Pregnancy and epilepsy.

Pregnant women with epilepsy are at risk for a variety of complications. This article reviews the extensive literature on pregnancy and epilepsy with special emphasis on the management of pregnancy. Information is presented concerning seizure frequency in pregnancy, effects of epileptic seizures on the fetus, occurrence of complications during pregnancy and delivery, the incidence of fetal congenital malformations, and infant development. Recommendations are given concerning prenatal counseling, antiepileptic drug management, breast feeding, vitamin K supplementation and folic acid supplementation.

Abdominal wall metastases after surgical resection of an immature teratoma of the ovary.

In this case report the diagnostic process is discussed leading to a rather late correct diagnosis of immature teratoma. The authors advice preoperative determination of alpha-fetoprotein in all women with ovarian tumours under 40 years of age. The limitations for pathologists to assess immaturity within a teratoma are stressed.

Pyogenic sacro-iliitis, a rare cause of peripartum pelvic pain.

A patient was presented suffering from severe pelvic pain several weeks after delivery. Symptoms pointed in the direction of a peripartum pelvic pain syndrome. One week after admission, the clinical course deteriorated. An infective endocarditis complicated by pyogenic sacro-iliitis was diagnosed.

Primary malignant lymphoma of the uterus: localization in a cervical polyp.

Distinction between benign and malignant lymphoid lesions of the uterine cervix can be difficult. Two patients showing atypical lymphoid tissue confined to a uterine cervical polyp are presented. In one patient a non-Hodgkin lymphoma stage IE was diagnosed. Treatment consisted of combination chemotherapy. In a second patient the lesion was classified as atypical lymphoid hyperplasia. No treatment was initiated. The presence of a non-Hodgkin lymphoma in a cervical polyp is extremely rare. Distinction between benign and malignant lymphoid tissue within a cervical polyp can be facilitated by immunohistochemical staining and application of the histological criteria for a reactive nature of such lesions.

Management of eclampsia: cardiopulmonary arrest resulting from magnesium sulfate overdose.

An eclamptic seizure occurring at 32+2 weeks of gestation was treated with magnesium sulfate. Accidentally an overdose was given. As a consequence, the patient had a cardiopulmonary arrest. Immediate resuscitation and calcium gluconate administration did restore vital functions. Pregnancy continued for 4 weeks after the accident. Both mother and child left the hospital in good condition.

Fetal heart rate patterns and chronic exposure to antiepileptic drugs.

Fetal heart rate (FHR) characteristics of fetuses exposed and not exposed to antiepileptic drugs (AEDs) were studied. FHR is considered to reflect central nervous system (CNS) integrity. Three intervals during pregnancy were investigated: 20, 32, and 38 weeks. At 32 and 38 weeks, FHR was studied in relation to quiet (C1F) and active (C2F) sleep periods. For each tracing, a baseline was determined and accelerations and decelerations were identified. To assess FHR variability, the long-term irregularity, interval difference and absolute beat-to-beat indexes, and the bandwidth were calculated for 30-s intervals between accelerations and decelerations. No marked differences were noted between study and control groups concerning basal FHR and the occurrence of accelerations. For FHR derived from the fetal ECG, all indexes of FHR variability and the bandwidth were lower for the study group as compared with the control group, although the differences did not reach statistical significance. Our study shows that chronic prenatal exposure to AEDs does not seriously interfere with modulation of fetal heart rhythm by the CNS.

Fetal motility and chronic exposure to antiepileptic drugs.

The potential influence of antiepileptic drugs (AEDs) on fetal CNS function was studied with respect to motility patterns. Quantitative and qualitative aspects of spontaneous fetal activity were investigated for chronic AED-exposed fetuses and controls at three intervals during pregnancy: i.e. 20, 32 and 38 weeks. Movements were observed applying real-time ultrasound. Third trimester rest-activity cycles were determined according to the fetal behavioural state concept. Quantitative analysis revealed no marked differences in gross fetal motility between AED-exposed fetuses and controls. Both groups demonstrated the same developmental trend from midterm towards the third trimester. The number of trunk movements decreased, while their median duration increased. The incidence of fetal eye movements during C2F was lower for AED-exposed fetuses than for controls (significant for 38 weeks). In qualitative analysis, general movements of AED-exposed fetuses were more often labeled as suspect or abnormal than those of control fetuses (respectively, 8 out of 31 and 1 out of 20; P = 0.06). Future studies concerning chronic fetal AED-exposure and fetal CNS function should focus on qualitative rather than quantitative aspects of motility.

