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OBJECTIVES: Our primary objective was to evaluate how prenatal diagnosis of a major fetal structural anomaly and resulting pregnancy outcome affected postpartum depression risk, as assessed by the Edinburgh Postnatal Depression Scale (EPDS). Secondary objectives were to review the rate of mental health follow-up and subsequent diagnosis of postpartum depression in screen-positive women. STUDY DESIGN: Singleton pregnancies with prenatal diagnosis of one or more major fetal structural anomalies were ascertained from prospectively maintained databases that included perinatal outcomes and subsequent EPDS responses from January 2010 to May 2018. EPDS scores of 13 or higher were considered positive and prompted referral for mental health follow-up, which was verified by medical record review. Statistical analyses were performed using Student's t-test, χ2, and odds ratios (ORs) with p < 0.05 considered significant. RESULTS: A total of 1,306 women had a prenatal diagnosis of one or more major fetal structural anomalies, 896 (68%) also had a postpartum EPDS screening, and 82 (9.2%) screened positive. Positive EPDS screening was more common with anomalies of multiple organ systems (16.5 vs 7.8%, p = 0.002) and aneuploidy (17.1 vs 9.3%, p = 0.02). Pregnancies complicated by fetal death, neonatal death, and termination for anomaly were significantly more likely to screen positive than those with neonatal survival to discharge (OR, 3.1 [95% confidence interval [CI], 1.6-6.2], 3.0 [95% CI, 1.5-5.8], and 4.4 [95% CI, 2.1-8.9], respectively, p ≤ 0.002). Of the 35 (43%) screen-positive women who attended follow-up appointments with mental health providers, 18 (51%) were diagnosed with a depressive disorder, accounting overall for 22% of those with a positive EPDS screen. CONCLUSION: Among women with a prenatal diagnosis of a major fetal structural anomaly, those experiencing a perinatal loss or pregnancy termination have an increased risk of positive EPDS screen result compared with who have a neonate surviving to discharge. A depressive disorder was diagnosed postpartum in 22% of these women with a positive EPDS screen. Our findings highlight the mental health needs in this vulnerable population. KEY POINTS: · Adverse pregnancy outcome increased positive EPDS screen risk among women with prenatal anomalies.. · A depressive disorder was diagnosed postpartum in 22% of such women with a positive EPDS screen.. · Our findings highlight the mental health needs in this vulnerable population..
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Transtornos Cromossômicos , Anormalidades Congênitas/diagnóstico , Depressão Pós-Parto , Diagnóstico Pré-Natal/psicologia , Adulto , Aneuploidia , Transtornos Cromossômicos/diagnóstico , Anormalidades Congênitas/psicologia , Feminino , Cardiopatias Congênitas/diagnóstico , Humanos , Malformações do Sistema Nervoso , Gravidez , Resultado da Gravidez , RiscoRESUMO
OBJECTIVES: The placenta accreta spectrum (PAS) incidence has risen substantially over the past century, paralleling a rise in cesarean delivery (CD) rates. Prenatal diagnosis of PAS improves maternal outcomes. The Placenta Accreta Index (PAI) is a standardized approach to prenatal diagnosis of PAS incorporating clinical risk and ultrasound (US) findings suggestive of placental invasion. We sought to validate the PAI for prediction of PAS in pregnancies with prior CD. METHODS: This work was a retrospective cohort study of pregnancies with 1 or more prior CDs that received a US diagnosis of placenta previa or low-lying placenta in the third trimester. Images of third-trimester US with a complete placental evaluation were read by 2 blinded physicians, and the PAI was applied. Surgical outcomes and pathologic findings were reviewed. Placenta accreta spectrum was diagnosed if clinical evidence of invasion was seen at time of delivery or if any placental invasion was identified histologically. International Federation of Gynecology and Obstetrics criteria were used. RESULTS: A total of 194 women met inclusion criteria. Cesarean hysterectomy was performed in 92 (47%), CD in 97 (50%), and vaginal delivery in 5 (3%). Of those who underwent hysterectomy, PAS was histologically confirmed in 79 (85%) pregnancies. Of the remaining 13 who underwent hysterectomy, all met International Federation of Gynecology and Obstetrics grade 1 clinical criteria for PAS. With a threshold of greater than 4, the PAI has a sensitivity of 87%, specificity of 77%, positive predictive value of 72%, and negative predictive value of 90% for PAS diagnosis. CONCLUSIONS: Contemporaneous application of the PAI, a standardized approach to US diagnosis, is useful in the prenatal prediction of PAS.
