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Amniotic fluid embolism is a leading cause of maternal mortality in developed countries. Our understanding of risk factors, diagnosis, treatment, and prognosis is hampered by a lack of uniform clinical case definition; neither histologic nor laboratory findings have been identified unique to this condition. Amniotic fluid embolism is often overdiagnosed in critically ill peripartum women, particularly when an element of coagulopathy is involved. Previously proposed case definitions for amniotic fluid embolism are nonspecific, and when viewed through the eyes of individuals with experience in critical care obstetrics, would include women with a number of medical conditions much more common than amniotic fluid embolism. We convened a working group under the auspices of a committee of the Society for Maternal-Fetal Medicine and the Amniotic Fluid Embolism Foundation whose task was to develop uniform diagnostic criteria for the research reporting of amniotic fluid embolism. These criteria rely on the presence of the classic triad of hemodynamic and respiratory compromise accompanied by strictly defined disseminated intravascular coagulopathy. It is anticipated that limiting research reports involving amniotic fluid embolism to women who meet these criteria will enhance the validity of published data and assist in the identification of risk factors, effective treatments, and possibly useful biomarkers for this condition. A registry has been established in conjunction with the Perinatal Research Branch of the Eunice Kennedy Shriver National Institute of Child Health and Human Development to collect both clinical information and laboratory specimens of women with suspected amniotic fluid embolism in the hopes of identifying unique biomarkers of this condition., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The past few years have seen extraordinary advances in prenatal genetic practice led by 2 major technological advances; next-generation sequencing of cell-free DNA in the maternal plasma to noninvasively identify fetal chromosome abnormalities, and microarray analysis of chorionic villus sampling and amniotic fluid samples, resulting in increased cytogenetic resolution. Noninvasive prenatal screening of cell-free DNA has demonstrated sensitivity and specificity for trisomy 21 superior to all previous screening approaches with slightly lower performance for other common aneuploidies. These tests have rapidly captured an increasing market share, with substantial reductions in the number of chorionic villus sampling and amniocentesis performed suggesting that physicians and patients regard such screening approaches as an equivalent replacement for diagnostic testing. Simultaneously, many clinical programs have noted significant decreases in patient counseling. In 2012 the Eunice Kennedy Shriver National Institute of Child Health and Human Development funded a blinded comparison of karyotype with the emerging technology of array comparative genomic hybridization showing that in patients with a normal karyotype, 2.5% had a clinically relevant microdeletion or duplication identified. In pregnancies with an ultrasound-detected structural anomaly, 6% had an incremental finding, and of those with a normal scan, 1.6% had a copy number variant. For patients of any age with a normal ultrasound and karyotype, the chance of a pathogenic copy number variant is greater than 1%, similar to the age-related risk of aneuploidy in the fetus of a 38 year old. This risk is 4-fold higher than the risk of trisomy 21 in a woman younger than 30 years and 5- to 10-fold higher than the present accepted risk of a diagnostic procedure. Based on this, we contend that every patient, regardless of her age, be educated about these risks and offered the opportunity to have a diagnostic procedure with array comparative genomic hybridization performed., (Copyright © 2016 Elsevier Inc. All rights reserved.)

The practice of obstetrics and gynecology in the United States has changed substantially over the past 50 years, but the structure of our residency programs has not evolved at a comparable pace. The number of hours available for training during the workweek has decreased significantly, whereas the amount of essential material to learn and clinical skills to acquire has increased dramatically. The switch to minimally invasive surgical approaches has reduced the number of open abdominal cases available for training, and the aptitude required to perform difficult laparoscopic and robotic cases for benign disease is such that many programs do not have enough surgical patients to teach all of their residents how to adequately master those procedures. Obstetric patients are older and heavier than those encountered several decades ago, and the comorbidities of some of these women make their antepartum and intrapartum management extremely complex. Furthermore, the explosion of genetic knowledge has made prenatal counseling infinitely more challenging. In this commentary we review these and related issues and then address the question of whether current training programs are preparing our graduates to optimally perform in the clinical arena they will enter after finishing their residencies. Some ways in which the current system could be modified are suggested, and a plea is made for the creation of a high-level task force to address this problem on a national level.

