Christopher Harman - Academia.edu (original) (raw)

Papers by Christopher Harman

Research paper thumbnail of A statement on abortion by 100 professors of obstetrics: 40 years later

American Journal of Obstetrics and Gynecology, 2013

In this Journal in 1972, 100 leaders in obstetrics and gynecology published a compelling statemen... more In this Journal in 1972, 100 leaders in obstetrics and gynecology published a compelling statement that recognized the legalization of abortion in several states and anticipated the 1973 Supreme Court decision in Roe v Wade. They projected the numbers of legal abortions that likely would be required by women in the United States and described the role of the teaching hospital in meeting that responsibility. They wrote to express their concern for women's health in a new legal and medical era of reproductive control and to define the responsibilities of academic obstetrician-gynecologists. Forty years later, 100 professors examine the statement of their predecessors in light of medical advances and legal changes and suggest a further course of action for obstetrician gynecologists.

Research paper thumbnail of Twin-Twin Transfusion Syndrome with and without Selective Fetal Growth Restriction Prior to Fetoscopic Laser Surgery: Short and Long-Term Outcome

Journal of Clinical Medicine, 2019

As twin-twin transfusion syndrome (TTTS) and selective fetal growth restriction (sFGR) are both p... more As twin-twin transfusion syndrome (TTTS) and selective fetal growth restriction (sFGR) are both prevalent complications of monochorionic (MC) twin pregnancies, its coexistence is not uncommon. The aim of this study is to evaluate the short and long-term outcome in TTTS with and without sFGR prior to fetoscopic laser coagulation. All TTTS cases treated with laser surgery at our center between 2001–2019 were retrospectively reviewed for the presence of sFGR, defined as an estimated fetal weight (EFW) <10th centile. We compared two groups: TTTS-only and TTTS + sFGR. Primary outcomes were perinatal survival and long-term severe neurodevelopmental impairment (NDI). Of the 527 pregnancies eligible for analysis, 40.8% (n = 215) were categorized as TTTS-only and 59.2% (n = 312) as TTTS + sFGR. Quintero stage at presentation was higher in the TTTS + sFGR group compared to the TTTS-only group (57% compared to 44% stage III). Separate analysis of donors showed significantly lower perinatal ...

Research paper thumbnail of Efficacy of long‐term indomethacin therapy in prolonging pregnancy after fetoscopic laser surgery for twin‐to‐twin transfusion syndrome: a collaborative cohort study

BJOG: An International Journal of Obstetrics & Gynaecology, 2021

This a preprint and has not been peer reviewed. Data may be preliminary.

Research paper thumbnail of Prediction of anemia with middle cerebral artery peak systolic velocity after serial intrauterine transfusions

American Journal of Obstetrics and Gynecology, Dec 1, 2006

To determine if there is increased risk of thromboembolic events among first-degree relatives (si... more To determine if there is increased risk of thromboembolic events among first-degree relatives (siblings and parents) of women who have suffered a placental abruption. STUDY DESIGN: Information about thromboembolic diseases in siblings and parents of women with abruption cases and controls were derived from an ongoing, case-control study, the New Jersey-Placental Abruption Study (NJ-PAS). Thromboembolic disease was defined as a history of embolism, deep vein thrombosis, myocardial infarction, or stroke. Associations were expessed using odds ratio (95% confidence interval). RESULTS: Rates of thromembolic events amongst male relatives were similar between abruption cases and controls. However, female relatives of cases were at significantly higher risk for thromboembolic disease. This difference was largely due to much greater rates of thrombotic disease in sisters of women with placental abruption (OR 9.1, 95% CI 1.1, 73.7). No difference in risk of thromboembolic disease was detected between mothers of cases and mothers of controls. CONCLUSION: These results underscore that abruption is highly correlated with thrombembolism in the patient's sisters, but not her brothers or parents. This suggests that placental abruption may share a common genetic factor with other vascular diseases that has penetrance only in women. Rates of thromboembolism in first-order relatives of women with and without placental abruption

Research paper thumbnail of 251 Early fetal exposure to long term indomethacin therapy to prevent preterm delivery: Neonatal outcome

American Journal of Obstetrics and Gynecology, Dec 1, 2001

Research paper thumbnail of OC109: Combining Doppler and biophysical assessment improves prediction of critical perinatal outcomes in growth restricted fetuses (IUGR)

Ultrasound in Obstetrics & Gynecology, 2003

Research paper thumbnail of OC27.04: Intervention thresholds for severe early onset growth restriction (IUGR)

