Toxoplasmosis, Parvovirus, and Cytomegalovirus in Pregnancy.

There are several infections in adults that warrant special consideration in pregnant women given the potential fetal consequences. Among these are toxoplasmosis, parvovirus B19, and cytomegalovirus. These infections have an important impact on the developing fetus, depending on the timing of infection. This article reviews the modes of transmission as well as maternal and neonatal effects of each of these infections. In addition, the article outlines recommended testing, fetal surveillance, and treatment where indicated.

Does early second-trimester sonography predict adverse perinatal outcomes in monochorionic diamniotic twin pregnancies?

OBJECTIVES: To determine whether intertwin discordant abdominal circumference, femur length, head circumference, and estimated fetal weight sonographic measurements in early second-trimester monochorionic diamniotic twins predict adverse obstetric and neonatal outcomes. METHODS: We conducted a multicenter retrospective cohort study involving 9 regional perinatal centers in the United States. We examined the records of all monochorionic diamniotic twin pregnancies with two live fetuses at the 16- to 18-week sonographic examination who had serial follow-up sonography until delivery. The intertwin discordance in abdominal circumference, femur length, head circumference, and estimated fetal weight was calculated as the difference between the two fetuses, expressed as a percentage of the larger using the 16- to 18-week sonographic measurements. An adverse composite obstetric outcome was defined as the occurrence of 1 or more of the following in either fetus: intrauterine growth restriction, twin-twin transfusion syndrome, intrauterine fetal death, abnormal growth discordance (≥20% difference), and very preterm birth at or before 28 weeks. An adverse composite neonatal outcome was defined as the occurrence of 1 or more of the following: respiratory distress syndrome, any stage of intraventricular hemorrhage, 5-minute Apgar score less than 7, necrotizing enterocolitis, culture-proven early-onset sepsis, and neonatal death. Receiver operating characteristic and logistic regression-with-generalized estimating equation analyses were constructed. RESULTS: Among the 177 monochorionic diamniotic twin pregnancies analyzed, intertwin abdominal circumference and estimated fetal weight discordances were only predictive of adverse composite obstetric outcomes (areas under the curve, 79% and 80%, respectively). Receiver operating characteristic curves showed that intertwin discordances in abdominal circumference, femur length, head circumference, and estimated fetal weight were not acceptable predictors of twin-twin transfusion syndrome or adverse neonatal outcomes. CONCLUSIONS: In our cohort, only second-trimester abdominal circumference and estimated fetal weight discordances in monochorionic diamniotic twin pregnancies were predictive of adverse composite obstetric outcomes. Twin-twin transfusion syndrome and adverse neonatal outcomes were not predicted by any of the intertwin discordances measured.

Nuchal translucency and cardiac abnormalities in euploid singleton pregnancies.

OBJECTIVE: To investigate different cut-off levels of nuchal translucency (NT) to predict abnormal cardiac findings (ACF) in second trimester ultrasound examination and confirmed postnatal congenital heart defects (CHD) in euploid pregnancies. METHODS: A retrospective analysis was performed on singleton pregnancies examined in our ultrasound units from 2006 to 2011. Fetuses with an abnormal karyotype were excluded. Different cut-off levels of NT thickness were analyzed to evaluate its performance to detect the ACF on second trimester ultrasound (2nd US) examination and also the CHD detected in neonatal follow-up evaluation of ACF cases. RESULTS: Of the 12,840 cases, a total number of 8541 euploid pregnancies were included in the study. Thirty-three had ACFs detected by 2nd US (3.86/1000). The mean NT thickness was found to be higher in fetuses with ACFs (p < 0.0001). Of 33 ACFs, 17 (52%, 1.99/1000) had major CHDs in neonatal follow-up. The area under the ROC curves for NT thickness to predict ACFs and CHDs were 0.67 and 0.65, respectively. CONCLUSIONS: Higher NT thickness is associated with higher risk of ACF. NT is a weak predictor of ACF and major CHD; however, fetuses with an unexplained increase in NT measurement should be referred for further cardiac investigations.

First-trimester sonographic prediction of obstetric and neonatal outcomes in monochorionic diamniotic twin pregnancies.

