-
Ultrasound in Obstetrics and Gynecology 09/2009; 34(3):245-6. · 3.01 Impact Factor
-
Ultrasound in Obstetrics and Gynecology 02/2009; 33(2):131-2. · 3.01 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Peri-viability, 22-26 completed weeks' gestational age, has generated ongoing clinical ethical controversies concerning the roles of abortion, caesarean delivery for fetal indication, neonatal resuscitation and limits on life-sustaining treatment of neonates. This paper provides a comprehensive, ethically justified approach to the clinical management of peri-viable fetuses and infants. We reviewed available data about the outcomes of peri-viable fetuses and developed an outcomes-based ethical framework that appeals to the ethical principles of beneficence, autonomy and justice. We identified beneficence-based, autonomy-based and justice-based considerations that should guide clinical judgement, the informed consent process, and decisions about termination of pregnancy, caesarean delivery and setting justified limits on life-sustaining treatment of neonatal patients. Ethics is an essential component of perinatal medicine because it provides physicians with an evidence-based, ethically justified, comprehensive approach to the gynaecological, obstetric, perinatal and neonatal dimensions of peri-viability.
Journal of Obstetrics and Gynaecology 02/2007; 27(1):3-7. · 0.54 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To evaluate whether a relationship exists between the antenatal umbilical coiling index (UCI) and umbilical cord Doppler flow characteristics.
During the fetal anatomical survey in 200 consecutive pregnant patients at 18-23 weeks' gestation, we recorded umbilical coiling patterns and blood flow characteristics. The antenatal UCI, calculated as a reciprocal value of the distance between a pair of umbilical cord coils, was compared with Doppler parameters including umbilical vein blood flow volume (in mL/min/kg), and mean resistance index (RI) and peak systolic velocity (PSV in cm/s) averaged from both umbilical arteries.
A total of 154 patients met the inclusion criteria of singleton pregnancy and having adequate sonographic umbilical cord images, Doppler flow indices, and all demographic, antenatal and labor data. The mean antenatal UCI was 0.40, with 10th and 90th centiles of 0.20 and 0.60, respectively. The mean +/- SD umbilical artery RI and PSV and umbilical vein blood flow volume were 0.74 +/- 0.07, 25.1 +/- 6.4 cm/s, and 264 +/- 106 mL/min/kg, respectively. All Doppler variables correlated significantly with antenatal UCI, with lower RI and higher PSV and umbilical vein blood flow volume values being associated with higher antenatal UCI (P = 0.016, P < 0.001, and P = 0.032, respectively). However, when stratified by antenatal UCI into hyper- (above 90th centile), normo- (10th-90th centile), and hypocoiled (below 10th centile) umbilical cord groups, a significant difference was observed for PSV only (P = 0.016).
It appears that umbilical cord coiling modulates noticeably blood flow through the umbilical cord. We speculate that more prominent umbilical coiling (higher antenatal UCI values) has a protective effect on blood flow in terms of decreased arterial resistance and higher blood flow velocities, as well as increased venous blood flow. However, due to lack of significant differences between Doppler characteristics when stratified by antenatal UCI into hypo-, normo-, and hypercoiled groups, the clinical implications of this observation are uncertain.
Ultrasound in Obstetrics and Gynecology 11/2006; 28(5):699-703. · 3.01 Impact Factor
-
Ultrasound in Obstetrics and Gynecology 08/2006; 28(1):1-4. · 3.01 Impact Factor
-
The Lancet 04/2006; 367(9514):883-5. · 38.28 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To assess the intra- and interobserver reproducibility of ultrasound measurements of fetal biometric parameters.
We assessed the intraobserver and the interobserver agreement in measurements of fetal biparietal diameter (BPD), abdominal circumference (AC), head circumference (HC) and femur length (FL) on 122 singleton pregnancies. Patients were each examined twice by the first sonographer to determine the intraobserver reliability of measurements of fetal biometry. Subsequently, during the same ultrasound examination, a second blinded sonographer measured fetal biometric parameters to assess interobserver reliability. The consensus between and among observers was analyzed using the intraclass correlation coefficient (intra-CC) and interclass correlation coefficient (inter-CC) and the reliability coefficients (RC, alpha) for the four biometric measurements. A value > 0.75 was considered a reliable consensus for the intra-CC and inter-CC. A Bland and Altman plot was also created for the fetal biometric parameters to assess the repeatability of the measurements.
