Abnormal Shape and Size of the Cardiac Ventricles Are Associated with a Higher Risk of Neonatal Death in Fetuses with Isolated Left Congenital Diaphragmatic Hernia.

INTRODUCTION: The objective of this study was to evaluate the association between fetal cardiac deformation analysis (CDA) and cardiac function with severe adverse perinatal outcomes in fetuses with isolated left congenital diaphragmatic hernia (CDH). METHODS: CDA in each ventricle (contractility, size, and shape), evaluated by speckle tracking and novel FetalHQ software, and markers of cardiac function (E/A ratios, pulmonary and aortic peak systolic velocities, and sigmoid annular valve diameters), were evaluated in fetuses with isolated left CDH. Two evaluations were performed: at referral (CDA and function) and within 3 weeks of delivery (CDA). Severe adverse neonatal outcomes were considered neonatal death (ND) or survival with CDH-associated pulmonary hypertension (CDH-PH). Differences and associations between CDA, cardiac function, and severe adverse outcomes were estimated. RESULTS: Fifty fetuses were included, and seventeen (34%) had severe adverse neonatal outcomes (11 ND and 6 survivors with CDH-PH). At first evaluation, the prevalence of a small left ventricle was 34% (17/50) with a higher prevalence among neonates presenting severe adverse outcomes (58.8 [10/17] vs. 21.2% [7/33]; p = 0.01; OR, 5.03 [1.4-19.1; p = 0.01]) and among those presenting with neonatal mortality (8/11 [72.7] vs. 9/39 [23.0%]; p = 0.03; OR, 8.9 [1.9-40.7; p = 0.005]). No differences in cardiac function or strain were noted between fetuses with or without severe adverse outcomes. Within 3 weeks of delivery, the prevalence of small left ventricle was higher (19/34; 55.8%) with a more globular shape (reduced transverse/longitudinal ratio). A globular right ventricle was significantly associated with ND or survival with CDH-PH (OR, 14.2 [1.5-138.3]; p = 0.02). CONCLUSION: Fetuses with isolated CDH at risk of perinatal death or survival with CDH-PH had a higher prevalence of a small left ventricle and abnormal shape of the right ventricle.

Does Prediction of Neonatal Mortality by the Observed/Expected Lung-To-Head Ratio Change during Pregnancy in Fetuses with Left Congenital Diaphragmatic Hernia?

INTRODUCTION: The aim of this study was to evaluate prediction of neonatal mortality in fetuses with isolated left congenital diaphragmatic hernia (CDH) when the observed/expected lung-to-head ratio (O/E LHR) was estimated at two different gestational time points during pregnancy. METHODS: Forty-four (44) fetuses with isolated left CDH were included. O/E LHR was estimated at the time of referral (first scan) and before delivery (last scan). The main outcome was neonatal death due to respiratory complications. RESULTS: There were 10/44 (22.7%) perinatal deaths. The areas under (AU) the ROC curves were: first scan, 0.76, best O/E LHR cut-off 35.5% with 76% sensitivity and 70% specificity; last scan, AU-ROC 0.79, best O/E LHR cut-off 35.2%, with 79.0% sensitivity and 80% specificity. Considering an O/E LHR cut-off ≤35% to define high-risk fetuses at any examination, prediction for perinatal mortality showed: 80% sensitivity, 73.5% specificity, 47.1% positive and 92.6% negative predictive values, and 3.02 (95% CI 1.59-5.73) positive and 0.27 (95% CI 0.08-0.96) negative likelihood ratios. Prediction was similar in the two evaluations as 16/21 (76.2%) of fetuses considered at risk had an O/E LHR ≤35% in the two examinations; in the remaining 5 cases, two were identified only in the first and three only in the last scan. CONCLUSION: The O/E LHR is a good predictor of perinatal death in fetuses with left isolated CDH. Approximately 80% of fetuses at risk of perinatal death can be identified with an O/E LHR ≤35%, and 90% of them will have similar O/E LHR values at the first and at the last ultrasound examinations prior to delivery. In general, 88.6% of all CDH fetuses have a similar severity classification based on the O/E LHR at the first diagnostic ultrasound or at the ultrasound examination prior to delivery.

Moderate-to-Severe Polyhydramnios: Cutoffs for Deepest Vertical Pocket Corresponding to Amniotic Fluid Index.

