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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ajog.2006.05.021 Byline: Cande V. Ananth (a), Anthony M. Vintzileos (b) Abstract: The objective of the study was to evaluate the extent to which maternal and fetal conditions necessitate medically indicated preterm birth. Author Affiliation: (a) Divisions of Epidemiology and Biostatistics (b) Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ Article History: Received 15 February 2006; Revised 18 April 2006; Accepted 11 May 2006 Article Note: (footnote) Supported in part through a grant (R01-HD038902) from the National Institutes of Health (to C.V.A.).

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ajog.2006.03.062 Byline: Martin R. Chavez (a), Cande V. Ananth (b), Lillian M. Kaminsky (a), John C. Smulian (a), Lami Yeo (a), Anthony M. Vintzileos (a) Abstract: This study was undertaken to determine the accuracy of our previously published and prospectively validated institution-specific singleton transcerebellar diameter (TCD) nomogram in the prediction of gestational age (GA) in twin pregnancies. We further evaluated whether the prediction of GA in twin gestations using the singleton TCD nomogram differs between monochorionic and dichorionic twins. Author Affiliation: (a) Division of Maternal-Fetal Medicine (b) Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology and Reproductive Sciences, UMDNJ-Robert Wood Johnson Medical School/Robert Wood Johnson University Hospital, New Brunswick, NJ Article History: Received 8 November 2005; Revised 27 February 2006; Accepted 18 March 2006 Article Note: (footnote) Supported through the 'Samuel A. Pasquale, MD' research grant awarded to Dr Chavez by the Department of Obstetrics, Gynecology, and Reproductive Sciences, UMDNJ-Robert Wood Johnson Medical School, NJ. Drs Ananth and Smulian are partly supported through a grant (R01-HD038902) from the National Institutes of Health awarded to Dr Ananth. Reprints not available from the authors.

A study identifying three major etiologies, ischemic placental disease, fetal malformations and placenta previa, for medically indicated preterm birth is illustrated. Pre-eclampsia was the most common indication among medically indicated preterm births followed by fetal distress, small-for-gestational-age, and pladpremature cental abruption.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ajog.2006.07.027 Byline: Darios Getahun (a), Cande V. Ananth (a), Morgan R. Peltier (b), John C. Smulian (b), Anthony M. Vintzileos (b) Abstract: This study was undertaken to examine the associations between maternal respiratory diseases and placental abruption. Author Affiliation: (a) Division of Epidemiology and Biostatistics (b) Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, UMDNJ-Robert Wood Johnson Medical School, New Brunswick, NJ Article History: Received 10 March 2006; Revised 12 July 2006; Accepted 20 July 2006 Article Note: (footnote) Presented at the 26th Annual Meeting of the Society for Maternal Fetal Medicine, January 30 through February 4, 2006, Miami, FL. D.G., C.V.A., and J.C.S. partly supported through a grant (R01-HD038902) from the National Institutes of Health awarded to C.V.A. Reprints not available from the authors. Address correspondence to Darios Getahun, MD, MPH, Division of Epidemiology and Biostatistics, Department of Obstetrics, Gynecology, and Reproductive Services, UMDNJ-Robert Wood Johnson Medical School, 125 Paterson Street, New Brunswick, NJ, 08901-1977.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.ajog.2006.05.022 Byline: Cande V. Ananth (a), Darios Getahun (a), Morgan R. Peltier (b), Hamisu M. Salihu (a), Anthony M. Vintzileos (b) Abstract: Despite the increased tendency of preterm birth to recur, little is known with regard to recurrence risks for spontaneous and medically indicated preterm birth as well as recurrence risks in relation to severity of preterm birth. We examined the recurrence of spontaneous and medically indicated preterm birth. Author Affiliation: (a) Divisions of Epidemiology and Biostatistics and Maternal-Fetal Medicine (b) Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick, NJ Article History: Received 15 February 2006; Revised 19 April 2006; Accepted 11 May 2006 Article Note: (footnote) Support for C. V. A. and D. G. provided through a grant (HD-038902) from the National Institutes of Health (Bethesda, MD), awarded to C. V. A. M. R. P. is partially supported through the National Institutes of Health Loan Repayment Program and through a University of Medicine and Dentistry of New Jersey Research Foundation award. H. M. S. was supported through a Young Clinical Scientist Award from the Flight Attendant Medical Research Institute.

