Fetal Ultrasound and Magnetic Resonance Imaging Findings in Suspected Septo-Optic Dysplasia: A Diagnostic Dilemma.

OBJECTIVES: To investigate prenatal imaging findings supporting a diagnosis of suspected septo-optic dysplasia (SOD) by fetal ultrasound (US), magnetic resonance imaging (MRI), or both. METHODS: A retrospective review identified 11 patients with SOD: 9 had a clinical diagnosis of SOD postnatally, and 2 were terminated on the basis of suspicious prenatal imaging. Prenatal and neonatal imaging of the cavum septi pellucidi (CSP), frontal horns (FHs), and lateral ventricles was evaluated. RESULTS: The appearance of the CSP varied on US and MRI. Complete ("fused") FHs or partial absence of the CSP was reported in 6 of 11 patients by fetal US and 7 of 8 patients by fetal MRI. The diagnosis of SOD was prospectively suspected prenatally in 6 of 11 and in an additional 5 of 11 cases retrospectively. Fetal MRI incorrectly initially reported normal morphologic abnormalities for 2 cases with partial absence of the CSP, whereas US accurately identified the morphologic abnormalities in 1 of these cases before MRI. Imaging features were first suggested at anatomic US (4 patients) and follow-up prenatal US (2 patients). Neonatal imaging was concordant in all 9 live births: 5 completely absent CSP, 3 partially absent CSP, and 1 completely present CSP. Clinical manifestations included optic nerve hypoplasia (9 of 9), panhypopituitarism (5 of 9), and neurodevelopmental delays. CONCLUSIONS: Primary imaging features of SOD are "continuous" FHs with complete or partial absence of the CSP. Septo-optic dysplasia can be suspected in utero and can appear isolated but has substantial associated central nervous system anomalies identified on fetal MRI or after birth. Partial absence of the CSP can be a prenatal sign of suspected SOD, although fetal MRI lacked the spatial resolution to identify it accurately in all cases.

Ultrasound Measurements of Frontal Horns and the Cavum Septi Pellucidi in Healthy Fetuses in the Second and Third Trimesters of Pregnancy.

OBJECTIVES: To assess the visualization rate and size of the frontal horns (FHs) and cavum septi pellucidi (CSP) in healthy fetuses throughout pregnancy. METHODS: After Institutional Review Board approval, 522 consecutive uncomplicated singleton pregnancies between 15 and 39 gestational weeks were enrolled in the study. Ultrasound measurements of the anterior horn width (AHW), center from the horn distance (CFHD), distance from the FHs to the CSP, and CSP width were retrospectively performed using axial transventricular or transcerebellar planes. Available maternal body mass indices were recorded. RESULTS: At least 1 FH was seen in 78% of the cases. The mean AHW decreased over the second trimester and plateaued in the third trimester. The CFHD plateaued in the second trimester and increased in the third trimester. Downside FHs were generally larger than upside FHs. More FHs were measured in transventricular (69%) than transcerebellar (31%) planes. Frontal horns were seen with high, low, and no confidence in 57%, 21%, and 22% of cases, respectively. No-confidence rates were 17% in the second trimester and 42% in the third trimester. The CSP was not visualized in 4% of cases; 15 of 19 cases of a nonvisualized CSP were scanned between 18 and 37 weeks. Mean body mass indices ± SDs were 27.6 ± 6.7 kg/m2 for the patients in cases of a visualized CSP and 32.4 ± 9.1 kg/m2 for the patients in cases of a nonvisualized CSP. CONCLUSIONS: Normative data for the fetal FH and CSP width were established. Frontal horns are more frequently seen on transventricular views and are difficult to confidently assess in the late third trimester. This study challenges previously reported data that the CSP is seen in 100% of cases from 18 to 37 weeks.

Second-Trimester Ultrasound as a Tool for Early Detection of Fetal Alcohol Spectrum Disorders.