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Placenta Acreta , Placenta Prévia , Feminino , Humanos , Placenta/diagnóstico por imagem , Placenta Acreta/diagnóstico por imagem , Placenta Prévia/diagnóstico por imagem , Gravidez , Estudos Retrospectivos , Ultrassonografia Pré-NatalRESUMO
OBJECTIVE: The study aimed to evaluate the association between hemoglobin A1c values and likelihood of fetal anomalies in women with pregestational diabetes. STUDY DESIGN: Women with pregestational diabetes who delivered at a single institution that serves a nonreferred population from May 1, 2009 to December 31, 2018 were ascertained. Hemoglobin A1c values were obtained at the first prenatal visit. Women who delivered a singleton live- or stillborn infant with a major malformation as defined by European Surveillance of Congenital Anomalies criteria were identified. In infants with multiple system anomalies, each malformation was considered separately. Hemoglobin A1c values were analyzed categorically by using Mantel-Haenszel method and continuously with linear regression for trend for fetal anomalies. RESULTS: A total of 1,676 deliveries to women with pregestational diabetes were delivered at our institution, and hemoglobin A1c was assessed in 1,573 deliveries (94%). There were 129 deliveries of an infant with at least one major malformation, an overall anomaly rate of approximately 8%. Mean hemoglobin A1c concentration was significantly higher in pregnancies with anomalous infants, 9.3 ± 2.1% versus 8.0 ± 2.1%, and p <0.001. There was no difference in gestational age at the time hemoglobin A1c was obtained, 13 ± 8.3 versus 14 ± 8.7 weeks. Hemoglobin A1c was associated with increased probability of a congenital malformation. This reached 10% with a hemoglobin A1c concentration of 10%, and 20% with a hemoglobin A1c of 13%. Similar trends were seen when examining risk of anomalies by organ system with increasing hemoglobin A1c levels, with the greatest increase in probability for both cardiac and genitourinary anomalies. CONCLUSION: In women with pregestational diabetes, hemoglobin A1c is strongly associated with fetal anomaly risk. Data from a contemporary cohort may facilitate counseling and also highlight the need for preconceptual care and glycemic optimization prior to entry to obstetric care. KEY POINTS: · Infants of diabetic mothers had an 8% major anomaly rate.. · HbA1c of 10% in pregnancy associated with 10% anomaly rate.. · HbA1c of 13% in pregnancy associated with 20% anomaly rate.. · Preconceptual care is important to reduce prevalence..
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Anormalidades Congênitas/epidemiologia , Hemoglobinas Glicadas/análise , Gravidez em Diabéticas , Adulto , Estudos de Coortes , Diabetes Mellitus Tipo 1 , Diabetes Mellitus Tipo 2 , Feminino , Cardiopatias Congênitas/epidemiologia , Humanos , Paridade , Gravidez , Anormalidades Urogenitais/epidemiologiaRESUMO
BACKGROUND: Placenta accreta spectrum (PAS) in women with previous cesarean delivery has become increasingly prevalent. Depending on the severity, patient management may involve cesarean hysterectomy. PURPOSE: To investigate textural analyses as the radiomics in MRI of the placenta in predicting the PAS requiring cesarean hysterectomy in a high-risk population. STUDY TYPE: Retrospective. POPULATION: Sixty-two women with prior cesarean delivery referred for MRI because of sonographic suspicion for PAS. FIELD STRENGTH/SEQUENCE: 1.5T with T1 W, T2 W, and diffusion-weighted imaging (DWI). ASSESSMENT: Two reviewers independently evaluated MR images based on five established PAS variables. Placental regions of interest (ROIs) were generated on T2 W, DWI, and an apparent diffusion coefficient (ADC) map, based on definitions of areas of placenta in proximity to and remote from previous surgical incision sites. STATISTICAL TESTS: Reader agreement was assessed by simple kappa and prevalence adjusted bias adjusted kappa (PABAK). T-tests and chi-square analyses between the primary outcome (hysterectomy vs. no hysterectomy) were performed. Thirteen Haralick texture features calculated from gray-level co-occurrence matrixes were extracted from manually drawn placental ROIs within each of three MR acquisitions. Univariate and multivariable logistic regression were used to assess the association with cesarean hysterectomy. RESULTS: Of 62 pregnancies at risk for PAS, 40 required cesarean hysterectomy (65%), with excellent correlation between need for hysterectomy and pathology confirmation of PAS in the hysterectomy specimen [κ = 0.82 (0.62, 1)]. Reader agreement was fair to moderate. Of the 13 Haralick variables within each of three acquisition groups, significant differences (P < 0.05) were seen in 22 of 39 parameters comparing placental ROIs in proximity to incision scar(s) to those ROIs remote from scar. A stepwise selection algorithm indicated that the combination of T2 W Fcm.sum.var , ADC Fcm.diff.entr , and DWI Fcm.energy gave the highest leave-one-out-AUC of 0.80 (0.68, 0.91). DATA CONCLUSION: Assessment of PAS severity is subjective and dependent on radiologist expertise. We identified textural features on placental MR images in the region of the prior uterine scar that differentiated pregnancies requiring cesarean hysterectomy based on clinical suspicion of PAS from those that did not, suggesting predictive capabilities of these objective radiomics features. LEVEL OF EVIDENCE: 3 Technical Efficacy Stage: 1 J. Magn. Reson. Imaging 2020;51:936-946.
