laparoscopic pelvic lymphadenectomy during pregnancy is

Laparoscopic Pelvic Lymphadenectomy During Pregnancy Is Safe and Accurate

Invasive Cervical Cancer During Pregnancy: Laparoscopic Nodal Evaluation Before Oncologic Treatment Delay.

Favero G, Chiantera V, et al:

Gynecol Oncol 2010; 118 (August 1): 123-127

Laparoscopic pelvic lymphadenectomy during pregnancy is safe, feasible, and accurately permits a planned delay of definitive treatment after lymph node metastasis has been ruled out.

Objective: To assess the efficacy and feasibility of laparoscopic nodal evaluation prior to a delay in treatment for invasive cervical cancer during pregnancy. Design/Methods: This was a retrospective study of patients with cervical cancer who underwent laparoscopic pelvic lymphadenectomy in the first and second trimesters of pregnancy to determine if delay in treatment was appropriate. Results: Mean age at diagnosis was 32 years and gestational age ranged between 6 and 23 weeks of pregnancy. Thirteen of 18 women had stage 1b1 tumors, 2 had 1a1 tumors and 1 each had 1a2, 1b2, and 2a lesions. Half were squamous cell and half were adenocarcinomas of the cervix. All laparoscopic procedures were successfully completed without related morbidity, conversion to laparotomy, or other complications. An average of 17 nodes per patient was removed and 14 of 18 patients had definitive treatment delayed until after fetal viability and delivery. Three of 18 had positive nodes and underwent second and third trimester chemotherapy. All 14 infants were delivered without complication and healthy, and all women were alive without evidence of disease at a mean follow-up time of 38 months. Conclusions: Laparoscopic pelvic lymphadenectomy during pregnancy is safe, feasible, and accurately permits a planned delay of definitive treatment after lymph node metastasis has been ruled out. Reviewer's Comments: This was an excellent article describing the indications and technique for laparoscopic pelvic lymphadenectomy when pregnancy is complicated by invasive cervical cancer. Since the procedure is feasible and safe, and lymph node status is the most important factor in determining survival with early stage cervical cancer, laparoscopic nodal evaluation during pregnancy represents the gold standard prognostic test for this entity. (Reviewer-Berel Held, MD). © 2010, Oakstone Medical Publishing

Keywords: Cervical Cancer, Pregnancy, Laparoscopic Nodal Evaluation

Print Tag: Refer to original journal article

Protein Biomarkers Correlate With Disease Severity, Px in Endometrial Cancer

The Prognostic Significance of the Triple Negative Phenotype in Endometrial Cancer.

Kothari R, Morrison C, et al:

Gynecol Oncol 2010; 118 (August 1): 172-175

The triple negative phenotype, as in breast cancer, is associated with advanced stage, high-grade, and high-risk endometrial pathology as well as poor survival, suggesting that its use for future targeted therapies may have relevance.

Objective: To correlate the triple negative phenotype (TNP) with surgical pathologic outcomes and survival in endometrial cancer patients, and to assess its prognostic significance. Design/Methods: This was a retrospective study examining 396 endometrial cancers diagnosed and treated at the Ohio State University Medical Center. Paraffin blocks of tissue from each of these patients were assessed for the protein biomarkers estrogen receptor, progesterone receptor, and HER2 expression. The TNP was statistically correlated with the clinical course of the patient, and progression-free and overall survival statistics were analyzed utilizing Kaplan-Meier curves. Results: One fourth of patients had the triple negative phenotype. This was associated with lymph node metastases, myometrial invasion, high-grade disease, advanced stage disease, and overall worse survival statistics. Conclusions: TNP, as in breast cancer, is associated with advanced stage, high-grade, and high-risk endometrial pathology as well as poor survival, suggesting that use of the triple negative phenotype for future targeted therapies may have relevance. Reviewer's Comments: This study assessed the triple negative phenotype in endometrial cancer in relation to prognostic significance, and association with various surgico-pathologic factors. As in breast cancer, the TNP is associated with more aggressive and advanced lesions, and poorer overall survival. It will have greater use in the future as targeted therapies are developed for specific histologic subtypes of cancer. (Reviewer-Berel Held, MD). © 2010, Oakstone Medical Publishing

Keywords: Endometrial Cancer, Triple Negative Phenotype, Outcomes, Survival Prognosis


Monozygotic Twinning Confers Higher Perinatal Morbidity Over Dizygotic Twinning

Monozygotic Twinning: An Eight-Year Experience at a Large IVF Center.

Knopman J, Krey LC, et al:

Fertil Steril 2010; 94 (July): 502-510

There is a higher incidence of monozygotic twinning following ART with the contribution coming from monochorionic diamniotic implantations.

Objective: To characterize incidence and pregnancy outcome for monozygotic twin pregnancies following IVF and to define chorionicity and amnionicity in this population. Design/Methods: This was a retrospective review of nearly 5000 pregnancies occurring in a large IVF center over an 8-year period. ART procedures were characterized and the incidence of monozygotic twinning was correlated with amnionicity, chorionicity, and ultimate pregnancy outcome. Results: 98 monozygotic twins were diagnosed and identified by first-trimester ultrasound evaluation. Eighty monozygotic twins occurred following fresh day 5 transfers and only 14 following day 3 transfers. There was no differing incidence of twinning, depending on whether or not ICSI was performed. The incidence of monoamniotic twinning was not increased over baseline, but monozygotic dichorionic twinning was. Conclusions: There is a higher incidence of monozygotic twinning following ART with the contribution coming from monochorionic diamniotic implantations. Risk factors are younger age and extended culture times, but not zona pellucida penetration or cryopreservation. Reviewer's Comments: This was a retrospective study of a large IVF population in which monozygotic twinning was examined. The reason for the increased incidence of monozygotic twinning with assisted reproductive techniques is unknown, but it is apparently associated with prolonged culture times and younger age. Monozygotic twinning confers a hazard to the pregnancy and in particular, a hazard when it is a monoamniotic twin pregnancy. Both patients and physicians should be aware of the increased incidence of monozygotic twinning with IVF, and also of the increased morbidity associated with this aberrant reproductive occurrence. (Reviewer-Berel Held, MD). © 2010, Oakstone Medical Publishing

Keywords: Monozygotic Twinning, IVF


Most Puerperal Morbidity Occurs Within 2 Weeks of Delivery

Emergency Department Use During the Postpartum Period: Implications for Current Management of the Puerperium.

Clark SL, Belfort MA, et al:

Am J Obstet Gynecol 2010; 203 (July): 38.e1-38.e6

Scheduling of the traditional 6-week postpartum visit does not correlate with the occurrence of puerperal morbidity, and an altered schedule of postpartum follow-up for patients to avoid excess emergency department visits is advisable.

