Developing a Nomogram for Prioritizing Hysteroscopy in Endometrial Cancer Diagnosis: A Case-Control Study

(1) Background: The pandemic led to significant healthcare disruptions, resulting in postponed surgeries and extended waiting times for non-urgent treatments, including hysteroscopies essential for diagnosing endometrial cancer. This study aims to formulate a risk stratification model to enhance the prioritization of hysteroscopy procedures in Brazil; (2) Methods: A case-control study was conducted at Vila Santa Catarina Hospital in São Paulo, analyzing the medical records of 2103 women who underwent hysteroscopy between March 2019 and March 2022. We used bivariate analysis and multivariate linear regression to identify risk factors associated with endometrial cancer and formulate a nomogram; (3) Results: The findings revealed a 5.5% incidence of pre-invasive and invasive endometrial disease in the study population, with an average waiting time of 120 days for hysteroscopy procedures. The main risk factors identified were hypertension, diabetes, postmenopausal bleeding, and obesity; (4) Conclusions: This research highlights the urgent need for efficient prioritization of hysteroscopy procedures in the wake of the pandemic. The developed nomogram is an innovative tool for identifying patients at higher risk of endometrial cancer, thus facilitating timely diagnosis and treatment and improving overall patient outcomes in a strained healthcare system.

Lung ultrasound versus chest computed tomography for pregnant inpatients with COVID-19

PURPOSE

To compare lung ultrasound (US) and computed tomography (CT) in the assessment of pregnant women with COVID-19.

METHODS

Prospective study comprising 39 pregnant inpatients with COVID-19 who underwent pulmonary assessment with CT and US with a maximum span of 48 h between the exams. The thorax was divided into 12 regions and assessed in terms of the following: the presence of B-lines (>2), coalescent B-lines, consolidation on US; presence of interlobular thickening, ground glass, consolidation on CT. The two methods were scored by adding up the scores from each thoracic region.

RESULTS

A significant correlation was found between the scores obtained by the two methods (rICC = 0.946; p < 0.001). They were moderately in agreement concerning the frequency of altered pulmonary regions (weighted kappa = 0.551). In US, a score over 15, coalescent B-lines, and consolidation were predictors of the need for oxygen, whereas the predictors in CT were a lung score over 16 and consolidation. The two methods, US (p < 0.001; AUC = 0.915) and CT (p < 0.001; AUC = 0.938), were fairly accurate in predicting the need for oxygen.

CONCLUSION

In pregnant women, lung US and chest CT are of similar accuracy in assessing lungs affected by COVID-19 and can predict the need for oxygen.

Cesarean rates according to the Robson classification: analysis in a municipal maternity in São Paulo

Objective

To investigate the distribution of parturients at Hospital Municipal da Vila Santa Catarina Dr. Gilson de Cássia Marques de Carvalho according to the Robson classification, identify the cesarean rate in each Robson Group, and understand which group contributes more to the prevalence of Cesarean sections.

Methods

This is a retrospective observational cross-sectional study conducted through the analysis of medical records of parturients admitted to Hospital Municipal da Vila Santa Catarina Dr. Gilson de Cássia Marques de Carvalho from October 2016 to August 2019.

Results

A total of 9,794 births were recorded, and 31% were by Cesarean section. The most prevalent Robson Groups were Group 3 (25.7%-2,519), 1 (22.8%-2,234), and 5 (20.5%-2,006). The relative contribution of Cesarean sections was greatest in Groups 5 (39%), 2 (18%), and 1 (12.5%).

Conclusion

This study demonstrated the Robson classification is useful to lead to a more critical view, identifying the groups that deserve more attention, since they are the major contributors to cesarean rates; hence, the management protocols could be modified aim to reduce cesarean rates.

The use of convalescent plasma therapy in the management of a pregnant woman with COVID-19: a case report

The coronavirus disease 19 (COVID-19) is responsible for the current worldwide pandemic. Treatment and prophylaxis are still under investigation. Convalescent plasma therapy could be an alternative. We report a case of a 41-year-old patient, at 28 weeks of gestation, was hospitalized with COVID-19. On the 10^th day after onset of symptoms, the clinical picture worsened, and she required high-flow oxygen therapy (30L/minute), with 92% oxygen saturation, and chest X-ray showing mild bilateral opacities at lung bases. Blood tests showed D-dimer 1,004ng/mL, C-reactive protein 81mg/L, pro-calcitonin 0.05ng/mL and interleukine-6 42.9pg/mL. The therapy chosen was Tazocin^® 12g/day, vancomycin 2g/day, and methylprednisolone 40mg/day. In addition, convalescent plasma therapy was administered (275mL) uneventfully, including SARS-CoV-2 antibodies and neutralizing antibodies >1:160. The patient had a fast recovery. The early administration of convalescent plasma, with high titers of neutralizing antibodies, may be an alternative option for severe COVID-19 during pregnancy, until further studies demonstrate an efficient and safe treatment or prophylaxis.

The anti-clockwise spiralization of the linea nigra sign

OBJECTIVE

To describe the morphology of the supra- and infraumbilical linea nigra in puerperal women.

METHODS

The study was conducted from September 2017 to April 2018, and included 157 puerperal women admitted for childbirth care at the Obstetrics Department of a public maternity hospital of the city of São Paulo (SP), Brazil. The abdomen of subjects was photographed on the first or second day postpartum, with the patient lying symmetrically in dorsal decubitus at a standardized distance. Contrast was slightly adjusted and the morphological pattern of supra and infraumbilical linea nigra in the proximity of the umbilical scar was characterized. The images were independently analyzed by two researchers and only the matching results from both observers were used.

RESULTS

Of the 157 observed cases, 139 (88.5%) images provided concordant results between the two researchers. Excluding 41 cases of absence or poor definition of the linea nigra, 98 images were analyzed. Supra- and infraumbilical linea nigra were analyzed separately and classified according to three directions (left, center and right of the umbilical scar). The combination of the supra- and infraumbilical images resulted in the formation of nine distinct patterns, being the most prevalent, in primiparous (72.2%) and multiparous women (50.0%), and the authors named as "anticlockwise spiralization of the linea nigra".

CONCLUSION

The analysis of supra- and infraumbilical linea nigra in puerperal women showed a predominance of what the authors named "anti-clockwise spiralization of the linea nigra sign".

Determination of Fetal RHD Genotype Including the RHD Pseudogene in Maternal Plasma

OBJECTIVE

To examine the accuracy of fetal RHD genotype and RHD pseudogene determination in a multiethnical population.

