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The world has encountered a new and serious epidemic which has disproportionately affected fetuses and infants. What makes the Zika virus (ZIKV) epidemic such a threat in our times, is that a whole generation can be affected by birth defects caused by a seemingly innocuous maternal infection, which in most cases go unnoticed and undiagnosed. Spreading to over 80 countries and affecting millions, it is associated with severe birth defects known as congenital Zika syndrome (CZS), which include fetal brain development abnormalities (microcephaly and brain calcifications), retinal abnormalities, and contractures and hypertonia of the extremities. Testing strategies are challenging because of the lack of symptoms and cross reactivity with other viral infections. Obstetrical complications include fetal loss and the need for an emergency cesarean delivery. The rate of CZS has been described as ranging from 5 to 6% among cohorts in the US, reaching 11% for 1st trimester exposure. Prolonged viremia during pregnancy has been documented in a few cases, reaching 89 days after the onset of symptoms in one case and 109 days after such onset in another. If the ZIKV can infect, multiply in, and persist in diverse placental cells, then movement across the placenta, the fetal brain, and the maternal peripheral blood is possible. There is a sense of urgency, and we need safe and effective vaccines and treatments, particularly for pregnant women. If we do not expand testing and develop methods for early diagnosis and treatment, thousands of infants will be exposed to a neurotropic virus that causes severe birth defects and that could also affect the lives of those who form the next generation.

Feto-fetal transfusion syndrome is a pathological process unique to diamniotic monochorionic pregnancies. It is the consequence of an unbalanced fetal blood flow through communicating vessels within a shared placenta. When it occurs, a polyuric, hypervolemic recipient twin co-exists with a hypovolemic oliguric donor. The presence of polyhydramnios or oligohydramnios is considered a poor prognostic indicator, whereas normal amniotic fluid volumes indicate a lack of clinically significant twintwin transfusion. In addition, the spontaneous normalization of amniotic fluid volume is usually seen as a favorable prognostic sign. Here, however, we present a case of feto-fetal transfusion in a 31 year-old primigravida at 19 week, in which the spontaneous normalization of amniotic fluid volume in the recipient twin preceded the death of the donor.

Down syndrome is the most studied chromosomal abnormality, and the risk of having a child with Down syndrome increases as maternal age increases. The prevalence of Down syndrome has been increasing in the last decade because more women older than 35 years of age are having children. In recent decades, the rate of identification of fetal anomalies in the uterus has substantially increased. Diagnostically speaking, serious concerns yet remain within the obstetrical community regarding who should be recommended for invasive procedures. The FASTER, SURUSS, and BUN studies have attempted to address this issue. In the United States, the quadruple screen for Down syndrome (hcG, AFP, estriol, and inhibin-A) is the most commonly used test today. During the first trimester, the nuchal translucency measurement combined with serum markers hcG and PAPP-A (pregnancy-associated plasma protein-A) results in high detection rates and low false-positive rates. For Down syndrome screening, new methods of evaluation have been proposed; among these are integrated, sequential, and contingent modalities. Different trials have demonstrated that first-trimester screening for Down syndrome is very effective, but all conclude that combining screening during both trimesters allows for lower false-positive values and higher detection rates. In Puerto Rico, in spite of the fact that a large proportion of the population undergoes serum screening, the rate of Down syndrome live births remains steady. One important aspect that appears to limit prenatal diagnosis of Down syndrome in our population is a poor acceptance rate of diagnostic testing techniques such as amniocentesis. Also, a limited efficiency in the implementation of these screening methods as well as their diagnostic success has been observed for our patient population.

