Nuchal Translucency Quality Review (NTQR) program: first one and half million results.

OBJECTIVE: To evaluate the performance of first-trimester nuchal translucency (NT) measurement by providers (physician-sonologists and sonographers) within the Nuchal Translucency Quality Review (NTQR) program. METHODS: After training and credentialing providers, the NTQR monitored performance of NT measurement by the extent to which an individual's median multiple of the normal median (MoM) for crown-rump length (CRL) was within the range 0.9-1.1 MoM of a published normal median curve. The SD of log10 MoM and regression slope of NT on CRL were also evaluated. We report the distribution between providers of these performance indicators and evaluate potential sources of variation. RESULTS: Among the first 1.5 million scans in the NTQR program, performed between 2005 and 2011, there were 1 485 944 with CRL in the range 41-84 mm, from 4710 providers at 2150 ultrasound units. Among the 3463 providers with at least 30 scans in total, the median of the providers' median NT-MoMs was 0.913. Only 1901 (55%) had a median NT-MoM within the expected range; there were 89 above 1.1 MoM, 1046 at 0.8-0.9 MoM, 344 at 0.7-0.8 MoM and 83 below 0.7 MoM. There was a small increase in the median NT-MoM according to providers' length of time in the NTQR program and number of scans entered annually. On average, physician-sonologists had a higher median NT-MoM than did sonographers, as did those already credentialed before joining the program. The median provider SD was 0.093 and the median slope was 13.5%. SD correlated negatively with the median NT-MoM (r = -0.34) and positively with the slope (r = 0.22). CONCLUSION: Even with extensive training, credentialing and monitoring, there remains considerable variability between NT providers. There was a general tendency towards under-measurement of NT compared with expected values, although more experienced providers had performance closer to that expected.

A blueprint for academic obstetrics and gynecology.

A consensus conference sponsored by the Council of University Chairs of Obstetrics and Gynecology in February 1997 formulated the organization's response to the many external issues affecting academic medicine and obstetrics and gynecology including 1) a new practice model based on "wellness," 2) reimbursement changes that have jeopardized traditional revenue sources, 3) an emphasis on quality assurance based on outcomes research and evidence-based medicine, 4) the concept of lifelong learning dictated by an expanding knowledge base and new technology, 5) insufficient resources for basic and clinical investigation in obstetrics and gynecology, 6) workforce statistics indicating stabilization in the number of subspecialists, 7) the increasing diversity of the United States population. Recommendations were developed that are intended to foster change and contribute to the design of academic programs. These include appropriate training for residents as providers of primary care, with an emphasis on continuity clinics, an interdisciplinary curriculum in women's health for medical students; promotion of gender, racial, and ethnic diversity at all levels of medical education and academic leadership; creation of clinical trials research units; and the development of expanded opportunities for research in obstetrics and gynecology supported by the National Institutes of Health.

Multifetal pregnancy reduction: evaluation of fetal growth in the remaining twins.

OBJECTIVE: Our purpose was to study fetal growth after reduction of high-order multiple gestations to twins. STUDY DESIGN: Birth weight and gestational age data were collected for 236 triplet and greater multiple pregnancies reduced to twins (113 triplets, 89 quadruplets, and 34 quintuplets or above) and was compared with those of a control group of unreduced twins. RESULTS: Rates of intrauterine growth restriction per pregnancy were significantly different between the nonreduced and all categories of reduced multifetal pregnancies. The incidence of intrauterine growth restriction was 19.4% in the nonreduced twins, 36.3% in pregnancies reduced from triplets, 41.6% in pregnancies reduced from quadruplets, and 50% from higher-order multiple gestations. There was a statistically significant trend toward increasing frequency of intrauterine growth restriction with increasing starting fetal number (p = 0.04). The increase in intrauterine growth restriction was primarily accounted for by twin pairs with only one growth-restricted newborn. CONCLUSION: Multifetal pregnancy reduction does not reduce the incidence of intrauterine growth restriction in the remaining fetuses to that of nonreduced twins.

Perinatal asphyxia: assessing its causal role and timing.