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Placenta Acreta , Imagem de Difusão por Ressonância Magnética , Feminino , Humanos , Histerectomia , Imageamento por Ressonância Magnética , Placenta Acreta/diagnóstico por imagem , Placenta Acreta/cirurgia , Gravidez , Estudos RetrospectivosRESUMO
BACKGROUND: In 2014, the Eunice Kennedy Shriver National Institute of Child Health and Human Development Fetal Imaging Workshop consensus recommended that sonograms be offered routinely to all pregnant women. In the absence of another indication, this examination is recommended at 18-22 weeks of gestation. Studies of anomaly detection often focus on pregnancies at risk for anomalies and on the yield of detailed sonography, topics less applicable to counseling low-risk pregnancies about the benefits and limitations of standard sonography. The clinical utility of follow-up sonogram in low-risk pregnancies for the purpose of fetal anomaly detection has not been established. OBJECTIVE: The objective of the study was to evaluate the utility of follow-up standard sonography for anomaly detection among low-risk pregnancies in a nonreferred population. STUDY DESIGN: We performed a retrospective cohort study of singleton pregnancies that underwent standard sonography at 18-21 6/7 weeks of gestation from October 2011 through March 2018 with subsequent delivery of a live-born infant at our hospital. Pregnancies with indications for detailed sonography in our system were excluded to evaluate fetal anomalies first identified with standard sonography. Anomalies were categorized according to the European Registration of Congenital Anomalies and Twins (EUROCAT) system, with confirmation based on neonatal evaluation. Among those with no anomaly detected initially, we evaluated the rate of subsequent detection according to number of follow-up sonograms, gestational age at sonography, organ system(s) affected, and anomaly severity. Statistical analyses were performed using χ2 and a Mantel-Haenszel test. RESULTS: Standard sonography was performed in 40,335 pregnancies at 18-21 6/7 weeks, and 11,770 (29%) had at least 1 follow-up sonogram, with a second follow-up sonogram in 3520 (9%). Major abnormalities were confirmed in 387 infants (1%), with 248 (64%) detected initially and 28 (7%) and 5 (1%) detected on the first and second follow-up sonograms. Detection of residual anomalies on follow-up sonograms was significantly lower than detection on the initial standard examination: 64% on initial examination, 45% for first follow-up, and 45% for second follow-up (P < .01). A larger number of follow-up examinations were required per anomalous fetus detected: 163 examinations per anomalous fetus detected initially, 420 per fetus detected at the first follow-up examination, and 705 per fetus detected at the second follow-up sonogram (P < .01). The number of follow-up examinations to detect each additional anomalous fetus was not affected by gestational age (P = .7). Survival to hospital discharge was significantly lower for fetuses with anomalies detected on initial (88%) than for fetuses with anomalies undetected until delivery (90 of 91, 99%; P < .002). CONCLUSION: In a low-risk, nonreferred cohort with fetal anomaly prevalence of 1%, follow-up sonography resulted in detection of 45% of fetal anomalies that had not been identified during the initial standard sonogram. Significantly more follow-up sonograms were required to detect each additional anomalous fetus.
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Anormalidades Congênitas/diagnóstico por imagem , Idade Gestacional , Guias de Prática Clínica como Assunto , Ultrassonografia Pré-Natal/métodos , Anormalidades Múltiplas/diagnóstico por imagem , Adulto , Doenças do Desenvolvimento Ósseo/congênito , Doenças do Desenvolvimento Ósseo/diagnóstico por imagem , Estudos de Coortes , Anormalidades Craniofaciais/diagnóstico por imagem , Anormalidades do Sistema Digestório/diagnóstico por imagem , Feminino , Cardiopatias Congênitas/diagnóstico por imagem , Humanos , Recém-Nascido , Malformações do Sistema Nervoso/diagnóstico por imagem , Gravidez , Segundo Trimestre da Gravidez , Anormalidades do Sistema Respiratório/diagnóstico por imagem , Estudos Retrospectivos , Ultrassonografia Pré-Natal/normas , Anormalidades Urogenitais/diagnóstico por imagemRESUMO
OBJECTIVE. The purpose of this study is to determine whether MRI parameters of placenta accreta spectrum correlate with pathologic and surgical outcomes in high-risk pregnancies. MATERIALS AND METHODS. This retrospective study evaluated second- and third-trimester pregnancies assessed by MRI from 2007 to the present. Women were included in the study if placental invasion was suspected on the basis of a clinical history of cesarean delivery, ultrasound findings, or both. MR images were reviewed by an experienced radiologist who was blinded to the clinical outcomes. Eighteen MRI parameters were assessed and compared with four clinical outcomes: surgical impression of invasion, need for cesarean hysterectomy, pathologic findings, and need for blood transfusion. RESULTS. Of 64 women, 43 required cesarean hysterectomy, 20 underwent cesarean delivery, and one delivered vaginally. There was no statistical difference among the women in terms of maternal age, gestational age, or the number of prior cesarean deliveries. Eight of the 18 MRI parameters assessed showed statistical significance. The five variables with the highest odds ratios were bulge (7.432), placenta previa (7.283), low-attenuation T2 linear bands (5.985), placental heterogeneity near the scar (4.384), and fibrin deposition (4.322), with additional significant variables including interruption of the bladder-serosa interface, the radiologist's interpretation of invasion, and the largest dimension of invasion. Some previously described parameters, such as the degree of maternal pelvic vascularity, were not statistically significant. CONCLUSION. MRI parameters are associated with placental invasion and correlate with the need for cesarean hysterectomy, as well as pathologic and surgical impressions of invasion. From these parameters, an organized template can be created to standardize reporting of placental invasion.
