Comparing Diagnosis of Fetal Growth Restriction and the Potential Impact on Management and Outcomes Using Different Growth Curves.

OBJECTIVES: The diagnosis of fetal growth restriction (FGR) is managed with close fetal surveillance and often requires iatrogenic delivery, as there is an associated increased risk of fetal demise. However, there is no standard reference for fetal growth. We sought to compare the intrauterine growth curve of Hadlock et al (Radiology 1991; 181:129-133) to other known growth curves to determine which one best identifies fetuses at risk without overburdening the patient and health care system with unnecessary intervention. METHODS: We retrospectively reviewed charts of singleton euploid pregnancies with a diagnosis of FGR (per Hadlock) at a tertiary care center from June 2014 to May 2015. We applied the estimated fetal weights from ultrasound at diagnosis of FGR to 4 population-based growth curves by Brenner et al (Am J Obstet Gynecol 1976; 126:555-564), Williams et al (Obstet Gynecol 1982; 59:624-632), Alexander et al (Obstet Gynecol 1996; 87:163-168), and Duryea et al (Obstet Gynecol 2014; 124:16-22) and reassessed the incidence of FGR using each curve. We reviewed pregnancy demographics, risk factors, pregnancy management, and outcomes of FGR cohorts on each curve to evaluate whether poor outcomes may be missed or interventions may be avoided using the population-based curves. A sensitivity analysis was also done to see how well each curve predicted small-for-gestational-age birth weights. RESULTS: Applying any of the population-based growth curves decreased the number of FGR diagnoses, iatrogenic deliveries, and primary cesarean deliveries. Brenner's growth curve identified the least number of FGR diagnoses at 22 of the 107 identified by Hadlock. Williams' growth curve performed best in the sensitivity analysis with sensitivity of 99% and specificity of 97%. A small number of patients with absent/reversed end-diastolic flow would have been missed by applying the population curves. CONCLUSIONS: Applying the population-based growth curves instead of Hadlock's for diagnosis of FGR decreases its incidence, therefore decreasing the number of visits for ultrasound and fetal surveillance and the number of iatrogenic deliveries. However, using these curves could miss a few fetuses with increased risk of fetal demise.

Diagnosing rupture of membranes using combination monoclonal/polyclonal immunologic protein detection.

OBJECTIVE: To compare the accuracy of a new combination monoclonal/polyclonal immunoassay point-of-care test with that of current conventional clinical assessment for diagnosis of ruptured amniotic membranes. STUDY DESIGN: This was a multicenter prospective observational study performed in patients presenting with signs or symptoms of ruptured amniotic membranes. This clinical trial included 3 sites in the United States. Initial evaluation included both the standard clinical assessment for rupture of membranes (ROM) (speculum examination for fluid pooling, ferning, and nitrazine test), as well as the use of a new combination immunoassay test containing a combination monoclonal/polyclonal antibody approach to detect placental protein 12 (PP12) and alpha-fetoprotein (AFP). ROM was diagnosed if fluid was seen leaking from the cervical os, or if 2 of the 3 conditions were present: pooling of fluid, positive nitrazine test, or ferning. ROM was confirmed on review of the medical records following delivery. RESULTS: Of the 285 patients (15-42 weeks of gestation), the false positive rate for the new combination immunoassay test was 9% and the false negative rate was 0.5%, sensitivity 99%, specificity 91%, positive and negative predictive values of 95% and 99%, respectively. The conventional clinical evaluation's sensitivity was 85%, specificity 98%, with positive and negative predictive values of 99% and 77%. Ferning's sensitivity was 99%, specificity 72%, with positive and negative predictive values of 80% and 99%. Nitrazine testing's sensitivity was 93%, specificity 83%, with positive and negative predictive values of 90% and 88%. CONCLUSION: This combination monoclonal and polyclonal immunoassay test that detects PP12 and AFP has an efficacy comparable to conventional testing and better than the individual components of conventional testing (ferning, nitrazine), is a quick and easy-to-use test that can be performed by a wider variety of care providers, and can improve triage and management of patients suspected of ROM.

Obesity and pregnancy.

UNLABELLED: Obesity is dramatically increasing throughout the world and is known to be a major cause of preventable morbidity and mortality. By screening women for obesity and obesity-related complications, the obstetrician/gynecologist can help improve health outcomes for women and their infants. Many pregnancy complications have been linked to obesity ranging from increased risk of gestational diabetes and hypertension to increased risk of cesarean delivery and postoperative wound infection. This article reviews antepartum, intrapartum, and postpartum complications associated with obesity in pregnancy and offers suggestions to optimize care and improve outcomes. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES: After completion of this article, the reader should be able to define obesity in pregnancy, to list the various complications associated with obesity, and to describe the limitations of ultrasonography in obese gravidas.

Hydrops fetalis secondary to parvovirus B19 infections.

BACKGROUND: Fetal infection by human parvovirus B19 is a common cause of fetal anemia, nonimmune hydrops fetalis, and spontaneous abortion and can result in fetal death. Recent improvements in diagnosing parvovirus infections and the availability of intrauterine transfusion have reduced the overall rate of fetal loss after maternal exposure. METHODS: We report two cases of maternal parvovirus infection with classic findings of hydrops fetalis and review various aspects of parvovirus infection with emphasis on the developing management options in pregnancy. RESULTS AND CONCLUSIONS: Different management led to different results. In the first case there was normal neonatal and infantile development, and in the second case, the fetus died. With accurate laboratory testing, obstetric sonography, and fetal transfusion, the fetal mortality from parvovirus infection has been reduced considerably, and most pregnancies complicated by maternal parvovirus infection result in healthy outcomes.

The microbiological effects of endovaginal sonographic assessment of cervical length.

OBJECTIVE: To determine whether performance of endovaginal sonography for the measurement of cervical length results in a statistically significant change in endocervical culture results. METHODS: Women attending a routine prenatal clinic were offered enrollment in the study. Exclusion criteria included the presence of a cervical cerclage, vaginal examination or coitus within the preceding 24 hours, antibiotic therapy within the preceding 7 days, or the presence of ruptured membranes. A sterile speculum examination and collection of cervical cultures were performed before (initial) and immediately after (final) endovaginal sonographic measurement of cervical length. Quantitative cultures were completed and evaluated for differences in growth by a standardized 4-quadrant technique. RESULTS: A total of 25 women enrolled and completed the study protocol. Quantitative assessment of colony growth showed that the mean growth in the initial samples +/- SD was 3.48+/-1.74, with 1+ indicating growth in 1 quadrant; 2+, growth in the first and second quadrants; 3+, growth in the first, second, and third quadrants; and 4+, growth in all quadrants. The mean growth cultured in the final sample was 3.79+/-2.26 (P = .364; 95% confidence interval of the difference, -1.00 to +381). CONCLUSIONS: The results of this study do not show a statistically significant inoculation effect associated with performance of endovaginal sonography for the measurement of cervical length.