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Nearly 80% of all pesticides applied to row crops are herbicides, and these applications pose potentially significant ecotoxicological risks to nontarget plants and associated pollinators. In response to the widespread occurrence of weed species resistant to glyphosate, biotechnology companies have developed crops resistant to the synthetic-auxin herbicides dicamba and 2,4-dichlorophenoxyacetic acid (2,4-D); and once commercialized, adoption of these crops is likely to change herbicide-use patterns. Despite current limited use, dicamba and 2,4-D are often responsible for injury to nontarget plants; but effects of these herbicides on insect communities are poorly understood. To understand the influence of dicamba on pollinators, the authors applied several sublethal, drift-level rates of dicamba to alfalfa (Medicago sativa L.) and Eupatorium perfoliatum L. and evaluated plant flowering and floral visitation by pollinators. The authors found that dicamba doses simulating particle drift (≈1% of the field application rate) delayed onset of flowering and reduced the number of flowers of each plant species; however, plants that did flower produced similar-quality pollen in terms of protein concentrations. Further, plants affected by particle drift rates were visited less often by pollinators. Because plants exposed to sublethal levels of dicamba may produce fewer floral resources and be less frequently visited by pollinators, use of dicamba or other synthetic-auxin herbicides with widespread planting of herbicide-resistant crops will need to be carefully stewarded to prevent potential disturbances of plant and beneficial insect communities in agricultural landscapes., (© 2015 SETAC.)

Grassland bird species have experienced substantial declines in North America. These declines have been largely attributed to habitat loss and degradation, especially from agricultural practices and intensification (the habitat-availability hypothesis). A recent analysis of North American Breeding Bird Survey (BBS) "grassland breeding" bird trends reported the surprising conclusion that insecticide acute toxicity was a better correlate of grassland bird declines in North America from 1980-2003 (the insecticide-acute-toxicity hypothesis) than was habitat loss through agricultural intensification. In this paper we reached the opposite conclusion. We used an alternative statistical approach with additional habitat covariates to analyze the same grassland bird trends over the same time frame. Grassland bird trends were positively associated with increases in area of Conservation Reserve Program (CRP) lands and cropland used as pasture, whereas the effect of insecticide acute toxicity on bird trends was uncertain. Our models suggested that acute insecticide risk potentially has a detrimental effect on grassland bird trends, but models representing the habitat-availability hypothesis were 1.3-21.0 times better supported than models representing the insecticide-acute-toxicity hypothesis. Based on point estimates of effect sizes, CRP area and agricultural intensification had approximately 3.6 and 1.6 times more effect on grassland bird trends than lethal insecticide risk, respectively. Our findings suggest that preserving remaining grasslands is crucial to conserving grassland bird populations. The amount of grassland that has been lost in North America since 1980 is well documented, continuing, and staggering whereas insecticide use greatly declined prior to the 1990s. Grassland birds will likely benefit from the de-intensification of agricultural practices and the interspersion of pastures, Conservation Reserve Program lands, rangelands and other grassland habitats into existing agricultural landscapes.

Objective: We sought to compare neonatal outcomes in twin pregnancies following moderately preterm birth (MPTB), late preterm birth (LPTB), and term birth and determine the indications of LPTB., Study Design: We performed a retrospective cohort study. MPTB was defined as delivery between 32(0/7) and 33(6/7) weeks and LPTB between 34(0/7) and 36(6/7) weeks. The composite neonatal adverse respiratory outcome was defined as respiratory distress syndrome and/or bronchopulmonary dysplasia. The composite neonatal adverse nonrespiratory outcome included early onset culture-proven sepsis, necrotizing enterocolitis, retinopathy of prematurity, intraventricular hemorrhage, or periventricular leukomalacia. LPTB cases were categorized as spontaneous (noniatrogenic), evidence-based iatrogenic, and non-evidence-based (NEB) iatrogenic., Results: Of the 747 twin deliveries during the study period, 453 sets met the inclusion criteria with 22.7% (n = 145) MPTB, 32.1% (n = 206) LPTB, and 15.9% (n = 102) term births. Compared with term neonates, the composite neonatal adverse respiratory outcome was increased following MPTB (relative risk [RR] 24; 95% confidence interval [CI] 3.0 to 193.6) and LPTB (RR 13.7; 95% CI 1.8 to 101.8). Compared with term neonates, the composite neonatal adverse nonrespiratory outcome was increased following MPTB (RR 22.3; 95% CI 3.9 to 127.8) and LPTB (RR 5.5; 95% CI 1.1 to 27.6). Spontaneous delivery of LPTB was 63.6% (n = 131/206) and the rate of iatrogenic delivery was 36.4% (n = 75/206). The majority, 66.6% (n = 50/75), of these iatrogenic deliveries were deemed NEB, giving a total of 24.2% (50/206) NEB deliveries in LPTB group., Conclusion: Our data demonstrate a high rate of late preterm birth among twin pregnancies, with over half of nonspontaneous early deliveries due to NEB indications. Although our morbidity data will be helpful to providers in counseling patients, our finding of high NEB indications underscores the need for systematic evaluation of indications for delivery in LPTB twin deliveries. Furthermore, this may lead to more effective LPTB rate reduction efforts., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Declining plant biodiversity in agroecosystems has often been attributed to escalating use of chemical herbicides, but other changes in farming systems, including the clearing of seminatural habitat fragments, confound the influence of herbicides. The present study introduces a new approach to evaluate the impacts of herbicide pollution on plant communities at landscape or regional scales. If herbicides are in fact a key factor shaping agricultural plant diversity, one would expect to see the signal of past herbicide impacts in the current plant community composition of an intensively farmed region, with common, successful species more tolerant to widely used herbicides than rare or declining species. Data from an extensive field survey of plant diversity in Lancaster County, Pennsylvania, USA, were compared with herbicide bioassay experiments in a greenhouse to test the hypothesis that common species possess higher herbicide tolerances than rare species. Five congeneric pairs of rare and common species were treated with 3 commonly used herbicide modes of action in bioassay experiments, and few significant differences were found in the tolerances of rare species relative to common species. These preliminary results suggest that other factors beyond herbicide exposure may be more important in shaping the distribution and abundance of plant species diversity across an agricultural landscape., (© 2014 SETAC.)

