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Telemedicine has transformed our ability to access and offer mental healthcare. There remain key questions to facilitate scalable, patient-centered solutions for perinatal mental health. We critically evaluate the recent literature and propose potential future directions.The current literature highlights the promise of telemedicine in the prevention and treatment of perinatal depression, including the preference for and the potential efficacy of telemedicine-delivered mental healthcare when compared to in-person treatments. There remains a need for large, adequately powered randomized controlled trials; integration of trauma into depression and anxiety trials, transdiagnostic treatment of perinatal women, and scaling up these effective treatments into existing health and payer systems. Pragmatic, evidence-based solutions exist to effectively scale-up treatments for perinatal mental health. While research is underway to address the growing treatment gap, questions remain regarding who will deliver and pay for these treatments and how we can leverage telemedicine to treat perinatal mental health transdiagnostically.

Depression is one of the most common complications of childbirth, and is experienced by approximately 17% of pregnant women and 13% of postpartum women. An estimated 85% of these women go untreated-an alarming statistic given the serious consequences for the mother, her child, other family members, and society. Professional societies (the American College of Obstetricians and Gynecologists and American Academy of Pediatrics) have recommended improvements in screening and treatment. Meta-analyses indicate that cognitive behavioral therapy eHealth interventions are efficacious for depression, generally, and for perinatal depression, specifically. Earlier controlled trials have established the effectiveness and acceptability of MomMoodBooster (including an Australian version, MumMoodBooster), an eHealth program for ameliorating postpartum depression.This study aimed to evaluate the effectiveness of a perinatal version of MomMoodBooster encompassing both prenatal and postpartum content in a healthcare delivery setting already providing universal screening and referral of at-risk patients as part of routine care.A practical effectiveness study randomly assigned 95 pregnant and 96 postpartum women screened as depressed and satisfying eligibility criteria to experimental groups: the healthcare organization's perinatal depression care program (routine-care group) and routine care+MomMoodBooster2 program (eHealth group). Eligibility criteria included: pregnant or1 year postpartum, ≥18 years of age, no active suicidal ideation, access to broadband internet via desktop/laptop, tablet, or smartphone, and English language proficiency.Intent-to-treat analyses of group effects used fixed-effects growth models to assess 12-week posttest change in outcomes. Results showed that both groups had significantly decreased depression severity, anxiety, stress, and automatic thoughts, and increased behavioral activation and self-efficacy. Relative to the routine-care group, the eHealth group displayed significantly greater decreases in depression severity and stress. These group comparisons were not moderated by depression severity (screening or baseline), anxiety, stress, or pregnant/postpartum status. Almost all (93%; n=89) women in the eHealth group visited their program, of whom 99% visited program sessions (M sessions visited=4.3±2.0; M total session duration=73.0±70.2 minutes; 49% viewed all 6 sessions). Among confirmed eHealth program users who provided ratings, 96% (79/82) rated their program as easy to use, 83% rated it helpful, and 93% (76/82) indicated that they would recommend it.Results support the effectiveness of using MomMoodBooster2 as a treatment option for perinatal women with depression, especially when combined with universal depression screening and referral. Consequently, the eHealth program shows promise as a tool to increase the reach of treatment delivery and to potentially reduce the number of untreated perinatal women with depression.

Item does not contain fulltext OBJECTIVE: To evaluate the associations of depressive symptoms and antidepressant use during pregnancy with the risks of preterm birth, low birth weight, small for gestational age (SGA), and low Apgar scores. DATA SOURCES: MEDLINE, EMBASE, ClinicalTrials.gov, and PsycINFO up to June 2016. METHODS OF STUDY SELECTION: Data were sought from studies examining associations of depression, depressive symptoms, or use of antidepressants during pregnancy with gestational age, birth weight, SGA, or Apgar scores. Authors shared the raw data of their studies for incorporation into this individual participant data meta-analysis. TABULATION, INTEGRATION, AND RESULTS: We performed one-stage random-effects meta-analyses to estimate odds ratios (ORs) with 95% CIs. The 215 eligible articles resulted in 402,375 women derived from 27 study databases. Increased risks were observed for preterm birth among women with a clinical diagnosis of depression during pregnancy irrespective of antidepressant use (OR 1.6, 95% CI 1.2-2.1) and among women with depression who did not use antidepressants (OR 2.2, 95% CI 1.7-3.0), as well as for low Apgar scores in the former (OR 1.5, 95% CI 1.3-1.7), but not the latter group. Selective serotonin reuptake inhibitor (SSRI) use was associated with preterm birth among women who used antidepressants with or without restriction to women with depressive symptoms or a diagnosis of depression (OR 1.6, 95% CI 1.0-2.5 and OR 1.9, 95% CI 1.2-2.8, respectively), as well as with low Apgar scores among women in the latter group (OR 1.7, 95% CI 1.1-2.8). CONCLUSION: Depressive symptoms or a clinical diagnosis of depression during pregnancy are associated with preterm birth and low Apgar scores, even without exposure to antidepressants. However, SSRIs may be independently associated with preterm birth and low Apgar scores. SYSTEMATIC REVIEW REGISTRATION: PROSPERO, CRD42016035711.

BACKGROUND: During the COVID-19 pandemic, essentially all outpatient psychotherapy with perinatal patients transitioned to telemedicine. The aim of this study was to examine how to resume in-person psychotherapy with perinatal patients within the Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) trial as the pandemic abates. METHODS: We conducted focus groups and individual interviews with perinatal participants (n=23), providers (n=28), and a range of stakeholders (n=18) who participated in the SUMMIT trial from August 2020 to March 2021. Content analysis was used to examine (1) previous barriers that impacted perinatal participants access or decision to access in-person healthcare during COVID-19; (2) perceived future barriers for perinatal participants to attend in-person sessions; and (3) potential facilitators to resuming in-person sessions with perinatal participants. RESULTS: Perinatal participants (69.6%) and providers (57.1%) reported that COVID-19 previously impacted perinatal SUMMIT patients’ access or decision to access in-person healthcare. Specifically, “external barriers” such as institutional regulations due to COVID-19 (100% perinatal participants and 68.8% providers) and “internal barriers” such as concerns about being exposed to COVID-19 (75.0% perinatal participants and 56.3% providers) impacted perinatal participants access to in-person care. Perceived barriers to resuming in-person psychotherapy sessions included concerns about virus exposure in a hospital setting (77.8% stakeholders, 73.9% perinatal participants, 71.4% providers); virus exposure while taking public transportation (50.0% stakeholders, 26.1% perinatal participants, 25.0% providers). Stakeholders (50.0%) were more likely than providers (25.0%) and participants (13.0%) to endorse wearing a mask during sessions as a barrier. Key facilitators to resuming in-person psychotherapy sessions were the implementation and effective communication of robust safety protocols (72.2% stakeholders, 47.8% perinatal participants, 39.3% providers) and providing alternative locations to where sessions are delivered, e.g., using large rooms (44.4% stakeholders, 32.1% providers, 17.4% perinatal participants). CONCLUSION: The results suggest that a significant majority of perinatal participants experienced barriers to accessing in-person healthcare during the pandemic, and concerns about contracting the virus within and en route to the hospital remain while the COVID-19 pandemic persists. To overcome these barriers, our study suggests that implementing and effectively communicating robust safety protocols may be the most effective methods to address these concerns when resuming in-person psychotherapy sessions.

