American Journal of Obstetrics and Gynecology, 2004
The aim of this study was to determine whether fetal nucleated red blood cells (fNRBCs) could be ... more The aim of this study was to determine whether fetal nucleated red blood cells (fNRBCs) could be distinguished from maternal cells in peripheral blood using an erythroblast scoring system based on the unique morphological and hemoglobin staining characteristics of this cell type. Presumptive fNRBCs were further analyzed for the presence of paternally inherited DNA polymorphisms to prove fetal origin. STUDY DESIGN: fNRBCs were isolated by density gradient separation, CD15/ 45 depletion, and gamma hemoglobin positive selection from peripheral blood of nine women following termination of pregnancy for trisomy 21 (4 cases), 18 (1 case), 13 (2 cases), and other genetic abnormalities (2 cases). Candidate fetal NRBCs, based on four discrete morphological and hemoglobin staining criteria, were then subjected to fluorescent PCR amplification of chromosome 21 (D21S1411, D21S11) and chromosome 18 (D18S535) short tandem repeat (STR) DNA polymorphisms. RESULTS: In all cases candidate fetal NRBCs were accurately identified based on morphologic and hemoglobin staining characteristics and confirmed to be fetal in origin based on the presence of shared and non-shared polymorphic DNA alleles when compared to DNA isolated from maternal cells. CONCLUSION: Using the erythroblast scoring system and subsequent analysis of inherited DNA polymorphisms, we were able to distinguish fetal NRBCs from maternal cells and prove fetal origin independent of gender. These results suggest that this novel combined approach to fetal cell isolation and genetic analysis is a promising method for noninvasive prenatal diagnostic applications.
American Journal of Obstetrics and Gynecology, 2008
Background: The aim of this study was to compare pregnancy-associated plasma protein A (PAPP-A) a... more Background: The aim of this study was to compare pregnancy-associated plasma protein A (PAPP-A) and the β-subunit of human chorionic gonadotropin (hCGβ) measured in maternal plasma at the first trimester screening, in women who later developed early or late pre-eclampsia (PE) to women with normal pregnancies. Methods: In the study were included 161 cases with PE and 88 controls with uncomplicated pregnancies. Plasma PAPP-A and hCGβ were measured between gestational age (GA) 8+2 and 14+0, and cases with early and late onset PE were compared with controls. Results: Median of hCGβ (MoM) was lower in women with early (p < 0.05) and late PE (p < 0.05) compared to healthy pregnant women. Median (range) of hCGβ (MoM) for women with early onset PE, late onset PE, and women with healthy pregnancies, were 0.75 (0.30-1.21), 0.93 (0.26-3.18), and 0.97 (0.33-4.12), respectively. No significant difference in the median of PAPP-A (MoM) was found between the groups. Conclusions: hCGβ was significantly lower in pregnancies that subsequently developed PE and might be of use in the effort of trying to find ways to predict PE. No significant difference was found for PAPP-A in our study.
American Journal of Obstetrics and Gynecology, 1996
To the Editors: 1 read with interest the article of van Stuijvenberg et al. (van Stuijvenberg ME,... more To the Editors: 1 read with interest the article of van Stuijvenberg et al. (van Stuijvenberg ME, Schabort I, Labadarios D, NelJT. The nutritional status and treatment of patients with hyperemesis gravidarum. AM J OBSTET GY-N~COL 1995;172:1585-91) about the effective treatment of hyperemesis gravidarum with an intravenous saline solution containing a multivitamin preparationl Our intervention study indicated that periconceptional supplementation with a multivitamin (Elevit prenatal) can reduce the first occurrence of neural tube defects? This primary preventive method has a great medical and ethical significance as a better alternative than prenatal diagnosis (maternal serum (x-fetoprotein or ultrasonographic scanning) and selective abortion of fetuses affected with neural tube defects. An unexpected finding of the Hungarian randomized double blind controlled trial of periconceptional multivitamin supplementation was a significant reduction in the occurrence of hyperemesis gravidarum (i.e., severe nausea and vomiting that resulted in dehydration and weight loss of >5% of body weight usually requiring hospitalization but at least medical treat-ment~). This figure was 3.0% in the supplemented and 6.6% in unsupplemented groups. In addition, there was a significant decrease in the rate of moderate nausea and vomiting. Thus the expected extensive use ofpericonceptional folic-containing multivitamin supplementation will contribute the reduction of these pregnancy complications-and prevention is better than cure.