Objective: To define cause of morbidity during the postpartum period in women who seek care in the emergency department (ED) within 42 and 100 days of discharge. Design/Methods: This was a chart review and retrospective examination of discharge diagnosis codes for ED visits occurring within a large inpatient health care delivery system in the United States. The authors also examined hospital readmissions following delivery over a 2-year period. Results: During 2007, 222,084 patients delivered in Hospital Corporation of America facilities were analyzed for ED visits subsequent to delivery. Within 6 weeks after delivery there were 10,751 visits for a prevalence of 4.8%. In total, 58% of patients were seen for conditions directly related to pregnancy. Half of patients who were seen in the ED or readmitted during both 2007 and 2008 had their initial encounter in the ED within 10 days of discharge. The most important conditions for ED visits included endometritis or wound infection, cholecystitis, headache, and mastitis. Conclusions: Scheduling of the traditional 6-week postpartum visit does not correlate with the occurrence of puerperal morbidity, and an altered schedule of postpartum follow-up for patients to avoid excess ED visits is advisable. Reviewer's Comments: This retrospective study of a large countrywide representative obstetric population shows patterns of postpartum morbidity, ED visits, and subsequent hospitalization. Our traditional 6-week postpartum follow-up examination does not address the real-world needs of patients postpartum and places excess stress on an already overburdened ED. The implications of this investigation offer opportunities for physicians to alter the postpartum follow-up of their obstetric patients and provide opportunity for redirecting large numbers of women away from ED care. (Reviewer-Berel Held, MD). © 2010, Oakstone Medical Publishing

Keywords: Emergency Department Visits, Post-Delivery, Puerperal Morbidity


MRSA Infections Are Decreasing in the Community

Health Care-Associated Invasive MRSA Infections, 2005-2008.

Kallen AJ, Mu Y, et al:

JAMA 2010; 304 (August 11): 641-648

Many invasive methicillin-resistant Staphylococcus aureus (MRSA) infections have onset outside of acute care hospitals. It is important that physicians’ offices and other ambulatory care facilities use preventive measures to maintain low rates of MRSA infection.

Objective: To study trends in associated methicillin-resistant Staphylococcus aureus (MRSA) infections occurring in invasive health care. Design: Population-based surveillance study. Participants: 21,503 cases of invasive MRSA infection. Methods: This database receives reports from a population base of approximately 15 million persons in 9 geographically diverse metropolitan areas. The intent is to monitor the incidence of MRSA infection. For purposes of this study, a case of invasive MRSA infection was defined as isolation of the MRSA organism from a normally sterile body site in a residence of the surveillance area. The microbiology reports provided by laboratories in acute care facilities and reference laboratories in the surveillance area were the source for the case identification. MRSA infections were classified as hospital onset if they occurred on or after hospital day 4. They were considered health care-associated community onset if MRSA was isolated ≤3 calendar days after admission, but with a history of recent exposure to health care. They were considered to be community-acquired MRSA if isolated ≤3 calendar days after hospital admission with no recent health care exposure documented. The focus of the evaluation was primary on health care-associated incidence rates, which were stratified by age, sex, rates by specific incidence, and rates by year and epidemiologic category. The authors used the population of the particular catchment area as the denominator for determining the change in incidence of invasive health care-associated MRSA infection and health care-associated MRSA blood stream infection. They used a hierarchal modeling method to estimate overall change in the MRSA infection for all sites from 2005 through 2008. Health care-associated infections accounted for 82% of total infections and were included in analysis. Results: There were 17,508 health care-associated infections among the 21,503 episodes of invasive MRSA infection that were identified from 2005 to 2008. Of the health care-associated MRSA infections, 15,458 were blood stream infections. This calculated to an incidence rate of MRSA infection in the hospital of 1.02 per 10,000 population. In 2005, the investigators observed a 9.4% decrease in MRSA infections over the study period. They observed that the most prominent decrease in MRSA invasive infection occurred in the subset of infections with blood stream infection. Conclusions: The rate of invasive health care-associated MRSA infections decreased both in associated infections that began in the community and in those that were associated with hospital-onset invasive disease. These decreases were noted in 9 diverse metropolitan areas over the study period. Reviewer's Comments: The implementation of preventive interventions for MRSA is apparently effective. Preventing the transmission of multidrug resistant organisms in health care facilities is a high priority for patient safety. (Reviewer-John C. Jennings, MD). © 2010, Oakstone Medical Publishing

Keywords: Infections, Health Care, MRSA


Is There a Relationship Between Antiviral Drugs and Birth Defects?

Use of Acyclovir, Valacyclovir, and Famciclovir in the First Trimester of Pregnancy and the Risk of Birth Defects.

Pasternak B, Hviid A:

JAMA 2010; 304 (August 25): 859-866

Acyclovir is the treatment of choice for herpes simplex in pregnancy primarily because it is the most extensively documented antiviral agent.

Objective: To determine if there is an association between the use of antiviral agents, acyclovir, valacyclovir, and famciclovir in the first trimester of pregnancy with a subsequent risk for major birth defects. Design: This is a population-based historical cohort study of 1804 pregnancies exposed to acyclovir, valacyclovir, and famciclovir in the first trimester of pregnancy. Methods: The Danish nationwide registry was used to perform a population-based cohort study involving all infants born alive between January 1, 1996, and September 30, 2008. The investigators analyzed individual level data linked to the registry to determine the association of dermatologic use of acyclovir, valacyclovir, and famciclovir to birth defects. The Danish Medical Birth Register records individual level information on all deliveries by women who live in Denmark. Antiviral drug exposure was identified by matching the Prescription Drug Register to determine utilization of antiviral drugs in pregnancy. The authors also used the National Patient Register to identify cases of birth defects. They obtained information on maternal diseases, drug exposures, and history of sexually transmitted diseases, diabetes, and immunodeficiency. For inclusion in the cohort, the subjects had no diagnosis of chromosomal aberrations, genetic syndromes, birth defect syndromes, or congenital viral infections. The data were analyzed to determine the prevalence odds ratios of any major birth defect that was diagnosed during the first year of life following exposure to an antiviral drug. Results: Acyclovir, valacyclovir, and famciclovir exposure occurred in 1804 pregnancies during the first trimester. Major birth defects were diagnosed in 40 (2.2%) infants who were exposed to the antivirals as compared to major birth defects at a rate of 2.4% in the non-exposed population. Acyclovir accounted for 32 major birth defects in 1561 infants receiving that drug for a rate of 2%. This compared to 7 infants with major birth defects among 229 infants receiving valacyclovir for a 3.1% rate. The exposure to famciclovir was so uncommon, with only 26 patients receiving the drug and only 1 infant diagnosed with a birth defect, that no conclusions could be reached relative to this particular antiviral. Conclusions: There is no association with increased risks of major birth defects with the exposure to acyclovir or valacyclovir in the first trimester of pregnancy. Reviewer's Comments: Of women who are susceptible to herpes simplex, >1% will acquire the infection during the first trimester of pregnancy. This study validates the relative safety of using antiviral treatment in the first trimester of pregnancy. (Reviewer-John C. Jennings, MD). © 2010, Oakstone Medical Publishing

Keywords: Antiviral Medication, Early Pregnancy, Risk of Birth Defects


Bariatric Surgery Has Positive Pregnancy Benefits

Reduced Incidence of Gestational Diabetes With Bariatric Surgery.

Burke AE, Bennett WL, et al:

J Am Coll Surgeons 2010; 211 (August): 169-175

Bariatric surgery is accompanied by post-surgical metabolic changes that can have adverse effects on pregnancy. For this reason, it has been recommended that pregnancy be delayed for as long as 2 years following bariatric surgery.

