The Utility of Screening Fetal Echocardiograms Following Normal Level II Ultrasounds in Fetuses with Maternal Congenital Heart Disease.

INTRODUCTION: Fetal echocardiograms (F-echo) are recommended in all pregnancies when maternal congenital heart disease (CHD) is present, even if there was a prior level II ultrasound (LII-US) that was normal. The goal of this study was to evaluate if any diagnosis of a critical CHD was missed in a fetus with maternal CHD who had a normal LII-US. METHODS: A retrospective chart review of all F-echoes where the indication was maternal CHD between 1/1/2015 to 12/31/2022 was performed. Fetuses were included if they had a LII-US that was read as normal and had an F-echo. Critical CHD was defined as CHD requiring catheterization or surgical intervention < 1 month of age. RESULTS: A total of 296 F-echoes on fetuses with maternal CHD were evaluated, of which 175 met inclusion criteria. LII-US was performed at 19.8 ± 2.9 weeks gestational age and F-echo was performed at 24.2 ± 2.8 weeks gestational age. No patient with a normal LII-US had a diagnosis of a critical CHD by F-echo (negative predictive value = 100%). Evaluating those patients that had a negative LII-US, ten patients were diagnosed with non-critical CHD postnatally (negative predictive value = 94.3%). F-echo correctly diagnosed two of the ten missed LII-US CHD. CONCLUSIONS: Critical CHD was not missed with a normal LII-US in this at risk population. F-echo also missed the majority of CHD when a LII-US was read as normal. A cost-benefit analysis of screening F-echo in fetuses with maternal CHD should be conducted if a normal LII-US has been performed.

Establishing a Fetal Center in a Freestanding Pediatric Hospital.

Advances in antenatal imaging have allowed early and accurate diagnosis of many fetal anomalies. This, together with the increasing understanding of the natural history of many fetal diseases, has opened the door to the possibility of offering timely fetal interventions in progressive or life-threatening conditions with the intention of improving perinatal outcomes. These interventions can occur at an adult hospital with obstetrical services (with or without pediatric care) or at a freestanding pediatric hospital. In this article, we provide an overview of the approach to develop a comprehensive fetal care center in a freestanding pediatric hospital. Services included prenatal consultation, advanced diagnostics, innovative fetal therapy, research, and special delivery services. We also review the importance of continuous improvement in achieving this goal.

Utility of Screening Fetal Echocardiograms at a Single Institution Following Normal Obstetric Ultrasound in Fetuses with Down Syndrome.

Fetal echocardiograms (F-echo) are recommended in all pregnancies when the fetus has Down syndrome (DS) even if there was a prior obstetric scan (OB-scan) that was normal. The utility of a screening F-echo in this high-risk population when an OB-scan is normal is unknown. Goal of this study was to evaluate if any diagnosis of a critical congenital heart disease (CHD) was missed in a fetus with DS who had a normal OB-scan. Secondary goal was to determine if any CHD was missed postnatally when an OB-scan was read as normal. Retrospective chart review of all fetuses that had a F-echo whose indication was DS between 1/1/2010 to 6/30/2022 was performed. Fetuses were included if they had an OB-scan that was read as normal and had a F-echo. Postnatal transthoracic echocardiogram (pTTE) was reviewed when available. Critical CHD was defined as CHD requiring catheterization or surgical intervention < 1 month of age. One hundred twenty-two F-echo on fetuses with DS were evaluated, of which 48 met inclusion criteria. OB-scan was performed at 20.4 ± 4.5 weeks gestational age and F-echo was performed at 24.0 ± 4.6 weeks gestational age. No patient with a normal OB-scan had a diagnosis of a critical CHD by F-echo (n = 48, negative predictive value = 100%). Evaluating those patients that had an OB-scan and a pTTE (n = 38), 14 patients were diagnosed with CHD (muscular ventricular septal defect (VSD) n = 5, perimembraneous VSD n = 3, secundum atrial septal defect (ASD) n = 2, primum ASD n = 1, transitional atrioventricular septal defect (AVSD) n = 2, and aortic valve abnormality n = 1; negative predictive value = 63.2%). F-echo correctly diagnosed 4 of the 14 missed OB-scan CHD (perimembraneous VSD n = 2, muscular VSD n = 1, and transitional AVSD n = 1). Critical CHD was not missed with a normal OB-scan in this high-risk population. F-echo also missed the majority of CHD when an OB-scan was read as normal. The cost/benefit of screening F-echo in fetuses with DS should be evaluated if a normal OB-scan has been performed, considering all these patients would have a pTTE performed per guidelines.

Relaxin confers cytotrophoblast protection from hypoxia-reoxygenation injury through the phosphatidylinositol 3-kinase-Akt/protein kinase B cell survival pathway.

