Chorionic villus sampling before multifetal pregnancy reduction

OBJECTIVE

This study was undertaken to determine the technical feasibility and accuracy of chorionic villus sampling before multifetal pregnancy reduction and to determine whether sampling increases the pregnancy loss rate after the reduction procedure.

STUDY DESIGN

Between January 22, 1986, and January 20, 2000, a total of 1183 patients underwent first-trimester multifetal pregnancy reduction at Mount Sinai Medical Center. Chorionic villus sampling was attempted in 86 patients before the reduction procedure. Information on the technical success and accuracy of chorionic villus sampling, as well as pregnancy outcome, was collected on all patients. Pregnancy loss rates before 24 weeks' gestation in patients undergoing chorionic villus sampling before multifetal pregnancy reduction were compared with rates in patients not undergoing sampling.

RESULTS

Chorionic villus sampling was successfully completed in 85 (98.8%) of 86 patients in whom sampling was attempted. Of 166 fetuses, 165 (99.4%) were successfully sampled. Of 165 fetuses, 3 (1.8%) had karyotypic abnormalities. Sampling errors were probably made in 2 (1.2%) of 165 fetuses. Of the 73 patients who have been delivered or are beyond 24 weeks' gestation, only 1 patient (1.4%) had a pregnancy loss after the multifetal pregnancy reduction.

CONCLUSIONS

Chorionic villus sampling before multifetal pregnancy reduction is technically feasible and accurate, with an acceptably low sampling error rate. Chorionic villus sampling before multifetal pregnancy reduction appears to be safe and does not increase the risk of loss after the reduction procedure.

Systematic identification and intervention for reading difficulty: case studies of children with EAL

Literacy underpins education. There is now very widespread concern over standards of literacy for children from multi-cultural backgrounds, who are learning English as a second or subsequent language, and who may have special educational needs. Research evidence suggests that the earlier children's difficulties can be identified, the more effective (and cost-effective) intervention will be, provided that the intervention is tailored to the child's abilities and skills. Nicolson and Fawcett have developed systematic procedures for identifying children at risk for reading difficulty, together with systematic teaching strategies to overcome reading difficulty. In this paper we present case studies of children with EAL (English as an additional language) drawn from a controlled study using computer interventions with secondary school children. Our findings indicate that children with EAL may be more resistant to remediation than some children with learning difficulties. The prognosis is more problematic for children with both EAL and dyslexia.

Magma flow instability and cyclic activity at soufriere hills volcano, montserrat, british west indies

Dome growth at the Soufriere Hills volcano (1996 to 1998) was frequently accompanied by repetitive cycles of earthquakes, ground deformation, degassing, and explosive eruptions. The cycles reflected unsteady conduit flow of volatile-charged magma resulting from gas exsolution, rheological stiffening, and pressurization. The cycles, over hours to days, initiated when degassed stiff magma retarded flow in the upper conduit. Conduit pressure built with gas exsolution, causing shallow seismicity and edifice inflation. Magma and gas were then expelled and the edifice deflated. The repeat time-scale is controlled by magma ascent rates, degassing, and microlite crystallization kinetics. Cyclic behavior allows short-term forecasting of timing, and of eruption style related to explosivity potential.

Reduction of distress in children undergoing sexual abuse medical examination

A participant modeling film to reduce distress in children (5 to 13 years old) undergoing sexual abuse medical examination was tested. Twenty-one children viewing the participant modeling film reported less fear after film viewing and were behaviorally less distressed and more compliant, as rated by nurses and mothers, during gynecological examination than 21 children viewing a nonrelevant film.

First-trimester growth restriction and fetal aneuploidy: the effect of type of aneuploidy and gestational age

OBJECTIVE

Our purpose was to determine the effect of type of aneuploidy and gestational age on first-trimester fetal growth.

STUDY DESIGN

Crown-rump length measurement was obtained in pregnancies undergoing chorionic villus sampling in three large prenatal diagnosis centers. One hundred forty-four aneuploid fetuses, from 9 to 13 weeks' gestation, were compared with 440 matched control fetuses for evidence of crown-rump length shortening. Shortening was defined by the observed/expected crown-rump length. Expected values of crown-rump length based on last menstrual period were obtained from regression equations generated from a separate normal group. Threshold values for aneuploidy screening were determined on the basis of receiver-operator characteristic curves.

