Julie Moldenhauer

Selective reduction in complicated monochorionic pregnancies: radiofrequency ablation vs. bipolar cord coagulation

To compare radiofrequency ablation (RFA) and bipolar cord coagulation (BPC) methods for selective fetal reduction in the treatment of complicated monochorionic (MC) multifetal gestations.

Early delivery as an alternative management strategy for selected high-risk fetal sacrococcygeal teratomas

BACKGROUNDnLarge, prenatally diagnosed sacrococcygeal teratomas (SCTs) present a formidable challenge because of their unpredictable growth and propensity for complications. In our experience, even with aggressive serial imaging, many fetuses have died under a policy of watchful waiting. We propose early delivery as the best option for selected cases of high-risk fetal SCT.nnnMETHODSnThe medical charts of all fetuses with SCT followed up at our institution and delivered before 32 weeks of gestation were reviewed for radiologic findings, fetal interventions, delivery information, perinatal inpatient course, and autopsy or discharge report.nnnRESULTSnBetween 1996 and 2009, excluding those that underwent fetal surgery, 9 patients with fetal SCT were delivered before 32 weeks of gestation. Four had type I tumors, and 5 had type II tumors. Of the 9 fetuses, 4 survived the neonatal period. The only surviving patient delivered before 28 weeks underwent an ex utero intrapartum therapy procedure.nnnCONCLUSIONSnA significant number of pregnancies complicated by high-risk SCT will manifest signs of fetal or maternal decompensation, or both, between 27 and 32 weeks of gestation. In the absence of fulminant hydrops, preemptive early delivery can be associated with surprisingly good outcomes in appropriately selected fetuses with high-risk SCT.

Preoperative predictors of death in twin-to-twin transfusion syndrome treated with laser ablation of placental anastomoses

OBJECTIVEnTo determine preoperative predictive factors for donor and recipient death after laser ablation of placental vessels in twin-to-twin transfusion syndrome.nnnSTUDY DESIGNnRetrospective analysis of North American Fetal Therapy Network center laser procedures, 2002-2009. Factors associated with donor and recipient death were identified by regression analysis.nnnRESULTSnThere were 466 patients from 8 centers. Factors significantly associated with donor fetal death were low donor estimated fetal weight (odds ratio [OR], 0.69; 95% confidence interval [CI], 0.55-0.87) and reversed end diastolic velocity in the umbilical artery (OR, 4.0; 95% CI, 1.54-10.2); for recipient fetal death-low recipient estimated fetal weight (OR, 0.65; 95% CI, 0.44-0.95), recipient reversed a wave in the ductus venosus (OR, 2.39; 95% CI, 1.27-4.51) and hydrops (OR, 3.7; 95% CI, 1.1-12.7); for recipient neonatal death-low donor estimated fetal weight (OR, 0.54; 95% CI, 0.30-0.95), high recipient estimated fetal weight (OR, 1.55; 95% CI, 1.06-2.26) and recipient reversed end diastolic velocity in the umbilical artery (OR, 7.8; 95% CI, 1.03-59.3).nnnCONCLUSIONnPreoperative findings predict fetal and neonatal demise in twin-to-twin transfusion syndrome treated with laser therapy.

Maternal antimullerian hormone levels do not predict fetal aneuploidy

PurposeTo determine if diminished ovarian reserve (measured by maternal antimullerian hormone (AMH) levels), is associated with fetal aneuploidy (determined by prenatal karyotype).MethodsThis case-control study included 213 women with singleton pregnancies who underwent both serum aneuploidy screening and invasive prenatal diagnosis. 18 patients carrying an aneuploid fetus served as cases and the remaining 195 women with a euploid fetus were controls. Serum AMH was measured using two assays: AMHbc (Beckman-Coulter) and AMHdsl (Diagnostic Systems Laboratories). Karyotypes were determined by chorionic villus sampling or amniocentesis.ResultsAMHbc levels did not differ between women with an aneuploid fetus and women with a euploid fetus (pu2009=u20090.46) and did not predict aneuploidy (ROC Areau2009=u20090.57). Additionally, AMHbc values declined significantly with advancing gestational age.ConclusionsMaternal AMH does not appear to be a marker of fetal aneuploidy in ongoing pregnancies. Contrary to previous reports, we found a significant decline in maternal AMH levels with advancing gestational age.