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Imageamento por Ressonância Magnética/métodos , Placenta Acreta/diagnóstico por imagem , Gravidez de Alto Risco , Adulto , Cesárea , Feminino , Humanos , Histerectomia , Interpretação de Imagem Assistida por Computador , Gravidez , Resultado da Gravidez , Segundo Trimestre da Gravidez , Terceiro Trimestre da Gravidez , Estudos Retrospectivos , Ultrassonografia Pré-NatalRESUMO
OBJECTIVES: To characterize population-based use of fetal magnetic resonance imaging (MRI) incorporating recent American College of Radiology (ACR)-Society of Perinatal Radiologists (SPR) guidelines about fetal anomalies for which MRI may provide valuable additional information when sonography is limited. METHODS: We conducted a retrospective review of nonreferred singleton pregnancies that received prenatal care and had prenatal sonographic diagnosis of 1 or more major structural anomalies at our hospital between January 2010 and May 2018. Detailed sonography was performed in all anomaly cases. Fetal anomaly information was obtained from a prospectively maintained database, and medical records were reviewed to determine the rationale for why MRI was or was not performed, according to the indication. RESULTS: A total of 104,597 singleton pregnancies underwent sonographic assessments of anatomy at our institution during the study period. Major structural anomalies were identified in 1650 (1.6%) of these pregnancies. Potential indications for fetal MRI per ACR-SPR guidelines were identified in 339 cases. However, fetal MRI was performed in only 253 cases, 15% of those with major anomalies and 75% with a potential indication. Magnetic resonance imaging was not performed in 41 (20%) of identified pregnancies because of an improved prognosis on serial sonography (36), because of a poor prognosis (3), or because it would not alter management (2). CONCLUSIONS: Fetal MRI was used in 15% of those pregnancies with prenatal diagnosis of a major structural anomaly. This amounted to fewer than 0.3% of singleton deliveries. Judicious application of ACR-SPR guidelines in the context of serial sonography results in a relatively small number of fetal MRI examinations in a nonreferred population.
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Cuidado Pré-Natal , Ultrassonografia Pré-Natal , Feminino , Humanos , Imageamento por Ressonância Magnética , Gravidez , Diagnóstico Pré-Natal , Estudos RetrospectivosRESUMO
OBJECTIVES: To evaluate fetal anomaly detection in pregnancies with pregestational diabetes, according to the gestational age at the time of specialized sonography, use of follow-up sonography, maternal body mass index, and organ system(s) involved. METHODS: Women with pregestational diabetes who received prenatal care and delivered a live-born or stillborn neonate at our hospital from October 2011 through April 2017 were ascertained. We included all pregnancies with at least 1 confirmed structural anomaly (EUROCAT classification) who had detailed sonography at 18 weeks' gestation or later. We analyzed detection of anomalous fetuses at the initial detailed sonogram and, if no abnormality was identified, during any follow-up sonograms. Statistical analyses were performed with the χ2 test and Mantel-Haenszel χ2 test for trend. RESULTS: Seventy-two anomalous neonates (72 of 1060 [6.8%]) were born. Overall detection was 55 of 72 (76%); 49 of 72 (68%) were detected at the initial detailed sonogram, compared to 6 of 15 (40%) of follow-up examinations (P = .04). Recognition at the initial or follow-up examination was not dependent on gestational age or body mass index category (all P > .05). Of individual organ system anomalies, 67 of 89 (75%) were identified. Detection exceeded 85% for central nervous system, genitourinary, and musculoskeletal abnormalities and 43% for craniofacial anomalies. Sixty-five percent of cardiac anomalies were detected, and 14 of 17 (82%) requiring specialized care in the immediate neonatal period were recognized. CONCLUSIONS: Approximately three-fourths of anomalous fetuses were identified, with greater detection at the initial detailed examination. Fetuses with central nervous system, genitourinary, musculoskeletal abnormalities and those with cardiac anomalies requiring specialized cardiac care were more likely to come to attention.