Ultrasound in Obstetrics & Gynecology, Sep 1, 2005

Oral communication abstracts intraventricular hemorrhagia and elevated nucleated red blood cell c... more Oral communication abstracts intraventricular hemorrhagia and elevated nucleated red blood cell counts at delivery. Results: 8 stillbirths (10.7%), 12 perinatal (16%) and 2 neonatal death (2%) occurred among 74 fetuses. Logistic regression analysis confirmed that abnormal Ductus venosus waveforms (R 2 = 0.57, p < 0.001) together with gestational age (R 2 = 0.57, p < 0.001) showed the strongest association with perinatal death, whereas gestational age only was significantly related with neonatal death (R 2 = 0.67, p < 0.05). Abnormal ductus venosus Doppler waveforms (R 2 = 0.86, p < 0.001) and gestation age (R 2 = 0.49, p < 0.05) were strongly associated with adverse outcome. Abnormal venous Doppler flow patterns performed better in the prediction of fetal or perinatal demise than died ARED flow or brain sparing. Conclusion: Abnormal Ductus venosus waveforms in preterm growth-related fetuses with ARED flow are strongly relates to adverse fetal and perinatal outcomes below 32 weeks of gestational age. The possible benefit of these pregnancies to be prolonged can only be evaluated in a prospective randomized study.

Research paper thumbnail of Lethal Progression of a Fetal Intracranial Arteriovenous Malformation

Journal of Ultrasound in Medicine, Jun 1, 2003

etal intracranial vascular tumors present unique clinical challenges. Accurate diagnosis of the l... more etal intracranial vascular tumors present unique clinical challenges. Accurate diagnosis of the lesion, as well as an understanding of the local and systemic impacts, will guide the antenatal surveillance and the treatment plan and will determine the prognosis. Management will be altered by and dependent on intrauterine progression, gestational age, and fetal condition at birth. In addition, large vascular tumors can lead to the development of the Kasabach-Merritt sequence in the fetus and to either fetal or maternal hemodynamic impairment. Vascular tumors are either malformations or neoplasms. 1 Color and pulsed wave Doppler sonography are useful for the identification of vascular lesions and help narrow the differential diagnosis. 2 Once a vascular malformation is identified, a comprehensive anatomic survey is mandatory to determine whether there are coexistent malformations that impact either the diagnosis or prognosis. These lesions can have local mass effects, systemic hemodynamic effects, or both. Therefore, longitudinal assessment of the fetus is focused on the detection of lesion progression and on any fetal or maternal status changes. We report the prenatal diagnosis of an intracranial arteriovenous malformation (AVM) with a dramatic progression affecting both mother and fetus.

Research paper thumbnail of Fetal coronary and cerebral blood flow in acute fetomaternal hemorrhage

Ultrasound in Obstetrics & Gynecology, Aug 1, 1998

A fetal heart rate tracing with absent variation and a sinusoidal pattern led to the diagnosis of... more A fetal heart rate tracing with absent variation and a sinusoidal pattern led to the diagnosis of acute fetomaternal hemorrhage at 29 + 2 weeks&#39; gestation. The middle cerebral artery had increased peak blood flow velocity with reversed end-diastolic flow. Fetal coronary arteries visualized by color-coded and pulsed wave Doppler sonography showed slight decrease of time-averaged maximum velocities after oxygen administration, while cerebral flows remained unchanged. After administration of 50 ml blood (pre-transfusion hematocrit &lt; 11%) the middle cerebral artery flow normalized and coronary artery velocities decreased further until coronary blood flow could no longer be visualized within 30 min of the transfusion (post-transfusion hematocrit 27%). Evidence of successful fetal resuscitation also included normalization of the fetal heart rate tracing and resumption of fetal activity (biophysical profile score 8/10). This was also observed after a second transfusion of 38 ml blood. Deterioration from repeated fetomaternal hemorrhage led to delivery of a severely anemic neonate (cord hematocrit 7%) by Cesarean section. Postnatally, a single seizure, moderate severity respiratory distress syndrome and grade III intraventricular hemorrhage were noted. Increased peak blood flow velocity with reversed end-diastolic flow may be observed in the middle cerebral artery of fetuses with acute anemia. Correction of this phenomenon with transfusion suggests that hypovolemia and low blood viscosity are major contributing factors. Furthermore, decreasing coronary artery blood flow velocities with supplemental oxygen and blood replacement confirm functional autoregulation of the fetal coronary circulation. Observation of these acute flow changes during fetal surveillance warrants investigation for a potentially serious underlying condition.