Birth defects represent one of the main causes of infant mortality and morbidity around the world.The purpose of this study is to identify seasonal changes in the incidence of various congenital anomalies in our population.We identified all cases of open neural tube defects, cardiac anomalies, cleft lip and palate and gastroschisis of children born in Puerto Rico and reported to the Health's Department Birth Registry Program between January 1995 and December 2005. The conception dates were determined by estimation based on the reported last menstrual period. All deliveries during this same period were recorded and their conception dates estimated in the same manner. The data for each anomaly was separated into 4 groups for each year studied corresponding to the four seasons. The sample was stratified based on the type of anomaly detected and the season when conception took place.There is a seasonal pattern in the rate of conceptions in Puerto Rico with the highest incidence during the winter and lowest during the summer months. We detected a statistically significant increase in the incidence and relative risk during the summer months (using winter as a reference) of conceiving a child with open neural tube defects (1.03/1000, RR:1.33), cardiac anomalies (5.22/1000, RR:1.39), or cleft lip and palate (1.68/1000, RR:1.89). Gastroschisis did not show a statistically significant difference in the rate of conceptions, but there was a tendency towards a higher incidence during spring (0.39/1000, RR:1.67).The reported seasonal variation in the incidence of open neural tube defects, cardiac anomalies, and cleft lip and palate may be secondary to the effect of yet to be identified teratogens acting on the population at large, or, more likely, to changes in activity and dietary patterns of the population.

To evaluate fetal growth parameters throughout gestation in Puerto Rican women and compare them to other mixed U.S. populations.Cross-sectional study of 548 patients who met inclusion criteria of Puerto Rican ancestry, no history of drug, alcohol or tobacco use, no identifiable fetal anomalies, normal amniotic fluid and certainty of last menstrual period. Standard sonographic biometric data (biparietal diameter, occipito-frontal diameter, head circumference, abdominal circumference, femur length and estimated fetal weight) was obtained for each gestational age between 13 and 38 weeks and the 10th, 50th, and 90th percentile determined for each one. Results were compared to those of other mixed U.S. populations.Biometric data on fetal growth throughout gestation among Puerto Ricans is presented. Comparison with other mixed populations did not show any significant differences in fetal biometric measurements throughout pregnancy.Different to other ethnic groups, Puerto Ricans show similar fetal growth patterns as those reported from mixed U.S. populations. This information validates the use of these reference values in the evaluation of fetuses in Puerto Rico.

The purpose of this study is to identify seasonal changes in the incidence of Cleft lip and Palate (CL/P) in our population.All cases of isolated CL/P born in Puerto Rico from January 1998 through December 2002 were identified through the Puerto Rican birth defect registry. Conception dates were estimated based on the reported last menstrual period. All deliveries during this same period were recorded and their conception dates estimated in the same manner. The data was separated into 4 groups for each year studied corresponding approximately to the four seasons.484 cases of CL/P were identified among 308,968 live births (incidence 1.57/1000 live births. The lowest incidence of CL/P was seen during fall and winter (1.24 and 1.38/1000 live births respectively) and the highest during spring and summer (1.77 and 1.97/1000 live births respectively) (p = 0.002). The seasons with the highest incidence correspond to the period when the least number of conceptions are occurring. Estimation of relative risks using winter as a reference point (relative risk of 1.0) showed a decrease in the risk of CL/P in fall to .89 (95th confidence interval 0.88 - 1.57), an increase in the risk to 1.28 (CI 1.16 - 2.03) during spring and 1.42 (CI 1.16 - 2.03) during summer.The reported seasonal variation in incidence may be secondary to the action of yet to be identified teratogens acting on the population at large, or more likely, changes in activity and diet patterns of the population.

The purpose of this study is to report the range of renal congenital anomalies identified by ultrasonography and to analyze the indications for the ultrasound study that lead to their diagnosis.All cases of renal malformations diagnosed at our institution from June 2001 through May 2004 were evaluated retrospectively. The indications for sonographic evaluation were reviewed. Cases were divided into those referred for routine ultrasound screening and those referred with other indications. Results were expressed as percents of total.A total of 117 cases of renal congenital anomalies were identified, in 14 cases (11.9%), other congenital anomalies were also present. Hydronephrosis was the most common diagnosis detected in 64 cases (54.7%). There were 21 lethal renal anomalies identified (17.9%). Multicystic dysplastic kidneys were present in 21 cases (17.9%). Renal agenesis was identified in 15 cases (12.8%). Other detected anomalies were: bladder outlet obstruction 15 (12.8%), echogenic kidneys 13 (11.1%), ectopic ureteral implantation 2 (1.7%), renal cysts 1 (0.8%), pelvic kidney 3 (2.6%), double collecting system 1 (0.8%), and unilateral atrophic kidney 1 (0.8%). A total of 94 cases (80.3%) had no indications for sonographic evaluation other than routine screening.Relying on risk factors as indications for ultrasound studies will not detect the majority of congenital anomalies, especially those associated to the urogenital system, a group of conditions that may particularly benefit form prenatal detection.

