William Cusick

Fetal Down Syndrome Screening: A Cost Effectiveness Analysis of Alternative Screening Programs

OBJECTIVEnTo compare the efficacy and cost effectiveness of different screening programs for fetal Down syndrome (DS).nnnMETHODSnScreening tools evaluated included maternal age, triple screening (TS), and ultrasound (U/S) for fetal markers of DS. Sensitivities used were TS: 55% <35 years, 80% > or = 35 years; U/S: 70%. Average regional fees used were TS:

Normative oxygen saturation values for pregnant women at sea level

80, U/S:

State-mandated prenatal screening for human immunodeficiency virus at a large community hospital: the first 10 months

200, amniocentesis (AM):

Mixed Umbilical Cord Blood Gas Values

1,000. Five screening programs were evaluated: 1) <35 years, no screening; > or = 35 years, AM; 2) <35 years, TS with AM for screen-positive subjects; > or = 35 years, AM; 3) all patients, TS with AM for screen-positive subjects; 4) <35 years, TS followed by U/S for screen-positive women, AM for women with fetal markers of DS on U/S; > or = 35 years TS with AM for screen-positive subjects; 5) all women, TS followed by U/S for screen-positive women, AM for women with fetal markers of DS on U/S. The sensitivity, total cost, cost/case DS detected (Cost/DS), AM losses, and residual risk (RR, undetected DS fetuses/women not receiving AM) were calculated for each screening program. Population analysis was performed using 1988 IL delivery statistics.nnnRESULTSnIt was estimated that 260 cases of DS would occur in the population of 167,654 women (8.4% > or = 35 years at delivery). Sensitivity for programs 1-5 was 30, 69, 62, 51, and 36 percent, respectively, and cost/DS was 181,000, 203,000, 162,000, 151,000, and 194,000 dollars, respectively.nnnCONCLUSIONSnDS screening incorporating TS in all patients with program #4 and without program #3 selective U/S in women <35 years yield the best combination of sensitivity and cost effectiveness while minimizing the number of AM-related losses.

Maternal, placental, and neonatal associations with early germinal matrix/intraventricular hemorrhage in infants born before 32 weeks' gestation.

Objective: To develop normative ranges of maternal arterial oxygen saturation (SpO(2)) for women residing at sea level throughout gestation and postpartum.Materials and Methods: Healthy, nonsmoking, non-laboring pregnant women, with no obstetrical risk factors, were recruited into this longitudinal study performed at The Stamford Hospital (elevation sea level). Maternal SpO(2) was measured in the dominant index finger while breathing room air with a Nelcor N-200 pulse oximeter and DS-100A sensor (Nellcor Puritan Bennett, Pleasanton, CA) at set antepartum (AP) and postpartum (PP) intervals. Oxygen saturation was measured in the following positions: sitting, lying on the left then right side, knee-chest, and supine. Five minutes were allowed between measurements. Measurements were taken at 12, 24, and 36 weeks of gestation and then at 12 weeks postpartum for each patient.Results: Thirty-six patients were initially enrolled. Three were excluded from this study, secondary to loss of follow-up (1), preterm delivery at 35 weeks (1), and complicated placenta previa (1). Of the 33 patients who remained in the study 5 have delivered and undergone postpartum evaluation. SpO(2) values (%) are summarized as mean +/- 2 SD in the Table.Conclusion: Preliminary data in this ongoing descriptive longitudinal study suggest that maternal SpO(2) is at least 97% throughout pregnancy for healthy, non-smoking women residing at sea level. These normative data may be useful in managing pregnant women at risk for hypoxia.

First trimester diagnosis of fetal abnormalities

Abstract Objective: To evaluate the impact of state-mandated human immunodeficiency virus (HIV) screening at a large community hospital. Study design: Beginning October 1,1999, HIV screening of all pregnant women was mandated by the Connecticut state legislature. Under this policy, all pregnant women are screened for HIV twice during pregnancy. Mothers without a documented HIV result on admission for delivery undergo HIV screening unless they refuse on religious grounds. In the absence of a documented maternal HIV result (antepartum or intrapartum), all newborns are screened for HIV. Results: 2,352 infants were born to 2,239 women between October 1999 and July 2000. Seven pregnant women (0.3%) tested positive for HIV. Two additional family members (child, spouse) were diagnosed as HIV positive following positive prenatal testing of the mother. We estimated that six of nine cases (66.6%) would have been missed under a policy of voluntary prenatal screening. HIV-positive pregnant women received aggressive antepartum and intrapartum therapy. All seven infants born to these women have tested negative for HIV. Assuming a 30% rate of vertical transmission of HIV without treatment, two neonatal cases of HIV were prevented. Conclusion: A policy of mandatory HIV prenatal screening is achievable and desirable. Benefits include: 1) prompt treatment of the affected mother; 2) earlier identification and treatment of HIV-infected relatives; and 3) prevention of vertically acquired neonatal HIV infection.

Nasal bone length hypoplasia based on multiples of the median in the second trimester confers a high risk for fetal trisomy 21 and 18

The objective of this study was to examine the relationship among a mixed umbilical cord blood gas sample and concomitantly drawn arterial and venous samples and to develop a regression equation relating the mixed cord pH to the arterial and venous pH.This study involved patients enrolled in the “Intrapartum Electronic Fetal Heart Rate Monitoring Study” performed in Athens, Greece, by members of our institution. Patients presenting to the obstetrics ward and delivered during the study period (October 1, 1990-June30, 1991) were included. In addition to cord venous and arterial samples, a mixed cord sample was obtained by milking the cord into a plastic heparinized syringe and evacuating the residual air. All blood gases were measured within 10 min of delivery on a blood gas analyzer. Parameters examined included pH, pO2, pCO2, HCO3, and base excess. Using computer-based statistical software, linear regression analyses relating the venous and arterial values to the mixed cord values were performed and regre...