Faculty Bibliography

Introduction: To evaluate whether maternal serum alpha-fetoprotein (MSAFP) improves the detection rate for open neural tube defects (ONTDs) and ventral wall defects (VWD) in patients undergoing first-trimester and early second-trimester fetal anatomical survey. Material and Methods: A cohort of women undergoing screening between 2005 and 2012 was identified. All patients were offered an ultrasound at between 11 weeks and 13 weeks and 6 days of gestational age for nuchal translucency/fetal anatomy followed by an early second-trimester ultrasound at between 15 weeks and 17 weeks and 6 days of gestational age for fetal anatomy and MSAFP screening. All cases of ONTD and VWD were identified via query of billing and reporting software. Sensitivity and specificity for detection of ONTD/VWD were calculated, and groups were compared using the Fisher exact test, with p < 0.05 as significance. Results: A total of 23,790 women met the criteria for inclusion. Overall, 15 cases of ONTD and 17 cases of VWD were identified; 100% of cases were diagnosed by ultrasound prior to 18 weeks' gestation; none were diagnosed via MSAFP screening (p < 0.001). First-trimester and early second-trimester ultrasound had 100% sensitivity and 100% specificity for diagnosing ONTD/VWD. Discussion: Ultrasound for fetal anatomy during the first and early second trimester detected 100% of ONTD/VWD in our population. MSAFP is not useful as a screening tool for ONTD and VWD in the setting of this ultrasound screening protocol. (c) 2014 S. Karger AG, Basel.

Abstract Objective: The objective was to determine if the rate of abnormal biochemical markers is different in pregnancies conceived by donor oocyte versus those conceived by autologous oocytes. Methods: This is a retrospective cohort study of patients who underwent risk assessment for aneuploidy. Pregnancies conceived by egg donation were matched with control groups who conceived using their own eggs. The primary outcomes were incidence of low PAPP-A or free bHCG in the first trimester or elevated MSAFP, free bHCG or Inhibin A, or low uE3 in the second trimester. Results: 260 singleton gestations were identified who conceived via oocyte donor. There was a significantly higher rate of unexplained elevated MSAFP in pregnancies conceived by egg donation (8% versus 2%, p = 0.028) compared to a control group matched by maternal age. There was also a significantly higher rate of unexplained elevated MSAFP in pregnancies conceived by egg donation (7% versus 2%, p = 0.01) compared to a control group matched by age of the egg donor. Conclusion: Pregnancies conceived by egg donation are more likely to have an unexplained elevation in MSAFP compared to pregnancies not conceived by egg donation regardless of age. Egg donation itself is not associated with other biochemical abnormalities.

Abstract Objective: To estimate whether the severity of uterine anomaly is associated with the risk of adverse pregnancy outcomes. Methods: Retrospective cohort study of patients delivered by one maternal fetal medicine group from 2005 to 2012. We included 158 patients with a singleton pregnancy and a uterine anomaly, as well as an equal number of randomly selected unexposed singleton pregnancies delivered by the same group. Patients with uterine anomalies were subdivided into those with major fusion defects (unicornuate, bicornuate and didelphys) and minor fusion defects (arcuate, septate and t-shaped). Results: The incidence of adverse pregnancy outcomes increased across unexposed patients, patients with minor fusion defects and patients with major fusion defects. These included preterm birth < 37 weeks, preterm birth < 35 weeks, birth weight < 10th percentile, birth weight < 5th percentile, preeclampsia, malpresentation and cesarean delivery. Conclusion: The incidence of adverse pregnancy outcomes and cesarean delivery is increased in patients with minor fusion defects and is further increased in patients with major fusion defects.

Abstract Objective: To report blood pressure (BP) across gestation in patients with twin pregnancy. Methods: Historical cohort of all twin pregnancies managed by one maternal-fetal medicine practice from 2005 to 2012. Patients with chronic hypertension were excluded. We reviewed all outpatient BP measurements taken during pregnancy and compared systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) for every 2-week interval starting at 6 weeks. All BP measurements were taken manually in the seated upright position. Results: There were 520 patients with twin pregnancies managed over the study period, 19 (3.7%) were excluded for chronic hypertension, leaving 501 patients for analysis. There were a total of 4985 BP measurements (9.95 per patient) during pregnancy. Starting at 6 weeks' gestation, the SBP, DBP and MAP remained stable until 30 weeks' gestation, when all three began to rise significantly until 38 weeks (p < 0.001). There was no drop in BP in the second trimester. The 95th percentile for systolic BP did not exceed 121 mmHg until 30 weeks and the 95th percentile for diastolic BP did not exceed 80 mmHg until 34 weeks. The 4 - to 10-week postpartum DBP and MAP were significantly higher than the initial DBP and MAP <10 weeks. Conclusions: In patients with twin pregnancies, the BP remains stable from 6 weeks until 30 weeks, at which time it begins to rise steadily. The 95th percentile for SBP and DBP prior to 30 weeks are approximately 120 and 80 mmHg, respectively.

Abstract Objective: To determine whether routine cervical length (CL) and fetal fibronectin (fFN) screening is associated with improved clinical outcomes in asymptomatic patients with twin pregnancies. Study design: We compared outcomes between two large cohorts of twin pregnancies who delivered in New York City from 2003 to 2012. One cohort (n = 532) was managed by a single group practice, delivered at one large academic medical center, and underwent routine serial CL and fFN screening. The second cohort (n = 456) delivered at a second large academic center and only underwent CL and fFN testing as clinically indicated. Outcomes measured include cerclage placement, preterm birth (PTB), spontaneous PTB (sPTB), and antenatal corticosteroid (ACS) exposure. Results: Rates of cerclage placement, PTB, and SPTB were similar between the two groups. However, routine CL and fFN screening was associated with improved rates of ACS exposure in patients who delivered <34 weeks (91.3% versus 74.7%, p = 0.005) and 34-36 6/7 weeks (41.3% versus 13.9%, p < 0.001) without increased ACS exposure in women who delivered at term. In patients who delivered <34 weeks, routine CL and fFN screening was significantly associated with improved rates of ACS exposure within 1-14 days of delivery and within 1-7 days of delivery. Conclusion: In twin pregnancies, routine CL and fFN screening does not reduce the risk of PTB or SPTB. However, the routine use of these tests is associated with significantly improved ACS exposure and timing for women who deliver preterm without increasing ACS exposure to women who deliver at term.