Perioperative prophylactic internal iliac artery balloon occlusion in the prevention of postpartum hemorrhage in placenta previa: a randomized controlled trial.

BACKGROUND: Placenta previa remains one of the major causes of massive postpartum hemorrhage and maternal mortality worldwide. OBJECTIVE: To determine whether internal iliac artery balloon occlusion during cesarean delivery for placenta previa could reduce postpartum hemorrhage and other maternal complications. STUDY DESIGN: This was a prospective randomized controlled trial conducted at a tertiary university obstetric unit in Hong Kong. Pregnant women who were diagnosed to have placenta previa at 34 weeks (defined as lower placenta edge within 2 cm from the internal os) and required cesarean delivery were invited to participate. Eligible pregnant women were randomized into internal iliac artery balloon occlusion (Occlusion) group or standard management (Control) group. Those randomized to the Occlusion group had internal iliac artery balloon catheter placement performed before cesarean delivery and then balloon inflation after delivery of the baby. The primary outcome was the reduction of postpartum hemorrhage in those with internal iliac artery balloon occlusion. Secondary outcome measures included hemoglobin drop after delivery; amount of blood product transfusion; incidence of hysterectomy; maternal complications including renal failure, ischemic liver, disseminated intravascular coagulation, and adult respiratory distress syndrome; length of stay in hospital; admission to intensive care unit; and maternal death. RESULTS: Between May 2016 and September 2018, 40 women were randomized (20 in each group). Demographic and obstetric characteristics were similar between the 2 groups. In the Occlusion group, 3 women did not receive the scheduled procedure, as it was preceded by antepartum hemorrhage that required emergency cesarean delivery, and 1 woman had repeated scan at 36 weeks showing the placental edge was slightly more than 2 cm from the internal os. Intention-to-treat analysis found no significant differences between the Occlusion and the Control groups regarding to the median intraoperative blood loss (1451 [1024-2388] mL vs 1454 [888-2300] mL; P = .945), the median length of surgery (49 [30-62] min vs 37 [30-51] min; P = .204), or the need for blood transfusion during operation (57.9% vs 50.0%; P = .621). None of the patients had rebleeding after operation, complication related to internal iliac artery procedure, or any other maternal complications. Reanalyzing the data using on-treatment approach showed the same results. CONCLUSION: The use of prophylactic internal iliac artery balloon occlusion in placenta previa patients undergoing cesarean delivery did not reduce postpartum hemorrhage or have any effect on maternal or neonatal morbidity.

Monochorionic twins with selective fetal growth restriction: insight from placental whole-transcriptome analysis.

BACKGROUND: The underlying pathomechanism in placenta-related selective fetal growth restriction in monochorionic diamniotic twin pregnancy is not known. OBJECTIVE: This study aimed to investigate any differences in placental transcriptomic profile between the selectively growth-restricted twins and the normally grown cotwins in monochorionic diamniotic twin pregnancies. STUDY DESIGN: This was a prospective study of monochorionic diamniotic twin pregnancies complicated by selective fetal growth restriction. Placental biopsy specimens were obtained from the subjects in the delivery suite. The placental transcriptome of the selectively growth-restricted twin was compared with that of the normally grown cotwin. This study was divided into 2 stages: (1) gene discovery phase in which placental tissues from 5 monochorionic diamniotic twin pregnancies complicated by selective fetal growth restriction plus 2 control twin pregnancies underwent transcriptome profiling, and transcriptome profiling was carried out using whole-genome RNA sequencing; and (2) validation phase in which placental tissues from 13 monochorionic diamniotic twin pregnancies with selective fetal growth restriction underwent RNA and protein validation. RNA and protein expression levels of candidate genes were determined using quantitative real-time polymerase chain reaction and immunohistochemistry staining. RESULTS: A total of 1429 transcripts were differentially expressed in the placentae of selectively growth-restricted twin pairs, where 610 were up-regulated and 819 were down-regulated. Endoplasmic reticulum lectin and mannose 6-phosphate receptor were consistently differentially up-regulated in all placentae of selectively growth-restricted twins. Quantitative real-time polymerase chain reaction and immunohistochemistry staining were used to validate the results (P<.05). CONCLUSION: The expression of endoplasmic reticulum lectin and mannose 6-phosphate receptor, which are important for angiogenesis and fetal growth, was significantly increased in the placentae of selectively growth-restricted twin of a monochorionic twin pair.