Screens and adjunctive treatments for perinatal mood are available, but barriers prevent many women from receiving them. Mobile technology may help bypass barriers. The purpose of this study was to evaluate the feasibility of screening and texting perinatal women via their personal smartphones. This prospective cohort study enrolled 203 pregnant and postpartum women receiving obstetric care at a Midwestern US academic medical center. Participants received one electronic mood screen and three text messages per week for two weeks. Texts were based on the Mothers and Babies Course, a CBT-based preventative program that addresses limited social support, lack of pleasant activities, and harmful thought patterns. Feasibility was defined as the ability to take the mood screen and receive texts without technical difficulties. Demographic variables were paired with results. Insurance type (private or public) was used as a proxy for socioeconomic status. Pearson chi-squared tests were used to analyze the data. A text-based satisfaction survey was also administered. The sample was 72% privately insured and 28% publicly insured. Sixty-seven percent completed electronic screening. Screen completion was significantly associated with private insurance (OR = 3.8, 95% CI 2.00-7.30) and "married" status (OR = 1.93, 95% CI 1.01-3.70). Most survey respondents (92%) found it easy to receive the texts, and 76% responded with very favorable comments about the texts. Smartphone mood screening and supportive texting were technically feasible. Screen completion was lower among single women with public insurance.

Background: Male medical student interest in the field of obstetrics-gynecology has significantly decreased in the last three decades. A perceived patient preference for female obstetrician- gynecologists (Ob-Gyn) and subsequent gender differences in clinical productivity and compensation may influence this trend. Objective: To explore how provider gender affects clinical productivity and salary among obstetrics- gynecology generalists. Methods: An analysis of productivity and salary data for generalist Ob-Gyns employed by an academic integrated health system was performed. Gross charges, net collections, physician payroll information, work relative value units (wRVUs), new and existing patient encounter volumes and clinical full-time equivalent (FTE) status were compared year over year by physician gender using a repeated measures ANOVA test. Results: On average, male providers earned a numerically higher salary in each year studied, but when the entire timeframe was evaluated, there was no significant difference in salary nor total productivity between women and men (p=0.19 and 0.15, respectively). There was a gender difference in how total productivity was achieved, with women seeing twice as many new patients (p= 0.0025), and men achieving higher average wRVUs per patient encounter (p=0.02). Conclusions: There was no significant difference in total productivity and there was no significant difference in salaries between male and female Ob-Gyns. However, there were differences in the type of care that contributed to productivity by gender. Female providers saw a higher proportion of new patient encounters, while male providers accrued a higher wRVU per encounter, likely as a result of higher procedure volumes. These findings are an encouraging sign that men are not disadvantaged in terms of productivity in obstetrics-gynecology and that compensation models such as the one in this system can promote fair payment in mixed-gender physician groups.

Background Depression and anxiety impact up to 1 in 5 pregnant and postpartum women worldwide. Yet, as few as 20% of these women are treated with frontline interventions such as evidence-based psychological treatments. Major barriers to uptake are the limited number of specialized mental health treatment providers in most settings, and problems with accessing in-person care, such as childcare or transportation. Task sharing of treatment to non-specialist providers with delivery on telemedicine platforms could address such barriers. However, the equivalence of these strategies to specialist and in-person models remains unproven. Methods This study protocol outlines the Scaling Up Maternal Mental healthcare by Increasing access to Treatment (SUMMIT) randomized trial. SUMMIT is a pragmatic, non-inferiority test of the comparable effectiveness of two types of providers (specialist vs. non-specialist) and delivery modes (telemedicine vs. in-person) of a brief, behavioral activation (BA) treatment for perinatal depressive and anxiety symptoms. Specialists (psychologists, psychiatrists, and social workers with ≥ 5 years of therapy experience) and non-specialists (nurses and midwives with no formal training in mental health care) were trained in the BA protocol, with the latter supervised by a BA expert during treatment delivery. Consenting pregnant and postpartum women with Edinburgh Postnatal Depression Scale (EPDS) score of ≥ 10 (N = 1368) will be randomized to one of four arms (telemedicine specialist, telemedicine non-specialist, in-person specialist, in-person non-specialist), stratified by pregnancy status (antenatal/postnatal) and study site. The primary outcome is participant-reported depressive symptoms (EPDS) at 3 months post-randomization. Secondary outcomes are maternal symptoms of anxiety and trauma symptoms, perceived social support, activation levels and quality of life at 3-, 6-, and 12-month post-randomization, and depressive symptoms at 6- and 12-month post-randomization. Primary analyses are per-protocol and intent-to-treat. The study has successfully continued despite the COVID-19 pandemic, with needed adaptations, including temporary suspension of the in-person arms and ongoing randomization to telemedicine arms. Discussion The SUMMIT trial is expected to generate evidence on the non-inferiority of BA delivered by a non-specialist provider compared to specialist and telemedicine compared to in-person. If confirmed, results could pave the way to a dramatic increase in access to treatment for perinatal depression and anxiety. Trial registration ClinicalTrials.gov NCT 04153864. Registered on November 6, 2019.

During the COVID-19 pandemic, outpatient psychotherapy transitioned to telemedicine. This study aimed to examine barriers and facilitators to resuming in-person psychotherapy with perinatal patients as the pandemic abates. We conducted focus group and individual interviews with a sample of perinatal participants (n = 23), psychotherapy providers (n = 28), and stakeholders (n = 18) from Canada and the U.S. involved in the SUMMIT trial, which is aimed at improving access to mental healthcare for perinatal patients with depression and anxiety. Content analysis was used to examine perceived barriers and facilitators. Reported barriers included concerns about virus exposure in a hospital setting (77.8% stakeholders, 73.9% perinatal participants, 71.4% providers) or on public transportation (50.0% stakeholders, 26.1% perinatal participants, 25.0% providers), wearing a mask during sessions (50.0% stakeholders, 25.0% providers, 13.0% participants), lack of childcare (66.7% stakeholders, 46.4% providers, 43.5% perinatal participants), general transportation barriers (50.0% stakeholders, 47.8% perinatal participants, 25.0% providers), and the burden of planning and making time for in-person sessions (35.7% providers, 34.8% perinatal participants, 27.8% stakeholders). Reported facilitators included implementing and communicating safety protocols (72.2% stakeholders, 47.8% perinatal participants, 39.3% providers), conducting sessions at alternative or larger locations (44.4% stakeholders, 32.1% providers, 17.4% perinatal participants), providing incentives (34.8% perinatal participants, 21.4% providers, 11.1% stakeholders), and childcare and flexible scheduling options (31.1% perinatal participants, 16.7% stakeholders). This study identified a number of potential barriers and illustrated that COVID-19 has fostered and amplified barriers. Future interventions to facilitate resuming in-person sessions should focus on patient-centered strategies based on empathy regarding ongoing risk-aversion among perinatal patients despite existing safety protocols, and holistic thinking to make access to in-person psychotherapy easier and more accessible for perinatal patients.