The Zavanelli maneuver applied to locked twins.

The Zavanelli maneuver was applied to locked twins. After the first infant was returned into the vagina, an emergency cesarean section was performed. After a not-too-good start, both children did well. The Zavanelli maneuver is presented as a method to reverse the potentially catastrophic situation of locked twins.

Quantitated fetal heart rhythm at 20, 32 and 38 weeks of gestation and dependence on rest-activity patterns.

Quantitative parameters of fetal heart rate (FHR) were automatically analysed at 20, 32 and 38 weeks of pregnancy. FHR was obtained both by the fetal ECG method and by wide range Doppler ultrasound with autocorrelation. At 32 and 38 weeks, FHR was studied in relation to fetal rest-activity according to the fetal behavioural state concept (coincidence 1F and 2F). Basal fetal heart rate was significantly higher at 20 weeks of gestation than at 32 and 38 weeks. The number of accelerations increased significantly from 20 weeks to 32 and 38 weeks for C2F periods. Parameters of FHR variability, i.e. ID, ABB, LTI indices and bandwidth, were higher during periods C2F compared to periods C1F. Lowest values of all four parameters were found at 20 weeks gestation. The ID index, which is a measure of short-term variability increased significantly between 32 to 38 (C2F). The absolute values of ID, ABB and LTI were lower for ultrasound recordings than for the fetal ECG.

Fetal rest-activity cycles and chronic exposure to antiepileptic drugs.

Rest-activity patterns were studied in fetuses exposed to antiepileptic drugs (AEDs) and in control fetuses at three intervals during pregnancy: 20, 32, and 38 weeks. At 20 weeks, periods of rest and activity were distinguished on the basis of fetal motility. Trunk, head, and arm movements were totaled. Periods of absence of movements for greater than 3 min were found in 20 of 31 recordings from AED-exposed fetuses compared with 11 of 20 recordings from controls (p greater than 0.05). The duration of these periods of inactivity did not differ significantly between the two groups. At 32 and 38 weeks, information on fetal motility and fetal heart rate (FHR) were combined to recognize rest-activity patterns according to the fetal behavioral state concept. At 32 weeks, three true fetal behavioral states were found for the study group, while there were none in the control group. Coincidence 1F through 4F occurred significantly less frequently at 32 weeks than at 38 weeks, regardless of whether fetuses were AED-exposed or not: 59% vs. 82% for the study group and 59% vs. 80% for the controls. At 38 weeks, true fetal behavioral states appeared in 20 of 34 fetuses exposed to AEDs and in 17 of 35 controls (p greater than 0.05). The sequence in which parameters changed within state transitions was found to follow the same preferred pattern in both groups. For transitions from behavioral state 1F (quiet sleep) into 2F (active sleep) the FHR pattern changed significantly earlier than fetal body or eye movements, while for the reverse transitions the FHR pattern changed significantly later (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Recording fetal breathing movements with a passive transducer based on an inductive principle.

A new transducer has been developed, based on an inductive principle, for recording fetal movements and sounds. The compliance of this transducer, the INductive PHOno-sensor (INPHO), can be matched to that of the maternal abdomen to provide an optimal transfer of displacement between maternal abdomen and transducer. In this manner, it is possible to detect fetal breathing movements by digital filtering of the INPHO signal in a frequency band between 0.5 and 2.0 Hz. Singular breathing movements can be detected and this was verified by real time ultrasound imaging. The INPHO transducer shows a flat (+/- 1.5 dB) frequency response between 0.2 and 200 Hz. The signal-to-noise ratio of the transducer system is better than 95 dB, and enables very weak movements and sounds to be detected. Spectral analysis of the processed signal shows that modulation of fetal breathing by maternal breathing takes place. The measuring setup allows for the quantitative assessment of fetal respiratory sinus arrhythmia.

Duration, amplitude and shape of accelerations in relation to fetal body movements in behavioral state 2F.