The Perinatal Quality Foundation has created an examination containing both knowledge-based and judgment questions relating to the interpretation of electronic fetal heart rate monitoring for credentialing all medical and nursing personnel working on a labor and delivery floor. A description of the examination and the rationale for its use throughout the United States is presented., (Copyright © 2014. Published by Mosby, Inc.)

There is currently no standard national approach to the management of category II fetal heart rate (FHR) patterns, yet such patterns occur in the majority of fetuses in labor. Under such circumstances, it would be difficult to demonstrate the clinical efficacy of FHR monitoring even if this technique had immense intrinsic value, since there has never been a standard hypothesis to test dealing with interpretation and management of these abnormal patterns. We present an algorithm for the management of category II FHR patterns that reflects a synthesis of available evidence and current scientific thought. Use of this algorithm represents one way for the clinician to comply with the standard of care, and may enhance our overall ability to define the benefits of intrapartum FHR monitoring., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Although maternal death remains rare in the United States, the rate has not decreased for 3 decades. The rate of severe maternal morbidity, a more prevalent problem, is also rising. Rise in maternal age, in rates of obesity, and in cesarean deliveries as well as more pregnant women with chronic medical conditions all contribute to maternal mortality and morbidity in the United States. We believe it is the responsibility of maternal-fetal medicine (MFM) subspecialists to lead a national effort to decrease maternal mortality and morbidity. In doing so, we hope to reestablish the vital role of MFM subspecialists to take the lead in the performance and coordination of care in complicated obstetrical cases. This article will summarize our initial recommendations to enhance MFM education and training, to establish national standards to improve maternal care and management, and to address critical research gaps in maternal medicine., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Fetal and neonatal alloimmune thrombocytopenia constitutes the most common cause of severe thrombocytopenia in fetuses and neonates and of intracranial hemorrhage among term newborns. The cornerstone of therapy involves the use of steroids and intravenous immunoglobulins. Despite the risk of potentially devastating consequences to the fetus, fetal blood sampling has typically been used to document response to therapy. We propose a therapeutic algorithm based on risk stratification with individualized treatment optimization without the use of fetal blood sampling.

Delay in diagnosis, failure to employ sufficient medical and surgical treatments, and poor teamwork all may contribute to suboptimal outcomes in cases of postpartum hemorrhage. A significant portion of hemorrhage-related maternal morbidity may be prevented through early diagnosis and rapid intervention. There is a small but growing body of literature describing the role of patient safety initiatives and simulation training in optimizing outcomes following postpartum hemorrhage. Rapid response teams may be used to facilitate coordination between various personnel involved in the management of postpartum hemorrhage. Hemorrhage drills and simulation-based training may help providers achieve timely and coordinated responses in the treatment of postpartum hemorrhage. Protocol may help to standardize management in cases of postpartum hemorrhage, thereby minimizing unnecessary errors or delays in care. Additional research is warranted to further determine the impact of patient safety initiatives and simulation training on outcomes in the setting of obstetric hemorrhage.

The current mechanism for obtaining financial support for families with neurologically impaired infants is seriously flawed. It relies on payment awarded through the tort system based on a claim that medical negligence was responsible for the infant's condition. The system is extraordinarily inefficient and expensive, as well as being unfair to many families with affected children and to physicians who are unjustly accused of contributing to outcomes they could not have prevented. Furthermore, the exorbitant malpractice premiums necessary to support the system are threatening the future of obstetric practice in the United States. This article describes a two-pronged program designed to correct these inequities and to assess each case for the occurrence of medical negligence, which has been submitted to the New York State legislature as a proposed bill entitled the Neurologically Impaired Program for New York State (S7748).