OBJECTIVES: The purpose of this study was to investigate whether discordant nuchal translucency and crown-rump length measurements in monochorionic diamniotic twins are predictive of adverse obstetric and neonatal outcomes. METHODS: We conducted a multicenter retrospective cohort study including all monochorionic diamniotic twin pregnancies with two live fetuses at the 11-week to 13-week 6-day sonographic examination who had serial follow-up sonography until delivery. Isolated nuchal translucency, crown-rump length, and combined discordances were correlated with adverse obstetric outcomes, individually and in composite, including the occurrence of 1 or more of the following in either fetus: intrauterine growth restriction (IUGR), twin-twin transfusion syndrome (TTTS), intrauterine fetal death (IUFD), growth discordance (≥ 20%), and preterm birth before 28 weeks' gestation. Correlations with adverse composite neonatal outcomes were also studied. A receiver operating characteristic curve analysis and a logistic regression analysis with a generalized estimating equation were conducted. RESULTS: Fifty-four of the 177 pregnancies included (31%) had an adverse composite obstetric outcome, with TTTS in 19 (11%), IUGR in 21 (12%), discordant growth in 14 (8%), IUFD in 14 (8%), and preterm birth before 28 weeks in 10 (6%). Of the 254 neonates included in the study, 69 (27%) were complicated by adverse composite neonatal outcomes, with respiratory distress syndrome being the most common (n = 59 [23%]). The areas under the curve for the combined discordances to predict composite obstetric and neonatal outcomes were 0.62 (95% confidence interval, 0.52-0.72), and 0.54 (95% confidence interval, 0.46-0.61), respectively. CONCLUSIONS: In our population, nuchal translucency, crown-rump length, and combined discordances in monochorionic diamniotic twin pregnancies were not predictive of adverse composite obstetric and neonatal outcomes.

Gestational diabetes mellitus screening using the one-step versus two-step method in a high-risk practice.

Screening for gestational diabetes mellitus is controversial. In their high-risk obstetrical practice, the authors did not find a difference in delivery or neonatal outcomes when using a one-step versus a two-step screening process. They did find lower rates of compliance with screening when using the one-step method.

Efficacy of the genetic sonogram in a stepwise sequential protocol for down syndrome screening.

OBJECTIVES: The purpose of this study was to evaluate the efficacy of the genetic sonogram in Down syndrome screening for women who have received the stepwise sequential test. METHODS: This retrospective cohort study included women with singleton pregnancies who underwent stepwise sequential (first-trimester combined and second-trimester serum) screening and then had a genetic sonogram between March 2005 and January 2010. Stepwise sequential Down syndrome risks were multiplied by either a positive or negative likelihood ratio based on the second-trimester sonographic findings to determine the final Down syndrome risk. A final Down syndrome risk of 1:270 or higher was considered screen positive. RESULTS: A total of 6286 women fulfilled our criteria, including 17 with Down syndrome-affected fetuses. After stepwise sequential testing, the Down syndrome detection rate was 88.2% (15 of 17), and after the genetic sonogram, there was a non-significant reduction in detection to 82.4% (14 of 17; P > .05). For the 6269 unaffected pregnancies, the genetic sonogram converted 58 screen-negative results (1%) to positive and 183 screen-positive results (3.1%) to negative. The net effect was a change in the false-positive rate from 6.2% (390 of 6269) after stepwise sequential screening to 4.2% (266 of 6269) after the genetic sonogram. CONCLUSIONS: The genetic sonogram should be applied cautiously for women who have received prior prenatal screening tests. Women with screen-positive results need to be counseled that a negative sonographic result can be falsely reassuring. Conversely, for women with screen-negative results who have a risk close to the cutoff, a sonographic examination could assist in the decision of whether to accept or reject amniocentesis.

Anemia in pregnancy.

Hemodynamic changes occur in pregnancy to prepare for expected blood loss at delivery. Physiologic anemia occurs in pregnancy because plasma volume increases more quickly than red cell mass. Anemia is most commonly classified as microcytic, normocytic, or macrocytic. Iron deficiency anemia accounts for 75% of all anemias in pregnancy. Oral iron supplementation is the recommended treatment of iron deficiency anemia in pregnancy. Parenteral iron and erythropoietin can also be used in severe or refractory cases. Outcomes and treatments for other forms of inherited and acquired anemias in pregnancy vary by disease, and include nutritional supplementation, corticosteroids, supportive transfusions, and splenectomy.

Increased neonatal morbidity despite pulmonary maturity for deliveries occurring before 39 weeks.