BACKGROUND: Early detection of fetal alcohol spectrum disorders (FASDs) is desirable to allow earlier and more comprehensive interventions to be initiated for the mother and infant. We examined prenatal ultrasound as an early method of detecting markers of the physical features and neurobehavioral deficits characteristic of FASD. METHODS: A longitudinal cohort of pregnant women in Ukraine was recruited as part of the Collaborative Initiative on Fetal Alcohol Spectrum Disorders. Women were enrolled into a moderately to heavy-alcohol-exposed group or a low- or no-alcohol exposure group and were followed to pregnancy outcome. In the second trimester, a fetal ultrasound was performed to measure transverse cerebellar diameter, occipital frontal diameter (OFD), caval-calvarial distance, frontothalamic distance (FTD), interorbital distance (IOD), outer orbital diameter, and orbital diameter (OD). Live born infants received a dysmorphological examination and a neurobehavioral evaluation using the Bayley Scales of Infant Development. These data were used to classify infants with respect to FASD. Comparisons were made on the ultrasound measures between those with and without features of FASD, adjusting for gestational age at ultrasound and maternal smoking. RESULTS: A total of 233 mother/child dyads were included. Children classified as FASD had significantly longer IOD and lower FTD/IOD, OFD/IOD, and FTD/OD ratios (p < 0.05). Children with a Bayley score <85 had significantly shorter FTD, longer IOD, lower OFD/IOD, and FTD/IOD ratios (p < 0.05). In general, mean differences were small. Ultrasound variables alone predicted <10% of the variance in the FASD outcome. CONCLUSIONS: Some ultrasound measurements were associated with FASD, selected facial features of the disorder, and lower neurobehavioral scores. However, mean differences were relatively small, making it difficult to predict affected children based solely on these measures. It may be advantageous to combine these easily obtained ultrasound measures with other data to aid in identifying high risk for an FASD outcome.

Effect of Depression on Risky Drinking and Response to a Screening, Brief Intervention, and Referral to Treatment Intervention.

We assessed alcohol consumption and depression in 234 American Indian/Alaska Native women (aged 18-45 years) in Southern California. Women were randomized to intervention or assessment alone and followed for 6 months (2011-2013). Depression was associated with risk factors for alcohol-exposed pregnancy (AEP). Both treatment groups reduced drinking (P < .001). Depressed, but not nondepressed, women reduced drinking in response to SBIRT above the reduction in response to assessment alone. Screening for depression may assist in allocating women to specific AEP prevention interventions.

Preventing alcohol-exposed pregnancy among an American Indian/Alaska Native population: effect of a screening, brief intervention, and referral to treatment intervention.

BACKGROUND: Fetal alcohol spectrum disorders are the result of alcohol-exposed pregnancies (AEP) and believed to be the leading known cause of developmental disabilities in the United States. Our objective was to determine whether a culturally targeted Screening, Brief Intervention, and Referral to Treatment (SBIRT) intervention may reduce risky drinking and vulnerability to AEP among American Indian/Alaska Native (AIAN) women in Southern California. METHODS: Southern California AIAN women of childbearing age who completed a survey including questions regarding alcohol consumption and contraceptive use were randomized into intervention or treatment as usual groups where the former group completed an online SBIRT intervention, and were followed up at 1, 3, and 6 months postintervention. RESULTS: Of 263 women recruited and 247 with follow-up data, one-third were at high risk of having an AEP at baseline. Both treatment groups decreased self-reported risky drinking behavior (drinks per week, p < 0.001; frequency of heavy episodic [binge] drinking episodes per 2 weeks, p = 0.017 and risk of AEP p < 0.001 at 6 months postintervention) in the follow-up period. There was no difference between treatment groups. Baseline factors associated with decreased risk of an AEP at follow-up included the perception that other women in their peer group consumed a greater number of drinks per week, having reported a greater number of binge episodes in the past 2 weeks, and depression/impaired functionality. CONCLUSIONS: Participation in assessment alone may have been sufficient to encourage behavioral change even without the web-based SBIRT intervention. Randomization to the SBIRT did not result in a significantly different change in risky drinking behaviors. The importance of perception of other women's drinking and one's own depression/functionality may have implications for future interventions.

