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Emery SP, Lopa S, Peterson E, Jelin AC, Treadwell MC, Gebb J, Galan HL, Bergh E, Criebaum A, McLennan A, Lillegard J, Blumenfeld YJ. Prenatal Diagnosis of Fetal Aqueductal Stenosis: A Multicenter Prospective Observational Study through the North American Fetal Therapy Network (NAFTNet). Fetal Diagn Ther 2024:000536037. [PMID: 38320542 DOI: 10.1159/000536037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 12/07/2023] [Indexed: 02/08/2024]
Abstract
INTRODUCTION A critical component of an evidence-based reassessment of in-utero intervention for fetal aqueductal stenosis (fetal AS) is determining if the prenatal diagnosis can be accurately made at a gestational age amenable to in-utero intervention. METHODS A multicenter, prospective, observational study was conducted through the North American Fetal Therapy Network (NAFTNet). Pregnancies complicated by severe CNS ventriculomegaly (lateral ventricle diameter >15 mm) not secondary to a primary diagnosis (myelomeningocele, encephalocele, etc.) were recruited at diagnosis. Imaging and laboratory findings were recorded in an online REDCap database. After evaluation, investigators were asked to render their degree of confidence in the diagnosis of fetal AS. The prenatal diagnosis was compared to the postnatal diagnosis obtained through neonatal neuroimaging. Performance characteristics of ultrasound and MRI were calculated, as was the mean gestational age at diagnosis. RESULTS Between April 2015 and October 2022, eleven NAFTNet centers contributed 64 subjects with severe fetal CNS ventriculomegaly. Of these, 56 had both prenatal and postnatal diagnoses recorded. Ultrasound revealed 32 fetal AS true positives, 4 false positives, 7 false negatives, and 13 true negatives rendering a sensitivity of 0.82, a specificity of 0.76, a positive predictive value of 0.89, and a negative predictive value of 0.65. The mean gestational age at diagnosis by ultrasound was 25.5 weeks (std +/- 4.7w). The proportion of agreement (true positive + true negative/n) was highest at 24 weeks gestation. For fetal MRI (n=35), the sensitivity for fetal AS was 0.95, specificity was 0.69, positive predictive value was 0.84, and negative predictive value was 0.90. MRI was performed at 25 weeks on average. CONCLUSION The prenatal diagnosis of fetal aqueductal stenosis can be made with accuracy at a gestational age potentially amenable to in-utero intervention. Only 7% of subjects were incorrectly diagnosed prenatally with fetal AS by ultrasound and 11% by MRI. Diagnostic accuracy of fetal AS will likely improve with increased experience.
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Dougherty D, Diaconescu A, Shah NR, VanHulle R, Ladino-Torres M, Treadwell MC, Mychaliska GB, Perrone EE. Prenatal Measurements of Congenital Lung Malformations: Can They Predict Postnatal Size? J Surg Res 2024; 293:259-265. [PMID: 37804795 DOI: 10.1016/j.jss.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/21/2023] [Accepted: 09/07/2023] [Indexed: 10/09/2023]
Abstract
INTRODUCTION Prenatally diagnosed congenital lung malformations (CLMs) are monitored via ultrasound and measured by congenital pulmonary airway malformation volume ratios (CVRs) which can predict postnatal respiratory symptoms. This study compared CVR to postnatal lesion size to help guide prenatal counseling. METHODS A retrospective chart review evaluated the prenatal imaging and postnatal outcomes for patients who were prenatally diagnosed with CLMs and had a postnatal computed tomography (CT) scan at one institution. RESULTS Fifty-seven patients were included. Four had symptoms requiring urgent resection. The remaining were discharged and had clinic follow-up with CT scan to determine next steps: five had no identified lesions, eight had lesions whose diagnosis did not warrant an operation, and 40 had lesions whose diagnosis rendered size a factor in operative decision-making. Of these 40, 26/40 patients (65%) underwent elective resection (median maximum CVR 0.97; median lesion size 4 cm) and 14/40 patients (35%) were observed without resection (median maximum CVR 0.5; median lesion size 3 cm). There was a positive correlation between prenatal CVR and postnatal lesion size, with R-squared = 0.46. Maximum CVRs were better than last CVRs when predicting whether postnatal CT size would fall above or below our institution's level of recommended resection, with an area under the curve of 0.85 and a CVR cut-point of 0.61. CONCLUSIONS For newborns with asymptomatic CLMs, higher maximum CVRs correlated with larger size on postnatal CT. A maximum CVR ≤0.6 was correlated with a smaller postnatal CT size that may be eligible for nonoperative management. While these results are not intended to recommend surgery based on higher CVRs alone, this information could potentially be used to reassure expectant parents whose babies' prenatal imaging demonstrate lower maximum CVRs.
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Affiliation(s)
- Danielle Dougherty
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Nikhil R Shah
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan.
| | - Rachel VanHulle
- Department of Radiology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Maria Ladino-Torres
- Department of Radiology, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Marjorie C Treadwell
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Michigan Medicine, University of Michigan, L4001 Women's Hospital, Ann Arbor, Michigan
| | - George B Mychaliska
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Erin E Perrone
- Section of Pediatric Surgery, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
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Townsel C, Hesson AM, Greco P, Kazzi NG, Treadwell MC. The Impact of Spontaneous versus Indicated Preterm Birth on Neonatal Outcomes among Extremely Premature Neonates. Am J Perinatol 2023. [PMID: 37774749 DOI: 10.1055/a-2184-1374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/01/2023]
Abstract
OBJECTIVE This study aimed to investigate whether neonatal morbidity differs in spontaneous compared with indicated preterm births in extremely premature neonates. STUDY DESIGN This is a retrospective cohort study including births ≤28 weeks at a single institution from 2011 to 2020. Births were categorized as either medically indicated or spontaneous preterm deliveries. The primary outcome was inhospital mortality and serious morbidity in survivors. t-tests, Fisher's exact tests, chi-square tests, and logistic regression models were utilized as appropriate. p < 0.05 was significant. RESULTS Two hundred and twenty-seven births were included, with two-thirds representing spontaneous births (65.6%, 149/227) and one-third categorized as medically indicated births (34.4%, 78/227). Inhospital mortality was more common in the spontaneous preterm birth group (p = 0.04), while inhospital morbidity did not significantly vary between the medically indicated and spontaneous birth groups (p = 0.32). There was no difference in inhospital morbidity or mortality by maternal race. In multivariate models of inhospital morbidity and mortality, gestational age was the only significant predictor of adverse outcomes. CONCLUSION Despite inhospital mortality being more common in spontaneous preterm births, inhospital mortality and significant morbidity are best accounted for by gestational age alone. KEY POINTS · Inhospital death is more common in spontaneous preterm births.. · Perinatal outcomes do not differ on the basis of racial/ethnic group.. · Gestational age is the best predictor of inhospital morbidity and mortality..
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Affiliation(s)
- Courtney Townsel
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ashley M Hesson
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Patricia Greco
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Nayla G Kazzi
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Texas-Houston, Houston, Texas
| | - Marjorie C Treadwell
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Michigan, Ann Arbor, Michigan
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Grady J, Clifford C, Treadwell MC, Parikh ND, Satishchandran A. The Use of Fenofibrate for Intrahepatic Cholestasis of Pregnancy. J Hepatol 2023:S0168-8278(23)00237-4. [PMID: 37084798 DOI: 10.1016/j.jhep.2023.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 04/23/2023]
Affiliation(s)
- John Grady
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Caitlin Clifford
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Michigan, Ann Arbor, MI
| | - Marjorie C Treadwell
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Michigan, Ann Arbor, MI
| | - Neehar D Parikh
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI.
| | - Abhishek Satishchandran
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
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Rubin JM, Kripfgans OD, Fowlkes JB, Weiner GM, Treadwell MC, Pinter SZ. Bedside Cerebral Blood Flow Quantification in Neonates. Ultrasound Med Biol 2022; 48:2468-2475. [PMID: 36182604 DOI: 10.1016/j.ultrasmedbio.2022.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 05/24/2022] [Accepted: 07/19/2022] [Indexed: 06/16/2023]
Abstract
Measurement of blood flow to the brain in neonates would be a very valuable addition to the medical diagnostic armamentarium. Such conditions such as assessment of closure of a patent ductus arteriosus (PDA) would greatly benefit from such an evaluation. However, measurement of cerebral blood flow in a clinical setting has proven very difficult and, as such, is rarely employed. Present techniques are often cumbersome, difficult to perform and potentially dangerous for very low birth weight (VLBW) infants. We have been developing an ultrasound blood volume flow technique that could be routinely used to assess blood flow to the brain in neonates. By scanning through the anterior fontanelles of 10 normal, full-term newborn infants, we were able to estimate total brain blood flows that closely match those published in the literature using much more invasive and technically demanding methods. Our method is safe, easy to do, does not require contrast agents and can be performed in the baby's incubator. The method has the potential for monitoring and assessing blood flows to the brain and could be used to routinely assess cerebral blood flow in many different clinical conditions.
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Affiliation(s)
- Jonathan M Rubin
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Oliver D Kripfgans
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA.
| | - J Brian Fowlkes
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Gary M Weiner
- Neonatal-Perinatal Medicine, Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
| | - Marjorie C Treadwell
- Department of Maternal and Fetal Medicine, Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Stephen Z Pinter
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
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Rubin JM, Fowlkes JB, Pinter SZ, Treadwell MC, Kripfgans OD. Umbilical Vein Pulse Wave Spectral Analysis: A Possible Method for Placental Assessment Through Evaluation of Maternal and Fetal Flow Components. J Ultrasound Med 2022; 41:2445-2457. [PMID: 34935157 PMCID: PMC10204125 DOI: 10.1002/jum.15927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 12/08/2021] [Accepted: 12/09/2021] [Indexed: 05/25/2023]
Abstract
OBJECTIVES Placental blood flow analysis is complicated by having both maternal and fetal flow components. Using the Fast Fourier Transform (FFT) of the umbilical venous pulse wave spectra (PW) envelope, we could simultaneously assess maternal/fetal blood flow in the placenta and investigate if normal and intrauterine growth restriction (IUGR)/pre-eclamptic pregnancies could be distinguished. METHODS This retrospective study included normal gestations (N = 11) and gestations with IUGR, pre-eclampsia, or both (N = 13). Umbilical vein PW were acquired and spectral envelopes were identified as a function of time and analyzed by FFT. Base-10 logarithms of the ratios of the maternal/fetal spectral peaks (LRSP) were compared in normal and IUGR/pre-eclamptic populations (two-tailed t-test). Body mass index (BMI), gestational age at scan time, placental position, and weight-normalized umbilical vein blood volume flow (two-tailed t-test, analysis of variance [ANOVA] analysis) were tested. P < .05 was considered significant. RESULTS The LRSP for normal and IUGR/pre-eclamptic pregnancies were 0.141 ± 0.180 and -0.072 ± 0.262 (mean ± standard deviation), respectively (P = .033). We detected differences between normal gestations and combinations of LRSP and weight-normalized umbilical venous blood flows. Placental effects based on LRSPs and blood flow may act synergistically in cases with both pre-eclampsia and IUGR (P = .014). No other significant associations were seen. CONCLUSIONS In this preliminary study, we showed that umbilical venous flow contains markers related to placental maternal/fetal blood flow, which can be used to assess IUGR and pre-eclampsia. When coupled with umbilical cord blood flow, this new marker may potentially identify the primary causes of the two conditions.
