Stephen T. Chasen

The Vecchietti procedure for surgical treatment of vaginal agenesis: comparison of laparoscopy and laparotomy

Objective: Our goal was to describe the outcomes of women with vaginal agenesis who had surgical creation of a neovagina using the Vecchietti technique over a 20‐year period. We also sought to determine whether the laparoscopic approach would result in similar outcomes as laparotomy. Method: Retrospective analysis of 76 women with vaginal agenesis treated at the University of Verona Hospital between 1976 and 1996 with the Vecchietti procedure. Operative and postoperative records were reviewed, and sexual histories were obtained. Data were analyzed based on surgical approach and postoperative sexual satisfaction. Continuous data were analyzed with students t‐test, and categoric data were analyzed using Fishers exact test. Result: Those who underwent the Vecchietti procedure with a laparoscopic approach (N=7) had similar complication rates (0% vs. 13.0%, P=0.59) and postoperative neovaginal depth (74.9 mm vs. 73.7 mm, P=0.93) as those with laparotomy (N=69). Similar proportions of women reported inadequate vaginal lubrication (28.6% vs. 17.4%, P=0.61) and sexual satisfaction (100% vs. 78.3%) in the laparoscopy and laparotomy groups as well. Operative complications, neovaginal depth, or degree of lubrication were not good predictors of sexual satisfaction. Conclusion: Outcomes in those women who underwent the Vecchietti technique via the laparoscopic approach are comparable to those who underwent laparotomy.

First trimester prediction of growth discordance in twin gestations

OBJECTIVE The purpose of this study was to determine whether first trimester ultrasound scanning can identify twin gestations that are at risk for subsequent growth discordance. STUDY DESIGN Ultrasound examinations of dichorionic twin pregnancies between 11 and 14 weeks of gestation were evaluated for growth discordance with crown-rump length. Pregnancies that were complicated by fetal death or anomalies were excluded from the analysis. Birth weight discordance was defined as >or=20% difference in birth weight, relative to the larger twin. Fishers exact, Mann Whitney U, and Spearman rho tests were used for statistical analysis. RESULTS Of 130 twin pregnancies, 16 pregnancies (12.3%) had discordant birth weight. Crown-rump length disparity was correlated positively with birth weight discordance (r=0.31; P<.001). Of pregnancies with a discrepancy of <or=3 days in estimated gestational age, only 9.2% were discordant at birth compared with 45.5% of pregnancies with >3 days discrepancy (P=.004), which resulted in a likelihood ratio of 5.9 for having discordant birth weight. CONCLUSION Twins who are ultimately discordant at birth may exhibit differences in growth as early as 11 to 14 weeks of gestation.

Fetal growth assessment and neonatal birth weight in fetuses with an isolated single umbilical artery

OBJECTIVE: To evaluate interval fetal growth and compare the incidence of small-for-gestational age (SGA) newborns between fetuses with an isolated single umbilical artery and those with a 3-vessel umbilical cord. METHODS: A retrospective, case-controlled study in which 84 singleton pregnancies with an isolated single umbilical artery were compared with 3-vessel umbilical cord fetuses as the control group. RESULTS: There was no statistical difference between the groups in maternal demographic data, except for ethnicity and neonatal outcomes, respectively. The mean newborn birth weight was similar between the isolated single umbilical artery and the control groups, 3,268 ± 596 g and 3,274 ± 627 g, respectively. The prevalence of SGA newborns was 7.1% (6 of 84) in the isolated single umbilical artery group and 4.8% (4 of 84) in the control group. An ultrasound examination demonstrated fetal growth restriction in 50% of cases (3 of 6) in the isolated single umbilical artery group and in 25% of subjects (1 of 4) in the control group, respectively. CONCLUSION: Fetuses with an isolated single umbilical artery are at similar risk for SGA compared with fetuses with 3-vessel umbilical cords. It appears that antepartum serial ultrasound examination does not provide more information for interval fetal growth assessment in fetuses with an isolated single umbilical artery. LEVEL OF EVIDENCE: II-2

First-trimester screening for aneuploidy with fetal nuchal translucency in a United States population

To examine the detection rate of chromosomal abnormalities using a combination of nuchal translucency (NT) and maternal age in a United States population.

Interleukin-1 receptor antagonist gene polymorphism and multifetal pregnancy outcome.

OBJECTIVE The purpose of this study was to determine whether interleukin-1 receptor antagonist and/or interleukin-1beta gene polymorphisms influence multifetal pregnancy outcome. STUDY DESIGN Maternal and neonatal buccal swabs from 51 multifetal gestations were analyzed for interleukin-1 receptor antagonist and interleukin-1beta alleles. Outcome data were obtained subsequently. RESULTS Fetal carriage of interleukin-1 receptor antagonist allele 1 was more than twice as prevalent as the carriage of allele 2. Preterm premature rupture of membranes was observed in 12 of 24 pregnancies (50.0%) in which 2 fetuses tested positive for interleukin-1 receptor antagonist allele 2, as opposed to only 3 of 27 pregnancies (11.1%) in which 1 or neither fetus tested positive for interleukin-1 receptor antagonist allele 2 (P=.005). Similarly, 20 of 26 neonates (76.9%) with documented morbidity tested positive for interleukin-1 receptor antagonist allele 2, as compared with 36 of 78 neonates (46.2%) without morbidity (P=.007). Fetal or maternal interleukin-1beta polymorphisms or maternal interleukin-1 receptor antagonist polymorphisms were unrelated to pregnancy outcome. CONCLUSION Fetal carriage of interleukin-1 receptor antagonist allele 2 was associated with both preterm premature rupture of membranes and neonatal morbidity in women with multifetal pregnancies.

