Kathleen F. Brookfield

Conjugated bisphenol A in maternal serum in relation to miscarriage risk.

OBJECTIVEnTo examine the relationship between the maternal serum bisphenol A (BPA) concentration at the time of the missed menstrual cycle and miscarriage risk.nnnDESIGNnRetrospective cohort of prospectively collected serum samples.nnnSETTINGnAcademic fertility center.nnnPATIENT(S)nWomen presenting for early pregnancy monitoring with singleton pregnancies.nnnINTERVENTION(S)nStored serum samples from 4 to 5xa0weeks gestation analyzed for conjugated serum BPA concentrations.nnnMAIN OUTCOME MEASURE(S)nLive birth, miscarriage, and chromosome content of miscarriage.nnnRESULT(S)nWith the 115 women included in the study, there were 47 live births and 68 clinical miscarriages (46 aneuploid and 22 euploid). Median conjugated BPA concentrations were higher in the women who had miscarriages than in those who had live births (0.101 vs. 0.075xa0ng/mL). Women with the highest quartile of conjugated BPA had an increased relative risk of miscarriage (1.83; 95% CI, 1.14-2.96) compared with the women in the lowest quartile. We found a similar increase risk for both euploid and aneuploid miscarriages.nnnCONCLUSION(S)nMaternal conjugated BPA was associated with a higher risk of aneuploid and euploid miscarriage in this cohort. The impact of reducing individual exposure on future pregnancy outcomes deserves further study.

Perioperative and transfusion outcomes in women undergoing cesarean hysterectomy for abnormal placentation.

Women with placenta increta (PI) and placenta percreta (PP) are at high risk of obstetric hemorrhage; however, the severity of hemorrhage and perioperative morbidity may differ according to the degree of placental invasion. We sought to compare blood component usage and perioperative morbidity between women with PI versus PP undergoing cesarean hysterectomy (CH).

Racial and Ethnic Disparities in Mode of Anesthesia for Cesarean Delivery.

BACKGROUND:Racial and ethnic disparities have been identified in the provision of neuraxial labor analgesia. These disparities may exist in other key aspects of obstetric anesthesia care. We sought to determine whether racial/ethnic disparities exist in mode of anesthesia for cesarean delivery (CD). METHODS:Women who underwent CD between 1999 and 2002 at 19 different obstetric centers in the United States were identified from the Maternal-Fetal Medicine Units Network Cesarean Registry. Race/ethnicity was categorized as: Caucasian, African American, Hispanic, and Non-Hispanic Others (NHOs). Mode of anesthesia was classified as neuraxial anesthesia (spinal, epidural, or combined spinal-epidural anesthesia) or general anesthesia. To account for obstetric and non-obstetric covariates that may have influenced mode of anesthesia, multiple logistic regression analyses were performed by using sequential sets of covariates. RESULTS:The study cohort comprised 50,974 women who underwent CD. Rates of general anesthesia among racial/ethnic groups were as follows: 5.2% for Caucasians, 11.3% for African Americans, 5.8% for Hispanics, and 6.6% for NHOs. After adjustment for obstetric and non-obstetric covariates, African Americans had the highest odds of receiving general anesthesia compared with Caucasians (adjusted odds ratio [aOR] = 1.7; 95% confidence interval [CI], 1.5–1.8; P < 0.001). The odds of receiving general anesthesia were also higher among Hispanics (aOR = 1.1; 95% CI, 1.0–1.3; P = 0.02) and NHOs (aOR = 1.2; 95% CI, 1.0–1.4; P = 0.03) compared with Caucasians, respectively. In our sensitivity analysis, we reconstructed the models after excluding women who underwent neuraxial anesthesia before general anesthesia. The adjusted odds of receiving general anesthesia were similar to those in the main analysis: African Americans (aOR = 1.7; 95% CI, 1.5–1.9; P < 0.001); Hispanics (aOR = 1.2; 95% CI, 1.1–1.4; P = 0.006); and NHOs (aOR = 1.2; 95% CI, 1.0–1.5; P = 0.05). CONCLUSIONS:Based on data from the Cesarean Registry, African American women had the highest odds of undergoing general anesthesia for CD compared with Caucasian women. It is uncertain whether this disparity exists in current obstetric practice.

Maternal bladder cancer diagnosed at routine first-trimester obstetric ultrasound examination.

BACKGROUND: Bladder cancer is exceedingly rare in pregnancy and most commonly presents with gross hematuria. CASES: We describe two patients with the incidental finding of maternal bladder masses identified during routine first-trimester obstetric ultrasonographic evaluation and an ultimate diagnosis of carcinoma. After referral for urology evaluation and biopsy confirmation of bladder cancer, patients underwent surgical resection during their pregnancies without the need for further treatment and had uncomplicated pregnancy courses. CONCLUSION: The distended maternal urinary bladder at the time of first-trimester ultrasonographic evaluation offers a unique opportunity for examination and early diagnosis of incidental maternal bladder carcinoma.