Research paper thumbnail of 433: A novel real-time ultrasound technique to assess human spiral artery transformation in vivo: SPARTAN Study

American Journal of Obstetrics and Gynecology, 2020

Research paper thumbnail of 889: Utility of Noninvasive Prenatal Testing (NIPT) in evaluation of Congenital Heart Defects (CHD)

American Journal of Obstetrics and Gynecology, 2019

When asked whether NIPT is as accurate as invasive testing, 54 (34%) answered no, 8 (5%) yes, and... more When asked whether NIPT is as accurate as invasive testing, 54 (34%) answered no, 8 (5%) yes, and 64 (40%) did not know, or did not respond (30; 19%). Forty-one (25%) answered that invasive testing should be considered if NIPT is abnormal, 33 reported that further testing was not warranted, while 58 did not know and 29 skipped the question. CONCLUSION: Even in a highly-educated metropolitan population, patient understanding of the role of NIPT in aneuploidy screening is suboptimal. This data suggests that women may not be making informed decisions regarding NIPT, and that providers need better tools for pre-test counseling.

Research paper thumbnail of Doppler and biophysical assessment in growth restricted fetuses: distribution of test results

Ultrasound in Obstetrics & Gynecology, 2005

ObjectiveMulti‐vessel Doppler ultrasonography and biophysical profile scoring (BPS) are used in t... more ObjectiveMulti‐vessel Doppler ultrasonography and biophysical profile scoring (BPS) are used in the surveillance of growth restricted fetuses (IUGR). The interpretation of both tests performed concurrently may be complex. This study examines the relationship between Doppler ultrasonography and biophysical test results in IUGR fetuses.MethodsThree hundred and twenty‐eight IUGR fetuses (abdominal circumference < 5th percentile, elevated umbilical artery (UA) pulsatility index (PI)) had concurrent surveillance with UA, middle cerebral artery (MCA) and ductus venosus (DV) Doppler ultrasonography and BPS (fetal tone, movement, breathing, maximal amniotic fluid pocket and fetal heart rate). Patients were stratified into three groups according to their Doppler examination: (1) abnormal UA alone; (2) brain sparing (MCA‐PI > 2 SD below mean for gestational age); and (3) abnormal DV (PI > 2 SD above the mean for gestational age) and BPS groups: (1) normal (> 6/10); (2) equivocal (...

Research paper thumbnail of Detection of Viral Deoxyribonucleic Acid in Amniotic Fluid: Association with Fetal Malformation and Pregnancy Abnormalities

Fetal Diagnosis and Therapy, 2005

Objective: To first test the hypothesis that the presence of viral nucleic acid in amniotic fluid... more Objective: To first test the hypothesis that the presence of viral nucleic acid in amniotic fluid (AF) is associated with an abnormal pregnancy outcome, and second, to determine if the overall rate of polymerase chain reaction (PCR) positivity and the distribution of virus types vary geographically. Study Design: Cytomegalovirus (CMV), parvovirus B19, adenovirus, enterovirus, herpes simplex virus, Epstein-Barr virus, and respiratory syncytial virus nucleic acids were sought in 423 AF samples obtained for clinical indications: 284 from the East Coast (EC) and 139 from the Midwest (MW). Results: Gestational age at sampling was 19.1 weeks for EC and 20.1 weeks for MW. 13.5% of karyotypically normal singleton pregnancies (57/423) had a positive AF PCR. 11% of AF PCR from the EC while 18% of AF PCR from the MW were positive (p = 0.06). The most commonly detected viruses were adenovirus (77%), enterovirus (12%), and CMV and parvovirus B19 (5% each). Twenty-four percent of sonographically abnormal pregnancies (33/136) had a positive AF PCR compared to only 8.4% (24/287) of normal pregnancies (p &lt; 0.001). Conclusion: A positive AF PCR is associated with an increased rate of fetal structural malformations, intrauterine growth restriction, hydrops and other fetal abnormalities. There were no significant geographic differences in the incidence of AF viral PCR positivity.

Research paper thumbnail of Prolonged PD1 Expression on Neonatal Vδ2 Lymphocytes Dampens Proinflammatory Responses: Role of Epigenetic Regulation

The Journal of Immunology, 2016

A successful pregnancy depends on the maintenance of tolerance at the fetal–maternal interface; s... more A successful pregnancy depends on the maintenance of tolerance at the fetal–maternal interface; strong inflammation in the placental bed is generally associated with adverse fetal outcomes. Among the mechanisms that foster tolerance and limit inflammation, the fetal immune system favors Th2 or regulatory responses over Th1 responses. The unintended consequence of this functional program is high susceptibility to infections. Human Vδ2 T cells mount innate-like responses to a broad range of microorganisms and are poised for Th1 responses before birth. In infants they likely play a key role in protection against pathogens by exerting early Th1 effector functions, improving function of other innate cells, and promoting Th1 polarization of adaptive responses. However, their propensity to release Th1 mediators may require careful regulation during fetal life to avoid exaggerated proinflammatory responses. We investigated molecules with the potential to act as a rheostat for fetal Vδ2 cell...

