Sara Nicholas

Predicting adverse neonatal outcomes in fetuses with abdominal wall defects using prenatal risk factors

OBJECTIVE The aim of this study was to determine whether prenatal variables can predict adverse neonatal outcomes in fetuses with abdominal wall defects. STUDY DESIGN A retrospective cohort study that used ultrasound and neonatal records for all cases of gastroschisis and omphalocele seen over a 16-year period. Cases with adverse neonatal outcomes were compared with noncases for multiple candidate predictive factors. Univariable and multivariable statistical methods were used to develop the prediction models, and effectiveness was evaluated using the area under the receiver operating characteristic curve. RESULTS Of 80 fetuses with gastroschisis, 29 (36%) had the composite adverse outcome, compared with 15 of 33 (47%) live neonates with omphalocele. Intrauterine growth restriction was the only significant variable in gastroschisis, whereas exteriorized liver was the only predictor in omphalocele. The areas under the curve for the prediction models with gastroschisis and omphalocele are 0.67 and 0.74, respectively. CONCLUSION Intrauterine growth restriction and exteriorization of the liver are significant predictors of adverse neonatal outcome with gastroschisis and omphalocele.

Discussion: ‘Hypnotic analgesia during first-trimester termination’ by Marc et al

In the roundtable that follows, clinicians discuss a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed: Marc I, Rainville P, Masse B, et al. Hypnotic analgesia intervention during first-trimester pregnancy termination: an open randomized trial. Am J Obstet Gynecol 2008;199:469.e1-469.e9.

Estimation of fetal weight in fetuses with abdominal wall defects: Comparison of 2 recent sonographic formulas to the Hadlock formula

Objective. Estimation of fetal weight is particularly challenging in fetuses with abdominal wall defects (AWDs). We sought to compare the accuracy and screening efficiency for intrauterine growth restriction (IUGR) of 2 recent sonographic formulas to those of the Hadlock formula (Am J Obstet Gynecol 1985; 151:333–337) in fetuses with AWDs. Methods. This was a retrospective cohort study of fetuses with AWDs. Fetuses with sonographically estimated fetal weights (EFWs) within 14 days before delivery were included. Using the individual biometric measurements, EFWs were calculated using the Honarvar (Int J Gynaecol Obstet 2001; 73:15–20; femur length [FL]), Siemer (Ultrasound Obstet Gynecol 2008; 31:397–400; FL, biparietal diameter [BPD], and occipitofrontal diameter), and Hadlock (BPD, head circumference, abdominal circumference, and FL) formulas. The calculated EFWs were adjusted for interval growth between the dates of sonography and delivery using published sonographic fetal growth velocity standards. Accuracy and screening efficiency for IUGR were compared. Results. Seventy‐six fetuses were included: 53 with gastroschisis and 23 with omphalocele. The median gestational age at delivery was 36.6 weeks (range, 25.0 to 39.0 weeks). The Siemer formula had the lowest mean percentage error (−2.5% [95% confidence interval (CI), −6.2% to +1.2%]) without systematic bias (P = .182). The Hadlock formula had the highest precision (random error, 11.4%), sensitivity (91%), and accuracy for predicting IUGR (85% [95% CI, 77% to 94%]). Conclusions. None of the 3 sonographic formulas is ideal for estimating fetal weight in fetuses with AWDs. The Siemer formula should be used when accuracy in the absolute EFW is the goal. For the purpose of making the more clinically relevant diagnosis of IUGR, use of the Hadlock formula is justified.

How many procedures does it take? Success of a CVS training program for Maternal Fetal Medicine fellows.

To quantify the learning curve for a training program for Maternal Fetal Medicine (MFM) fellows in obtaining successful transvaginal chorionic villus sampling (CVS) results in women with early pregnancy failure (EPF).

Second Trimester Cervical Length and Its Association with Vaginal Birth after Cesarean Delivery

OBJECTIVE This study aims to evaluate the relationship between cervical length (CL) and trial of labor after cesarean (TOLAC) delivery. STUDY DESIGN This retrospective cohort study evaluated second trimester CL and likelihood of successful TOLAC. Women undergoing TOLAC from January 2009 to December 2011 who underwent transvaginal ultrasound CL between 18(0/7) to 23(6/7) weeks gestation were included. The threshold for CL was assessed using a receiver operating characteristics curve, with ≥ 45 mm determined to be the optimal threshold. Women with CL < 45 mm were compared with women with CL ≥ 45 mm with respect to TOLAC. Multivariate analysis was used to assess the association of CL with TOLAC. RESULTS A total of 45 patients met inclusion criteria, 14 (31%) with a long CL (≥ 45 mm) and 31 (69%) with CL < 45 mm. Groups did not differ in demographics or factors predictive of vaginal birth after cesarean (VBAC) delivery. More women with CL < 45 mm had successful VBAC (81%) than women with long CL (43%, relative risk 1.9, p = 0.03). Prior vaginal delivery and CL < 45 mm were both significant predictors of VBAC (odds ratio 1.8 and 2.0, respectively). CONCLUSION CL < 45 mm is associated with VBAC.

Early pregnancy failure as a training tool for chorionic villus sampling

The goal of this study is to evaluate the success of a training program in chorionic villus sampling (CVS) of early pregnancy failure (EPF) for maternal‐fetal medicine (MFM) fellows.

Hypnotic analgesia during first-trimester termination : Marc et al

The article below summarizes a roundtable discussion of a study published in this issue of the Journal in light of its methodology, relevance to practice, and implications for future research. Article discussed: Marc I, Rainville P, Masse B, et al. Hypnotic analgesia intervention during first-trimester pregnancy termination: an open randomized trial. Am J Obstet Gynecol 2008;199:469.e1-469.e9. The full discussion appears at www.AJOG.org, page e1-e5.