Daniel W. Skupski

Intrauterine restriction (IUGR)

Abstract Perinatal mortality and morbidity is markedly increased in intrauterine growth restricted (IUGR) fetuses. Prenatal identification of IUGR is the first step in clinical management. For that purpose a uniform definition and criteria are required. The etiology of IUGR is multifactorial and whenever possible it should be assessed. When the cause is of placental origin, it is possible to identify the affected fetuses. The major complication is chronic fetal hypoxemia. By monitoring the changes of fetal vital functions it is thus possible to improve both management and outcome. The timing of delivery is crucial but the optimal management scheme has not yet been identified. When IUGR is identified at very early gestational ages, serial assessments of the risk of continuing the in utero fetal life under adverse conditions versus the risks of the prematurity should be performed. Delivery of IUGR fetuses should take place in centers where appropriate neonatal assistance can be provided. Careful monitoring of the IUGR fetus during labor is crucial as the IUGR fetus can quickly decompensate once uterine contractions have started.

How accurate is fetal biometry in the assessment of fetal age

OBJECTIVE The purpose of the study was to assess the accuracy of fetal biometry in the midtrimester of pregnancy in the assignment of fetal age. STUDY DESIGN A total of 152 singleton, 67 twin, and 19 triplet gestations resulting from in vitro fertilization with ultrasonographic fetal biometry from 14 to 22 weeks made up the study population. A gestational age prediction equation was derived from singletons with the use of stepwise linear regression. This equation was compared with 38 previously published equations and then applied to the twin and triplet populations. RESULTS Head circumference was the best predictor of gestational age (random error [SD] 3.77 days). Addition of abdominal circumference and femur length to head circumference improved the accuracy of the dating equation (random error 3.35 days). Most dating formulas had systematic errors of <1 week. The systematic error was -0.32 day for averaging the singleton-based predictions for twins and -1.26 days for triplets. CONCLUSIONS Gestational age assessment with the use of fetal biometry from 14 to 22 weeks is accurate for singleton, twin, and triplet gestations.

Heat shock protein-containing exosomes in mid-trimester amniotic fluids

Exosomes are multivesicular bodies formed by inverse membrane budding into the lumen of an endocytic compartment. Fusion with the plasma membrane leads to their release into the external milieu. The incorporation of heat shock proteins into exosomes has been associated with immune regulatory activity. We have examined whether heat shock protein-containing exosomes are present in mid-trimester amniotic fluid. Exosomes were isolated from mid-trimester amniotic fluids by sequential low-speed and high-speed centrifugation followed by sucrose density gradient centrifugation. Biochemical characterization included floatation pattern in sucrose gradients, acetylcholinesterase (AChE) activity and Western blot analysis for exosome-containing proteins. Exosomes were present in each of 23 amniotic fluids tested. They banded at a density of 1.17g/ml in sucrose gradients, were positive for AChE activity and contained tubulin, the inducible 72kDa heat shock protein, Hsp72 and the constitutively expressed heat shock protein, Hsc73; they were negative for calnexin. Exosome concentrations correlated positively with the number of pregnancies. Heat shock protein-containing exosomes are constituents of mid-trimester amniotic fluids and may contribute to immune regulation within the amniotic cavity.

Improving hospital systems for the care of women with major obstetric hemorrhage.

OBJECTIVE: When 2 maternal deaths due to hemorrhage occurred at New York Hospital Queens in 2000–2001, a multidisciplinary team implemented systemic change. Our objective was to improve outcomes of episodes of major obstetric hemorrhage. METHODS: We report outcomes before (2000–2001) and after (2002–2005) the introduction of a patient safety program aimed at improving the care of women with major obstetric hemorrhage. Process changes were instituted in late 2001 at the direction of a multidisciplinary patient safety team. A rapid response team was formulated using the cardiac arrest team as a model. Protocols for early diagnosis, assessment, and management of patients at high risk for major obstetric hemorrhage were developed and communicated to staff. RESULTS: There were significant increases in cesarean births (P < .001), repeat cesarean births (P = .002), and cases of major obstetric hemorrhage (P = .02) between the periods of 2000–2001 and 2002–2005. There was a significant improvement in mortality due to hemorrhage (P = .036), lowest pH (P = .004), and lowest temperature (P < .001) when comparing 2000–2001 with 2002–2005. There were no differences in measures of severity of obstetric hemorrhage between the 2 periods, including Acute Physiology and Chronic Health Evaluation II scores, occurrence of placenta accreta and estimated blood loss. CONCLUSION: Despite a significant increase in major obstetric hemorrhage cases, we found improved outcomes and fewer maternal deaths after implementing systemic approaches to improve patient safety. Attention to improving the hospital systems necessary for the care of women at risk for major obstetric hemorrhage is important in the effort to decrease maternal mortality from hemorrhage. LEVEL OF EVIDENCE: II-3

Intraobserver and interobserver reproducibility of fetal biometry

To assess the intra‐ and interobserver reproducibility of ultrasound measurements of fetal biometric parameters.