OBJECTIVE: Society for Maternal-fetal medicine Consult Series (#46) states "antenatal fetal surveillance is not required for mild idiopathic" polyhydramnios defined as amniotic fluid index (AFI) of 24 cm or a deepest vertical pocket (DVP) between 8 and 11 cm. The objective of this study was to determine the cutoff for DVP which correlates with AFI ≥ 30 cm. METHODS: This retrospective study of singleton third trimester ultrasounds included a study group randomly divided into test and validation. In the test group, DVP cutoffs correlating with AFI ≥ 30 cm which was used to define moderate-severe polyhydramnios were calculated in two ways, rounded to the nearest whole number: 1) a receiver operating curve and Youden's J statistic (DVP-Youden) and 2) calculation of the DVP percentile that corresponded with AFI of 30 cm (DVP-Percentile). Using the validation group, diagnostic characteristics were DVP-Youden and DVP-Percentile for diagnosis of AFI ≥ 30 cm and were compared against SMFM cutoffs (DVP-SMFM). RESULTS: Seventy one thousand eight hundred and ninety three ultrasound exams in the 3rd trimester had assessment of AFI and DVP. Moderate-severe polyhydramnios occurred in 286 (1.2%) in test group and 571 (1.2%) in validation group. AFI of 30 cm corresponded to the 98.9th percentile, which in turn correlated to a DVP of 10 cm (DVP-Percentile). The calculated cutoff for moderate-severe polyhydramnios was 8 cm for DVP-Youden. CONCLUSION: Using 8.0 cm rather than 12.0 cm increased the detection of moderate-severe polyhydramnios to 100% with a false positive rate under 5%. For those utilizing DVP for amniotic fluid evaluation, identification of a DVP ≥ 8.0 cm should prompt further evaluation with complete AFI.

Weekly Differences in the Prevalence of a Short Cervix at 18+0 to 23+6 Weeks of Gestation in Pregnant Women with and without a History of Preterm Delivery.

OBJECTIVE: The study aimed to estimate weekly differences in the prevalence of a short cervix during the period of 18+0 to 23+6 weeks of gestation in pregnant women with and without a history of previous preterm delivery (PTD). DESIGN: An observational study was conducted. METHODS: Setting and participants: 20,002 pregnant women, 18,591 without a history of previous PTD (low risk) and 1,411 with at least one previous PTD (high risk), were evaluated at 18+0 to 23+6 weeks + days of gestation. Weekly differences in the prevalence of a short cervix (≤25 mm, ≤20 mm, and ≤15 mm) between women with and without previous PTD were estimated. RESULTS: High-risk women had a significantly higher prevalence of a short cervix, defined as either ≤25 mm (4.4% vs. 2.2%; p < 0.0001) or ≤20 mm (2.4% vs. 1.2%; p < 0.0001) but not for ≤15 mm (1.2% vs. 0.9%; p < 0.2) as compared to low-risk pregnant women. The odds ratio for a short cervix ≤25 mm in high-risk as compared to low-risk women was 2.0 (95% CI 1.54-2.61; p < 0.0001). Among low-risk women, those evaluated at 22 or 23 weeks of gestation had a significantly higher prevalence of a short cervix ≤25 mm (3.8% vs. 1.9%; p < 0.0001), ≤20 mm (2.4% vs. 0.98%; p < 0.0001), and ≤15 mm (1.6% vs. 0.7%; p < 0.0001) than low-risk women scanned between 18 and 21 weeks of gestation. Similar results were observed for high-risk women. LIMITATIONS: No gestational age at delivery was evaluated. CONCLUSION: There is higher prevalence of short cervix when pregnant women are evaluated at 22+0 to 23+6 than at 18+0 to 21+6 weeks of gestation.

Implementing a Universal Cervical Length Screening Program in a Large Hospital System: It Takes Some Time to Achieve Consistent Results.