We assessed differential item functioning (DIF) based on computerized adaptive testing (CAT) to examine how perinatal mood disorders differ from adult psychiatric disorders. The CAT-Mental Health (CAT-MH) was administered to 1614 adult psychiatric outpatients and 419 perinatal women with IRB approval. We examined individual item-level differences using logistic regression and overall score differences by scoring the perinatal data using the original bifactor model calibration based on the psychiatric sample data and a new bifactor model calibration based on the perinatal data and computing their correlation. To examine convergent validity, we computed correlations of the CAT-MH with contemporaneously administered Edinburgh Postnatal Depression Scales (EPDS). The rate of major depression in the perinatal sample was 13 %. Rates of anxiety, mania, and suicide risk were 5, 6, and 0.4 %, respectively. One of 66 depression items, one of 69 anxiety items, and 15 of 53 mania items exhibited DIF (i.e., failure to discriminate between high and low levels of the disorder) in the perinatal sample based on the psychiatric sample calibration. Removal of these items resulted in correlations of the original and perinatal calibrations of r = 0.983 for depression, r = 0.986 for anxiety, and r = 0.932 for mania. The 91.3 % of cases were concordantly categorized as either "at-risk" or "low-risk" between the EPDS and the perinatal calibration of the CAT-MH. There was little evidence of DIF for depression and anxiety symptoms in perinatal women. This was not true for mania. Now calibrated for perinatal women, the CAT-MH can be evaluated for longitudinal symptom monitoring.

To estimate the incidence and clinical significance of suicidal ideation revealed during perinatal depression screening and estimate the associated suicide risk.Retrospective cohort study of women completing the Edinburgh Postnatal Depression Scale at 24-28 weeks of gestation and 6 weeks postpartum through a suburban integrated health system with approximately 5,000 annual deliveries on two hospital campuses. Suicidal ideation on the Edinburgh Postnatal Depression Scale and prediction of suicide risk were examined through multivariable modeling and qualitative analysis of clinical assessments.Among 22,118 Edinburgh Postnatal Depression Scale questionnaires studied, suicidal ideation was reported on 842 (3.8%, 95% confidence interval [CI] 3.5-4.1%) and was positively associated with younger maternal age (antepartum mean age 30.9 compared with 31.9 years, P=.001), unpartnered relationship status (antepartum 29.5% compared with 16.5%, P.001 and postpartum 25.0% compared with 17.5%, P.01), non-Caucasian race (antepartum 62.1% compared with 43.8%, P.001 and postpartum 62.4% compared with 45.2%, P.001), non-English language (antepartum 11.0% compared with 6.6%, P.001 and postpartum 12.4% compared with 7.7%, P.01), public insurance (antepartum 19.9% compared with 12.5%, P.001 and postpartum 18.2% compared with 14.2%, P.001), and preexisting psychiatric diagnosis (antepartum 8.4% compared with 4.2%, P.001 and postpartum 12.0% compared with 5.8%, P.001). Multivariable antepartum and postpartum models retained relationship status, language, relationship status by language interaction, and race; the postpartum model also found planned cesarean delivery negatively associated with suicidal ideation risk (odds ratio [OR] 0.56, 95% CI 0.36-0.87) and severe vaginal laceration positively associated with suicidal ideation risk (OR 2.1, 95% CI 1.00-4.40). A qualitative study of 574 women reporting suicidal ideation indicated that 330 (57.5%, 95% CI 53.5-61.5%) experienced some degree of suicidal thought. Six patients (1.1%, 95% CI 0.2-1.9%) demonstrated active suicidal ideation with plan, intent, and access to means. Within this highest risk group, three patients reported a suicide attempt within the perinatal period.Among perinatal women screened for depression, 3.8% reported suicidal ideation, but only 1.1% of this subgroup was at high risk for suicide. These findings support the need for systematic evaluation of those who report suicidal ideation to identify the small subset requiring urgent evaluation and care.

To explore the potential of an integrated outpatient electronic health record (EHR) for preconception health optimization. An automated case-finding EHR-derived algorithm was designed to identify women of child-bearing age having outpatient encounters in an 85-site, integrated health system. The algorithm simultaneously cross-referenced multiple discrete data fields to identify selected preconception factors (obesity, hypertension, diabetes, teratogen use including ACE inhibitors, multivitamin supplementation, anemia, renal insufficiency, untreated sexually transmitted infection, HIV positivity, and tobacco, alcohol or illegal drug use). Surveys were mailed to a random sample of patients to obtain their self-reported health profiles for these same factors. Concordance was assessed between the algorithm output, survey results, and manual data abstraction. Between 8/2010-2/2012, 107,339 female outpatient visits were identified, from which 29,691 unique women were presumed to have child-bearing potential. 19,624 (66 %) and 8,652 (29 %) had 1 or ≥2 health factors, respectively while only 1,415 (5 %) had none. Using the patient survey results as a reference point, health-factor agreement was similar comparing the algorithm (85.8 %) and the chart abstraction (87.2 %) results. Incorrect or missing data entries in the EHR encounters were largely responsible for discordances observed. Preconception screening using an automated algorithm in a system-wide EHR identified a large group of women with potentially modifiable preconception health conditions. The issue most responsible for limiting algorithm performance was incomplete point of care documentation. Accurate data capture during patient encounters should be a focus for quality improvement, so that novel applications of system-wide data mining can be reliably implemented.

FROM: Khalifeh H, Hunt IM, Appleby L, et al . Suicide in perinatal and non-perinatal women in contact with psychiatric services: 15 year findings from a UK national inquiry. Lancet Psychiatry 2016;3(3):233–42. Perinatal suicide is a rare but tragic complication of pregnancy and childbirth with significant public health implications.1 Among women with psychiatric illness, prior research suggests that suicide risk may be increased as much as 70-fold if compared with the general population.2 Beyond this, little is known about risk factors for completed suicide among perinatal women and there is a lack of population-based research on this topic. The authors used 1997–2012 data from the UK National Confidential Inquiry into Suicide and Homicide by People with Mental Illness, which includes all suicides by people in the UK (age ≥10 years) who had been in contact with psychiatric services in the previous year. The study sample comprised all women who died by suicide in pregnancy …

To investigate obstetric care provider attitudes toward perinatal depression screening and factors associated with variable screening rates. Provider attitudes about depression screening were investigated via structured interviews (open-ended and rating scale questions) and analyzed using qualitative content analysis. Most providers (86%) found screening effective at identifying women at risk for perinatal depression (average rating of 8.7 on 10-point analog scale). However, 95% overestimated their own screening rates and 67% inaccurately thought they achieved universal screening. Providers not directly involved in their office-based screening process demonstrated lower average screening rates (37%) than those who maintained active involvement (59%; p = 0.07). Obstetric care providers support perinatal depression screening in the context of a program that assumes responsibility for processing screens, conducts assessments of at-risk women and provides referrals to mental health professionals. Provider participation in screening and tying screening to routine obstetric outpatient activities such as glucose tolerance testing are associated with higher screening rates.