Objective To determine if first trimester fetal growth is associated with birth weight, duration ... more Objective To determine if first trimester fetal growth is associated with birth weight, duration of pregnancy, and the risk of delivering a small for gestational age infant. Design Prospective cohort study of 38 033 pregnancies between 1999 and 2003. Setting 15 centres representing major regions of the United States. Participants 976 women from the original cohort who conceived as the result of assisted reproductive technology, had a first trimester ultrasound measurement of fetal crown-rump length, and delivered live singleton infants without evidence of chromosomal or congenital abnormalities. First trimester growth was expressed as the difference between the observed and expected size of the fetus, expressed as equivalence to days of gestational age. Main outcome measures Birth weight, duration of pregnancy, and risk of delivering a small for gestational age infant. Results For each one day increase in the observed size of the fetus, birth weight increased by 28.2 (95% confidence interval 14.6 to 41.2) g. The association was substantially attenuated by adjustment for duration of pregnancy (adjusted coefficient 17.1 (6.6 to 27.5) g). Further adjustments for maternal characteristics and complications of pregnancy did not have a significant effect. The risk of delivering a small for gestational age infant decreased with increasing size in the first trimester (odds ratio for a one day increase 0.87, 0.81 to 0.94). The association was not materially affected by adjustment for maternal characteristics or complications of pregnancy. Conclusion Variation in birth weight may be determined, at least in part, by fetal growth in the first 12 weeks after conception through effects on timing of delivery and fetal growth velocity.
Background Alpha-thalassemia is one of the most common genetic disorders in the world and is beco... more Background Alpha-thalassemia is one of the most common genetic disorders in the world and is becoming more common in the United States with the increase in immigration of susceptible populations. This disease has been stated previously to be incompatible with extrauterine life. Case A Filipino woman with a prior loss due to hemoglobin Bart's underwent prenatal diagnosis that confirmed recurrence in the index pregnancy. Intravascular intrauterine exchange transfusions maintained appropriate fetal growth. A cesarean delivery yielded a 2190-g male infant with minor malformations. The postnatal course was characterized by mild respiratory insufficiency. Postnatal chronic transfusion therapy is underway pending consideration for bone marrow transplantation. Conclusion Antenatal diagnosis and therapy of homozygous α-thalassemia can prevent the prenatal consequences of hydrops and fetal death. New technologies such as stem cell transplantation may help to avert both prenatal and postna...
Background: Alpha-thalassemia is one of the most common genetic disorders in the world and is bec... more Background: Alpha-thalassemia is one of the most common genetic disorders in the world and is becoming more common in the United States with the increase in immigration of susceptible populations. This disease has been stated previously to be incompatible with extrauterine life.Case: A Filipino woman with a prior loss due to hemoglobin Bart&#39;s underwent prenatal diagnosis that confirmed recurrence in the index pregnancy. Intravascular intrauterine exchange transfusions maintained appropriate fetal growth.A cesarean delivery yielded a 2190-g male infant with minor malformations. The postnatal course was characterized by mild respiratory insufficiency. Postnatal chronic transfusion therapy is underway pending consideration for bone marrow transplantation.Conclusion: Antenatal diagnosis and therapy of homozygous a-thalassemia can prevent the prenatal consequences of hydrops and fetal death. New technologies such as stem cell transplantation may help to avert both prenatal and postnatal consequences.
To evaluate the outcome of twin-to-twin transfusion syndrome (TTTS) treated using a combination o... more To evaluate the outcome of twin-to-twin transfusion syndrome (TTTS) treated using a combination of endoscopic fetal surgery-specific techniques and surgical restraint. TTTS is a condition of identical twins that, if progressive and left untreated, leads to 100% mortality. The best treatment option is obliteration of the intertwin placental anastomoses, but fetal surgery carries significant maternal and fetal risks. Even if successful, percutaneous endoscopic laser ablation of placental vessels (LASER) causes premature rupture of membranes (PROM) in 10% to 20% of pregnancies. Patient selection is particularly critical because the progression of the disease is unpredictable. This has prompted many to intervene early, yielding survival rates of >=1 twin of 75% to 80%. We developed a minimally invasive approach to fetal surgery, a unique membrane sealing technique and a conservative algorithm that reserves intervention for severe TTTS. Pregnancies with TTTS (stages I-IV) managed in t...