Reliable consensus was observed for both the intra-CC and inter-CC and RC for all four biometric parameters. The intra-CC with the 95% CI and RC for the BPD, AC, HC and FL were as follows: 0.996 (0.995, 0.997), alpha 0.998; 0.994 (0.992, 0.996), alpha 0.997; 0.996 (0.994, 0.997), alpha 0.998; and 0.994 (0.992, 0.996), alpha 0.997, respectively. Similarly, the inter-CC with the 95% CI and RC for the same parameters were as follows: 0.995 (0.993, 0.997), alpha 0.998; 0.980 (0.971, 0.990), alpha 0.990; 0.994 (0.992, 0.996), alpha 0.997; and 0.990 (0.985,0.993), alpha 0.995, respectively. The Bland and Altman plots demonstrated a high degree of repeatability of BPD, AC, HC, and FL measurements.
Our results demonstrate that the intra- and interobserver reproducibility of ultrasound measurements of fetal biometry are highly reliable.
Ultrasound in Obstetrics and Gynecology 12/2004; 24(6):654-8. · 3.01 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To examine the detection rate of chromosomal abnormalities using a combination of nuchal translucency (NT) and maternal age in a United States population.
A total of 2131 pregnancies with 2339 fetuses underwent NT screening from April 2000 to April 2002 in our ultrasound unit. Nuchal translucency was measured from 11 to 14 weeks' gestation. Fetal crown-rump length (CRL) was also measured. The risk for trisomy 21 was calculated from a combination of maternal age and fetal NT with the use of software provided by The Fetal Medicine Foundation (FMF). Sensitivity and false-positive rates were calculated for different risk cut-offs.
Chromosomal defects were diagnosed in 32 cases, including 12 cases of trisomy 21 and 10 cases of trisomy 18. The estimated risk based on maternal age and fetal NT was 1 in 300 or greater in 195 (8.3%) cases and these included 10/12 (83.3%) pregnancies with trisomy 21 and 9/10 (90.0%) pregnancies with trisomy 18.
A combination of maternal age and fetal NT provides an effective method of screening for chromosomal defects. Using ultrasound techniques and risk algorithms from The FMF, the performance of the test in an American population is similar to that described in international populations.
Ultrasound in Obstetrics and Gynecology 09/2003; 22(2):149-51. · 3.01 Impact Factor
-
Ultrasound in Obstetrics and Gynecology 02/2003; 21(1):97-8. · 3.01 Impact Factor
-
Journal of ultrasound in medicine: official journal of the American Institute of Ultrasound in Medicine 12/2001; 20(11):1147-52. · 1.25 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The purpose of this study was to determine the incidence of cystic fibrosis, aneuploidy, and intrauterine infection with toxoplasmosis and cytomegalovirus in second-trimester fetuses with the sonographic finding of echogenic bowel.
All cases of echogenic bowel that were diagnosed in our ultrasound unit from 1993 to 2000 were identified. Only cases in which bowel echogenicity was as bright as bone with no associated major fetal anomalies were included. Patients who were referred from other hospitals were excluded. Echogenicity was classified as focal or multifocal. Fetal karyotypes, cystic fibrosis carrier testing, and maternal serologic test results were determined.
One hundred seventy-five fetuses in 171 pregnancies met inclusion criteria. Cystic fibrosis mutations were identified in 7 of 138 mothers (5%) and 9 of 86 fathers (10.5%) who were tested. Five fetuses were affected with cystic fibrosis. Fetal karyotype was obtained in 139 cases, and autosomal trisomy was diagnosed in 5 cases (3.6%). One hundred sixty-six patients were tested for toxoplasmosis, and 111 patients were tested for cytomegalovirus. There were no cases of congenital toxoplasmosis. There was maternal serologic and fetal pathologic evidence of cytomegalovirus infection in 1 case. In all cases of cystic fibrosis and aneuploidy, echogenicity was multifocal; in the case of cytomegalovirus, echogenicity was focal.
In our population, mid-trimester fetal echogenic bowel was associated with a high prevalence of cystic fibrosis, aneuploidy, and cytomegalovirus (11/175 fetuses [6.3%]). This information should be considered when counseling patients after mid-trimester echogenic bowel is diagnosed.
American Journal of Obstetrics and Gynecology 12/2001; 185(5):1035-8. · 3.47 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The purpose of this study was to determine risk factors associated with intrauterine fetal demise in fetuses with unexplained echogenic bowel that is diagnosed in the second trimester.