Echogenic intracardiac foci (EIF) are small areas of increased echogenicity inside the fetal ventricles. When isolated, they are considered to be a normal finding with prevalence differing among ethnic groups. It has been described as a weak marker for trisomy 21 and other chromosomal anomalies. Little information exists regarding the incidence of these foci among Hispanic fetuses. We examined prospectively 485 normal fetuses between 14 and 32 weeks of gestation from January through March 2001. Nine cases of isolated intracardiac foci were identified (incidence of 1.8%). None of these cases had a chromosomal anomaly. Our data shows a frequency in our population similar to that reported among Caucasians.

Risk assessment for aneuploidy is an integral part of modern obstetrics. However, patients might choose or reject an amniocentesis, based, not on the risk, but on the screening method used. We examined records of patients referred for evaluation of aneuploidy risk from January 1999 to December 2000. Patients found to have a risk above 1/250 were offered amniocentesis. Out of 555 patients found at risk, 336 (60.5%) accepted. Acceptance rate varied depending on risk factor identified: advanced maternal age 178/290 (61.4%), abnormal serum screening 107/198 (54%), sonographic markers 35/48 (72.9%) or a previous child aneuploidy 16/19 (84.2%). The risk assessment method used influences significantly the amniocentesis acceptance rate and may affect sensitivity of testing.

Cesarean section is a common delivery route for breech fetuses1000 gm to prevent trauma. However, abdominal and vaginal delivery maneuvers are similar. Cesarean section avoids the risk of head entrapment but long bone trauma can still occur.We identified three neonates with femoral fractures during a one year period. All mothers were in active labor. All were premature newborns less than 32 weeks gestation, in breech presentation and delivered by a low vertical cesarean section. Review of all cesarean sections done due to mal presentation (n = 26) during that time showed 11 classic and 15 lower segment vertical incisions (both vertical and transverse).The interest to reduce maternal morbidity may prompt physicians to perform a low segment vertical incision for delivery of a preterm breech. This decision may increase the chances of trauma by providing less area for the required obstetric maneuvers.

Although highly popularized among obstetricians, there are conflicting results regarding the efficacy of high-resolution ultrasound and other fetal well-being tests on improving neonatal outcome and morbidity. To assess the impact of unrestricted fetal well-being tests and sonographic evaluations on the stillbirth rate, we evaluated a total of 1,810 pregnancies 20 weeks of gestation or more from a single private clinic serving a mixed population of high and low-risk patients. All patients were performed high-resolution sonography during each trimester of pregnancy. In addition, on each prenatal visit, fetal heart rate, position and amniotic fluid index were documented by a limited sonographic scan. Further sonographic studies were done whenever deemed necessary depending on the clinical situation. Biophysical profiles were performed in the third trimester at any time a risk factor was identified, and repeated as frequently as estimated necessary. All cases of fetal death in utero were documented and the associated maternal risk factors assessed. A total of 14 stillbirths occurred among the 1,810 patients. The stillbirth rate for this population was determined to be 7.7/1000 births (U.S. national average of 6.7-7.8/1000 births). The most common associated maternal complications were Diabetes (4 cases) and Antiphospholipid syndrome (3 cases). All except for one fetus lost at 37 weeks had at least one identifiable maternal risk factor. These results prove that intensive fetal surveillance, even when unrestricted by economic concerns, has limited effectiveness in avoiding fetal demise. This is most probably due to acute placental and cord accidents that cannot be detected promptly enough or that are simply unavoidable.