What are the risks of intrauterine adhesions after "open" fetal procedures? Has there been any fo... more What are the risks of intrauterine adhesions after "open" fetal procedures? Has there been any follow-up showing how these patients do in subsequent pregnancies? Is there any evidence of issues with abnormal placentation such as placenta accreta? A few follow-up studies have been done at the centers with the longest history of performing "open" fetal surgeries, and these indicate that there is an increased risk of uterine dehiscence, uterine rupture, and placenta accreta, requiring cesarean hysterectomy in subsequent pregnancies. One of the largest studies reported a 14% risk of uterine dehiscence and a 14% risk of uterine rupture in pregnancies following open fetal surgeries (see Wilson et al,
To examine the predictive value of amniotic fluid (AF) insulin at 14-20 weeks&amp;amp;#39; ge... more To examine the predictive value of amniotic fluid (AF) insulin at 14-20 weeks&amp;amp;#39; gestation for subsequent gestational diabetes and macrosomia in unselected gravidas 35 years or older at time of genetic amniocentesis. We identified 296 pregnancies through stored AF samples from genetic amniocenteses (collected March 1987 through August 1992) in women meeting the following criteria: age 35 years or older, amniocentesis at 14-20 weeks, performance of a 50-g glucose challenge test, and adequate delivery data. A modified double-antibody radioimmunoassay reliably measured AF insulin with a detection limit of 0.35 microU/mL. Pregnant women in whom gestational diabetes was later diagnosed had higher median AF insulin levels than women who did not (0.60 versus 0.42 microU/mL, respectively; P = .026). A stepwise logistic regression analysis of gestational age at amniocentesis, maternal second-trimester weight, maternal age, and log AF insulin value on gestational diabetes showed only AF insulin to have a significant association with gestational diabetes (P = .004). Seven of 21 cases of gestational diabetes had AF insulin values exceeding the 95th percentile (1.33 microU/mL) compared with only 14 of 275 women with normal glucose tolerance (P &amp;amp;lt; .001). Amniotic fluid insulin did not predict macrosomia in either nondiabetic or gestational diabetic pregnancies. Gestational diabetes is associated with increased AF insulin at 14-20 weeks, suggesting augmentation of fetal insulin production in the early fetal period in at least some cases of gestational diabetes.
Oral poster abstracts brachiocephalic trunk. In the fetus it can be detected in the threevessel-t... more Oral poster abstracts brachiocephalic trunk. In the fetus it can be detected in the threevessel-trachea view using color Doppler. Preliminary results showed a prevalence of this vessel in 1.5% of the normal population but in one third of fetuses with Trisomy 21. The aim of the present study was to find out the prevalence of this vascular variant in fetuses with chromosomal anomalies. Patients: In the 20 months study fetuses with abnormal karyotype and a documented course of the right subclavian artery (RSA) were included in the evaluation. In the last 12 months cases at 11-14 weeks scan were attempted to be included in the study as well. Results: A total of 47 fetuses could be assessed and an ARSA was found in 16 cases (34%) 7 being before 14 weeks. Following distribution was found: In Trisomy-21 4/14 (28.5%), in Trisomy-18 5/9 (55.5%), in Trisomy 13 2/4 (50%), in Turner-S. 3/7 (43%), in 1/7 (14%) with del22q.11 (but in 1/3 with left aortic arch) and in 1/6 miscellaneous, including a case with del.4p-. In only one case with T21 (mat.age 31y) it was besides an echogenic focus the only sign detected on ultrasound. In the remaining fetuses additional soft markers or malformations were found. Conclusions: An ARSA is a common finding in chromosomal anomalies and could be used as an additional soft marker not only in DS screening but also in other chromosomal anomalies. Its detection, possible already at early fetal echocardiography, increases the risk of a chromosomal anomaly. Further studies are needed to confirm these observations.