Over the last century, the incidence of placenta accreta, increta, and percreta, collectively referred to as morbidly adherent placenta, has risen dramatically. Planned cesarean hysterectomy at the time of cesarean delivery is the standard recommended treatment in the United States. Recently, interest in conservative management has resurged, especially in Europe. The aims of this review are the following: (1) to provide an overview of methods used for conservative management, (2) to discuss clinical implications for both clinicians and patients, and (3) to identify areas in need of further research.

Objective To evaluate the performance and use of second-trimester multiple-marker maternal serum screening for trisomy 21 by women who had previously undergone first-trimester combined screening (nuchal translucency, pregnancy-associated plasma protein A, and free beta-hCG), with disclosure of risk estimates. Methods In a multicenter, first-trimester screening study sponsored by the National Institute of Child Health and Human Development, multiple-marker maternal serum screening with alpha-fetoprotein, unconjugated estriol, and total hCG was performed in 4,145 (7 with trisomy 21) of 7,392 (9 with trisomy 21) women who were first-trimester screen-negative and 180 (7 with trisomy 21) of 813 (52 with trisomy 21) who were first-trimester screen-positive. Second-trimester risks were calculated using multiples of the median and a standardized risk algorithm with a cutoff risk of 1:270. Results Among the first-trimester screen-negative cohort, 6 of 7 (86%) trisomy 21 cases were detected by second-trimester multiple-marker maternal serum screening with a false-positive rate of 8.9%. Among the first-trimester screen-positive cohort, all 7 trisomy 21 cases were also detected in the second trimester, albeit with a 38.7% false-positive rate. Conclusion Our data demonstrate that a sequential screening program that provides patients with first-trimester results and offers the option for early invasive testing or additional serum screening in the second trimester can detect 98% of trisomy 21-affected pregnancies. However, such an approach will result in 17% of patients being considered at risk and, hence, potentially having an invasive test. Level of evidence II-2

OBJECTIVE: To identify potential geographic and temporal clustering of folate-sensitive fetal malformations as a prelude to a targeted preconception curriculum in folic acid supplementation. METHODS: Our comprehensive prenatal anomaly database was queried to select fetal malformations presumed to be sensitive to preconception folate insufficiency. Evidence of geographic clustering was evaluated by distribution of individual cases using zip codes of maternal residence. Potential temporal clustering of anomalies was sought by tabulating the frequency of each anomaly category during 5 consecutive 2-year intervals between 1992 and 2001. RESULTS: Over a 10-year period, approximately 2000 fetal anomalies were identified, of which 400 (20%) were considered potentially folaic sensitive. We found geographic clustering of ventral wall defects as well as obstructive uropathy by zip code analysis. Significant increases in the frequencies of cardiac defects (P

Objective To describe the process of training for measuring nuchal translucency at five clinical centers in North America and to evaluate methods of quality assurance and feedback. Design Throughout a period of 18 months, the performance of sonographers in measuring fetal nuchal translucency was monitored using qualitative and quantitative methods of review. After 12 months, different approaches (written and personal feedback) were used to inform sonographers of technical aspects that needed to or could be improved. Results On initial qualitative review, discrepancies in judgment from different reviewers coincided with suboptimal magnification, failure to visualize the amniotic membrane and/or use of cross-shaped calipers. At subsequent global review, 13 (29%) images of nuchal translucency measurements were considered unacceptable. Quantitative assessment revealed that, during the first part of the study, the means from four sonographers were significantly smaller and the mean from the fifth sonographer was significantly larger than expected on the basis of findings from The Fetal Medicine Foundation (P < 0.0001). Following feedback, sonographers who underestimated nuchal translucency and who received a written report only did not change measurements overall ( P = 0.9759). In contrast, those who received additional intervention showed a marked difference ( P < 0.0001). Conclusions Global qualitative review of images from one sonographer may be preferable to assessment of individual aspects of images. Results from global qualitative review correspond well with findings from quantitative analysis, indicating that the latter can be applied for ongoing audit. Observation of divergent results should prompt extensive personal feedback, rather than a written report, to prevent sonographers from settling in their own, inappropriate technique.

Objective: To compare lamellar body counts with the lecithin/sphingomyelin ratio and phosphatidylglycerol analysis in terms of assessment of risk of respiratory distress syndrome (RDS). Methods: Lamellar body counts, lecithin-sphingomyelin ratios (L/Ss), and phosphatidylglycerol levels were assessed in 1611 amniotic fluid samples obtained at four clinical sites from pregnant women whose fetuses were at risk for RDS. Cases in which delivery occurred within 72 hours of sample collection (n = 833) were analyzed. Specific cutoffs for predicting the likelihood of RDS for both the lamellar body count and the L/S had been derived previously at each of the clinical sites based on receiver operating characteristic curves using unrelated samples, whereas phosphatidylglycerol was reported as either mature (present) or immature (absent). Standard clinical and radiographic criteria were used to diagnose RDS, and the diagnosis was confirmed by review of newborn records. Results: One hundred (12.0%) of the 833 infants delivered within 72 hours of sample collection developed RDS. The negative predictive value of the lamellar body count (97.7%) was similar to that of the L/S (96.8%) and slightly better than that of phosphatidylglycerol analysis (94.7%) (P = .048). The lamellar body count performed as well as phospholipid analysis irrespective of gestational age or patient population. Conclusion: The lamellar body count compares favorably with traditional phospholipid analysis as an assay for assessment of fetal lung maturity. Lamellar body counts are preferable because they are faster, more objective, less labor intensive, less technique dependent, and less expensive and because they can be performed with equipment available in every hospital laboratory.

Objective:To determine the role of endothelin (ET) in fetal and placental growth in rats with and without long-term nitric oxide synthase (NOS) inhibition.Methods:Pregnant rats were treated with Nω...

