Toxoplasmosis, Parvovirus, and Cytomegalovirus in Pregnancy.

There are several infections in adults that warrant special consideration in pregnant women given the potential fetal consequences. Among these are toxoplasmosis, parvovirus B19, and cytomegalovirus. These infections have an important impact on the developing fetus, depending on the timing of infection. This article reviews the modes of transmission as well as maternal and neonatal effects of each of these infections. In addition, the article outlines recommended testing, fetal surveillance, and treatment where indicated.

Ultrasound evaluation of the postpartum endometrial cavity.

OBJECTIVE: To establish normal ultrasonographic findings for the postpartum uterus. STUDY DESIGN: We performed a prospective cohort study on women delivering during the study period. Ultrasounds were performed abdominally within 48 hours of delivery. Measurements of the endometrial cavity and remarkable findings such as echogenic debris or uterine abnormalities were documented. Additionally, we followed patients during their hospital course for bleeding complications and the need for medical or surgical treatment of such complications. RESULTS: Of the 114 patients enrolled during our study period, 79 (69%) delivered vaginally and 35 (31%) delivered by cesarean; 39 (34%) were primiparous and 75 (66%) were multiparous. The mean endometrial cavity measurement was 1.15 ± 0.3 cm. There was no difference in endometrial cavity when evaluating parity (p = 0.26) or vaginal versus cesarean delivery (p = 0.8). Echogenic material in the endometrial cavity was noted in 22 (19%) of the 114 patients. The presence of echogenic material was significantly higher following vaginal delivery (p = 0.008). None of the patients had a complication in the postpartum period. CONCLUSION: Air endometrial cavity measurement of < 1.2 cm after a vaginal or cesarean delivery should be considered normal. Presence of echogenic material in the endometrial cavity appears to be a normal variant.

Fetal growth restriction: risk factors for unplanned primary cesarean delivery.

OBJECTIVE: The purpose of this study was to identify risk factors before or during labor to predict primary cesarean delivery for non-reassuring fetal heart tracing in cases of fetal growth restriction (FGR) undergoing a trial of labor. STUDY DESIGN: We reviewed charts of all patients with singleton, non-anomalous fetuses found to have FGR and delivered from January 2008 to December 2012. Characteristics of patients delivered by cesarean were compared to those who had delivered vaginally. RESULTS: Two hundred and twenty-two patients were delivered with FGR. Fifty-nine patients were excluded due to cesarean delivery prior to labor. Of the remaining 153 patients, 84% delivered vaginally and 16% underwent cesarean delivery. Of the 131 patients who underwent induction, 83% delivered vaginally. Rates of cesarean were higher for primigravity, oligohydramnios and prostaglandin use. However, logistic regression showed that oligohydramnios (odds ratio [OR]: 3.98; CI: 1.35-11.76) and prostaglandin use (OR: 3.67; CI: 1.07-12.60) were significantly associated with cesarean delivery. CONCLUSIONS: The rate of vaginal delivery is high in cases of FGR undergoing a trial of labor. We recommend that these patients undergo a trial of labor. Patients with oligohydramnios and those requiring prostaglandins for cervical ripening should be counseled regarding a significantly higher risk of cesarean delivery.

Minimal evidence of response shift in the absence of a catalyst.