RESULTS

There was significant crown-rump length shortening in trisomy 18 compared with normal fetuses, with observed/expected values < or = 0.80 (odds ratio 13.78, 95% confidence interval 5.64 to 33.88, p < 0.000001); for trisomy 13 the observed/expected crown-rump length was < or = 0.90 (odds ratio 3.64, 95% confidence interval 1.08 to 12.96, p < 0.03). There was no significant shortening of crown-rump length in Down syndrome, with observed/expected values < or = 0.92 (odds ratio 0.86, 95% confidence interval 0.50 to 1.47, p = 0.6). With shortened crown-rump length (observed/expected value < 0.86) the risk of any aneuploidy is increased (odds ratio 2.52, 95% confidence interval 1.6 to 3.96, p < 0.0001). When the first-trimester crown-rump length was shortened by > or = 14 mm, the aneuploidy risk was high (odds ratio 9.04, 95% confidence interval 3.26 to 28.67, p < 0.00001).

CONCLUSION

In the first trimester fetuses with trisomy 18 and 13 appear to be growth restricted, in contrast to fetuses with trisomy 21. In at-risk pregnancies crown-length that is shorter than expected significantly increase the odds that aneuploidy is present.

Twin pregnancies conceived by assisted reproductive techniques: maternal and neonatal outcomes

OBJECTIVE

To determine whether twin pregnancies conceived by assisted reproductive techniques are at increased risk for obstetric complications or perinatal morbidity.

METHODS

A computerized perinatal data base was reviewed for all twin pregnancies managed by private obstetricians and delivered between 1990 and 1995. The obstetric and neonatal outcomes of those conceived following in vitro fertilization (IVF) or gamete intrafallopian transfer (GIFT) were compared to the outcomes of those conceived spontaneously.

RESULTS

There were 105 twin deliveries following IVF or GIFT and 279 following natural fertilization. Discordant birth weight and low birth weight occurred more frequently in pregnancies conceived by IVF or GIFT (adjusted odds ratio [OR] 2.11, 95% confidence interval [CI] 1.14, 3.91; OR 1.65, 95% CI 0.98, 2.79, respectively). Elective cesarean delivery was more frequent in twin pregnancies conceived after IVF GIFT (relative risk [RR] 4.02, 95% CI 1.28, 12.6). There were no statistically significant differences in the frequency of antepartum or intrapartum complications, preterm delivery, or mean gestational age at delivery. There was no statistically significant increase in the frequency of neonatal complications among infants born after IVF GIFT.

CONCLUSION

Although twin pregnancies following IVF or GIFT are more likely to result in discordant birth weight infants, the perinatal outcome is comparable to that of spontaneously conceived twin pregnancies.

Pregnancy outcome at age 40 and older

OBJECTIVE

To examine pregnancy outcome among women age 40 years and older.

METHODS

A retrospective cohort study, including 1404 pregnant women at least 40 years of age and 6978 controls age 20-29 years, was conducted. The two groups were stratified, according to parity, to facilitate separate analysis. Associations between maternal age and pregnancy outcomes were assessed with the contingency chi 2 or two-tailed Fisher exact test. Multiple logistic regression was used to evaluate these associations and allowed for calculation of adjusted odds ratios (OR).

RESULTS

Older gravidas were more likely to develop gestational diabetes (nulliparas: OR 2.7, 95% confidence interval [CI] 1.9-3.7; multiparas: OR 3.8, 95% CI 2.7-5.4), preeclampsia (nulliparas: OR 1.8, 95% CI 1.3-2.6; multiparas: OR 1.9, 95% CI 1.2-2.9), and placenta previa (nulliparas: OR 13.0, 95% CI 4.8-35.0; multiparas: OR 6.4, 95% CI 2.6-15.6). Older women were also at increased risk for cesarean delivery (nulliparas: OR 3.1, 95% CI 2.6-3.7; multiparas: OR 3.3, 95% CI 2.6-4.1), operative vaginal delivery (nulliparas: OR 2.4, 95% CI 1.9-2.9; multiparas: OR 1.5, 95% CI 1.2-1.9), and induction of labor (nulliparas: OR 1.5, 95% CI 1.2-1.8; multiparas: OR 1.4, 95% CI 1.1-1.7). Older nulliparas had an increased incidence of abnormal labor patterns (OR 1.4, 95% CI 1.2-1.7), neonatal intensive care unit admissions (OR 1.6, 95% CI 1.2-2.2), and low 1-minute Apgar scores (OR 2.3, 95% CI 1.1-4.9). Older multiparas were more likely to experience fetal distress (OR 2.0, 95% CI 1.4-2.8), antepartum vaginal bleeding (OR 1.8, 95% CI 1.1-3.1), and preterm premature rupture of membranes (OR 1.7, 95% CI 1.1-2.9).

