Cohort Analysis of Immigrant Rhetoric on Timely and Regular Access of Prenatal Care.

OBJECTIVE: To assess whether recent anti-immigration rhetoric is significantly associated with inadequate prenatal care. METHODS: This was a population-based cohort study (2011-2017). In their native language, patients were consented and queried regarding country of origin and time in the United States. Additional variables were collected or abstracted from the medical record, including documentation and timing of prenatal visits. Based on relevance and prevalence during the study period, publicly available Google search trends were mined for the terms "Make America Great Again," "Mexico Wall," and "Deportation" by geographic region. The time of first deviation from the mode Google search popularity value for each term was ascertained (mode inflection date). Perinatal data was averaged over 15 days moving windows, and the Adequacy of Prenatal Care Utilization Index was used to categorically define inadequate prenatal care by validated standards. RESULTS: Twenty-four thousand nine hundred thirty-three deliveries occurred during the study period. A mode inflection date was extrapolated from Google trend analytics and used to define the period before change in trends use pre (before rhetoric) and post (after rhetoric). Coincident to the rhetoric change, there was a significant increase in days until the first prenatal visit, fewer prenatal visits, and a decreased trend of mean hemoglobin nadir among U.S. non-native Hispanic women (P<.001). Immigrant status was an independent predictor of inadequate prenatal care as defined by the Adequacy of Prenatal Care Utilization Index standard, with increased adjusted odds among Hispanic women (adjusted odds ratio 1.581, 95% CI 1.407-1.777 [1.4-1.8]) coincident with anti-immigration rhetoric. CONCLUSION: Our findings are of likely significant public health importance and suggest that recent anti-immigrant rhetoric is associated with adequate, timely, and regular access to prenatal care among nearly 25,000 deliveries in Houston, Texas.

Clinical assessment and brain findings in a cohort of mothers, fetuses and infants infected with ZIKA virus.

BACKGROUND: Congenital Zika virus (ZIKV) infection can be detected in both the presence and absence of microcephaly and manifests as a number of signs and symptoms that are detected clinically and by neuroimaging. However, to date, qualitative and quantitative measures for the purpose of diagnosis and prognosis are limited. OBJECTIVES: Main objectives of this study conducted on fetuses and infants with confirmed congenital Zika virus infection and detected brain abnormalities were (1) to assess the prevalence of microcephaly and the frequency of the anomalies that include a detailed description based on ultrasound and magnetic resonance imaging in fetuses and ultrasound, magnetic resonance imaging, and computed tomography imaging postnatally, (2) to provide quantitative measures of fetal and infant brain findings by magnetic resonance imaging with the use of volumetric analyses and diffusion-weighted imaging, and (3) to obtain additional information from placental and fetal histopathologic assessments and postnatal clinical evaluations. STUDY DESIGN: This is a longitudinal cohort study of Zika virus-infected pregnancies from a single institution in Colombia. Clinical and imaging findings of patients with laboratory-confirmed Zika virus infection and fetal brain anomalies were the focus of this study. Patients underwent monthly fetal ultrasound scans, neurosonography, and a fetal magnetic resonance imaging. Postnatally, infant brain assessment was offered by the use of ultrasound imaging, magnetic resonance imaging, and/or computed tomography. Fetal head circumference measurements were compared with different reference ranges with <2 or <3 standard deviations below the mean for the diagnosis of microcephaly. Fetal and infant magnetic resonance imaging images were processed to obtain a quantitative brain volumetric assessment. Diffusion weighted imaging sequences were processed to assess brain microstructure. Anthropometric, neurologic, auditory, and visual assessments were performed postnatally. Histopathologic assessment was included if patients opted for pregnancy termination. RESULTS: All women (n=214) had been referred for Zika virus symptoms during pregnancy that affected themselves or their partners or if fetal anomalies that are compatible with congenital Zika virus syndrome were detected. A total of 12 pregnant patients with laboratory confirmation of Zika virus infection were diagnosed with fetal brain malformations. Most common findings that were assessed by prenatal and postnatal imaging were brain volume loss (92%), calcifications (92%), callosal anomalies (100%), cortical malformations (89%), and ventriculomegaly (92%). Results from fetal brain volumetric assessment by magnetic resonance imaging showed that 1 of the most common findings associated with microcephaly was reduced supratentorial brain parenchyma and increased subarachnoid cerebrospinal fluid. Diffusion weighted imaging analyses of apparent diffusion coefficient values showed microstructural changes. Microcephaly was present in 33.3-58.3% of the cases at referral and was present at delivery in 55.6-77.8% of cases. At birth, most of the affected neonates (55.6-77.8%) had head circumference measurements >3 standard deviations below the mean. Postnatal imaging studies confirmed brain malformations that were detected prenatally. Auditory screening results were normal in 2 cases that were assessed. Visual screening showed different anomalies in 2 of the 3 cases that were examined. Pathologic results that were obtained from 2 of the 3 cases who opted for termination showed similar signs of abnormalities in the central nervous system and placental analyses, including brain microcalcifications. CONCLUSION: Congenital microcephaly is not an optimal screening method for congenital Zika virus syndrome, because it may not accompany other evident and preceding brain findings; microcephaly could be an endpoint of the disease that results from progressive changes that are related to brain volume loss. Long-term studies are needed to understand the clinical and developmental relevance of these findings.

