Irwin R. Merkatz

An association between low maternal serum α-fetoprotein and fetal chromosomal abnormalities

Abstract An index case of “undetectable” maternal serum α-fetoprotein at 16 weeks in the first pregnancy of a 28-year-old woman was associated with birth of an infant with trisomy 18. This fortuitous finding stimulated a retrospective study of prenatally diagnosed chromosomal abnormalities. From among a series of 3,862 genetic amniocenteses, 32 cases of fetal autosomal trisomy were diagnosed for which corresponding maternal serum and amniotic fluid α-fetoprotein data could be retrieved. From a second laboratory, nine additional cases were added. The maternal serum α-fetoprotein levels expressed as multiples of the median were significantly lower in distribution for these 41 women than those from a group of normal matched control subjects (p

Quad screen as a predictor of adverse pregnancy outcome

Objective: To estimate the effect of second-trimester levels of maternal serum alpha-fetoprotein (AFP), human chorionic gonadotrophin (hCG), unconjugated estriol (uE3), and inhibin A (the quad screen) on obstetric complications by using a large, prospectively collected database (the FASTER database). Methods: The FASTER trial was a multicenter study that evaluated first- and second-trimester screening programs for aneuploidy in women with singleton pregnancies. As part of this trial, patients had a quad screen drawn at 15–18 6/7 weeks. We analyzed the data to identify associations between the quad screen markers and preterm birth, intrauterine growth restriction, preeclampsia, and fetal loss. Our analysis was performed by evaluating the performance characteristics of quad screen markers individually and in combination. Crude and adjusted effects were estimated by multivariable logistic regression analysis. Patients with fetal anomalies were excluded from the analysis. Results: We analyzed data from 33,145 pregnancies. We identified numerous associations between the markers and the adverse outcomes. There was a relatively low, but often significant, risk of having an adverse pregnancy complication if a patient had a single abnormal marker. However, the risk of having an adverse outcome increased significantly if a patient had 2 or more abnormal markers. The sensitivity and positive predictive values using combinations of markers is relatively low, although superior to using individual markers. Conclusion: These data suggest that components of the quad screen may prove useful in predicting adverse obstetric outcomes. We also showed that the total number and specific combinations of abnormal markers are most useful in predicting the risk of adverse perinatal outcome. Level of Evidence: II-2

Changing trends of neonatal and postneonatal deaths in very-low-birth-weight infants

Advances in perinatal care have resulted in a decline in mortality of very-low-birth-weight infants (< 1.5 kilograms) and also in an extension of the mortality period. To determine the current relevance of neonatal mortality results as indicators of outcome, all deaths among 427 very-low-birth-weight infants admitted during 1975-1977 were documented. A total of 145 infants died; 90 of the deaths (62%) occurred during the early neonatal period (0 to 6 days), 35 (24%) in the late neonatal period (7 to 27 days), and 20 (14%) in the postneonatal period. Death in 17 of the 20 postneonatal losses was due to neonatal complications of prematurity, and 16 of the 20 deaths occurred during the initial hospitalization. The postponement of these deaths to the postneonatal period has important epidemiologic implications and indicates a need for a reconsideration of accepted reporting mechanisms for infants of very low birth weight.

Preterm delivery and low birth weight - A dire legacy

The poor performance of the United States in the international ranking of infant mortality rates is mainly due to high rates of premature birth and associated low birth weight, which have changed l...

Fetal umbilical artery flow velocimetry in postdate pregnancies

This study prospectively examined the use of umbilical artery flow velocimetry for monitoring fetal health in postdate pregnancies. Forty-six patients with well-established dates were evaluated with semiweekly biophysical profiles and umbilical artery flow velocimetry (characterized by the ratio of the peak systolic to end-diastolic velocity). Their labor records were reviewed, and neonates were examined for signs of postmaturity. Twenty neonates had an abnormal test result or outcome (identified as an abnormal nonstress test, oligohydramnios, meconium, intrapartum fetal distress, or a 5-minute Apgar score less than 7). Nine neonates had a physical examination consistent with the postmaturity syndrome. Twenty-one neonates were entirely normal. Comparisons of the mean systolic/diastolic ratios for neonates with and without the complications associated with postdatism showed no significant differences. In addition, all systolic/diastolic ratios were within the normal range. Therefore, umbilical artery flow velocimetry is unlikely to be useful for the routine antenatal assessment of the postdate fetus.

