Byron C. Calhoun

Maternal Ethnicity and Variation of Fetal Femur Length Calculations When Screening for Down Syndrome

Objective. To determine whether current methods for detecting Down syndrome based on fetal femur length calculations are influenced by ethnicity. Methods. The study population consisted of all fetuses scanned between 14 and 20 completed weeks gestation from April 1, 1997, to January 1, 2000. The expected femur length was calculated from the biparietal diameter. The variance from the expected femur length, compared with the biparietal diameter, was calculated, and the mean variations were compared by maternal race. Ethnic‐specific formulas for expected femur length were derived by simple regression. Results. There was a statistically significant difference in femur length in the Asian group compared with all other groups, as well as the white group compared with the black and Asian groups (P < .05). However, there was no significant difference between the black and Hispanic groups or the white and Hispanic groups. The Asian group had the largest variation, with the measured femur length being less than the expected femur length. All groups studied had a mean expected femur length less than the mean measured femur length. On the basis of the ethnic‐specific formulas for femur length, there was a significant decrease in patients that would undergo further evaluation for Down syndrome. Conclusions. There is a significant difference in the mean expected femur length by biparietal diameter among fetuses in the second trimester with regard to ethnicity. Using ethnic‐specific formulas for expected femur length can have a considerable impact on the use of sonographic risk factors for Down syndrome screening. Further data are required for use of femur length as a screening tool in the genetic sonogram.

Smoking in Pregnancy in West Virginia: Does Cessation/ Reduction Improve Perinatal Outcomes?

To determine if pregnant women decreasing/quitting tobacco use will have improved fetal outcomes. Retrospective analysis of pregnant smokers from 6/1/2006–12/31/2007 who received prenatal care and delivered at a tertiary medical care center in West Virginia. Variables analyzed included birth certificate data linked to intervention program survey data. Patients were divided into four study groups: <8 cigarettes/day–no reduction, <8 cigarettes/day–reduction, ≥8 cigarettes/day–no reduction, and ≥8 cigarettes/day–reduction. Analysis performed using ANOVA one-way test for continuous variables and Chi-square for categorical variables. Inclusion criteria met by 250 patients. Twelve women (4.8%) quit smoking; 150 (60%) reduced; 27 (10.8%) increased; and 61 (24.4%) had no change. Comparing the four study groups for pre-term births (<37xa0weeks), 25% percent occurred in ≥8 no reduction group while 10% occurred in ≥8 with reduction group (Pxa0=xa00.026). The high rate of preterm birth (25%) in the non-reducing group depended on 2 factors: (1) ≥8 cigarettes/day at beginning and (2) no reduction by the end of prenatal care. Finally, there was a statistically significant difference in birth weights between the two groups: ≥8 cigarettes/day with no reduction (2,872.6xa0g) versus <8 cigarettes/day with reduction (3,212.4xa0g) (Pxa0=xa00.028). Smoking reduction/cessation lowered risk of pre-term delivery (<37xa0weeks) twofold. Encouraging patients who smoke ≥8 cigarettes/day during pregnancy to decrease/quit prior to delivery provides significant clinical benefit by decreasing the likelihood of preterm birth. These findings support tobacco cessation efforts as a means to improve birth outcome.

Fetoplacental vascular tone during fetal circuit acidosis and acidosis with hypoxia in the ex vivo perfused human placental cotyledon

