The utility of fetal echocardiography after an unremarkable anatomy scan.

OBJECTIVE: To estimate whether fetal echocardiography detects major cardiac anomalies after normal anatomy ultrasound scan in patients at increased risk for having a fetus with congenital heart disease. METHODS: A computerized database was used to identify patients who underwent fetal echocardiography at the New York University Division of Pediatric Cardiology after anatomy ultrasound scan at the New York University Obstetrics and Gynecology Ultrasound Unit. Only patients with normal anatomy ultrasound scan results were included in the primary analysis. Patients were excluded if they had suspicious cardiac views on anatomy ultrasound scan or extracardiac anomalies. Major cardiac anomalies were defined as those judged by a blinded pediatric cardiologist as likely to require medical or surgical intervention in the first 6 months of life. RESULTS: Of 1,034 patients in the pediatric cardiology database, 536 patients underwent anatomy ultrasound scan at the New York University Obstetrics and Gynecology Department. Eighty patients in the case group were excluded for suspicious or inadequate cardiac views and 139 were excluded for extracardiac ultrasound findings. Of the remaining 317 patients with normal obstetric ultrasound scan results, none had a major cardiac malformation diagnosed on fetal echocardiography. CONCLUSION: In a tertiary care center with operators performing a high volume of ultrasound screenings, fetal echocardiography after normal anatomy ultrasound scan may be of limited benefit. LEVEL OF EVIDENCE: III.

Angiogenic imbalances: the obstetric perspective.

Clinical and experimental evidence indicates that angiogenic imbalances may participate in the mechanisms of disease of several pregnancy complications, some of which may be life threatening. This article reviews current evidence in support of this view and the possibility that the fetus may play a central role in these imbalances; it also reviews recent experimental observations that modulation of angiogenic imbalances during pregnancy may have prophylactic and/or therapeutic value.

Indications for fetal echocardiography high referral, low yield?

UNLABELLED: An excellent imaging tool in the prenatal diagnosis and ongoing evaluation of congenital heart defects, fetal echocardiography is indicated in a selected population at increased risk compared with the general population. For certain "soft markers" of fetal congenital heart defects, ambiguity in the indications for fetal echo may result in a high referral rate, but low yield of congenital heart disease. Here, we critically examine 4 conditions, 2 maternal and 2 fetal: maternal gestational diabetes, advanced maternal age, isolated echogenic focus, and single umbilical artery. This critical review reveals that more prospective population-based studies with higher power and minimal bias need to be performed to establish the absolute risk of congenital heart defects in a selected population compared with that of the general population. Nonetheless, our analysis indicates that the absolute risk of congenital heart defects associated with each of these markers is low. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader should be able to define which patients should be referred for fetal echocardiography based on known risks, distinguish between relative and absolute risks for fetal congenital heart disease, and summarize fetal anomaly risks for women with altered glucose metabolism.

Universal tuberculosis screening in pregnancy.

We reviewed our practice of universal tuberculosis (TB) screening in an at-risk pregnant population with regards to utility and patient compliance. The Gouverneur Healthcare Services prenatal database was analyzed for compliance with TB screening. Age, ethnicity, country of origin, and education level were also analyzed. Of 4049 patients, 95.0% were compliant with their purified protein derivative (PPD) testing. Universal screening identified 1935 (50.4%) PPD+ patients, with chest X-rays (CXR) available for 95.1%. Only one patient had a CXR consistent with active TB, although sputum testing was negative for acid-fast bacilli. Asian women were more likely to be PPD-compliant (adjusted odds ratio [aOR]: 4.94, 95% confidence interval [CI]: 2.34 to 10.45). Similarly, PPD+ Asian women were more likely to be compliant with CXR (aOR: 12.67, 95% CI: 3.44 to 46.7). U.S.-born women were significantly less likely to be compliant with PPD (aOR: 0.44, 95% CI: 0.30 to 0.64) or with CXR (aOR: 0.22, 95% CI: 0.08 to 0.61). Universal prenatal TB screening is associated with excellent compliance rates and is an effective way to identify a high prevalence of latent TB, but not active disease.

Predictors of severe perineal lacerations in Chinese women.

