. RESULTS: Of the 966 first-trimester studies performed, 477 met the inclusion criteria. Of these, 244 (51%) were female and 233 (49%) were males. There were no statistical differences in mean maternal age, gravidity, parity, and mean gestational age at the time of the first study (9.0 +/- 2.3 weeks for female fetuses and 9.0 +/- 2.3 weeks for males, p = 0.7). The average female FHR was 151.7 +/- 22.7 bpm and male FHR was154.9 +/- 22.8 bpm (p = 0.13). DISCUSSION: Contrary to beliefs commonly held by many pregnant women and their families, there are no significant differences between male and female FHR during the first trimester.

Vulvodynia is characterised by the presence of vulval allodynia (pain evoked by non-painful stimuli) and vulval dysaesthesias (burning, soreness, rawness, stinging and irritation). We assessed a protocol for the evaluation and management of vulvodynia. The protocol was based on the most recent evidence available. We began a simple evaluation and proceeded to an aggressive one. From the cohort of 74 patients, 69 patients (93.2%) were adherent to the protocol. A total of 25 patients (36.3%) improved after antibiotic therapy: 14 patients (20.4%) had a positive fungal culture and 11 patients (15.9%) had a positive bacterial culture; none with a positive viral culture. Eight patients (11.6%) improved with dietary modification. Ten patients (14.5%) benefitted from tricyclic medications; 13 patients (18.8%) improved after gabapentin therapy; 13 patients (18.8%) did not show improvement of their condition. Some 56 patients (81.2%) manifested an improvement of their symptoms, which allowed them to achieve painless sexual intercourse.

Osteosarcoma of the penile bone was diagnosed in a 5-year-old neutered male Rottweiler with recurrent dysuria. Imaging and cytological findings raised the suspicion for an osteosarcoma and ablation of the entire penis and scrotal urethrostomy was performed. The diagnosis was confirmed histologically. The dog recovered well and no postoperative signs of dysuria were observed. The dog survived without adjuvant chemotherapy for 12 months when multiple tumours in the thorax and abdomen led to it being euthanased. Penile osteosarcoma is a rare disease, but must be considered as a differential diagnosis in dogs presenting with dysuria. This is the second recorded case of a penile osteosarcoma in a dog, but the first with a detailed description of the diagnosis, treatment and outcome.

Background: Mycobacterium avium subspecies paratuberculosis (MAP) is the cause of paratuberculosis. MAP infections have not been reliably detected in dogs, but a reemerging debate about the link between MAP and Crohn's disease has renewed interest about the occurrence of MAP in pets. Hypothesis: This study was undertaken to examine canine intestinal biopsies for the presence of MAP-specific DNA. Animals: Forty-two dogs with chronic vomiting, diarrhea, or both; and 14 dogs with no gastrointestinal disease. Methods: All dogs with signs of gastrointestinal disease had a standard work-up for chronic gastrointestinal disease. Endoscopically obtained intestinal biopsies were submitted for histopathologic and molecular investigations. Biopsies were screened for MAP-specific DNA by 3 polymerase chain reaction (PCR) methods (nested, seminested, and triplex real-time PCR). Samples from control dogs were obtained during necropsy. Results: Histopathology of the biopsies was indicative of inflammatory bowel disease (IBD) in 17 and neoplasia in 6 dogs. Six dogs showing nonspecific changes responded to diet and were classified as having food-responsive enteropathy. In 13 dogs a final diagnosis was not established. MAP-specific DNA was detected and confirmed by sequencing in 8 dogs (19%). These dogs were diagnosed with food-responsive enteropathy (n = 3), IBD (n = 2), and open diagnosis (n = 3). MAP-specific DNA was not detected in dogs with no gastrointestinal disease. Conclusions and clinical importance: MAP-specific DNA was detected in approximately one fifth of dogs with chronic gastrointestinal disease and might play a role as a pathogenic agent. Apart from animal welfare, the zoonotic aspect warrants further studies addressing the viability of MAP organism in canine intestinal biopsies by culture.