BACKGROUND: Individuals with chronic conditions experience fluctuations in health status and thus may experience response shift. We sought to test the hypothesis that response shift effects would be non-significant among individuals with chronic disease who experienced relatively small changes in their health status over a 1-year period. METHODS: This secondary analysis utilized longitudinal cohort data on a community-based sample (n = 776) representing four chronic diseases (arthritis, heart failure, diabetes, or chronic obstructive pulmonary disease). Information on health-care utilization was obtained from the provincial health insurance database. Participants completed the SF-36 twice annually. Parameter invariance over 1 year in a second-order SF-36 factor structure was evaluated by adapting Oort's approach by fitting a second-order measurement structure with first-order factors for the SF-36 subscales and second-order factors for physical and mental health status while accommodating ordinal data. RESULTS: Over 80 % of participants had no hospitalizations or emergency room visits over follow-up. The model had an acceptable fit when all measurement model parameters were constrained at both time points (RMSEA = .035, CFI = .97). There was no substantial difference in fit when measurement model parameters (item thresholds, first-order factor intercepts, and factor loadings) were allowed to vary over time. CONCLUSION: Among chronically ill individuals with stable health, substantial response shift effects were not detected. These results support the theoretical proposition that response shift is not expected to occur in patients with relatively stable conditions.

Nuchal translucency and cardiac abnormalities in euploid singleton pregnancies.

OBJECTIVE: To investigate different cut-off levels of nuchal translucency (NT) to predict abnormal cardiac findings (ACF) in second trimester ultrasound examination and confirmed postnatal congenital heart defects (CHD) in euploid pregnancies. METHODS: A retrospective analysis was performed on singleton pregnancies examined in our ultrasound units from 2006 to 2011. Fetuses with an abnormal karyotype were excluded. Different cut-off levels of NT thickness were analyzed to evaluate its performance to detect the ACF on second trimester ultrasound (2nd US) examination and also the CHD detected in neonatal follow-up evaluation of ACF cases. RESULTS: Of the 12,840 cases, a total number of 8541 euploid pregnancies were included in the study. Thirty-three had ACFs detected by 2nd US (3.86/1000). The mean NT thickness was found to be higher in fetuses with ACFs (p < 0.0001). Of 33 ACFs, 17 (52%, 1.99/1000) had major CHDs in neonatal follow-up. The area under the ROC curves for NT thickness to predict ACFs and CHDs were 0.67 and 0.65, respectively. CONCLUSIONS: Higher NT thickness is associated with higher risk of ACF. NT is a weak predictor of ACF and major CHD; however, fetuses with an unexplained increase in NT measurement should be referred for further cardiac investigations.

Efficacy of the genetic sonogram in a stepwise sequential protocol for down syndrome screening.

OBJECTIVES: The purpose of this study was to evaluate the efficacy of the genetic sonogram in Down syndrome screening for women who have received the stepwise sequential test. METHODS: This retrospective cohort study included women with singleton pregnancies who underwent stepwise sequential (first-trimester combined and second-trimester serum) screening and then had a genetic sonogram between March 2005 and January 2010. Stepwise sequential Down syndrome risks were multiplied by either a positive or negative likelihood ratio based on the second-trimester sonographic findings to determine the final Down syndrome risk. A final Down syndrome risk of 1:270 or higher was considered screen positive. RESULTS: A total of 6286 women fulfilled our criteria, including 17 with Down syndrome-affected fetuses. After stepwise sequential testing, the Down syndrome detection rate was 88.2% (15 of 17), and after the genetic sonogram, there was a non-significant reduction in detection to 82.4% (14 of 17; P > .05). For the 6269 unaffected pregnancies, the genetic sonogram converted 58 screen-negative results (1%) to positive and 183 screen-positive results (3.1%) to negative. The net effect was a change in the false-positive rate from 6.2% (390 of 6269) after stepwise sequential screening to 4.2% (266 of 6269) after the genetic sonogram. CONCLUSIONS: The genetic sonogram should be applied cautiously for women who have received prior prenatal screening tests. Women with screen-positive results need to be counseled that a negative sonographic result can be falsely reassuring. Conversely, for women with screen-negative results who have a risk close to the cutoff, a sonographic examination could assist in the decision of whether to accept or reject amniocentesis.

Use of oral hypoglycemic and insulin agents in pregnant patients.

Although insulin remains the standard medication for the treatment of all types of patients with diabetes during pregnancy, oral hypoglycemics may be considered as alternative medications in the treatment of some types of diabetes in pregnancy.

