Joseph Canterino

Maternal age and risk of fetal death in singleton gestations: USA, 1995–2000

Objective: To determine the magnitude of risk for fetal death among singleton pregnancies in relation to maternal age, and to compare the risks with other common indications for fetal testing.Study design: We performed a retrospective cohort analysis of singleton births delivered between 1995 and 2000 using the US linked birth/infant death data. Gestational age at <24 weeks and fetuses with anomalies were excluded. Fetal death rates at ≥24 and ≥32 weeks were calculated among women aged 15–19, 20–24, 25–29, 30–34, 35–39, 40–44 and 45–49 years, as well as for other common indications for testing: chronic and pregnancy-induced hypertension, diabetes and smallfor-gestational age (SGA). The association between maternal age and fetal deaths was derived after adjusting for potential confounders through multivariable logistic regression models. Relative risks (RR) and 95% confidence intervals (CI) were derived from these models after adjusting for the effects of gravidity, race, marital status, prenatal care, education, smoking and placental abruption.Results: Among the 21 610 873 singleton births delivered at ≥24 weeks, fetal deaths occurred in 58 580 (2.7 per 1000). Births to young (15–19 years) and older (≥35 years) women comprised 12.6% and 11.4%, respectively. Compared with women aged 20–24 years, young women did not experience an increased risk of fetal death. However, increasing rates of fetal death at ≥24 and at ≥32 weeks were seen with increasing maternal age. The RR for fetal death at ≥24 and at ≥32 weeks among women 35–39 years were 1.21 and 1.31, respectively, while the RRs were 1.62 and 1.67 among women aged 40–44 years. Women 45–49 years were 2.40-fold (95% CI 1.77, 3.27) and 2.38-fold (95% CI 1.64, 3.46) as likely to deliver a stillborn fetus at ≥24 weeks and ≥32 weeks, respectively. RRs for fetal death at ≥24 and ≥32 weeks for hypertensive disease, diabetes, and SGA ranged between 1.46 and 4.95.Conclusion: Fetal deaths are increased among older women (≥35 years). Fetal testing in women of advanced maternal age may be beneficial.

Vasa Previa Prenatal Diagnosis and Evaluation With 3-Dimensional Sonography and Power Angiography

Vasa previa is a condition in which the cord inserts into the membranes through which vessels then run, unprotected, until they insert into the placenta. These vessels run between the fetal presenting part above and the cervix below. When the membranes rupture, these vessels almost invariably rupture also, with resulting severe fetal hemorrhage and a high likelihood of fetal death from exsanguination. 1 - 4 The key to a good outcome lies in prenatal sonographic diagnosis of the condition and cesarean delivery before the membranes rupture.1-6 We describe the diagnosis and evaluation of vasa previa with 3-dimensional (3D) sonography and power angiography and discuss how these techniques were helpful in achieving a good outcome.

Screening for postpartum depression with the Edinburgh Postnatal Depression Scale in an indigent population: does a directed interview improve detection rates compared with the standard self-completed questionnaire?

Background. The Edinburgh Postnatal Depression Scale (EPDS) is a well-validated screening tool for the detection of patients at risk for postpartum depression. It was postulated that screening utilizing the EPDS in a directed interview would increase the detection rate compared with a self-completed EPDS in an indigent population. Objective. To compare the results of a self-completed EPDS with those of a directed interview utilizing the EPDS in the identification of patients at increased risk for postpartum depression. Methods. All patients undergoing a 6-week postpartum evaluation in the obstetric clinic at a community teaching hospital between November 1, 2003 and March 31, 2004 were screened for postpartum depression using the self-completed EPDS. This was followed by a directed interview, which consisted of a verbally administered EPDS by a social worker blinded to the results of the self-completed EPDS. A positive screen was defined as an EPDS score of ≥12 by either method. The number of patients with a positive screen to either the self-completed EPDS, the directed interview EPDS, or both were recorded. The two techniques were compared by the McNemar Chi-square test. The self-completed and directed interview EPDS scores were compared by Pearsons correlation coefficient to examine differences in screening techniques. Demographic data and characteristics in each group were examined. Results. Among the 134 patients evaluated, 24 (17.9%) screened positively for being at an increased risk of having postpartum depression. The self-completed EPDS and the directed interview EPDS screening detection rates were not different, identifying 23 (17.2%) and 22 (16.4%) patients, respectively (p = 1.0). The use of the self-completed EPDS and the directed interview EPDS in parallel detected one additional subject (0.7%; p = 0.99). The self-completed EPDS and directed interview EPDS scores correlated significantly (r = 0.94; p = 0.01). The demographics and characteristics of patients with a positive screen were not different from those with a negative screen. Conclusions. The self-completed EPDS and directed interview EPDS are equivalent screening techniques for postpartum depression. There is no evidence to suggest that parallel screening improves detection. Either technique should be incorporated into the postpartum visit to screen for postpartum depression.

Depression in pregnancy: time of screening and access to psychiatric care

Objective. To determine the timing of screening for postpartum depression that optimizes access to psychiatric care. Methods. Cross-sectional evaluation of women receiving obstetric care in a community-based medical center clinic from March to July 2006, who were screened for depression at 36 weeks gestation, delivery, and 6 weeks postpartum using the Edinburgh Postnatal Depression Scale. Positive screens generated referrals for psychiatric evaluation. The rate of positive screens for depression and psychiatric follow-up at each time point was evaluated. Results. Of the 293 patients evaluated, the distribution of the first screen which occurred during the study period was 21% at 36 weeks, 31% at delivery, and 48% at 6 weeks postpartum. The incidence of a positive screen was 5% at 36 weeks, 16% at delivery and 14% at 6 weeks postpartum. Access to psychiatric care occurred in 33% at 36 weeks, 15% at 6 weeks postpartum and 100% at delivery (p = 0.001). Conclusion. Screening for depression in the hospital after delivery improves access to psychiatric care.

