Procedure-related Pregnancy Loss Research Articles

A Multi-centre Experience of Trans-abdominal Chorionic Villus Sampling in Pakistan.

To determine the safety and outcomes of trans-abdominal chorionic villus sampling technique. Observational study. Departments of Obstetrics and Gynaecology, PNS Shifa Karachi, Pak-Emirates Military Hospital Rawalpindi and CMH Lahore, from 2005-2020. Methodology: A total of 1530 consecutive chorionic villus samplings (CVS) were performed on pregnant females between 10-20 weeks of gestation using the transabdominal approach. Patients were subjected to integrated, stepwise sequential screening. Analysis of data was based on demographic features, indications for sampling, gestational age, attempts of CVS, needle aspiration time, assessment, placental location, sample yield, complications, pain estimation by visual analogue scale (VAS), CVS culture results and pregnancy outcomes. The most common indication for CVS was couple having thalassemia traits and history of having a thalassemia major child previously (55.2%). Pain was the most common complication (64.1%). Procedure-related pregnancy loss (considered to be till 20 weeks of gestation) was observed in two cases (0.1%) only. The most common abnormal karyotype was found to be β-Thalassemia trait (23.6%) followed by β-Thalassemia major (22.1%) and Trisomy 21(16.8%). No abnormality was detected in 33.5% of the cases. Five hundred and eighty-nine (38.4%) interruptions of pregnancies were done on the basis of CVS results. CVS is a safe and useful technique for sampling in prenatal diagnosis of genetic disorders, markedly affecting the management. Chorionic villus sampling, Pre-natal diagnosis, Karyotype.

Transabdominal fetal reduction: a report of 124 cases

To prevent fetal loss, preterm delivery, and perinatal morbidity of multifetal pregnancies (MPs), fetal reduction (FR) is offered to some patients. We retrospectively analysed the data of 124 MPs that underwent transabdominal FR to twin (n = 63) and singleton (n = 61) pregnancies at a mean gestational age of 12 + 6 weeks between December 2006 and January 2018. FR was performed transabdominally with the injection of potassium chloride into the intracardiac or intrathoracic space of the fetus or fetuses after ultrasound screening for nuchal translucency and anatomical defects. The initial number of embryos were 48 twins, 63 triplets, 11 quadruplets, and 2 quintuplets. The procedure-related pregnancy loss rate was 0.8% (1/124), the overall pregnancy loss rate was 2.4% (3/124), the fetal loss rate was 1.6% (2/124), and the neonatal death rate was 0.8% (1/124). The baby take-home rates were 96% for twin pregnancies and 96.7% for singletons. This study shows that transabdominal FR is an effective and safe procedure with a pregnancy loss rate of 2.4%. Impact statement What is already known on this subject? The incidence of multifetal pregnancies has increased over the years. Because multifetal pregnancies increase perinatal morbidity and mortality due to prematurity, fetal reduction is offed to some patients. What the results of this study add? The results of this study add to the growing body of research on fetal reduction. The study showed that transabdominal fetal reduction is a safe procedure with a pregnancy loss rate of 2.4%. What the implications are of these findings for clinical practice and/or further research? The results of this study can be used in counselling couples with multifetal pregnancies who are considering fetal reduction. Further research is needed to confirm the current findings.

Trials and tribulations of meta-analyzing procedure-related risks of amniocentesis and chorionic villus sampling.

Trials and tribulations of meta-analyzing procedure-related risks of amniocentesis and chorionic villus sampling.

920: Microsoft Excel-based decision analysis to determine the cost effectiveness of fetal aneuploidy screening