Background: Postprandial (PP) serum bile acid (SBA) stimulation is an important test for detecting hepatic dysfunction in dogs. However, this test is influenced by numerous variables, and a standardized approach using an injectable cholecystokinin analog (ceruletide) may be advantageous. Hypothesis: Ceruletide SBA stimulation test is more sensitive than PP SBA stimulation in dogs. Animals: Animals with portosystemic shunt (PSS)(n = 11) and dogs with upper respiratory disease (URD)(n = 9) were investigated. Healthy dogs (n = 13) and dogs with other diseases (n = 17) served as controls. Methods: All dogs underwent SBA stimulation with food and ceruletide. Stimulation blood samples were drawn at 60/120 minutes and 20/30/40 minutes, respectively. Results were compared statistically, and the sensitivity and specificity were determined with receiver-operating characteristic curves. Results: Stimulated SBA were significantly higher in both study groups than in controls. For dogs with PSS, the sensitivity and specificity (>35 mumol/L) were 100% postprandially (120 minutes) and 91 and 100%, respectively, postceruletide (30 minutes). The difference between these values was not statistically significant. For dogs with URD, the sensitivity and specificity (>22 mumol/L) were 44 and 88% postprandially (120 minutes) and 100 and 88% postceruletide (30 minutes). Conclusions and Clinical Importance: Ceruletide SBA stimulation circumvents exogenous and endogenous influences associated with PP SBA stimulation. The results indicate that ceruletide SBA stimulation performs as well as PP SBA stimulation in dogs with PSS and is more sensitive for the detection of hepatic dysfunction in dogs with URD.

BACKGROUND: The neonatal period is regarded as the first 4 weeks of extrauterine life. In the literature, there are numerous articles about the skin findings in neonates and the results of these studies show differences according to races and environmental factors. AIMS: Our objective was to evaluate the skin lesions seen in neonates delivered in our hospital and to determine their relationship to gender, gestational age and route of delivery. METHODS: Newborns delivered at the Obstetrics Clinics of our hospital between November 2007 and April 2008 were included in this study. Dermatologic examination was performed and relationship between the 10 most common skin findings and gender, gestational age and route of delivery were statistically evaluated. RESULTS: A total of 572 newborns were examined for the presence of skin lesions. Most common skin findings were Epstein pearls (58.76%), sebaceous hyperlasia (48.45%) and xerosis (31.29%). Milia and sebaceous hyperplasia in girls, desquamation and xerosis in preterms, Epstein pearls, sebaceous hyperplasia and desquamation in vaginally delivered babies were found to be more frequent and the differences were statistically significant. CONCLUSION: We found that 90.7% of the neonates had one or more cutaneous lesions. Maturity and type of delivery of the babies were important factors in their causation. In Turkey, this study is the first study performed on the skin lesions seen during the neonatal period. With this study, we want to increase the awareness about the skin findings in neonates.

With the increasing survival of extremely preterm (EP) birth infants in the surfactant era, the longer-term outcome of infants born at the threshold of viability has become a vital topic of study. The goal of this investigation was twofold. First, while taking into account the influence of sociodemographic confounds, we wished to investigate neuropsychological outcome differences between two groups of EP preschoolers: 23-24 weeks (n = 20), and 25-26 weeks'(n = 21) gestation at delivery. Second, we wished to explore whether, within the population of EP preschoolers, gestational maturity accounts for a unique portion of the variance in neuropsychological outcome, over and above the variance explained by ante-, peri-, and neonatal complications, or treatment factors. The findings revealed group differences, ranging from .70 to .80 of a standard deviation in general intellectual abilities, nonverbal intelligence, and global motor performance, in favor of the more mature EP group. Additionally, gestational maturity was found to explain a unique portion of the variance in global intellectual and motor abilities. These findings are interpreted from the perspective that gestational age is an index of the vulnerability of the central nervous system to disruption of developmentally regulated processes.(JINS, 2009, 1-11.).