OBJECTIVE: The aim of the study was to describe changes in the acceptance of transvaginal (TV) cervical length (CL) assessment and in the variance of CL measurements among operators, after implementation of universal TV-CL screening at 18+0 - to 23+6 weeks/days of gestation. DESIGN: Retrospective cohort. PARTICIPANTS/MATERIALS, SETTING, METHODS: This study was performed after universal TV-CL screening was implemented at the University of Texas Health Science Center in Houston, TX, USA, for all women undergoing an anatomy ultrasound (US) between 18 0/6 and 23 6/7 weeks/days of gestation. Pregnant women carrying singletons without prior history of preterm delivery who underwent anatomy US evaluation between September 2017 and March 2020 (30 months) were included. The complete study period was divided into five epochs of 6 months each. Changes in patient's acceptance for the TV scan, in CL distribution, in the prevalence of short cervix defined as ≤15, ≤20, or ≤25 mm, and in the performance of US operators across the five epochs were evaluated. Success rate was defined as the percentage of TV-CL measurements obtained in relation to the number of second-trimester anatomy scans. RESULTS: A total of 22,207 low-risk pregnant women evaluated by 36 trained sonographers (operators) were analyzed. Overall, the acceptance for TV-CL measurement was 82.3% (18,289/22,207), increasing from 76.7% in the first epoch to 82.8% (p < 0.0001) in the last epoch. The mean CL did not significantly change from 38.6 mm in the first epoch to 38.5 mm in the last epoch (p = 0.7); however, the standard deviation decreased from 7.9 mm in the first epoch to 7.04 mm in the last epoch (p = <0.01). The prevalence of a short cervix ≤25 mm was 2.2% (n = 399/18,289), ≤20 mm was 1.2% (224/18,289), and ≤15 mm was 0.9% (162/18,289). This prevalence varied only for CL ≤25 mm from 3.02% (88/2,907) in the first epoch to 1.77% (64/3,615) in the last epoch (p = 0.0009). There was a variation in CL measurements among operators (mean 3.3 mm). Sonographers with less than 1 year of experience had a lower success rate for completing TV-CL examinations than more experienced sonographers (80.8% vs. 85.8%; p < 0.03). In general, 77% (27/35) of operators had a success rate ≥80% for completing TV-CL scans. LIMITATIONS: Characteristics of individuals who accepted versus those who declined TV-CL were not compared; CL values were not correlated with clinical outcomes. CONCLUSIONS: During the first 6 months after implementation of a universal CL screening program, there was greater variation in CL measurements, lower acceptance for TV US, and a higher number of women diagnosed with a CL ≤25 mm, as compared to subsequent epochs. After the first 6 months, these metrics improved and remained stable. Most operators improved their performance over time; however, there were a few with a low success rate for TV-CL and others who systematically over- or underestimate CL measurements.

Novel Speckle Tracking Analysis Showed Excellent Reproducibility for Size and Shape of the Fetal Heart and Good Reproducibility for Strain and Fractional Shortening.

INTRODUCTION: This study aimed to evaluate reproducibility and agreement of fetal cardiac shape and deformation using FetalHQ. METHODS: Fifty normal fetuses at 20-38 weeks of gestation were evaluated. Two operators independently selected an optimal cardiac cycle using FetalHQ®™software for speckle tracking analysis. Intra- and interobserver correlation coefficient and limits of agreement for cardiac shape and deformation were estimated. RESULTS: Global cardiac markers: high correlation (r = 0.98) and agreement (mean difference, standard deviation [MD, SD] 5.07, 75.8) for ventricular area; moderate correlation (r = 0.78) and agreement (MD, SD: 0.016, 0.08) for global sphericity index (SI) and for left ventricle (LV) global strain (r = 0.65; MD, SD: -4.48, 11.9); and low but still significant correlation (r = 0.58) and agreement (MD, SD: -3.77, 12.27) for right ventricle (RV) global strain. For individual ventricular parameters: high correlation for LV ([median r; range] 0.98; 0.93-0.99) and RV (r = 0.98; 0.97-1.0) SI, and for LV (r = 0.92: 0.56-0.99) and RV (r = 0.96; 0.67-0.99) end diastolic diameters; moderate correlation for LV fractional shortening (r = 0.53; 0.87-0.98); and no significant correlation for RV fractional shortening (r = 0.36; 0.32-0.97). Inter- and intraobserver correlation and agreement were similar for all evaluated parameters. CONCLUSION: Speckle tracking analysis of the fetal heart provides reliable estimations of global and LV shape and deformation. Low correlation in the RV can be related to anatomical structures such as the moderator band.