Objective: The objective of this study is to assess the opinions of Fellows of the American College of Obstetricians and Gynecologists on expanded carrier testing (molecular detection of >100 genetic diseases of variable severity) and noninvasive prenatal testing (NIPT)., Methods: A survey conducted between March and August 2012, assessed current use of testing, provision of genetic counseling, types of disorders that should be identified, preferences for future use, ethical aspects, and views on regulatory oversight., Results: Expanded carrier testing was offered to all patients by 15% of the responders and 52.1% upon patient request. Most (67.3%) favored testing only for mutations of known significance. In this study, 79.1% supported the use of NIPT as a screen for Down syndrome for all women with 47.9% viewing NIPT as a complete substitution for invasive testing. Most supported expansion to other aneuploidies (97.5%) and severe early-onset Mendelian disorders (90.4%) but not for adult-onset disorders (29.8%) or nonmedical sex identification (15.7%). A majority (73.2%) believed that NIPT would increase pregnancy terminations for mild disease states. Respondents favored a role for professional societies in providing regulatory oversight., Conclusion: Rapid incorporation of new genetic technologies may be limited by the availability of genetic counseling, concerns regarding inclusion of clinically mild disorders, results of unknown significance, and costs., (© 2013 John Wiley & Sons, Ltd.)

Objectives: The purpose of this study was to evaluate the efficacy of the genetic sonogram in Down syndrome screening for women who have received the stepwise sequential test., Methods: This retrospective cohort study included women with singleton pregnancies who underwent stepwise sequential (first-trimester combined and second-trimester serum) screening and then had a genetic sonogram between March 2005 and January 2010. Stepwise sequential Down syndrome risks were multiplied by either a positive or negative likelihood ratio based on the second-trimester sonographic findings to determine the final Down syndrome risk. A final Down syndrome risk of 1:270 or higher was considered screen positive., Results: A total of 6286 women fulfilled our criteria, including 17 with Down syndrome-affected fetuses. After stepwise sequential testing, the Down syndrome detection rate was 88.2% (15 of 17), and after the genetic sonogram, there was a non-significant reduction in detection to 82.4% (14 of 17; P > .05). For the 6269 unaffected pregnancies, the genetic sonogram converted 58 screen-negative results (1%) to positive and 183 screen-positive results (3.1%) to negative. The net effect was a change in the false-positive rate from 6.2% (390 of 6269) after stepwise sequential screening to 4.2% (266 of 6269) after the genetic sonogram., Conclusions: The genetic sonogram should be applied cautiously for women who have received prior prenatal screening tests. Women with screen-positive results need to be counseled that a negative sonographic result can be falsely reassuring. Conversely, for women with screen-negative results who have a risk close to the cutoff, a sonographic examination could assist in the decision of whether to accept or reject amniocentesis.

Herbicides are the most commonly applied pesticides in agroecosystems, and therefore pose potentially significant ecotoxicological risks to plants and insects. Glyphosate is the most common herbicide worldwide, and glyphosate-resistant weeds are quickly becoming serious challenges in some agroecosystems. Because of this resistance epidemic and the recent development of crops with resistance to dicamba or 2,4-D, herbicide-use patterns are likely to change. Presently, dicamba and 2,4-D cause most herbicide-drift damage to nontarget plants despite limited agricultural usage, but the effects of these synthetic auxin herbicides on insects have been poorly explored. To understand the influence of dicamba on insects, we applied several sublethal, drift-level rates of dicamba to soybean, Glycine max L., and Carduus thistle, and measured growth and survival of Helicoverpa zea (Boddie) and Vanessa cardui (L.) larvae, respectively. For thistle, we measured percent nitrogen content before and after dicamba application. We also performed direct toxicity bioassays on the two caterpillar species with several rates of dicamba. Dicamba was not directly toxic to larvae of either species, and H. zea showed no negative effects when feeding on soybeans dosed with dicamba. We did, however, detect significant negative, indirect effects of higher rates of dicamba on V. cardui larval and pupal mass, total nitrogen of thistles post application, and thistle biomass in the presence of V. cardui larvae. Notably, thistle biomass was not related to dicamba dose in absence of larvae. Our results indicate that dicamba can indirectly influence the performance of some caterpillar species, possibly by altering plant nutritional content.

Pregnant women were queried to determine if racial and ethnic disparities exist in prenatal care by assessing their satisfaction in private and clinic practices. An anonymous survey was distributed in both English and Spanish and focused on demographics, satisfaction and cultural sensitivity. A total of 273 surveys were collected. Demographics of clinic patients (Hispanic 62%, Black 26.4%, and Caucasian 5%) varied significantly (P < 0.001) from private patients (Caucasian 62.5%, Black 14.1%, and Hispanic 18.8%). Significant differences were noted between clinic and private patients' in their country of birth, education, income, insurance, employment status, home ownership, and planned pregnancies. Patients reported that their prenatal care was influenced by race (27% clinic vs 5% private, P < 0.001) and language (24.9% clinic vs 4.9% private, P = 0.004). Race andlanguagewere morelikelyto influence clinic patients' perceptions of the prenatal care received as compared to those seeking care in private practices.

Objectives: The ability to predict surgically relevant fetal renal hydronephrosis is limited. We sought to determine the most efficacious second- and third-trimester fetal renal pelvis anteroposterior diameter cutoffs to predict the need for postnatal surgery., Methods: We retrospectively reviewed the medical records of mothers and neonates who had a prenatal sonographic examination in our Perinatal-Pediatric Urology Clinic and received follow-up care. Hydronephrosis was defined as a renal pelvis anteroposterior diameter of 5 mm or greater in the second trimester and 7 mm or greater in the third trimester. Hydronephrosis was subdivided into mild, moderate, and severe., Results: Of 8453 fetuses, 96 met the criteria and were referred to our clinic. Isolated hydronephrosis was diagnosed in 74 fetuses, of which 53 received postnatal follow-up evaluations. The areas under the receiver operating characteristic curves for predicting postnatal surgery in the second and third trimesters were 0.770 and 0.899, respectively. The second-trimester renal anteroposterior diameter threshold that best predicted post-natal surgery was 9.5 mm (sensitivity, 71.4%; specificity, 81.1%). The third-trimester threshold that best predicted postnatal surgery was 15.0 mm (sensitivity, 85.7%; specificity, 94.6%)., Conclusions: The fetal renal anteroposterior diameter on second- and third-trimester sonography is predictive of an increased risk for neonatal urologic surgery. Surgical risk is best predicted by a third-trimester renal anteroposterior diameter threshold of 15 mm.

Recent advances in biotechnology have produced cultivars of corn, soybean, and cotton resistant to the synthetic-auxin herbicide dicamba. This technology will allow dicamba herbicides to be applied in new crops, at new periods in the growing season, and over greatly expanded areas, including postemergence applications in soybean. From past and current use in corn and small grains, dicamba vapor drift and subsequent crop injury to sensitive broadleaf crops has been a frequent problem. In the present study, the authors measured dicamba vapor drift in the field from postemergence applications to soybean using greenhouse-grown soybean as a bioassay system. They found that when the volatile dimethylamine formulation is applied, vapor drift could be detected at mean concentrations of 0.56 g acid equivalent dicamba/ha (0.1% of the applied rate) at 21 m away from a treated 18.3 × 18.3 m plot. Applying the diglycolamine formulation of dicamba reduced vapor drift by 94.0%. With the dimethylamine formulation, the extent and severity of vapor drift was significantly correlated with air temperature, indicating elevated risks if dimethylamine dicamba is applied early to midsummer in many growing regions. Additional research is needed to more fully understand the effects of vapor drift exposures to nontarget crops and wild plants., (Copyright © 2012 SETAC.)

