First-trimester biochemical markers of aneuploidy and the prediction of small-for-gestational age fetuses

OBJECTIVES

To examine the clinical utility of the first-trimester biochemical markers of aneuploidy in their ability to predict subsequent delivery of a small-for-gestational age (SGA) infant.

METHODS

We examined singleton pregnancies with no chromosomal abnormality and with complete outcome data that had undergone screening for trisomy 21 by a combination of fetal nuchal translucency (NT) thickness and maternal serum free beta-human chorionic gonadotropin (beta-hCG) and pregnancy-associated plasma protein-A (PAPP-A) at 11 + 0 and 13 + 6 weeks' gestation. The biochemical markers were converted to multiples of the expected normal median (MoM) for a pregnancy of the same gestation. The association between free beta-hCG and PAPP-A and the incidence of SGA were assessed by comparing the relative incidence at MoM cut-offs and birth-weight centile cut-offs. At various marker levels the likelihood ratios (LR) for SGA were also calculated after excluding other adverse pregnancy complications.

RESULTS

There were 46,262 pregnancies resulting in live births with birth weight at or above the 10(th) centile, and 3,539 below the 10(th) centile for gestation (SGA). There was a significant inverse association between the risk for SGA and maternal serum PAPP-A MoM but not free beta-hCG MoM. At the 5(th) centile of the normal outcome group for PAPP-A (0.415 MoM) the odds ratios for SGA below the 10(th), 5(th) and 3(rd) centiles of normal were 2.70, 3.21 and 3.66 and the respective detection rates for SGA were 12.0%, 14.0% and 16.0%.

CONCLUSIONS

Low levels of maternal serum PAPP-A are associated, in the absence of an abnormal karyotype, with an increased risk for subsequent delivery of an SGA infant.

Dilemmas in the management of twins discordant for anencephaly diagnosed at 11 + 0 to 13 + 6 weeks of gestation

OBJECTIVE

To help develop an evidence-based approach to the best management of twin pregnancies discordant for anencephaly.

METHODS

We retrospectively examined the management and outcome of 18 pregnancies discordant for anencephaly diagnosed at 11 + 0 to 13 + 6 weeks of gestation in our center. We combined these data with those from other publications. In total, there were 44 dichorionic pregnancies that were managed expectantly (n = 35) or by selective feticide (n = 9) and 19 monochorionic pregnancies that were managed expectantly. We also reviewed the literature to ascertain the outcome of monochorionic twin pregnancies undergoing cord occlusion.

RESULTS

In the 35 dichorionic pregnancies that were managed expectantly, 20 (57.1%) developed polyhydramnios at 25-31 weeks; 13 were managed expectantly, five had amniodrainage and two had selective feticide. In 34 of the 35 cases the non-anencephalic twin was liveborn at a median gestation of 36 (range, 28-39) weeks and in six (17.6%) of these it was born before 33 weeks. In the dichorionic pregnancies that had selective feticide, there was one miscarriage and eight (88.9%) live births at a median gestation of 37 (range, 30-40) weeks and in one (12.5%) of these it was born before 33 weeks. In the monochorionic pregnancies, four (21.1%) anencephalic fetuses died at 20-32 weeks and in three of these the normal co-twin also died. In the 16 (84.2%) cases resulting in the live birth of the normal twin, delivery occurred at a median gestation of 33 (range, 27-39) weeks and in six (37.5%) of these it was before 33 weeks. Ultrasound-guided bipolar cord coagulation in 92 pregnancies, mostly complicated by twin reversed arterial perfusion sequence or severe twin-to-twin transfusion syndrome, was associated with a survival rate of 77.2% and early preterm delivery rate of 31.0%.

CONCLUSION

Dichorionic twins discordant for anencephaly are best managed with serial ultrasound examinations for early diagnosis of polyhydramnios, which can then be treated either by amniodrainage or selective feticide. In monochorionic twins it is uncertain whether the best management is expectant or by cord occlusion.