Objective: The FASTER trial compared first and second trimester screening methods for aneuploidy. We examined relationships between maternal serum markers and common congenital anomalies in the pediatric outcome data set of 36 837 subjects., Methods: We used nested case-control studies, with cases defined by the most common anomalies in our follow-up database, and up to four controls matched by enrollment site, maternal age and race, enrollment gestational age, and infant gender. Serum markers were dichotomized to > or = 2 or < 0.5 multiples of the median (MoM). Odds ratios (ORs) and 95% confidence intervals (CI) were estimated., Results: Statistically significant (p < 0.05) associations were found between inhibin A > or = 2 MoM with fetal multicystic dysplastic kidney (MCDK) (OR = 27.5, 95% CI: 2.8-267.7) and two-vessel cord (OR = 4.22, 95% CI:1.6-10.9); hCG of > or = 2 MoM with MCDK (OR = 19.56, 95% CI: 1.9-196.2) and hydrocele (OR = 2.48, 95% CI: 1.3-4.6); and PAPP-A > or = 2.0 MoM with hydrocele (OR = 1.88, 95% CI:1.1-3.3)., Conclusion: In this large prospective study, significant associations were found between several maternal serum markers and congenital anomalies. This suggests potential additional benefits to screening programs that are primarily designed to detect aneuploidy.

Objective: To evaluate the effectiveness and safety of two antenatal treatment regimens designed to optimally protect fetuses against intracranial hemorrhage resulting from alloimmune thrombocytopenia while minimizing the risks associated with fetal blood sampling. The study was limited to "standard-risk" patients, who were defined as women with documented alloimmune thrombocytopenia who had not delivered an infant with an intracranial hemorrhage in a prior pregnancy., Methods: In this prospective multicenter study of 73 women with documented alloimmune thrombocytopenia, patients were randomized to receive either intravenous immunoglobulin (IVIG) 2 g/kg/wk (group A) or IVIG 1 g/kg/wk plus prednisone 0.5 mg/kg/d (group B), starting at approximately 20 weeks of gestation. Fetal blood sampling was performed at approximately 32 weeks of gestation, and those with fetal platelet counts less than 30,000/mL(3) were given salvage therapy., Results: There were two intracranial hemorrhages; neither was due to treatment failure. The average platelet counts at the time of fetal blood sampling were 121,600/mL(3) and 116,100/mL(3), and the average birth platelet counts were 169,400/mL(3) and 134,000/mL(3) for groups A and B, respectively. Twenty-seven percent of patients in group A and 17% in group B received salvage therapy, and only one neonate in each of these subsets had a birth platelet count less than 30,000/mL(3). There were four complications after 79 fetal blood sampling procedures, leading to cesarean deliveries between 32 and 37 weeks. There was a higher incidence of gestational diabetes and a tendency to more fluid retention, mood swings, insomnia, and jitteriness in patients on prednisone and of moderate-to-severe fatigue in those on high-dose IVIG alone., Conclusion: The outcomes of both treatment groups were excellent and comparable. Early cordocentesis is not necessary when treating alloimmune thrombocytopenia in patients who have not delivered an infant with an intracranial hemorrhage in a prior pregnancy., Clinical Trial Registration: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00194987, Level of Evidence: I.

Sexual size dimorphism is thought to contribute to the greater mortality and morbidity of men compared with women. However, the timing of onset of sexual size dimorphism remains uncertain. The authors determined whether human fetuses exhibit sexual size dimorphism in the first trimester of pregnancy. Using a prospective cohort study, conducted in 1999-2002 in the United States, they identified 27,655 women who conceived spontaneously and 1,008 whose conception was assisted by in vitro fertilization or intrauterine insemination and for whom a first-trimester measurement of fetal crown-rump length was available. First-trimester size was expressed as the difference between the observed and expected size of the fetus, expressed as equivalence to days of gestational age. The authors evaluated the association between fetal sex, first-trimester size, and birth weight. Eight to 12 weeks after conception, males were larger than females (mean difference: assisted conception = 0.4 days, 95% confidence interval (CI): 0.1, 0.7, p = 0.008; spontaneous conception = 0.3 days, 95% CI: 0.2, 0.4, p < 0.00001). The size discrepancy remained significant at birth (mean birth weight difference: assisted conception = 90 g, 95% CI: 22, 159, p = 0.009; spontaneous conception = 120 g, 95% CI: 107, 132, p < 0.00001). These data demonstrate that human fetuses exhibit sexual size dimorphism in the first trimester of pregnancy.