Decision analysis is a powerful tool in determining the cost effectiveness of medical interventions. However, such analyses require access to expensive and unintuitive software. As a proof of concept, we attempt to use Microsoft Excel—a more widely used program—to analyze the cost effectiveness of aneuploidy screenings. Though both sequential screening and cell free DNA (cfDNA) testing are widely offered in the clinic, various professional organizations disagree on which method is better suited for younger, low-risk populations. This issue is further complicated by inconsistent insurance coverage for cfDNA tests and low-risk patients’ willingness to pay out- of-pocket. Thus, we designed an Excel algorithm that outputs the most cost-effective aneuploidy screening based on the patient’s age and out-of-pocket costs for both types of screenings. The algorithm is fed up-to-date risks for common trisomy disorders (13, 18, 21), screening sensitivities, costs of diagnostic tests (CVS or amniocentesis), procedure related pregnancy loss in case of false positives, and the possibility of missing aneuploidy (Table 1). The program was simplified with macro functions that quickly recalculate costs after changing one or more inputs. The program successfully calculates the three most cost-effective combinations of screenings/diagnostics based on the patient’s age and ability to pay. In addition, the algorithm calculates the exact price point at which an initial cfDNA test becomes more cost effective than a sequential screening from ages 19-44 (Table 2). In other words, a patient could easily determine the maximum price of a cfDNA test at which it would be more cost-effective for the patient to pay for the test herself, rather than undergoing sequential screening. Microsoft Excel can be used to carry out complex decision analysis and be useful in helping patients and physicians plan the most cost-effective screening/diagnostic regiment. Up-to-date risks statistics and more accurate assumptions on costs can further improve this algorithm, while such inexpensive and more intuitive Excel-based algorithms can be applied to other clinical settings beyond aneuploidy screening.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

OP23.05: Procedure outcomes of embryo reduction and selective feticide with multifetal pregnancy to twin or singleton pregnancy: a retrospective study

To study the procedure related adverse events and the outcomes of women with multifetal pregnancy, defined as twin or more fetuses that was reduced to twin or singleton pregnancy at different gestational ages. We analysed retrospective data consisted of 382 multifetal pregnancy cases that underwent embryo reduction and selective feticide between 2006.12 and 2017.01. Out of total cases, 179 cases underwent early transvaginal selective embryo reduction (mean 7.6 weeks gestation) and 203 cases underwent selective feticide (mean 13.4 weeks gestation) with KCL injection in the vicinity of the fetal heart via transabdominal approach after ultrasound screening for nuchal translucency and anatomical defects. Procedure outcomes were compared between the two groups. The results showed significant differences between 2 groups (embryo reduction vs. selective feticide) in incidence of procedure related adverse events. The percentage of women with all surviving fetuses after 4 weeks of procedure was significantly higher in selective feticide group (92.0% vs. 98.2%, p=0.009) and the percentage of women with overall procedure related pregnancy loss (defined one and two losses of fetuses after 4 weeks of procedure) was significantly less in selective feticide group (8.0% vs. 1.8%, p=0.009). Incidence of subchorionic hematoma defined by ultrasound after 1 and 4 weeks of the procedure was significantly higher in the embryo reduction group (1 week; 59.8% vs. 27.9% p<0.001, 4 weeks; 34.2% vs. 4.8% p<0.001). Selective feticide group showed less incidence of procedure related adverse events, such as subchorionic hematoma and fetal loss compared to embryo reduction group. Although both procedures are accepted approach in multifetal pregnancy reduction, spontaneous demise of one fetus may occur after embryo reduction, and selective feticide has benefit in enabling chorionic villus sampling and ultrasound screening for nuchal translucency and anatomical defects before the procedure.

Total pregnancy loss after chorionic villus sampling and amniocentesis: a cohort study.