Objective To evaluate nuchal translucency measurement quality assurance techniques in a large-sca... more Objective To evaluate nuchal translucency measurement quality assurance techniques in a large-scale study. Methods From 1999 to 2001, unselected patients with singleton gestations between 10 + 3 weeks and 13 + 6 weeks were recruited from 15 centers. Sonographic nuchal translucency measurement was performed by trained technicians. Four levels of quality assurance were employed: (1) a standardized protocol utilized by each sonographer; (2) local-image review by a second sonographer; (3) central-image scoring by a single physician; and (4) epidemiological monitoring of all accepted nuchal translucency measurements crosssectionally and over time. Results Detailed quality assessment was available for 37 018 patients. Nuchal translucency measurement was successful in 96.3% of women. Local reviewers rejected 0.8% of images, and the single central physician reviewer rejected a further 2.9%. Multivariate analysis indicated that higher body mass index, earlier gestational age and transvaginal probe use were predictors of failure of nuchal translucency measurement and central image rejection (P = 0.001). Epidemiological monitoring identified a drift in measurements over time. Conclusion Despite initial training and continuous image review, changes in nuchal translucency measurements occur over time. To maintain screening accuracy, ongoing quality assessment is needed.
The Journal of Maternal-Fetal & Neonatal Medicine, 2003
Fetal medicine is a new and evolving specialty. Complex fetal conditions may require the multidis... more Fetal medicine is a new and evolving specialty. Complex fetal conditions may require the multidisciplinary input of clinicians from many different specialties. Referral of fetal patients was made to a multidisciplinary antenatal diagnosis and management (MADAM) board if more than one specialty (in addition to maternal-fetal medicine) needed to be intimately involved in the evaluation or care of the fetus; consultation would probably lead to alterations in fetal or perinatal management; or development or revision of management guidelines was anticipated. The case log of the MADAM conferences was reviewed retrospectively for number and type of fetal anomalies, and outcome of the presentation to the MADAM board. During a 5-year period, 1% of 25654 pregnant women who were evaluated required consultations with individual pediatric and pediatric surgical specialists. Of these, 114 patients were referred to one of 77 MADAM conferences for consensus recommendation. Of these 77 discussions, 32 (42%) led to an alteration in prenatal management, 14 (18%) led to co-ordination of postnatal management and 12 (16%) led to the establishment of a new treatment guideline, or the modification of an existing one. In all, perinatal management was altered in 75% of cases. The MADAM model functions as a forum for exchange of up-to-date scientific information, development of evidence-based treatment protocols and continuity of care through the pre-, peri- and postnatal periods.
Background: Laser ablation of placental vessels effectively halts severe twin-to-twin transfusion... more Background: Laser ablation of placental vessels effectively halts severe twin-to-twin transfusion syndrome (TTTS), but fetal surgery remains a dangerous approach. The authors present the technical aspects of endoscopic fetal surgery in their initial clinical experience. Methods: Altogether, 11 women underwent endoscopic fetal surgery for severe TTTS. Access to the recipient's sac was obtained by the Seldinger technique via minilaparotomy. A 12-Fr peel-away introducer was used as a cannula to accommodate a custom-curved 9-Fr sheath containing a 1.9-mm semirigid fiber endoscope. Laser ablation was performed on all unpaired vessels crossing the intertwin membrane using a 400-lm neodymium: yttrium-aluminum-garnet (Nd: YAG) fiber. The cannula was removed over a gelatin sponge plug. Results: The median operating time was 65 min (range, 45-105 min). No patient experienced amniotic leak postoperatively. The length of hospital stay was 2.8 ± 1.6 days. Immediate improvement of the TTTS was noted in all but two patients. Pneumonia developed, in one mother leading to premature labor. There were no other major surgical complications. Fetal survival at 2 weeks was 73%. Conclusions: The safety and efficacy of endoscopic fetal surgery for severe TTTS can be optimized with the application of current minimal-access techniques. The superiority of this approach over less invasive means is still being evaluated through prospective studies.
