George P. Henry

Screening Advances and Diagnostic Choice: The Problem of Residual Risk

Objective: Over the past decade some authorities have suggested that advanced screening methodologies obviate the need for more invasive, diagnostic procedures. Data on Down syndrome (DS) births for Colorado from 1989 to 2005 were used to examine the implications of a decreasing use of amniocentesis. Methods: Publicly available, State of Colorado Department of Public Health data on DS birth rates for women were compared to amniocentesis use at Colorado’s largest prenatal diagnostic center. Longitudinal changes on DS birth rates by maternal age (>35 and <35), and utilization of amniocentesis. Results: In Colorado, from 1989 to 2005, the rate for DS births for women 35+ rose considerably, while <35, rates remained stable (Cochran-Armitage test, p < 0.001). An autocorrelation-corrected test yielded a significant negative relationship between amniocentesis use (in 1,000s) and AMA DS rates (b = –11.30; p < 0.006; DW = 1.55). Confounding explanations involving sampling problems, socio-demographic factors, political conservatism and prevention orientation do not appear to account for these results. Conclusions: Replacement of definitive diagnosis with screening tests must be implemented with caution, particularly when using technologies with wide individual operator-dependent variability. Screening paradigms when performed with accuracy can markedly improve assessment of risks, but caution must be used in presenting negative screening results to women who still have a relatively high residual risk after a negative screen, and more generally in the displacement of technologies that provide definitive answers.

Midtrimester abortion produced by intra-amniotic prostaglandin F2α augmented with intravenous oxytoxin

Abstract Prostaglandin F 2α was administered by a single intra-amniotic injection of either 10 or 15 mg. in combination with continuous intravenous infusion of oxytocin to produce second-trimester abortion. Eight of the 10 patients aborted in less than 20 hours. The only toxicity encountered was a brief episode of vomiting in one patient.

Crown–Rump Length Dating of Pregnancy: Error Estimates Based on Measurement of Embryos Conceived by In Vitro Fertilization

Biometric measurements of the first trimester embryo are accurate in obtaining gestational age information, providing the obstetrician with important data in pregnancy management. We evaluated 92 embryos conceived following in vitro fertilization and embryo replacement by measurement of fetal crown—rump length. Comparison to standard tables currently available showed that the actual age of these embryos were underestimated by the available information. Our table provides for adjustment of standard measured ages with 95% confidence, allowing an estimate of the youngest as well as the oldest an embryo might actually be. Until new information by endovaginal scanning is available on embryos with known gestational ages by in vitro fertilization, this may be the most practical way of assessing first trimester gestational age.

Human in vitro fertilization in a private program: Reproductive genetics in vitro, P.C.

Reproductive Genetics in Vitro, P.C., began a program of human in vitro fertilization in a private practice setting in September of 1982, after nearly 1 year of preparation prior to the cycling of the first patient. Ovarian stimulation is most often by Clomid, 50 mg tid, on days 3 through 9 of the cycle. Follicle development is monitored by daily ultrasound, estradiol, follicle-stimulating hormone (FSH), and luteinizing hormone (LH) measurements. Serum progesterone measurements are made the last few days prior to anticipated ovulation to detect early signs of luteinization. In the first phase of our program 12 patients with pure tubal obstruction have had one or more oocytes retrieved by laparoscopy. All oocytes fertilized such that every patient who had oocytes retrieved had embryos placed in the uterus. Of the first 12 patients who had embryo placement, 2 are ongoing and normal in the second trimester of pregnancy, with delivery expected shortly after the first issue of this journal. Five others showed early signs of clinical pregnancy as indicated by acentrically located gestational sacs (as opposed to the typical centrally located pseudogestational sac) or transiently elevated human chorionic gonadotropin (HCG).

Contents Vol. 23, 2008

R. Achiron, Tel Hashomer N.S. Adzick, Philadelphia, Pa. L. Allan, London K.J. Blakemore, Baltimore, Md. T.-H. Bui, Stockholm F.A. Chervenak, New York, N.Y. T. Chiba, Tokyo Y. Chiba, Osaka W.H. Clewell, Phoenix, Ariz. J.E. De Lia, Milwaukee, Wisc. Y.M.D. Lo, Hong Kong J.A. Deprest, Leuven G.C. Di Renzo, Perugia M. Dommergues, Paris J.W. Dudenhausen, Berlin Y. Dumez, Paris N.M. Fisk, Herston, Brisbane A.W. Flake, Philadelphia, Pa. W.D.A. Ford, North Adelaide U. Gembruch, Bonn P.D. Gluckman, Auckland M. Hansmann, Bonn M.R. Harrison, San Francisco, Calif. J.C. Hobbins, Denver, Colo. L.K. Hornberger, San Francisco, Calif. E.R.M. Jauniaux, London M.P. Johnson, Philadelphia, Pa. C. Jorgensen, Copenhagen J.-M. Jouannic, Paris H.H.H. Kanhai, Leiden A. Kurjak, Zagreb P.M. Kyle, London S. Lipitz, Tel-Hashomer S. Mancuso, Roma G. Mari, Detroit, Mich. M. Martinez-Ferro, Buenos Aires P. Miny, Basel K.J. Moise, Houston, Tex. K.H. Nicolaides, London U. Nicolini, Milan L. Otaño, Buenos Aires Z. Papp, Budapest R. Quintero, Tampa, Fla. G. Ryan, Toronto J. Rychik, Philadelphia, Pa. G.R. Saade, Galveston, Tex. H. Sago, Tokyo W. Sepulveda, Santiago P. Stone, Auckland D.V. Surbek, Bern M. Tanemura, Nagoya S. Tercanli, Basel J.-L. Touraine, Lyon B.J. Trudinger, Westmead J.M.G. van Vugt, Amsterdam S.L. Warsof, Virginia Beach, Va. C.P. Weiner, Kansas City, Kans. R.D. Wilson, Philadelphia, Pa. R. Zimmermann, Zürich Clinical Advances and Basic Research

Equivocal amniotic fluid levels of alpha fetoprotein in prenatal diagnosis of neural tube defects

The following case is reported as an example of problems of interpreting alpha fetoprotein (AFP) results of amniocentesis. A 26-year-old underwent amniocentesis at 16 weeks of gestation because a previous infant had been born with myelomeningocele. Sonography revealed the placenta posteriorly implanted and there was no evidence of twin gestation. The fluid was clear and AFP was measured at 2.75 mg% (upper limit of normal 2.3 mg%). The results were called borderline abnormal and amniography was suggested to the patient to attain a diagnosis but the patient decided on termination without supporting tests. The fetus was found to have a lumbar spina bifida with myeloschisis and segmental agenesis of the lumbar spinal cord. A borderline measurement (greater than 2 standard deviations above normal) requires further testing before diagnosis can be made.