Objective: To determine if first trimester fetal growth is associated with birth weight, duration of pregnancy, and the risk of delivering a small for gestational age infant., Design: Prospective cohort study of 38 033 pregnancies between 1999 and 2003., Setting: 15 centres representing major regions of the United States., Participants: 976 women from the original cohort who conceived as the result of assisted reproductive technology, had a first trimester ultrasound measurement of fetal crown-rump length, and delivered live singleton infants without evidence of chromosomal or congenital abnormalities. First trimester growth was expressed as the difference between the observed and expected size of the fetus, expressed as equivalence to days of gestational age., Main Outcome Measures: Birth weight, duration of pregnancy, and risk of delivering a small for gestational age infant., Results: For each one day increase in the observed size of the fetus, birth weight increased by 28.2 (95% confidence interval 14.6 to 41.2) g. The association was substantially attenuated by adjustment for duration of pregnancy (adjusted coefficient 17.1 (6.6 to 27.5) g). Further adjustments for maternal characteristics and complications of pregnancy did not have a significant effect. The risk of delivering a small for gestational age infant decreased with increasing size in the first trimester (odds ratio for a one day increase 0.87, 0.81 to 0.94). The association was not materially affected by adjustment for maternal characteristics or complications of pregnancy., Conclusion: Variation in birth weight may be determined, at least in part, by fetal growth in the first 12 weeks after conception through effects on timing of delivery and fetal growth velocity.

In alloimmune thrombocytopenia maternal immunoglobulin G anti-platelet alloantibodies cross the placenta and cause fetal thrombocytopenia. The diagnosis requires laboratory demonstration of incompatibility between a maternal and paternal platelet alloantigen, and detection of maternal antibody to the discordant paternal alloantigen. This disorder should be treated in utero because of its propensity to cause fetal intracranial bleeding. Administration of intravenous immunoglobulin 1 gm/kg/wk to the mother is successful in substantially raising the platelet count in many fetuses, but this is most successful if the count is >20,000/mL3 at the time that the therapy is initiated. The addition of prednisone administered daily to the mother and/or increasing the dose of intravenous immunoglobulin has a therapeutic benefit in cases that have failed to respond to initial therapy with intravenous immunoglobulin alone. The only reliable noninvasive indicator of the potential for severe fetal thrombocytopenia is a history of an antenatal intracranial hemorrhage in a prior affected sibling. Because fetal blood sampling to determine the fetal platelet count may be associated with significant fetal morbidity, attempts are being made to derive a rational, non-invasive, stratified approach to patient-specific therapy of this disorder in affected pregnancies.

Objective: The purpose of this study was to evaluate whether there is a nuchal translucency (NT) measurement, independent of gestational age, above which immediate diagnostic testing should be offered without waiting for first trimester serum markers., Study Design: Thirty-six thousand one hundred twenty patients had successful measurement of simple NT at 10 3/7 to 13 6/7 weeks and had first trimester serum screening. No risks were reported until second trimester serum screening was completed., Results: Thirty-two patients (0.09%) had NT > or = 4.0 mm; the lowest combined first trimester trisomy 21 risk assessment in euploid cases was 1 in 8 and among aneuploidy cases was 7 in 8. One hundred twenty-eight patients (0.3%) had simple NT > or = 3.0 mm: the lowest combined first trimester trisomy 21 risk assessment of any patient in this group was 1 in 1479 and the lowest risk assessment among aneuploid cases was 1 in 2. Ten patients (8%) had first trimester trisomy 21 risk assessments lowered to less that 1:200 and none of these 10 cases had an abnormal outcome., Conclusion: During first trimester Down syndrome screening, whenever an NT measurement of 3.0 mm or greater is obtained there is minimal benefit in waiting for serum screening results, and no benefit for NT of 4.0 mm or greater. Differentiation between cystic hygroma and enlarged simple NT (> or = 3.0 mm) is now a moot point as both are sufficiently high risk situations to warrant immediate CVS.