Early Second Trimester Weight Gain in Obese Women Predicts Excessive Gestational Weight Gain in Pregnancy.

OBJECTIVE: To assess gestational weight gain (GWG) in obese women to determine an inflection point that identifies women at risk for excessive weight gain. STUDY DESIGN: This is an observational prospective cohort study of pregnancies managed through the UC San Diego Maternal Weight and Wellness Program from 2011 to 2014. The primary outcome was total gestational weight gain. GWG was categorized as inadequate (<11 pounds), adequate (11-20 pounds), and excessive (>20 pounds) based on Institute of Medicine (IOM) recommendations. Other outcomes were GWG by trimester and postpartum weight retention. Bivariate and multivariate analyses were used to assess factors associated with GWG. RESULTS: Ninety-five patients had a mean prepregnancy body mass index (BMI) of 41.9 ± 8.9 kg/m(2) and a net weight gain of 21.9 ± 19 pounds. First trimester GWG was -0.3 ± 4.9 pounds, second trimester was 10.4 ± 10.8 pounds, and third trimester was 11.4 ± 8.5 pounds for all participants. Women who exceeded IOM recommendations accelerated weight gain at 12-14 weeks and gained a majority of weight during the second trimester. Weight gain of more than two pounds at 12-14 weeks had a 96 % positive predictive value (95 % CI 79-99) for excessive GWG. Postpartum women with excessive GWG retained more weight than those with inadequate GWG (10.7 ± 15.6 pounds compared with -13.6 ± 10.9 pounds, P < 0.001). On multiple linear regression GWG by trimester was predictive of total GWG with second and third trimester GWG having the greatest effect on total GWG. Prepregnancy BMI and gestational diabetes were not predictors of total GWG. CONCLUSIONS: Obese women at risk for excessive GWG may be identified as early as 12-14 weeks and gain most weight during the second trimester. GWG less than 11 pounds resulted in significant postpartum weight loss among obese women.

Two-dimensional sonographic cine imaging improves confidence in the initial evaluation of the fetal heart.

OBJECTIVES: Initial screening sonography of the fetal heart with static images is often inadequate, resulting in repeated imaging or failure to detect abnormalities. We hypothesized that the addition of short cine clips would reduce the need for repeated imaging. METHODS: Two-dimensional (2D) static sonograms and short 2D cine clips of the 4-chamber view and left and right ventricular outflow tracts were obtained from 342 patients with gestational ages of greater than 16 weeks. A diagnostic radiologist and a perinatologist retrospectively reviewed the static and cine images independently and graded them as normal, abnormal, or suboptimal. RESULTS: A statistically significant increase in the number of structures called normal was seen when 2D cine clips were added to static imaging for both observers (P < .05); the radiologist called 86.5% normal with combined static and cine images versus 61.9% with static images alone, whereas the perinatologist recorded 68.1% as normal versus 58.8%, respectively. The radiologist called 77.8% of structures normal with cine images only versus 61.9% with static images only (P < .001), whereas the perinatologist called fewer structures normal with cine images alone (38.9%) versus static images alone (58.8%). The use of cine loops alone resulted in no significant increase in the ability to clear the heart as normal. The maternal body mass index was inversely associated with the ability to clear structures when 2D cine images were added to static images (P < .05). CONCLUSIONS: The addition of 2D cine clips to standard 2D static imaging of the fetal heart significantly improves the number of structures cleared as normal. Two-dimensional cine clips are easily obtained, add little time to a study, and require minimal archival space.

Fictional father?: Oliver Sacks and the revalidation of pathography.

This paper is a revalidation of Oliver Sacks's role in the development of medicine's narrative turn and, as such, a reinterpretation of the history of narrative in medicine. It suggests that, from the late 1960s, Sacks pioneered in his 'Romantic Science' a new medical mode that reunited the seemingly incommensurable art and science of medicine while also offering a way for medical humanities to shape clinical reasoning more effectively.

