Paola Aghajanian

Prenatal Diagnosis of Spontaneous Septostomy of the Dividing Membranes in Complicated Monochorionic Diamniotic Multiple Gestations

Objective. The purpose of this series is to describe the prenatal diagnostic and management challenges of spontaneous septostomy of the dividing membrane (SSDM) in complicated monochorionic diamniotic (MoDi) pregnancies. Methods. A retrospective review of all MoDi multiple gestations referred for fetal therapy was conducted. Spontaneous septostomy of the dividing membrane was suspected if a prior invasive procedure had not been performed and the following sonographic hallmarks were identified: twins occupying the same side of the dividing membrane, twin‐twin transfusion syndrome (TTTS) with polyhydramnios in the donors sac despite a collapsed donor bladder, and umbilical cord entanglement. Spontaneous septostomy of the dividing membrane was confirmed in all cases at the time of surgical fetoscopy, which was performed to treat an underlying condition of TTTS, selective intrauterine growth restriction (SIUGR), or the twin reversed arterial perfusion (TRAP) sequence. Results. Of 217 complicated MoDi multiple gestations without prior invasive procedures referred for possible fetal therapy, 4 (1.8%) were identified with SSDM. The mean (range) gestational age at diagnosis was 19.7 (18–20.9) weeks. Two cases were diagnosed with TTTS complicated by SSDM after both fetuses were identified on the same side of the dividing membranes (1 case) or polyhydramnios was noted in the donors sac despite a collapsed donor bladder (1 case). Both cases had substantial preoperative fetal deterioration because of a delay in diagnosis and treatment of TTTS. The remaining 2 SSDM cases, 1 with SIUGR and 1 with the TRAP sequence, were diagnosed after umbilical cord entanglement was recognized. Conclusions. Spontaneous septostomy of the dividing membrane in MoDi gestations is a rare condition that poses diagnostic and management challenges.

Evaluation of risk-factor-based screening for thyroid peroxidase antibody positivity in pregnancy

To determine whether risk‐factor‐based screening for thyroid dysfunction in pregnancy performs well for detecting thyroid peroxidase antibodies (TPOAb), a marker for autoimmune thyroid disease.

Noninvasive prenatal testing compared with invasive diagnostic testing in the setting of an abnormal state aneuploidy screen.

INTRODUCTION: To describe the abnormal results of invasive prenatal diagnostic testing performed for the indication of positive state aneuploidy screening at our institution and to further identify among those results the genetic abnormalities that would not have been detected by noninvasive (cell-free fetal DNA) prenatal testing. METHODS: This was a retrospective review of all patients that underwent invasive prenatal genetic testing (chorionic villus sampling, amniocentesis, or both) for the indication of positive state aneuploidy screening from June 2012 to June 2013 at a single, large academic medical center. Abnormal results were identified. Abnormalities that would not be detected by noninvasive cell- free DNA testing were further noted. RESULTS: There were 84 chorionic villus sampling and 38 amniocentesis procedures (total n=122) performed for the indication of positive state aneuploidy screening during this period. No karyotypic abnormality was detected in 89 (73%). Abnormalities detected included: 22 (18%) trisomy 21, three (2%) trisomy 18, two (2%) 45, X, and two (2%) 47, XYY. The remaining two were abnormalities that are not detected by current commercially available noninvasive tests: a balanced translocation and a loss of an oligonucleotide on the X chromosome. CONCLUSION: Most patients undergoing invasive testing for positive state screen results had aneuploidies that would have been detectable by current available noninvasive tests. However, some of the abnormalities would not have been identified by noninvasive prenatal testing. These limitations should be taken into account when counseling patients who test positive on state prenatal screening programs. Larger studies are needed to validate these findings.

Risks of parenteral antihypertensive therapy for the treatment of severe maternal hypertension are low.

ABSTRACT Objective: To determine whether the incidence of hypotension or adverse fetal heart tracing (FHT) category change differed following antepartum administration of intravenous (IV) labetalol versus hydralazine. Methods: Blood pressure and FHT categories were assessed one hour before and after medication administration. Hypotension was defined as ≥30% reduction in baseline systolic blood pressure (SBP) or SBP <90 mmHg. Changes in mean arterial pressure (MAP) were also compared. The National Institute for Child Health and Human Development (NICHD) three-tier category system was used to describe the FHT. For all category II tracings, Parer and Ikeda’s system was also used. Results: Sixty-nine women received hydralazine and 31 women received labetalol during the study period. The incidence of hypotension (≥30% reduction in SBP) was similar between the labetalol (10%) and hydralazine (11%) groups (p = 0.98). No women experienced post-treatment SBP <90 mmHg. No association was observed between fetal heart rate category change and drug used. No women required emergent delivery for fetal indications. Conclusions: The incidence of maternal hypotension was low and did not differ following antepartum IV labetalol versus hydralazine use. These data should reassure providers about the use of parenteral labetalol and hydralazine for the treatment of severe hypertension.