To identify maternal-, operator- and procedure-related variables that affect procedure-related pregnancy loss after transcervical (TC) and transabdominal (TA) chorionic villus sampling (CVS) and amniocentesis and to estimate the rates of spontaneous and procedure-related loss in comparable subgroups of women. This was a retrospective cohort study conducted at the University Medical Center Groningen and the Academic Medical Center, The Netherlands. Databases of both centers were searched to identify singleton pregnancies that had undergone a combined test and/or anomaly scan at around 20 weeks' gestation, or an invasive procedure (CVS and/or amniocentesis) between January 2001 and December 2011. Maternal characteristics, obstetric history, technical aspects of the invasive procedure, ultrasound examinations and fetal and neonatal outcomes were available for 29 201 cases. Women were categorized, according to the type of examination they had received, into the following five groups: first-trimester combined test (and 20-week anomaly scan); 20-week anomaly scan only; CVS; amniocentesis; amniocentesis after unsuccessful CVS. Rates of fetal loss were compared between groups. Variables significantly associated with a higher rate of fetal loss were, for CVS, repeat attempts during the procedure, use of TC cannula instead of biopsy forceps, gestational age at procedure ≥ 13 weeks and a pregnancy after assisted reproductive techniques, and, for amniocentesis, if indication was fetal anomaly or family history of anomalies and repeat attempts during the procedure. In women aged ≥ 36 years who did not undergo an invasive procedure, spontaneous fetal loss rate (FLR) after first-trimester combined test was 1.40%, whereas after CVS, FLR was 2.76% and 2.43% for a TC and TA approach, respectively. The additional risk of fetal loss with TC-CVS was therefore 1.36% (1 : 74), which varied according to the instrument used (0.27% for forceps and 3.12% for cannula), and with TA-CVS was 1.03% (1 : 97). In women aged ≥ 36 years who underwent a 20-week anomaly scan only, spontaneous FLR was 0.63%. In women who underwent amniocentesis solely because of advanced maternal age, FLR was 1.11%. The additional risk of fetal loss with amniocentesis was 0.48% (1 : 208). The total rate of procedure-related fetal loss after TA- and TC-CVS and amniocentesis appears lower than the risks on which women are currently counseled. There was a trend for a decrease in risk when the level of experience of the operator increased. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Multi-fetal pregnancy reduction (MFPR) to twins or singleton - medical justification and ethical slippery slope.

Multi-fetal pregnancy reduction (MFPR) is an ethically acceptable procedure aimed to increase survival and well-being of the remaining fetuses from high-order multiple gestations. In most cases we offer the procedure to triplets or quadruplets and opt to preserve twins; lately, the option to maintain a single fetus was suggested. We examined the outcomes of 140 pregnancies that underwent MFPR in our center and were followed to delivery - 105 were reduced to twins and 35 to singletons. The rate of procedure-related pregnancy loss was identical (2.9%). Leaving only one fetus was associated with a higher gestational age at delivery (35.4±2.4 weeks vs. 37.7±2.1 weeks, P<0.0001), with heavier neonates (2222 g vs. 3017 g, P<0.0001) and with a reduction in the cesarean section (CS) rate (76% in twins vs. 51.4% in singletons, P=0.02). Six pregnancies reduced to twins (5.8%) ended before 32 weeks as compared to one pregnancy reduced to a singleton. We conclude that reduction of triplets to singletons is medically and ethically acceptable, after thorough counseling of patients. However, considering the pregnancy loss risk of MFPR and the relatively good outcome of twin gestations, reduction of twins to singletons is ethically acceptable only in extraordinary maternal or fetal conditions.

The implications of non-invasive prenatal testing failures: a review of an under-discussed phenomenon.

Non-invasive prenatal testing (NIPT) using cell-free DNA in maternal blood is a relatively new screening modality for the common trisomies of chromosomes 21, 18 and 13 and sex chromosome aneuploidies. For some patients, however, results are not reported because of laboratory technical issues such as low fetal fraction and sequencing failures. In this review, the clinical implications of NIPT test failures are discussed. A Medline search was performed for all studies on NIPT that include >1000 samples. The failure rates were assessed by technology. Methods based on massive parallel sequencing have been found to have the lowest failure rate (1.58%), while tests based on single-nucleotide polymorphism analysis have the highest failure rate (6.39%). Recent publications suggest that patients who receive a 'no call' result are at increased risk of aneuploidy. Some professional societies have therefore recommended that these patients undergo genetic counseling and be offered invasive diagnostic testing. NIPT technology that has a high failure rate may increase the false positive rates, decrease the positive predictive value, and increase the procedure-related pregnancy loss. © 2016 John Wiley & Sons, Ltd.

A 26-Year Experience in Chorionic Villus Sampling Prenatal Genetic Diagnosis.

