Is there a role for fetal ductus venosus and hepatic artery Doppler in screening for fetal aneuploidy in the first trimester?

Objective: The aim of the present study was to evaluate the utility of ductus venosus (DV) and hepatic artery (HA) doppler in pregnant women who have high risk for aneuploidy in first trimester combined screening.

Methods: This prospective study was performed between February 2011 and February-2012, at a tertiary referral hospital. Singleton pregnancies with high risk for aneuploidy in combined screening test and normal nuchal translucency (NT) measurements were included in the study group. Measurements of DV Pulsatility Index of Veins (PIV) and HA Pulsatility Index (PI) were compared between the study group and controls.

Results: Within the study period, 104 women with singleton pregnancies were evaluated for DV and HA measurements and among these, 64 women met the inclusion criteria. A control group that comprised 40 women with similar gestational age, normal NT measurements and low-risk in first trimester combined tests was generated. DV-PIV measurements were significantly higher (p?=?0.03), whereas HA-PI measurements were similar (p?>?0.05) in women who had high-risk for aneuploidy in first trimester combined test.

Conclusion: We concluded that the addition of DV-PIV and HA-PI measurements to the first trimester combined screening might increase the accuracy for Down syndrome detection.     

First trimester fetal ultrasound parameters associated with PAPP-A and fβ-hCG

Objective: To study the association of fβ-hCG and PAPP-A measured at 11–14 weeks of gestation with delta crown-rump-length (dCRL), delta fetal heart rate (dFHR) and delta nuchal translucency (dNT). To calculate adjusted MoM taking into consideration these associations. Methods: Retrospective cross-sectional study on 5,536 singleton euploid pregnancies participating in a first trimester screening program for chromosomal abnormalities by nuchal translucency and maternal serum biochemistry. Adjusted MoM were calculated for fβ-hCG and PAPP-A and compared to the observed MoM (calculated by the Fetal Medicine Foundation screening algorithm). Results: fβ-hCG correlates positively with dCRL and negatively with dNT, whereas PAPP-A shows a positive correlation with dNT and a negative one with dCRL and dFHR. After adjustment for the ultrasound parameters, the median MoM values for fβ-hCG and PAPP-A changed from 1.02 and 0.92 observed MoM to 0.98 and 0.99 adjusted MoM respectively. The difference between the observed and adjusted MoM was statistically significant (p?<?0.001). Delta CRL increases with gestation and this effect manifests mainly after CRL of 62?mm. Conclusions: Adjustment for dCRL, dFHR and dNT improves the calculation of MoM for fβ-hCG and PAPP-A. CRL measurement overestimates fetal size at the end of the screening period 11–14 weeks.     

Non-invasive prenatal testing for fetal sex determination: is ultrasound still relevant?

Early prenatal diagnosis of fetal sex is necessary to optimize pregnancy management in families known to be at risk of some heritable disorders. The demonstration of cell-free fetal DNA (cffDNA) in the mother's blood has made it possible to identify Y chromosome sequences in maternal blood and to determine fetal sex noninvasively, during the first trimester. This procedure can significantly reduce the number of invasive procedures for women with fetuses at risk of sex-linked diseases and optimize the management of these pregnancies. Fetal sex can be diagnosed by ultrasound with the same sensitivity and specificity, but later in pregnancy.     

Spontaneous abortions of first trimester pregnancy: is uterine aspiration still in line?

Spontaneous abortions of first trimester pregnancy is a frequent pathology in gynecology (more than 10% of clinical pregnancy). Since the mid of twentieth century, the gold standard of evacuation of spontaneous abortion is manual vacuum aspiration most of the time under general anesthesia. This method is used in France for all miscarriages after 7 weeks' gestation at the sonography (about 40,000 women in 1999) but complications are not rare. The vaginal sonography and new medical management changes the view. We can now use expectative management or medical management with misoprostol and/or mifepristone. We summarise the current literature and propose a randomised multicentric control trial.     

Glucose screening test results in first and early third trimester of pregnancy: is there any correlation?

