Outcomes of expectant management after betamethasone for hypertensive disorders of pregnancy.

OBJECTIVE: Review the latency period after betamethasone (BMZ) for pregnancies complicated by hypertensive disorders of pregnancy (HDP). STUDY DESIGN: A retrospective chart review of patients that received BMZ for the reduction of preterm morbidity for HDP. Patients were grouped by gestational age of administration of BMZ and type of hypertensive disorder of pregnancy for analysis. The primary outcome was the interval between the gestational age of the patient at BMZ administration and delivery. RESULTS: One-hundred and forty-seven subjects received BMZ for HDP during the study period delivering 168 infants. The median interval between administration of BMZ and delivery was 5 days [interquartile range (IQR) 2-20 days]. The median neonatal intensive care unit length of stay (NICU LOS) was 20 days (IQR 6-33 days). Fifty-seven percent of subjects delivered within 7 days of diagnosis and 32% had a latency period >14 days. Seventy-five percent of subjects were ultimately delivered for worsening hypertension. CONCLUSIONS: The median latency period between diagnosis and delivery in the setting of HDP is <7 days. Further studies are warranted to address the use of antihypertensive pharmacotherapy to prolong the latency period for fetal benefit.

Three-dimensional fast acquisition with sonographically based volume computer-aided analysis for imaging of the fetal heart at 18 to 22 weeks' gestation.

OBJECTIVE: The purpose of this study was to determine how frequently cardiac images derived from 3-dimensional (3D) volume sets, acquired by fast acquisition and evaluated with sonographically based volume computer-aided analysis (sonoVCAD), were satisfactory for prenatal screening at 18 to 22 weeks' gestation. METHODS: A prospective study of 100 women with singleton pregnancies was undertaken. Three fast acquisition 3D volume sets were obtained from each patient. Four reviewers independently evaluated the 4-chamber and 5 extracted VCAD views. Factors contributing to unsatisfactory screening were also evaluated. RESULTS: The frequency with which adequate views for cardiac screening could be obtained varied widely; some single views, such as that of the stomach, were well seen frequently, whereas others, such as the ductal arch, were well seen significantly less frequently (P < .05). A satisfactory screening examination, defined as a visualized 4-chamber, left ventricular outflow tract, right ventricular outflow tract, and axial stomach view, was obtained for 43% to 65% of patients (dependent on reviewer). Logistic regression revealed that obesity (odds ratio, 3.0; 95% confidence interval, 1.7-5.0) and a fetus with the spine toward the maternal abdomen (odds ratio, 1.7; 95% confidence interval, 1.1-2.5) were independently associated with an unsatisfactory screening examination CONCLUSIONS: Three-dimensional fast acquisition volumes evaluated with sonoVCAD did not allow a satisfactory fetal cardiac screening examination to be obtained a high percentage of the time in a general obstetric population during the second trimester. Certain patient factors, such as body habitus and fetal position, are associated with unsatisfactory 3D imaging.

Quality of 2- and 3-dimensional fast acquisition fetal cardiac imaging at 18 to 22 weeks: ramifications for screening.

OBJECTIVE: The purpose of this study was to evaluate the frequency with which 6 different fetal cardiac views taken during a fetal ultrasound examination at 18 to 22 weeks' gestation can be obtained satisfactorily for cardiac anomaly screening using either a 2-dimensional (2D) static or 3-dimensional (3D) fast acquisition technique. METHODS: A prospective study of 100 low-risk women undergoing an anatomic survey was performed. Standard static 2D and 3D fast acquisition volumes were obtained on all patients. The 2D and 3D images were assigned, in a random order, to be independently graded by 3 reviewers. The degree of inter-reviewer agreement was assessed through the use of the Cohen kappa statistic. The factors contributing to satisfactory imaging were evaluated by random effects logistic regression. RESULTS: A significant proportion of both 2D and 3D images were judged unsatisfactory for screening purposes. However, 2D images were significantly more likely, for all cardiac views, to be judged satisfactory (P < .05). The odds ratios for the 2D technique's being more likely than the 3D technique to provide images satisfactory for screening were 2.6 for the 4-chamber view, 2.4 for the right ventricular outflow tract, 4 for the left ventricular outflow tract, 3.2 for the 3-vessel view, 8.6 for the aortic arch, and 2.2 for the ductal arch. CONCLUSIONS: In this prospective study, static 2D imaging was significantly more likely than fast acquisition 2D imaging to yield cardiac views of high enough quality to satisfactorily screen for anomalies.

Contrasting effects of chronic hypoxia and nitric oxide synthase inhibition on circulating angiogenic factors in a rat model of growth restriction.