Influence of maternal body mass index on the clinical estimation of fetal weight in term pregnancies.

OBJECTIVE: To estimate the effect of maternal body mass index (BMI) on clinical estimated fetal weight in term pregnancies. METHODS: We compared the clinical estimated fetal weight to the actual birth weight on 400 consecutive term pregnant patients admitted for delivery. We then evaluated whether the maternal BMI was significantly associated with the clinical estimated fetal weight accuracy in estimating birth weight. Patients with singleton pregnancies at 37–42 weeks of gestation were included. Patients with an ultrasound-estimated fetal weight within 3 weeks of admission were excluded. Estimated fetal weight accuracy was defined as the absolute error (absolute value of estimated fetal weight minus birth weight) and absolute percent error (absolute error divided by birth weight multiplied by 100). The primary outcome was an absolute percent error of less than 10% (ie, an estimated fetal weight within ±10% of the birth weight). RESULTS: The proportion of clinical estimated fetal weights within ±10% and within ±20% of the birth weight significantly decreased with increasing BMI categories (&khgr;2 for trend P=.040 and 0.020, respectively). Clinical estimated fetal weights obtained in women with BMI at or greater than 30 were significantly less likely to be within ±10% of the birth weight when compared with women with a BMI less than 25 (66.4% compared with 82.5%, P=.011). Body mass index was significantly positively associated with the absolute error (P=.046) and the absolute percent error (P=.011), even after controlling for birth weight. CONCLUSION: Increased maternal BMI is significantly associated with decreased clinical estimated fetal weight accuracy. LEVEL OF EVIDENCE: II

Contemporary practice patterns and beliefs regarding tocolysis among u.s. Maternal-fetal medicine specialists.

OBJECTIVE: To estimate maternal–fetal medicine specialists’ practice patterns and perceived risks and benefits to tocolysis. METHODS: We performed a mail-based survey of all Society for Maternal–Fetal Medicine (SMFM) members in the United States. Subjects were asked whether they would recommend tocolysis and what would be their first-line tocolytic in five scenarios: 1) acute preterm labor; 2) maintenance tocolysis after arrested preterm labor; 3) repeat acute preterm labor; 4) preterm premature rupture of membranes (PROM) without contractions; and 5) preterm PROM with contractions. RESULTS: A total of 827 (46%) SMFM members responded. Ninety-six percent, 56%, 56%, 32%, and 29% would recommend tocolysis for acute preterm labor, repeat acute preterm labor, preterm PROM with contractions, preterm PROM without contractions, and maintenance tocolysis, respectively. The most common first-line tocolytic was magnesium for acute preterm labor (45%) and repeat acute preterm labor (41%); nifedipine was the most common maintenance tocolysis (79%). Eighty percent believed tocolysis was associated with moderate or significant benefit in the setting of acute preterm labor; however, fewer than 50% responded similarly for the other four scenarios. In all five scenarios, more than 50% of respondents indicated there was minimal or no risk associated with tocolysis. Having a nonacademic practice was independently associated with the recommendation for tocolysis. CONCLUSION: Almost all maternal–fetal medicine specialists recommend tocolysis in the setting of acute preterm labor, and many recommend tocolysis for other indications. Magnesium and nifedipine are the most commonly prescribed first-line tocolytics. LEVEL OF EVIDENCE: III

Prenatal informed consent for sonogram: the time for first-trimester nuchal translucency has come.

ltrasonographic screening in pregnancy has been and continues to be a matter of controversy. For the past 20 years, second-trimester ultrasonographic screening has been debated. Even today, the American College of Obstetricians and Gynecologists does not endorse this as a standard of care. Nonetheless, secondtrimester ultrasonography is widely offered. In 1989, two of us (F.A.C. and L.B.M.) made the argument that “the standard of care demands that prenatal informed consent for sonogram be accepted as an indication for the prudent use of obstetric ultrasonography performed by qualified personnel.”1 The purpose of this editorial is to extend that argument to first-trimester ultrasonographic screening for aneuploidy using nuchal translucency determination.

The recommendation for bed rest in the setting of arrested preterm labor and premature rupture of membranes

OBJECTIVE The objective of the study was to estimate practice patterns regarding bed rest in women with preterm premature rupture of membranes (PPROM) and arrested preterm labor. STUDY DESIGN This was a mail-based survey of all Society for Maternal-Fetal Medicine members in the United States asking whether they would recommend bed rest in the setting of arrested preterm labor or PPROM at 26 weeks. Bed rest was defined as no more than 1-2 hours per day out of bed, with permitted activities including bathroom use, bathing, and brief ambulation inside the home/hospital. RESULTS Seventy-one percent and 87% would recommend bed rest for women with cervical dilation and arrested preterm labor and women with PPROM, respectively, even though the majority believed bed rest was associated with minimal or no benefit. Female sex, nonacademic practice, and practice location in the South or West were independently associated with the recommendation for bed rest. CONCLUSION Despite the belief that bed rest is associated with minimal or no benefit, most maternal-fetal medicine specialists recommend bed rest for arrested preterm labor and PPROM. Randomized, prospective trials are needed to evaluate the efficacy of bed rest in these settings.

Assessment of Umbilical Cord Coiling During the Routine Fetal Sonographic Anatomic Survey in the Second Trimester

The purpose of this study was to evaluate the sonographic accuracy to determine the umbilical coiling index (UCI) during the routine fetal anatomic survey in the second trimester.