Fetoscopic Endoluminal Tracheal Occlusion for Severe, Left-Sided Congenital Diaphragmatic Hernia: The North American Fetal Therapy Network Fetoscopic Endoluminal Tracheal Occlusion Consortium Experience.

OBJECTIVE: To report the outcomes of fetoscopic endoluminal tracheal occlusion in a multicenter North American cohort of patients with isolated, left-sided congenital diaphragmatic hernia (CDH) and to compare neonatal mortality and morbidity in patients with severe left-sided congenital diaphragmatic hernia who underwent fetoscopic endoluminal tracheal occlusion with those expectantly managed. METHODS: We analyzed data from 10 centers in the NAFTNet (North American Fetal Therapy Network) FETO (Fetoscopic Endoluminal Tracheal Occlusion) Consortium registry, collected between November 1, 2008, and December 31, 2020. In addition to reporting procedure-related surgical outcomes of fetoscopic endoluminal tracheal occlusion, we performed a comparative analysis of fetoscopic endoluminal tracheal occlusion compared with contemporaneous expectantly managed patients. RESULTS: Fetoscopic endoluminal tracheal occlusion was successfully performed in 87 of 89 patients (97.8%). Six-month survival in patients with severe left-sided congenital diaphragmatic hernia did not differ significantly between patients who underwent fetoscopic endoluminal tracheal occlusion and those managed expectantly (69.8% vs 58.1%, P =.30). Patients who underwent fetoscopic endoluminal tracheal occlusion had higher rates of preterm prelabor rupture of membranes (54.0% vs 14.3%, P <.001), earlier gestational age at delivery (median 35.0 weeks vs 38.3 weeks, P <.001), and lower birth weights (mean 2,487 g vs 2,857 g, P =.001). On subanalysis, in patients for whom all recorded observed-to-expected lung/head ratio measurements were below 25%, patients with fetoscopic endoluminal tracheal occlusion required fewer days of extracorporeal membrane oxygenation (ECMO) (median 9.0 days vs 17.0 days, P =.014). CONCLUSION: In this cohort, fetoscopic endoluminal tracheal occlusion was successfully implemented across several North American fetal therapy centers. Although survival was similar among patients undergoing fetoscopic endoluminal tracheal occlusion and those expectantly managed, fetoscopic endoluminal tracheal occlusion in North American centers may reduce morbidity, as suggested by fewer days of ECMO in those patients with persistently reduced lung volumes (observed-to-expected lung/head ratio below 25%).

Neonatal Survival After Serial Amnioinfusions for Bilateral Renal Agenesis: The Renal Anhydramnios Fetal Therapy Trial.

Importance: Early anhydramnios during pregnancy, resulting from fetal bilateral renal agenesis, causes lethal pulmonary hypoplasia in neonates. Restoring amniotic fluid via serial amnioinfusions may promote lung development, enabling survival. Objective: To assess neonatal outcomes of serial amnioinfusions initiated before 26 weeks' gestation to mitigate lethal pulmonary hypoplasia. Design, Setting, and Participants: Prospective, nonrandomized clinical trial conducted at 9 US fetal therapy centers between December 2018 and July 2022. Outcomes are reported for 21 maternal-fetal pairs with confirmed anhydramnios due to isolated fetal bilateral renal agenesis without other identified congenital anomalies. Exposure: Enrolled participants initiated ultrasound-guided percutaneous amnioinfusions of isotonic fluid before 26 weeks' gestation, with frequency of infusions individualized to maintain normal amniotic fluid levels for gestational age. Main Outcomes and Measures: The primary end point was postnatal infant survival to 14 days of life or longer with dialysis access placement. Results: The trial was stopped early based on an interim analysis of 18 maternal-fetal pairs given concern about neonatal morbidity and mortality beyond the primary end point despite demonstration of the efficacy of the intervention. There were 17 live births (94%), with a median gestational age at delivery of 32 weeks, 4 days (IQR, 32-34 weeks). All participants delivered prior to 37 weeks' gestation. The primary outcome was achieved in 14 (82%) of 17 live-born infants (95% CI, 44%-99%). Factors associated with survival to the primary outcome included a higher number of amnioinfusions (P = .01), gestational age greater than 32 weeks (P = .005), and higher birth weight (P = .03). Only 6 (35%) of the 17 neonates born alive survived to hospital discharge while receiving peritoneal dialysis at a median age of 24 weeks of life (range, 12-32 weeks). Conclusions and Relevance: Serial amnioinfusions mitigated lethal pulmonary hypoplasia but were associated with preterm delivery. The lower rate of survival to discharge highlights the additional mortality burden independent of lung function. Additional long-term data are needed to fully characterize the outcomes in surviving neonates and assess the morbidity and mortality burden. Trial Registration: ClinicalTrials.gov Identifier: NCT03101891.