First-trimester ultrasound and biochemical markers of aneuploidy and the prediction of impending fetal death

OBJECTIVES

To examine the clinical utility of the first-trimester markers of aneuploidy in their ability to predict future fetal loss.

METHODS

We examined 54,722 singleton pregnancies with no chromosomal abnormality and with complete outcome data that had undergone screening for trisomy 21 by a combination of fetal nuchal translucency (NT) thickness, maternal serum free beta-human chorionic gonadotropin (beta-hCG) and pregnancy-associated plasma protein-A (PAPP-A) at 11 + 0 and 13 + 6 weeks' gestation. The biochemical markers were converted to multiples of the expected normal median for a pregnancy of the same gestation (MoM) and the measurements of fetal NT were expressed as the difference (delta) from the normal median NT for crown-rump length (CRL). The association between free beta-hCG, PAPP-A and delta NT and the incidence of fetal loss prior to 24 weeks, at or after 24 weeks or at any time, was assessed by comparing the relative incidence at a number of MoM or delta NT cut-offs and at various centile cut-offs. At various marker levels the likelihood ratio (LR) for fetal loss was also calculated.

RESULTS

The rate of fetal loss increased with decreasing maternal serum free beta-hCG and PAPP-A and increasing delta NT. At the 5th centile of the normal outcome group for free beta-hCG (0.41 MoM) the odds ratio for fetal loss before 24 weeks, at or above 24 weeks and at any gestation was 3.1, 1.8 and 2.6, respectively. The respective values for the 5th centile of PAPP-A (0.415 MoM) were 3.3, 1.9 and 2.8 and for the 95th centile of delta NT they were 2.5, 1.9 and 2.2, respectively. There was almost no correlation between reduced levels (<or=0.50 MoM) of PAPP-A and reduced levels of free beta-hCG in either the normal pregnancy group (r = 0.041) or the group with fetal death (r = 0.072), indicating relatively independent prediction by either biochemical marker.

CONCLUSIONS

Low levels of maternal serum PAPP-A and free beta-hCG and increased fetal NT are associated, in the absence of an abnormal karyotype, with an increased risk of impending fetal death. The likelihood ratio profiles provided at various levels of PAPP-A or free beta-hCG may be of some help in counseling women with such results and raise awareness among health-care professionals for increased surveillance in such cases.

Risks of miscarriage and early preterm birth in trichorionic triplet pregnancies with embryo reduction versus expectant management: new data and systematic review

BACKGROUND

Triplet pregnancies are associated with a high risk of miscarriage and early preterm birth. It is uncertain if the outcome is improved by embryo reduction (ER).

METHODS

We examined trichorionic triplet pregnancies with three live fetuses at 10-14 weeks of gestation that were managed expectantly or by ER. The two groups were compared for the rates of miscarriage, defined as pregnancy loss before 24 weeks, and preterm delivery prior to 32 weeks. In addition, systematic searches were performed to identify studies comparing outcomes in expectant management versus ER in triplet pregnancies.

RESULTS

We combined data from 365 pregnancies managed in our centre with those of five previous studies. In total there were 893 pregnancies. In the ER group (n=482) compared to the expectantly managed group (n=411), the rate of miscarriage was higher [8.1 versus 4.4%; relative risk (RR)=1.83, 95% confidence interval (CI)=1.08-3.16, P=0.036] and the rate of early preterm delivery was lower (10.4 versus 26.7%, RR=0.37, 95% CI=0.27-0.51, P<0.0001). It was calculated that seven (95% CI=5-9) reductions needed to be performed to prevent one early preterm delivery, while the number of reductions that would cause one miscarriage was 26 (95% CI=14-193).

CONCLUSIONS

In trichorionic triplets, ER to twins is associated with an increase in the risk of subsequent miscarriage and decrease in risk of early preterm birth.

Multicenter study of first-trimester screening for trisomy 21 in 75 821 pregnancies: results and estimation of the potential impact of individual risk-orientated two-stage first-trimester screening

OBJECTIVES

To evaluate the performance of first-trimester screening for trisomy 21 by a combination of maternal age, fetal nuchal translucency (NT) and maternal serum free beta-human chorionic gonadotropin (beta-hCG) and pregnancy-associated plasma protein-A (PAPP-A). In addition, the potential impact of a new individual risk-orientated two-stage approach to first-trimester screening was examined.