The relationship between fetal movements and fetal heart rate accelerations was analyzed in 34 healthy near term fetuses. Periods of coincidence 2F (C2F) with a mean duration of 34 +/- 6 minutes per fetus were selected, with a total of 463 accelerations. Nineteen percent of single body movements and 71% of compilations of movements were accompanied by an acceleration. The minimal duration of single movements associated with accelerations was 4-5 seconds. Movements with associated accelerations differed significantly in duration from movements without accelerations. The duration of accelerations was strongly correlated with the duration of movements. The amplitude of accelerations was not clearly correlated with the duration of movements, but depended on the type of movement. The shape of accelerations appeared to be dependent on the timing of the various fetal movements. In 77%, the number of notches in the accelerations was equal to the number of pauses in the movement complications. A discrepancy between notches in accelerations and pauses in movements could be explained in the majority of cases when the timing of the various movements in relation to one another was considered, or by the presence of fetal mouth movements.

Coincidence of behavioural state parameters in the human fetus at three gestational ages.

The fetal behavioural state concept was used to study fetal rest-activity cycles in normal pregnancies at gestational ages of 32 and 38 weeks. In addition, it was investigated if clustering of fetal movements was already present in recordings obtained at 20 weeks. At 20 weeks, 17 periods lasting longer than 3 min were found in which fetal body movements were absent. The mean duration of these periods was 4.0 +/- 0.8 min. On the basis of random scattering of movements on a time axis, it appeared unlikely that these periods of inactivity occurred by chance alone. At 32 and 38 weeks, data on body movements were combined with data on eye movements and the FHR pattern. At 32 weeks, true fetal behavioural states were not found. The average coincidence of 1F to 4F was 58%, while only 23% was to be expected if state parameters had fulfilled state criteria purely by chance. At 38 weeks, coincidence of 1F to 4F had increased to 80% (P less than 0.001). Expected coincidence purely by chance was 30%. True fetal behavioural states were found in 17 out of 35 recordings. For transitions from 1F into 2F, the FHR changed relatively early, i.e. as first or second parameter, while for the reverse transitions it changed relatively late (P less than 0.05). There was no clearly preferred sequence for body and eye movements within transitions.

Computer analysis of antepartum fetal heart rate: 1. Baseline determination.

A consequent and reproducible determination of baseline is an essential prerequisite for objective interpretation of fetal heart rate. A fully automated off-line method of baseline determination has been developed and tested on 50 normal antepartum fetal heart rate recordings of two hours duration. The method is constructed around two functional units, a digital filter and a trim function, which interact in an iterative process. The results were evaluated in comparison with automated baseline determination according to Dawes and coworkers. A panel of 3 experts agreed that in 14 of the 50 recordings (28%), the new developed procedure resulted in a substantially better baseline fit. In the remaining 34 recordings (72%), baseline fit from both methods was judged as equivalent. The described procedure of baseline determination provides a solid base for automated detection of accelerations and decelerations in fetal heart rate recordings. It enables the study of the relation between the fetal heart rate pattern and fetal movements. Finally, it provides an objective tool for analysis of variables within the fetal heart rate with the highest predictive value with respect to fetal outcome.

Computer analysis of antepartum fetal heart rate: 2. Detection of accelerations and decelerations.

Based upon a previously described procedure for automated baseline determination in antepartum fetal heart rate recordings, a programme has been developed for recognition of accelerations and decelerations. Detection of these deviations from the baseline depends on criteria for amplitude and duration, with special account for signal loss. The described automated analysis provides an objective tool for description of antepartum fetal heart rate patterns. A first evaluation with respect to its capacity to discriminate between different fetal heart rate patterns in relation to fetal rest-activity patterns shows promising results.

Automated assignment of behavioural states in the human near term fetus.

Thirty-five 2-h recordings of fetal heart rate and fetal movements, made at 38-39 weeks of gestational age, have been analyzed in a partly automated procedure. Involved were 17 nulliparous and 19 multiparous women. To minimize subjectivity the classification of the heart rate was performed in a Delphi group opinion procedure consisting of three rounds. In the third round, three independent investigators classified 89.1% of the total tracing time as pattern A through D. The investigators could not classify 6.1% of the tracing time in any of the available categories. The percentages of coincidence of state parameters did not differ significantly between the fetuses of nulli- and multiparous women. Fifty percent of the fetuses showed true behavioural states, both in the nulli and the multiparous women. The percentage of time spent in state 1F was higher in the multiparous group (P less than 0.05). The other percentages of states did not differ significantly, neither did the duration of the enclosed epochs. The advantages and disadvantages of the automated assignment of fetal behavioural states are discussed.