Nonopioid versus opioid analgesia after hospital discharge following cesarean delivery: a randomized equivalence trial.

OBJECTIVE: To determine whether pain score after cesarean delivery is equivalent among women receiving outpatient nonopioid vs opioid analgesics. STUDY DESIGN: In this trial 170 women with cesarean delivery were randomized to outpatient ibuprofen plus acetaminophen (nonopioid, n=85) or ibuprofen plus hydrocodone-acetaminophen (opioid, n=85). Primary outcome was pain score on a visual analog scale at 2-4 weeks postpartum, which was obtained from 149 (88%) women. Treatments were considered equivalent if the difference between the mean pain scores of each group and its 95% confidence interval were between -10 and 10 mm. A zero-inflated negative binomial model was used to estimate the difference between group means. RESULTS: Treatments were not equivalent; mean pain score was lower (better) in the nonopioid group (12.3±19.5 vs 15.9±20.4 mm, adjusted mean difference, 4.8; 95% CI, -2.1 to 11.9 mm). CONCLUSION: Pain score 2-4 weeks after cesarean delivery was lower in women receiving nonopioid analgesics.

Fortnightly surveillance of monochorionic diamniotic twins for twin to twin transfusion syndrome: Compliance and effectiveness.

OBJECTIVES: To determine the compliance and effectiveness of fortnightly ultrasound surveillance for detection of twin-twin transfusion syndrome (TTTS) in monochorionic diamniotic (MCDA) twin gestations. METHODS: This is a retrospective study of ultrasound surveillance of MCDA twins for TTTS. Our surveillance protocol requires fortnightly ultrasounds starting at 16 weeks of gestational age (GA) continuing until delivery. Compliance was assessed by determining the GA of surveillance initiation and time between ultrasounds. GA and Quintero Stage at diagnosis were evaluated to determine whether TTTS was detected prior to advanced disease (Quintero Stage III +) or fetal demise. RESULTS: Of 442 women, 264 (59.7%) initiated surveillance after 16 weeks; follow-up ultrasounds were late in 17.4% of cases. TTTS was diagnosed in 43 (9.7%) women at a median GA of 19.7 [17.4, 23.9] weeks. Of 25/43 (58.1%) cases diagnosed during protocol compliance, 12 had advanced disease and two had fetal demise. A similar proportion of diagnoses (n = 18), made while non-compliant, exhibited advanced disease (11/18, 61.1%, P = .40). Thirteen diagnoses occurred during periods of increased ultrasound frequency due to abnormalities (ie, fluid/estimated fetal weight discrepancies or Doppler abnormalities). CONCLUSIONS: In this population, fortnightly ultrasound compliance was suboptimal. Advanced disease and fetal demise occurred during protocol compliance.

Clinical experience with sex chromosome aneuploidies detected by noninvasive prenatal testing (NIPT): Accuracy and patient decision-making.

OBJECTIVE: The objectives of the study are to assess the accuracy of noninvasive prenatal testing (NIPT) for sex chromosome aneuploidies (SCAs) and to investigate patient decision-making in clinical practice. STUDY DESIGN: This is a retrospective cohort study review of positive NIPT results for SCAs from January 2013 to September 2017. RESULTS: Of the 136 positive NIPT results for SCAs, 73 (53.7%) were positive for 45,X, 62 (45.6%) were a sex chromosome trisomy, and 1 was a sex chromosome tetrasomy. Of the 134 viable pregnancies, 46 (34.3%) elected to pursue prenatal diagnosis. Fewer women underwent invasive prenatal testing when counseled regarding a positive NIPT for monosomy X in the presence of suggestive ultrasound findings (4/23; 17.4%) compared with those who had a positive NIPT result without ultrasound findings (24/46, 52.2%). Abnormal karyotypes consistent with the NIPT result were confirmed in 30/64 (46.9%). Even in the context of ultrasound abnormalities, there was not 100% concordance. CONCLUSIONS: The majority (88/134; 65.7%) of patients in our cohort declined prenatal diagnosis even in the presence of associated ultrasound findings. Comprehensive pretest and posttest counseling is recommended and should address the importance of confirmatory testing and benefits of early diagnosis. Practice guidelines are needed to address provider responsibilities about postnatal testing.