This report describes the trends of chorionic villus sampling (CVS) referred for prenatal genetic diagnosis in the past two and a half decades in a Portuguese Center. Our cohort of 491 CVS was mostly performed by the transcervical method at the 12th gestational week. Data collected within the framework of this study relate to the following: sampling method, referral reason versus abnormality and incidence of procedure-related pregnancy loss, that declined to about 0.5% over the last 15 years. The year 2000 represented a change in referral reasons for chorionic tissue collection, shifting from almost exclusively for cytogenetic testing to an increasing number of molecular tests for monogenic disorders. Herein, success rates as well as cytogenetic and/or molecular DNA results are presented. These latter include not only tests for several monogenic disorders, but also aneuploidy and maternal cell contamination screening. This retrospective analysis reiterates that CVS is a safe and reliable first trimester technique for prenatal diagnosis in high genetic risk pregnancies.

Pregnancy Loss Following Amniocentesis or CVS Sampling-Time for a Reassessment of Risk.

Risk of procedure-related pregnancy loss is currently widely quoted in the UK as 1% for amniocentesis and 1.5% for chorionic villus sampling. Published data suggest that these risk figures are out of date and inaccurate, and that new guidelines are required for pre-test counseling. It is our opinion that accurate and evidence-based information concerning miscarriage risk is vital when counseling women, as exaggeration of this risk may deter women from testing, or cause unjustified remorse if a miscarriage ensues. It is also essential that health-care economists are aware of the up-to-date evidence on “procedure-related risk” when applying risk-benefit analysis to assess new technology for non-invasive screening.

Noninvasive Prenatal Testing

INTRODUCTION: Our objective was to assess the effect of the availability of noninvasive prenatal testing using circulating cell-free fetal DNA on the uptake of routine chorionic villus sampling (CVS) or genetic amniocentesis for advanced maternal age greater than or equal to 35 years. METHODS: Retrospective cohort study of all women who chose noninvasive prenatal testing from May to December 2012 at the University of California San Diego Fetal Care and Genetics Center. Indications for noninvasive prenatal testing were advanced maternal age, high-risk aneuploidy screening, abnormal ultrasound findings, and a family history of aneuploidy. Data were collected by chart review. The numbers of CVS and amniocenteses performed from May to December 2012 were recorded. RESULTS: Two hundred six patients chose noninvasive prenatal testing and 155 (75%) had advanced maternal age. The remaining 51 had abnormal aneuploidy screening, ultrasound findings, or both suggestive of aneuploidy. For 70 women (34%), advanced maternal age alone was the indication for noninvasive prenatal testing. The mean age of this group was 37.7±2.5 years (range 35–44 years). One of the tests done for advanced maternal age alone was positive for trisomy 21, which was confirmed by CVS. The remaining 69 women (98.6%) declined invasive testing. None of these 69 neonates had abnormal karyotypes. CONCLUSIONS: In our practice, women are choosing noninvasive prenatal testing rather than undergoing invasive testing for the sole indication of advanced maternal age. Although detection of aneuploidy with noninvasive prenatal testing is not 100%, patients with reassuring serum aneuploidy screening and normal ultrasound findings appear to favor a small risk of missing a diagnosis of aneuploidy over the risk of procedure-related pregnancy loss.

Noninvasive Prenatal Test Raises Concern Over Screening Strategies and the Role of Ultrasound

Noninvasive Prenatal Test Raises Concern Over Screening Strategies and the Role of Ultrasound

Outcome After Second-Trimester Amniocentesis and First-Trimester Chorionic Villus Sampling for Prenatal Diagnosis in Multiple Gestations

