Richard L. Berkowitz

Pregnancy outcome at age 40 and older

Objective To examine pregnancy outcome among women age 40 years and older. Methods A retrospective cohort study, including 1404 pregnant women at least 40 years of age and 6978 controls age 20–29 years, was conducted. The two groups were stratified, according to parity, to facilitate separate analysis. Associations between maternal age and pregnancy outcomes were assessed with the contingency χ2 or two-tailed Fisher exact test. Multiple logistic regression was used to evaluate these associations and allowed for calculation of adjusted odds ratios (OR). Results Older gravidas were more likely to develop gestational diabetes (nulliparas: OR 2.7,95% confidence interval [CI] 1.9–3.7; multiparas: OR 3.8, 95% CI 2.7–5.4), preeclampsia (nulliparas: OR 1.8, 95% CI 1.3–2.6; multiparas: OR 1.9, 95% CI 1.2–2.9), and placenta previa (nulliparas: OR 13.0, 95% CI 4.8–35.0; multiparas: OR 6.4, 95% CI 2.6–15.6). Older women were also at increased risk for cesarean delivery (nulliparas: OR 3.1, 95% CI 2.6–3.7; multiparas: OR 3.3, 95% CI 2.6–4.1), operative vaginal delivery (nulliparas: OR 2.4, 95% CI 1.9–2.9; multiparas: OR 1.5, 95% CI 1.2–1.9), and induction of labor (nulliparas: OR 1.5, 95% CI 1.2–1.8; multiparas: OR 1.4, 95% CI 1.1–1.7). Older nulliparas had an increased incidence of abnormal labor patterns (OR 1.4, 95% CI 1.2–1.7), neonatal intensive care unit admissions (OR 1.6, 95% CI 1.2–2.2), and low l-minute Apgar scores (OR 2.3, 95% CI 1.1–4.9). Older multiparas were more likely to experience fetal distress (OR 2.0, 95% CI 1.4–2.8), antepartum vaginal bleeding (OR 1.8, 95% CI 1.1–3.1), and preterm premature rupture of membranes (OR 1.7, 95% CI 1.1–2.9). Conclusion Although maternal morbidity was increased in the older gravidas, the overall neonatal outcome did not appear to be affected.

Fetal growth in early pregnancy and risk of delivering low birth weight infant: prospective cohort study

Objective To determine if first trimester fetal growth is associated with birth weight, duration of pregnancy, and the risk of delivering a small for gestational age infant. Design Prospective cohort study of 38 033 pregnancies between 1999 and 2003. Setting 15 centres representing major regions of the United States. Participants 976 women from the original cohort who conceived as the result of assisted reproductive technology, had a first trimester ultrasound measurement of fetal crown-rump length, and delivered live singleton infants without evidence of chromosomal or congenital abnormalities. First trimester growth was expressed as the difference between the observed and expected size of the fetus, expressed as equivalence to days of gestational age. Main outcome measures Birth weight, duration of pregnancy, and risk of delivering a small for gestational age infant. Results For each one day increase in the observed size of the fetus, birth weight increased by 28.2 (95% confidence interval 14.6 to 41.2) g. The association was substantially attenuated by adjustment for duration of pregnancy (adjusted coefficient 17.1 (6.6 to 27.5) g). Further adjustments for maternal characteristics and complications of pregnancy did not have a significant effect. The risk of delivering a small for gestational age infant decreased with increasing size in the first trimester (odds ratio for a one day increase 0.87, 0.81 to 0.94). The association was not materially affected by adjustment for maternal characteristics or complications of pregnancy. Conclusion Variation in birth weight may be determined, at least in part, by fetal growth in the first 12 weeks after conception through effects on timing of delivery and fetal growth velocity.

Pregnancy outcome in liver transplant recipients.

OBJECTIVE To evaluate pregnancy course, complications, and outcomes in liver transplant recipients. METHODS We conducted a retrospective review of 38 pregnancies conceived between 1992 and 2002 in 29 women who underwent liver transplantation at Mount Sinai Medical Center. RESULTS The most common primary liver disease was autoimmune hepatitis. All patients were on immunosuppressive regimens that included cyclosporine A or tacrolimus. There were four spontaneous first-trimester abortions and ten first-trimester terminations for worsening liver function. The interval from transplantation to pregnancy was shorter in the group that had abortions and terminations (24.4 ± 24.3 months) as compared with the group that had live births (47.8 ± 28.7 months), P = .02. There were 24 live births to 20 patients. The mean gestational age at delivery was 36.4 weeks, and the mean birth weight was 2762 g. Pregnancy complications included preeclampsia (20.8%), chronic hypertension (20.8%), hemolysis, elevated liver enzymes, low platelets syndrome (8.3%), creatinine 1.3 mg/dL or more (25.0%), anemia (33.3%), diabetes (37.5%), cesarean delivery (45.8%), preterm birth less than 37 weeks (29.2%), intrauterine growth restriction (16.7%), and biopsy-proven graft rejection during pregnancy (16.7%). There were no intrauterine or neonatal deaths. All 5-minute Apgar scores were greater than 7. Four minor congenital anomalies were noted. Before 1997, there were five maternal deaths, 10–54 months after pregnancy. Pregnancy complications in our population were more common in those patients who delivered from 1992 to 1997 than in those who delivered from 1998 to 2002. CONCLUSION Pregnancy planned at least 2 years after liver transplantation with stable allograft function can have excellent maternal and neonatal outcome.