Fetal surgery is not associated with increased inflammatory placental pathology.

OBJECTIVE: Fetal surgery has improved neonatal outcomes; however, it is unknown if the intervention contributes to the developmental of inflammatory pathologies in the placenta. Here, an association between fetal surgery and placental pathology was examined. METHOD: This case-control study compared pregnancies with fetal surgery (n = 22), pregnancies with an indication for fetal surgery but without an intervention being done (n = 13), and gestational-age and fetus-number matched controls (n = 36). Data on maternal, infant, and placental outcomes were abstracted. Additionally, immunohistochemistry identified expression of lymphoid and myeloid cells in the placenta on a subset of cases. Comparisons were performed using Kruskal-Wallis or Pearson's chi-squared tests. RESULTS: Maternal characteristics were comparable between groups. Most fetal interventions were for diaphragmatic hernia, spina bifida, or twin-to-twin transfusion syndrome. Fetuses who were operated on before birth were more likely to be born preterm (p = 0.02). There was no increase in the rate of observed placental pathologies or immune cell infiltration in fetal surgery cases compared to controls. CONCLUSION: The data suggest that fetal surgery is not associated with increased inflammatory or morphologic pathology in the placenta. This observation supports the growing field of fetal surgery.

Ethical considerations of maternal-fetal surgery.

The practice of maternal-fetal surgery (MFS) has expanded from lethal fetal conditions to conditions which are significantly disabling but not a lethal fetal abnormality. The inclusion of myelomeningocele within the scope of MFS in the 1990s sparked a renewed debate over the ethics of MFS. While demonstrating increasing efficacy and range of application, MFS continues to be ethically fraught due to the inherent tension between maternal and fetal interests. Ethical issues central to MFS include the patienthood of the fetus; the balance of risks and benefits between the woman and fetus; informed consent for experimental procedures; and determination of conditions that meet ethical qualifications for MFS intervention. These concerns are likely to persist and evolve as perinatal medicine continues to advance. Here we summarize the current state of MFS ethics, highlighting the major positions in the literature thus far as well as examine future directions. It is essential robust discussions of these important issues continue both to ensure ethical medical practice and to provide support to clinicians, pregnant women, and their families.

Estimated fetal weight accuracy in pregnancies with preterm prelabor rupture of membranes by the Hadlock method.

OBJECTIVE: We aimed to assess the accuracy of the estimated fetal weight (EFW) to predict the birthweigth (BW) in pregnancies complicated by PPROM. STUDY DESIGN: This study was a secondary analysis of a prospective cohort of pregnancies with PPROM. We included singleton pregnancies from 23 to 36 + 6 weeks, mothers from 13 to 46 years of age, and those with an EFW within two weeks of delivery. We excluded pregnancies with complex fetal anomalies and fetal demise. The accuracy of the EFW was determined by the absolute percent difference between BW and EFW ([BW-EFW]/BW*100%). T tests and linear regression were performed for statistical analysis. RESULTS: The mean percent difference of BW vs. EFW was 8.72 ± 6.94%. The EFW was more accurate (8.24 ± 6.81 vs. 13.31 ± 6.88%, p = .027) and had more measurements with a absolute difference < 10% (70% vs. 30%; p = .034) when performed within seven days of delivery. The EFW accuracy decreased with anhydramnios (11.37 ± 7.06 vs. 7.69 ± 6.77%, p = .020), but the measurements with an absolute difference <10% was not significantly different (p = .27) with anhydramnios. CONCLUSION: In PPROM, the EFW within seven days to delivery by Hadlock accurately predicts the birthweight with a mean absolute difference of 8.2%. BRIEF RATIONALE: There are a limited number of studies evaluating the accuracy of the EFW in pregnancies with PPROM in the last four decades.

