Chorionic Villus Sampling, Early Amniocentesis, and Termination of Pregnancy Without Diagnostic Testing: Comparison of Fetal Risk Following Positive Non-invasive Prenatal Testing.

BACKGROUND: With the increased accuracy of non-invasive prenatal testing (NIPT) based on cell-free DNA (cfDNA) techniques, the likelihood of false-positive screening results has been reduced for high-risk populations. Following a positive screening test, a diagnostic procedure to confirm the result is strongly recommended, although some patients have terminated pregnancies because of a positive NIPT alone. Chorionic villus sampling (CVS), the diagnostic procedure of choice in the first trimester, is not available in all locations. Amniocentesis before 15 weeks, referred to as early amniocentesis (EA), is associated with a 1% rate of talipes and an increased rate of early pregnancy loss compared with CVS. Our objective was to compare the level of risk for euploid pregnancies following a positive NIPT based on the invasive procedure chosen. METHOD: Using data from a 2003 meta-analysis, we estimated the rates of adverse pregnancy outcome in euploid pregnancies based on the positive predictive value (PPV) of NIPT and the invasive procedure used-that is, CVS, EA, or termination of pregnancy (TOP). RESULTS: Following NIPT, we found that the rate of adverse fetal outcomes in euploid pregnancies was lower for CVS than for EA at all PPV levels. As the PPV of NIPT increased, the difference in risk between EA and CVS decreased. The risk to euploid pregnancies of TOP was excessive at all PPVs. CONCLUSION: CVS is the recommended diagnostic test in the first trimester because it is safer than EA for the fetus. However, EA is better than no testing when early TOP is planned. Patients should be strongly counselled against TOP without confirmatory testing.

Complications from Roux-en-Y gastric bypass mistaken for medical complications in gravid patients.

BACKGROUND: The increased frequency of bariatric surgery has resulted in a growing number of intrapartum surgical emergencies including internal hernia, bowel obstruction, and gastric rupture. CASE: We describe the cases of three gravid women with history of laparoscopic Roux-en-Y gastric bypass surgery who experienced significant complications during subsequent pregnancy. Two patients became hemodynamically unstable and required emergent laparotomy. In both cases, fetal outcomes were poor but the patients ultimately recovered after prolonged hospital courses. In the third patient, early recognition allowed for a minimally invasive surgical correction. CONCLUSION: After bariatric surgery, patients who become pregnant are at risk for serious postoperative complications. Because symptoms can be subtle, a high index of suspicion and early intervention by a multidisciplinary team is necessary to prevent catastrophic outcomes.

The use of middle cerebral artery Doppler ultrasonography to guide delivery of a viable pregnancy complicated by metastatic gestational chroriocarinoma.

Background: Choriocarcinoma is a rare, aggressive subtype of gestational trophoblastic neoplasia. The diagnosis of metastatic choriocarcinoma in the setting of a viable intrauterine pregnancy is exceedingly rare and often associated with feto-maternal hemorrhage. Case: An otherwise healthy Gravida 1 Para 0 at 34 weeks gestational age presented with metastatic choriocarcinoma and a viable fetus. Measured Doppler peak systolic velocity of the middle cerebral artery was used to detect fetal anemia, thus optimising the timing of delivery. Conclusion: This is the first case report to our knowledge using Doppler ultrasonography to detect fetal anemia in an effort to guide delivery in a case of choriocarcinoma diagnosed during pregnancy. If choriocarcinoma is diagnosed during pregnancy, middle cerebral artery Doppler ultrasonography may serve as a critical tool to help detect anemia, allowing pregnancy prolongation to promote fetal maturity while screening for the development of feto-maternal hemorrhage.

Persistent pulmonary hypertension of the newborn is associated with mode of delivery and not with maternal use of selective serotonin reuptake inhibitors.

We sought to determine if maternal use of selective serotonin reuptake inhibitors (SSRIs) in the second half of pregnancy is associated with persistent pulmonary hypertension of the newborn (PPHN). We performed a case-controlled study (1:6 ratio) of infants delivered at Madigan Army Medical Center with primary PPHN from 2003 through 2009. Study and control patients were compared for the following clinical factors: SSRI use after 20 weeks gestation, mode of delivery, maternal disease, body mass index, tobacco use, fetal gender, maternal age, and parity. We identified 20 cases of primary PPHN out of 11,923 births for an incidence of 0.17%. Mode of delivery was the only factor we found to be associated with PPHN. Specifically, cesarean delivery (CD) prior to the onset of labor increased the risk for PPHN: odds ratio (OR) = 4.9, confidence interval (CI) 1.7 to 14.0. Importantly, use of SSRIs in the second half of pregnancy was identified in 5% of the controls but none of the cases (OR = 0, CI 0 to 3). PPHN is associated with CD prior to the onset of labor but not with SSRI use in the second half of pregnancy. Previous studies linking PPHN to SSRI use relied on after-the-fact patient interviews and incomplete records. Additional studies are needed to verify these results.

Intramuscular 17α-hydroxyprogesterone caproate administration attenuates immunoresponsiveness of maternal peripheral blood mononuclear cells.

OBJECTIVE: 17α-hydroxyprogesterone caproate (17P) may decrease risk of prematurity by suppressing maternal immunity. We hypothesized that in vivo 17P treatment attenuates immunoresponsiveness of peripheral blood mononuclear cells (PBMCs). STUDY DESIGN: Study subjects were gravidas receiving weekly prophylactic intramuscular 17P injections. Peripheral blood samples were obtained at 21-27 weeks' gestation. Gestational age-matched, drug-naïve gravidas served as controls. To simulate infection, isolated PBMCs were stimulated with lipoteichoic acid (LTA) or lipopolysaccharide (LPS). Extracellular interleukin-6 (IL-6) concentrations were quantified by an enzyme-linked immunosorbent assay. RESULTS: Unstimulated IL-6 levels were comparable in PBMCs derived from drug-naïve and 17P-treated subjects. LPS and LTA induced a dose-dependent elevation of IL-6 in control PBMCs. In patients who received exogenous 17P, LPS, and LTA stimulated induction of IL-6 was significantly decreased compared with controls (P = .005 and P = .02). CONCLUSION: In vivo 17P attenuated immunoreactivity of PBMCs in our in vitro model of Gram-positive and Gram-negative bacterial infection.