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Affiliation(s)
- Jonathan M Rubin
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - J Brian Fowlkes
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Stephen Z Pinter
- Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Marjorie C Treadwell
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
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Mitchell SJ, Ngo G, Maurel KA, Hasegawa J, Arakaki T, Melcer Y, Maymon R, Vendittelli F, Shamshirsaz AA, Erfani H, Shainker SA, Saad AF, Treadwell MC, Roman AS, Stone JL, Rolnik DL. Timing of birth and adverse pregnancy outcomes in cases of prenatally diagnosed vasa previa: a systematic review and meta-analysis. Am J Obstet Gynecol 2022; 227:173-181.e24. [PMID: 35283090 DOI: 10.1016/j.ajog.2022.03.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 03/06/2022] [Accepted: 03/06/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE The ideal time for birth in pregnancies diagnosed with vasa previa remains unclear. We conducted a systematic review aiming to identify the gestational age at delivery that best balances the risks for prematurity with that of pregnancy prolongation in cases with prenatally diagnosed vasa previa. DATA SOURCES Ovid MEDLINE, PubMed, CINAHL, Embase, Scopus, and Web of Science were searched from inception to January 2022. STUDY ELIGIBILITY CRITERIA The intervention analyzed was delivery at various gestational ages in pregnancies prenatally diagnosed with vasa previa. Cohort studies, case series, and case reports were included in the qualitative synthesis. When summary figures could not be obtained directly from the studies for the quantitative synthesis, authors were contacted and asked to provide a breakdown of perinatal outcomes by gestational age at birth. METHODS Study appraisal was completed using the National Institutes of Health quality assessment tool for the respective study types. Statistical analysis was performed using a random-effects meta-analysis of proportions. RESULTS The search identified 3435 studies of which 1264 were duplicates. After screening 2171 titles and abstracts, 140 studies proceeded to the full-text screen. A total of 37 studies were included for analysis, 14 of which were included in a quantitative synthesis. Among 490 neonates, there were 2 perinatal deaths (0.4%), both of which were neonatal deaths before 32 weeks' gestation. In general, the rate of neonatal complications decreased steadily from <32 weeks' gestation (4.6% rate of perinatal death, 91.2% respiratory distress, 11.4% 5-minute Apgar score <7, 23.3% neonatal blood transfusion, 100% neonatal intensive care unit admission, and 100% low birthweight) to 36 weeks' gestation (0% perinatal death, 5.3% respiratory distress, 0% 5-minute Apgar score <7, 2.9% neonatal blood transfusion, 29.2% neonatal intensive care unit admission, and 30.9% low birthweight). Complications then increased slightly at 37 weeks' gestation before decreasing again at 38 weeks' gestation. CONCLUSION Prolonging pregnancies until 36 weeks' gestation seems to be safe and beneficial in otherwise uncomplicated pregnancies with antenatally diagnosed vasa previa.
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Dunietz GL, Hao W, Shedden K, Holzman C, Chervin RD, Lisabeth LD, Treadwell MC, O’Brien LM. Maternal habitual snoring and blood pressure trajectories in pregnancy. J Clin Sleep Med 2022; 18:31-38. [PMID: 34170225 PMCID: PMC8807914 DOI: 10.5664/jcsm.9474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
STUDY OBJECTIVES Habitual snoring has been associated with hypertensive disorders of pregnancy. However, exactly when blood pressure (BP) trajectories diverge between pregnant women with and without habitual snoring is unknown. Moreover, the potentially differential impact of chronic vs pregnancy-onset habitual snoring on maternal BP trajectories during pregnancy has not been examined. This study compared patterns of BP across pregnancy in 3 groups of women: those with chronic habitual snoring, those with pregnancy-onset habitual snoring, and nonhabitual snoring "controls." METHODS In a cohort study of 1,305 pregnant women from a large medical center, participants were asked about habitual snoring (≥ 3 nights/week) and whether their symptoms began prior to or during pregnancy. Demographic, health, and BP data throughout pregnancy were abstracted from medical charts. Linear mixed models were used to examine associations between habitual snoring-onset and pregnancy BP trajectories. RESULTS A third of women reported snoring prior to pregnancy (chronic snoring) and an additional 23% reported pregnancy-onset snoring. Mean maternal age (SD) was 29.5 (5.6), 30 (6), and 30.5 (5.7) years in controls, chronic, and pregnancy-onset snoring, respectively. Overall, women with pregnancy-onset snoring had higher mean systolic BP and diastolic BP compared to those with chronic habitual snoring or nonhabitual snoring. In gestational week-specific comparisons with controls, systolic BP became significantly higher around 18 weeks' gestation among women with pregnancy-onset snoring and in the third trimester among women with chronic snoring. These differences became detectable at 1 mm Hg and increased thereafter, reaching 3 mm Hg-BP difference at 40 weeks' gestation in women with pregnancy-onset snoring relative to controls. Pairwise mean differences in diastolic BP were significant only among women with pregnancy-onset snoring relative to controls, after 15 weeks' gestation. CONCLUSIONS Pregnancy-onset and chronic maternal snoring are associated with higher BPs beginning in the second and third trimester, respectively. Pregnancy BP trajectories could identify critical windows for enhanced BP surveillance; the divergent BP trajectories suggest that the 2 groups of women with habitual snoring in pregnancy may need to be considered separately when gestational time intervals are evaluated for increased BP monitoring. CITATION Dunietz GL, Hao W, Shedden K, et al. Maternal habitual snoring and blood pressure trajectories in pregnancy. J Clin Sleep Med. 2022;18(1):31-38.
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Affiliation(s)
- Galit Levi Dunietz
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan,Address correspondence to: Galit Levi Dunietz, MPH, PhD, Division of Sleep Medicine, Department of Neurology, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109-5845; Tel: (734) 647-9241; Fax: (734) 647-9065;
| | - Wei Hao
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Kerby Shedden
- Department of Statistics, University of Michigan, Ann Arbor, Michigan
| | - Claudia Holzman
- Department of Epidemiology and Biostatistics, College of Human Medicine, Michigan State University, East Lansing, Michigan
| | - Ronald D. Chervin
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Lynda D. Lisabeth
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Marjorie C. Treadwell
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
| | - Louise M. O’Brien
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, Michigan,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan
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Lillegard JB, Eyerly-Webb SA, Watson DA, Bahtiyar MO, Bennett KA, Emery SP, Fisher AJ, Goldstein RB, Goodnight WH, Lim FY, McCullough LB, Moehrlen U, Moldenhauer JS, Moon-Grady AJ, Ruano R, Skupski DW, Treadwell MC, Tsao K, Wagner AJ, Zaretsky MV. Placental Location in Maternal-Fetal Surgery for Myelomeningocele. Fetal Diagn Ther 2021; 49:117-124. [PMID: 34915495 DOI: 10.1159/000521379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 12/06/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Uterine incision based on placental location in open maternal-fetal surgery (OMFS) has never been evaluated in regards to maternal or fetal outcomes. OBJECTIVE To investigate whether an anterior placenta was associated with increased rates of intraoperative, perioperative, antepartum, obstetric, or neonatal complications in mothers and babies who underwent OMFS for myelomeningocele (fMMC) closure. METHODS Data from the international multi-center prospective registry of patients who underwent OMFS for fMMC closure (fMMC Consortium Registry, 12/15/2010-7/31/2019) was used to compare fetal and maternal outcomes between anterior and posterior placental locations. RESULTS Placental location for 623 patients was evenly distributed between anterior (51%) or posterior (49%). Intraoperative fetal bradycardia (8.3% vs 3.0%, p=0.005) and performance of fetal resuscitation (3.6% vs 1.0%, p=0.034) occurred more frequently in cases with an anterior placenta when compared to those with a posterior placenta. Obstetric outcomes including membrane separation, placental abruption, and spontaneous rupture of membranes were not different among the two groups. However, thinning of the hysterotomy site (27.7% vs 17.7%, p=0.008) occurred more frequently in cases of anterior placenta. Gestational age at delivery (p=0.583) and length of stay in the neonatal intensive care unit (p=0.655) were similar between the two groups. Fetal incision dehiscence and wound revision were not significantly different between groups. Critical clinical outcomes including fetal demise, perinatal death, and neonatal death were all infrequent occurrences and not associated with placental location. CONCLUSIONS Anterior placental location is associated with increased risk of intraoperative fetal resuscitation and increased thinning at the hysterotomy closure site. Individual institutional experiences may have varied but the aggregate data from the fMMC Consortium did not show a significant impact on the gestational age at delivery or maternal or fetal clinical outcomes.
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Affiliation(s)
- Joseph B Lillegard
- Midwest Fetal Care Center, Children's Minnesota, Minneapolis, Minnesota, USA
- Division of General Surgery Research, Mayo Clinic, Rochester, Minnesota, USA
- Pediatric Surgical Associates, Minneapolis, Minnesota, USA
| | | | - David A Watson
- Research Design and Analytics, Children's Minnesota, Minneapolis, Minnesota, USA
| | | | | | | | | | - Ruth B Goldstein
- University of California San Francisco, San Francisco, California, USA
| | - William H Goodnight
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Foong-Yen Lim
- Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | | | | | | | | | - Rodrigo Ruano
- University of Texas Health Science Center, Houston, Texas, USA
| | | | | | - KuoJen Tsao
- University of Texas Health Science Center, Houston, Texas, USA
| | - Amy J Wagner
- Children's Hospital of Wisconsin Fetal Concerns Center, Milwaukee, Wisconsin, USA
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Zhang M, Townsel CD, Akers LB, Kiros L, Treadwell MC, Maturen KE. Biomechanical Cervical Assessment Using 2-Dimentional Transvaginal Shear Wave Elastography in Nonpregnant and Pregnant Women: A Prospective Pilot Study. Ultrasound Q 2021; 37:183-190. [PMID: 34057917 DOI: 10.1097/ruq.0000000000000561] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
ABSTRACT This study evaluated the technical feasibility of 2-dimensional transvaginal shear wave elastography to quantify cervical stiffness in nonpregnant and pregnant women and established normal values in each group. With institutional review board approval, we performed a prospective study with an age-matched historical control design. Sixteen premenopausal nonpregnant women without cervical pathology and 17 low-risk pregnant women (gestational age 17-33 weeks) were enrolled. Cervical shear wave speeds were measured on a SuperSonic Aixplorer machine. The mean shear wave speeds of anterior cervix were 4.96 ± 1.96 m/s in nonpregnant women and 1.92 ± 0.31 m/s in pregnant women. No significant stiffness difference was found between the anterior and posterior cervix (P = 0.15). The upper cervix was stiffer than the lower cervix in the pregnant women (P = 0.00012). Transvaginal shear wave elastography reveals that cervix at a midterm gestation is significantly softer than nonpregnant cervix (P < 0.0001) and suggests a spatial stiffness gradient along the length of the cervix, consistent with histopathology and limited elastography literature. Our results indicate the potential of transvaginal shear wave elastography to provide objective and quantitative estimates of cervical stiffness, especially during pregnancy.