METHODS

Prospective study involving D-negative pregnant women. Cell-free DNA was extracted from 1 ml of maternal plasma by an automated system (MagNA Pure Compact, Roche) and real-time PCR was performed in triplicate targeting the RHD gene exons 5 and 7. Inconclusive samples underwent RHD pseudogene testing by real-time PCR analysis employing novel primers and probe.

RESULTS

A positive result was observed in 128/185 (69.2%) samples and negative in 50 (27.0%). Umbilical cord blood phenotype confirmed all cases with a positive or negative PCR result. Seven (3.8%) cases were found inconclusive (exon 7 amplification only) and RHD pseudogene testing with both conventional and real-time PCR demonstrated a positive result in five of them, while two samples were also RHD pseudogene negative.

CONCLUSION

Real-time PCR targeting RHD exons 5 and 7 simultaneously in maternal plasma is an accurate method for the diagnosis of fetal D genotype in our population. The RHD pseudogene real-time PCR assay is feasible and is particularly useful in populations with a high prevalence of this allele.

Intrauterine death in singleton pregnancies with trisomy 21, 18, 13 and monosomy X

Summary A retrospective study from November 2004 to May 2012, conducted at the Obstetric Clinic of Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo (HC-FMUSP), which included 92 singleton pregnancies with prenatal diagnosis of trisomy of chromosome 21 (T21), 18, 13 (T13/18) and monosomy X (45X), with diagnosis performed until the 26th week of pregnancy. The aim of the study was to describe the frequency and to investigate predictors of spontaneous fetal death (FD). Diagnosis (T21, n=36; T13/18, n=25; 45X, n=31) was made at a mean gestational age of 18.3±3.7 weeks, through chorionic villus biopsy (n=22,24%), amniocentesis (n=66, 72%) and cordocentesis (n=4, 4%). Major malformations were present in 45 (49%); with hydrops in 32 (35%) fetuses, more frequently in 45X [n=24/31, 77% vs. T21 (n=6/36, 17%) and T13/18 (n=2/25, 8%), p<0.001]. Specialized fetal echocardiography was performed in 60% (55/92). Of these, 60% (33/55) showed changes in heart morphology and/or function. Fetuses with T13/18 had a higher incidence of cardiac anomalies [60 vs. 25% (T21) and 29% (45X), p= 0.01]. FD occurred in 55 (60%) gestations, being more frequent in 45X [n=26/31, 84% vs. T21 (n=13/36, 36%) and T13/18 (n=16/25, 64%), p<0.01]. Stepwise analysis showed a correlation between hydrops and death in fetuses with T21 (LR= 4.29; 95CI=1.9-8.0, p<0.0001). In fetuses with 45X, the presence of echocardiographic abnormalities was associated with lower risk of FD (LR= 0.56; 95CI=0.27- 0.85, p=0.005). No predictive factors were identified in the T13/18 group. Intra- uterine lethality of aneuploid fetuses is high. Occurrence of hydrops increases risk of FD in pregnancies with T21. In pregnancies with 45X, the occurrence of echocardiographic changes reduces this risk.

Fetal growth according to different reference ranges in twin pregnancies with placental insufficiency

The aim of this study was to compare different fetal growth curves in twin pregnancies with severe placental insufficiency. A retrospective cross-sectional analysis of 47 twin pregnancies with absent or reverse end diastolic flow in the umbilical artery of one fetus was performed. Pregnancies with major fetal abnormalities, twin-twin transfusion or three or more fetuses were not included. The estimated fetal weight zeta-scores were calculated for both fetuses (abnormal Doppler and co-twin) according to the following criteria: Hadlock, Liao and Araújo. The abdominal circumference zeta-scores were calculated according to Hadlock, Liao, Araújo, Ong and Stirrup. The mean estimates of the zeta-score values were calculated using generalized estimating equation regression analysis. The mean gestational age at inclusion was 27.4 ± 4.7 weeks. The fetal sex and the interaction Doppler findings × criteria correlated significantly with the zeta-score values (p < 0.001 for both variables). The estimated fetal weight mean zeta-scores (standard error) according to each criteria were as follows: Hadlock - abnormal Doppler: -2.98 (0.18), co-twin: -1.16 (0.15); Liao - abnormal Doppler: -2.89 (0.24), co-twin: -0.58 (0.19); and Araújo - abnormal Doppler: -3.05 (0.29), co-twin: -0.75 (0.18). Values for abdominal circumference were as follows: Hadlock - abnormal Doppler: -3.14 (0.26), co-twin: -1.13 (0.19); Liao - abnormal Doppler: -2.63 (0.27), co-twin: -0.42 (0.19); Araújo - abnormal Doppler: -2.44 (0.22), co-twin: -0.71 (0.14); Ong - abnormal Doppler: -3.36 (0.34), co-twin: -1.48 (0.23); and Stirrup AD -- -2.36 (0.14), co-twin: -1.18 (0.10). Sex- and plurality-specific charts should be used in the evaluation of fetal growth in twin pregnancies with placental insufficiency.

Changes in fetal myocardial performance index following intravascular transfusion: preliminary report

OBJECTIVE

To investigate the changes in fetal left ventricle myocardial performance index (MPI) following intrauterine intravascular transfusion (IUT).

METHODS

Prospective study, including 25 IUT performed in 13 singleton pregnancies with maternal Rh D alloimmune disease. Left ventricle MPI was evaluated prior to transfusion and repeated 24 h after each procedure. Delta MPI was calculated as the difference between post- and pre-transfusion MPI z-scores. Multilevel regression analysis was used to examine the association between delta MPI and gestational age at procedure, fetal middle cerebral artery peak velocity MoM, pre- and post-MPI and hemoglobin z-score values, the volume of blood transfused and feto-placental volume percentage expansion. Adjustments were made for repeated measurements within the same fetus, and across different time points. The significance level was set as 0.05.

RESULTS

MPI z-score values increased significantly following transfusion (delta MPI = 1.10 ± 2.47, p=0.036). Delta MPI showed a significant correlation with gestational age at transfusion (r= -0.47, p=0.018), pre-transfusion MPI z-score (r= -0.50, p=0.012) and feto-placental volume percentage expansion (r= -0.41, p=0.044).

CONCLUSION

Left ventricle MPI increases significantly after intrauterine blood transfusion and greater changes are associated with procedures at an earlier gestational age, lower pre-transfusion MPI z-scores and smaller feto-placental volume expansion.

