Early Second Trimester Of Pregnancy Research Articles

An audit of pregnant women with prosthetic heart valves at a tertiary hospital in South Africa

Cardiac disease in pregnancy is a common problem in under-resourced countries and a significant cause of maternal morbidity and mortality. A large proportion of patients with cardiac disease have prosthetic mechanical heart valve replacements, warranting prophylactic anticoagulation. To evaluate obstetric outcomes in women with prosthetic heart valves in an under-resourced country. A retrospective chart review was performed of 61 pregnant patients with prosthetic valve prostheses referred to our tertiary hospital over a five-year period. Sixty-one (6%) of 1 021 pregnant women with A diagnosis of cardiac disease had prosthetic heart valves. Fifty-nine had mechanical valves and were on prophylactic anticoagulation therapy, three had stopped their medication prior to pregnancy and two had bioprosthetic valves. There were forty-one (67%) live births, two (3%) early neonatal deaths, 12 (20%) miscarriages and six (10%) stillbirths. Maternal complications included mitral valve thrombosis (n = 4), atrial fibrillation (n = 8), infective endocarditis (n = 6), caesarean section wound haematomas (n = 7), broad ligament haematoma (n = 1) and warfarin embryopathy (n = 4). Haemorrhagic complications occurred in five patients and all five required blood transfusions. Prophylactic anticoagulation with warfarin in patients with mechanical heart valve prostheses was associated with high rates of maternal and neonatal complications, including significant foetal wastage in the first and early second trimesters of pregnancy. Health professionals providing care for pregnant women with prosthetic heart valves must consistently advise on family planning matters, adherence to anticoagulation regimes and consider the use of prophylactic anticoagulant regimens other than warfarin, particularly during the first trimester of pregnancy.

Early childhood development when second-trimester ultrasound dating disagrees with last menstrual period: a prospective cohort study

BackgroundWhen an ultrasound-based estimate of gestational age (GA) is less (greater) than an estimate based on a definite last menstrual period, the fetus may grow slower (faster) than average. While the association between these discrepancies in GA estimates and adverse perinatal outcomes has been examined extensively, there is scant evidence about long-term effects, such as child neurodevelopment.MethodsUsing data from a prospective cohort study titled, NICHD Study of Successive Small-for-Gestational Age Births, we examined if GA discrepancies in early second trimester of pregnancy (17 weeks’ gestation) are associated with: (1) impaired motor and mental function at 13 months (measured using Bayley Scales of Infant Development (Bayley)), and (2) impaired cognitive development at five years (assessed by Wechsler Preschool and Primary Scale of Intelligence – Revised Intelligence Quotient (WPPSI-R)) in the infant. The study population consisted of 572 (30% of the overall sample of 1,945) women who presented for prenatal care in Norway and Sweden between 1986 and 1988.ResultsOur results showed that GA discrepancies in early second trimester are significantly associated with birthweight. We found no significant relationship, however, with the Bayley development scores at 13 months and with the WPPSI-R IQ measures at five years.ConclusionsGA discrepancies at 17 weeks’ gestation are not associated child neurodevelopment. These discrepancies do, however, relate to birthweights, providing a basis for detecting fetal growth patterns early in the second trimester of pregnancy. Our study, however, was unable to evaluate the impact of first-trimester discrepancies on impaired neurodevelopment in the infant.

The value of early second trimester PAPP-A and ADAM12 in screening for pre-eclampsia

To estimate the pre-eclampsia screening performance of PAPP-A (pregnancy-associated plasma protein-A) and ADAM12 (A Disintegrin And Metalloprotease 12) in the early second trimester of pregnancy. Stored frozen serum samples from a previously published nested case-control study comprising 77 women who developed pre-eclampsia and 224 unaffected controls were thawed and assayed for PAPP-A and ADAM12. Levels were converted into multiple of the unaffected median (MoM) values. Neither PAPP-A or ADAM12 were significantly different in women who developed pre-eclamspia compared with unaffected controls (PAPP-A: 0.97 MoM [95% confidence interval 0.73 to 1.25], ADAM12: 1.01 MoM [0.91 to 1.13]). Our results do not support the use of PAPP-A or ADAM12 in early second trimester antenatal screening for pre-eclampsia.

