The Role of Preprocedure Genetic Counseling in Pregnancies Interrupted for Fetal Abnormalities.

OBJECTIVE: Congenital birth defects affect 3 to 5% of pregnancies. Genetic counseling can help patients navigate the testing process and understand results. The study objective was to identify predictors and utility of genetic counseling at the time of pregnancy termination. Additionally, we aimed to see what proportion of patients would benefit from additional testing based on the results of the genetic testing. STUDY DESIGN: This was a retrospective cohort review of all terminations performed for fetal anomalies by an academic center from July 2016 to May 2020. Indications were stratified by abnormal serum screening or types of abnormal ultrasound findings. Data were abstracted regarding uptake of genetic counseling and testing results. Abnormal results that warranted additional testing regarding recurrence risks were noted. Multivariable logistic regression was performed to identify predictors of receipt of genetic counseling and testing. RESULTS: Of 387 patients, 57% (n = 220) received preprocedure genetic counseling and 43% (n = 167) did not. Among patients who received diagnostic testing, 62% (n = 194) had genetic counseling compared with 38% (n = 121) without counseling (adjusted odds ratio 2.46, 95% confidence interval [1.41-4.29], p < 0.001). Among the entire cohort, 38% (n = 148) had suspected aneuploidy based on serum screening. Of these, 89% (n = 132/148) had definitive testing, 92% (n = 122/132) confirming the aneuploidy. Among the other 68% (n = 239) with structural anomalies, 76% (n = 183) had diagnostic testing with 29% (n = 53) yielding an abnormal result. Among those fetuses with structural anomalies, 36% (n = 19/53) of genetic diagnoses warranted additional parental testing because of risk of recurrence compared with only 2% (n = 2/122) of patients with abnormal serum screening results alone. CONCLUSION: Genetic counseling was associated with increased uptake of diagnostic testing, which yielded useful information and prompted additional testing. This is important for determining etiology and recurrence risk and should be offered to patients presenting for termination for fetal indications, as well as providing diagnostic closure for patients. KEY POINTS: · Genetic counseling increases the uptake of diagnostic testing in patients with fetal anomalies.. · Patients with ultrasound anomalies received less diagnostic testing despite actionable results 36% of the time.. · Genetic testing is invaluable for recurrence risk counseling even if patients chose to terminate..

Recurrent High-Grade Squamous Intraepithelial Lesion After Loop Excision Procedure Versus Loop Procedure With Top Hat.

OBJECTIVE: To evaluate single-pass loop electrosurgical excision procedure (LEEP-SP) versus LEEP with top hat (LEEP-TH) in terms of treatment failure defined as high-grade squamous intraepithelial lesion (HSIL) cytology within 2 years' follow-up. METHODS: This single-institution cohort study used a prospectively collected cervical dysplasia database including all patients who underwent LEEP-SP or LEEP-TH for biopsy-proven cervical intraepithelial neoplasia between 2005 and 2019. RESULTS: Of 340 patients included, 178 underwent LEEP-SP and 162 LEEP-TH. The LEEP-TH patients were more likely to be older (mean age, 40.4 vs 36.5 years; p < .001) and have a positive preprocedure endocervical sampling (68.5% vs 11.8%; p < .001). Positive margins were found in 23 LEEP-SP (12.9%) and in 25 LEEP-TH (15.4%; p = .507). There was no significant difference in depth of excision between LEEP-SP (13.21 ± 23.19 mm) and LEEP-TH (17.37 ± 28.26 mm; p = .138). At 2 years, there was no difference in the rates of HSIL cytology (5.2% vs 6.3%; p = .698), any positive human papillomavirus test, or HSIL cytology (25% vs 15%; p = .284). The 57 patients undergoing repeat excision were more likely to be older (mean age, 40.95 vs 37.52 years; p = .023), have had a LEEP-TH (26.3% vs 73.7%; p < .001), and have initial cytologic HSIL (64.9% vs 35.0%; p < .001). CONCLUSIONS: In this single-institution study, there is no difference in the rate of recurrent HSIL in patients undergoing LEEP-SP versus LEEP-TH. A LEEP-TH may have limited additional benefit over a LEEP-SP in the treatment of cervical HSIL.

