The use of assisted reproductive technology has increased in the United States in the past several decades. Although most of these pregnancies are uncomplicated, in vitro fertilization is associated ...with an increased risk for adverse perinatal outcomes primarily caused by the increased risks of prematurity and low birthweight associated with in vitro fertilization pregnancies. This Consult discusses the management of pregnancies achieved with in vitro fertilization and provides recommendations based on the available evidence. The recommendations by the Society for Maternal-Fetal Medicine are as follows: (1) we suggest that genetic counseling be offered to all patients undergoing or who have undergone in vitro fertilization with or without intracytoplasmic sperm injection (GRADE 2C); (2) regardless of whether preimplantation genetic testing has been performed, we recommend that all patients who have achieved pregnancy with in vitro fertilization be offered the options of prenatal genetic screening and diagnostic testing via chorionic villus sampling or amniocentesis (GRADE 1C); (3) we recommend that the accuracy of first-trimester screening tests, including cell-free DNA for aneuploidy, be discussed with patients undergoing or who have undergone in vitro fertilization (GRADE 1A); (4) when multifetal pregnancies do occur, we recommend that counseling be offered regarding the option of multifetal pregnancy reduction (GRADE 1C); (5) we recommend that a detailed obstetrical ultrasound examination (CPT 76811) be performed for pregnancies achieved with in vitro fertilization and intracytoplasmic sperm injection (GRADE 1B); (6) we suggest that fetal echocardiography be offered to patients with pregnancies achieved with in vitro fertilization and intracytoplasmic sperm injection (GRADE 2C); (7) we recommend that a careful examination of the placental location, placental shape, and cord insertion site be performed at the time of the detailed fetal anatomy ultrasound, including evaluation for vasa previa (GRADE 1B); (8) although visualization of the cervix at the 18 0/7 to 22 6/7 weeks of gestation anatomy assessment with either a transabdominal or endovaginal approach is recommended, we do not recommend serial cervical length assessment as a routine practice for pregnancies achieved with in vitro fertilization (GRADE 1C); (9) we suggest that an assessment of fetal growth be performed in the third trimester for pregnancies achieved with in vitro fertilization; however, serial growth ultrasounds are not recommended for the sole indication of in vitro fertilization (GRADE 2B); (10) we do not recommend low-dose aspirin for patients with pregnancies achieved with IVF as the sole indication for preeclampsia prophylaxis; however, if 1 or more additional risk factors are present, low-dose aspirin is recommended (GRADE 1B); (11) given the increased risk for stillbirth, we suggest weekly antenatal fetal surveillance beginning by 36 0/7 weeks of gestation for pregnancies achieved with in vitro fertilization (GRADE 2C); (12) in the absence of studies focused specifically on timing of delivery for pregnancies achieved with IVF, we recommend shared decision-making between patients and healthcare providers when considering induction of labor at 39 weeks of gestation (GRADE 1C).
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
Coronavirus disease 2019 (COVID-19) has been declared a public health emergency for the entire United States. Providing access to prenatal health care while limiting exposure of both obstetric health ...care professionals and patients to COVID-19 is challenging. Although reductions in the frequency of prenatal visits and implementation of telehealth interventions provide some options, there still remains a need for patient–health care professional visits. A drive-through prenatal care model was developed in which pregnant women would remain in their automobiles while being assessed by the health care professional, thus reducing potential patient, health care professional, and staff exposure to COVID-19. Drive-through prenatal visits would include key elements that some institutions cannot perform by telehealth encounters, such as blood pressure measurements for evaluation for hypertensive disorders of pregnancy, fetal heart rate assessment, and selected ultrasound-based measurements or observations, as well as face-to-face patient–health care professional interaction, thereby reducing patient anxiety resulting from the reduction in the number of planned clinic visits with an obstetric health care professional as well as fear of virus exposure in the clinic setting. We describe the rapid development of a drive-through prenatal care model that is projected to reduce the number of in-person clinic visits by 33% per patient compared with the traditional prenatal care paradigm, using equipment and supplies that most obstetric clinics in the United States can access.
