Richard A. Bronsteen

Prognostic factors and complication rates for cervical cerclage: A review of 482 cases

Charts from 482 singleton pregnancies undergoing cerclage placement in patients over a 6-year period were reviewed. Cervical dilatation at time of surgery, number of previous spontaneous losses, and gestational age at placement were key determinants of outcome. The most frequent complication, premature rupture of the membranes, ultimately occurred in 38% of patients. The 6.6% infection rate was increased in patients undergoing emergent versus elective surgery (12.7% vs 4.7%, p less than 0.005) and in patients at increased dilatation at time of surgery (5.7% for less than or equal to 2 cm vs 41.7% for greater than 2 cm, p less than 0.005). McDonald and Shirodkar procedures had similar obstetric outcomes in patients undergoing their first cerclage. The subgroup of patients with prior cerclage surgery showed improved birth weight when the Shirodkar procedure was performed instead of the McDonald cerclage (mean birth weight 3020 vs 2470 gm, p less than 0.005). An increased rate of primary cesarean section was found in the Shirodkar group (31% vs 17%, p less than 0.005). Complication rates and pregnancy outcome appear to reflect cervical dilatation more than gestational age at time of surgery.

Gestational diabetes mellitus: metabolic and blood glucose parameters in singleton versus twin pregnancies.

OBJECTIVES This study compared the frequency, glucose tolerance test results, and parameters of blood glucose control in twin and singleton pregnancies associated with gestational diabetes mellitus and carbohydrate intolerance. STUDY DESIGN Twin and singleton pregnancies associated with gestational diabetes mellitus and carbohydrate intolerance were compared as follows: frequency, maternal age, weight, 1-hour screen, glucose tolerance test results, posttreatment blood glucose values, insulin requirement, and insulin dose. Statistical analysis included the chi(2) and Student t tests. RESULTS Gestational diabetes mellitus was increased in twins (7.7% vs 4.1%; P <.05). The maternal weight at first visit was significantly less, and the 3-hour glucose tolerance test value was significantly greater than that for singletons. The other parameters were not different. CONCLUSIONS There is a significant increase in the incidence of gestational diabetes mellitus and disturbance of the 3-hour glucose tolerance test in twin pregnancies. However, insulin requirements were not different, suggesting a mild disturbance of carbohydrate tolerance that was effectively managed by the strategies used to achieve blood glucose control in singletons.

Vasa previa: clinical presentations, outcomes, and implications for management.

OBJECTIVE: To review experience with diagnosis, clinical associations, and outcomes of vasa previa in a single institution. METHODS: This was a retrospective review of all identified vasa previa cases from January 1 1990, to June 30, 2010. RESULTS: Sixty cases of vasa previa were identified (53 singletons, seven twins); 56 cases were diagnosed before delivery. An abnormal cord insertion or abnormal placental location was present in 55 cases. Missed diagnoses were attributed to technical and observer factors. Preterm bleeding was encountered in 25 (42%) case group participants. Seven case group participants required an emergent delivery, with significant neonatal morbidity and mortality. Twin pregnancies had a significantly earlier median age at delivery of 32 weeks of gestation compared with 35 weeks of gestations in singletons (P=.01). The seven twin pregnancies had a 28.6% emergent preterm delivery rate, whereas singletons had a 4.1% rate (P=.07). In 14 case group participants, the membranous fetal vessel was located in the lower uterus and not directly over the cervix. The vessel location was not related to the risk of emergent delivery. CONCLUSION: Transvaginal ultrasound scans of at-risk patients can identify most cases of vasa previa. Preterm bleeding does not usually require immediate delivery. The rate of emergent preterm delivery was low in singleton pregnancies. Twins were delivered, on average, 3 weeks earlier than singletons. LEVEL OF EVIDENCE: III

Second-Trimester Sonography and Trisomy 18 The Significance of Isolated Choroid Plexus Cysts After an Examination That Includes the Fetal Hands

