Monochorionic diamniotic triplet pregnancy with prenatal diagnosis of cord entanglement.

BACKGROUND: Monozygotic monochorionic triplet pregnancies in which triplets share an amniotic cavity (di- or monoamniotic) are very rare. In addition to the other risks of high-order multiple pregnancy, such triplets are at risk for cord entanglement and therefore cord accident and intrauterine demise. CASE: A 32-year-old primigravid woman was found on ultrasound at 25 to 26 weeks' gestation to have a monochorionic diamniotic triplet pregnancy, a short dilated cervix, one fetus with biometry < 10th centile, and cord entanglement. The woman was hospitalized, ultrasound assessment was performed three times per week, and elective Caesarean section was performed at 30 weeks. The triplets subsequently did well. CONCLUSION: Monochorionic diamniotic triplet pregnancy with cord entanglement can be successfully managed by admission, close inpatient monitoring, and elective delivery.

Diagnosis and outcome of dextrocardia diagnosed in the fetus.

A retrospective review of 5,539 fetal echocardiograms over a 22-year period revealed 85 cases of dextrocardia. In primary dextrocardia (46 cases), the incidence of situs solitus, inversus, and ambiguous, was similar and associated with a high incidence of complex cardiac malformations in situs solitus and situs ambiguous. Secondary dextrocardia (39 cases) was due to intrathoracic displacement and, when caused by diaphragmatic hernia, was associated with cardiac malformations in 31% of cases. Even in complex cases, fetal echocardiography was highly accurate; therefore, specific counseling can be given to parents.

Screening for fetal well-being in a high-risk pregnant population comparing the nonstress test with umbilical artery Doppler velocimetry: a randomized controlled clinical trial.

OBJECTIVE: The purpose of this study was to evaluate the ability of two different modes of antepartum fetal testing to screen for the presence of peripartum morbidity, as measured by the cesarean delivery rate for fetal distress in labor. STUDY DESIGN: Over a 36-month period, all patients who were referred to the Fetal Assessment Unit at BC Women's Hospital because of a perceived increased fetal antepartum risk at a gestational age of > or =32 weeks of gestation were approached to participate in this study. Fetal surveillance of these women was allocated randomly to either umbilical artery Doppler ultrasound testing or nonstress testing as a screening test for fetal well-being. If either the umbilical artery Doppler testing or the nonstress testing was normal, patients were screened subsequently with the same technique, according to study protocol. When the Doppler study showed a systolic/diastolic ratio of >90th percentile or the nonstress testing was equivocal (ie, variable decelerations), an amniotic fluid index was performed, as an additional screening test. When the amniotic fluid index was abnormal (<5th percentile), induction and delivery were recommended. When the Doppler study showed absent or reversed diastolic blood flow or when the nonstress test result was abnormal, induction and delivery were recommended to the attending physician. Statistical comparisons between groups were performed with an unpaired t test for normally distributed continuous variables and chi(2) test for categoric variables. RESULTS: One thousand three hundred sixty patients were assigned randomly to groups in the study; 16 patients were lost to follow up. Six hundred forty-nine patients received Doppler testing and 691 received nonstress testing. The mean number of visits for the Doppler test and nonstress test groups was two versus two, respectively. The major indications for fetal assessment included postdates (43%), decreased fetal movement (22%), diabetes mellitus (11%), hypertension (10%), and intrauterine growth restriction (7%). The incidence of cesarean delivery for fetal distress was significantly lower in the Doppler group compared with the nonstress testing group (30 [4.6%] vs 60 [8.7%], respectively; P <.006). The greatest impact on the reduction in cesarean deliveries for fetal distress was seen in the subgroups in which the indication for testing was hypertension and suspected intrauterine growth restriction. CONCLUSION: Umbilical artery Doppler as a screening test for fetal well-being in a high-risk population was associated with a decreased incidence of cesarean delivery for fetal distress compared to the nonstress testing, with no increase in neonatal morbidity.

Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia.

BACKGROUND: The choice to give birth at home with a regulated midwife in attendance became available to expectant women in British Columbia in 1998. The purpose of this study was to evaluate the safety of home birth by comparing perinatal outcomes for planned home births attended by regulated midwives with those for planned hospital births. METHODS: We compared the outcomes of 862 planned home births attended by midwives with those of planned hospital births attended by either midwives (n = 571) or physicians (n = 743). Comparison subjects who were similar in their obstetric risk status were selected from hospitals in which the midwives who were conducting the home births had hospital privileges. Our study population included all home births that occurred between Jan. 1, 1998, and Dec. 31, 1999. RESULTS: Women who gave birth at home attended by a midwife had fewer procedures during labour compared with women who gave birth in hospital attended by a physician. After adjustment for maternal age, lone parent status, income quintile, use of any versus no substances and parity, women in the home birth group were less likely to have epidural analgesia (odds ratio 0.20, 95% confidence interval [CI] 0.14-0.27), be induced, have their labours augmented with oxytocin or prostaglandins, or have an episiotomy. Comparison of home births with hospital births attended by a midwife showed very similar and equally significant differences. The adjusted odds ratio for cesarean section in the home birth group compared with physician-attended hospital births was 0.3 (95% CI 0.22-0.43). Rates of perinatal mortality, 5-minute Apgar scores, meconium aspiration syndrome or need for transfer to a different hospital for specialized newborn care were very similar for the home birth group and for births in hospital attended by a physician. The adjusted odds ratio for Apgar scores lower than 7 at 5 minutes in the home birth group compared with physician-attended hospital births was 0.84 (95% CI 0.32-2.19). INTERPRETATION: There was no increased maternal or neonatal risk associated with planned home birth under the care of a regulated midwife. The rates of some adverse outcomes were too low for us to draw statistical comparisons, and ongoing evaluation of home birth is warranted.