Intrapartum management of category II fetal heart rate tracings: towards standardization of care

There is currently no standard national approach to the management of category II fetal heart rate (FHR) patterns, yet such patterns occur in the majority of fetuses in labor. Under such circumstances, it would be difficult to demonstrate the clinical efficacy of FHR monitoring even if this technique had immense intrinsic value, since there has never been a standard hypothesis to test dealing with interpretation and management of these abnormal patterns. We present an algorithm for the management of category II FHR patterns that reflects a synthesis of available evidence and current scientific thought. Use of this algorithm represents one way for the clinician to comply with the standard of care, and may enhance our overall ability to define the benefits of intrapartum FHR monitoring.

Putting the “M” back in maternal–fetal medicine

Although maternal death remains rare in the United States, the rate has not decreased for 3 decades. The rate of severe maternal morbidity, a more prevalent problem, is also rising. Rise in maternal age, in rates of obesity, and in cesarean deliveries as well as more pregnant women with chronic medical conditions all contribute to maternal mortality and morbidity in the United States. We believe it is the responsibility of maternal-fetal medicine (MFM) subspecialists to lead a national effort to decrease maternal mortality and morbidity. In doing so, we hope to reestablish the vital role of MFM subspecialists to take the lead in the performance and coordination of care in complicated obstetrical cases. This article will summarize our initial recommendations to enhance MFM education and training, to establish national standards to improve maternal care and management, and to address critical research gaps in maternal medicine.

Intracranial hemorrhage in alloimmune thrombocytopenia: stratified management to prevent recurrence in the subsequent affected fetus

OBJECTIVE We sought to prevent intracranial hemorrhage (ICH) through antenatal management of alloimmune thrombocytopenia. STUDY DESIGN A total of 33 women (37 pregnancies) with alloimmune thrombocytopenia and ICH in a previous child were stratified according to the timing of the previous childs ICH: extremely high risk (HR) (n = 8) had ICH <28 weeks, very HR (n = 17) between 28-36 weeks, and HR (n = 12) in the perinatal period. Treatment was initiated at 12 weeks with intravenous immunoglobulin 1 or 2 g/kg/wk, and if the fetal platelet count by cordocentesis was <30,000/mL despite treatment, prednisone and/or more intravenous immunoglobulin were added. RESULTS Five of 37 fetuses suffered ICHs. Two ICHs had platelet counts >100,000/mL, and 1 was grade I. The other 2 ICHs were unequivocal treatment failures; both were grade III-IV and resulted in fetal demise. CONCLUSION These findings demonstrate the success of stratified treatment in these HR patients, which tailored interventions according to the timing of the siblings ICH.

Efficacy and side effects of magnesium sulfate and ritodrine as tocolytic agents.

Ritodrine as the first-line drug in the treatment of established preterm labor has been supplanted in some centers by magnesium sulfate. To assess the relative efficacy and rates of side effects of these two agents, 120 patients were randomly assigned to receive one of these two drugs. Patients were included if they had intact membranes and met strict criteria for the definition of labor. In both groups excellent outcome was achieved, with 96.3% and 92.3% of patients receiving ritodrine and magnesium sulfate, respectively, obtaining a delay in delivery of greater than 48 hours. Side effects were comparable in both groups, although they tended to be more serious in the patients receiving ritodrine. In patients receiving both drugs together, the rate of side effects was 77% without a demonstrable benefit over a single agent. We conclude that ritodrine and magnesium sulfate are tocolytics of comparable efficacy and when used aggressively are highly successful in delaying delivery.

Contingent screening for Down syndrome—results from the FaSTER trial

Comparison of contingent, step‐wise and integrated screening policies.

Contemporary outcomes with the latest 1000 cases of multifetal pregnancy reduction (MPR).

OBJECTIVE This study was undertaken to report on the outcome of multifetal pregnancy reduction in the most up-to-date largest single center experience with this procedure, and compare the outcome to the first 1000 cases performed at the same institution. STUDY DESIGN 1000 consecutive cases of multifetal pregnancy reduction performed at the Mount Sinai Medical Center between the years 1999-2006 were identified. Pregnancy outcomes were retrieved from a large database as well as chart review. Differences in means and proportions were evaluated by analysis of variance, chi-square, Cochran-Armitage test for trend or 2-tailed Fisher exact test as appropriate. RESULTS Outcomes were available on 841 cases, for a follow-up rate of 84.1%; 95.2% of patients delivered after 24 weeks, for a complete loss rate of 4.7%. There was a significant trend toward decreasing loss rates with decreasing starting numbers. Mean gestational age at delivery was later, and birthweights greater, for reduction to singletons vs twins. CONCLUSION Loss rates after multifetal pregnancy reduction have remained stable at 4.7%. The lowest loss rate occurred in the patients reducing from twins to a singleton (2.1%). Reduction to a singleton was also associated with higher birthweights and lower rates of preterm deliveries.

Maintaining quality assurance for sonographic nuchal translucency measurement : lessons from the FASTER Trial

To evaluate nuchal translucency measurement quality assurance techniques in a large‐scale study.