Low grade endometrial stromal sarcoma in pregnancy: A case in support of safe abortion access.

Background: Endometrial stromal sarcoma (ESS) is extremely rare in pregnancy. It shares clinical and imaging features with more common pregnancy findings such as leiomyoma and molar gestations, which makes diagnosis challenging. Case: A 36-year-old patient presented at 8 weeks and 1 day gestation for vaginal bleeding. An intrauterine pregnancy with an appropriately sized embryo with heart motion and a 9.5 cm complex uterine mass was found on ultrasound. MRI showed an 11.4 cm cystic mass with nodular septations causing mass effect on the endometrial cavity. After extensive counseling, the patient underwent a gravid abdominal hysterectomy and bilateral salpingectomy. Final pathology showed low grade ESS. Conclusion: This case highlights the importance of evaluating suspicious uterine masses in pregnancy and the necessity for safe abortion access.

Correction: Work-Related and Personal Factors Associated With Mental Well-Being During the COVID-19 Response: Survey of Health Care and Other Workers.

[This corrects the article DOI: 10.2196/21366.].

Work-Related and Personal Factors Associated With Mental Well-Being During the COVID-19 Response: Survey of Health Care and Other Workers.

BACKGROUND: The response to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has created an unprecedented disruption in work conditions. This study describes the mental health and well-being of workers both with and without clinical exposure to patients with coronavirus disease (COVID-19). OBJECTIVE: The aim of this study is to measure the prevalence of stress, anxiety, depression, work exhaustion, burnout, and decreased well-being among faculty and staff at a university and academic medical center during the SARS-CoV-2 pandemic and describe work-related and personal factors associated with their mental health and well-being. METHODS: All faculty, staff, and postdoctoral fellows of a university, including its medical school, were invited in April 2020 to complete an online questionnaire measuring stress, anxiety, depression, work exhaustion, burnout, and decreased well-being. We examined associations between these outcomes and factors including work in high-risk clinical settings and family/home stressors. RESULTS: There were 5550 respondents (overall response rate of 34.3%). Overall, 34% of faculty and 14% of staff (n=915) were providing clinical care, while 61% of faculty and 77% of staff were working from home. Among all workers, anxiety (prevalence ratio 1.37, 95% CI 1.09-1.73), depression (prevalence ratio 1.28, 95% CI 1.03-1.59), and high work exhaustion (prevalence ratio 1.24, 95% CI 1.13-1.36) were independently associated with community or clinical exposure to COVID-19. Poor family-supportive behaviors by supervisors were also associated with these outcomes (prevalence ratio 1.40, 95% CI 1.21-1.62; prevalence ratio 1.69, 95% CI 1.48-1.92; and prevalence ratio 1.54, 95% CI 1.44-1.64, respectively). Age <40 years and a greater number of family/home stressors were also associated with these poorer outcomes. Among the subset of clinicians, caring for patients with COVID-19 and working in high-risk clinical settings were additional risk factors. CONCLUSIONS: Our findings suggest that the pandemic has had negative effects on the mental health and well-being of both clinical and nonclinical employees. Mitigating exposure to COVID-19 and increasing supervisor support are modifiable risk factors that may protect mental health and well-being for all workers.

Smaller fetal size in singletons after infertility therapies: the influence of technology and the underlying infertility.

OBJECTIVE: To determine whether fetal size differences exist between matched fertile and infertile women and among women with infertility achieving pregnancy through various treatment modalities. DESIGN: Retrospective cohort study with propensity score analysis. SETTING: Tertiary care center and affiliated community hospitals. PATIENT(S): 1,246 fertile and 461 infertile healthy women with singleton livebirths over a 10-year period. INTERVENTION(S): Infertile women conceiving without medical assistance, with ovulation induction, or with in vitro fertilization. MAIN OUTCOME MEASURE(S): Birthweight; secondary outcomes included crown-rump length, second-trimester estimated fetal weight, and incidence of low birth weight and preterm delivery. RESULT(S): Compared with matched fertile women, infertile women had smaller neonates at birth (3,375 ± 21 vs. 3,231 ± 21 g) and more low-birth-weight infants (relative risk = 1.68, 95% confidence interval, 1.06, 2.67). Neonates conceived via ovulation induction were the smallest among the infertility subgroups compared with the neonates of fertile women (3,092 ± 46 vs. 3,397 ± 44 g). First-trimester fetal size was smaller in infertile versus fertile women (crown-rump length 7.9 ± 0.1 vs. 8.5 ± 0.1 mm). Within the infertility subgroups, no differences in fetal or neonatal size were found. CONCLUSION(S): The inherent pathologic processes associated with infertility may have a larger impact on fetal growth than infertility therapies.

