Unique risk factors for unplanned preterm delivery in the uterus transplant recipient

STUDY QUESTION

Do characteristics of the lower uterine segment and cervix modify the risk of preterm delivery in uterus transplant (UTx) recipients?

SUMMARY ANSWER

The cervical length showed little association with preterm delivery, however, cervical inflammation deserves further exploration as a cause of preterm delivery.

WHAT IS KNOWN ALREADY

UTx recipients do not have the risk factors normally used to stratify pregnancies that would benefit from cervical length assessment. In addition, unique factors related to absent tissues, a different blood supply, inflammatory processes of rejection, cervical biopsies, and a different microbiome challenge the normal progressive remodeling of the cervix and thus cervical competence.

STUDY DESIGN, SIZE, DURATION

This is a subanalysis of a clinical trial of 20 women undergoing uterus transplantation at Baylor University Medical Center from 2016 to 2020, in addition to two women who received transplantation outside of a research protocol at our institution through September 2022. In this report, the first 16 UTx recipients that achieved live birth are included.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The focus of this study was 20 pregnancies that reached the second trimester in 16 women following UTx. We analyzed recipient, transplant, and donor factors to determine if characteristics were associated with delivery outcome. We compared obstetrical outcomes, including planned versus unplanned delivery, by factors such as number of superior venous anastomoses, warm ischemia and cold ischemia times, donor factors including cesarean sections, cervical biopsy results, and cervical ultrasound results.

MAIN RESULTS AND THE ROLE OF CHANCE

Planned term deliveries occurred in 44% (8/18) of live births. Of the preterm births, 30% (3/10) were planned and 70% (7/10) were unplanned. Unplanned deliveries occurred in women with spontaneous preterm labor, severe rejection, subchorionic hematoma, and placenta previa. Cervical length in UTx recipients averaged 33.5 mm at 24 weeks and 31.5 mm at 28 weeks, comparable to values from the general population. No relationship was seen between delivery outcome and number of veins used, ischemic time, or number of previous cesarean sections.

LIMITATIONS, REASONS FOR CAUTION

The study's small size allows limited conclusions. The obstetric history of all donors was limited to mode of delivery.

WIDER IMPLICATIONS OF THE FINDINGS

Cervical length measurements in the UTx population are not expected to deviate from those with a native uterus. While cervical length surveillance remains important, attention must be paid to the results of cervical biopsies which are obtained to monitor rejection. Inflammatory processes seem most predictive of preterm delivery.

STUDY FUNDING/COMPETING INTEREST(S)

No funding was provided for this study. The authors report no conflicts of interest.

TRIAL REGISTRATION NUMBER

NCT02656550.

Persistence Pays Off: Live Birth after Uterus Transplant, Overcoming Recurrent Pregnancy Loss with Cerclage Placement

Recipients of uterus transplantation have unique factors that may increase their risk of cervical insufficiency. This report describes a uterus transplant recipient with cervical insufficiency resulting in two second-trimester miscarriages. After McDonald cerclages (one that failed), she underwent an interval transabdominal cerclage and delivered a healthy term child in her third pregnancy. The longitudinal information of this case provides observations from which we can propose testable hypotheses that address venous outflow and inflammation. This case also suggests that there could be a role for prophylactic cerclage placement at the time of transplantation.

Doppler Flow Indices and Prediction of Embryo Transfer Success and Pregnancy Outcome in Uterus Transplant Recipients

OBJECTIVE

 Doppler velocimetry of the uterine and umbilical arteries is used to predict preeclampsia and monitor fetal outcomes. There have been no reports of Doppler velocimetry indices in pregnancies conceived after uterus transplantation, which differ from traditional pregnancies because of different uterine vascular inflow and outflow and exposure to immunosuppressive agents. We sought to examine whether Doppler indices can be used to predict embryo transfer success after uterus transplantation and whether Doppler indices across pregnancy predict fetal growth restriction.

STUDY DESIGN

 This was a single-center cohort observational study of 14 uterus transplant recipients who underwent embryo transfer. Of these, 12 women successfully delivered 14 babies. Five Doppler investigations were performed within the cohort: (1) prepregnancy; (2) uterine artery assessment across pregnancy; (3) umbilical artery assessment across pregnancy; (4) successive pregnancies; and (5) fetal growth.

RESULTS

 Prepregnancy uterine artery Doppler indices did not correlate with successful implantation after embryo transfer. Uterine artery Doppler indices in uterus transplant recipients decreased across pregnancy as described in pregnancies without uterus transplantation. The umbilical artery systolic/diastolic velocity ratio was lower at all weeks of gestation after uterus transplantation compared with values described in pregnancies without uterus transplantation. In those women who delivered two successive babies after uterus transplant, umbilical artery Doppler indices were significantly lower during the second pregnancy. There was always forward flow throughout diastole in the umbilical arteries, and no babies experienced fetal growth restriction.

CONCLUSION

 In our study, uterus transplantation was not associated with abnormal blood flow indices in either the uterine or umbilical arteries. Although Doppler indices were not predictive of embryo transfer success, they supported the expectation that pregnancies after uterus transplantation at our center result in normally grown babies.

