Faculty Bibliography

PURPOSE OF REVIEW/OBJECTIVE:Fetal growth restriction is a complicated perinatal condition, with multiple causes. It shares common pathophysiologies with other important disorders, such as preeclampsia and abruption. As a group, these conditions associated with ischemic placental disease are responsible for a large percentage of indicated preterm births. The ability to accurately predict, diagnose and manage these pregnancies has significant and far-reaching implications, including potential effects on long-term adult health. RECENT FINDINGS/RESULTS:Placental ischemia is the most common cause of fetal growth restriction. Alterations in placental development are being linked to various angiogenic mediators, which may be of future use in early risk-determination. Until then, the use of ultrasound to accurately diagnose fetal growth restriction and time delivery is the mainstay of management. Research in this area has revealed some commonalities in the deterioration of the growth restricted fetus, but has also indicated that not every affected fetus will follow the same progression in Doppler and other wellbeing parameters. Most importantly, gestational age at delivery is consistently being documented as a critical factor in perinatal morbidity and mortality. SUMMARY/CONCLUSIONS:Fetal growth restriction is a late manifestation of early abnormal placental development. Once abnormal Doppler velocimetry is present, surveillance and timing of delivery should be based on the antepartum test results and on the gestational age.

Preterm birth complicates over 500,000 births annually, affecting 12.5% of pregnancies in the United States. Much of the temporal increase in preterm birth (<37 weeks) over the past decade is largely driven by a concurrent temporal increase in medically indicated preterm birth. Maternal and fetal indications that prompt an intervention at preterm gestational ages include preeclampsia, intrauterine growth restriction, and placental abruption-conditions that constitute "ischemic placental disease." Ischemic placental disease is implicated in over one of every two indicated preterm births compared with less than one in five births at term. Comprehensive evaluation of risk factors, with careful consideration of heterogeneity in the syndrome of medically indicated preterm birth and ischemic placental disease may provide important clues to predict and consequently prevent preterm birth.

OBJECTIVE:The objective of the study was to evaluate whether the association between low birthweight and placental abruption is mediated through preterm birth or restricted fetal growth and whether these associations were influenced by maternal thrombophilia status. STUDY DESIGN/METHODS:Data were derived from the New Jersey-Placental Abruption Study, an ongoing, multicenter, case-control study conducted in New Jersey since August 2002. Abruption cases (n = 156) were identified based on a clinical diagnosis, and controls (n = 170) were matched to cases based on parity and maternal race. Low birthweight (<2500 g) was stratified based on preterm birth (<37 weeks' gestation) and small for gestational age (birthweight < the 10th percentile for gestational age). Maternal thrombophilia assessment was based on serum evaluation (protein C and S deficiency, activated protein C resistance ratio, and anticardiolipin antibodies) as well as genetic polymorphisms (methylenetetrahydrofolate reductase, prothrombin gene, and factor V Leiden). Associations were expressed based on odds ratios (ORs) with 95% confidence interval (CI). RESULTS:Among abruption cases, 60.3% (n = 94) were low birthweight in comparison with 11.2% (n = 19) of controls (OR, 13.7; 95% CI, 7.4-25.2). Furthermore, placental abruption had a significantly increased association with preterm birth in both small for gestational age (OR, 17.4; 95% CI, 4.6-64.9) and appropriately grown fetuses (OR, 15.8; 95% CI, 8.4-29.8). However, the association between abruption and low birthweight were similar between women with and without thrombophilia. CONCLUSION/CONCLUSIONS:The association between placental abruption and low birthweight is chiefly mediated through preterm birth, and this association does not appear to be modified by maternal thrombophilia status.

BACKGROUND:Hereditary hemorrhagic telangiectasia (HHT) is a condition characterized by multiple telangiectases and arteriovenous malformations. Women with HHT may develop life-threatening complications in pregnancy. In particular, death from pulmonary hemorrhage has been reported. Consequently, these women are often advised not to conceive or to terminate their pregnancies. CASE/METHODS:We report a case of conservative management of HHT in pregnancy with a good outcome. CONCLUSION/CONCLUSIONS:This case demonstrates that in carefully selected cases, women with HHT who are managed conservatively may have good pregnancy outcomes. A diagnosis of HHT alone is not reason to advise women against pregnancy, nor should these women routinely be advised to undergo pregnancy termination.