CONCLUSION

Although maternal morbidity was increased in the older gravidas, the overall neonatal outcome did not appear to be affected.

Antenatal management of alloimmune thrombocytopenia with intravenous gamma-globulin: a randomized trial of the addition of low-dose steroid to intravenous gamma-globulin

OBJECTIVES

Our purposes were to investigate maternal infusions of intravenous gamma-globulin, to prevent intracranial hemorrhage, and to determine whether 1.5 mg dexamethasone and 60 mg prednisone per day add to the effect of intravenous gamma-globulin.

STUDY DESIGN

Fifty-four women with alloimmune thrombocytopenia and thrombocytopenic fetuses were randomized to intravenous gamma-globulin 1 gm/kg per week with or without dexamethasone. Nonresponders after 4 to 6 weeks received continued intravenous gamma-globulin plus 60 mg of prednisone per day ("salvage").

RESULTS

Dexamethasone did not add to the effect of intravenous gamma-globulin. Overall, there was a mean platelet increase from the first to the second fetal blood sampling of 36,000/microliters (n = 47) and from the first fetal blood sampling to birth of 69,000/microliters (n = 54). A total of 62% to 85% of fetuses responded. There were no intracranial hemorrhages. "Salvage" increased the platelet count in 5 of 10 nonresponders to intravenous gamma-globulin.

CONCLUSION

Intravenous gamma-globulin treatment is appropriate for thrombocytopenic fetuses with alloimmune thrombocytopenia before use of weekly in utero platelet transfusions, even in severe thrombocytopenia.

The current status of multifetal pregnancy reduction

The number of women conceiving three or more fetuses has increased dramatically as a result of successful infertility therapy with ovulation-inducing agents and assisted reproductive technology. Higher-order multiple gestations have an increased risk of premature delivery and its attendant sequelae of increased neonatal mortality or irreversible morbidity. Multifetal pregnancy reduction is a procedure designed to decrease the increased propensity to deliver very prematurely in these patients by reducing the number of live fetuses they are carrying. The procedure has proved to be both safe and effective, and pregnancies reduced to twins proceed as if that were the number of fetuses originally conceived. Nevertheless, this invasive procedure does have the potential to result in loss of the entire pregnancy and causes considerable emotional distress for some couples who view it as their "least bad" alternative. The medical benefits of performing multifetal pregnancy reduction in women with four or more fetuses seem fairly well established, but this is less true for triplets. Serious attention should be paid to reducing the number of higher-order multiple pregnancies resulting from infertility therapy. In the meantime, when three or more fetuses have been conceived, multifetal pregnancy reduction offers a reasonable option to patients whose only choices in the past were either to accept the risk of delivering extremely prematurely or to terminate the entire pregnancy.

The clinical outcome of preterm premature rupture of membranes in twin versus singleton pregnancies

The purpose of this study was to determine the clinical outcome of preterm premature rupture of the membranes (PPROM) in twin versus singleton pregnancies at less than or equal to 36 weeks' gestation. A retrospective cohort study was conducted in 116 twin pregnancies with PPROM at less than or equal to 36 weeks' gestational age and 116 matched singleton pregnancies. The two groups were analyzed for differences in maternal demographics and perinatal and neonatal outcome. Perinatal and neonatal outcomes were similar in the two groups. The median latency period, however, was significantly decreased in the twin group (11.4 hours, Inter Quartile Range: 6.3-26.4) versus the singleton group (19.5 hours, Inter Quartile Range: 10.2-49.3, p < 0.05). The latency period in each group was notably longer when PPROM occurred at less than 30 weeks' gestation, but was still shorter in the twin pregnancies (27.6 hours, Inter Quartile Range: 20-307 versus 75.1 hours, Inter Quartile Range: 15-189, p < 0.05). Twin pregnancies with PPROM at less than or equal to 36 weeks' gestational age have a decreased latency period when compared to matched singletons. The perinatal and neonatal outcomes, however, are similar.