American Journal of Obstetrics and Gynecology, 2004
The aim of this study was to determine whether fetal nucleated red blood cells (fNRBCs) could be ... more The aim of this study was to determine whether fetal nucleated red blood cells (fNRBCs) could be distinguished from maternal cells in peripheral blood using an erythroblast scoring system based on the unique morphological and hemoglobin staining characteristics of this cell type. Presumptive fNRBCs were further analyzed for the presence of paternally inherited DNA polymorphisms to prove fetal origin. STUDY DESIGN: fNRBCs were isolated by density gradient separation, CD15/ 45 depletion, and gamma hemoglobin positive selection from peripheral blood of nine women following termination of pregnancy for trisomy 21 (4 cases), 18 (1 case), 13 (2 cases), and other genetic abnormalities (2 cases). Candidate fetal NRBCs, based on four discrete morphological and hemoglobin staining criteria, were then subjected to fluorescent PCR amplification of chromosome 21 (D21S1411, D21S11) and chromosome 18 (D18S535) short tandem repeat (STR) DNA polymorphisms. RESULTS: In all cases candidate fetal NRBCs were accurately identified based on morphologic and hemoglobin staining characteristics and confirmed to be fetal in origin based on the presence of shared and non-shared polymorphic DNA alleles when compared to DNA isolated from maternal cells. CONCLUSION: Using the erythroblast scoring system and subsequent analysis of inherited DNA polymorphisms, we were able to distinguish fetal NRBCs from maternal cells and prove fetal origin independent of gender. These results suggest that this novel combined approach to fetal cell isolation and genetic analysis is a promising method for noninvasive prenatal diagnostic applications.
American Journal of Obstetrics and Gynecology, 2008
Background: The aim of this study was to compare pregnancy-associated plasma protein A (PAPP-A) a... more Background: The aim of this study was to compare pregnancy-associated plasma protein A (PAPP-A) and the β-subunit of human chorionic gonadotropin (hCGβ) measured in maternal plasma at the first trimester screening, in women who later developed early or late pre-eclampsia (PE) to women with normal pregnancies. Methods: In the study were included 161 cases with PE and 88 controls with uncomplicated pregnancies. Plasma PAPP-A and hCGβ were measured between gestational age (GA) 8+2 and 14+0, and cases with early and late onset PE were compared with controls. Results: Median of hCGβ (MoM) was lower in women with early (p < 0.05) and late PE (p < 0.05) compared to healthy pregnant women. Median (range) of hCGβ (MoM) for women with early onset PE, late onset PE, and women with healthy pregnancies, were 0.75 (0.30-1.21), 0.93 (0.26-3.18), and 0.97 (0.33-4.12), respectively. No significant difference in the median of PAPP-A (MoM) was found between the groups. Conclusions: hCGβ was significantly lower in pregnancies that subsequently developed PE and might be of use in the effort of trying to find ways to predict PE. No significant difference was found for PAPP-A in our study.
American Journal of Obstetrics and Gynecology, 1996
To the Editors: 1 read with interest the article of van Stuijvenberg et al. (van Stuijvenberg ME,... more To the Editors: 1 read with interest the article of van Stuijvenberg et al. (van Stuijvenberg ME, Schabort I, Labadarios D, NelJT. The nutritional status and treatment of patients with hyperemesis gravidarum. AM J OBSTET GY-N~COL 1995;172:1585-91) about the effective treatment of hyperemesis gravidarum with an intravenous saline solution containing a multivitamin preparationl Our intervention study indicated that periconceptional supplementation with a multivitamin (Elevit prenatal) can reduce the first occurrence of neural tube defects? This primary preventive method has a great medical and ethical significance as a better alternative than prenatal diagnosis (maternal serum (x-fetoprotein or ultrasonographic scanning) and selective abortion of fetuses affected with neural tube defects. An unexpected finding of the Hungarian randomized double blind controlled trial of periconceptional multivitamin supplementation was a significant reduction in the occurrence of hyperemesis gravidarum (i.e., severe nausea and vomiting that resulted in dehydration and weight loss of >5% of body weight usually requiring hospitalization but at least medical treat-ment~). This figure was 3.0% in the supplemented and 6.6% in unsupplemented groups. In addition, there was a significant decrease in the rate of moderate nausea and vomiting. Thus the expected extensive use ofpericonceptional folic-containing multivitamin supplementation will contribute the reduction of these pregnancy complications-and prevention is better than cure.