Screening for the risk of fetal aneuploidy can be effectively performed in either the first or second trimester. When obtained independently, the interpretation of those data is straightforward. However, the effectiveness of screening can be enhanced by combining studies performed in each trimester in a variety of ways. In this commentary we will define and discuss both the advantages and disadvantages of using integrated, stepwise, sequential or contingency screening for risk assessment of fetal aneuploidy.

Objective: Antenatal therapy with intravenous immunoglobulin (IVIG) and prednisone has been shown to improve fetal thrombocytopenia and reduce the incidence of intracranial hemorrhage in neonatal alloimmune thrombocytopenia. Optimization of this therapy for individual patients, however, has yet to be achieved., Methods: In these parallel, randomized, multicenter studies, 78 patients in 79 pregnancies were stratified to 2 different treatment arms based on the presence of a peripartum intracranial hemorrhage in a previously affected sibling and/or the initial fetal platelet count. Patients with a history of an antenatal intracranial hemorrhage in a prior pregnancy were excluded., Results: Forty women whose children from a previous birth had a peripartum intracranial hemorrhage or whose current fetus had an initial platelet count less than 20,000/mL3 were randomly assigned to receive IVIG plus prednisone or IVIG alone. The mean increase in fetal platelet counts in the following 3 to 8 weeks was 67,100/mL3 and 17,300/mL3, respectively (P < .001). Thirty-nine patients whose prior affected child did not have an intracranial hemorrhage and whose initial platelet count was more than 20,000/mL3 were randomly assigned to receive IVIG alone or prednisone alone. There were no significant differences, and 33 (85%) had birth platelet counts more than 50,000/mL3. There were 11 (6%) significant complications after a total of 175 fetal blood sampling procedures, 2 of which led to fetal or neonatal deaths., Conclusion: The spectrum of disease severity of alloimmune thrombocytopenia is reflected in the initial fetal platelet count and response to therapy. Fetal blood sampling may be associated with significant fetal/neonatal morbidity and mortality. Empiric therapy sufficient to treat the most severely affected fetuses will overtreat others and is likely to be associated with additional maternal morbidity.

The incidence of twins, triplets, and high-order multiples has increased substantially in the last two decades secondary to fertility treatments and to delayed childbearing. Prenatal diagnosis in these patients is challenging. Options for screening tests are limited. First trimester screening for Down syndrome in patients with multiples appears promising. This paper will review the advantages of first trimester screening in this high-risk patient population.

The incidence of twins, triplets, and high-order multiples has increased dramatically in the last two decades secondary to greater reliance on fertility treatments and to delayed childbearing. Offspring of a multiple gestation are at increased risk for both chromosomal and structural abnormalities. Prenatal diagnosis in these patients is challenging. Options for screening tests are limited. Invasive diagnostic procedures are complex. Likewise, physicians and patients may be faced with the dilemma of deciding how to manage discordant results. The following paper will review the unique concerns associated with prenatal diagnosis in a multiple pregnancy and the current methods of prenatal screening in these patients. Invasive prenatal diagnosis will also be explored.

Objective: The purpose of this study was to determine whether maternal serum levels of pregnancy-associated plasma protein A, free-beta subunit human chorionic gonadotropin, or nuchal translucency size are associated with obstetric complications., Study Design: Data were obtained from the First and Second Trimester Evaluation of Risk trial. Pregnancy-associated plasma protein A and free-beta subunit human chorionic gonadotropin levels were analyzed, and nuchal translucency was measured between 10 weeks 3 days and 13 weeks 6 days of gestation in 34,271 pregnancies., Results: Women with pregnancy-associated plasma protein A of < or =5th percentile were significantly more likely to experience spontaneous fetal loss at < or =24 weeks of gestation, low birth weight, preeclampsia, gestational hypertension, preterm birth ( P < .001) and stillbirth, preterm premature rupture of membranes, and placental abruption ( P < .02). Nuchal translucency at > or =99th percentile and free-beta subunit human chorionic gonadotropin at < or =1st percentile were associated with an increased risk of spontaneous loss at < or =24 weeks of gestation (adjusted odds ratios, 3.90, 3.62, respectively; P < .001)., Conclusion: Low pregnancy-associated plasma protein A levels in the first trimester were associated strongly with a number of adverse pregnancy outcomes. Low free-beta subunit human chorionic gonadotropin levels and large nuchal translucency were both associated with early fetal loss.