The study evaluates temporal trends in abruption risk and assesses how much underlying changes in the clinical determinants might have affected these trends. The temporal increase in rates of abruption might reflect a true increase in risk or might be the result of improved diagnosis of both abruption and its determinants.

The study examines if neonatal mortality rates (NMR) based on birth weight discordance (BWD) differ based on mode of delivery. The twins with BWD

The study determines the feasibility and noninvasive fetal pulse oximetry in the human fetus with transabdominal continuous-wave near-infrared spectroscopy. The preliminary data indicates that transabdominal fetal pulse oximetry is feasible for human patient application.

A study is conducted to determine the best available antepartum fetal testing methods according to the underlying pathophysiologic condition. It is recommended that the nature of the risk to the fetus be determined on the basis of clinical information, which is followed by condition-specific antenatal fetal testing, an approach that takes into account essential pathophysiologic processes.

Guidelines for design, interpretation, execution and reporting of economic evaluation studies in obstetrics are presented. A PubMed search of economic evaluation articles to identify the quality of published studies is also included.

The purpose of the study was to validate prospectively a previous retrospectively established nomogram for the prediction of gestational age using transcerebellar diameter, especially in the third trimester. This prospective study demonstrates that transcerebellar diameter measurement is an accurate predictor of gestational age, even in the third trimester of pregnancy.

Babies born to women who have placenta previa are about four times more likely to die at birth than other babies, especially if born at term. They also had lower birth weights, according to a study of 22,368,235 pregnancies. Placenta previa occurs when the placenta is so low inside the uterus that it partially or totally covers the opening into the vagina.

A fever during labor may not necessarily be a sign of an intrauterine infection, according to a study of 94 pregnant women. Only 31% of the women with fever had evidence of an intrauterine infection. However, all of these women had higher blood levels of interleukin-6 than women who did not have fever.

Risk factors for placenta previa include a twin pregnancy, older age, a history of several previous pregnancies, and smoking. Placenta previa is a complication of pregnancy in which the placenta blocks the opening from the uterus into the vagina. It can cause bleeding, fetal death, premature birth, and low birth weight.

Regular prenatal care can lower the risk of death among newborn babies, particularly if the pregnancy is longer than normal, or the mother has high blood pressure. An analysis of data on 10,512,269 births from the National Center for Health Statistics shows that prenatal care reduced the rate of neonatal death from 5.3 to 1.7 deaths per 1,000 births in white women and from 11.2 to 3.8 per 1,000 births in African-American women. In this study, African-American women had higher rates of neonatal death even if they received prenatal care.

Regular prenatal care can reduce the number of premature births among women, even women who have a high risk of premature birth. An analysis of data on 14,071,757 births from the National Center for Health Statistics shows that prenatal care reduced the percentage of premature births from 22% to 8% in white women and from 35% to 15% in African-American women. This study shows that African-American women have higher rates of premature birth even when they receive prenatal care.

Pregnant women younger than 35 whose baby has an isolated choroid plexus do not necessarily have a baby with trisomy 18 and do need amniocentesis, according to a review of eight studies covering 106,732 pregnant women. None of the young women whose baby had an isolated choroid plexus had trisomy 18. Isolated choroid plexus is a brain abnormality that is considered benign.

A normal genetic sonogram reduces the chance that an older pregnant woman has a baby affected by Down syndrome by over 80%, according to a study of 4,344 pregnancies. A genetic sonogram is an ultrasound scan that identifies certain fetal anatomical abnormalities that are associated with Down syndrome. A normal scan means none of the abnormalities are present. Women with a normal scan can avoid having amniocentesis.

