Correlation of bile acids and aspartate-aminotransferase with outcomes in cholestasis of pregnancy.

OBJECTIVE: To identify laboratory data that correlates with poor perinatal outcomes. METHODS: A retrospective chart review of women with intrahepatic cholestasis of pregnancy (ICP), admitted for delivery between January 1, 2013 and December 31, 2017, was performed. Chi-square, student's t-test, and ANOVA statistical analysis was performed. The receiver-operator characteristic curves were plotted for the prediction of each category of perinatal outcome and the areas under the curves were determined. All p-values were two-sided, and p < 0.05 was considered statistically significant. RESULTS: Analysis of the 61 ICP cases showed no occurrence of the intrauterine fetal demise (IUFD), stillbirth, abruption, or neonatal demise. ROC curve analysis revealed a statistically significant correlation between bile acid and AST levels and perinatal outcomes. A bile acid (BA) level equal to or greater than 37µmol/L strongly predicted spontaneous preterm labor in women affected by ICP with a sensitivity of 100% and specificity of 60.70% (p = 0.002). A BA level equal to or greater than 42µmol/L strongly predicted meconium-stained amniotic fluid with a sensitivity of 85.70% and specificity of 66.70% (p = 0.006). AST levels equal to or greater than 62 IU/L strongly predicted NICU admission with a sensitivity of 81.30% and specificity of 62.20% (p = 0.002). AST levels equal to or greater than 75 IU/L strongly predicted hyperbilirubinemia in the neonates with a sensitivity of 87.50% and specificity of 69.80% (p = 0.001). CONCLUSIONS: There is a statistically significant correlation between elevated BA and elevated AST levels and adverse perinatal outcomes.

Campomelic dysplasia: case report and review.

Initial ultrasound of a fetus in the third trimester demonstrated shortened and bent fetal extremities with a narrow and misshapen thorax. These findings were suggestive of a fetus affected with a possible lethal skeletal dysplasia. Decisions regarding antepartum, intrapartum and neonatal care were made in this context. A newborn with campomelic dysplasia was delivered and suffered a rapid downhill course.

Fetal heart rate monitoring casebook. Amnioinfusion as fetal therapy.

Amniotic fluid (AF) plays multiple roles in fetal development and wellbeing. A global consideration of the possibilities of AF manipulation allows for the maximum benefits to be derived from assessing and selectively augmenting AF in clinical practice.

Funic presentation as a complication of external cephalic version. A case report.

BACKGROUND: Breech presentation is associated with increased risk. External cephalic version (ECV) has been successful in decreasing the incidence of intrapartum breech presentation. CASE: Funic presentation occurred as a complication of successful ECV. CONCLUSION: The wide-spread use of version calls for increased surveillance for adverse sequelae. At the completion of ECV, ultrasound analysis, pelvic examination and fetal heart rate monitoring are appropriate to exclude serious cord complications.

Impact of genetic counseling on primary and preventive care in obstetrics and gynecology.

OBJECTIVE: To evaluate the utility of the prenatal three-generation pedigree in assessment of the obstetric patient's primary medical risks. STUDY DESIGN: In a case series, 250 charts of patients referred for amniocentesis on the basis of advanced maternal age were reviewed for a significant genetic risk of a primary care disorder. RESULTS: A total of 40 patients (16%) were at significantly increased risk for a primary care disorder. Thirty-eight patients (15.2%) were at increased risk for medical conditions for which early screening, detection and/or intervention are established. CONCLUSION: For the advanced maternal age population, formal genetic risk assessment performed prior to amniocentesis can be beneficial in primary care risk assessment.

The importance of genetic counseling before amniocentesis.

OBJECTIVE: To determine the adequacy of genetic risk assessment among primary care providers and to evaluate the efficacy of genetic counseling before "routine" genetic amniocentesis. STUDY DESIGN: A retrospective cohort study was undertaken. Charts of 275 consecutive patients referred for genetic counseling and amniocentesis on the basis of advanced maternal age (AMA) were compared with charts of 103 consecutive patients referred for an abnormal maternal serum alpha-fetoprotein (MSAFP) finding. Pedigree information obtained during counseling of these patients was compared with the family histories charted by the referring physician. RESULTS: In 35.6% of pedigrees evaluated, a significant genetic risk was discovered during genetic consultation that had not been noted by the referring physician. Furthermore, 9.8% of AMA patients and 10.7% of patients with abnormal MSAFP results underwent additional genetic testing or screening on the basis of genetic counseling. Additional genetic testing of 0.8% of amniotic fluid specimens was done on the basis of the genetic risk assessment elicited during counseling. Although a significant difference in increased genetic risk was observed between the AMA and abnormal MSAFP groups (AMA 30.8% positive, MSAFP 48.5% positive; relative risk 0.81, confidence limit 0.70 to 0.93), no significant difference was observed between the two groups with regard to patient interventions (relative risk 0.97, confidence limit 0.79 to 1.21) or amniotic fluid testing (p = 0.57, not significant). CONCLUSIONS: The data support the importance of genetic counseling before amniocentesis. Furthermore, the findings support the relevancy and usefulness of genetic counseling in more accurately ascertaining genetic risk and in maximizing the benefits of genetic evaluation of patients seemingly at low risk for other genetic diseases.

CAD modeling of the birth process. Part II.

We are engaged in studying the process of human birth by developing a computer-based dynamic model that can be adapted to specific birth scenarios. The individual characteristics of a given pregnant woman and fetus, embedded in their clinical measurements and CT and MRI images, are captured in the model. One can thereby predict adverse events that might happen during labor and delivery. Based on our findings from a preliminary design and execution of this model, we believe it holds great promise as an accurate, cost-effective diagnostic and teaching tool that will help predict conditions during individual labor scenarios that might cause traumatic birth injuries, and thereby enable us to make the most informed clinical decisions possible.

Abnormal fetal presentations.

Current trends in the obstetrical management of abnormal fetal presentations have contributed to the sharp rise in the overall use of cesarean section for delivery. Recent literature questions this need. Many investigators are re-evaluating this shift from more traditional approaches.

Assessment of computed tomographic pelvimetry within a selective breech presentation management protocol.

A vital component of selective protocols in term breech presentation management is exclusion of the gravida with borderline pelvic dimensions. Computed tomographic (CT) pelvimetry was employed to evaluate potential candidates for a trial of labor with a breech fetus at term. Thirty-seven of 39 women who underwent labor after this selection had a successful assisted vaginal breech delivery. Adequate pelvic dimensions by CT pelvimetry reliably predicted a safe vaginal delivery in patients managed within a standard breech protocol.