The predictive value of cervical shear wave elastography in the outcome of labor induction.

INTRODUCTION: Bishop score, the traditional method to assess cervical condition, is not a promising predictive tool of the outcome of labor induction. As an objective assessment tool, many cervical ultrasound measurements have been proposed to represent the individual components of the Bishop score, but none of them can measure the cervical stiffness. Cervical shear wave elastography is a novel tool to assess the cervical stiffness quantitatively. MATERIAL AND METHODS: A total of 475 women who required labor induction were studied prospectively. Prior to routine digital assessment of the Bishop score, transvaginal sonographic measurement of cervical length, posterior cervical angle, angle of progression and shear wave elastography was performed. Shear wave elastography measurement was made at the inner, middle and outer regions of the cervix to assess homogeneity. Association of labor induction outcomes including the overall cesarean section and subgroups of cesarean section for failure to enter active phase, with cervical sonographic parameters and the Bishop score, were assessed using multivariate regression analyses. The predictive accuracy of the outcomes using models based on ultrasound measurement and the Bishop score was compared using the area under the receiver-operating characteristics curves. RESULTS: Among 475 women, 82 (17.3%) required cesarean section. Shear wave elasticity was significantly higher in the inner cervical region than in other regions, indicating a greater stiffness (P < 0.001). Both inner cervical shear wave elasticity and cervical length were independent predictors of overall cesarean section (respective adjusted odds ratio [95% CI] 1.338 [1.001-1.598] and 1.717 [1.077-1.663]) and cesarean section for failure to enter active phase (respective adjusted odds ratio [95% CI] 1.689 [1.234-2.311] and 2.556 [1.462-4.467]), after adjusting for other covariates. Outcome prediction models using inner cervical shear wave elasticity and cervical length, had increased area under curve compared with models using the Bishop score (0.888 vs 0.819, P = 0.009). CONCLUSIONS: The cervix is not a homogenous structure, with the inner cervix having the highest stiffness, which is an independent predictor of overall cesarean section, and specifically for those indicated because of failure to enter active phase. Models based on shear wave elastography and cervical length had higher predictive accuracy than models based on the Bishop score.

Objective assessment of the fetal facial profile at second and third trimester of pregnancy.

OBJECTIVE: To investigate the intraobserver and interobserver reproducibility of a novel sonographic parameter named facial maxillary angle (FMA) and to establish nomograms of FMA, inferior facial angle (IFA), frontal nasal-mental angle (FNMA), maxilla-nasion-mandible angle (MNMA), and fetal profile line (FPL) in Chinese fetuses. METHODS: In this prospective cross-sectional study, FMA, IFA, FNMA, MNMA, and FPL were measured in 592 normal fetuses between 16 and 36 gestational weeks. FMA was measured twice by the same and another operator with a blinded method on the first 50 cases. The reference interval was defined as ±2SD. The efficacy of five sonographic markers was tested in 10 fetuses with micrognathia retrieved from the database of our unit. RESULTS: The intraclass correlation coefficient (95% CI) of intraobserver and interobserver reproducibility of FMA was 0.937 (0.890-0.964) and 0.891 (0.809-0.938), respectively. FMA, FNMA, and IFA increased slightly from 16 weeks till 28-31 weeks and decreased minimally thereafter. FMA and FNMA made correct diagnosis in all affected fetuses; MNMA and IFA identified nine and eight cases respectively, and FPL only detected five cases. CONCLUSION: A fixed cutoff of 66° for FMA and 136° for FNMA may be adopted as simple screening criteria of micrognathia.

Pitfalls in assessing chorioamnionicity: novel observations and literature review.