Research paper thumbnail of Chronic hypoxia differentially increases glutathione content and γ-glutamyl cysteine synthetase expression in fetal guinea pig organs

Early Human Development, 2008

Research paper thumbnail of Predictors of Fetal Growth in Maternal HIV Disease

American Journal of Perinatology, 2010

We sought to determine predictors of fetal growth restriction in maternal HIV disease. Pregnant H... more We sought to determine predictors of fetal growth restriction in maternal HIV disease. Pregnant HIV-positive women on antiretroviral therapy were monitored with serial viral load and CD4 counts. Individualized growth potential (GP) percentile was calculated for birth weight (BW). BW &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;10th GP percentile defined fetal growth restriction (FGR). Multiple medical and social factors, CD4 count, viral load, and antiretroviral therapy were tested for impact on fetal growth using chi-square and multiple regression analysis. Two hundred eleven women were studied. CD4 count &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;200 in the first trimester was strongly associated with FGR (odds ratio 8.75, 95% confidence interval 2.88 to 26.52). Maternal age ( P = 0.02) and smoking ( P = 0.03) were independent cofactors for FGR (Nagelkerke R(2) = 0.33). No other factors demonstrated an independent effect. Severity of maternal HIV disease as indicated by the CD4 count, rather than placental exposure to viral load, predicts FGR. Smoking has an independent detrimental effect on fetal growth.

Research paper thumbnail of Comparative Analysis of 2-D Versus 3-D Ultrasound Estimation of the Fetal Adrenal Gland Volume and Prediction of Preterm Birth

American Journal of Perinatology, 2012

Objective-We aim to test the hypothesis that 2D fetal AGV measurements offer similar volume estim... more Objective-We aim to test the hypothesis that 2D fetal AGV measurements offer similar volume estimates as volume calculations based on 3D technique Methods-Fetal AGV was estimated by 3D ultrasound (VOCAL) in 93 women with signs/ symptoms of preterm labor and 73 controls. Fetal AGV was calculated using an ellipsoid formula derived from 2D measurements of the same blocks (0.523× length × width × depth). Comparisons were performed by intra-class correlation coefficient (ICC), coefficient of repeatability, and Bland-Altman method. The cAGV (AGV/fetal weight) was calculated for both methods and compared for prediction of PTB within 7 days. Results-Among 168 volumes, there was a significant correlation between 3D and 2D methods (ICC=0.979[95%CI: 0.971-0.984]). The coefficient of repeatability for the 3D was superior to the 2D method (Intra-observer 3D: 30.8, 2D:57.6; inter-observer 3D: 12.2, 2D: 15.6). Based on 2D calculations, a cAGV≥433mm 3 /kg, was best for prediction of PTB (sensitivity: 75%(95%CI=59-87); specificity: 89%(95%CI=82-94). Sensitivity and specificity for the 3D cAGV (cut-off ≥420mm 3 /kg) was 85%(95%CI=70-94) and 95%(95%CI=90-98), respectively. In receiver-operating-curve curve analysis, 3D cAGV was superior to 2D cAGV for prediction of PTB (z=1.99, p=0.047). Conclusion-2D volume estimation of fetal adrenal gland using ellipsoid formula cannot replace 3D AGV calculations for prediction of PTB.

Research paper thumbnail of 420: Fetoscopic laser of placental vascular anastomoses for TTTS; a single-center experience and comparison of selective versus equatorial dichorionization methods

American Journal of Obstetrics and Gynecology, 2013

Research paper thumbnail of 444: Fetoscopic laser ablation for twin twin transfusion syndrome - outcomes with a modified technique

American Journal of Obstetrics and Gynecology, 2008

OBJECTIVE: Fetoscopic laser ablation (FLOC) for twin-twin transfusion (TTTS) has evolved to a sel... more OBJECTIVE: Fetoscopic laser ablation (FLOC) for twin-twin transfusion (TTTS) has evolved to a selective technique targeting anastomoses along the intertwin vascular equator. While this optimizes residual donor placenta compared to non-selective (NS) FLOC, TTTS recurrence up to 17% is reported, presumably from small anastomoses remaining open between coagulation points. Aim of this study was to report outcomes when the placental surface along the vascular equator is also coagulated between anastomoses (X) (equatorial dichorionizationϭ[ED], figure). STUDY DESIGN: Prospective study of patients referred for FLOC. Intraoperative characteristics, outcomes, recurrence rates (twin-anemia-polycythemia [TAPS] and oligo/polyhydramnios sequence [TOPS}) were studied for ED-FLOC. RESULTS: 71 twin and 1 triplet pregnancy had FLOC for TTTS. At similar stages and procedure characteristics, ED-FLOC had lower recurrence complications at identical survival rates compared to the selective technique (table). CONCLUSION: Deliberate equatorial dichorionization along the vascular equator minimizes TTTS recurrence and offers identical survival rates compared to selective FLOC.