DNA methylation is thought to be an important determinant of human phenotypic variation, but its inherent cell type specificity has impeded progress on this question. At exceptional genomic regions, ...interindividual variation in DNA methylation occurs systemically. Like genetic variants, systemic interindividual epigenetic variants are stable, can influence phenotype, and can be assessed in any easily biopsiable DNA sample. We describe an unbiased screen for human genomic regions at which interindividual variation in DNA methylation is not tissue-specific.
For each of 10 donors from the NIH Genotype-Tissue Expression (GTEx) program, CpG methylation is measured by deep whole-genome bisulfite sequencing of genomic DNA from tissues representing the three germ layer lineages: thyroid (endoderm), heart (mesoderm), and brain (ectoderm). We develop a computational algorithm to identify genomic regions at which interindividual variation in DNA methylation is consistent across all three lineages. This approach identifies 9926 correlated regions of systemic interindividual variation (CoRSIVs). These regions, comprising just 0.1% of the human genome, are inter-correlated over long genomic distances, associated with transposable elements and subtelomeric regions, conserved across diverse human ethnic groups, sensitive to periconceptional environment, and associated with genes implicated in a broad range of human disorders and phenotypes. CoRSIV methylation in one tissue can predict expression of associated genes in other tissues.
In addition to charting a previously unexplored molecular level of human individuality, this atlas of human CoRSIVs provides a resource for future population-based investigations into how interindividual epigenetic variation modulates risk of disease.
Background
Published data on coronavirus disease 2019 (COVID‐19) convalescent plasma (CCP) use in children and obstetric patients are limited. We describe a single‐center experience of hospitalized ...patients who received CCP for acute COVID‐19.
Methods
A retrospective review of children 0–18‐years‐old and pregnant patients hospitalized with laboratory‐confirmed acute COVID‐19 who received CCP from March 1, 2020 to March 1, 2021 was performed. Clinical and laboratory data were collected to assess the safety of CCP administration. Antibodies to severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) were measured in the CCP products and in patients before transfusion and at various time points post‐transfusion. Correlation between the administered SARS‐CoV‐2 administered versus the SARS‐CoV‐2 anti‐spike immunoglobulin response in patient serum was assessed.
Results
Twenty‐two children and ten obstetric patients were eligible. Twelve pediatric and eight obstetric patients had moderate disease and ten pediatric and two obstetric patients had severe disease. Five pediatric patients died. Eighteen of 37 (48.6%) CCP titers that were measured met US Food and Drug Administration (FDA) criteria for high immunoglobulin G (IgG) antibody titer. There were no complications with transfusion. High‐titer CCP showed a positive correlation with rise in patient total immunoglobulin levels only in obstetric patients but not in pediatric patients. Among pediatric patients, the median serum antibody level increased over time after transfusion.
Conclusions
Coronavirus 2019 convalescent plasma was administered safely to our patients. Our study suggested that CCP did not interfere with endogenous antibody production. The antibody titer of CCP correlated with post‐transfusion response only in obstetric patients. Randomized trials in pediatric and obstetric patients are needed to further understand how to dose CCP and evaluate efficacy.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Abstract Peer review serves as an important adjunct to other hospital quality and safety programs. Despite its importance, the available literature contains virtually no guidance regarding the ...structure and function of effective peer review committees. This Clinical Perspective provides a summary of the purposes, structure and functioning of effective peer review committees. We also discuss important legal considerations that are a necessary component of such processes. This discussion includes useful templates for case selection and review. Proper committee structure, membership, work flow and leadership, as well as close cooperation with the hospital medical executive committee and legal representatives are essential to any effective peer review process. A thoughtful, fair, systematic and organized approach to creating a peer review process will lead to confidence in the committee by providers, hospital leadership and patients. If properly constructed, such committees may also assist in monitoring and enforcing compliance with departmental protocols, thus reducing harm and promoting high- quality practice.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
6.
Cardiac disease in pregnancy Gandhi, Manisha; Martin, Stephanie R
Obstetrics and gynecology clinics of North America,
06/2015, Volume:
42, Issue:
2
Journal Article
Peer reviewed
Physiologic changes in pregnancy can place extra demands on cardiac function. Preconception counseling is key to improving pregnancy outcomes. The most commonly encountered cardiac events are ...pulmonary edema and dysrhythmias. A team approach to antepartum care is recommended and should include maternal-fetal medicine, cardiology, and anesthesia as indicated, particularly for patients with congenital cardiac disease.
