Nancy C. Chescheir

Prevalence of domestic violence among women seeking abortion services

Interviews with 51 consecutive women presenting to the University of North Carolinas abortion clinic over a two-month period in 1994 confirmed the hypothesis that this population has experienced an above-average incidence of domestic violence. 31.4% of the abortion seekers reported a lifetime history of physical or sexual abuse; 21.6% of these women had been abused in the prior calendar year and 7.8% had experienced abuse during the current pregnancy (none for the first time). 54.5% of women with a self-reported lifetime history of abuse had witnessed domestic violence in their family of origin and 36.4% had been abused as a child. The interviews further revealed that 70% of abused women had experienced the standard cycle of domestic violence involving tension building, acute battering, and contrition phases. Although 80% of battered women were aware of community resources, they were unlikely to use them. Prior studies of domestic violence in obstetric populations have identified prevalences of 11-24%; some of this variability is likely attributable to womens reluctance to acknowledge abuse. Overall, these findings indicate that a lifetime or current history of domestic violence should be considered a risk factor for abuse during pregnancy. Regardless of her decision regarding the outcome of the pregnancy, a pregnant woman with such a history should be offered counseling about an exit plan, safety issues, and community resources.

Unexplained Elevations of Maternal Serum Alpha-fetoprotein

Alpha-fetoprotein (AFP) is a commonly used prenatal screening test for congenital anomalies. However, when anomalies are excluded after high resolution ultrasound and/or amniocentesis, an elevated maternal serum AFP (MSAFP) has been found to be associated with a 2- to 4-fold increase in low birthweight resulting from both preterm delivery and intrauterine growth retardation. Unexplained MSAFP elevations are also associated with up to 10-fold increase of placental abruption and a 10-fold increase in perinatal mortality. Results from studies of over 225,000 screened pregnancies indicate that 20 and 38 per cent of women with an unexplained MSAFP elevation may have an adverse pregnancy outcome. Twin gestations with MSAFP elevations greater than four multiples of the median are associated with similar constellations of pregnancy complications. Maternal serum AFP elevations in women with pregnancy complications are most likely the result of a leak of AFP across the placenta. Optimum management of women with unexplained elevations has not yet been established; however, evaluation of fetal growth throughout gestation is important in these patients.

Myelomeningocele: A Review of the Epidemiology, Genetics, Risk Factors for Conception, Prenatal Diagnosis, and Prognosis for Affected Individuals

Although the use of folic acid before conception decreases the chance that a fetus will have an open neural tube defect, this condition still affects 0.5–1.0/1000 pregnancies in the United States. Results of a recent survey suggest that there are gaps in obstetrician-gynecologists’ knowledge of risk factors for conception, strategies for prenatal diagnosis, and prognosis for affected individuals. To address these gaps this paper reviews the epidemiology, genetics, risk factors for conception, prenatal diagnosis, and prognosis for affected individuals, presents current information, and makes suggestions for expanding obstetrician-gynecologists’ knowledge of myelomeningocele. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to state that despite a large amount of professional and public education on the use of folic acid in prevention of open neural tube defects (ONTDs) the incidence still affects 0.5–1.0/1000 pregnancies and recall that a recent survey conducted by the ACOG shows substantial misunderstanding and misinformation on major categories of neural tube birth defects.

Outcome in children with fetal mild ventriculomegaly : a case series

Mild enlargement of the lateral ventricles is associated with schizophrenia and other neurodevelopmental disorders. While it has been hypothesized that ventricle abnormalities associated with neurodevelopmental disorders arise during fetal brain development, there is little direct evidence to support this hypothesis. Using ultrasound, it is possible to image the fetal ventricles in utero. Fetal mild ventriculomegaly (MVM) has been associated with developmental delays in early childhood, though longer-term neurodevelopmental outcome has not been studied. Follow-up of five children (aged 4--9 years) with mild enlargement of the lateral ventricles on prenatal ultrasound and two unaffected co-twins is reported: one child had attention deficit hyperactivity disorder (ADHD), one had autism, and two had evidence of learning disorders. These cases suggest that the mild enlargement of the lateral ventricles associated with these neurodevelopmental disorders arises during fetal brain development and can be detected with prenatal ultrasound. In addition, the presence of mildly enlarged, asymmetric ventricles in two children on prenatal ultrasound and on follow-up MRI at age 6 years indicates that ventricle structure present in utero can persist well into childhood brain development. The study of fetal ventricle development with ultrasound may provide important insights into neurodevelopmental disorders and allow the identification of children at high risk.