Objective: We sought to study the frequency, and reasons that third-year medical students on an ObGyn clerkship are denied the opportunity to be involved in patient care., Methods: Students from four hospitals affiliated with the University of Connecticut Medical School completed an anonymous postclerkship survey., Results: Among the 157 students studied (66 males and 91 females), 51% (n = 80) were denied the opportunity to participate in a gynecologic examination and 47% (n = 73) were denied the opportunity for routine ObGyn care by patients. Among these students, 55% (n = 44) and 38% (n = 28) stated that being male was the reason they were excluded from gynecologic and routine care, respectively. Of the 80 students who were denied involvement in a gynecologic examination, 81% (n = 65) were denied involvement by clinic patients. Of the 44 males who stated they were denied the opportunity to be involved in a gynecologic examination due to their gender, 89% (n = 39) were refused by clinic patients. Compared with female students, male students are statistically more likely to be denied the opportunity to be involved in gynecologic examinations (RR = 1.69 [1.24-2.29]), especially by clinic patients (RR = 2.07 [1.41-3.03])., Conclusion: A significant number of students were denied the opportunity to be involved in ObGyn care experiences. More frequently male students were denied involvement in care, with a higher incidence among clinic patients. We hypothesize that being denied involvement provides a negative perception of the ObGyn specialty, especially to male students, possibly affecting their decision to choose ObGyn training., Precis: A significant number of medical students, particularly males, were denied involvement in patient care, primarily by clinic patients, during the ObGyn clerkships.

Strategies for conserving plant diversity in agroecosystems generally focus on either expanding land area in non-crop habitat or enhancing diversity within crop fields through changes in within-field management practices. In this study, we compare effects on landscape-scale species richness from such land-sharing or land-sparing strategies. We collected data in arable field, grassland, pasture, and forest habitat types (1.6 ha sampled per habitat type) across a 100-km2 region of farmland in Lancaster County, Pennsylvania, USA. We fitted species-area relationships (SARs) for each habitat type and then combined extrapolations from the curves with estimates of community overlap to estimate richness in a 314.5-ha landscape. We then modified these baseline estimates by adjusting parameters in the SAR models to compare potential effects of land-sharing and land-sparing conservation practices on landscape richness. We found that species richness of the habitat types showed a strong inverse relationship to the relative land area of each type in the region, with 89 species in arable fields (66.5% of total land area), 153 in pastures (6.7%), 196 in forests (5.2%), and 213 in grasslands (2.9%). Relative to the baseline scenario, major changes in the richness of arable fields produced gains in landscape-scale richness comparable to a conversion of 3.1% of arable field area into grassland habitat. Sensitivity analysis of our model indicated that relative gains from land sparing would be greatest in landscapes with a low amount of non-crop habitat in the baseline scenario, but that in more complex landscapes land sharing would provide greater gains. These results indicate that the majority of plant species in agroecosystems are found in small fragments of non-crop habitat and suggest that, especially in landscapes with little non-crop habitat, richness can be more readily conserved through land-sparing approaches.

Unlabelled: There is paucity of data regarding tick-borne diseases during pregnancy. Here, we report a case of human granulocytic anaplasmosis during pregnancy with successful treatment and a favorable neonatal outcome. We also review diagnosis, treatment, and outcomes of published case reports from 1983 to 2010 of human granulocytic anaplasmosis, Lyme disease, babesiosis, and human monocytic ehrlichiosis in the United States., Target Audience: Obstetricians and Gynecologists and Family Physicians., Learning Objectives: After the completing the CME activity, physicians should be better able to diagnose tick-born diseases, implement best treatment options during the pregnancy, and assess the neonatal outcomes.

Objective: The normal male to female livebirth sex ratio ranges from 1.03 to 1.07. Higher ratios in China, India and Korea reflect prenatal sex selection. We reviewed sex ratios for US births to investigate potential prenatal sex selection., Methods: We reviewed all US livebirths from 1975 to 2002 using National Center for Health Statistics birth certificates in 4-year intervals. We compared the sex ratios of Blacks, Chinese, Filipinos, Asian Indians and Koreans relative to Whites. We also compared the sex ratios by birth order for first, second and third and more births (third+) from 1991 to 2002., Results: The male to female sex ratio from 1975 to 2002 was 1.053 for Whites, 1.030 (p < 0.01) for Blacks, 1.074 (p < 0.01) for Chinese and 1.073 (p < 0.01) for Filipinos. From 1991 to 2002, the sex ratio increased from 1.071 to 1.086 for Chinese, 1.060 to 1.074 for Filipinos, 1.043 to 1.087 for Asian Indians and 1.069 to 1.088 for Koreans. The highest sex ratios were seen for third+ births to Asian Indians (1.126), Chinese (1.111) and Koreans (1.109)., Conclusion: The male to female livebirth sex ratio in the United States exceeded expected biological variation for third+ births to Chinese, Asian Indians and Koreans strongly suggesting prenatal sex selection., (Copyright © 2011 John Wiley & Sons, Ltd.)

Objective: To explore demographic differences in Down syndrome livebirths in the United States., Methods: Using National Center for Health Statistics (NCHS) birth certificate data from 1989 to 2006 we analyzed Down syndrome livebirths after correcting for under-reporting. We created six subsets based on maternal age (15-34 and 35-49 years old); US regions, that is, Northeast, Midwest, South and West; marital status, (married, unmarried); education, ( ≤ 12 years, ≥ 13 years); race, (white, black); and Hispanic ethnicity, (non-Hispanic, Hispanic). We estimated expected Down syndrome livebirths assuming no change in birth certificate reporting. The percentage of expected Down syndrome livebirths actually born was calculated by year., Results: There were 72 613 424 livebirths from 1989 to 2006. There were 122 519 Down syndrome livebirths expected and 65 492 were actually born. The Midwest had the most expected Down syndrome livebirths actually born (67.6%); the West was lowest (44.4%). More expected Down syndrome livebirths were born to women who were 15 to 34 years old (61 vs 43.8%) and to those with ≤ 12 years education (60.4 vs 46.9%), white race (56.6 vs 37%), unmarried (56.0 vs 52.5%), and of Hispanic ethnicity (55.0 vs 53.3%)., Conclusion: The percentage of expected Down syndrome livebirths actually born varies by demographics., (Copyright © 2011 John Wiley & Sons, Ltd.)