KEY POINTS

· Uterus transplantation is not associated with abnormal blood flow indices.. · Prepregnancy uterine artery Doppler indices did not correlate with successful embryo implantation.. · Doppler assessment supports the expectation of normal placentation, fetal growth, and healthy live births after uterus transplantation..

Neonatal Outcomes after Uterus Transplantation: Dallas Uterus Transplant Study

OBJECTIVE

Limited data are available on the outcome of infants born after uterus transplantation. Our aim was to describe the hospital course and laboratory findings in the first 2 months of life of the 12 infants born in the Dallas UtErus Transplant Study (DUETS).

STUDY DESIGN

Based on the trial protocol, information about infants was collected in a prospective fashion, including infant demographics, hospital course, and laboratory values.

RESULTS

Twelve infants were delivered, all by cesarean section, from 11 mothers who had undergone uterus transplantation (one mother had two pregnancies and delivered two babies). All pregnancies were singleton. The mothers received immunosuppressive therapy, and one had a rejection episode that was detected during pregnancy. The rejection episode resolved after steroid treatment. The infants had a median gestational age of 36^6/7 weeks (range: 30^6/7-38^0/7 weeks) and median birth weight of 2,920 g (range: 1,770-3,470 g). The lowest Apgar's score at 5 minutes was 8. All infants were appropriate size for gestational age. Two infants presented with bandemia but negative blood cultures. At 2 months of age, all infants achieved the developmental and behavioral milestones outlined by the American Academy of Pediatrics.

CONCLUSION

The 12 infants born from mothers with uterus transplants had a neonatal course that reflected the gestational age at delivery. No baby was born with an identified malformation or organ dysfunction. Longer follow-up and a larger number of infants are needed to confirm these observations.

KEY POINTS

· Normal fetal development after uterus transplantation.. · No baby was born with malformations or showed any organ dysfunction.. · At 2 months, all infants achieved appropriate developmental and behavioral milestones..

Carrier frequency of autosomal recessive genetic conditions in diverse populations: lessons learned from the Genome Aggregation Database

An equitable approach by the American College of Medical Genetics and Genomics (ACMG) has recently recommended carrier screening for genes associated with moderate to severe autosomal recessive conditions with a carrier frequency of ≥1/200 in the Genome Aggregation Database exomes (gnomADv2.0.2). We analyzed carrier frequencies in gnomADv3.1.1 genomes representing diverse populations. ClinVar data on 35,996 pathogenic/likely pathogenic variants in 419 genes were used to estimate the gnomAD frequency of heterozygous carriers. We found that ninety-two genes had a carrier frequency of ≥1/200, of which 63 were shared between v3.1.1 and v2.0.2 and 29 were new in v3.1.1. Addition of new populations (Amish, Finnish and Middle Eastern) increased the number of new genes with a carrier frequency of ≥1/200 to 71. Changes in carrier frequencies were attributed to new gnomAD populations, different sample sizes, new ClinVar data, and technical differences between exomes and genomes. This study highlights the dynamic changes in carrier frequencies due to new datasets from diverse populations and provides updated carrier frequencies based on the combined data from 184,352 genomes and exomes in gnomAD. We recommend a periodic review for inclusion of new population data to update carrier screening panels in the future. This article is protected by copyright. All rights reserved.

Genetic Screening and Teratogenic Exposures: Considerations in Caring for the Uterus Transplant Patient

Counseling the uterus transplant patient requires an enhanced knowledge of unique genetic challenges that include an understanding of the spectrum of Mayer-Rokitansky-Küster-Hauser syndrome. Patients should understand their options for genetic screening and testing including preimplantation genetic testing for aneuploidy, genetic screening, and diagnostic testing. This patient population is potentially at risk for fetal anomalies due to the increased susceptibility to infections, such as cytomegalovirus. There are management strategies to minimize this risk. The risk of teratogenicity from mycophenolate is eliminated by a washout period before embryo transfer.

Screening for autosomal recessive and X-linked conditions during pregnancy and preconception: a practice resource of the American College of Medical Genetics and Genomics (ACMG)

Carrier screening began 50 years ago with screening for conditions that have a high prevalence in defined racial/ethnic groups (e.g., Tay-Sachs disease in the Ashkenazi Jewish population; sickle cell disease in Black individuals). Cystic fibrosis was the first medical condition for which panethnic screening was recommended, followed by spinal muscular atrophy. Next-generation sequencing allows low cost and high throughput identification of sequence variants across many genes simultaneously. Since the phrase "expanded carrier screening" is nonspecific, there is a need to define carrier screening processes in a way that will allow equitable opportunity for patients to learn their reproductive risks using next-generation sequencing technology. An improved understanding of this risk allows patients to make informed reproductive decisions. Reproductive decision making is the established metric for clinical utility of population-based carrier screening. Furthermore, standardization of the screening approach will facilitate testing consistency. This practice resource reviews the current status of carrier screening, provides answers to some of the emerging questions, and recommends a consistent and equitable approach for offering carrier screening to all individuals during pregnancy or preconception.