Predicting the risk of pre-eclampsia between 11 and 13 weeks' gestation by combining maternal characteristics and serum analytes, PAPP-A and free ß-hCG.

OBJECTIVE: To determine if a simplified model for predicting pre-eclampsia (PEC) can be developed by combining first-trimester serum analytes, pregnancy-associated plasma protein A (PAPP-A) and free beta human chorionic gonadotrophin (ß-hCG), and maternal characteristics. METHODS: A retrospective cohort study of patients seen for first-trimester aneuploidy screening from 2003 to 2009. The 5th, 10th, 90th, and 95th percentiles for the analyte multiples of the medians (MoMs) for our population were determined and evaluated for association with PEC. Univariate and backward stepwise logistic regression analyses were performed and the area under the receiver operating characteristic (ROC) curves [area under curve (AUC)] used to determine the best models for predicting PEC. RESULTS: Among 4020 women meeting the inclusion criteria, outcome data was available for 3716 (93%). There were 293 cases of PEC. The final model identified a history of pre-gestational diabetes [aOR 2.6, 95% confidence interval (CI) 1.7-3.9], chronic hypertension (cHTN) (aOR 2.6, 95% CI 1.7-3.9), maternal body mass index (BMI) > 25 (aOR 2.5, 95% CI 1.9-3.4), African American race (aOR 1.8, 95% CI 1.3-2.6), and PAPP-A MoM < 10th percentile (aOR 1.6, 95% CI 1.1-2.4) to be significant predictors of PEC (AUC = 0.70, 95% CI 0.65-0.72). CONCLUSION: Low first-trimester PAPP-A levels are associated with the development of PEC; however, the model was only modestly efficient in its predictive ability.

The effect of fetal gender in predicting Down syndrome using long bone ultrasonographic measurements.

OBJECTIVE: To determine if fetal gender affects the screening efficiency of short femur and humerus lengths in the prediction of trisomy 21. METHODS: Retrospective cohort study of 62 111 patients presenting for ultrasound from 1990 to 2006. Short humerus and femur lengths were defined using (1) biparietal diameter (BPD) to femur/humerus length (FL/HL) ratios > 1.5 standard deviations above the mean, (2) the observed to expected (O/E) ratio of femur length ≤ 0.91 or humerus length ≤ 0.89, and (3) femur and humerus lengths < 5th percentile. The sensitivity, specificity, and likelihood ratios were calculated for the association of short FL/HL and trisomy 21 stratified by gender. RESULTS: Both BPD/long bone ratios as well as O/E ratios demonstrated a statistically significant higher specificity for the detection of trisomy 21 in female fetuses. This difference was most clinically significant when using the O/E ratio, which yielded a specificity of 82.6% in males and 90.6% in females for short femur, and 69.7% in males and 77.9% in females for short humerus, when these markers were evaluated as isolated findings. CONCLUSION: Gender-specific differences in the effectiveness of both short femur and humerus lengths for the prediction of trisomy 21 may exist, but their presence and magnitude are largely dependent on the formula used.

Is chorionic villus sampling associated with hypertensive disorders of pregnancy?

OBJECTIVE: Our objective is to evaluate for potential associations between chorionic villus sampling (CVS) and hypertensive disorders of pregnancy. METHODS: Using our genetic database, we compared the rates of hypertensive disorders between women who underwent CVS at 10-13 and 6/7 weeks with those seen for other indications at similar gestational ages who had no invasive procedure. Only singleton and euploid pregnancies were included. Statistical methods including univariable and multivariable logistic regression, supplemented by stratified analyses were used for comparisons. RESULTS: Among 11 012 pregnant women seen between 1990 and 2006 in our center and meeting the inclusion criteria, information on hypertensive disorders of pregnancy were available in 9386, and 9098 met the inclusion criteria. The overall incidence of hypertensive disorders was 421/9098 (4.6%), with 138/5096 (2.7%) in the CVS group and 283/4002 (7.1%) in the control group [adjusted odds ratio (adjOR) 0.47, 95% confidence interval (CI), 0.38-0.59]. Similar findings were seen on stratified analyses for gestational age of procedure and the type or severity of hypertensive disorder, and other potential confounders. CONCLUSION: The rate of hypertensive disorders of pregnancy is significantly lower in women having CVS compared with the control group. Placental disruption from CVS is not associated with preeclampsia or gestational hypertension.

Echogenic intracardiac foci: associated with increased risk for fetal trisomy 21 or not?