OBJECTIVE: This study aims to find correlation between glucose screening test (GST) results done in the first trimester and again in the early third trimester of pregnancy. METHODS: Analysis of the records of 458 cases of pregnant women (non-diabetic in early pregnancy as detected by glucose screening test and glucose tolerance test) between 22 and 35 years of age with a body mass index of less than 25 kg/m2 was done. These women underwent GST in the first trimester (GST-1) and again in the early third trimester (GST-2). When the GST-2 was 140 mg% or above, a standard '3 hour glucose tolerance test' was done (GT TEST) with 100 g of glucose. The GST was done by measuring the plasma glucose level 1 hour after taking 50 g of glucose, irrespective of food intake. RESULTS: A substantial correlation between the two groups of measurements was found. Based on the available data, a GST-1 value of 99 mg% or less was seldom associated with GST-2 value of 140 mg% or more (GT TEST was positive in none). It was observed that 100% of cases with GST-1 value of 140 mg% or more had GST-2 of 140 mg% or more. Out of those having GST-2 value of 140 mg% or more, 72% had GT TEST positive. In the intermediate group (i.e. those patients having GST-1 value of 100 mg%-139 mg%), 51.7% had GST-2 values of 140 mg% or more. Out of these 51.7% cases, only 23% cases turned out to be GT TEST positive. The correlation coefficients (CC) worked out to be 0.38 (substantial correlation for 0.20 < CC < 0.70). CONCLUSION: From the observations stated above, it is concluded that for women with GST-1 of 99 mg% or less, a GST-2 is not necessary. For those having GST-1 of 140 mg% or more, a GT TEST is absolutely necessary instead of repeating the screening test again in the third trimester. But it is in the intermediate group (i.e. with GST-1 value of 100 mg%-139 mg%) where the glucose screening test should be repeated in the early third trimester and GT TEST as and when necessary.     

Can third trimester ultrasound predict the presentation of the first twin at delivery?

Objective: To determine the ability of early sonogram to predict the presentation of twin A at birth. Methods: A retrospective cohort study was conducted on all twin pregnancies evaluated at our Fetal Evaluation Unit from 2007 to 2009. Sonogram records were reviewed for the presentation of twin A at seven gestational age intervals and inpatient medical records were reviewed for the presentation of twin A at delivery. The positive predictive value, sensitivity, and specificity of presentation as determined by ultrasound, at each gestational age interval, for the same presentation at delivery were calculated. Results: Two hundred and thirty-eight twin pregnancies met inclusion criteria. A total of 896 ultrasounds were reviewed. The positive predictive value of cephalic presentation of twin A as determined by ultrasound for the persistence of cephalic presentation at delivery reached 95% after 28 weeks gestation. The positive predictive value for noncephalic presentation as established by sonogram for noncephalic at delivery was >90% after 32 weeks gestation. Conclusions: The presentation of the first twin at delivery can be determined by sonogram by the 32nd week of gestation in over 90% of twin pregnancies.     

Transobturator tapes: better than TVT?

Suburethral slings (or tapes) placed by a transobturator approach may be an alternative to established retropubic tension-free vaginal tapes. Comparisons are hampered by the number of available systems. Injury of the bladder, bowel and major vessels appears less frequent with transobturator systems whereas vaginal tape erosion and infectious complications appear to be more common. Results of adequately powered randomized trials are not yet available.     

Third trimester abortion: is compassion enough?

One comprehensive ethical framework that can be applied to cases of third trimester abortion is based on the following notion: patient trust depends upon physicians developing specific virtues and basing their professional actions on these virtues. One such virtue, as described by Dr. John Gregory in 1772, is sympathy for the distress of others that overcomes self-interest. This application of sympathy and desire to relieve suffering can justify late term abortion in some cases. The compassionate response to sympathy forwarded by Gregory, however, must be properly regulated by reason, as Gregory himself recognized. Thomas Percival (1740-1803), author of the classic text "Medical Ethics," charged physicians with uniting "tenderness" (Gregory's "sympathy") with "steadiness." This combination of virtues reoccurs in the contemporary work of bioethicists Edmund Pellegrino and David Thomasma. The intellectual component of compassion requires physicians to exhibit compassion towards their patients, and this includes fetal patients. Thus, third trimester abortion is only justified in cases where fetal abnormalities are associated with the certainty or near certainty of early death or of a complete absence of cognitive developmental capacity. Most anomalies fail to meet these criteria, and physicians must exhibit the virtues of self-effacement and integrity to make rigorous, clinical, ethical judgements and properly balance the interests of the pregnant woman and the fetus.     

Adverse perinatal outcome in teenage pregnancies: is it all due to lack of prenatal care and ethnicity?

Objective: To investigate teenage pregnancy outcomes controlling for lack of prenatal care (LOPC) and ethnicity. Methods: A retrospective population-based cohort study comparing singleton deliveries of nulliparous women classified into two teenage groups: 15–17, 18–19, and a comparison group of 20–24 years was performed. Multiple logistic regressions were used to control for confounders. Results: The study population consisted of 31,985 women, 1,482 15–17 years old, 5,876 18–19 years old and 24,627 20–24 years old. A significant linear association was found between maternal age and perinatal mortality, low birth weight (LBW) and preterm delivery (PTD). Using multivariable logistic regression models, controlling for LOPC and ethnicity, the association between maternal age and perinatal mortality was no longer statistically significant, but both LBW and PTD were significantly associated with young maternal age (>17 years). Conclusion: Teenage pregnancy is a risk factor for LBW and PTD especially for parturient younger than 17.