Preoperative intravascular balloon catheters and surgical outcomes in pregnancies complicated by placenta accreta: a management paradox.

OBJECTIVE: The objective of the study was to compare outcomes between patients who did and did not receive preoperative uterine artery balloon catheters in the setting placenta accreta. STUDY DESIGN: This was a retrospective case-control study of patients with placenta accreta from 1990 to 2011. RESULTS: Records from 117 patients with pathology-proven accreta were reviewed. Fifty-nine patients (50.4%) had uterine artery balloons (UABs) placed preoperatively. The mean estimated blood loss (EBL) was lower (2165 mL vs 2837 mL; P = .02) for the group that had UABs compared with the group that did not. There were more cases with an EBL greater than 2500 mL and massive transfusions of packed red blood cells (>6 units) in the group that did not have UABs. Percreta was diagnosed more often on final pathology in the group with UABs. Surgical times did not differ between the 2 groups. Two patients (3.3%) had complications related to the UABs. CONCLUSION: Preoperative placement of UABs is relatively safe and is associated with a reduced EBL and fewer massive transfusions compared with a group without UABs.

Identifying sonographic markers for placenta accreta in the first trimester.

Our study attempted to identify whether sonographic markers for placenta accreta may be present as early as the first trimester. We reviewed 10 cases with pathologically proven accreta and retrospectively analyzed their first-trimester images. The gestational ages ranged from 8 weeks 4 days to 14 weeks 2 days. Sonographic findings included anechoic placental areas (9 of 10), low implantation of the gestational sac (9 of 10), an irregular placental-myometrial interface (9 of 10), and placenta previa (7 of 10). Nine patients had at least 1 prior cesarean delivery; 3 had additional uterine surgical procedures. One patient underwent hysteroscopic myomectomy. Our case series suggests that signs of placenta accreta may be present in the first trimester.

Case Report: Erroneous Human Immunodeficiency Virus-1 Diagnosis in a Pregnant Woman Using Centers for Disease Control and Prevention Diagnostic Algorithm.

We describe a case of a pregnant cisgender woman diagnosed with human immunodeficiency virus (HIV)-1 using the current Centers for Disease Control and Prevention diagnostic algorithm who subsequently had her diagnosis overturned after additional testing outside of the algorithm, including an HIV-1 proviral deoxyribonucleic acid test that was negative.

Placenta accreta and postpartum hemorrhage.

Placenta accreta is the abnormal adherence of the placenta to the uterine wall. Where placenta accreta is present, the failure of the placenta to separate normally from the uterus after delivery is accompanied by severe postpartum hemorrhage. The best outcomes in placenta accreta are in prenatally diagnosed electively delivered cases. Management should take place in centers with special expertise. All obstetric units should have an obstetric hemorrhage protocol in place.

Three-dimensional ultrasonographic depiction of fetal abdominal blood vessels.

OBJECTIVE: The purpose of this study was to identify fetal abdominal vasculature with 3-dimensional (3D) ultrasonography and to describe a systematic method for analysis of volume data sets. METHODS: Three-dimensional volumes of the fetal abdomen were acquired prospectively in 30 patients between 15 and 34 weeks' gestation with color Doppler, high-definition (HD) flow, power Doppler, and B-flow imaging. All volumes were analyzed offline by 2 examiners separately. The feasibility of identifying the fetal abdominal blood vessels was analyzed. A standardized approach was applied to identify specific vessels by correlating the images with known anatomic landmarks. RESULTS: The volumes were rotated into an anatomic orientation in the multiplanar mode, and then the vessels were identified in the following order: aorta (30 of 30), celiac trunk (29 of 30), superior mesenteric vein (28 of 30 and 26 of 30 for readers 1 and 2, respectively), superior mesenteric artery (29 of 30), left renal artery (25 of 30 and 26 of 30), right renal artery (27 of 30), common iliac arteries (30 of 30), umbilical arteries (26 of 27), external iliac arteries (20 of 22), umbilical vein (29 of 30), ductus venosus (30 of 30), hepatic vein (29 of 30), right portal vein (29 of 30), inferior vena cava (28 of 30), adrenal artery (2 of 30), hepatic artery (24 of 30 and 23 of 30), splenic artery (24 of 30 and 23 of 30), gastric artery (14 of 30 and 9 of 30), splenic vein (19 of 30 and 15 of 30), and renal vein (1 of 30). A step-by-step systematic approach to identify the abdominal vasculature from the ultrasonographic volume data set was developed. CONCLUSIONS: Fetal abdominal vessels can be easily visualized when a systematic analysis is performed on 3D data set volumes. Visualization of the vessels was optimal when volumes were acquired with HD flow imaging.

