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DOES CERVICAL CERCLAGE IN THE SECOND TRIMESTER PREVENT PREGNANCY LOSS OR PRETERM BIRTH? |
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Written by Administrator
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Saturday, 11 September 2010 15:56 |
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In the past, cervical cerclage (sewing the cervix closed) has been advocated in patients with history of second trimester miscarriage associated with spontaneous premature shortening and opening of the cervix called cervical incompetence. The use of cerclage for this purpose has been controversial as there as been scant evidence-based medicine to support its use despite clinical experience which suggested in select patients, cerclage placement appeared to prevent not only second trimester miscarriage, but preterm delivery. An article was published in The American Journal of Obstetrics and Gynecology (October 2009), titled “Multicenter randomized trial of cerclage for preterm birth prevention in high-risk women with shortened midtrimester cervical length”. In this study 302 patients with a prior spontaneous preterm between 17 and 34 weeks were found to have a short transvaginal ultrasound cervical length less than 25 mm (normal cervical length is greater than or equal to 30 mm). These 302 patients with a shortened cervical length were randomized to placement of a cerclage (149 patients) vs. no cerclage (153 patients). They found cerclage significantly reduced the number of births less than 24 weeks and reduced the loss of babies shortly after birth as compared to the group of patients that did not undergo cerclage placement. They also found the number of preterm births less than 35 weeks was significantly reduced in the group that underwent cerclage if the cervical length was very short measuring less than15 mm. CMFM strives to provide the most up-to-date High-Risk Obstetrical care possible. We use state of the art obstetrical ultrasound equipment as needed to follow your pregnancy. If you are pregnant or considering a pregnancy in the near future and you have a history of risk factors for incompetent cervix and preterm birth which include a prior second trimester miscarriage (between 14 and 24 weeks), prior preterm birth under 37 weeks gestation, congenital uterine anomaly, multiple gestation (twins or triplets), more than one D and C, prior cervical LEEP procedure, cryosurgery, or cervical cone biopsy, we feel you need this follow-up. If desired, CMFM would be happy to provide consultation and make recommendations regarding the need for serial transvaginal cervical length scans and placement of cervical cerclage if necessary. |
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The Next Big Thing --Possibly? |
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Written by Administrator
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Saturday, 11 September 2010 15:55 |
Most of us by now have heard of saving stem cells from the cord blood for an insurance policy for our families. The problem with "embryonic" cord stem cells is that with current technology most embryonic stem cell transplantion from cord stem cells has limited usage for mainly blood disorders.
A company called biocell is now utilizing a different technique. Stem cell harvesting at the time of genetic amniocentesis. The amniotic fluid has a different kind of stem cell that is called a "mesenchymal" stem cell. Mesenchymal stem cells have several advantages: 1) they grow faster, 2) they are genetically stable - meaning they have less ability to turn into cancer and are hence thought to be non-neoplastic or non-cancer causing (embryonic stem cells are only stable for 50 or more duplications), and 3) they can change or differentiate into many different tissue types. This last advantage allows these cells to grow into many different tissues such as bone, muscle, cartilage, nerves, kidney, liver and skin . Thus, amniotic stem cells may have numerous future medical applications, including in tissue regeneration, organ transplantation, and potentially in neurodegenerative diseases and diabetes.
Imagine a trachea for disorders of the respiratory tract, a diaphragm for congenital diaphragmatic hernia, or fabrication of a heart valve for congenital heart disorders. All of this tissue has already been developed from these types of "mesenchymal" stem cells. This technology holds a lot of promise. All of this from only 3 cc of fluid from amniocentesis. This is the type of science that changes our boundaries of medical care and changes routine thought into other higher possibilities. Our office will be meeting with this company shortly and possibly offering this technology in the future.
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Genetic Sonography: the historical and clinical role of fetal echocardiography |
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Written by Dr. Brian Iriye
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Friday, 04 June 2010 17:35 |
An interesting research editorial was published last month by Dr. Greggory Devore in the journal Ultrasound in Obstetrics and Gynecology. Approximately 45-50% of cases of Down Syndrome have a congenital heart abnormality. In his article Dr. Devore, a known expert in fetal echocardiography, discusses the evaluation of the fetal heart and the comparison to other known screening tests for Down Syndrome (trisomy 21 or T21).
First trimester blood screening with ultrasound of multiple ultrasound markers trimester blood tests can find approximately 90% of cases. Second trimester screening finds an estimated 80% of T21 fetuses. Many patients present to late for these tests to be performed or do not desire to perform these tests due to the possibility of false postive results. Ultrasound results, without utilizing fetal echocardiography, vary widely depending on centers with results of approximately 40-80% detection. This last fact is the important one. The use of fetal echocardiography finds on the average 85% of heart defects. So you can see that usage of fetal echocardiography may enhance detection of T21 as these fetuses are more likely to have a congenital heart abnormality. Devore in his artilce talks about 3 finding that specifically increase the risk of a fetus having Down Syndrome: 1) VSD ( a hole in the lower main pumping chambers), 2) pericardial effusion (a small rim of fluid near the heart), and 3) heart size discrepancy with the right side being significantly larger than the left. These findings increase the risk of Down syndrome from 10 times with VSD, 12 times with pericardial effusion, and 88 times with heart size discrepancy.
