Anthony Odibo

Cerclage for short cervix on ultrasonography: meta-analysis of trials using individual patient-level data.

Objective: Preterm birth is the main cause of perinatal morbidity and mortality. A short cervical length on transvaginal ultrasonography predicts preterm birth. Our aim was to estimate by meta-analysis of randomized trials whether cerclage prevents preterm birth in women with a short cervical length. Data Sources: MEDLINE, PubMed, EMBASE, and the Cochrane Library were searched with the terms “cerclage,” “cervical cerclage,” “short cervix,” “ultrasound,” and “randomized trial.” We included randomized trials involving the use of cerclage in women with short cervical length on transvaginal ultrasonography using patient-level data. Tabulation, Integration, and Results: Four properly conducted trials were identified. In the total population, preterm birth at less than 35 weeks of gestation occurred in 29.2% (89/305) of the cerclage group, compared with 34.8% (105/302) of the no-cerclage groups (relative risk [RR] 0.84, 95% confidence interval [CI] 0.67–1.06). There was no significant heterogeneity in the overall analysis (P = .29). There was a significant reduction in preterm birth at less than 35 weeks in the cerclage group compared with the no-cerclage groups in singleton gestations (RR 0.74, 95% CI 0.57–0.96), singleton gestations with prior preterm birth (RR 0.61, 95% CI 0.40–0.92), and singleton gestations with prior second-trimester loss (RR 0.57, 95% CI 0.33–0.99). There was a significant increase in preterm birth at less than 35 weeks in twin gestations (RR 2.15, 95% CI 1.15–4.01). Conclusion: Cerclage does not prevent preterm birth in all women with short cervical length on transvaginal ultrasonography. In the subgroup analysis of singleton gestations with short cervical length, especially those with a prior preterm birth, cerclage may reduce preterm birth, and a well-powered trial should be carried out in this group of patients. In contrast, in twins, cerclage was associated with a significantly higher incidence of preterm birth.

Position statement from the Aneuploidy Screening Committee on behalf of the Board of the International Society for Prenatal Diagnosis

Department of Genetics and Developmental Biology, University of Connecticut Health Center, Farmington, CT, USA Prenatal Diagnosis Unit, Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic, Maternitat Campus, University of Barcelona Medical School, Catalonia, Spain Department of Chemical Pathology, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, USA Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA Department of Human Genetics, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands Department of Obstetrics and Gynecology, Albert Einstein College of Medicine, New York, NY, USA Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, USA Department of Obstetrics and Gynecology, Washington University in St Louis, St Louis, MO, USA Laboratory for Infectious Diseases and Perinatal Screening, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands Prenatal Screening Unit, Clinical Biochemistry Department, Barking Havering & Redbridge University Hospitals, King George Hospital, Goodmayes, UK Genetics Program, North York General Hospital, Toronto, ON, Canada Department of Mathematics and Statistics, University of Plymouth, Plymouth, UK Prenatal Diagnosis Unit, Genetic Institute, Sourasky Medical Center, Tel Aviv, Israel *Correspondence to: Peter Benn. E-mail: benn@nso1.uchc.edu This Statement replaces the January 2011 Statement (Prenatal Diagnosis 2011;31:519–522) and the Rapid Response Statement (Prenatal Diagnosis 2012;32:1–2).

Prenatal Detection of Down Syndrome using Massively Parallel Sequencing (MPS): a rapid response statement from a committee on behalf of the Board of the International Society for Prenatal Diagnosis, 24 October 2011