MATERNAL UNIPARENTAL DISOMY OF CHROMOSOME 2 AND CONFINED PLACENTAL MOSAICISM FOR TRISOMY 2 IN A FETUS WITH INTRAUTERINE GROWTH RESTRICTION, HYPOSPADIAS, AND OLIGOHYDRAMNIOS

We present a case of maternal uniparental heterodisomy for chromosome 2 (UPD 2) detected after trisomy 2 mosaicism was found on placental biopsy. This case presented prenatally with severe intrauterine growth restriction (IUGR) and oligohydramnios. The diploid newborn had hypospadias and features consistent with oligohydramnios sequence. He died shortly after birth of severe pulmonary hypoplasia. The term placenta had high levels of trisomy 2 in both the trophoblast and the stroma. A comparison of this case with others reported in the literature suggests that the IUGR and oligohydramnios are likely related to placental insufficiency due to the high levels of trisomy 2 present in the trophoblast of the term placenta and the presence of UPD 2 in the diploid placental line.

Prenatal Mild Ventriculomegaly Predicts Abnormal Development of the Neonatal Brain

BACKGROUND Many psychiatric and neurodevelopmental disorders are associated with mild enlargement of the lateral ventricles thought to have origins in prenatal brain development. Little is known about development of the lateral ventricles and the relationship of prenatal lateral ventricle enlargement with postnatal brain development. METHODS We performed neonatal magnetic resonance imaging on 34 children with isolated mild ventriculomegaly (MVM; width of the atrium of the lateral ventricle >/= 1.0 cm) on prenatal ultrasound and 34 age- and sex-matched control subjects with normal prenatal ventricle size. Lateral ventricle and cortical gray and white matter volumes were assessed. Fractional anisotropy (FA) and mean diffusivity (MD) in corpus callosum and corticospinal white matter tracts were determined obtained using quantitative tractography. RESULTS Neonates with prenatal MVM had significantly larger lateral ventricle volumes than matched control subjects (286.4%; p < .0001). Neonates with MVM also had significantly larger intracranial volumes (ICV; 7.1%, p = .0063) and cortical gray matter volumes (10.9%, p = .0004) compared with control subjects. Diffusion tensor imaging tractography revealed a significantly greater MD in the corpus callosum and corticospinal tracts, whereas FA was significantly smaller in several white matter tract regions. CONCLUSIONS Prenatal enlargement of the lateral ventricle is associated with enlargement of the lateral ventricles after birth, as well as greater gray matter volumes and delayed or abnormal maturation of white matter. It is suggested that prenatal ventricle volume is an early structural marker of altered development of the cerebral cortex and may be a marker of risk for neuropsychiatric disorders associated with ventricle enlargement.

Mild ventriculomegaly detected in utero with ultrasound : clinical associations and implications for schizophrenia

The most consistent structural abnormality of the brain associated with schizophrenia is that of mild enlargement of the lateral cerebral ventricles. Mild ventriculomegaly (MVM) of the fetal brain detected in utero with ultrasound is associated with developmental delays similar to those described in children at high risk of schizophrenia. Fetal mild ventriculomegaly may be a marker for increased risk of schizophrenia and other neurodevelopmental abnormalities. Given the association between schizophrenia and obstetrical complications, pre- and perinatal complications and pregnancy outcomes were retrospectively reviewed in 51 pregnancies in which the fetus exhibited mild ventriculomegaly on routine ultrasonography and 49 control pregnancies. Mothers of children with MVM were older than controls and had shorter gestations. There were no significant between-group differences in numbers of pregnancy complications or pregnancy outcomes as reflected in gestational age at birth, birthweight, or Apgar scores. Children with isolated mild ventriculomegaly tended to be male. This study indicates that isolated mild ventriculomegaly detected in utero is not associated with pregnancy complications and suggests that isolated mild ventriculomegaly of the fetus is genetically determined or caused by environmental events not routinely considered pregnancy complications.

