Fetal and neonatal cytopenias: what have we learned?

Rh disease has largely disappeared as a result of prophylaxis with anti-D. However, the cases that remain are more complicated with a combination of novel challenges with regard to in utero management with transfusion and its effects on the course of the neonate, both early and late. Thrombocytopenia in the neonate can be severe and recurrent if it is a result of alloimmunization. Newer techniques in the laboratory have improved the security of diagnosis. Antenatal management of affected fetuses with treatment administered to the mother is now well established although studies are ongoing. Neutropenia is a complication of pre-eclampsia; the mechanism is still not well understood.     

Neonatal management and outcome in complicated monochorionic twins: What have we learned in the past decade and what should you know?

Monochorionic (MC) twin pregnancies are at increased risk of neonatal morbidity and mortality due to the shared placenta with vascular connections that can give rise to various complications, including twin-twin transfusion syndrome, twin anemia polycythemia sequence (TAPS), selective fetal growth restriction, and other hematological imbalances at birth. Each complication presents its own challenges and considerations in the neonatal period. Measurement of hemoglobin levels and reticulocyte count is required to establish a correct diagnosis. Placenta dye injection is needed to properly distinguish between the various conditions. Risk factors for adverse outcome in MC twins include prematurity, severe cerebral injury, and the type of MC pregnancy complication. We, therefore, recommend cerebral ultrasound examinations in all complicated MC twins at birth to rule out a severe brain injury. Lastly, we strongly encourage screening for hearing loss using automated auditory brainstem response in all spontaneous TAPS donors to prevent permanent speech development delay.     

What have we learned about vaginal infections and preterm birth?

Asymptomatic maternal genital tract infection during pregnancy, particularly bacterial vaginosis, has been consistently associated with preterm birth. In response to this evidence, the Maternal-Fetal Medicine Units Network (MFMU) designed and conducted 2 large randomized, placebo-controlled clinical trials of metronidazole treatment of asymptomatic pregnant women with bacterial vaginosis or trichomoniasis in a general obstetrical population. These studies showed that treatment of women with bacterial vaginosis failed to prevent preterm birth, regardless of their history of prior preterm birth. Metronidazole treatment of women with trichomoniasis significantly increased the risk of preterm birth compared to placebo. These results formed the basis of the US Preventive Services Task Force recommendation that screening for bacterial vaginosis not be undertaken in low-risk pregnant women, and show that MFMU network studies can have a direct and immediate impact on obstetrical practice.     

What have we learned about uterine contractions and preterm birth? The HUAM Prediction Study

Measurement of uterine contraction frequency has been employed as a screening test to identify women with increased risk of preterm birth, and as an aid in the early diagnosis of preterm labor. The National Institute of Child Health and Human Development Maternal-Fetal Medicine Units (NICHD MFMU) Network performed a prospective, blinded observational study of uterine contraction frequency to detect and predict preterm labor and birth, respectively. The goal of the study was to assess the sensitivity, specificity, and positive and negative predictive value of various measures of uterine contraction frequency. Data collected from 306 women revealed that contraction frequency was significantly greater in women who would ultimately deliver before rather than after 35 weeks' gestation. However, both sensitivity and positive predictive value of any measure of contraction frequency to predict preterm birth were poor. Contraction frequency did not increase significantly within 1 or 2 weeks of an episode of preterm labor. These results serve to explain the absence of an association between contraction-based surveillance and preterm birth in randomized trials conducted in women at risk of preterm birth.     

Preterm twins: what threshold of birth weight discordance heralds major adverse neonatal outcome?

OBJECTIVE: This study was undertaken to establish the optimal threshold of birth weight discordance for prediction of adverse outcome in liveborn, non-malformed preterm twins. STUDY DESIGN: We accessed a cohort of twin gestations for the period 1990 through 2000 delivered at less than 37.0 weeks' gestation. Adverse neonatal outcome was defined as stillbirth or occurrence of major morbidities. RESULTS: A total of 335 twin gestations (670 twins) were included, of which 104 (31%) experienced adverse neonatal outcome. The average birth weight discordance was 12.4% +/- 10.6% versus 19.4% +/- 14.8% in those with good versus adverse outcome (P < .001). Birth weight discordance was a significant predictor of adverse neonatal outcome that was independent of gestational age at delivery, small for gestational age, and chorionicity. Receiver operating characteristic curve analysis suggested that optimal thresholds of birth weight discordance for clinical use should take into account gestational age. CONCLUSION: Birth weight discordance is an independent predictor of adverse neonatal outcome in liveborn, non-malformed preterm twins.     