Accurate diagnosis of chorioamnionicity in multiple pregnancies is the key to appropriate clinical management of multiple gestation. Although prenatal ultrasound assessment of chorioamnionicity is well established and highly accurate if performed in early pregnancy, exceptions and artifacts arise from anatomic variations in multiple pregnancies and unusual sonographic features do exist. We have summarized our own experiences and reports from the literature on these pitfalls as follows: (1) discordant fetal sex in monochorionic pregnancies due to sex chromosome abnormalities, genital malformation in 1 fetus, or dizygotic twins forming a monochorionic placenta; (2) separate placental masses in monochorionic pregnancies due to bipartite placenta; (3) false-negative and false-positive λ sign can arise for various reasons, and in partial monochorionic/dichorionic placentas both T and λ sign may co-exist; (4) intrauterine synechia appearing as a thick and echogenic intrauterine septum may lead to erroneous diagnosis of dichorionic twins; and (5) errors in ascertaining amnionicity by the visualization of thin intertwin amniotic membranes and the number of yolk sacs. The ultrasound techniques to reduce inaccuracy in prenatal determination of chorioamnionicity and the use of single nucleotide polymorphisms based on noninvasive prenatal test to determine zygosity are also reviewed.

Prenatal Diagnosis of a Retroesophageal Left Brachiocephalic Vein: Two Case Reports.

A retroesophageal left brachiocephalic vein is an extremely rare anomaly and has only been reported in 6 postnatal cases. Two prenatally diagnosed cases are reported. On the 3-vessel view, the vein appears as an aberrant vessel transversely coursing behind the aorta and trachea, which subsequently drains into the superior vena cava, giving rise to a U-shaped configuration. On color Doppler sonography, the U sign is bicolored. This anomaly should prompt the sonographer to carefully assess for other congenital heart defects, suggest consideration for genetic testing, and alert the cardiologist because it could affect central line procedures and cardiac interventions after delivery.

Procedure-Related Fetal Loss following Chorionic Villus Sampling after First-Trimester Aneuploidy Screening.

OBJECTIVE: The aim was to determine the institutional procedure-related fetal loss rate after chorionic villus sampling (CVS) and the factors which may identify pregnancies at increased risk of having a procedure-related loss. MATERIALS AND METHODS: Pregnancy outcomes were retrieved of all women having a singleton pregnancy and undergoing a CVS procedure between 2004 and 2013 at a university hospital in Hong Kong. The incidence of procedure-related fetal loss due to unintended miscarriages adjusted for the background loss incidence of miscarriages was determined. Multivariate regression was performed to examine the factors contributing to an unintended fetal loss and miscarriage. RESULTS: CVS was performed on 1,906 fetuses. The procedure-related fetal loss rate was 0.17% (95% CI -0.2 to 0.7). After multivariate analysis, a decreased plasma protein-A (PAPP-A) multiple of the median (OR 0.27; 95% CI 0.08-0.98, p = 0.046) was significantly associated with miscarriage in women who did not undergo a CVS. Patient-specific prediction of spontaneous abortion in women who did not undergo CVS was not statistically significant (AUC 0.56; 95% CI 0.49-0.6, p = 0.14). CONCLUSIONS: The CVS-related fetal loss rate adjusted for background loss was 0.17%. Pregnancies with reduced PAPP-A carry an increased risk of miscarriage irrespective of whether they had undergone an invasive procedure.

Ultrasound-Guided Percutaneous Embolisation of Placental Chorioangioma Using Cyanoacrylate.

We describe a case of large chorioangioma diagnosed at 22 weeks of gestation. As the tumour progressively enlarged to 8 cm with fetal cardiomegaly and increased middle cerebral arterial peak systolic velocity, embolisation of its feeding artery by percutaneous injection of cyanoacrylate was performed under ultrasound guidance. Devascularisation was immediate and complete, and the fetal cardiomegaly and anaemic features resolved after 3 weeks. A healthy infant was born at 34 weeks of gestation following spontaneous preterm labour. Pathological examination of the placenta confirmed an infarcted chorioangioma. Literature on the various prenatal treatments of chorioangioma was reviewed and showed that embolisation using cyanoacrylate is a feasible, simple, and effective treatment for large chorioangiomas. The techniques to optimise the success of the procedure were also discussed.