Clinical pregnancy rates and experience with in vitro fertilization after uterus transplantation: Dallas Uterus Transplant Study

BACKGROUND

The clinical pregnancy rates among patients with uterus transplantation have been reported by only a limited number of centers, and those centers have not used preimplantation genetic testing for aneuploidy in their protocol.

OBJECTIVE

This study examined clinical pregnancy rates among women with absolute uterine-factor infertility undergoing in vitro fertilization using good-quality, expanded-blastocyst-stage, euploid embryos after uterus transplantation.

STUDY DESIGN

This cohort observational study involved 20 women who underwent uterus transplantation over 3 years. Notably, 14 of these patients had successful transplants and were followed prospectively for a median of 14.1 months (range, 11-34.8 months). In vitro fertilization was performed before subjects underwent uterus transplantation, and good-quality expanded-blastocyst-stage euploid embryos were obtained and frozen for future embryo transfer. Interventions consisted of in vitro fertilization, preimplantation genetic testing for aneuploidy, uterus transplantation, and frozen embryo transfer.

RESULTS

All 14 subjects with successful transplants underwent single embryo transfer of a warmed, good-quality, euploid, expanded blastocyst and had at least 1 documented clinical pregnancy within the uterus. In 71.4%, the first embryo transfer resulted in clinical pregnancy. The median time from successful uterus transplantation to first embryo transfer was 4.5 months; from successful uterus transplantation to first clinical pregnancy, 7.3 months; and from successful uterus transplantation to first live birth, 14.1 months. A total of 13 live births have occurred in 12 subjects.

CONCLUSION

Women with absolute uterine-factor infertility who have surgically successful uterus transplantation and in vitro fertilization using preimplantation genetic testing for aneuploidy can achieve high clinical pregnancy rates. We have reduced the time interval from uterus transplantation to embryo transfer by at least 50% and the interval from uterus transplantation to clinical pregnancy by >6 months compared with previous studies. We believe our approach may shorten the time from transplant to clinical pregnancy and therefore decrease patient exposure to immunosuppressant therapies.

CFTR variant testing: a technical standard of the American College of Medical Genetics and Genomics (ACMG)

Pathogenic variants in the CFTR gene are causative of classic cystic fibrosis (CF) as well as some nonclassic CF phenotypes. In 2001, CF became the first target of pan-ethnic universal carrier screening by molecular methods. The American College of Medical Genetics and Genomics (ACMG) recommended a core panel of 23 disease-causing variants as the minimal set to be included in pan-ethnic carrier screening of individuals with no family history of the disease, and these variants were usually assessed using targeted methods. The original recommendation also left open the option for laboratories to offer expanded CFTR variant panels; however, at the time, expanded CFTR variant panels were met with some controversy on the basis of the available technologies and the limited phenotypic knowledge of rare variants. Both of those aspects have now evolved, prompting this update of the ACMG technical standards for CFTR variant testing.

Adherence of cell-free DNA noninvasive prenatal screens to ACMG recommendations

PURPOSE

Noninvasive prenatal screening (NIPS) for fetal aneuploidy via cell-free DNA has been commercially available in the United States since 2011. In 2016, the American College of Medical Genetics and Genomics (ACMG) issued a position statement with specific recommendations for testing laboratories. We sought to evaluate adherence to these recommendations.

METHODS

We focused on commercial laboratories performing NIPS testing in the United States as of 1 January 2018. Sample laboratory reports and other materials were scored for compliance with ACMG recommendations. Variables scored for common and sex chromosome aneuploidy detection included detection rate, specificity, positive and negative predictive value, and fetal fraction. Labs that performed analysis of copy-number variants and results for aneuploidies other than those commonly reported were identified. Available patient education materials were similarly evaluated.

RESULTS

Nine of 10 companies reported fetal fraction in their reports, and 8 of 10 did not offer screening for autosomal aneuploidies beyond trisomy 13, 18, and 21. There was inconsistency in the application and reporting of other measures recommended by ACMG.

CONCLUSIONS

Laboratories varied in the degree to which they met ACMG position statement recommendations. No company adhered to all laboratory guidance.

Expanded Carrier Screening

Prenatal carrier screening has expanded to include a larger number of genes and variants offered to all couples considering or with an ongoing pregnancy. Panethnic screening for cystic fibrosis and spinal muscular atrophy and screening for a limited number of conditions based on ethnicity are recommended by the American College of Obstetricians and Gynecologists. Residual risk calculations have become an obsolete part of posttest counseling when expanded carrier screening (ECS) is selected. The Perception of Uncertainties in Genome Sequencing scale offers a useful understanding of the pretest and posttest counseling concerns that should be considered as part of ECS implementation.

