Diana L. Gray

Congenital hydronephrosis: Correlation of fetal ultrasonographic findings with infant outcome

Although congenital hydronephrosis is a common fetal disorder, ultrasonographic criteria for prenatal diagnosis remain poorly defined. In this study prenatal ultrasonographic findings were correlated with postnatal outcome in 63 fetuses with suspected hydronephrosis. Prenatal ultrasonographic measurements included length, anteroposterior diameter, and transverse diameter of the kidney and renal pelvis, as well as dorsal renal parenchymal thickness. In 45 of the 63 fetuses, hydronephrosis was confirmed postnatally. These infants were divided into two groups on the basis of renal status: (1) abnormal renal function and/or surgery required (n = 31) and (2) normal renal function with no surgery required (n = 14). The anteroposterior diameter of the renal pelvis was the simplest and most sensitive technique for prenatal diagnosis of congenital hydronephrosis, allowing identification of 100% of cases. Postnatal follow-up studies are warranted if an anteroposterior pelvic diameter is greater than or equal to 4 mm before 33 weeks or greater than or equal to 7 mm after 33 weeks.

Predictors of persistence of adnexal masses in pregnancy.

OBJECTIVE To determine factors predicting the persistence of sonographically identified adnexal masses in pregnancy. METHODS All patients from March 1988 to April 1993 diagnosed with an adnexal mass by obstetric sonography were reviewed. Examinations had been entered prospectively into our sonography database. Follow-up data were collected from the database, from hospital and pathology department records, and from interviews with referring obstetricians. Adnexal masses were characterized by size, sonographic appearance, and anatomic site. Persistence of the masses was determined by subsequent sonography, operative findings, or postpartum physical examinations. RESULTS The rate of adnexal masses during pregnancy was 2.3% (432 of 18,391). Complete follow-up was available for 422 of 432. Most of the adnexal masses (76%; 320 of 422) were simple cysts with a mean diameter less than 5 cm. The remainder of the masses were simple or complex, measuring 5 cm or more in diameter. Seventy of 102 large or complex masses resolved. By multivariate analysis, the best predictors for persistence of these masses were complex appearance on sonography and size of the mass (P < .05 for both categories). CONCLUSION Most adnexal masses identified by sonography during pregnancy were small, simple cysts that did not pose a risk to the pregnancy. Even the majority of large or sonographically complex masses resolved. The best predictors of persistence of the masses were sonographic appearance and size.

Decision-making for termination of pregnancies with fetal anomalies: analysis of 53,000 pregnancies.

OBJECTIVE To evaluate the degree to which prenatal knowledge of fetal anomalies and sociodemographic characteristics determined outcome of 53,000 pregnancies. METHODS Pregnancies were consecutively evaluated at a university hospital between 1984 and 1997. The severity of anomalies was graded by using an ordinal scale, in which 0 was no anomalies, 1 was no impact on quality of life, 2 was little impact but possibly requiring medical therapy, 3 was serious impact on quality of life even with optimal medical therapy, and 4 was incompatible with life. RESULTS The abortion rates for grades 1 and 3 anomalies increased from 0.9% to 72.5%, and 0.9% to 37.1% for central nervous system and non–central nervous system anomalies, respectively (P < .001). Multiple logistic regression showed that mothers without a high school education were more likely than those who completed high school to abort a normal pregnancy (odds ratio [OR] 1.62, 95% confidence interval [CI] 1.07, 2.45). In the 452 pregnancies in which there was one grade 3 anomaly, logistic regression also showed that the abortion rate decreased by 6% per year as maternal age decreased (OR 0.94, 95% CI 0.91, 0.97). CONCLUSIONS The severity of anomalies directly correlates with abortion rates, but at similar degrees of severity, central nervous system anomalies are more likely to lead to abortion. Maternal level of education inversely correlates with likelihood of termination of a normal pregnancy, whereas maternal age directly correlates with pregnancy termination when serious anomalies are present. Serious congenital anomalies may disproportionately affect children from families with the youngest mothers because these mothers are likely to continue these pregnancies.