Predictive factors for the success of McRoberts' manoeuvre and suprapubic pressure in relieving shoulder dystocia: a cross-sectional study.

BACKGROUND: McRoberts' and suprapubic pressure are often recommended as the initial choices of manoeuvres to manage shoulder dystocia, as they are believed to be less invasive compared to other manoeuvres. However, their success rates range from 23 to 40 %. This study aims to investigate the predictive factors for the success of McRoberts' manoeuvre with or without suprapubic pressure (M+/-S). METHODS: All cases of shoulder dystocia in a tertiary hospital in South East Asia were recruited from 1995 to 2009. Subjects were analysed according to either 'success' or 'failure' of M+/-S. Maternal and fetal antenatal and intrapartum factors were compared by univariate and multivariate analysis. RESULTS: Among 198 cases of shoulder dystocia, M+/-S as the primary manoeuvre was successful in 25.8 %. The other 74.2 % needed either rotational or posterior arm manoeuvres or combination of manoeuvres. Instrumental delivery was the single most significant factor associated with an increased risk of failed M+/-S on logistic regression (p < 0.001, OR 4.88, 95 % CI 2.05-11.60). The success rate of M+/-S was only 15.0 % if shoulder dystocia occurred after instrumental delivery but was 47.7 % after spontaneous vaginal delivery. CONCLUSIONS: When shoulder dystocia occurs after instrumental vaginal delivery, the chance of failure of M+/-S is 85 %, which is 4.7 times higher than that after spontaneous vaginal delivery. Hence all operators performing instrumental delivery should be proficient in performing all manoeuvres to relieve shoulder dystocia when M+/-S cannot do so.

Pseudoamniotic Band Syndrome after In Utero Intervention for Twin-to-Twin Transfusion Syndrome: Case Reports and Literature Review.

Pseudoamniotic band syndrome (PABS) is a rare iatrogenic complication that arises after invasive procedures in monochorionic twins. We report 3 cases of PABS, 2 after fetoscopic laser photocoagulation and 1 after bipolar cord coagulation. Two cases were detected antenatally by ultrasound; out of the two, one underwent successful fetoscopic release of amniotic band, which is the first report in twin pregnancy to our knowledge. In our centre, the incidence of PABS was found to be 2%. There were 25 cases of PABS reported previously, of which 12 cases with clinical details were reviewed together with our 3 cases. The fetal limbs were involved in all 15 cases, leading to constriction or amputation. The umbilical cord was involved in 2 cases, resulting in fetal death in one and pregnancy termination in the other. Antenatal detection of PABS is rare (27%; 4/15) as this requires a high index of suspicion. Serial postoperative targeted ultrasound surveillance of the fetal limbs and umbilical cord is necessary, particularly when features of septostomy or chorioamniotic membrane separation are found. Colour Doppler examination for the perfusion of the affected limb should be performed when PABS is detected. Fetoscopic release of amniotic band could salvage the fetal limb from amputation when impaired blood flow is detected.

Women's uptake of non-invasive DNA testing following a high-risk screening test for trisomy 21 within a publicly funded healthcare system: findings from a retrospective review.

