Detection of fetal structural anomalies in a basic first-trimester screening program for aneuploidy.

OBJECTIVES: The purpose of this study was to determine whether first-trimester aneuploidy screening sonography initially performed by credentialed sonographers was useful for detecting fetal anomalies between 11 and 14 weeks' gestation. METHODS: We conducted a retrospective cohort study of consecutive patients referred to a private ultrasound facility between January 1, 2008, and June 30, 2012, for measurement of the nuchal translucency (NT) and crown-rump length as part of a screening protocol for aneuploidy. Patients were included if there was at least 1 live fetus with a crown-rump length between 34 and 84 mm. No specific anatomic imaging protocol was followed. The presence of anomalies was based on the sonographic report and review of the medical record. The absence of anomalies was based on the report from the anatomic survey. Anomalies were categorized as lethal, major, and minor. The anomaly category and gestational age at diagnosis (≤14 versus >14 weeks) were compared. RESULTS: An NT scan was performed on 9692 fetuses. Anatomic surveys were done on 9077 (93.7%) of these fetuses at a mean of 18 weeks' gestation. Anomalies were detected in 180 fetuses (1.8%): 50 (0.5%) at the NT scan and 130 (1.3%) at the anatomic scan. Overall, 46 of 111 fetuses (41.4%) with major or lethal anomalies were detected at the NT scan. Two suspected abnormalities at the NT scan were not present at the anatomic scan. CONCLUSIONS: First-trimester aneuploidy screening sonography initially performed by credentialed sonographers can identify a substantial proportion of major and lethal anomalies.

What is the importance of second-trimester "soft markers" for trisomy 21 after an 11- to 14-week aneuploidy screening scan?

OBJECTIVES: The purpose of this study was to evaluate the importance of second-trimester "soft markers" for trisomy 21 after an 11- to 14-week aneuploidy screening scan. METHODS: We conducted a retrospective cohort study of consecutive patients referred for measurement of the nuchal translucency (NT) as part of a screening protocol for aneuploidy. Patients who returned for an anatomic survey between 16 and 20 weeks' gestation were evaluated. The sonographic markers and anomalies associated with the detection of trisomy 21 in the second trimester were analyzed. RESULTS: There were 42 fetuses (0.4%) with trisomy 21 identified in the study cohort of 9692 patients. Trisomy 21 was suspected at the NT scan in 28 fetuses (67%) and at the second-trimester anatomic survey in 14 (33%). In fetuses first suspected of having trisomy 21 in the second trimester, 9 of 14 had normal anatomic survey results, and 5 of 14 had congenital malformations. All 14 fetuses had soft markers for aneuploidy. A thickened nuchal fold was identified in 5 of 9 fetuses with trisomy 21 and normal anatomic survey results, all of whom had an NT of less than 3.0 mm at the initial screening scan. CONCLUSIONS: Second-trimester soft markers, especially a thickened nuchal fold, remain important observations in the detection of trisomy 21 by sonography among fetuses who have had first-trimester sonographic screening for aneuploidy.

Trends in preterm birth: an academic center's campaign to reduce the incidence.

OBJECTIVE: To evaluate if the implementation of five protocols aimed at reducing the preterm birth rate were associated with a decrease in incidence of PTBs at an academic center. METHODS: This is an observational study of women with singleton gestations delivered at TJUH between 2004 and 2014. Primary outcome was the annual incidence of PTB <37 weeks at TJUH. Secondary outcome was the rate of change for PTBs at TJUH compared against that of the nation. Linear regression, Pearson correlation coefficients, and t-tests were used to analyze preterm birth rates over time. RESULTS: TJUH incidence of PTB < 37 weeks significantly decreased from 10.8% (n = 206) in 2004 to 9.1% (n = 169) in 2014 (p = .001). Linear regression showed a dramatically greater rate of decline at TJUH (0.32% per year, p = .001) compared to that of the USA (0.14% per year, p < .0001). Early PTBs (28-33 6/7 week) at TJUH had the steepest rate of decline at 0.13% per year (p = .001). Late PTBs (34-36 6/7 week) at TJUH were the only group to not have a significant rate of decline (p = .114). CONCLUSION: The incidence of PTBs at TJUH decreased more than the USA national average in the study period, which may be due to early adoption of guidelines for prevention of PTB. CONDENSATION: The incidence of PTBs at TJUH decreased more than the USA national average in the study period, which may be due to early adoption of guidelines for prevention of PTB.

Clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnancies: a United States cohort study.

Background: The coronavirus disease 2019 pandemic has had an impact on healthcare systems around the world with 3 million people contracting the disease and 208,000 cases resulting in death as of this writing. Information regarding coronavirus infection in pregnancy is still limited. Objective: This study aimed to describe the clinical course of severe and critical coronavirus disease 2019 in hospitalized pregnant women with positive laboratory testing for severe acute respiratory syndrome coronavirus 2. Study Design: This is a cohort study of pregnant women with severe or critical coronavirus disease 2019 hospitalized at 12 US institutions between March 5, 2020, and April 20, 2020. Severe disease was defined according to published criteria as patient-reported dyspnea, respiratory rate >30 per minute, blood oxygen saturation ≤93% on room air, ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen <300 mm Hg, or lung infiltrates >50% within 24-48 hours on chest imaging. Critical disease was defined as respiratory failure, septic shock, or multiple organ dysfunction or failure. Women were excluded from the study if they had presumed coronavirus disease 2019, but laboratory testing was negative. The primary outcome was median duration from hospital admission to discharge. Secondary outcomes included need for supplemental oxygen, intubation, cardiomyopathy, cardiac arrest, death, and timing of delivery. The clinical courses are described by the median disease day on which these outcomes occurred after the onset of symptoms. Treatment and neonatal outcomes are also reported. Results: Of 64 hospitalized pregnant women with coronavirus disease 2019, 44 (69%) had severe disease, and 20 (31%) had critical disease. The following preexisting comorbidities were observed: 25% had a pulmonary condition, 17% had cardiac disease, and the mean body mass index was 34 kg/m2. Gestational age was at a mean of 29±6 weeks at symptom onset and a mean of 30±6 weeks at hospital admission, with a median disease day 7 since first symptoms. Most women (81%) were treated with hydroxychloroquine; 7% of women with severe disease and 65% of women with critical disease received remdesivir. All women with critical disease received either prophylactic or therapeutic anticoagulation during their admission. The median duration of hospital stay was 6 days (6 days [severe group] and 10.5 days [critical group]; P=.01). Intubation was usually performed around day 9 on patients who required it, and peak respiratory support for women with severe disease was performed on day 8. In women with critical disease, prone positioning was required in 20% of cases, the rate of acute respiratory distress syndrome was 70%, and reintubation was necessary in 20%. There was 1 case of maternal cardiac arrest, but there were no cases of cardiomyopathy or maternal death. Thirty-two of 64 (50%) women with coronavirus disease 2019 in this cohort delivered during their hospitalization (34% [severe group] and 85% [critical group]). Furthermore, 15 of 17 (88%) pregnant women with critical coronavirus disease 2019 delivered preterm during their disease course, with 16 of 17 (94%) pregnant women giving birth through cesarean delivery; overall, 15 of 20 (75%) women with critical disease delivered preterm. There were no stillbirths or neonatal deaths or cases of vertical transmission. Conclusion: In pregnant women with severe or critical coronavirus disease 2019, admission into the hospital typically occurred about 7 days after symptom onset, and the duration of hospitalization was 6 days (6 [severe group] vs 12 [critical group]). Women with critical disease had a high rate of acute respiratory distress syndrome, and there was 1 case of cardiac arrest, but there were no cases of cardiomyopathy or maternal mortality. Hospitalization of pregnant women with severe or critical coronavirus disease 2019 resulted in delivery during the clinical course of the disease in 50% of this cohort, usually in the third trimester. There were no perinatal deaths in this cohort.