Outcomes of pregnancies with more than one positive prenatal screening result in the first or second trimester

OBJECTIVE

To describe adverse outcomes and fetal abnormalities in women with a positive prenatal screening result for more than one disorder.

STUDY DESIGN

Study participants were drawn from a population of 452 901 women pregnant with singletons entering the California Prenatal Screening Program in their first-trimester. Risk assessment was provided for trisomy 21 and trisomy 18 in the first-trimester and trisomy 21, trisomy 18, neural tube defects, and Smith-Lemli-Opitz syndrome in the second-trimester. Inclusion in this study required positive screening for more than one of the screened conditions and a completed outcome of pregnancy survey.

RESULTS

A total of 874 women met our study inclusion criteria. Over 25% of these pregnancies had a fetus with a chromosomal abnormality. Of the euploid pregnancies, 6.9% had a fetus with a major birth defect. Of the pregnancies with a fetus with neither a chromosomal abnormality nor a major birth defect, 9.3% ended in fetal demise. Overall, more than 50% of women with multiple positive screening results had either a fetus with a birth defect or a poor pregnancy outcome.

CONCLUSION

Although it is rare to screen positive for more than one condition, such results indicate a very high risk for chromosomal abnormality, fetal demise, or structural abnormality.

Transporting without infusions: effect on door-to-needle time for acute coronary syndrome patients

BACKGROUND

Standard of care for patients with acute coronary syndrome/ST-segment elevation myocardial infarction (ACS/STEMI) is rapid revascularization of ischemic myocardium. Current optimal treatment is primary percutaneous coronary intervention (PCI) within 90 minutes after the patient accesses the health care system, and strategies to lower this time may improve outcomes.

OBJECTIVE

To compare interhospital transport times (TTs) before and after instituting a no-medication-infusion policy during transport of ACS patients. Our hypothesis was that transporting patients using only bolus medications would significantly reduce transport times without increasing hospital length of stay (LOS) or increasing mortality.

METHODS

We conducted an institutional review board (IRB)-approved retrospective chart review of all patients transferred from an outlying hospital to a primary PCI center using either critical care helicopter or ground transport. The study period was January 2006 through January 2008, with the policy of discontinuing infusions instituted in April 2007. The TT was calculated using departure and arrival times from dispatch logs. The LOS was determined via electronic medical record review. The TT and LOS differences were calculated using two-tailed t-tests with Welch's correction where appropriate. Results. A total of 154 ACS/STEMI transports were completed during the study period (74 before and 80 after policy initiation). The mean (+/- standard error of the mean) TT was 43.5 +/- 1.2 minutes before the policy and 37.1 +/- 0.9 minutes after the policy (p < 0.01). To specifically address different transport distances, we analyzed TTs from an identical group of referral hospitals in both the before- and after-policy groups. A significant reduction in TT remained in this after-policy group (TTs 43.5 +/- 1.2 minutes before the policy and 37.1 +/- 0.9 minutes after; p = 0.01). Data on LOS were available for 127 patients (58 patients before and 69 patients after) and averaged 4.6 +/- 0.8 days prior to the new policy and 3.9 +/- 0.4 days after (p = 0.41). Overall, only one patient died (after-policy group) (p = not significant).

CONCLUSIONS

A policy of transferring patients from one hospital directly to a cardiac catheterization laboratory using only bolus medications significantly reduces total door-to-needle time without adverse effects on LOS or mortality. Other institutions may want to consider such policies for interfacility transport of ACS patients.

Cervical length measurements in pregnancy are longer when measured with three-dimensional transvaginal ultrasound

OBJECTIVE

To compare cervical length measurements obtained by transvaginal two-dimensional (2D) and transvaginal three-dimensional (3D) ultrasound.

STUDY DESIGN

Thirty-four consecutive women having transvaginal assessment of cervical length as part of an obstetric ultrasound examination consented to have a 3D ultrasound scan. The cervical lengths obtained by the two methods were compared by Student's t test and regression equations.

RESULTS

The mean cervical 2D length was 35.7 +/- 1.4 (SE) mm and 3D length was 43.7 +/- 1.9 mm (difference 8.0 mm +/- 0.98, p < 0.001). In the 12 women with cervical length on 2D < 35 mm, there was a 7.5 +/- 1.7 (SE) mm difference (p = 0.007). In all but one woman the 3D length obtained was the same or longer than the 2D length. The longer the cervical length on 3D imaging, the greater the difference from the 2D length (p < 0.001).

CONCLUSION

The longer 3D cervical measurements may reflect the inability to measure the cervix adequately with 2D imaging, owing to anatomical factors. This finding may be useful in improving the predictive value of transvaginal ultrasound in assessing the risk for preterm delivery.

Electrooptic modulation up to 40 GHz in a barium titanate thin film waveguide modulator

The high frequency operation of a low-voltage electrooptic modulator based on a strip-loaded BaTiO3 thin film waveguide structure has been demonstrated. The epitaxial BaTiO3 thin film on an MgO substrate forms a composite structure with a low effective dielectric constant of 20.8 at 40 GHz. A 3.9 V half-wave voltage with a 3.7 GHz 3-dB bandwidth and a 150 pm/V effective electrooptic coefficient is obtained for the 3.2mm-long modulator at 1.55 ?m. Broadband modulation up to 40 GHz is measured with a calibrated detection system. Numerical simulations indicate that the BaTiO3 thin film modulator has the potential for a 3-dB operational bandwidth in excess of 40 GHz through optimized design.