METHODS

First-trimester combined screening for trisomy 21 was carried out in 75 821 singleton pregnancies with live fetuses at 11 + 0 to 13 + 6 gestational weeks. The detection and false-positive rates for different risk cut-offs were calculated. To examine the potential impact of an individual risk-orientated two-stage approach to first-trimester screening it was assumed that, after first-trimester combined screening, chorionic villus sampling (CVS) would be performed in all patients with a risk estimate of 1 in 100 or more and in none of those with a risk estimate of less than 1 in 1000. Those in the intermediate-risk category, with a risk estimate of between 1 in 101 and 1 in 1000, would have further assessment of risk by first-trimester ultrasound examination to determine presence/absence of the nasal bone, presence/absence of tricuspid regurgitation or normal/abnormal Doppler velocity waveform in the ductus venosus, and CVS would be performed if their adjusted risk became 1 in 100 or more.

RESULTS

Fetal NT and maternal serum free beta-hCG and PAPP-A were successfully measured in all cases. The median maternal age was 31 (range, 13-49) years, the median gestation at screening was 12 (range, 11 + 0 to 13 + 6) weeks and the median fetal crown-rump length was 62 (range, 45-84) mm. Chromosomal abnormalities were identified in 544 pregnancies, including 325 cases of trisomy 21. The estimated risk for trisomy 21 was 1 in 300 or greater in 5.2% of normal pregnancies, in 92.6% of those with trisomy 21, in 88.5% of those with trisomy 18 or 13 and in 85.6% of those with other chromosomal defects. The detection rates for trisomy 21 were about 75% and 80% for respective false-positive rates of 1% and 2%. In the proposed individual risk-orientated two-stage screening for a risk cut-off of 1 in 100 the total false-positive rate would vary with the method used for the second stage of screening from 2.1% for absence of the nasal bone to 2.7% for increased impedance in the ductus venosus and 2.7% for tricuspid regurgitation and the respective detection rates would be 92.0%, 94.2% and 91.7%.

CONCLUSIONS

First-trimester combined screening for trisomy 21 is associated with a detection rate of about 90% for a false-positive rate of 5%. Individual risk-orientated two-stage screening for trisomy 21 can potentially identify, in the first trimester of pregnancy, more than 90% of affected fetuses for a false-positive rate of 2-3%.

Correlation between biomagnetic and Doppler findings of the uterine artery in normal and preeclamptic pregnancies

OBJECTIVES

To elucidate the hemodynamics of the uterine artery in normal and abnormal pregnancies by use of Doppler ultrasound and SQUID biomagnetometry.

METHOD

Two hundred and three women (gestational age 28-42 weeks) were included in the study. Forty-three of them had preeclampsia and/or intrauterine growth restriction and 160 were normal. Uterine artery waveform measurements were evaluated by use of pulsatility index (PI) (normal value PI<1.45). Biomagnetic signals of uterine arteries were recorded and analyzed with Fourier analysis. The biomagnetic signals were distributed according to spectral amplitudes as high (140-300 fT/ radicalHz), low (50-110 fT/ radicalHz) and borderline (111-139 fT/ radicalHz).

RESULTS

There was a statistically significant difference between normal and abnormal pregnancies concerning the waveform amplitudes (p < 0.001) and the PI index (p < 0.001). Specifically, we noticed high biomagnetic amplitudes in most normal pregnancies (92.5%) and low biomagnetic amplitudes in most preeclamptic cases (90.7%).

CONCLUSIONS

Our study results indicated that biomagnetic measurements of uterine artery might prove to be useful in the evaluation of the fetal well being, especially in cases of preeclampsia and intrauterine growth restriction.