Preeclampsia is a hypertensive syndrome that manifests after 20 wk of gestation. Contemporary understanding of the maternal-fetal interface in preeclampsia suggests a major role for placental oxidative stress resulting from ischemia-reperfusion injury. We hypothesized that the pregnancy hormone relaxin would reduce cytotrophoblast apoptosis and necrosis (aponecrosis) and, hence, the export of placental debris into the maternal circulation. If so, then relaxin might be employed as a therapeutic intervention to diminish the activation of the maternal systemic inflammatory response central to the development of clinical disease. HTR-8/SVneo cells, a model for first trimester extravillous trophoblast, were subjected to serum deprivation and hypoxia or hypoxia-reoxygenation. The cells were treated with recombinant human relaxin or vehicle and apoptosis and/or necrosis evaluated by terminal deoxynucleotidyl transferase-mediated dUTP nick end labeling (TUNEL), CellEvent Caspase-3/7 and SYTOX AADvanced kit, and propidium iodide staining as determined by fluorescence microscopy or flow cytometry. To interrogate mechanisms of relaxin cytoprotection, HTR-8/SVneo cells were pretreated with pharmacological inhibitors of PI3-kinase LY294004, Akt/PKB MK-2206, or DMSO vehicle. HTR-8/SVneo cell identity was first confirmed by RT-PCR. The cells expressed placental alkaline phosphatase, aromatase, and human leukocyte antigen G. In addition, the cells expressed the relaxin receptor RXFP1 as well as H1 and H2 relaxins. Serum deprivation and hypoxia increased apoptotic cell death in HTR-8/SVneo cells, which was significantly ameliorated by concurrent treatment with relaxin. Serum deprivation and hypoxia-reoxygenation increased necrotic cell death in HTR-8/SVneo cells, which was also significantly rescued by concurrent treatment with relaxin. Pretreatment with LY294002 or MK-2206, to inhibit the phosphatidylinositol 3-kinase-Akt/protein kinase B cell survival pathway, significantly blunted the cytoprotective effect of relaxin. We demonstrated trophoblast cytoprotection by intervention with supraphysiological concentrations of relaxin, a process in part mediated through the PI3-kinase-Akt/PKB cell survival pathway. These results provide further rationale for clinical investigation of relaxin as a potential therapeutic in preeclampsia.

Perinatal outcomes after adopting 1- versus 2-step approach to diagnosing gestational diabetes.

OBJECTIVE: The American College of Obstetricians and Gynecologists (ACOG) and the IADPSG (International Association of Diabetes and Pregnancy Study Groups) proposed distinct approaches to diagnosing gestational diabetes mellitus (GDM). We sought to analyze these paradigms: (1) ACOG 2-step approach where screening is followed by diagnostic testing, (2) IADPSG 1-step diagnostic testing. STUDY DESIGN: We reviewed data from pregnant women (24-28 wks) screened for GDM over two periods: (1) November 2011-May 2012 (2) November 2012-May 2013. Period 1: 2-step approach (screening 1-h glucose challenge test (GCT) followed by a diagnostic 3-h 100-g glucose tolerance test (GTT) when abnormal (≥140 mg/dl)). Period 2: an abnormal value after a 2-h 75-g GTT result was diagnostic of GDM. We compared the incidence of GDM and perinatal outcomes using either approach. RESULTS: Out of 471 patients screened by ACOG 2-step approach, 72 (15.3%) had an abnormal 1-h screening and underwent the 3-h diagnostic GTT, and 26 (5.5%) developed GDM. The 1-step approach resulted in 53 (15.96%) with GDM of a total 332 evaluated. There was no statistically significant difference in perinatal outcomes between the two cohorts. Maternal weight at the start and the end of pregnancy was greater for patients diagnosed by the ACOG 2-step approach. CONCLUSION: Adopting 1-step approach (ADA) to diagnose GDM resulted in a 3-fold increase in prevalence of GDM with no differences in perinatal outcomes.

Autoimmune Hepatitis in Pregnancy: Hematological Perturbation and Management Dilemma. A Case Report.

BACKGROUND: Autoimmune hepatitis (AIH) is a progressive chronic hepatitis of unknown cause that occurs in children and adults, with a paucity of informa- tion of this disorder existing -__ in pregnancy. CASE: A primigravid pa- tient presented at 30 weeks with altered mental status, abdominal pain, vomiting, and epistaxis. Her history was significant for por- tal hypertension, encepha- lopathy, ascites, coagulopathy, hyperammonemia, and end-stage liver disease secondary to AIH. Ultrasound revealed cirrhosis, ascites, splenomegaly, and an appro- priately grown singleton gestation. She received 2 intra- muscular doses of betamethasone over 24 hours, subcuta- neous vitamin K, and oral prednisone. A lower extremity venous Doppler study was negative for thrombosis. She received ceftriaxone 1 g daily x 5 days to treat sponta- neous bacterial peritonitis. A unit of packed red blood cells and 1 unit of platelets were transfused prior to a primary cesarean 2 weeks after the initial presentation. Postoperative agitation was managed with risperidone, and wound infection was treated with vancomycinl metronidazole. She discharged herself against medical advice on postoperative day 15, and the infant was dis- charged to foster care on day 15 of life. CONCLUSION: Multiple management challenges usu- ally arise in pregnancies com- plicated by end-stage - liver disease. However, with com- prehensive multidisciplin- ary care a successful perina- tal outcome can be accom- - plished.