Prenatal genetic carrier screening in the genomic age

The Society for Maternal-Fetal Medicine, American College of Obstetricians and Gynecologists (ACOG), and American College of Medical Genetics and Genomics (ACMG) held a workshop entitled "Prenatal Genetic Testing" on January 25, 2017 to address several questions arising from the increasing implementation of preconception and prenatal expanded carrier screening (ECS). ECS allows for identification of a greater number of genetic sequencing changes (not all of which cause disease) and simultaneous testing for an increased number of genetic conditions without limitation to specific ethnic groups. The workshop participants reached consensus on the following: ethnicity based testing cannot be completely abandoned in favor of panethnic ECS; the specific approach to screening should be a patient's choice and not driven solely by provider preference; organizations should work to develop a framework for vetting conditions that should be reported on ECS panels; compared with prenatal screening, preconception screening is ideal and, at this time, due to the costs and the need for timeliness associated with prenatal screening posttest counseling and testing, that when ECS is offered it should be presented as a preconception option; preconception and prenatal panels should be identical across the spectrum of patients, including those undergoing assisted reproduction; adult-onset conditions should not be included on ECS panels; partners should be offered next-generation sequencing to identify rare variants when the first partner screened is determined to be a carrier; re-screening in subsequent pregnancies is not indicated, despite the potential for expansion of carrier screening conditions and variants; and more education about ECS for providers and patients is necessary to implement prenatal carrier screening in a responsible way.

Photoplethysmography and Heart Rate Variability for the Diagnosis of Preeclampsia

BACKGROUND

The goal of this study was to determine a set of timing, shape, and statistical features available through noninvasive monitoring of maternal electrocardiogram and photoplethysmography that identifies preeclamptic patients.

METHODS

Pregnant women admitted to Labor and Delivery were monitored with pulse oximetry and electrocardiogram for 30 minutes. Photoplethysmogram features and heart rate variability were extracted from each data set and applied to a sequential feature selection algorithm to discriminate women with preeclampsia with severe features, from normotensive and hypertensive controls. The classification boundary was chosen to minimize the expected misclassification cost. The prior probabilities of the misclassification costs were assumed to be equal.

RESULTS

Thirty-seven patients with clinically diagnosed preeclampsia with severe features were compared with 43 normotensive controls; all were in early labor or beginning induction. Six variables were used in the final model. The area under the receiver operating characteristic curve was 0.907 (standard error [SE] = 0.004) (sensitivity 78.2% [SE = 0.3%], specificity 89.9% [SE = 0.1%]) with a positive predictive value of 0.883 (SE = 0.001). Twenty-eight subjects with chronic or gestational hypertension were compared with the same preeclampsia group, generating a model with 5 features with an area under the curve of 0.795 (SE = 0.007; sensitivity 79.0% [SE = 0.2%], specificity 68.7% [SE = 0.4%]), and a positive predictive value of 0.799 (SE = 0.002).

CONCLUSIONS

Vascular parameters, as assessed noninvasively by photoplethysmography and heart rate variability, may have a role in screening women suspected of having preeclampsia, particularly in areas with limited resources.

The Obstetric Hemorrhage Initiative (OHI) in Florida: The Role of Intervention Characteristics in Influencing Implementation Experiences among Multidisciplinary Hospital Staff

Objectives Obstetric hemorrhage is one of the leading causes of maternal mortality. The Florida Perinatal Quality Collaborative coordinates a state-wide Obstetric Hemorrhage Initiative (OHI) to assist hospitals in implementing best practices related to this preventable condition. This study examined intervention characteristics that influenced the OHI implementation experiences among Florida hospitals. Methods Purposive sampling was employed to recruit diverse hospitals and multidisciplinary staff members. A semi-structured interview guide was developed based on the following constructs from the intervention characteristics domain of the Consolidated Framework for Implementation Research: evidence strength; complexity; adaptability; and packaging. Interviews were audio-recorded, transcribed and analyzed using Atlas.ti. Results Participants (n = 50) across 12 hospitals agreed that OHI is evidence-based and supported by various information sources (scientific literature, experience, and other epidemiologic or quality improvement data). Participants believed the OHI was 'average' in complexity, with variation depending on participant's role and intervention component. Participants discussed how the OHI is flexible and can be easily adapted and integrated into different hospital settings, policies and resources. The packaging was also found to be valuable in providing materials and supports (e.g., toolkit; webinars; forms; technical assistance) that assisted implementation across activities. Conclusions for Practice Participants reflected positively with regards to the evidence strength, adaptability, and packaging of the OHI. However, the complexity of the initiative adversely affected implementation experiences and required additional efforts to maximize the initiative effectiveness. Findings will inform future efforts to facilitate implementation experiences of evidence-based practices for hemorrhage prevention, ultimately decreasing maternal morbidity and mortality.

Second-Trimester Uterine Model for Teaching Ultrasound-Guided Obstetric Procedures

The declining number of ultrasound-guided obstetric procedures in clinical practice mandates a shift toward simulation-based teaching. Current uterine simulation aids are animal tissue-sourced or expensive, and improvement is needed. We describe a low-cost reusable uterine model with "fetus," cord and skin, constructed from synthetic gel and silicone rubber. Ultrasound appearance and tactile feedback approximate clinical use, and all parts of the model are portable, durable, and shelf-stable. Those made of ballistics gel can be recycled numerous times without noticeable effect. This appears to be ideal for proctored learning and independent practice within an ultrasound procedural curriculum.