Comparison of Preliminary Clinical Efficacy for Two Cervical Preparations for Early Second-trimester Pregnancy Termination at 12-17 Weeks Gestation

Objective To compare clinical efficacy for two cervical preparations for early second-trimester pregnancy termination at 12-17 weeks gestation. Methods Seventy healthy women aged 18-41 years requesting legal termination of pregnancy at 12-17 weeks of gestation were equally randomized into two groups. Two cervical preparations, the Dilapan-S™ combined with mifepristone and misoprostol (DMM) method, and the mifepristone combined with misoprostol (MM) method, were used to end early second-trimester pregnancy for group DMM and group MM, respectively. Clinical outcomes and complications for these two methods were compared. Results No differences were found on rates of successful abortion within 48 h and blood loss after abortion at 2 h between the two groups (P>0.05). DMM group had significant shorter induction-to-abortion interval and hospital stay compared with group MM (P 0.05). Conclusion DMM method would have similar clinical efficacies with MM method for early second-trimester pregnancy termination. Besides, DMM method has shorter induction-to-abortion interval and hospital stay, which benefits its clinical application.

Laparoscopic Management of Placenta Increta after Late First-Trimester Dilation and Evacuation Manifesting as an Unusual Uterine Mass

Placenta increta is a rare and potentially life-threatening complication of pregnancy. The initial symptoms are generally vaginal bleeding during difficult placental removal in the third trimester. However, placenta increta may complicate first- and early second-trimester pregnancy loss. The diagnosis may be difficult during early pregnancy because the lesion is difficult to identify. Herein is reported the case of a woman with a diagnosis of placenta increta that caused prolonged bleeding after a late first-trimester abortion and manifested as an unusual lower segment uterine mass. Management included laparoscopy, and the placental tissue was completely removed successfully and uneventfully.

The Absence of the Vomer in the First and Early Second Trimester of Pregnancy – A New Marker of Trisomy 21 and Trisomy 13

The aim of this study was to measure the two frontomaxillo-facial (FMF) angles: the FMF-vomer (FMF-v) and the FMF-palate (FMF-p), and to visualize the vomer in the 1(st) and early 2(nd) trimester, in order to ascertain whether they can be used as markers for trisomy 21 and trisomy 13. A 2D ultrasound scan was performed in the 340 normal and 12 abnormal pregnancies, using the linear, convex and endovaginal probes. We visualized the FMF angles within 1 to 5 minutes in 253 (72 %) of cases by using the linear probe. FMF-v angle was significantly smaller that the FMF-p angle (79.8° vs. 89.7°, 71.5° vs. 84.5° for the two trimesters, respectively), and that the value of both angles decreased in the second trimester. There was not one single case of trisomy in which vomer could be identified in the 1 (st) and early 2 (nd) trimester. The FMF-p angle failed to present difference between normal cases and the ones with trisomy (89.5°). There was not one single case of trisomy (21 or 13) in which vomer or FMF-v could be identified in the first or early second trimester. The diagnostic accuracy of vomer as a marker for trisomy was 0.985. If the vomer cannot be visualized in the 1 (st) and early 2 (nd) trimester, it is important to check the karyotype, and it is not necessary to measure the FMF-p angle. The high resolution probe (L 12 - 5 Mhz) enables easier assessment of the vomer.

162 - Correlates of maternal cardiorespiratory fitness in the early second trimester of pregnancy

162 - Correlates of maternal cardiorespiratory fitness in the early second trimester of pregnancy

Fetal Demise Secondary to Massive Rhabdomyoma in the Early Second Trimester of Pregnancy

Rhabdomyoma is the most common cardiac tumor in fetuses, often associated with tuberous sclerosis complex and usually diagnosed in the third trimester of pregnancy, with a benign course in the majority of cases. The hemodynamic impact of cardiac tumor depends on the location and size of the mass and the presence of dysrhythmia (4). Fetal cardiac rhabdomyoma accounts for less than 10% of fetal demise cases (1). This report presents a case of massive cardiac rhabdomyoma filling the entire right heart with pericardial extension, leading to hydrops and subsequent fetal death in the early second trimester of pregnancy.