Placental transfer of IgG antibodies specific to Klebsiella and Pseudomonas LPS and to group B Streptococcus in twin pregnancies

Group B Streptococcus (GBS), Klebsiella spp. and Pseudomonas spp. are important aetiological agents of neonatal infections in Brazil. There is a lack of data in the literature regarding the specific transport of immunoglobulin G (IgG) against these pathogens in multiple pregnancies. Maternal (n = 55) and umbilical cord (n = 110) blood samples were prospectively collected at birth from 55 twin pregnancies. The factors associated with cord levels and transfer ratios of IgG against GBS, Klebsiella and Pseudomonas were examined. The IgG umbilical cord serum levels specific to GBS, Klebsiella LPS and Pseudomonas LPS were significantly associated with maternal-specific IgG concentrations and the presence of diabetes. The anti-Klebsiella IgG cord serum concentrations were also related to birthweight and the presence of hypertension. The transfer ratios against GBS and Pseudomonas LPS were associated with maternal-specific IgG concentrations. The transfer ratios for GBS and Pseudomonas LPS were associated with gestational age at delivery and the presence of diabetes, respectively. None of the examined parameters were related to Klebsiella LPS transfer ratios. We conclude that in twin pregnancies, specific maternal IgG serum concentrations and diabetes were the parameters associated with umbilical cord serum IgG concentrations reactive with the three pathogens investigated. All the other parameters investigated showed different associations with neonatal-specific IgG levels according to the antigen studied. There was no uniformity of the investigated parameters regarding association with placental IgG transfer ratios against the GBS, Pseudomonas LPS and Klebsiella LPS.

Longitudinal reference range for umbilical cord cross-sectional area in twin pregnancies at 18-32 weeks of gestation

OBJECTIVES

The objectives of this study were to establish gestational age-specific reference ranges for cross-sectional area of the umbilical cord, and its components, in twin pregnancies and to compare them with previously reported singleton reference ranges.

METHODS

This was a prospective longitudinal study involving uncomplicated dichorionic twin pregnancies. Sonographic measurements of the cross-sectional area of the umbilical cord, umbilical vein and arteries and Wharton's jelly were obtained in a plane adjacent to the fetal abdomen, every 3 weeks, between 18 and 32 weeks of gestations. Multilevel regression analysis was used to determine gestational age-specific reference ranges for each parameter, and these were plotted against singleton pregnancy references.

RESULTS

Three hundred and thirty four ultrasound scans were performed in 44 twin pregnancies, between 18 and 32.9 weeks (mean: 3.8 ± 0.7 scans/pregnancy and mean interval between scans: 3.3 ± 0.9 weeks). All umbilical cord cross-sectional areas (total, vein, artery and Wharton's jelly) showed a significant increase with gestational age. Compared with singleton pregnancy ranges, mean values were considerably lower in twin pregnancies and resemble the lower limits observed in singletons.

CONCLUSION

In twin pregnancies, cross-sectional area of the umbilical cord, and its components, increases between 18 and 32 weeks, and mean values are substantially lower compared with singleton pregnancies.

Maternal postpartum complications according to delivery mode in twin pregnancies

OBJECTIVE

We aimed to examine maternal postpartum complications of twin deliveries according to mode of delivery and investigate the associated risk factors.

METHODS

This was a retrospective cohort review of twin pregnancies with delivery after 26 weeks at a tertiary teaching hospital (1993-2008). The rates of maternal postpartum complications were compared among vaginal, elective cesarean and emergency cesarean deliveries. Significant predictors of complications were investigated with stepwise regression analysis and relative risks were calculated.

RESULTS

A total of 90 complications were observed in 56/817 (6.9%) deliveries: 7/131 (5.3%) vaginal, 10/251 (4.0%) elective cesarean and 39/435 (9.0%) emergency cesarean deliveries. Significant predictors included high-risk pregnancy, gestational age at birth and delivery mode. The occurrence of complications was significantly increased in emergency compared to elective cesarean deliveries (RR=2.34).

CONCLUSIONS

Maternal postpartum complications in twin pregnancies are higher in emergency compared to elective cesarean deliveries and are also related to preexisting complications and earlier gestational age at delivery.

Fetal venous circulation in monochorionic twin pregnancies with placental insufficiency: prediction of acidemia at birth or intrauterine fetal death

OBJECTIVES

To investigate fetal venous Doppler measurements in monochorionic twin pregnancies complicated by placental insufficiency and the relationship between fetal venous flow and acidemia at birth or intrauterine fetal death.

METHODS

This was a prospective study of 18 monochorionic twin pregnancies with placental insufficiency. Inclusion criteria were monochorionic-diamniotic twin pregnancy, abnormal umbilical artery (UA) Doppler indices, intact membranes and absence of fetal congenital abnormalities. Cases of twin-to-twin transfusion syndrome were excluded. The following Doppler measurements were studied: UA pulsatility index (PI), ductus venosus PI, middle cerebral artery PI and peak systolic velocity, intra-abdominal umbilical vein (UV) time-averaged maximum velocity (TAMXV) and left portal vein (LPV) TAMXV. Doppler parameters were transformed into Z-scores (SD values from the mean) or multiples of the median according to normative references.

RESULTS

UA pH < 7.20 occurred in nine (25.0%) neonates, pH < 7.15 in four (11.1%) and intrauterine death in four (11.1%) fetuses. The UV-TAMXV and LPV-TAMXV Z-scores were significantly lower in the group with pH < 7.20 or intrauterine fetal death (-1.79 vs -1.22, P = 0.006 and -2.26 vs -1.13, P = 0.04, respectively). In cases with pH < 7.15 or intrauterine fetal death, UV pulsations were more frequent (50.0% vs 10.7%, P = 0.03) and UV-TAMXV Z-score was significantly lower (-1.89 vs -1.26, P = 0.003). Mixed effects logistic regression analysis, accounting for the paired nature of the outcomes for the two twins in each pregnancy, demonstrated that the UV-TAMXV Z-score significantly predicted UA pH at birth < 7.20 or intrauterine fetal death. The Doppler parameter that independently predicted pH < 7.15 or intrauterine fetal death was presence of pulsation in the UV.

CONCLUSION

UV Doppler parameters may predict acidemia at birth or intrauterine fetal death in monochorionic twins complicated by placental insufficiency.

