The impact of prior preeclampsia on the risk of superimposed preeclampsia and other adverse pregnancy outcomes in patients with chronic hypertension

OBJECTIVE: We sought to compare the rates of superimposed preeclampsia and adverse outcomes in women with chronic hypertension with or without prior preeclampsia.STUDY DESIGN: We conducted secondary analysis of 369 women with chronic hypertension (104 with prior preeclampsia) enrolled at 12-19 weeks as part of a multisite trial of antioxidants to prevent preeclampsia (no reduction was found). Outcome measures were rates of superimposed preeclampsia and other adverse perinatal outcomes.RESULTS: Prepregnancy body mass index, blood pressure, and smoking status at enrollment were similar between groups. The rates of superimposed preeclampsia (17.3% vs 17.7%), abruptio placentae (1.0% vs 3.1%), perinatal death (6.7% vs 8.7%), and small for gestational age (18.4% vs 14.3%) were similar between groups, but preterm delivery <37 weeks was higher in the prior preeclampsia group (36.9% vs 27.1%; adjusted risk ratio, 1.46; 95% confidence interval, 1.05-2.03; P = .032).CONCLUSION: In women with chronic hypertension, a history of preeclampsia does not increase the rate of superimposed preeclampsia, but is associated with an increased rate of delivery at <37 weeks.

Mild gestational hyperglycaemia as a risk factor for metabolic syndrome in pregnancy and adverse perinatal outcomes

Objective The aims of this study were to evaluate the prevalence of metabolic syndrome (MS) in a cohort of pregnant women with a wide range of glucose tolerance, pre-pregnancy risk factors for MS during pregnancy and the effects of MS in the occurrence of adverse perinatal outcomes.Research Design and Methods One hundred and thirty six women with positive screening for gestational diabetes (GDM) were classified by two diagnostic methods: glycaemic profile and 100 g oral glucose tolerance test (OGTT) as normoglycaemic, mild gestational hyperglycaemic, GDM, and overt GDM. Markers of insulin resistance were measured between 24-28 and 36th week of gestation, and 6 weeks after delivery.Results The prevalence of MS was 0; 20.0; 23.5 and 36.4% in normoglycaemic, mild hyperglycaemic, GDM and overt GDM groups, respectively. Previous history of GDM with or without insulin use, body mass index (BMI) >= 25, hypertension, family history of diabetes in first-degree relatives, non-Caucasian ethnicity, history of prematurity and polyhydramnios were statistically significant pre-pregnancy predictors for MS in the index pregnancy, that by its turn increased the occurrence of adverse perinatal outcomes (p = 0.01).Conclusions The prevalence of MS increases with the worsening of glucose tolerance and is an independent predictor of adverse perinatal outcomes; impaired glycaemic profile identifies pregnancies with important metabolic abnormalities that are linked to the occurrence of adverse perinatal outcomes even in the presence of a normal OGTT, in patients that are not currently classified as having GDM. Copyright (C) 2008 John Wiley & Sons, Ltd.

Single-embryo transfer reduces clinical pregnancy rates and live births in fresh IVF and Intracytoplasmic Sperm Injection (ICSI) cycles: a meta-analysis

Background: It has become an accepted procedure to transfer more than one embryo to the patient to achieve acceptable ongoing pregnancy rates. However, transfers of more than a single embryo increase the probability of establishing a multiple gestation. Single-embryo transfer can minimize twin pregnancies but may also lower live birth rates. This meta-analysis aimed to compare current data on single-embryo versus double-embryo transfer in fresh IVF/ICSI cycles with respect to implantation, ongoing pregnancy and live birth rates.Methods: Search strategies included on-line surveys of databases from 1995 to 2008. Data management and analysis were conducted using the Stats Direct statistical software. The fixed-effect model was used for odds ratio (OR). Fixed-effect effectiveness was evaluated by the Mantel Haenszel method. Seven trials fulfilled the inclusion criteria.Results: When pooling results under the fixed-effect model, the implantation rate was not significantly different between double-embryo transfer (34.5%) and single-embryo transfer group (34.7%) (P = 0.96; OR = 0.99, 95% CI 0.78, 1.25). on the other hand, double-embryo transfer produced a statistically significantly higher ongoing clinical pregnancy rate (44.5%) than single-embryo transfer (28.3%) (P < 0.0001; OR: 2.06, 95% CI = 1.64,2.60). At the same time, pooling results presented a significantly higher live birth rate when double-embryo transfer (42.5%) (P < 0.001; OR: 1.87, 95% CI = 1.44,2.42) was compared with single-embryo transfer (28.4%).Conclusion: Meta-analysis with 95% confidence showed that, despite similar implantation rates, fresh double-embryo transfer had a 1.64 to 2.60 times greater ongoing pregnancy rate and 1.44 to 2.42 times greater live birth rate than single-embryo transfer in a population suitable for ART treatment.