Objective: To study the association of bariatric surgery with the risk for gestational diabetes mellitus and its related complications. Design: Retrospective cohort study. Participants: 700 women undergoing bariatric surgery either before or after a pregnancy. Methods: The investigators used a private insurance claims database containing information on 23,594 women who had undergone bariatric surgery over the 4-year period between 2002 and 2006. They then matched this group to women who had codes within that same period of insurance coverage who had had both bariatric surgery and pregnancy that resulted in a delivery or a pregnancy loss of >22 weeks gestation. Those subjects who had a diagnosis of pre-existing diabetes were excluded from the cohort. They also excluded a code diagnosis of gestational diabetes if it was reported prior to 20 weeks, in order to avoid a misclassification of a pre-existing diabetic condition. The incidence of gestational diabetes mellitus was the primary outcome for the study, but there were 6 secondary outcomes, including cesarean section, macrosomia, shoulder dystocia, postpartum hemorrhage, intra- or postpartum infection, and fetal demise. Results: Bariatric surgery was performed after pregnancy in 346 women and before pregnancy in 354 women. There was a lower incidence of gestational diabetes in the women who had undergone bariatric surgery prior to their delivery (OR, 0.2; 95% CI, 0.15 to 0.36) when comparing this group to those women who underwent bariatric surgery following their pregnancy. In those women who were pregnant following bariatric surgery, 28% underwent cesarean section as compared to 43% of patients who had not undergone bariatric surgery. Conclusions: There is a decreased incidence of gestational diabetes mellitus and cesarean section in obese women who have undergone bariatric surgery. Reviewer's Comments: Obese women should be encouraged to reduce weight prior to pregnancy regardless of the method they use to do so. This retrospective study suggests that bariatric surgery is a reliable means of reducing weight in reproductive women with subsequent favorable consequences for pregnancy. (Reviewer-John C. Jennings, MD). © 2010, Oakstone Medical Publishing

Keywords: Bariatric Surgery, Diabetes


Risk of Obstetric Anal Sphincter Injury Has Increased

Trends in Risk Factors for Obstetric Anal Sphincter Injuries in Norway.

Baghestan E, Irgens LM, et al:

Obstet Gynecol 2010; 116 (July): 25-33

Anal sphincter injury parallels many other observed changes in obstetric and maternal care in recent years. The birth population is older, there is a more common usage of epidural anesthesia, and the use of instrumental delivery has changed.

Objective: To study risk factors that might contribute to obstetric anal sphincter injury. Design: Population-based cohort study of 1,673,442 births occurring between 1967 and 2004. Methods: The Medical Birth Registry of Norway was used to study the frequency and risk factors for obstetrical anal sphincter injury. The authors used independent variables of the year of delivery, either 1967 through 1976, 1977 through 1986, 1987 through 1996, or 1997 through 2004, and maternal age as <20, 20 to 24, 25 to 29, 30 to 34, 35 to 39, and ≥40 years. The effect of the previous vaginal birth was assessed by using the Variable Vaginal Birth Order based on the number of previous vaginal deliveries. The deliveries were grouped according to the history of vaginal birth or cesarean delivery: first vaginal delivery before previous cesarean delivery; first vaginal delivery after ≥1 previous cesarean deliveries; delivery after ≥1cesarean or vaginal deliveries; and delivery after ≥1 vaginal deliveries without previous cesarean delivery. Other independent variables evaluated included the mother's country of birth, presence of diabetes, smoking, and educational level. Also evaluated were the size of the maternity units, the presence of operative delivery, the presence of episiotomy, whether or not the patients were induced, birth weight, and head circumference. Odds ratios were used to determine the association of obstetric anal sphincter injuries with possible risk factors, with employment of a logistic regression analysis. Results: Obstetric anal sphincter injuries increased from a rate of 0.5% in 1967 to 4.1% in 2004. There was a persistent increase in sphincter injuries even after adjusting for obstetric factors, demographic factors, and other risk factors as possible confounders. The authors found a significant association of obstetric anal sphincter injury with maternal age ≥30 years, vaginal birth order of 1, a previous cesarean delivery, instrumental delivery, episiotomy, type 1 diabetes, gestational diabetes, induction of labor by prostaglandins, the size of the maternity unit, and a birth weight of ≥3500 g, or a head circumference ≥35 cm. Conclusions: From 1967 to 2004, there was a significant increase in the risk for obstetric anal sphincter injuries. This increase could not be accounted for by changes in the risk factors that were studied. Reviewer's Comments: This study is from the large Norwegian database, and it contains an enormous amount of information about both maternal and infant outcomes. Although there is not a firm explanation for the increased sphincter injuries, this observation could be due largely to just increased diagnostic attention and improved record keeping. (Reviewer-John C. Jennings, MD). © 2010, Oakstone Medical Publishing

Keywords: Obstetric Anal Sphincter Injuries, Risk Factors, Maternal Age


CVS Not Associated With Increased Risk of Hypertensive Disorder in Pregnancy

Chorionic Villus Sampling at 11 to 13 Weeks of Gestation and Hypertensive Disorders in Pregnancy.

Khalil A, Akolekar R, et al:

Obstet Gynecol 2010; 116 (August): 374-380

Performance of chorionic villus sampling between 11 and 14 weeks gestation is not associated with the development of hypertensive disorder in pregnancy.

Objective: To determine if there is an association between chorionic villus sampling (CVS) performed between 11 and 14 weeks gestation and subsequent development of a hypertensive disorder. Participants//Methods: This retrospective study was done over an approximate 3.5-year period. During this time, singleton pregnancies evaluated between 11 and 14 weeks gestation and continuing past 23 weeks were evaluated. Patients underwent first trimester screening with serum analyte assessment of free β-hCG and pregnancy-associated plasma protein-A (PAPP-A). Patients were divided into 2 groups; those undergoing CVS and those not having the procedure. Outcomes evaluated included the development of early preeclampsia, late preeclampsia, and gestational hypertension. Early preeclampsia was defined as <34 weeks gestation. Results: 2,278 patients were in the CVS group, and 28,860 were in the control group. In the control group, 0.3% of patients developed early preeclampsia compared to 0.4% in the CVS group. Late preeclampsia developed in 1.9% of the control group compared to 1.5% of the CVS group. Gestational hypertension was seen in 2.8% of the control group compared to 2.7% of the CVS group. When parity was considered, for a nulliparous patient, there was no difference with respect to development of early preeclampsia, late preeclampsia, or gestational hypertension between the control group and the CVS group. Multiparous patients also showed no difference in early preeclampsia, late preeclampsia, or gestational hypertension. Factors associated with development of early preeclampsia included ethnicity, maternal body mass index (BMI), chronic hypertension, assisted reproduction, family history of preeclampsia, PAPP-A level, and free β-hCG level. CVS, maternal age, tobacco use, and maternal diabetes were not associated with development of early preeclampsia. Ethnicity, maternal BMI, family history of preeclampsia, chronic hypertension, and PAPP-A levels were associated with the development of late preeclampsia. CVS, maternal age, maternal diabetes, tobacco use, and free β-hCG levels were not associated with the development of late preeclampsia. Significant factors for gestational hypertension included ethnicity, maternal age, increased BMI, family history of preeclampsia, tobacco use, assisted reproduction, and PAPP-A level, but again, CVS, chronic hypertension, maternal diabetes, and free β-hCG levels were not associated with the development of gestational hypertension. Conclusions: There is no association between the subsequent development of hypertensive disorders in pregnancy and the performance of CVS in the first trimester. Reviewer's Comments: One of the strengths of this study was the large unselected population that underwent screening. Also, multiple factors were included in assessing risk factors for development of preeclampsia; preeclampsia was divided into early and late preeclampsia, as well as gestational hypertension, which may have different pathophysiologies. Again, it does not appear that CVS is associated with the subsequent development of any hypertensive complication of pregnancy. (Reviewer-Thomas N. Tabb, MD). © 2010, Oakstone Medical Publishing

Keywords: Chorionic Villus Sampling, Hypertensive Disorder


Fetal MRI for Evaluation of Spina Bifida

Central Nervous System Findings on Fetal Magnetic Resonance Imaging and Outcomes in Children With Spina Bifida.