OBJECTIVE: The purpose of this study was to evaluate the impact of an echogenic intracardiac focus (EIF) on the risk for fetal trisomy 21 (T21) in populations with differing prevalence of T21. METHODS: A retrospective cohort study of pregnancies presenting to our prenatal ultrasound units over 16 years (1990-2006) was conducted. Contingency table analysis of the presence of an EIF and diagnosis of fetal T21 was performed. The groups analyzed included the following: (1) all fetuses with EIF plus other sonographic markers, (2) EIF as an isolated sonographic marker, (3) those younger than 35 years with an isolated finding of EIF, and (4) a group with an isolated finding of EIF excluding those at increased risk for T21 on serum screening. RESULTS: Echogenic intracardiac foci were found in 2223 of 62,111 pregnancies (3.6%), and T21 was diagnosed in 218 pregnancies (0.4%). The presence of an EIF along with other markers was associated with a statistically significant risk for T21 (positive likelihood ratio [LR], 4.4; 95% confidence interval [CI], 3.2-6.0; P < .05). An isolated EIF was not associated with a statistically significant increased risk for T21 in patients younger than 35 years (positive LR, 1.7; 95%, CI 0.7-4.1) and those without abnormal serum screening results for aneuploidy (positive LR, 1.6; 95% CI, 0.8-3.1). CONCLUSIONS: The finding of an isolated EIF on prenatal sonography does not significantly increase the risk for fetal T21 in populations not otherwise at an increased risk for the disorder. An isolated EIF should be considered an incidental finding in patients younger than 35 years and in those without abnormal serum aneuploidy screening results.

Predicting adverse neonatal outcomes in fetuses with abdominal wall defects using prenatal risk factors.

OBJECTIVE: The aim of this study was to determine whether prenatal variables can predict adverse neonatal outcomes in fetuses with abdominal wall defects. STUDY DESIGN: A retrospective cohort study that used ultrasound and neonatal records for all cases of gastroschisis and omphalocele seen over a 16-year period. Cases with adverse neonatal outcomes were compared with noncases for multiple candidate predictive factors. Univariable and multivariable statistical methods were used to develop the prediction models, and effectiveness was evaluated using the area under the receiver operating characteristic curve. RESULTS: Of 80 fetuses with gastroschisis, 29 (36%) had the composite adverse outcome, compared with 15 of 33 (47%) live neonates with omphalocele. Intrauterine growth restriction was the only significant variable in gastroschisis, whereas exteriorized liver was the only predictor in omphalocele. The areas under the curve for the prediction models with gastroschisis and omphalocele are 0.67 and 0.74, respectively. CONCLUSION: Intrauterine growth restriction and exteriorization of the liver are significant predictors of adverse neonatal outcome with gastroschisis and omphalocele.

The efficiency of first-trimester serum analytes and maternal characteristics in predicting fetal growth disorders.

OBJECTIVE: To evaluate the association between first-trimester serum analytes, pregnancy-associated plasma protein A and free beta-human chorionic gonadotropin, and fetal growth disorders, and to determine whether a prediction model for these growth disorders can be developed. STUDY DESIGN: Retrospective cohort study of patients seen for first-trimester aneuploidy screening. Pregnancy-associated plasma protein A and free beta-human chorionic gonadotropin multiples of the median were evaluated for association with small- and large-for-gestational-age infants in combination with maternal characteristics. Univariate and backward stepwise logistic regression analyses were performed and the area under the receiver-operator curves used to determine the best prediction models. RESULTS: Neither pregnancy-associated plasma protein A nor free beta-human chorionic gonadotropin levels were associated with an increased risk of large-for-gestational-age infants. For small-for-gestational-age infants, the final model included black race, free beta-human chorionic gonadotropin multiples of the median >90th percentile, and pregnancy-associated plasma protein A multiples of the median <5th percentile as significant predictors (area under the curve = 0.58). CONCLUSION: Low pregnancy-associated plasma protein A and high free beta-human chorionic gonadotropin levels are associated with a small-for-gestational-age growth pattern; however, additional factors to improve the prediction model are needed.

Prevalence and likelihood ratios for aneuploidy in fetuses diagnosed prenatally with isolated congenital cardiac defects.

