Geeta Sharma

First trimester prediction of growth discordance in twin gestations

OBJECTIVE The purpose of this study was to determine whether first trimester ultrasound scanning can identify twin gestations that are at risk for subsequent growth discordance. STUDY DESIGN Ultrasound examinations of dichorionic twin pregnancies between 11 and 14 weeks of gestation were evaluated for growth discordance with crown-rump length. Pregnancies that were complicated by fetal death or anomalies were excluded from the analysis. Birth weight discordance was defined as >or=20% difference in birth weight, relative to the larger twin. Fishers exact, Mann Whitney U, and Spearman rho tests were used for statistical analysis. RESULTS Of 130 twin pregnancies, 16 pregnancies (12.3%) had discordant birth weight. Crown-rump length disparity was correlated positively with birth weight discordance (r=0.31; P<.001). Of pregnancies with a discrepancy of <or=3 days in estimated gestational age, only 9.2% were discordant at birth compared with 45.5% of pregnancies with >3 days discrepancy (P=.004), which resulted in a likelihood ratio of 5.9 for having discordant birth weight. CONCLUSION Twins who are ultimately discordant at birth may exhibit differences in growth as early as 11 to 14 weeks of gestation.

First-trimester screening for aneuploidy with fetal nuchal translucency in a United States population

To examine the detection rate of chromosomal abnormalities using a combination of nuchal translucency (NT) and maternal age in a United States population.

Meaningful features of voice range profiles from patients with organic vocal fold pathology: A preliminary study

This preliminary study identifies features that have the potential to be meaningful descriptors of voice range profiles (VRPs) for 15 patients with organic vocal fold pathologies before and after laryngeal surgery. This study also explores the utility of the VRP as an outcome measure of change in vocal function after surgery. Potentially meaningful features for these patients are the semitone range, intensity level of the lower contour, frequency locus of the lower frequency values, smoothness of the contours, and the presence of intermittencies in the VRP contours. These features are not suggested for differential diagnosis, but for aiding the understanding of each individual patients phonatory status. Initial use of these features suggests that the VRP may be a useful outcome measure for these patients.

Enhancing patient autonomy with risk assessment and invasive diagnosis: an ethical solution to a clinical challenge.

The purpose of this study was to describe a clinically based, ethically justified informed consent process for risk assessment and invasive genetic diagnosis that enhances patient autonomy. Appealing to the ethical principle of respect for the autonomy of pregnant women, we show that patients can exercise their autonomy meaningfully in the informed consent process in response to the offer of risk assessment (RA) and invasive diagnosis (ID) and in response to the results of risk assessment. All pregnant patients in the first trimester should be offered both RA and ID. Women will sort themselves, in response, into 4 groups; those who refuse both RA and ID, those who are uncertain about RA, those who accept RA, and those who accept ID. Women who proceed to RA will sort themselves, in response to its results, into 3 groups: women for whom the risk of aneuploidy is acceptable or unacceptable and women who are not certain whether such risk is acceptable. For this last group only, the informed consent process should present information about current controversies of first-trimester and second-trimester further testing to better assess risk. Clinical strategies are identified for the implementation of the varied responses of pregnant women to the offer of RA and ID. Autonomy-enhancing strategies for the evaluation of pregnancy provide the basis for solving the ethical challenge that is presented by the wide variety of evaluation techniques.

Clinical significance of the umbilical cord twist.

OBJECTIVE The objective of this study was to determine the clinical significance of the umbilical cord twist direction. STUDY DESIGN Two hundred singleton third-trimester placentas with a right umbilical cord twist and 200 placentas with a left umbilical cord twist, which was determined by pathologic examination, were included. Maternal and neonatal outcomes were compared with the use of Fishers exact and Mann Whitney U tests; a probability value of <.05 considered statistically significant. RESULTS Placenta previa was more common in patients with a right umbilical cord twist compared with a left umbilical cord twist (6.0% vs 1.5%; P<.05). There was a trend towards an increased incidence of single umbilical artery in patients with a right umbilical cord twist (2.5% vs 0%; P=.06). The incidence of fetal demise, intrauterine growth restriction, chromosomal abnormalities, congenital anomalies, preterm delivery, infant gender, birth weight, maternal age, and parity were similar between the 2 groups. CONCLUSION Placenta previa is associated with a right umbilical cord twist.