Objective To determine if first trimester fetal growth is associated with birth weight, duration ... more Objective To determine if first trimester fetal growth is associated with birth weight, duration of pregnancy, and the risk of delivering a small for gestational age infant. Design Prospective cohort study of 38 033 pregnancies between 1999 and 2003. Setting 15 centres representing major regions of the United States. Participants 976 women from the original cohort who conceived as the result of assisted reproductive technology, had a first trimester ultrasound measurement of fetal crown-rump length, and delivered live singleton infants without evidence of chromosomal or congenital abnormalities. First trimester growth was expressed as the difference between the observed and expected size of the fetus, expressed as equivalence to days of gestational age. Main outcome measures Birth weight, duration of pregnancy, and risk of delivering a small for gestational age infant. Results For each one day increase in the observed size of the fetus, birth weight increased by 28.2 (95% confidence interval 14.6 to 41.2) g. The association was substantially attenuated by adjustment for duration of pregnancy (adjusted coefficient 17.1 (6.6 to 27.5) g). Further adjustments for maternal characteristics and complications of pregnancy did not have a significant effect. The risk of delivering a small for gestational age infant decreased with increasing size in the first trimester (odds ratio for a one day increase 0.87, 0.81 to 0.94). The association was not materially affected by adjustment for maternal characteristics or complications of pregnancy. Conclusion Variation in birth weight may be determined, at least in part, by fetal growth in the first 12 weeks after conception through effects on timing of delivery and fetal growth velocity.
Background Alpha-thalassemia is one of the most common genetic disorders in the world and is beco... more Background Alpha-thalassemia is one of the most common genetic disorders in the world and is becoming more common in the United States with the increase in immigration of susceptible populations. This disease has been stated previously to be incompatible with extrauterine life. Case A Filipino woman with a prior loss due to hemoglobin Bart's underwent prenatal diagnosis that confirmed recurrence in the index pregnancy. Intravascular intrauterine exchange transfusions maintained appropriate fetal growth. A cesarean delivery yielded a 2190-g male infant with minor malformations. The postnatal course was characterized by mild respiratory insufficiency. Postnatal chronic transfusion therapy is underway pending consideration for bone marrow transplantation. Conclusion Antenatal diagnosis and therapy of homozygous α-thalassemia can prevent the prenatal consequences of hydrops and fetal death. New technologies such as stem cell transplantation may help to avert both prenatal and postna...
Background: Alpha-thalassemia is one of the most common genetic disorders in the world and is bec... more Background: Alpha-thalassemia is one of the most common genetic disorders in the world and is becoming more common in the United States with the increase in immigration of susceptible populations. This disease has been stated previously to be incompatible with extrauterine life.Case: A Filipino woman with a prior loss due to hemoglobin Bart&#39;s underwent prenatal diagnosis that confirmed recurrence in the index pregnancy. Intravascular intrauterine exchange transfusions maintained appropriate fetal growth.A cesarean delivery yielded a 2190-g male infant with minor malformations. The postnatal course was characterized by mild respiratory insufficiency. Postnatal chronic transfusion therapy is underway pending consideration for bone marrow transplantation.Conclusion: Antenatal diagnosis and therapy of homozygous a-thalassemia can prevent the prenatal consequences of hydrops and fetal death. New technologies such as stem cell transplantation may help to avert both prenatal and postnatal consequences.
To evaluate the outcome of twin-to-twin transfusion syndrome (TTTS) treated using a combination o... more To evaluate the outcome of twin-to-twin transfusion syndrome (TTTS) treated using a combination of endoscopic fetal surgery-specific techniques and surgical restraint. TTTS is a condition of identical twins that, if progressive and left untreated, leads to 100% mortality. The best treatment option is obliteration of the intertwin placental anastomoses, but fetal surgery carries significant maternal and fetal risks. Even if successful, percutaneous endoscopic laser ablation of placental vessels (LASER) causes premature rupture of membranes (PROM) in 10% to 20% of pregnancies. Patient selection is particularly critical because the progression of the disease is unpredictable. This has prompted many to intervene early, yielding survival rates of >=1 twin of 75% to 80%. We developed a minimally invasive approach to fetal surgery, a unique membrane sealing technique and a conservative algorithm that reserves intervention for severe TTTS. Pregnancies with TTTS (stages I-IV) managed in t...