BACKGROUND: Diabetes insipidus is rare in pregnancy. It is characterized by hypoosmolar polyuria and may be central, nephrogenic, or transient in etiology; the latter is presumably related to excess placental vasopresinase production. In theory, fetal effects of this endocrine condition may include hydramnios secondary to fetal polyuria. CASE: A pregnant patient developed rapid-onset second-trimester hydramnios that prompted a thorough fetal and maternal evaluation. She ultimately was diagnosed with transient diabetes insipidus of pregnancy because of an abrupt change in her voiding pattern at 20 weeks of gestation, significant polydipsia, and laboratory studies that revealed a hypoosmolar polyuria with normal serum and urine electrolytes. Transient neonatal polyuria also was confirmed in association with this unique maternal endocrine syndrome. CONCLUSION: The most likely cause of hydramnios in this case is transient maternal diabetes insipidus of pregnancy from excessive secretion of placental vasopressinase resulting in fetal polyuria. In cases of hydramnios of unknown etiology, if a history of maternal polyuria is elicited and confirmed, diabetes insipidus of pregnancy may play a role in some cases.

To identify risk factors for severe (third/fourth degree) perineal laceration with operative vaginal delivery (OVD, forceps or vacuum).Case-control study comparing singleton OVDs with or without severe laceration (n=138).In multivariable analyses, severe perineal laceration was associated with occiput posterior (OP) position at delivery, vaginal nulliparity, use of forceps, longer period pushing in the second stage and lower gestational age, but not birth weight, labor induction or episiotomy. Among 29 OP patients at full dilation, 9/13 (69%) attempted rotations to occiput anterior (OA) were successful, and 14/16 (88%) patients in whom rotation was not attempted remained OP at delivery. Successful rotation from OP to OA was associated with fewer severe lacerations than no attempt or unsuccessful rotation (22 vs 75%, P=0.01).Severe perineal laceration during OVD is associated with OP position at delivery and is reduced threefold in patients successfully rotated from OP to OA.

To characterize the active phase of labor in triplet pregnancies and compare it with gestational age-matched twins and singletons. Active phase rates were calculated beginning at 5 cm of dilation for women with triplet gestations longer than 24 weeks who labored and reached the second stage. Twin and singleton cohorts that also completed the first stage of labor were matched for gestational age at deliverty (± 1 week), parity, and epidural use. Intrapartum variables included oxytocin use (induction or augmentation, duration of infusion, and maximum dosage), cervical dilation at membrane rupture, and active phase dilation rate. Thirty-two triplet pregnancies met inclusion criteria between January 1994 and September 1998 and were each compared with twin and singleton cases in a 1:2 ratio. Triplet and twin active phase rates, while similar (1.8 versus 1.7 cm/hour, respectively), were significantly lower than the mean singleton dilation rate (2.3 cm/hour, P = .02). No other intrapartum variables differed between the three groups. Despite controlling for gestational age of delivery, mean birth weights were significantly higher in singletons and correspondingly lower in twins and triplets (2493 versus 2112 and 1968 g, respectively; P = .001). An analysis of active phase dilation rates as a function of the cumulative birth weight per pregnancy demonstrated an inverse correlation, with slower progress in active labor associated with increasing total fetal weight (R = − .24; P = .002). Triplet and twin active phase dilation proceeds at a slower rate than that observed in singleton pregnancies. The rate of active phase dilation is inversely correlated to total fetal weight.

Objective: Treatment with heparin and low-dose aspirin improves fetal survival among women with antiphospholipid syndrome. Despite treatment, however, these pregnancies are frequently complicated by preeclampsia, fetal growth restriction, and placental insufficiency, often with the result of preterm birth. Small case series suggest that intravenous immune globulin may reduce the rates of these obstetric complications, but the efficacy of this treatment remains unproven. This pilot study was undertaken to determine the feasibility of a multicenter trial of intravenous immune globulin and to assess the impact on obstetric and neonatal outcomes among women with antiphospholipid syndrome of the addition of intravenous immune globulin to a heparin and low-dose aspirin regimen. Study Design: This multicenter, randomized, double-blind pilot study compared treatment with heparin and low-dose aspirin plus intravenous immune globulin with heparin and low-dose aspirin plus placebo in a group of women who met strict criteria for antiphospholipid syndrome. All patients had lupus anticoagulant, medium to high levels of immunoglobulin G anticardiolipin antibodies, or both. Patients with a single live intrauterine fetus at ≤12 weeks' gestation were randomly assigned to receive either intravenous immune globulin (1 g/kg body weight) or an identical-appearing placebo for 2 consecutive days each month until 36 weeks' gestation in addition to a heparin and low-dose aspirin regimen. Maternal characteristics, obstetric complications, and neonatal outcomes were compared with the Student t test and the Fisher exact test as appropriate. Results: Sixteen women were enrolled during a 2-year period; 7 received intravenous immune globulin and 9 were given placebo. The groups were similar with respect to age, gravidity, number of previous pregnancy losses, and gestational age at the initiation of treatment. Obstetric outcomes were excellent in both groups, with all women being delivered of live-born infants after 32 weeks' gestation. The rates of antepartum complications such as preeclampsia, fetal growth restriction, and placental insufficiency (as manifested by fetal growth restriction or fetal distress) were similar between the 2 groups. Gestational age at delivery (intravenous immune globulin group, 34.6 ± 1.1 weeks; placebo group, 36.7 ± 2.1 weeks) and birth weights (intravenous immune globulin group, 2249.7 ± 186.1 g; placebo group; 2604.4 ± 868.9 g) were similar between the 2 groups. There were fewer cases of fetal growth restriction (intravenous immune globulin group, 0%; placebo group, 33%) and neonatal intensive care unit admission (intravenous immune globulin group, 20%; placebo group, 44%) among the infants in the intravenous immune globulin group than those in the placebo group, but these differences were not significant. Conclusion: A multicenter treatment trial of intravenous immune globulin is feasible. In this pilot study intravenous immune globulin did not improve obstetric or neonatal outcomes beyond those achieved with a heparin and low-dose aspirin regimen. Although not statistically significant, the findings of fewer cases of fetal growth restriction and neonatal intensive care unit admissions among the intravenous immune globulin–treated pregnancies may warrant expansion of the study. (Am J Obstet Gynecol 2000;182:122-7.)

The objective of this study was to evaluate the effect of increased circulating endothelin on fetal and placental growth in the rat. Indwelling arterial and venous catheters were placed on day 14 of a 22-day gestation in timed-pregnant Sprague-Dawley rats. Saline, 0.2 nmol/kg/h endothelin, or 0.5 nmol/kg/h endothelin was continuously infused from day 15 through 21 in randomly assigned animals (n = 12 in each group). Maternal arterial blood pressure and serum endothelin levels were evaluated on days 15, 18, and 21 of gestation. On day 21, pregnancy outcome data including fetal and placental weights, litter size, and the occurrence of stillbirths were ascertained, and fetal blood was obtained for serum endothelin levels. All data were compared among the three groups, and statistical significance was determined by analysis of variance. Endothelin infusion resulted in a dose-dependent decrease in fetal and placental weights when compared to saline-treated pregnancies. A significant increase in maternal arteri...

