Nuchal Translucency Quality Review (NTQR) program: first one and half million results.

OBJECTIVE: To evaluate the performance of first-trimester nuchal translucency (NT) measurement by providers (physician-sonologists and sonographers) within the Nuchal Translucency Quality Review (NTQR) program. METHODS: After training and credentialing providers, the NTQR monitored performance of NT measurement by the extent to which an individual's median multiple of the normal median (MoM) for crown-rump length (CRL) was within the range 0.9-1.1 MoM of a published normal median curve. The SD of log10 MoM and regression slope of NT on CRL were also evaluated. We report the distribution between providers of these performance indicators and evaluate potential sources of variation. RESULTS: Among the first 1.5 million scans in the NTQR program, performed between 2005 and 2011, there were 1 485 944 with CRL in the range 41-84 mm, from 4710 providers at 2150 ultrasound units. Among the 3463 providers with at least 30 scans in total, the median of the providers' median NT-MoMs was 0.913. Only 1901 (55%) had a median NT-MoM within the expected range; there were 89 above 1.1 MoM, 1046 at 0.8-0.9 MoM, 344 at 0.7-0.8 MoM and 83 below 0.7 MoM. There was a small increase in the median NT-MoM according to providers' length of time in the NTQR program and number of scans entered annually. On average, physician-sonologists had a higher median NT-MoM than did sonographers, as did those already credentialed before joining the program. The median provider SD was 0.093 and the median slope was 13.5%. SD correlated negatively with the median NT-MoM (r = -0.34) and positively with the slope (r = 0.22). CONCLUSION: Even with extensive training, credentialing and monitoring, there remains considerable variability between NT providers. There was a general tendency towards under-measurement of NT compared with expected values, although more experienced providers had performance closer to that expected.

Alpha1-antitrypsin deficiency. Severe obstructive lung disease and pregnancy.

The case of a 37-year-old primigravida with severe obstructive lung disease and alpha1-antitrypsin deficiency is reported. Serial pulmonary function studies and arterial blood gases were obtained during the antenatal and postpartum periods. Intrauterine fetal growth was monitored with serial ultrasonic fetal biparietal diameter determinations. Serial oxytocin challenge tests were used to monitor uteroplacental function. Aggressive chest physiotherapy was used to maintain good maternal bronchopulmonary hygiene. A normal female infant was delivered vaginally at 38 weeks' gestation following an uneventful labor. The available obstetric literature regarding the outcome of pregnancy in patients with obstructive lung disease and cystic fibrosis is reviewed. This literature suggests that pregnancy in a patient with severe obstructive lung disease should be considered a medical indication for therapeutic abortion. Successful delivery of this patient with severe obstructive lung disease and alpha1-antitrypsin deficiency suggests that these conditions are not a contraindication to successful outcome of preganncy for both mother and child.

Growth adjusted sonographic age. A simplified method.

It recently has been shown that the sonar predictive accuracy of gestational age can be markedly enhanced by separating fetuses into one of three cephalic growth patterns, namely, large, average, and small. In this way it becomes possible to adjust fetal age in relation to biparietal diameter (BPD) growth. In this report we are defining the application of a growth adjusted sonographic age (GASA). Additionally, we are introducing a table which simplifies the assignment of GASA on a routine basis.

Doppler evaluation of umbilical and uterine-arcuate arteries in the postdates pregnancy.

To assess the correlation between Doppler velocimetry and perinatal outcome in the postdates pregnancy, 75 women who were at least 41 weeks' gestation were evaluated twice weekly until delivery. Evaluation included Doppler velocimetry of the umbilical and uterine-arcuate arteries, as well as nonstress testing and amniotic fluid volume estimation. The mean umbilical artery systolic-diastolic ratio (S/D) was significantly higher in the pregnancies with subsequent abnormal perinatal outcomes than in those with normal outcomes (2.42 versus 2.19; P = .03). Using a receiver operating characteristic curve, an abnormal umbilical artery S/D was defined as 2.40 or greater. Using this value, sensitivity was 57.1% and specificity was 77.8%. Our study suggests that an umbilical artery S/D of 2.40, rather than the more traditionally accepted cutoff of 3.0, may be a useful threshold to identify those postdates pregnancies at high risk for abnormal perinatal outcome.

A hypothetical model suggesting suboptimal intrauterine growth in infants delivered preterm.

Infants delivered preterm often reflect accelerated maturation. The present study examines the occurrence of suboptimal intrauterine growth in infants delivered preterm by comparing their birth weights to the weights sonographically predicted for in utero fetuses at similar gestational ages but who ultimately deliver at term. Two weight-predicting formulas based on different sonographic parameters were used. In the fifth, tenth, and 50th percentiles of birth weight, the predicted weights were persistently and significantly greater than the actual birth weights between 24 and 31 weeks' gestation. The results of this model support the concept that the growth of infants delivered prematurely has been suboptimal. The authors hypothesize that preterm delivery may be in some instances another manifestation of the same underlying stress that hastens pulmonary and neurologic maturity.