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Diabetes Mellitus , Cardiopatias Congênitas , Feminino , Feto/diagnóstico por imagem , Idade Gestacional , Humanos , Recém-Nascido , Gravidez , Ultrassonografia Pré-NatalRESUMO
OBJECTIVES: To prospectively evaluate low implantation of the gestational sac and other first-trimester ultrasound (US) parameters for prediction of placenta accreta spectrum (PAS). METHODS: Women with a diagnosis of low implantation on clinically indicated first-trimester US underwent a transvaginal US examination at 10 to 13 weeks' gestation to assess the trophoblast location, anechoic areas, bridging vessels, and smallest myometrial thickness (SMT). The placental location was evaluated in the second trimester, and serial US examinations were performed in cases of low placentation. Placenta accreta spectrum was based on clinical findings and confirmed by histologic results. RESULTS: Of 68 women, 40 (59%) had prior cesarean delivery (CD). Hysterectomy was performed in 8, all with prior CD. Of these, 7 (88%) had US suspicion of PAS. In 16 with prior CD and basalis overlying the internal os, 9 (56%) had second-trimester placenta previa, and 7 of 9 (78%) underwent hysterectomy with pathologic confirmation of PAS. Of 28 without prior CD, there were no cases of persistent low placentation in the third trimester regardless of the trophoblast location. Ultrasound parameters associated with PAS were a smaller distance from the inferior trophoblastic border to the external os, disruption of the bladder-serosal interface, bridging vessels, anechoic areas, and the SMT. In women with prior CD, use of the SMT in the sagittal plane yielded an area under the receiver operating characteristic curve of 0.96 (95% confidence interval, 0.91-1.00). CONCLUSIONS: First-trimester low implantation increases the risk of persistent placenta previa and PAS in women with prior CD. All parameters were associated with PAS, the most predictive being the SMT.
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Placenta Acreta , Placenta Prévia , Feminino , Humanos , Placenta Acreta/diagnóstico por imagem , Placenta Prévia/diagnóstico por imagem , Gravidez , Primeiro Trimestre da Gravidez , Estudos Prospectivos , Ultrassonografia , Ultrassonografia Pré-NatalRESUMO
OBJECTIVE: The objective of this study was to evaluate risk factor prevalence in pregnancies with fetal Down syndrome, in an effort to characterize efficacy of population-based screening. STUDY DESIGN: Retrospective review of singleton pregnancies with delivery of live born or stillborn infant with Down syndrome from 2009 through 2015. Risk factor categories included maternal age ≥35 years, abnormal serum screening, identification of ≥1 ultrasound marker at 16 to 22 weeks (nuchal thickness ≥6 mm, echogenic intracardiac focus, echogenic bowel, renal pelvis dilatation, femur length
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Síndrome de Down/diagnóstico , Feto/diagnóstico por imagem , Diagnóstico Pré-Natal , Ultrassonografia Pré-Natal , Adulto , Biomarcadores/sangue , Feminino , Humanos , Idade Materna , Gravidez , Resultado da Gravidez/epidemiologia , Segundo Trimestre da Gravidez/sangue , Cuidado Pré-Natal/métodos , Diagnóstico Pré-Natal/métodos , Diagnóstico Pré-Natal/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Ultrassonografia Pré-Natal/métodos , Ultrassonografia Pré-Natal/estatística & dados numéricos , Estados UnidosRESUMO
Polyhydramnios, or hydramnios, is an abnormal increase in the volume of amniotic fluid. Identification of polyhydramnios should prompt a search for an underlying etiology. Although most cases of mild polyhydramnios are idiopathic, the 2 most common pathologic causes are maternal diabetes mellitus and fetal anomalies, some of which are associated with genetic syndromes. Other causes of polyhydramnios include congenital infection and alloimmunization. The purpose of this document is to provide guidance on the evaluation and management of polyhydramnios. The following are Society for Maternal-Fetal Medicine recommendations: (1) we suggest that polyhydramnios in singleton pregnancies be defined as either a deepest vertical pocket of ≥8 cm or an amniotic fluid index of ≥24 cm (GRADE 2C); (2) we recommend that amnioreduction be considered only for the indication of severe maternal discomfort, dyspnea, or both in the setting of severe polyhydramnios (GRADE 1C); (3) we recommend that indomethacin should not be used for the sole purpose of decreasing amniotic fluid in the setting of polyhydramnios (GRADE 1B); (4) we suggest that antenatal fetal surveillance is not required for the sole indication of mild idiopathic polyhydramnios (GRADE 2C); (5) we recommend that labor should be allowed to occur spontaneously at term for women with mild idiopathic polyhydramnios; that induction, if planned, should not occur at <39 weeks of gestation in the absence of other indications; and that mode of delivery should be determined based on usual obstetric indications (GRADE 1C); and (6) we recommend that women with severe polyhydramnios deliver at a tertiary center due to the significant possibility that fetal anomalies may be present (GRADE 1C).