Perinatal asphyxia, whether prenatal, intrapartum, or neonatal is thought to be a significant contributor to newborn morbidity and mortality as well as long-term neurological deficits. Development of an intrapartum tool/test that can reliably identify and discriminate between varying degrees of fetal acidemia and suggest whether it is respiratory or metabolic in nature would be highly desirable. This article critically reviews the available experience with the currently available monitoring techniques and the significance of abnormalities of fetal and intrapartum measurements with respect to the predictive value of the observations available to the clinician.

Antibiotic treatment of preterm labor with intact membranes: a multicenter, randomized, double-blinded, placebo-controlled trial.

OBJECTIVE: Although an association between subclinical intrauterine infection and preterm birth is well established, there is conflicting evidence regarding the benefits of antibiotic administration to women in preterm labor with intact membranes. We attempted to determine the effect of ampicillin-amoxicillin and erythromycin treatment on prolongation of pregnancy, the rate of preterm birth, and neonatal morbidity in patients with preterm labor and intact membranes. STUDY DESIGN: A multicenter, randomized, double-blinded, placebo-controlled trial was designed and implemented by the Maternal-Fetal Medicine Units Network of the National Institute of Child Health and Human Development. Two hundred seventy-seven women with singleton pregnancies and preterm labor with intact membranes (24 to 34 weeks) were randomly allocated to receive either antibiotics or placebos. RESULTS: Of the 2373 patients screened for participation in this study in six medical centers, 277 women were enrolled (n = 133 for antibiotics group vs n = 144 for placebo group). In each study group, 60% of patients completed all the study medications. The overall prevalence of microbial invasion of the amniotic cavity was 5.8% (14/239). No significant difference between the antibiotic group and the placebo group was found in maternal outcomes, including duration of randomization-to-delivery interval, frequency of preterm delivery (< 37 weeks), frequency of preterm premature rupture of membranes, clinical chorioamnionitis, endometritis, and number of subsequent admissions for preterm labor. Similarly, no significant difference in neonatal outcomes could be detected between the two groups including respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, sepsis, and admission and duration of newborn intensive special care unit hospitalization. CONCLUSION: The results of this study do not support the routine use of antibiotic administration to women in preterm labor with intact membranes.

Doppler evaluation of umbilical and uterine-arcuate arteries in the postdates pregnancy.

To assess the correlation between Doppler velocimetry and perinatal outcome in the postdates pregnancy, 75 women who were at least 41 weeks' gestation were evaluated twice weekly until delivery. Evaluation included Doppler velocimetry of the umbilical and uterine-arcuate arteries, as well as nonstress testing and amniotic fluid volume estimation. The mean umbilical artery systolic-diastolic ratio (S/D) was significantly higher in the pregnancies with subsequent abnormal perinatal outcomes than in those with normal outcomes (2.42 versus 2.19; P = .03). Using a receiver operating characteristic curve, an abnormal umbilical artery S/D was defined as 2.40 or greater. Using this value, sensitivity was 57.1% and specificity was 77.8%. Our study suggests that an umbilical artery S/D of 2.40, rather than the more traditionally accepted cutoff of 3.0, may be a useful threshold to identify those postdates pregnancies at high risk for abnormal perinatal outcome.

A prospective, randomized evaluation of intrapartum amnioinfusion. Fetal acid-base status and cesarean delivery.

Pregnancies with decreased amniotic fluid volume are prediposed to umbilical cord compression and variable fetal heart rate declerations. Intrapartum amnioinfusion has been utilized in an effort to reduce cord compression. Previous studies suggested that amnioinfusion may improve the fetal metabolic state and reduce the incidence of cesarean delivery in selected patients. In this study the hypothesis was tested that intrapartum amnioinfusion will relieve cord compression in pregnancies complicated by oligohydramnios and will result in a reduced incidence of fetal intolerance to labor as well as improved fetal acid-base status at delivery. Thirty-five patients fulfilling the inclusion criteria were randomized to either the control (n = 16) or amnioinfusion treatment group (n = 19). Analysis of the data suggested that the two groups were similar for the perinatal parameters evaluated. No differences were observed in the umbilical artery blood gas analysis or incidence of cesarean section between the two groups. Intrapartum amnioinfusion does not appear to improve the perinatal outcome in pregnancies with oligohydramnios.