Diabetic macrosomia: accuracy of third trimester ultrasound.

Sonar biparietal diameter, head circumference, and abdominal circumference percentile values obtained late in the third trimester were compared with birth weight percentile (relative to dates) in 147 diabetic mothers and 40 control fetuses of nondiabetics. Estimates of fetal weight by the method of Shepard et al were also calculated from these sonar data and compared with birth weight percentile. Abdominal circumference values greater than the 90th percentile correctly predicted macrosomia (defined as birth weight greater than 90th percentile) in 78% of cases. Biparietal diameter and head circumference percentiles were significantly less predictive of macrosomia. When analyzed in a similar manner, estimated fetal weights greater than the 90th percentile correctly predicted macrosomia at birth in 74% of cases. However, when both the abdominal circumference and the estimated fetal weight exceeded the 90th percentile, macrosomia was correctly diagnosed in 88.8% of pregnant women with diabetes mellitus.

Fetal surgery for hydrocephalus: successful in utero ventriculoamniotic shunt for Dandy-Walker syndrome.

The diagnosis of fetal hydrocephalus based on dilation of the ventricular system presents a broad range of management decisions. The options are presented and a case of Dandy-Walker syndrome managed by fetal ventriculoamniotic shunt placement is presented as an example. Under ultrasonic guidance, a shunt was placed at 30 weeks' gestation by later newborn Dubowitz examination. Delivery was delayed for five weeks, one to two weeks following probable shunt malfunction, after achieving fetal lung maturation. Follow-up six months after definitive neonatal ventricular shunting and three weeks after shunt revision revealed a socially active male infant with a motor development index of 87 and a psychomotor development index of 95. Potential advantages of fetal surgery including achievement of term gestation are presented. Proposed guidelines for determining the benefit of such procedures are also presented.

Urinary estriols in diabetic pregnancy: a reappraisal.

The clinical usefulness of serial urinary estriols was tested in 138 insulin-dependent diabetic pregnant women. No action was taken on an estriol drop if fetal well-being was demonstrated by a reactive nonstress test and/or negative contraction stress test within 24 hours. Of 3085 estriol values, a greater than or equal to 40% estriol drop, confirmed by a greater than or equal to 40% decrease in the estriol-creatine ratio, was observed in 21 tests. In only two of these tests, was fetal distress indicated by a nonstress test or contraction stress test. A significant linear correlation was demonstrated between the mean level of estriol excretion and birth weight, placental weight, and fetal abdominal circumference measured by ultrasound. Chronically low estriol excretion (less than 12 mg per 24 hours at greater than 36 weeks' gestation) related to smaller placentas but not to fetal jeopardy.

A blueprint for academic obstetrics and gynecology.

A consensus conference sponsored by the Council of University Chairs of Obstetrics and Gynecology in February 1997 formulated the organization's response to the many external issues affecting academic medicine and obstetrics and gynecology including 1) a new practice model based on "wellness," 2) reimbursement changes that have jeopardized traditional revenue sources, 3) an emphasis on quality assurance based on outcomes research and evidence-based medicine, 4) the concept of lifelong learning dictated by an expanding knowledge base and new technology, 5) insufficient resources for basic and clinical investigation in obstetrics and gynecology, 6) workforce statistics indicating stabilization in the number of subspecialists, 7) the increasing diversity of the United States population. Recommendations were developed that are intended to foster change and contribute to the design of academic programs. These include appropriate training for residents as providers of primary care, with an emphasis on continuity clinics, an interdisciplinary curriculum in women's health for medical students; promotion of gender, racial, and ethnic diversity at all levels of medical education and academic leadership; creation of clinical trials research units; and the development of expanded opportunities for research in obstetrics and gynecology supported by the National Institutes of Health.

Perinatal asphyxia: assessing its causal role and timing.

Perinatal asphyxia, whether prenatal, intrapartum, or neonatal is thought to be a significant contributor to newborn morbidity and mortality as well as long-term neurological deficits. Development of an intrapartum tool/test that can reliably identify and discriminate between varying degrees of fetal acidemia and suggest whether it is respiratory or metabolic in nature would be highly desirable. This article critically reviews the available experience with the currently available monitoring techniques and the significance of abnormalities of fetal and intrapartum measurements with respect to the predictive value of the observations available to the clinician.

Acoustic stimulation testing.

The nonstress test is the most widely employed method of fetal health assessment. The current approach is to use the OCT or biophysical profile as a means of identifying the fetus at very high risk should the nonstress test be either nonreassuring or equivocal. The acoustic stimulation test may have a predictive ability similar to that of the biophysical profile and thus may be used to complement nonstress testing as early as 28 weeks' gestation. It reliably invokes a reactive NST in those fetuses destined to demonstrate reactivity with persistence in monitoring and facilitates more rapid and efficient testing. The acoustic test may have the additional benefit of providing a screening mechanism for anomalies in which neurologic performance is suboptimal. However, because the test has not been studied on large numbers of patients and because different applications of such stimuli may elicit differing responses, its adaptation for clinical use should be cautious at the present time.