Increased neonatal morbidity despite pulmonary maturity for deliveries occurring before 39 weeks.

OBJECTIVE: To compare neonatal outcomes following deliveries <39 weeks after confirmation of fetal lung maturity with scheduled deliveries ≥39 weeks. METHODS: A retrospective cohort study examining neonatal outcomes of women who were delivered following documented fetal pulmonary maturity at 36, 37, and 38 weeks compared to women undergoing a scheduled delivery at 39, 40, and 41 weeks. The χ(2)-test and Student's t-test were used to compare categorical and continuous data, respectively. RESULTS: Delivery prior to 39 weeks following fetal pulmonary maturity was associated with a 8.4% composite neonatal morbidity rate as compared to 3.3% for deliveries at 39 weeks or greater (relative risk [RR] 2.9; confidence interval [CI] 2.4-3.6). Neonatal respiratory morbidity was significantly higher (5.4%) for those delivering at less than 39 weeks with documented fetal pulmonary maturity as compared to 2.1% for those delivering at 39 weeks or greater (RR 3.0; CI 2.3-3.9). Increased neonatal morbidity persisted for those delivered prior to 39 weeks even after excluding all diabetics (p < 0.001). Significant increases in neonatal morbidity were noted for deliveries prior to 39 weeks regardless of the mode of delivery. CONCLUSION: Despite fetal pulmonary maturity, delivery before 39 weeks is associated with significantly increased neonatal morbidity when compared to scheduled deliveries at 39 weeks or greater.

Full-term neonatal intenstive care unit admission in an urban community hospital: the role of respiratory morbidity.

OBJECTIVE: To investigate the incidence of respiratory morbidity among full-term neonatal intenstive care unit (NICU) admissions and identify risk factors for such admissions. METHODS: We performed a retrospective cohort study of NICU admissions between 1/06 and 12/08. We included neonates between 37 and 40 weeks with a diagnosis of transient tachypnea of the newborn (TTN), respiratory distress syndrome (RDS), pneumonia, pneumothorax, and meconium aspiration syndrome. Obstetrical outcomes were compared with a control group of women during the same period whose neonates were not admitted to the NICU. RESULTS: Two-hundred two infants admitted to the NICU with respiratory morbidity were compared with 9580 controls. TTN comprised the majority of the respiratory morbidity. Only RDS was associated with cesarean delivery. CONCLUSION: RDS remains a significant morbidity in full-term NICU admission. When compared with controls, admissions to our NICU with any respiratory morbidity were more likely to be delivered by cesarean to a mother with hypertension or diabetes during pregnancy.

Toxoplasmosis, parvovirus, and cytomegalovirus in pregnancy.

Several infections in adults warrant special consideration in pregnant women given the potential fetal consequences. Among these are toxoplasmosis, parvovirus B19, and cytomegalovirus. These infections have an important effect on the developing fetus depending on the timing of infection. This article reviews the modes of transmission as well as maternal and neonatal effects of each of these infections. In addition, recommended testing, fetal surveillance, and treatment where indicated are outlined.

Identifying relative cut-off scores with neural networks for interpretation of the Minnesota Living with Heart Failure questionnaire.