Racial/ethnic standards for fetal growth: The NICHD Fetal Growth Studies

OBJECTIVE Fetal growth is associated with long-term health yet no appropriate standards exist for the early identification of undergrown or overgrown fetuses. We sought to develop contemporary fetal growth standards for 4 self-identified US racial/ethnic groups. STUDY DESIGN We recruited for prospective follow-up 2334 healthy women with low-risk, singleton pregnancies from 12 community and perinatal centers from July 2009 through January 2013. The cohort comprised: 614 (26%) non-Hispanic whites, 611 (26%) non-Hispanic blacks, 649 (28%) Hispanics, and 460 (20%) Asians. Women were screened at 8w0d to 13w6d for maternal health status associated with presumably normal fetal growth (aged 18-40 years; body mass index 19.0-29.9 kg/m(2); healthy lifestyles and living conditions; low-risk medical and obstetrical history); 92% of recruited women completed the protocol. Women were randomized among 4 ultrasonography schedules for longitudinal fetal measurement using the Voluson E8 (GE Healthcare, Milwaukee, WI). In-person interviews and anthropometric assessments were conducted at each visit; medical records were abstracted. The fetuses of 1737 (74%) women continued to be low risk (uncomplicated pregnancy, absent anomalies) at birth, and their measurements were included in the standards. Racial/ethnic-specific fetal growth curves were estimated using linear mixed models with cubic splines. Estimated fetal weight (EFW) and biometric parameter percentiles (5th, 50th, 95th) were determined for each gestational week and comparisons made by race/ethnicity, with and without adjustment for maternal and sociodemographic factors. RESULTS EFW differed significantly by race/ethnicity >20 weeks. Specifically at 39 weeks, the 5th, 50th, and 95th percentiles were 2790, 3505, and 4402 g for white; 2633, 3336, and 4226 g for Hispanic; 2621, 3270, and 4078 g for Asian; and 2622, 3260, and 4053 g for black women (adjusted global P < .001). For individual parameters, racial/ethnic differences by order of detection were: humerus and femur lengths (10 weeks), abdominal circumference (16 weeks), head circumference (21 weeks), and biparietal diameter (27 weeks). The study-derived standard based solely on the white group erroneously classifies as much as 15% of non-white fetuses as growth restricted (EFW <5th percentile). CONCLUSION Significant differences in fetal growth were found among the 4 groups. Racial/ethnic-specific standards improve the precision in evaluating fetal growth.

Effect of a comprehensive obstetric patient safety program on compensation payments and sentinel events

Our objective was to describe a comprehensive obstetric patient safety program and its effect on reducing compensation payments and sentinel adverse events. From 2003 to 2009, we implemented a comprehensive obstetric patient safety program at our institution with multiple integrated components. To evaluate its effect on compensation payments and sentinel events, we gathered data on compensation payments and sentinel events retrospectively from 2003, when the program was initiated, through 2009. Average yearly compensation payments decreased from

Selective reduction of multifetal pregnancies to twins improves outcome over nonreduced triplet gestations.

27,591,610 between 2003-2006 to

Intrapartum fetal stimulation tests: A meta-analysis

2,550,136 between 2007-2009, sentinel events decreased from 5 in 2000 to none in 2008 and 2009. Instituting a comprehensive obstetric patient safety program decreased compensation payments and sentinel events resulting in immediate and significant savings.

Unique alterations in infection-induced immune activation during pregnancy

OBJECTIVE Our purpose was to evaluate effects of multifetal pregnancy reduction on pregnancy complications and birth weights of remaining twin fetuses compared with expectantly managed triplets and nonreduced twins. STUDY DESIGN Medical records of 54 triplet pregnancies, 59 twin pregnancies resulting from multifetal pregnancy reduction, and 88 sets of twins conceived with assisted reproductive techniques and delivered at New York Hospital after 24 weeks were retrospectively reviewed. Birth weights were corrected for gestational age at delivery by use of a formula derived from composite standardized growth curves. Statistical analysis was performed with chi(2) analysis and Student t test. RESULTS Twins remaining after reduction and nonreduced twins were less likely to have preeclampsia than were triplets (14% and 23% vs 30%) and to be delivered before 36 weeks (39% and 27% vs 72%). They had birth weights that were > 100 gm larger than those of triplets even when corrected for gestational age. Reduced twins were similar to nonreduced twins in all parameters studied. CONCLUSIONS Multifetal pregnancy reduction results in pregnancy complications, gestational age, and birth weights closer to those of nonreduced twins than to expectantly managed triplets.