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Affiliation(s)
| | | | | | - Leah Kiros
- Psychology, Michigan Medicine, University of Michigan, Ann Arbor, MI
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11
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Rubin JM, Li S, Fowlkes JB, Sethuraman S, Kripfgans OD, Shi W, Treadwell MC, Jago JR, Leichner RD, Pinter SZ. Comparison of Variations Between Spectral Doppler and Gaussian Surface Integration Methods for Umbilical Vein Blood Volume Flow. J Ultrasound Med 2021; 40:369-376. [PMID: 32770569 PMCID: PMC7924168 DOI: 10.1002/jum.15411] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 06/10/2020] [Accepted: 06/21/2020] [Indexed: 05/05/2023]
Abstract
OBJECTIVES We are studying a new method for estimating blood volume flow that uses 3-dimensional ultrasound to measure the total integrated flux through an ultrasound-generated Gaussian surface that intersects the umbilical cord. This method makes none of the assumptions typically required with standard 1-dimensional spectral Doppler volume flow estimates. We compared the variations in volume flow estimates between techniques in the umbilical vein. METHODS The study was Institutional Review Board approved, and all 12 patients gave informed consent. Because we had no reference standard for the true umbilical vein volume flow, we compared the variations of the measurements for the flow measurement techniques. At least 3 separate spectral Doppler and 3 separate Gaussian surface measurements were made along the umbilical vein. Means, standard deviations, and coefficients of variation (standard deviation/mean) for the flow estimation techniques were calculated for each patient. P < .05 was considered significant. RESULTS The ranges of the mean volume flow estimates were 174 to 577 mL/min for the spectral Doppler method and 100 to 341 mL/min for the Gaussian surface integration (GSI) method. The mean standard deviations (mean ± SD) were 161 ± 95 and 45 ± 48 mL/min for the spectral Doppler and GSI methods, respectively (P < .003). The mean coefficients of variation were 0.46 ± 0.17 and 0.18 ± 0.14 for the spectral Doppler and GSI methods respectively (P < 0.002). CONCLUSIONS The new volume flow estimation method using 3-dimensional ultrasound appears to have significantly less variation in estimates than the standard 1-dimensional spectral Doppler method.
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Affiliation(s)
- Jonathan M Rubin
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Sibo Li
- Philips Research North America, Cambridge, Massachusetts, USA
| | - J Brian Fowlkes
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Oliver D Kripfgans
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - William Shi
- Philips Research North America, Cambridge, Massachusetts, USA
| | - Marjorie C Treadwell
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - James R Jago
- Philips Research North America, Cambridge, Massachusetts, USA
| | | | - Stephen Z Pinter
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
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12
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LaBarre JL, McCabe CF, Jones TR, Song PX, Domino SE, Treadwell MC, Dolinoy DC, Padmanabhan V, Burant CF, Goodrich JM. Maternal lipodome across pregnancy is associated with the neonatal DNA methylome. Epigenomics 2020; 12:2077-2092. [PMID: 33290095 DOI: 10.2217/epi-2020-0234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Aim: To classify the association between the maternal lipidome and DNA methylation in cord blood leukocytes. Materials & methods: Untargeted lipidomics was performed on first trimester maternal plasma (M1) and delivery maternal plasma (M3) in 100 mothers from the Michigan Mother-Infant Pairs cohort. Cord blood leukocyte DNA methylation was profiled using the Infinium EPIC bead array and empirical Bayes modeling identified differential DNA methylation related to maternal lipid groups. Results: M3-saturated lysophosphatidylcholine was associated with 45 differentially methylated loci and M3-saturated lysophosphatidylethanolamine was associated with 18 differentially methylated loci. Biological pathways enriched among differentially methylated loci by M3 saturated lysophosphatidylcholines were related to cell proliferation and growth. Conclusion: The maternal lipidome may be influential in establishing the infant epigenome.
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Affiliation(s)
- Jennifer L LaBarre
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Carolyn F McCabe
- Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Tamara R Jones
- Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Peter Xk Song
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Steven E Domino
- Department of Obstetrics & Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Marjorie C Treadwell
- Department of Obstetrics & Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Dana C Dolinoy
- Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA.,Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Vasantha Padmanabhan
- Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA.,Department of Obstetrics & Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA.,Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Charles F Burant
- Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jaclyn M Goodrich
- Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
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13
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Perrone EE, Galganski LA, Tarantal AF, Olstad KJ, Treadwell MC, Berman DR, Jarboe MD, Mychaliska GB, Farmer DL. Fetal Surgery in the Primate 4.0: A New Technique 30 Years Later. Fetal Diagn Ther 2020; 48:43-49. [PMID: 33108788 DOI: 10.1159/000511355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 09/02/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Open fetal surgery requires a hemostatic hysterotomy that minimizes membrane separation. For over 30 years, the standard of care for hysterotomy in the gravid uterus has been the AutoSuture Premium Poly CS*-57 stapler. OBJECTIVE In this study, we sought to test the feasibility of hysterotomy in a rhesus monkey model with the Harmonic ACE®+7 Shears. METHODS A gravid rhesus monkey underwent midgestation hysterotomy at approximately 90 days of gestation (2nd trimester; term = 165 ± 10 days) using the Harmonic ACE®+7 Shears. A two-layer uterine closure was completed and the dam was monitored by ultrasound intermittently throughout the pregnancy. At 58 days after hysterotomy (near term), a final surgery was performed to evaluate the uterus and hysterotomy site. RESULTS A 3.5-cm hysterotomy was completed in 2 min 7 s. The opening was hemostatic and the membranes were sealed. Immediately after closure and throughout the pregnancy, ultrasound revealed intact membranes without separation and normal amniotic fluid levels. At term, the scar was well healed without signs of thinning or dehiscence. CONCLUSIONS The Harmonic ACE®+7 Shears produced a hemostatic midgestation hysterotomy with membrane sealing in the rhesus monkey model. Importantly, healing was acceptable.
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Affiliation(s)
- Erin E Perrone
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA, .,Fetal Diagnosis and Treatment Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA,
| | - Laura A Galganski
- Department of Surgery, UC Davis Children's Hospital, University of California, Davis, Sacramento, California, USA
| | - Alice F Tarantal
- Departments of Pediatrics and Cell Biology and Human Anatomy, School of Medicine, and California National Primate Research Center, University of California, Davis, California, USA
| | - Katie J Olstad
- Laboratory Animal Pathology, California National Primate Research Center, University of California, Davis, California, USA
| | - Marjorie C Treadwell
- Fetal Diagnosis and Treatment Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, C.S. Mott Children's Hospital and Von Voigtlander Women's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Deborah R Berman
- Fetal Diagnosis and Treatment Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, C.S. Mott Children's Hospital and Von Voigtlander Women's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Marcus D Jarboe
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Fetal Diagnosis and Treatment Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - George B Mychaliska
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children's Hospital, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA.,Fetal Diagnosis and Treatment Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Diana L Farmer
- Department of Surgery, UC Davis Children's Hospital, University of California, Davis, Sacramento, California, USA.,Fetal Care and Treatment Center, University of California, Davis, Davis, California, USA
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14
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Zampi JD, Treadwell MC, Fifer CG, van de Ven C, Rocchini AP, Whiteside W, Gelehrter SK. Intracardiac Hemodynamics During Fetal Balloon Aortic Valvuloplasty. JACC Cardiovasc Interv 2020; 12:1628-1630. [PMID: 31439346 DOI: 10.1016/j.jcin.2019.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 03/08/2019] [Accepted: 03/12/2019] [Indexed: 11/15/2022]
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15
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Kim AG, Norwitz G, Karmakar M, Ladino-Torres M, Berman DR, Kreutzman J, Treadwell MC, Mychaliska GB, Perrone EE. Discordant prenatal ultrasound and fetal MRI in CDH: wherein lies the truth? J Pediatr Surg 2020; 55:1879-1884. [PMID: 31813580 DOI: 10.1016/j.jpedsurg.2019.11.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 10/23/2019] [Accepted: 11/05/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE Prenatal risk assessment of congenital diaphragmatic hernia (CDH) relies on prenatal ultrasound (U/S) and fetal magnetic resonance imaging (MRI). When the modalities differ in prognosis, it is unclear which is more reliable. METHODS Retrospective chart review identified cases of prenatally diagnosed CDH from 4/2010-6/2018 meeting inclusion criteria. Demographic, radiologic, and postnatal outcomes data were collected. Ultrasound- versus MRI-based prognosis (mild, moderate, and severe) was compared with clinical outcomes. Kappa measures compared congruency in disease severity scaling between imaging modalities, while logistic regression and receiver operating characteristics curves compared the ability of each modality to predict outcomes. RESULTS Forty-two patients met criteria. Both U/S- and MRI-based prognosis categories differentiated for survival. MRI categories differentiated for ECMO use, surgical repair, and defect type. O/e TFLV better discriminated for survivors and defect type than o/e LHR. Seventeen (40.5%) had discordant prenatal prognostic categories. In 13/17 (76.5%), o/e TFLV predicted higher severity when compared to o/e LHR, but sample size was insufficient to compare accuracy in cases of discordance. CONCLUSIONS Clinical outcomes suggest fetal MRI may more accurately predict severe pulmonary hypoplasia compared to prenatal ultrasound. Our analysis suggests fetal MRI is a valuable adjunct in the prenatal evaluation of CDH. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective Review.
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Affiliation(s)
- Aimee G Kim
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine
| | - Gabriella Norwitz
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine
| | - Monita Karmakar
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine
| | - Maria Ladino-Torres
- Department of Radiology, Division of Pediatric Radiology, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine
| | - Deborah R Berman
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine
| | - Jeannie Kreutzman
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine
| | - Marjorie C Treadwell
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine
| | - George B Mychaliska
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine
| | - Erin E Perrone
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine; Fetal Diagnosis and Treatment Center, University of Michigan, Michigan Medicine.
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16
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LaBarre JL, Puttabyatappa M, Song PXK, Goodrich JM, Zhou L, Rajendiran TM, Soni T, Domino SE, Treadwell MC, Dolinoy DC, Padmanabhan V, Burant CF. Maternal lipid levels across pregnancy impact the umbilical cord blood lipidome and infant birth weight. Sci Rep 2020; 10:14209. [PMID: 32848180 PMCID: PMC7449968 DOI: 10.1038/s41598-020-71081-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 07/20/2020] [Indexed: 12/14/2022] Open
Abstract
Major alterations in metabolism occur during pregnancy enabling the mother to provide adequate nutrients to support infant development, affecting birth weight (BW) and potentially long-term risk of obesity and cardiometabolic disease. We classified dynamic changes in the maternal lipidome during pregnancy and identified lipids associated with Fenton BW z-score and the umbilical cord blood (CB) lipidome. Lipidomics was performed on first trimester maternal plasma (M1), delivery maternal plasma (M3), and CB plasma in 106 mother-infant dyads. Shifts in the maternal and CB lipidome were consistent with the selective transport of long-chain polyunsaturated fatty acids (PUFA) as well as lysophosphatidylcholine (LysoPC) and lysophosphatidylethanolamine (LysoPE) species into CB. Partial correlation networks demonstrated fluctuations in correlations between lipid groups at M1, M3, and CB, signifying differences in lipid metabolism. Using linear models, LysoPC and LysoPE groups in CB were positively associated with BW. M1 PUFA containing triglycerides (TG) and phospholipids were correlated with CB LysoPC and LysoPE species and total CB polyunsaturated TGs. These results indicate that early gestational maternal lipid levels influence the CB lipidome and its relationship with BW, suggesting an opportunity to modulate maternal diet and improve long-term offspring cardiometabolic health.
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Affiliation(s)
- Jennifer L LaBarre
- Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | | | - Peter X K Song
- Department of Biostatistics, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Jaclyn M Goodrich
- Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Ling Zhou
- Center of Statistical Research, Southwestern University of Finance and Economics, Chengdu, Sichuan, China
| | - Thekkelnaycke M Rajendiran
- Michigan Regional Comprehensive Metabolomics Resource Core, Ann Arbor, MI, USA.,Department of Pathology, Michigan Regional Comprehensive Metabolomics Resource Core, Ann Arbor, MI, USA
| | - Tanu Soni
- Michigan Regional Comprehensive Metabolomics Resource Core, Ann Arbor, MI, USA
| | - Steven E Domino
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Marjorie C Treadwell
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Dana C Dolinoy
- Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA.,Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Vasantha Padmanabhan
- Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA.,Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA.,Department of Environmental Health Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Charles F Burant
- Department of Nutritional Sciences, University of Michigan School of Public Health, Ann Arbor, MI, USA. .,Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA.