Defining the fetal cardiac axis between 11 + 0 and 14 + 6 weeks of gestation: experience with 100 consecutive pregnancies

The purpose of this study was to establish normal fetal cardiac axis values during the first and early second trimesters of pregnancy. This was a prospective observational cohort study in which the fetal cardiac axis was assessed during ultrasound examinations in 100 consecutive fetuses between 11 + 0 and 14 + 6 weeks of gestation. Transabdominal, and, when indicated, transvaginal, approaches were used. Intraobserver and interobserver reproducibility were calculated. The cardiac axis ranged from 34.5 to 56.8° (mean (SD) 47.6 ± 5.6°) in 94 fetuses with normal cardiac anatomy. The fetal cardiac axis tended to be significantly higher in fetuses at 11 + 0 to 11 + 6 weeks of gestation than in fetuses at 12 + 0 to 14 + 6 weeks of gestation. Congenital heart defects were found in six out of 100 fetuses, four of which had abnormal cardiac axis values at 11 + 0 to 14 + 6 weeks of gestation. Cardiac axis measurement is possible in the first and early second trimesters of pregnancy. The assessment of cardiac axis at an early gestational age may help to identify pregnancies at high risk for congenital heart defects. Copyright

Radical abdominal trachelectomy for stage IB1 cervical cancer at 15-week gestation

Objective The management of stage IB1 cervical cancer at 15 weeks pregnancy remains a significant challenge from both the oncologic and obstetrical standpoints. Abdominal trachelectomy has been recently described as a potential option in patients who have a very strong desire to attempt preservation of pregnancy and treat the cancer without delay. Case: A 37-year-old female, presented for prenatal care in the first trimester and was diagnosed with a FIGO stage IB1 poorly differentiated lymphoepithelioma like cervical cancer on conization. After extensive counseling she underwent a radical abdominal trachelectomy with pelvic lymphadenectomy and placement of permanent cerclage at 15 weeks gestation. Final trachelectomy pathology revealed 7/19 mm invasion with no lymphovascular invasion, negative margins and nodes. She successfully carried the pregnancy to 39 weeks gestation and delivered a healthy female infant by elective planned cesarean hysterectomy. The patient remains without evidence of disease at the time of this report. Conclusion Recent advances in fertility-sparing surgery for stage IB1 cervical cancer lead to the successful utilization of radical abdominal trachelectomy during the early second trimester of pregnancy. This approach in early gestation is feasible and resulted in a favorable oncologic and obstetrical outcome. Radical trachelectomy may broaden the treatment options for pregnant women with stage IB1 cervical cancer who have a strong desire to avoid definitive pregnancy termination and commence treatment without delay.

Plasma level of soluble c-Met is tightly associated with the clinical risk of preeclampsia

The objective of the study was to examine the relevance of the soluble form c-Met (sMet) with the clinical risk for severe preeclampsia. This prospective case-control study was performed by using plasma derived from 44 preeclamptic and 51 uncomplicated pregnant women. Plasma concentration of sMet was measured with specific enzyme-linked immunosorbent assay, and the predictive values were determined based on the receiver-operating characteristic (ROC) curves analysis. Plasma s-Met level in normal pregnant women changed in a gestation-dependent manner, peaking at weeks 19-24. In women with severe preeclampsia, the circulating sMet level was significantly lower than that in the gestational stage-matched controls during gestational weeks 15-30. The ROC curve analysis revealed a significant correlation between plasma sMet level and the risk of developing severe preeclampsia. Plasma sMet could serve as a potential biomarker for predicting severe preeclampia at early second trimester of pregnancy.

P15.16: Sonographic measurements of fetal nuchal fold, cerebellum and cisterna magna, in normal fetuses at the early second trimester of pregnancy