The Pharmacokinetics of Recombinant Human Relaxin in Nonpregnant Women After Intravenous, Intravaginal, and Intracervical Administration

The pharmacokinetics of recombinant human relaxin (rhRlx) after intravenous (iv) bolus administration and the absorption of rhRlx after intracervical or intravaginal administration were determined in nonpregnant women. The study was conducted in two parts. In part I, 25 women received 0.01 mg/kg rhRlx iv. After a minimum 7-day washout period, these women were dosed intracervically (n = 10) or intravaginally (n = 15) with 0.75 or 1.5 mg rhRlx, respectively, in 3% methylcellulose gel. Part II was a double-blind, randomized, three-way crossover study in 26 women. At 1-month intervals, each woman received one of three intravaginal treatments consisting of 0 (placebo), 1, or 6 mg rhRlx in 3% methylcellulose gel. The serum concentrations of relaxin following iv administration were described as the sum of three exponentials. The mean (±SD) initial, intermediate, and terminal half-lives were 0.09 ± 0.04, 0.72 ± 0.11, and 4.6 ± 1.2 hr, respectively. Most of the area under the curve was associated with the intermediate half-life. The weight-normalized clearance was 170 ± 50 mL/hr/kg. The observed peak concentration was 98 ± 29 ng/mL, and the weight-normalized initial volume of distribution was 78 ± 40 mL/kg, which is approximately equivalent to the serum volume. If central compartment elimination was assumed, the volume of distribution at steady state (Vss/W) was 280 ± 100 mL/kg, which is approximately equivalent to extracellular fluid volume. Vss/W could be as large as 1300 ± 400 mL/kg without this assumption. After intravaginal administration of the placebo gel, endogenous relaxin concentrations were evident (i.e., ≥20 pg/mL) in 9 of the 26 women (maximum concentrations, 23–234 pg/mL). A similar proportion of women (approximately 35–40%) exhibited measurable serum concentrations of relaxin following intravaginal rhRlx treatment; this proportion increased to 90% following intracervical rhRlx treatment. For both routes of administration, the maximum serum concentrations of relaxin were usually within the range of values observed for endogenous relaxin, suggesting that the absorption of rhRlx was minimal.

Prenatal ultrasonographic findings associated with short bowel syndrome in two fetuses with gastroschisis

Background Studies on the importance of prenatal ultrasonographic findings in gastroschisis have shown variable significance in predicting neonatal outcome. We report two cases of short bowel syndrome and poor neonatal outcome that had interesting prenatal ultrasonographic findings. Cases Gastroschisis was confirmed in both cases. Throughout gestation, the extra-abdominal bowel remained unchanged in size, hyperechoic, and clustered. Amniotic fluid volume increased with increasing intra-abdominal bowel dilation. Both fetuses were delivered prematurely and found to have short bowel syndrome incompatible with life. Conclusion Prenatal ultrasonographic findings of hyperechoic and clustered extra-abdominal bowel with progressive intra-abdominal bowel dilation and associated polyhydramnios may be indicative of high bowel obstruction, atresia, and poor neonatal outcome. Families should be counseled cautiously.

Fetal brain development of twins assessed in utero by ultrasound: implications for schizophrenia

There is evidence that some forms of schizophrenia are due to alterations of in utero brain development. Given the concordance rate for schizophrenia in monozygotic twins is approx. 45%, it is not clear how a shared genetic predisposition for schizophrenia and a shared in utero environment might selectively lead to schizophrenia in one but not the other twin in a monozygotic twin pair. This study was undertaken to test the hypothesis that there is a difference in brain development between twins in a monozygotic twin pair that may contribute to the observed concordance rates for schizophrenia. Fetal ultrasound measures of brain (biparietal diameter, head circumference, ventricular width) and body size (femur length, abdominal circumference) obtained during the second trimester of fetal development were retrospectively analyzed in 41 monozygotic and 103 dizygotic twin pairs. In monozygotic twin pairs, there was a significant difference in measures of biparietal diameter, head circumference, and ventricular width, as well as in femur length and abdominal circumference, between twins. There was a similar difference in dizygotic twin pairs. These results indicate that in monozygotic twins, brain development is not identical. This difference in brain development may contribute to the observed concordance rates in monozygotic twins with schizophrenia.