First-trimester cesarean scar pregnancy: a comparative analysis of treatment options from the international registry.

BACKGROUND: A cesarean scar pregnancy is an iatrogenic consequence of a previous cesarean delivery. The gestational sac implants into a niche created by the incision of the previous cesarean delivery, and this carries a substantial risk for major maternal complications. The aim of this study was to report, analyze, and compare the effectiveness and safety of different treatments options for cesarean scar pregnancies managed in the first trimester through a registry. OBJECTIVE: This study aimed to evaluated the ultrasound findings, disease behavior, and management of first-trimester cesarean scar pregnancies. STUDY DESIGN: We created an international registry of cesarean scar pregnancy cases to study the ultrasound findings, disease behavior, and management of cesarean scar pregnancies. The Cesarean Scar Pregnancy Registry collects anonymized ultrasound and clinical data of individual patients with a cesarean scar pregnancy on a secure, digital information platform. Cases were uploaded by 31 participating centers across 19 countries. In this study, we only included live and failing cesarean scar pregnancies (with or without a positive fetal heart beat) that received active treatment (medical or surgical) before 12+6 weeks' gestation to evaluate the effectiveness and safety of the different management options. Patients managed expectantly were not included in this study and will be reported separately. Treatment was classified as successful if it led to a complete resolution of the pregnancy without the need for any additional medical interventions. RESULTS: Between August 29, 2018, and February 28, 2023, we recorded 460 patients with cesarean scar pregnancies (281 live, 179 failing cesarean scar pregnancy) who fulfilled the inclusion criteria and were registered. A total of 270 of 460 (58.7%) patients were managed surgically, 123 of 460 (26.7%) patients underwent medical management, 46 of 460 (10%) patients underwent balloon management, and 21 of 460 (4.6%) patients received other, less frequently used treatment options. Suction evacuation was very effective with a success rate of 202 of 221 (91.5%; 95% confidence interval, 87.8-95.2), whereas systemic methotrexate was least effective with only 38 of 64 (59.4%; 95% confidence interval, 48.4-70.4) patients not requiring additional treatment. Overall, surgical treatment of cesarean scar pregnancies was successful in 236 of 258 (91.5%, 95% confidence interval, 88.4-94.5) patients and complications were observed in 24 of 258 patients (9.3%; 95% confidence interval, 6.6-11.9). CONCLUSION: A cesarean scar pregnancy can be managed effectively in the first trimester of pregnancy in more than 90% of cases with either suction evacuation, balloon treatment, or surgical excision. The effectiveness of all treatment options decreases with advancing gestational age, and cesarean scar pregnancies should be treated as early as possible after confirmation of the diagnosis. Local medical treatment with potassium chloride or methotrexate is less efficient and has higher rates of complications than the other treatment options. Systemic methotrexate has a substantial risk of failing and a higher complication rate and should not be recommended as first-line treatment.

Qualitative analysis of Doppler assessment used for surveillance of alloimmunized individuals.

OBJECTIVES: To summarize image quality variables for alloimmunized women at risk for fetal anemia. To investigate the association between image quality with the highest and median middle cerebral artery peak systolic velocity (MCA-PSV) at the last visit and fetal anemia based on hemoglobin. STUDY DESIGN: This study was a qualitative retrospective analysis of 192 Doppler ultrasound images used in the detection of fetal anemia in 26 alloimmunized women seen in a Minneapolis hospital over the past 3 years. Images were graded on seven criteria found in literature. RESULTS: Of the images analyzed, 23 (12.0%) of the 192 met all seven image quality criteria. Using the highest MCA-PSV value, the sensitivity, and specificity were 55.6% and 94.1%, respectively. Using the median MCA-PSV value, the sensitivity, and specificity were 44.4% and 94.1%, respectively. CONCLUSIONS: Only a minority of Doppler images meet all suggested image criteria. This could negatively impact the accuracy of the MCA-PSV measurements as indicated by the decreased sensitivity in our evaluations.

Population based cohort study of fetal deaths, and neonatal and perinatal mortality at term within a Somali diaspora.