Caroli's syndrome. A case report and review of the literature

Personal experience in the treatment of a female patient presenting a pure monolobar Caroli's disease, is described. The woman was asymptomatic so far; during the last 2 weeks she was admitted on 3 occasions with repeated attacks of cholangitis and obstructive jaundice. Surgery was performed for relief of the jaundice. A diagnosis of segmental Caroli's disease (congenital dilatation of intrahepatic bile ducts) with congenital fibrosis was made on the basis of marked fibrous septa with the characteristic ductal plate formation on left hepatectomy specimen and the cysts seen on ultrasound.

Laparoscopic evaluation of congenital absence of the uterus. a case report

Anatomic gynecologic anomalies, including congenital absence of the uterus, occur with surprising frequency in referral practice of reproductive endocrinology and reproductive surgery. Female individuals with uterus agenesis have normal external genitalia and, therefore, the diagnosis is rarely made in infancy. We report a case of congenital absence of the uterus in a young woman 25 years old, presenting with primary amenorrhea. The patient had a normal karyotype and normal secondary sex characteristics. Sex hormones were within normal limits, indicating normal function of the hypothalamic-pituitary-ovarian axis. The diagnosis was set by bimanual gynecologic examination, which was followed by vaginal ultrasound examination. The patient underwent a laparoscopic investigation, which revealed the absence of the uterus and the presence of small rudimentary uterine horns, connected to normal fallopian tubes. Ovarian morphology was bilaterally normal. In conclusion we believe that every patient with genital tract abnormalities has to be dealt with individually, depending on the patient's anatomy, desires and age.

Correlation between biomagnetic and Doppler findings of umbilical artery in fetal growth restriction

OBJECTIVE

To assess the value of biomagnetic recordings of the umbilical artery over Doppler ultrasound screening in order to predict complications of impaired uteroplacental blood flow in fetuses with intrauterine growth restriction (IUGR).

METHODS

Our study population included 11 IUGR preeclamptic (34-37-weeks gestation; birth weight 1969 +/- 129 g) and 19 normal pregnancies (34-37-weeks gestation; birth weight 3195 +/- 229 g). Umbilical artery Doppler ultrasound waveform measurements were expressed in terms of pulsatility index (PI). Biomagnetic signals (waveforms) recorded from the IUGR umbilical artery were expressed in terms of magnetic power spectral amplitudes.

RESULTS

In all cases, the frequency band considered was 2 to 7 Hz. The spectral amplitudes were low (mean: 117+/-24 fT/ radical Hz) in most (90.9%) IUGR pregnancies and high (mean: 224+/-37 fT/ radical Hz) in most normal pregnancies (89.5%). There was a statistically significant difference between normal and IUGR pregnancies with respect to spectral amplitudes (p < 0.0001), Doppler PI (p < 0.0005), pH (p < 0.0005) and Apgar score (p < 0.0005). Multiple linear regression analysis revealed an influence of PI, pH and Apgar scores on the biomagnetic values (ANOVA: p < 0.0005).

CONCLUSION

Our data imply that biomagnetic values of the umbilical artery flow could prove to be a helpful method for the evaluation of fetal well being especially in pregnancies complicated with preeclampsia and growth restriction.

Peritoneal cancer index: a prognostic indicator of survival in advanced ovarian cancer

AIM

The peritoneal cancer index (PCI) has been used for the detailed evaluation of the peritoneal spread in tumors of gastrointestinal origin and has been found to be a prognostic indicator of survival. The aim of this study was the identification of the significance of the peritoneal cancer index in advanced ovarian cancer.

METHODS

From 1990 to 2001, 60 women, mean age 65+/-10.84 (41-86), were treated for advanced ovarian cancer. The performance status (Karnofsky performance scale), age, prior surgery score (PSS), peritoneal cancer index (PCI), tumor volume, tumor grade, residual tumor, the presence of ascites, treatment with adjuvant chemotherapy, histopathologic subtype and FIGO stage were retrospectively correlated to survival using univariate model of statistical analysis.

