Embryonic heart rate as a predictor of first-trimester pregnancy loss in infertility patients after in vitro fertilization.

OBJECTIVE: To determine if embryonic heart rate (EHR) is useful to predict first-trimester pregnancy outcome after in vitro fertilization (IVF). DESIGN: Retrospective analysis. SETTING: University-based infertility center. PATIENT(S): Six hundred fifty patients who completed IVF with singleton implantations from October 2002 to September 2006 were identified. INTERVENTION(S): Transvaginal sonography at 4-6 weeks' embryonic age. MAIN OUTCOME MEASURE(S): Embryonic heart rate at 4-6 weeks' embryonic age and first-trimester pregnancy outcome. RESULT(S): Ninety-five patients (14.6%) spontaneously aborted, and 555 (85.4%) patients had clinical pregnancies beyond the first trimester. Groups were similar regarding gravidity, parity, embryos transferred, embryonic age at time of sonogram for EHR, and infertility diagnosis. Mean maternal age was significantly higher in the group that spontaneously aborted. Mean EHR was significantly lower in the group that spontaneously aborted. Multivariate logistic regression confirmed the best predictors of poor pregnancy outcome: increasing maternal age (odds ratio [OR] 1.18) and lower EHR (OR 1.07). CONCLUSION(S): Embryonic heart rate, independent of maternal age, is useful to help predict first-trimester pregnancy prognosis after IVF. Infertility patients with a low EHR (

Inpatient management for a shortened cervix: who is really at risk?

OBJECTIVE: The objective of the study was to identify risk factors associated with spontaneous preterm delivery (SPD) within 2 weeks of admission in patients with a shortened cervix. STUDY DESIGN: We reviewed records of patients hospitalized in 2003-2004 with a cervix of 25 mm or less at less than 32 weeks' gestation. The primary outcome was SPD 2 weeks or less of admission. RESULTS: Sixty-six patients met inclusion criteria. Twelve delivered at 2 weeks or less of admission. There were no differences in maternal and gestational age at admission, history of SPD, and rate of multifetal pregnancy. Those with cervical length (CL) of 5 mm or less were more likely to deliver within 2 weeks than those with CLs 6-25 mm (50% vs 12.5%; P = .01). Logistic regression identified CL less than 5 mm as the only independent predictor of delivery within 2 weeks of admission (P = .01). CONCLUSION: CL of less than 5 mm in patients at less than 32 weeks' gestation is associated with a high rate of SPD within 2 weeks of diagnosis.

Intrapartum maternal glycemic control in women with insulin requiring diabetes: a randomized clinical trial of rotating fluids versus insulin drip.

OBJECTIVE: The purpose of this study was to determine whether continuous insulin infusion provides a greater degree of intrapartum maternal glycemic control than rotating between glucose and non-glucose containing intravenous fluids. STUDY DESIGN: Laboring patients with pregestational or gestational diabetes were recruited and randomized to an "insulin drip" or "rotating fluids" protocol. The primary outcome measure was mean maternal capillary blood glucose (CBG) levels (mg/dL). Power analysis indicated that 16 patients were needed in each arm to find a difference of 10 mg/dL. RESULTS: Fifteen patients were randomized to the rotating fluids protocol and 21 patients to an insulin drip. There was no difference in mean intrapartum maternal CBG levels (103.9 +/- 8.7 mg/dL and 103.2 +/- 17.9 mg/dL in the rotating fluids and insulin drip group, respectively, P = .89). Neonatal outcomes were also similar between the 2 treatment groups. CONCLUSION: In patients with insulin requiring gestational diabetes, intrapartum glycemic control may be comparable with a standard adjusted insulin drip or a rotation of intravenous fluids between glucose and non-glucose containing fluids.

Pregnancy interruption after second trimester diagnosis of fetal structural anomalies: the New Jersey Fetal Abnormalities Registry.

OBJECTIVE: The purpose of this study was to identify factors that predict a decision to interrupt a pregnancy in which there are fetal anomalies in the second trimester. STUDY DESIGN: The New Jersey Fetal Abnormalities Registry prospectively recruits and collects information on pregnancies (> or = 15 weeks of gestation) from New Jersey residents in whom a fetal structural anomaly has been suspected by maternal-fetal medicine specialists. Enrolled pregnancies that have major fetal structural abnormalities identified from 15 to 23 weeks of gestation were included. Outcomes were classified as either elective interruption or a natural pregnancy course, which might include a spontaneous fetal death or live birth. Predictors of elective interruption of pregnancy were examined with univariable and multivariable logistic regression analyses. RESULTS: Of the 97 cases, 33% of the women (n = 32) interrupted the pregnancy. Significant variables in the regression model that were associated with a decision to interrupt a pregnancy were earlier identification of fetal anomalies (19.0 +/- 2 weeks of gestation vs 20.5 +/- 2 weeks of gestation; P = .003), the presence of multiple anomalies (78% [25/32] vs 52% [33/63]; P = .01], and a presumption of lethality (56% [18/32] vs 14% [9/65]; P = .0001). These variables corresponded to an odds ratio for pregnancy interruption of 4.2 (95% CI, 1.0, 17.0) for multiple anomalies, 0.8 (95% CI, 0.7, 1.0) for each week of advancing gestational age, and 36.1 (95% CI, 2.9, 450.7) for presumed lethal abnormalities. CONCLUSION: Early diagnosis, the identification of multiple abnormalities, and an assessment of likely lethality of fetal anomalies are important factors for the optimization of parental autonomy in deciding pregnancy management.