Fetal anomalies and long-term effects associated with substance abuse in pregnancy: a literature review.

OBJECTIVES: Substance abuse in pregnancy remains a major public health problem. Fetal teratogenicity results from the effect of these substances during fetal development, particularly when used in combination. This review will focus on and attempt to clarify the existing literature regarding the association of substance abuse on the development of congenital anomalies and the long-term implications in exposed offspring. METHODS: Systematic review of available English literature using the PubMed database of all peer-reviewed articles on the subject. RESULTS: A total of 128 articles were included in this review. Alcohol was the most common substance associated with fetal anomalies, particularly facial dysmorphisms and alterations in the central nervous system development. Adverse maternal environments associated with risky behaviors and lack of adequate prenatal care precludes the timely detection of fetal anomalies, confounding most studies linking causality. In addition, although methodological differences and limited availability of well-designed trials exist, substance abuse in pregnancy has been associated with adverse long-term outcomes in infant growth, behavior, cognition, language and achievement. CONCLUSION: The literature summarized in this review suggests that drug exposure during pregnancy may increase the risk of congenital anomalies and long-term adverse effects in exposed children and adolescents. These conclusions must be tempered by the many confounders associated with drug use. A multidisciplinary approach is paramount for appropriate counseling regarding the known immediate and long-term risks of substance abuse in pregnancy.

Optimal visualization of the fetal four-chamber and outflow tract views with transabdominal ultrasound in the morbidly obese: Are we there yet?

BACKGROUND: To compare optimal visualization of the four-chamber and outflow-tract views of the fetal heart on sonographic examination between morbidly obese (body mass index [BMI] ≥ 40 kg/m(2) ) and nonobese (BMI < 25 kg/m(2) ) pregnant women. METHODS: In this retrospective cohort study, we included records and images from 509 pregnant women who had first undergone sonographic examination between 18 and 36 weeks' fetal gestational age. RESULTS: Compared with the nonobese women, morbidly obese women had lower optimal visualization of the four-chamber and outflow-tract heart views: four-chamber view, morbidly obese, 83/186 (44.6%), versus nonobese, 283/323 (87.6%), and outflow-tract view, morbidly obese, 80/186 (43%) versus nonobese, 258/290 (89%); p < 0.0001 for each comparison. Similar outcomes were observed when the results from each subcategory of morbidly obese women (ie, BMI 40-49.9, 50-59.9, and ≥60 kg/m(2) ) were compared with that from nonobese women; p < 0.0001 for each comparison. These outcomes remained the same regardless of whether this comparison was made among those who had their examination before or at 19 weeks' or more gestational age. Among the morbidly obese women, there was no difference in optimal visualization of the four-chamber or outflow-tract views regardless of whether the examination was performed at <23 weeks' or at ≥23 weeks' gestational age: four-chamber view <23 weeks, 44.8% (78/174), versus four-chamber view ≥23 weeks, 41.7% (5/12); p = 0.8, and outflow-tract view <23 weeks, 43.1% (75/174), versus outflow-tract view ≥23 weeks, 41.7% (5/12); p = 0.9. After controlling for maternal age and race, the odds of visualizing the four-chamber and outflow-tract views in the morbidly obese were reduced compared with those in their nonobese counterparts: odds ratio (OR) for four-chamber, 0.13; 95% confidence interval (CI), 0.08-0.21, and OR for outflow-tract, 0.11; 95% CI, 0.07-0.17. CONCLUSIONS: Optimal visualization of the fetal four-chamber and outflow-tract views was achieved in less than 50% of morbidly obese women, compared with almost 90% in nonobese women.

Indicated vs universal third-trimester ultrasound examination in low-risk pregnancies: a pre-post-intervention study.