Association between different levels of dysglycemia and metabolic syndrome in pregnancy

Background: In this study, we sought to evaluate the prevalence of metabolic syndrome (MS) in a cohort of pregnant women with a wide range of glucose tolerance, prepregnancy risk factors for MS during pregnancy, and the effects of MS in the outcomes in the mother and in the newborn.Methods: One hundred and thirty six women with positive screening for gestational diabetes mellitus (GDM) were classified by two diagnostic methods: glycemic profile and 100 g OGTT as normoglycemic, mild gestational hyperglycemic, GDM, and overt GDM. Markers of MS were measured between 2428(th) during the screening.Results: The prevalence of MS was: 0%; 20.0%; 23.5% and 36.4% in normoglycemic, mild hyperglycemic, GDM, and overt GDM groups, respectively. Previous history of GDM with or without insulin use, BMI >= 25, hypertension, family history of diabetes in first degree relatives, non-Caucasian ethnicity, history of prematurity and polihydramnios were statistically significant prepregnancy predictors for MS in the index pregnancy, that by its turn increased the adverse outcomes in the mother and in the newborn.Conclusion: The prevalence of MS increases with the worsening of glucose tolerance; impaired glycemic profile identifies pregnancies with important metabolic abnormalities even in the presence of a normal OGTT, in patients that are not classified as having GDM.

Association Between Insulin Resistance, Glucose Intolerance, and Hypertension in Pregnancy

There is an association between insulin resistance, glucose intolerance, and essential hypertension, but the relation between insulin resistance, glucose intolerance, and hypertension diagnosed during pregnancy is not well understood. Transient hypertension of pregnancy, the new-onset nonproteinuric hypertension of late pregnancy, is associated with a high risk of later essential hypertension and glucose intolerance; thus, these conditions may have a similar pathophysiology. To assess the association between insulin resistance, glucose intolerance, essential hypertension, and subsequent development of proteinuric and nonproteinuric hypertension in pregnancy in women without underlying essential hypertension, we performed a prospective study comparing glucose (fasting, I and 2 hours postglucose load), insulin, glycosylated hemoglobin (HbA1c), high-density lipoprotein cholesterol (HDL-C), and triglycerides levels on routine screening for gestational diabetes mellitus. Women who developed hypertension in pregnancy (n = 37) had higher glycemic levels (fasting, 1 and 2 hours postglucose load) on a 100-gram oral glucose loading test, although only the fasting values showed a statistical significance (p < 0.05), and a significantly higher frequency of abnormal glucose loading tests, two hours after glucose load (>= 140 mg/dL) (p < 0.05) than women who remained normotensive (n = 180). Glucose intolerance was common in women who developed both subtypes of hypertension, particularly preeclampsia. Women who developed hypertension had greater prepregnancy body mass index (p < 0.0001), higher frequency and intensity of acanthosis nigricans (p < 0.0001), and higher baseline systolic and diastolic blood pressures (p <= 0.0001 for both), although all subjects were normotensive at baseline by study design; they also presented lower levels of HDL-C (p < 0.05). However, after adjustment for these and other potential confounders, an abnormal glucose loading test remained a significant predictor of development of hypertension (p < 0.05) and, specifically, preeclampsia (p < 0.01). There was a trend toward higher insulin and homeostasis model assessment-insulin resistance (HOMA-IR) levels in women developing any type of hypertension. When comparing women that remained normotensive to term with those with transient hypertension and preeclampsia, the preeclamptic women were born with lower weight (p < 0.05) and shorter length (p < 0.005); at screening they were older (p < 0.005), showed higher frequency and intensity of acanthosis nigricans (p < 0.0001), had higher prepregnancy BMI (p < 0.0005), as well as higher baseline systolic and diastolic blood pressures (p <= 0.0001 for both). They also showed higher HOMA-IR levels that did not show a statistical significance. When glucose tolerance status was taken in account, an association was found between increasing indexes of hypertension (p < 0.05) and of HOMA-IR (p < 0.05) with the worsening of glucose tolerance. These results suggest that insulin resistance and relative glucose intolerance are associated with an increased risk of new-onset hypertension in pregnancy, particularly preeclampsia, and support the hypothesis that insulin resistance may play a role in the pathogenesis of this disorder.