Cardiac Lesions in the Critical Care Setting Gandhi, Manisha; Shamshirsaz, Amir A
Obstetrics and gynecology clinics of North America,
12/2016, Volume:
43, Issue:
4
Journal Article
Peer reviewed
The long-held belief that pregnancy is absolutely contraindicated in maternal cardiovascular disease is no longer justifiable using evidence-base medicine. There are some conditions in which ...pregnancy is contraindicated, and high maternal risk and poor fetal outcome can be predicted. However, in many women with heart disease, a more favorable maternal and fetal outcome is expected. This article focusses on the cardiac conditions that require more attention and have the potential to require observation in the intensive care unit setting.
Background and aimsMost patients with heart failure (HF) are diagnosed following a hospital admission. The clinical and health economic impacts of index HF diagnosis made on admission to hospital ...versus community settings are not known.MethodsWe used the North West London Discover database to examine 34 208 patients receiving an index diagnosis of HF between January 2015 and December 2020. A propensity score-matched (PSM) cohort was identified to adjust for differences in socioeconomic status, cardiovascular risk and pre-diagnosis health resource utilisation cost. Outcomes were stratified by two pathways to index HF diagnosis: a ‘hospital pathway’ was defined by diagnosis following hospital admission; and a ‘community pathway’ by diagnosis via a general practitioner or outpatient services. The primary clinical and health economic endpoints were all-cause mortality and cost-consequence differential, respectively.ResultsThe diagnosis of HF was via hospital pathway in 68% (23 273) of patients. The PSM cohort included 17 174 patients (8582 per group) and was matched across all selected confounders (p>0.05). The ratio of deaths per person-months at 24 months comparing community versus hospital diagnosis was 0.780 (95% CI 0.722 to 0.841, p<0.0001). By 72 months, the ratio of deaths was 0.960 (0.905 to 1.020, p=0.18). Diagnosis via hospital pathway incurred an overall extra longitudinal cost of £2485 per patient.ConclusionsIndex diagnosis of HF through hospital admission continues to dominate and is associated with a significantly greater short-term risk of mortality and substantially increased long-term costs than if first diagnosed in the community. This study highlights the potential for community diagnosis—early, before symptoms necessitate hospitalisation—to improve both clinical and health economic outcomes.
We present a fetus with bilaterally enlarged and echogenic kidneys. Prenatal testing detected compound heterozygosity for a 0.676 Mb de novo deletion and an inherited pathogenic variant in PKHD1. ...This is the first case of autosomal recessive polycystic kidney disease (ARPKD) with a prenatally detected disease‐causing PKHD1 deletion.
In a fetus with the enlargement of both kidneys, we identified a 0.676 Mb deletion involving exons 1‐52 of one copy of the PKHD1 gene, and a deleterious variant c.10452dupT in exon 61 of the other copy of the gene. This is the first case of autosomal recessive polycystic kidney disease (ARPKD) with a prenatally detected disease‐causing PKHD1 deletion. Additionally, the fetus had an atypical deletion in chromosome 22 while the father carried a duplication of the same region.
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FZAB, GIS, IJS, KILJ, NLZOH, NUK, OILJ, SAZU, SBCE, SBMB, UL, UM, UPUK
Purpose of the Review
The purpose of this review was to compare physiological and metabolic changes in singleton and twin gestations and to review pregnancy outcomes with respect to current weight ...gain guidelines.
Recent Findings
Reviews in singleton gestations show that weight gain below the recommended guidelines has been associated with small for gestational age infants (less than the 10th percentile) which place these infants at increased risk for neonatal morbidities. Observational studies have shown that adequate and excessive gestational weight gain in twin gestations has been associated with longer gestations and less preterm birth along with increased birth weight at delivery.
Summary
Weight gain in pregnancy has been identified as a factor that affects both maternal and infant health outcomes in singleton and twin gestations. There is a larger body of research examining these effects in singleton gestations than twin gestations; however, in both groups, the data remain mostly observational and retrospective. Thus far, the research supports the Institute of Medicine recommended weight gain guidelines in singleton and twin gestations for women with normal BMI, but future research should be directed toward underweight and overweight women and the long-term outcomes in all mothers and their offspring.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OBVAL, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ
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