Antepartum fetal intracranial hemorrhage, predisposing factors and prenatal sonography: a review.

Our objective was to review current literature pertaining to antepartum fetal intracranial hemorrhage. To this goal we selected all manuscripts published in the English language regarding this topic obtained from a MEDLINE search for 1966 through January 1998. Additional sources were identified through cross-referencing. Antenatal fetal intracranial hemorrhage may occur spontaneously, or occur in association with various maternal or fetal conditions. Predisposing maternal conditions at risk for this occurrence include alloimmune and idiopathic thrombocytopenia, von Willebrand's disease, specific medications (warfarin) or illicit drug (cocaine) abuse, seizures, severe abdominal trauma inflicting subsequent fetal injury, amniocentesis, cholestasis of pregnancy and febrile disease. Predisposing fetal conditions include congenital factor-X and factor-V deficiencies, hemorrhage into various congenital tumors, twin-twin transfusion, demise of a co-twin, or fetomaternal hemorrhage. Currently, antepartum fetal intracranial hemorrhage may be diagnosed by imaging techniques including ultrasonography and less frequently, magnetic resonance imaging. Early real-time sonographic signs of intracranial hemorrhage consist of irregular echogenic patterns representing the associated hematoma that may clearly distort normal intracranial structures. Recent reports have suggested Doppler flow velocimetry and color Doppler imaging as additional tools in detecting fetal intracranial hemorrhage. Various types of antenatal fetal intracranial hemorrhages that have been visualized sonographically include intraventricular, periventricular, subependymal, parenchymal, subdural, and intracerebellar events. Active hemorrhages may be associated with fetal distress manifested by fetal heart rate changes. Infrequently, antenatal ultrasonographic depiction of intracranial hemorrhage may precede devastating sequelae such as hydrocephalus, hydranencephaly, porencephaly, or microcephaly. Due to the significant associated neonatal neurological impairment and potential medicolegal implications of antepartum fetal intracranial hemorrhage, it follows that obstetricians and sonographers should be familiar with predisposing factors and typical diagnostic imaging findings of these events.

Intra- and early postpartum ultrasonography: a review. Part I.

The objective of this article is to review current literature pertaining to intra- and early postpartum sonography. All the manuscripts published in the English language regarding this topic were selected from a MEDLINE search from 1966 through August 1997. Additional sources were identified through cross-referencing. Currently, intra- and early postpartum sonography may be performed for either maternal or fetal indications. Maternal indications include cervical assessment in preterm labor/rupture of membranes, assessment of the lower uterine segment, size and position of uterine fibroids, guided-placement of central venous or pulmonary artery catheters, detection of intraoperative venous air embolism, deep venous thrombosis, assist management of the third-stage of labor, postpartum hemorrhage or febrile morbidity. Fetal indications include an anatomical survey in patients presenting without prenatal care, verification of fetal presentation, estimated fetal weight, assessment of the breech-presenting fetus, external cephalic version, management of delivery of the second-twin, and internal podalic version. Doppler flow velocimetry is a useful tool in depicting both maternal and fetal intrapartum physiologic changes. We conclude that intra- and early postpartum sonography is an established versatile diagnostic and interventional-guiding modality for many obstetric conditions and should be readily available on labor and delivery suites.

Postpartum uterine-artery velocity waveforms in women with sickle cell disease.