Fetal heart rate patterns during labor: neurologic and cognitive development at six to nine years of age.

The development of 50 children relative to the fetal heart rate patterns they demonstrated during labor and delivery was prospectively studied. Normal deceleration patterns were recorded for 12 of the children, while 16 were recorded as moderately severe and 22 as severe variable or late deceleration patterns. The parity and socioeconomic status of the mothers and the sexes of the infants were similar among the groups. A statistically significant developmental difference in favor of children with normal fetal heart rate patterns was seen in the first year of life. However, at 6 to 9 years of age the difference in neurologic and cognitive development was no longer evident. These data do not support the hypothesis that brief abnormal fetal heart rate patterns recorded during labor are indicative of irreversible central nervous system injury.

Fetal acidosis in prolonged pregnancy cannot be attributed to cord compression alone.

Fetal heart rate abnormalities associated with prolonged pregnancy have been attributed to umbilical cord vulnerability rather than placental insufficiency. Although intrapartum fetal heart rate patterns indicative of umbilical cord compression are common beyond 41 weeks' gestation, fetal intolerance to labor develops only in a subset of such patients. To test the hypothesis that suboptimal placental function contributes to reduced amniotic fluid volume and, ultimately, to fetal intolerance to labor, we prospectively collected biochemical and clinical data on 112 prolonged pregnancies. Data analysis was blinded to outcome and included cord blood acid-base measurements and intrapartum fetal heart rate interpretation. We observed a high incidence of umbilical cord compression (46.4%), but this finding was not predictive of emergent delivery in 32 of 52 cases (61.5%). Fetal acidosis (arterial pH less than 7.20) occurred more often in patients with cord compression, but the anticipated increase in carbon dioxide tension was not observed. Instead, a primary metabolic or combined acidosis was encountered in those fetuses delivered emergently. The additional findings of lower amniotic fluid volume and diminished birth weight in those patients delivered for fetal intolerance to labor suggest a direct role for suboptimal placental function in selected patients with prolonged pregnancy.

Apgar scores and umbilical cord arterial pH in the breech neonate.

Apgar scores and umbilical cord arterial pH measurements of 449 singleton breech deliveries are compared retrospectively to those of 1425 singleton vertex neonates. In the vaginal deliveries the Apgar scores and umbilical arterial pH were higher for the vertex neonates. There were no differences in either Apgar scores or umbilical arterial pH between the breech and vertex neonates delivered by cesarean section. Whereas Apgar scores in the less than 1000 g and greater than or equal to 2500 g weight groups were lower in the breech neonates delivered vaginally compared to cesarean section, umbilical arterial pH measurements were similar. The data suggest that liberal use of cesarean section may improve the Apgar scores but will probably not appreciably improve the acid-base status of the breech neonate.

Acoustic stimulation testing.

The nonstress test is the most widely employed method of fetal health assessment. The current approach is to use the OCT or biophysical profile as a means of identifying the fetus at very high risk should the nonstress test be either nonreassuring or equivocal. The acoustic stimulation test may have a predictive ability similar to that of the biophysical profile and thus may be used to complement nonstress testing as early as 28 weeks' gestation. It reliably invokes a reactive NST in those fetuses destined to demonstrate reactivity with persistence in monitoring and facilitates more rapid and efficient testing. The acoustic test may have the additional benefit of providing a screening mechanism for anomalies in which neurologic performance is suboptimal. However, because the test has not been studied on large numbers of patients and because different applications of such stimuli may elicit differing responses, its adaptation for clinical use should be cautious at the present time.

Caution in antenatal intervention.