Research paper thumbnail of 725: First trimester detection of fetal anomalies in pregestational diabetes

American Journal of Obstetrics and Gynecology, 2008

Research paper thumbnail of A statement on abortion by 100 professors of obstetrics: 40 years later

American Journal of Obstetrics and Gynecology, 2013

In this Journal in 1972, 100 leaders in obstetrics and gynecology published a compelling statemen... more In this Journal in 1972, 100 leaders in obstetrics and gynecology published a compelling statement that recognized the legalization of abortion in several states and anticipated the 1973 Supreme Court decision in Roe v Wade. They projected the numbers of legal abortions that likely would be required by women in the United States and described the role of the teaching hospital in meeting that responsibility. They wrote to express their concern for women's health in a new legal and medical era of reproductive control and to define the responsibilities of academic obstetrician-gynecologists. Forty years later, 100 professors examine the statement of their predecessors in light of medical advances and legal changes and suggest a further course of action for obstetrician gynecologists.

Research paper thumbnail of Twin-Twin Transfusion Syndrome with and without Selective Fetal Growth Restriction Prior to Fetoscopic Laser Surgery: Short and Long-Term Outcome

Journal of Clinical Medicine, 2019

As twin-twin transfusion syndrome (TTTS) and selective fetal growth restriction (sFGR) are both p... more As twin-twin transfusion syndrome (TTTS) and selective fetal growth restriction (sFGR) are both prevalent complications of monochorionic (MC) twin pregnancies, its coexistence is not uncommon. The aim of this study is to evaluate the short and long-term outcome in TTTS with and without sFGR prior to fetoscopic laser coagulation. All TTTS cases treated with laser surgery at our center between 2001–2019 were retrospectively reviewed for the presence of sFGR, defined as an estimated fetal weight (EFW) <10th centile. We compared two groups: TTTS-only and TTTS + sFGR. Primary outcomes were perinatal survival and long-term severe neurodevelopmental impairment (NDI). Of the 527 pregnancies eligible for analysis, 40.8% (n = 215) were categorized as TTTS-only and 59.2% (n = 312) as TTTS + sFGR. Quintero stage at presentation was higher in the TTTS + sFGR group compared to the TTTS-only group (57% compared to 44% stage III). Separate analysis of donors showed significantly lower perinatal ...

Research paper thumbnail of Efficacy of long‐term indomethacin therapy in prolonging pregnancy after fetoscopic laser surgery for twin‐to‐twin transfusion syndrome: a collaborative cohort study

BJOG: An International Journal of Obstetrics & Gynaecology, 2021

This a preprint and has not been peer reviewed. Data may be preliminary.

Research paper thumbnail of Prediction of anemia with middle cerebral artery peak systolic velocity after serial intrauterine transfusions

American Journal of Obstetrics and Gynecology, Dec 1, 2006

To determine if there is increased risk of thromboembolic events among first-degree relatives (si... more To determine if there is increased risk of thromboembolic events among first-degree relatives (siblings and parents) of women who have suffered a placental abruption. STUDY DESIGN: Information about thromboembolic diseases in siblings and parents of women with abruption cases and controls were derived from an ongoing, case-control study, the New Jersey-Placental Abruption Study (NJ-PAS). Thromboembolic disease was defined as a history of embolism, deep vein thrombosis, myocardial infarction, or stroke. Associations were expessed using odds ratio (95% confidence interval). RESULTS: Rates of thromembolic events amongst male relatives were similar between abruption cases and controls. However, female relatives of cases were at significantly higher risk for thromboembolic disease. This difference was largely due to much greater rates of thrombotic disease in sisters of women with placental abruption (OR 9.1, 95% CI 1.1, 73.7). No difference in risk of thromboembolic disease was detected between mothers of cases and mothers of controls. CONCLUSION: These results underscore that abruption is highly correlated with thrombembolism in the patient's sisters, but not her brothers or parents. This suggests that placental abruption may share a common genetic factor with other vascular diseases that has penetrance only in women. Rates of thromboembolism in first-order relatives of women with and without placental abruption

Research paper thumbnail of 251 Early fetal exposure to long term indomethacin therapy to prevent preterm delivery: Neonatal outcome

American Journal of Obstetrics and Gynecology, Dec 1, 2001

Research paper thumbnail of OC109: Combining Doppler and biophysical assessment improves prediction of critical perinatal outcomes in growth restricted fetuses (IUGR)

Ultrasound in Obstetrics & Gynecology, 2003

Research paper thumbnail of OC27.04: Intervention thresholds for severe early onset growth restriction (IUGR)