Spontaneous preterm birth remains a significant problem in the United States despite intense research to decrease its prevalence. Strategies have been limited by inability to identify patients at risk for preterm birth, as the majority of patients do not have historical risk factors. The development of an assay to detect vaginal fetal fibronectin, along with the use of transvaginal ultrasonography to determine cervical length, has greatly increased our ability to identify those patients at highest risk. This article reviews the most significant studies on this topic, providing a context for suggested management algorithms for both symptomatic and asymptomatic patients at risk for spontaneous preterm birth.

INTRODUCTION/BACKGROUND:A 28-year old female presented with a non-radiating persistent left upper quadrant pain and tenderness for 5 weeks. METHODS:A preliminary CT scan displayed bony structures in the spleen. A delayed scanning subsequently showed the bones to have changed position, consistent with a life fetus. RESULTS:Ultrasound confirmed the CT findings, and ascertained the fetus to be consistent with 13 weeks of gestation. Laparoscopic splenectomy was performed and examination of the intact spleen confirmed a male fetus that was morphologically normal. CONCLUSION/CONCLUSIONS:This is the first report of fetal bony structures in the spleen associated with an advanced intra-splenic pregnancy.

OBJECTIVE:The objective of the study was to examine whether the risk and indications for primary cesarean in the second pregnancy are influenced by changes in prepregnancy body mass index (BMI) between pregnancies. STUDY DESIGN/METHODS:We performed a cohort analysis using the Missouri maternally linked birth and infant death surveillance datasets (1989-1997), comprised of women with their first 2 consecutive live births (n = 113,789). BMI (kilograms per square meter) was categorized as underweight (less than 18.5 kg/m2), normal (18.5 to 24.9 kg/m2), overweight (25 to 29.9 kg/m2), and obese (30 kg/m2 or greater). Indications for primary cesarean were categorized as breech, dystocia, fetal distress, and others. Timing of primary cesarean was categorized as elective (prior to labor) and emergent (after initiation of labor). Adjusted odds ratio (OR) was used to quantify the associations between changes in prepregnancy BMI and indications for primary cesarean. RESULTS:The rate of primary cesarean in the second pregnancy was 9.2%. Compared with women with normal BMI in their first 2 pregnancies, women who increased their BMI between pregnancies had increased risk of primary cesarean for all indications. Women who remained obese or overweight in both pregnancies were at increased risk of primary cesarean following breech (OR 1.28 and 1.13, respectively); dystocia (OR 1.94 and 1.41, respectively); fetal distress (OR 1.43 and 1.26, respectively); others (OR 3.17 and 1.63, respectively); and elective (OR 2.31 and 1.43, respectively) and emergent (OR 1.66 and 1.30, respectively) cesarean section. Women who lowered their BMI from obese to overweight or overweight to normal between pregnancies had risks of primary cesarean comparable with those with normal BMI in both pregnancies. Any increase in BMI from underweight to overweight or obese between the first 2 pregnancies was associated with increased risk of primary cesarean (OR 1.20 to 3.04) in the second pregnancy. CONCLUSION/CONCLUSIONS:Increases in prepregnancy BMI between first 2 pregnancies from normal to obese is associated with increased risk of indications for primary cesarean. The association between being overweight or obese or increases in prepregnancy BMI between pregnancies and primary cesarean in the second pregnancy suggests that counseling women with regard to their high BMI may be beneficial.

OBJECTIVE: The purpose of this study was to determine the accuracy of our previously published and prospectively validated transcerebellar diameter (TCD) nomogram in the prediction of gestational age (GA) in intrauterine growth-restricted (IUGR) and large fetuses. METHODS: We established a cross-sectional nomogram of TCD in 24,026 well-dated singleton fetuses and prospectively validated the nomogram using 2597 fetuses from a separate population. This nomogram was validated in both IUGR (n = 55) and large (n = 16) fetuses (estimated fetal weight, <10th and >90th percentiles, respectively). The actual GA was subtracted from the TCD-predicted GA in IUGR and large fetuses, and the concordance between the actual and predicted GAs was assessed using the Pearson correlation coefficient. RESULTS: Concordance between the actual and predicted GA based on our previously published singleton TCD nomogram was high for both IUGR and large fetuses (Pearson correlation, r = 0.98 and 0.95, respectively; P < .001). The means (SDs) of actual and predicted GA based on TCD in IUGR fetuses were 24.9 (6.5) and 25.1 (6.3) weeks, respectively. The predicted GA based on TCD in IUGR fetuses was within 3 days in 97.5% in the second trimester and 93.3% in the third trimester. In large fetuses, the difference between the actual and predicted GA based on TCD within 3 days was 100% in both the second and third trimesters. CONCLUSIONS: This study shows that our institution-specific TCD nomogram is reliable and accurate in predicting GA even at extremes of fetal growth.