Anti‐Müllerian hormone as a marker of ovarian reserve: What have we learned,and what should we know?

Ovarian reserve reflects the quality and quantity of available oocytes. This reserve has become indispensable for the better understanding of reproductive potential. Measurement of the serum anti‐Müllerian hormone (AMH) level allows quantitative evaluation of ovarian reserve. It has been applied to a wide range of clinical conditions, and it is well established that the measurement of serum AMH levels is more useful than qualitative evaluation based on the menstrual cycle. AMH levels are monitored during infertility treatments; in patients undergoing medically assisted reproductive technology; and in the diagnosis of ovarian failure, polycystic ovarian syndrome, and granulosa cell tumor. It is also useful in the evaluation of iatrogenic ovarian damage. Population‐based studies have indicated a potential role for serum AMH in the planning of reproductive health management. While AMH is currently the best measure of ovarian reserve, its predictive value for future live births remains controversial. Furthermore, there is a serious practical issue in the interpretation of test results, as currently available assay kits use different assay ranges and coefficients of variation due to the absence of an international reference standard. The pros and cons of the serum AMH level as a definitive measure of ovarian reserve merits further review in order to guide future research.     

Severe preeclampsia and the very low birth weight infant: is induction of labor harmful?

OBJECTIVE: To compare the effects of labor induction with the effects of cesarean delivery without labor on neonatal outcome in pregnancies complicated by severe preeclampsia and delivery of very low birth weight infants. METHODS: This was a retrospective study of 278 singleton, live-born infants who weighed 750-1500 g and were delivered because of severe preeclampsia between 1988 and 1997. Outcomes of infants delivered by cesarean without labor were compared with those of infants exposed to labor induction. Statistical analysis was performed using Student t test, Mann-Whitney U test, chi2 analysis, and Fisher exact test, where appropriate. Multiple logistic regression analysis was used to adjust for outcomes of interest. RESULTS: One hundred forty-five (52%) of the 278 women with severe preeclampsia who delivered infants weighing between 750 and 1500 g had labor induced and 133 (48%) delivered by cesarean without labor. Vaginal delivery was accomplished by 50 (34%) women in the induced group. Apgar scores of 3 or less at 5 minutes were more likely in the induced-labor group (6 versus 2%, P = .04), but other neonatal outcomes, including respiratory distress syndrome, grade 3 or 4 intraventricular hemorrhage, sepsis, seizures, and neonatal death, were similar in the two groups. Adjustment for birth weight and gestational age did not affect those results. Analysis of data from the induced-labor group did not reveal an effect by route of delivery on neonatal outcome. CONCLUSION: Induction of labor in cases of severe preeclampsia is not harmful to very low birth weight infants.     

Hyperbilirubinemia in the 2000s: what should we do next?

Changes in healthcare policy mandating early discharge of healthy, full-term infants and the higher prevalence of breast-feeding of newborns have contributed to an increased number of term infants being readmitted to the hospital for hyperbilirubinemia. At high levels, total serum bilirubin causes kernicterus, which is associated with severe neurological sequelae. This article provides a review of prior studies that have examined whether and at what levels total serum bilirubin affects neurodevelopmental outcome in term infants. In addition, the article reviews some approaches in the literature that suggest means of preventing high levels of hyperbilirubinemia in term infants.     

Aspirin use in pregnancy: where are we and what next?

Aspirin is currently recommended from 12 weeks gestation until the birth of the baby for women with one high, or two moderate risk factors for pre-eclampsia, to reduce the risk of developing the condition. There is evidence to suggest aspirin use in pregnancy potentially reduces the risk of preterm birth and small for gestational age or fetal growth restricted babies. For women with recurrent pregnancy loss associated with anti-phospholipid syndrome, aspirin is recommended in combination with heparin. In this review, we discuss the history of aspirin use and its application to improving pregnancy outcomes. We also highlight the current evidence surrounding aspirin use in pregnancy and explore avenues for further research.