BACKGROUND: Somali women deliver at greater gestational age with limited information on the associated perinatal mortality. Our objective is to compare perinatal mortality among Somali women with the population rates. METHODS: This is a retrospective cohort study from all births that occurred in Minnesota between 2011 and 2017. Information was obtained from certificates of birth, and neonatal and fetal death. Data was abstracted from 470,550 non-anomalous births ≥37 and ≤ 42 weeks of gestation. The study population included U.S. born White, U.S. born Black, women born in Somalia or self-identified as Somali, and women who identified as Hispanic regardless of place of birth (377,426). We excluded births < 37 weeks and > 42 weeks, > 1 fetus, age < 18 or > 45 years, or women of other ethnicities. The exposure was documented ethnicity or place of birth, and the outcomes were live birth, fetal death, neonatal death prior to 28 days, and perinatal mortality rates. These were calculated using binomial proportions with 95% confidence intervals and compared using odds ratios adjusted (aOR) for diabetes, hypertension and maternal body mass index. RESULTS: The aOR [95%CI] for stillbirth rate in the Somali cohort was greater than for U.S. born White (2.05 [1.49-2.83]) and Hispanic women (1.90 [1.30-2.79]), but similar to U.S. born Black women (0.88 [0.57-1.34]). Neonatal death rates were greater than for U.S. born White (1.84 [1.36-2.48], U.S. born Black women (1.47 [1.04-2.06]) and Hispanic women (1.47 [1.05-2.06]). This did not change after analysis was restricted to those with spontaneous onset of labor. When analyzed by week, at 42 weeks Somali aOR for neonatal death was the same as for U.S. born White women, but compared against U.S. born Black and Hispanic women, was significantly lower. CONCLUSIONS: The later mean gestational age at delivery among women of Somali ethnicity is associated with greater overall risk for stillbirth and neonatal death rates at term, except compared against U.S. born Black women with whom stillbirth rates were not different. At 42 weeks, Somali neonatal mortality decreased and was comparable to that of the U.S. born White population and was lower than that of the other minorities.

Fetal exposure to mercury and lead from intrauterine blood transfusions.

BACKGROUND: Mercury (Hg) and lead (Pb) exposure during childhood is associated with irreversible neurodevelopmental effects. Fetal exposure to Hg and Pb from intrauterine blood transfusion (IUBT) has not been reported. METHODS: Fetal exposure was estimated based on transfusion volume and metal concentration in donor packed red blood cell (PRBCs). As biomarkers to quantify prenatal exposure are unknown, Hg and Pb in donor PRBCs were compared to estimated intravenous (IV) RfDs based on gastrointestinal absorption. RESULTS: Three pregnant women received 8 single-donor IUBTs with volumes ranging from 19 to 120 mL/kg. Hg and Pb were present in all donor PRBC units. In all, 1/8 IUBT resulted in Hg dose five times higher than the estimated IV RfD. Median Pb dose in one fetus who received 5 single-donor IUBTs between 20-32 weeks gestation was 3.4 µg/kg (range 0.5-7.9 µg/kg). One donor unit contained 12.9 µg/dL of Pb, resulting in a fetal dose of 7.9 µg/kg, 40 times higher than the estimated IV RfD at 20 weeks gestation. CONCLUSION: This is the first study documenting inadvertent exposure to Hg and Pb from IUBT and quantifying the magnitude of exposure. Screening of donor blood is warranted to prevent toxic effects from Hg and Pb to the developing fetus.

Mild fetal cerebral ventriculomegaly: prevalence, characteristics, and utility of ancillary testing in cases presenting to a tertiary referral center.

OBJECTIVE: Ventriculomegaly is the most common fetal brain anomaly identified during prenatal anatomy ultrasound. The aim of our study was to characterize cases of mild ventriculomegaly and investigate the utility of ancillary tests. METHOD: We reviewed 121 cases of mild ventriculomegaly, defined as lateral ventricle diameter of 10 to 15 mm. Characteristics of the ventricular dilation as well as each pregnancy were investigated. Ancillary tests performed included follow-up magnetic resonance imaging (MRI), chromosomal abnormality testing, and maternal serologic infection screening. The utility of each test was analyzed. RESULTS: We identified 56 cases of isolated and 65 cases of complex ventriculomegaly. Seventy-two (59.5%) were unilateral, and 49 (40.5%) were bilateral, with a mean gestational age at diagnosis of 24.5 weeks. MRI provided additional information in 3/24 (12.5%) cases of isolated ventriculomegaly compared with 18/23 (78.2%) cases of complex ventriculomegaly. Chromosomal abnormality testing identified 4/9 (44.4%) genetic abnormalities compared with 8/30 (26.7%) in cases of isolated and complex mild ventriculomegaly, respectively. Finally, maternal serology infection screening was negative in all cases. CONCLUSION: Ancillary testing is useful in isolated mild ventriculomegaly. Follow-up MRI and chromosome abnormality testing specifically provided clinically useful information. Although there were no cases of maternal infection, screening may be an important component in management. © 2017 John Wiley & Sons, Ltd.