Renal tubular dysgenesis with hypocalvaria and ileocecal valve agenesis: an autopsy report

Renal tubular dysgenesis (RTD) is a rare, lethal, autosomal recessive disorder characterized by non-differentiation of the renal proximal convoluted tubules, resulting in oligohydramnios. It is usually diagnosed in the second trimester of pregnancy, following the oligohydramnios sequence, pulmonary hypoplasia and hypocalvaria. The prognosis is poor, and death usually occurs in utero or within the first few days of life. The pathogenesis of RTD is associated with the perinatal use of drugs, such as angiotensin- converting enzyme inhibitors, angiotensin II receptor antagonists, and anti- inflammatory drugs, as well as with fetal transfusion syndrome, genetic mutations in the pathway of the renin-angiotensin system pathway, cocaine snorting, or other pathological mechanisms that reduce renal blood flow. Here, we report the autopsy of a neonate born to consanguineous parents at 38 weeks of gestation, with RTD, decreased amniotic fluid, oligohydramnios sequence, hypocalvaria, pulmonary hypoplasia, and ileocecal valve agenesis. To our knowledge, the latter has never been reported associated with RTD.

[Influence of maternal nutritional status, weight gain and energy intake on fetal growth in high-risk pregnancies]

PURPOSE

To analyze the influence of maternal nutritional status, weight gain and energy consumption on fetal growth in high-risk pregnancies.

METHODS

A prospective study from August 2009 to August 2010 with the following inclusion criteria: puerperae up to the 5th postpartum day; high-risk singleton pregnancies (characterized by medical or obstetrical complications during pregnancy); live fetus at labor onset; delivery at the institution; maternal weight measured on the day of delivery, and presence of medical and/or obstetrical complications characterizing pregnancy as high-risk. Nutritional status was assessed by pregestational body mass index and body mass index in late pregnancy, and the patients were classified as: underweight, adequate, overweight and obese. A food frequency questionnaire was applied to evaluate energy consumption. We investigated maternal weight gain, delivery data and perinatal outcomes, as well as fetal growth based on the occurrence of small for gestational age and large for gestational age neonates.

RESULTS

We included 374 women who were divided into three study groups according to newborn birth weight: adequate for gestational age (270 cases, 72.2%), small for gestational age (91 cases, 24.3%), and large for gestational age (13 cases, 3.5%). Univaried analysis showed that women with small for gestational age neonates had a significantly lower mean pregestational body mass index (23.5 kg/m², p<0.001), mean index during late pregnancy (27.7 kg/m², p<0.001), and a higher proportion of maternal underweight at the end of pregnancy (25.3%, p<0.001). Women with large for gestational age neonates had a significantly higher mean pregestational body mass index (29.1 kg/m², p<0.001), mean index during late pregnancy (34.3 kg/m², p<0.001), and a higher proportion of overweight (30.8%, p=0.02) and obesity (38.5%, p=0.02) according to pregestational body mass index, and obesity at the end of pregnancy (53.8%, p<0.001). Multivariate analysis revealed the index value during late pregnancy (OR=0.9; CI95% 0.8-0.9, p<0.001) and the presence of hypertension (OR=2.6; 95%CI 1.5-4.5, p<0.001) as independent factors for small for gestational age. Independent predictors of large for gestational age infant were the presence of diabetes mellitus (OR=20.2; 95%CI 5.3-76.8, p<0.001) and obesity according to body mass index during late pregnancy (OR=3.6; 95%CI 1.1-11.7, p=0.04).

CONCLUSION

The maternal nutritional status at the end of pregnancy in high-risk pregnancies is independently associated with fetal growth, the body mass index during late pregnancy is a protective factor against small for gestational age neonates, and maternal obesity is a risk factor for large for gestational age neonates.

Second-trimester soft markers: relation to first-trimester nuchal translucency in unaffected pregnancies

OBJECTIVE

Genetic sonography following first-trimester combined screening appears to increase substantially detection rates for Down syndrome but it relies on the unproved assumption of independence between these tests. In this study we aimed to investigate the relationship between first-trimester nuchal translucency (NT) and a series of second-trimester soft markers and structural defects in unaffected pregnancies.

METHODS

NT measurement in the first trimester was followed by second-trimester scan (18 to 23 + 6 weeks) including examination for three categorical markers (intracardiac echogenic foci, hyperechogenic bowel and structural defects) and measurement of nasal bone length, nuchal-fold thickness, femur length, humerus length, renal pelvis diameter and prenasal thickness. All continuous variables were expressed in multiples of the median (MoM) for gestation and correlation coefficients between log-transformed NT and second-trimester variables were calculated. In addition, frequencies of soft markers and structural defects in cases with increased NT were compared to those with normal NT, using MoM cut-offs.

RESULTS

In a dataset of 1970 cases, NT was significantly correlated (P < 0.05) with all second-trimester continuous variables, the correlation being strongest for nuchal-fold thickness (r = 0.10). There was a higher frequency of cases with second-trimester nuchal-fold thickness above the 97.5(th) centile (10.7 vs. 2.2%) and hyperechogenic bowel (2.4 vs. 0.1%) in cases with increased NT.

CONCLUSIONS

Straightforward reassessment of risk using likelihood ratios derived from the second-trimester genetic sonogram might lead to inaccurate estimates. Multivariate models using continuous second-trimester variables might be preferable in sequential screening strategies.

Conjoined twins and legal authorization for abortion

OBJECTIVE

To describe pregnancies with conjoined twins according to the request for legal termination of pregnancy.

METHODS

Retrospective review of pregnancies with conjoined twins, with no possibility of extrauterine survival or postnatal surgical separation, observed at a tertiary teaching hospital, between 1998 and 2010.

RESULTS

Amongst 30 cases seen during the study period, six (20.0%) couples decided to continue with the pregnancy, termination of pregnancy was not requested due to advanced gestational age (> 25 weeks) in 5 cases (16.7%). Legal authorization to terminate the pregnancy was requested in 19 (63.3%) cases: permission was granted in 12 (63.2%), denied in five (26.3%) and information was missing in two (10.5%) cases. A successful vaginal delivery was performed in 83.3% of the cases undergoing termination of pregnancy and a cesarean section was performed in all the remaining cases (p < 0.01).

CONCLUSION

In pregnancies with conjoined twins and without fetal prognosis, legal termination of the pregnancy is an alternative. Moreover, a successful vaginal delivery can be performed in most cases before the third trimester, further reducing maternal risks and parental suffering.

Longitudinal reference ranges for fetal ultrasound biometry in twin pregnancies

OBJECTIVE

The purpose of this study was to establish longitudinal reference ranges for fetal ultrasound biometry measurements and growth parameters in twin pregnancies.

METHOD

A total of 200 uncomplicated twin pregnancies before 21 weeks of gestation were recruited for this prospective, longitudinal study. Women who abandoned follow-up, pregnancies with unknown outcomes or pregnancies with complications were excluded. Ultrasound scans were performed every three weeks, and biparietal and occipitofrontal diameters, head and abdominal circumferences, and femur diaphysis length measurements were obtained for each fetus at each visit. Estimated fetal weight, biparietal/occipitofrontal diameter, head circumference/abdominal circumference, and femur diaphysis length/abdominal circumference ratios were also calculated. Multilevel regression analysis was performed on normalized data.