We assessed 18 fetuses who harbored a urinary tract malformation that was diagnosed by antenatal sonography. The antenatal diagnosis corresponded to the postnatal diagnosis in 66 per cent of the cases. We review the course of 6 fetuses who had catheters placed percutaneously to drain dilated urinary tracts that were believed to be caused by posterior urethral valves (5) or an obstructed megaureter (1). Only 2 of these fetuses exhibited valves postnatally. No fetus had any recognized benefit from the antenatal intervention. We found that sonography may not readily differentiate fetuses with hydronephrosis with obstruction from those without obstruction. From this experience we conclude that intervention in pregnancies suspected of harboring a fetus with a malformed urinary tract should be done cautiously. Antenatal sonography is useful to identify the fetus with a dilated urinary tract. This identification permits perinatal specialists to be alerted so that preparations for reconstructive surgery in such cases can be made early postpartum.

The Northwestern University Twin Study. V: Twin deliveries at Prentice Women's Hospital and Maternity Center, 1978-83.

Two hundred fifty-one twin deliveries between January 1, 1978 and June 30, 1983 at Prentice Women's Hospital and Maternity Center were reviewed. Cases were excluded if birth weight was less than 500 g, if gestational age was less than 26 weeks or if an antenatal fetal demise had occurred. Maternal demographic characteristics, delivery data and infant characteristics are described. The effect of providing care to a high-risk population of mothers in whom approximately 60% either deliver their infants preterm or with a birth weight of less than 2,500 g is discussed in terms of costs of care.

Ultrasonic imaging of normal fetal response to external vibratory acoustic stimulation.

Fetal facial reactions and response decrement patterns to external noise stimulation were studied to characterize normal fetal neurobehavior in the third trimester. Response decrement, or habituation, is thought to reflect higher central nervous system function. Two hundred women with uncomplicated pregnancies, who were subsequently delivered of healthy infants at term, were studied between 26 and 41 weeks' gestation. After ultrasound views of the fetal face were obtained, a vibratory acoustic stimulus was applied repetitively to the maternal abdomen near the fetal head. Response decrement was defined as cessation of all components of the facial reaction, except eye blinking, over two sequential stimuli. Three response patterns were scored: (1) no startle, (2) startle without response decrement, and (3) response decrement by 12 stimuli. Whereas only 53% of fetuses between 26 and 27 weeks displayed startle reaction, all fetuses displayed startle responses by 28 weeks. As gestational age advances, an increasing number of fetuses exhibit response decrement, from no decrement at 26 to 27 weeks to 100% decrement at 40 to 41 weeks. A maturation of neurobehavioral response patterns takes place in normal third-trimester pregnancies. Response decrement testing may be a useful tool for in utero neurologic evaluation.

The Northwestern University Twin Study. VII: The mode of delivery in twin pregnancy. North American considerations.

No consensus exists for the optimal mode of delivery for twin fetuses. Opinions vary by type of institution (university medical center vs community hospital), country or continent (North America vs Western Europe) and personal preference of individual physicians. This article lists clinical considerations in arriving at the decision and presents them in the form of a decision tree.

Umbilical cord size and amniotic fluid volume in prolonged pregnancy.

Expectant management of prolonged pregnancy is predicated on reassuring biophysical testing. However, even the combination of a reactive nonstress test and normal amniotic fluid volume may not prevent subsequent morbidity. To test the hypothesis that diminished cord Wharton's jelly incurs risk of peripartum cord compression in addition to decreased amniotic fluid, 68 patients with confirmed gestational age greater than or equal to 41 weeks were evaluated prospectively with semiweekly nonstress tests and weekly ultrasound examinations. Amniotic fluid volume was assessed, and umbilical cord diameter was measured and then correlated with the quantity of Wharton's jelly at delivery, determined by cord circumference. A significant correlation between cord circumference and umbilical cord diameter was observed, even in those patients with decreased amniotic fluid volume. Either an amniotic fluid volume less than 3.8 cm or an umbilical cord diameter less than 1.6 cm was associated with significant cord compression patterns. Peripartum morbidity was greatest in the presence of a smaller cord and decreased fluid, suggesting a synergism between these two factors for the risk of cord compression in prolonged pregnancy.

Low maternal serum alpha-fetoprotein and perinatal outcome.