Reference Values for Sonographically Estimated Fetal Weight in Twin Gestations Stratified by Chorionicity: A Single Center Study.

OBJECTIVES: To determine reference values for sonography-based estimated fetal weight (EFW) in twin gestations in one single tertiary medical center in the United States. METHODS: A retrospective longitudinal analysis of EFW evaluations of fetuses of twin gestations between November 2006 and June 2016. Fetuses with major congenital anomalies or chromosomal abnormalities were excluded. Estimated fetal weight was calculated using the Hadlock 1985 formula. Linear mixed models were used to allow for multiple but inconsistent observations among individuals, and to account for intertwin differences as well as for gender. Reference values were constructed using a best-fit regression model for estimation of mean and standard deviation at each gestational age after normalization of variables. Chorionicity-specific curves were constructed. RESULTS: A total of 5515 ultrasound examinations were performed in 2115 twin pregnancies between 24 and 38 weeks of gestation (2.6 ± 4.0 scans/pregnancy). Values corresponding to the 5th, 10th, 50th, 90th, and 95th percentiles for EFW are presented for every gestational age. At 28, 32, and 36 weeks, values were as follows: 855, 1109, and 1363 g; 1351, 1732, and 2294 g; and 1363, 2112, and 2881 g for the 10th, 50th, and 90th percentiles, respectively. Chorionicity-specific curves are presented for comparison with previously published references. CONCLUSIONS: Reference values for sonographic-based fetal growth are presented for clinical and research use.

Sex-specific effect of antenatal betamethasone exposure on renal oxidative stress induced by angiotensins in adult sheep.

Prenatal glucocorticoid administration in clinically relevant doses reduces nephron number and renal function in adulthood and is associated with hypertension. Nephron loss in early life may predispose the kidney to other insults later but whether sex influences increases in renal susceptibility is unclear. Therefore, we determined, in male and female adult sheep, whether antenatal glucocorticoid (betamethasone) exposure increased 8-isoprostane (marker of oxidative stress) and protein excretion after acute nephron reduction and intrarenal infusions of angiotensin peptides. We also examined whether renal proximal tubule cells (PTCs) could contribute to alterations in 8-isoprostane excretion in a sex-specific fashion. In vivo, ANG II significantly increased 8-isoprostane excretion by 49% and protein excretion by 44% in male betamethasone- but not in female betamethasone- or vehicle-treated sheep. ANG-(1-7) decreased 8-isoprostane excretion but did not affect protein excretion in either group. In vitro, ANG II stimulated 8-isoprostane release from PTCs of male but not female betamethasone-treated sheep. Male betamethasone-exposed sheep had increased p47 phox abundance in the renal cortex while superoxide dismutase (SOD) activity was increased only in females. We conclude that antenatal glucocorticoid exposure enhances the susceptibility of the kidney to oxidative stress induced by ANG II in a sex-specific fashion and the renal proximal tubule is one target of the sex-specific effects of antenatal steroids. ANG-(1-7) may mitigate the impact of prenatal glucocorticoids on the kidney. P47 phox activation may be responsible for the increased oxidative stress and proteinuria in males. The protection from renal oxidative stress in females is associated with increased SOD activity.

Maternal preeclampsia and risk for cardiovascular disease in offspring.

Hypertensive disease of pregnancy (HDP) has been associated with elevated lifetime cardiovascular risk, including stroke, myocardial disease, coronary artery disease, and peripheral arterial disease. These two entities share common risk factors such as obesity, insulin resistance, diabetes, and hypertension. This article will evaluate the current literature on the maternal and fetal cardiovascular risks posed by HDP. The landmark study by Barker et al. demonstrated increased cardiovascular risk in growth-restricted infants, which may also be associated with HDP. Research has demonstrated the effects that HDP may have on the vascular and nephron development in offspring, particularly with respect to endothelial and inflammatory markers. In order to control for confounding variables and better understand the relationship between HDP and lifetime cardiovascular risk, future research will require following blood pressure and metabolic profiles of the parturients and their offspring.