A framework for widespread replication of a highly spatially resolved childhood lead exposure risk model.

BACKGROUND: Preventive approaches to childhood lead poisoning are critical for addressing this longstanding environmental health concern. Moreover, increasing evidence of cognitive effects of blood lead levels < 10 microg/dL highlights the need for improved exposure prevention interventions. OBJECTIVES: Geographic information system-based childhood lead exposure risk models, especially if executed at highly resolved spatial scales, can help identify children most at risk of lead exposure, as well as prioritize and direct housing and health-protective intervention programs. However, developing highly resolved spatial data requires labor-and time-intensive geocoding and analytical processes. In this study we evaluated the benefit of increased effort spent geocoding in terms of improved performance of lead exposure risk models. METHODS: We constructed three childhood lead exposure risk models based on established methods but using different levels of geocoded data from blood lead surveillance, county tax assessors, and the 2000 U.S. Census for 18 counties in North Carolina. We used the results to predict lead exposure risk levels mapped at the individual tax parcel unit. RESULTS: The models performed well enough to identify high-risk areas for targeted intervention, even with a relatively low level of effort on geocoding. CONCLUSIONS: This study demonstrates the feasibility of widespread replication of highly spatially resolved childhood lead exposure risk models. The models guide resource-constrained local health and housing departments and community-based organizations on how best to expend their efforts in preventing and mitigating lead exposure risk in their communities.

Placenta accreta: an association with fibroids and Asherman syndrome.

OBJECTIVE: Placenta accreta is a life-threatening problem that is rising in incidence in the developed world. The increased risk of placenta accreta in women with placenta previa and 1 or more prior cesarean deliveries is well established and prompts careful sonographic evaluation. Our objective was to emphasize that accreta is also identified at sites other than cesarean scars. METHODS: Two cases of placenta accreta without placenta previa seen in association with uterine scarring from myomectomy and uterine fibroids are described. RESULTS: The sonographic and magnetic resonance imaging findings of accreta are reviewed in the classic setting of prior cesarean deliveries as well as myomectomy and uterine fibroids. CONCLUSIONS: We suggest that when the placenta overlies any uterine abnormality, a careful search for invasive placentation is warranted.

A fetal diagnostic center's referral rate for perinatal palliative care.

BACKGROUND: Fetal specialists support standardizing the practice of offering women palliative care for life limiting fetal diagnoses. However, there is little data available regarding what fetal specialists do in practice. Since 2003, our center has kept a database of all women referred for fetal complications. METHODS: Retrospective electronic chart review of pregnant women between 2006 and 2012 using UCSD's Fetal Care and Genetics Center referral database. Objectives were to determine: (I) how many high risk pregnancies referred to the University of California San Diego Medical Center (UCSD) over a 6-year period have potentially life limiting fetal diagnoses; (II) pregnancy outcome; and (III) referral rate to perinatal palliative care. RESULTS: Between July 2006 and July 2012, 1,144 women were referred to UCSD's Fetal Care and Genetics Center, a tertiary care center. Of that cohort, 332 women (29%) were diagnosed prenatally with a potentially life limiting fetal diagnosis. Most women were Hispanic or Latino, married, and had previous children. The median gestation at confirmed diagnosis was 19 weeks. Trisomy 13, Trisomy 18, and anencephaly comprised 21% of cases. The pregnancy outcome was determined in 95% cases: 56% therapeutic abortion, 16% intrauterine fetal demise, and 23% live birth. Only 11% of cases were referred to perinatal palliative care. CONCLUSIONS: The vast majority of women with potentially life limiting fetal diagnoses are not referred to perinatal palliative care. Evaluation of how to integrate palliative care into high-risk obstetrics is needed.

