When the prenatal diagnosis of a lethal fetal anomaly has been established, some patients choose to continue their pregnancy. Currently, there is a paucity of medical literature addressing the specific management of families in this unique circumstance. We propose a model of care that incorporates the strengths of prenatal diagnosis, perinatal grief management, and hospice care to address the needs of these families. We discuss the identification of candidates for this form of care; the multidisciplinary team approach; and the aspects of antepartum, intrapartum, and postpartum care. Finally, we discuss some barriers that might need to be overcome when attempting to implement perinatal hospice care.

Apart from their key role in immunologic signaling, cytokines are thought to play a part in ovulation, implantation, placentation, and parturition. There is mounting evidence that cytokines can contribute to preterm births associated with intrauterine infection. This study measured levels of cytokines produced by maternal peripheral blood mononuclear cells after stimulation by mitogen, autologous placental cells, and an extract of trophoblast antigen. Cytokine levels were compared in 30 women admitted in active preterm labor with intact membranes who had preterm delivery (PTD) and 54 control women who had had at least 3 normal pregnancies. Mean gestational ages were 26.8 weeks in the PTD group and 39.4 weeks in the control women. Without stimulation, serum levels of interleukin-6 (IL-6) were significantly higher in the PTD group from the second trimester onward. Levels of interferon-␥ (IFN-␥) also were higher in PTD, whereas levels of tumor necrosis factor-␣ were significantly higher in normal women. Analysis of stimulated cultures confirmed significantly higher levels of the type 1 cytokines IFN-␥ and IL-2 in the PTD group. Women with normal pregnancies exhibited significantly greater production of the type 2 cytokines IL-4, IL-5, and IL-10. The ratios of type 2 to type 1 cytokines suggested a bias to type 1 cytokines in women with PTD. This study indicated a bias toward increased production, by maternal lymphocytes of women with PTD, of type 1 cytokines that are known to induce numerous cytotoxic and inflammatory actions. Production of type 2 cytokines, which augment humoral immunity, is less evident in these women. Reportedly normal pregnancy is associated with a predisposition to type 2 immunity, whereas predominantly type 1 reactivity can lead to failed pregnancy. ABSTRACTApproximately 1% of pregnant women are asthmatic and the prevalence could be increasing, like it is in the general population. The authors used data from a nested case-control study to learn whether maternal asthma is associated with a greater risk of preterm labor and delivery. The study group included 312 women who delivered before 37 completed weeks gestation and, as a control group, 424 women who delivered a singleton infant at term. Women with a history of asthma were approximately twice as likely as others to have preterm delivery (odds ratio [OR], 2.03; 95% confidence interval [CI], 1.01-4.09). A slightly stronger association (OR, 2.37; 95% CI, 1.15-4.88) was evident after adjusting for maternal age, race/ethnicity, parity, Medicaid payment status, and smoking during pregnancy. Asthma correlated with a greater than 2-fold increase in risk of both spontaneous and medically induced preterm delivery, but the association was statistically significant only for the latter. Maternal asthma was associated with both moderate (34-36 weeks) and very (before 34 weeks) preterm deliveries. These findings point to an increased risk of preterm delivery in asthmatic women. ABSTRACTPreterm delivery before 37 completed weeks gestation remains the major...

The purpose of this study was to evaluate pelvic organ support during pregnancy and following delivery. This was a prospective observational study. Pelvic organ prolapse quantification (POPQ) examinations were performed during each trimester of pregnancy and in the postpartum. Statistical comparisons of POPQ stage and of the nine measurements comprising the POPQ between the different time intervals were made using Wilcoxon's signed rank and the paired t-test. Comparison of POPQ stage by mode of delivery was made using Fisher's exact test. One hundred thirty-five nulliparous women underwent 281 pelvic organ support evaluations. During both the third trimester and postpartum, POPQ stage was significantly higher compared to the first trimester (p<0.001). In the postpartum, POPQ stage was significantly higher in women delivered vaginally compared to women delivered by cesarean (p=0.02). In nulliparous pregnant women, POPQ stage appears to increase during pregnancy and does not change significantly following delivery. In the postpartum, POPQ stage may be higher in women delivered vaginally compared to women delivered by cesarean.

Little is known about the anatomic and physiologic changes in the pelvic floor that occur during pregnancy. The purpose of this study was to prospectively document pelvic organ support throughout pregnancy using the standardized system of the International Continence Society, also known as the Pelvic Organ Prolapse Quantification (POPQ) Staging System. Pelvic organ support evaluations were performed in nulliparous pregnant women presenting for routine obstetric care during each trimester. POPQ stage assignments and POPQ component measurements were compared for first-, second- and third-trimester examinations. Overall POPQ stage was significantly higher in the third trimester than in the first (P=0.001). Individual POPQ points which showed significant differences between the first and third trimesters include Aa, PB, Ap, Ba, Bp, TVL and GH. These findings probably represent normal physiologic changes of the pelvic floor during pregnancy, but suggest that significant changes may be objectively demonstrated prior to delivery.

This study offers a broad perspective on reproductive history and mortality rates, with the results indicating a need for further research on possible underlying mechanisms.