Introduction/hypothesis: To identify factors that influence nulliparous women to choose cesarean delivery on maternal request (CDMR)., Methods: Nulliparous women at > or = 34 weeks completed a 76-item survey about concerns during labor, delivery and postpartum., Results: Mean age of the 294 respondents was 28.4 years (+/- 6.13 years SD) and mean gestational age was 35.4 weeks (+/- 2.8 weeks). Sixteen patients (5.4%) would request CDMR if offered. Women who would request CDMR were more likely to plan breastfeeding (OR 5.1, P=0.02), have a mother who delivered by C-section (OR 5.1, P= 0.01), and be concerned about the number of family members present (OR 1.75, P=0.002). Pelvic muscle damage, urinary incontinence, fecal incontinence, or need for prolapse surgery were notcited by any patient as her top concern., Conclusions: Few women in our sample desire CDMR. Concern for pelvic-floor problems was low.

Considerable advances have been made in identifying women whose pregnancies are at the greatest risk for fetal Down syndrome and other aneuploidies. Maternal serum tests and ultrasonography in either the first or second trimester provide effective prenatal screening. However, the most efficacious protocols are based on the combination of first- and second-trimester tests. In this article the advantages and best strategies in providing these sequential screening protocols are discussed., (Copyright 2010 Elsevier Inc. All rights reserved.)

The purpose of our study was to evaluate perinatal and neonatal outcomes in triplet gestations in relation to placental chorionicity. We hypothesized that triplets containing a monochorionic pair (dichorionic triamniotic) would have increased morbidity compared with triplets without a monochorionic pair (trichorionic triamniotic). We retrospectively analyzed all triplet sets > or =20 weeks delivering at our institutions from January 1995 through April 2007. Data were collected via perinatal and neonatal databases, chart review, and placental pathology. Individuals in dichorionic triamniotic triplet sets (N = 75), when compared with trichorionic triamniotic triplets (N = 309), were more likely to have a lower mean birth weight (P < 0.001) and lower gestational age at delivery (P < 0.001), spend more days in the neonatal intensive care unit (P = 0.045), have culture-proven sepsis (P = 0.02), and require intubation (P = 0.05). Multivariate analysis demonstrated that dichorionicity is not an independent cause of morbidity, but results in earlier delivery and lower birth weight. Dichorionic triamniotic triplets are at increased risk for earlier deliveries and lower birth weight at delivery compared with trichorionic triamniotic triplets., (Thieme Medical Publishers.)

Objective: The purpose of this study was to determine changes in screening and performance of invasive diagnostic procedures for Down syndrome between 2001 and 2007., Study Design: The Society for Maternal-Fetal Medicine members completed a survey in 2007 regarding screening tests and diagnostic procedures for Down syndrome. With the use of descriptive statistics, the chi(2) test, and the Student t test, responses from 2007 were compared with responses from a similar 2001 survey., Results: Performance of first-trimester screening more than doubled from 2001-2007 (43.1% in 2001, 97.3% in 2007; P < .0001). Between 2001 and 2007, the use of the quad screen increased 10-fold (8.5% in 2001, 85.6% in 2007; P < .0001). There was an estimated 20% decrease in invasive diagnostic procedures that were performed in risk-positive women (53.7% in 2001, 34.2% in 2007; P < .0001). In 2007, the average fetal loss rates that were quoted by maternal-fetal medicine specialists after chorionic villous sampling was 1:160 and after an amniocentesis was 1:493., Conclusion: Down syndrome screening evolved from 2001-2007, with an increasing emphasis on first-trimester screening. With more efficacious screening, the number of invasive procedures has declined.

Objective: A lamellar body count (LBC) >or= 50,000/microl is suggested to document fetal lung maturity (FLM). We sought to determine the LBC threshold for FLM with the Cell-dyn 4000 hematology analyser., Methods: We queried our database for patients who underwent LBC testing from 2001 to 2007. Included were deliveries between 35 and 38 weeks gestation with testing

Objective: To compare maternal and neonatal outcomes of pregestational and gestational diabetics treated with insulin glargine versus Neutral Protamine Hagedorn (NPH) insulin., Methods: A retrospective cohort study examining outcomes from pregestational and gestational diabetics treated with either insulin regimen. Comparisons were made using the t-test for continuous data and the Chi-square or Fisher's exact test for categorical data., Results: Fifty-two pregnant women treated with insulin glargine were compared with 60 pregnant women treated with NPH. No significant differences in rates of maternal complications were noted. No significant differences in neonatal outcomes for gestational diabetics were noted. Among pregestational diabetics treated with insulin glargine, significantly fewer macrosomic infants (relative risk [RR], 0.38; 95% confidence intervals (CI), 0.17-0.87; p = 0.04) and lower rates of neonatal hyperbilirubinemia (RR, 0.27; 95% CI, 0.07-0.98; p = 0.05) were noted when compared with those treated with NPH. There were no cases of neonatal hypoglycemia in pregestational diabetics treated with glargine; however, 25% of infants born to mothers treated with NPH experienced hypoglycemia (p = 0.01). No fetal anomalies or deaths were observed in either treatment group., Conclusion: Insulin glargine use during pregnancy is not associated with increased maternal or neonatal morbidity compared with NPH insulin. Among pregestational diabetics, insulin glargine use was associated with lower rates of macrosomia, neonatal hypoglycemia and neonatal hyperbilirubinemia.

Recently, applications for subspecialty fellowship positions in obstetrics and gynecology have increased dramatically. A survey completed by fellows in Maternal-Fetal Medicine (MFM), Reproductive Endocrinology (REI), Gynecologic Oncology (Gyn Onc), and Urogynecology (Urogyn) training programs in the United States between January and March 2006 was aimed at determining why this trend was occuring. Of 449 fellows in 2006, 192 (42.8%) responded. The two most influential factors in all four subspecialties were interest and lifestyle (P < .001). Although these factors were similar throughout all subspecialties, variations exist in how fellows rated each factor by subspecialty. An overwhelming majority (99%) of fellows were either "very satisfied" or "satisfied" with their decisions to pursue fellowship training. The majority of fellows believe that when compared to a generalist Obstetrician/Gynecologist (OB/GYN) they will have a reduced workload, decreased liability, and a higher salary. The recent increase in the number of fellowship applicants is most likely due to a complex interplay of multiple factors.

Like many species, the model plant Arabidopsis thaliana exhibits multiple different life histories in natural environments. We grew mutants impaired in different signaling pathways in field experiments across the species' native European range in order to dissect the mechanisms underlying this variation. Unexpectedly, mutational loss at loci implicated in the cold requirement for flowering had little effect on life history except in late-summer cohorts. A genetically informed photothermal model of progression toward flowering explained most of the observed variation and predicted an abrupt transition from autumn flowering to spring flowering in late-summer germinants. Environmental signals control the timing of this transition, creating a critical window of acute sensitivity to genetic and climatic change that may be common for seasonally regulated life history traits.