RESULTS

Hospital mortality and morbidity were 11.7 and 16.7% respectively. The recurrence rate was 23.3%. Overall 5-year survival rate was 41% and mean survival 63+/-8 months. The peritoneal cancer index was related to survival (P=0.0253). The other favorable clinical prognostic indicators of survival were low grade and small volume tumors, treatment with adjuvant chemotherapy and complete cytoreductive surgery (P<0.05).

CONCLUSIONS

The peritoneal spread in advanced ovarian cancer can be assessed in detail using the peritoneal cancer index. It is a significant prognostic factor of survival and is useful in identifying subgroups.

Neonatal magnetoencephalography and spectral analysis

PURPOSE

We performed a prospective study of neonatal brain function on 44 respective term neonates who were delivered normally, without any clinical signs of brain damage. Thirty were associated with a normal pregnancy and labor with normal values of Apgar scores, umbilical cord pH and birth weight, while 14 neonates were the result of pre-eclamptic pregnancy.

METHODS-RESULTS

Biomagnetic measurements were performed by means of a Superconducting Quantum Interference Device (SQUID) in an electrically shielded room of low magnetic noise. Biomagnetic signals (waveforms) recorded from neonatal brains in the frequency range of 2-7 Hz were expressed in terms of magnetic power spectral amplitudes. These were low (mean value 163.2, SD 22.57) in almost all neonates from the "normal pregnancy" group, while they were high (mean value 211.6, SD 37.74) in most neonates from the "pre-eclamptic" group. The difference between the two groups was statistically significant (Student's t-test, p < 0.005).

CONCLUSION

A statistically significant difference in spectral amplitudes of neonatal brain activity was observed between normal term neonates and the pre-eclamptic neonates. Biomagnetic measurements of neonatal brain activity could provide clinical practice with a promising procedure for assessing brain function.

SQUID biomagnetometry of the uterine arteries in normal and pre-eclamptic pregnancies

AIM

This study was designed to investigate the hemodynamics of the uteroplacental circulation in normal and pre-eclamptic pregnancies using the biomagnetometer SQUID.

METHOD

Twenty-two pregnancies complicated by pre-eclampsia and 49 normal pregnancies were included in this study. All were near term. Biomagnetic signals were recorded from the uterine arteries. After statistical Fourier analysis, the findings were designated in terms of spectral amplitudes as high (140-300 fT/square root of Hz), low (50-110 fT/square root of Hz) and borderline (111-139 fT/square root of Hz).

RESULTS

The uterine artery waveforms and the corresponding spectral densities were of high amplitudes in most (89.7%) normal pregnancies and of low amplitudes in most (81.8%) pregnancies complicated by pre-eclampsia (p < 0.005). These findings were of statistical significance and were correlated with fetal heart rate (FHR) monitoring, pH, Apgar score at 1 and 5 minutes and birth weight percentiles: high amplitude cases were related with normal FHR patterns, pH > 7.25, Apgar score > 7 and birth weight > 75th percentile, while low amplitude recordings were connected with abnormal FHR patterns, pH < 7.25, Apgar score < 7, and birth weight < 10th percentile (8 cases) and < 50th percentile (10 cases).

CONCLUSION

Biomagnetic measurement of the uterine artery flow, is a promising procedure in assessing fetal health, especially in high-risk pregnancies.

Linear analysis of fetal magnetocardiogram recordings in normal pregnancies at various gestational ages

In this study we investigated the fetal magnetocardiogram recordings (FMCG) in 64 women, 21-30 years old, with single normal pregnancies and gestational ages 28-40 weeks. Spectral analysis was used to quantify heart rate variability and to identify the maturation of the autonomic nervous system. According to our results, there was an increase of the ratio LF/HF of the power spectrum, which reflects the maturation of the autonomous nervous system and also an increase in heart rate variability in the course of pregnancies, which was statistically significant (ANOVA test, P < 0.0005) comparing the R-R intervals of the number of cases in the four groups of 28-30, 37-40, 31-33 and 37-40 weeks of gestation. This study highlights some of the advantages of FMCG as a novel, non-invasive technique for obtaining useful clinical information.