Revisiting the challenges of training Maternal Fetal Medicine fellows in chorionic villus sampling

BACKGROUND

More than a decade ago, researchers described a survey of Maternal Fetal Medicine fellows that showed that chorionic villus sampling training was limited for Maternal Fetal Medicine fellows in the United States. Prenatal screening and diagnosis have rapidly evolved since then and include the introduction of noninvasive aneuploidy screening that uses cell-free fetal DNA. Yet, chorionic villus sampling remains the only method available for first-trimester genetic diagnosis.

OBJECTIVE

This study evaluated the chorionic villus sampling training of Maternal Fetal Medicine fellows with respect to availability, competency standards, and education methods.

STUDY DESIGN

In November 2015, an electronic survey was sent to Maternal Fetal Medicine fellows and fellowship directors of accredited Maternal Fetal Medicine fellowship programs in the United States.

RESULTS

Fifty-eight percent of fellows (179/310) and 46% of program directors (35/76) responded. Ninety-five percent of Maternal Fetal Medicine fellows think that invasive diagnostic testing is essential to their training; 100% of fellows have amniocentesis training; and 65% have chorionic villus sampling training. The median number of chorionic villus sampling procedures that are expected during a fellowship in those who trained was 10. Eighty-eight percent of fellows and 89% of program directors state that chorionic villus sampling training could be better; 89% of fellows and 97% of directors would like access to simulated models. Barriers to training included lack of patients (71%) and lack of proficient attending supervisors (43%).

CONCLUSION

Since the last survey, >10 years ago, chorionic villus sampling training has declined further. A decrease in the number of procedures that are performed is the leading barrier to this training.

Noninvasive prenatal screening for fetal aneuploidy, 2016 update: a position statement of the American College of Medical Genetics and Genomics

DISCLAIMER

This statement is designed primarily as an educational resource for clinicians to help them provide quality medical services. Adherence to this statement is completely voluntary and does not necessarily assure a successful medical outcome. This statement should not be considered inclusive of all proper procedures and tests or exclusive of other procedures and tests that are reasonably directed toward obtaining the same results. In determining the propriety of any specific procedure or test, the clinician should apply his or her own professional judgment to the specific clinical circumstances presented by the individual patient or specimen. Clinicians are encouraged to document the reasons for the use of a particular procedure or test, whether or not it is in conformance with this statement. Clinicians also are advised to take notice of the date this statement was adopted and to consider other medical and scientific information that becomes available after that date. It also would be prudent to consider whether intellectual property interests may restrict the performance of certain tests and other procedures.Noninvasive prenatal screening using cell-free DNA (NIPS) has been rapidly integrated into prenatal care since the initial American College of Medical Genetics and Genomics (ACMG) statement in 2013. New evidence strongly suggests that NIPS can replace conventional screening for Patau, Edwards, and Down syndromes across the maternal age spectrum, for a continuum of gestational age beginning at 9-10 weeks, and for patients who are not significantly obese. This statement sets forth a new framework for NIPS that is supported by information from validation and clinical utility studies. Pretest counseling for NIPS remains crucial; however, it needs to go beyond discussions of Patau, Edwards, and Down syndromes. The use of NIPS to include sex chromosome aneuploidy screening and screening for selected copy-number variants (CNVs) is becoming commonplace because there are no other screening options to identify these conditions. Providers should have a more thorough understanding of patient preferences and be able to educate about the current drawbacks of NIPS across the prenatal screening spectrum. Laboratories are encouraged to meet the needs of providers and their patients by delivering meaningful screening reports and to engage in education. With health-care-provider guidance, the patient should be able to make an educated decision about the current use of NIPS and the ramifications of a positive, negative, or no-call result.Genet Med 18 10, 1056-1065.

Monitoring Uterine Activity during Labor: Clinician Interpretation of Electrohysterography versus Intrauterine Pressure Catheter and Tocodynamometry

Objective The aim of this article was to compare clinical interpretation of uterine activity tracings acquired by tocodynamometry and electrohysterography with the gold standard, intrauterine pressure. Study Design Using data from a previous study, subjects who had simultaneous monitoring with all three uterine activity devices were included in this study. These were parturients who required intrauterine pressure catheter (IUPC) placement for obstetric indication. A Web-based application displayed scrolling 30-minute segments of uterine activity. Two blinded obstetricians and two blinded obstetric nurses independently reviewed the segments, marking uninterpretable segments and the peak of each contraction. Interpretability was compared using positive percent agreement. False positives are contractions marked in the noninvasive strip that have no corresponding contraction in the IUPC strip. False negatives are the reverse. Results A total of 135 segments, acquired during either Stage 1 (active labor) or Stage 2 (pushing), from 105 women, were included in this analysis. For all four observers, both interpretability and sensitivity of electrohysterography exceeded that of tocodynamometry (p < 0.0001). This remained true for the obese population (96 segments). Conclusion Compared with the IUPC, electrohysterography is more sensitive and provides tracings that are more often interpretable than tocodynamometry for intrapartum monitoring; electrohysterography is also less affected by increasing maternal body mass index.