Ultrasound in Obstetrics & Gynecology, Sep 1, 2005

Oral communication abstracts intraventricular hemorrhagia and elevated nucleated red blood cell c... more Oral communication abstracts intraventricular hemorrhagia and elevated nucleated red blood cell counts at delivery. Results: 8 stillbirths (10.7%), 12 perinatal (16%) and 2 neonatal death (2%) occurred among 74 fetuses. Logistic regression analysis confirmed that abnormal Ductus venosus waveforms (R 2 = 0.57, p < 0.001) together with gestational age (R 2 = 0.57, p < 0.001) showed the strongest association with perinatal death, whereas gestational age only was significantly related with neonatal death (R 2 = 0.67, p < 0.05). Abnormal ductus venosus Doppler waveforms (R 2 = 0.86, p < 0.001) and gestation age (R 2 = 0.49, p < 0.05) were strongly associated with adverse outcome. Abnormal venous Doppler flow patterns performed better in the prediction of fetal or perinatal demise than died ARED flow or brain sparing. Conclusion: Abnormal Ductus venosus waveforms in preterm growth-related fetuses with ARED flow are strongly relates to adverse fetal and perinatal outcomes below 32 weeks of gestational age. The possible benefit of these pregnancies to be prolonged can only be evaluated in a prospective randomized study.

Research paper thumbnail of Lethal Progression of a Fetal Intracranial Arteriovenous Malformation

Journal of Ultrasound in Medicine, Jun 1, 2003

etal intracranial vascular tumors present unique clinical challenges. Accurate diagnosis of the l... more etal intracranial vascular tumors present unique clinical challenges. Accurate diagnosis of the lesion, as well as an understanding of the local and systemic impacts, will guide the antenatal surveillance and the treatment plan and will determine the prognosis. Management will be altered by and dependent on intrauterine progression, gestational age, and fetal condition at birth. In addition, large vascular tumors can lead to the development of the Kasabach-Merritt sequence in the fetus and to either fetal or maternal hemodynamic impairment. Vascular tumors are either malformations or neoplasms. 1 Color and pulsed wave Doppler sonography are useful for the identification of vascular lesions and help narrow the differential diagnosis. 2 Once a vascular malformation is identified, a comprehensive anatomic survey is mandatory to determine whether there are coexistent malformations that impact either the diagnosis or prognosis. These lesions can have local mass effects, systemic hemodynamic effects, or both. Therefore, longitudinal assessment of the fetus is focused on the detection of lesion progression and on any fetal or maternal status changes. We report the prenatal diagnosis of an intracranial arteriovenous malformation (AVM) with a dramatic progression affecting both mother and fetus.

Research paper thumbnail of Fetal coronary and cerebral blood flow in acute fetomaternal hemorrhage

Ultrasound in Obstetrics & Gynecology, Aug 1, 1998

A fetal heart rate tracing with absent variation and a sinusoidal pattern led to the diagnosis of... more A fetal heart rate tracing with absent variation and a sinusoidal pattern led to the diagnosis of acute fetomaternal hemorrhage at 29 + 2 weeks&#39; gestation. The middle cerebral artery had increased peak blood flow velocity with reversed end-diastolic flow. Fetal coronary arteries visualized by color-coded and pulsed wave Doppler sonography showed slight decrease of time-averaged maximum velocities after oxygen administration, while cerebral flows remained unchanged. After administration of 50 ml blood (pre-transfusion hematocrit &lt; 11%) the middle cerebral artery flow normalized and coronary artery velocities decreased further until coronary blood flow could no longer be visualized within 30 min of the transfusion (post-transfusion hematocrit 27%). Evidence of successful fetal resuscitation also included normalization of the fetal heart rate tracing and resumption of fetal activity (biophysical profile score 8/10). This was also observed after a second transfusion of 38 ml blood. Deterioration from repeated fetomaternal hemorrhage led to delivery of a severely anemic neonate (cord hematocrit 7%) by Cesarean section. Postnatally, a single seizure, moderate severity respiratory distress syndrome and grade III intraventricular hemorrhage were noted. Increased peak blood flow velocity with reversed end-diastolic flow may be observed in the middle cerebral artery of fetuses with acute anemia. Correction of this phenomenon with transfusion suggests that hypovolemia and low blood viscosity are major contributing factors. Furthermore, decreasing coronary artery blood flow velocities with supplemental oxygen and blood replacement confirm functional autoregulation of the fetal coronary circulation. Observation of these acute flow changes during fetal surveillance warrants investigation for a potentially serious underlying condition.

Research paper thumbnail of 433: A novel real-time ultrasound technique to assess human spiral artery transformation in vivo: SPARTAN Study

American Journal of Obstetrics and Gynecology, 2020

Research paper thumbnail of 889: Utility of Noninvasive Prenatal Testing (NIPT) in evaluation of Congenital Heart Defects (CHD)

American Journal of Obstetrics and Gynecology, 2019

When asked whether NIPT is as accurate as invasive testing, 54 (34%) answered no, 8 (5%) yes, and... more When asked whether NIPT is as accurate as invasive testing, 54 (34%) answered no, 8 (5%) yes, and 64 (40%) did not know, or did not respond (30; 19%). Forty-one (25%) answered that invasive testing should be considered if NIPT is abnormal, 33 reported that further testing was not warranted, while 58 did not know and 29 skipped the question. CONCLUSION: Even in a highly-educated metropolitan population, patient understanding of the role of NIPT in aneuploidy screening is suboptimal. This data suggests that women may not be making informed decisions regarding NIPT, and that providers need better tools for pre-test counseling.

