Erica Heitmann

Evidence-based approach to umbilical artery Doppler fetal surveillance in high-risk pregnancies: an update.

Antepartum fetal surveillance with Doppler ultrasound of umbilical artery has shown significant diagnostic efficacy in identifying fetal compromise in pregnancies complicated with fetal growth restriction and preeclampsia. Moreover, randomized clinical trials and their meta-analyses have shown its effectiveness in decreasing perinatal mortality (level I evidence). This is the only antepartum fetal test that has shown this level of effectiveness. There is no evidence that routine Doppler in low-risk pregnancies improves the outcome. It is recommended that umbilical artery Doppler should be the standard of practice in managing high-risk pregnancies complicated with fetal growth restriction and preeclampsia (level A recommendation). However, its use should be integrated with other current fetal monitoring tests (levels B and C recommendation). The overall management should also be guided by additional clinical considerations such as the gestational age, fetal and maternal status, and obstetrical conditions.

Umbilical artery Doppler in the assessment of fetal growth restriction.

Antepartum fetal surveillance with Doppler ultrasound of umbilical artery has shown significant diagnostic efficacy in identifying fetal compromise in pregnancies complicated with fetal growth restriction (FGR). Its effectiveness in decreasing perinatal mortality has been shown by randomized clinical trials (Level I evidence). This test is the only antepartum fetal test that has shown this level of effectiveness and should be the standard of practice in managing FGR (Level A recommendation). The overall management considerations should encompass other standard fetal monitoring tests (Level B and C recommendations).

3q26 Amplification Is an Effective Negative Triage Test for LSIL: A Historical Prospective Study

Background Women with low grade squamous intraepithelial lesions (LSIL) at cervical cancer screening are currently referred for further diagnostic work up despite 80% having no precancerous lesion. The primary purpose of this study is to measure the test characteristics of 3q26 chromosome gain (3q26 gain) as a host marker of carcinogenesis in women with LSIL. A negative triage test may allow these women to be followed by cytology alone without immediate referral to colposcopy. Methods and Findings A historical prospective study was designed to measure 3q26 gain from the archived liquid cytology specimens diagnosed as LSIL among women attending colposcopy between 2007 and 2009. 3q26 gain was assessed on the index liquid sample; and sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were measured at immediate triage and at 6–16 months after colposcopic biopsy. The sensitivity of 3q26 gain measured at immediate triage from automated and manually reviewed tests in 65 non-pregnant unique women was 70% (95% CI: 35, 93) with a NPV of 89% (95% CI: 78, 96). The sensitivity and NPV increased to 80% (95% CI: 28, 99) and 98% (95% CI: 87, 100), respectively, when only the automated method of detecting 3q26 gain was used. Conclusions 3q26 gain demonstrates high sensitivity and NPV as a negative triage test for women with LSIL, allowing possible guideline changes to routine surveillance instead of immediate colposcopy. Prospective studies are ongoing to establish the sensitivity, specificity, PPV and NPV of 3q26 gain for LSIL over time.

Prophylactic HPV Vaccines and Prevention of Cervical Intraepithelial Neoplasia

Cervical cancer kills women of all ages. The irrefutable link to oncogenic human papillomavirus (HPV), a sexually transmitted infection, forever changed society’s attitude toward cervical cancer. The advent of HPV vaccines has brought the link of sexual practices and personal behavior to the forefront. The vaccines were aggressively marketed to parents, young girls, public health officials, physicians, and all payor sources before the scientific data defining their actual benefit could be delineated. At this early time, the HPV vaccines prevent persistent type-specific HPV infections, some abnormal Pap tests, some colposcopies, and some excisional procedures in women who are HPV-DNA negative before vaccination. Health-modeling exercises have demonstrated that duration of vaccine efficacy is the most important parameter for any long-term cancer prevention benefit. Implementation efforts have demonstrated that a three-dose series is difficult to achieve and results in a high vaccine wastage rate.

