Rita Driggers

Zika Virus Infection with Prolonged Maternal Viremia and Fetal Brain Abnormalities

The current outbreak of Zika virus (ZIKV) infection has been associated with an apparent increased risk of congenital microcephaly. We describe a case of a pregnant woman and her fetus infected with ZIKV during the 11th gestational week. The fetal head circumference decreased from the 47th percentile to the 24th percentile between 16 and 20 weeks of gestation. ZIKV RNA was identified in maternal serum at 16 and 21 weeks of gestation. At 19 and 20 weeks of gestation, substantial brain abnormalities were detected on ultrasonography and magnetic resonance imaging (MRI) without the presence of microcephaly or intracranial calcifications. On postmortem analysis of the fetal brain, diffuse cerebral cortical thinning, high ZIKV RNA loads, and viral particles were detected, and ZIKV was subsequently isolated.

Isolated bilateral anophthalmia in a girl with an apparently balanced de novo translocation: 46,XX,t(3;11)(q27;p11.2).

Primary anophthalmos is a heterogeneous condition. In its nonsyndromal form, it is usually considered an autosomal recessive trait. However, other causes such as chromosomal abnormalities and prenatal insults need to be considered. We report on a unique reciprocal translocation 46,XX,t(3;11)(q27;p11.2) in a baby with isolated anophthalmos. Both Chitayat et al. [1996] and Alvarez Arratia et al. [1984] have reported on cases of terminal deletion of the long arm of chromosome 3. In each case the child had multiple anomalies including microphthalmia or anophthalmia. Because our patient appears to have no other anomalies, this break point may indicate that a genetic locus for eye formation exists at chromosome site 3q27. Published 1999 Wiley-Liss, Inc.

Large Fetal Sacrococcygeal Teratomas: Could Early Delivery Improve Outcome?

Objective: To determine if gestational age (GA) at delivery or tumor size impacts outcome in neonates with very large sacrococcygeal teratomas (SCTs). Methods: Retrospective chart review from 1990 to 2006 of live-born infants with very large SCTs, defined as diameters exceeding 10 cm. Data analyzed using the independent t test and Fisher’s exact test, with p values <0.05 considered significant. Results: Nine infants with very large SCTs were identified. Six of the 9 infants survived, 4 of whom had evidence of early hydrops. Mean GA of survivors was 32.2 ± 3.7 versus 31.7 ± 0.6 weeks in nonsurvivors (p = 0.85). Infants with the largest SCTs did not survive. Conclusion: Risks of preterm delivery must be weighed against complications from further enlargement of very large SCTs and against the risks of in utero intervention.

Fetal Anatomic and Functional Echocardiography A 5-Year Review

Objective. To assess the concordance of fetal and postnatal echocardiography when congenital heart disease is suspected prenatally. Methods. The perinatology and pediatric cardiology ultrasound databases were searched for fetal echocardiograms obtained between June 1995 and June 2000. All cases with abnormal fetal echocardiographic findings in which postnatal echocardiography was performed were included. A perinatologist, pediatric cardiologist, or both interpreted all fetal echocardiograms; a pediatric cardiologist interpreted all postnatal echocardiograms. The fetal and postnatal echocardiograms were compared for the presence of 25 specific components. The κ statistic was calculated to evaluate concordance between fetal and postnatal studies. Positive and negative predictive values for fetal studies were calculated under the assumption that the postnatal study yielded the correct diagnosis. Results. Sixty‐five patients were included. Congenital heart disease ranged from an isolated atrial septal defect to complex disease. Images adequately showed all 25 components in more than 85% of the fetal studies. Concordance between fetal and postnatal echocardiograms was excellent (κ > 0.75) for 20 of the 25 components evaluated. Four of the remaining 5 components had fair concordance (κ = 0.4–0.75) between fetal and postnatal studies. Structural abnormalities without excellent concordance included partial anomalous pulmonary venous return, secundum atrial septal defects, and heart malposition. Concordance between fetal and postnatal right and left ventricular function was fair; however, differences may have been due to physiologic changes that occurred after birth rather than to inferior diagnostic accuracy of fetal echocardiography. Conclusions. Fetal echocardiography is an extremely useful and accurate clinical tool for prenatal and postnatal evaluation of congenital heart disease.

Is 40 the New 30?: Pregnancy Outcomes by Degree of Weight Gain Among Obesity Subclasses

INTRODUCTION: The objective of this study was to evaluate pregnancy outcomes by obesity classification using the 2009 Institute of Medicine weight gain guidelines. METHODS: We conducted a retrospective cohort analysis of 1,886 obese women who delivered a singleton pregnancy at our institution from 2009 to 2012. Women were stratified based on prepregnancy body mass index (BMI) into subclasses of obesity: class I (BMI 30.0–34.9 kg/m2), class II (BMI 35.0–39.9 kg/m2), and class III (BMI 40.0 kg/m2 or greater). The primary outcome was cesarean delivery. Secondary outcomes included hypertensive disorders of, gestational diabetes, preterm delivery, small for gestational age, and large for gestational age. Odds ratios and 95% confidence intervals were calculated based on weight gain less than or greater than the recommended 11–20 pounds. Weight gain within guidelines was the referent for each class. RESULTS: Before pregnancy, 957 women were obese class I, 508 women were obese class II, and 421 women were obese class III. During pregnancy, 60.1% of women gained more than the recommended amount of weight; only 18.7% of women gained the recommended 11–20 pounds. Women with class I obesity increased their risk of hypertensive disorders and large for gestational age with excessive weight gain. Women with class II obesity increased their risk of cesarean delivery with excessive weight gain. Women with class III obesity increased their risk of cesarean delivery and hypertensive disorders with excessive weight gain. Less than recommended weight gain had no clear associations. CONCLUSION: Weight gain above the guideline was common and associated with adverse pregnancy outcomes among all subclasses of obesity.