Fetal hiccups; characteristics and relation to fetal heart rate.

In 35 two-hour recordings of fetal heart rate and fetal movements, 14 periods of fetal hiccups were present (1.2% of the recording time) with a median duration of 3.5 min (range 1 to 8 min). No specific relation to behavioural states or movement patterns could be identified. The hiccupping frequency varied from 10 to 21 per min. Within a hiccupping spell, the mean frequency decreased from 20 +/- 11 to 12 +/- 6.2 per min. A small but evident increase in baseline frequency was present during the hiccupping spells, independent from other movements performed by the fetus.

Fetal mouth movements during behavioural states 1F and 2F.

The aim of this study was to investigate the characteristics of mouth movements during behavioural states 1F (quiet sleep) and 2F (active sleep) in the near term human fetus. Thirty-six women participated. Fetal heart rate and fetal movements were recorded for 2 hours continuously. Videotapes with enclosed periods 1F and 2F were replayed to record fetal mouth movements in detail. During 1F, regular mouthing movements dominated (present in 74%), while jaw opening, yawn and grimace were only observed in 5 to 16% of the recordings. Tongue protrusion was not observed in 1F. In all 2F periods jaw opening was present (100%), while tongue protrusion, yawn and grimace were also frequently observed. Regular mouthing was observed in 2F in only two fetuses. For regular mouthing and sucking, onset-to-onset intervals of clusters, cluster duration, and number and frequency of movements within clusters were calculated. In all aspects the differences between these two types of movement were statistically significant. Within the clusters of regular mouthing a decline in the mouthing frequency was found. The data on fetal regular mouthing correspond with observations in the neonate.

Fetal heart rhythms during behavioural state 1F.

Behavioural state 1F (quiet sleep) of the term fetus is defined on the basis of absence of eye and body movements, and the presence of a specific heart rate pattern (FHRP A), characterized by a stable heart rate with a small oscillation bandwidth. In the present paper the fetal heart rate pattern was studied in 39 enclosed periods with absence of fetal eye and body movements. In 37 periods the heart rate pattern met the criteria of FHRP A. Within FHRP A various distinct types of heart rhythm could be distinguished related to presence of breathing or regular mouthing and complete absence of movements. The bandwidth in the various heart rhythms differed significantly and was largest during breathing movements. During regular mouthing an oscillatory pattern was present with a frequency similar to the frequency of the clusters of mouthing movements. In 2 periods the heart rate deviated from the definition for FHRP A, i.e. a sinusoidal-like rhythm associated with sucking movements. These observations demonstrate the strong association between the fetal heart rate pattern and fetal movements during behavioural state 1F.

Computerized assessment of fetal behavioral states.

Fetal heart rate and fetal movements provide information on the fetal condition. In the near term human fetus, four behavioural states have been described based upon heart rate patterns and presence or absence of eye and body movements. For our studies concerning fetal physiology as well as the influence of maternal antiepileptic medication and the effects of intrauterine growth retardation on the fetal condition, we developed a computerized system for acquisition and storage of fetal heart rate signals and observed fetal movements. Fetal heart rate is recorded using a commercially available monitor combined with a home-made computer interface. Fetal movements are observed using two real-time ultrasound units. The observers handle keyboards to mark occurrence and duration of various types of fetal movements, and pedals to mark the visibility of the observed part of the fetal body. Keyboards and pedals are scanned by the computer. Special techniques are used to store heart rate and movement signals in an efficient way. Three experts determine fetal heart rate patterns by application of a Delphi group opinion procedure. Fetal behavioral states are identified by the computer using the results of the Delphi procedure, and performing the so-called extended automatic window procedure. This procedure identifies periods of presence and periods of absence of fetal eye and body movements, and incorporates the loss of visibility of the ultrasound images during the recording session. Fetal heart rate variability indices and distributions of fetal movements can be computed in the context of the fetal behavioral state concept.