Risk factors for delayed termination of pregnancy following increased nuchal translucency.

OBJECTIVES: Termination of pregnancy after increased nuchal translucency (NT) is a common occurrence. This study aimed to identify characteristics of a cohort with a NT ≥3.0 mm who underwent a pregnancy termination ≥15 weeks compared with those who terminated <15 weeks. METHODS: All NT ≥3.0 mm identified within our department over an 11-year period (2010-2021) (n = 689) were retrospectively examined and characteristics of the cohort of increased NTs ending in termination were further categorized. RESULTS: There were 221 (32.1%) individuals with an increased NT (≥3 mm) who underwent a termination of pregnancy within our study period (2010-2021). Pregnancy termination occurred at a gestational age <15 weeks in 162 (73.3%) and ≥15 weeks in 59 individuals. Pregnant individuals without positive NIPT for aneuploidy were at a higher risk for a ≥15-week termination (p = 0.004). In 29% (17/59) of late terminations, there were additional imaging findings after the NT scan (ultrasound, echocardiogram, magnetic resonance imaging) that ultimately triggered the decision to pursue termination. CONCLUSIONS: As the options for workup of an increased NT expand, potential delays in decision-making surrounding termination increase. This study identifies multiple reasons for delayed termination and proposes several approaches to care aimed at maximizing diagnostic information by imaging and diagnostic testing in an expedited manner.

Increased use of diagnostic testing after increased nuchal translucency: The influence of non-invasive prenatal testing and chromosomal microarray.

OBJECTIVE: The utilization of non-invasive prenatal testing (NIPT) and chromosomal microarray (CMA) has significantly altered the options for testing following the diagnosis of an increased nuchal translucency (NT). This study defines the rates of utilization of diagnostic testing in the pre-NIPT, pre-CMA, and post-CMA eras. METHODS: We retrospectively examined NT scans performed in our department from January 2010 to December 2020 and identified all NTs ≥3.0 mm for analysis. We divided our data into three distinct periods (2010-2012, 2013-2016, and 2017-2020) corresponding to our institutional practice shifts in recommending and offering use of NIPT (2013) and CMA (2016), respectively. RESULTS: 689 patients with NT ≥ 3.0 mm met inclusion criteria in our study, of which 355 (51.5%) individuals underwent diagnostic testing and 334 (48.5%) did not. There was a significant decline in rates of diagnostic testing with NIPT (2013), which has returned to pre-NIPT levels with the availability of microarray. CONCLUSIONS: Since the routine use of CMA (2016), the rates of diagnostic testing for increased NT have returned to pre-NIPT levels. This study validates data suggesting an initial decline in the rates of diagnostic testing following abnormal NT but suggests that the decline may be reversing in the post-CMA era due to a rise in rates of chorionic villus sampling.

Fetal adrenal gland volume and preterm birth: a prospective third-trimester screening evaluation.

OBJECTIVE: Given the importance of the fetal adrenal gland in producing hormones critical to labor, we sought to evaluate whether sonographic three-dimensional measurements of the adrenal gland are a useful screening tool for spontaneous preterm birth (SPTB). METHOD: We prospectively screened 128 non-anomalous singletons from 24 to 36 weeks' gestation with volumetric measurements of the fetal adrenal gland at their indicated antenatal sonogram. Labor and delivery outcomes were assessed and compared with respect to adrenal volume. RESULTS: When corrected for estimated fetal weight, the 11 women (9%) who delivered following SPTB had smaller adrenals than those who did not, 0.33 cm(3)/kg compared with 0.57 cm(3)/kg, respectively (p = 0.006). There was no difference in volumes between those who delivered by SPTB within 7 days or greater than 14 days from measurement (0.34 cm(3)/kg versus 0.33 cm(3)/kg, p = 0.79). Among women at increased risk of SPTB, those with SPTB had smaller adrenals than those who did not: 0.32 cm(3)/kg versus 0.53 cm(3)/kg, p = 0.06. CONCLUSION: We found fetal adrenal glands significantly smaller for those delivering preterm. Given the prior literature and our asymptomatic population, our data support multiple pathways leading to SPTB.

Discovery and management of diaphragmatic hernia related to abandoned epicardial pacemaker wires in a pregnant woman with {S,L,L} transposition of the great arteries.

Epicardial pacemaker leads placed during childhood are often not removed when transvenous systems are placed later in life. The risk of complications related to retained pacemaker leads and generators is not clear but is generally considered low. We report the case of a 23-year-old pregnant woman who presented with left upper quadrant pain at 20 weeks gestation. The patient was born with {S,L,L} transposition of the great arteries and had high-grade conduction disease in infancy compelling epicardial pacemaker placement. A standard transvenous pacemaker was placed at age 9 years, without removal of the epicardial system. The patient's abdominal pain was attributed to herniation of abdominal contents through a diaphragmatic defect at the site of the abandoned epicardial pacing wire. Her pain improved spontaneously but worsened later in pregnancy leading to repair of the diaphragmatic hernia via anterolateral thoracotomy at 30 weeks gestation. The procedure was well tolerated by mother and fetus. At 38 3/7 weeks gestation, the patient underwent uneventful delivery by cesarean section for breech presentation. This case illustrates the importance of multidisciplinary collaboration in the care of women with congenital heart disease.