Prevalence of hypertensive disorders of pregnancy at or beyond 39 weeks gestational age and associated maternal complications.

OBJECTIVE: Estimate the prevalence of hypertensive disorder of pregnancy (HDP) at term, define population characteristics, and calculate adverse maternal outcomes. METHODS: Retrospective study. RESULTS: We included 4,702,468 pregnancies. HDP increased linearly from 4.5% (2014) to 6.0% (2018). HDP was more frequent among black (PR 1.19), obese (PR 2.31 to 3.70), with gestational (PR 1.87) or pregestational diabetes (PR 2.16). Increased transfusion (PR 2.52), intensive care unit admission (PR 3.38), and unplanned hysterectomy (PR 1.78) with HDP. CONCLUSION: Our study quantifies the increased risks for maternal and neonatal complications related to the development of HDP at or beyond 39 weeks among nulliparous women.

Impact of labor induction at 39 weeks gestation compared with expectant management on maternal and perinatal morbidity among a cohort of low-risk women.

OBJECTIVE: To determine maternal and perinatal outcomes after induction of labor (IOL) at 39 weeks compared with expectant management. METHODS: This is a retrospective national cohort study from the National Center for Health Statistics birth database. The study included singleton, low-risk pregnancies with a non-anomalous fetus delivered at 39-42 weeks gestation between 2015 and 2018. Maternal outcomes available included chorioamnionitis (Triple I), blood transfusion, intensive care unit (ICU) admission, uterine rupture, cesarean delivery (CD), and cesarean hysterectomy. Fetal and infant outcomes included stillbirth, 5-min Apgar ≤3, prolonged ventilation, seizures, ICU admission, and death within 28 days. We compared women undergoing IOL at 39 weeks to those managed expectantly. Non-adjusted and adjusted relative risks (aRRs) were estimated using multivariate log-binomial regression analysis. RESULTS: There were 15,900,956 births available for review of which 5,017,524 met inclusion and exclusion criteria. For the maternal outcomes, the IOL group was less likely to require a CD (aRR 0.880; 95% CI [0.874-0.886]; p value < .01) or develop Triple I (aRR 0.714; 95% CI [0.698-0.730]; p value < .01) but demonstrated a small increase in the cesarean hysterectomy rate (aRR 1.231; 95% CI [1.029-1.472]; p value < .01). Among perinatal outcomes, the stillbirth rate (aRR 0.195; 95% CI [0.153-0.249]; p value < .01), 5-min Apgar ≤3 (aRR 0.684; 95% CI [0.647-0.723]; p value < .01), prolonged ventilation (aRR 0.840; 95% CI [0.800-0.883]; p value < .01), neonatal intensive care (NICU) admission (aRR 0.862; 95% CI [0.849-0.875]; p value < .01) were lower after 39 week IOL compared with expectant management. There were no differences in risk for neonatal seizures (aRR 0.848; 95% CI [0.718-1.003]; p value 0.011) or death (aRR 1.070; 95% CI [0.722-1.586]; p value 0.660). CONCLUSIONS: IOL at 39 weeks of gestation in a low-risk cohort is associated with a lower risk of CD and maternal infection, stillbirth, and lower neonatal morbidity. There was no effect on the risk for neonatal seizures or death.

Outcomes of labor induction at 39 weeks in pregnancies with a prior cesarean delivery.