What are the risks of intrauterine adhesions after "open" fetal procedures? Has there been any fo... more What are the risks of intrauterine adhesions after "open" fetal procedures? Has there been any follow-up showing how these patients do in subsequent pregnancies? Is there any evidence of issues with abnormal placentation such as placenta accreta? A few follow-up studies have been done at the centers with the longest history of performing "open" fetal surgeries, and these indicate that there is an increased risk of uterine dehiscence, uterine rupture, and placenta accreta, requiring cesarean hysterectomy in subsequent pregnancies. One of the largest studies reported a 14% risk of uterine dehiscence and a 14% risk of uterine rupture in pregnancies following open fetal surgeries (see Wilson et al,
To examine the predictive value of amniotic fluid (AF) insulin at 14-20 weeks&amp;amp;#39; ge... more To examine the predictive value of amniotic fluid (AF) insulin at 14-20 weeks&amp;amp;#39; gestation for subsequent gestational diabetes and macrosomia in unselected gravidas 35 years or older at time of genetic amniocentesis. We identified 296 pregnancies through stored AF samples from genetic amniocenteses (collected March 1987 through August 1992) in women meeting the following criteria: age 35 years or older, amniocentesis at 14-20 weeks, performance of a 50-g glucose challenge test, and adequate delivery data. A modified double-antibody radioimmunoassay reliably measured AF insulin with a detection limit of 0.35 microU/mL. Pregnant women in whom gestational diabetes was later diagnosed had higher median AF insulin levels than women who did not (0.60 versus 0.42 microU/mL, respectively; P = .026). A stepwise logistic regression analysis of gestational age at amniocentesis, maternal second-trimester weight, maternal age, and log AF insulin value on gestational diabetes showed only AF insulin to have a significant association with gestational diabetes (P = .004). Seven of 21 cases of gestational diabetes had AF insulin values exceeding the 95th percentile (1.33 microU/mL) compared with only 14 of 275 women with normal glucose tolerance (P &amp;amp;lt; .001). Amniotic fluid insulin did not predict macrosomia in either nondiabetic or gestational diabetic pregnancies. Gestational diabetes is associated with increased AF insulin at 14-20 weeks, suggesting augmentation of fetal insulin production in the early fetal period in at least some cases of gestational diabetes.
Oral poster abstracts brachiocephalic trunk. In the fetus it can be detected in the threevessel-t... more Oral poster abstracts brachiocephalic trunk. In the fetus it can be detected in the threevessel-trachea view using color Doppler. Preliminary results showed a prevalence of this vessel in 1.5% of the normal population but in one third of fetuses with Trisomy 21. The aim of the present study was to find out the prevalence of this vascular variant in fetuses with chromosomal anomalies. Patients: In the 20 months study fetuses with abnormal karyotype and a documented course of the right subclavian artery (RSA) were included in the evaluation. In the last 12 months cases at 11-14 weeks scan were attempted to be included in the study as well. Results: A total of 47 fetuses could be assessed and an ARSA was found in 16 cases (34%) 7 being before 14 weeks. Following distribution was found: In Trisomy-21 4/14 (28.5%), in Trisomy-18 5/9 (55.5%), in Trisomy 13 2/4 (50%), in Turner-S. 3/7 (43%), in 1/7 (14%) with del22q.11 (but in 1/3 with left aortic arch) and in 1/6 miscellaneous, including a case with del.4p-. In only one case with T21 (mat.age 31y) it was besides an echogenic focus the only sign detected on ultrasound. In the remaining fetuses additional soft markers or malformations were found. Conclusions: An ARSA is a common finding in chromosomal anomalies and could be used as an additional soft marker not only in DS screening but also in other chromosomal anomalies. Its detection, possible already at early fetal echocardiography, increases the risk of a chromosomal anomaly. Further studies are needed to confirm these observations.