Prognostic factors associated with antenatal subchorionic echolucencies

OBJECTIVE This study was undertaken to determine prognostic factors in pregnancies with a subchorionic echolucency. STUDY DESIGN One hundred twenty-nine pregnancies with a subchorionic echolucency detected by ultrasound in our unit were identified. Ultrasound reports were reviewed for subchorionic echolucency location, size, gestational age, amniotic fluid volume, and fetal abnormalities. Adverse outcomes evaluated were pregnancy loss before 24 or 37 weeks (PTD) and intrauterine growth restriction. Medical records were reviewed for antenatal complications and neonatal outcomes. RESULTS There were 7 (5.4%) pregnancy losses before 24 weeks and 24 (18.6%) pregnancies complicated by PTD. Of the 122 pregnancies reaching viability, those complicated by antepartum bleeding were more likely to deliver prematurely than those without bleeding, (26.6% vs 7.0%, P=.009). Maximum area of subchorionic echolucency, gestational age at subchorionic echolucency detection, amniocentesis, maternal age, and parity were not associated with PTD. CONCLUSION Patients with subchorionic echolucency appear to have a high incidence of PTD. Bleeding appears to be a reliable prognostic indicator.

Use of fetal magnetic resonance imaging in patients electing termination of pregnancy by dilation and evacuation

OBJECTIVE The purpose of this study was to determine whether magnetic resonance imaging of the fetal brain before dilation and evacuation enhances diagnosis when equivocal ultrasound findings and disrupted autopsy specimens exist. STUDY DESIGN Patients with equivocal fetal brain abnormalities on ultrasound examination who were considering termination of pregnancy were evaluated retrospectively. Abdominal and pelvic magnetic resonance imaging was performed for further evaluation, and orthogonal fetal brain images were obtained. A multidisciplinary team reviewed all cases and discussed the findings, possible causes, and recurrence risks with each patient. RESULTS Seven patients with fetal brain anomalies underwent magnetic resonance imaging before dilation and evacuation. Magnetic resonance imaging diagnoses included intracranial hemorrhages, semilobar holoprosencephaly, intracranial teratoma, multiple cerebral infarcts, and unilateral cerebellar hypoplasia. In all cases, magnetic resonance imaging provided valuable information and helped distinguish possible genetic syndromes from likely sporadic disorders of brain development. CONCLUSION Magnetic resonance imaging can provide insight into diagnosis, cause, and recurrence risks for patients who choose dilation and evacuation because of fetal brain abnormalities.

The ponderal index in triplets: I. Relationship to small for gestational age neonates

Abstract The aim of the study was to examine the ponderal index in small for gestational age (SGA) triplets. Prospectively collected data from a cohort of triplets born at 28 to 37 weeks were analyzed. A low neonatal ponderal index (birth weight / [length] [3]) was defined as less than 1 SD below the mean (2.0), and SGA was considered as birth weight below the 10th percentile by triplet standards. We studied 2181 sets of triplets. Triplets delivered at <=33 weeks have a lower mean ponderal index compared with those delivered at >33 weeks. About 70% of SGA triplets do not have a low ponderal index, whereas 79.2% of infants with a low ponderal index are not SGA by triplet standards. Both the frequency of a low ponderal index and the frequency of infants with a low ponderal index who are not SGA decrease with increasing gestational age. We conclude that the majority of triplets with a low ponderal index might not be considered growth restricted, supporting the concept that reduced fetal weight of triplets is more likely a physiological rather than a pathological phenomenon.

Ethical considerations in elective cesarean delivery.

*Department of Obstetrics and Gynecology, Weill Medical College of Cornell University, New York, New York; †Department of Medicine and Medical Ethics, The Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas; ‡Department of Obstetrics and Gynecology, Maimonides Medical Center, New York, New York, and Department of Obstetrics and Gynecology, State University of New York–Health Sciences Center at Brooklyn, Brooklyn, New York

The ponderal index in triplets: II. Gestational age-related patterns of neonatal weights and lengths

Abstract In order to evaluate the determinants of high and low ponderal indices in triplets, we analyzed prospectively collected data from a cohort of 2181 triplet births. Low and high neonatal ponderal indices (birth weight/ [length] [3]) were defined as below or above 1 SD from the mean. The mean ponderal index was of 2.4+=0.4. At 30-31 weeks, there were significantly more infants with a low ponderal index; after 33 weeks, more infants were born with a high index. Birth weights of infants with a high index were significantly higher throughout the entire range of gestational ages, whereas their lengths were significantly smaller. Both birth weights and infant length had significant correlations with gestational ages for infants with a low (R[2]=0.97 and R[2]=0.94, respectively) as well as with high ponderal indices (R[2]=0.95 and R[2]=0.94, respectively). The regression analyses suggest, however, different patterns for infants with low or high ponderal indices.