Family planning is essential to most prenatal care programs. It is generally believed that maternal age influences the planning of pregnancy with younger patients having higher incidences of unplanned pregnancies. To test this hypothesis we evaluated 470 consecutive cases of pregnant patients regarding pregnancy planning in their current pregnancy. A total of 170 (36.1%) were planned. The incidence of planned pregnancies was evaluated among three age groups and results were as follows: less than 20 years old, 18/60 (30.0%), patients 20 to 29 years old, 105/270 (37%) and more than 29 years old, 47/140 (33.6%). These differences were not statistically significant. Surprisingly, no differences among age groups regarding pregnancy planning were identified in this study.

A nationwide program directed at stimulating the preconceptional use of folic acid (FA) for the prevention of open neural tube defects has been in effect in Puerto Rico for the last 4 years. To evaluate its effectiveness, 479 questionnaires were distributed among pregnant patients. The average age was 27 (range 14-21), and 64.9% of the pregnancies were unplanned. Preconceptional use of FA was 31.5%, despite 87.7% of patients reporting knowledge about the importance of FA use. Only 35.4% of patients who had knowledge about FA used it prior to conception. Among patients who planned their pregnancies and knew about the importance of FA, 92/168 (54.6%) used it prior to pregnancy. With these dismal results, we believe these campaigns should re-evaluate their educational strategies and consider reduction of unplanned pregnancies as part of their goals.

To examine the incidence of obstetric complications in fetuses with unrecognized chromosomal anomalies compare with those in which the diagnosis was known before hand.All cases followed at a private facility in San Juan, PR during the time from January 1993 through February 1997 were evaluated in terms of gestational age and method of diagnosis and eventual pregnancy outcome.There where 9 cases of chromosomal anomalies documented by karyotype analysis among 1377 (0.65%). Among this group, 5 cases were detected by a combination of maternal serum screening, analysis of risk factors and sonography. Among these, 3 cases elected pregnancy termination, one case of trisomy 21 was delivered stillborn vaginally at 32 weeks and one case of trisomy 18 delivered vaginally at 29 weeks. Among the 4 cases not recognized prenatally, one case of trisomy 21 was delivered at 27 weeks by classical cesarean section due to malpresentation and 3 cases (2 of trisomy 18 and one trisomy 21) where delivered by emergency transverse cesarean section due to suspected fetal hypoxia.The very high frequency of emergency cesarean section (100%) among fetuses with unrecognized major chromosomal anomalies should make us increase our efforts to obtain at prenatal diagnosis. In all of these cases, a prior diagnosis would have probably avoided a cesarean section and the associated potential maternal morbidity.The high incidence of emergency cesarean section among fetuses with unrecognized chromosomal anomalies should make prenatal diagnosis of these conditions a primary goal.

A preliminary investigation to test the efficacy of intravenous propranolol in reducing the cesarean section rate in nulliparas in active labor and evaluate its effect on neonatal and maternal outcomes.Fifty seven nulliparous patients admitted in active labor were randomly divided into two groups: a control group consisting of 23 patients, and a treatment group consisting of 34 patients given 2 mg of propranolol intravenously every 4 hours until delivery. Total length of labor, time from first administration of medication to delivery, incidence of cesarean section, APGAR scores, maternal and fetal morbidity were assessed.A total of 4 cesarean sections were performed in each group (11.7% in the treatment group and 17.3% in the control group). The rate of cesarean section due to dystocia was 6.25 and 13.6% respectively (P = .367). Statistical significance was not reached due to the small number of subjects (students t test analysis). There was no increase in the incidence of low APGAR scores, intensive care unit admissions, abnormal heart rate patterns during labor, cesarean sections for fetal distress or maternal morbidity in the treated group.Intravenous administration of 2 mg of propranolol every four hours is safe and not associated to increased neonatal or maternal morbidity. A 50% decrease in the incidence of cesarean sections can be documented among nulliparous patients treated with propranolol although the small numbers and overall low incidence of cesarean section in our population (14%) did not permit these differences to reach statistical significance.