Evaluating the Rate and Risk Factors for Fetal Loss After Chorionic Villus Sampling

OBJECTIVE: To estimate the fetal loss rate in our center and evaluate the risk factors associated with such losses after chorionic villus sampling (CVS). METHODS: This is a retrospective cohort study including all women undergoing chorionic villus sampling and a control group that had no invasive procedure at a single center over a 16-year period. Fetal loss was defined as any loss before 24 weeks of gestation. Univariable and multiple logistic regression analyses were used to compare pregnancies resulting in fetal loss to those without a loss and to adjust for potential confounders between the groups. RESULTS: Of 5,243 women who had CVS who were compared with 4,917 women seen before 14 weeks who had no invasive procedure, there were 138 (2.7%) fetal losses before 24 weeks of gestation in the CVS group compared with 161 (3.3%) in the control group (relative risk 0.80, 95% confidence interval, 0.64–1.0). The difference in loss rate of –0.7% (95% confidence interval, –0.02 to 1.3) between the CVS group and those who had no procedure was not statistically significant at P<.05. The significant risk factors for fetal loss were African-American maternal race, at least two aspirations/needle insertions, heavy bleeding during CVS, maternal age younger than 25 years, and gestational age at performing CVS before 10 weeks. CONCLUSION: The estimated fetal loss rate after CVS was not significantly different from the group that had no procedure. Significant predictors of fetal loss after CVS were identified, but the accuracy of the final model for predicting fetal loss was only modest. LEVEL OF EVIDENCE: II

Predicting the risk of pre-eclampsia between 11 and 13 weeks gestation by combining maternal characteristics and serum analytes, PAPP-A and free β-hCG

To determine if a simplified model for predicting pre‐eclampsia (PEC) can be developed by combining first‐trimester serum analytes, pregnancy‐associated plasma protein A (PAPP‐A) and free beta human chorionic gonadotrophin (β‐hCG), and maternal characteristics.

Predicting adverse neonatal outcomes in fetuses with abdominal wall defects using prenatal risk factors

OBJECTIVE The aim of this study was to determine whether prenatal variables can predict adverse neonatal outcomes in fetuses with abdominal wall defects. STUDY DESIGN A retrospective cohort study that used ultrasound and neonatal records for all cases of gastroschisis and omphalocele seen over a 16-year period. Cases with adverse neonatal outcomes were compared with noncases for multiple candidate predictive factors. Univariable and multivariable statistical methods were used to develop the prediction models, and effectiveness was evaluated using the area under the receiver operating characteristic curve. RESULTS Of 80 fetuses with gastroschisis, 29 (36%) had the composite adverse outcome, compared with 15 of 33 (47%) live neonates with omphalocele. Intrauterine growth restriction was the only significant variable in gastroschisis, whereas exteriorized liver was the only predictor in omphalocele. The areas under the curve for the prediction models with gastroschisis and omphalocele are 0.67 and 0.74, respectively. CONCLUSION Intrauterine growth restriction and exteriorization of the liver are significant predictors of adverse neonatal outcome with gastroschisis and omphalocele.

The efficiency of first-trimester serum analytes and maternal characteristics in predicting fetal growth disorders

OBJECTIVE To evaluate the association between first-trimester serum analytes, pregnancy-associated plasma protein A and free beta-human chorionic gonadotropin, and fetal growth disorders, and to determine whether a prediction model for these growth disorders can be developed. STUDY DESIGN Retrospective cohort study of patients seen for first-trimester aneuploidy screening. Pregnancy-associated plasma protein A and free beta-human chorionic gonadotropin multiples of the median were evaluated for association with small- and large-for-gestational-age infants in combination with maternal characteristics. Univariate and backward stepwise logistic regression analyses were performed and the area under the receiver-operator curves used to determine the best prediction models. RESULTS Neither pregnancy-associated plasma protein A nor free beta-human chorionic gonadotropin levels were associated with an increased risk of large-for-gestational-age infants. For small-for-gestational-age infants, the final model included black race, free beta-human chorionic gonadotropin multiples of the median >90th percentile, and pregnancy-associated plasma protein A multiples of the median <5th percentile as significant predictors (area under the curve = 0.58). CONCLUSION Low pregnancy-associated plasma protein A and high free beta-human chorionic gonadotropin levels are associated with a small-for-gestational-age growth pattern; however, additional factors to improve the prediction model are needed.