Obstetric and Gynecologic Ultrasound Curriculum and Competency Assessment in Residency Training Programs: Consensus Report: Obstetric and Gynecologic Ultrasound Training

Ultrasound imaging has become integral to the practice of obstetrics and gynecology. With increasing educational demands and limited hours in residency programs, dedicated time for training and achieving competency in ultrasound has diminished substantially. The American Institute of Ultrasound in Medicine assembled a multisociety task force to develop a consensus‐based, standardized curriculum and competency assessment tools for obstetric and gynecologic ultrasound training in residency programs. The curriculum and competency assessment tools were developed based on existing national and international guidelines for the performance of obstetric and gynecologic ultrasound examinations and thus are intended to represent the minimum requirement for such training. By expert consensus, the curriculum was developed for each year of training, criteria for each competency assessment image were generated, the pass score was established at, or close to, 75% for each, and obtaining a set of 5 ultrasound images with pass score in each was deemed necessary for attaining each competency. Given the current lack of substantial data on competency assessment in ultrasound training, the task force expects that the criteria set forth in this document will evolve with time. The task force also encourages use of ultrasound simulation in residency training and expects that simulation will play a significant part in the curriculum and the competency assessment process. Incorporating this training curriculum and the competency assessment tools may promote consistency in training and competency assessment, thus enhancing the performance and diagnostic accuracy of ultrasound examination in obstetrics and gynecology.

Obstetric and gynecologic ultrasound curriculum and competency assessment in residency training programs: consensus report

&NA; Ultrasound imaging has become integral to the practice of obstetrics and gynecology. With increasing educational demands and limited hours in residency programs, dedicated time for training and achieving competency in ultrasound has diminished substantially. The American Institute of Ultrasound in Medicine assembled a multisociety task force to develop a consensus‐based, standardized curriculum and competency assessment tools for obstetric and gynecologic ultrasound training in residency programs. The curriculum and competency assessment tools were developed based on existing national and international guidelines for the performance of obstetric and gynecologic ultrasound examinations and thus are intended to represent the minimum requirement for such training. By expert consensus, the curriculum was developed for each year of training, criteria for each competency assessment image were generated, the pass score was established at, or close to, 75% for each, and obtaining a set of 5 ultrasound images with pass score in each was deemed necessary for attaining each competency. Given the current lack of substantial data on competency assessment in ultrasound training, the task force expects that the criteria set forth in this document will evolve with time. The task force also encourages use of ultrasound simulation in residency training and expects that simulation will play a significant part in the curriculum and the competency assessment process. Incorporating this training curriculum and the competency assessment tools may promote consistency in training and competency assessment, thus enhancing the performance and diagnostic accuracy of ultrasound examination in obstetrics and gynecology.

Use of cell-free DNA in the investigation of intrauterine fetal demise and miscarriage.

OBJECTIVE: To estimate whether cell-free DNA is present in nonviable pregnancies and thus can be used in diagnostic evaluation in this setting. METHODS: We conducted a prospective cohort study of 50 participants at MedStar Washington Hospital Center, Washington, DC, between June 2013 and January 2014. Included were women with pregnancies complicated by missed abortion or fetal demise. All gestational ages were considered for study participation. Participants with fetal demise were offered the standard workup for fetal death per the American College of Obstetricians and Gynecologists. Maternal blood samples were processed to determine the presence of cell-free DNA, the corresponding fetal fractions, and genetic abnormalities. RESULTS: Fifty samples from nonviable pregnancies were analyzed. The average clinical gestational age was 16.9 weeks (standard deviation 9.2). The mean maternal body mass index was 30.3 (standard deviation 9.1). Seventy-six percent (38/50) of samples yielded cell-free DNA results, that is, had fetal fractions within the detectable range of 3.7–65%. Among the 38, 76% (29) were classified as euploid, 21% (8) as trisomies, and 3% (1) as microdeletion. A cell-free DNA result was obtained more frequently at ultrasonographic gestational ages of 8 weeks or greater compared with less than 8 weeks (87.9% [n=29/33, 95% confidence interval (CI) 72.7–95.2; and 52.9%, n=9/17, 95% CI 31.0–73.8] of the time, respectively, P=.012). Time from demise was not associated with obtaining a result. CONCLUSION: Among nonviable pregnancies, cell-free DNA is present in the maternal plasma with fetal fractions greater than 3.7% in more than three fourths of cases after an ultrasonographic gestational age of 8 weeks. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01916928. LEVEL OF EVIDENCE: III

Ultrasound Findings Associated with Antepartum Viral Infection

This article reviews the sonographic manifestations of fetal infection and the role of ultrasound in the evaluation of the fetus at risk for congenital infection. Several ultrasound findings have been associated with in utero fetal infections. For the patient with a known or suspected fetal infection, sonographic identification of characteristic abnormalities can provide useful information for counseling and perinatal management. Demonstration of such findings in the low-risk patient may serve to identify the fetus with a previously unsuspected infection. The clinician should understand the limitations of ultrasound in the prenatal diagnosis of congenital infection and discuss them with the patient.

Perinatal findings in a patient with a novel large chromosome 19p deletion

We describe the prenatal and postnatal course of an infant with a large 19p deletion. Cases such as ours will improve the knowledge of specific gene functions for every medical specialist. The goal is to allow for a more rapid diagnosis, accurate prognosis and to decrease the likelihood of complications.