RESULTS

A total of 807 ultrasound examinations were performed in 125 twin pregnancies between 14 and 38 weeks of gestation (6.5 ± 1.4 scans/pregnancy). Regression analysis demonstrated significant correlations for all variables with gestational age, namely log of the biparietal diameter (r = 0.98), log of the occipitofrontal diameter (r = 0.98), log of the head circumference (r = 0.99), log of the abdominal circumference (r = 0.98), square root of the femur length (r = 0.99), log of the estimated fetal weight (r = 0.99), biparietal/occipitofrontal ratio (r = -0.11), head/abdomen circumference ratio (r = -0.56), and log of the femur length/abdominal circumference ratio (r = 0.61). Values corresponding to the 10(th), 50(th), and 90(th) percentiles for estimated fetal weight at 28, 32, and 36 weeks, respectively, were as follows: 937, 1,096, 1,284 g; 1,462, 1,720, 2,025 g; and 2,020, 2,399, 2,849 g.

CONCLUSION

In twin pregnancies, fetal ultrasound biometry measurements and growth parameters show a significant correlation with gestational age.

Conjoined twins pregnancies: experience with 36 cases from a single center

OBJECTIVE

To review a single center's experience in the management of twin pregnancies with conjoined fetuses.

METHODS

Retrospective study describing prenatal findings, delivery details, surgical treatment and perinatal outcome.

RESULTS

The study included 36 twin pregnancies with conjoined twins seen over a period of 12 years in a single tertiary hospital: 69.4% were thoracopagus, 13.9% parapagus, 8.3% omphaloischiopagus 5.6% omphalopagus and 2.8% cephalopagus. Cardiac defects were present in 91.6% of twin pairs and associated malformations were present in 61.8% of the cases: limb abnormalities in 36.1%, abdominal wall defects in 25.0%, cleft lip and/or palate in 13.9% and congenital diaphragmatic hernia in 5.5%. Surgical separation was considered not feasible and prognosis lethal in 30 (83.3%) cases. Termination of pregnancy was performed in 12 pregnancies of poor prognosis. Cesarean section was performed in all remaining cases. Five sets of twins underwent surgical separation and six children survived. Overall survival in our series was 8.3% and, among the livebirths, 13.6%.

CONCLUSION

Conjoined twin pregnancies should be referred to tertiary centers for detailed fetal anomaly and echocardiographic assessment to evaluate prognosis and determine the possibility of postnatal surgical separation.

[Ultrasonographic accuracy of fetal weight estimation and influence of maternal and fetal factors]

PURPOSE

To determine the accuracy of ultrasound in fetal weight estimation and to evaluate maternal and/or fetal factors that could interfere in the result.

METHODS

This was a transverse prospective study, involving 106 patients, with 212 fetal weight evaluations, by two observers, within 24 h to delivery. The following parameters were measured: biparietal diameter, head circumference, abdominal circumference, and femoral length. Fetal weight was estimated using the Hadlock formula and the results were compared to birth weight. The maternal factors examined were: weight, BMI, and skin to uterus distance measured by ultrasound, and the fetal factors were: presentation, position, placental localization and thickness, fetal weight, and amniotic fluid index (AFI).

RESULTS

There was good correlation between estimated fetal weight and birth weight (R=0.97). In 79.2% and in 92.4% of cases the estimated fetal weight was within 10% and 15% of birth weight, respectively. The only maternal factor that presented a positive correlation with percent error in the estimate of fetal weight was the skin to uterus distance (R ≥ 0.56). Fetal weight showed negative correlation with percent error (R>-0.36; p<0.001), with a significant tendency to overestimate fetal weight in the group of very low weight - <1000 g (p<0.05). The AFI showed a low negative correlation with percent error (R=-0.21; p<0.001) with no difference between AFI groups (p=0.516).

CONCLUSION

Ultrasound presented good accuracy in the estimation of fetal weight. The error of weight estimate was directly proportional to the skin to uterus distance and inversely proportional to fetal weight. AFI did not interfere significantly in the ultrasound prediction of fetal weight.

[Conjoined twins: prenatal diagnosis, delivery and postnatal outcome]

PURPOSE

The aim of this study was to analyze conjoined twins in terms of antenatal, delivery and postnatal aspects.

METHODS

A retrospective descriptive analysis of prenatally diagnosed conjoined twins. Prenatal ultrasound and echocardiography, delivery details, postnatal follow-up, surgical separation and post mortem data were reviewed. The twins were classified according to the type of fusion between fetal structures. The following data were analyzed: ultrasound and echocardiographic findings, antenatal lethality and possibility of surgical separation, delivery details and survival rates.

RESULTS

Forty cases of conjoined twins were included in the study. There were 72.5% cases of thoracophagus, 12.5% of paraphagus, 7.5% of omphalo-ischiophagus, 5.0% of omphalophagus, and 2.5% of cephalophagus. Judicial termination of pregnancy was requested in 58.8% of the cases. Cesarean section was performed in all cases in which pregnancy was not terminated. The mean gestational age at delivery was 35 weeks; all twins were live births with a mean birth weight of 3,860 g and 88% died postnatally. Ten percent of the live borns were submitted to surgical separation with a 60% survival rate. The total survival rate was 7.5% and postnatal survival was 12%. Antenatal evaluation of lethality and possibility of surgical separation were precise. There were no maternal complications related to delivery.

CONCLUSION

Conjoined twins present a dismal prognosis mainly related to the complex cardiac fusion present in the majority of cases with thoracic sharing. At referring centers, prenatal ultrasound and echocardiographic evaluation accurately delineate fetal prognosis and the possibility of postnatal surgical separation.

First-trimester maternal serum activin A in pre-eclampsia and fetal growth restriction

OBJECTIVE

To investigate whether the reported increase in maternal serum activin A concentration in pre-eclampsia is evident from the first trimester.

DESIGN

This was a case-control study carried out in antenatal clinics among singleton pregnancies at 10-14 weeks of gestation.

METHODS

Activin A concentration was measured in stored maternal serum samples obtained at 11-14 weeks of gestation from 131 women who subsequently developed pre-eclampsia, 77 who developed non-proteinuric pregnancy-induced hypertension, 141 with fetal growth restriction in the absence of hypertensive complications and from 494 normotensive controls.