Trophoblast expression of the minor histocompatibility antigen HA-1 is regulated by oxygen and is increased in placentas from preeclamptic women

INTRODUCTION Maternal T-cells reactive towards paternally inherited fetal minor histocompatibility antigens are expanded during pregnancy. Placental trophoblast cells express at least four fetal antigens, including human minor histocompatibility antigen 1 (HA-1). We investigated oxygen as a potential regulator of HA-1 and whether HA-1 expression is altered in preeclamptic placentas. METHODS Expression and regulation of HA-1 mRNA and protein were examined by qRT-PCR and immunohistochemistry, using first, second, and third trimester placentas, first trimester placental explant cultures, and term purified cytotrophoblast cells. Low oxygen conditions were achieved by varying ambient oxygen, and were mimicked using cobalt chloride. HA-1 mRNA and protein expression levels were evaluated in preeclamptic and control placentas. RESULTS HA-1 protein expression was higher in the syncytiotrophoblast of first trimester as compared to second trimester and term placentas (P<0.01). HA-1 mRNA was increased in cobalt chloride-treated placental explants and purified cytotrophoblast cells (P = 0.04 and P<0.01, respectively) and in purified cytotrophoblast cells cultured under 2% as compared to 8% and 21% oxygen (P<0.01). HA-1 mRNA expression in preeclamptic vs. control placentas was increased 3.3-fold (P = 0.015). HA-1 protein expression was increased in syncytial nuclear aggregates and the syncytiotrophoblast of preeclamptic vs. control placentas (P = 0.02 and 0.03, respectively). DISCUSSION Placental HA-1 expression is regulated by oxygen and is increased in the syncytial nuclear aggregates and syncytiotrophoblast of preeclamptic as compared to control placentas. Increased HA-1 expression, combined with increased preeclamptic syncytiotrophoblast deportation, provides a novel potential mechanism for exposure of the maternal immune system to increased fetal antigenic load during preeclampsia.

Traditional Dressing Compared With an External Negative Pressure System in Preventing Wound Complications

INTRODUCTION: The cesarean delivery rate has increased and accounts for 32.8% of all births. Wound complications are one of the most frequent risks of cesarean delivery. Our objective is to determine whether the use of a Prevena negative pressure dressing can reduce the incidence of wound complications after cesarean delivery when compared with traditional dressings. METHODS: We performed a retrospective review of all patients undergoing cesarean delivery at our institution between November 2011 and March 2013. Information was obtained regarding demographics, indication for cesarean delivery, duration of labor, infections, incision and dressing type, and postoperative course. Comparisons were made between traditional dressing and those who had a Prevena placed. RESULTS: Wound complications occurred in 50 patients (5.2%). Comparisons of the Prevena (n=103) and traditional dressing (n=867) groups revealed higher wound complications for the Prevena dressing with an odds ratio (OR) of 3.37 (confidence interval [CI] 1.68–6.39). Prevena was more commonly used in patients who are obese and have preexisting diabetes. After controlling for body mass index and preexisting diabetes in logistic regression, Prevena was equivalent to traditional dressing for risk of wound complications with an adjusted OR of 1.70 (CI 0.76–3.84). CONCLUSIONS: Prevena dressing is equivalent to traditional dressing for preventing any wound complications after controlling for the higher-risk population selected for its use. A randomized clinical trial and cost analysis should be performed before the adoption of the routine use of Prevena™ in clinical practice.

New Horizons in Doppler Ultrasound Technology: Relevance for Obstetrical Applications

Technologic advances and clinical research have been extending the scope of Doppler sonography and have resulted in the emergence of new diagnostic tools that show significant promise in clinical applications. This article aims to review some of these developments that are relevant for obstetrical practice. One of the major recent technical developments in ultrasound imaging is the ability to assess tissue deformation. This has led to several clinical applications including functional echocardiography that allows evaluation of myocardial function using Doppler and speckle tracking techniques, and sonoelastography, which is ultrasound evaluation of tissue stiffness. Another relevant innovation is power Doppler imaging of regional perfusion. With further critical investigations, these emerging techniques may evolve into useful clinical tools.