Research paper thumbnail of Doppler and biophysical assessment in growth restricted fetuses: distribution of test results

Ultrasound in Obstetrics & Gynecology, 2005

ObjectiveMulti‐vessel Doppler ultrasonography and biophysical profile scoring (BPS) are used in t... more ObjectiveMulti‐vessel Doppler ultrasonography and biophysical profile scoring (BPS) are used in the surveillance of growth restricted fetuses (IUGR). The interpretation of both tests performed concurrently may be complex. This study examines the relationship between Doppler ultrasonography and biophysical test results in IUGR fetuses.MethodsThree hundred and twenty‐eight IUGR fetuses (abdominal circumference < 5th percentile, elevated umbilical artery (UA) pulsatility index (PI)) had concurrent surveillance with UA, middle cerebral artery (MCA) and ductus venosus (DV) Doppler ultrasonography and BPS (fetal tone, movement, breathing, maximal amniotic fluid pocket and fetal heart rate). Patients were stratified into three groups according to their Doppler examination: (1) abnormal UA alone; (2) brain sparing (MCA‐PI > 2 SD below mean for gestational age); and (3) abnormal DV (PI > 2 SD above the mean for gestational age) and BPS groups: (1) normal (> 6/10); (2) equivocal (...

Research paper thumbnail of Detection of Viral Deoxyribonucleic Acid in Amniotic Fluid: Association with Fetal Malformation and Pregnancy Abnormalities

Fetal Diagnosis and Therapy, 2005

Objective: To first test the hypothesis that the presence of viral nucleic acid in amniotic fluid... more Objective: To first test the hypothesis that the presence of viral nucleic acid in amniotic fluid (AF) is associated with an abnormal pregnancy outcome, and second, to determine if the overall rate of polymerase chain reaction (PCR) positivity and the distribution of virus types vary geographically. Study Design: Cytomegalovirus (CMV), parvovirus B19, adenovirus, enterovirus, herpes simplex virus, Epstein-Barr virus, and respiratory syncytial virus nucleic acids were sought in 423 AF samples obtained for clinical indications: 284 from the East Coast (EC) and 139 from the Midwest (MW). Results: Gestational age at sampling was 19.1 weeks for EC and 20.1 weeks for MW. 13.5% of karyotypically normal singleton pregnancies (57/423) had a positive AF PCR. 11% of AF PCR from the EC while 18% of AF PCR from the MW were positive (p = 0.06). The most commonly detected viruses were adenovirus (77%), enterovirus (12%), and CMV and parvovirus B19 (5% each). Twenty-four percent of sonographically abnormal pregnancies (33/136) had a positive AF PCR compared to only 8.4% (24/287) of normal pregnancies (p &lt; 0.001). Conclusion: A positive AF PCR is associated with an increased rate of fetal structural malformations, intrauterine growth restriction, hydrops and other fetal abnormalities. There were no significant geographic differences in the incidence of AF viral PCR positivity.

Research paper thumbnail of Prolonged PD1 Expression on Neonatal Vδ2 Lymphocytes Dampens Proinflammatory Responses: Role of Epigenetic Regulation

The Journal of Immunology, 2016

A successful pregnancy depends on the maintenance of tolerance at the fetal–maternal interface; s... more A successful pregnancy depends on the maintenance of tolerance at the fetal–maternal interface; strong inflammation in the placental bed is generally associated with adverse fetal outcomes. Among the mechanisms that foster tolerance and limit inflammation, the fetal immune system favors Th2 or regulatory responses over Th1 responses. The unintended consequence of this functional program is high susceptibility to infections. Human Vδ2 T cells mount innate-like responses to a broad range of microorganisms and are poised for Th1 responses before birth. In infants they likely play a key role in protection against pathogens by exerting early Th1 effector functions, improving function of other innate cells, and promoting Th1 polarization of adaptive responses. However, their propensity to release Th1 mediators may require careful regulation during fetal life to avoid exaggerated proinflammatory responses. We investigated molecules with the potential to act as a rheostat for fetal Vδ2 cell...