Apgar scores and umbilical cord arterial pH in the breech neonate.

Apgar scores and umbilical cord arterial pH measurements of 449 singleton breech deliveries are compared retrospectively to those of 1425 singleton vertex neonates. In the vaginal deliveries the Apgar scores and umbilical arterial pH were higher for the vertex neonates. There were no differences in either Apgar scores or umbilical arterial pH between the breech and vertex neonates delivered by cesarean section. Whereas Apgar scores in the less than 1000 g and greater than or equal to 2500 g weight groups were lower in the breech neonates delivered vaginally compared to cesarean section, umbilical arterial pH measurements were similar. The data suggest that liberal use of cesarean section may improve the Apgar scores but will probably not appreciably improve the acid-base status of the breech neonate.

A prospective, randomized evaluation of intrapartum amnioinfusion. Fetal acid-base status and cesarean delivery.

Pregnancies with decreased amniotic fluid volume are prediposed to umbilical cord compression and variable fetal heart rate declerations. Intrapartum amnioinfusion has been utilized in an effort to reduce cord compression. Previous studies suggested that amnioinfusion may improve the fetal metabolic state and reduce the incidence of cesarean delivery in selected patients. In this study the hypothesis was tested that intrapartum amnioinfusion will relieve cord compression in pregnancies complicated by oligohydramnios and will result in a reduced incidence of fetal intolerance to labor as well as improved fetal acid-base status at delivery. Thirty-five patients fulfilling the inclusion criteria were randomized to either the control (n = 16) or amnioinfusion treatment group (n = 19). Analysis of the data suggested that the two groups were similar for the perinatal parameters evaluated. No differences were observed in the umbilical artery blood gas analysis or incidence of cesarean section between the two groups. Intrapartum amnioinfusion does not appear to improve the perinatal outcome in pregnancies with oligohydramnios.

Acupuncture in obstetrics.

Electroacupuncture (ACP) during childbirth was used in 12 parturients. On the average, it produced 66 percent analgesia in 7 patients for 139 minutes while patients were in active, progressive labor. When ACP no longer could relieve pain, spinal, epidural, or double-catheter technic produced complete analgesia in all patients. ACP did not adversely affect the fetus or uterine contractions and had no harmful aftereffect on mother or neonate. However, its use as a routine method had disadvantages because analgesia was inconsistent, unpredictable, and incomplete. The technic was time-consuming, limited the patient's movement, added more wires and machinery, and interfered with electronic monitoring of the mother and fetus.

The Northwestern University Twin Study. VII: The mode of delivery in twin pregnancy. North American considerations.

No consensus exists for the optimal mode of delivery for twin fetuses. Opinions vary by type of institution (university medical center vs community hospital), country or continent (North America vs Western Europe) and personal preference of individual physicians. This article lists clinical considerations in arriving at the decision and presents them in the form of a decision tree.

Fetal heart rate patterns and development in the first year of life.

The development of 50 high-risk infants who were provided intrauterine monitoring during labor was prospectively evaluated. Twelve infants had normal fetal heart rate patterns, 16 moderate-severe variable patterns, and 22 severe variable or late deceleration patterns. The parity, socioeconomic status, race of the mothers, and sex of the infants were similar in each group. The infants were examined neurologically 48 to 72 hours after birth and at 2, 4, 6, 9, and 12 months of age. Denver Developmental Standard testing was performed at 2, 4, 6, 9, and 12 months of age. A statistically significant developmental bias was seen favoring those infants with normal fetal heart patterns. Fetal heart rate patterns predicted abnormal performance more accurately than did Apgar scores. Although this data is incomplete, the duration of ominous fetal heart rate patterns appears to adversely affect development.

The Northwestern University multihospital twin study. I. A description of 588 twin pregnancies and associated pregnancy loss, 1971 to 1975.

Five hundred eighty-eight women who were delivered of twins at 13 hospitals affiliated with the Northwestern University Medical School or its outreach institutions between 1971 and 1975 were studied. Eighty-six of the infants did not survive the pregnancy, delivery, or the first week post partum. Maternal demographic and obstetric characteristics are outlined. Infants are categorized by birth order and by birth weight. The mean weight (and standard deviation) of first twins was 2,388 gm (+/- 742 gm) and that of second twins was 2.314 gm (+/- 766 gm). The rate of pregnancy wastage was highest in mothers who were under 20 years of age, who were of low parity, and who were delivered prior to the physiologic maturation of the fetus. The crude mortality rate of twin 1 was 6.1/100 versus 8.5/100 for twin 2. The causes of death in all infants over 2,000 gm are listed. All pregnancy losses are categorized into unavoidable deaths (26.6%), probably not avoidable deaths (59.4%), and possibly avoidable deaths (13.9%).