Department of Genetics and Developmental Biology, University of Connecticut Health Center, Farmington, CT, USA Prenatal Diagnosis Unit, Institute of Gynecology, Obstetrics and Neonatology, Hospital Clinic, Maternitat Campus, University of Barcelona Medical School, Catalonia, Spain Department of Obstetrics and Gynecology, Columbia University Medical Center, New York, NY, USA Department of Obstetrics and Gynecology, University of Pennsylvania, Philadelphia, PA, USA Department of Obstetrics and Gynecology, Albert Einstein College of Medicine, New York, NY, USA Department of Obstetrics and Gynecology, University of Calgary, Calgary, AB, Canada Department of Obstetrics and Gynecology, Assaf Harofe Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel Department of Obstetrics and Gynecology, Washington University in St Louis, St Louis, MO, USA Laboratory for Infectious Diseases and Perinatal Screening, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands Prenatal Screening Unit, Clinical Biochemistry Department, Barking Havering and Redbridge University Hospital, King George Hospital, Goodmayes, UK Department of Mathematics and Statistics, University of Plymouth, Plymouth, UK Prenatal Diagnosis Unit, Genetic Institute, Sourasky Medical Center, Tel Aviv, Israel *Correspondence to: Peter Benn. E-mail: benn@nso1.uchc.edu

Management of parvovirus infection in pregnancy and outcomes of hydrops : A survey of members of the Society of Perinatal Obstetricians

OBJECTIVE Our purpose was to investigate the evaluation and management of parvovirus infection during pregnancy. STUDY DESIGN Surveys were mailed to members of the Society of Perinatal Obstetricians residing in the United States and Canada in July 1997. They were asked about their evaluation and management of parvovirus infection, including whether they repeated and confirmed serologic studies, what their initial and follow-up evaluations included, whether they had had any cases of parvovirus-associated hydrops in the past 2 years, and if so, what were the management and outcomes of the hydropic fetuses. RESULTS Surveys were mailed to 1623 members of the Society of Perinatal Obstetricians and 541 completed surveys were returned. Sixty-eight percent of the respondents repeated and confirmed serologic studies. Eighty-nine percent used ultrasonography in their initial management of pregnant patients with recent parvovirus infection, 7.5% used amniocentesis for polymerase chain reaction, and 2% used fetal blood sampling. The outcomes of the 539 cases of parvovirus-induced hydrops included spontaneous resolution in 34%, death without intrauterine transfusion in 30%, resolution after intrauterine transfusion in 29%, death after intrauterine transfusion in 6%, and pregnancy termination in 1%. Almost all cases of nonimmune hydrops reported occurred between 16 and 32 weeks. CONCLUSIONS Approximately one third of the cases of parvovirus-induced nonimmune hydrops resolved spontaneously, whereas 83.5% of hydropic fetuses transfused survived.

Revisiting the Fetal Loss Rate After Second-Trimester Genetic Amniocentesis : A Single Center's 16-Year Experience

OBJECTIVE: To estimate an institution’s specific fetal loss rate after a second-trimester genetic amniocentesis. METHODS: This is a retrospective cohort study using our prenatal diagnosis database for all pregnant women presenting for care between 1990 and 2006. We compared the fetal loss rate in women who underwent amniocentesis between 15 and 22 weeks of gestation with those women who did not have any invasive procedure and had a live fetus documented on ultrasound examination between 15 and 22 weeks. Only singleton gestations were included. Logistic regression analysis was used to adjust for potential confounders between the groups. RESULTS: Among 58,436 women meeting the inclusion criteria, complete outcome data were available for 51,557 (88%), 11,746 (91%) in the amniocentesis group and 39,811 (87%) in the group that did not have amniocentesis. The fetal loss (miscarriages and intrauterine fetal death) rate in the amniocentesis group was 0.4% compared with 0.26% in those without amniocentesis (relative risk 1.6, 95% confidence interval [CI] 1.1–2.2). Fetal loss less than 24 weeks (including induction for ruptured membranes and oligohydramnios) occurred in 0.97% of the amniocentesis group and 0.84% of the group with no procedure (P=.33). The fetal loss rate less than 24 weeks attributable to amniocentesis was 0.13% (95% CI –0.07 to 0.20%) or 1 in 769. The only subgroup that had a significantly higher amniocentesis attributable fetal loss rate was women with a normal serum screen (0.17%, P=.03). CONCLUSION: The institutional fetal loss rate attributable to amniocentesis is 0.13%, or 1 in 769 at Washington University School of Medicine. The total fetal loss rate was not significantly different from that observed in patients who had no procedure. LEVEL OF EVIDENCE: II