Objective: To compare pregnancy outcome in twin gestations resulting from multifetal reduction to "primary" twin pregnancies derived from either spontaneous conception or infertility therapy. Design: Case-control study. Setting: University-affiliated tertiary center. Patient(s): Multifetal pregnancies (quadruplets or more) reduced to twins (group A) compared with twin gestations conceived either spontaneously (group B) or through infertility therapy (group C). Intervention(s): Multifetal reduction for group A; perinatal care for groups A, B, and C. Main Outcome Measure(s): Comparison of perinatal complications between groups including antepartum bleeding, premature membrane rupture, and preterm labor. Neonatal outcomes compared including gestational age at delivery, birth weight, incidence of fetal growth restriction, and twin discordancy. Result(s): A higher incidence of idiopathic preterm labor was noted in group A cases (14/18) compared with either of the control groups (B: 26/54, or C: 24/54). As a consequence, group A had the lowest gestational age at delivery (32.6 ± 3.9 weeks) compared with groups B (33.6 ± 4.4 weeks) and C (36.0 ± 3.4 weeks). Corresponding birth weights of both first- and second-born twins were significantly lower in group A compared with group C, whereas the birth weight comparison between groups A and B showed a nonsignificant difference. The proportion of pregnancies in which one or both twins weighed less than the 10th percentile was greatest in group A pregnancies (A: 5/18 versus C: 5/54). Discordant birth weight among twin pairs was proportionately greater for group A cases at both the 20% and 30% discordance levels. Conclusion(s): Twin gestations resulting from multifetal reduction are at increased risk for preterm birth, fetal growth restriction, and discordancy when compared with fertility therapy-derived, nonreduced twins.

Prostaglandin metabolites, including thromboxane, prostacyclin, and platelet-activating factor, may participate as intermediaries in the pathophysiology of the primary antiphospholipid syndrome (PAPS). In order to determine safe and effective therapies for patients with PAPS, we must improve our knowledge base and specific understanding of the mechanisms that link circulating antiphospholipid antibodies to decidual vasculopathy and fetal death. A review of current research is presented along with an evaluation of medical therapy whose rationale for use is consistent with current evidence.

We wished to identify the types and frequencies of malformations among continuing pregnancies exposed to chorionic villus sampling (CVS) and to determine whether selected procedure-related variables differ between the normal and anomalous cohorts. CVS was performed in 1048 patients between May 1988 and January 1992. Prospective assessment of perinatal outcome was ascertained by (1) physician-patient phone contact within 1 week of sampling, (2) ultrasound evaluation of the fetal anatomy at mid-gestation, (3) a detailed post-partum questionnaire completed by the referring obstetrician, and (4) a telephone interview with each patient after the expected date of confinement. Twenty-seven major malformations were documented among 938 pregnancies (live born, n = 934; electively terminated, n = 4), and included cardiac malformations (5), hypospadias (5), craniosynostosis (2), pyloric stenosis (2), inguinal hernia (2), polydactyly (2), syndactyly, distal extremely hemimelia, anencephaly, hydrocephalus, cleft lip and palate, omphalocele, diaphragmatic hernia, thanatophoric dysplasia, and unilateral cataract. Normal and anomalous cohorts were similar with respect to sampling method (transabdominal/transcervical ratio), mean gestational age at CVS, single-pass success rate, and mean total sample weight. No relationship between any procedure-related variable and the risk of malformation was observed.

Objective: We compared the use of aspirin alone with combined therapy (prednisone plus aspirin) in antiphospholipid antibody-positive obstetric patients with prior adverse pregnancy outcome. Study Design: Thirty-nine patients meeting specific laboratory and clinical inclusion criteria were randomized to receive either combined therapy (prednisone plus low-dose aspirin, n = 17) or aspirin alone ( n = 22). The daily aspirin dose was 81 mg; prednisone was begun at 20 mg/day and increased or decreased on the basis of observed changes in serial antibody levels. Perinatal outcomes were compared between groups. Evaluation of treatment-related maternal complications and serial antibody titers was also accomplished. Results: Thirty-four randomized subjects were evaluable (prednisone plus low-dose aspirin, n = 12 vs aspirin only, n = 22); no perinatal losses were observed in the study cohort. Preterm delivery was experienced by significantly more patients receiving prednisone plus low-dose aspirin than aspirin only (8/12 vs 3/22, respectively; p = 0.003), and prednisone exposure appeared to be an independent risk factor for preterm birth. Conclusions: The use of prednisone therapy in conjunction with low-dose aspirin does not appear to improve outcome and may provoke obstetric complications in antiphospholipid antibody-positive patients.

Enhanced endothelial cell PAF synthesis has been identified as a consequence of anticardiolipin antibody (ACA)-positive serum exposure. We proposed this observation as a contributing factor to thrombogenesis in women with the antiphospholipid syndrome. Since acetylsalicylic acid (ASA) is an accepted therapeutic alternative in these patients, we sought to determine if ASA would attenuate endothelial cell PAF production resulting from ACA exposure. Using primary, confluent monolayers of umbilical vein endothelial cells, experiments were performed to evaluate PAF synthesis after incubation with antibody-positive serum and ASA. Total PAF and its radyl-derivatives (1-alkyl- and 1-acyl-PAF) were quantified by tritiated acetate incorporation, phospholipid extraction, thin-layer chromatography and scintillation spectroscopy. ASA consistently decreased ACA-induced PAF synthesis (No ASA, 9573 ± 443 vs 1mmol/L ASA, 4829 ± 838 dpm/ml; p=0.016) and the observed reduction was dose-dependent over a range of ASA concentrations (0.1, 1, 10 and 100 mmol/L; ANOVA, p=.00015). Reduced PAF synthesis was also observed in cultures exposed to ASA and incubated with antibody-negative serum. These observations suggest that in ACA-positive women, the antithrombotic effects of ASA may relate in part, to reduced endothelial cell PAF synthesis.

Pregnant women who are placed on hospitalized bed rest experience increased antepartum-related distress. We sought to examine the efficacy of a single session music or recreation therapy intervention to reduce antepartum-related distress among women with high-risk pregnancies experiencing extended antepartum hospitalizations.In a randomized, single-blinded study, participants (n = 80) received 1 hour of music or recreation therapy or were placed in an attention-control group. Antepartum-related distress was measured by the Antepartum Bedrest Emotional Impact Inventory, which was administered before and after the intervention and at a follow-up period between 48 and 72 hours.Significant associations were found between the delivery of music and recreation therapy and the reduction of antepartum-related distress in women hospitalized with high-risk pregnancies. These statistically significant reductions in distress persisted over a period of up to 48-72 hours.Single session music and recreation therapy interventions effectively alleviate antepartum-related distress among high-risk women experiencing antepartum hospitalization and should be considered as valuable additions to any comprehensive antepartum program.