OBJECTIVE: To compare neonatal outcomes following deliveries <39 weeks after confirmation of fetal lung maturity with scheduled deliveries ≥39 weeks. METHODS: A retrospective cohort study examining neonatal outcomes of women who were delivered following documented fetal pulmonary maturity at 36, 37, and 38 weeks compared to women undergoing a scheduled delivery at 39, 40, and 41 weeks. The χ(2)-test and Student's t-test were used to compare categorical and continuous data, respectively. RESULTS: Delivery prior to 39 weeks following fetal pulmonary maturity was associated with a 8.4% composite neonatal morbidity rate as compared to 3.3% for deliveries at 39 weeks or greater (relative risk [RR] 2.9; confidence interval [CI] 2.4-3.6). Neonatal respiratory morbidity was significantly higher (5.4%) for those delivering at less than 39 weeks with documented fetal pulmonary maturity as compared to 2.1% for those delivering at 39 weeks or greater (RR 3.0; CI 2.3-3.9). Increased neonatal morbidity persisted for those delivered prior to 39 weeks even after excluding all diabetics (p < 0.001). Significant increases in neonatal morbidity were noted for deliveries prior to 39 weeks regardless of the mode of delivery. CONCLUSION: Despite fetal pulmonary maturity, delivery before 39 weeks is associated with significantly increased neonatal morbidity when compared to scheduled deliveries at 39 weeks or greater.

Full-term neonatal intenstive care unit admission in an urban community hospital: the role of respiratory morbidity.

OBJECTIVE: To investigate the incidence of respiratory morbidity among full-term neonatal intenstive care unit (NICU) admissions and identify risk factors for such admissions. METHODS: We performed a retrospective cohort study of NICU admissions between 1/06 and 12/08. We included neonates between 37 and 40 weeks with a diagnosis of transient tachypnea of the newborn (TTN), respiratory distress syndrome (RDS), pneumonia, pneumothorax, and meconium aspiration syndrome. Obstetrical outcomes were compared with a control group of women during the same period whose neonates were not admitted to the NICU. RESULTS: Two-hundred two infants admitted to the NICU with respiratory morbidity were compared with 9580 controls. TTN comprised the majority of the respiratory morbidity. Only RDS was associated with cesarean delivery. CONCLUSION: RDS remains a significant morbidity in full-term NICU admission. When compared with controls, admissions to our NICU with any respiratory morbidity were more likely to be delivered by cesarean to a mother with hypertension or diabetes during pregnancy.

Optimal time for delivery with preterm premature rupture of membranes from 32 to 36 6/7 weeks.

OBJECTIVE: To evaluate the optimal time for delivery in singleton pregnancies with preterm premature rupture of membranes (PPROM) when delivered between 32 and 36 6/7 weeks gestational age (GA). STUDY DESIGN: We performed a retrospective cohort study of all singleton pregnancies with PPROM who delivered between 32 and 36 6/7 weeks gestation at our institution. We matched the delivery and NICU datasets to determine composite morbidity (COMP MORB) and NICU length of stay (LOS) stratified by weeks of gestation. COMP MORB was defined as one or more of: bronchopulmonary dysplasia, respiratory distress syndrome, necrotizing entercolitis, intraventricular hemorrhage, dissiminated intravascular coagulation, and culture proven sepsis. We used χ² and student 't' test as appropriate and a receiver operating characteristc curve (ROC). RESULTS: There were 195 newborns with PPROM with a range of 30 babies at 36 weeks to a high of 53 at 34 weeks. The mean (± SD) NICU LOS was 22.5 (± 9.9) days at 32 weeks, 17.8 (± 10.0) days at 33 weeks, 14.8 (± 11.0) days at 34 weeks, 4.5 (± 4.7) days at 35 weeks, and 1.5 (± 4.4) days at 36 weeks (p < 0.0001). There was no difference in duration of ROM by GA with a range of 6.8 to 1.9 by week (p = NS). The ROC curve had a cut point for COMP MORB at 34.1 weeks GA (sens = 95%, FPR 48.6%, area under curve 0.782, p = 0.0002). CONCLUSION: Our study suggests that delivery of PPROM pregnancies at 34.1 weeks GA avoids 95% of composite morbidity, and delivery after 35 weeks GA will decrease the NICU LOS.

Toxoplasmosis, parvovirus, and cytomegalovirus in pregnancy.

Several infections in adults warrant special consideration in pregnant women given the potential fetal consequences. Among these are toxoplasmosis, parvovirus B19, and cytomegalovirus. These infections have an important effect on the developing fetus depending on the timing of infection. This article reviews the modes of transmission as well as maternal and neonatal effects of each of these infections. In addition, recommended testing, fetal surveillance, and treatment where indicated are outlined.

Primary sclerosing cholangitis in pregnancy refractory to ursodeoxycholic acid treatment: a case report.