Relationship between the sonographic pattern of intrauterine growth restriction and acid-base status at the time of cordocentesis

Abstractu2002Objective: To determine whether there is a difference in acid-base status at the time of cordocentesis between fetuses with symmetric and asymmetric intra- uterine growth restriction (IUGR). Study Design: Non-anomalous singleton fetuses with IUGR who underwent fetal blood sampling for rapid karyotype analysis from 1992–1995 were retrospectively identified. Cases with gestational age <24 weeks, abnormal karyotype, or evidence of congenital infection were excluded. Fetuses were divided into two groups based on Head Circumference/ Abdominal Circumference Ratio (HC/AC). The asymmetric-IUGR group had HC/AC ≥95% tile for GA, and the symmetric-IUGR group had HC/AC <95% tile. GA adjusted values of umbilical venous pH, pCO2, pO2, HCO3, hemoglobin and reticulocyte count were calculated by subtracting the mean values for GA from the observed and compared between groups. Results: Both symmetric-IUGR (n=7) and asymmetric-IUGR (n=9) had umbilical venous pH and pO2 levels lower than GA normative values. However, there were no differences between groups for any of the parameters studied. Conclusions: Fetuses with symmetric and asymmetric IUGR due to UPI display a similar degree of acid-base impairment.

Monochorionic Diamniotic Twin Pregnancy Timing and Duration of Sonographic Surveillance for Detection of Twin-Twin Transfusion Syndrome

Twin‐twin transfusion syndrome complicates up to 15% of monochorionic diamniotic gestations. Current recommendations for sonographic surveillance in monochorionic diamniotic pregnancies for detection of twin‐twin transfusion syndrome vary. Our objective was to determine an appropriate frequency of sonographic surveillance to optimize detection of twin‐twin transfusion syndrome in monochorionic diamniotic gestations.

Meconium staining and meconium aspiration syndrome : Is there seasonal variation?

Objective: To determine whether the incidence of pregnancies complicated by meconium-stained amniotic fluid (MSAF) or meconium aspiration syndrome (MAS) differs with seasonal changes. Methods: An established perinatal database was used to identify all term (≧37 weeks) singleton gestations resulting in a live birth from January 1, 1997 to December 31, 1999. Patients were divided into groups based on the season of delivery: winter (December-February), spring (March-May), summer (June-August), and fall (September-November). Rates of MSAF (%MSAF/total deliveries) and MAS (%MAS/total deliveries) were calculated and compared among seasons. Local climatic data (average monthly temperature and monthly precipitation) were obtained from the National Weather Service. Multiple logistic regression analysis was performed to control for the effects of confounding variables and odds ratio (OR) with 95% confidence intervals (CI) were calculated. p < 0.05 was considered significant. Results: Over the 3-year study period there were a total of 14,888 deliveries meeting the criteria. MSAF occurred in 3,206 (21.5%) deliveries and MAS developed in 92 (0.6% of total, 2.9% of MSAF). There were no differences in the rate of MSAF (p = 0.2) or MAS (p = 0.6) between seasons. By logistic regression neither season, temperature, nor precipitation were associated with MSAF or MAS. Conclusions: Our findings suggest that over the period examined there were no significant seasonal variations in the incidence of MSAF or MAS.

Molecular confirmation of nine cases of Cornelia de Lange syndrome diagnosed prenatally

Cornelia de Lange syndrome (CdLS) is characterized by distinct facial features, growth retardation, upper limb reduction defects, hirsutism, and intellectual disability. NIPBL mutations have been identified in approximately 60% of patients with CdLS diagnosed postnatally. Prenatal ultrasound findings include upper limb reduction defects, intrauterine growth restriction, and micrognathia. CdLS has also been associated with decreased PAPP‐A and increased nuchal translucency (NT). We reviewed NIPBL sequence analysis results for 12 prenatal samples in our laboratory to determine the frequency of mutations in our cohort.

Evaluation of the cardiovascular system in twin–twin transfusion syndrome: it's not about ‘scores’ but about ‘goals’