BACKGROUND: The optimal timing of induction for those undergoing a trial of labor after cesarean section has not been established. The little data which supports the consideration of induction at 39 weeks gestation excludes those with a history of prior cesarean section. OBJECTIVE: To determine the risks and benefits of elective induction of labor (IOL) at 39 weeks compared with expectant management (EM) until 42 weeks in pregnancies complicated by one previous cesarean delivery. STUDY DESIGN: This is a retrospective cohort analysis of singleton non-anomalous pregnancies in the United States between January 2015 and December 2017. Data was provided by the CDC National Center for Health Statistics, Division of Vital Statistics. Analyses included only pregnancies with a history of one previous cesarean delivery (CD). Perinatal outcomes of pregnancies electively induced at 39 weeks (IOL) were compared to pregnancies that were induced, augmented or underwent spontaneous labor between 40 and 42 weeks (EM). Unlabored cesarean deliveries were excluded. Outcomes of interest included: cesarean delivery, intra-amniotic infection, blood transfusion, adult intensive care unit (ICU) admission, uterine rupture, hysterectomy, 5-minute Apgar score ≤3, prolonged neonatal ventilation, neonatal ICU (NICU) admission, neonatal seizure, perinatal/neonatal death. Log-binomial regression analysis was performed to calculate the relative risk (RR) for each outcome of interest, adjusting for confounding variables. RESULTS: There were 50,136 pregnancies included for analysis with 9,381 women in the IOL group. Compared with EM, IOL at 39 weeks decreased the risk of intra-amniotic infection (1.7% vs 3.0%, p < .001; aRR: 0.58, 95% CI: [0.49-0.68]), blood transfusion (0.3% vs. 0.5%, p = .03; aRR: 0.66, 95% CI: [0.45-0.98]), and low 5-minute Apgar score (0.31% vs 0.47%, p = .031; aRR: 0.66, 95% CI: [0.44-0.97]). Conversely, IOL increased the risk of cesarean delivery (49.0% vs 27.6%, p < .001; aRR: 1.72, 95% CI: [1.68-1.77]). Furthermore, in the EM group, 919 pregnancies developed preeclampsia and 42 progressed to eclampsia. There were no differences in other perinatal outcomes. CONCLUSION: In pregnancies complicated by one previous cesarean delivery, elective induction of labor at 39 weeks reduced the risk of intra-amniotic infection, blood transfusion, and low 5-minute Apgar score while increased the risk of repeat cesarean delivery.

Maternal ADHD and Perinatal Prescription Stimulant Use.

OBJECTIVE: To describe patterns and predictors of perinatal prescription stimulant use. METHODS: We used MarketScan® commercial claims data (2013-2018) and a repeated cross-sectional study design to assess perinatal use of prescription stimulants. Clinical/demographic characteristics were compared across cohorts of women who continued versus discontinued stimulant treatment at various stages of pregnancy. Associations were tested for significance using chi-square tests (categorical variables) and independent t-tests (continuous variables). RESULTS: Out of 612,001 pregnancies, 15,413 involved pre-pregnancy stimulant use. Of these, stimulant treatment was discontinued prior to conception in 6,416 (42%), discontinued during trimester 1 in 5,977 (39%), and continued into later trimesters in 3,020 (19%). Compared with pregnancies involving stimulant discontinuation prior to conception, those that continued into pregnancy occurred in women who were older (29.9 vs. 28.9 years) and had more severe ADHD (3.1 vs. 1.8 ADHD-related billing claims). CONCLUSIONS: There is considerable heterogeneity in the management of ADHD during pregnancy.

Use of the Renal Artery Doppler to Identify Small for Gestational Age Fetuses at Risk for Adverse Neonatal Outcomes.

OBJECTIVE: To measure the sensitivity and positive predictive value (PPV) for an adverse neonatal outcome among growth-restricted fetuses (FGR) comparing the cerebral-placental ratio (CPR) with the cerebral-renal ratio (CRR). METHODS: Retrospective analysis of 92 women who underwent prenatal ultrasound at the University of Maryland and the University of Padua. Renal, middle cerebral and umbilical artery Doppler waveforms were recorded for all scans during the third trimester. The last scan prior to delivery was included for analysis. We calculated the test characteristics of the pulsatility indices (PI) of the umbilical and renal arteries in addition to the derived CPR and CRR to detect a composite adverse neonatal outcome. RESULTS: The test characteristics of the four Doppler ratios to detect increased risk for the composite neonatal outcome demonstrated that the umbilical artery pulsatility index had the best test performance (sensitivity 64% (95% CI: 47-82%), PPV 24% (95% CI: 21-27), and positive likelihood ratio 2.7 (95% CI: 1.4-5.2)). There was no benefit to using the CRR compared with the CPR. The agreement between tests was moderate to poor (Kappa value CPR compared with CRR: 0.5 (95%CI 0.4-0.70), renal artery PI:-0.1 (95% CI -0.2-0.0), umbilical artery PI: 0.5 (95% CI 0.4-0.7)). Only the umbilical artery had an area under the receiver operating curve that was significantly better compared with the CPR as a reference (p-value < 0.01). CONCLUSIONS: The data that we present do not support the use of renal artery Doppler as a useful clinical test to identify a fetus at risk for an adverse neonatal outcome. Within the various indices applied to this population, umbilical artery Doppler performed the best in identifying the fetuses at risk for an adverse perinatal outcome.