Objective. To estimate the risk of trisomy 18 with the finding of isolated choroid plexus cysts after a standard sonographic examination that is extended to include the fetal hands. Methods. A retrospective chart review was performed on all fetuses with choroid plexus cysts on second‐trimester sonographic examinations. When choroid plexus cysts were identified, our standard protocol for fetal evaluation was expanded to include the hands. If no other findings were noted on completion of this examination, the choroid plexus cysts were classified as “isolated.” These results were correlated with the presence or absence of trisomy 18 to determine the impact of this approach for the detection of fetuses with this aneuploidy. Results. From March 1990 to the end of 2001, 49,435 fetuses that were subsequently delivered at our hospital were scanned between 16 and 25 menstrual weeks. At least 1 choroid plexus cyst was detected in 1209 fetuses (2.3%), of which 1060 were isolated. No fetuses with isolated choroid plexus cysts had trisomy 18. However, 3 fetuses with trisomy 18 had choroid plexus cysts and abnormal hands as their only abnormal findings. Conclusions. Fetuses with an apparently isolated finding of choroid plexus cysts can be further evaluated by extending the standard examination to include the hands. If no other findings are identified, the risk of trisomy 18 appears to be low.

Fetal Mediastinal Lymphangiomas

The purpose of this series was to evaluate the prenatal sonographic findings and postnatal outcomes in 2 fetuses with mediastinal lymphangiomas.

Insights into angiogenic imbalances during pregnancy.

BACKGROUND: An excess of either angiogenic or antiangiogenic factors may participate in the pathophysiology of life-threatening pregnancy complications. CASES: We describe two patients with severe early onset preeclampsia associated with partial mole or sacrococcygeal teratoma who had an excess of circulating concentrations of the antiangiogenic factors soluble vascular endothelial growth factor receptor-1 and soluble endoglin. In contrast, a patient with severe ovarian hyperstimulation syndrome at 5 weeks of gestation had an excess of circulating free vascular endothelial growth factor, a key angiogenic factor. CONCLUSION: Angiogenic imbalances may participate in the pathophysiology of early onset preeclampsia associated with partial mole or sacrococcygeal teratoma as well as in the pathophysiology of severe ovarian hyperstimulation syndrome during pregnancy.

Clinical Implications of the Prenatal Sonographic Finding of Fetal Myocardial Echogenic Foci

The purpose of this study was to investigate the clinical implications of fetal echogenic foci limited to the myocardium of the ventricular wall (EMF) or intraventricular septum detected during prenatal sonography.

Idiopathic Granulomatous Angiitis of the Central Nervous System in Pregnancy: The First Case Report

Idiopathic granulomatous angiitis of the central nervous system (IGANS) is a rare vasculitis primarily affecting the spinal cord and brain not related to any underlying systemic disease. Clinical manifestations range from simple headache to cerebral vascular accidents secondary to vascular occlusion. The management of a pregnancy complicated by multiple risk factors including underlying IGANS is reported. An expectant, empiric approach was adopted and resulted in excellent maternal and neonatal outcomes. The first report of the management of a pregnancy complicated by IGANS is presented. Underlying maternal IGANS may not necessarily represent an indication for pregnancy termination.

Fetal Heart: A 4-chamber View Is Not Enough

The majority of children born with congenital heart disease have no identifiable risk factors and, therefore, prenatal diagnosis relies on routine ultrasonographic screening. First proposed in 1985, the 4-chamber view is a component of the basic fetal cardiac examination. However, many life-threatening conditions (eg, transposition of the great arteries) can present with a normal 4-chamber view and may only be detected by systematic evaluation of the outflow tracts. Although this is a technically challenging skill, its mastery is a worthwhile goal of ultrasonography training, as it likely to improve the lives of at least some of the children affected by the most severe forms of congenital heart disease.

Prenatal Identification of a Tetraploid Fetus with fish

The first prenatal diagnosis of a tetraploid fetus via fluorescent in situ hybridization (FISH) technology is reported. FISH analysis of uncultured amniotic fluid cells utilizing probes for chromosomes 13, 21, 18, X, and Y revealed that greater than 65% of hybridized nuclei had four signals. Standard cytogenetic analysis revealed a 92, XXXX karyotype