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17
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Kim AG, Mon RA, Karmakar M, Kreutzman J, Ladino-Torres M, Treadwell MC, Mychaliska GB, Perrone EE. Calculating Observed-to-Expected Total Fetal Lung Volume in CDH Fetuses in Twin Gestation: Is There a Better Way? Fetal Diagn Ther 2019; 47:545-553. [PMID: 31865353 DOI: 10.1159/000504510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/31/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND Congenital diaphragmatic hernia (CDH) is a potentially lethal birth defect, and identifying prenatal predictors of outcome is important. Observed-to-expected total fetal lung volume (o/e TFLV) has been shown to be a predictor of severity and useful in risk stratification but is variable due to different TFLV formulas. OBJECTIVES To calculate o/e TFLV for CDH patients part of a twin gestation using the unaffected sibling as an internal control and comparing these values to those calculated using published formulas for TFLV. METHODS Seven twin gestations with one fetus affected by CDH were identified between 2006 and 2017. The lung volume for each twin was calculated using magnetic resonance imaging (MRI), and o/e TFLV was calculated using the unaffected twin's TFLV. This percentage was then compared to the o/e TFLV calculated using published formulas. RESULTS Lung volumes in the unaffected twins were within normal ranges at the lower end of the spectrum. No single TFLV formula was found to correlate perfectly. Intraclass correlation coefficient estimate was most consistent for o/e TFLV calculated with the Meyers formula and supported by Bland-Altman plots. CONCLUSIONS O/e TFLV measured in CDH/non-CDH twin gestations using the unaffected sibling demonstrated agreement with o/e TFLV calculated using the Meyers formula. We urge the fetal community to standardize the method, use, and interpretation of fetal MRI in the prenatal evaluation of CDH.
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Affiliation(s)
- Aimee G Kim
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA.,Fetal Diagnosis and Treatment CenterUniversity of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Rodrigo A Mon
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Monita Karmakar
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jeannie Kreutzman
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA.,Fetal Diagnosis and Treatment CenterUniversity of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Maria Ladino-Torres
- Fetal Diagnosis and Treatment CenterUniversity of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Radiology, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Marjorie C Treadwell
- Fetal Diagnosis and Treatment CenterUniversity of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - George B Mychaliska
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA.,Fetal Diagnosis and Treatment CenterUniversity of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Erin E Perrone
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA, .,Fetal Diagnosis and Treatment CenterUniversity of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA,
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18
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Kim AG, Berman DR, Kreutzman J, Treadwell MC, Mychaliska GB, Perrone EE. Prenatal Dilated Rectum: Do We Need to Worry? J Surg Res 2019; 244:291-295. [PMID: 31302327 DOI: 10.1016/j.jss.2019.06.066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/01/2019] [Accepted: 06/14/2019] [Indexed: 11/15/2022]
Abstract
BACKGROUND Advances in prenatal imaging is increasing detection of abnormally dilated bowel. There is no literature to date defining the criteria for a dilated rectum or its association with postnatal pathology. The aim of this study is to investigate the clinical significance of a prenatally identified dilated rectum. METHODS A retrospective review was performed of all cases of "dilated bowel" on prenatal ultrasound between January 2000 and December 2017 at a single institution. We excluded ventral wall defects from review and sought to include only cases of a prominent or dilated rectum. Collected data included prenatal bowel measurements, postnatal diagnoses, need for surgical intervention, and outcomes. Descriptive statistics were applied. RESULTS One hundred and ninety-three cases of prenatal "dilated bowel" were identified in which 12 (6.2%) had specifically visualized a prominent or dilated rectum. Nine of these (75.0%) had no rectal or intestinal abnormality on postnatal evaluation and were discharged feeding and defecating normally. The remaining three cases exhibited clinical pathology necessitating additional management: (1) meconium plug, (2) jejunal atresia with cecal perforation, and (3) rectal perforation with retroperitoneal abscess. All three had rectal biopsies with identification of ganglionated submucosa. CONCLUSIONS Although a prenatal dilated rectum is a normal variant in the vast majority of cases, it may be associated with a gastrointestinal abnormality requiring surgical intervention. Interestingly, there were no cases of Hirschsprung's disease or anorectal malformations in this cohort. These results, in conjunction with continued efforts to identify and define rectal dilation, are useful for prenatal counseling and postnatal evaluation.
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Affiliation(s)
- Aimee G Kim
- Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Michigan Medicine, Ann Arbor, Michigan; University of Michigan, Michigan Medicine, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan
| | - Deborah R Berman
- University of Michigan, Michigan Medicine, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan; University of Michigan, Michigan Medicine, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, C.S. Mott Children's Hospital and Von Voigtlander Women's Hospital, Ann Arbor, Michigan
| | - Jeannie Kreutzman
- Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Michigan Medicine, Ann Arbor, Michigan; University of Michigan, Michigan Medicine, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan
| | - Marjorie C Treadwell
- University of Michigan, Michigan Medicine, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan; University of Michigan, Michigan Medicine, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, C.S. Mott Children's Hospital and Von Voigtlander Women's Hospital, Ann Arbor, Michigan
| | - George B Mychaliska
- Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Michigan Medicine, Ann Arbor, Michigan; University of Michigan, Michigan Medicine, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan
| | - Erin E Perrone
- Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's Hospital, University of Michigan, Michigan Medicine, Ann Arbor, Michigan; University of Michigan, Michigan Medicine, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan.
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19
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Mon RA, Johnson KN, Ladino-Torres M, Heider A, Mychaliska GB, Treadwell MC, Kunisaki SM. Diagnostic accuracy of imaging studies in congenital lung malformations. Arch Dis Child Fetal Neonatal Ed 2019; 104:F372-F377. [PMID: 30049725 DOI: 10.1136/archdischild-2018-314979] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 06/22/2018] [Accepted: 07/04/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND Although fetal ultrasound, fetal MRI and postnatal CT are now widely used in the evaluation of congenital lung malformations (CLM), their diagnostic accuracy remains undefined. OBJECTIVE To correlate prenatal and postnatal imaging studies with pathological data after CLM resection. DESIGN Retrospective, descriptive case series study. SETTING A North American tertiary care centre. PATIENTS One hundred and three consecutive lung resections for a suspected CLM between 1 January 2005 and 31 December 2015. MAIN OUTCOME MEASURES Diagnostic accuracy of imaging diagnosis compared with pathological evaluation. RESULTS Pathological diagnoses included congenital pulmonary airway malformation ((CPAM) n=45, 44%), bronchopulmonary sequestration (BPS; n=25, 24%), CPAM/BPS hybrid lesions (n=22, 21%) and pleuropulmonary blastoma (n=2, 2%). Fetal ultrasound detected 85 (82.5%) lesions and correctly diagnosed whether or not a lesion was a CPAM in 75% of cases (sensitivity 93%, specificity 32%). Fetal MRI had a similar concordance rate (73%) but was superior in correctly determining whether a systemic feeding vessel was present in 80% of cases (sensitivity 71%, specificity 88%) compared with an ultrasound accuracy rate of 72% (sensitivity 49%, specificity 93%). By comparison, postnatal CT correctly diagnosed whether a CPAM was present in 84% of cases (sensitivity 86%, specificity 77%) and whether a systemic feeding vessel was present in 90% of cases (sensitivity 92%, specificity 88%). CONCLUSIONS Fetal ultrasound remains an important tool in the detection and evaluation of congenital lung malformations. However, it does not correctly predict histology in approximately 25% of prenatally detected CLMs and remains limited by relatively poor sensitivity for systemic feeding vessels pathognomic for a bronchopulmonary sequestration. These data suggest the importance of obtaining additional cross-sectional imaging, preferably a postnatal CT scan, in all patients to help counsel families and to guide in the optimal management of these lesions.
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Affiliation(s)
- Rodrigo A Mon
- Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's and Von Voigtlander Women's Hospital, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Surgery, Fetal Diagnosis and Treatment Center, C.S. Mott Children's and Von Voigtlander Women's Hospital, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Kevin N Johnson
- Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's and Von Voigtlander Women's Hospital, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Maria Ladino-Torres
- Department of Surgery, Fetal Diagnosis and Treatment Center, C.S. Mott Children's and Von Voigtlander Women's Hospital, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Radiology, Section of Pediatric Radiology, C.S. Mott Children's and Von Voigtlander Women's Hospital, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Amer Heider
- Department of Pathology, Section of Pediatric Pathology, C.S. Mott Children's and Von Voigtlander Women's Hospital, Michigan Medicine, Ann Arbor, Michigan, USA
| | - George B Mychaliska
- Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's and Von Voigtlander Women's Hospital, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Surgery, Fetal Diagnosis and Treatment Center, C.S. Mott Children's and Von Voigtlander Women's Hospital, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Marjorie C Treadwell
- Department of Surgery, Fetal Diagnosis and Treatment Center, C.S. Mott Children's and Von Voigtlander Women's Hospital, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, C.S. Mott Children's and Von Voigtlander Women's Hospital, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Shaun M Kunisaki
- Department of Surgery, Section of Pediatric Surgery, C.S. Mott Children's and Von Voigtlander Women's Hospital, Michigan Medicine, Ann Arbor, Michigan, USA.,Department of Surgery, Fetal Diagnosis and Treatment Center, C.S. Mott Children's and Von Voigtlander Women's Hospital, Michigan Medicine, Ann Arbor, Michigan, USA
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20
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Church JT, McLeod JS, Coughlin MA, Bergin IL, Perkins EM, Hoffman HR, Bilger M, Rojas-Peña A, Treadwell MC, Berman DR, Jarboe MD, Mychaliska GB, Perrone EE. An Early Investigation into Possible Alternatives to Stapled Hysterotomy in Open Fetal Surgery. Am J Perinatol 2019; 36:742-750. [PMID: 30372770 DOI: 10.1055/s-0038-1673664] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
PURPOSE We hypothesized that surgical energy could be used to create hysterotomies in open fetal surgery. STUDY DESIGN Initial studies compared the LigaSure Impact and Harmonic ACE + 7 Shears in the efficiency of hysterotomy and thermal damage. Pregnant ewes at an estimated gestational age (EGA) of 116 to 120 days (term = 145; n = 7) underwent hysterotomy using either device. Hysterotomy edges were resected, and thermal injury extent was determined by histopathological assessment. Upon determining a superior device, subsequent studies compared this to the AutoSuture Premium Poly CS*-57 Stapler in uterine healing. Pregnant ewes (n = 6) at an EGA of 87 to 93 days underwent 6-cm hysterotomy in each gravid horn with either the stapler (n = 5) or Harmonic (n = 5) followed by closure and animal recovery. After 37 to 42 days, uterine healing was assessed by evaluating tensile strength and histopathology. RESULTS Thermal damage was more extensive with the LigaSure (n = 11 hysterotomies) than with the Harmonic (n = 11; 5.6 ± 1 vs. 3.1 ± 0.6 mm; p < 0.0001);therefore, the Harmonic was selected for healing studies. Gross scar appearance and tensile strength were the same between the Harmonic and stapler. The stapler caused more fibrosis (4/7 samples with "moderate" fibrosis vs. 0/8 with the Harmonic; p = 0.02). CONCLUSION The Harmonic ACE + 7 caused less thermal injury than the LigaSure Impact and performed similar to the CS*-57 Stapler in uterine healing with continued gestation.