Prenatal ultrasound findings in a fetus with paternal uniparental disomy 14q12-qter

We present the prenatal ultrasound findings in a case of postnatally identified paternal uniparental isodisomy 14q12-qter. Increased nuchal translucency and a large omphalocele were identified at 14 weeks' gestation. Karyotyping revealed a normal male, 46,XY. As gestation advanced, polyhydramnios developed, skeletal abnormalities involving the long bones and chest became evident, hand contractures developed, and the presumed large omphalocele was in part found to be a large ventral hernia, as echogenic adipose tissue could be seen in the abdominal wall near to the cord insertion. Prenatal findings were confirmed after delivery and central nervous system imaging revealed lissencephaly. The combination of an abdominal wall defect with either increased nuchal translucency or skeletal abnormalities should prompt an investigation for uniparental disomy 14 even if the karyotype is normal.

Effect of mode of delivery in nulliparous women on neonatal intracranial injury

BACKGROUND

Infants delivered by vacuum extraction or other operative techniques may be more likely to sustain major injuries than those delivered spontaneously, but the extent of the risk is unknown.

METHODS

From a California data base, we identified 583,340 live-born singleton infants born to nulliparous women between 1992 and 1994 and weighing between 2500 and 4000 g. One third of the infants were delivered by operative techniques. We evaluated the relation between the mode of delivery and morbidity in the infants.

RESULTS

Intracranial hemorrhage occurred in 1 of 860 infants delivered by vacuum extraction, 1 of 664 delivered with the use of forceps, 1 of 907 delivered by cesarean section during labor, 1 of 2750 delivered by cesarean section with no labor, and 1 of 1900 delivered spontaneously. As compared with the infants delivered spontaneously, those delivered by vacuum extraction had a significantly higher rate of subdural or cerebral hemorrhage (odds ratio, 2.7; 95 percent confidence interval, 1.9 to 3.9), as did the infants delivered with the use of forceps (odds ratio, 3.4; 95 percent confidence interval, 1.9 to 5.9) or cesarean section during labor (odds ratio, 2.5; 95 percent confidence interval, 1.8 to 3.4), but the rate of subdural or cerebral hemorrhage associated with vacuum extraction did not differ significantly from that associated with forceps use (odds ratio for the comparison with vacuum extraction, 1.2; 95 percent confidence interval, 0.7 to 2.2) or cesarean section during labor (odds ratio, 0.9; 95 percent confidence interval, 0.6 to 1.4).

CONCLUSIONS

The rate of intracranial hemorrhage is higher among infants delivered by vacuum extraction, forceps, or cesarean section during labor than among infants delivered spontaneously, but the rate among infants delivered by cesarean section before labor is not higher, suggesting that the common risk factor for hemorrhage is abnormal labor.

Congenital malformations in pregnancies complicated by NIDDM

OBJECTIVE

To determine whether the use of oral hypoglycemic agents during early pregnancy is associated with a risk of congenital malformations in infants of mothers with non-insulin-dependent diabetes mellitus (NIDDM) independent of maternal metabolic control.

RESEARCH DESIGN AND METHODS

From a prospectively collected data-base of pregnancies complicated by diabetes at a large urban medical center, we identified 332 consecutive infants born to women with NIDDM who did not participate in a preconceptional diabetes care program. Stepwise logistical regression was used to identify maternal characteristics that were independently associated with risks of major and minor congenital malformations in infants.

RESULTS

Overall, 56 (16.9%) of the 332 infants were born with congenital anomalies (11.7% major anomalies and 5.1% minor anomalies). Analysis of data from subgroups of women who were treated with diet therapy, exogenous insulin, or sulfonylurea compounds during the first 8 weeks of gestation did not reveal statistically significant differences in major or minor malformation rates among the three groups. Stepwise logistic regression analysis revealed two maternal characteristics that were independently associated with major malformations in infants: maternal HbA1c at initial presentation for care (direct relationship; P = 0.0007) and the maternal age at onset of diabetes (inverse relationship; P = 0.009). The risk of major malformations was unrelated to the mode of antidiabetic therapy during early pregnancy. No relationship was found between maternal glycemia or treatment modality and rates of minor congenital anomalies.

CONCLUSIONS

These data indicate that, in the absence of special preconceptional care, NIDDM is associated with a risk for major congenital anomalies that is in the range reported for pregnancies complicated by insulin-dependent diabetes mellitus. Moreover, the risk in individual patients appears to be related to maternal glycemic control rather than to the mode of antidiabetic therapy during early pregnancy.

Ultrafast laser scanner microscope: design and construction

The design of an ultrafast laser scanner microscope has been completed, and an experimental model has been constructed. Details of the novel objective lens design, the automatic focus system, the high-speed polygon scanner and the fast clock system are given. Results from initial tolerance testing as well as the first recorded images are presented.