Dara Seybold

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.

Prenatal diagnosis of spontaneous bladder rupture in a female fetus.

Spontaneous bladder rupture is a rare condition, with diagnosis more rare in the prenatal than postnatal period. To our knowledge, there have been 7 cases of prenatally diagnosed bladder ruptures and all have been males. We report the first case of prenatal diagnosis of spontaneous bladder rupture in a female fetus. After a primary Cesarean-section birth, a tear in the newborn infant bladder dome was identified and repaired in 2 layers. The cause of the bladder rupture remains unknown.

Endometriosis-associated infertility: double intrauterine insemination improves fecundity in patients positive for antiendometrial antibodies.

Citation 
Subit M, Gantt P, Broce M, Seybold DJ, Randall G. Endometriosis‐associated infertility: double intrauterine insemination improves fecundity in patients positive for antiendometrial antibodies. Am J Reprod Immunol 2011; 66: 100–107

Outcomes in an obstetrical population with hereditary thrombophilia and high tobacco use

Abstract Objective: The purpose of this study was to examine birth outcomes in women treated or untreated for thrombophilia during pregnancies affected or not by tobacco exposure. Methods: This was a retrospective cohort study of consecutive women from a single maternal fetal medicine clinic who delivered between January 2009 and December 2013. We compared birth outcomes by four groups of thrombophilia and smoking combinations and then by treated or untreated groups. Results: Of the 8889 pregnant women in this study, 113 had thrombophilia and 97 received treatment. Thromboprophylaxis included: low molecular weight heparin, aspirin, unfractionated heparin, folic acid, and combinations of these. Smokers with thrombophilia had significantly higher rates of preeclampsia, intrauterine growth restriction, preterm birth (<37 weeks gestation) and low birth weight (all p ≤ .001). Conversely, this group had significantly lower rates of hemolysis, elevated liver enzymes, low platelet count (HELLP syndrome) and placental abruption. Women with thrombophilia who received thromboprophylaxis had lower rates of adverse birth outcomes, reaching significance for preterm birth <32 weeks gestation (4.3% versus 21.1%, p = .026). Conclusion: Pregnant women who smoke and have thrombophilia may be more likely to experience adverse birth outcomes and receive more benefit from thromboprophylaxis than their nonsmoking counterparts.

Improving screening for alcohol consumption during pregnancy with phosphatidylethanol

OBJECTIVE The study objective was to compare rates of alcohol use between urine ethanol testing and self- reporting (Method: 1) and Phosphatidylethanol (PEth) dried blood spot testing and self-reporting (Method: 2). METHODS This was a prospective observational study in an obstetric clinic with universal alcohol screening. RESULTS Method: 1 identified 11 patients with alcohol use (5 urine and 6 self-reported); Method: 2 identified 28 (22 PEth and 6 self-reported) out of 315 patients (one patient positive for both urine and PEth). The six patients with self-reported use had negative urine and PEth testing. We had fair agreement between the two methods (282 negative and 7 positive; 289/314=92.0%; Kappa 0.32, p<0.001); method 2 identified significantly more women (McNemar, p<0.001). Combining methods: resulted in an alcohol detection rate of 10.2% (32/314). CONCLUSION Method: 2 identified more alcohol users than Method: 1. Combining both methods: identified the most alcohol consumption.

Doppler screening and predictors of adverse outcomes in high risk pregnancies affected by tobacco.

OBJECTIVE The purpose of this study was to investigate associations between Doppler measurements and adverse outcomes in an obstetric population with high tobacco use. METHODS This retrospective study included patients with Doppler data (umbilical systolic/diastolic velocity ratios (S/D), uterine S/D, uterine left/right ratio index (RI)). Receiver operator characteristic curve analysis determined cut-off elevated Doppler indices. Stepwise logistic regression was used to predict adverse outcomes. RESULTS 338 of 745 patients (45.4%) had adverse outcomes. Doppler artery indices identified significant associations with IUGR, preeclampsia, low birth weight, pre-term birth and composite adverse outcome variable. An elevated Umbilical S/D was 2.1 (95% Confidence Interval (CI): 1.5-2.9; p<0.001) times was more likely to have an adverse outcome. For left uterine artery S/D and nulliparity, the odds ratios were 1.8 (95% CI: 1.3-2.5) and 1.4 (95% CI: 1.0-1.9), respectively. CONCLUSION Umbilical and uterine left S/D indices and nulliparity are significant independent predictors of adverse outcomes.

