Michael G. Pinette

Comparison of six different ultrasonographic methods for predicting lethal fetal pulmonary hypoplasia

Nomograms of six different ultrasonographic fetal parameters were established by studying uncomplicated, singleton pregnancies, with well-established dates, between 16 and 40 weeks of gestation. The studied parameters could reflect fetal lung mass and included the following: chest circumference (CC), chest area (CA), chest area minus heart area (CA - HA), chest circumference/abdominal circumference ratio (CC X 100/AC), chest area/heart area ratio (CA/HA), and chest area minus heart area divided by chest area ratio [(CA - HA) X 100/CA]. The effect of ruptured membranes on these six ultrasonographic parameters was assessed by studying patients who had premature rupture of the membranes of less than 1 weeks duration. It was found that premature rupture of the membranes is associated with increased frequency of CC, CA, and CA - HA measurements at or below the 5th percentile. However, in patients with premature rupture of the membranes all measurements were within the normal range for the three ratios. The efficacy of each of the six parameters was determined by studying 13 fetuses at high risk for development of lethal pulmonary hypoplasia. The (CA - HA) X 100/CA parameter had the best diagnostic accuracy (sensitivity 85%, specificity 85%, positive predictive value 83%, and negative predictive value 85%).

Maternal and newborn morbidity by birth facility among selected United States 2006 low-risk births

OBJECTIVE We sought to evaluate perinatal morbidity by delivery location (hospital, freestanding birth center, and home). STUDY DESIGN Selected 2006 US birth certificate data were accessed online from the Centers for Disease Control and Prevention. Low-risk maternal and newborn outcomes were tabulated and compared by birth facility. RESULTS A total of 745,690 deliveries were included, of which 733,143 (97.0%) occurred in hospital, 4661 (0.6%) at birth centers, and 7427 (0.9%) at home. Compared with hospital deliveries, home and birthing center deliveries were associated with more frequent prolonged and precipitous labors. Home births experienced more frequent 5-minute Apgar scores <7. In contrast, home and birthing center deliveries were associated with less frequent chorioamnionitis, fetal intolerance of labor, meconium staining, assisted ventilation, neonatal intensive care unit admission, and birthweight <2500 g. CONCLUSION Home births are associated with a number of less frequent adverse perinatal outcomes at the expense of more frequent abnormal labors and low 5-minute Apgar scores.

Female reproductive issues following bariatric surgery

One in 3 adult American women is obese. Almost half of the approximately 100,000 bariatric surgeries performed in 2004 were on reproductive-aged women. Anatomic and physiologic changes resulting from such surgery may have significant clinical implications for preconception, pregnancy, and postpartum care. This review summarizes these issues and the available related literature, and offers guidelines for care of these patients. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to recall that bariatric surgery has many anatomic and physiologic changes that potentially will affect future pregnancies, and state that attention to these physiologic changes and attention to potential nutritional deficiencies significantly improves the chances of a good pregnancy outcome.

Congenital jejunal and ileal atresia: natural prenatal sonographic history and association with neonatal outcome.

Objective. The purpose of this study was to describe the prenatal sonographic features and natural course of congenital jejunal and ileal atresia and correlate the findings with neonatal outcomes. Methods. We identified all neonates with surgically confirmed jejunal or ileal atresia that had prenatal sonography and neonatal surgery in our center from January 1, 1995, to April 1, 2005. Sonography reports and images were reviewed, without knowledge of neonatal outcomes, for features of intestinal obstruction. Obstetric and neonatal outcomes were evaluated. Results. Fifteen (60%) of 25 offspring with atresias (10 jejunal, 4 ileal, and 1 jejunoileal) had sonography, of which 13 (86.6%) had features of atresia. Findings, number of affected fetuses, and gestational age at recognition included fetal echogenic bowel (n = 8), mean ± SD, 21.3 ± 3.8 weeks (range, 17.7–28.4 weeks); enlarged stomach (n = 5), 27.5 ± 5.0 weeks (range, 22.0–34.3 weeks); dilated bowel (n = 13), 27.8 ± 5.8 weeks (range, 18.3–35.9 weeks); and polyhydramnios (n = 6), 33.3 ± 1.7 weeks (range, 31.0–35.6 weeks). No fetus with ileal atresia had an enlarged stomach or polyhydramnios. Delivery occurred at a mean of 34.7 ± 3.6 weeks, with 9 (60%) cesarean deliveries. Neonatal outcomes of age at surgery, neonatal intensive care unit days, hospital days, total parenteral nutrition days, and death were similar whether or not fetal echogenic bowel, enlarged stomach, dilated bowel, or polyhydramnios was present. Likewise, these outcomes did not vary by type of atresia or time of diagnosis (prenatal or neonatal). Conclusions. Jejunal and ileal atresia have specific sonographic patterns allowing specific prenatal diagnoses in most affected fetuses. Prenatal sonographic findings and time of diagnosis did not affect neonatal outcome.