Pregnancy outcome was followed prospectively in women showing maternal serum alpha-fetoprotein values less than 0.4 multiple of the median. Using a radioimmunoassay later shown by others to produce a disproportionate number of low values, we nonetheless detected all three cases of autosomal trisomy (+18, +18, +21) at amniocentesis in 1531 women screened. Although two fetal losses and two autosomal trisomies (trisomy 18) occurred among a subgroup of only 15 women having two values less than 0.25 multiple of the median, fetal losses were in general far less frequent among the 99 women with at least one maternal serum alpha-fetoprotein value less than 0.4 multiple of the median than among women in previous reports. Comparing women with maternal serum alpha-fetoprotein values less than 0.4 multiple of the median against those with normal values (0.4 to 2.49 multiples of the median) also revealed no significant differences with respect to presence or absence of a variety of antepartum or intrapartum complications. Birth weight, gestational age, arterial cord pH, and Apgar scores also failed to differ significantly (one-way analysis of variance, p greater than 0.05). Women with a viable pregnancy who show low maternal serum alpha-fetoprotein values have a more favorable prognosis than previously claimed.

Gestational diabetes mellitus: a syndrome with phenotypic and genotypic heterogeneity.

One hundred ninety-nine gravida with gestational diabetes mellitus (GDM) defined as "carbohydrate intolerance of varying severity with onset or first recognition during pregnancy" have been stratified into subgroups on the basis of fasting plasma glucose and evaluated for further phenotypic and genotypic heterogeneity. A significantly greater proportion of the women in all our groups were older and heavier than in a "control" population of 148 consecutive gravida with documented normal oral glucose tolerance. After correction for age and weight by covariate analysis, absolute insulinopenia in response to oral glucose could be demonstrated in all GDM groups, although exceptions were present in each. The incidence of diabetes in the mothers of our patients with GDM was 8-fold greater than in controls; the incidence in fathers did not deviate from control patterns. HLA-DR3 and DR4 antigens were more frequently present in GDM and the increase was statistically significant in blacks. At the time of diagnosis, cytoplasmic islet cell antibodies (ICA) were significantly more common in GDM associated with elevated fasting plasma glucose than in controls; the frequency of ICA was 18.4% (7/38) in women with fasting plasma glucose greater than or equal to 130 mg/dl. Our findings indicate that GDM entails genotypic as well as phenotypic diversity and may include patients with slowly-evolving Type I diabetes mellitus, as well as patients with Type II diabetes mellitus, and women with asymptomatic diabetes which antedated the pregnancy (i.e. pregestational diabetes mellitus). Appreciation of this heterogeneity should be incorporated into any evaluation of intervention strategies for women with GDM or into prognoses concerning their postpartum metabolic status.

Diabetic macrosomia: accuracy of third trimester ultrasound.

Sonar biparietal diameter, head circumference, and abdominal circumference percentile values obtained late in the third trimester were compared with birth weight percentile (relative to dates) in 147 diabetic mothers and 40 control fetuses of nondiabetics. Estimates of fetal weight by the method of Shepard et al were also calculated from these sonar data and compared with birth weight percentile. Abdominal circumference values greater than the 90th percentile correctly predicted macrosomia (defined as birth weight greater than 90th percentile) in 78% of cases. Biparietal diameter and head circumference percentiles were significantly less predictive of macrosomia. When analyzed in a similar manner, estimated fetal weights greater than the 90th percentile correctly predicted macrosomia at birth in 74% of cases. However, when both the abdominal circumference and the estimated fetal weight exceeded the 90th percentile, macrosomia was correctly diagnosed in 88.8% of pregnant women with diabetes mellitus.

Meconium below the vocal cords at delivery: correlation with intrapartum events.

Intrapartum events were studied in 272 patients with meconium-stained amniotic fluid. All infants underwent DeLee suction followed by intubation and 58 of 272 had meconium present below the vocal cords at delivery. Neither the total duration of variable fetal heart rate decelerations or a continuous saltatory pattern nor the presence or absence of late decelerations could be related to an increased risk of meconium below the vocal cords. When a rising baseline fetal heart rate and decreased variability were present as well, a significantly greater proportion of patients had meconium below the vocal cords. Routine obstetric and pediatric suctioning did not prevent the single death that occurred in a fetus who had deep meconium aspiration in utero.