Research paper thumbnail of Chronic hypoxia differentially increases glutathione content and γ-glutamyl cysteine synthetase expression in fetal guinea pig organs

Early Human Development, 2008

Research paper thumbnail of Predictors of Fetal Growth in Maternal HIV Disease

American Journal of Perinatology, 2010

We sought to determine predictors of fetal growth restriction in maternal HIV disease. Pregnant H... more We sought to determine predictors of fetal growth restriction in maternal HIV disease. Pregnant HIV-positive women on antiretroviral therapy were monitored with serial viral load and CD4 counts. Individualized growth potential (GP) percentile was calculated for birth weight (BW). BW &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;10th GP percentile defined fetal growth restriction (FGR). Multiple medical and social factors, CD4 count, viral load, and antiretroviral therapy were tested for impact on fetal growth using chi-square and multiple regression analysis. Two hundred eleven women were studied. CD4 count &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;200 in the first trimester was strongly associated with FGR (odds ratio 8.75, 95% confidence interval 2.88 to 26.52). Maternal age ( P = 0.02) and smoking ( P = 0.03) were independent cofactors for FGR (Nagelkerke R(2) = 0.33). No other factors demonstrated an independent effect. Severity of maternal HIV disease as indicated by the CD4 count, rather than placental exposure to viral load, predicts FGR. Smoking has an independent detrimental effect on fetal growth.

Research paper thumbnail of Comparative Analysis of 2-D Versus 3-D Ultrasound Estimation of the Fetal Adrenal Gland Volume and Prediction of Preterm Birth

American Journal of Perinatology, 2012

Objective-We aim to test the hypothesis that 2D fetal AGV measurements offer similar volume estim... more Objective-We aim to test the hypothesis that 2D fetal AGV measurements offer similar volume estimates as volume calculations based on 3D technique Methods-Fetal AGV was estimated by 3D ultrasound (VOCAL) in 93 women with signs/ symptoms of preterm labor and 73 controls. Fetal AGV was calculated using an ellipsoid formula derived from 2D measurements of the same blocks (0.523× length × width × depth). Comparisons were performed by intra-class correlation coefficient (ICC), coefficient of repeatability, and Bland-Altman method. The cAGV (AGV/fetal weight) was calculated for both methods and compared for prediction of PTB within 7 days. Results-Among 168 volumes, there was a significant correlation between 3D and 2D methods (ICC=0.979[95%CI: 0.971-0.984]). The coefficient of repeatability for the 3D was superior to the 2D method (Intra-observer 3D: 30.8, 2D:57.6; inter-observer 3D: 12.2, 2D: 15.6). Based on 2D calculations, a cAGV≥433mm 3 /kg, was best for prediction of PTB (sensitivity: 75%(95%CI=59-87); specificity: 89%(95%CI=82-94). Sensitivity and specificity for the 3D cAGV (cut-off ≥420mm 3 /kg) was 85%(95%CI=70-94) and 95%(95%CI=90-98), respectively. In receiver-operating-curve curve analysis, 3D cAGV was superior to 2D cAGV for prediction of PTB (z=1.99, p=0.047). Conclusion-2D volume estimation of fetal adrenal gland using ellipsoid formula cannot replace 3D AGV calculations for prediction of PTB.

Research paper thumbnail of 420: Fetoscopic laser of placental vascular anastomoses for TTTS; a single-center experience and comparison of selective versus equatorial dichorionization methods

American Journal of Obstetrics and Gynecology, 2013

Research paper thumbnail of 444: Fetoscopic laser ablation for twin twin transfusion syndrome - outcomes with a modified technique

American Journal of Obstetrics and Gynecology, 2008

OBJECTIVE: Fetoscopic laser ablation (FLOC) for twin-twin transfusion (TTTS) has evolved to a sel... more OBJECTIVE: Fetoscopic laser ablation (FLOC) for twin-twin transfusion (TTTS) has evolved to a selective technique targeting anastomoses along the intertwin vascular equator. While this optimizes residual donor placenta compared to non-selective (NS) FLOC, TTTS recurrence up to 17% is reported, presumably from small anastomoses remaining open between coagulation points. Aim of this study was to report outcomes when the placental surface along the vascular equator is also coagulated between anastomoses (X) (equatorial dichorionizationϭ[ED], figure). STUDY DESIGN: Prospective study of patients referred for FLOC. Intraoperative characteristics, outcomes, recurrence rates (twin-anemia-polycythemia [TAPS] and oligo/polyhydramnios sequence [TOPS}) were studied for ED-FLOC. RESULTS: 71 twin and 1 triplet pregnancy had FLOC for TTTS. At similar stages and procedure characteristics, ED-FLOC had lower recurrence complications at identical survival rates compared to the selective technique (table). CONCLUSION: Deliberate equatorial dichorionization along the vascular equator minimizes TTTS recurrence and offers identical survival rates compared to selective FLOC.

Research paper thumbnail of 725: First trimester detection of fetal anomalies in pregestational diabetes

American Journal of Obstetrics and Gynecology, 2008