Objective: To review the treatment options presented on the New York State Health Care Proxy for Jehovah's Witnesses, which is signed by pregnant women when they present for care., Methods: Chart reviews were performed for all women who presented to labor and delivery at our institution from 1997 to 2002 and identified themselves as Jehovah's Witnesses. A patient was included in the study if a completed health care proxy was available in her chart. Data were derived from the health care proxy and from the Mount Sinai School of Medicine's Blood Product Checklist for Jehovah's Witness Patients. Variables of interest included age, race, parity, and antenatal and perinatal complications., Results: A total of 61 patients were identified. Of these, 39.3% agreed to accept a variety of donated blood products, 9.8% would accept donated packed red blood cells, and 50.1% would accept neither from a homologous donor. With respect to nonstored autologous blood, 55% of respondents would accept either intraoperative normovolemic hemodilution or transfusion of their own blood obtained by a cell salvage system. No significant differences in responses were noted for any of the above-mentioned variables., Conclusion: This review refutes the commonly held belief that all Jehovah's Witnesses refuse to accept blood or any of its products. In this population of pregnant women, the majority were willing to accept some form of blood or blood products. This information can be used to help health care providers counsel a patient when she is initially faced with considering these issues and may help to remove the stigma of accepting one of the options.

Objective: The purpose of this study was to determine whether patients with first-trimester threatened abortion are at increased risk for poor pregnancy outcome., Study Design: A large prospective multicenter database was studied. Subjects were divided into three groups: (1) no bleeding, (2) light bleeding, and (3) heavy bleeding. Univariate and multivariable logistic regression analyses were used., Results: The study comprised 16,506 patients: 14,160 patients without bleeding, 2094 patients with light bleeding, and 252 patients with heavy bleeding. Patients with vaginal bleeding, light or heavy, were more likely to experience a spontaneous loss before 24 weeks of gestation (odds ratio, 2.5 and 4.2, respectively) and cesarean delivery (odds ratio, 1.1 and 1.4, respectively). Light bleeding subjects were more likely to have preeclampsia (odds ratio, 1.5), preterm delivery (odds ratio, 1.3), and placental abruption (odds ratio, 1.6). Heavy vaginal bleeding subjects were more likely to have intrauterine growth restriction (odds ratio, 2.6), preterm delivery (odds ratio, 3.0), preterm premature rupture of membranes (odds ratio, 3.2), and placental abruption (odds ratio, 3.6)., Conclusion: First-trimester vaginal bleeding is an independent risk factor for adverse obstetric outcome that is directly proportional to the amount of bleeding.

Objective: To estimate whether discordant growth is associated with adverse perinatal outcomes in twins after adjusting for growth restriction., Methods: This was a retrospective, hospital-based cohort study of twin gestations with 2 live births delivered at 24 weeks or later from 1992 to 2001. Twin gestations were classified as small for gestational age (SGA) if one or both infants was less than the 10th percentile at birth by singleton Brenner norms and discordant if there was a 20% or more weight discordance., Results: Of 1318 twin pairs, 856 were appropriate for gestational age (AGA) and concordant, 70 pairs were AGA and discordant, 254 pairs were SGA and concordant, and 138 pairs were SGA and discordant. The 4 groups had similar maternal demographics and medical comorbidity. When adjusting for chorionicity, antenatal steroid use, oligohydramnios, preeclampsia, and gestational age at delivery, discordant twins were more likely to have a cesarean delivery (odds ratio 1.87; 95% confidence interval 1.22, 2.87) and to be associated with some adverse neonatal outcomes (low and very low birthweight, neonatal intensive care unit admission, neonatal oxygen requirement and hyperbilirubinemia) independent of SGA status. A statistically nonsignificant trend (odds ratio 2.4; 95% confidence interval 0.99, 6.01) toward higher rates of intraventricular hemorrhage was noted in discordant twins, and no difference was seen for ventilator requirement, respiratory distress syndrome, or necrotizing enterocolitis., Conclusion: Discordance places twins at increased risk for some adverse perinatal outcomes, whether they are AGA or SGA. Discordance was not an independent risk factor for serious neonatal morbidity or mortality; however, this study was underpowered to detect those differences.