OBJECTIVESnOur purpose was to determine the effects of acidosis and acidosis-hypoxia on fetoplacental perfusion pressure and its response to angiotensin II.nnnSTUDY DESIGNnPerfused cotyledons from 14 placentas were studied with either an acidotic fetal circuit perfusate (n = 7) or an acidotic-hypoxic fetal circuit perfusate (n = 7). Each cotyledons fetal vasculature was initially perfused under standard conditions and bolus injected with 1 x 10(-10) moles of angiotensin II. Fetoplacental perfusate was then replaced with either an acidotic medium (pH 6.90 to 7.00 and Po2 516 to 613 mm Hg) or an acidotic-hypoxic medium (pH 6.90 to 7.00 and Po2 20 to 25 mm Hg) followed by an angiotensin II injection. The vasculature was subsequently recovered with standard perfusate and again injected with angiotensin II. Perfusion pressures within each group were compared by one-way analysis of variance, and results were expressed as mean pressure +/- SEM.nnnRESULTSnResting fetoplacental perfusion pressure did not change when the fetal circuit perfusate was made acidotic (28 +/- 1 mm Hg vs 25 +/- 2 mm Hg) or acidotic-hypoxic (26 +/- 2 mm Hg vs 25 +/- 2 mm Hg). The maximal fetoplacental perfusion pressure achieved in response to angiotensin II did not differ with an acidotic perfusate (41 +/- 2 mm Hg vs 38 +/- 1 mm Hg) or with an acidotic-hypoxic perfusate (39 +/- 2 mm Hg vs 36 +/- 2 mm Hg).nnnCONCLUSIONSnIn the perfused placental cotyledon fetoplacental perfusion pressure and pressor response to angiotensin II are not affected by fetal circuit acidosis or acidosis-hypoxia. This suggests that neither fetal acidosis nor fetal acidosis combined with hypoxia has a direct effect on fetoplacental vascular tone.

THE ROUTINE OBSTETRIC ULTRASOUND EXAMINATION

Ultrasound is a readily available, noninvasive, and safe means of evaluating fetal health, determining gestational age, and assessing the intrauterine environment. It is an indispensable tool for the practice of obstetrics. The routine ultrasound examination is a beginning. It is a diagnostic test, yielding results that must be interpreted and integrated in a knowledgeable way. As is true for physical examination, the ultrasound study is most helpful when performed in a consistent and reproducible fashion, carefully documenting the pertinent positive and negative findings that are important in clinical decision making. The information gained from routine obstetric ultrasound may provide reassurance, guide therapy, or identify a pathologic condition that merits further investigation. It is always informative.

Adrenomedullin concentrations in umbilical cord plasma of uncomplicated term pregnancies

OBJECTIVEnThe studys objective was to determine whether there is a difference in the plasma concentration of adrenomedullin, a hypotensive peptide, between arterial and venous umbilical cord blood of uncomplicated gestations with vaginal delivery.nnnSTUDY DESIGNnArterial and venous umbilical cord blood was obtained immediately after vaginal delivery of 44 term infants with uncomplicated antepartum and intrapartum courses. Radioimmunoassay was performed to assess adrenomedullin concentrations in the plasma. The paired t test was used to compare arterial and venous concentrations. Significance was set at P < .05.nnnRESULTSnMean +/- SE adrenomedullin concentrations were 178.7 +/- 4.7 pg/mL and 190.6 +/- 6.3 pg/mL for arterial and venous cord plasma, respectively. The difference between the 2 concentrations was not significant (11.8 pg/mL, P = .09).nnnCONCLUSIONnArterial and venous umbilical plasma concentrations of adrenomedullin do not differ significantly in uncomplicated gestations terminating with uncomplicated vaginal deliveries. This suggests that in the normal state there is neither net production nor net clearance of adrenomedullin in the placenta.

The Ability of the Quadruple Test to Predict Adverse Perinatal Outcomes in a High-risk Obstetric Population:

Objective To determine the ability of the quadruple Downs syndrome screening test (quad screen) to predict other adverse perinatal outcomes (APO) in a high-risk obstetric population. Setting A tertiary medical centre in West Virginia. Methods We retrospectively reviewed 342 obstetric patients with quad screen data from a single clinic. The quad screen included maternal serum levels of alphafetoprotein (AFP), human chorionic gonadotrophin (hCG), uncongjugated oestriol (uE3), and inhibin A. The risk of APO was compared between patients with at least one abnormal marker versus no abnormal markers and ≥2 abnormal markers versus <2 abnormal markers. Abnormal markers were determined by cut-off values produced by Receiver Operator Characteristic (ROC) curves and the FASTER trial. Unadjusted and adjusted effects were estimated using logistic regression analysis. Results The risk of having an APO increased significantly for patients with abnormal markers by about three-fold using ROC and two-fold using FASTER trial thresholds. Conclusions The quad screen shows value in predicting risk of APO in high-risk patients.