OBJECTIVE: To investigate the changes in uterine Doppler velocimetry during the postpartum period in women with homozygous sickle cell (SS) disease and to correlate these findings with values in the third trimester and with neonatal outcomes. METHODS: We studied the postpartum changes in uterine Doppler velocimetry in 16 women with SS disease in relation to third-trimester systolic/diastolic (S/D) ratios and neonatal outcome. All patients had repeated measures of uterine S/D ratios biweekly in the third trimester from 28 weeks of pregnancy until delivery, and at 24 h, and 3 and 6 weeks postpartum. RESULTS: Overall the mean S/D ratio in the first 24 h for these 16 women was 2.72 +/- 0.72 and increased progressively to a mean S/D ratio of 6.88 +/- 0.96 at 6 weeks postpartum, with the reappearance of a diastolic notch by the 3rd postpartum week. Twelve women who had normal (< or = 2.6) uterine S/D ratios during pregnancy delivered appropriate-for-gestational-age (AGA) infants. The remaining 4 women had abnormal uterine S/D ratios, and in 3 of these pregnancies, small-for-gestational-age (SGA) infants were delivered. The mean S/D ratios for the subgroups with abnormal value at each of the three postpartum periods were significantly higher than for the 12 SS patients with normal third-trimester values. Postpartum S/D ratios for the 3 women with SGA births were also significantly higher at 24 h and 6 weeks postpartum when compared to SS patients with AGA infants. CONCLUSION: We concluded that postpartum S/D ratios are higher in women with SS disease that have abnormal values in the third trimester and that they are associated with SGA births. In SS patients the nonpregnant pattern of uterine artery velocity waveforms which reappears postpartum may reflect an increase in the uteroplacental circulatory impedence due to reversal of the alterations in the spiral arteries induced by trophoblastic invasion during pregnancy or subinvolution of the placental bed. Additional studies are needed to further elucidate these important hemodynamic changes in women with hemoglobinopathies and to identify patterns predictive of neonatal outcomes in these high-risk patients.

Intra- and early postpartum ultrasonography: a review. Part II.

Part II is a continuation of the preceding segment, which appeared in the previous issue (Survey 1998;53:000-000). This part presents data pertaining to ultrasound-guided procedures (invasive and noninvasive), physiology (fetal behavior), intrapartum hemorrhage, the third stage of labor, post-partum hemorrhage, and postcaesarean ultrasonography. In addition, this article includes data regarding nonobstetric ultrasound including anesthesiology, catheter placement, venous air embolism, effect of epidural anesthesia on uterine blood flow, and urinary retention. Finally, this part presents ultrasonographic data of the maternal cerebral circulation in preeclampsia/eclampsia and of the maternal deep venous system.

Prenatal ultrasonographic morphologic assessment of the umbilical cord: a review. Part I.

Our objective was to review current data pertaining to prenatal ultrasonographic morphology of the umbilical cord. To this goal we identified studies published in the English language regarding prenatal ultrasonographic morphology of this structure. The studies were obtained from a MEDLINE search from 1966 through May 1997; additional sources were identified through cross-referencing. All published reports, case studies, and articles regarding ultrasonographic morphology of the umbilical cord were reviewed. Data pertaining to Doppler flow velocimetry in association with umbilical cord structural anomalies and umbilical cord compression, were also included. Review of the literature supports that prenatal ultrasound may outline normal anatomy or alternatively depict various congenital abnormalities of the umbilical cord including: cysts; pseudocysts; umbilical vein varix; persistent right umbilical vein; hemangiomas; umbilical vessel aneurysm (arterial or venous); single, hypoplastic, or fused umbilical artery; hematomas (spontaneous or iatrogenic); velamentous insertion; and vasa previa. The umbilical cord coiling index, an additional ultrasonographic morphologic feature may identify patients at risk for adverse perinatal outcome. Conditions of potential fetal compromise due to umbilical cord compression including nuchal cords, true knots, occult prolapse, cord presentation, fetal grasping, and cord entanglement in monoamniotic twins, may be detected prenatally and impaired umbilical flow confirmed with Doppler flow velocimetry. Ultrasound has been widely applied to guide invasive diagnostic and therapeutic procedures involving access to umbilical circulation. In conclusion, precise prenatal ultrasonographic depiction of the morphology of the umbilical cord may enhance perinatal management.

Prenatal ultrasonographic morphologic assessment of the umbilical cord: a review. Part II.

Ultrasonographic assessment, although not always possible throughout the entire length of the umbilical cord, may assist in the diagnosis of congenital and functional anomalies of this structure. In such fashion, prenatal ultrasound may outline normal anatomy or alternatively depict various congenital abnormalities of the umbilical cord including: cysts; pseudocysts umbilical vein varix; persistent right umbilical vein; angiomyxomas; aneurysm (arterial or venous); single, hypoplastic or fused umbilical artery; hematomas (spontaneous or iatrogenic); velamentous insertion; vasa previa. The umbilical cord coiling index, an additional ultrasonographic morphologic feature, may identify patients at risk for adverse perinatal outcome. Conditions of potential fetal compromise due to umbilical cord compression including nuchal cords, true knots, occult prolapse, cord presentation, fetal grasping, and cord entanglement in monoamniotic twins, may be detected prenatally; and impaired umbilical flow can be confirmed with Doppler flow velocimetry. Ultrasound has been widely used to guide invasive diagnostic and therapeutic procedures involving access to umbilical circulation. We conclude that the review of current literature supports that precise prenatal ultrasonographic depiction of the morphology of the umbilical cord may enhance perinatal management.