Unlabelled: Severe maternal neurologic injury during pregnancy has the potential for fetal demise without advanced critical care support to the mother. Brain death is the unequivocal and irreversible loss of total brain function, whereas patients in a vegetative state, by contrast, have preserved brain stem function but lack cerebral function. They can appear to be awake, have sleep-wake cycles, be capable of swallowing, and have normal respiratory control, but there are no purposeful interactions. These conditions have different maternal prognoses, but both have resulted in near-normal neonatal outcomes with long latencies from maternal injury to delivery in previously published cases. This article compares and contrasts the 11 cases of brain death with 15 cases of persistent vegetative state in pregnancy. We found that the mean latency between maternal brain injury and delivery was significantly shorter in the brain-dead patients as compared with those in a vegetative state (46 days vs. 124 days, P

Objective: Multifetal pregnancy reduction (MPR) is a technique developed to reduce the risks of a multifetal pregnancy. The objective of this article was to report the outcome of MPR in the largest single-center experience to date., Study Design: A computerized database was used to determine the outcome of 1000 consecutive cases patients undergoing transabdominal MPR between the years 1986 and 1999. Outcomes analyzed included pregnancy loss rates, preterm delivery rates, and mean birth weights., Results: The complete pregnancy loss rate was 5.9%, whereas the unintended pregnancy loss rate was 5.4%. The loss rate was 9.5% in the first 200 cases and remained stable at 4.5% to 6.0% over the next 800 cases. The loss rate was lowest with starting numbers of two fetuses (2.5%), remained stable for three, four, and five fetuses, and increased to 12.9% with starting numbers of six fetuses or greater. Loss rates were similar with a finishing number of one or two (3.5 % and 5.5%, respectively) but were highest for a finishing number of three (16.7%). Analysis of birth weights showed a linear decline with increasing starting and finishing numbers. Mean gestational age of delivery for finishing numbers of one, two, and three fetuses was 37.9, 35.3, and 33.5 weeks., Conclusion: Unintended loss rates associated with MPR have stabilized at 5.4%. Loss rates are highest with starting numbers of six or more fetuses, but did not differ for starting numbers of three, four, or five fetuses. Gestational age of delivery for finishing numbers of one, two, and three fetuses are similar to that of nonreduced pregnancies.

Objective: The objective of this study was to summarize the outcome of 200 selective termination (ST) procedures performed at a single center., Study Design: Two hundred patients underwent ST at the Mt Sinai Medical Center from 1986 to 2000. The following data were collected for each patient: indication for the ST, gestational age (GA) at the time of the procedure, starting and ending number of fetuses, which fetus(es) underwent ST (presenting vs nonpresenting), and GA at delivery or at spontaneous pregnancy loss less than 24 weeks., Results: ST was performed on 164 sets of twins, 32 triplets, and 4 quadruplets. Median GA at the time of ST was 19.6 weeks. The presenting fetus was terminated in 91 (45.5%) cases. There were 8 (4%) unintended pregnancy losses less than 24 weeks, 4 of 164 (2.4%) in twins, 4 of 32 (12.5%) in triplets, and none of the 4 in quadruplets. The median GA at delivery in the remaining 190 patients was 37.1 weeks. One hundred sixty (84.2%) patients were delivered at >or=32 weeks' gestation., Conclusion: ST at our institution has an overall unintended pregnancy loss rate of 4%. The loss rate is almost 5-fold higher in patients carrying 3 or more fetuses (11.1%) than for those carrying twins (2.4%). ST is a reasonable alternative in multifetal pregnancies in which 1 or more fetuses have a significant abnormality.