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OBJECTIVES: The purpose of this study was to evaluate the association between first-trimester sonographic findings and morbidly adherent placenta at delivery. METHODS: We conducted a retrospective review of all first-trimester sonographic examinations from pregnancies that underwent third-trimester sonography for placenta previa or low-lying placenta between September 1997 and October 2011. Only women with a prior cesarean delivery were included. Transabdominal and transvaginal images from these first-trimester studies were reviewed for the following sonographic parameters: distance from the inferior border of the gestational sac to the external cervical os, location of the decidua basalis, presence of anechoic areas, uterine-bladder interface irregularity, and smallest anterior myometrial thickness. Morbidly adherent placentation was confirmed on histologic examination of hysterectomy specimens. Statistical methods included univariate and multivariate analyses. RESULTS: Thirty-nine patients met inclusion criteria, of whom 14 (36%) had confirmed placental invasion. The number of prior cesarean deliveries was significantly associated with placental invasion (P < .0001). The only first-trimester sonographic finding associated with invasion was the smallest anterior myometrial thickness measured in the sagittal plane (P < .02). Multivariate analysis based on these two variables yielded an area under the receiver operating characteristic curve of 0.94 (95% confidence interval, 0.87-1.00) and significantly improved the prediction of placental invasion compared to using the number of prior cesarean deliveries alone. CONCLUSIONS: In women with persistent placenta previa or low-lying placenta and prior cesarean delivery, the smallest anterior myometrial thickness on first-trimester sonography significantly improved detection of morbidly adherent placenta.
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Placenta Acreta/diagnóstico por imagem , Ultrassonografia Pré-Natal , Adulto , Feminino , Humanos , Gravidez , Primeiro Trimestre da Gravidez , Estudos RetrospectivosRESUMO
OBJECTIVE: Nonimmune hydrops is the presence of ≥2 abnormal fetal fluid collections in the absence of red cell alloimmunization. The most common etiologies include cardiovascular, chromosomal, and hematologic abnormalities, followed by structural fetal anomalies, complications of monochorionic twinning, infection, and placental abnormalities. We sought to provide evidence-based guidelines for the evaluation and management of nonimmune hydrops fetalis. METHODS: A systematic literature review was performed using MEDLINE, PubMed, EMBASE, and Cochrane Library. The search was restricted to English-language articles published from 1966 through June 2014. Priority was given to articles reporting original research, although review articles and commentaries also were consulted. Abstracts of research presented at symposia and scientific conferences were not considered adequate for inclusion in this document. Evidence reports and guidelines published by organizations or institutions such as the National Institutes of Health, Agency for Health Research and Quality, American Congress of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine were also reviewed, and additional studies were located by reviewing bibliographies of identified articles. Grading of Recommendations Assessment, Development, and Evaluation methodology was employed for defining strength of recommendations and rating 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: Evaluation of hydrops begins with an antibody screen (indirect Coombs test) to determine if it is nonimmune, detailed sonography of the fetus(es) and placenta, including echocardiography and assessment for fetal arrhythmia, and middle cerebral artery Doppler evaluation for anemia, as well as fetal karyotype and/or chromosomal microarray analysis, regardless of whether a structural fetal anomaly is identified. Recommended treatment depends on the underlying etiology and gestational age; preterm delivery is recommended only for obstetric indications including development of mirror syndrome. Candidates for corticosteroids and antepartum surveillance include those with an idiopathic etiology, an etiology amenable to prenatal or postnatal treatment, and those in whom intervention is planned if fetal deterioration occurs. Such pregnancies should be delivered at a facility with the capability to stabilize and treat critically ill newborns. The prognosis depends on etiology, response to therapy if treatable, and the gestational age at detection and delivery. Aneuploidy confers a poor prognosis, and even in the absence of aneuploidy, neonatal survival is often <50%. Mirror syndrome is a form of severe preeclampsia that may develop in association with fetal hydrops and in most cases necessitates delivery.
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Parto Obstétrico/métodos , Hidropisia Fetal/diagnóstico , Hidrotórax/diagnóstico , Anemia/complicações , Anemia/diagnóstico , Anemia/terapia , Arritmias Cardíacas/complicações , Arritmias Cardíacas/diagnóstico , Arritmias Cardíacas/terapia , Transfusão de Sangue Intrauterina/métodos , Teste de Coombs , Drenagem , Ecocardiografia , Feminino , Doenças Fetais/diagnóstico , Doenças Fetais/terapia , Humanos , Hidropisia Fetal/terapia , Hidrotórax/terapia , Gravidez , Ultrassonografia Doppler , Ultrassonografia Pré-NatalRESUMO
Vasa previa occurs when fetal blood vessels that are unprotected by the umbilical cord or placenta run through the amniotic membranes and traverse the cervix. If membranes rupture, these vessels may rupture, with resultant fetal hemorrhage, exsanguination, or even death. Prenatal diagnosis of vasa previa by ultrasound scans is approximately 98%. Approximately 28% of prenatally diagnosed cases result in emergent preterm delivery. Management of prenatally diagnosed vasa previa includes antenatal corticosteroids between 28-32 weeks of gestation, considerations for preterm hospitalization at 30-34 weeks of gestation, and scheduled delivery at 34-37 weeks of gestation.