OBJECTIVE: The objective of the study was to evaluate the uptake of non-invasive cell-free fetal DNA screening test (NIDT) after a high-risk screening result for trisomy 21 METHODS: Association between maternal and pregnancy characteristics on women's test choice was assessed after adjusting for confounding factors in Hong Kong Chinese women who had a high-risk (term risk ≥1:250) first-trimester or second-trimester screening test at three public hospitals. Main outcome measures were rate of declining further testing and obstetric and maternal factors impacting on patient's selection of testing options. RESULTS: Compared with the pre-NIDT period, the availability of NIDT resulted in a 45% (P < 0.001) reduction in the rate of refusal for further testing and a decrease from 92.2% to 66.7% in the use of invasive diagnostic test after a positive screening test. Nulliparous women with a spontaneous [adjusted odds ratio (aOR) = 2.18, 95% confidence interval (CI) 1.63-2.92] or assisted reproduction pregnancy (aOR = 3.95, 95% CI 1.6-9.32) were more likely to choose NIDT. Women with an adjusted risk of '>1:10' (aOR = 7.36, 95% CI 4.22-12.8) and '1:10 to 1:50' (aOR = 1.53, 95% CI 1.01-2.32) were more likely to opt for chorionic villi sampling or amniocentesis. CONCLUSIONS: NIDT reduced the refusal rate. Uptake of NIDT was highest in pregnancies of nulliparous women.

Patient's choice between a non-invasive prenatal test and invasive prenatal diagnosis based on test accuracy.

OBJECTIVE: To assess how pregnant women choose between a non-invasive DNA test (NIDT) and an invasive prenatal test (IPD) based on the accuracy of the test. MATERIALS AND METHODS: Pregnant women who attended for first-trimester combined screening assessment of risk of Down syndrome were invited to participate in an interviewer-administered survey. Women were asked to choose between NIDT (variable detection rate but no miscarriage risk) and IPD (∼100% detection rate but 0.5-1% miscarriage risk) if their screening test was positive for Down syndrome using the standard gamble technique. RESULTS: 358 women were approached of which 106 (29.6%) were unwilling to participate in the study as it had already been decided in advance which additional test they would have if they were screened positive. Of these 106 women, 70 (19.6%) would only choose IPD whereas 36 (10%) would only choose NIDT. Among those who agreed to undertake the gamble and participate in the study (n=252), 50% were willing to accept NIDT as an alternative to IPD provided that NIDT had a detection rate of 95%. CONCLUSION: The majority can accept NIDT as an alternative to IPD provided that the test is 95% accurate in the diagnosis of Down syndrome. Current evidence indicates that the detection rate of NIDT will be higher than this level. Health professionals should consider NIDT as an alternative to IPD when counseling women with a positive screening test.

Whole genome miRNA profiling revealed miR-199a as potential placental pathogenesis of selective fetal growth restriction in monochorionic twin pregnancies.

INTRODUCTION: Placental-related mechanism of fetal growth restriction (FGR) is still unknown. Here we aimed to profile whole-genome miRNA between selective FGR twin (sFGR-T) and normally larger co-twin (sL-T) in monochorionic (MC) twin pregnancies and to further investigate effect of the miRNA on placental pathogenesis, including angiogenesis and mitochondrial functions. METHODS: MC twin pregnancies with or without sFGR were recruited, and their placental miRNAs were profiled (n = 3 vs 5). Ratio of placental miRNAs in the sFGR twin pairs (sFGR-T/sL-T) were calculated and compared to that in the control twin pairs (cS-T/cL-T). Differentially expressed miRNAs and associated markers were validated qRT-PCR, immunohistochemistry staining (n = 8 vs 13) and electron microscopy (n = 3 vs 3). RESULTS: Placental miR-199a-5p was significantly upregulated in sFGR-T (p = 0.004), which was validated by qRT-PCR (1.03 vs 0.56; p = 0.020). Compared to control twin pairs, ratio of CD31-positive vessels and volume density of vessels in sFGR twin pairs was lower (0.65 vs 0.92 and 18.7% vs 36.3%; both p < 0.001), while that of cyclooxygenase 2 (COX2)-positive trophoblast cells was higher (3.50 vs 2.22; p = 0.001), indicating an impaired angiogenesis and oxidative stress in the sFGR placenta. In addition, ratio of mitochondrial DNA (mtDNA) mitochondrial encoded NADH dehydrogenase 1 (MTND1) copy numbers (2.10 vs 0.90; p = 0.013), H-score ratios of mitochondrial markers citrate synthase (CS) and cytochrome c oxidase subunit 4 isoform 1 (COX4, 0.53 vs 0.95, p < 0.001; 0.29 vs 1.06, p < 0.001) in trophoblast cells of sFGR twin pairs were also altered significantly and correlated with angiogenesis. Furthermore, ratio of mitochondrial numbers per trophoblasts (8.67 vs 18.67; p = 0.006) and percentage of swollen mitochondria (84.33 vs 11.33; p = 0.003) were converted significantly, indicating mitochondrial damage. DISCUSSION: Our results suggested miR-199a-5p may play a role in the placental angiogenesis, oxidative stress and mitochondrial damage and dysfunction as an underlying pathogenesis of sFGR.