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Affiliation(s)
- Joseph T Church
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jennifer S McLeod
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Megan A Coughlin
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ingrid L Bergin
- Unit for Laboratory Animal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Elena M Perkins
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Hayley R Hoffman
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Mark Bilger
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Alvaro Rojas-Peña
- Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Marjorie C Treadwell
- Department of Obstetrics and Gynecology, Fetal Diagnosis and Treatment Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Deborah R Berman
- Department of Obstetrics and Gynecology, Fetal Diagnosis and Treatment Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Marcus D Jarboe
- Department of Surgery, Fetal Diagnosis and Treatment Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - George B Mychaliska
- Department of Surgery, Fetal Diagnosis and Treatment Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Erin E Perrone
- Department of Surgery, Fetal Diagnosis and Treatment Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
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Goodnight WH, Bahtiyar O, Bennett KA, Emery SP, Lillegard JB, Fisher A, Goldstein R, Jatres J, Lim FY, McCullough L, Moehrlen U, Moldenhauer JS, Moon-Grady AJ, Ruano R, Skupski DW, Thom E, Treadwell MC, Tsao K, Wagner AJ, Waqar LN, Zaretsky M. Subsequent pregnancy outcomes after open maternal-fetal surgery for myelomeningocele. Am J Obstet Gynecol 2019; 220:494.e1-494.e7. [PMID: 30885769 PMCID: PMC6511319 DOI: 10.1016/j.ajog.2019.03.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 03/08/2019] [Accepted: 03/11/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Open maternal-fetal surgery for fetal myelomeningocele results in reduction in neonatal morbidity related to spina bifida but may be associated with fetal, neonatal, and maternal complications in subsequent pregnancies. OBJECTIVE The objective of this study was to ascertain obstetric risk in subsequent pregnancies after open maternal-fetal surgery for fetal myelomeningocele closure. STUDY DESIGN An international multicenter prospective observational registry created to track and report maternal, obstetric, fetal/neonatal, and subsequent pregnancy outcomes following open maternal-fetal surgery for fetal myelomeningocele was evaluated for subsequent pregnancy outcome variables. Institutional Review Board approval was obtained for the registry. RESULTS From 693 cases of open maternal-fetal surgery for fetal myelomeningocele closure entered into the registry, 77 subsequent pregnancies in 60 women were identified. The overall live birth rate was 96.2%, with 52 pregnancies delivering beyond 20 weeks gestational age and median gestational age at delivery of 37 (36.3-37.1) weeks. The uterine rupture rate was 9.6% (n = 5), resulting in 2 fetal deaths. Maternal transfusion was required in 4 patients (7.7%). CONCLUSION The risk of uterine rupture or dehiscence in subsequent pregnancies with associated fetal morbidity after open maternal-fetal surgery is significant, but is similar to that reported for subsequent pregnancies after classical cesarean deliveries. Future pregnancy considerations should be included in initial counseling for women contemplating open maternal-fetal surgery.
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Affiliation(s)
| | | | | | | | - J B Lillegard
- Midwest Fetal Care Center, Children's Hospital of Minnesota, Minneapolis, MN
| | | | - Ruth Goldstein
- University of California San Francisco, San Francisco, CA
| | | | | | | | | | | | | | | | | | | | | | - KuoJen Tsao
- University of Texas Health Center, Houston, TX
| | - Amy J Wagner
- Children's Hospital of Wisconsin Fetal Concerns Center, Milwaukee, WI
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Papanna R, Bahtiyar O, Bennett KA, Emery S, Lillegard J, Goldstein R, Goodnight W, Jatres J, Lim FY, McCullough LB, Moehrlen U, Moldenhauer JS, Moon-Grady AJ, Ruano R, Skupski DW, Thom E, Treadwell MC, Tsao K, Wagner A, Waqar LN, Zaretsky M, Fisher A. 229: Use of tissue grafts for in-utero spina bifida closure of large skin defects. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Moldenhauer JS, Bahtiyar O, Bennett KA, Emery SP, Lillegard J, Fisher A, Goldstein R, Goodnight W, Jatres J, Lim FY, McCullough LB, Moehrlen U, Moon-Grady AJ, Ruano R, Skupski DW, Thom E, Treadwell MC, Tsao K, Wagner AJ, Waqar LN, Zaretsky M. 213: Fetal myelomeningocele closure: outcomes from the fMMC consortium registry sponsored by NAFTNet. Am J Obstet Gynecol 2019. [DOI: 10.1016/j.ajog.2018.11.234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Dunietz GL, Shedden K, Schisterman EF, Lisabeth LD, Treadwell MC, O’Brien LM. Associations of snoring frequency and intensity in pregnancy with time-to-delivery. Paediatr Perinat Epidemiol 2018; 32:504-511. [PMID: 30266041 PMCID: PMC6261672 DOI: 10.1111/ppe.12511] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Revised: 07/19/2018] [Accepted: 08/17/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Sleep-disordered breathing (SDB) is linked to adverse pregnancy outcomes. However, little is known about the association of SDB with timing of delivery. We examined the association of snoring frequency, a key SDB marker, and snoring intensity, a correlate of SDB severity, with time-to-delivery among a cohort of pregnant women. METHODS In this prospective cohort study, 1483 third trimester pregnant women were recruited from the University of Michigan prenatal clinics. Women completed a questionnaire about their sleep, and demographic and pregnancy information was abstracted from medical charts. After exclusion of those with hypertension or diabetes, 954 women were classified into two groups by their snoring onset timing, chronic or pregnancy-onset. Within each of these groups, women were divided into four groups based on their snoring frequency and intensity: non-snorers; infrequent-quiet; frequent-quiet; or frequent-loud snorers. Cox proportional hazard regression models were used to investigate the association between snoring frequency and intensity and time-to-delivery, adjusting for maternal characteristics. RESULTS Chronic snoring was reported by half of the pregnant women, and of those, 7% were frequent-loud snorers. Deliveries before 38 weeks' gestation are completed occurred among 25% of women with chronic, frequent-loud snoring. Compared with pre-pregnancy non-snorers, women with chronic frequent-loud snoring had an increased hazard ratio for delivery (adjusted hazard ratio 1.60, 95% confidence interval 1.04, 2.45). CONCLUSIONS Snoring frequency and intensity is associated with time-to-delivery in women absent of hypertension or diabetes. Frequent-loud snoring may have a clinical utility to identify otherwise low-risk women who are likely to deliver earlier.
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Affiliation(s)
- Galit Levi Dunietz
- Sleep Disorders Center, Department of Neurology, University of Michigan, Ann Arbor, MI 48109
| | - Kerby Shedden
- Department of Statistics, University of Michigan, Ann Arbor, MI 48109
| | - Enrique F. Schisterman
- Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health & Human Development, National Institute of Health, Rockville, MD 20847
| | - Lynda D. Lisabeth
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, MI 48109
| | | | - Louise M. O’Brien
- Sleep Disorders Center, Department of Neurology, University of Michigan, Ann Arbor, MI 48109
- Department of Obstetrics & Gynecology, University of Michigan, Ann Arbor, MI 48109
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Dunietz GL, Shedden K, Lisabeth LD, Treadwell MC, O’Brien LM. Maternal Weight, Snoring, and Hypertension: Potential Pathways of Associations. Am J Hypertens 2018; 31:1133-1138. [PMID: 29788196 DOI: 10.1093/ajh/hpy085] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Accepted: 05/15/2018] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy (HDP) are linked to excessive maternal weight and frequent snoring. However, pathways between maternal excessive weight, pregnancy-onset snoring, and HDP are only partially estimated. We examined and quantified the total and direct associations between excessive maternal weight and incident HDP and their indirect pathway through pregnancy-onset snoring. METHODS Third trimester pregnant women enrolled from prenatal clinics of a large tertiary medical center. Sleep data were collected through a questionnaire. Demographic and pregnancy information and first trimester maternal weight were abstracted from medical charts. After exclusion of women with prepregnancy hypertension and/or chronic snoring, causal mediation analysis was used to estimate the total and direct association between maternal weight and incident HDP and their indirect association through pregnancy-onset snoring. The proportion of the mediated association through pregnancy-onset snoring from the total association of maternal weight and HDP was also quantified. RESULTS After excluding those with chronic hypertension and/or snoring, the final sample included 1,333 pregnant women. In adjusted analysis, excessive maternal weight was directly associated with incident HDP; odds ratio (OR) = 1.87 (95% confidence interval (CI) 1.30, 2.70). Pregnancy-onset snoring significantly mediated the association between maternal weight and incident HDP; OR = 1.08 (95% CI 1.01, 1.17). The mediated pathway accounted for 15% of the total association between maternal weight and incident HDP. CONCLUSIONS Pregnancy-onset snoring mediates the association between maternal weight and incident HDP in women without prepregnancy snoring or hypertension. These findings demonstrate the relative contributions of excessive maternal weight and pregnancy-onset snoring to incident HDP.
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Affiliation(s)
- Galit Levi Dunietz
- Sleep Disorders Center, Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
| | - Kerby Shedden
- Department of Statistics, University of Michigan, Ann Arbor, Michigan, USA
| | - Lynda D Lisabeth
- Department of Epidemiology, School of Public Health, University of Michigan, Ann Arbor, Michigan, USA
| | - Marjorie C Treadwell
- Department of Obstetrics & Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Louise M O’Brien
- Sleep Disorders Center, Department of Neurology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Obstetrics & Gynecology, University of Michigan, Ann Arbor, Michigan, USA
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26
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Berman DR, Walkovich K, Treadwell MC. Fetal Hydrops Secondary to in utero Pancytopenia. Fetal Diagn Ther 2018; 45:131-134. [PMID: 29972823 DOI: 10.1159/000490103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 05/02/2018] [Indexed: 11/19/2022]
Abstract
Nonimmune hydrops remains a challenge in the prenatal setting with many cases not having a clear etiology determined prior to birth. We present an unusual case of one fetus of a dichorionic twin pair presenting at 24 weeks' gestation with hydrops and fetal pancytopenia with complete absence of white cells of unknown etiology, as revealed by cordocentesis. Serial red blood cell transfusions resulted in resolution of hydrops and continuation of the pregnancy until 35 weeks' gestation. Pancytopenia was noted throughout gestation and persisted in the newborn period. Moreover, the T-cell receptor excision circle (TREC) assay, a newborn screening test for severe T-cell deficiency, was abnormal at birth. Further evaluation revealed detectable TRECs and normal response to lymphocyte mitogens indicating some preserved thymic and lymphocyte function. The affected child had spontaneous resolution of the pancytopenia, including her severe T-cell deficiency, by 10 weeks of life. There has been no recurrence as of 24 months of age. The self-resolving nature of the pancytopenia is an important feature of this case of nonimmune hydrops. The abnormal TREC assay at birth in the affected infant may help explain the discordant prenatal findings.