OBJECTIVE: We hypothesized that nitric oxide (NO) inhibition has synergistic effects with chronic hypoxia in altering maternal serum levels of soluble fms-like tyrosine kinase 1 (sFlt-1), vascular endothelial growth factor (VEGF), and placental growth factor (PlGF). We tested our hypothesis in a rodent model of intrauterine growth restriction induced by chronic hypoxia and NO inhibition with N(G)-nitro-L-arginine methyl ester (L-NAME). STUDY DESIGN: Timed pregnant adult Sprague-Dawley rats were assigned to the following groups: (1) 20% (oxygen) O2 + saline (n = 7); (2) 20% O2 + L-NAME (n = 8); (3) 14% O2 + saline (n = 5); (4) 14% O2 + L-NAME (n = 5); (5) 10% O2 + saline (n = 6); and (6) 10% O2 + L-NAME (n = 6). Seven nulliparous females served as nonpregnant controls. L-NAME (50 mg/rat/day) or saline was administered via subcutaneous osmotic pumps, inserted on day 17 of gestation. A hypoxic chamber was used to assure mild (14% O2) or severe (10% O2) hypoxic environment after surgical placement of the minipumps and until the animals were killed on day 21 of gestation before the onset of labor. Maternal blood was collected preceding death. Free serum levels of VEGF, PlGF, and sFlt-1 were measured by highly specific immunoassays. Two composite indices were calculated (sFV: log [(sFlt-1)/VEGF] and sFP: log [(sFlt-1)/PlGF] and compared among groups. RESULTS: Fetal growth restriction was induced by both severe hypoxia (10% O2) and L-NAME infusion (2-way analysis of variance, P = .02 O2 levels, P < .001 L-NAME), whereas their combination proved to be the most damaging (P < .001). Pregnancy was characterized by higher maternal serum concentrations of VEGF (P < .001) and PlGF (P < .001), but lower levels of sFlt-1 (P = .037) compared with nonpregnant controls. Serum VEGF levels were not altered by either hypoxia or L-NAME infusion (P = .348 O2 levels, P = .205 L-NAME). In contrast, L-NAME significantly increased sFlt-1 serum levels independent of O2 levels (P = .032, L-NAME treatment, P = .991 O2 levels). Chronic hypoxia significantly decreases the circulating levels of PlGF (P < .001) independent of L-NAME treatment. The sFV ratio was neither altered by hypoxia nor by L-NAME infusion. In contrast, the sFP ratio was significantly increased by both L-NAME (P < .001) and severe hypoxia (P < .001), but the effect was not synergistic (P = .655). CONCLUSION: Chronic NO inhibition as well as hypoxia induce fetal growth restriction and significantly change maternal circulating levels of sFlt-1 and PlGF, but not of VEGF. The primary effect of chronic hypoxia is in decreasing circulating levels of PlGF that contrasts with that of NO inhibition, which selectively increases sFlt-1 levels. Their effect is thus not synergistic, suggesting independent pathways.

Second-trimester ductus venosus measurement and adverse perinatal outcome in fetuses with congenital heart disease.

OBJECTIVE: The purpose of this study was to determine whether Doppler velocimetry of the ductus venosus (DV) predicts adverse perinatal outcome in congenital heart disease (CHD). METHODS: We conducted a retrospective cohort study of all pregnant women undergoing fetal echocardiography for CHD in a single perinatal center during a 2-year period. We compared outcomes for fetuses having a diagnosis of CHD in the second trimester and abnormal DV Doppler velocimetric findings with those having CHD and normal DV Doppler findings. Karyotype, gestational age at delivery, fetal loss rate, and rate of termination were assessed. The referral value for an abnormal DV pulsatility index was above the 95th percentile for gestational age. Statistical analysis included the t test, Fisher exact test, and chi(2) test. RESULTS: The incidence of CHD in our population was 7%. There were 98 patients with CHD; of those, 31 had DV measurement. A total of 9 patients had an abnormal DV. Three of this group (33%) had intrauterine fetal death or perinatal death. In patients with CHD and normal DV measurements, 83% had living children versus 33% in the group with an abnormal DV (P < .05). There was no statistically significant difference in the rate of aneuploidy between the normal DV (15%) and abnormal DV (20%) groups (P = .65). The mean gestational age at delivery was similar between the normal (37.63 weeks) and abnormal (38.33 weeks) DV groups (P = .71). There was no difference in the rate of pregnancy termination. CONCLUSIONS: Abnormal second-trimester DV measurements are predictive of adverse perinatal outcome in patients with CHD, independent of karyotype or gestational age at delivery. This information may have a role in the counseling of parents with CHD.

Prior cesarean delivery is not associated with an increased risk of stillbirth in a subsequent pregnancy: analysis of U.S. perinatal mortality data, 1995-1997.

OBJECTIVE: An association between cesarean delivery and an increased risk of stillbirth in a subsequent pregnancy has been reported in the United Kingdom. This study investigated the association between prior cesarean delivery and unexplained intrauterine fetal demise at term in the United States. STUDY DESIGN: We conducted a cross-sectional study using the U.S. perinatal mortality data (1995 to 1997). Women aged 15 to 44 years with singleton term (37 weeks or longer) pregnancies were included in the analysis. Study groups were defined as pregnant women with a prior cesarean delivery (prior cesarean delivery) and women with no prior cesarean delivery (no cesarean delivery). Adjustments were made for maternal age, race, underlying medical conditions, and fetal congenital abnormalities. The Cochran-Mantel-Haenszel method was used for relative risk estimation at the 95% confidence interval calculation. RESULTS: A total of 11,061,599 deliveries of singleton pregnancies were recorded in the United States from January 1, 1995, to December 31, 1997. The cesarean delivery rate was 19.6%. The crude term intrauterine fetal demise rate was 1.5 per 1000 births for no cesarean delivery and 1.3 per 1000 births for prior cesarean delivery. After correction for parity greater than 1, congenital anomalies, and underlying maternal medical conditions, term intrauterine fetal demise rates were 0.6 and 0.4 per 1000 births for no cesarean delivery and prior cesarean delivery, respectively. Restriction of the analysis to women with only 1 prior delivery resulted in term intrauterine fetal demise rates of 0.8 and 0.7 per 1000 births for no cesarean delivery and prior cesarean delivery, respectively (relative risk 0.90; 95% confidence interval 0.76-1.06). CONCLUSION: A prior cesarean delivery is not associated with an increased risk of stillbirth in a subsequent pregnancy.