Fundamental discrepancies in abortion estimates and abortion-related mortality: A reevaluation of recent studies in Mexico with special reference to the International Classification of Diseases

In countries where induced abortion is legally restricted, as in most of Latin America, evaluation of statistics related to induced abortions and abortion-related mortality is challenging. The present article reexamines recent reports estimating the number of induced abortions and abortion-related mortality in Mexico, with special reference to the International Classification of Diseases (ICD). We found significant overestimations of abortion figures in the Federal District of Mexico (up to 10-fold), where elective abortion has been legal since 2007. Significant overestimation of maternal and abortion-related mortality during the last 20 years in the entire Mexican country (up to 35%) was also found. Such overestimations are most likely due to the use of incomplete in-hospital records as well as subjective opinion surveys regarding induced abortion figures, and due to the consideration of causes of death that are unrelated to induced abortion, including flawed denominators of live births. Contrary to previous publications, we found important progress in maternal health, reflected by the decrease in overall maternal mortality (30.6%) from 1990 to 2010. The use of specific ICD codes revealed that the mortality ratio associated with induced abortion decreased 22.9% between 2002 and 2008 (from 1.48 to 1.14 deaths per 100,000 live births). Currently, approximately 98% of maternal deaths in Mexico are related to causes other than induced abortion, such as hemorrhage, hypertension and eclampsia, indirect causes, and other pathological conditions. Therefore, only marginal or null effects would be expected from changes in the legal status of abortion on overall maternal mortality rates. Rather, maternal health in Mexico would greatly benefit from increasing access to emergency and specialized obstetric care. Finally, more reliable methodologies to assess abortion-related deaths are clearly required.

Intracranial cavernous angioma initially presenting in pregnancy with new-onset seizures ☆ ☆☆ ★ ★★

A case of an intracranial cavernous angioma, which presented with headaches and seizures in a pregnant patient, is described. Diagnosis was established with magnetic resonance imaging. A computer-assisted literature search uncovered no previously reported case of intracranial cavernous angioma initially presenting during pregnancy.

Compound presentation resulting from the forward-roll technique of external cephalic version: A possible mechanism

Limited reports exist about the frequency of compound presentation after external cephalic version. A compound hand and foot presentation is reported after external cephalic version in a woman desiring vaginal birth after cesarean delivery. We report a mechanism by which a forward roll during external cephalic version may predispose an infant in complete breech position to a compound foot presentation.

Abortion legislation, maternal healthcare, fertility, female literacy, sanitation, violence against women and maternal deaths: A natural experiment in 32 mexican states

Objective To test whether there is an association between abortion legislation and maternal mortality outcomes after controlling for other factors thought to influence maternal health. Design Population-based natural experiment. Setting and data sources Official maternal mortality data from 32 federal states of Mexico between 2002 and 2011. Main outcomes Maternal mortality ratio (MMR), MMR with any abortive outcome (MMRAO) and induced abortion mortality ratio (iAMR). Independent variables Abortion legislation grouped as less (n=18) or more permissive (n=14); constitutional amendment protecting the unborn (n=17); skilled attendance at birth; all-abortion hospitalisation ratio; low birth weight rate; contraceptive use; total fertility rates (TFR); clean water; sanitation; female literacy rate and intimate-partner violence. Main results Over the 10-year period, states with less permissive abortion legislation exhibited lower MMR (38.3 vs 49.6; p<0.001), MMRAO (2.7 vs 3.7; p<0.001) and iAMR (0.9 vs 1.7; p<0.001) than more permissive states. Multivariate regression models estimating effect sizes (β-coefficients) for mortality outcomes showed independent associations (p values between 0.001 and 0.055) with female literacy (β=−0.061 to −1.100), skilled attendance at birth (β=−0.032 to −0.427), low birth weight (β=0.149 to 2.166), all-abortion hospitalisation ratio (β=−0.566 to −0.962), clean water (β=−0.048 to −0.730), sanitation (β=−0.052 to −0.758) and intimate-partner violence (β=0.085 to 0.755). TFR showed an inverse association with MMR (β=−14.329) and MMRAO (β=−1.750) and a direct association with iAMR (β=1.383). Altogether, these factors accounted for (R2) 51–88% of the variance among states in overall mortality rates. No statistically independent effect was observed for abortion legislation, constitutional amendment or other covariates. Conclusions Although less permissive states exhibited consistently lower maternal mortality rates, this finding was not explained by abortion legislation itself. Rather, these differences were explained by other independent factors, which appeared to have a more favourable distribution in these states.