Sensitivity and specificity of ultrasound for the detection of neural tube and ventral wall defects in a high-risk population

OBJECTIVE To test the hypothesis that with experienced operators, sonography alone is sensitive and specific for diagnosing open neural tube and ventral wall defects in a population at risk for these disorders. METHODS Consecutive women at risk for a fetus with an open neural tube defect because of elevated maternal serum alpha-fetoprotein (MSAFP) or family history were evaluated prospectively using prenatal sonography. Amniocentesis was not done routinely but was done for specific indications, such as limited visualization by sonography, markedly elevated MSAFP, or other risk factors for fetal chromosomal disorders. Complete postnatal outcome information was obtained, and the diagnostic accuracy of sonography was compared with that of amniocentesis plus sonography. RESULTS Sonography alone was 97% (66 of 68) (95% confidence interval [CI] 0.898, 0.996) sensitive and 100% (n = 2189) (CI 0.998, 1.0) specific in diagnosing open neural tube defect, and was 100% sensitive (n = 17) (CI 0.805, 1.0) and specific (n = 2240) (CI 0.998, 1.0) in diagnosing ventral wall defect. In two cases of neural tube defect, there were other suspicious findings on sonography, and amniocentesis was performed for confirmation. CONCLUSION When used by experienced operators, prenatal sonography is sensitive and specific for the diagnoses of neural tube and ventral wall defects in a targeted at-risk population.

Is genetic amniocentesis warranted when isolated choroid plexus cysts are found

Our aim was to evaluate the prevalence of trisomy 18 in the setting of isolated fetal choroid plexus cysts and then to consider the risk of trisomy 18 versus the risks of genetic amniocentesis. Fetuses with choroid plexus cysts were prospectively obtained from a total mid‐trimester population of 18 861 fetuses with known outcomes. If the fetuses had trisomy 18, they were part of the study group and part of the control group if they had normal karyotypes. Scans were retrospectively reviewed for the characterization of cysts according to size, laterality, and appearance (simple or complex echo patterns). Chi‐square analysis of contingency tables of results was performed. 208/18 861 (1·1 per cent) fetuses had choroid plexus cysts. 201/208 (96·6 per cent) were normal fetuses or newborns, while 7/208 (3·4 per cent) of the fetuses with choroid plexus cysts had trisomy 18. Overall, 16 fetuses had trisomy 18 and seven (44 per cent) of these had choroid plexus cysts. 0/16 fetuses had choroid plexus cysts as the only sonographic finding. Although laterality or complexity of the cysts did not correlate with the presence or absence of a cytogenetic abnormality, cysts ⩾10 mm were more often associated with trisomy 18 than with a normal karyotype (P<0·01). We conclude that the discovery of choroid plexus cysts in otherwise normal fetuses in the late second trimester does not by itself justify the risks of genetic amniocentesis.

Abdominal circumference vs. estimated weight to predict large for gestational age birth weight in diabetic pregnancy

Early third trimester fetal abdominal circumference and sonographic fetal weight estimates were compared to predict large for gestational age birth weight in diabetic pregnancy. Both parameters have similar sensitivity, specificity, and predictive values. However, the optimal percentile cutoff values differ. Choice of birth weight standard significantly influences test characteristics. Negative prediction of large birth weight is more accurate than positive prediction. At third trimester sonography with maternal diabetes, the abdominal circumference percentile is potentially useful and should be routinely reported.