Objective: The purpose of this study was to determine whether there have been changes in the use of second-trimester genetic sonograms and in the second-trimester sonographic markers used to screen for fetal aneuploidy by maternal-fetal medicine specialists in the United States from 2001 to 2007., Methods: A survey was mailed to Society for Maternal-Fetal Medicine members in the United States in April 2007 inquiring about their practice patterns regarding the genetic sonogram. Specific sonographic markers used for risk adjustment as part of the genetic sonogram were also assessed. The responses from 2007 were compared with responses from a similar survey administered in 2001 (Am J Obstet Gynecol 2002; 187:1230-1234) using descriptive statistics, the chi(2) test, and the Wilcoxon rank sum test., Results: A total of 991 responses were analyzed: 543 of 1638 (32%) in 2001 and 448 of 1756 (26%) in 2007. Significant increases (P < .0001) were noted in the number of specialists who used the genetic sonogram as a screening tool for Down syndrome and for every single sonographic marker used to adjust a woman's risk for having a fetus with Down syndrome during a genetic sonogram, except for choroid plexus cyst, clinodactyly, sandal gap toes, and widened pelvic angle., Conclusions: Practitioners in the United States are using an increasing number of second-trimester sonographic markers to help identify aneuploid fetuses. The growing acceptance of sonography to screen for fetal aneuploidy and the recommendation by the American College of Obstetricians and Gynecologists for universal screening suggest that more resources may be necessary to meet the growing demand for second-trimester sonograms.

Objective: To determine the prevalence of human papillomavirus (HPV) in our inner-city indigent population (clinic population) of women with previously normal Pap tests and to identify any associated risk factors., Materials and Methods: A prospective cohort of 187 women between the ages of 15 and 49 years, with previously normal Pap tests, was recruited from a university affiliated outpatient clinic. A demographic questionnaire of social and sexual history was elicited, and ThinPrep cytology (Cytyc, Marlborough, MA) and HPV Digene Hybrid Capture II results (Digine, Gaithersburg, MD) were obtained., Results: The prevalence of HPV in our primarily Hispanic clinic population was 21%. The mean age of women with HPV was 28.9 years and those without were 32.1 years (p <.046). In women with HPV, 24% had abnormal Pap tests, whereas in those without HPV, 5% had abnormal Pap tests (p <.001). Women who were older and parous were less likely to have HPV (7.5%; p <.024). The presence of HPV was not influenced by sexual behaviors, sexually transmitted diseases, smoking, race, or contraceptive use., Conclusions: The prevalence of HPV in an inner-city indigent population, despite previously normal cytology, was consistent with earlier reported rates of HPV. Our data suggest that younger, nulliparous women have a high prevalence of HPV.

Objective: To assess the efficacy of screening for fetal Down syndrome through the sequential provision of second trimester maternal serum tests and fetal ultrasound (the 'genetic sonogram')., Methods: Monte Carlo modeling was used to generate typical results for second trimester serum screening. Serum test likelihood ratios were then multiplied by likelihood ratios associated with the provision of a genetic sonogram. The impact of adding the genetic sonogram on the detection rate (DR) and false-positive rate (FPR) were assessed for typical protocols that are currently in use. The effect of expanding the number of women who receive the genetic sonogram, variation in the marker frequencies in the genetic sonogram, and a multivariate Gaussian model that incorporated both serum and ultrasound measurements as continuous variables were also considered., Results: When the genetic sonogram is offered only to those women who are screen-positive by serum testing, there can be a substantial reduction in the number of women with an indication for amniocentesis but also some loss in detection. The extent of these changes will partially depend on the serum tests and cutoff used. Providing the genetic sonogram to more women can reduce loss in detection without resulting in high amniocentesis rates. As a sequential screening tool, the genetic sonogram can be improved by incorporating markers that have a high frequency in affected pregnancies and by using ultrasound measurements as continuous variables., Conclusion: It should be possible to provide highly effective multistep screening protocols that maximize the benefits of both maternal serum and ultrasound while minimizing the amount of testing offered., (Copyright (c) 2008 John Wiley & Sons, Ltd.)

Objective: The purpose of this study was to evaluate stepwise sequential screening for fetal aneuploidy., Study Design: Women who received first-trimester screening were also offered second-trimester tests with second-trimester risks that were based on both sets of markers. Screen-positive rates, use of second-trimester testing and invasive testing, sensitivity, and changes in risks were evaluated., Results: Of 1528 women who received first-trimester screening, 133 women (8.7%) had an indication for invasive testing that was based on first-trimester results alone; 1173 women (76.8%) received second-trimester tests, which reduced the net number of women with an indication for invasive testing to 105 (6.9%). In unaffected pregnancies, the addition of the second-trimester testing reduced the median Down syndrome risk from 1:2368 to 1:10,301. Six of 10 chromosome abnormalities (60%) were identified by first-trimester screening, and 9 of 10 chromosome abnormalities (90%) were identified by sequential screening., Conclusion: Sequential screening can be introduced successfully into clinical practice, is effective, and can reduce the number of invasive tests that are performed.

Objective: This study evaluated whether utilization of prenatal care, as measured by the Kessner index, affects the number of Down syndrome live births., Methods: A retrospective analysis of birth certificate data of Down syndrome live births comparing 1989 to 2001 by year, maternal age, gestational age at first prenatal visit, and adequacy of prenatal care according to Kessner categories of adequacy of prenatal care., Results: Down syndrome live births were inversely correlated with adequacy of prenatal care. Reductions in Down syndrome live births were seen in all categories of prenatal care in all age groups. In 2001 a minimum 30% reduction was seen in any category rising to a 58% reduction in women > or =35 years with adequate prenatal care. The largest reductions were seen in women > or =35 years of age., Conclusions: Reductions in Down syndrome live births occurred in all age groups between 1989 and 2001. Utilization of prenatal care as measured by the Kessner index was associated with reductions in Down syndrome live births, with a greater reduction in women > or =35 years of age.

Objective: To estimate the accuracy of evaluating nasal bone length, expressed as multiples of the median (MoM), for the detection of Down syndrome in second- trimester fetuses., Methods: Expected normal median nasal bone measurements were established for an initial cohort of women receiving fetal ultrasound examinations at 15-24 weeks of gestation. Nasal bone lengths were converted to MoM with adjustment for maternal race and ethnicity using whites as the referent group. Nasal bone MoM were compared in euploid and Down syndrome fetuses. The sensitivity and specificity were evaluated in this initial cohort and in a second cohort in which all ultrasound measurements were carried out prospectively., Results: For the combined data set, 10 of 21 affected pregnancies had an absence of the nasal bone (sensitivity 47.6%), but absence was noted in only 1 of 2,515 unaffected pregnancies (false-positive rate 0.04%). Using less than 0.80 MoM as a cutoff, the sensitivity was 20 of 21 (95.2%), and the false-positive rate was 185 of 2,515 (7.4%). Changing the cutoff to 0.75 MoM resulted in 18 of 21 (85.7%) sensitivity and 74 of 2,515 (2.9%) false-positive rate. Using medians derived from whites to calculate MoM for the entire population resulted in higher false-positive rates., Conclusion: Nasal bone length expressed as MoM seems to be an useful ultrasound marker for Down syndrome in second-trimester fetuses with a high sensitivity and a low false-positive rate., Level of Evidence: III.