Assessment of fetal well-being in methadone-maintained pregnancies: abnormal nonstress tests.

OBJECTIVE: To investigate parameters of fetal well-being (characteristics of nonstress test, NST, and antepartum fetal heart rate, FHR, patterns) and selected neonatal outcomes in pregnant women on methadone maintenance. STUDY DESIGN: A matched case-control study of methadone-treated women receiving prenatal and intrapartum care at a Bronx municipal hospital during 1992-1994. 102 NSTs obtained from 24 methadone-treated women after 35 weeks of pregnancy were compared to 96 NSTs from a control group (n = 24), matched for maternal age, parity, and gestational age. All NSTs were evaluated for general characteristics including time interval between initiation and achievement of reactive NST (2 accelerations > or = 15 bpm lasting for at least 15 s in a 20-min period), baseline, amplitude of fluctuation, frequency of fluctuation, accelerations and decelerations. The scoring system described by Lyons et al. was used for all NSTs. All nonreactive NSTs were followed with biophysical profile tests. RESULTS: The frequency of nonreactive NSTs was significantly higher for methadone-maintained women compared to controls (19.6 vs. 4.2%; p < 0.01). The average length of time to achieve reactive NST was significantly (p = 0.0016) longer for the methadone-treated group when compared to controls (35.50 +/- 20.96 vs. 14.85 +/- 9.03 min). The total score (Lyons et al.) was significantly lower (p < 0.0007) for the methadone-treated group compared to controls. Mean birth weight, Apgar scores at 1 and 5 min, meconium, and umbilical cord artery pH were not significantly different for methadone-exposed neonates compared to controls. CONCLUSION: Methadone-maintained pregnancies are significantly associated with a higher incidence of nonreactive NSTs, longer intervals to achieve reactive NSTs and lower NST scores compared to controls. This may reflect an altered response in fetal central nervous system neurotransmitters and changes in fetal behavior induced by methadone.

Clinical significance of increasing histologic severity of acute inflammation in the fetal membranes and umbilical cord.

The purpose of this study was to determine the importance of varying histologic stages of inflammation in the placental membranes and cord. Acute inflammation was histologically staged in fetal membranes and umbilical cord sections from 2899 placentas received from consecutive singleton deliveries. Then clinical data were collected for a subset of randomly selected placentas with stage 1 through stage 4 membrane inflammation (n = 212) and without significant inflammation (stage 0, n = 216). Statistical analyses revealed that increasing stage of membrane inflammation was associated with an increasing rate of funisitis, perinatal death, and preterm birth (P < .05). Inflammation permeating the entire trophoblastic layer of the chorion (stage 1) was associated with clinical symptoms of intrauterine infection and thus was an important pathologic finding. Acute necrotizing chorioamnionitis was very strongly associated with perinatal death and preterm birth. Acute funisitis was a more specific but less sensitive marker for perinatal complications than inflammation in the membranes. With increasing stage of funisitis, there was an increased incidence of clinical symptoms of intrauterine infection, preterm birth, and perinatal death. Almost three-fourths of the cases with histologic evidence of membrane inflammation were clinically silent. In conclusion, increasing histologic stages of inflammation of the membranes and cord are associated with an increased rate of perinatal morbidity and mortality. Stage I membrane inflammation provides a clinically acceptable minimum threshold for the reporting of pathologic changes.

Intraoperative embolization for pelvic hemorrhage following termination of pregnancy.

We describe a 37-year-old patient with placenta previa, placenta accreta and a history of four previous cesarean sections who experienced massive hemorrhage after mid-trimester abortion by dilation and evacuation.

Lower urinary tract dysfunction in pregnancy: a review.