Uterine artery pulsatility index for the prediction of obstetrical complications in preterm prelabor rupture of membranes.

INTRODUCTION: Abnormal uterine artery Doppler studies have been associated with an increased risk of preeclampsia, fetal growth restriction (FGR), placental abruption, and fetal demise. These obstetrical complications can affect pregnancies with preterm prelabor rupture of membranes (PPROM). Therefore, our objective was to assess the prediction accuracy of the uterine artery pulsatility index (UtAPI) to detect these complications in pregnancies with PPROM. MATERIALS AND METHODS: This was a prospective study of pregnancies complicated by PPROM from October 2015 to May 2018. We included mothers aged 13-46 years old with singleton pregnancies from 23 to 36 + 6 weeks with PPROM. Those without UtAPI measurements and complex fetal anomalies were excluded. Our primary outcome was a composite of obstetrical complications, defined as having one or more of the following: gestational hypertension or preeclampsia, placenta abruption, FGR, or fetal demise. The UtAPI was obtained at the time of enrollment. Logistic regression models with receiver operating curves were used to determine the predictive value of the UtAPI for obstetrical complications. A p value of <.05 was considered significant. RESULTS: A total of 103 patients met inclusion criteria, of those 37 (36%) developed an obstetrical complication (FGR = 22 (21.5%); preeclampsia or gestational hypertension = 9 (9%); placental abruption = 8 (8%); fetal demise = 1 (1%)). Six mothers had more than one complication. The UtAPI was not a statistically significant predictor of a composite of obstetrical complications (AUC = 0.61; p = .07) or for any of the individual complications studied. CONCLUSIONS: The UtAPI appears to have limited clinical value for the prediction of obstetrical complications previously associated with abnormal uterine artery Doppler indices in pregnancies with PPROM. Larger and more diverse studies are needed to corroborate our findings. BRIEF RATIONALE: An accurate prediction for adverse outcomes in patients with PPROM may help identify those that may benefit from increased surveillance protocols.

Estimated fetal weight and severe neonatal outcomes in preterm prelabor rupture of membranes.

Objectives Our aim was to study the association of clinical variables obtainable before delivery for severe neonatal outcomes (SNO) and develop a clinical tool to calculate the prediction probability of SNO in preterm prelabor rupture of membranes (PPROM). Methods This was a prospective study from October 2015 to May 2018. We included singleton pregnancies with PPROM and an estimated fetal weight (EFW) two weeks before delivery. We excluded those with fetal anomalies or fetal death. We examined the association between SNO and variables obtainable before delivery such as gestational age (GA) at PPROM, EFW, gender, race, body mass index, chorioamnioitis. SNO was defined as having at least one of the following: respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, neonatal sepsis, or neonatal death. The most parsimonious logistic regression models was constructed using the best subset selection model approach, and receiver operator curves were utilized to evaluate the prognostic accuracy of these clinical variables for SNO. Results We included 106 pregnancies, 42 had SNO (39.6%). The EFW (area under the receiver operating characteristic curve [AUC]=0.88) and GA at PPROM (AUC=0.83) were significant predictors of SNO. The addition of any of the other variables did not improve the predictive probability of EFW for the prediction of SNO. Conclusions The EFW had the strongest association with SNO in in our study among variables obtainable before delivery. Other variables had no significant effect on the prediction probability of the EFW. Our findings should be validated in larger studies.