Background: Analytical error affects 2nd-trimester maternal serum screening for Down syndrome risk estimation. We analyzed the between-laboratory reproducibility of risk estimates from 2 laboratories., Methods: Laboratory 1 used Bayer ACS180 immunoassays for alpha-fetoprotein (AFP) and human chorionic gonadotropin (hCG), Diagnostic Systems Laboratories (DSL) RIA for unconjugated estriol (uE3), and DSL enzyme immunoassay for inhibin-A (INH-A). Laboratory 2 used Beckman immunoassays for AFP, hCG, and uE3, and DSL enzyme immunoassay for INH-A. Analyte medians were separately established for each laboratory. We used the same computational algorithm for all risk calculations, and we used Monte Carlo methods for computer modeling., Results: For 462 samples tested, risk figures from the 2 laboratories differed >2-fold for 44.7%, >5-fold for 7.1%, and >10-fold for 1.7%. Between-laboratory differences in analytes were greatest for uE3 and INH-A. The screen-positive rates were 9.3% for laboratory 1 and 11.5% for laboratory 2, with a significant difference in the patients identified as screen-positive vs screen-negative (McNemar test, P<0.001). Computer modeling confirmed the large between-laboratory risk differences., Conclusion: Differences in performance of assays and laboratory procedures can have a large effect on patient-specific risks. Screening laboratories should minimize test imprecision and ensure that each assay performs in a manner similar to that assumed in the risk computational algorithm.

Objectives: To determine antenatal complications, mode of delivery, and birth outcomes for Saint Francis Hospital and Medical Center and Burgdorf Obstetric clinic patient population based on their body mass index (BMI)., Material and Methods: This is a retrospective cohort study of 2,270 women who delivered at our institution from 1996 to 2002. Our patient population ranged from ages 23.8 to 26.6 years. The majority of the patients in the study were Black or Hispanic. BMI at delivery was calculated. Maternal data were obtained from our computerized obstetrical database. Exclusion criteria included: nonviable fetus, no recorded maternal height or other incomplete data. For statistical analysis we used a one-way analysis of variance (ANOVA) and a post-hoc Tukey's test, using a computer statistics program (Statmost, Datamost Crop., Salt Lake City, UT), with, P<0.05 considerd significant., Results: This study revealed that those patients with a higher BMI had greater weight gain during pregnancy. Operative delivery rates were also higher with increasing BMI, as was the infant birth weight. Diabetes and hypertension were directly related to the BMI; the higher the BMI the higher their prevalence. The low number of events recorded did not allow a statistical comparison to determine any increase in shoulder dystocia., Conclusion: A statistically significant increase in rate of operative delivery, hypertension, diabetes and a trend toward higher birth weight are associated with increased maternal BMI.

Objective: The purpose of this study was to determine the influence of race and ethnicity on the expected nasal bone length (NBL) based on biparietal diameter (BPD) measured in second-trimester fetuses., Methods: We searched our ultrasound, obstetric, and cytogenetic databases for all second-trimester fetuses with measured NBLs. Fetuses with Down syndrome were identified and excluded from the analysis. Linear regression curves were generated for NBL by BPD according to race and ethnicity. Categories used were African American, Hispanic, Asian, and white. Analysis of variance was used to compare mean variation of observed from expected NBL by BPD according to race and ethnicity., Results: There were 717 fetuses with NBL-by-BPD pairs who were available for analysis in our population, including 139 African American, 58 Hispanic, 22 Asian, and 498 white fetuses. Nasal bone length was highly correlated with BPD for each race (P < .001). Mean variances of observed from expected NBL by BPD were statistically different according to race or ethnicity (P = .0092)., Conclusions: Race and ethnicity significantly affect the mean regression line of expected NBL by BPD among fetuses in the second trimester. Genetic sonographic norms, therefore, appear to require race- and ethnicity-specific formulas for NBL.

Objective: To determine the frequency of echogenic intracardiac focus (EIF) by race/ethnicity., Methods: We performed a retrospective analysis from January 1996 through June 2003. We reviewed all initial sonograms from 14 to 23 weeks gestation in singleton pregnancies. Mothers on admission for delivery provided race/ethnicity., Results: There were 8207 ultrasounds and deliveries that met study criteria. There were 4636 (56.5%) Caucasian, 2087 (25.4%) African-American, 1261 (15.4%) Hispanic and 223 (2.7 %) Asian subjects. There were 347 (4.2%) EIF detected. The frequency by race/ethnicity varied significantly (p < 0.0001)., Conclusions: This large, population-based study showed that fetuses born to Asian mothers were significantly more likely to have an EIF. This racial difference should be taken into account when counseling patients about the potential for Down syndrome.

Purpose: To identify trends in the utilization of second trimester maternal serum screening, follow-up amniocenteses, and the detection of Down syndrome-affected pregnancies between 1991 and 2003., Methods: We reviewed all triple and quadruple maternal serum screening tests referred to the University of Connecticut screening laboratory from women with singleton pregnancies. For each calendar year, the total number of tests, proportion to women aged 35 or older, number of follow-up amniocenteses, and the number of prenatally and postnatally diagnosed Down syndrome cases were recorded., Results: A total of 109,469 women received screening. In 1991, the proportion of older women who received screening was 58% of that present in the Connecticut population but by 2003 this had increased to 83% (P < 0.001). In Down syndrome screen-positive pregnancies, there was no significant change in the rate of amniocentesis utilization (average 73%), but in false-positives, there was a decline from 70% in 1991 to 27% in 2003 (P < 0.001)., Conclusion: Increased use of maternal serum screening by older women, use of second trimester ultrasound, and improvements in screening methodology have resulted in sharply reduced numbers of amniocenteses in unaffected pregnancies.

Objective: The purpose of this study was to compare the mitral valve-tricuspid valve distance in second-trimester fetuses with normal cardiac anatomy versus those fetuses with endocardial cushion defects., Study Design: We identified fetuses between 16 and 24 weeks of gestation. The distance between the insertions of the medial leaflets of the mitral and tricuspid valves were obtained. Linear regression curves were generated., Results: The mean mitral valve-tricuspid valve distance for 86 fetuses with normal cardiac anatomy was 2.02 mm, compared with 0.37 mm in 13 fetuses with endocardial cushion defects ( P = .0001). Linear regression curve correlating mitral valve-tricuspid valve distance with gestational age showed a gradual slope (R 2 = 0.28; P < .0001). With a mitral valve-tricuspid valve distance < 5th percentile as a marker for the diagnosis of endocardial cushion defect gave a sensitivity of 69.2%, a specificity of 100%, a positive predictive value of 100%, a negative predictive value of 95.6%, and a false-positive rate of 0% ( P = .0001)., Conclusion: The mitral valve-tricuspid valve distance is useful clinically in the detection of endocardial cushion defects in second-trimester fetuses.

