Amy E. Wong

Medically Indicated—Iatrogenic Prematurity

Premature delivery of an infant is occasionally performed because of complications of pregnancy. This article reviews common medical indications for preterm delivery and the available evidence supporting delivery before 37 weeks of gestation. In many conditions, few data exist to guide optimal timing of delivery and management is guided by expert opinion. Ultimately, an individual assessment must be made in each case to weigh the risks that pregnancy continuation poses to the mother and/or fetus with the risks of prematurity and its associated morbidities.

Second-Trimester Placental Location and Postpartum Hemorrhage

The purpose of this study was to assess whether low placentation in the second trimester is an independent risk factor for postpartum hemorrhage.

Discordant Lower Urinary Tract Obstruction in Early Twin Gestations: Management and Outcome

OBJECTIVE: To report our experience with the management of twin pregnancies discordant for lower urinary tract obstruction. METHODS: Cases of twin pregnancies discordant for lower urinary tract obstruction were identified from our fetal medicine database. Information on ultrasonographic findings, antenatal course, pregnancy complications, and perinatal outcome was obtained by reviewing medical records or contacting the referring obstetricians. RESULTS: Five twin pregnancies discordant for lower urinary tract obstruction were diagnosed between 11 and 15 weeks of gestation. There were 3 dichorionic and 2 monochorionic pregnancies (1 diamniotic and 1 monoamniotic). The dichorionic pregnancies were managed conservatively, resulting in a pregnancy loss of both twins in 1 case, a single fetal death at 29 weeks in 1 case, and an early neonatal death due to lung hypoplasia of the affected twin in 1 case. On the other hand, both monochorionic twin pregnancies were managed with serial vesicocenteses. In both cases, the prenatal course was complicated, 1 by premature rupture of the membranes and the other by cord entanglement, requiring delivery at 29 and 31 weeks, respectively. Among the 4 continuing pregnancies with complete perinatal outcome, none of the affected twins survived, and the structurally normal twins were delivered between 29 and 36 weeks and discharged from the hospital in good condition. CONCLUSION: Twin pregnancies discordant for lower urinary tract obstruction are at high risk of perinatal death and premature delivery. Prenatal intervention seems not to be associated with an improved perinatal outcome of the affected twin, but it may be beneficial in selected cases to attain viability of the unaffected twin. LEVEL OF EVIDENCE: III

Antenatal identification of major depressive disorder: a cohort study

OBJECTIVE The purpose of this study was to estimate the frequency of identification of major depressive disorder by providers during prenatal care. STUDY DESIGN A cohort of pregnant women who were participating in a randomized controlled trial and who had received a diagnosis of major depressive disorder was examined. Women were included in the current study if prenatal clinic records were available and legible. RESULTS Clinical depression was noted in 56% of prenatal charts and on 24% of problem lists. Physicians and certified nurse midwives noted depression equally (P = .935); physicians more frequently noted mental health referral (23% vs 0%; P = .01), and midwives more frequently included depression on the problem list (P = .01). Recent medication use, which was stopped before conception or study participation, predicted notation of depression in the chart (P = .001). CONCLUSION Depression frequently is missed during pregnancy and, when identified, is underacknowledged as a problem. Women who have not recently used antidepressant medication are more likely to be missed. Better screening and acknowledgment are needed.

Prenatal Diagnosis of Double Trisomy 48,XXX,+18 in the First Trimester

Double trisomy is a relatively common event in pregnancies ending in early miscarriage and usually involves at least 1 nonviable aneuploidy. 1 However, cases that continue beyond the first trimester of pregnancy are exceptionally rare. Among these cases, double trisomies usually involve the sex chromosomes in combination with potentially viable autosomal trisomies such as 21, 18, and 13. 2 In this report, we present a case of double trisomy 48,XXX,+18 diagnosed in the first trimester of pregnancy as the result of nuchal translucency screening for Down syndrome.