Bladder Obstruction in Monochorionic Monoamniotic Twins

Posterior urethral valves (PUVs) may lead to complete urinary tract obstruction and profound oligohydramnios. This typically results in lethal pulmonary hypoplasia. We present a case of monoamniotic male twins discordant for urinary tract obstruction resulting from a PUV After delivery, the twin with the PUV had no evidence of pulmonary hypoplasia. Previous reports of diamniotic twins discordant for complete urinary tract obstruction have described universal mortality from lung hypoplasia in the twin with the obstruction. We propose that, in our case, the normal amniotic fluid in the shared sac was protective of lung development in the affected fetus. This case may provide powerful insight into the pathophysiologic process of lung hypoplasia because it supports the concept that the lethal lung hypoplasia that occurs in PUVs results from oligohydramnios due to reduced fetal urinary production.

Paternal age and risk for cesarean delivery

Objective: To determine whether advanced paternal age is associated with increased risk for cesarean delivery. Study design: We used the 1990–2002 US linked live birth and infant death data files restricted to primiparous Caucasian and African-American women that delivered a singleton birth at ≥20 week’s gestation (12.5 million). We examined temporal trends and risk ratios of cesarean birth in relation to paternal age before and after adjustments for known confounders. Results: Among Caucasians, the cesarean delivery rates were 21.1%, 26.7% and 31.8% in fathers aged 20–29, 30–39 and ≥40 years, respectively. Among African-Americans, the corresponding rates were 24.1%, 33.2%, and 38.1%, respectively. These increased cesarean delivery rates persisted in analyses stratified by maternal age before and after adjustment for a variety of confounders. Conclusions: These findings suggest that increasing paternal age may be associated with an increased risk for cesarean delivery in primiparous women.

The significance of a positive second trimester serum screen for trisomy 18

Objectives. We designed this study to estimate the proportion of fetuses in pregnancies with positive second trimester serum screens for trisomy 18 who actually have trisomy 18, to estimate the proportion of women with trisomy 18 who have a negative serum screen, and to assess the role of ultrasound in the diagnosis of trisomy 18. Methods. Retrospective study of two cohorts of pregnant women in 2004 and 2005: (1) those with a second trimester serum screen positive for trisomy 18 and (2) those with fetuses having trisomy 18. Results. There were 93 women with positive serum screens for trisomy 18. Of these, only three had a fetus with trisomy 18. There were five other cases of trisomy 18, three of which had a negative second trimester serum screen for trisomy 18. All fetuses with trisomy 18 had multiple major structural abnormalities detected on targeted genetic sonography. Conclusions. A positive second trimester serum screen has a poor sensitivity and poor prediction for trisomy 18. Trisomy 18 is highly unlikely if a woman with a positive screen for trisomy 18 has no fetal abnormalities detected on targeted genetic sonography. Women with a positive second trimester serum screen for trisomy 18 should be offered genetic sonography, and the practice of routine amniocentesis for all women with a positive screen should be discouraged when targeted genetic sonography is available.

Personalized medicine in a patient with the antenatal diagnosis of an umbilical cord knot and a previous adverse outcome for this reason.

Sonography has allowed for the in vivo detailed observation of the morphologic characteristics and hemodynamics of the umbilical cord in cases of a true knot of the umbilical cord1–7 as well as for insights into the relevance of this antenatal finding.8,9 Indeed, the fetoplacental circulation can be compromised by a true knot of the umbilical cord, leading to fetal demise. However, umbilical cord knots have been reported in up to 2% of deliveries, with an overwhelming good perinatal outcome, prompting controversy regarding the clinical utility of reporting this isolated antenatal diagnosis to avoid maternal distress. Until now, there were no reports concerning the antenatal management of a recurrent true knot of the umbilical cord in a patient with a previous pregnancy loss for this reason, which was not diagnosed prenatally. We now show how serial sonographic scans combined with other fetal surveillance techniques can be used to personalize the antenatal care of such a patient. A 20-year-old woman, gravida 4, para 1, was referred to our institute because of a prior cesarean delivery and 2 fetal demises: the first at 22 weeks after rupture of membranes and the second at 37 weeks, reportedly due to “a knot of the umbilical cord.” The sonographic fetal size, fetal activity, and amniotic fluid volume were normal, and no fetal, umbilical cord, or placental abnormalities were visualized at 20 weeks’ gestation. During the 32-week follow-up scan, the fetal growth, surveillance, and amniotic fluid volume were appropriate, but a knot of the umbilical cord was also visualized on 2-dimensional and power Doppler sonography (Figure 1). The patient was informed of the findings, which were consistent with the CLINICAL LETTERS

Placenta Previa and Placenta Accreta

The term placenta previa refers to a placenta that is abnormally located in the lower part of the uterus, often covering the cervix. The words are derived from the Latin pre, meaning before, and via, which comes from the same derivation as “viaduct” and “avenue,” meaning passageway. Thus, placenta previa means that the placenta lies before the baby in the birth canal. The placenta normally implants in the upper uterus, but in fewer than 1% of pregnancies it implants in the lower uterine segment. It was probably the French man-midwife Portal in 1683 who first described a placenta previa [1]. Placenta previa is one of the leading causes of bleeding during the third trimester. The condition is associated with significantly increased perinatal and maternal mortality and morbidity [2]. Perhaps the most important fetal consequence is prematurity with its associated sequelae, such as respiratory distress syndrome, high perinatal mortality, and long-term neurodevelopmental handicap. Placenta previa is also associated with significant maternal hemorrhage, a need for surgical delivery, placenta accreta, and cesarean hysterectomy [2].