RESULTS

Compared to the median activin A level in the control group (1.00 MoM), the median MoM in the patients who subsequently developed pre-eclampsia and pregnancy-induced hypertension (1.49 MoM and 1.32 MoM, respectively) was significantly increased (p < 0.001), and in patients with fetal growth restriction (1.02 MoM) it was not significantly different (p = 0.57). In the pre-eclampsia group (n = 131) the disease was considered to be sufficiently severe to necessitate iatrogenic delivery before 35 weeks in 25 patients, and in this group the median MoM was 1.92.

CONCLUSION

Maternal serum activin A concentration at 12 weeks of gestation in pregnancies which subsequently develop hypertensive disease is increased, whereas in those complicated by fetal growth restriction it is normal.

[Fetal abnormalities and prognosis associated with increased nuchal translucency and abnormal karyotype]

OBJECTIVES

This study aimed to evaluate the incidence of chromosomal abnormalities in fetuses with increased nuchal translucency (NT) measurement. Incidence of structural abnormalities and pregnancy outcome was also described in fetuses with increased NT and abnormal karyotype.

METHODS

This was a retrospective study involving 246 fetuses with increased NT and known karyotype followed at the Fetal Medicine Unit, Hospital das Clínicas, São Paulo University Medical School.

RESULTS

Fetal karyotype was abnormal in 14.2% of the cases. Ultrasound anomaly scan and specialized echocardiographic studies in these cases showed fetal structural abnormalities in 80.8% and cardiac defects were found in 61.5% of the fetuses. Pregnancy outcome was abnormal in 76.5% of these women.

CONCLUSION

Increased NT measurement at 11 to 13 weeks and 6 days is an important marker for fetal chromosomal and structural abnormalities, mainly fetal cardiac defects. This finding also indicates increased risk of spontaneous fetal and neonatal death.

Selective fetoscopic laser photocoagulation of superficial placental anastomoses for the treatment of severe twin-twin transfusion syndrome

OBJECTIVE

To report our initial institutional experience with fetoscopic laser photocoagulation of placental anastomoses in severe twin-twin transfusion syndrome using a 1.0 mm endoscope.

METHODS

Between July 2006 and June 2008, 19 monochorionic diamniotic twin pregnancies complicated by severe TTTS (Quintero stages III and IV) underwent fetoscopic laser therapy. Perinatal data were prospectively collected and compared according to the Quintero stages.

RESULTS

Nine patients were classified as stage III and ten as stage IV. The Mean gestational ages at diagnosis and procedure were 20 (range: 17-25) and 22.0 (range: 19.0-26.0) weeks, respectively, with no statistical difference between the two groups. Preterm premature rupture of the membranes occurred in two cases (10.5%), and spontaneous preterm delivery in eight (42.1%). Overall mean gestational age at delivery was 32.1 (range: 26.0-38.0) weeks. Prematurity was more severe in stage IV patients (p<0.01). Among all cases, the overall survival rate was 52.6%, and the percentages of pregnancies with survival of both babies and at least one twin were 26.3% and 78.9%, respectively. In the case of stage III patients, the overall survival rate was 61.1%. Of the stage III pregnancies, 33.3% resulted in both babies surviving, and 88.9% of these pregnancies resulted in at least one surviving twin. For stage IV, as the corresponding statistics were 45.0%, 20.0% and 70.0% respectively.

CONCLUSIONS

Our initial institutional experience with 1.0 mm fetoscopic laser therapy for severe TTTS showed results similar to those reported in the literature for larger endoscopes.

Ductus venosus blood flow assessment at 11 to 14 weeks of gestation and fetal outcome

OBJECTIVE

To evaluate the association between abnormal ductus venosus (DV) at 11-14 weeks' gestation and chromosomal abnormalities, structural defects and fetal outcome.

METHODS

DV flow-velocity waveform (DV-FVW) and nuchal translucency thickness (NT) were prospectively evaluated in 1217 singleton pregnancies.

RESULTS

The DV-FVW was abnormal in 84 fetuses, NT was above the 95th centile in 160 fetuses and both markers were observed in 41 fetuses. Chromosomal defects were diagnosed in 22 fetuses. The sensitivity, specificity and positive and negative predictive values for an abnormal karyotype were 86.4%, 86.9%, 11.9% and 99.7%, respectively, for an increased NT. These values were 68.2%, 96.9%, 31.3% and 99.3%, respectively, for DV-FVW abnormalities and 68.2%, 97.6%, 36.6% and 99.3%, respectively, when both markers were found simultaneously. Regarding structural defects, these values were 43.8%, 92.9%, 8.3% and 99.1% for an abnormal NT, 25.0%, 92.6%, 4.8% and 98.8% for DV-FVW abnormalities and 25.0%, 97.9%, 15.4% and 98.9% for both together. Considering those cases of unexplained fetal demise, the values were 44.4%, 85.9%, 5.0% and 98.9% for NT abnormalities, 22.2%, 92.6%, 4.8% and 98.6% for an abnormal DV-FVW and 22.2%, 98%, 15.4% and 98.7% for both. In cases with increased NT, the percentage of live births with normal karyotype and no major fetal structural defects decreased from 93.8% in normal DV-FVW fetuses to 77.3% in abnormal ones.

CONCLUSION

DV assessment at 11-14 weeks' gestation is useful in screening for fetal chromosomal abnormalities and may help to reduce the false-positive rate when combined with NT measurement. Abnormal DV-FVW is also associated with an increase in adverse perinatal outcome in fetuses with enlarged NT. However, the value of DV-FVW assessment in cases with normal NT is unclear.

Megacystis at 10-14 weeks of gestation: chromosomal defects and outcome according to bladder length

AIMS

To examine the prevalence of chromosomal defects and outcome of fetuses with megacystis at 10-14 weeks of gestation.

METHODS

At the 10-14-week scan fetal megacystis was defined by a longitudinal bladder diameter of 7 mm or more. In 145 such fetuses the fetal karyotype and pregnancy outcome were examined in relation to the longitudinal diameter of the fetal bladder.

RESULTS

Chromosomal defects, mainly trisomies 13 and 18, were present in 30 cases. In the group with longitudinal bladder diameter of 7-15 mm the incidence of chromosomal defects was 23.6% (26/110), whereas in those with bladder diameter > 15 mm the incidence was 11.4% (4/35). The fetal nuchal translucency (NT) was above the 95th centile of the normal range for crown-rump length in a higher proportion of cases with abnormal rather than normal karyotype (76.7% compared to 31.3%; Chi-square P < 0.0001). The expected number of cases of trisomy 21, estimated on the basis of maternal age, gestational age and fetal NT, was 6.2 rather than the observed 2 and the corresponding numbers for trisomies 13 or 18 were 4.2 for expected and 24 for observed. In the chromosomally normal group with longitudinal bladder diameter of 7-15 mm follow-up scans demonstrated spontaneous resolution of the megacystis in 90% of the cases and enlargement of the megacystis and/or the development of echogenic kidneys in 10%. In contrast, none of the cases with bladder diameter > 15 mm demonstrated spontaneous resolution of the megacystis.