Placental microRNA dataset of monochorionic twin pregnancies with and without selective fetal growth restriction.

To compare the whole genomic microRNA (miRNA) between the selective fetal growth restriction (sFGR) twin and the normally growing (control) co-twin in monochorionic (MC) twin pregnancies. MC twin pregnancies with or without sFGR were recruited, and their placental miRNAs were profiled by microarray. The ratio of the placental miRNA of the sFGR twin to that of the normally larger co-twin were calculated and compared to that of the control twin pairs. The miRNA microarray intensity amongst normal and sFGR large and small twins are shown. The expression data presented here will facilitate other researchers who are working on placental regulation and mechanism in pregnancy complicated by fetal growth restriction. The dataset supports the research article entitle "Whole genome miRNA profiling revealed miR-199a as potential placental pathogenesis of selective fetal growth restriction in monochorionic twin pregnancies" [1].

Inter-manufacturer comparison of automated immunoassays for the measurement of soluble FMS-like tyrosine kinase-1 and placental growth factor.

OBJECTIVE: To assess inter-manufacturer automated immunoassays for soluble FMS-like tyrosine kinase 1 (sFlt-1) to placental growth factor (PlGF). METHODS: sFlt-1 and PlGF levels were measured using the AutoDelfia PlGF1-2-3 (PerkinElmer Inc. Turku, Finland), BRAHMS Kryptor sFlt-1, PlGF plus and PlGF-2 (BRAHMS ThermoFisher, Germany) and Cobas e411 Elecsys® sFlt-1 and PLGF (Roche Diagnostics GmbH, Mannheim, Germany) in 965 asymptomatic pregnancies between 20 and 39 weeks of gestation and in in-vitro samples with predefined levels of glycosylated PlGF isomers (1, 2 and 3), sFlt-1 in human male serum. Percentage PlGF isoform recovery and cross-reactivities were determined. Paired Bland-Altman and Passing-Bablok analyses were performed to determine bias, precision and accuracy. Inter-manufacturer sFlt-1:PlGF ratio were compared. RESULTS: PlGF-1 isomer recovery ranged from 36 to 39% for Elecsys® to 52-60% for PlGF plus and PlGF-1-2-3 assays. PlGF-2 and PlGF-3 isoform cross-reactivity was assay dependent, ranging from 10 to 21% and 16-36% respectively. BRAHMS PlGF-2 assay had high cross-reactivity to PlGF-1 (37-41%) and PlGF-3 isomers (48-65%). Elecsys® recovery of sFlt-1 was 13% vs 6% for BRAHMS. Passing-Bablok indicated significant proportional and systematic differences between all paired PlGF assay comparisons. PlGF Bland-Altman percentage biases ranged from 12 to 37% for PlGF and 18% for sFlt-1. A linear relationship existed between log transformed sFlt-1:PlGF ratios. The clinical equivalent of the BRAHMS sFlt-1:PlGF plus to the Elecsys® sFlt-1:PlGF ratios of 38 and 110 are 55 and 188 respectively. CONCLUSION: Inter-manufacture immunoassay differences are significantly different. sFlt-1:PlGF rule in/rule out criteria are manufacturer specific, not interchangeable and require separate clinical validation.

Body mass index at 11-13 weeks' gestation and pregnancy complications in a Southern Chinese population: a retrospective cohort study.