It has long been observed that pregnancy may influence the development and course of urinary tract disorders. The physiological and anatomical changes inherent in normal pregnancy and the changing hormonal environment are generally assumed to play a role in the pathogenesis of urinary tract symptomatology. The purpose of this review is to examine the reported effect(s) of pregnancy on the lower urinary tract and to evaluate the possible role of pregnancy and delivery in lower urinary tract dysfunction.

Computerized colposcopy and conservative management of cervical intraepithelial neoplasia in pregnancy.

BACKGROUND: Computerized colposcopy is the noninvasive digital processing of colposcopic images acquired using a charge-coupled device camera. The purpose of this study was to evaluate the clinical applications of computerized colposcopy, and to record the colposcopic changes associated with progression or regression of cervical intraepithelial neoplasia in pregnancy. METHODS: Forty-one pregnant patients, with abnormal Papanicolaou smears and a fully visualized squamo-columnar junction, were serially monitored throughout their pregnancies using computerized colposcopy. All patients had baseline computer-assisted measurements of their cervical lesions and a repeat measurement at monthly intervals and at 3-months postpartum. RESULTS: During the period of gestation, 17.1% of lesions increased in size, 21.9% remained unchanged, 41.5% decreased in size and 19.5% disappeared completely. In patients with an increase in lesion size, a colposcopically directed punch biopsy was performed which revealed CIN III but no microinvasion. Cervical biopsy during pregnancy was unnecessary in 82.9% of cases. CONCLUSION: The ability to sequentially monitor and quantify colposcopically visualized lesions, using computerized colposcopy, provides a noninvasive objective mode to evaluate progression, stability, or regression of CIN lesions during pregnancy.

Cultural diversity as a factor in self-monitoring blood glucose in gestational diabetes.

The routine use of self-monitoring of capillary blood glucose by pregnant diabetic patients currently provides the basis for both clinical management and ongoing investigation. Strategies must therefore be developed to ensure that these data are reliable and accurately reported by patients and are not influenced by diverse socioeconomic levels or varied geographic locations. To explore this issue, we used glucose reflectance meters with a memory microchip capable of storing up to 440 consecutive blood glucose determinations. Two diverse groups of women from Texas and New York who had gestational diabetes performed self-monitoring of blood glucose from diagnosis until delivery. Both groups recorded their blood glucose results daily in a logbook. The reporting performance of all the participating subjects resulted in an actual compliance rate of 60% to 70% of testings required of the patients. Comparison of African-American, Mexican-American, and white populations revealed no significant differences in patient performance or compliance. Moreover, no differences were found between the groups at different geographic locations (New York, Texas) in patients' willingness and ability to comply with the regimen of self-monitoring blood glucose. These findings suggest that the use of memory reflectance meters, in conjunction with patient education and positive interaction between patient and care provider, will result in high patient compliance regardless of socioeconomic level or ethnic diversity.

Chronic hypertension in gestational diabetes: influence on pregnancy outcome.

Our objective was to study the influence of chronic hypertension on pregnancy outcome in women with gestational diabetes (GDM). 418 women with GDM (30 with chronic hypertension and 388 nonhypertensives) were referred to our diabetes in pregnancy program. All patients were followed and assessed biweekly until delivery. When hypertensive GDM women (n = 30) wer compared to all nonhypertensive GDM (n = 388), there were significant (p < 0.05) differences in mean maternal age (34 +/- 4.1 vs. 30 +/- 4.6 years), maternal weight (90 +/- 21.2 vs. 70.6 +/- 14.9 kg) and gestational age at delivery (38.5 +/- 1.2 vs. 39.6 +/- 1.2 weeks). The mean birth weight for the hypertensive GDM group was significantly higher than that of the nonhypertensive GDM (3,360 +/- 578 vs. 3,293 +/- 581 g; p < 0.05). The frequencies of LGA (23.3 vs. 9.8%) and induction prior to onset of spontaneous labor were significantly (p < 0.05) higher in the hypertensive GDM group when compared to the nonhypertensive GDM. There were no differences with respect to the average blood glucose and frequencies of SGA deliveries. However, when the 30 hypertensive GDM pregnancies were compared to a control group of 60 nonhypertensive GDM women matched for age, weight and height, the only significant difference was a higher rate of inductions of labor (36.7 vs. 6.6%, p < 0.05) in hypertensive diabetic women. There were no significant differences in the incidence of LGA, low Apgar scores and SGA deliveries when hypertensive GDM were compared to nonhypertensive GDM women.(ABSTRACT TRUNCATED AT 250 WORDS)

Decreased maternal-fetal attachment in methadone-maintained pregnant women: a preliminary study.