Diabetes during pregnancy increases the risk of fetal death at all birth weights over three pounds, according to a study of 10,733,983 births. However, birth weights over nine pounds are a risk factor for fetal death in both diabetic and non-diabetic pregnant women. This shows that high birth weights are a risk factor for fetal death independently of gestational diabetes.

Prenatal care can reduce infant mortality rates, especially if the pregnancy is prolonged or is complicated by premature rupture of membranes, fetal growth restriction, or placenta previa. However, African-American babies still have higher death rates than whites, even when their mothers receive prenatal care.

Most obstetricians will refer a pregnant women with a high-risk pregnancy to a maternal-fetal medicine specialist, according to a survey of 106 obstetricians. High-risk conditions included fatty liver, portal hypertension, pulmonary hypertension, transplantations, fetal hydrops, cytogenetic abnormalities, fetal heart diseases, isoimmunization, and twin-twin transfusion syndrome.

Women with a triplet pregnancy whose cervix is less than one inch in length have a greater risk of premature birth, according to a study of 51 women. An abnormally short cervix was as good as other predictors of premature birth.

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1067/mob.2000.103943 Byline: Anthony M. Vintzileos (a), Cande V, Ananth (b), John C. Smulian (a)(b), Tryfon Beazoglou (c), Robert A. Knuppel (a)(b) Abstract: The objective of this study was to perform a cost-benefit analysis of routine second-trimester screening ultrasonography in the United States as compared with performing ultrasonography only in the presence of indications. Author Affiliation: (a) Division of Maternal-Fetal Medicine, Piscataway, New Jersey, USA (b) Center for Perinatal Health Initiatives, Piscataway, New Jersey, USA (c) Department of Obstetrics, Gynecology and Reproductive Sciences, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, and the Department of Pediatric Dentistry, University of Connecticut Health Center, Farmington, Connecticut, USA Article History: Received 14 July 1999; Revised 17 September 1999; Accepted 26 October 1999 Article Note: (footnote) * The Center for Perinatal Health Initiatives is supported in part through a grant from the Robert Wood Johnson Foundation, Princeton, New Jersey. The opinions, views, and conclusions expressed in this manuscript are those of the authors and not necessarily those of the Robert Wood Johnson Foundation.

Genetic ultrasound scans are 80%to 100% accurate in detecting Down's syndrome prenatally. During these scans, doctors look for anatomic signs of trisomy 21, such as facial and hand abnormalities, short arm and leg bones, a thick neck, and other signs.

A shortening of the cervix before a pregnant woman's due date may be a sign of placental inflammation. This could explain why premature shortening of the cervix is associated with premature birth.

Ultrasound scans appear to be more cost-effective than amniocentesis for detecting spina bifida in pregnant women with elevated blood levels of alpha-fetoprotein (AFP). Spina bifida occurs when the fetal spinal column does not close completely, leaving the spinal cord exposed. Elevated blood levels of AFP indicate some kind of spinal column defect, and many women were offered amniocentesis and genetic testing of amniotic fluid. When specific signs on an ultrasound scan were found to be very accurate in diagnosing spina bifida, ultrasound scans were recommended. Cost-benefit analysis reveals ultrasound scans could save $36 million to $49 million and prevent 268 fetal deaths per year.

Routine amniocentesis to detect trisomy 18 in pregnant women with abnormal screening tests or choroid plexus cysts cannot be justified in a cost-benefit analysis. Trisomy 18 is a chromosomal defect which causes the death of 95% of affected children before birth or during the first year of life. Researchers compared no diagnostic testing, amniocentesis for every high-risk patient, or genetic ultrasonography plus amniocentesis, when indicated. Universal amniocentesis would cost about $12 million annually, and result in 40 fetal losses from the test procedure. Genetic ultrasonography with targeted amniocentesis would cost $5 million annually and cause 8 fetal losses.