OBJECTIVE: To determine the prevalence and likelihood ratios for aneuploidy in fetuses diagnosed prenatally with isolated congenital cardiac defects. STUDY DESIGN: Retrospective cohort study over a 16-year period using our computerized perinatal database. Cardiac diagnosis was confirmed before establishing karyotype by prenatal diagnosis or postnatal chromosome testing. The screening efficiency and likelihood ratios for any aneuploidy and for trisomy 21, 18, 13, and 45, X were calculated with 95% confidence intervals. RESULTS: A total of 233 (0.4%) isolated congenital cardiac defects were diagnosed among 62,111 patients who had obstetric ultrasounds during the study period. The likelihood ratio (LR+) for any aneuploidy was 24.9 (95% confidence interval [CI], 17.8-35.0). The corresponding likelihood ratio for trisomy 21, 18, and 13 were 29.8 (95% CI, 19.6-45.4), 26 (95% CI, 10.5-64.6), and 19.7 (95% CI, 4.7-82.2), respectively. CONCLUSION: Prenatal diagnosis of congenital cardiac defects is highly associated with aneuploidy.

Reevaluating humeral length for the detection of fetal trisomy 21.

OBJECTIVE: The purpose of this study was to analyze humeral length (HL) in a normal population and to compare that with HL in a population of fetuses with trisomy 21 to determine the most efficient discriminating parameters for diagnostic accuracy. METHODS: A nested case-control study comparing HLs from a normal population and a population of fetuses with trisomy 21 was conducted. Humeral length was regressed against gestational age for a consecutive well-dated population of normal singleton gestations presenting to the Washington University School of Medicine prenatal diagnosis units over a 5-year period. A second population of well-dated pregnancies with trisomy 21 diagnosed either prenatally or postnatally was also selected on the basis of the same criteria, except that anomalous fetuses were included. Various discriminating thresholds for a short HL were compared for efficiency in the detection of trisomy 21. These included the following: observed/expected HL (

Evaluating the rate and risk factors for fetal loss after chorionic villus sampling.

OBJECTIVE: To estimate the fetal loss rate in our center and evaluate the risk factors associated with such losses after chorionic villus sampling (CVS). METHODS: This is a retrospective cohort study including all women undergoing chorionic villus sampling and a control group that had no invasive procedure at a single center over a 16-year period. Fetal loss was defined as any loss before 24 weeks of gestation. Univariable and multiple logistic regression analyses were used to compare pregnancies resulting in fetal loss to those without a loss and to adjust for potential confounders between the groups. RESULTS: Of 5,243 women who had CVS who were compared with 4,917 women seen before 14 weeks who had no invasive procedure, there were 138 (2.7%) fetal losses before 24 weeks of gestation in the CVS group compared with 161 (3.3%) in the control group (relative risk 0.80, 95% confidence interval, 0.64-1.0). The difference in loss rate of -0.7% (95% confidence interval, -0.02 to 1.3) between the CVS group and those who had no procedure was not statistically significant at P<.05. The significant risk factors for fetal loss were African-American maternal race, at least two aspirations/needle insertions, heavy bleeding during CVS, maternal age younger than 25 years, and gestational age at performing CVS before 10 weeks. CONCLUSION: The estimated fetal loss rate after CVS was not significantly different from the group that had no procedure. Significant predictors of fetal loss after CVS were identified, but the accuracy of the final model for predicting fetal loss was only modest.

Decision-making for termination of pregnancies with fetal anomalies: analysis of 53,000 pregnancies.

OBJECTIVE: To evaluate the degree to which prenatal knowledge of fetal anomalies and sociodemographic characteristics determined outcome of 53,000 pregnancies. METHODS: Pregnancies were consecutively evaluated at a university hospital between 1984 and 1997. The severity of anomalies was graded by using an ordinal scale, in which 0 was no anomalies, 1 was no impact on quality of life, 2 was little impact but possibly requiring medical therapy, 3 was serious impact on quality of life even with optimal medical therapy, and 4 was incompatible with life. RESULTS: The abortion rates for grades 1 and 3 anomalies increased from 0.9% to 72.5%, and 0.9% to 37.1% for central nervous system and non-central nervous system anomalies, respectively (P <.001). Multiple logistic regression showed that mothers without a high school education were more likely than those who completed high school to abort a normal pregnancy (odds ratio [OR] 1.62, 95% confidence interval [CI] 1.07, 2.45). In the 452 pregnancies in which there was one grade 3 anomaly, logistic regression also showed that the abortion rate decreased by 6% per year as maternal age decreased (OR 0.94, 95% CI 0.91, 0.97). CONCLUSIONS: The severity of anomalies directly correlates with abortion rates, but at similar degrees of severity, central nervous system anomalies are more likely to lead to abortion. Maternal level of education inversely correlates with likelihood of termination of a normal pregnancy, whereas maternal age directly correlates with pregnancy termination when serious anomalies are present. Serious congenital anomalies may disproportionately affect children from families with the youngest mothers because these mothers are likely to continue these pregnancies.