Renal artery Doppler compared with the cerebral placental ratio to identify fetuses at risk for adverse neonatal outcome.

Background: Current clinical practice incorporates an umbilical artery resistance index or a ratio of the middle cerebral artery (MCA PI) to the umbilical artery pulsatility index (UA PI) known as the cerebral placental ratio (CPR) to assess wellbeing in the small for gestational age fetus. Previous reports using the renal artery Doppler indices have not been consistent in regards to their design and clinical use. Our objective is to develop reference values for renal artery Doppler indices and validate their use compared with the UA PI or CPR to identify fetuses that will develop a composite neonatal outcome.Methods: We performed 9700 ultrasounds among 2852 women at 20-40 weeks of gestation at the University of Maryland between 1 June 2016 and 1 December 2016. Nomograms were first developed using one randomly selected scan from each of a subgroup of 860 women without any comorbidities. The nomograms were validated among a cohort of 550 women who subsequently delivered at the University of Maryland Medical Center. We compared the area under the receiver operating characteristic curve (AUROC) between the CPR and UA PI, and the renal artery Doppler parameters (renal artery pulsatility index (RA PI), systolic diastolic ratio (RA SDR), and peak systolic velocity (RA PSV)). The primary outcome was the development any one of the composite neonatal outcome components (death, intensive care unit admission, ventilator for more than 6 h, hypoxic ischemic encephalopathy or necrotizing enterocolitis) or admission to the neonatal intensive care unit (NICU) for any indication.Results: The renal artery Doppler indices did not improve identification of fetuses that would subsequently develop one of the components of the composite neonatal outcome (AUROC for CPR 0.54, 95% CI (0.49-0.59), versus the UA PI: 0.59 (0.54-0.64) p = .07, the RA PI: 0.51 (0.48-0.55) p = .41, RA SDR 0.54 (0.49-0.58) p = .99, or RA PSV 0.51 (0.47-0.55) p = .37). There was no difference when comparing AUROC to detect NICU admission (AUROC for CPR 0.53, 95% CI (0.49-0.58), versus the UA PI: 0.57 (0.52-0.62) p = .14, the RA PI: 0.50 (0.47-0.54) p = .44, RA SDR: 0.54 (0.50-0.59) p = .62 or RAPSV: 0.51 (0.47-0.55) p = .54).Conclusion: The renal artery indices do not improve detection of fetuses at risk for adverse neonatal outcomes compared with the CPR or the UA PI.

Fetal growth standards for Somali population.

BACKGROUND: Accurate assessment of fetal size is essential in providing optimal prenatal care. National Institute of Child Health and Human Development (NICHD) study from 2015 demonstrated that estimated fetal weight (EFW) differed significantly by race/ethnicity after 20 weeks. There is a large Somali population residing in Minnesota, many of whom are cared for at our maternal fetal medicine practice at the University of Minnesota. Anecdotally, we noticed an increased proportion of small-for-gestational age diagnoses within this population. We sought to use our ultrasound data to create a reference standard specific for this population and compare to currently applied references. PURPOSE: We aimed to model fetal growth standards within a healthy Somali population between 16 and 40 weeks gestation, and address possible differences in the growth patterns compared with standards for non-Hispanic White, non-Hispanic Black, Hispanic, and Asian singleton fetuses published by the NICHD in the Fetal Growth Study. MATERIALS AND METHODS: This is a retrospective cohort study using ultrasound data from 527 low risk pregnancies of Somali ethnicity at single tertiary care center between 2011 and 2017. A total of 1107 scans were identified for these pregnancies and maternal and obstetrical data were reviewed. Women 18-40 years of age with low-risk pregnancies and established dating consistent with first trimester ultrasound scan were included. Exclusion criteria were any maternal, fetal or obstetrical conditions known to affect fetal growth. RESULTS: Estimated fetal weight among Somali pregnancies differed significantly at some time points from the NICHD four ethnic groups, but generally the EFW graph curves crossed over at most time points between the study groups. At week 18, EFW was significantly larger than all other four ethnic groups (all p<.001), it was also significantly larger from the Hispanic, Black, and Asian ethnic groups at some time points between 18 and 27 weeks gestation (p < .05). Additionally, EFW among Somali pregnancies was significantly smaller than the Black and Asian ethnicity at 32 and 35-36 weeks and smaller than the White ethnicity at 30 and 38-39 weeks (p < .05). Abdominal circumference (AC) for the Somali population was significantly smaller than the other ethnic groups, especially than the White ethnicity at various time points across 16-40 weeks (p < .05). Femur and humerus length were significantly longer when compared to all other ethnic groups at most time points from 16 to 40 weeks of gestation (p < .05). Biparietal diameter (BPD) was significantly smaller than all other ethnic groups specifically at time of fetal survey (18 weeks) and at time of fetal growth assessment (32 weeks) (p < .05). CONCLUSIONS: Significant differences in fetal growth standards were found between the Somali ethnicity and other ethnic groups (White, Black, Asian, and Hispanic) at various time points from 16 to 40 weeks of gestation. Racial/ethnic-specific standards improve the precision for evaluating fetal growth and may decrease the proportion of fetuses of Somali ethnicity labeled as small-for-gestational age.

