Faculty Bibliography

The purpose of this study was to identify maternal and neonatal characteristics affecting marked neonatal neutropenia in pregnancies complicated by hypertension. A single institution retrospective chart review over 2 years of singleton and multifetal pregnancies with hypertensive disorders meeting American College of Obstetricians and Gynecologists criteria was performed. Neutropenia and sepsis occurring within the first 16 days of life (DOL) were studied. Neutropenia was defined as an absolute neutrophil count of <1500/microL and sepsis as any positive blood, cerebrospinal fluid, or urine culture. The study group contained neonates with neutropenia. From all other hypertensive pregnancies, a presumed nonneutropenic control group was randomly generated with a 4:1 ratio; these neonates may or may not have had a complete blood count (CBC) performed because they were clinically stable. Multiple gestations were separately analyzed and compared with hypertensive multifetal neonates with confirmed CBCs showing no neutropenia. Chi-square, Mann-Whitney U, and regression analyses were performed. Five hundred forty-three hypertensive pregnancies representing 633 births, 173 (27.3%) of which were from multiple gestations, were studied. There were 32 (5.9%) cases of neutropenia, with 22 (68.8%) from multiple gestations. Of premature multiple gestations, 45.2% born between 24 and 34 weeks' gestation developed neutropenia. The median time to diagnosis of neutropenia was 1.2 hours with 80.6% detected on the first DOL. Resolution of neutropenia occurred within 7 days in 84.4% of surviving neonates. Univariate analysis showed significant associations of neutropenia with gestational age at delivery, multiple gestations, birth weight, severe preeclampsia, and development of neonatal sepsis. When multiple gestations were analyzed, linear regression showed only sepsis to be significantly associated with neutropenia (p = 0.027). Hypertensive disorders of pregnancy and premature delivery are common in multiple gestations and are associated with neutropenia (12.7% versus 2.2% neutropenia in singletons (p < 0.001). Furthermore, multiple gestations with neutropenia had a higher incidence of sepsis than singletons with neutropenia.

The purpose of this study was to describe a clinically based, ethically justified informed consent process for risk assessment and invasive genetic diagnosis that enhances patient autonomy. Appealing to the ethical principle of respect for the autonomy of pregnant women, we show that patients can exercise their autonomy meaningfully in the informed consent process in response to the offer of risk assessment (RA) and invasive diagnosis (ID) and in response to the results of risk assessment. All pregnant patients in the first trimester should be offered both RA and ID. Women will sort themselves, in response, into 4 groups; those who refuse both RA and ID, those who are uncertain about RA, those who accept RA, and those who accept ID. Women who proceed to RA will sort themselves, in response to its results, into 3 groups: women for whom the risk of aneuploidy is acceptable or unacceptable and women who are not certain whether such risk is acceptable. For this last group only, the informed consent process should present information about current controversies of first-trimester and second-trimester further testing to better assess risk. Clinical strategies are identified for the implementation of the varied responses of pregnant women to the offer of RA and ID. Autonomy-enhancing strategies for the evaluation of pregnancy provide the basis for solving the ethical challenge that is presented by the wide variety of evaluation techniques.

We discuss the clinical implications regarding disclosure of risk assessment for trisomy 21 screening results in the first versus second trimester. Based on the ethical principles of respect for autonomy, beneficence, and justice, we argue that routinely offering first trimester risk assessment in centers qualified to provide it is ethically obligatory and routinely withholding the results of first trimester risk assessment is ethically unjustified. As risk for trisomy 21 occurs along a continuum, no pregnant woman is without risk; thus, offering diagnostic testing to all women is ethically justified. Informed consent and personal choice regarding diagnostic testing and termination of pregnancy shape patients' decisions to undergo first trimester risk assessment for trisomy 21. Appropriate counseling is required to allow for individual choice regarding timing of disclosure.

OBJECTIVE:The purpose of this study was to determine whether magnetic resonance imaging of the fetal brain before dilation and evacuation enhances diagnosis when equivocal ultrasound findings and disrupted autopsy specimens exist. STUDY DESIGN/METHODS:Patients with equivocal fetal brain abnormalities on ultrasound examination who were considering termination of pregnancy were evaluated retrospectively. Abdominal and pelvic magnetic resonance imaging was performed for further evaluation, and orthogonal fetal brain images were obtained. A multidisciplinary team reviewed all cases and discussed the findings, possible causes, and recurrence risks with each patient. RESULTS:Seven patients with fetal brain anomalies underwent magnetic resonance imaging before dilation and evacuation. Magnetic resonance imaging diagnoses included intracranial hemorrhages, semilobar holoprosencephaly, intracranial teratoma, multiple cerebral infarcts, and unilateral cerebellar hypoplasia. In all cases, magnetic resonance imaging provided valuable information and helped distinguish possible genetic syndromes from likely sporadic disorders of brain development. CONCLUSION/CONCLUSIONS:Magnetic resonance imaging can provide insight into diagnosis, cause, and recurrence risks for patients who choose dilation and evacuation because of fetal brain abnormalities.

OBJECTIVE:This study was undertaken to determine prognostic factors in pregnancies with a subchorionic echolucency. STUDY DESIGN/METHODS:One hundred twenty-nine pregnancies with a subchorionic echolucency detected by ultrasound in our unit were identified. Ultrasound reports were reviewed for subchorionic echolucency location, size, gestational age, amniotic fluid volume, and fetal abnormalities. Adverse outcomes evaluated were pregnancy loss before 24 or 37 weeks (PTD) and intrauterine growth restriction. Medical records were reviewed for antenatal complications and neonatal outcomes. RESULTS:There were 7 (5.4%) pregnancy losses before 24 weeks and 24 (18.6%) pregnancies complicated by PTD. Of the 122 pregnancies reaching viability, those complicated by antepartum bleeding were more likely to deliver prematurely than those without bleeding, (26.6% vs 7.0%, P=.009). Maximum area of subchorionic echolucency, gestational age at subchorionic echolucency detection, amniocentesis, maternal age, and parity were not associated with PTD. CONCLUSION/CONCLUSIONS:Patients with subchorionic echolucency appear to have a high incidence of PTD. Bleeding appears to be a reliable prognostic indicator.

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