In an effort to determine the normal sizes and relationships between the cranial structures, we measured the nuchal fold (NF), transverse cerebellar diameter (TCD), and cisterna magna (CM) in normal fetuses in the early second trimester of pregnancy using transvaginal sonography. In this prospective study of uncomplicated pregnancies, the CM NF and TCD were measured. This was a part of early screening of malformation. The examination was preformed between 14–16 weeks' gestation. The TCD and the anteroposterior (AP) diameter of the CM and the NF were measured on the transcerebellar plane. In addition, we measured the biparietal diameters (BPDs). 197 parturient were evaluated. The mean age of the women was 33.28 ± 4.2 years (range, 18–38 years), and the mean gestational age of the fetuses was 15.01 ± 0.43 weeks (range, 14.14–16 weeks). The mean BPD was 29.01 ± 18.7 mm (range, 30–96 mm). The mean diameters of the CM and NF were 2.55 ± 1.63 mm, 2.03 ± 0.52 mm respectively, no correlation was found between the week and CM or NF (r = 0.05, p = 0.41), (r = − 0.03, p = 0.62) respectively. The mean TCD was 14.14 ± 1.22 mm and positively correlated with gestational week (r = 0.4, p < 0.0001). In normal fetuses, the cerebellum, NF and CM should be measured by ultrasound examination between 14 and 16 weeks' menstrual age. Because abnormalities in these cranial structures may be indicative of central nervous system malformations, the availability of mean sonographic measurements from normal fetuses should be helpful in determining the need for additional testing in fetuses with abnormal measurements.

OP28.06: Fetal cardiac axis in the first and early second trimester of pregnancy

OP28.06: Fetal cardiac axis in the first and early second trimester of pregnancy

Feasibility and accuracy of fetal echocardiography using four‐dimensional spatiotemporal image correlation technology before 16 weeks' gestation

To evaluate the potential value of early fetal echocardiography (EFE) by means of four-dimensional (4D) spatiotemporal image correlation (STIC) technology for either reassurance of normality or prenatal diagnosis of major congenital heart defects (CHDs). Sixty-nine pregnant women from 11 to 15 weeks' gestation underwent EFE. 4D-STIC volumes were acquired by the transvaginal approach for later review by two different examiners. STIC evaluation was considered complete when the four-chamber view, and the origin and double-crossing of the great arteries were identified correctly. Color Doppler imaging was used to detect either septal shunts or transvalvular regurgitation/aliasing suggesting abnormalities. STIC diagnoses were compared with those of conventional EFE. Reliability was assessed by postnatal examination, or autopsy in cases of termination of pregnancy or perinatal death. The median gestational age at volume acquisition was 13 + 3 weeks. Eleven (15.9%) cases of CHD were diagnosed. A complete EFE was possible in 64 cases. We were able to provide reassurance of normality in 51 of the 53 confirmed normal hearts, with no false-positive results for major defects, although two minor defects (one ventricular septal defect (VSD) and one persistent left superior vena cava) were falsely suspected. The only false negative was a significant VSD at birth overlooked by both observers. Therefore, the total accuracy of STIC-EFE was 95.3% (61/64), with sensitivity, specificity, and positive and negative predictive values of 90.9%, 96.2%, 83.3% and 98.1%. The accuracy of conventional EFE (98.4%, 63/64) was slightly better than that of STIC, with no false-positive results recorded. Offline evaluation of 4D-STIC acquired volumes of the fetal heart in the first and early second trimester of pregnancy is reliable not only for early reassurance of normal cardiac anatomy but also to diagnose most major structural heart defects.

Antenatal screening for Down's syndrome using the Integrated test at two London hospitals

We carried out an audit of antenatal screening for Down's syndrome using the Integrated test (which provides a single screening result from information collected in the late first and early second trimesters of pregnancy) which was introduced into routine antenatal care at two London hospitals, University College Hospital (UCH) and St Mary's Hospital, in 2003-4. The audit was based on 15,888 women who accepted screening and booked in the first trimester. The Down's syndrome detection rate was 87% (95% confidence interval [CI], 74-95) consistent with an expected detection rate of 89% based on applying the estimates of screening performance of the Serum, Urine and Ultrasound Screening Study (SURUSS) to the maternal age distribution of women who were screened at UCH and St Mary's. The observed false-positive rate was 2.1% (95% CI, 1.9-2.3), compared with an expected of 2.5% for women of the same age. An audit trail (conducted at UCH) indicated that 98% (10,746/10,961) of women accepted integrated screening (2% having a first trimester test) and of these, 94% (10,116) completed both stages of the test. The audit demonstrated that it is feasible to conduct integrated screening within the NHS with a high acceptance rate and a screening performance consistent with that determined from previous research studies.