Prenatal diagnosis of spina bifida: from intracranial translucency to intrauterine surgery

Accurate and timely prenatal diagnosis of spina bifida (SB) is a major goal of modern antenatal care. Prenatal screening for open SB should be first performed at the time of routine first-trimester ultrasound by examining the posterior fossa for obliteration or non-visualization of the fourth ventricle (“intracranial translucency”) and cisterna magna. The second step of screening is the second-trimester anatomy scan, at which time the features of the Chiari type II malformation should be looked for, including ventriculomegaly, scalloping of the frontal bones (“lemon” sign), and backward and caudal displacement of the cerebellar vermis with obliteration of the cisterna magna (“banana” sign). In cases with positive findings, evaluation must include a focused examination of the spine for defects. In cases of closed SB and SB occulta, the cranial and posterior fossa features will not be present as they are not associated with leaking of spinal fluid and resultant hindbrain herniation, highlighting the fact that the spine should be examined thoroughly whenever possible during the second-trimester scan. In tertiary fetal medicine centers, two-dimensional and three-dimensional ultrasound allows an accurate determination of the location, type, extent, and upper level of the spinal defect as well as the presence of associated anomalies. Fetal magnetic resonance imaging should be restricted to candidates for intrauterine surgery as part of the preoperative protocol.

Patient and provider attitudes toward screening for Down syndrome in a Latin American country where abortion is illegal

To examine patient and provider attitudes toward first trimester nuchal translucency (NT) screening for Down syndrome and to assess how patients consent to screening in a country where abortion is illegal.

Socioeconomic Disparities in Diagnostic Testing after Positive Aneuploidy Screening

OBJECTIVE The objective of this study was to investigate the association between type of health insurance (Medicaid vs. private) and uptake of diagnostic testing for fetal aneuploidy after a positive screening test result. METHODS We performed a retrospective cohort study of pregnant women who underwent aneuploidy screening in the first and/or second trimesters of pregnancy and received positive results. The characteristics of and outcomes for women with Medicaid were compared with those of women with private insurance in both univariable and multivariable analyses. RESULTS In this study, 75 women with Medicaid and 75 with private insurance were analyzed. Those with Medicaid were younger (33.8 vs. 36.9 years, p < 0.01), and more likely to be of non-white race/ethnicity (88 vs. 27%, p < 0.01), unmarried (65 vs. 19%, p < 0.01), non-English speaking (12 vs. 0%, p < 0.01), and multiparous (76 vs. 59%, p = 0.02). They also were less likely to undergo diagnostic testing after a positive aneuploidy screen (35 vs. 57%, p < 0.01). In multivariable analysis, those with Medicaid remained significantly less likely to undergo diagnostic testing (odds ratio, 0.26; 95% confidence interval, 0.09-0.80). CONCLUSION Women with Medicaid are less likely than women with private insurance to undergo diagnostic testing after positive screening for aneuploidy. These results emphasize the potential importance of improved counseling for low-income women.

Perinatal HIV testing and diagnosis in Illinois after implementation of the Perinatal Rapid Testing Initiative

OBJECTIVE The objective of the study was to assess whether implementation of a statewide initiative was associated with changes in perinatal human immunodeficiency virus (HIV) testing practices. STUDY DESIGN This was an observational cohort study of all 1,141,799 women who delivered in Illinois birthing hospitals over a 7 year period after the introduction of the Perinatal Rapid Testing Implementation in Illinois (PRTII) initiative. Changes in the frequencies of HIV status documentation, rapid test utilization, and newborns discharged with unknown HIV status were assessed. RESULTS The comparison of annual data from 2005 to 2011 demonstrated a 63% decrease in women with undocumented HIV status (11.7% vs 4.3%, P < .001), a 98% decrease in women with unknown status who did not receive rapid testing (29.6% vs 0.5%, P < .001), and a greater than 99% decrease in newborns with undocumented status at discharge (2.74% vs 0.01%, P < .001). CONCLUSION This statewide initiative resulted in a significant and sustained increase in the frequency of maternal-baby pairs who were discharged from the hospital with documented HIV status.

Evaluation of the Fetal Face in the First Trimester

Evaluation of the fetal face during the first trimester of pregnancy is a relatively new area of research in Fetal Medicine. The first attempts to examine the fetal face in early pregnancy were performed using transvaginal or transabdominal embryofetoscopy in the early 1990s [1–3]. Although this invasive technique allowed the early diagnosis of facial abnormalities in several high-risk cases [4, 5], the high rate of miscarriage made this approach unacceptable for diagnostic and therapeutic purposes in ongoing pregnancies [6]. Currently, the use of this technique is confined to confirm ultrasound diagnosis before first-trimester termination of pregnancy [7].