Does left ventricular hypertrophy by electrocardiogram predict adverse outcomes in pregnancies with chronic hypertension?

Objectives: The American College of Obstetricians and Gynecologists Task Force on Hypertension in Pregnancy recommends assessing left ventricular function with echocardiogram or electrocardiogram (ECG) in women with severe hypertension of long duration. We aim to compare the rates of superimposed preeclampsia (SIP) and other obstetrical outcomes in pregnancies with chronic hypertension (CHTN) and left ventricular hypertrophy (LVH) by ECG criteria with mothers without LVH.Study design: After IRB approval, we performed a retrospective chart review from January 2015 to December 2016. Singleton pregnancies with CHTN who carried the pregnancy beyond 20 weeks and planned to deliver at our institution were included for analysis. Patients with insufficient data, multiple gestations, and those with systemic lupus erythematosus were excluded from this study. Rates of SIP and other obstetrical outcomes were compared among those with LVH and those without LVH. Univariate parametric and nonparametric statistical models were applied as appropriate. Associations were considered statistically significant at an alpha level of 0.05.Results: We included 218 pregnancies. Nineteen (8.7%) had LVH. The rate of SIP was higher in pregnancies with LVH than in those without it (68 versus 41%; OR = 3.01; 95% CI 1.1-8.5; p = .022). The birthweight was lower in the LVH group (2432 g [2120-2990] versus 2870 g [2430-3440]; p = .016). Other obstetrical outcomes were not significantly different between those patients with LVH and those without.Conclusions: LVH by ECG criteria may be associated with higher rates of SIP and with lower birthweight in pregnancies with CHTN. ECG may be a cost-effective tool to identify patients with CHTN at risk of adverse outcomes. Larger trials are necessary to corroborate our findings.

Fetal pulmonary artery acceleration/ejection time prognostic accuracy for respiratory complications in preterm prelabor rupture of membranes.

Objective: To determine the prognostic accuracy of the fetal pulmonary artery acceleration time/ejection time (PATET) for the prediction of neonatal respiratory complications (NRCs) in pregnancies with preterm premature rupture of membranes (PPROM).Methods: This is a prospective cohort of singleton pregnancies complicated by PPROM managed in our institution from October 2015 to April 2018. Inclusion criteria included mothers from 13 to 46 years of age and singleton pregnancies with PATET measurements <7 days prior to delivery. PATET was obtained by placing the Doppler caliper in the main pulmonary artery proximal to the bifurcation of this vessel. NRC was defined as: need for ventilatory support, respiratory distress syndrome (RDS), or lung hypoplasia. Logistic regression models and area under the receiver operating characteristic curves (ROC) were utilized to determine the prognostic accuracy of PATET and gestational age for NRC and RDS.Results: Of 95 patients included, 46 had NRC (RDS = 33). PATET was a significant predictor of NRC (AUC 0.74; 95%CI: 0.61-0.83; p < .001) and RDS (AUC 0.69; 95%CI: 0.57-0.80; p = .021) in PPROM. Gestational age at delivery and gestational age at PPROM were also significantly associated with NRC and RDS. Their predictive accuracy for NRC was 0.87 and 0.84, and for RDS 0.85 and 0.86, respectively.Conclusions: PATET is a statistically significant predictor for NRC in pregnancies with PPROM; however, its clinical use may be limited as gestational age is a better predictor of these outcomes.Rationale: NRCs are common in pregnancies complicated by preterm prelabor rupture of membranes (PPROM). We aim to determine the prognostic accuracy of the fetal PATET for the prediction of neonatal NRC in these pregnancies. Our results indicate that PATET is a statistically significant predictor for NRC in pregnancies with PPROM; however, its clinical use may be limited, as gestational age is a better predictor of these outcomes.

Middle cerebral artery peak systolic velocity in perinatal cytomegalovirus infection.