Hemoglobin A1C as a Diagnostic Test for Gestational Diabetes [17C]

INTRODUCTION: ACOG recommends gestational diabetes mellitus (GDM) testing using a 1-hour 50-gram oral glucose challenge test (24–28 weeks gestation) and if elevated (>140 mg/dL), a 3-hr 100-gram oral glucose tolerance test. Objective was to determine if HbA1c testing can replace ACOG guidelines, offering a more tolerable, less time-consuming test for GDM. METHODS: This is a prospective cohort study of patients presenting <14 weeks gestation for prenatal care between 11/2011 and 6/2014. HbA1c levels obtained at initial visit and 24–28 weeks gestation were compared between patients with and without GDM and tested as a replacement for ACOG guidelines. RESULTS: Study was comprised of 146 of 364 consented patients meeting inclusion criteria (mean age: 25 years, obesity: 41.5%, and DM family history: 50%). Initial HbA1c values compared to 24–28 weeks revealed a small but significant decrease (5.2 vs 5.1, P<.001). However, mean HbA1c levels were higher in patients with GDM (5.3 vs 5.1, P=.027). Elevated HbA1c (>5.5) and positive GDM showed significant, but weak agreement (Kappa=0.69, P=.041), (sensitivity: 25% and specificity: 92.5%). ROC curve analysis determined optimal threshold 5.15 yielding sensitivity: 66.7%; specificity: 66.4%, PPV: 15.1%, and NPV: 95.7%. Analysis of mean change from initial to 24–28 HbA1c resulted in no main effect for GDM, but a significant GDM by HbA1c interaction (P=.002). GDMA patients demonstrated increased mean HbA1c and non-diabetics decreased mean HbA1c. CONCLUSION: While our data showed that patients with GDM had elevated levels of HbA1c at 24–28 weeks gestation, this test is not a reliable replacement for ACOG guidelines.

First trimester fetal heart rate as a predictor of newborn sex.

Abstract Objective: To predict the sex of newborns using first trimester fetal heart rate (FHR). Methods: This was a retrospective review of medical records and ultrasounds performed between 8 and 13 weeks of gestation. Continuous variables were compared using Student’s t-tests while categorical variables were compared using Chi-square test. Results: We found no significant differences between 332 (50.7%) female and 323 (49.3%) male FHRs during the first trimester. The mean FHR for female fetuses was 167.0 ± 9.1 bpm and for male fetuses 167.3 ± 10.1 bpm (p = 0.62). There was no significant difference in crown rump length between female and male fetuses (4.01 ± 1.7 versus 3.98 ± 1.7 cm; p = 0.78) or in gestational age at birth (38.01 ± 2.1 versus 38.08 ± 2.1 weeks; p = 0.67). The males were significantly heavier than females (3305.3 ± 568.3 versus 3127.5 ± 579.8 g; p < 0.0001) but there were no differences in the proportion of small for gestational age (SGA), average for gestational age (AGA) and large for gestational age (LGA) infants. Conclusions: We found no significant difference between the female and male FHR during the first trimester in contrast to the prevailing lay view of females having a faster FHR. The only statistically significant difference was that males weighed more than female newborns.

Association of Urine Cotinine and Self-Reported Tobacco Use With Birth Outcomes in an Appalachian Population [166]

OBJECTIVE: To determine whether there is an association between cotinine levels and self-reported tobacco use and birth outcomes. STUDY DESIGN: Retrospective analysis of patients receiving prenatal care from January 1, 2012, to March 31, 2013, at a tertiary care center in West Virginia with universal urine drug screening. Analysis was by Spearmans &rgr;, one-way analysis of variance, t test for continuous variables, and &khgr;2 for categorical variables. RESULTS: There was a significant moderate positive correlation between cotinine and self-reported tobacco use (R=0.63, P<.001), with 47.9% (291/607) of patients with positive cotinine assays (=500 ng/mL) and 42.2% (256/607) with self-reported tobacco use. There was good agreement between both methods (self-report and cotinine testing) to identify smokers (&kgr;=0.632; P<.001). Birth outcome data were available for 503 of 607 (83%) patients (471 live births). Poor fetal outcome (one or more of the following: small for gestational age, low birth weight [less than 2,500 g], or preterm birth [less than 37 weeks of gestation]) was found in 19.9% (n=45) patients with positive cotinine assays (compared with negative: 11.4%; n=36; P=.005). Eighteen percent (n=46) of smokers had poor fetal outcome (compared with negative: 13.7%, n=48; P=.173). Head circumferences were significantly smaller in the positive group (33.2 compared with 33.9 cm; P=.001) but not for smokers (33.3 compared with 33.7 cm; P=.064). Similar results were found for birth length: significantly smaller for positive cotinine patients (48.4 compared with 49.9 cm; P<.001) and for smokers (48.6 compared with 49.6 cm; P=.004). CONCLUSION: There was good agreement between cotinine testing and self-reporting. Although both were comparable in association with birth length, only cotinine results were significantly associated with poor fetal outcome and head circumference.

Cytokines and cervical length: a pilot study of relationship to incidence of preterm birth

Abstract Objective: To test if levels of interleukins (IL) in a low risk obstetric population coupled with transvaginal cervical length help predict spontaneous pre-term birth. Materials and