An economic model predicts that second-trimester genetic ultrasonography is cost-effective for diagnosing Down syndrome only if the test detects at least 74 of every 100 fetuses with the chromosomal defect. Ultrasound diagnosis, along with other demographic and biochemical markers, can accurately indicate Down syndrome. Researchers reviewed seven studies of genetic ultrasonography and compared the costs of diagnosis with the costs of raising a mentally retarded child with Down syndrome. Local data on disease prevalence and diagnostic ultrasound sensitivity could be used with this model for cost-benefit analyses.

Women who have had cesarean sections or abortions may be at greater risk for placenta previa, with increasing risk as the number of prior cesarean sections increase. Placenta previa is an abnormally low placental attachment in the uterus. A systematic review of all published studies on placenta previa, including four studies involving 170,640 women, indicates that the risk of placenta previa increases with the number of prior cesarean sections. Risk is also increased in women having had a previous abortion. Uterine scarring may account for this increased risk.

Applying pressure across the cervix appears to provide a more active assessment of cervical competence than standing or coughing does. Vaginal and cervical measurements were performed on 89 at-risk pregnant women before and after stress tests involving coughing, standing, and transfundal pressure. These examinations were done twice in conjunction with ultrasound scans between 15 and 24 weeks of pregnancy. The greatest change in vaginal and cervical measurements occurred after transfundal pressure was applied. Women who experienced these physically measured changes after transfundal pressure were significantly more likely to also have observable changes on ultrasound.

Pregnant women whose cervices shorten in response to pressure on the uterus may require cervical cerclage to prevent preterm delivery. Researchers performed transvaginal ultrasound examinations in the midtrimester of pregnancy on 10 women at risk for cervical incompetence. Women whose cervices appeared on ultrasound to shorten in response to pressure applied to the uterus were considered to be at risk for preterm delivery. The cervices of these women changed over the next one to three weeks in preparation delivery. These women received cervical cerclage, or surgical suturing of the cervical opening, to prevent preterm delivery.

Modifying practice patterns could increase the vaginal birth after cesarean rate. Of 376 women who had at least one prior cesarean section, 45% had an elective cesarean delivery and 31% labored, but the labor ended in another cesarean. Women with insurance were seven times more likely to have an elective cesarean compared with Medicaid or self-pay patients. Women who labored but had a repeat cesarean were more likely to have labor induced, not to have the amniotic sac artificially broken, and to have early placement of an epidural.

Byline: Edwin R. Guzman, Christopher Houlihan, Anthony Vintzileos, Joseph Ivan, Carlos Benito, Kenneth Kappy Keywords: Incompetent cervix; emergency cerclage; transvaginal ultrasonography Abstract: OBJECTIVE: Our purpose was to determine whether perioperative transvaginal ultrasonographic evaluation of the incompetent cervix treated with emergency cerclage is predictive of pregnancy outcome. STUDY DESIGN: Twenty-nine women who underwent emergency cerclage at 16 to 26 weeks of gestation had transvaginal ultrasonographic evaluation of the cervix within 48 hours before and after surgery and at least three times thereafter until 28 weeks of gestation. The following measurements were obtained: (1) funnel width, (2) funnel length, (3) endocervical canal length, (4) the distance between the internal and external os, (5) upper cervix (length of closed endocervical canal above the cervical cerclage), (6) lower cervix (endocervical canal length below suture), and (7) cervical index (1 + Funnel length/Endocervical canal length). Values are reported as the median in millimeters, and statistical analysis was performed by use of the Mann-Whitney U test, Wilcoxon signed-rank test, Spearman rank correlation, 2 x 2 contingency tables, and multiple regression analysis with significance set at p < 0.05. RESULTS: Cerclage procedures resulted in significant improvement in postoperative median measurements of funnel width (15 vs 4.0 mm, p < 0.0001), funnel length (29 vs 3 mm, p < 0.0001), and endocervical canal length (2 vs 27 mm, p < 0.0001). There was a significant relationship between gestational age at delivery and the following measurements: preoperative funnel width (r = -0.51, p = 0.007), postoperative endocervical canal length (r = 0.39, p = 0.04), length of the lower cervix (r = 0.39, p = 0.038), and the cervical index (r = -0.39, p = 0.038). An upper cervical length Author Affiliation: New Brunswick and Newark, New Jersey Article History: Received 5 December 1995; Revised 23 January 1996; Accepted 19 February 1996 Article Note: (footnote) [star] From the Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology and Reproductive Sciences, University of Medicine and Dentistry of New Jersey - Robert Wood Johnson Medical School, St. Peter's Medical Center,a and the Department of Obstetrics and Gynecology, Newark Beth Israel Medical Center. b , [star][star] Reprint requests: Edwin R. Guzman, MD, St. Peter's Medical Center, Fourth Floor, MOB, 254 Easton Ave., New Brunswick, NJ 08903-0591., a 0002-9378/96 $5.00 + 0 6/1/72775