Preterm delivery after selective termination in twin pregnancies

OBJECTIVE

To determine the effect of selective termination of an abnormal twin on the rate of preterm delivery.

METHODS

The study group consisted of 69 patients with twin pregnancies who underwent selective termination between 1987-1994. The comparison groups consisted of singleton (n = 42,362) and twin pregnancies (n = 825) delivered at our institution during the same period. The data were analyzed by Chi2 and Fisher exact test, as appropriate. P < .05 was considered significant. Adjusted odds ratios(OR) and 95% confidence intervals (CI) were calculated by multiple logistic regression.

RESULTS

Terminating the presenting twin was associated with a significantly higher risk of delivery before 37 weeks (adjusted OR 4.1, 95% CI 1.4-12.3) and low birth weight (adjusted OR 3.8, 95% CI 1.3-11.4) compared with terminating the nonpresenting twin. When the termination was performed at or after 20 weeks' gestation, only the risk of preterm premature rupture of the membranes or preterm labor was significantly increased (adjusted OR 3.7, 95% CI 1.2-11.5). Selective termination patients had a lower rate of preterm delivery than twin pregnancies (40 versus 58%, P < .005) but higher than singleton pregnancies (40 versus 10%,P < .001).

CONCLUSION

Selective termination of the presenting twin at 20 weeks or later was associated with a worse perinatal outcome than terminating the nonpresenting twin or performing the procedure before 20 weeks.

A sensitive and specific PCR method to detect Helicobacter felis in a conventional mouse model

Although many detection methods have been used to determine Helicobacter colonization in small animal models, the sensitivity and specificity of these detection methods are limited. To improve the Helicobacter felis conventional mouse model for accurate evaluation of therapeutic regimens, we developed a PCR for detection of, and a competitive PCR for quantitation of, H. felis in viral antibody-free (VAF) mice. The PCR was based on the H. felis 16S rRNA gene. An internal control DNA was used for competitive quantitation of the PCR. VAF conventional Swiss-Webster mice were infected with an H. felis culture by oral gavage. At various times after H. felis challenge and therapy, stomach mucosa was collected and evaluated by PCR. PCR detected approximately 50 to 100 H. felis cells per mouse stomach and showed no cross-reaction with other bacteria commonly found in mouse stomachs. Colonization of H. felis in the mouse stomach was confirmed by culture isolation from germfree mice and histological examination of VAF mice. Response to therapy in this H. felis model correlated well with results seen in human clinical trials with H. pylori. A model utilizing PCR detection which may be useful for discovering new antibiotics and/or vaccines against Helicobacter ulcer disease has been developed.

International, collaborative experience of 1789 patients having multifetal pregnancy reduction: a plateauing of risks and outcomes

OBJECTIVE

To develop the most up-to-date, complete data base of multifetal pregnancy reduction (MFPR) from cases, and to provide the best counseling for couples with multifetal pregnancies.

METHODS

From nine centers in five countries, 1789 completed MFPR cases were collected and outcomes evaluated. Pregnancy losses were defined as through 24 weeks and deliveries categorized in groups of 25-28, 29-32, 33-36, and 37 or more weeks.

RESULTS

Overall, the pregnancy loss rate was 11.7% but varied from a low of 7.6% for triplets to twins and increased with each additional starting number to 22.9% for sextuplets or higher. Early premature deliveries (25-28 weeks) were 4.5% and varied with starting number. Loss rates by finishing number were highest for triplets and lowest for twins, but gestational age at delivery was highest for singletons.

CONCLUSIONS

Multifetal pregnancy reduction has been shown to be a safe and effective method to improve outcome in multifetal pregnancies. Outcomes are worse with higher-order gestations and support the need for continued vigilance of fertility therapy.