BACKGROUND: In low-risk pregnancies, a third-trimester ultrasound examination is indicated if fundal height measurement and gestational age discrepancy are observed. Despite potential improvement in the detection of ultrasound abnormality, prior trials to date on universal third-trimester ultrasound examination in low-risk pregnancies, compared with indicated ultrasound examination, have not demonstrated improvement in neonatal or maternal adverse outcomes. OBJECTIVE: The primary objective was to determine if universal third-trimester ultrasound examination in low-risk pregnancies could attenuate composite neonatal adverse outcomes. The secondary objectives were to compare changes in composite maternal adverse outcomes and detection of abnormalities of fetal growth (fetal growth restriction or large for gestational age) or amniotic fluid (oligohydramnios or polyhydramnios). STUDY DESIGN: Our pre-post intervention study at 9 locations included low-risk pregnancies, those without indication for ultrasound examination in the third trimester. Compared with indicated ultrasound in the preimplementation period, in the postimplementation period, all patients were scheduled for ultrasound examination at 36.0-37.6 weeks. In both periods, clinicians intervened on the basis of abnormalities identified. Composite neonatal adverse outcomes included any of: Apgar score ≤5 at 5 minutes, cord pH <7.00, birth trauma (bone fracture or brachial plexus palsy), intubation for >24 hours, hypoxic-ischemic encephalopathy, seizure, sepsis (bacteremia proven with blood culture), meconium aspiration syndrome, intraventricular hemorrhage grade III or IV, periventricular leukomalacia, necrotizing enterocolitis, stillbirth after 36 weeks, or neonatal death within 28 days of birth. Composite maternal adverse outcomes included any of the following: chorioamnionitis, wound infection, estimated blood loss >1000 mL, blood transfusion, deep venous thrombus or pulmonary embolism, admission to intensive care unit, or death. Using Bayesian statistics, we calculated a sample size of 600 individuals in each arm to detect >75% probability of any reduction in primary outcome (80% power; 50% hypothesized risk reduction). RESULTS: During the preintervention phase, 747 individuals were identified during the initial ultrasound examination, and among them, 568 (76.0%) met the inclusion criteria at 36.0-37.6 weeks; during the postintervention period, the corresponding numbers were 770 and 661 (85.8%). The rate of identified abnormalities of fetal growth or amniotic fluid increased from between the pre-post intervention period (7.1% vs 22.2%; P<.0001; number needed to diagnose, 7; 95% confidence interval, 5-9). The primary outcome occurred in 15 of 568 (2.6%) individuals in the preintervention and 12 of 661 (1.8%) in the postintervention group (83% probability of risk reduction; posterior relative risk, 0.69 [95% credible interval, 0.34-1.42]). The composite maternal adverse outcomes occurred in 8.6% in the preintervention and 6.5% in the postintervention group (90% probability of risk; posterior relative risk, 0.74 [95% credible interval, 0.49-1.15]). The number needed to treat to reduce composite neonatal adverse outcomes was 121 (95% confidence interval, 40-200). In addition, the number to reduce composite maternal adverse outcomes was 46 (95% confidence interval, 19-74), whereas the number to prevent cesarean delivery was 18 (95% confidence interval, 9-31). CONCLUSION: Among low-risk pregnancies, compared with routine care with indicated ultrasound examination, implementation of a universal third-trimester ultrasound examination at 36.0-37.6 weeks attenuated composite neonatal and maternal adverse outcomes.

Maternal plasma concentrations of angiogenic/antiangiogenic factors in the third trimester of pregnancy to identify the patient at risk for stillbirth at or near term and severe late preeclampsia.

OBJECTIVE: To determine whether maternal plasma concentrations of placental growth factor (PlGF), soluble endoglin (sEng), and soluble vascular endothelial growth factor receptor-1 (sVEGFR-1) at 30-34 weeks of gestation can identify patients at risk for stillbirth, late preeclampsia, and delivery of small-for-gestational-age (SGA) neonates. STUDY DESIGN: A prospective cohort study included 1269 singleton pregnant women from whom blood samples were obtained at 30-34 weeks of gestation and who delivered at >34 weeks of gestation. Plasma concentrations of PlGF, sEng, and sVEGFR-1 were determined by enzyme-linked immunosorbent assay. RESULTS: The prevalence of late (>34 weeks of gestation) preeclampsia, severe late preeclampsia, stillbirth, and SGA was 3.2% (n = 40), 1.8% (n = 23), 0.4% (n = 5), and 8.5% (n = 108), respectively. A plasma concentration of PlGF/sEng <0.3 MoM was associated with severe late preeclampsia (adjusted odds ratio, 16); the addition of PlGF/sEng to clinical risk factors increased the area under the receiver-operating characteristic curve from 0.76 to 0.88 (P = .03). The ratio of PlGF/sEng or PlGF/sVEGFR-1 in the third trimester outperformed those obtained in the first or second trimester and uterine artery Doppler velocimetry at 20-25 weeks of gestation for the prediction of severe late preeclampsia (comparison of areas under the receiver-operating characteristic curve; each P ≤ .02). Both PlGF/sEng and PlGF/sVEGFR-1 ratios achieved a sensitivity of 74% with a fixed false-positive rate of 15% for the identification of severe late preeclampsia. A plasma concentration of PlGF/sVEGFR-1 <0.12 MoM at 30-34 weeks of gestation had a sensitivity of 80%, a specificity of 94%, and a likelihood ratio of a positive test of 14 for the identification of subsequent stillbirth. Similar findings (sensitivity 80%; specificity 93%) were observed in a separate case-control study. CONCLUSION: Risk assessment for stillbirth and severe late preeclampsia in the third trimester is possible with the determination of maternal plasma concentrations of angiogenic and antiangiogenic factors at 30-34 weeks of gestation.