Chao TT, Dashe JS, et al:


The degree of cerebellar herniation in a fetus with spina bifida is associated with an increase in subsequent adverse outcomes.

Objective: To determine if there are specific MRI findings at time of fetal evaluation that would help in predicting neonatal outcomes. Design/Methods: This retrospective study was done over a 7-year period. Fetal spina bifida was evaluated by sonography and fetal MRI. MRI images were evaluated according to the degree of ventriculomegaly, the presence of subarachnoid space above the tentorium, and the degree of herniation of the cerebellum. Cerebellar herniation was determined according to the cervical spine level and classified as C2, C3, or C4. Infant outcomes included placement of ventriculoperitoneal shunt, dysphagia, seizure activity, ambulation status, and high-risk bladder dysfunction. The level of the spina bifida lesion was classified into 3 categories: T to L2, L3 to L4, or L5 to S1. Infant outcomes were evaluated according to the MRI findings. Results: 36 mother-infant pairs were included; 34 of the children (94%) required ventriculoperitoneal (VP) shunts. Five infants (14%) had subsequent seizures, and dysphagia was found in 12 children (33%). All 36 infants had neurogenic bladders, and 18 (50%) had high-risk bladder dysfunction. At age ≥3 years, 7 children (30%) ambulated independently, 7 (30%) ambulated with a device, and 9 (39%) required a wheelchair. In those with a ventricular size <10 mm, 60% required a VP shunt; there were no infants with seizures, 20% had dysphagia, 40% had high-risk bladder dysfunction, and 50% had independent ambulation. The degree of ventriculomegaly was only associated with a need for ventricular shunt placement and not with the other outcomes. With respect to extra-axial space effacement, the degree of effacement was associated with the need for shunt placement and not with any of the other outcomes. As the degree of herniation increased, so did shunt requirement, seizure activity, and high-risk bladder dysfunction. When the herniation was at C2, 100% required shunts; 7% had seizures, 27% had dysphagia, 33% had high-risk bladder dysfunction, and 30% ambulated independently. With herniation at C3, 100% required shunts, and 21% had seizures, 43% had dysphagia, 71% had high-risk bladder dysfunction, and none ambulated independently. At C4, 100% required shunts; 100% had seizures, none had dysphagia, and 100% had high-risk bladder dysfunction, and there was no independent ambulation. Conclusions: In fetuses with spina bifida, the degree of cerebellar herniation was associated with an increase in seizure activity, high-risk bladder dysfunction, and an inability to ambulate independently. Reviewer's Comments: Whether the degree of cerebellar herniation can be determined sonographically has not been determined. It would be important to know if the MRI findings could be used to assess subsequent cognitive outcomes. (Reviewer-Thomas N. Tabb, MD). © 2010, Oakstone Medical Publishing

Keywords: Spina Bifida, Fetal MRI, Outcome


Subchorionic Hemorrhage Increases Risk of Placental Abruption, Preterm Delivery

Ultrasound-Detected Subchorionic Hemorrhage and the Obstetric Implications.

Norman SM, Odibo AO, et al:


A subchorionic hemorrhage occurring in the second trimester is associated with an increased risk of both preterm delivery and placental abruption.

Objective: To determine if there is an association between sonographically detected subchorionic hemorrhage and adverse perinatal outcomes. Design: Retrospective study done over a 14-year period. Methods: During this time, patients undergoing sonographic evaluation between 17 and 22 weeks gestation were evaluated. These pregnancies were divided into 2 groups of those with a subchorionic hemorrhage present and those without. A subchorionic hemorrhage was defined as a retroplacental hypoechoic region of any size or any location. The primary outcomes were placental abruption, intrauterine growth restriction, and intrauterine fetal death after 20 weeks gestation. Secondary outcomes included preeclampsia (mild and sever), preterm premature rupture of membranes (PROM), and preterm delivery before 37 weeks gestation and before 34 weeks gestation. Results: 63,966 patients were evaluated; 1081 patients were in the subchorionic hemorrhage group and 62,885 patients were in hemorrhage-absent group. In the subchorionic hemorrhage group, the risk of abruption was 3.6% compared to 0.6% in the hemorrhage-absent group. There was also increased risk of placental abruption in the subchorionic hemorrhage group, regardless of there being bleeding prior to the sonographic evaluation or if the subchorionic hemorrhage was only an incidental finding. Preterm delivery before 37 weeks gestation was seen in 15.5% of the hemorrhage group compared to 10.5% of those without hemorrhage. Preterm delivery before 34 weeks gestation was seen in 5.3% of the hemorrhage group compared to 2.8% of the hemorrhage-absent group. Preterm delivery prior to 34 and 37 weeks gestation continued to be significant in the subchorionic hemorrhage group even after cases of abruption were excluded. Subchorionic hemorrhage was not associated with PROM, intrauterine fetal death, or preeclampsia when compared to the group without hemorrhage. Conclusions: A subchorionic hemorrhage detected at a second trimester ultrasound is associated with an increased risk of placental abruption and preterm delivery. Reviewer's Comments: This study is significant for the finding of an association between sonographic detection of subchorionic hemorrhage and placental abruption and preterm delivery although no preventive measure is available for these outcomes. Patients found to have a subchorionic hemorrhage should be counseled on not only the signs and symptoms of placental abruption, but also that of preterm labor. (Reviewer-Thomas N. Tabb, MD). © 2010, Oakstone Medical Publishing

Keywords: Subchorionic Hemorrhage, Placental Abruption, Preterm Delivery


Subsequent Outcomes of MCDA Twins Discussed

Contemporary Management of Monochorionic Diamniotic Twins: Outcomes and Delivery Recommendations Revisited.

Smith NA, Wilkins-Haug L, et al:

Am J Obstet Gynecol 2010; 203 (August): 133.e1-133.e6

Uncomplicated monochorionic diamniotic twins have a low risk of intrauterine fetal demise or preterm delivery.