Byline: Christopher M. Houlihan, Robert A. Knuppel, Anthony M. Vintzileos, Jian-Zhong Guo, Do Won Hahn Keywords: Tissue-type plasminogen activator; plasminogen activator inhibitor-1; endothelium; pregnancy; estradiol-17[beta]; progesterone; prolactin; hydrocortisone Abstract: OBJECTIVE: Plasminogen activator inhibitor-1, the major serum protease inhibitor of fibrinolysis, increases steadily during pregnancy. The study objective was to examine four hormones, namely, estradiol-17[beta], progesterone, prolactin, and hydrocortisone to determine their individual contributions in the production of tissue plasminogen activator antigen, plasminogen activator inhibitor-1 antigen, and plasminogen activator inhibitor-1 activity. STUDY DESIGN: Human umbilical vein endothelial cells were grown with physiologic third-trimester concentrations of the above hormones, and fibrinolytic parameters were measured. RESULTS: Of the four hormones evaluated, only hydrocortisone significantly increased plasminogen activator inhibitor-1 antigen and activity at both concentrations tested (p < 0.001). Estradiol-17[beta] significantly increased tissue plasminogen activator antigen and progesterone significantly decreased tissue plasminogen activator antigen, but neither affected the overall fibrinolytic balance. CONCLUSION: Hydrocortisone demonstrated antifibrinolytic properties at physiologic concentrations in pregnancy, suggesting that there may be a role for hydrocortisone in the prothrombotic tendency associated with pregnancy. The overall process of fibrinolysis was unaffected by estradiol-17[beta], progesterone, or prolactin. (Am J Obstet Gynecol 1996;175:168-72.) Author Affiliation: New Brunswick and Raritan, New Jersey Article History: Received 1 August 1995; Revised 24 October 1995; Accepted 27 December 1995 Article Note: (footnote) [star] From the Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Medicine and Dentistry of New Jersey - Robert Wood Johnson Medical School, St. Peter's Medical Center,a and the Robert Wood Johnson Pharmaceutical Research Institute. b , [star][star] Reprint requests: C.M. Houlihan, MD, 132 Winding Way, Morrisville, PA 19067., a 0002-9378/96 $5.00 + 0 6/1/71491

Male and female second-trimester fetuses may show slightly different growth patterns as measured by ultrasound, but these differences may not be significant. Researchers measured the head diameter and length of thigh bone and upper arm bone of 288 male fetuses and 251 female fetuses. Gender was found to influence the measurements, but the difference between the two sexes was too small to affect changes in the predicted gestational age of the fetus. Different growth curves for male and female fetuses may not be warranted as accurate estimates of gestational age may be obtained when more than one ultrasonic measurement is used.