Position statement from the Chromosome Abnormality Screening Committee on behalf of the Board of the International Society for Prenatal Diagnosis

President President-Elect Past President Secretary Treasurer Lucas Otano MD, PhD (Argentina) Ignatia B. Van den Veyver MD (USA) Jan M.M. van Lith MD, PhD (Netherlands) Louise Wilkins-Haug MD (USA) Antoni Borrell MD, PhD (Spain) Directors Peter Benn PhD, DSc (USA) Lyn Chitty PhD (UK) Rossa Chiu (Hong Kong) Roland Devlieger MD, PhD (Belgium) Sylvie Langlois MD, CCMG (Canada) Anthony O. Odibo MD, MSCE (USA) R. Doug Wilson MD, Msc, FRCSC (Canada) Yuval Yaron MD (Israel) Diana W. Bianchi MD, ex officio (USA) Position Statement from the Chromosome Abnormality Screening Committee on Behalf of the Board of the International Society for Prenatal Diagnosis

Multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilation (UTD classification system)

OBJECTIVE Urinary tract (UT) dilation is sonographically identified in 1-2% of fetuses and reflects a spectrum of possible uropathies. There is significant variability in the clinical management of individuals with prenatal UT dilation that stems from a paucity of evidence-based information correlating the severity of prenatal UT dilation to postnatal urological pathologies. The lack of correlation between prenatal and postnatal US findings and final urologic diagnosis has been problematic, in large measure because of a lack of consensus and uniformity in defining and classifying UT dilation. Consequently, there is a need for a unified classification system with an accepted standard terminology for the diagnosis and management of prenatal and postnatal UT dilation. METHODS A consensus meeting was convened on March 14-15, 2014, in Linthicum, Maryland, USA to propose: 1) a unified description of UT dilation that could be applied both prenatally and postnatally; and 2) a standardized scheme for the perinatal evaluation of these patients based on sonographic criteria (i.e. the classification system). The participating societies included American College of Radiology, the American Institute of Ultrasound in Medicine, the American Society of Pediatric Nephrology, the Society for Fetal Urology, the Society for Maternal-Fetal Medicine, the Society for Pediatric Urology, the Society for Pediatric Radiology and the Society of Radiologists in Ultrasounds. RESULTS The recommendations proposed in this consensus statement are based on a detailed analysis of the current literature and expert opinion representing common clinical practice. The proposed UTD Classification System (and hence the severity of the UT dilation) is based on six categories in US findings: 1) anterior-posterior renal pelvic diameter (APRPD); 2) calyceal dilation; 3) renal parenchymal thickness; 4) renal parenchymal appearance; 5) bladder abnormalities; and 6) ureteral abnormalities. The classification system is stratified based on gestational age and whether the UT dilation is detected prenatally or postnatally. The panel also proposed a follow-up scheme based on the UTD classification. CONCLUSION The proposed grading classification system will require extensive evaluation to assess its utility in predicting clinical outcomes. Currently, the grading system is correlated with the risk of postnatal uropathies. Future research will help to further refine the classification system to one that correlates with other clinical outcomes such as the need for surgical intervention or renal function.