Objective: To determine the outcomes of monochorionic diamniotic (MCDA) twins according to their specific pregnancy complications. Methods: This retrospective study was done over an 8-year period. Patients with MCDA twin gestations at ≥14 weeks gestation were evaluated. Pregnancy outcomes evaluated were gestational age at delivery, birth weight, and neonatal survival. Obstetric complications were also evaluated as were neonatal outcomes. Twin gestations were divided into 1 of 3 groups: those with twin-twin transfusion syndrome (TTTS); those with severe growth discordance; and those that were uncomplicated. A 25% difference in birth weights without the presence of TTTS was considered severe growth discordance. Results: 322 pregnancies at 24 weeks gestation had complete information and were included. Of those, 13 had a single intrauterine fetal demise (IUFD) at <24 weeks. Therefore, at 24 weeks, there were 309 ongoing twin gestations. Of these, there were 5 single IUFDs and 2 double IUFDs. This left a total of 302 pregnancies that resulted in 2 liveborn infants. The risk of an IUFD from 24 weeks onward was 2.3%, and from 32 weeks onward, the risk was 1.6% if the entire group was evaluated. At 24 weeks’ gestation, 234 (68%) pregnancies were uncomplicated. After 24 weeks’ gestation, the risk of IUFD in the uncomplicated group was 1.3%. Fifty-nine percent of patients delivered prior to 37 weeks’ gestation. In the TTTS group, the mean gestational age at delivery was 32 weeks, in the growth discordant group, 33 weeks, and in the uncomplicated group, 35 weeks. In the uncomplicated twin group, 14% delivered at <32 weeks’ gestation and 49% delivered >37 weeks’ gestation. In the TTTS group, 59% delivered <32 weeks’ gestation and 13% delivered at term. In the severe discordance group, 31% delivered <32 weeks’ gestation, and 17% delivered at term. Fifty-two percent of the pregnancies that had either a single or double loss were complicated by TTTS. Overall, the rate of pregnancy loss prior to 24 weeks’ gestation was 17% in the TTTS group and 3% in the other groups. In most cases, neonatal death was the result of complications from prematurity. Conclusions: MCDA twin gestations complicated by either TTTS or severe growth discordance are more likely to result in IUFD or preterm delivery. In MCDA twin gestations, the risk of either preterm delivery or intrauterine fetal demise is low in an uncomplicated group and does not justify early preterm delivery. Reviewer's Comments: Patients with MCDA having either TTTS or severe growth discordance are typically delivered preterm secondary to pregnancy complications; however, in the uncomplicated group of MCDA twins, there is no indication for a delivery prior to 36 to 37 weeks gestation secondary to an extremely low fetal loss rate. (Reviewer-Thomas N. Tabb, MD). © 2010, Oakstone Medical Publishing

Keywords: Twin Gestation, Monochorionic Diamniotic, Outcomes


How Does Sleep Deprivation Alter Glucose Metabolism?

A Single Night of Partial Sleep Deprivation Induces Insulin Resistance in Multiple Metabolic Pathways in Healthy Subjects.

Donga E, van Dijk M, et al:

J Clin Endocrinol Metab 2010; 95 (June): 2963-2968

Sleep deprivation, even for 1 night, adversely reduces insulin sensitivity.

Background: Epidemiological and experimental studies have been carried out on the role of sleep in the homeostasis of normal glucose metabolism. Both kinds of studies have shown impaired glucose tolerance in individuals with sleep restrictions. While these studies have looked at sleep deprivation over ≥2 nights, the effects of even 1 night of partial sleep restriction on insulin sensitivity have not been studied. Objective: To evaluate a single night of partial sleep deprivation on glucose tolerance and insulin sensitivity. Participants/Methods: 9 healthy volunteers (4 women and 5 men; mean age, 44.5 years) were studied in a laboratory setting following a normal night's sleep and once after a night of 4 hours of sleep. Sleep characteristics and insulin sensitivity were measured by a variety of means. Results: Partial sleep restriction did not affect basal levels of glucose, insulin, or endogenous glucose production, but did reduce insulin sensitivity by 19% to 25%. Conclusions: Partial sleep deprivation, even just a single night's restriction, induces insulin resistance via multiple metabolic pathways in healthy individuals. Reviewer's Comments: This laboratory experiment emphasizes that sleep plays a key role in normal glucose metabolism. Glucose utilization is highest during wakefulness and lowest during rapid eye movement sleep. Sleep deprivation alters these patterns and thus alters insulin sensitivity. Sleep duration has shortened in our Western “always on the go” society over the past decade coincidental with an increased prevalence of insulin resistance and diabetes. Sleep deprivation does not cause type II diabetes, but it certainly is a factor that contributes to glucose intolerance and reduced insulin resistance even after a single bad night's sleep. (Reviewer-Berel Held, MD). © 2010, Oakstone Medical Publishing

Keywords: Sleep Deprivation, Insulin Resistance, Metabolic Pathways


Vitamin D Has Tenuous Link to Ovarian Cancer

A Systematic Literature Review of Vitamin D and Ovarian Cancer.

Cook LS, Neilson HK, et al:

Am J Obstet Gynecol 2010; 203 (July): 70.e1-70.e8

Vitamin D levels and the risk of ovarian cancer are poorly correlated.

Objective: To assess evidence supporting the protective effect of vitamin D exposure to ovarian cancer occurrence. Methods: 10 electronic databases were plumbed as well as select governmental websites reviewing relevant articles published in the English and French literature. Results: Following data analysis, the studies were summarized via tables and written descriptions. Among the cohort studies, no overall reduction in risk to ovarian cancer was noted with increasing dietary or supplemental consumption of vitamin D or with plasma levels of vitamin D. In one-half of the case control and ecologic studies, reductions in mortality from ovarian cancer with increasing solar radiation levels, dietary or supplemental consumption of vitamin D, or geographic latitude were noted. In the other half, no associations were noted. Conclusions: Despite various claims in the literature purporting a relationship between vitamin D levels and ovarian cancer, there is no consistent or compelling evidence that supplemental vitamin D can alter the incidence of ovarian cancer. Reviewer's Comments: There is a theoretic reason for associating vitamin D levels with ovarian cancer incidence. 1,25-dihydroxyvitamin D is found in human ovarian tumor specimens and cell lines. Dihydroxyvitamin D has been shown to inhibit cell proliferation in ovarian cancer cell lines and induce apoptosis. There has also been some anecdotal evidence of a relationship between vitamin D levels and ovarian cancer. It would be nice if taking a vitamin pill could reduce the risk of ovarian cancer, but rigorous epidemiologic studies to date just have not shown this to be so, as this current literature review demonstrates. (Reviewer-Berel Held, MD). © 2010, Oakstone Medical Publishing

Keywords: Vitamin D, Ovarian Cancer


Surgery May Negatively Impact Attention, Concentration in Some Elderly Patients

Does Mild Cognitive Impairment Increase the Risk of Developing Postoperative Cognitive Dysfunction?

Bekker A, Lee C, et al:

Am J Surg 2010; 199 (June): 782-788

Following surgery, cognitive dysfunction may be accelerated in elderly patients with pre-existing mild cognitive impairment.

Background: With the advances in surgical techniques and anesthetic care, patients with multiple medical problems are undergoing more complex surgical procedures at a later age. There has been increased recognition that central nervous system dysfunction is complication following cardiac and noncardiac surgery in elderly patients. While postoperative cognitive dysfunction is transient in most cases, cognitive decline is permanent in some older patients. The term mild cognitive impairment (MCI) is now used to describe the intermediate state between normal aging and dementia. Objective: To determine if patients with MCI have accelerated progression of dementia following surgery and anesthesia. Participants/Methods: 169 patients met inclusion criteria; of these, 48 had MCI based on at least 2 neuropsychiatric assessments. Fourteen of the 48 patients had surgery between their evaluations. There were 121 normal control subjects who had 2 assessments, 50 of whom had surgery between evaluations. In all of these patients, cognitive performance was able to be compared both pre- and postoperatively. Results: Analysis of the data suggested that surgery may negatively impact auditory working memory, attention, and concentration in patients with MCI, but not in normal individuals. There were no other statistically significant differences in performance with other cognitive tests. Conclusions: Surgery and anesthesia, based on this retrospective study, negatively impacts attention concentration in patients with pre-existing MCI, but not in normal individuals. Reviewer's Comments: Postoperative cognitive dysfunction is a recognized complication following surgery in the elderly, and is related to a number of factors, not the least of which is surgical procedure, duration of anesthesia, and postoperative morbidity. However, this study suggests that individuals already mildly cognitively impaired may be at risk for accelerated progression to dementia based on postoperative cognitive studies. The specific deficits identified in this study are related to memory, attention, and concentration. (Reviewer-Berel Held, MD). © 2010, Oakstone Medical Publishing

Keywords: Postoperative Cognitive Impairment, Risks


Menstrual Cycle Affects HPV Detection

Effect of the Menstrual Cycle and Hormonal Contraceptives on Human Papillomavirus Detection in Young, Unscreened

Women.