Aneuploidy rates and blastocyst formation after biopsy of morulae and early blastocysts on day 5

PurposeStudies have demonstrated high implantation rates after trophectoderm biopsy of day 5 expanded blastocysts. However, biopsy of cleavage stage embryos may adversely affect embryo development and implantation. No studies have assessed the utility of day 5 morulae and early blastocyst biopsy. This study sought to better understandxa0these slower embryos’ aneuploidy rates and implantation potential.MethodsThis was a retrospective review of all autologous IVF cycles utilizing PGS at a single academic infertility center.ResultsThe biopsy of day 5 morulae and early blastocysts provided 22xa0% additional euploid blastocysts available for fresh day 6 transfer compared to day 5 biopsy of only expanded blastocysts. Aneuploidy did correlate with embryo stage on day 5, even after controlling for maternal age, with 16xa0% of morulae and 35xa0% of blastocysts being euploid. The majority (83xa0%) of euploid morulae progressed to the blastocyst stage by day 6. Experience transferring slower developing embryos is limited, but preliminary pregnancy and implantation rates appear similar to euploid embryos biopsied as expanded blastocysts.ConclusionsThe biopsy of all non-arrested embryos on day 5 provides genetic information for all blastocysts on day 6, increasing the pool of euploid blastocysts available for fresh transfer and avoiding the need to cryopreserve developmentally competent embryos without genetic information.

Does Infection During Pregnancy Outside of the Time of Delivery Increase the Risk of Cerebral Palsy

Objective We sought to evaluate whether maternal antepartum infection (excluding chorioamnionitis) is associated with cerebral palsy (CP). Study Design This is a secondary analysis from a multicenter trial in women at risk of preterm delivery who received antenatal magnesium sulfate versus placebo. We compared the risk of CP in the children of women who had evidence of antepartum infection over the course of pregnancy to those women who had no evidence of antepartum infection during pregnancy. Results Within a cohort of 2,251 women who met our inclusion criteria, 1,350 women had no history of infection in pregnancy and 801 women had a history of some type of antepartum infection during pregnancy. The incidence of CP was similar between the two groups (4.9 vs 5.0%; p = 0.917). After adjustment for maternal and obstetric confounders, we observed no significantly increased risk of CP among infants born to women with evidence of antepartum infection; (adjusted relative risk [aRR], 1.09 (0.72, 1.66); p = 0.68). Conclusion Compared with women with no evidence of antepartum infection during pregnancy, those women with infections excluding chorioamnionitis may not be at an increased risk of delivering an infant with CP.

Antenatal Corticosteroids for Preterm Premature Rupture of Membranes: Single or Repeat Course?

OBJECTIVEnThe aim of this article is to determine the risk of maternal chorioamnionitis and neonatal morbidity in women with preterm premature rupture of membranes (PPROM) exposed to one corticosteroid course versus a single repeat corticosteroid steroid course.nnnSTUDY DESIGNnSecondary analysis of a cohort of women with singleton pregnancies and PPROM. The primary outcome was a clinical diagnosis of maternal chorioamnionitis. Using multivariate logistic regression, we controlled for maternal age, race, body mass index, diabetes, gestational age at membrane rupture, preterm labor, and antibiotic administration. Neonatal morbidities were compared between groups controlling for gestational age at delivery.nnnRESULTSnOf 1,652 women with PPROM, 1,507 women received one corticosteroid course and 145 women received a repeat corticosteroid course. The incidence of chorioamnionitis was similar between groups (single courseu2009=u200912.3% vs. repeat courseu2009=u200911.0%; pu2009=u20090.8). Women receiving a repeat corticosteroid course were not at increased risk of chorioamnionitis (adjusted odds ratio, 1.28; 95% confidence interval, 0.69-2.14). A repeat course of steroids was not associated with an increased risk of any neonatal morbidity.nnnCONCLUSIONnCompared with a single steroid course, our findings suggest that the risk of maternal chorioamnionitis or neonatal morbidity may not be increased for women with PPROM receiving a repeat corticosteroid course.

Isolated umbilical vein varix with a poor outcome despite close fetal surveillance.