Using Simulation Training to Improve Shoulder Dystocia Documentation

OBJECTIVE: To estimate whether shoulder dystocia documentation could be improved with a simulation-based educational experience. METHODS: Obstetricians at our institution (n=71) participated in an unanticipated simulated shoulder dystocia followed by an educational debriefing session. A second shoulder dystocia simulation was completed at a later date. Delivery notes were a required component of each simulation. Notes were evaluated using a standardized checklist for 16 key components. One point was awarded for each element present. Wilcoxon signed rank tests were used to compare documentation between simulations. RESULTS: Participants consisted of 43 (61%) attending and 28 (39%) resident physicians. Ages ranged from 25–63 years (mean±standard deviation 37.0±9.0), and 75% were female. Years of obstetric experience for our attendings ranged from 4 to 31 years (14.5±8.1). Documentation scores were significantly improved after training. Attendings’ baseline documentation scores were 8.5±2.2 and improved to 9.4±2.3, P=.03. Residents’ documentation scores also improved (9.0±2.1 compared with 10.6±2.2, P=.001). In particular, improvement was seen in two components of documentation: 1) providers present for shoulder dystocia (P=.007) and 2) which shoulder was anterior (P<.001). No improvement was seen in standard delivery note components (eg, date, time) or infant characteristics (eg, weight, Apgar scores). CONCLUSION: Although we showed a significant improvement in the quality of documentation through this simulation program, notes were still suboptimal. Use of standardized forms for shoulder dystocia delivery notes may provide the best solution to ensure appropriate documentation. LEVEL OF EVIDENCE: II

First-trimester 3-dimensional power Doppler of the uteroplacental circulation space: a potential screening method for preeclampsia

OBJECTIVE The objective of the study was to compare 3-dimensional power Doppler (3DPD) of the uteroplacental circulation space (UPCS) in the first trimester between women who develop preeclampsia (PEC) and those who do not and to assess the 3DPD method as a screening tool for PEC. STUDY DESIGN This was a prospective observational study of singleton pregnancies at 10 weeks 4 days to 13 weeks 6 days. The 3DPD indices, vascularization index (VI), flow index (FI), and vascularization flow index (VFI), were determined on a UPSC sphere biopsy with the virtual organ computer-aided analysis (VOCAL) program. RESULTS Of 277 women enrolled, 24 developed PEC. The 3DPD indices were lower in women who developed PEC. The area under the receiver-operating characteristics curve for the prediction of PEC was 78.9%, 77.6%, and 79.6% for VI, FI, and VFI, respectively. CONCLUSION Patients who develop PEC have lower 3DPD indices of their UPCS during the first trimester. Our findings suggest that this ultrasonographic tool has the potential to predict the development of PEC.