A middle cerebral artery peak systolic velocity value (MCA-PSV) persistently greater than 1.5 times the median of the normal population is utilized to detect moderate and severe anemia in fetuses at risk. Cytomegalovirus (CMV) is the most common perinatal infection and can cause fetal anemia. We present four cases with CMV perinatal infection. Although their MCA-PSV values were the highest recorded in normal as well as in anemic fetuses, only two of them developed moderate or severe anemia. These findings suggest that high MCA-PSV values in cases with perinatal CMV infection may have a different pathophysiologic mechanism than anemia.

Placental Location and the Development of Hypertensive Disorders of Pregnancy.

OBJECTIVES: Abnormal placentation is an important factor in the pathogenesis of preeclampsia. As a result of diminished blood flow, the incidence of preeclampsia might be higher in patients with laterally located placentas compared to patients with centrally located placentas. The objective of this study was to evaluate the relationship between placental location and the development of hypertensive disorders of pregnancy. METHODS: Patients with singleton pregnancies who were seen in our ultrasound unit and delivered at our institution from October 2014 to April 2015 were included. The incidence of hypertensive disorders was compared in those with a lateral placental location and those with centrally located placentas (placental locations other than lateral). Baseline characteristics and pregnancy outcomes were compared between groups. The χ2 test, Fisher exact test, Mann-Whitney U test, and t test were used when appropriate. P < .05 was considered significant. RESULTS: We included 464 patients; 411 (88.57%) had centrally located placentas, and 53 (11.42%) had laterally located placentas. The incidence of hypertensive disorders of pregnancy was similar between groups (21% versus 19%; P = .71). Gestational age at delivery (P = .73), and small for gestational age (P = .96) were also similar between our study groups. CONCLUSIONS: In our study, there was no difference in the rate of hypertensive disorders of pregnancy between patients with central and laterally located placentas.

Doppler evaluation of the fetal pulmonary artery pressure.

Background The Doppler effect has allowed the characterization of several vessels in maternal-fetal circulation that have been used for practical purposes. Our review of the literature showed a paucity of information about fetal pulmonary artery pressure (FMPAP) and its behavior in regard to gestational age (GA). The objectives of the study were to evaluate a formula to calculate the main FMPAP and its correlation with GA. Methods A total of 337 fetuses without obvious pathology were studied prospectively using Doppler evaluation of the FMPAP. Using the fetal main pulmonary artery Doppler acceleration time (FMPAT), we obtained the FMPAP using the following formula: FMPAP=90 - (0.62×FMPAT). Regression analyses, Pearson's bivariate correlation and paired sample t-test were used when appropriate. Results FMPAT increases while FMPAP decreases with GA. Pearson's correlation coefficient for FMPAP and GA was -0.544 (P-value<0.001) and for FMPAT and GA was 0.556 (P-value<0.001). FMPAP and FMPAT were highly correlated (R=-0.972; P<0.001). Conclusion Pulmonary artery pressure in the fetus decreases with GA.

Bilateral salpingectomy versus bilateral partial salpingectomy during cesarean delivery.

OBJECTIVE: To compare surgical outcomes in patients undergoing bilateral salpingectomy (salpingectomy group) with those who had partial salpingectomy (partial salpingectomy group) during cesarean delivery. MATERIALS AND METHODS: A chart review from July 2015 to November 2016 was performed. We included women who had sterilization during cesarean delivery. We excluded sterilization by occlusive methods. Our primary outcomes were total operative time and a composite score of transfusion rate, internal organ injury, hospital readmission, and endometritis. Secondary outcomes included menstrual abnormalities, pelvic pain, quality of life assessment, and regrets rate. We compared these outcomes between women in the salpingectomy and partial salpingectomy groups. Chi-squared, Fisher's exact, t-test, and Mann-Whitney U were utilized for statistical analysis where appropriate. A P<0.05 was considered significant. RESULTS: We included a total of 160 pregnancies. Of these, 41 were in the salpingectomy and 119 in the partial salpingectomy group. The median total operative time was longer for the salpingectomy group (62 [IQR 54, 71] vs 60 minutes [IQR 46, 72]; P=0.03). The composite of surgical complications (19.5% vs 12.6%; P=0.28) was not significantly different between our study groups. Menstrual irregularities (P≥0.99), quality of life (P≥0.99), dyspareunia (P≥0.99), dysmenorrhea (P=0.36), and regrets (P≥0.99) were not different between groups. CONCLUSION: Salpingectomy during cesarean delivery increased the median operative time by 2 minutes and may not be associated with an increased risk of surgical complications. We acknowledge the need for larger multi-center trials to corroborate our outcomes.