A retrospective case-control study compared fetuses with echogenic bowel and fetal demise with fetuses with echogenic bowel who were live born. Fetuses affected with cystic fibrosis, aneuploidy, or congenital infection and fetuses diagnosed with major anomalies were excluded. Variables examined in the determination of risk factors for intrauterine fetal demise included intrauterine growth restriction, oligohydramnios, elevated maternal serum alpha-fetoprotein levels, and elevated maternal serum beta-hCG levels. Statistical analysis was performed with the Fisher exact test, Student t test, and logistic regression analysis.
One hundred fifty-six fetuses met the inclusion criteria. There were 9 cases of intrauterine fetal demise and 147 live born control fetuses. The median gestational age of intrauterine fetal demise was 22.0 weeks (range, 17-39 weeks). Intrauterine growth restriction occurred more frequently in cases of intrauterine fetal demise than in live born infants (22.2% vs 0.7%; P =.009), as did oligohydramnios (44.4% vs 2.0%; P <.001) and elevated maternal serum alpha-fetoprotein levels (80.0% vs 7.7%; P: =.001). With the use of logistic regression analysis, elevated maternal serum alpha-fetoprotein was the strongest independent risk factor that was associated with intrauterine fetal demise (odds ratio, 39.48; 95% CI, 11.04%-141.25%).
In our series, there was a 5.8% incidence of intrauterine fetal demise in fetuses with unexplained echogenic bowel. Elevated maternal serum alpha-fetoprotein is the strongest predictor of fetal demise in fetal echogenic bowel.
American Journal of Obstetrics and Gynecology 12/2001; 185(5):1039-43. · 3.47 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Destructive procedures to permit vaginal delivery of the fetus with hydrocephalus are rarely performed.
We performed intrapartum cephalocentesis in 3 cases in which alobar holoprosencephaly was diagnosed in the third trimester.
All 3 fetuses were stillborn. Two delivered vaginally, and one delivered abdominally with a lower uterine incision.
A reappraisal of the proper role of cephalocentesis in modern obstetrics is offered.
American Journal of Obstetrics and Gynecology 10/2001; 185(3):734-6. · 3.47 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Little data is available correlating the in utero order of presentation and the birth order of twins. Our objective was to determine whether birth order in twin pregnancies corresponds to the order of presentation early in pregnancy. All twin pregnancies in which amniocentesis was performed from 1996 to 1998 were identified. Those with discordant genders that delivered at our hospital were included. Order of presentation was documented by ultrasound at the time of amniocentesis. Delivery data were obtained from review of medical records. Statistical comparison was done using two-tailed Fisher's exact test, Student's t-test, and Mann-Whitney U test. Sixty patients met inclusion criteria. Birth order corresponded to the order at the time of amniocentesis in 55 of 60 cases (91.7%). There was no difference in the rate of concordance of prenatal and neonatal birth order in twins delivered vaginally compared with those delivered abdominally (90.9 vs. 91.8%, p = 1.0). Cases with discordant prenatal and neonatal birth order had similar maternal ages, gestational ages at amniocentesis and delivery, and fetal presentation at delivery as cases with concordant birth orders. In dichorionic twin pregnancies, birth order is established early in gestation in >90% of cases regardless of route of delivery.
American Journal of Perinatology 05/2001; 18(3):151-4. · 1.32 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Leadership in medicine, as in other settings, should be based on values that provide appropriate direction for the use of institutional power and authority. Leadership also requires managerial competence. Managerial knowledge and skills can be used for worthy and unworthy goals and therefore require a moral foundation. Using the methods of ethics, we argue that the concept of the physician as the moral fiduciary of the patient should be the moral foundation of management decisions by physician-leaders. We take this concept from the history of eighteenth century medical ethics and develop it in terms of four professional virtues--self-effacement, self-sacrifice, compassion, and integrity. We apply these four virtues to show how physician-leaders should create a moral culture of professionalism in health care organizations. We then identify four vices--unwarranted bias, primacy of self-interest, hard-heartedness, and corruption--that undermine this moral culture of professionalism. Because health care organizations now play a central role in patient care, their moral culture and therefore physician-leaders have become vital elements in physicians being able to maintain their professionalism. Physician-leaders bear major responsibility to shape organizational cultures that support the fiduciary professionalism of physicians.
American Journal of Obstetrics and Gynecology 05/2001; 184(5):875-9; discussion 879-80. · 3.47 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The purpose of this study is to evaluate the outcome of infants born between 23 and 28 completed weeks of gestational age for whom aggressive obstetric management was performed.
Prenatal data were collected retrospectively from medical records. Neonatal mortality, early morbidity, and the outcome at one year corrected for postconceptional age (corrected age) were determined.