CONCLUSIONS

In fetal megacystis with longitudinal bladder diameter of 7-15 mm there is a risk of about 25% that the fetus will have a chromosomal defect but in the chromosomally normal group there is spontaneous resolution of the megacystis in about 90% of cases. If the bladder diameter is > 15 mm the risk of chromosomal defects is about 10% and in the chromosomally normal group the condition is invariably associated with progressive obstructive uropathy.

Effect of maternal position on cervical length measurement in twin pregnancies

OBJECTIVE

To compare cervical length measurements in twin pregnancies obtained from patients in the recumbent and standing positions.

METHODS

Fifty women with uncomplicated twin pregnancies underwent monthly transvaginal ultrasound examinations for cervical length measurement in the recumbent and standing positions. The correlation between cervical length measurements obtained in the recumbent and standing positions, and between these measurements and gestational age, were examined. The significance of the differences between measurements obtained in the recumbent and standing positions was also analyzed.

RESULTS

Based on data obtained at the first ultrasound examination, there was a significant correlation between cervical length measurements in the recumbent and standing positions (r = 0.77; t = 8.25; P < 0.0001) and both measurements showed a significant inverse correlation with gestational age (recumbent position: r = -0.60, P < 0.0001; standing position: r = -0.46; P = 0.0008). The mean of the differences (standing - recumbent) was -1.8 mm (95% confidence interval = -3.7-0.04; t = -1.96; P = 0.06) and the mean of percentage differences ((standing - recumbent)/recumbent x 100) was -2.9% (95% confidence interval = -8.6-2.7; t = -1.04; P = 0.3). When the data obtained at all examinations were examined by multiple regression analysis, cervical length measurement in the recumbent position was the only parameter that correlated significantly with the percentage difference between cervical length measurements (P < 0.0001).

CONCLUSIONS

Cervical length in twin pregnancies decreases with gestation and there is a good correlation between measurements obtained from women in the recumbent and standing positions. No significant changes in cervical length were observed comparing measurements obtained in the two maternal positions.

Trichorionic triplet pregnancies at 10-14 weeks: outcome after embryo reduction compared to expectant management

OBJECTIVE

To compare the outcome of trichorionic triplet pregnancies managed expectantly with those reduced to twins or singletons.

METHODS

This was a retrospective study of trichorionic triplet pregnancies with three live fetuses at 10-14 (median 12) weeks' gestation referred to our unit for consideration of embryo reduction. Women were counselled as to the available options of either expectant management or embryo reduction. In those choosing reduction, a needle was inserted into the uterus transabdominally and potassium chloride was injected into the fetal heart. Using data derived from this study and from a review of studies reporting on survival and handicap by gestational age in singletons, the effects of embryo reduction on survival and handicap rates were estimated. Main outcome measures were miscarriage before 24 weeks of gestation, preterm delivery before 32 weeks, perinatal death and handicap rates.

RESULTS

In total, there were 280 trichorionic triplet pregnancies and 125 of these were managed expectantly, 133 were reduced to two fetuses and 22 were reduced to one fetus. The rates of miscarriage were 3.2% for those managed expectantly, 8.3% for those reduced to twins and 13.6% for those reduced to singletons. The rates of early preterm delivery in those pregnancies that did not miscarry were 23.1%, 9.8% and 5.3%, respectively. The percentages for pregnancies with at least one survivor were 95.2%, 91.0% and 81.8%, respectively, and the median gestation at delivery was 34 weeks for the non-reduced, 36 weeks for those reduced to twins and 38 weeks for those reduced to singletons. From the published series on early preterm delivery, it was estimated that survival increases from about 27% at 24 weeks to about 98% at 32 weeks, and handicap decreases from 28% at 24 weeks to less than 5% at 32 weeks. From these estimates and the data on triplet pregnancies, it was calculated that, in triplets reduced to twins, compared to those managed expectantly, the chance of survival is similar (90.3% compared to 93.3%), but the risk of handicap may be lower (0.6% compared to 1.5% per fetus).

CONCLUSIONS

In trichorionic triplet pregnancies, embryo reduction to twins does not improve the chance of survival but may reduce the rate of handicap. Reduction from triplets to singletons may reduce both the survival rate and the handicap rate among survivors.

First-trimester screening for chromosomal abnormalities by fetal nuchal translucency in a Brazilian population

OBJECTIVES

To examine the detection rate of chromosomal abnormalities using nuchal translucency (NT) thickness in a Brazilian population.

METHODS

This was a prospective study of 2996 singleton pregnancies with a live fetus at 10-14 weeks of gestation attending for routine antenatal care in a teaching hospital in Brazil. Fetal crown-rump length (CRL) and NT thickness were measured and the risks for trisomy 21 were calculated by a combination of maternal age and fetal NT with the use of software provided by The Fetal Medicine Foundation. Sensitivity and positive predictive values for different risk cut-offs were calculated.

RESULTS

Chromosomal defects were diagnosed in 22 cases, including 10 cases of trisomy 21. The estimated risk based on maternal age and fetal NT was 1 in 300 or greater in 222 (7.4%) cases and these included nine of 10 (90.0%) pregnancies with trisomy 21 and nine of 12 (75.0%) pregnancies with other chromosomal defects. The NT was above the 95th centile in 5.8% of cases and this group included 70% of the trisomy 21 cases.

CONCLUSION

A combination of maternal age and fetal NT provides an effective method of screening for chromosomal defects. The performance of the test in a Brazilian population is similar to that in Britain.

First-trimester maternal serum levels of placenta growth factor as predictor of preeclampsia and fetal growth restriction

OBJECTIVE

To determine whether the reported decrease in maternal serum placenta growth factor concentration in preeclampsia is evident from the first trimester and before clinical onset of the disease. We also examined levels in pregnancies that subsequently resulted in fetal growth restriction (FGR).

METHODS

Placenta growth factor concentration was measured in stored maternal serum samples obtained at 11-14 weeks of gestation from 131 women who subsequently developed preeclampsia, 137 women who subsequently developed FGR, and 400 randomly selected controls who did not develop preeclampsia or FGR. Preeclampsia was defined as diastolic blood pressure of 90 mmHg or more on two occasions 4 hours apart, accompanied by proteinuria (more than 300 mg of total protein in a 24-hour urine collection or a positive test for albumin on reagent strip) in women with no pre-existing hypertensive or renal disease. Fetal growth restriction was considered present if a woman subsequently delivered a live infant with a birth weight below the fifth centile for gestation.