International fetal cardiac intervention registry: a worldwide collaborative description and preliminary outcomes

BACKGROUND: Invasive fetal cardiac intervention (FCI) has been reported in single-institution series, promoting technical and physiologic success. OBJECTIVES: This study describes the creation of an international registry of cases presenting for FCI, intended to compile technical and outcome data from a multicenter cohort. METHODS: For this initial analysis, the entire database of the International Fetal Cardiac Intervention Registry (IFCIR) was queried for details of diagnoses, procedures, and outcomes. Maternal-fetal dyads from January 2001 through June 2014 were included.RESULTS:Eighteen institutions submitted data by data harvest. Of 370 cases entered, 245 underwent FCI: 100 aortic valvuloplasties from a previous single-center report (excluded from additional reporting here), an additional 86 aortic and 16 pulmonary valvuloplasties, 37 atrial septal cases, and 6 unclassified cases. FCI did not appear to affect overall survival to hospital discharge. Among live-born infants with a fetal diagnosis of aortic stenosis/evolving hypoplastic left heart syndrome, more than twice as many were discharged with biventricular circulation after successful FCI versus those meeting institutional criteria but without any or successful FCI (42.8% vs. 19.4%, respectively). When fetal deaths were counted as treatment failures, the percentages were similar: biventricular circulation at discharge was 31.3% versus 18.5% for those discharged with univentricular palliation. Survival to discharge for live-born fetuses with atrial restriction was similar to that of those undergoing technically successful versus unsuccessful FCI (63.6% vs. 46.7%, respectively), although criteria for diagnosis were nonuniform. CONCLUSIONS: We describe the contents of the IFCIR and present post-natal data to suggest potential benefit to fetal therapy among pregnancies considered for possible intervention and support proposals for additional work.

Reference ranges for 2-dimensional sonographic lung measurements in healthy fetuses: a longitudinal study.

OBJECTIVES: The purpose of this study was to establish reference ranges for 2-dimensional sonographic measurements of fetal lungs from longitudinal data. METHODS: A total of 214 fetal lung measurements were longitudinally evaluated in 62 healthy fetuses between 20 and 36 weeks' menstrual age. Both right and left lung areas were measured in the heart 4-chamber view using lung area tracing and axis diameter methods. Multilevel modeling was used to evaluate the expected values and variability with respect to menstrual age and to generate reference ranges for the lung area, lung-to-head ratio, quantitative lung index, and observed-to-expected lung-to-head ratio for both lungs. RESULTS: The expected values varied with menstrual age for all parameters. Variance was menstrual age dependent for all parameters except the longest diameter area measurements and their lung-to-head ratios. CONCLUSIONS: Models are presented for expected 2-dimensional sonographic lung size parameters and their variance as a function of menstrual age. These data have been used to generate age-specific reference ranges for both measurements and indices.