A rare case of a mosaic unbalanced translocation after chorionic villous sampling.

BACKGROUND: Most of the literature suggests that unbalanced chromosomal translocations may lead to poor obstetrical outcomes. We present a case of an unbalanced translocation resulting in trisomy 1q and partial monosomy 20p identified on chorionic villous sampling (CVS). METHOD: Case report with expert-derived clinical management and guidance. RESULTS: After the abnormal CVS result, a subsequent amniocentesis revealed a normal 46,XX fetal karyotype. Detailed second trimester ultrasound of the fetus revealed no gross structural abnormalities. The CVS karyotype results were attributed to confined placental mosaicism (CPM) of the unbalanced translocation. The infant is 18 months old and has normal phenotype and karyotype. CONCLUSION: We recommend that if CPM with an unbalanced translocation is diagnosed on CVS, parental karyotype and an amniocentesis should be offered in conjunction with genetic counseling. In rare instances, such as this one, an unbalanced translocation may have a favorable outcome.

Fetal abnormal growth associated with substance abuse.

Substance abuse remains a major concern in pregnancy. The current review summarizes the best available literature on the subject. The findings of most studies are confounded by multiple drug use and environmental and social factors that by themselves are known to adversely affect the pregnancy outcomes of interest. Overall, however, substance abuse during pregnancy was associated with negative effects on birth weight and head circumference.

Successful Vaginal Delivery during Acute Small Bowel Obstruction: A Case Report and Review of the Literature.

Small bowel obstruction during pregnancy is rare and can be detrimental to both mother and fetus. In most cases, management eventually involves surgical intervention. Little is known regarding optimal mode of delivery in those with bowel obstruction during pregnancy. We present a case of vaginal delivery during acute small bowel obstruction as well as a review of recent literature regarding mode of delivery in the setting of bowel obstruction. Our case and literature review demonstrates that in pregnancies complicated by small bowel obstruction, successful vaginal delivery can be achieved in those with stable maternal-fetal status.

Lunar Cycle Influences Reproductive Performance of Crossbred Brahman Cows Under Tropical Conditions.

Evidence has accumulated over the years indicating that the moon influences some aspects of the reproductive activity in animals and humans. However, little is known about the influence of the lunar cycle on the reproductive performance of cows under tropical conditions, where the environment strongly affects reproduction. This retrospective study was conducted with the aim of assessing the influence of the lunar cycle on some reproductive traits of tropical crossbred cows managed in a pasture-based system. Data from 5869 reproductive records from two commercial farms localized in the Maracaibo Lake Basin of Zulia State, Venezuela, were analyzed. Variables studied were first service conception rate, calving frequency, first postpartum estrous frequency, and pregnancy frequency. In addition to the lunar cycle, the effects of farm, season, and predominant breed were also considered. Data were analyzed using logistic regression and general linear model from SAS. First service conception was affected by lunar phases and predominant breed, but not by farm or season. For frequencies of calving, first postpartum estrus, and pregnancy, there was no main effect of farm, season, and predominant breed, whereas the effect of lunar phases was highly significant. First service conception was significantly greater in waning than in crescent phase of the lunar cycle. Frequencies of calving, first estrus, and pregnancy were highly correlated and showed greater figures around full moon and new moon. In conclusion, lunar cycle influenced first service conception, attaining greater values in the waning phase of the moon cycle. Frequencies of calving, first postpartum estrus, and pregnancy in crossbred cows showed a clear bimodal rhythm, whose greatest values coincided with new moon and full moon.