Schmeink CE, Massuger LF, et al:

Obstet Gynecol 2010; 116 (July): 67-75

Changes in mucosal immunity during the natural menstrual cycle can explain the fluctuation in high-risk human papillomavirus detection. In an ovulatory cycle, mucosal immunity reaches its lowest level around ovulation.

Objective: To study the prevalence, incidence, and persistence of human papillomavirus (HPV) as it relates to the menstrual cycle and oral contraceptive pill (OCP) use. Design: One-year prospective longitudinal study. Participants: 2065 women unscreened for HPV. Methods: 2065 unscreened women (age range, 18 to 29 years) were recruited between 2007 and 2008 for participation in the study. After excluding women who were pregnant, vaccinated against HPV, or lost to follow-up, the final number of subjects for analysis was 1812. The subjects received a self-collected sample kit that contained an explanatory letter on how to perform a cervical vaginal sample. They also answered a questionnaire that included demographic information and questions on sexual behavior, OCP use, and menstrual history. Broad-spectrum HPV-DNA amplification was performed by short polymerase chain reaction. HPV testing was performed at baseline, at 6 months, and at 12 months. The investigators compared the demographics and sexual behavior between OCP users and nonusers. The timing of the sample was classified into the first half of the menstrual cycle (days 1 to 14) and the second half of the menstrual cycle (days 15 to 28). Results: At the time of entry into the study, there was an 8.9% rate of low-risk HPV detection and an 11.8% rate of high-risk HPV detection. The annual incidence of low-risk HPV infections was 12.5% during the 1-year study, with a 2.0% rate of persistence. The incidence of high-risk HPV during the 1-year study was 12.1%, with a 4.5% persistence rate. No difference in the incidence rate of HPV or the persistence rate was observed between OCP users and nonusers. When the OCP users and nonusers were analyzed separately, there was a significant relationship between high-risk HPV detection and the timing of the sample. In OCP nonusers, high-risk HPV detection decreased in the second half of the menstrual cycle, while detection increased in the second half for patients using OCPs. Conclusions: The timing of the menstrual cycle influences the detection of high-risk HPV. Reviewer's Comments: This study used a self sampling kit that has been shown to be comparable to physician-taken samples. HPV sampling is becoming a primary screening tool for cervical cancer. Information from this study suggests that it is best to sample for HPV in the first half of the cycle for nonusers of OCPs and during the second half of the cycle for oral OCP users. (Reviewer-John C. Jennings, MD). © 2010, Oakstone Medical Publishing

Keywords: Menstrual Cycles, Hormonal Contraceptives, HPV Detection


Partner Violence Requires Effective Intervention

Effect of an Advocacy Intervention on Mental Health in Chinese Women Survivors of Intimate Partner Violence. A

Randomized Controlled Trial.

Tiwari A, Fong DYT, et al:

JAMA 2010; 304 (August 4): 536-543

Women who are subjected to partner abuse often have other factors such as financial problems, unemployment, lack of education, or other factors that contribute to a continuing depression.

Objective: To study the effects of advocacy intervention on depressive symptoms in Chinese women who are survivors of intimate partner violence. Design: Assessor-blinded, randomized, controlled trial. Participants: 200 Chinese women aged ≥18 years with a history of intimate partner violence. Methods: Over a period from February 2007 to June 2009, subjects in community center outreach programs who were positive for intimate partner violence on screening were identified. The advocacy program comprising the intervention of the study consisted of 2 components of empowerment and telephone social support. The program intended to link subjects to community services providing ongoing support, informal counseling, or both. The empowerment component of the intervention included enhanced choice making and problem solving. The social support component included a 24-hour access to hotline for study participants and 12 scheduled weekly telephone calls by a designated research assistant. Of the 200 subjects, 100 were assigned to the intervention group and 100 were assigned to a control group receiving the usual community services (including child care, health care, and promotion and recreational programs). A change in depressive symptoms was considered to be the primary outcome as documented by the Chinese version of the Beck Depression Inventory II. The authors also used the Health Related Quality of Life Assessment (a 12-Item Short Form Health Survey) and the Interpersonal Support Evaluation List. The success of the intervention compared to the usual community services was evaluated at 9 months. Results: The depressive symptoms score had a mean change of 11.6 in the control group and 14.9 in the intervention group at the 3-month interval. There was a significant reduction of depressive symptoms in the intervention group versus the control group at 3 and 9 months. This was less than the 5-unit minimum that was considered clinically important. More women in the intervention group believed that the social advocacy intervention was useful in improving intimate relations versus the control group using community services only. Conclusions: There was no clinically meaningful improvement in depressive symptoms in community-dwelling abused Chinese women using an advocacy intervention versus a group that used the usual community services only. Reviewer's Comments: This study uses proven tools to assess clinical improvement in depressive symptoms. It demonstrates that the depressive symptoms associated with intimate partner violence require more than empowerment and social support. Physical violence against women crosses cultural lines and, in that respect, this Chinese study, can be applicable to a U.S. population. (Reviewer-John C. Jennings, MD). © 2010, Oakstone Medical Publishing

Keywords: Mental Health Intervention, Partner Violence


Is Esophageal Cancer Related to Bisphosphonates?

Exposure to Oral Bisphosphonates and Risk of Esophageal Cancer.

Cardwell CR, Abnet CC, et al:

JAMA 2010; 304 (August 11): 657-663

There is a well-documented association of gastroesophageal reflux disease with esophageal cancer. Esophagitis is associated with bisphosphonates and is apparently different than reflux esophagitis in both the pathologic mechanism and the duration of exposure.