Developmental effect of antenatal exposure to betamethasone on renal angiotensin II activity in the young adult sheep.

Antenatal corticosteroids may have long-term effects on renal development which have not been clearly defined. Our objective was to compare the responses to intrarenal infusions of ANG II in two groups of year-old, male sheep: one group exposed to a clinically relevant dose of betamethasone before birth and one not exposed. We wished to test the hypothesis that antenatal steroid exposure would enhance renal responses to ANG II in adult life. Six pairs of male sheep underwent unilateral nephrectomy and renal artery catheter placement. The sheep were infused for 24 h with ANG II or with ANG II accompanied by blockade of the angiotensin type 1 (AT(1)) or type 2 (AT(2)) receptor. Baseline mean arterial blood pressure among betamethasone-exposed sheep was higher than in control animals (85.8 +/- 2.2 and 78.3 +/- 1.0 mmHg, respectively, P = 0.003). Intrarenal infusion of ANG II did not increase systemic blood pressure (P >/= 0.05) but significantly decreased effective renal plasma flow and increased renal artery resistance (P < 0.05). The decrease in flow and increase in resistance were significantly greater in betamethasone- compared with vehicle-exposed sheep (betamethasone P < 0.05, vehicle P >/= 0.05). This effect appeared to be mediated by a heightened sensitivity to the AT(1) receptor among betamethasone-exposed sheep. Sodium excretion initially decreased in both groups during ANG II infusion; however, a rebound was observed after 24 h. AT(1) blockade was followed by a significant rebound after 24 h in both groups. AT(2) blockade blunted the 24-h rebound effect among the vehicle-exposed sheep compared with the betamethasone-exposed sheep. In conclusion, antenatal corticosteroid exposure appears to modify renal responsiveness to ANG II by increasing AT(1)- and decreasing AT(2) receptor-mediated actions particularly as related to renal blood flow and sodium excretion.

Contemporary management of migrainous disorders in pregnancy.

PURPOSE OF REVIEW: Migraine is a frequent event among women of reproductive age. It is difficult to predict the course and severity of disease that migraineurs will endure during pregnancy. Treatment is often compromised during pregnancy because of concerns regarding pharmacotherapy and fetal well being. RECENT FINDINGS: The majority of women with migraine during pregnancy will not require ongoing pharmacotherapy or prophylaxis. Nonpharmacologic strategies should be the first-line treatment of migraines. For severe migraines, recent cohort studies documenting the use of triptans for treatment during pregnancy have shown no increase in adverse pregnancy and fetal outcomes above the average rate. High-dose valproate is the only antiepileptic drug available for migraine prophylaxis that has been shown to cause long-term cognitive effects in infants exposed during gestation. Congenital syndromes have been described for most of the older antiepileptic drugs but less so for many of the newer drugs. These newer medications appear to have improved safety profiles for use in pregnancy but there is still information lacking from larger patient cohorts and longitudinal studies of neurodevelopmental outcomes. There is also evidence to support use of beta-blockers and calcium-channel blockers for migraine prevention during pregnancy. SUMMARY: For those patients who develop debilitating migraine or whose migraines interfere with activities of daily living, there are several options for treatment and headache prevention that have a low likelihood of compromising fetal well being.

Neonatal outcomes and operative vaginal delivery versus cesarean delivery.