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Affiliation(s)
- Deborah R Berman
- University of Michigan, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Ann Arbor, Michigan,
| | - Kelly Walkovich
- University of Michigan, Department of Pediatrics, Division of Hematology and Oncology, Ann Arbor, Michigan, USA
| | - Marjorie C Treadwell
- University of Michigan, Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Ann Arbor, Michigan, USA
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Pinter SZ, Kripfgans OD, Treadwell MC, Kneitel AW, Fowlkes JB, Rubin JM. Evaluation of Umbilical Vein Blood Volume Flow in Preeclampsia by Angle-Independent 3D Sonography. J Ultrasound Med 2018; 37:1633-1640. [PMID: 29243838 DOI: 10.1002/jum.14507] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Revised: 08/15/2017] [Accepted: 09/24/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To investigate the association between umbilical vein blood volume flow and the condition of preeclampsia in an at-risk maternal patient cohort. Umbilical vein volume flow was quantified by a 3-dimensional (3D) sonographic technique that overcomes several limitations of standard sonographic flow measurement methods. METHODS A total of 35 patients, each with a singleton pregnancy, were recruited to provide 5 patients with preeclampsia, derived as a subset from a 26-patient at-risk group, and 9 patients with normal pregnancies. An ultrasound system equipped with a 2.0-8.0-MHz transducer was used to acquire multivolume 3D color flow and power mode data sets to compute the mean umbilical vein volume flow in patients with normal pregnancies and preeclampsia. RESULTS The gestational ages of the pregnancies ranged from 29.7 to 34.3 weeks in the patients with preeclampsia and from 25.9 to 34.7 weeks in the patients with normal pregnancies. Comparisons between patients with normal pregnancies and those with preeclampsia showed weight-normalized flow with a moderately high separation between groups (P = .11) and depth-corrected, weight-normalized flow with a statistically significant difference between groups (P = .035). Umbilical vein volume flow measurements were highly reproducible in the mean estimate, with an intrapatient relative SE of 12.1% ± 5.9% and an intrameasurement relative SE of 5.6% ± 1.9 %. In patients who developed pregnancy-induced hypertension or severe pregnancy-induced hypertension, umbilical vein volume flow suggested gestational hypertensive disorder before clinical diagnosis. CONCLUSIONS Results indicate that mean depth-corrected, weight-normalized umbilical vein volume flow is reduced in pregnancies complicated by preeclampsia and that volume flow may indicate hypertensive disorder earlier in gestation. Volume flow measurements are highly reproducible, and further study in a larger clinical population is encouraged to determine whether 3D volume flow can complement the management of preeclampsia and, in general, at-risk pregnancy.
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Affiliation(s)
- Stephen Z Pinter
- Departments of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Oliver D Kripfgans
- Departments of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Marjorie C Treadwell
- Departments of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Anna W Kneitel
- Departments of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - J Brian Fowlkes
- Departments of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jonathan M Rubin
- Departments of Radiology, University of Michigan, Ann Arbor, Michigan, USA
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28
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Mon RA, Mozurkewich E, Treadwell MC, Berman DR. Cutis Marmorata Telangiectatica Congenita Presenting as a Fetal Hemothorax. Fetal Diagn Ther 2018; 45:281-284. [PMID: 29791897 DOI: 10.1159/000488487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 03/14/2018] [Indexed: 11/19/2022]
Abstract
We report a case of a fetus diagnosed at 28 weeks' gestation with a spontaneous prenatal hemothorax. Fetal intervention consisted of 2 thoracenteses with analysis of the pleural effusion. The pregnancy was further complicated by recurrence of the hemothorax, with subsequent mediastinal shift, hydrops, and nonreassuring antenatal testing requiring delivery at 31 weeks' gestation. Postnatal workup established the diagnoses of cutis marmorata telangiectatica congenita (CMTC) and pulmonary lymphangiectasia. The child is currently 4 years old and without any active medical issues or sequelae from the CMTC, pulmonary lymphangiectasia, or prenatal interventions.
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Affiliation(s)
- Rodrigo A Mon
- Division of Pediatric Surgery, Department of Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Ellen Mozurkewich
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Marjorie C Treadwell
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
| | - Deborah R Berman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA,
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Dunietz GL, Shedden K, Lisabeth LD, Treadwell MC, O’Brien LM. 0897 Maternal Body Mass Index, Pregnancy-onset Snoring and Hypertensive Disorders of Pregnancy; Potential Pathways of Associations. Sleep 2018. [DOI: 10.1093/sleep/zsy061.896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- G L Dunietz
- University of Michigan Department of Neurology, Sleep Disorders Center, Ann Arbor, MI
| | - K Shedden
- University of Michigan Department of Statistics, Ann Arbor, MI
| | - L D Lisabeth
- University of Michigan School of Public Health Department of Epidemiology, Ann Arbor, MI
| | - M C Treadwell
- University of Michigan Department of Obstetrics and Gynecology, Ann Arbor, MI
| | - L M O’Brien
- University of Michigan Department of Neurology, Sleep Disorders Center, Ann Arbor, MI
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Montrose L, Padmanabhan V, Goodrich JM, Domino SE, Treadwell MC, Meeker JD, Watkins DJ, Dolinoy DC. Maternal levels of endocrine disrupting chemicals in the first trimester of pregnancy are associated with infant cord blood DNA methylation. Epigenetics 2018. [PMID: 29513082 DOI: 10.1080/15592294.2018.1448680] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Endocrine disrupting chemicals (EDCs) pose a public health risk through disruption of normal biological processes. Identifying toxicoepigenetic mechanisms of developmental exposure-induced effects for EDCs, such as phthalates or bisphenol A (BPA), is essential. Here, we investigate whether maternal exposure to EDCs is predictive of infant DNA methylation at candidate gene regions. In the Michigan Mother-Infant Pairs (MMIP) cohort, DNA was extracted from cord blood leukocytes for methylation analysis by pyrosequencing (n = 116) and methylation changes related to first trimester levels of 9 phthalate metabolites and BPA. Growth and metabolism-related genes selected for methylation analysis included imprinted (IGF2, H19) and non-imprinted (PPARA, ESR1) genes along with LINE-1 repetitive elements. Findings revealed decreases in methylation of LINE-1, IGF2, and PPARA with increasing phthalate concentrations. For example, a log unit increase in ΣDEHP corresponded to a 1.03 [95% confidence interval (CI): -1.83, -0.22] percentage point decrease in PPARA methylation. Changes in DNA methylation were also inversely correlated with PPARA gene expression determined by RT-qPCR (r = -0.34, P = 0.02), thereby providing evidence in support of functional relevance. A sex-stratified analysis of EDCs and DNA methylation showed that some relationships were female-specific. For example, urinary BPA exposure was associated with a 1.35 (95%CI: -2.69, -0.01) percentage point decrease in IGF2 methylation and a 1.22 (95%CI: -2.27, -0.16) percentage point decrease in PPARA methylation in females only. These findings add to a body of evidence suggesting epigenetically labile regions may provide a conduit linking early exposures with disease risk later in life and that toxicoepigenetic susceptibility may be sex specific.
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Affiliation(s)
- Luke Montrose
- a Department of Environmental Health Sciences, School of Public Health , University of Michigan , Ann Arbor , MI , USA
| | - Vasantha Padmanabhan
- a Department of Environmental Health Sciences, School of Public Health , University of Michigan , Ann Arbor , MI , USA.,b Department of Pediatrics , University of Michigan , Ann Arbor , MI , USA.,c Department of Obstetrics and Gynecology , University of Michigan , Ann Arbor , MI , USA
| | - Jaclyn M Goodrich
- a Department of Environmental Health Sciences, School of Public Health , University of Michigan , Ann Arbor , MI , USA
| | - Steven E Domino
- c Department of Obstetrics and Gynecology , University of Michigan , Ann Arbor , MI , USA
| | - Marjorie C Treadwell
- c Department of Obstetrics and Gynecology , University of Michigan , Ann Arbor , MI , USA
| | - John D Meeker
- a Department of Environmental Health Sciences, School of Public Health , University of Michigan , Ann Arbor , MI , USA
| | - Deborah J Watkins
- a Department of Environmental Health Sciences, School of Public Health , University of Michigan , Ann Arbor , MI , USA
| | - Dana C Dolinoy
- a Department of Environmental Health Sciences, School of Public Health , University of Michigan , Ann Arbor , MI , USA.,d Department of Nutritional Sciences , University of Michigan , Ann Arbor , MI , USA
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Abstract
Twins represent 1%-2% of all pregnancies, yet continue to account for a disproportionate share of neonatal adverse events including neonatal intensive care admission, morbidity, and mortality. Ultrasonography is central to the proper diagnosis of the type of twinning. Ideally, ultrasonography is performed before 14 weeks of gestation to determine chorionicity and amnionicity. Correct identification of the chorionicity in a twin pregnancy facilitates proper counseling and management of the gestation, including ultrasonography follow-up. Herein, the different types of twinning are reviewed, together with the implications for ultrasonography monitoring of each specific type of twin gestation.
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Affiliation(s)
- Jessica Smith
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Marjorie C Treadwell
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Deborah R Berman
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
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Abstract
Twin gestations are increasing in prevalence worldwide, and are potentially subject to medical complications which present uniquely complex ethical and psychosocial challenges for the pregnant patient and obstetrician to navigate. In this article, we explore these issues as they relate to medical decision-making in cases of discordant growth and discordant anomalies in both monochorionic and dichorionic twin pregnancies, including those affected by twin-twin transfusion syndrome, with particular attention to scenarios in which the individual fetuses hold competing interests. For each of these scenarios, we consider how decisions may positively or negatively impact one or both fetuses, and how familiarity with population outcomes, as well as sensitivity to the complex psychosocial circumstances surrounding these pregnancies, can support and inform shared decision-making.
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Gold KJ, Treadwell MC, Mieras ME, Laventhal NT. Who tells a mother her baby has died? Communication and staff presence during stillbirth delivery and early infant death. J Perinatol 2017; 37:1330-1334. [PMID: 29192693 DOI: 10.1038/jp.2017.125] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 04/04/2017] [Accepted: 05/15/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Perinatal loss (stillbirth or early infant death) is often a sudden, unexpected event for families. We evaluated who communicates the loss to the parents and who is there for support at the delivery or death. STUDY DESIGN We conducted a mail survey of 900 bereaved and 500 live-birth mothers to assess emotional, physical and reproductive health outcomes. RESULTS We had a 44% response rate at 9 months after birth or loss from 377 bereaved mothers and 232 with surviving infants. Bereaved women were less likely to have hospital staff or family members present at delivery. African-American (versus Caucasian) mothers were half as likely to have first heard about their stillbirth from a physician or midwife. CONCLUSION This is the first large study documenting who communicates perinatal death to families and who is present for support. Hospitals should be aware that many bereaved families may lack support at critical times.
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Affiliation(s)
- K J Gold
- Department of Family Medicine and Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - M C Treadwell
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
| | - M E Mieras
- Department of Social Work, University of Michigan, Ann Arbor, MI, USA
| | - N T Laventhal
- Department of Pediatrics and Communicable Diseases, Division of Neonatal-Perinatal Medicine, University of Michigan, Ann Arbor, MI, USA
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Balistreri M, Davis JA, Campbell KF, Da Rocha AM, Treadwell MC, Herron TJ. Effect of Glucose on 3D Cardiac Microtissues Derived from Human Induced Pluripotent Stem Cells. Pediatr Cardiol 2017; 38:1575-1582. [PMID: 28752324 DOI: 10.1007/s00246-017-1698-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 07/21/2017] [Indexed: 11/29/2022]
Abstract
Maternal hyperglycemia is a risk factor for fetal cardiac anomalies. This study aimed to assess the effect of high glucose on human induced pluripotent stem cell-derived cardiomyocyte self-assembly into 3D microtissues and their calcium handling. Stem cells were differentiated to beating cardiomyocytes using established protocols. On the final day of the differentiation process, cells were treated with control media, 12 mM glucose, or 12 mM mannitol (an osmolality control). Once beating, the cardiac cells were dissociated with trypsin, collected, mixed with collagen, and plated into custom-made silicone micro molds in order to generate 3D cardiac microtissues. A time-lapse microscope took pictures every 4 h to quantify the kinetics of cellular self-assembly of 3D cardiac tissues. Fiber widths were recorded at 4-h intervals and plotted over time to assess cardiomyocyte 3D fiber self-assembly. Microtissue calcium flux was recorded with optical mapping by pacing microtissues at 0.5 and 1.0 Hz. Exposure to high glucose impaired the ability of cardiomyocytes to self-assemble into compact microtissues, but not their ability to spontaneously contract. Glucose-exposed cardiomyocytes took longer to self-assemble and finished as thicker fibers. When cardiac microtissues were paced at 0.5 and 1.0 Hz, those exposed to high glucose had altered calcium handling with shorter calcium transient durations, but larger amplitudes of the calcium transient when compared to controls. Additional studies are needed to elucidate a potential mechanism for these findings. This model provides a novel method to assess the effects of exposures on the cardiomyocytes' intrinsic abilities for organogenesis in 3D.
