The use of ultrasound in fetal surgery.

Obstetric ultrasound (US) is an integral part of fetal surgery for open and minimally invasive techniques. With advances in US imaging, the ability to refine diagnosis, predict prognosis, and contribute to fetal treatment continues to grow. Current research in fetal diagnosis and treatment includes identifying the most reliable sonographic features for determining prognosis before and after surgery.

First-trimester combined screening: experience with an instant results approach.

OBJECTIVE: This study was undertaken to assess an instant results protocol for first-trimester combined screening. STUDY DESIGN: Retrospective analysis of patients having first-trimester combined screening between Nov. 1, 2003 and Oct. 31, 2005. We evaluated the feasibility of patient self-collection and mail-in of blood samples before nuchal translucency ultrasound. Primary outcome was success with providing in-office, immediate screening results after the ultrasound. Predictor variables included age, ethnicity, insurance, and provider. The chi2 analysis was performed. RESULTS: Two thousand three hundred ten women completed first-trimester combined screening, and 60.6% received instant results. When the biochemistry sample was collected at home, 80% received instant results. Age 35 years or older predicted instant results (P = .001), whereas ethnicity, insurance, and referring provider did not. Comparing the prior 24 months, clinic volume increased by 18%. Diagnostic procedure volume was unchanged, although chorionic villus sampling increased by 12% (P = .02) and amniocentesis decreased by 6% (P = .049). CONCLUSION: Patients were able to obtain instant results in 60.6% of cases, which appeared to increase the use of chorionic villus sampling.

Chorionic villus sampling compared with amniocentesis and the difference in the rate of pregnancy loss.

OBJECTIVE: To compare loss rates following amniocentesis and chorionic villus sampling (CVS) over time. METHODS: A retrospective cohort study of all amniocentesis and CVS procedures resulting in a normal karyotype from 1983-2003 at a single prenatal diagnostic referral center was conducted. Pregnancy loss rates for amniocentesis, CVS, and nonintervention groups (ie, those who had nuchal translucency screening or counseling, but no procedure) were compared using the chi 2 test. Year of procedure, maternal age, parity, race or ethnicity, and gestational age at procedure were controlled for in multivariable logistic regression models. RESULTS: There were 9,886 CVS and 30,893 amniocentesis procedures performed during the study period that resulted in a normal karyotype. The overall loss rates were 3.12% for CVS and 0.83% for amniocentesis (P < .001). When examined by 5-year intervals, there was a statistically significant decrease in the CVS loss rate (P < .001) and a nonsignificant lesser decrease in the loss rate for amniocentesis over time. Although the pregnancy loss rate from CVS over the entire study period was higher than from amniocentesis (adjusted odds ratio 4.23, 95% confidence interval 2.29-7.81), in the most recent time period, 1998 to 2003, there was no difference between the two procedures (adjusted odds ratio 1.03, 95% confidence interval 0.23-4.52). CONCLUSION: The loss rates for both amniocentesis and CVS at our institution have decreased over time. Because the decrease in loss rate for CVS has been greater, there is no longer a statistically significant difference between the two. These results are informative in both patient counseling and establishing widespread prenatal diagnostic and screening programs.

Gestational weight gain, macrosomia, and risk of cesarean birth in nondiabetic nulliparas.

OBJECTIVE: To examine how the association between excessive weight gain and cesarean birth is modified by infant birth weight in nondiabetic women. METHODS: We designed a retrospective cohort study of singleton, term, nulliparous women with cephalic presentations delivering at a single university hospital. Subjects with diabetes were excluded. Bivariate and multivariate analyses were performed. Regression models controlled for maternal age, maternal prepregnancy body mass index, gestational age, ethnicity, smoking, birth weight, and date of delivery. RESULTS: Women gaining above Institute of Medicine guidelines were more likely to have a cesarean birth, even if birth weight was less than 4,000 g. In the multivariate analysis, women with excessive weight gain had an odds ratio of 1.40 (95% confidence interval 1.22-1.59) for cesarean birth. When absolute weight gain (total pregnancy weight gain minus birth weight and placental weight) was used in the multivariate analysis, excessive weight gain was still an independent predictor of cesarean delivery. Although macrosomia was a stronger predictor of cesarean than weight gain alone, excessive weight gain was much more common than macrosomia in our cohort. CONCLUSION: Excessive weight gain during pregnancy is an independent risk factor for cesarean birth, even when birth weight is not excessive. Other mechanisms besides macrosomia may be involved in the association between high weight gain and cesarean birth. We estimate that of the approximately 288,000 primary cesarean deliveries performed in nulliparas annually in the United States, 64,000 would be prevented if no women gained above Institute of Medicine recommendations. LEVEL OF EVIDENCE: II-2