BACKGROUND: Fetal endoscopic tracheal occlusion (FETO) is a promising treatment for severe congenital diaphragmatic hernia, a condition that carries significant morbidity and mortality. It is hypothesised that balloon occlusion of the fetal trachea leads to an improvement in lung growth and development. The major documented complications of FETO to date are related to preterm delivery. OBJECTIVE: To report a series of five infants who developed tracheomegaly following FETO. MATERIALS AND METHODS: Review of all children referred with tracheomegaly to the paediatric intensive care and tracheal service at two referral centres. RESULTS: Five neonates presented with features of respiratory distress shortly after birth and were subsequently found to have marked tracheomegaly. Two neonates had tracheomalacia in addition. CONCLUSION: There are no previous reports in the literature describing tracheomalacia, or more specifically, tracheomegaly, as a consequence of FETO. We propose that the particularly compliant fetal airway is at risk of mechanical damage from in utero balloon occlusion. This observation of a new problem in this cohort suggests a thorough evaluation of the trachea should be performed in children who have had FETO in utero. It may be that balloon occlusion of the trachea earlier in utero (before 26 weeks' gestation) predisposes to this condition.

AIM: To construct a predictive model for respiratory distress syndrome (RDS) from gestational age (GA) at delivery and TDx-FLM II value. METHODS: Pregnant women who underwent an amniocentesis in which TDx-FLM II was determined were included in the study. A model for the occurrence of RDS was constructed by means of a logistic regression procedure from TDx-FLM II values and GA at delivery. RESULTS: The mean value of TDx-FLM II was 47.11 mg/g. The mean GA at delivery was 33.4 weeks. The incidence of RDS was 7.8%(18/231). The optimal cutoff of predicted risk for respiratory distress was found to be 8.8%, resulting in a sensitivity and specificity of 89 and 83%, respectively. CONCLUSIONS: The adjustment of the TDx-FLM II value for GA at delivery results in a significant improvement in the predictive capacity of the test for the occurrence of RDS. The use of GA-specific cutoff values may simplify clinical decisions.

Chronic lung disease (CLD), defined as chronic oxygen dependency, is a common outcome of neonatal intensive care. It occurs most frequently in infants born very prematurely, but also in infants born at term who had severe lung disease and those with abnormal antenatal lung growth due particularly to reduction in fetal breathing movements, amniotic fluid volume or intrathoracic space. There are, however, other causes and the importance of antenatal infection/inflammation regarding impairment of antenatal lung growth is increasingly recognised. Affected infants can suffer chronic respiratory morbidity including an excess of respiratory symptoms and lung function abnormalities even in adulthood. Antenatal interventions directed at improving lung growth are available, but require testing inappropriately designed trials with pulmonary function at follow-up as an outcome.

OBJECTIVE: Fetal lung maturity (FLM) studies using vaginal pool can guide management in near-term gestations with rupture of membranes. Because an adequate sample may be difficult to collect using a syringe, we tested collection using a sterile sponge. STUDY DESIGN: In this prospective study, vaginal pool was collected via both a syringe and a sponge from each gravida. Study patients experienced rupture of membranes between 34-41 weeks of gestation. Each sample was analyzed using the TDx-FLM II assay and phosphatidylglycerol (PG) testing. RESULTS: Fifty patients were enrolled; 44 demonstrated concordant syringe/sponge results. There was 1 instance of mature TDx-FLM testing using a sponge but not a syringe; PG testing in this case was absent in both samples. Using the kappa statistic, agreement between the methods was "substantial" for TDx-FLM and "almost perfect" for PG. CONCLUSION: Collecting vaginal pool with a sponge may provide clinically useful information, particularly when PG is present.