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Vasa Previa/diagnóstico , Vasa Previa/terapia , Algoritmos , Cesárea , Feminino , Hospitalização , Humanos , Gravidez , Fatores de Risco , Ultrassonografia Doppler em Cores , Vasa Previa/diagnóstico por imagem , Vasa Previa/epidemiologiaRESUMO
OBJECTIVE: We sought to apply a standardized evaluation of ultrasound parameters for the prediction of placental invasion in a high-risk population. STUDY DESIGN: This was a retrospective review of gravidas with ≥1 prior cesarean delivery who received an ultrasound diagnosis of placenta previa or low-lying placenta in the third trimester at our institution from 1997 through 2011. Sonographic images were reviewed by an investigator blinded to pregnancy outcome and sonography reports. Parameters assessed included loss of retroplacental clear zone, irregularity and width of uterine-bladder interface, smallest myometrial thickness, presence of lacunar spaces, and bridging vessels. Diagnosis of placental invasion was based on histologic confirmation. Statistical analyses were performed using linear logistic regression and multiparametric analyses to generate a predictive equation evaluated using a receiver operating characteristic curve. RESULTS: Of 184 gravidas who met inclusion criteria, 54 (29%) had invasion confirmed on hysterectomy specimen. All sonographic parameters were associated with placental invasion (P < .001). Constructing a receiver operating characteristic curve, the combination of smallest sagittal myometrial thickness, lacunae, and bridging vessels, in addition to number of cesarean deliveries and placental location, yielded an area under the curve of 0.87 (95% confidence interval, 0.80-0.95). Using logistic regression, a predictive equation was generated, termed the "Placenta Accreta Index." Each parameter was weighted to create a 9-point scale in which a score of 0-9 provided a probability of invasion that ranged from 2-96%, respectively. CONCLUSION: Assignment of the Placenta Accreta Index may be helpful in predicting individual patient risk for morbidly adherent placenta.
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Placenta Acreta/diagnóstico por imagem , Ultrassonografia Pré-Natal , Adulto , Técnicas de Apoio para a Decisão , Feminino , Humanos , Modelos Logísticos , Placenta Prévia/diagnóstico por imagem , Gravidez , Terceiro Trimestre da Gravidez , Gravidez de Alto Risco , Curva ROC , Estudos Retrospectivos , Medição de Risco , Sensibilidade e Especificidade , Ultrassonografia Doppler em Cores , Ultrassonografia Pré-Natal/métodosRESUMO
OBJECTIVES: The purpose of this study was to estimate the utility of sonography to detect small-for-gestational-age (SGA) neonates in pregnancies with gastroschisis and to evaluate neonatal outcomes according to birth weight percentile. METHODS: We conducted a retrospective cohort study of singleton pregnancies with fetal gastroschisis delivered at our hospital between August 1997 and December 2012. Diagnosis of growth restriction was based on estimated fetal weight below the 10th percentile using the nomogram of Hadlock et al (Am J Obstet Gynecol 1985; 151:333-337), evaluated at 4-week intervals throughout gestation and compared with subsequent birth weight, to evaluate the accuracy of sonography to detect and exclude SGA neonates. Pregnancy and neonatal outcomes were evaluated according to birth weight percentile. RESULTS: There were 111 births with gastroschisis (6 per 10,000), and one-third (n = 37) had birth weight below the 10th percentile. The sensitivity and negative predictive value of sonography for an SGA neonate both approached 90% by 32 weeks and were approximately 95% thereafter. Detection increased with advancing gestational age (P = .02). The birth weight percentile was not associated with preterm birth, infection, bowel complications requiring surgery, duration of hospitalization, or perinatal mortality. Delayed closure of the gastroschisis defect was more frequent with birth weights at or below the 3rd percentile (P = .03). CONCLUSIONS: Sonography reliably identified SGA neonates with gastroschisis in our series, and its utility improved with advancing gestation. Apart from delayed closure of the defect, a low birth weight percentile was not associated with an increased risk of morbidity or mortality in the immediate neonatal period.