Objective: To study the possible association of bisphosphonate therapy with esophageal cancer. Design: This was a retrospective, cohort study with controls. Participants: 46,036 oral bisphosphonate users and 46,036 matched controls. Methods: The U.K. General Practice Research Database was used to extract data with the intent of comparing the rates of esophageal and gastric cancer in patients treated with oral bisphosphonates versus matched controls. The initial bisphosphonate cohort was established by identifying all patients receiving a prescription for oral bisphosphonates over the period from January 1, 1996, to December 31, 2006. Esophageal cancers were identified from the relevant Read/Oxford Medical Information System codes in the patient's clinical files within the database. The date of the first recorded esophageal or gastric cancer code was considered the date of diagnosis. The investigators used a defined daily dose as the assumed average maintenance level per day of a drug use for its main indication in adults. The investigators used the defined daily dose and the number of the days of follow-up to determine categorization of high, medium, and low usage of the bisphosphonates. The data were then analyzed to determine the hazard ratio for the risk of esophageal and gastric cancer in bisphosphonates users compared to bisphosphonate non-users. Results: After excluding patients who were followed for <6 months, there were 41,826 persons in each of the 2 cohorts. Eighty-one percent of these subjects were women, and the mean age of the cohort was 70 years, with a standard deviation of 11.4 years. Subjects were followed up for a mean of 4.5 years in the bisphosphonate user group versus 4.4 years in the non-user group. There were 116 esophageal or gastric cancers identified in the bisphosphonate cohort and 115 in the control cohort. Of these, 70 and 79 esophageal cancers were identified in the user versus non-user cohorts, respectively. The combined incidence of esophageal and gastric cancer was 0.7 per 1000 person-years of risk in both the bisphosphonate cohort and the control cohort. For esophageal cancer alone, bisphosphonate users had a risk of 0.48 per 1000 person-years versus 0.44 per 1000 person-years for non-users. There was no difference between the cohorts in the risk of esophageal or gastric cancer. The duration of use of bisphosphonates did not affect the risk of either esophageal or gastric cancer. Conclusions: There is no significant association with the use of oral bisphosphonates and the incidence of esophageal or gastric cancer. Reviewer's Comments: Patients with severe gastroesophageal reflux disease (GERD) are less likely to use bisphosphonates since the severity and duration of GERD are related to the incidence of esophageal cancer. This study does not have the ability to address a relationship in this subset of GERD patients. (Reviewer-John C. Jennings, MD). © 2010, Oakstone Medical Publishing

Keywords: Bisphosphonates, Esophageal Cancer


Respiratory Morbidity Common in Late Preterm Births

Respiratory Morbidity in Late Preterm Births.

Consortium on Safe Labor:

JAMA 2010; 304 (July 28): 419-425

The odds of respiratory distress syndrome are increased by 40-fold at 34 weeks’ gestation versus term birth. The risk of respiratory distress syndrome decreases each week until 38 weeks of gestation.

Objective: To study a cohort of late preterm births to determine the short-term respiratory morbidity. Design: This is a retrospective review of a large electronic database involving 19,334 late preterm births and 165,993 term births. Methods: Data were collected through the Consortium on Safe Labor over a period between 2002 and 2008 relative to births in 12 clinical centers. The Consortium was designed to represent all geographic areas of the country, and the authors contributed to this validated and comprehensive database. Information collection included demographics, prenatal complications, labor and delivery information, maternal and neonatal outcomes, and data from neonatal intensive care units (NICU). Late preterm birth was defined as delivery between 34 weeks and 36 6/7 weeks. Term birth was defined as 37 weeks to 40 6/7 weeks. Neonates who were delivered from 34 weeks to 40 6/7 weeks’ gestation requiring intervention with oxygen or ventilation and admission to the NICU for respiratory support were included. Comparisons were then made between the late preterm group and the term group in regard to resuscitation, respiratory support, and respiratory diagnosis. The outcome measures for the study included respiratory distress syndrome, transient tachypnea of the newborn, pneumonia, respiratory failure, and ventilator support. Results: There were 7055 admissions to the NICU, with a total of 19,334 late preterm births at a rate of 36.5%. Of these admissions, 2032 infants were diagnosed with respiratory compromise. This compared to an admission rate of 7.2% to the NICU among 165,993 term infants. Of the 11,980 term infants admitted to the NICU, 1874 were diagnosed with respiratory morbidity. At 34 weeks’ gestation, 10.5% of the infants were diagnosed with respiratory distress syndrome compared to 0.3% at 38 weeks’ gestation. Transient tachypnea occurred in 6.4% of the late preterm infants versus 0.4% at 38 weeks’ gestation. Pneumonia, respiratory failure, and standard oscillatory ventilator support had similar patterns. There was a decrease in the odds ratio for respiratory arrest from 40.1 at 34 weeks to 1.1 at 38 weeks. At 37 weeks, the odds ratio for respiratory distress syndrome was 3.1. There was no difference in the odds ratio at 38 weeks compared to 39 and 40 weeks. Conclusions: There is a well-documented increased risk of respiratory distress syndrome in late preterm birth infants compared to term delivery infants. Reviewer's Comments: This study is from a large database and controls for multiple factors. (Reviewer-John C. Jennings, MD). © 2010, Oakstone Medical Publishing

Keywords: Respiratory Morbidity, Late Preterm Births


Recurrence Risk of Stillbirth Is Low in Second Pregnancy

Recurrence Risk of Stillbirth in a Second Pregnancy.

Bhattacharya S, Prescott GJ, et al:

Br J Obstet Gynecol 2010; 117 (September): 1243-1247

Although the risk of recurrent stillbirth is low, it is still increased over patients with no history of a stillbirth.

Objective: To determine the risk of stillbirth in a subsequent pregnancy. Design: Retrospective cohort study done over approximately a 20-year period. Methods: Data were collected from the Scottish morbidity records for evaluation. Two groups of patients were evaluated. The first group involved those who had a previous live birth infant, and the second involved those who had a previous stillbirth infant. Obstetric complications evaluated for both the first and second pregnancies were placental abruption, pre-eclampsia, preterm delivery <37 weeks’ gestation, placental previa, postterm delivery >42 weeks’ gestation, cesarean delivery, low birth weight, and labor induction. The primary outcome was the risk of recurrent stillbirth. Results: 300,627 patients were in the previous live birth group, and 2677 patients were in the previous stillbirth group. Compared to patients having an initial live birth, pre-eclampsia was actually less common in the stillbirth in the first pregnancy but was more common in the second pregnancy. In the stillbirth group, placental abruption was more common in the first pregnancy. A stillbirth in the second pregnancy occurred in 0.4% of those having a previous live birth infant compared to 1.9% of those having a previous stillbirth. Overall, when considering other confounding factors, the odds ratio for a recurrence of stillbirth in the second pregnancy was 1.94 compared to those having a livebirth in the first pregnancy. Factors found to be associated with recurrent stillbirth in a subsequent pregnancy included preterm delivery (OR, 7.45), low birth weight (OR, 6.69), and placental abruption (OR, 1.96). The occurrence of pre-eclampsia in the second pregnancy appeared to actually decrease the risk of recurrent stillbirth in the second pregnancy. Conclusions: In a first pregnancy complicated by a stillbirth, there is an increased risk of recurrence in a second pregnancy. Reviewer's Comments: One limitation of this study is the lack of information regarding the cause of stillbirth in the first pregnancy. Although the overall risk of stillbirth in a subsequent pregnancy is low, it is still increased. Again, data regarding the cause of stillbirth in the index pregnancy were not provided in this study, which would have been helpful with respect to recurrence risk. (Reviewer-Thomas N. Tabb, MD). © 2010, Oakstone Medical Publishing

Keywords: Stillbirth, Recurrence Risk, Second Pregnancy


Isolated Microcephaly -- What Exactly Does This Mean?

Developmental Outcome of Isolated Fetal Microcephaly.

Stoler-Poria S, Lev D, et al:

Ultrasound Obstet Gynecol 2010; 36 (August): 154-158

There is no increased risk for abnormal neurodevelopment in an infant who has a prenatally detected head circumference between -2 and -3 standard deviations.