We read with interest the paper by Stirnemann et al.1 evaluating the utility of the CHOP (Children’s Hospital of Philadelphia) cardiovascular score for twin–twin transfusion syndrome (TTTS) as a predictor of outcome following laser photocoagulation of placental vessels. They found the CHOP score not to be predictive of survival. In an accompanying Opinion, Quintero, amongst a number of other points, questioned the role of fetal echocardiography in the evaluation of TTTS patients2. In developing the CHOP score, our intent was not to develop a tool to predict survival after laser therapy, nor to replace the Quintero staging system, but rather to add an additional layer of understanding to the evaluation, utilizing an analysis scheme specific to the cardiovascular system3. Cardiovascular abnormalities are prevalent in TTTS and contribute to the origins and foundation of the disease. Some of these abnormalities are subtle, and some are not so subtle, but they are readily evident to those who look. The CHOP score provides a means of characterizing and quantifying the degree of cardiovascular disease burden present in a systematic and logical manner, tailored to our current understanding of the mechanisms of the disease. It provides a sense of scale to the physiological aberration present that is not adequately provided by the Quintero staging system. We have learned much since our initial description of the CHOP score in 2007. We find it is most helpful when utilized as a continuous variable with points ranging from 0 to 20, and not as a categorical variable divided into quartiles or ‘cardiac stages’ as evaluated in part by Stirnemann et al.1. We have found it to be a tool that provides the capacity to improve our understanding of the physiological impact of laser photocoagulation therapy. At the 2010 ISUOG World Congress we present data in an abstract4 looking at the CHOP score in a serial manner, before and after therapy. We found no change in CHOP score at 24 hours, but noted a significant reduction at 1 week after laser photocoagulation. Furthermore, assessment of change in the individual elements of the CHOP score provides insight into the physiological effects of therapy, as diastolic elements such as filling properties of the ventricle improve well in advance of systolic elements such as atrioventricular valve regurgitation. Is there value in assessment of the cardiovascular system in TTTS? Stirnemann et al.1 did not find the CHOP score to be predictive of outcome as defined by survival; however, as most fetuses are now expected to survive, it has become more important to look at other outcome variables, such as cardiovascular morbidity. Such morbidity, if present, also demands scrutiny and serial follow-up during the course of gestation. Development of right-sided outflow tract obstruction continues to plague 10–20% of recipient fetuses3. Persistent ventricular dysfunction or valvular regurgitation in laser treatment survivors may require intervention in the neonatal period. Furthermore, ongoing gestation and development within the inhospitable physiological storm of TTTS may impact negatively on postnatal cardiovascular health in childhood and later adult life5. The means to measure this degree of cardiovascular derangement by utilization of the CHOP score at initial diagnosis, after therapy and in a serial manner throughout gestation provides a way with which to assess continued disease manifestations and correlate these findings with longterm outcome – a role not fulfilled by the Quintero staging system. TTTS is a multidimensional disease and as such it demands a multidimensional approach to evaluation. Both the Quintero staging system and the CHOP score are tools to be wielded in the battle against TTTS. But perhaps the perspective needs to be broadened beyond simple fetal survival. The objective in the current era should be to optimize outcome and provide the best quality of life, free of residual disease. This, undoubtedly, is the goal.

Influence of maternal asthma and asthma severity on newborn morphometry.

Objective. To determine if maternal asthma or asthma severity affects newborn morphometry. Study Design. A secondary analysis was performed on data collected in a multicenter prospective observational cohort study of asthma in pregnancy. Patients enrolled included women with asthma stratified by severity of disease and controls. Asthma severity was defined according to the classification proposed by the National Asthma Education Program (NAEP) Report of the Working Group on Asthma and Pregnancy, modified to include medication requirements. Newborn morphometry measurements included birth weight (BW) and multiples of the median birth weight (BW-MOM), head circumference (HC), length (L), HC:BW ratio, and ponderal index (PI). Results. Of 2480 patients there were 828 nonasthmatic controls, 828 with mild, 775 with moderate, and 49 with severe disease. Comparing all groups, there were statistically significant differences in maternal age (p < .001), race (p = .005), parity (p = .006), prepregnancy weight (p = .028), and medical care source (p = .001), with the severe asthma group having the highest mean maternal age (25.7 years), and proportion of African Americans (71.4%), proportion of multiparous patients (63.3%), and proportion of patients receiving government assistance (85.7%). When the control group was excluded from the comparisons, differences in prepregnancy weight and medical care source were no longer significant. BW-MOM and L did not differ between groups. The HC:BW ratio increased with asthma severity (p = .029) and was increased compared to controls (p = .010). This remained significant after controlling for confounding variables (both p <.001). HC was statistically significantly different between all groups (p = .032), as well as among women with varying degrees of asthma severity (p = .013), which was not clinically significant. After covariates adjustment, HC was not significantly different among all groups (p = .228), nor the asthma groups (p = .144). Conclusion. Asthma severity is associated with an increased HC:BW ratio. Severity was not found to impact HC, BW-MOM, L, or PI independently. However, the magnitudes of the effects were too small to suggest a clinically significant effect of asthma on neonatal morphometry in this large prospectively studied sample.