BACKGROUND: Quality of life (QoL) is an important end point in heart failure (HF) studies. The Minnesota Living with Heart Failure questionnaire (MLHFQ) is the instrument most widely used to evaluate QoL in Heart Failure (HF) patients. It is a questionnaire containing 21 questions with scores ranging from 0 to 105. A best cut-off value for MLHFQ scores to identify those patients with good, moderate or poor QoL has not been determined. OBJECTIVE: To determine a cut-off score for the MLHFQ based on the neural network (NN) approach. These cut-off scores will help discriminate between HF patients having good, moderate or poor QoL. METHODS: This research was carried out in the context of a longitudinal cohort study of new patients attending specialized HF clinics in six participating centers in Quebec, Canada. Patients completed a questionnaire that included the MLHFQ. In addition to this scale, self-perceived health status and clinical information related to the severity of HF were obtained including: the New York Heart Association (NYHA) functional class, 6 minute walk test and survival status. We analyzed the database using NN and conventional statistical tools. The NN is a statistical program that recognizes clusters of MLHFQ and relates similar QoL measures to one another. Among the 531 eligible patients, 447 patients with complete questionnaires were used to build randomly two sets for training (learning set) and for testing (validation set) the NN. RESULTS: Participants had a mean age of 65 years and 24% were women. The median MLHFQ score was 45 (inter-quartile range: 27 to 64). NN identified 3 distinct clusters of MLHFQ that represent the full spectrum of possible scores on the MLHFQ. We estimated that a score of < 24 on the MLHFQ represents a good QoL, a score between 24 and 45 represents a moderate QoL, and a score > 45 represents a poor QoL. Validation with the different severity measures confirmed these categories. These cut-offs allowed us to reach a good total accuracy (91%). These cutoffs were strongly correlated with survival status (p = 0.004), self-perceived health status (p = 0.0032), NYHA functional class (p<0.0001) and standardized 6 minutes walk test (p = 0.05) CONCLUSION: The identification of three levels of MLHFQ should be useful in clinical decision making.

Prevalence of high-risk human papillomavirus in an inner-city population with atypical squamous cells of undetermined significance.

OBJECTIVE: To compare the prevalence of high-risk human papillomavirus (HPV) in patients with atypical squamous cells of undetermined significance (ASCUS) cytology in an inner-city clinic and a private office population to determine if HPV screening is useful in either group before colposcopy. METHODS: After an institutional review board approval at Hartford Hospital, we reviewed the charts of patients with ASCUS cytology and high-risk HPV DNA who were seen at the Community Health Services, Inc. in Hartford, CT (clinic patients), between January 1, 2000, and July 1, 2004, and at a private practice site in Hartford, CT (private patients), between January 1, 2004, and December 31, 2004. All charts were reviewed for demographic information, history of sexually transmitted diseases, tobacco, alcohol, and other drug use. A power analysis indicated that 32 patients would be needed in each group for a p <.05 with 80% confidence. RESULTS: A total of 257 patient's charts were reviewed: 79 clinic charts and 178 private office charts. Three patients were eliminated due to a lack of HPV testing. High-risk HPV was identified in 94.9% of the clinic patients and 45.5% of the private patients. The populations were statistically different with regard to history of chlamydia (26.6% of clinic patients and 6.2% of private office patients; p <.0001), gonorrhea (11.4% clinic patients and 1.1% of private patients; p =.0005), and trichomonas (7.6% of clinic patients and 0% of private office patients; p =.0007). The prevalence of herpes simplex virus in clinic patients was 2.5%, whereas it was present in 6.2% of private patients (p =.35). Tobacco use was significantly higher in clinic patients (31.6% of clinic patients and 15.2% of private patients; p =.009). CONCLUSIONS: In our study, 94.9% of the women in the clinic population with an ASCUS cytology had high-risk HPV compared with a rate of 45.5% in the private patients studied. Because most clinic patients with ASCUS have high-risk HPV, it is reasonable to defer reflex testing for HPV in these high-risk patients and proceed straight to colposcopy.

Betamethasone vs dexamethasone for the prevention of morbidity in very-low-birthweight neonates.

OBJECTIVE: The purpose of this study was to compare neonatal outcomes in very-low-birthweight infants who were exposed to antenatal betamethasone vs dexamethasone. STUDY DESIGN: We reviewed all inborn very-low-birthweight infants from January 1997 through February 2006. Maternal medical records were reviewed to determine the type of antenatal steroids that each patient received; neonatal outcomes were compared using chi-square and Student t tests. RESULTS: There were 334 very-low-birthweight infants who met the criteria for evaluation: 186 infants received betamethasone, and 148 infants received dexamethasone. There were no differences in race, gestational age at delivery, or mean birthweight between the 2 groups. There were significantly lower rates of respiratory distress syndrome and bronchopulmonary dysplasia in the betamethasone group, compared with the dexamethasone group. Other neonatal outcomes were similar in both groups. CONCLUSION: Antenatal betamethasone was associated with a significantly lower rate of pulmonary complications caused by prematurity, when compared with dexamethasone.