A fetal umbilical vein varix is an enlargement of the umbilical vein, which has been previously defined as an index portion of the umbilical vein that is at least 50% wider than the nondilated portion, dilatation of 9 mm or greater, or greater than 2 SDs above the mean for gestational age.1,2 Characteristics frequently described with respect to an umbilical vein varix include the diameter, presence or absence of turbulent flow or hydrops, and presence or absence of other fetal anomalies. More than 100 cases of umbilical vein varices have been reported in the literature, with varying fetal mortality rates.3 Many of the fatal cases have been associated with chromosomal or other anomalies, and some have been associated with intrauterine growth restriction.4 Multiple case series of isolated fetal intraabdominal umbilical vein varices report an average diameter of 12 mm and a range of 8 to 30 mm.2,5 Mankuta et al3 reported that in pregnancies affected by an umbilical vein varix, the rate of intrauterine growth restriction was 10.7%, and 17% of these varices had turbulent flow. Despite the wide range in the size and presence or absence of turbulence, there were no reported cases of intrauterine fetal demise associated with an isolated umbilical vein varix in the series. Other studies have reported an association between the presence of turbulent flow and poor obstetric outcomes.2,6,7 In the following case, we report a pregnancy affected by an isolated fetal umbilical vein varix presenting at 9 mm of dilatation and progressing to 18 mm of dilatation with turbulence. Despite close monitoring, the patient had an intrauterine fetal demise at 32 weeks. The patient was a 27-year-old woman, gravida 2, para 0, with a history of well-controlled hypothyroidism who had a diagnosis of a 9-mm intra-abdominal umbilical vein varix at 23 weeks’ gestation. At the time of diagnosis, there was low turbulent flow within the varix; otherwise, results of a detailed fetal anatomic survey were normal. The remainder of her medical and pregnancy histories were uncomplicated. She was considered low risk for aneuploidy by sequential screening with nuchal translucency measurement and declined amniocentesis after the diagnosis. Another sonographic examination performed at 28 weeks 2 days showed that the varix had increased to 12 to 14 mm with turbulent flow, and a prominent portal vein was seen (Figure 1). Fetal echocardiography performed at 29 weeks did not show any evidence of cardiac abnormalities. A sonographic examination performed at 30 weeks 2 days showed further progression in the size of the umbilical varix and in the dilatation of the portal vein. At this Clinical Letters

Optimization of Maternal Magnesium Sulfate Administration for Fetal Neuroprotection: Application of a Prospectively Constructed Pharmacokinetic Model to the BEAM Cohort

The aim of the study was to identify the optimal therapeutic maternal magnesium drug exposure and maternal serum concentration to prevent cerebral palsy in the extremely preterm fetus. We applied a previously constructed pharmacokinetic model adjusted for indication to a large cohort of pregnant women receiving magnesium sulfate to prevent cerebral palsy in their preterm offspring at 20 different US academic centers between December 1997 and May 2004. We simulated the population‐based individual maternal serum magnesium concentration at the time of delivery and the total magnesium dose for each woman who received magnesium sulfate to determine the relationship between maternal serum magnesium level at the time of delivery and the development of cerebral palsy. Among 1905 women who met inclusion criteria, the incidence of cerebral palsy in the cohort was 3.6% for women who had received magnesium sulfate and 6.4% for controls. The simulated maternal serum concentration at delivery associated with the lowest probability of delivering an infant with cerebral palsy was 4.1 mg/dL (95%CI 3.7 to 4.4). Our population‐based estimates of magnesium disposition suggest that to optimize fetal neuroprotection and prevent cerebral palsy, magnesium sulfate administration should target a maternal serum magnesium level between 3.7 and 4.4 mg/dL at delivery.

Should delivery timing for repeat cesarean be reconsidered based on dating criteria

Abstract Purpose: We sought to examine if the method of pregnancy dating at five increasing term gestational ages is associated with increasing neonatal morbidity. Materials and methods: A cohort of women who underwent elective repeat cesarean delivery at ≥37 weeks’ gestation were identified from the NICHD MFMU Network registry. We excluded women who were in labor, those carrying a fetus with a congenital anomaly, those with a non-reassuring fetal heart tracing, and those with preeclampsia, preexisting chronic hypertension or diabetes. Composite neonatal morbidity was defined for our study as any of the following: NICU admission, hypotonia, meconium aspiration, seizures, need for ventilator support, NEC, RDS, TTN, hypoglycemia, or neonatal death. We compared composite neonatal morbidity rates among infants born at five different gestational age cutoffs according to their method of pregnancy dating. Results: At 39 and 40 weeks’ gestation, the lowest rate of neonatal complications was seen in pregnancies dated by first trimester ultrasound (5.8% and 5.5%, respectively), while those with the highest neonatal morbidity rates were seen when dated by a second or third trimester ultrasound (8.1% and 6.0%, respectively); pu2009<u2009.001. Additionally within each pregnancy dating category, the neonatal morbidity rates declined from 37 to 40 weeks’ gestation and then significantly increased at 41u2009+u20090 weeks’ gestation. Conclusion: Even with suboptimal dating methods, amongst women undergoing elective repeat cesarean delivery, neonatal morbidity was lowest when delivery occurred between 40 and 40u2009+u20096 weeks gestation.