The contribution of birth defects to preterm birth and low birth weight

OBJECTIVE: To assess the impact of birth defects on preterm birth and low birth weight. METHODS: Data from a large, prospective multi-center trial, the First and Second Trimester Evaluation of Risk (FASTER) Trial, were examined. All live births at more than 24 weeks of gestation with data on outcome and confounders were divided into two comparison groups: 1) those with a chromosomal or structural abnormality (birth defect) and 2) those with no abnormality detected in chromosomes or anatomy. Propensity scores were used to balance the groups, account for confounding, and reduce the bias of a large number of potential confounding factors in the assessment of the impact of a birth defect on outcome. Multiple logistic regression analysis was applied. RESULTS: A singleton liveborn infant with a birth defect was 2.7 times more likely to be delivered preterm before 37 weeks of gestation (95% confidence interval [CI] 2.3–3.2), 7.0 times more likely to be delivered preterm before 34 weeks (95% CI 5.5–8.9), and 11.5 times more likely to be delivered very preterm before 32 weeks (95% CI 8.7–15.2). A singleton liveborn with a birth defect was 3.6 times more likely to have low birth weight at less than 2,500 g (95% CI 3.0–4.3) and 11.3 times more likely to be very low birth weight at less than 1,500 g (95% CI 8.5–15.1). CONCLUSION: Birth defects are associated with preterm birth and low birth weight after controlling for multiple confounding factors, including shared risk factors and pregnancy complications, using propensity scoring adjustment in multivariable regression analysis. The independent effects of risk factors on perinatal outcomes such as preterm birth and low birth weight, usually complicated by numerous confounding factors, may benefit from the application of this methodology, which can be used to minimize bias and account for confounding. Furthermore, this suggests that clinical and public health interventions aimed at preventing birth defects may have added benefits in preventing preterm birth and low birth weight. LEVEL OF EVIDENCE: II

Using an electronic medical record to improve communication within a prenatal care network.

OBJECTIVE: In 2002, the Institute of Medicine called for the introduction of information technologies in health care settings to improve quality of care. We conducted a review of hospital charts of women who delivered before and after the implementation of an intranet-based computerized prenatal record in an inner-city practice. Our objective was to assess whether the use of this record improved communication among the outpatient office, the ultrasonography unit, and the labor floor. METHODS: The charts of patients who delivered in August 2002 and August 2003 and received their prenatal care at the Comprehensive Family Care Center at Montefiore Medical Center were analyzed. Data collected included the presence of a copy of the prenatal record in the hospital chart, the date of the last documented prenatal visit, and documentation of any prenatal ultrasonograms performed. RESULTS: Forty-three charts in each group were available for review. The prenatal chart was absent in 16% of the charts of patients from August 2002 compared with only 2% in August 2003 charts (P < .05). Among charts with prenatal records available, the median length of time between the last documented prenatal visit and delivery was significantly longer for August 2002 patients compared with August 2003 patients (36 compared with 4 days, respectively, P < .001). All patients received prenatal ultrasonograms, but documentation of the ultrasonogram was missing from 16% of the August 2002 charts compared with none of the August 2003 charts (P = .01). CONCLUSION: The use of a paperless, hospital intranet–based prenatal chart significantly improves communication among providers. LEVEL OF EVIDENCE: II-3

Improved performance of maternal-fetal medicine staff after maternal cardiac arrest simulation-based training

OBJECTIVE To determine the impact of simulation-based maternal cardiac arrest training on performance, knowledge, and confidence among Maternal-Fetal Medicine staff. STUDY DESIGN Maternal-Fetal Medicine staff (n = 19) participated in a maternal arrest simulation program. Based on evaluation of performance during initial simulations, an intervention was designed including: basic life support course, advanced cardiac life support pregnancy modification lecture, and simulation practice. Postintervention evaluative simulations were performed. All simulations included a knowledge test, confidence survey, and debriefing. A checklist with 9 pregnancy modification (maternal) and 16 critical care (25 total) tasks was used for scoring. RESULTS Postintervention scores reflected statistically significant improvement. Maternal-Fetal Medicine staff demonstrated statistically significant improvement in timely initiation of cardiopulmonary resuscitation (120 vs 32 seconds, P = .042) and cesarean delivery (240 vs 159 seconds, P = .017). CONCLUSION Prompt cardiopulmonary resuscitation initiation and pregnancy modifications application are critical in maternal and fetal survival during cardiac arrest. Simulation is a useful tool for Maternal-Fetal Medicine staff to improve skills, knowledge, and confidence in the management of this catastrophic event.