2008 Annual Meeting
ABSTRACT 1
Antenatal Corticosteroid Treatment: What’s Happened Since Liggins and Howie?
By Invitation
Ronald Wapner, MD
In 1972 Liggins and Howie demonstrated that the administration of betamethasone to the mother will accelerate the maturation of the fetal lung and markedly reduce the occurrence of neonatal respiratory distress syndrome (called hyaline membrane disease at the time). Despite an almost 50% reduction in fetal death, RDS and IVH, routine clinical use of this modality didn’t occur until the NIH sponsored a consensus conference in 1994 recommending the routine use of antenatal steroids in all women potentially delivering between 24 and 34 weeks gestation.
In 2008 we are still investigating questions about the appropriate use of antenatal steroids. These include the choice and dose of drug, the need for and risks of repeat dosing, and the gestational ages at which treatment is efficacious. Recent trials have helped answer some of these questions but have raised others. For example, repeat dosing for fetuses remaining in-utero for a week after their initial exposure seems to be beneficial for the neonate but multiple repeat exposures (4 or more) will decrease birth-weight. Similarly, recent studies have suggested that expanding the treatment window to include the peri-viable fetus, the late-preterm fetus and perhaps even the term fetus being delivered by elective Cesarean section may be beneficial and present little risk. However, before any recommendations can be implemented further studies quantifying their risks and benefits and better defining the appropriate treatment approach are required.
ABSTRACT 2
Tissue Microarray Analysis of Hormonal Signaling Pathways in Uterine Carcinosarcoma
By Invitation
Gary L. Goldberg, MD
Gloria S. Huang, MD; Rebecca C. Arend; Maomi Li, MD, PhD; Marc J. Gunter, PhD; Lydia G. Chiu, MPH; Susan Band Horwitz, PhD
OBJECTIVE: To evaluate the relationship of hormone (ERα, ERβ, PR) and growth factor receptor (IGF1R, HER2) expression with disease progression in uterine carcinosarcoma.
STUDY DESIGN: Immunohistochemistry was performed on tissue arrays using standard methodology. Differences between groups were evaluated by the Wilcoxon rank-sum test. Interactions between tumor stage and receptor expression were determined by linear trend analysis.
RESULTS: Compared to normal endometrium, carcinosarcomas exhibited low ERα and PR expression (all P<0.01), but overexpressed ERβ (P=0.02). ERβ expression increased in advanced stage disease (P=0.02). IGF1R expression was lower in carcinosarcoma compared with normal endometrium (P=0.01). HER2 expression was elevated and increased with disease progression (P<0.01).
CONCLUSIONS: In uterine carcinosarcoma, ERβ expression is elevated and increases with disease progression, whereas ERα and PR are suppressed. HER2 expression is increased while IGF1R is lower than in normal endometrium. These data support a potential role for ERβ in disease progression via crosstalk with HER2.
ABSTRACT 3
Infant Morbidity and Mortality Associated With Vaginal Delivery in Twin Gestations
By Invitation
Alan M. Peaceman, MD
Lindsay Kuo, BS and Joe Feinglass, PhD
OBJECTIVE: To compare infant outcomes for twin gestations delivered vaginally to those with cesarean delivery using a large national data set containing birth certificate data.
METHODS: The Matched Multiple Birth Data Set containing information from all multiple births in the United States from 1995-2000 was used. Vertex/vertex presenting twins delivering at ≥ 30 weeks’ gestation were separated by method of delivery and compared for neonatal morbidities and death in the first year of life. Similar comparisons were performed for vertex/non-vertex presenting twins. Sub-analyses were also performed for deliveries performed at or after 34 weeks’ gestation, and for deliveries where the birth weight of the second twin exceeded that of the first twin.
RESULTS: For vertex/vertex presenting twins, vaginal delivery was not associated with an increase in composite morbidity or mortality compared to cesarean birth. For vertex/non-vertex presenting twins, vaginal delivery was associate with increases of <1% in the incidences of 5 minute Apgar scores ≤ 3, ventilation for <30 minutes, and birth injury, but not seizures or infant death. Results were similar when only deliveries at or after 34 weeks’ gestation were considered. When the birth weight of the second twin exceeded that of the first by 25% or more, excess morbidity with vaginal delivery was not seen.
CONCLUSION: For both vertex/vertex and vertex/non-vertex presentations, morbidity and mortality are similar for vaginal and cesarean deliveries of twin gestations at or beyond 30 weeks’ gestation.
ABSTRACT 4
Screening for Down Syndrome: Changing Practice of Obstetricians
By Invitation
Deborah A. Driscoll, MD
Jay Schulkin, PhD and Maria A. Morgan, PhD
OBJECTIVE: To assess the impact of American College of Obstetrician and Gynecologists (ACOG) guidelines on the practices and knowledge of obstetricians regarding screening for Down syndrome.
STUDY DESIGN: A questionnaire on Down syndrome screening was mailed to 968 ACOG Fellows and Junior Fellows.
RESULTS: The majority (95%) of respondents offer Down syndrome screening to all pregnant patients; 70% of general obstetricians offer the first trimester screen and 86% the quad screen. Almost two-thirds (63%) of respondents are offering patients one or more combinations of first and second trimester screening tests. For women less than 35 years, 70% offer amniocentesis selectively and 15% routinely. Chorionic villus sampling is offered less frequently. Respondents who read the bulletin more closely were more likely to say their practice had changed, answered more knowledge questions correctly and felt more qualified to counsel patients. Most obstetricians (85%) personally counsel patients about Down syndrome risk and screening tests. The majority (94-95%) of respondents have access to adequate resources for screening within a 90-minute drive.
CONCLUSION: Obstetricians have adopted a new paradigm for Down syndrome screening. First trimester screening has been incorporated into prenatal care. Experience with these current screening tests will likely influence future guidelines and challenge the long-standing tradition of offering diagnostic testing based on maternal age. This study highlights the need for concise, unambiguous guidelines and a need to address unresolved issues in Down syndrome screening