Roderick F. Hume

Differential increases in AFP, hCG, and uE3 in twin pregnancies: Impact on attempts to quantify Down syndrome screening calculations

Since the advent of multiple marker screening (MMS) for Down syndrome (DS) risk calculations, limitations for twins have been apparent. Recent attempts have been made to extrapolate mathematically singleton risks to twins. Here we investigate the pattern of levels among AFP, hCG, and uE3 in twins. MMS screening data from 4,443 twin pregnancies were compared to those from 258,885 singletons from 14-21 weeks of gestational age during a 3-year period (1992-1994) in our laboratory. Medians were determined for singletons and twins, and the ratios of twins to singletons were derived. Median AFP levels for twins are approximately double those of singletons, but median increases for hCG and uE3 are less than double. The data were divided further by ethnic groups (white, African American, Asian, and Hispanic), among which there were significant variations in medians, but not in the ratios of twins to singletons. The increased serum levels of different markers in twins are not consistent across analytes, possibly reflecting independent development of different compartments. Such differences mean that a mere mathematical conversion of singleton DS risks would be imbalanced among the analytes and cannot be applied reasonably to twins. Ethnic-specific databases are as important in twins as they are in singletons.

Vascular Disruption Birth Defects and History of Prenatal Cocaine Exposure: A Case Control Study

OBJECTIVE To test the hypothesis that prenatal cocaine exposure is associated with a 3-fold increased risk for vascular disruption among malformations. STUDY DESIGN A retrospective case-control study was based upon >68,000 delivery records at Hutzel Hospital for a 9-year period. Ascertainment was based upon ICD-9 codes for limb defects, abdominal wall defects, and facial clefts. Transverse limb defects and gastroschisis were defined as cases, and nondisruption anomalies served as controls. Statistical analysis for history of maternal cocaine use reported during pregnancy was performed by chi(2) analysis and the odds ratio determined. RESULTS A total of 190 cases of limb anomalies, abdominal wall defects, and cleft lips were identified after exclusion criteria. Statistical analysis was performed on the 119 cases informative for maternal cocaine use during pregnancy. Seven of 34 vascular disruption cases had cocaine exposure reported versus 12 of 85 other malformations controls. The odds ratio for cocaine exposure and vascular disruption is 1.58 (95% confidence interval = 0.55-4.47). CONCLUSION The putative association of prenatal cocaine exposure and vascular disruption birth defects remains unresolved, but the attributable risk is very likely less than the 3-fold odds ratio previously reported.

10 Multifetal pregnancy reduction

Multifetal pregnancy reduction (MFPR) has become a mainstay of infertility therapy as its development has allowed physicians to become more aggressive in treating patients resistant to more conservative therapies. Over the course of the past decade, MFPR has become practised in a limited number of tertiary specialty centres, which have improved its performance and very substantially lowered its risks. The majority of physicians performing MFPR employ a transabdominal needle injection of potassium chloride into the fetal thorax. Risks for pregnancy losses of patients starting with triplets and/or quadruplets reduced to twins have improved over the past decade and are not substantially different from those in patients whose pregnancy began as twins. There have been no substantiated risks of coagulopathies or damage to surviving fetuses.

Extreme elevation of maternal serum alpha-fetoprotein associated with mosaic trisomy 8 in a liveborn.

Constitutional mosaic trisomy 8 has been associated with syndromic dysmorphology, corneal opacities, leukemias, and trophoblastic disease. However, abnormal maternal serum alpha-fetoprotein (MSAFP) has not been reported in association with mosaic trisomy 8. Our case first presented for evaluation of an extremely elevated MSAFP with mild elevation of MShCG in an otherwise normal pregnancy: MSAFP 13.89 MoM, MShCG 3.57 MoM, and MSuE3 1.04 MoM. Fetal dysmorphism was limited to bilateral pyelectasis and a prominent third ventricle. Spontaneous labor at 38 weeks resulted in the birth of a 3,570-gram AGA male with APGARs 71/85. The neonate had facial asymmetry, 5th finger clinodactyly, 2–3 toe syndactyly, undescended testicle, abnormal prepuce, and mild pyelectasis. CT scan revealed hypoplasia of the corpus callosum, while echocardiography demonstrated bicuspid aortic valve, and the neonatal karyotype (blood) returned 46,XY/47,XY+8. Evaluation at 3 months revealed more prominent facial asymmetry, plagiocephaly, plantar creases, descent of the testis, and mild developmental delay. Review of the literature does not include any previously reported maternal serum alpha-fetoprotein aberrations in mosaic trisomy 8.

Cost Consequences of Elimination of the Routine Group B Streptococcus Culture at a Teaching Hospital

OBJECTIVE To evaluate the cost consequence of the elimination of routine Group B streptococcus (GBS) cultures in pregnancy utilizing risk factor assessment management recommendations of the Center for Disease Control. METHODS This retrospective study cohort population included all delivering patients from June 1, 1996, to May 31, 1997, managed by the Morbidity Mortality Weekly Report (MMWR) guidelines May 31, 1996, for GBS in pregnancy compared to the previous 29 months cohort from January 1, 1994, to May 31, 1996, managed with routine GBS cultures done at 35-37 weeks. RESULTS Of the 7,681 culture management control cohort patients, there were four neonates with culture-positive GBS sepsis (1/1,900). The cost for detection of a single positive culture in an affected neonate was

Use of a focussed teen prenatal clinic at a military teaching hospital: model for improved outcomes of unmarried mothers.

8,627 (

Effects of lipopolysaccharide on interleukin-6 production in perfused human placental cotyledons

34,509/4) and there were 2,875 personnel hours expended. In contrast, of the 2,011 patients in the risk factor management cohort, there were two cases of neonatal GBS sepsis (

Cost consequences of implementation of an early obstetrical discharge program in a military teaching hospital.

111,005). The cost for detection of a positive culture in an affected neonate was

Hypoperfusion causes increased production of interleukin 6 and tumor necrosis factor α in the isolated, dually perfused placental cotyledon

1,579 (

The effects of hypoxia and hyperoxia on fetal-placental vascular tone and inflammatory cytokine production

3,159/2) and there were 263 personnel hours expended in the risk factor management group. In spite of these significant laboratory savings, we noted a concurrent increase in the total cost in the newborn nursery for septic work-ups and treatment from