OBJECTIVE: A lamellar body count (LBC)>or=50,000/microl is suggested to document fetal lung maturity (FLM). We sought to determine the LBC threshold for FLM with the Cell-dyn 4000 hematology analyser. METHODS: We queried our database for patients who underwent LBC testing from 2001 to 2007. Included were deliveries between 35 and 38 weeks gestation with testing <or=7 days from delivery. We excluded twins, anomalies and cases of ruptured membranes. Data were analysed for sensitivity and specificity of predicting respiratory distress syndrome (RDS) and plotted on a receiver operating characteristic curve. RESULTS: There were 209 patients meeting study criteria. Of these, 120 had diabetes. Five neonates experienced RDS, all born to non-diabetic mothers with LBC values <or=72,000/microl. At this value the sensitivity is 100%, false positive rate 18% and the p value is 0.0146. CONCLUSION: Our results question the 50,000/microl threshold and demonstrate the need for hematology analyser specific thresholds.

The reported incidence of the preterm deliveries in Bulgaria is 7-11% and it has increased in the recent years. The neonatal respiratory distress syndrome (NRDS) is the most frequent pulmonary disease caused by the biological immaturity. It affects 40-50% of the neonates born before 32 weeks of gestation and results in high morbidity and mortality. There is plenty of evidence, proving that the antenatal corticosteroid (CS) administration decreases the incidence of NRDS in preterm infants. OBJECTIVE: To study the influence of the implicated algorithm for antenatal prophylaxis of NRDS on the neonatal morbidity and mortality in premature infants. MATERIALS AND METHODS: Two groups of preterm neonates were studied. First group included preterm neonates either without or with a single application of CS before delivery. Second group consisted of preterm newborns with completed CS prophylaxis. The applied antenatal corticosteroid treatment included 4 doses of Betamethazon 7 mg i.m. in 12 hour intervals. It was indicated in cases of a preterm labor between 24-32 gestational weeks. The neonatal mortality, the incidence of NRDS and intraventricular hemorrhage (IVH), the neonatal intensive care unit (NICU) stay and treatment were compared between both groups. RESULTS: The incidence of NRDS, the need of exogenous surfactant treatment, and the incidence of severe IVH (grades II-IV) were significantly lower in the group with completed CS prophylaxis compared to the control group (p < 0.05). The neonatal mortality rate and the duration of NICU stay and treatment were also reduced among infants with antenatal CS. CONCLUSIONS: The antenatal treatment with CS reduces significantly the risk of development of NRDS and IVH 3d-4th degrees and the neonatal mortality rate of the prematurely born infants. It has also important influence on the duration of NICU stay and treatment and decreases the cost of the neonatal intensive treatment.

The increasing rates of repeat cesarean delivery necessitate, more than ever, the need to time deliveries to optimize neonatal outcomes. A recent large multicenter cohort study demonstrated that, contrary to current recommendations, a high proportion of elective cesarean deliveries in the USA are performed before 39 weeks' gestation. These early deliveries are associated with a significant increase in several adverse neonatal events, including respiratory complications, treated hypoglycemia, newborn sepsis and admission to the neonatal intensive care unit. This, together with results of previous studies, supports the recommendation to delay elective delivery to 39 weeks' gestation. From the current data, it is uncertain whether delivery before 39 weeks' gestation with documented fetal lung maturity will prevent the increased neonatal morbidity.

OBJECTIVES: The lecithin/sphingomyelin (L/S) ratio and the lamellar body count (LBC) can be used to predict respiratory distress syndrome (RDS). DESIGN: We performed a retrospective cohort study among consecutive women who underwent amniotic fluid sampling for the assessment of fetal lung maturity. Logistic regression was used to construct models for the prediction of RDS in three gestational age categories, with models based on clinical characteristics only, clinical characteristics and the LBC, and on clinical characteristics and L/S ratio. RESULTS: When amniotic fluid was collected <30 weeks, the specificity of the LBC was 30% and the sensitivity 100%. Addition of the L/S ratio increased the specifity to 60%, for a sensitivity of 100%. When amniocentesis was performed between 30 and 33 weeks, addition of the L/S ratio only marginally improved the performance of the LBC. CONCLUSIONS: At a gestational age <30 weeks, the L/S ratio has additional value over the LBC. Above 30 weeks of gestation, single use of the LBC seems sufficient.