Mild fetal cerebral ventriculomegaly: Diagnosis, clinical associations, and outcomes

The normal fetal lateral ventricular diameter remains stable at 10 mm over gestation. Mild ventriculomegaly, defined as a lateral ventricular diameter of ≥10 mm but ≤15 mm or a choroid-lateral ventricular separation ≥3 mm but ≤8 mm occurs bilaterally in 0.15–0.7% of fetuses and unilaterally in 0.07% of pregnancies. This finding is associated with an increased risk of fetal chromosomal abnormalities, congenital anomalies and infections, syndromes, perinatal death, and childhood developmental delays. Prenatal evaluation includes targeted sonographic examination for central nervous system and extra-central nervous system abnormalities, and diagnostic amniocentesis for chromosomal analysis and infectious disease studies. Individualized patient counseling is based on these test results. Optimal postnatal care involves appropriate pediatric neurologic and developmental specialists. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to define the normal appearance and size of the fetal cerebral ventricles, to list the conditions associated with mild ventriculomegaly, and to explain the natural course of mild bilateral isolated ventriculomegaly.

Prenatal Sonographic Diagnosis of Hemivertebrae Associations and Outcomes

Objective. The purpose of this study was to evaluate associated anomalies and outcomes of fetuses with prenatally diagnosed hemivertebrae. Methods. Fetuses with prenatally diagnosed hemivertebrae, excluding those associated with spina bifida, were identified by searching the prospectively maintained ultrasound databases of 4 institutions from 1997 to August 2007. Associated birth defects were tabulated by organ system and hemivertebra location. Outcomes included karyotypes, gestational ages, and routes and outcomes of deliveries. Results. Nineteen fetuses had a diagnosis of hemivertebrae at a mean gestational age ± SD of 20.5 ± 5.4 weeks. Fourteen (73.7%) fetuses had additional anomalies, of which 5 (35.7%) were syndromic (4 with cloacal exstrophy and omphaloceles and 1 with Jarcho‐Levin syndrome). Karyotypes were normal in all 11 available cases, each of which had additional anomalies. Fourteen (73.7%) neonates were live born at a mean gestational age of 34.9 ± 4.3 weeks, of which 7 (50%) were born by cesarean delivery. Ten neonates (71.4%) were delivered before term, and 4 (28.6%) were growth restricted (<10th percentile). Two (14.3%) of these neonates died; both had cloacal exstrophy and large omphaloceles. The remaining pregnancies were terminated (4 [21.1%]) or had a fetal death (1 [5.3%]). Conclusions. Most fetuses with prenatally diagnosed hemivertebrae have additional anomalies, often syndromic, which affect the prognosis. Affected pregnancies have high rates of cesarean delivery and growth restriction. Neonates with nonisolated hemivertebrae are more often delivered before term and have higher mortality rates.

Bilateral inferior petrosal sinus corticotropin sampling with corticotropin-releasing hormone stimulation in a pregnant patient with Cushing's syndrome

A patient was diagnosed with Cushings syndrome during her first pregnancy. Bilateral simultaneous inferior petrosal sinus corticotropin sampling with corticotropin-releasing hormone stimulation was performed before transphenoidal pituitary adenomectomy, with successful localization of the pituitary adenoma. Her Cushings syndrome was controlled postoperatively with resolution of hypertension. This case report demonstrates that the procedure of bilateral simultaneous inferior petrosal venous corticotropin sampling can be safely performed during pregnancy.

Third-trimester uterine rupture without previous cesarean: a case series and review of the literature.

We sought to describe a case series and literature review of uterine rupture in the absence of a previous cesarean delivery. In addition to four cases in our institution, a search of the literature from 1994 to 2008 identified cases of uterine rupture unrelated to a prior cesarean. Uterine rupture in the absence of a previous cesarean may be associated with remote unrecognized uterine perforation, myomectomy, thermal injury, and obstructed labor. Such ruptures may occur before or after labor onset, at term or preterm, and with or without nonreassuring fetal heart rate patterns. Spontaneous uterine rupture is associated with highly variable and nonspecific maternal complaints and fetal status, requiring a high index of diagnostic suspicion.

Normal midtrimester (17-20 weeks) genetic sonogram decreases amniocentesis rate in a high-risk population.

To evaluate a screening protocol using advanced maternal age, triple‐marker screening, and genetic sonography.

Noninvasive prenatal testing: Impact on genetic counseling, invasive prenatal diagnosis, and trisomy 21 detection

The aim of this study was to compare rates of genetic counseling, invasive prenatal diagnosis, and trisomy 21 detection among women at increased risk for aneuploidy, before versus after the availability of noninvasive prenatal testing (NIPT).