Favorable Simplified Bishop Score after cervical ripening associated with decreased cesarean birth rate.

BACKGROUND: A favorable Simplified Bishop Score (>5) before the induction of labor is associated with successful vaginal birth. Patients with an unfavorable Simplified Bishop Score (≤5) undergo cervical ripening before the administration of oxytocin. However, data are limited regarding the utility of the Simplified Bishop Score after cervical ripening. OBJECTIVE: The objective of this study was to determine if the Simplified Bishop Score before oxytocin induction but after cervical ripening is associated with cesarean delivery. STUDY DESIGN: We conducted a retrospective cohort study on patients undergoing induction of labor from the Consortium on Safe Labor. The patients with a singleton term pregnancy who initially underwent cervical ripening were included. Those with a history of cesarean delivery were excluded. The outcomes of patients with a favorable Simplified Bishop Score after cervical ripening were compared with those with an unfavorable Simplified Bishop Score. The primary outcome was the mode of birth. A log-binomial regression was performed to calculate the relative risk and control for confounders such as admission Simplified Bishop Score and parity. RESULTS: A total of 5807 patients met the criteria to be included in the study. 4235 (73%) patients had a favorable cervix, and 1572 (27%) patients had an unfavorable cervix after cervical ripening. The favorable group had a decreased rate of cesarean delivery than the unfavorable group (risk ratio, 0.35; 95% confidence interval, 0.30-0.40). Both the groups had low rates of maternal chorioamnionitis, though the patients with an unfavorable cervix were at a higher risk. There was no significant difference in the rates of postpartum hemorrhage or neonatal intensive care unit admission. Lower rates of cesarean delivery among the favorable group persisted when stratifying by parity (nulliparous: risk ratio, 0.37; 95% confidence interval, 0.31-0.43; multiparous: risk ratio, 0.22; 95% confidence interval, 0.14-0.36). After controlling for maternal age, prepregnancy body mass index, parity, gestational age, and Simplified Bishop Score at admission, a favorable cervix remained significantly associated with fewer cesarean births (risk ratio, 0.55; 95% confidence interval, 0.46-0.66). CONCLUSION: In women undergoing labor induction, a favorable Simplified Bishop Score after cervical ripening and before the start of oxytocin is associated with a decreased rate of cesarean delivery, even after adjusting for parity and Simplified Bishop Score at admission. Moreover, the Simplified Bishop Score assigned after cervical ripening could be used to inform the timing of oxytocin initiation. However, further research is necessary to determine the ideal endpoint of cervical ripening.

Burrowing behavior in mud and sand of morphologically divergent polychaete species (Annelida: Orbiniidae).

Muddy and sandy sediments have different physical properties. Muds are cohesive elastic solids, whereas granular beach sands are non-cohesive porous media. Infaunal organisms such as worms that burrow through sediments therefore face different mechanical challenges that potentially lead to a variety of burrowing strategies and morphologies. In this study we compared three morphologically distinct polychaete species representing different clades in the family Orbiniidae and related differences in their burrowing behaviors and morphologies to their natural environments (mud or sand). Worms burrowed in transparent analogs for muds and sands, and kinematic analysis showed differences both among species and between materials. Leitoscoloplos pugettensis lives in mud and burrows by fracture, using its pointed head to concentrate stress at the tip of the burrow. Naineris dendritica lives in sand and uses its broader head that fluctuates in width over a burrowing cycle to decrease backward slipping in sand, potentially preventing burrow collapse. Orbinia johnsoni lives in sand and uses internal body expansions to pack sand grains, another mechanism to prevent burrow collapse. By combining data from species and materials to obtain a broad range of burrowing velocities, we show that burrowing worms control their velocity by increasing or decreasing their burrowing frequency rather than by altering cycle distance as shown previously for crawling earthworms. This study demonstrates how fairly small evolutionary divergences in morphologies and behaviors facilitate locomotion in environments with different physical constraints.