Leisure Time Physical Activity is Associated With a Reduced Risk of Preterm Delivery

OBJECTIVE: This study was undertaken to study the association between the times spent on sports activities and leisure time physical activity in the first and early second trimester of pregnancy and the risk of preterm delivery. STUDY DESIGN: Population-based follow-up study of 5749 healthy pregnant women who delivered in Aarhus University Hospital, Denmark. RESULTS: Women who practiced more than 1 type of sports had a significantly reduced adjusted risk (odds ratio = 0.09 95% CI, 0.01-0.66) of preterm delivery compared with women with no sports activity. Compared with sedentary pregnant women, women engaged in light leisure time physical activity had a 24% nonsignificantly reduced adjusted risk (odds ratio = 0.76, 95% CI, 0.60-1.02) of preterm delivery and those engaged in moderate-to-heavy leisure time activity had a 66% reduced adjusted risk (odds ratio = 0.34, 95% CI, 0.14-0.85). CONCLUSION: Moderate-to-heavy leisure time physical activity during pregnancy is associated with a significantly reduced risk of preterm delivery.

Association of Prenatal and Childhood Blood Lead Concentrations with Criminal Arrests in Early Adulthood

BackgroundChildhood lead exposure is a purported risk factor for antisocial behavior, but prior studies either relied on indirect measures of exposure or did not follow participants into adulthood to examine the relationship between lead exposure and criminal activity in young adults. The objective of this study was to determine if prenatal and childhood blood lead concentrations are associated with arrests for criminal offenses.Methods and FindingsPregnant women were recruited from four prenatal clinics in Cincinnati, Ohio if they resided in areas of the city with a high concentration of older, lead-contaminated housing. We studied 250 individuals, 19 to 24 y of age, out of 376 children who were recruited at birth between 1979 and 1984. Prenatal maternal blood lead concentrations were measured during the first or early second trimester of pregnancy. Childhood blood lead concentrations were measured on a quarterly and biannual basis through 6.5 y. Study participants were examined at an inner-city pediatric clinic and the Cincinnati Children's Hospital Medical Center in Cincinnati, Ohio. Total arrests and arrests for offenses involving violence were collected from official Hamilton County, Ohio criminal justice records. Main outcomes were the covariate-adjusted rate ratios (RR) for total arrests and arrests for violent crimes associated with each 5 μg/dl (0.24 μmol/l) increase in blood lead concentration. Adjusted total arrest rates were greater for each 5 μg/dl (0.24 μmol/l) increase in blood lead concentration: RR = 1.40 (95% confidence interval [CI] 1.07–1.85) for prenatal blood lead, 1.07 (95% CI 0.88–1.29) for average childhood blood lead, and 1.27 (95% CI 1.03–1.57) for 6-year blood lead. Adjusted arrest rates for violent crimes were also greater for each 5 μg/dl increase in blood lead: RR = 1.34 (95% CI 0.88–2.03) for prenatal blood lead, 1.30 (95% CI 1.03–1.64) for average childhood blood lead, and 1.48 (95% CI 1.15–1.89) for 6-year blood lead.ConclusionsPrenatal and postnatal blood lead concentrations are associated with higher rates of total arrests and/or arrests for offenses involving violence. This is the first prospective study to demonstrate an association between developmental exposure to lead and adult criminal behavior.

The Influence of Gestational Stage on Urinary Iodine Excretion in Pregnancy

Median urinary iodine concentration (UIC) is the most commonly used indicator of population iodine nutrition. However, its validity as an indicator of dietary intake relies on a stable relationship between dietary iodine intake and urinary excretion. Physiological alterations in normal pregnancy, such as increased glomerular filtration rate, potentially invalidate UIC as an assessment tool in pregnancy. The objective of the study was to document the impact of advancing gestation on UIC in normal pregnancy and determine whether the current reference intervals for general population iodine monitoring are appropriate for use in the context of pregnancy. Tasmania has a well-described history of mild iodine deficiency (school-age median UIC of 84 microg/liter). We assessed UIC in 759 urine samples from 431 women attending the Antenatal Clinic at the Royal Hobart Hospital, Tasmania's primary teaching hospital. The overall median UIC during pregnancy was 75 microg/liter (95% confidence interval 70.03-79.97 microg/liter) at a median gestation of 19.4 wk. Stratification by gestation, however, revealed a dynamic relationship between ioduria and gestation. Median UIC was elevated in early pregnancy and subsequently declined with advancing gestation. In this mildly iodine-deficient population, current reference intervals for UIC overestimated the adequacy of iodine nutrition during the first and early second trimester of pregnancy. Gestation-specific UIC reference intervals are required to classify iodine nutrition during pregnancy. This is particularly important in populations with borderline iodine deficiency.