Ninety-seven infants were included in the study. Serious early morbidity decreased with increasing gestational age. All the infants born prior to 24 weeks showed serious early morbidity: only 26% of the infants born at 24 weeks or later did. There was a significant decline in mortality with increasing gestational age, as there was also in birth weight (p<0.001, p<0.001). Sixty-seven percent of the infants prior to 24 weeks showed disability at one year corrected age whereas only 13% at 24 weeks or older did. The likelihood of having a surviving child without disability was 12.5% at 23 weeks, 39% at 24 weeks, 50% at 25 weeks, 52% at 26 weeks, and 70% at 27 weeks.
Viability of fetuses at 23 and 24 weeks of gestation remains ethically and clinically controversial. It cannot be reliably established at that time that there is a fair balance of clinical goods over harms for the survivor at 23 weeks. On the other hand we should continue to treat fetuses at 24 weeks as viable, because 50% of them survived and 78% of those survived without disability. Neonatal mortality and survival with disability further decreases with increasing gestational age.
Acta Obstetricia Et Gynecologica Scandinavica 02/2001; 80(2):120-5. · 1.77 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: We evaluated the timing of twin delivery associated with perinatal outcome in gestations of at least 36 completed weeks.
This was a retrospective analysis of infant and maternal hospital records for a consecutive series of twin deliveries at New York Hospital-Cornell Medical Center. The inclusion criteria were delivery after 36 weeks' gestation during a 7-year period (1987 to 1993), without congenital anomalies or early fetal demise. Adverse perinatal outcomes were compared between deliveries before 38 weeks' gestational age and those at or after 38 weeks' gestation.
Of 776 twin deliveries during the study period, 329 met the inclusion criteria. Adverse perinatal outcome was significantly higher among the twin pregnancies that delivered before 38 weeks' gestation compared with those that delivered at or after 38 weeks' gestation. Twin pregnancies that delivered between 36 and 37 weeks' gestation were 13 times more likely to require neonatal intensive care compared with those who delivered at or after 38 weeks' gestation (95% confidence interval 1.8 to 95.9; p < 0.001).
In uncomplicated twin gestations, delivery at between 36 and 37 weeks' gestation was not associated with a reduction in neonatal complications compared with deliveries at or after 38 weeks' gestation.
Journal of Perinatology 07/2000; 20(4):231-4. · 1.80 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This review explores some of the implications for a balanced approach to the ethics of maternal participation in clinical research, from the perspective of the fetus as a patient, which is a central concept in obstetric ethics. The review therefore begins with an account of this topic, followed by an examination of some of its ethical implications for a balanced approach to the ethics of clinical research that involves pregnant women.
Current Opinion in Obstetrics and Gynecology 01/2000; 11(6):549-51. · 2.38 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: In this chapter we provide an overview of current ethical issues in fetal medicine. We begin with an introduction to the language and concepts of ethics. We then show how ethical principles can be applied to fetal medicine. In this part of the chapter we introduce the concept of the fetus as a patient and explain its implications for directive versus non-directive counselling. We then take up two current clinical controversies, routine obstetric ultrasound and termination of third trimester pregnancy.
Bailliè re s Best Practice and Research in Clinical Obstetrics and Gynaecology 01/2000; 13(4):491-502. · 1.73 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The objective of this study was to evaluate the risk of neonatal respiratory disorders when cesarean delivery is performed before labor in twin pregnancies.
We reviewed the charts of all patients with twin pregnancies who underwent cesarean delivery before labor after 36 weeks' gestation. All cases in which delivery was done for a clear maternal or fetal indication were excluded. Neonatal respiratory disorders included transient tachypnea of the newborn and respiratory distress syndrome.
Delivery was performed between 36 weeks' and 37 weeks 6 days' gestation in 79 patients (62.7%) and between 38 weeks' and 40 weeks 2 days' gestation in 47 patients (37.3%). Respiratory disorders were diagnosed in 15 neonates from 11 pregnancies. Pregnancies in which one or both neonates were diagnosed with respiratory disorders were more likely to have been delivered before 38 weeks' gestation (90.9% vs 60.0%; P =.04) and were more likely to have been conceived spontaneously (54.5% vs 21.7%; P =.03) than those pregnancies with no affected neonates.
Neonatal respiratory disorders are more common in twin pregnancies with cesarean delivery performed before labor before 38 weeks' gestation. Without a clear indication for delivery, waiting until labor or until after 38 weeks' gestation should be considered.
American Journal of Obstetrics and Gynecology 12/1999; 181(5 Pt 1):1052-6. · 3.47 Impact Factor