Prenatal diagnosis of sub-microscopic partial trisomy 10q using chromosomal microarray analysis in a phenotypically abnormal fetus with normal karyotype

Partial trisomy of the 10q region was originally reported in 1979 [1]. For 25 years, the diagnosis was made microscopically based on large, visible insertions in the region identified by karyotype analysis. Previous case reports have included both unbalanced translocations and large duplications/insertions in the 10q region [2]. Probands with partial trisomy 10q syndrome often have an abnormal phenotype that may include developmental delay [3-5], craniofacial abnormalities [3, 5], talipes (clubfoot) [2], microcephaly [2-4], or congenital heart disease [2-6]. Prenatal diagnoses by karyotype have been made following ultrasound diagnosis of sacrococcygeal teratoma [7], renal pyelectasis [3, 8-10], and other fetal abnormalities [4]. In this case, we report the first prenatal diagnosis of partial trisomy 10q (10q22.3-10q23.2) with a normal karyotype and an abnormal chromosomal microarray analysis (CMA). This is the smallest copy number variant (CNV) (7.5 Mb) in the 10q22.3-10q23.2 regions yet reported.

Expanded carrier screening in reproductive medicine-points to consider: a joint statement of the American College of Medical Genetics and Genomics, American College of Obstetricians and Gynecologists, National Society of Genetic Counselors, Perinatal Quality Foundation, and Society for Maternal-Fetal Medicine

The Perinatal Quality Foundation and the American College of Medical Genetics and Genomics, in association with the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine, and the National Society of Genetic Counselors, have collaborated to provide education for clinicians and laboratories regarding the use of expanded genetic carrier screening in reproductive medicine. This statement does not replace current screening guidelines, which are published by individual organizations to direct the practice of their constituents. As organizations develop practice guidelines for expanded carrier screening, further direction is likely. The current statement demonstrates an approach for health care providers and laboratories who wish to or who are currently offering expanded carrier screening to their patients.

Carrier testing for Ashkenazi Jewish disorders in the prenatal setting: navigating the genetic maze

Exciting developments in the fields of genetics and genomics have facilitated the identification of the etiological basis of many Mendelian disorders. Several of the methods used in gene discovery have focused initially on homogeneous populations, including the Ashkenazi Jewish population. The founder effect is well recognized in this community, in which historical events and cultural behaviors have resulted in a limited number of mutations underlying genetic disorders with substantial health impact. New technologies have made it possible to rapidly expand the test panels, changing testing paradigms, and thereby creating challenges for the physician in deciphering the appropriate approach to genetic screening in this population. The goal of this review is to help primary obstetric health care providers navigate through this quickly moving field so as to better counsel and support their patients of Ashkenazi Jewish heritage.

Noninvasive prenatal screening by next-generation sequencing

Noninvasive prenatal screening (NIPS) has emerged as a highly accurate method of screening for fetal Down syndrome, with a detection rate and specificity approaching 100%. Challenging the widespread use of this technology are cost and the paradigm shift in counseling that accompanies any emerging technology. The expense of the test is expected to decrease with increased utilization, and well beyond the current NIPS technology, its components (fetal genome measurements, sequencing technology, and bioinformatics) will be utilized alone or in combinations to interrogate the fetal genome. The end goal is simple: to offer patients information early in pregnancy about fetal genomes without incurring procedural risks. This will allow patients an opportunity to make informed reproductive and pregnancy management decisions based on precise fetal genomic information.

Second trimester amniotic fluid is reliably fern positive and α1-microglobulin positive: dispelling a labor deck myth

OBJECTIVE

Many physicians erroneously believe and have propagated the "myth" that a second trimester amniotic fluid sample will not fern. We attempted to redemonstrate ferning and to demonstrate the efficacy of an assay for α1-microglobulin in second trimester amniotic fluid samples.

STUDY DESIGN

Amniotic fluid samples were collected from women undergoing routine genetic amniocentesis between 15 and 26 weeks. A total of 97 samples of second trimester amniotic fluid were placed on slides and examined for ferning at 5 and 10 minutes. An α1-microglobulin assay was performed on each sample. Data were recorded and reported.

RESULTS

Approximately 93% of samples were fern positive at 5 minutes and 100% were fern positive at 10 minutes. All samples were α1-microglobulin positive.

CONCLUSION

Pure amniotic fluid is reliably fern and α1-microglobulin positive in the second trimester. Republication of data only available in pre-online sources will benefit physicians and patients.

Monitoring uterine activity during labor: a comparison of 3 methods

OBJECTIVE

Tocodynamometry (Toco; strain gauge technology) provides contraction frequency and approximate duration of labor contractions but suffers frequent signal dropout, necessitating repositioning by a nurse, and may fail in obese patients. The alternative invasive intrauterine pressure catheter (IUPC) is more reliable and adds contraction pressure information but requires ruptured membranes and introduces small risks of infection and abruption. Electrohysterography (EHG) reports the electrical activity of the uterus through electrodes placed on the maternal abdomen. This study compared all 3 methods of contraction detection simultaneously in laboring women.