BACKGROUND: Primary sclerosing cholangitis (PSC) is a chronic cholestatic liver disease associated with fibrosis and inflammation of the bile ducts. Its complications include symptoms from pruritis and fatigue to dominant strictures, cholangiocarcinoma and liver failure necessitating liver transplant. Due to its predominance in young males, little is reported regarding PSC and pregnancy. CASE: We report a case of a pregnant woman with PSC whose symptoms were initially unresponsive to the traditional treatment of ursodeoxycholic acid (UDCA) early in her pregnancy but subsequently did well using high dose steroids for the duration of her pregnancy. CONCLUSION: With close management, successful pregnancy outcomes seem possible with patients with PSC, even when diagnosed multiple years prior to pregnancy, if not with UDCA, then possibly with steroid treatment.

Perinatal and neonatal outcomes of triplet gestations based on placental chorionicity.

The purpose of our study was to evaluate perinatal and neonatal outcomes in triplet gestations in relation to placental chorionicity. We hypothesized that triplets containing a monochorionic pair (dichorionic triamniotic) would have increased morbidity compared with triplets without a monochorionic pair (trichorionic triamniotic). We retrospectively analyzed all triplet sets > or =20 weeks delivering at our institutions from January 1995 through April 2007. Data were collected via perinatal and neonatal databases, chart review, and placental pathology. Individuals in dichorionic triamniotic triplet sets (N = 75), when compared with trichorionic triamniotic triplets (N = 309), were more likely to have a lower mean birth weight (P < 0.001) and lower gestational age at delivery (P < 0.001), spend more days in the neonatal intensive care unit (P = 0.045), have culture-proven sepsis (P = 0.02), and require intubation (P = 0.05). Multivariate analysis demonstrated that dichorionicity is not an independent cause of morbidity, but results in earlier delivery and lower birth weight. Dichorionic triamniotic triplets are at increased risk for earlier deliveries and lower birth weight at delivery compared with trichorionic triamniotic triplets.

Betamethasone vs dexamethasone for the prevention of morbidity in very-low-birthweight neonates.

OBJECTIVE: The purpose of this study was to compare neonatal outcomes in very-low-birthweight infants who were exposed to antenatal betamethasone vs dexamethasone. STUDY DESIGN: We reviewed all inborn very-low-birthweight infants from January 1997 through February 2006. Maternal medical records were reviewed to determine the type of antenatal steroids that each patient received; neonatal outcomes were compared using chi-square and Student t tests. RESULTS: There were 334 very-low-birthweight infants who met the criteria for evaluation: 186 infants received betamethasone, and 148 infants received dexamethasone. There were no differences in race, gestational age at delivery, or mean birthweight between the 2 groups. There were significantly lower rates of respiratory distress syndrome and bronchopulmonary dysplasia in the betamethasone group, compared with the dexamethasone group. Other neonatal outcomes were similar in both groups. CONCLUSION: Antenatal betamethasone was associated with a significantly lower rate of pulmonary complications caused by prematurity, when compared with dexamethasone.

Evaluation of gabapentin in the treatment of generalized vulvodynia, unprovoked.

OBJECTIVE: To determine the efficacy of gabapentin in the treatment of generalized vulvodynia, unprovoked, to determine the most common presenting symptoms in patients with this diagnosis, to evaluate the prevalence of comorbidities in these patients and to determine the possibility of comorbidities or specific presenting symptoms that decrease the efficacy of this drug. STUDY DESIGN: The charts of all women seen in our facility with a diagnosis of generalized vulvodynia between January 1, 2002, and September 30, 2004, were reviewed. A total of 601 charts were reviewed. Patients were included in the study if they had a diagnosis of generalized vulvodynia, they were treated with single-agent gabapentin, had follow-up for 30 months or more and had adequately documented follow-up. RESULTS: A total of 152 patients were included in the study. Ninety-eight (64%) patients treated with gabapentin had resolution of at least 80% of their symptoms during the study period. Forty-nine (32%) did not have adequate resolution. There was a high percentage of comorbidities in patients with generalized vulvodynia. Sleep disturbance was the only comorbidity that negatively affected the efficacy of gabapentin. In addition, there appeared to be a trend toward a less favorable response in patients with a longer period of untreated illness (p value not less than 0.05). Side effects of gabapentin were few. Forty (26%) reported some side effects. Fatigue was the most common complaint. Seventeen patients (11%) discontinued the medication secondary to side effects. CONCLUSION: Gabapentin appears to be very effective in the treatment of generalized vulvodynia, unprovoked. It has a very low side effect profile. Certain patients may be less likely to benefit from gabapentin, including those with the comorbidity of sleep disturbance. Patients with symptoms of longer-standing generalized vulvodynia, unprovoked, may also be less likely to benefit from this treatment.

