Severe congenital anomalies of the kidney and urinary tract: epidemiology can inform ethical decision-making.

OBJECTIVE: Decision-making for pregnancies complicated by severe congenital anomalies of the kidneys and urinary tract (CAKUT) are ethically challenging, partly because the outcomes are not well studied. STUDY DESIGN: Retrospective cohort study of severe cases of CAKUT over 14 years. RESULTS: Seventy-one of the 108 cases could be completely analyzed. Forty-six percent (n=33) infants were live-born; one-third (n=11) survived to 12 months. Twice as many non-surviving infants received a trial of therapy vs comfort care only. Two-thirds of non-survivors who received a trial of therapy died within the first 9 h of life. Live-born infants faced morbidities such as pneumothorax and neonatal dialysis. CONCLUSIONS: Over half of pregnancies complicated by severe CAKUT ended in termination or stillbirth, but one-third of live-born infants survived to 12 months and the majority of non-survivors died within hours. This may allay concerns about prolonged and futile intensive care for parents considering a trial of therapy.

The effect of perinatal omega-3 fatty acid supplementation on inflammatory markers and allergic diseases: a systematic review.

BACKGROUND: Maternal supplementation with omega-3 polyunsaturated fatty acids (n-3 PUFA) may modulate immune responses and allergy in neonates and children. OBJECTIVE: To determine if n-3 PUFA supplementation during pregnancy and lactation reduces risk for childhood allergic disease. SEARCH STRATEGY: We searched Medline and all evidence-based medicine reviews for randomised controlled trials comparing the effects of n-3 PUFA and placebo supplementation during pregnancy and/or lactation on childhood allergic diseases and inflammatory cytokines. SELECTION CRITERIA: We included studies reporting on food allergy, response to the egg skin prick test (SPT), atopy and asthma in infancy and childhood as well as production of interleukin-13 and interferon-gamma, two cytokines involved in the pathogenesis of asthma. For assessment of inclusion, two authors reviewed all abstracts for suitability and independently extracted data. DATA COLLECTION AND ANALYSIS: Two-by-two tables were constructed and odds ratios (OR) were calculated for the outcomes: response to the SPT, food allergy, atopy and asthma in childhood. The assays differed so data on inflammatory markers were reported in narrative form. MAIN RESULTS: Five randomised controlled trials (n = 949) were included. n-3 PUFA supplementation during pregnancy reduced 12-month prevalence of positive egg SPT (two trials, 12/87 versus 32/100, OR 0.33, 95% CI 0.16, 0.70) and childhood asthma (two trials, 10/303 versus 17/179, OR 0.349, 95% CI 0.154, 0.788) and significantly reduced cord blood interleukin-13 levels. Supplementation during lactation did not prevent asthma, food allergy or atopy. CONCLUSION: n-3 PUFA supplementation during pregnancy decreases childhood asthma and response to SPT.

Non-invasive pulsed cavitational ultrasound for fetal tissue ablation: feasibility study in a fetal sheep model.

OBJECTIVES: Currently available fetal intervention techniques rely on invasive procedures that carry inherent risks. A non-invasive technique for fetal intervention could potentially reduce the risk of fetal and obstetric complications. Pulsed cavitational ultrasound therapy (histotripsy) is an ablation technique that mechanically fractionates tissue at the focal region using extracorporeal ultrasound. In this study, we investigated the feasibility of using histotripsy as a non-invasive approach to fetal intervention in a sheep model. METHODS: The experiments involved 11 gravid sheep at 102-129 days of gestation. Fetal kidney, liver, lung and heart were exposed to ultrasound pulses (< 10 µs) delivered by an external 1-MHz focused ultrasound transducer at a 0.2-1-kHz pulse-repetition rate and 10-16 MPa peak negative pressure. Procedures were monitored and guided by real-time ultrasound imaging. Treated organs were examined by gross and histological inspection for location and degree of tissue injury. RESULTS: Hyperechoic, cavitating bubble clouds were successfully generated in 19/31 (61%) treatment attempts in 27 fetal organs beneath up to 8 cm of overlying tissue and fetal bones. Histological assessment confirmed lesion locations and sizes corresponding to regions where cavitation was monitored, with no lesions found when cavitation was absent. Inability to generate cavitation was primarily associated with increased depth to target and obstructing structures such as fetal limbs. CONCLUSION: Extracorporeal histotripsy therapy successfully created targeted lesions in fetal sheep organs without significant damage to overlying structures. With further improvements, histotripsy may evolve into a viable technique for non-invasive fetal intervention procedures.

Model of family medicine and obstetrics-gynecology collaboration in obstetric care at the University of Michigan.

OBJECTIVE: To assess concordance between family physician obstetric privilege delineation and actual care delivered, and describe associated clinical and educational collaborations between family medicine and obstetrics and gynecology. METHODS: We conducted a descriptive retrospective review of the care and complications of 962 consecutive patients admitted to a family medicine obstetric service in a research-intensive academic medical center, and compared the results with a structured obstetric privilege delineation. RESULTS: Of 962 women admitted by family medicine faculty members, 741 (77.9%) were managed exclusively by family physicians, 63 (6.6%) were comanaged by family physicians and obstetricians, and 147 (15.5%) were transferred to obstetricians (data missing for 11 patients). Spontaneous vaginal deliveries were performed in 772 patients (81%), cesarean delivery in 116 patients (12.2%), and assisted delivery by forceps or vacuum in 19 (2%) and 44 (4.6%) patients, respectively. Of 926 intrapartum obstetric complications identified in 604 obstetric deliveries, 615 complications (66.4%) in 418 deliveries were managed exclusively by family physicians consistent with privilege delineation, comanagement occurred in 56 patients with 92 complications (9.9%), and care was transferred in 130 patients with 219 complications (23. 7%). CONCLUSION: A structured method of obstetric privilege delineation for family medicine faculty members and associated guidelines for family physician-obstetrician interactions has led to a successful family medicine obstetric service at a research-intensive, tertiary-care medical center, with a high concordance between privilege delineation and actual care delivered. This success has resulted in incremental clinical and educational collaborations that have improved the quality of women's health care and education.