Maternal-fetal attachment represents the mother's affiliation and interaction with her unborn fetus. It develops during pregnancy and may be critical to successful mother-infant adaptation. The purpose of this study was to investigate maternal-fetal attachment in methadone-maintained pregnant women. We studied a cross-sectional sample of women (n = 67), 15 to 35 years of age, with uncomplicated, singleton pregnancies, at 28 to 37 weeks of gestation. The study population comprised two groups: group 1 consisted of 17 women enrolled in a substance abuse program who were using methadone, 40 to 80 mg a day, for a period of more than 3 months; group 2 included 50 women with no history of substance abuse. The Cranley 24-item scale was used as a measure of maternal-fetal attachment. Methadone-maintained pregnant women had diminished maternal-fetal attachment scores compared with controls (P < .05). This may be attributed to methadone use or to behavior characteristics of women with substance abuse. In either case, decreased maternal-fetal attachment may conceivably reduce women's compliance with prenatal health care, interfere with maternal adjustment during pregnancy, and/or have negative long-term effects on mother-child attachment.

Lipid profile in women with preeclampsia: relationship between plasma triglyceride levels and severity of preeclampsia.

It has been hypothesized that, in preeclampsia, hypertriglyceridemia may lead to increased endothelial triglyceride accumulation that, in turn, may result in endothelial cell damage. The purpose of our study was to determine whether hypertriglyceridemia is associated with the severity of preeclampsia. We studied 29 preeclamptic patients and 46 normal pregnant women, aged 15 to 35 years, with singleton pregnancies, at 28 to 37 weeks' gestation. Total cholesterol, low-density lipoprotein cholesterol, and triglyceride levels were measured enzymatically. High-density lipoprotein cholesterol was determined using a dextran sulfate-magnesium precipitation method. Patients with mild preeclampsia had a significant increase in plasma triglyceride levels (P < .001), while patients with severe preeclampsia had triglyceride levels comparable to controls. Our findings suggest that there is no direct relationship between triglyceride levels and severity of preeclampsia.

Decreased beta-carotene levels in exfoliated vaginal epithelial cells in women with vaginal candidiasis.

PROBLEM: Women are more susceptible to vaginal candidiasis when the host immune response is suppressed. The antioxidant nutrient beta-carotene is postulated to possess immunoenhancing properties. The purpose of this study was to investigate beta-carotene concentrations in exfoliated vaginal epithelial (EVE) cells in women with vaginal candidiasis. METHODS: Beta-carotene levels in EVE cells, collected by a saline lavage technique from 22 women with vaginal candidiasis and 20 normal controls, were analyzed. The diagnosis of vaginal candidiasis was established by the presence of pruritus, white cheesy vaginal discharge, and a positive potassium hydroxide preparation. Beta-carotene levels were assayed using high pressure liquid chromatography. RESULTS: Vaginal cell concentrations of beta-carotene were significantly decreased in women with vaginal candidiasis (P < 0.001). CONCLUSIONS: Decreased beta-carotene levels, and possibly other antioxidants, may alter the local immune response resulting in disturbances in the vaginal flora, overgrowth of candida, and the development of vaginal candidiasis.

Preeclampsia and antioxidant nutrients: decreased plasma levels of reduced ascorbic acid, alpha-tocopherol, and beta-carotene in women with preeclampsia.

OBJECTIVE: Our purpose was to investigate the plasma levels of three potent antioxidant nutrients in women with preeclampsia. STUDY DESIGN: Fasting venous blood samples were collected from 30 women with preeclampsia and from 44 women with uncomplicated pregnancies. The criteria for recruitment included age 15 to 35 years, gestational age 28 to 42 weeks, singleton pregnancy, intact membranes, absence of labor contractions, and absence of any other medical complication concurrent with preeclampsia. Reduced ascorbic acid, alpha-tocopherol, and beta-carotene levels were assayed with high-pressure liquid chromatography. RESULTS: Plasma levels of reduced ascorbic acid were significantly decreased in patients with mild and severe preeclampsia (p < 0.01). Plasma alpha-tocopherol and beta-carotene levels were significantly decreased only in severe preeclampsia compared with controls (p < 0.05 and p < 0.05, respectively). CONCLUSION: In patients with preeclampsia antioxidant nutrients may be utilized to a greater extent to counteract free radical-mediated cell disturbances, resulting in a reduction in antioxidant plasma levels. Water-soluble antioxidant nutrients may initially be consumed, followed by lipid-soluble antioxidants.