We compared outcomes for neonates with forceps-assisted, vacuum-assisted, or cesarean delivery in the second stage of labor. This is a secondary analysis of a randomized trial in laboring, low-risk, nulliparous women at >or=36 weeks' gestation. Neonatal outcomes after use of forceps, vacuum, and cesarean were compared among women in the second stage of labor at station +1 or below (thirds scale) for failure of descent or nonreassuring fetal status. Nine hundred ninety women were included in this analysis: 549 (55%) with an indication for delivery of failure of descent and 441 (45%) for a nonreassuring fetal status. Umbilical cord gases were available for 87% of neonates. We found no differences in the base excess (P = 0.35 and 0.78 for failure of descent and nonreassuring fetal status) or frequencies of pH below 7.0 (P = 0.73 and 0.34 for failure of descent and nonreassuring fetal status) among the three delivery methods. Birth outcomes and umbilical cord blood gas values were similar for those neonates with a forceps-assisted, vacuum-assisted, or cesarean delivery in the second stage of labor. The occurrence of significant fetal acidemia was not different among the three delivery methods regardless of the indication.

Catecholaminergic polymorphic ventricular tachycardia in pregnancy: a case report.

INTRODUCTION: Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a genetic disorder that can cause fatal tachyarrhythmias brought on by physical or emotional stress. There is little reported in the literature regarding management of CPVT in pregnancy much less during labor. CASE PRESENTATION: A gravida 2, para 1 presented to our high-risk clinic at 15 weeks gestation with known CPVT. The Caucasian female patient had been diagnosed after experiencing a cardiac arrest following a motor vehicle accident and found to have a pathogenic cardiac ryanodine receptor mutation. An implantable cardioverter defibrillator was placed at that time. Her pregnancy was uncomplicated, and she was medically managed with metoprolol, flecainide, and verapamil. Her labor course and successful vaginal delivery were uncomplicated and involved a multidisciplinary team comprising specialists in electrophysiology, maternal fetal medicine, anesthesiology, general obstetrics, lactation, and neonatology. CONCLUSIONS: CPVT is likely underdiagnosed and, given that cardiovascular disease is a leading cause of death in pregnancy, it is important to bring further awareness to the diagnosis and management of this inherited arrhythmia syndrome in pregnancy.

The role of fetal growth restriction in the association between Down syndrome and perinatal mortality.

Objective: Down syndrome (DS) is associated with significant risk of perinatal mortality. We hypothesize that this association is primarily mediated through the effects of fetal growth restriction (FGR).Methods: This was a retrospective cohort analysis using the US Natality Database from 2011 to 2013. Analysis was limited to singleton nonanomalous pregnancies or confirmed DS pregnancies without severe structural anomalies between 24 and 42 w in gestation. The risk of stillbirth (SB) associated with DS was estimated using both Cox proportional Hazard (HR) regression and accelerated failure time (AFT) methods. The risk of neonatal mortality was estimated using logistic regression analyses. Mediation analysis was then performed to estimate the effect of small for gestational age (SGA), defined as birthweight ≤10th percentile for gestational age, on perinatal mortality associated with DS. All regression models were selected using backward stepwise elimination method. The final regression models included adjustment for maternal age, hypertension, and diabetes.Results: The final cohort included 2446 DS cases among 9,804,718 births. The overall SB rate was 223.6/1000 births in DS group and 4.7/1000 births without DS (p < .001, adjusted hazard ratio (aHR): 58.25; 95% CI [53.44,63.49]). Based on the AFT model, DS survival-to-delivery rate is 4.3 times lower (TR: 0.23; 95% CI [0.22,0.24]). Thirty-five percentage of the effect of DS on stillbirth was mediated through SGA (% mediation:35.1%; 95% CI [33.7,36.4]). The rate of neonatal mortality among DS was 69.0/1000 births compared with 2.8/1000 births without DS (p < .001, adjusted odds ratio (aOR): 27.16; 95% CI: [22.63,32.60]). Only 11.6% of the effect of DS on neonatal deaths was mediated through SGA (%mediation:11.6%; 95% CI [8.4,10.6]).Conclusion: Over one-third of overall stillbirths were mediated through SGA. Routine surveillance of fetal growth and standard SGA surveillance protocols may reduce the risk of perinatal mortality in DS pregnancies. Conversely, it is important to point out that these surveillance strategies may not be effective two-third of the cases not affected by growth restriction.