Congenital uterine anomalies and adverse pregnancy outcomes

OBJECTIVE We sought to estimate whether the presence of a maternal uterine anomaly is associated with adverse pregnancy outcomes. STUDY DESIGN This retrospective cohort study included singleton pregnancies undergoing routine anatomic survey from 1990 through 2008 at a major tertiary care medical center. Pregnancies with a diagnosis of uterine anomaly (uterine septum, unicornuate uterus, bicornuate uterus, uterine didelphys) were compared to those with normal anatomy. Primary outcomes of interest were spontaneous preterm birth (PTB), breech presentation, and cesarean delivery. RESULTS The presence of an anomaly was associated with PTB <34 weeks (adjusted odds ratio [aOR], 7.4; 95% confidence interval [CI], 4.8-11.4; P < .01), PTB <37 weeks (aOR, 5.9, 95% CI, 4.3-8.1; P < .01), primary nonbreech cesarean delivery (aOR, 2.6; 95% CI, 1.7-4.0; P < .01), preterm premature rupture of membranes (aOR, 3.2; 95% CI, 1.8-5.6; P < .01), and breech presentation (aOR, 8.6; 95% CI, 6.2-12.0; P < .01). CONCLUSION Women with a uterine anomaly are at risk for PTB, highlighting an at-risk population that needs additional study for possible interventions for PTB prevention.

First-trimester assessment of placenta function and the prediction of preeclampsia and intrauterine growth restriction

Preeclampsia and intrauterine growth restriction (IUGR) are major contributors to perinatal mortality and morbidity worldwide. Both are characterized by impaired trophoblastic invasion of the maternal spiral arteries and their conversion from narrow muscular vessels to wide non‐muscular channels. Despite improvement in the understanding of the pathophysiology of these conditions, ability to accurately identify pregnant woman who will develop them is limited. This greatly impairs the development and testing of preventive interventions. While different measures of placental dysfunction have been associated with increased risk for adverse pregnancy outcomes, the ability of any single one to accurately predict these outcomes is poor. Developing predictive tests is further challenged by difficulty in the timing of the measurements, as both the structural and biochemical characteristics of the placenta change with increasing gestational age. The ideal screening test would accurately predict the development of adverse pregnancy outcomes early enough to provide a window for preventive interventions. Improvement in ultrasound technology provides potentially useful novel tools for evaluating placental structure, but measuresments need to be standardized in order to be useful. Maternal serum analyte screening is a noninvasive test of placental biochemical function, but present serum marker alone is not sufficiently accurate to suggest its routine use in clinical practice. The use of first trimester biochemical markers in combination with uterine artery Doppler screening is promising as a potential screening tool. Prospective longitudinal studies using standardized methodology are necessary to further evaluate the choice of parameters and strategies of combination to achieve the best predictive models. Copyright

Short interpregnancy interval: risk of uterine rupture and complications of vaginal birth after cesarean delivery.

OBJECTIVE: To investigate whether short or long interpregnancy interval is associated with uterine rupture and other major maternal morbidities in women who attempt vaginal birth after cesarean delivery (VBAC). METHODS: We performed a secondary analysis of a U.S. multi-center, record-based, retrospective cohort study of 13,331 pregnant women, identified by a validated International Classification of Disease, 9th Revision, code search, with at least one prior cesarean delivery, who attempted VBAC between 1995 and 2000. We performed univariable and multivariable logistic regression analyses to evaluate the association between long or short interpregnancy interval and three maternal outcomes: 1) uterine rupture, 2) composite major morbidity (including rupture, bladder or bowel injury, and uterine artery laceration), and 3) blood transfusion. We evaluated short interpregnancy interval with cutoffs at less than 6, less than 12, and less than 18 months between prior delivery and conception and defined long interval as 60 months or more. RESULTS: A total of 128 cases (0.9%) of uterine rupture occurred, and 286 (2.2%), 1,109 (8.3%), 1,741 (13.1%), and 2,631 (19.7%) women had interpregnancy intervals of less than 6, 6–11, 12–17, and 60 months or more, respectively. An interval less than 6 months was associated with increased risk of uterine rupture (adjusted odds ratio [aOR] 2.66, 95% confidence interval [CI] 1.21–5.82), major morbidity (aOR 1.95, 95% CI 1.04–3.65), and blood transfusion (aOR 3.14, 95% CI 1.42–6.95). Long interpregnancy interval was not associated with an increase in major morbidity. CONCLUSION: Short interpregnancy interval increases risk for uterine rupture and other major morbidities twofold to threefold in VBAC candidates. LEVEL OF EVIDENCE: II