Pregnancy outcomes in women with repeated implantation failures after intracytoplasmic morphologically selected sperm injection (IMSI)

Background: The purpose of this study was to compare laboratory and clinical outcomes of intracytoplasmic morphologically selected sperm injection (IMSI) and conventional intracytoplasmic sperm injection (ICSI) in couples with repeated implantation failures.Methods: A total of 200 couples with at least two prior unsuccessful ICSI cycles were enrolled: 100 couples were submitted to IMSI and 100 were submitted to routine ICSI. For IMSI, spermatozoa were selected at 8400x magnification using an inverted microscope equipped with Nomarski (differential interference contrast) optics. For conventional ICSI, spermatozoa were selected at 400x magnification. Clinical outcomes were evaluated between the two groups.Results: Study patients were comparable in age, number of treatment failures, aetiology of infertility, percentage of normal form assessed by MSOME (motile sperm organelle morphology examination), semen parameters, total number of oocytes collected, number of mature oocytes collected, total number of embryos transferred and number of high-quality embryos transferred. No statistically significant differences between the two groups were observed with regard to rates of fertilisation, implantation and pregnancy/cycle. Although not statistically significant, rates of miscarriage (IMSI:15.3% vs ICSI:31.7%), ongoing pregnancy (IMSI:22% vs ICSI:13%) and live births (IMSI:21% vs ICSI:12%) showed a trend towards better outcomes in the IMSI group. In addition, analysis of subpopulations with or without male factor showed similar results.Conclusions: Our results suggest that IMSI does not provide a significant improvement in clinical outcome compared to ICSI, at least in couples with repeated implantation failures after conventional ICSI. However, it should be noted that there were clear trends for lower miscarriage rates (approximate to 50% reduced) and higher rates of ongoing pregnancy and live births (both nearly doubled) within the IMSI group. Further confirmation as well as randomized large-scale trials are needed to confirm the beneficial effects of IMSI in couples with poor reproductive prognoses.

Effects of exposure to cigarette smoke prior to pregnancy in diabetic rats

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Efficacy of the motile sperm organelle morphology examination (MSOME) in predicting pregnancy after intrauterine insemination

Background: Although the motile sperm organelle morphology examination (MSOME) was developed merely as a selection criterion, its application as a method for classifying sperm morphology may represent an improvement in the evaluation of semen quality. The aim of this study was to determine the prognostic value of normal sperm morphology using MSOME with regard to clinical pregnancy (CP) after intrauterine insemination (IUI).Methods: A total of 156 IUI cycles that were performed in 111 couples were prospectively analysed. Each subject received 75 IU of recombinant FSH every second day from the third day of the cycle. Beginning on the 10th day of the cycle, follicular development was monitored by vaginal ultrasound. When one or two follicles measuring at least 17 mm were observed, recombinant hCG was administered, and IUI was performed 12-14 h and 36-40 h after hCG treatment. Prior to the IUI procedure, sperm samples were analysed by MSOME at 8400x magnification using an inverted microscope that was equipped with DIC/Nomarski differential interference contrast optics. A minimum of 200 motile spermatozoa per semen sample were evaluated, and the percentage of normal spermatozoa in each sample was determined.Results: Pregnancy occurred in 34 IUI cycles (CP rate per cycle: 21.8%, per patient: 30.6%). Based on the MSOME criteria, a significantly higher percentage of normal spermatozoa was found in the group of men in which the IUI cycles resulted in pregnancy (2.6+/-3.1%) compared to the group that did not achieve pregnancy (1.2+/-1.7%; P = 0.019). Logistic regression showed that the percentage of normal cells in the MSOME was a determining factor for the likelihood of clinical pregnancy (OR: 1.28; 95% CI: 1.08 to 1.51; P = 0.003). The ROC curve revealed an area under the curve of 0.63 and an optimum cut-off point of 2% of normal sperm morphology. At this cut-off threshold, using the percentage of normal sperm morphology by MSOME to predict pregnancy was 50% sensitive with a 40% positive predictive value and 79% specificity with an 85% negative predictive value. The efficacy of using the percentage of normal sperm morphology by MSOME in predicting pregnancy was 65%.Conclusions: The present findings support the use of high-magnification microscopy both for selecting spermatozoa and as a routine method for analysing semen before performing IUI.