Ultrasonographic prenatal imaging of fetal ocular and orbital abnormalities.

Technological progress in medicine has provided earlier diagnosis, even into the prenatal period. We address ultrasonographic imaging of the prenatal eye and orbit. During development of these structures, multiple pathologies and diseases can arise. Orbital anomalies can be detected prenatally using ultrasound or magnetic resonance imaging. Some of these include congenital cataracts, hypertelorism, hypotelorism, dacryocystocele, microphthalmia, anophthalmia, orbital tumors/masses, and septo-optic dysplasia. We describe characteristic ultrasound findings of these diseases. Prenatal ocular and orbital diagnosis is best facilitated by a team approach between ophthalmology, radiology, obstetrics, neonatology, and genetic counselors to optimize diagnostic accuracy, familial expectations, and early treatment.

The relationship between early childhood blood lead levels and performance on end-of-grade tests.

BACKGROUND: Childhood lead poisoning remains a critical environmental health concern. Low-level lead exposure has been linked to decreased performance on standardized IQ tests for school-aged children. OBJECTIVE: In this study we sought to determine whether blood lead levels in early childhood are related to educational achievement in early elementary school as measured by performance on end-of-grade (EOG) testing. METHODS: Educational testing data for 4th-grade students from the 2000-2004 North Carolina Education Research Data Center were linked to blood lead surveillance data for seven counties in North Carolina and then analyzed using exploratory and multivariate statistical methods. RESULTS: The discernible impact of blood lead levels on EOG testing is demonstrated for early childhood blood lead levels as low as 2 microg/dL. A blood lead level of 5 microg/dL is associated with a decline in EOG reading (and mathematics) scores that is roughly equal to 15% (14%) of the interquartile range, and this impact is very significant in comparison with the effects of covariates typically considered profoundly influential on educational outcomes. Early childhood lead exposures appear to have more impact on performance on the reading than on the mathematics portions of the tests. CONCLUSIONS: Our emphasis on population-level analyses of children who are roughly the same age linked to previous (rather than contemporaneous) blood lead levels using achievement (rather than aptitude) outcome complements the important work in this area by previous researchers. Our results suggest that the relationship between blood lead levels and cognitive outcomes are robust across outcome measures and at low levels of lead exposure.

Changes in blood lead levels associated with use of chloramines in water treatment systems.

BACKGROUND: More municipal water treatment plants are using chloramines as a disinfectant in order to reduce carcinogenic by-products. In some instances, this has coincided with an increase in lead levels in drinking water in those systems. Lead in drinking water can be a significant health risk. OBJECTIVES: We sought to test the potential effect of switching to chloramines for disinfection in water treatment systems on childhood blood lead levels using data from Wayne County, located in the central Coastal Plain of North Carolina. METHODS: We constructed a unified geographic information system (GIS) that links blood lead screening data with age of housing, drinking water source, and census data for 7,270 records. The data were analyzed using both exploratory methods and more formal multivariate techniques. RESULTS: The analysis indicates that the change to chloramine disinfection may lead to an increase in blood lead levels, the impact of which is progressively mitigated in newer housing. CONCLUSIONS: Introducing chloramines to reduce carcinogenic by-products may increase exposure to lead in drinking water. Our research provides guidance on adjustments in the local childhood lead poisoning prevention program that should accompany changes in water treatment. As similar research is conducted in other areas, and the underlying environmental chemistry is clarified, water treatment strategies can be optimized across the multiple objectives that municipalities face in providing high quality drinking water to local residents.