The Accuracy and Cost-Effectiveness of Selective Fetal Echocardiography for the Diagnosis of Congenital Heart Disease in Patients with Pregestational Diabetes Stratified by Hemoglobin A1c.

OBJECTIVE: To evaluate the accuracy of antenatal diagnosis of congenital heart disease (CHD) using screening methods including a combination of elevated hemoglobin A1c, detailed anatomy ultrasound, and fetal echocardiography. STUDY DESIGN: This is a retrospective cohort study of all pregnancies complicated by pregestational diabetes from January 2012 to December 2016. The sensitivity, specificity, positive predictive value, and negative predictive value were calculated for each screening regimen. The incremental cost-effectiveness ratio (ICER) was calculated for each regimen with effectiveness defined as additional CHD diagnosed. RESULTS: A total of 378 patients met inclusion criteria with an overall prevalence of CHD of 4.0% (n = 15). When compared with a detailed ultrasound, fetal echocardiography had a higher sensitivity (73.3 vs. 40.0%). However, all cases of major CHD were detected by detailed ultrasound (n = 6). Using an elevated early A1c > 7.7% and a detailed ultrasound resulted in a sensitivity and specificity of 60.0 and 99.4%, respectively. The use of selective fetal echocardiography for an A1c > 7.7% or abnormal detailed anatomy ultrasound would result in a 63.3% reduction in cost per each additional minor CHD diagnosed (ICER: $18,290.52 vs. $28,875.67). CONCLUSION: Fetal echocardiography appears to have limited diagnostic value in women with pregestational diabetes. However, these results may not be generalizable outside of a high-volume academic setting.

Determination of free and total myo-inositol in infant formula and adult/pediatric nutritional formula by high- performance anion exchange chromatography with pulsed amperometric detection, including a novel total extraction using microwave-assisted acid hydrolysis and enzymatic treatment: first action 2012.12.

After an assessment of data generated from a single-laboratory validation study published in J. AOAC Int. 95, 1469-1478 (2012), a method for determining total myo-inositol in infant formula and adult/ pediatric nutritional formula by high-performance anion exchange chromatography with pulsed amperometric detection (HPAEC-PAD), including extraction by using microwave-assisted acid hydrolysis and enzymatic treatment was presented for consideration by AOAC during the AOAC Annual Meeting held in Las Vegas, NV, from September 30 to October 3, 2012. The Expert Review Panel on Infant Formula and Adult Nutritionals concluded that the method met the criteria set by the standard method performance requirements (SMPRs) for the determination of free myo-inositol and approved the method as AOAC Official First Action. The method also determines total myo-inositol, but includes bound sources that the SMPRs exclude. The method involves using HPAEC-PAD for free myo-inositol and a total myo-inositol determination by two different techniques. The first technique uses the conventional acid hydrolysis with 6 h incubation in an autoclave. The second uses a microwave-assisted acid hydrolysis with enzymatic treatment that decreases the extraction time.

Evaluation of the fetal heart at 14 to 18 weeks' gestation in fetuses with a screening nuchal translucency greater than or equal to the 95th percentile.

OBJECTIVES: The purpose of this study was to determine whether normal fetal cardiac anatomy could be successfully demonstrated and congenital heart disease detected transabdominally at 14 to 18 weeks' gestation in fetuses with a nuchal translucency greater than or equal to the 95th percentile. METHODS: In this retrospective chart review, grayscale images, Z scores, and Doppler evaluations, including pulsed, color, and spectral Doppler imaging, were reviewed to determine whether fetal heart evaluation findings at 14 to 18 weeks' gestation were normal or abnormal. RESULTS: Normal cardiac anatomy was successfully evaluated in 32 of 33 normal cases; only an aortic arch and a ductal arch were not successfully visualized in 1 case. Major congenital heart disease was detected prenatally in 4 abnormal cases. CONCLUSIONS: The fetal heart can be successfully evaluated at an earlier gestational age but may be dependent on the skill of the sonographer and reading physician. Maternal decisions can be made earlier in gestation, before the pregnancy is obvious, and can allow planning for a pregnancy that will need to be delivered at a medical center that has a level 3 nursery.

Analysis of free and total myo-inositol in foods, feeds, and infant formula by high-performance anion exchange chromatography with pulsed amperometric detection, including a novel total extraction using microwave-assisted acid hydrolysis and enzymatic treatment.