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Affiliation(s)
- Michael Balistreri
- Department of Obstetrics and Gynecology, Von Voigtlander Women's Hospital, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Justin A Davis
- Department of Obstetrics and Gynecology, Von Voigtlander Women's Hospital, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA.,Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA.,Department of Cardiology, University of Michigan, Ann Arbor, MI, 48109, USA.,Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Katherine F Campbell
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA
| | | | - Marjorie C Treadwell
- Department of Obstetrics and Gynecology, Von Voigtlander Women's Hospital, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Todd J Herron
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA.,Department of Cardiology, University of Michigan, Ann Arbor, MI, 48109, USA.,Department of Molecular and Integrative Physiology, University of Michigan, Ann Arbor, MI, 48109, USA
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Triebwasser JE, Treadwell MC. In Utero Evidence of Impaired Somatic Growth in Hypoplastic Left Heart Syndrome. Pediatr Cardiol 2017; 38:1400-1404. [PMID: 28689327 DOI: 10.1007/s00246-017-1676-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 07/01/2017] [Indexed: 10/19/2022]
Abstract
We hypothesized that fetuses with hypoplastic left heart syndrome (HLHS) have impaired growth compared to expected growth for gestational age. This is a retrospective cohort study including singleton fetuses with isolated HLHS identified from a single, referral center's ultrasound database. To account for variable timing of ultrasounds, z-scores for gestational age were assigned for each biometric parameter. We identified 169 fetuses, of which 96 had more than one ultrasound. The median number of ultrasound evaluations per fetus was 2 (range 1-5). The mean gestational age at time of last ultrasound was 33.7 ± 4.3 weeks with a range of 20.4-39.6 weeks. While fetal growth restriction (11%) and microcephaly (3%) were relatively rare, mean z-scores at the time of last ultrasound for estimated fetal weight (mean difference z-score -0.20, p = 0.04) and head circumference (-0.28, p = 0.02) were lower than at the time of the initial ultrasound. Impaired somatic growth, defined as a decrement in z-score of 0.5 or more over time, was common (32%). There is a deceleration in somatic and head growth in fetuses with hypoplastic left heart syndrome that can be identified by routine ultrasound evaluation.
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Affiliation(s)
- Jourdan E Triebwasser
- Department of Obstetrics and Gynecology, Michigan Medicine, University of Michigan, L4001 Women's Hospital, 1500 East Medical Center Drive, Ann Arbor, MI, 48109-5276, USA.
| | - Marjorie C Treadwell
- Department of Obstetrics and Gynecology, Michigan Medicine, University of Michigan, L4001 Women's Hospital, 1500 East Medical Center Drive, Ann Arbor, MI, 48109-5276, USA
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Mon RA, Treadwell MC, Berman DR, Day L, Kreutzman J, Mychaliska GB, Perrone EE. Outcomes of fetuses with primary hydrothorax that undergo prenatal intervention (prenatal intervention for hydrothorax). J Surg Res 2017; 221:121-127. [PMID: 29229117 DOI: 10.1016/j.jss.2017.08.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 08/08/2017] [Accepted: 08/16/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Primary hydrothorax is a congenital anomaly affecting 1 in 10,000-15,000 pregnancies. The natural history of this condition is variable with some fetuses having spontaneous resolution and others showing progression. The associated pulmonary hypoplasia leads to increased perinatal morbidity and mortality. Optimal prenatal intervention remains controversial. METHODS After obtaining the Institutional Review Board approval, a retrospective review of all patients evaluated for a fetal pleural effusion in the Fetal Diagnosis and Treatment Center at The University of Michigan, between 2006 and 2016 was performed. Cases with secondary etiologies for an effusion or when families decided to pursue elective termination were excluded. RESULTS Pleural effusions were identified in 175 patients. Primary hydrothorax was diagnosed in 15 patients (8%). The effusions were bilateral in 13/15 cases (86%) and 10/15 (66%) had hydrops at presentation. All 15 patients with primary hydrothorax underwent prenatal intervention. Thoracentesis was performed in 14/15 cases (93%). Shunt placement was performed in 10/15 cases (66%). Shunt migration was seen in four patients (40%) and all of these underwent prenatal shunt replacement. Overall survival was 76%. The rates of prematurity and preterm premature rupture of membranes were 69% and 35%, respectively. CONCLUSIONS Fetal intervention for the treatment of primary hydrothorax is effective, and it appears to confer a survival advantage. Both the fetuses and the mothers tolerated the procedures well. Preterm labor and preterm premature rupture of membranes remain an unsolved problem. Further studies are needed to understand the mechanisms behind the development of fetal hydrothorax.
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Affiliation(s)
- Rodrigo A Mon
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan; University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan
| | - Marjorie C Treadwell
- University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan Health System, Ann Arbor, Michigan
| | - Deborah R Berman
- University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan Health System, Ann Arbor, Michigan
| | - Lori Day
- University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan Health System, Ann Arbor, Michigan
| | - Jeannie Kreutzman
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan; University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan
| | - George B Mychaliska
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan; University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan
| | - Erin E Perrone
- Section of Pediatric Surgery, Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan; University of Michigan Health System, Fetal Diagnosis and Treatment Center, Ann Arbor, Michigan.
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Perrone EE, Jarboe MD, Maher CO, Berman DR, Ladino-Torres M, Kreutzman J, Treadwell MC, Mychaliska GB. Early Delivery of Sacrococcygeal Teratoma with Intraspinal Extension. Fetal Diagn Ther 2017; 43:72-76. [DOI: 10.1159/000472714] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 03/21/2017] [Indexed: 11/19/2022]
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Triebwasser JE, Treadwell MC. 273: Fetal growth in hypoplastic left heart syndrome. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Balistreri M, Da Rocha AM, Campbell KF, Treadwell MC, Herron TJ. 491: Effect of high glucose level on the development of human 3D cardiac micro-tissues derived from induced pluripotent stem cells. Am J Obstet Gynecol 2017. [DOI: 10.1016/j.ajog.2016.11.226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Coughlin MA, Werner NL, Gajarski R, Gadepalli S, Hirschl R, Barks J, Treadwell MC, Ladino-Torres M, Kreutzman J, Mychaliska GB. Prenatally diagnosed severe CDH: mortality and morbidity remain high. J Pediatr Surg 2016; 51:1091-5. [PMID: 26655216 DOI: 10.1016/j.jpedsurg.2015.10.082] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Revised: 10/26/2015] [Accepted: 10/28/2015] [Indexed: 11/18/2022]
Abstract
PURPOSE This study sought to evaluate prenatal markers' ability to predict severe congenital diaphragmatic hernia(CDH) and assess this subgroup's morbidity and mortality. METHODS A retrospective review was performed between 2006 and 2014. Prenatal criteria for severe CDH included: liver herniation, lung-to-head ratio (LHR) <1 on prenatal ultrasound and/or observed-to-expected LHR (o/eLHR) <25%, and/or observed-to-expected total lung volume (o/eTLV) <25% on fetal MRI. Postnatal characteristics included: mortality, ECMO utilization, patch closure, persistent suprasystemic pulmonary hypertension (PHtn), O2 requirement at discharge, and few ventilator-free days in the first 60. Statistics performed used unpaired t-test, p<0.05 significant. RESULTS Overall, 47.5%(29/61) of patients with prenatally diagnosed, isolated CDH met severe criteria. Mean LHR: 1.04±0.35, o/eLHR: 31±10% and o/eTLV: 20±7%. Distribution was 72% LCDH, 24% R-CDH. Overall survival: 38%. ECMO requirement: 92%. Patch rate: 91%. Mean ventilator-free days in 60: 7.1±14. Supplemental oxygen at discharge was required in 27%. In this prenatally diagnosed severe cohort, 58%(15/26) had persistent PHtn post-ECMO requiring inhaled nitric oxide±epoprostenol. Comparing patients with and without PHtn: mean ECMO duration 18±10 days versus 9±7 days (p=0.01) and survival 20% versus 72% (p=0.006). CONCLUSION A combination of prenatal markers accurately identified severe CDH patients. Outcomes of this group remain poor and persistent PHtn contributes significantly to mortality.
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Affiliation(s)
- Megan A Coughlin
- Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School, C.S. Mott Children's Hospital, and the Fetal Diagnosis and Treatment Center, Ann Arbor, MI.