Objective: We investigated the observed and expected Down syndrome livebirths in the US from 1989 to 2001., Study Design: Using birth certificate data, we recorded maternal age-specific live births from 1989 to 2001, and stratified them by women 15 to 34 and 35 to 49 years old. We estimated Down syndrome live births from 1989 to 2001, assuming no terminations. We recorded Down syndrome live births by year from 1989 to 2001., Results: Despite an expected 1.32-fold increase in Down syndrome live birth rates from 1989 to 2001, Down syndrome live births actually declined. In 1989, the rate of Down syndrome cases was 15% lower than expected, decreasing to 51% by 1998. Women 15 to 34 had 45% fewer affected pregnancies in 2001, while women 35 to 49 had 53% fewer in 2001. We estimated that Down syndrome live births decreased from 3962 in 1989 to 3654 in 2001., Conclusion: Down syndrome live births declined in the US despite an expected increase caused by delayed or extended childbearing.

Objective: The impact of prenatal screening for Down syndrome has largely been assessed under the assumption that screening protocols and policies are fully used. To measure the overall effectiveness in actual clinical practice, we analyzed the tests performed by a single cytogenetics laboratory., Methods: We reviewed all amniotic fluid and chorionic villus samples (CVS) processed by the University of Connecticut Health Center's cytogenetics laboratory for the years 1991 to 2002. We evaluated trends in the use of prenatal testing, referral indications, and the numbers of cytogenetic abnormalities identified., Results: The number of women receiving amniocentesis or CVS declined more than 50% from 1,988 in 1991 to 933 in 2002 (P <.001), despite an increase in the number of women of advanced maternal age in the population served. There was a 68% decline in the number of women who underwent invasive prenatal testing solely on the basis of their age (1,314 in 1991 to 423 in 2002, P <.001). The number of Down syndrome fetuses detected prenatally increased from 20 to 31 (P =.08), representing approximately one half of the affected pregnancies present in the population served. Between 1991 and 2002, the proportion of antenatal cytogenetic tests with a significant chromosomal abnormality increased from 1 in 43 (2.3%) to 1 in 14 (7.0%; P <.001)., Conclusion: Advances in maternal serum screening and second-trimester ultrasonography have resulted in more judicious use of amniocentesis and chorionic villus sampling., Level of Evidence: II-2

Objective: The fetal mechanical PR interval obtained via pulsed Doppler has previously been demonstrated to correlate with electrocardiographic PR interval measured in the neonate. We sought to further analyze the influence of fetal heart rate and gestational age upon the fetal mechanical PR interval., Methods: We searched our database for mechanical PR intervals, which were obtained during fetal echocardiography performed in our antenatal diagnostic unit. We included fetuses with a normal cardiac structural survey. The mechanical PR interval is measured from the A wave of the mitral valve to the beginning of ventricular systole corresponding to the opening of the aortic valve. Linear regression curves were generated to examine the correlation of mechanical PR interval with gestational age and fetal heart rate. Analysis of variance was used to compare the mean variation across three gestational age groups: 17-21.9 weeks (n = 24), 22-25.9 weeks (n = 52) and 26-38 weeks (n = 20)., Results: Mechanical PR intervals were measured in 96 fetuses with normal fetal echocardiography. The mechanical PR interval was 123.9 +/- 10.3 ms (mean +/- SD), with a range of 90-150 ms. Linear regression curves correlating mechanical PR interval with fetal heart rate and gestational age demonstrated a flat slope with R2 = 0.016, p = 0.22 and R2 = 0.0004, p = 0.85, respectively. The mechanical PR interval measured over the three gestational ages was as follows (mean +/- SD): 122.3 +/- 10.5 ms for 17-21.9 weeks; 125.0 +/- 9.6 ms for 22-25.9 weeks; and 123.1 +/- 11.9 ms for 26-38 weeks. Analysis of variance revealed no difference among the mechanical PR interval means measured over the three gestational age groups (p = 0.53)., Conclusions: Fetal mechanical PR interval ranges from 90 to 150 ms in fetuses with sonographically normal fetal cardiac structure and rate. The mechanical PR interval appears to be independent of gestational age and fetal heart rate.

Objective: To compare maternal and fetal outcomes after elective repeat Cesarean section versus a trial of labor in women after one prior uterine scar., Study Design: All women with a previous single low transverse Cesarean section delivered at term with no contraindications to vaginal delivery were retrospectively identified in our database from January 1995 to October 1998. Outcomes were first analyzed by comparing mother-neonate dyads delivered by elective repeat Cesarean section to those undergoing a trial of labor. Secondarily, outcomes of mother-neonatal dyads who achieved a vaginal delivery or failed a trial of labor were compared to those who had elective repeat Cesarean delivery., Results: Of 1408 deliveries, 749/927 (81%) had a successful vaginal birth after a prior Cesarean delivery. There were no differences in the rates of transfusion, infection, uterine rupture and operative injury when comparing trial of labor versus elective repeat Cesarean delivery. Neonates delivered by elective repeat Cesarean delivery were of earlier gestation and had higher rates of respiratory complications (p < 0.05). Mother-neonatal dyads with a failed trial of labor sustained the greatest risk of complications., Conclusion: Overall, neonatal and maternal outcomes compared favorably among women undergoing a trial of labor versus elective repeat Cesarean delivery. The majority of morbidity was associated with a failed trial of labor. Better selection of women likely to have a successful vaginal birth after a prior Cesarean delivery would be expected to decrease the risks of trial of labor.

The use of ultrasound in the diagnosis of twins, its role of determining chorionicity, the management of unique twin complications, the value of cervical length determination in twins, the use of ultrasound in screening for aneuploidy in multiples, and the intrapartum role of ultrasound in twin gestations have been reviewed. The availability of high-resolution ultrasound has significantly im-proved the management of multiple gestations.

