Lillian Kaminsky

Combined second-trimester biochemical and ultrasound screening for Down syndrome.

OBJECTIVE To evaluate the efficacy of a Down syndrome screening protocol that combines second‐trimester maternal serum analytes and the continuous ultrasound measures of nuchal fold thickness and proximal long bone length. METHODS Ultrasound measurements of nuchal fold, femur length, and humerus length were reviewed for 72 second‐trimester Down syndrome and 7063 unaffected fetuses. Derived statistical variables for these parameters were entered into a multivariable Gaussian model together with the statistical variables used in the “quad” test (maternal serum alpha‐fetoprotein, unconjugated estriol, human chorionic gonadotropin, and inhibin A). Maternal age‐specific sensitivities, false‐positive rates, and positive predictive values were generated together with receiver operating characteristic curves. Overall efficacy of ultrasound screening alone, the quad test, and the combination of the ultrasound and quad test were compared using a 1:270 second‐trimester risk cutoff applied to 1999 US births. RESULTS Using ultrasound, a sensitivity of 79.9% and false‐positive rate of 6.7% may be achieved (positive predictive value: 1 in 42). The quad test has a sensitivity of 81.5% and false‐positive rate of 6.9% (positive predictive value: 1 in 42). The combination of the quad test with nuchal fold and long bone measurements may achieve 90% sensitivity and a 3.1% false‐positive rate (positive predictive value: 1 in 18). CONCLUSION Combining second‐trimester serum testing and fetal biometry is a feasible approach to Down syndrome screening, compatible with current obstetric practice. This modality is substantially more effective than either serum screening or ultrasound alone. Efficacy may be comparable to that reported for combined first‐ and second‐trimester (integrated) screening.

Meconium-stained amniotic fluid across gestation and neonatal acid-base status.

OBJECTIVE: To estimate whether the acid-base status of neonates born to women with meconium-stained amniotic fluid varies across gestation. METHODS: We carried out a retrospective cohort study of all pregnancies that were complicated by meconium-stained amniotic fluid in 2004. Cases were identified from a perinatal pathology database that contained data on all pregnancies complicated by meconium-stained amniotic fluid. Data abstracted from the charts included gestational age at delivery, umbilical arterial pH, birth weight, and the presence or absence of labor. Cases were stratified according to gestational age at delivery. The distribution of meconium-stained amniotic fluid across gestation was computed. The mean umbilical arterial pH values (with 95% confidence intervals) across gestation were assessed by analysis of variance. RESULTS: The mean umbilical arterial pH in women with meconium-stained amniotic fluid did not differ across gestation. The overall incidence of meconium-stained amniotic fluid was 12.0% (766 of 6,403 deliveries). The rates of meconium-stained amniotic fluid increased from 1.2% at 32 weeks to 100% at 42 weeks. CONCLUSION: The rising incidence of meconium-stained amniotic fluid with gestational age is consistent with the hypothesis that fetal maturation is a major etiologic factor in meconium passage. Also, the lack of variation of mean umbilical arterial pH across gestation suggests that fetal acidemia is not increased when meconium passage occurs earlier in pregnancy rather than at later gestational ages. LEVEL OF EVIDENCE: II-3

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.