Resident education and training in urogynecology and pelvic reconstructive surgery: a survey.

The aim of the study is to assess satisfaction with urogynecology education among obstetrics and gynecology residents. An Internet-based survey was designed to obtain a cross-sectional sample of third- and fourth-year residents. Didactic and surgical training as well as perceived surgical competency were assessed. Responses were received from 205 residents for this convenience sample. Nearly half (46%) of the respondents were unsatisfied with urogynecology resident education. There was no significant difference between respondents from academic programs and community programs with regard to overall satisfaction, the opportunity to work with the presence of a fellowship-trained urogynecologist or having a dedicated urogynecology rotation. Respondents were more satisfied with their education if they did a urogynecology rotation or worked with a fellowship-trained urogynecologist. Female pelvic medicine and reconstructive surgery fellows were involved in the education of 23.9% of the respondents. Most respondents indicated comfort performing cystoscopy, anterior and posterior repairs, and McCall's culdoplasty following graduation. Overall, respondents indicated that residency training in urogynecology is less and later than desired, although they did feel competent at some urogynecologic surgeries.

A randomized comparison of two regimens of misoprostol for second-trimester pregnancy termination.

OBJECTIVE: The purpose of this study was to compare the efficacy and side effects of two different misoprostol regimens for second-trimester pregnancy termination. STUDY DESIGN: We performed a randomized clinical trial in patients who were at 14 to 23 weeks of gestation and who were admitted for medical termination of pregnancy. All patients received 800 microg of vaginal misoprostol and were assigned randomly to 400 microg of oral misoprostol or 400 microg of vaginal misoprostol every 8 hours. Efficacy and side effects were compared. The mean induction time of the study group was compared with that of an historic control group that had received 400 microg vaginally every 12 hours. RESULTS: Forty-three women were assigned randomly, 22 women to vaginal misoprostol and 21 women to oral misoprostol. Induction time and hospital stay were slightly shorter for the oral group; however, the differences were not significant. Side effects were similar for both groups. CONCLUSION: After an initial 800 microg dose of vaginal misoprostol, a regimen of 400 microg of oral misoprostol every 8 hours is as effective as the same dose of vaginal misoprostol with no additional side effects, which provides a convenient alternative for midtrimester pregnancy termination.

Clinical implications of velamentous cord insertion in triplet gestations.

OBJECTIVE: The purpose of this study was to determine the incidence of velamentous cord insertion and to evaluate the association between velamentous cord insertion and small-for-gestational age infants in triplet gestations. STUDY DESIGN: We reviewed our computerized database to identify all cases of velamentous cord insertion in triplet gestations who were delivered at our institution from January 1995 through December 1999. Triplet gestations without velamentous cord insertion who were delivered during this period were used as control subjects. Birth weights and pregnancy outcomes were obtained from medical records. Data were analyzed with descriptive statistics, analysis of variance, and chi(2) with Fisher exact test, where appropriate. RESULTS: Thirty-nine sets of triplets (117 infants) were delivered during the study period. Of these, 11 sets of triplets (28.2%) had a velamentous insertion of at least one umbilical cord. Infants with velamentous cord insertion were more likely to be small-for-gestational age than infants without velamentous cord insertion (33% vs 8%, P =.02). There were no significant differences in the rates of pregnancy complications between the two groups. CONCLUSION: Velamentous cord insertion is found frequently in triplet gestations and is significantly associated with small-for-gestational age in triplet neonates.