The purpose of this study was to classify pregnancy loss and fetal loss as well as the influence of maternal risk factors in multiple pregnancies. Details of the procedure and pregnancy outcome of all patients were extracted from the clinical audit database of two tertiary centers. The files were collected in the time from January 1993 to May 2011. The procedure-related pregnancy and fetal loss rate was classified as all unplanned abortions without important fetal abnormalities or obstetric complications within 14 days after AC and CVS. We had a total number of 288 multiple pregnancies with a total of 637 fetuses. After the exclusion of 112 pregnancies with abnormal karyotype or fetal abnormalities detected by ultrasound as well as cases of selective feticide, repeated invasive procedures and monochorionic-monoamniotic pregnancies, 176 pregnancies and 380 fetuses were left for final analysis. Overall 132 amniocenteses and 44 chorionic villous sampling procedures were performed. The total pregnancy loss rate was 8.0 % (14/176), 6.1 % (n = 8) for amniocentesis and 13.6 % (n = 6) for CVS. The procedure-related pregnancy loss rate was 3.4 %, 2.3 % after amniocentesis (3 cases) and 6.8 % after CVS (3 cases). There was no statistical significance between the two procedures (p = 0.15). The procedure-related loss rate of 3.4 % can be compared to the rates in the literature. The higher loss rates in multiple pregnancies than in singleton pregnancies have to be discussed when counseling parents.

Procedure-related pregnancy loss following invasive prenatal sampling: time for a new approach to risk assessment and counseling

Recent publications have indicated that the risk of fetal loss following amniocentesis or chorionic villus sampling is lower than the figure widely quoted in pretest counseling. This review examine...

Fetal loss rates after mid-trimester amniocentesis

Objective: Amniocentesis is an invasive cytogenic test traditionally associated with a 1/200 procedure–related pregnancy loss rate. Recent studies have questioned the validity of the traditionally stated rate. The purpose of this study was to document the results of second-trimes- ter genetic amniocentesis performed at our pe- rinatalogy clinic. Study Design: A retrospective review of all the amniocentesis procedures per- formed between 15 and 22 weeks of gestation on singleton pregnancies between May 2004 and December 2008 was performed. Spontaneous loss was defined as any unintentional preg- nancy loss at < 24 weeks of gestation. Setting: Zonguldak Karaelmas University, Faculty of Me- dicine, Department of Obstetrics and Gynecology. Population: Pregnant women followed at the Obstetrics Department. Methods: A retrospective review of all the amniocentesis procedures performed between May 2004 and December 2008 was performed. Main outcome measure: Pregnancy loss due to amniocentesis. Results: A total of 447 amniocentesis procedures were performed during the study period. The major indication for amniocentesis was positive maternal triple screening (44%). The mean gestational age at amniocentesis was 18.80 ± 2.70 weeks. The results of cytogenetic analyses revealed an abnormal karyotype in 19 pregnancies (4.3%), nine of which were trisomy 21. The overall spontaneous loss rate was 0.89% (n = 4). Conclusion: It would be useful for each center to investigate its own pregnancy loss rate and thereby provide a firmer basis for its policy for counseling women requesting amniocentesis. If enough such investigations were reported, a true benchmark figure could also emerge.

Antibiotic Prophylaxis before second‐trimester Genetic Amniocentesis (APGA): a single‐centre open randomised controlled trial

To compare procedure-related pregnancy loss after second-trimester genetic amniocentesis in women given an antibiotic prophylaxis and controls. Prospective, open randomised controlled single-centre study between January 1999 and December 2005 at Artemisia Fetal Maternal Medical Centre. A follow-up within 4 weeks after the procedure was done.Of 36,347 eligible women, 1424 refused to participate and 34,923 were enrolled and randomised with unequal chance of selection, 21,991 were assigned to treatment group and 12,932 were assigned to the control group, and did not receive any placebo. Oral azithromycin, 500 mg per day, was administered 3 days before amniocentesis. The primary endpoint was the procedure-related pregnancy loss. The secondary endpoint was the rate of preterm premature rupture of membranes. The rate of abortion related to the amniocentesis was 7/21 219 women (0.03%, 95% CI 0.009-0.057) in the intervention group, and 36/12 529 (0.28%, 0.28-0.30) in controls (p = 0.0019). The rate of preterm premature rupture of membranes was 14/21 219 (0.06%, 0.031-0.101) in the intervention group, and 140/12 529 (1.12%, 0.94-1.30) in the control group (p = 0.001). Antibiotic prophylaxis before second-trimester amniocentesis reduced the risk of abortion and of rupture of the membranes.