Objective: To evaluate the efficacy of fetal nuchal fold thickness and proximal long bone biometric measurements in modifying Down syndrome serum screening risk in a population of women referred for second-trimester sonography., Methods: Sonographic biometric measurements and biochemical markers were combined retrospectively for 2533 women with known pregnancy outcomes. Four different screening methods were compared: (1) advanced maternal age; (2) biochemical serum screening markers; (3) modification of serum screening risks on the basis of categorical cutoffs for nuchal fold and femur and humerus length; and (4) a combined approach in which the sonographic measurements were treated as multiples of the medians and entered, together with the serum screening results, into a multivariable algorithm. The efficacy was compared at second-trimester risk cutoffs of 1:270 and 1:100., Results: Down syndrome was present in 30 of the 2533 pregnancies (1 in 84). With the use of the 1:270 cutoff, biochemical screening had 93% sensitivity and a 40% false-positive rate. With application of the categorical method of fixed cutoffs to incorporate fetal biometry, the false-positive rate was reduced to 33% with no loss of sensitivity. The combined model had 83% sensitivity and a 19% false-positive rate. The combined method had the highest positive predictive value (1 in 20). Similar gains in efficacy could be shown with the 1:100 cutoff., Conclusions: For this high-risk group, the multivariate model that combines serum screening and sonography can result in a substantial reduction in the number of amniocenteses. Although the addition of the sonographic biometric measurements resulted in some Down syndrome cases being missed, the net effect was a large improvement in the overall positive predictive value of the screening.

Objective: The study was undertaken to evaluate the influence of maternal race on fetal femur length when screening for Down syndrome., Study Design: We reviewed our patient databases to obtain fetal biometry from 15 to 22 weeks' gestation, maternal race, and cases of Down syndrome. Institution and race-specific regression lines for femur length (FL) to biparietal diameter (BPD) were created. The efficiency of using published expected FL was compared with our institution and race-specific regression in screening for Down syndrome., Results: There were 4350 African American, 4271 white, 2315 Hispanic, and 654 Asian subjects and 42 cases of Down syndrome (1:276) included in the study. Our institutionally derived regression for FL by BPD had an R(2) of 0.82. Regression lines for FL by BPD generated by race had an R(2) of 0.86, 0.84, 0.83, and 0.80 for African American, Hispanic, Asian, and white subjects, respectively. The race-specific regression was no better than institution-specific data., Conclusion: Using institution-specific FL was more efficient in screening for Down syndrome than published expected FL; race-specific analysis did not improve efficiency.

Objective: To determine the relationship between gestational age and renal pelvic anterior-posterior diameter and the feasibility of developing gestational age-specific thresholds for the diagnosis of mild pyelectasis., Methods: Cross-sectional study of 420 singleton fetuses between 16 and 39 weeks' gestation. The mean renal AP diameter as a function of gestational age was determined using fractional polynomial regression models and centile plots were generated. Assessment of goodness of fit for each regression model was performed., Results: There was a positive correlation between gestational age and renal pelvic AP diameter (Pearson's Correlation Coefficient 0.65). Using the derived mean and standard deviations of renal AP diameter, gestational-age specific 95% reference levels were generated. The sensitivity, specificity, positive, and negative predictive values of using the gestational age-specific cutoffs for predicting persistent postnatal renal anomaly were 80%; 99%; 29%; and 99% respectively., Conclusion: There is a positive correlation between gestational age and renal pelvic AP diameters. Reliable gestational age-specific renal AP thresholds for diagnosis of pyelectasis are provided., (Copyright 2003 John Wiley & Sons, Ltd.)

Objective: To determine the influence of race and ethnicity on the expected humeral length based on biparietal diameter measured in second-trimester fetuses., Methods: We searched our ultrasound, obstetric, and cytogenetic databases from 1995 through 2001 for all fetuses who underwent an anatomic survey between 15 and 22 weeks' gestation. Fetuses with Down syndrome were identified and removed for separate analysis. Linear regression curves were generated for humeral length by biparietal diameter according to race and ethnicity. Analysis of variance was used to compare the mean variation of observed from expected humeral length by biparietal diameter according to race and ethnicity., Results: There were 11,278 humeral length-by-biparietal diameter pairs that were available for analysis in our population, including 4202 African American, 2269 Hispanic, 639 Asian, and 4168 white fetuses. Humeral length was highly correlated with biparietal diameter for each race (R2 = 0.8). There were no differences in mean variances according to race or ethnicity (P = .75)., Conclusions: Race and ethnicity do not affect the mean regression line of expected humeral length by biparietal diameter among fetuses in the second trimester. Genetic sonographic norms, therefore, do not require race- or ethnic-specific formulas for humeral length.

Objective: To evaluate the efficacy of the second-trimester quadruple test (maternal serum alpha-fetoprotein, unconjugated estriol, human chorionic gonadotropin, and inhibin-A) in prenatal screening for Down syndrome., Methods: All quadruple tests performed on singleton pregnancies over a 32-month period were reviewed. The sensitivity and false-positive rates were compared with the theoretic rates predicted by the screening model when applied to a population of women with the same maternal age distribution., Results: Twenty-three thousand seven hundred four women with unaffected pregnancies and 45 women with Down syndrome-affected pregnancies received the quadruple test. Mean analyte values for both unaffected and affected pregnancies were similar to those expected. The sensitivity of the quadruple test, which was based on ascertainment of all viable affected pregnancies in the screened population, was 85.8%. This sensitivity did not significantly differ from an expected 83.8% (P =.8). The initial false-positive rate, 9.0%, was significantly below that expected (9.9%) (P =.002) and was further reduced to 8.2% after correction for major gestational age errors. The positive predictive value of the quadruple test was one in 51. Women with an affected pregnancy and a positive test result (true positives) generally had very high risks (median 1:22) relative to women with false-positive results (median risk 1:111)., Conclusion: The quadruple test meets or exceeds performance expectations and appears to represent an improvement over the widely used triple test.

Objective: To analyze the potential cost and efficacy of Down syndrome screening in the population with advanced maternal age., Methods: Three screening methods defining Down syndrome risk for women with advanced maternal age were analyzed: advanced maternal age; advanced maternal age and maternal serum triple screen; and advanced maternal age, maternal serum triple screen and genetic sonogram. Costs for all tests and procedures were estimated. Procedure-related loss for amniocentesis was assumed to be 1:200. Efficacy was defined as: number of amniocenteses performed, number of Down syndrome cases detected, procedure-related losses, Down syndrome cases detected per fetal loss, cost per Down syndrome case detected and total cost of screening., Results: In 1999 in the USA, there were 530,610 women with advanced maternal age at 16 weeks' gestation carrying an estimated 4,043 fetuses with Down syndrome. Screening by maternal age alone would result in the 100% detection of Down syndrome cases, but would require over 530,000 amniocenteses and result in 2,653 procedure-related losses. Combining age with serum screen and genetic sonogram would detect 97.6% of Down syndrome cases, but would require only 119,791 amniocenteses and result in 599 procedure-related losses. The projected cost per Down syndrome case detected using age screening is 219,109 dollars versus 155,992 dollars using serum screen and genetic sonogram., Conclusions: The combination of advanced maternal age, maternal serum screen and genetic sonogram would result in the fewest procedure-related losses and lowest cost per Down syndrome case detected.