Accuracy of ultrasound estimation of fetal weight in multiple pregnancies

Our objective was to assess the accuracy of ultrasonographic estimation of fetal weight in twins and triplets as compared to singleton pregnancies. Retrospective analysis was undertaken of ultrasound data of all fetuses who underwent an examination within 1 week of delivery (singletons 1832, twins 518, triplets 51). At birth weights below 2500 g, there was a significant overestimation of fetal weight in twins as compared to singletons, but the accuracy of the estimate was the same, except in twins between 1500 and 2499 g, when the weight was based on abdominal circumference and femur length alone. At birth weights of more than 2500 g, no difference was detected between twins and singletons. At all birth weights below 2500 g, the accuracy of weight estimation in triplets was equal to that in singletons and there were no triplets above this weight. We conclude that ultrasonographic estimation of fetal weight is as accurate in twins and triplets as it is in singletons.

Maternal serum levels of alpha-fetoprotein and fetal fibronectin as markers of labor in the third trimester

Unexplained elevations of maternal serum alpha-fetoprotein (MSAFP) in the second trimester have been found to be associated with a two- to fourfold increase in the rate of preterm delivery, but the sensitivity is low. Therefore, we reasoned that MSAFP levels in the third trimester could prove to be a more useful biochemical marker to predict labor. The presence of placental and membrane-derived fetal fibronectin (FFN) in cervicovaginal secretions has recently been shown to predict preterm delivery with a sensitivity of 81.7% and specificity of 82.5%. We postulated that damage to membranes and microscopic breakdown of fetomaternal blood barrier during labor might result in release of AFP or FFN into maternal serum. Maternal serum alpha fetoprotein and fetal fibronectin levels were measured prospectively in 29 patients in active labor at term and in 25 controls undergoing elective cesarean section. Neither MSAFP nor serum FFN levels were associated with labor at term. We did, however, note significantly higher MSAFP levels in mothers bearing male fetuses versus female fetuses (p < 0.01). Since the current literature supports a sex difference in the MSAFP levels in the second trimester, this does not appear to change as gestation advances. Further studies are needed to determine if, in addition to maternal weight and race, MSAFP levels should be also adjusted for fetal sex diagnosed on sonography.

In vitro evaluation of the pneumocandin antifungal agent L-733560, a new water-soluble hybrid of L-705589 and L-731373

Lipopeptide L-733560 is a hybrid analog of L-731373 and L-705589. All are water-soluble semisynthetic pneumocandin Bo derivatives. In vitro susceptibility testing of L-705589, L-731373, and L-733560 against more than 200 clinical isolates consisting of eight Candida species, Cryptococcus neoformans, and three Aspergillus species was performed by the broth microdilution methods. All three pneumocandins exhibited potent anti-Candida activity and moderate anti-C. neoformans activity. However, anti-Aspergillus activity was demonstrated only by an agar disk diffusion method. Antifungal agent-resistant Candida species and C. neoformans showed susceptibility comparable to that of susceptible isolates. Growth inhibition kinetic studies against Candida albicans revealed fungicidal activity within 3 to 5 h. Drug combination studies with pneumocandins and amphotericin B revealed indifferent activity against C. albicans and additive effects against C. neoformans and Aspergillus fumigatus. The activities of the compounds were not dramatically affected by the presence of serum. Resistance induction studies showed that the susceptibility of C. albicans MY1055 was not significantly altered by repeated exposure to subinhibitory concentrations of L-733560. Erythrocyte hemolysis studies indicated minimal hemolytic potential with pneumocandins. Results from preclinical evaluations and development studies performed thus far indicate that the pneumocandins should be safe, broad-spectrum fungicidal agents and potent parenteral antifungal agents.

The effect of multifetal pregnancy reduction on serum relaxin

OBJECTIVE

To determine the effect of multifetal pregnancy reduction on circulating relaxin levels.

METHODS

Patients with multifetal pregnancies had relaxin levels determined on the day of multifetal pregnancy reduction, after the procedure, and late in pregnancy.

RESULTS

Forty-eight women (26 presenting with three fetuses and 22 with four or more) were studied. All pregnancies followed some form of ovulation induction. All pregnancies (except for one, which was reduced to a singleton) were reduced to twins. Pre-procedure, post-procedure and late-pregnancy relaxin levels were significantly higher in the in vitro fertilization (IVF)-gamete intrafallopian transfer (GIFT) group compared with the human menopausal gonadotropin (hMG)-alone group (P < .05). The initial number of fetuses had no significant effect on relaxin levels. Although post-procedure relaxin levels were significantly lower than pre-procedure levels (P = .002), relaxin levels continued to decrease throughout pregnancy, as evidenced by even lower levels later on (P = .0001).