The possible role of selenium status in adverse pregnancy outcomes

Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)

Haematic Mummification in a Mare With Twin Pregnancy

Mummification occurs when the fetus dies during the second or third trimester of gestation and remains in the uterine cavity because of the persistence of the corpus luteum or existence of another live fetus. Generally, the mummified fetus and fetal membranes undergo desiccation. The hematic process is similar, but the fetus appears like melted chocolate and becomes lodged between the uterus and chorion. This report describes the treatment of dystocia in a mare with twin pregnancy, with one fetus having undergone hematic mummification. Although difficult to diagnose, the possibility of a second fetus should be investigated in mares with dystocia. (C) 2012 Elsevier B.V. All rights reserved.

Influence of sire and sire breed (Gyr versus Holstein) on establishment of pregnancy and embryonic loss in lactating Holstein cows during summer heat stress

Heat stress has negative effects on pregnancy rates of lactating dairy cattle. There are genetic differences in tolerance to heat stress; Bos taurus indicus (B. t. indicus) cattle and embryos are more thermotolerant than Bos taurus taurus (B. t. taurus). In the present study, the effects of sire and sire breed on conception and embryonic/fetal loss rates of lactating Holstein cows during the Brazilian summer were determined. In Experiment 1, cows (n = 302) were AI after estrus detection or at a fixed-time with semen from one Gyr (B. t. indicus) or one Holstein sire (B. t. taurus). Pregnancy was diagnosed 80 days after AI. In Experiment 2, cows (n = 811) were AI with semen from three Gyr and two Holstein sires. Pregnancy was diagnosed at 30-40 and at 60-80 days after AI. Cows diagnosed pregnant at the first examination but non-pregnant at the second were considered as having lost their embryo or fetus. Data were analyzed by logistic regression. The model considered the effect of sire within breed, sire breed, days postpartum, period of lactation, and AI type (AI after estrus versus fixed-time). There was no effect of the AI type, days postpartum or milk production on conception or embryonic loss rates. The use of Gyr bulls increased pregnancy rate when compared to Holstein bulls [9.1% (60/657) versus 5.0% (23/456), respectively, P = 0.008; data from Experiments 1 and 2 combined]. Additionally, in Experiment 2, cows inseminated using semen from sire #4 (Gyr) had lower embryonic loss (10%) when compared with other B. t. indicus (35.3% and 40%) or B. t. taurus sires (18.2% and 38.5%, P = 0.03). In conclusion, the use of B. t. indicus sires may result in higher conception rates in lactating Holstein cows during summer heat stress. Moreover, sire can affect embryonic loss and selection of bulls according to this criterion may result in higher parturition rates in lactating Holstein cows. (c) 2006 Elsevier B.V. All rights reserved.

Ultrasonographic monitoring of early pregnancy development in Murrah buffalo heifers (Bubalus bubalis)

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Associations among milk production and rectal temperature on pregnancy maintenance in lactating recipient dairy cows

The objective of this study was to evaluate the associations among milk production, rectal temperature, and pregnancy maintenance in lactating recipient dairy cows. Data were collected during an 11-mo period from 463 Holstein cows (203 primiparous and 260 multiparous) assigned to a fixed-time embryo transfer (ET) protocol. Only cows detected with a visible corpus luteum immediately prior to ET were used. Rectal temperatures were collected from all cows on the same day of ET. Milk production at ET was calculated by averaging individual daily milk production during the 7 d preceding ET. Pregnancy diagnosis was performed by transrectal ultrasonography 21 d after ET. Cows were ranked and assigned to groups according to median milk production (median = 35 kg/d; HPROD = above median; LPROD = below median) and rectal temperature (<= 39.0 degrees C = LTEMP; >39.0 degrees C = HTEMP). A milk production x temperature group interaction was detected (P = 0.04) for pregnancy analysis because HTEMP cows ranked as LPROD were 3.1 time more likely to maintain pregnancy compared with HTEMP cows ranked as HPROD (P = 0.03). Milk production did not affect (P = 0.55) odds of pregnancy maintenance within LTEMP cows, however, and no differences in odds of pregnancy maintenance were detected between HTEMP and LTEMP within milk production groups (P > 0.11). Within HTEMP cows, increased milk production decreased the probability of pregnancy maintenance linearly, whereas within LTEMP cows, increased milk production increased the probability of pregnancy maintenance linearly. Within HPROD, increased rectal temperature decreased the probability of pregnancy maintenance linearly, whereas within LPROD cows, no associations between rectal temperatures and probability of cows to maintain pregnancy were detected. In summary, high-producing dairy cows with rectal temperatures below 39.0 degrees C did not experience reduced pregnancy maintenance to ET compared to cohorts with reduced milk production. (C) 2011 Elsevier B.V. All rights reserved.