Variation of fetal nasal bone length in second-trimester fetuses according to race and ethnicity.

OBJECTIVE: The purpose of this study was to determine the influence of race and ethnicity on the expected nasal bone length (NBL) based on biparietal diameter (BPD) measured in second-trimester fetuses. METHODS: We searched our ultrasound, obstetric, and cytogenetic databases for all second-trimester fetuses with measured NBLs. Fetuses with Down syndrome were identified and excluded from the analysis. Linear regression curves were generated for NBL by BPD according to race and ethnicity. Categories used were African American, Hispanic, Asian, and white. Analysis of variance was used to compare mean variation of observed from expected NBL by BPD according to race and ethnicity. RESULTS: There were 717 fetuses with NBL-by-BPD pairs who were available for analysis in our population, including 139 African American, 58 Hispanic, 22 Asian, and 498 white fetuses. Nasal bone length was highly correlated with BPD for each race (P < .001). Mean variances of observed from expected NBL by BPD were statistically different according to race or ethnicity (P = .0092). CONCLUSIONS: Race and ethnicity significantly affect the mean regression line of expected NBL by BPD among fetuses in the second trimester. Genetic sonographic norms, therefore, appear to require race- and ethnicity-specific formulas for NBL.

Frequency of echogenic intracardiac focus by race/ethnicity in euploid fetuses.

OBJECTIVE: To determine the frequency of echogenic intracardiac focus (EIF) by race/ethnicity. METHODS: We performed a retrospective analysis from January 1996 through June 2003. We reviewed all initial sonograms from 14 to 23 weeks gestation in singleton pregnancies. Mothers on admission for delivery provided race/ethnicity. RESULTS: There were 8207 ultrasounds and deliveries that met study criteria. There were 4636 (56.5%) Caucasian, 2087 (25.4%) African-American, 1261 (15.4%) Hispanic and 223 (2.7 %) Asian subjects. There were 347 (4.2%) EIF detected. The frequency by race/ethnicity varied significantly (p < 0.0001). CONCLUSIONS: This large, population-based study showed that fetuses born to Asian mothers were significantly more likely to have an EIF. This racial difference should be taken into account when counseling patients about the potential for Down syndrome.

Use of the mitral valve-tricuspid valve distance as a marker of fetal endocardial cushion defects.

OBJECTIVE: The purpose of this study was to compare the mitral valve-tricuspid valve distance in second-trimester fetuses with normal cardiac anatomy versus those fetuses with endocardial cushion defects. STUDY DESIGN: We identified fetuses between 16 and 24 weeks of gestation. The distance between the insertions of the medial leaflets of the mitral and tricuspid valves were obtained. Linear regression curves were generated. RESULTS: The mean mitral valve-tricuspid valve distance for 86 fetuses with normal cardiac anatomy was 2.02 mm, compared with 0.37 mm in 13 fetuses with endocardial cushion defects ( P = .0001). Linear regression curve correlating mitral valve-tricuspid valve distance with gestational age showed a gradual slope (R 2 = 0.28; P < .0001). With a mitral valve-tricuspid valve distance < 5th percentile as a marker for the diagnosis of endocardial cushion defect gave a sensitivity of 69.2%, a specificity of 100%, a positive predictive value of 100%, a negative predictive value of 95.6%, and a false-positive rate of 0% ( P = .0001). CONCLUSION: The mitral valve-tricuspid valve distance is useful clinically in the detection of endocardial cushion defects in second-trimester fetuses.

Down syndrome births in the United States from 1989 to 2001.

OBJECTIVE: We investigated the observed and expected Down syndrome livebirths in the US from 1989 to 2001. STUDY DESIGN: Using birth certificate data, we recorded maternal age-specific live births from 1989 to 2001, and stratified them by women 15 to 34 and 35 to 49 years old. We estimated Down syndrome live births from 1989 to 2001, assuming no terminations. We recorded Down syndrome live births by year from 1989 to 2001. RESULTS: Despite an expected 1.32-fold increase in Down syndrome live birth rates from 1989 to 2001, Down syndrome live births actually declined. In 1989, the rate of Down syndrome cases was 15% lower than expected, decreasing to 51% by 1998. Women 15 to 34 had 45% fewer affected pregnancies in 2001, while women 35 to 49 had 53% fewer in 2001. We estimated that Down syndrome live births decreased from 3962 in 1989 to 3654 in 2001. CONCLUSION: Down syndrome live births declined in the US despite an expected increase caused by delayed or extended childbearing.