Technique for bilateral salpingectomy at the time of Cesarean delivery: a case series.

The American Congress of Obstetricians and Gynecologists and the Society of Gynecologic Oncology endorse bilateral salpingectomy for ovarian cancer prevention. We describe a bilateral salpingectomy technique in 23 patients during Cesarean delivery. Operative time, hospital length of stay and complications are reported. Bilateral salpingectomy during Cesarean delivery appears feasible.

Effects of selective reduced uterine perfusion pressure in pregnant rats.

INTRODUCTION: To assess the effects of selective reduced uterine perfusion pressure (SRUPP) in pregnant rats. METHODS: 20 pregnant Sprague-Dawley rats were allocated either to an intervention group, exposed to SRUPP (n = 10) or a control group, exposed to sham surgery (n = 10). Such procedures were performed on gestational day (GD) 14. The Mean arterial pressure (MAP) was measured on GD14 (before surgery) and GD20. We measured 18 h proteinuria on GD20. On GD21, mean fetal (MFW) and placental (MPW) weights were obtained. Oxidative stress and angiogenic markers were measured in placental tissue and urine. Mann Whitney U or Independent samples T test were used when appropriate. A two-sided P < 0.05 indicated statistical significance. RESULTS: MAP on GD20 was higher in the intervention group (109 ± 1.7 mmHg) when compared with the control group (83 ± 1.5 mmHg) (P = 0.002). There was no significant difference in urinary protein excretion (117 ± 3.1 mg/24 h versus 136 mg ± 2.8/24 h, P = 0.18), MFW (4.14 ± 0.05 versus 4.39 ± 0.04 g, P = 0.19) or MPW (0.43 ± 0.008 versus 0.44 ± 0.006 g, P = 0.73) between the intervention and the control groups, respectively. The oxidative stress was increased; whereas, the sFLT1 expression was not increased when the SRUPP group was compared with controls. DISCUSSION: SRUPP is associated with an increase in maternal MAP and oxidative stress and therefore it may become a useful tool in the study of pregnancy-related hypertensive disorders.

Society for Maternal-Fetal Medicine (SMFM) Clinical Guideline #8: the fetus at risk for anemia--diagnosis and management.

OBJECTIVE: We sought to provide evidence-based guidelines for the diagnosis and management of fetal anemia. METHODS: A systematic literature review was performed using MEDLINE, PubMed, EMBASE, and the Cochrane Library. The search was restricted to English-language articles published from 1966 through May 2014. Priority was given to articles reporting original research, in particular randomized controlled trials, although review articles and commentaries were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion. Evidence reports and published guidelines were also reviewed, and additional studies were located by reviewing bibliographies of identified articles. GRADE (Grading of Recommendations Assessment, Development, and Evaluation) methodology was used for defining the strength of recommendations and rating the quality of evidence. Consistent with US Preventive Task Force guidelines, references were evaluated for quality based on the highest level of evidence. RESULTS AND RECOMMENDATIONS: We recommend the following: (1) middle cerebral artery peak systolic velocity (MCA-PSV) measured by ultrasound Doppler interrogation be used as the primary technique to detect fetal anemia; (2) amniotic fluid delta OD450 not be used to diagnosis fetal anemia; (3) MCA-PSV assessment be reserved for those patients who are at risk of having an anemic fetus (proper technique for MCA-PSV evaluation includes assessment of the middle cerebral artery close to its origin, ideally at a zero degree angle without angle correction); (4) if a fetus is deemed at significant risk for severe fetal anemia (MCA greater than 1.5 multiples of the median or hydropic), fetal blood sampling be performed with preparation for an intrauterine transfusion, unless the pregnancy is at a gestational age when the risks associated with delivery are considered to be less than those associated with the procedure; (5) if a fetus is deemed at significant risk for severe fetal anemia, the patient be referred to a center with expertise in invasive fetal therapy; (6) MCA-PSV be considered to determine the timing of a second transfusion in fetuses with anemia, and, alternatively, a predicted decline in fetal hemoglobin may be used for timing the second procedure; and (7) pregnancies with a fetus at significant risk for fetal anemia be delivered at 37-38 weeks of gestation unless indications develop prior to this time.