Objective To evaluate nuchal translucency measurement quality assurance techniques in a large-sca... more Objective To evaluate nuchal translucency measurement quality assurance techniques in a large-scale study. Methods From 1999 to 2001, unselected patients with singleton gestations between 10 + 3 weeks and 13 + 6 weeks were recruited from 15 centers. Sonographic nuchal translucency measurement was performed by trained technicians. Four levels of quality assurance were employed: (1) a standardized protocol utilized by each sonographer; (2) local-image review by a second sonographer; (3) central-image scoring by a single physician; and (4) epidemiological monitoring of all accepted nuchal translucency measurements crosssectionally and over time. Results Detailed quality assessment was available for 37 018 patients. Nuchal translucency measurement was successful in 96.3% of women. Local reviewers rejected 0.8% of images, and the single central physician reviewer rejected a further 2.9%. Multivariate analysis indicated that higher body mass index, earlier gestational age and transvaginal probe use were predictors of failure of nuchal translucency measurement and central image rejection (P = 0.001). Epidemiological monitoring identified a drift in measurements over time. Conclusion Despite initial training and continuous image review, changes in nuchal translucency measurements occur over time. To maintain screening accuracy, ongoing quality assessment is needed.
The Journal of Maternal-Fetal & Neonatal Medicine, 2003
Fetal medicine is a new and evolving specialty. Complex fetal conditions may require the multidis... more Fetal medicine is a new and evolving specialty. Complex fetal conditions may require the multidisciplinary input of clinicians from many different specialties. Referral of fetal patients was made to a multidisciplinary antenatal diagnosis and management (MADAM) board if more than one specialty (in addition to maternal-fetal medicine) needed to be intimately involved in the evaluation or care of the fetus; consultation would probably lead to alterations in fetal or perinatal management; or development or revision of management guidelines was anticipated. The case log of the MADAM conferences was reviewed retrospectively for number and type of fetal anomalies, and outcome of the presentation to the MADAM board. During a 5-year period, 1% of 25654 pregnant women who were evaluated required consultations with individual pediatric and pediatric surgical specialists. Of these, 114 patients were referred to one of 77 MADAM conferences for consensus recommendation. Of these 77 discussions, 32 (42%) led to an alteration in prenatal management, 14 (18%) led to co-ordination of postnatal management and 12 (16%) led to the establishment of a new treatment guideline, or the modification of an existing one. In all, perinatal management was altered in 75% of cases. The MADAM model functions as a forum for exchange of up-to-date scientific information, development of evidence-based treatment protocols and continuity of care through the pre-, peri- and postnatal periods.
Background: Laser ablation of placental vessels effectively halts severe twin-to-twin transfusion... more Background: Laser ablation of placental vessels effectively halts severe twin-to-twin transfusion syndrome (TTTS), but fetal surgery remains a dangerous approach. The authors present the technical aspects of endoscopic fetal surgery in their initial clinical experience. Methods: Altogether, 11 women underwent endoscopic fetal surgery for severe TTTS. Access to the recipient's sac was obtained by the Seldinger technique via minilaparotomy. A 12-Fr peel-away introducer was used as a cannula to accommodate a custom-curved 9-Fr sheath containing a 1.9-mm semirigid fiber endoscope. Laser ablation was performed on all unpaired vessels crossing the intertwin membrane using a 400-lm neodymium: yttrium-aluminum-garnet (Nd: YAG) fiber. The cannula was removed over a gelatin sponge plug. Results: The median operating time was 65 min (range, 45-105 min). No patient experienced amniotic leak postoperatively. The length of hospital stay was 2.8 ± 1.6 days. Immediate improvement of the TTTS was noted in all but two patients. Pneumonia developed, in one mother leading to premature labor. There were no other major surgical complications. Fetal survival at 2 weeks was 73%. Conclusions: The safety and efficacy of endoscopic fetal surgery for severe TTTS can be optimized with the application of current minimal-access techniques. The superiority of this approach over less invasive means is still being evaluated through prospective studies.
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