Assuntos
Retardo do Crescimento Fetal/diagnóstico por imagem , Retardo do Crescimento Fetal/mortalidade , Gastrosquise/diagnóstico por imagem , Gastrosquise/mortalidade , Resultado da Gravidez/epidemiologia , Ultrassonografia Pré-Natal/estatística & dados numéricos , Adolescente , Adulto , Criança , Comorbidade , Feminino , Humanos , Recém-Nascido , Recém-Nascido Pequeno para a Idade Gestacional , Masculino , Gravidez , Prevalência , Prognóstico , Reprodutibilidade dos Testes , Fatores de Risco , Sensibilidade e Especificidade , Taxa de Sobrevida , Texas/epidemiologia , Ultrassonografia Pré-Natal/métodos , Adulto JovemRESUMO
OBJECTIVES: To assess the utility of biometric indices and amniotic fluid volume in identifying fetuses with lethal skeletal dysplasia. METHODS: A review of pregnancies with sonographic diagnosis of skeletal dysplasia between January 1997 and March 2012 from a single institution was conducted. Biometric indices and amniotic fluid volumes were reviewed from the initial targeted sonograms and all subsequent examinations. Outcomes were verified in all cases. Pregnancies that resulted in fetal or neonatal death were considered to have lethal dysplasia, and those with survival to hospital discharge were considered to have nonlethal dysplasia. RESULTS: Of 45 fetuses with suspected skeletal dysplasia, 27 (60%) survived to hospital discharge; 9 (20%) died in the immediate neonatal period; 2 (4%) resulted in stillbirth; and in 7 cases (16%), pregnancy termination was elected. Those with lethal dysplasia were more likely to have hydramnios on initial detection than those who survived to hospital discharge (83% versus 27%; P < .01). Pregnancies complicated by lethal skeletal dysplasia had a significantly lower femur length-to-abdominal circumference ratio and were more likely to have a ratio below 0.16 than those with neonatal survival (91% versus 11%; P < 0.01). The lowest femur length-to-abdominal circumference ratio and the proportion with a ratio below 0.16 at any point in gestation were significantly different between those with lethal and nonlethal dysplasia (P< .01). As fetal size increased with advancing gestation, the relationship of sonographic parameters (eg, femur length-to-abdominal circumference ratio) became more pronounced. There was no infant survival when hydramnios was encountered at any point during gestation in the setting of a femur length-to-abdominal circumference ratio below 0.16. CONCLUSIONS: In our series, a femur length-to-abdominal circumference ratio below 0.16 in conjunction with hydramnios effectively identified fetuses with lethal skeletal dysplasia.
Assuntos
Doenças do Desenvolvimento Ósseo/diagnóstico por imagem , Doenças do Desenvolvimento Ósseo/mortalidade , Anormalidades Craniofaciais/diagnóstico por imagem , Anormalidades Craniofaciais/mortalidade , Morte Fetal , Imagem Multimodal/métodos , Poli-Hidrâmnios/diagnóstico por imagem , Poli-Hidrâmnios/mortalidade , Ultrassonografia Pré-Natal/estatística & dados numéricos , Líquido Amniótico/diagnóstico por imagem , Biometria/métodos , Feminino , Mortalidade Hospitalar , Humanos , Interpretação de Imagem Assistida por Computador/métodos , Incidência , Recém-Nascido , Masculino , Modelos Biológicos , Modelos Estatísticos , Morte Perinatal , Mortalidade Perinatal , Gravidez , Reprodutibilidade dos Testes , Medição de Risco , Sensibilidade e Especificidade , Taxa de Sobrevida , Texas/epidemiologiaRESUMO
OBJECTIVE: The purpose of this study was to analyze the obstetric and neonatal impact of an opioid detoxification program during pregnancy, as well as to examine variables associated with successful opioid detoxification. STUDY DESIGN: This is a retrospective cohort study of women electing inpatient detoxification and subsequently delivering at our hospital from Jan. 1, 2006, through Dec. 31, 2011. Detoxification was considered successful if women had no illicit drug supplementation at the time of delivery. Maternal characteristics were ascertained by chart review and analyzed for variables associated with success. Obstetric and neonatal outcomes were also assessed based on maternal success at delivery. RESULTS: Of the 95 women during the study period with complete data, 53 (56%) were successful. There were no demographic or social risk factors identified associated with success. Women with successful detoxification at delivery had longer inpatient detoxification admissions (median 25 vs 15 days, P < .001) and were less likely to leave prior to completion of the program than women who had relapsed at delivery (9% vs 33%, respectively, P < .001). Infants of mothers who were successfully detoxified had shorter hospitalizations (median 3 vs 22 days, P < .001), lower maximum neonatal abstinence syndrome scores (0 vs 8.3, P < .001), and were less likely to be treated for withdrawal (10% vs 80%, P < .001). CONCLUSION: Opiate detoxification in pregnancy requires a significant time commitment and extended treatment, however, can be successfully achieved in compliant parturients. Importantly, maternal demographics and drug histories do not portend success, supporting continued opiate detoxification being offered to all women expressing intent.