Short-term neonatal outcomes in diamniotic twin pregnancies delivered after 32 weeks and indications of late preterm deliveries.

OBJECTIVE: We sought to compare neonatal outcomes in twin pregnancies following moderately preterm birth (MPTB), late preterm birth (LPTB), and term birth and determine the indications of LPTB. STUDY DESIGN: We performed a retrospective cohort study. MPTB was defined as delivery between 32(0/7) and 33(6/7) weeks and LPTB between 34(0/7) and 36(6/7) weeks. The composite neonatal adverse respiratory outcome was defined as respiratory distress syndrome and/or bronchopulmonary dysplasia. The composite neonatal adverse nonrespiratory outcome included early onset culture-proven sepsis, necrotizing enterocolitis, retinopathy of prematurity, intraventricular hemorrhage, or periventricular leukomalacia. LPTB cases were categorized as spontaneous (noniatrogenic), evidence-based iatrogenic, and non-evidence-based (NEB) iatrogenic. RESULTS: Of the 747 twin deliveries during the study period, 453 sets met the inclusion criteria with 22.7% (n = 145) MPTB, 32.1% (n = 206) LPTB, and 15.9% (n = 102) term births. Compared with term neonates, the composite neonatal adverse respiratory outcome was increased following MPTB (relative risk [RR] 24; 95% confidence interval [CI] 3.0 to 193.6) and LPTB (RR 13.7; 95% CI 1.8 to 101.8). Compared with term neonates, the composite neonatal adverse nonrespiratory outcome was increased following MPTB (RR 22.3; 95% CI 3.9 to 127.8) and LPTB (RR 5.5; 95% CI 1.1 to 27.6). Spontaneous delivery of LPTB was 63.6% (n = 131/206) and the rate of iatrogenic delivery was 36.4% (n = 75/206). The majority, 66.6% (n = 50/75), of these iatrogenic deliveries were deemed NEB, giving a total of 24.2% (50/206) NEB deliveries in LPTB group. CONCLUSION: Our data demonstrate a high rate of late preterm birth among twin pregnancies, with over half of nonspontaneous early deliveries due to NEB indications. Although our morbidity data will be helpful to providers in counseling patients, our finding of high NEB indications underscores the need for systematic evaluation of indications for delivery in LPTB twin deliveries. Furthermore, this may lead to more effective LPTB rate reduction efforts.

Prediction of proteinuria and microalbuminuria in diabetic pregnancies with a random single void.

OBJECTIVE: To determine whether a single urine specimen could effectively replace the 24 hour (24-h) urine collection in screening for microalbuminuria and proteinuria in pregnant women with pregestational diabetes. MATERIALS AND METHODS: A total of 42 pregnant women with pregestational diabetes mellitus were involved in the eventual analysis. Demographic and clinical variables were collected and analyzed. Urinary Protein (P) to Creatinine (Cr) ratio and microalbumin (MA) to Cr ratios were measured for the spot sample, and the total P, total MA, and serum Cr were measured for the 24-h urine sample. Analysis was done using linear regression and the Pearson correlation coefficient (r). RESULTS: Mean maternal age was 30.8 years, and the mean gestational age at collection was 19.8 weeks. A strong correlation exists between the spot MA to Cr value and 24-h MA, with an r = 0.81 (P < 0.0001). The association between the spot P to Cr ratio and 24-h urinary P was not as strong, r = 0.58 (P < 0.0001). CONCLUSIONS: A strong association between spot MA to Cr ratio and 24-h urinary microalbuminuria may suggest a predictive role for random urine assessment of MA in pregnant pregestational diabetic patients. However, based on our data, the spot P to Cr ratio may be inadequate for assessing proteinuria in pregestational diabetic pregnancies.

Preferences for labor and delivery practices between pregnant immigrants and U.S.-born patients: a comparative prospective antenatal survey study.

OBJECTIVE: To compare preferences in pregnant Somali and Sudanese immigrants with US-born women for different labor and delivery procedures and practices. STUDY DESIGN: Pregnant women who received prenatal care services at the Jericho Road Family Practice were surveyed. Ninety-three consecutive patients agreed to participate. A translator-facilitated questionnaire was administered to Somali-, Sudanese-, and U.S.-born women during antenatal visits. RESULTS: For pain relief in labor, 66.7% of U.S.-born, 64.0% of Somali, and 12.5% of Sudanese women preferred epidural analgesia (p = .002). More U.S.-born women preferred for the umbilical cord to be cut by their partners (76.2%) vs. Somali (6.7%) and Sudanese (0%) (p < .001). For infant feeding, more U.S.-born women (47%) preferred only formula feeding (Somali, 3.4%; Sudanese, 0%; p < .001). Responses were not statistically different for other preference questions, such as mobility/position in labor, attendants in labor, and duration of hospital stay. CONCLUSIONS: This prospective survey quantifies the differences in preferences for labor and delivery practices from two foreign populations and from U.S.-born women. This information is useful for all physicians who wish to better meet the needs of individual patients, especially those who are from different cultures and backgrounds.