Twin-to-twin transfusion syndrome: an antiangiogenic state?

OBJECTIVE: An imbalanced chronic blood flow between the donor and recipient twin through placental vascular anastomoses is the accepted pathophysiology of twin-to-twin transfusion syndrome (TTTS). Vascular endothelial growth factor receptor-1 (VEGFR-1) mRNA is overexpressed only in the syncytiotrophoblast of the donor twin in some cases of TTTS. This study was conducted to determine maternal plasma concentrations of placental growth factor (PlGF), soluble VEGFR-1, and soluble endoglin (s-Eng) in monochorionic-diamniotic pregnancies with and without TTTS. STUDY DESIGN: This case-control study included monochorionic-diamniotic pregnancies between 16-26 weeks with and without TTTS. Maternal plasma concentrations of PlGF, sVEGFR-1, and s-Eng were determined with ELISA. A P value < .05 was considered statistically significant. RESULTS: Patients with TTTS had higher median plasma concentrations of s-Eng (14.8 ng/mL vs 7.8 ng/mL; P < .001) and sVEGFR-1 (6383.1 pg/mL vs 3220.1 pg/mL; P < .001]; and lower median plasma concentrations of PlGF (115.5 pg/mL vs 359.3 pg/mL; P = .002) than those without TTTS. CONCLUSION: We propose that an antiangiogenic state may be present in some cases of TTTS.

Genetic origin and proportion of basal plate surface-lining cells in normal and abnormal pregnancies.

The human placenta is a transient organ, the villous surface of which is in direct contact with the maternal circulation during pregnancy. Thus, the syncytiotrophoblast and the basal plate-lining cells are considered continuous with the endothelial layer of the maternal vasculature. Two types of cells are found on the surface of the basal plate: trophoblasts (of fetal origin) and endothelial cells of putative maternal origin. Histologic abnormalities have been described in the basal plate of the placenta obtained from patients with preeclampsia and intrauterine growth restriction. Moreover, endothelial cell dysfunction and intravascular inflammation are key features of preeclampsia. The objectives of this study were to: (1) determine the origin of the endothelial cells located in the basal plate surface of the placenta (from male fetuses); and (2) analyze the relative proportion of the intervillous surface of the basal plate occupied by trophoblasts and endothelial cells. Immunohistochemistry and morphometry were performed in placentas from women in the following clinical groups: (1) normal-term pregnancies (n = 15); (2) severe preeclampsia at term (n = 15); (3) small-for-gestational-age (SGA) neonates delivered at term (n = 15); (4) preterm deliveries (<37 weeks) without inflammation (n = 5); and (5) preterm preeclampsia (n = 5). Laser capture microdissection and polymerase chain reaction were used to determine the allelic pattern of the amelogenin gene of the endothelial cells on the intervillous surface of the basal plate. Our results showed that: (1) the endothelial cells lining the basal plate in placentas of male fetuses were uniformly of maternal origin; and (2) in placentas from uncomplicated pregnancies, the median proportion of trophoblasts and endothelial cells covering the surface of the basal plate were 27.7% and 46.5%, respectively. The remaining area of the intervillous surface of the basal plate was composed of fibrin and anchoring villi. Of interest, placentas from women who delivered an SGA neonate had a higher proportion of trophoblasts and a lower proportion of endothelial cells lining the basal plate than those from normal pregnancies (P < .05). The same tendency was observed in placentas from patients with preeclampsia. This study demonstrates that endothelial cells of maternal origin cover the intervillous surface of the basal plate of the placenta, along with trophoblasts of fetal origin. The proportion of this surface lined by trophoblasts is greater in placentas from SGA and preeclampsia than in normal pregnancy. We propose that this change reflects a compensatory mechanism whereby the basal plate surface covered by injured endothelial cells is replaced by trophoblasts or results from a failure of trophoblastic involution in abnormal pregnancies. Our observations also suggest that the lining of the basal plate can provide information about the pathology of endothelial cells in complications of pregnancy.