STUDY DESIGN

Upon consent, laboring women were monitored simultaneously with Toco, EHG, and IUPC. Contraction curves were generated in real-time for the EHG, and all 3 curves were stored electronically. A contraction detection algorithm was used to compare frequency and timing between methods. Seventy-three subjects were enrolled in the study; 14 were excluded due to hardware failure of 1 or more of the devices (n = 12) or inadequate data collection duration (n = 2).

RESULTS

In comparison with the gold-standard IUPC, EHG performed significantly better than Toco with regard to the Contractions Consistency Index (CCI). The mean CCI for EHG was 0.88 ± 0.17 compared with 0.69 ± 0.27 for Toco (P < .0001). In contrast to Toco, EHG was not significantly affected by obesity.

CONCLUSION

Toco does not correlate well with the gold-standard IUPC and fails more frequently in obese patients. EHG provides a reliable noninvasive alternative, regardless of body habitus.

An integrated ultrasound curriculum (iUSC) for medical students: 4-year experience

A review of the development and implementation of a 4-year medical student integrated ultrasound curriculum is presented. Multiple teaching and assessment modalities are discussed as well as results from testing and student surveys. Lessons learned while establishing the curriculum are summarized. It is concluded that ultrasound is a well received, valuable teaching tool across all 4 years of medical school, and students learn ultrasound well, and they feel their ultrasound experience enhances their medical education.

Blood pressure regulation across pregnancy: evidence of a paradigm shift in gene expression

OBJECTIVES

The authors aimed to provide evidence for a major gene effect on blood pressure across normal pregnancy.

METHODS

Blood pressure measurements from 265 patients of Mexican descent derived from medical records were grouped into 4-week blocks by gestational age. Analyses of normality in the distribution of measurements for each block were applied to determine the emergence of a major gene effect and identify the gestational age at which that occurs. Systolic and diastolic blood pressures were used to determine median and percentile values for each block.

RESULTS

There was a shift from normal to non-normal distribution in systolic blood pressure between 12 and 15 weeks' gestation. This was similar for diastolic blood pressure. Median blood pressure values increased from 10 to 40 weeks' gestation without evidence of a decline during the second trimester of pregnancy.

CONCLUSION

Genetic regulation of blood pressure across pregnancy is dynamic, as demonstrated by the emergence of a major gene effect beginning around 12 weeks' gestation.

Fetal peritonitis due to appendiceal rupture: a rare complication of hydrops

A rare complication (appendiceal perforation with meconium peritonitis) was observed in a second trimester fetus affected by nonimmune fetal hydrops due to parvovirus B-19 infection. The complication is not considered specific to this or any other etiology for hydrops, which is highly heterogeneous; rather it is an expression of the fragility and friability of edematous tissues.

Hypertension in pregnancy

The hypertensive diseases of pregnancy commonly refer to a group of disorders whose definitions have changed over time within and among professional organizations. Pre-eclampsia, either mild or severe, is managed best with a policy of delivery at or beyond 37 and 34 weeks' gestation, respectively. Similarly, chronic hypertension,gestational hypertension, and chronic hypertension with superimposed pre-eclampsia are conditions wherein it is difficult to justify expectant management beyond 37 weeks' gestation. The approach to management before these gestational ages is subject to interpretation of a limited body of literature.

Mouse models and the role of nitric oxide in reproduction

As a group, nitric oxide synthase (NOS) isoforms are localized to a wide variety of tissues. Understanding the role of NOS in reproductive physiology was facilitated by the introduction of genetically engineered mice. Specifically, "knock-out" mice with targeted disruptions in neuronal NOS, endothelial NOS and inducible NOS have been made. These models have been useful in addressing the of role of nitric oxide in areas of reproductive biology that include: hypothalamic-pituitary-ovarian axis, mating behavior, maternal blood pressure regulation and fetal development. Despite several promising observations using "knock-out" mouse models, one must exercise caution in interpreting data from individual experiments. Very often the need to draw on two mouse strains to generate the founder NOS deficient line, purity of the strain used for observing phenotypes (presence or absence of backcrossing to achieve a pure strain), and the strain used for comparison purposes (control strains are often not identical in their genetic make-up to the deficient line) make wide spread applicability of results open to criticism.

An endothelial nitric oxide synthase gene polymorphism is associated with preeclampsia

OBJECTIVE

We sought to test the hypothesis that a polymorphism of the endothelial nitric oxide synthase gene (NOS3) is associated with preeclampsia.

METHODS

We collected and performed polymerase chain reaction (PCR) on genomic DNA from pregnant patients with and without preeclampsia. Patient history and clinical course were evaluated.

MAIN OUTCOME MEASURE(S)

Frequency of the intron 4 polymorphism of NOS3 (designated allele A) among patients with preeclampsia compared with controls. Clinical features of patients with preeclampsia and the A allele compared with those patients with preeclampsia who did not have the A allele.