Effects of temperament on pregnancy rates to fixed-timed AI in Bos indicus beef cows

The objective of the present experiment was to assess the effects of temperament on pregnancy rates to fixed-time AI (FTAI) in Bos indicus beef cows. A total of 761 multiparous lactating Nelore cows, originated from 4 different commercial cow-calf ranches, were evaluated for BCS and temperament at the time of FTAI (day 0). Temperament was assessed by chute score and exit velocity. Further, individual exit score was calculated by dividing exit velocity results into quintiles and assigning cows with a score from 1 to 5 (exit score: 1 = slowest cows; 5 = fastest cow). Temperament scores were calculated by averaging cow chute score and exit score. Cows were also classified for temperament type according to temperament score (<= 3 = adequate temperament, >3 = excitable temperament). Pregnancy status was verified by detecting a viable conceptus with rectal ultrasonography approximately 40 days after FTAI. Chute score, exit velocity, and temperament score were not correlated to BCS (P>0.31). Hence, BCS did not differ (P=0.30) according to temperament type (4.13 vs. 4.09 for cows with excitable and adequate temperament, respectively; SEM = 0.070). Pregnancy rates to FTAI tended to be negatively affected by temperament score (P=0.08), whereas the probability of cows becoming pregnant to FTAI was negatively associated with temperament score (linear effect, P<0.01). Accordingly, pregnancy rates were reduced (P=0.05) in cows with excitable temperament compared to cows with adequate temperament (35.3 vs. 42.8% of pregnant cows/total cows, respectively; SEM = 2.85). Pregnancy rates to FTAI were not affected by chute score (P=0.25), although the probability of cows becoming pregnant to FTAI tended to be negatively associated with chute score (linear effect, P=0.07). Pregnancy rates to FTAI were negatively affected by exit score (P=0.05), and the probability of cows becoming pregnant to FTAI was negatively associated with exit score and with actual exit velocity (linear effects, P<0.01). Results from this experiment indicate that excitable temperament is detrimental to pregnancy rates of B. indicus cows assigned to an estrus synchronization + FTAI protocol. Published by Elsevier B.V.

Ovarian activity and plasma concentrations of progesterone and estradiol during pregnancy in jennies

The objectives of this study were to determine ovarian activity (with ultrasound) and plasma concentrations of progesterone and estradiol during pregnancy in jennies. There was considerable ovarian activity during the second month of pregnancy. Secondary corpora lutea (total of 2 to 7 per jenny) were formed (mainly by luteinization) starting on Day 41.8 +/- 1.0 (range Days 38 to 46; ovulation = Day 0). The echogenicity of the primary and secondary corpora lutea gradually decreased during pregnancy. Plasma progesterone concentrations increased between Days 0 and 10 (0.9 and 19.9 ng/mL, respectively), gradually decreased to Day 30 (12.1 ng/mL), increased between Days 30 and 40 (plateau, at approximately 17 ng/mL), gradually declined from Days 110 to 160 (nadir of approximately 6 ng/mL), and remained nearly constant until increasing again just before parturition. Plasma estradiol concentrations increased gradually from Day 65, peaked (1.2 ng/mL) on Day 165 (greater than or equal to 1 ng/mL on Days 150 to 210), and decreased thereafter, with very low concentrations during the last 20 d before parturition. Ovarian function and hormone profiles were generally similar to those previously reported during pregnancy in mares. (C) 1998 by Elsevier B.V.