Objective: Because of the widespread use of antiphospholipid antibody testing in the evaluation of patients with recurrent pregnancy loss, we evaluated the consistency of results among laboratories testing for anticardiolipin antibody and the lupus anticoagulant. Study Design: A questionnaire regarding methods used and samples of blood from 20 patients were sent to five university-based and five commercial facilities for antiphospholipid antibody testing. Results: The responses of the participating laboratories to the questionnaires revealed significant differences in methods, standardization, and units of reporting. For anticardiolipin antibody, the number of specimens found to be positive for any isotype (immunoglobulin G, M, or A) varied considerably among laboratories, with a range of 5 to 13. All laboratories were in agreement (i.e., at least one isotype was present or all were absent) for only 5 of 20 specimens (25%). In contrast, lupus anticoagulant results were more reproducible, although one facility reported results markedly discordant from the other four laboratories. Conclusion: These observations suggest that significant interlaboratory variation exists in antiphospholipid antibody, and particularly anticardiolipin antibody, testing and might lead to unnecessary therapeutic interventions.

The objective of the study was to examine mental health referrals outcomes among obstetric patients at risk for depression.Fifty-one perinatal women who were offered mental health referrals were queried about their behaviors at 4 steps in the treatment engagement process and factors facilitating or impeding each step.Although 59% of at-risk women accepted mental health referrals, only 27% ultimately engaged in treatment. Women who proactively sought help via a hotline were more likely to accept referrals (P.001), contact a referred provider (P.001), and engage in treatment (P.05) than those who received unsolicited referrals after screening at-risk for depression. Barriers to successful treatment linkage were identified at the patient, provider, and system levels.Only a minority of women who are at risk for perinatal depression and receive mental health referrals ultimately engage in treatment. Successful linkage may be enhanced via interventions targeting identified barriers; such interventions require prospective evaluation.

Circulating antiphospholipids have been linked to recurrent pregnancy loss by a mechanism involving placental and decidual thrombosis. We hypothesized that platelet-activating factor, an autacoid synthesized by vascular endothelium, might mediate this phenomenon through its ability to promote platelet aggregation and fibrin deposition. Alternatively, antiphospholipid antibodies might exert a procoagulant effect by inhibiting the synthesis of prostacyclin. To evaluate these theories, endothelial cells (harvested from human umbilical veins) were grown to confluence and incubated for 48 hours with 20% concentrations of anticardiolipin antibody-positive and -negative human sera as well as fetal bovine serum. After incubation culture wells were stimulated with 10 mumol/ml calcium ionophore A23187 (an agonist of platelet-activating factor and prostacyclin synthesis). Intracellular platelet-activating factor was measured by tritiated acetate incorporation, phospholipid extraction, thin-layer chromatography, and scintillation spectrophotometry. Enhanced platelet-activating factor synthesis was identified in cultures incubated with anticardiolipin antibody-positive serum (25,544 +/- 2604 disintegrations per minute, mean +/- SD) when compared with anticardiolipin antibody-negative serum (18,600 +/- 3316 dpm) or fetal bovine serum (19,014 +/- 4233 dpm; analysis of variance, p = 0.033). In similar experiments, prostacyclin synthesis was determined by measuring its primary metabolite, 6-keto-prostaglandin F1 alpha, in culture supernatants. No differences between anticardiolipin antibody-positive and control cultures were observed (analysis of variance, p = 0.90). We conclude that in this endothelial cell model, anticardiolipin antibody-positive serum enhances ionophore-mediated platelet-activating factor synthesis but has no apparent effect on the production of prostacyclin. These findings suggest a potential role for platelet-activating factor in anticardiolipin antibody-mediated vascular thrombosis.

Supernatants from human trophoblast cultures have been reported to be both suppressive and stimulatory of mitogen-induced T-lymphocyte transformation. These discordant observations have been attributed to methodologic differences among laboratories, but may instead relate to inadvertant cellular contamination during long-term culture. Retrieval of chorionic villi for genetic analysis has provided an opportunity to evaluate the immunoregulatory activity of the isolated villus preparation, unencumbered by extended culture techniques. Primary cytotrophoblast cultures were established from karyotypically and clinically normal pregnancies and the supernatants were recovered. Allogenic mononuclear cells, stimulated by phytohemagglutinin, were uniformly inhibited by trophoblast supernatant (mean inhibition, 34.3%). This inhibition was verified in one-way, mixed lymphocyte cultures and suppression of T cells occurred in a dose-dependent fashion over a range of trophoblast supernatant concentrations. No evidence of suppressor T-cell induction by trophoblast supernatant was noted with the use of both phenotypic studies of lymphocytes incubated with trophoblast supernatant and a functional suppressor T-cell inducer assay. We believe that the immunoregulatory properties of trophoblast supernatants identified with the use of these methods more closely approximate the paracrine function of the in situ villus.

A case of posterior urethral valve syndrome is presented. Four weeks after a normal 24-week ultrasound examination, diminished amniotic fluid, megacystis, and renal hyperechogenicity were observed. A repeat ultrasound examination at 30 weeks' gestation identified oligohydramnios and increased renal echogenicity. These findings prompted the performance of a percutaneous cystocentesis to assess fetal renal function indirectly. The specimen was evaluated for osmolality and sodium and chloride concentrations. The urine electrolyte concentrations (sodium 115 mEq/L; chloride 93 mEq/L) and the osmolality (230 mOsm/L) were elevated, suggesting impaired renal function and a poor prognosis. Despite these findings, aggressive management was used, including administration of antenatal corticosteroids and elective preterm delivery. A percutaneous cystocentesis was required during the infant's initial resuscitation, followed by a difficult urethral catheterization. Ultimately, a vesicostomy performed on day 4 of life was associated with prompt return of renal function (serum creatinine 0.7 mg/dL at the time of discharge). At 6 months of age, normal renal function has been documented and the vesicostomy has been closed. This case demonstrates the potential limitations of available prognostic criteria in evaluating fetal urinary obstruction and residual renal function. In selected cases (when the onset of obstruction is documented in the third trimester), refinement of these prognostic criteria may be indicated. Similar cases may be best managed by preterm delivery and prompt postnatal decompression.

Objective The purpose of this study was to estimate the prevalence of maternal depressive risk in patients during the third trimester and to determine whether unique at-risk women are identified when the data are compared with postpartum screening. Study Design As part of a comprehensive program for universal perinatal depression screening and behavioral health referral of at-risk women, patients completed the Edinburgh Postnatal Depression Scale both during pregnancy (24-28 weeks of gestation) and again at 6 weeks after delivery. Based on Edinburgh Postnatal Depression Scale scores of ≥12, the prevalence of antepartum depressive risk and the rates of concordant/discordant risk status with the corresponding postpartum results were calculated. Discordant-risk cases were further analyzed to determine whether obstetric, psychosocial, or demographic variables were associated with changing risk status over time. Results We screened 1584 women in the third trimester and again after delivery: 7.7% and 6.8% of the women scored in the at-risk range in the antepartum and postpartum time frames, respectively; 88.9% of patients had the same risk status, and 11.1% were discordant before and after delivery. Statistically significant associations were found between premature birth, newborn infant admission to the intensive care nursery, and acquisition of postpartum depressive risk. Conclusion Screening for depression in the third trimester resulted in a comparable prevalence rate of depressive risk identification when compared with the postpartum time frame. Unique women were identified before and after delivery who may have been missed if screening had not been performed twice.