Antipsychotics leading to neuroleptic malignant syndrome in pregnancy.

BACKGROUND: Neuroleptic malignant syndrome (NMS) is characterized by a tetrad of mental status changes, extrapyramidal symptoms, hyperpyrexia, and autonomic instability and can develop after the use of antipsychotics. CASE: A young, multiparous woman presented at 26 weeks of gestation with acute psychosis and was treated with haloperidol until she developed rigidity of her extremities and then was switched to risperidone. She subsequently developed mental status changes, rigidity, hyperthermia, and autonomic instability, leading to a diagnosis of NMS. Risperidone was discontinued and, owing to ongoing psychosis, olanzapine was initiated. Subsequently, her symptoms resolved. CONCLUSION: Neuroleptic malignant syndrome may complicate the treatment of pregnant women using antipsychotics. Clinicians should take into account the risks of untreated psychosis when discontinuing the offending agent and consider initiating alternative pharmacotherapy.

Can We Accurately Time the Administration of Antenatal Corticosteroids for Preterm Labor

Background. Accurate timing of antenatal corticosteroids (ACS) has resulted in improved neonatal outcomes. Objectives. Our primary objective was to determine predictors for optimal timing of ACS in women presenting with spontaneous preterm labor. Study Design. A retrospective cohort study of women receiving ACS for spontaneous preterm birth was conducted. Women were included if they presented with preterm labor or preterm premature rupture of membranes. Accurate timing of ACS was defined as administration within 7 days of delivery. Maternal demographic and obstetrics characteristics were compared between the groups receiving ACS ≤7 days and >7 days from delivery. Statistical analyses were performed using parametric and nonparametric tests. P < 0.05 was considered significant. Results. The study included 215 subjects. Median latency from ACS administration to delivery was 6 days (IQR 32). Accurate timing of ACS occurred in 113 (53%) women and was associated with rupture of membranes (OR 13.8, 95% CI 5.9–32.6), cervical change (OR 7.1, 95% CI 3.0–17.1), and cervical dilation ≥ 2 cm (OR 3.9, 95% CI 1.5–10.3). Conclusions. Rupture of membranes, cervical change, and cervical dilation ≥ 2 cm were strong predictors of optimal timing. 53% of women with preterm labor received ACS optimally.

Predictors for Choosing Array-Comparative Genomic Hybridization for Prenatal Diagnosis

INTRODUCTION: The objective of this study was to investigate the indications for which women choose to have prenatal diagnosis with array-comparative genomic hybridization. METHODS: This is a retrospective review of the invasive prenatal diagnostic testing procedures (chorionic villus sampling and amniocentesis) with array-comparative genomic hybridization testing that were performed from December 2012 to June 2013 at a single, large academic medical center. The indications for testing were evaluated to determine the predictors for electing to have array-comparative genomic hybridization testing performed among this cohort of women. RESULTS: During this time period, there were 479 patients who underwent invasive testing. Of these, 162 (34%) women chose to have array-comparative genomic hybridization testing. In this group, 132 (81%) were of advanced maternal age. Advanced maternal age was the only indication for array-comparative genomic hybridization in 100 (62%) of the women. Other indications included: 14 (8%) advanced maternal age with multiple gestation, 22 (14%) ultrasound abnormalities (15 increased nuchal translucency, three first-trimester cystic hygroma, four second-trimester fetal anomalies); seven (4%) abnormal prenatal state screening; six (3.5%) prior aneuploidy; six (3.5%) maternal or paternal carriers of genetic abnormalities; and eight (5%) for maternal concern. Of these, two women were surrogates. Of this cohort, 34 (21%) had an abnormal array-comparative genomic hybridization result. Of these, only three were karyotypic abnormalities. CONCLUSIONS: The most common predictor of choosing array-comparative genomic hybridization was advanced maternal age followed by ultrasound abnormalities. Almost one fourth of abnormalities would not have been identified on routine karyotype. Pretest counseling and appropriate selection of pregnancies for testing continues to be important in this setting. Larger studies are needed to validate these findings.