| | - Nicole L Werner
- Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School, C.S. Mott Children's Hospital, and the Fetal Diagnosis and Treatment Center, Ann Arbor, MI
| | - Robert Gajarski
- Division of Pediatric Cardiology, The University of Michigan Medical School, C.S. Mott Children's Hospital, and the Fetal Diagnosis and Treatment Center, Ann Arbor, MI
| | - Samir Gadepalli
- Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School, C.S. Mott Children's Hospital, and the Fetal Diagnosis and Treatment Center, Ann Arbor, MI
| | - Ronald Hirschl
- Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School, C.S. Mott Children's Hospital, and the Fetal Diagnosis and Treatment Center, Ann Arbor, MI
| | - John Barks
- Division of Neonatology, The University of Michigan Medical School, C.S. Mott Children's Hospital, and the Fetal Diagnosis and Treatment Center, Ann Arbor, MI
| | - Marjorie C Treadwell
- Division of Maternal Fetal Medicine, The University of Michigan Medical School, C.S. Mott Children's Hospital, and the Fetal Diagnosis and Treatment Center, Ann Arbor, MI
| | - Maria Ladino-Torres
- Division of Pediatric Radiology, The University of Michigan Medical School, C.S. Mott Children's Hospital, and the Fetal Diagnosis and Treatment Center, Ann Arbor, MI
| | - Jeannie Kreutzman
- Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School, C.S. Mott Children's Hospital, and the Fetal Diagnosis and Treatment Center, Ann Arbor, MI
| | - George B Mychaliska
- Section of Pediatric Surgery, Department of Surgery, The University of Michigan Medical School, C.S. Mott Children's Hospital, and the Fetal Diagnosis and Treatment Center, Ann Arbor, MI
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Moise KJ, Moldenhauer JS, Bennett KA, Goodnight W, Luks FI, Emery SP, Tsao K, Moon-Grady AJ, Moore RC, Treadwell MC, Vlastos EJ, Wetjen NM. Current Selection Criteria and Perioperative Therapy Used for Fetal Myelomeningocele Surgery. Obstet Gynecol 2016; 127:593-597. [DOI: 10.1097/aog.0000000000001296] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Macardle CA, Ehrenberg-Buchner S, Smith EA, Dillman JR, Mychaliska GB, Treadwell MC, Kunisaki SM. Surveillance of fetal lung lesions using the congenital pulmonary airway malformation volume ratio: natural history and outcomes. Prenat Diagn 2016; 36:282-9. [DOI: 10.1002/pd.4761] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/30/2015] [Accepted: 12/16/2015] [Indexed: 01/10/2023]
Affiliation(s)
- Catriona A. Macardle
- Department of Obstetrics and Gynecology; St. Joseph Mercy Health System; Ann Arbor MI USA
| | - Stacey Ehrenberg-Buchner
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine; C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan Health System; Ann Arbor MI USA
| | - Ethan A. Smith
- Department of Radiology, Section of Pediatric Radiology; C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan Health System; Ann Arbor MI USA
| | - Jonathan R. Dillman
- Department of Radiology, Section of Pediatric Radiology; C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan Health System; Ann Arbor MI USA
| | - George B. Mychaliska
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine; C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan Health System; Ann Arbor MI USA
- Department of Surgery, Section of Pediatric Surgery; C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan Health System; Ann Arbor MI USA
| | - Marjorie C. Treadwell
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine; C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan Health System; Ann Arbor MI USA
| | - Shaun M. Kunisaki
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine; C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan Health System; Ann Arbor MI USA
- Department of Surgery, Section of Pediatric Surgery; C.S. Mott Children's and Von Voigtlander Women's Hospital, University of Michigan Health System; Ann Arbor MI USA
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Jarboe MD, Berman DR, Wright T, Treadwell MC, Mychaliska GB. Novel Application of Laparoscopic Ultrasound for Fetoscopic Laser Ablation in Twin-Twin Transfusion Syndrome with Complete Anterior Placenta. Fetal Diagn Ther 2015; 41:71-75. [PMID: 26555815 DOI: 10.1159/000439526] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Accepted: 08/15/2015] [Indexed: 11/19/2022]
Abstract
Fetoscopic laser coagulation of the placental communicating vessels has become the standard treatment for monochorionic/diamniotic twin pregnancies complicated by severe twin-twin transfusion syndrome. Fetoscopic trocar placement can be performed with transabdominal ultrasound guidance with a posterior placenta and most anterior placentas that have a safe avascular window for entry. However, trocar insertion is challenging in cases of a complete anterior placenta without an avascular window. Current techniques to deal with this situation include mini-laparotomy with exteriorization to allow for dorsal entry, percutaneous lateral entry under transabdominal ultrasound/Doppler guidance, and laparoscopic assisted access with direct visualization of trocar entry. We describe a modified technique of laparoscopic assisted fetoscopic trocar placement using a laparoscopic ultrasound probe, which allows for precise, real-time guidance of trocar placement.
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Affiliation(s)
- Marcus D Jarboe
- Pediatric Surgery Section, Department of Surgery, C.S. Mott Children's and Von Voigtlander Women's Hospital, Fetal Diagnosis and Treatment Center, University of Michigan, Ann Arbor, Mich., USA
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VanKoevering KK, Morrison RJ, Prabhu SP, Torres MFL, Mychaliska GB, Treadwell MC, Hollister SJ, Green GE. Antenatal Three-Dimensional Printing of Aberrant Facial Anatomy. Pediatrics 2015; 136:e1382-5. [PMID: 26438708 PMCID: PMC4621796 DOI: 10.1542/peds.2015-1062] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2015] [Indexed: 01/17/2023] Open
Abstract
Congenital airway obstruction poses a life-threatening challenge to the newborn. We present the first case of three-dimensional (3D) modeling and 3D printing of complex fetal maxillofacial anatomy after prenatal ultrasound indicated potential upper airway obstruction from a midline mass of the maxilla. Using fetal MRI and patient-specific computer-aided modeling, the craniofacial anatomy of the fetus was manufactured using a 3D printer. This model demonstrated the mass to be isolated to the upper lip and maxilla, suggesting the oral airway to be patent. The decision was made to deliver the infant without a planned ex utero intrapartum treatment procedure. The neonate was born with a protuberant cleft lip and palate deformity, without airway obstruction, as predicted by the patient-specific model. The delivery was uneventful, and the child was discharged without need for airway intervention. This case demonstrates that 3D modeling may improve prenatal evaluation of complex patient-specific fetal anatomy and facilitate the multidisciplinary approach to perinatal management of complex airway anomalies.
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Affiliation(s)
| | | | - Sanjay P. Prabhu
- Department of Radiology, Harvard Medical School, Boston, Massachusetts;,Department of Radiology, Boston Children’s Hospital, Boston, Massachusetts
| | | | | | - Marjorie C. Treadwell
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, Fetal Diagnosis and Treatment Center, University of Michigan, Ann Arbor, Michigan; and
| | | | - Glenn E. Green
- Division of Pediatric Otolaryngology, Department of Otolaryngology-Head & Neck Surgery, University of Michigan, Ann Arbor, Michigan
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Abstract
This study sought to identify delivery complications associated with stillbirth labour and delivery. We conducted a retrospective chart review evaluating stillbirth demographics, pregnancy and maternal risk factors, and complications of labour and delivery. We performed bivariable analysis and multivariable logistic regression to evaluate factors associated with medical complications and variations by race. Our cohort included 543 mothers with stillbirth, of which two-thirds were African-American. We noted high rates of shoulder dystocia, clinical chorioamnionitis, postpartum haemorrhage and retained placenta in women with stillbirths. Thirty-three women (6%) experienced at least one serious maternal complication. Complication rates did not vary by maternal race. Providers who perform obstetrical care should be alert to the high rate of maternal medical complications associated with labour and delivery of a stillbirth foetus.
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Affiliation(s)
- K J Gold
- a Department of Family Medicine and Department of Obstetrics and Gynecology , University of Michigan , US
| | - E L Mozurkewich
- b Department of Obstetrics and Gynecology , University of New Mexico , US
| | - K S Puder
- c Department of Obstetrics and Gynecology , Wayne State University , US
| | - M C Treadwell
- d Department of Obstetrics and Gynecology , University of Michigan , US
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Abstract
Noonan syndrome is a multisystem genetic disorder caused by genes encoding proteins involved in the RAS-MAPK pathway. Affected fetuses have variable presentations ranging from the absence of prenatal findings to increased nuchal fold, cystic hygromas, pleural effusions, cardiac malformations, or skin edema. We describe a male fetus who had features consistent with Noonan syndrome at the time of fetal anatomic survey, including hydrops and a possible cardiac defect. Subsequent scan revealed persistent bilateral pleural effusions (with predominance of lymphocytes). After bilateral thoracoamniotic shunt placement, the fetus did well and delivered at term. Prenatal testing revealed an S650F missense mutation in the RAF1 gene, which had not previously been associated with Noonan syndrome.
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Affiliation(s)
- Anna W Kneitel
- a University of Michigan Department of Obstetrics and Gynecology , Ann Arbor , Michigan , USA
| | - Audrey Norby
- a University of Michigan Department of Obstetrics and Gynecology , Ann Arbor , Michigan , USA
| | | | - Marjorie C Treadwell
- a University of Michigan Department of Obstetrics and Gynecology , Ann Arbor , Michigan , USA
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Kunisaki SM, Bruch SW, Hirschl RB, Mychaliska GB, Treadwell MC, Coran AG. The diagnosis of fetal esophageal atresia and its implications on perinatal outcome. Pediatr Surg Int 2014; 30:971-7. [PMID: 25056797 DOI: 10.1007/s00383-014-3562-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/16/2014] [Indexed: 11/24/2022]
Abstract
The current diagnostic accuracy and perinatal outcome of fetuses with esophageal atresia (EA) continues to be debated. In this review, we report on our experience at a tertiary care fetal center with the prenatal ultrasound diagnosis of EA. Enrollment criteria included a small/absent stomach bubble with a normal or elevated amniotic fluid index between 2005 and 2013. Perinatal outcomes were analyzed and compared to postnatally diagnosed EA cases. Of the 22 fetuses evaluated, polyhydramnios occurred in 73%. Three (14%) died in utero or shortly after birth, but none had EA. In the presence of an absent/small stomach and polyhydramnios, the positive predictive value for EA was 67%. In fetal EA cases confirmed postnatally (group 1, n = 11), there were no differences in gestational age, birthweight, or mortality when compared to postnatally diagnosed infants (group 2, n = 59). Group 1 was associated with long-gap EA, need for esophageal replacement, and increased hospital length of stay. When taken in context with the current literature, we conclude that ultrasound findings suggestive of EA continue to be associated with a relatively high rate of false positives. However, among postnatally confirmed cases, there is an increased risk for long-gap EA and prolonged hospitalization.
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Affiliation(s)
- Shaun M Kunisaki
- Department of Surgery, C.S. Mott Children's Hospital, University of Michigan Health System, 1540 E. Hospital Drive, SPC 4211, Ann Arbor, MI, 48109, USA,
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Dugan RB, Pletneva MA, Salari K, Berman DR, Treadwell MC. Nonimmune fetal hydrops and lysosomal storage disease: the finding of vacuolated lymphocytes in ascitic fluid in two cases. Prenat Diagn 2013; 34:199-201. [PMID: 24284886 DOI: 10.1002/pd.4274] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 10/23/2013] [Accepted: 11/03/2013] [Indexed: 11/08/2022]
Affiliation(s)
- R B Dugan
- Fetal Diagnostic Center, University of Michigan Health System, Ann Arbor, MI, USA
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Mozurkewich EL, Clinton CM, Chilimigras JL, Hamilton SE, Allbaugh LJ, Berman DR, Marcus SM, Romero VC, Treadwell MC, Keeton KL, Vahratian AM, Schrader RM, Ren J, Djuric Z. The Mothers, Omega-3, and Mental Health Study: a double-blind, randomized controlled trial. Am J Obstet Gynecol 2013; 208:313.e1-9. [PMID: 23531328 DOI: 10.1016/j.ajog.2013.01.038] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 01/06/2013] [Accepted: 01/16/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Maternal deficiency of the omega-3 fatty acid, docosahexaenoic acid (DHA), has been associated with perinatal depression, but there is evidence that supplementation with eicosapentaenoic acid (EPA) may be more effective than DHA in treating depressive symptoms. This trial tested the relative effects of EPA- and DHA-rich fish oils on prevention of depressive symptoms among pregnant women at an increased risk of depression. STUDY DESIGN We enrolled 126 pregnant women at risk for depression (Edinburgh Postnatal Depression Scale score 9-19 or a history of depression) in early pregnancy and randomly assigned them to receive EPA-rich fish oil (1060 mg EPA plus 274 mg DHA), DHA-rich fish oil (900 mg DHA plus 180 mg EPA), or soy oil placebo. Subjects completed the Beck Depression Inventory (BDI) and Mini-International Neuropsychiatric Interview at enrollment, 26-28 weeks, 34-36 weeks, and at 6-8 weeks' postpartum. Serum fatty acids were analyzed at entry and at 34-36 weeks' gestation. RESULTS One hundred eighteen women completed the trial. There were no differences between groups in BDI scores or other depression endpoints at any of the 3 time points after supplementation. The EPA- and DHA-rich fish oil groups exhibited significantly increased postsupplementation concentrations of serum EPA and serum DHA respectively. Serum DHA- concentrations at 34-36 weeks were inversely related to BDI scores in late pregnancy. CONCLUSION EPA-rich fish oil and DHA-rich fish oil supplementation did not prevent depressive symptoms during pregnancy or postpartum.
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Affiliation(s)
- Ellen L Mozurkewich
- Department of Obstetrics and Gynecology, University of Michigan Medical School, Ann Arbor, MI, USA
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