Predicting fetal lung maturity using the fetal pulmonary artery Doppler wave acceleration/ejection time ratio.

OBJECTIVE: To determine whether the acceleration/ejection time ratio of the fetal main pulmonary artery Doppler waveform (PATET) can accurately predict the results of fetal lung maturity testing in amniotic fluid. METHODS: We prospectively studied pregnant women attending our ultrasound unit for clinically indicated fetal lung maturity testing. An ultrasound examination that included measurement of the PATET was performed before the results of the amniocentesis were reported. The results of the PATET and the surfactant/albumin ratio were compared, and a receiver operating characteristic curve was used to determine the PATET cutoff with the optimal sensitivity and specificity for predicting surfactant/albumin ratio results. p < 0.05 was considered statistically significant. RESULTS: Forty-three patients were included in this study. The receiver operating characteristic curve demonstrated that a PATET cutoff of 0.3149 provided a specificity of 93% (95% CI 77-98%), a sensitivity of 73% (95% CI 48-89%), a negative predictive value of 87% (95% CI 70-95%), and a positive predictive value of 85% (95% CI 58-96%) for predicting immature surfactant/albumin ratio results. CONCLUSION: The PATET may provide a noninvasive means of determining fetal lung maturity with acceptable levels of sensitivity, specificity, and predictive values.

Eclampsia characteristics and outcomes: a comparison of two eras.

OBJECTIVE: To describe the trends in incidence, characteristics, and outcomes of women with eclampsia. METHODS: We reviewed and abstracted data from medical records of all women diagnosed with eclampsia in our institution from August 1998 to April 2011. In addition to overall characteristics and outcomes, the cases were stratified by onset: antenatal versus postnatal and early (<32 weeks of gestation) versus late antenatal cases (≥32 weeks of gestation). Comparisons were made using chi-square, Fisher's exact, Mann-Whitney U, and t-tests. A two-sided P < 0.05 was considered statistically significant. RESULTS: We identified 87 eclampsia cases out of 59,388 deliveries; 62 cases were diagnosed before delivery, and 25 had a postnatal onset. Among the 62 antenatal cases, 41 were diagnosed before 32 weeks and 21 at or after 32 weeks of gestation. Antenatal cases had higher systolic (P = 0.03) and diastolic (P = 0.01) blood pressures, more abnormal dipstick-test proteinuria (P = 0.002), and lower platelet counts (P ≤ 0.001) than postnatal cases. Early eclampsia cases were complicated more often with HELLP syndrome than late eclampsia cases (P = 0.007). CONCLUSION: The occurrence of eclampsia has decreased over time. The earlier the onset is, the worse the outcome appears to be.

The MCA Doppler and its role in the evaluation of fetal anemia and fetal growth restriction.

Doppler velocimetry of the middle cerebral artery (MCA) has played a major role in fetal medicine for the last 23 years, both in intrauterine growth-restricted (IUGR) and anemic fetuses. Its utility in the diagnosis and management of cases of fetal anemia was initially demonstrated in cases of red cell alloimmunization and later extended to other types of anemia. In addition, MCA Doppler studies are crucial in the evaluation of IUGR fetuses. This article is a review of the role of the MCA in these 2 conditions.