CONCLUSIONS

Serum relaxin levels were significantly higher in the IVF-GIFT group than in the hMG-alone group, which probably reflects more aggressive ovulation induction in the former. Because relaxin levels continued to decrease throughout pregnancy, the difference observed between pre- and post-procedure levels are not considered to be due to the procedure itself.

Alloimmune thrombocytopenia: fetal and neonatal losses related to cordocentesis

OBJECTIVE

This report describes the increased risks of cordocentesis in fetuses affected with alloimmune thrombocytopenia.

STUDY DESIGN

As part of a multicenter treatment study clinical and laboratory data from five pregnancies with alloimmune thrombocytopenia in which there was a fetal or neonatal loss associated with cordocentesis were reviewed. The fetal or neonatal deaths were all thought to be a result of exsanguination. These fetuses were compared with a group of 44 affected fetuses who underwent the same procedure but who survived. The data were analyzed by the Wilcoxon rank-sum test and the two-tailed Fisher's exact test. A p value < 0.05 was considered significant.

RESULTS

The mean platelet count at cordocentesis was significantly lower in the cases than in the controls (5.8 vs 32.8 x 10(9)/L, p = 0.005). The incidence of antenatal intracranial hemorrhage in the untreated sibling of the prior affected pregnancy was significantly greater in the cases than in the controls (two of five vs one of 42, p = 0.02).

CONCLUSION

Fetuses affected with alloimmune thrombocytopenia are at increased risk for fatal exsanguination associated with cordocentesis.

First-trimester multifetal pregnancy reduction: acute and persistent psychologic reactions

OBJECTIVE

Our purpose was to determine acute and persistent psychologic impacts of multifetal pregnancy reductions and patients' ability to cope with fetal loss while simultaneously bonding to surviving infants.

STUDY DESIGN

The first 100 women to undergo a multifetal reduction were invited to participate in a retrospective telephone study assessing their emotional reactions and attitudes toward multifetal reduction. The semistructured interview elicited demographic and obstetric data and contained scales used in previous studies of reproductive loss, which assessed repetitive thoughts about reduced fetuses, catastrophic fears, and lingering depressive feelings.

RESULTS

More than 65% of the sample recalled acute feelings of emotional pain, stress, and fear during the reduction procedure. Mourning for the lost fetuses was reported by 70% of women, but most grieved for only 1 month. Thoughts about reduced fetuses occurred moderately frequently after the reduction but rarely at follow-up. Persistent depressive symptoms were mild, although moderately severe levels of sadness and guilt continued for many. Nonetheless, 93% would make the same decision again. Emotional reactions of patients who miscarried differed little. The small subsample who continued to be most affected were younger (p < 0.02), were more religious (p < 0.003), and had viewed the multifetal pregnancy on ultrasonography more often (p < 0.009).

CONCLUSIONS

Multifetal reductions, although highly stressful psychologically, are well tolerated. Sadness and guilt may persist, especially for an identifiable subgroup. Normal maternal bonding and achievement of parenthood goals facilitate grief resolution. The large majority were reconciled to the termination of some fetuses to perserve the lives of a remaining few.

Evaluations of children who have disclosed sexual abuse via facilitated communication

OBJECTIVE

To review the findings of interdisciplinary team evaluations of children who disclosed sexual abuse via facilitated communication.

DESIGN

Case series.

SETTING

Tertiary care hospital outpatient child sexual abuse program in central New York.

PATIENTS

Between January 1990 and March 1993, 13 children who disclosed sexual abuse via facilitated communication and were referred to a university hospital child abuse referral and evaluation center. The range of previously determined developmental diagnosis included mental retardation, speech delay, and autism.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Medical records were reviewed for (1) disclosure, (2) physical evidence, (3) child's behavioral and medical history, (4) disclosures by siblings, (5) perpetrator's confession, (6) child protective services determinations, and (7) court findings.

RESULTS

Four children had evidence of sexual abuse: two had physical findings consistent with sexual abuse, one also disclosed the allegation verbally, and one perpetrator confessed.

CONCLUSIONS

These results neither support nor refute validation of facilitated communication. However, many children had other evidence of sexual abuse, suggesting that each child's case should be evaluated without bias.