The importance of this data is that these findings are subtle and can only be detected with top flight ultrasound equipment with trained sonography personnel. Additionally, these 3 findings are not generally known to be associated with Down Syndrome by most health professionals. Furthermore, within the las vegas area, a study by our local pediatric cardiologists showed that 65% of heart defects are missed prenatally when scanned by a general obstetrician or radiologist. However, this number matches the national average! In this same local study, a heart defect was not missed by a perinatologist over a 3 year period. The importance of the Devore editorial is that scanning for heart defects is an essential component of prenatal identification of fetuses with Down Syndrome. However, our local and national data shows that this information is often not detected by routine exams. Perinatologists play a key role in this detection of trisomy 21 prior to delivery.This allows parents to make informed decisions, prepare for children with special needs, and delivery at hospitals that can properly care for children with heart defects to provide optimal outcomes. Lastly, CMFM still is the only center accredited by the American Institute of Ultrasound in Medicine to perform obstetrical ultrasound in southern Nevada. |
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Society for Maternal Fetal Medicine Booklet |
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Written by Administrator
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Monday, 22 March 2010 10:05 |
Society for Maternal Fetal Medicine- The State of High Risk Pregnancy. This booklet was released by our national high-risk society last month. It was written to provide a clearer understanding who maternal-fetal medicine specialists are and what we do. It offers examples of the kinds of patients cared for by maternal-fetal medicine specialists and what is done for them. This monograph highlights important research that has emerged to improve the outcomes of mothers and babies and describes the challenges that face us as we strive to provide optimal pregnancy outcomes for mothers and their babies.
https://smfm.org/attachedfiles/SMFMMonograph3.1.pdf |
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Written by Administrator
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Monday, 22 March 2010 10:03 |
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When is a number just a number?
That is the important issue on advanced maternal age. The population of patients having children in the United States is getting older as patients delay child bearing due to multiple factors. The issue is what are the risks? How can they be altered? And what do patients need to know?
As a general rule, AMA is classified as 35 or above at the time of the mother's due date. It is commonly known that AMA status is associated with an increased risk of chromosomal abnormality in a fetus. That is the reason for genetic testing such as amniocentesis to look for chromosomal differences. However, risk of miscarriage from amniocentesis ranges from 1 in 200 to 1 in 1500 procedures. The generally accepted median is about 1 in 500 to 600 procedures. Our office in the most part would like to avoid the risk of invasive procedures. Thus we utilize both ultrasound and lab tests to further clarify a patient's risk of chromosome abnormality. Ways of doing this are:
a) first trimester genetic screening- combining a first trimester blood test with ultrasound (90-95% detection rate).
b)second trimester screening - a blood test often called a quad marker screen (80-85% detection rate)
c) integrated screening - combining a and b(90-97 % detection rate) and
d) second trimester ultrasound (74% detection rate in our office)
Our office uses a combination of tests to clarify risk for patients.
AMA is also associated with an increased risk of stillbirth. The excess risk can be eliminated by "antepartum testing". This combines ultrasound and fetal heart rate monitoring to look for early signs of problems and hence deliver patients when warranted to avoid later abnormalities of blood flow causing stillbirth.
Increased age is associated with an increased risk of preeclampsia or toxemia- a high blood pressure and affect on organ systems such as the kidneys to cause early delivery. Being aware of this may have us suggest more frequent outpatient visits with your physician.
AMA is also associated with an increased risk of abnormal growth. Macrosomia or large babies may be increased due to increased risk of diabetes with advancing age. Thus glucose testing is recommended in this population. Poor growth or intrauterine growth restriction is increased. This is similar to athe analogy of a house getting older the pipes get worse. Our pipes are the blood vessels and problems with worsening blood vessels in the uterus may worsen blood flow causing abnormal growth. Due to this factor, we recommend a mid third trimester ultrasound for growth (32-34 weeks of gestation) in AMA patients.
Other newer findings are an increased rate of autism in children or mothers of AMA status. The ability to prevent this is limited. Some research suggests there may be affects of several interventions (not fully proven at this time) such as vitamin D and DHA. Our practice is always attempting to keep up to date with this newer data to assist in your pregnancy.
Therefore, there are risks of having a baby as you grow older. However, many of these problems can be discovered with close observation, knowing what to look for, and acting upon information obtained from a little extra testing and care. |
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