Objective: To determine the neurodevelopmental outcome of infants prenatally diagnosed with isolated microcephaly defined as a head circumference greater than or equal to -2 standard deviations (SD) below the mean. Design: Retrospective study done over a 4-year period. Participants/Methods: Infants were included if they had a fetal head circumference of greater than -2 SD below the mean. All infants underwent physical examination, neurodevelopmental evaluation, and behavioral and emotional evaluation. Infants were evaluated between 2 and 6 years of age. A control group of patients who were normocephalic were also included. Twenty patients were in the microcephaly group, and 20 were in the normal group. For the infants in the microcephaly group, all prenatal diagnoses were made in the third trimester. Results: All prenatally determined head circumferences were between -2 and -4.8 SD below the mean, with only one having a head circumference below -3 SD. Forty-five percent of the infants had symmetrical growth restriction, and 55% had a small head but normal weight. There was no difference between groups with respect to cognitive function, language, and motor function. There was, however, a difference with respect to behavioral issues. The study group had an increase in the rate of behavioral problems and emotional issues, as well as anxiety and depression. There was no difference between these 2 groups with either cognitive function or language functioning. Among the infants in the study group, 25% had at least 1 parent with a small head circumference. This did not result in any significant difference between these infants and those with parents with a normal head circumference. Only 2 of the 20 infants at birth were found to have a head circumference less than -2 SD. Three infants were microcephalic at the time of neurological evaluation—a significant discrepancy from prenatally detected microcephaly. Conclusions: A prenatally detected head circumference between -2 and -3 SD below the mean does not place the infant at increased risk for future abnormal neurodevelopment. Reviewer's Comments: It appears that the term “fetal microcephaly” should be used only when the head circumference is less than -3 SD below the mean. Also, a head circumference between -2 and -3 SD detected in utero will most likely be normocephalic at birth. (Reviewer-Thomas N. Tabb, MD). © 2010, Oakstone Medical Publishing

Keywords: Head Circumference, Microcephaly, Abnormal Neuro Development


Isolated Macrocephaly Not Risk Factor for Adverse Neurodevelopmental Outcome

Developmental Outcome of Isolated Fetal Macrocephaly.

Biran-Gol Y, Malinger G, et al:

Ultrasound Obstet Gynecol 2010; 36 (August): 147-153

In utero detection of macrocephaly does not place the infant at increased risk for long-term adverse neurodevelopmental outcomes.

Objective: To determine the neurodevelopmental outcome of infants who had a prenatal sonographic diagnosis of isolated macrocephaly. Design: Retrospective study done over a 9-year period. Methods: The authors defined macrocephaly as a head circumference (HC) >2 standard deviations (SD) for a specific gestational age. Patients were excluded from the study if there were other associated anomalies. Seventeen patients were in the macrocephaly group, and 17 patients were in the control group who were normocephalic. Patients were divided into subgroups according to their age. The first was 24 to 42 months old and second was 43 to 84 months old. All patients underwent neuropsychological evaluation as well as a detailed physical and neurologic examination. A standard battery of neuropsychological tests was given between 2 and 7 years of age. HC was determined at birth as well as that the time of neurodevelopmental assessment. Parental HC was also obtained. Neurodevelopmental outcomes were determined in each group for comparison. Results: Among the 17 infants in the study group, 11 (64.7%) had macrocephaly at birth, 7 (41.2%) had macrocephaly at 18 months, and 6 (35.2%) had macrocephaly at the time of developmental assessment. Eight fathers and 2 mothers were also noted to have a large HC. Neither the neurologic examinations nor the physical examinations differed between the study group and the control group. Neither cognitive language nor motor function was different between the 2 groups. There was a difference, however, in 3 study parameters reflecting executive functioning as well as behavioral and emotional development. These were found to be worse in the study group. Eight of the 17 infants of the study group had familial macrocephaly. For an infant with a familial macrocephaly, the executive functioning was better than in those with nonfamilial macrocephaly. Conclusions: Isolated macrocephaly detected in utero should not be considered a significant risk factor for long-term adverse neurodevelopmental outcome. Reviewer's Comments: It appears that isolated macrocephaly, defined as an HC >2 SD from the mean, is not associated with any significant abnormal long-term neurodevelopmental outcomes. However, familial macrocephaly does appear to be associated with better cognitive functioning. (Reviewer-Thomas N. Tabb, MD). © 2010, Oakstone Medical Publishing

Keywords: Macrocephaly, Neurodevelopmental Outcome


Placental Abruption Increased With Thyroid Peroxidase Antibodies

Pregnancy Outcomes in Women With Thyroid Peroxidase Antibodies.

Abbassi-Ghanavati M, Casey BM, et al:


There is a 3-fold increase in placental abruption in patients with thyroid peroxidase antibodies.

Objective: To determine the prevalence of thyroid peroxidase antibodies in women obtaining routine prenatal care and to determine if there are any adverse pregnancy outcomes associated with the presence of thyroid peroxidase antibodies. Design: Retrospective study done over a 2.5-year period. Methods: Patients presenting for routine obstetric care had blood obtained for serum thyrotropin (TSH), free thyroxine (T4), and thyroid peroxidase antibodies. Patients with an elevated TSH level, but a normal free T4 were considered as having clinical hyperthyroidism. Women with normal TSH levels but low free T4 levels were considered as having maternal hypothyroxinemia. Patients were divided into 2 groups; those who were thyroid peroxidase antibody-positive and those who were thyroid peroxidase antibody-negative. Perinatal outcomes were assessed and compared between the 2 groups. These outcomes included hypertensive disorders, diabetes, gestational age at delivery, preterm premature rupture of membranes (PPROM), placental abruption, and mode of delivery. Neonatal outcomes were also assessed. Results: 17,219 patients who were entered into the study; 1012 (6%) were in the antibody-positive group, and 16,207 were in the antibody-negative group. The incidence of thyroid peroxidase antibodies in patients who were overtly hyperthyroid was 61%, while those with isolated maternal hypothyroxinemia had an incidence of 5%, and those with subclinical hypothyroidism had an incidence of 31%. No difference in the incidence of diabetes, hypertensive disorders, PPROM, preterm delivery, and cesarean section rate were noted between the 2 groups. However, the incidence of placental abruption was different occuring in 1% of the antibody-positive group compared to 0.3% of the antibody-negative group (OR, 3.4). Neonatal outcomes were also no different between the 2 groups. Even when only considering euthyroid women who were thyroid peroxidase antibody-positive, there still was a 4-fold increase in the rate of placental abruption compared to the antibody-negative group that was euthyroid. Conclusions: The prevalence of thyroid peroxidase antibodies are seen in 6% of the general population presenting for prenatal care, and are associated with a 3-fold increase in placental abruption compared to thyroid peroxidase antibody-negative patients. Reviewer's Comments: It appears that approximately 6% of the obstetric population has thyroid peroxidase antibodies. Most adverse perinatal outcomes did not seem to be increased in this group; however, there was an increased risk of placental abruption. It was also interesting that the serum TSH and free T4 levels did not influence the rate of adverse outcomes. At present, although placental abruption was found to be increased in this group, there is no mechanism available to decrease this risk of abruption. Until a preventable risk factor is identified, routine assessment of antithyroid peroxidase antibodies is not recommended. (Reviewer-Thomas N. Tabb, MD). © 2010, Oakstone Medical Publishing

Keywords: Thyroid Peroxidase Antibodies, Placental Abruption


laparoscopic pelvic lymphadenectomy during pregnancy is

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