RESULTS

In the control group, maternal serum placenta growth factor concentration increased with gestation. Compared with the controls (median multiple of the median 0.98, standard deviation [SD] 0.51), levels in the preeclampsia group (median multiple of the median 1.09, SD 0.52) were not significantly different (t = 1.83, P = .07), but in the FGR group (median multiple of the median 1.57, SD 0.74), levels were significantly increased (t = 10.85, P < .001).

CONCLUSION

The previously reported decrease in serum placenta growth factor levels in women with preeclampsia might not precede clinical onset of the disease and is not apparent in the first trimester of pregnancy. Levels are significantly increased in pregnancies resulting in FGR.

Cervical length and funneling at 23 weeks of gestation in the prediction of spontaneous early preterm delivery

OBJECTIVES

To establish the relationship of cervical length at 23 weeks of gestation to the risk of spontaneous delivery before 33 weeks and to determine the possible additional risk if funneling is present.

METHODS

During a 36-month period, 6819 women with singleton pregnancies underwent transvaginal sonographic cervical assessment at 22-24 weeks as a screening test for preterm delivery. The distribution of cervical length and the prevalence of funneling, defined as dilatation of the internal os of > or = 5 mm in width, were established. Women who underwent cervical cerclage, iatrogenic preterm delivery or were lost to follow-up were excluded from further analysis. In the remaining 6334 pregnancies, logistic regression was used to examine the contribution of cervical length and funneling to the risk of spontaneous preterm delivery before 33 weeks.

RESULTS

The median cervical length was 36 mm and in 1.6% of cases the length was < or = 15 mm. There was a significant inverse association between cervical length and percentage rate of spontaneous delivery before 33 weeks. Funneling of the internal os was present in about 4% of pregnancies and the prevalence decreased with increasing cervical length from 98% when the length was < or = 15 mm to about 25% for lengths of 16-30 mm and less than 1% at lengths of > 30 mm. The rate of preterm delivery was 6.9% in those with funneling compared to 0.7% in those without funneling (chi2 = 86.7; P < 0.0001). However, logistic regression analysis demonstrated that funneling did not provide a significant additional contribution to cervical length in the prediction of spontaneous delivery before 33 weeks (odds ratio for short cervix = 24.9, Z = 4.43, P < 0.0001; odds ratio for funneling = 1.8, Z = 0.84, P = 0.40).

CONCLUSION

In the prediction of preterm delivery, funneling does not provide any significant contribution in addition to cervical length.

First trimester maternal serum placenta growth factor (PIGF)concentrations in pregnancies with fetal trisomy 21 or trisomy 18

Placenta growth factor (PIGF), an angiogenic factor belonging to the vascular endothelial growth factor family, pregnancy-associated plasma protein A (PAPP-A) and free beta-human chorionic gonadotrophin (beta-hCG) were measured in maternal serum from 45 pregnancies with trisomy 21, 45 with trisomy 18 and 493 normal controls at 10-13 completed weeks of gestation. In the normal pregnancies maternal serum PIGF levels increased exponentially with gestation. The median multiple of the median (MoM) PIGF concentration in the trisomy 21 group (1.26 MoM) was significantly higher (p<0.0001) than in the control group (1.00 MoM). In the trisomy 18 group the median PIGF was lower (0.889 MoM) but this did not quite reach significance (p=0.064). The corresponding median MoM values for PAPP-A were 1.00 MoM for the controls, 0.49 MoM for trisomy 21 and 0.16 MoM for trisomy 18. The median MoM values for free beta-hCG were 1.00 MoM for the controls, 2.05 MoM for trisomy 21 and 0.38 MoM for trisomy 18. In the control group there was a small but significant correlation of PIGF with free beta-hCG (r=+0.1024) and PAPP-A (r=+0.2288). In the trisomy 18 group there was a significant association between PIGF and free beta-hCG (r=+0.2629) but not with PAPP-A (r=+0.0038). In the trisomy 21 group there was a small but significant association with PAPP-A (r=+0.1028) but not with free beta-hCG (r=+0.0339). The separation of affected and unaffected pregnancies in maternal serum PIGF is small, and therefore it is unlikely that measurement of PIGF would improve screening for these abnormalities provided by the combination of fetal nuchal translucency and maternal serum PAPP-A and free beta-hCG.

First-trimester screening for trisomy 21 in singleton pregnancies achieved by assisted reproduction

BACKGROUND

The possible effect of assisted reproduction on first-trimester screening for trisomy 21 was examined by fetal nuchal translucency thickness (NT), maternal serum free beta-human chorionic gonadotrophin (HCG) and pregnancy-associated plasma protein-A (PAPP-A).

METHODS

Parameters were measured at 11-14 weeks in 411 singleton pregnancies achieved by controlled ovarian stimulation, including 220 that had undergone IVF. Results were compared with 1233 singleton pregnancies conceived spontaneously.

RESULTS

In the IVF pregnancies, the median fetal NT was not significantly different from that in controls, whilst the median free beta-HCG was significantly increased, and PAPP-A was significantly decreased. In the intracytoplasmic sperm injection group, fetal NT and free beta-HCG values were not significantly different from those in controls, but PAPP-A was significantly decreased. In those pregnancies achieved by ovarian stimulation, neither fetal NT, free beta-HCG nor PAPP-A were significantly different from the control group.

CONCLUSIONS

In IVF pregnancies, screening for trisomy 21 by fetal NT, maternal serum free beta-HCG and PAPP-A levels may be associated with a 1.2% higher false-positive rate than in natural conception.

Maternal serum activin A and inhibin A in trisomy 18 pregnancies at 10-14 weeks

In 45 cases of trisomy 18 and 493 control pregnancies at 10-14 weeks of gestation, maternal serum inhibin A, total activin A, free beta-hCG and PAPP-A were measured. In the trisomy 18 pregnancies the median values were 0.74 MoM for inhibin A, 1.23 MoM for activin A, 0.38 MoM for free beta-hCG and 0.16 MoM for PAPP-A. The degree of deviation from normal in the levels of inhibin and activin is small in comparison with free beta-hCG and PAPP-A and they are therefore unlikely to be of value in improving the sensitivity of 90% for a 1% false-positive rate achieved by screening with fetal nuchal translucency and maternal serum free beta-hCG and PAPP-A.