Vibroacoustic stimulation of the fetus entering the second stage of labor.

OBJECTIVE: To evaluate the fetal heart rate (FHR) response to vibroacoustic stimulation of fetuses entering the second stage of labor as a predictor of neonatal outcome. METHODS: Three hundred sixteen cases and 316 controls were studied during the second stage of labor. All cases had vibroacoustic stimulation on entering the second stage of labor using an electronic artificial larynx. For control patients, the artificial larynx was not activated. The patients were stratified into groups based on the quality of FHR response: acceleration (n = 124), acceleration followed by deceleration (n = 120), and no response (n = 72). RESULTS: Subsequent FHR accelerations and accelerations followed by decelerations were significantly more frequent in the study group than in controls (77.2 versus 15.2%; P < .05). The frequencies of low 5-minute Apgar scores (below 7) and low umbilical cord arterial pH (below 7.20) did not differ significantly in the group with the acceleration response when compared to those with acceleration followed by deceleration and the no-response groups. The incidence of nuchal cord was significantly higher for the group with a response pattern of acceleration followed by deceleration than for the acceleration and no-response groups (39.2 versus 10.5 versus 11.1%; P < .05). CONCLUSIONS: Vibroacoustic stimulation in the second stage of labor is associated with FHR reactivity, but the quality of FHR response does not predict neonatal outcome and therefore appears to have little value in enhancing the management of the second stage of labor. However, an acceleration followed by deceleration response suggests the presence of nuchal cord.

Hypertension in pregnancy.

Hypertension, which is the most common complication of pregnancy, is a leading cause of both maternal and perinatal morbidity. Advances in research related to hypertensive disorders in pregnancy have facilitated a better general understanding of the pathophysiologic processes associated with this disease. Strategies of prevention, early diagnosis, and newer treatments have contributed to a more favorable outcome for mothers and their babies. The exact cause of preeclampsia remains elusive; however, recent investigations suggest that endothelial cell injury due to free radical-mediated lipid peroxidation may be the initiator of the pathophysiologic events of preeclampsia. Future challenges in this area should include efforts to elucidate mechanisms involved in free radical cell-mediated vascular disturbances and antioxidant defenses.

Oxytocin augmentation in arrest disorders in the presence of thick meconium: influence on neonatal outcome.

The objective of this report was to study the effect of oxytocin augmentation in arrest disorders in the presence of thick meconium on meconium aspiration and fetal acidosis. We evaluated 3,321 singleton, term deliveries with cephalic presentation at our institution. Eight percent (253/3,321) had thick meconium in labor, and these patients comprised the study sample. Of the 253 women with thick meconium, 84 had an arrest disorder in the active phase of labor with normal fetal heart rate tracing at the time of diagnosis. Seventy-four percent (62/84) of the women with arrest were treated with oxytocin (group 1) and 26% (22/84) delivered by cesarean section without augmentation (group 2). There was a significant (p < 0.05) increase in the incidence of meconium aspiration (14.5 vs. 4.5%) and low (< 7.20) cord arterial pH (27.8 vs. 4.5%) in patients who received oxytocin compared to those who did not. Of the women who received oxytocin, 36 delivered vaginally, and 2 neonates had meconium aspiration. The remaining 26 women had cesarean sections following oxytocin augmentation and had a significantly higher (p < 0.05) frequency of meconium aspiration (26.9 vs. 4.5%) and low cord arterial pH (38.5 vs. 4.5%) compared to women who had cesarean sections without oxytocin augmentation. The findings suggest that oxytocin augmentation in arrest disorders in the presence of thick meconium may be associated with a higher risk of meconium aspiration and low umbilical cord arterial pH.