Leisure time physical activity is associated with a reduced risk of preterm delivery

This study was undertaken to study the association between the times spent on sports activities and leisure time physical activity in the first and early second trimester of pregnancy and the risk of preterm delivery. Population-based follow-up study of 5749 healthy pregnant women who delivered in Aarhus University Hospital, Denmark. Women who practiced more than 1 type of sports had a significantly reduced adjusted risk (odds ratio = 0.09 95% CI, 0.01-0.66) of preterm delivery compared with women with no sports activity. Compared with sedentary pregnant women, women engaged in light leisure time physical activity had a 24% nonsignificantly reduced adjusted risk (odds ratio = 0.76, 95% CI, 0.60-1.02) of preterm delivery and those engaged in moderate-to-heavy leisure time activity had a 66% reduced adjusted risk (odds ratio = 0.34, 95% CI, 0.14-0.85). Moderate-to-heavy leisure time physical activity during pregnancy is associated with a significantly reduced risk of preterm delivery.

Reply

We appreciate Dr Welsh's interest and remarks on our recent study on three-dimensional (3D) ultrasound- and power Doppler-assessed placental vascularity in first-trimester normal and aneuploid fetuses1. Although we agree that caution is necessary in interpreting ‘numerical values derived for flow’ including when, as in the case of our study, an identical ultrasound machine setting is used for all patients, we would like to comment briefly on the two main issues raised by Dr Welsh, namely, the influence of placental position and the number of placental sections analyzed. In evaluating our data we were aware of the possible effects of placental position on the attenuation of power Doppler signals. However, when we analyzed placental vascularization in the 100 control pregnancies, we found, as shown here in Figure 1, no relationship between placental position and the distribution of the vascular indices. This suggests that, at least at 11 + 0 to 13 + 6 weeks, it is not necessary to standardize the vascular measures for placental position. Of course, this may be different later in gestation, or when fetal organs are analyzed, two situations in which the effects of beam path should be taken into account. Distribution of placental vascularization values (vascularization index (VI), flow index (FI) and vascularization flow index (VFI)) in 100 pregnancies with euploid fetuses (control group of Rizzo et al.1) according to placental position (anterior, n = 29; posterior, n = 27; lateral, n = 44). Analysis of variance did not indicate significant differences for the vascular indices tested. We further tested the effect of varying the number of placental sections by analyzing 20 consecutive placental volumes in which the vascular indices were calculated on a sequence of 12, 20 and 30 sections, obtained after rotations from the previous section of 15°, 9° and 6°, respectively (Figure 2). Since analysis of variance for repeated measurements did not show significant differences between the three methods, we chose the one using the fewest sections in order to reduce the time required for analysis. Effects of the number of placental sections performed (12, 20 or 30) on the calculation of vascular indices in 20 placental volumes. Individual values are connected by lines. There were no significant differences when analysis of variance for repeated measurements was applied. the evidence found in our study of an increase in placental vascularity with advancing gestation consistent with histological data as shown by a progressive increase in placental flow indices during the early second trimester of pregnancy; the lower vascularization values found in the placenta of trisomy 13 and trisomy 18 fetuses, syndromes characterized by decreased vascularization and trophoblastic hypoplasia; recent data from other groups2 showing that the prognostic value of VOCAL-assessed lung vascularity in fetuses with diaphragmatic hernia is higher compared with that of conventional two-dimensional (2D) and 3D sonographic parameters. With all due respect to the fine work of Dr Welsh and other groups3, 4, we found their approach difficult to apply in clinical practice. We are therefore inclined to continue following our technique until internal standardizing methods become available. G. Rizzo*, D. Arduini*, * Department of Obstetrics and Gynecology, Università Roma Tor Vergata, Roma, Italy