RESULTS

The frequency of the A allele was 0.10 among controls versus 0.39 among patients with preeclampsia (p < 0.01). The odds ratio of developing preeclampsia when at least one A allele was present was 6.5 [95% confidence interval (CI): 2.1-19.7]. After adjusting for ethnic variation, the odds ratio increased to 7.2 (95% CI: 2.0-25.5). Among patients with preeclampsia, systolic blood pressure at the time of admission was higher for patients with at least one A allele compared with patients homozygous for the B allele (168 versus 156 mm Hg; p = 0.03), independent of gestational age (p = 0.01).

CONCLUSION

These data provide evidence for an association between NOS3 and preeclampsia. In defined ethnic groups, this NOS3 may offer predictive information regarding the subsequent development of preeclampsia and its clinical course.

Elements of a genetics counseling service

Providing genetic information and counseling can be complex and time consuming. A Genetic Counseling Service consists of individuals that are certified by the American Board of Medical Genetics and others. These include Masters Degree trained genetic counselors, physicians that have completed special training in clinical genetics, nurses with special skills in genetics, and support staff. A team approach is required in order to provide patients comprehensive genetic counseling services.

Genetic screening for cystic fibrosis

The importance of the recent recommendations that address cystic fibrosis carrier screening cannot be overemphasized. For the first time, a systematic approach to offering or making screening available to all pregnant women in the hopes of providing refined risk estimates for a genetic disease has been established. Caucasian of European or Ashkenazi-Jewish descent should be offered screening. Within the proposed guidelines are ethnic-specific carrier frequencies (1/29) used to establish who should be offered testing and to whom testing should be made available. Recent recommendations have made clear that in a pan-ethnic population a frequency of 1/1,000 is required for inclusion into the cystic fibrosis mutation panel. A general framework for screening during pregnancy has been established (either concurrent or sequential). It will be interesting to watch as the fruits of the human genome project are inspected and applied to everyday clinical practice. No doubt the cost of screening will be reduced through advances in technology. The combined efforts of NIH, ACOG, and ACMG have provided the first set of comprehensive standards for screening of recessive diseases. How time changes these guidelines deserves following.

Inducible and endothelial nitric oxide synthase: genetic background affects ovulation in mice

OBJECTIVE

Inducible nitric oxide synthase (NOS) and endothelial NOS are involved in female reproductive physiology. We sought to investigate the influence of the inducible (Nos2) and endothelial (Nos3) NOS genes as a function of genetic background on ovulatory capacity and early embryonic development in a mouse model.

DESIGN

Observational study of genetically altered mice and their response to a superovulation protocol.

SETTING

Academic research institution.

ANIMALS

Wild-type mice and mice deficient for Nos2 or Nos3 were bred to C57BL/6J and 129/Sv genetic backgrounds.

INTERVENTION(S)

Superovulation protocol, oocyte culture.

MAIN OUTCOME MEASURE(S)

Number of oocytes harvested, early embryonic development of zygotes, evaluation of ovarian histology.

RESULT(S)

The mean number of oocytes was significantly reduced in Nos3 deficient mice on a C57BL/6J background compared with controls. Oocytes deficient for Nos3 on a C57BL/6J background also showed reduced progression to two-cell stage embryos after 24 hours, two-cell stage embryos to blastocyst stage embryos, and survival to 48 hours. Those effects were distinctly absent in mice deficient for Nos3 on a 129/Sv background and in mice deficient for Nos2 on either genetic background.

CONCLUSION(S)

Our data show that disruption of Nos2 had no effect on ovulation in our mice. The negative effect of Nos3 deficiency on ovulatory capacity and early embryonic development is modulated by genetic background. This suggests a role for strain-specific modifier genes in these processes.

Clinical value of postnatal autopsy and genetics consultation in fetal death

The aim of the present study was to investigate the clinical use of postnatal autopsy and genetics consultation in cases of fetal death in a teaching hospital. A retrospective analysis of medical records including pathology and genetics reports was performed in all cases of fetal death in which a woman delivered at Ben Taub General Hospital, Houston, Texas over a 2-year period. Cases were excluded when gestational age of the fetus was less than 20 weeks. Fetuses were only included when the 1- and 5-min Apgar scores were 0 and 0, respectively. There were 139 fetal deaths and 12,209 live born infants during the study period (stillbirth rate 1.125%). Although pathology services were used in 96.2%, a genetics consultation was obtained in only 12% of cases. Fetal autopsy provided a certain cause of fetal death in 19.4%, a probable cause for death in 36.3%, and was inconclusive in 44.3%. Among the cases in which a genetics consultation was obtained, a certain and probable cause for fetal death was found in 20% and 20% of cases, respectively. The utilization of genetics consultation was found to be independent of multiple clinical variables examined including ultrasound data, identification of maceration, and training level of resident. Our data show a frequent use of pathologic examination in cases of fetal death and an infrequent use of genetics consultation services. The request for genetics consultation seemed to have been made at random.