To assess the feasibility of applying postoperative objective criteria for preoperative evaluation of scheduled gynecologic cases.A preoperative evaluation program was introduced in which all surgeons were asked to voluntarily submit a 1-page case summary questionnaire for each elective gynecologic surgical procedure. A committee of departmental peers reviewed each submission for appropriateness of indications and completeness of preoperative evaluation. Cases were evaluated against quality assessment criteria sets created by the American College of Obstetricians and Gynecologists. Reviewed summaries were categorized as either meeting criteria, not meeting criteria but appropriate, not meeting criteria or no pertinent criteria available for the procedure planned.In all, 2,005 elective gynecologic surgical procedures were performed by 70 active surgeons during the 1-year study period; 1,166 procedures (58%) were reported. Of 70 surgeons, 57 reported at least 1 procedure, but only 6 were 100% compliant with their surgical submissions. In total, 1,008 procedures (86% of reported cases) met the criteria or were deemed appropriate by committee review. In 166 instances, additional information was requested from and provided by the surgeon before the case could be adjudicated.A voluntary program of preoperative surgical case review for scheduled gynecologic procedures appeared feasible but resulted in only modest initial participation.

To develop a department-based program to identify and treat women at risk for perinatal depression.Private and employed physician groups were engaged to conduct antepartum maternal depression screening using the Edinburgh Postnatal Depression Scale. A comprehensive program was established to ensure that patients identified as being at risk would receive appropriate care. The program 1) developed a network of existing community mental health providers to accommodate screen-positive referrals, 2) created a 24/7 hotline staffed by mental health workers to respond to urgent/emergent patient needs, 3) provided nursing and physician education via a comprehensive curriculum on perinatal depression, and 4) facilitated outpatient depression screening that included a centralized scoring and referral system.A total of 4,322 women completed 4,558 screens during the initial 24 months (June 2003-May 2005). Although initial uptake of the screening program was gradual, all 20 departmental obstetric practices were screening their patients at the end of the first year. Depression screening was accomplished between 28-32 weeks of gestation, and postpartum screening (during the 6-week postpartum visit) was subsequently added. Overall, 11.1% of women screened positive in the antenatal period, and 7.3% screened positive in the postnatal period. Three hundred three women were referred for evaluation and care.Department-based, perinatal depression screening was feasible when individual physician practices were not required to develop the infrastructure necessary to respond to at-risk patients. We believe that the provision of clinical safety nets (mental health provider network and the hotline) were essential to the universal acceptance of this program by practitioners.III.

We sought to evaluate the association between first trimester nuchal translucency measurement and the risk for major congenital heart defect in chromosomally normal fetuses.First trimester (10 weeks 4 days of gestation to 13 weeks 6 days of gestation) nuchal translucency was obtained in a large prospective multicenter National Institute of Child Health and Human Development study for Down syndrome prediction. The study, which was conducted between May 1998 and December 2000, was restricted to singleton pregnancies. Gestational age was determined by crown rump length measurements. Perinatal outcomes were determined and included the frequency of major congenital heart defect, which was defined as those cases that potentially could require surgery, intensive medical therapy, or prolonged follow-up time. Logistic regression analysis was used to determine whether nuchal translucency was a significant predictor of congenital heart defect.There were 8167 chromosomally normal pregnancies, of which 21 cases of major congenital heart defect were identified at follow-up examination (incidence, 2.6/1000 pregnancies). The risk of congenital heart defect rose with increasing nuchal translucency measurements. The mean nuchal translucency value for the normal and congenital heart defect groups were 1.5 mm and 1.9 mm, respectively (P = .05). With a nuchal translucency measurement of2.0 mm, the incidence of congenital heart defect was 13 of 6757 pregnancies (1.9 of every 1000 pregnancies). At 2.0 to 2.4 mm, the incidence was 5 of 1032 pregnancies (4.8 of every 1000 pregnancies). At 2.5 to 3.4 mm, the incidence was 2 of 335 pregnancies (6.0 of every 1000 pregnancies). Ator = 3.5 mm, the incidence was 1 of 43 pregnancies (23 of every 1000 pregnancies). Logistic regression analysis confirmed that nuchal translucency was associated significantly with congenital heart defect (odds ratio, 2.1; 95% CI, 1.4-3.1; P = .0004).Increased first trimester nuchal translucency measurement was associated with a higher risk of major congenital heart defect in chromosomally normal pregnancies. The practical implications of our findings are that patients with unexplained elevations of nuchal translucency may need referral for a fetal echocardiogram.

OBJECTIVE: To evaluate the potential relationship between placental disruption in weeks 13 and 14 and the subsequent development of gestational hypertension or preeclampsia. METHODS: Using subjects recruited during a randomized trial funded by the National Institute of Child Health and Human Development, which compared early amniocentesis and late transabdominal chorionic villas sampling (CVS) in weeks 13 and 14, rates of gestational hypertension and preeclampsia were compared between cases with varying degrees of placental disruption. RESULTS: A total of 3,698 of 3,775 randomized subjects had cytogenetically normal pregnancies and were analyzed. A significantly higher rate of hypertension/preedampsia was observed in the late CVS group (5.4%, n = 1,878) compared with the early amniocentesis cohort (3.5%, n = 1,820; P = .005). This difference persisted after controlling for maternal age, body mass index, parity, previous preterm delivery, smoking, and fetal gender. Early amniocentesis cases were further stratified on the basis of whether the placenta had been penetrated (n = 460) or not (n = 1,360). Risk of hypertensive complications was lowest if the placenta was not traversed (3.4%), greater with placental penetration (3.9%), and highest when the placenta was directly sampled during CVS (5.4%, P = .02). CONCLUSION: We hypothesize that focal disruption of the placenta at 13-14 weeks may increase the risk of hypertension/preeclampsia. These findings provide support for the theory that disturbances in early placentation lead subsequently to maternal hypertension.

The well-documented risks associated with perinatal depression provide a strong argument for universal screening. However, uncertainty about what to do with findings is a significant barrier to implementing screenings where obstetric care is provided. Based on experience with a comprehensive screening program, we describe a protocol for those critical communication pathways that encourage a dynamic phone exchange between a mental health caller and the patient who has scored in the high range on the Edinburgh Postnatal Depression Scale. In addition, we present guidelines for developing an action plan for addressing intervention needs and closing the feedback loop to the original administrators of the scale.