Revisiting Amniocentesis Risk

Midtrimester amniocentesis has long been reported to carry a procedure-related pregnancy loss rate of 1 in 200. However, that figure was derived during an era when ultrasound guidance was unavailable and experienced operators were uncommon. Using data from the First and Second Trimester Evaluation of Risk (FASTER) multicenter trial, investigators assessed the rate of …

Fetal anaemia as a cause of fetal injury: diagnosis and management

This review provides up-to-date information on the diagnosis and management of fetal anaemia. Exciting advances in the field of red blood cell isoimmunization are phasing out the need for invasive procedures. Rhesus blood group genotyping using fetal DNA in maternal plasma has been introduced into clinical practice with remarkable success. The role of middle cerebral artery peak systolic velocity in screening for fetal anaemia has been confirmed in various causes of fetal anaemia. A recent review of a successful Iran national screening programme for thalassaemia provided a timely and valuable educational opportunity. The value of intrauterine transfusion as a treatment for fetal anaemia was demonstrated by both high success rate and low procedure-related pregnancy loss rate. Fetal anaemia is one of the severe fetal conditions that affect the worldwide population. Rhesus isoimmunization remains an important health issue despite the recommendation for anti-D immunoglobulin prophylaxis and injection after sensitizing events. Noninvasive ultrasound diagnostic methods have replaced traditional invasive procedures in the assessment of fetus at risk of anaemia due to various causes, including red blood cell isoimmunization, parvovirus B19 infection and thalassaemia. The increased availability of intrauterine transfusion will help to improve the prognosis of these anaemic fetuses.

Challenging the Strategy of Maternal Age–Based Prenatal Genetic Counseling

THE DECISION TO OFFER PREGNANT WOMEN PRENATAL diagnosis for genetic diseases has long had an agebased trigger. Early studies convincingly demonstrated an escalating rate of aneuploidy with advancing maternal age, but risks related to amniocentesis are independent of maternal age. When the flat risk-line from the invasive diagnostic procedure (iatrogenic pregnancy loss) crossed the age-related ascending risk-line of aneuploidy on a graph of adverse events, an intersection was determined that became the age standard for offering the procedure. Data from the 1970s appeared to suggest that at the age of 35 years a woman had a similar chance of delivering a child with aneuploidy as experiencing a miscarriage after an amniocentesis, and that age became “the” prompt for genetic counseling. Much has been learned since then, but despite the substantially increased efficiency of diagnostic technologies and possibly reduced risks of procedure-related pregnancy loss, the recommendation remains unchanged. According to the current guidelines of the American College of Obstetricians and Gynecologists, “Women with singleton pregnancies who will be age 35 years or older at delivery should be offered prenatal diagnosis.” We suggest that advances in science and careful consideration of the ethics of testing should undermine any residual support for that standard.

A Cost-Effectiveness Analysis of Prenatal Screening Strategies for Down Syndrome

To evaluate which Down syndrome screening strategy is the most cost-effective. Using decision-analysis modeling, we compared the cost-effectiveness of 9 screening strategies for Down syndrome: 1) no screening, 2) first-trimester nuchal translucency (NT) only, 3) first-trimester combined NT and serum screen, 4) first-trimester serum only, 5) quadruple screen, 6) integrated screening, 7) sequential screening, 8) integrated serum only, or 9) maternal age. Costs included cost of tests and resources used for raising a child with Down syndrome. One-way and multiway sensitivity analyses were performed for all model variables. The main outcome measures were cost per Down syndrome case detected, rate of delivering a liveborn neonate with Down syndrome, and rate of diagnostic procedure-related pregnancy loss for each strategy. Sequential screening detected more Down syndrome cases compared with the other strategies, but it had a higher procedure-related loss rate. Integrated serum screening was the most cost-effective strategy. Sensitivity analyses revealed the model to be robust over a wide range of values for the variables. The addition of the cost of genetic sonogram to the second-trimester strategies resulted in first-trimester combined screening becoming the most cost-effective strategy. Within our baseline assumptions, integrated serum screening was the most cost-effective screening strategy for Down syndrome. If the cost of nuchal translucency is less than dollars 57 or when genetic sonogram is included in the second-trimester strategies, first-trimester combined screening became the most cost-effective strategy. III.