OBJECTIVE: To assess the association between body mass index (BMI) and adverse pregnancy outcomes. MATERIALS AND METHODS: A multicentre retrospective cohort study was conducted in three hospitals in Hong Kong including 67,248 women with singleton pregnancy at 11-13 weeks between 2010 and 2016. The relationship between maternal BMI and (1) miscarriage or stillbirth, (2) development of preeclampsia (PE), (3) gestational hypertension (GH), (4) development of gestational diabetes mellitus (GDM), (5) spontaneous preterm delivery (sPTD) <34 and <37 weeks, (6) delivery of a small for gestational age (SGA) or large for gestational age (LGA) neonate, (7) caesarean section (CS), and (8) postpartum haemorrhage (PPH) were examined after adjusting for confounding factors. RESULTS: The prevalence of maternal overweight (BMI 25-29.9 kg/m2) and obesity (BMI ≥30 kg/m2) were 13.2% and 2.9%, respectively. Women with a BMI ≥30 kg/m2 were nine times more likely to develop GH (95%CI 7.3-11.7), five times more likely to develop PE (95%CI 4.3-6.8) and GDM (95%CI 5.0-6.5) and 1.5-2 times more likely to deliver SGA/LGA neonate. sPTD, required delivery by CS and developed PPH, than those with a BMI of 18.5-22.9 kg/m2, and that maternal underweight (BMI <18.5 kg/m2) significantly reduced the risk of GDM, delivery by CS, and PPH. Increased risk of subsequent development of adverse outcomes was observed when BMI was ≥23.0 kg/m2. CONCLUSIONS: Maternal overweight and obesity are associated with an increased risk for subsequent development of various pregnancy complications. The need of increased awareness and health surveillance is essential when BMI ≥23 kg/m2.

Health professionals' involvement and information provision in genetic counseling following prenatal diagnosis of sex chromosome aneuploidy in Hong Kong.

This study supports training in genetic counseling for obstetricians and adoption of a multidisciplinary approach in the counseling process following prenatal diagnosis of sex chromosome aneuploidy.

Soluble fms-like tyrosine kinase-1, placental growth factor and their ratio as a predictor for pre-eclampsia in East Asians.

OBJECTIVE: To assess the clinical utility of the sFlt-1:PlGF ratio rule-in/rule-out pre-eclampsia either directly or after correcting each marker for gestation and maternal weight. METHODS: This was a prospective cohort study. sFlt-1, PlGF were measured in 965 women randomized to undergo a single blood withdraw between 20 and 39 weeks of gestation. sFlt-1, PlGF and the sFlt-1:PlGF ratio temporal relationship was determined. sFlt-1 and PlGF were converted to multiples of the expected gestational median (MoM) and adjusted for maternal weight. The 90th centile of the adjusted sFlt-1MoM:PlGFMoM ratio was determined. Clinical utility of the sFlt-1:PlGF ratio (≥38) to rule in/rule-out pre-eclampsia (PE) after 20 weeks of gestation versus that of the sFlt-1MoM:PlGFMoM 90th percentile was assessed in 81 women admitted for management of antenatal hypertension. RESULTS: The sFlt-1:PlGF ratio had quadratic relationship with gestation whereas the sFlt-1MoM:PlGFMoM ratio log distribution that was Gaussian with a mean of zero and a standard deviation of 0.85 with a 90th percentile equal to 1.08. Thirty-four (42%) of the 81 women admitted for management of their antenatal hypertension had PE, 26 (76.4%) had a sFlt-1:PlGF ratio ≥ 38. Four of the remaining 8 PE affected pregnancies with sFlt-1:PlGF ratio <38 delivered within 7 days, 3 were preterm. Two of the 3 preterm PE pregnancies had sFlt-1MoM:PlGFMoM exceeding 90th percentile. CONCLUSION: The relative level of the sFlt-1 to PlGF carries prognostic value. A sFlt-1MoM:PlGFMoM ratio exceeding the 90th centile resulted in additional detection of pregnancies which developed PE compared to the conventional sFlt-1:PlGF ratio.