OBJECTIVE:The purpose of this study was to evaluate whether the increased risk of placental abruption among women with chronic hypertension is modified by ischemic placental disease, specifically pregnancy-induced hypertension (PIH) and fetal growth restriction (FGR). STUDY DESIGN/METHODS:We used the US linked natality and fetal death data files (1995-2002) and restricted the analysis to women who had a singleton birth at > or = 22 weeks of gestation and to fetuses who weighed > or = 500 g (n = 30,189,949). Fetal growth was defined both on a continuum (<1, 1-2, 3-4, 5-9, 10-19, ..., > or = 90) and as birthweight of < 10th percentile for gestational age (FGR) or birthweight of > 90th percentile (large for gestational age [LGA]). All analyses were adjusted for potential confounding factors through multivariable logistic regression. RESULTS:Rates of abruption among women with and without chronic hypertension were 15.6 and 5.8 per 1000 pregnancies, respectively (relative risk [RR], 2.4; 95% CI, 2.3, 2.5). In comparison with normotensive women with appropriately grown babies (ie, 10th-90th percentile), the association between chronic hypertension and abruption was modified in the presence of FGR (RR, 3.8; 95% CI, 3.6, 4.1) and PIH (RR, 7.7; 95% CI, 6.6, 8.9). However, the highest risk was seen among women with chronic hypertension, PIH, and LGA (RR, 9.0; 95% CI, 7.2, 11.3). A dose-response relationship was observed between the risk of abruption and fetal growth (assessed on a continuum), with the risk being lowest among LGA babies. CONCLUSION/CONCLUSIONS:The association between chronic hypertension and abruption is strong; ischemic placental disease (PIH and FGR) modified this relationship. These findings suggest an etiologic relationship between abruption and chronic placental disease. Chronic hypertension, if associated with LGA, is not associated with abruption; however, chronic hypertension with superimposed PIH accompanied by LGA is associated with significantly increased risk.

OBJECTIVE:To examine whether acute and chronic respiratory diseases are associated with an increased risk of spontaneous premature rupture of the membranes (PROM). METHODS:We used the 1993-2004 National Hospital Discharge Survey data of singleton deliveries in the USA (N = 41 250 539). The International Classification of Diseases Ninth Revision was utilized to identify acute (acute upper respiratory diseases, viral/bacterial pneumonia, and acute bronchitis/bronchiolitis) and chronic (chronic bronchitis and asthma) respiratory conditions and spontaneous PROM. All analyses were adjusted for potential confounders. RESULTS:The incidence of PROM was 5%, and rates of acute and chronic respiratory conditions were 2.1 and 9.5 per 1000 pregnancies, respectively. Chronic bronchitis was associated with a reduced risk of PROM (RR 0.39, 95% CI 0.31, 0.48). Asthma was significantly associated with PROM at preterm (RR 1.15, 95% CI 1.14, 1.17) and term (RR 1.27, 95% CI 1.23, 1.30). Stratification by race showed that acute upper respiratory disease was associated with preterm PROM in whites (RR 1.90, 95% CI 1.71, 2.11) and blacks (RR 6.76, 95% CI 5.67, 8.07). Viral/bacterial pneumonia was associated with preterm PROM in blacks and term PROM in both races. Asthma was associated with term PROM in blacks but not whites. CONCLUSIONS:Acute respiratory diseases and asthma during pregnancy are associated with spontaneous PROM, with substantially stronger association among blacks than whites. We speculate that timely diagnosis and treatment, coupled with closely mentoring of pregnant women may help reduce the rate of PROM and associated complications.