OBJECTIVE: Chinese women have been shown to have a higher incidence of severe perineal laceration compared to other ethnic groups. We sought to test the hypothesis that this risk is related to body mass index (BMI) or to a relative fetal-maternal size disproportion as measured by the ratio of the newborn birthweight to maternal BMI (BW:BMI). METHODS: A retrospective cohort study was performed using a pre-existing obstetric database. Third- and fourth-degree perineal lacerations served as the primary outcome of interest. Logistic regression was used to compare Chinese women to other ethnic groups and adjust for confounders. RESULTS: Three thousand and eighty-five singleton vaginal deliveries were identified, with BMI data available for 2281. Chinese women had a greater risk for severe perineal laceration compared to Caucasian (OR: 3.22; 95% CI: 0.73-14.32) and Hispanic women (OR: 2.88; 95% CI: 1.92-4.30). Multivariate analysis found that newborn birth weight plays a role (OR: 1.0012; 95% CI: 1.0007-1.0016), but BMI alone did not explain the discrepancy (P=0.89). However, the BW:BMI ratio appears to be a stronger predictor of laceration rate than either variable alone (OR: 1.011; 95% CI: 1.003-1.020). CONCLUSION: The higher risk of severe perineal laceration in Chinese women compared to other ethnicities can be attributed, in part, to a relative fetal-maternal size disproportion.

Debate preparation/participation: an active, effective learning tool.

BACKGROUND: Passive educational techniques (such as lectures) are thought to be less productive than active learning. PURPOSE: We examined whether preparing for and participating in a debate would be an effective, active way to learn about a controversial topic. METHODS: We compared quiz performance in residents who attended a lecture to residents who prepared for/participated in a debate. Twelve residents each participated in one lecture session and one debate session. Learning was evaluated via a quiz. Quizzes were given twice: before the debate/lecture and 1 week after the debate/lecture. Quiz scores were compared using repeated measures analysis of variance, with a p value of < .05 considered significant. A survey evaluating the usefulness of debating was given to all participants. RESULTS: There was a statistically significant difference in the pretest mean quiz score between the debate and lecture groups: 78.3% and 52.5%, respectively (p = .02). Similarly, on posttest quizzes, the average debater scored 85.8%, versus 61.7% for the lecture group (p = .003). Although no one in the debate group scored lower on a follow-up quiz, 3 residents in the lecture group did worse on follow-up. CONCLUSIONS: When learning about a controversial topic, residents who prepared for/participated in a debate achieved higher quiz scores and were better at retaining information than those who attended a lecture. When faced with teaching a controversial topic, organizing a debate may be more effective than giving a lecture.

Intrahepatic cholestasis of pregnancy: detection with urinary bile acid assays.

AIMS: To determine sensitivity and specificity of urine bile acid sulfate (UBAS) and non-sulfated urine bile acid (UBA) assays for detection of intrahepatic cholestasis of pregnancy (ICP). METHODS: Urine was collected prospectively from healthy and pruritic patients evaluated for ICP. Results were expressed as a ratio to urinary creatinine. RESULTS: Of 20 patients evaluated for ICP, 14 had confirmed ICP by serum testing and six had pruritus only. UBAS results were higher with ICP (P<0.001) and increased with gestational age in healthy controls. Adjusted for gestational age, the multiples of the median (MoM) were still higher (2.64+/-1.11, 1.05+/-0.54, P<0.001). The sensitivity was 100% and specificity 83% at 1.5 MoM in pruritic patients. UBA results were higher with ICP (23.0+/-9.8, 12.8+/-7.4, P<0.001), with sensitivity of 100% and specificity of 50% at 10.2 micromol/g cretinine. CONCLUSION: Urinary bile acids can detect or exclude ICP with serum abnormalities. Urine bile acid sulfates have higher specificity than non-sulfated urine bile acids at equivalent sensitivities, but co-detection of progestin sulfates is suspected.

Medical legal issues in the prevention of prematurity.

Preterm birth remains the leading cause of neonatal morbidity and mortality in the world today. This article discusses ways the treatment team can inform parents of probable outcomes and help them reach decisions about treatment for the newborn under emotionally fraught conditions. In addition to supporting the patient, these approaches may help the clinician avoid malpractice litigation.

Comparison of three outpatient regimens in the management of nausea and vomiting in pregnancy.

OBJECTIVE: This study compares pyridoxine-metoclopramide combination therapy to prochlorperazine and promethazine monotherapies in the outpatient treatment of nausea and vomiting in pregnancy. STUDY DESIGN: In total, 174 first trimester, singleton pregnancies were evaluated for nausea and vomiting. Patients were prospectively randomized into three treatment groups: pyridoxine-metoclopramide, prochlorperazine, or promethazine. Prior to, and on the third day, patients recorded their subjective responses to the given treatment and their number of emesis episodes. The three treatment groups were compared for therapy response. RESULTS: There were no differences in the number of emesis episodes prior to treatment. Both subjective and objective responses to treatment differed among the three groups when comparing the combination therapy to the monotherapies (p<0.05). CONCLUSION: Combination therapy with pyridoxine and metoclopramide appears to be superior to either monotherapy in the treatment of nausea and vomiting in pregnancy.