A method for the analysis of free and total myo-inositol in foods, feeds, and infant formulas has been developed and validated using high-performance anion exchange chromatography with pulsed amperometric detection. The option of a free myo-inositol determination or a complete total myo-inositol determination from main bound sources can be achieved. These sources include phytates, lower'phosphorylated forms, and phosphatidylinositol. This approach gives the option for subtraction of myo-inositol from nonbioavailable sources when it is quantified using other methods if a total bioavailable myo-inositol result is desired for nutritional labeling of a product. The free analysis was validated in a milk-based infant formula, giving RSD(R) of 2.29% and RSD, of 2.06%. A mean recovery of 97.9% was achieved from various spike levels of myo-inositol. Certified National Institute of Standards and Technology reference material verified the method's compatibility and specificity. Two different total analyses were validated in a soy-based infant formula and compared. One technique involved using a conventional acid hydrolysis with autoclave incubation for 6 h, while the other used a novel technique of microwave-assisted acid hydrolysis with enzymatic treatment that can minimize extraction to 1 day. The autoclave analysis had RSD(R) of 2.08% and RSDr of 1.55%, along with a mean spike recovery of 102.1% at various myo-inositol spike levels. The microwave/enzyme total analysis had RSD(R) of 4.34% and RSD, of 4.70%, along with a mean spike recovery of 104.2% at various spike levels of myo-inositol. Main sources of myo-inositol including phytic acid and phosphatidylinositol were tested with both total analyses. Mean recoveries of phytic acid and phosphatidylinositol through the autoclave total analysis were 90.4 and 98.3%, respectively. Mean spike recoveries for these same sources in soy- based infant formula through the microwave/enzyme total analysis were 97.2 and 96.3%, respectively. Comparison of soy-based infant formula and corn grain samples with high levels of these main sources showed in similar results, indicating both total analyses are acceptable for use. An additional glycerol kinase step was also developed to remove glycerol from the chromatographic elution window of myoinositol in samples with high levels of glycerol.

Influence of maternal body mass index and gestational age on accuracy of first trimester gender assignment.

OBJECTIVE: To determine the influence of maternal body mass index (BMI) and gestational age on the accuracy of image acquisition, first trimester fetal gender determination, and correct assignment. METHODS: Women presenting for first trimester aneuploidy risk assessment at 11(0) to 13(6) weeks were prospectively enrolled. A mid-sagittal view of the fetus including the genital tubercle was obtained. The angle of the genital tubercle was measured with male assigned for angle >30°, female <10°, and indeterminate if 10-30°. This was compared with gender at birth. The influence of maternal and pregnancy characteristics on both image acquisition and correct gender assignment were evaluated. RESULTS: A total of 256 women with 260 fetuses undergoing first trimester risk assessment were enrolled. The genital tubercle was identified in 247/260 (95%) of cases. Image acquisition was negatively influenced by increasing maternal BMI and early gestational age (34.8 ± 7.7 vs. 27.0 ± 6.1 kg/m(2), p < 0.0001 and 12.3 ± 0.5 vs. 12.6 ± 0.5 weeks, p = 0.02). Gender was assigned in 93.1% and correctly matched in 85.8% of fetuses. Positive predictive value (PPV) for male and female fetuses were 88.9% and 79.8%, respectively. Correct gender assignment was more likely in male compared with female fetuses (91.4 vs. 80.5%, p = 0.02). CONCLUSION: Increasing maternal BMI negatively influences image acquisition during the first trimester for gender determination, but does not decrease the accuracy of correct gender assignment if the image is obtained.

Ultrasound prediction of growth abnormalities in fetuses with gastroschisis.

OBJECTIVE: We seek to determine whether (1) mean abdominal circumference (AC) of fetuses with gastroschisis is smaller than published normative values, (2) diagnosis of AC ≤ 2.5th percentile is supported by postnatal diagnosis of small-for-gestational age (SGA) and (3) adverse neonatal outcomes are more common in fetuses affected by gastroschisis with a sonographically measured small AC. METHODS: Retrospective review of pregnancies complicated with gastroschisis between 2000 and 2008. Patient demographics, method of closure, length of stay, use of ventilator support and gastrointestinal complications were compared. RESULTS: Seventy-four fetuses were identified with 368 ultrasound observations. Mean AC of fetuses with gastroschisis fell between the 2.5th and 50th percentile for gestational age. Thirty patients had AC measurements ≤ 2.5th of which 50% were SGA at delivery. Eleven of the 74 fetuses were diagnosed with intrauterine growth restriction (IUGR) and all were SGA. Birth weight was lower in those with a small AC (2104 g vs. 2665 g, p<0.001). There were no other differences in outcomes. CONCLUSION: AC values fell within the normal range of normative curves. Fifty percent of fetuses with small AC were SGA at birth. Neonatal outcomes in patients with small AC are similar to those with a normal AC.