The preterm placentas of pregnant women with preeclampsia may sustain more chronic inflammatory lesions and lesions involving blood coagulation than do preterm placentas of women without preeclampsia. Preeclampsia is a complication of pregnancy involving high blood pressure and protein in the urine. Researchers studied the placentas of infants born between 22 and 32 weeks of pregnancy. Seventy-six mothers had preeclampsia and 353 did not. The inflammatory lesions and lesions involving coagulation may be representative of the disease processes of preeclampsia. In turn, abnormal development of the placenta may trigger preeclampsia. Inflammation of the placenta may lead to uterine contractions and preterm delivery. Such findings may further research into treatments for preeclampsia that preserve the mother's and fetus's health.

Placental lesions represent placental damage that may stunt fetal growth and cause fetuses to be born prematurely. Researchers studied 420 placentas delivered with preterm infants. Infants were born prematurely because of premature rupture of membranes, preterm labor, maternal preeclampsia, or vaginal bleeding before birth. Preeclampsia is a condition of pregnancy involving high blood pressure and protein in the urine. Preterm infants whose size was appropriate for their gestational age had placentas with fewer lesions and fewer severe lesions. The number and severity of placental lesions, and how early in pregnancy they occur, may determine whether infants are born early or at term, as well as their size. Preeclampsia may cause preterm birth independent of placental lesions, as it may deprive fetuses of nutrition.

Placental lesions may reduce the respiratory function of the placenta, causing the fetus to experience a chronic lack of oxygen and stunted growth. Researchers studied 431 placentas and fetuses born between 22 and 32 weeks' gestation. Lesions of blood vessels and villous lesions in the placenta and uterus were thought to restrict blood and fluid flow and were associated with poor blood gas values. Preterm placentas without lesions may be less able to withstand the stress of labor than term placentas, as evidenced by the greater incidence of fetal distress among fetuses delivered preterm. Fetuses whose placentas have lesions that compromise placental function may adapt to the lack of oxygen and not show the signs of distress during labor that fetuses with healthier placentas may exhibit.

Unnoticed bleeding before birth coming from the decidua of the placenta may be associated with preterm birth. Researchers studied 462 placentas delivered before 32 weeks' gestation for the presence of hemosiderin, a blood pigment that indicates old bleeding. Hemosiderin deposits in the basal plate membranes of the placenta were associated with placental lesions indicating damage to the placenta. The presence of hemosiderin may cause inflammation of the basal plate decidua, leading to premature rupture of the membranes or preterm contractions. Most (73%) of the 196 patients with hemosiderin deposits in the placenta did not have a history of bleeding during pregnancy. Hemosiderin deposits in the membranes outside the placental decidua were not associated with placental lesions.

A second trimester ultrasound scan may help determine whether a pregnant woman is at high or low risk for a fetus with Down syndrome. The medical literature was searched for second trimester ultrasound studies of physical markers of Down syndrome. A table was generated of the association of the presence or absence of these factors with Down syndrome. The results showed an average detection rate for physicial abnormalities in the fetus of 28%. Scan results can be combined with maternal age and a maternal blood test to help women determine whether to have an amniocentesis. Women of any age may wish to consider amniocentesis if an ultrasound scan is positive for one or more these factors. Reducing the number of amniocenteses would reduce the number of normal fetuses exposed to its risks, which include a pregnancy loss rate of about one per 270 scans. Some preliminary data suggest that the number of women age 35 or more having an amniocentesis can be reduced to 20% of this group without missing any cases of Down syndrome, although this cannot be guaranteed.

Magnesium sulfate, a medication given to stop preterm labor, had no effect on the biophysical profiles of healthy preterm fetuses. Previous reports found adverse effects on this test of fetal well-being among full-term fetuses. Thirty-one fetuses between 24 and 35 weeks gestation had a biophysical profile just before their mothers were administered magnesium sulfate to stop labor. The fetuses were evaluated again at two and twelve hours after administration of magnesium sulfate. No differences in total score or in the score components were found. Possible explanations for the difference from other studies include lower dosages used, failure to rule out infection in other studies, adaptation over time, or normal differences in physiology between the preterm and the mature fetus. Longer studies should be carried out because duration of magnesium sulfate therapy may extend to one or two days.