Polymicrogyria in a fetus with human parvovirus B19 infection: a case with radiologic-pathologic correlation.

We report the prenatal magnetic resonance imaging (MRI) appearance of polymicrogyria with pathologic correlation in a fetus with congenital parvovirus B19 infection. Prenatal ultrasound revealed non-immune hydrops, but detected no fetal brain abnormalities. A subsequent fetal MRI scan performed at 23 weeks' gestation demonstrated bilateral polymicrogyria, which was confirmed at autopsy. To our knowledge, prenatal diagnosis of polymicrogyria in association with congenital parvovirus B19 infection has not been previously described. This case provides further evidence for brain abnormalities resulting from congenital parvovirus B19 infection, and suggests that fetal neuroimaging with MRI would be of value in suspected cases of congenital parvovirus infection.

Supermarket sales of high-sugar products in predominantly Black, Hispanic, and white census tracts of Houston, Texas.

Sales of 488 sweet foods and beverages by supermarkets located in predominantly Black, Hispanic, and white census tracts of Houston, TX, were examined in relation to sales of a number of commodity foods. Mean sweet energy/commodity food sales ratios in Black and Hispanic census tract supermarkets were 122 and 108%, respectively, of those in white census tracts. Ethnic differences in sweet energy/commodity sales ratios were almost always statistically significant (p less than 0.05), but variation within ethnic groups of supermarkets remained large, indicating that nonethnic factors also influenced the food purchase patterns. Supermarket sales records offer a relatively inexpensive source of data for comparative or longitudinal studies of community purchase of food products postulated to play a role in the development of nutrition-associated health problems. The major problems in interpreting the data result from a need to use ratios, and lack of a valid measure of the population consuming the foods purchased.

Natural history of fetal ventriculomegaly.

The natural history of in utero ventriculomegaly was defined by a retrospective review of the outcome of 47 fetuses evaluated during a 5-year period by the Fetal Treatment Program at the University of California. In 20 fetuses, a diagnosis of ventriculomegaly associated with other severe abnormalities was made early in pregnancy. Termination of pregnancy was elected in 19 of 20 cases, and no fetus survived. In five fetuses, the diagnosis was made late in pregnancy and was associated with severe abnormalities. Fetuses were handled in a routine obstetric fashion and none survived. Of the other 22 fetuses 19 had stable and two had progressive ventriculomegaly; in one case, ventriculomegaly resolved in utero. Nineteen of these fetuses have survived, 13 with normal intellectual development and six with moderately to severely delayed development. Associated abnormalities were detected with ultrasonography in 74% of fetuses; there was a 20% false-negative rate of detection. Ventriculomegaly was isolated and progressive in two fetuses. In both cases, fetuses were delivered at term, and postnatally a shunting procedure was performed. Both children are neurologically normal. From our results and a review of the literature, which supports our findings, we were unable to define a group of fetuses with in utero ventriculomegaly that would benefit from in utero shunting.

The prognostic value of loculations in parapneumonic pleural effusions.

Forty-eight patients with pleural effusions who had sonographically directed thoracocentesis were evaluated retrospectively for radiologic findings, pleural fluid chemistries, and outcome. Loculation was found to be a radiologic marker of diagnostic and prognostic significance. The presence of loculations correlated with exudative pleural fluid chemistries, but no radiologic finding was specific for empyema. "Extreme" pleural fluid chemistries were associated with loculation, but not with empyema. Patients with loculated effusions had larger effusions, longer hospitalizations, and more frequent tube thoracostomy procedures than patients with nonloculated effusions. Light's criteria for tube thoracostomy were found to be unreliable in patients with loculated parapneumonic effusions or in patients treated with prolonged antibiotic therapy prior to thoracocentesis.

First trimester molar pregnancy: nonspecific ultrasonographic appearance.

Ultrasonographers and gynecologists have come to anticipate not only a high diagnostic sensitivity of ultrasonic detection of hydatidiform mole, but also that the examination will suggest specifically the correct pathologic diagnosis. Although this appears true for molar gestations examined in the second trimester, molar pregnancies detected in the first trimester do not appear to demonstrate the characteristic features necessary to diagnose this abnormality specifically. Three cases of early molar pregnancy examined in the past year with good quality gray-scale ultrasonographic units failed to demonstrate specific diagnostic findings.

Ultrasonography in the evaluation of intrauterine transfusion.

Numerous techniques have been described in the literature to aid the obstetrician in safely and easily performing an intrauterine transfusion. None, however, have addressed themselves to the question of whether the transfused cells actually enter the fetal peritoneal cavity. We have used gray-scale ultrasonography to evaluate this question in 4 patients who had undergone a total of 8 intrauterine transfusions. By scanning the fetal abdomen both before and after the transfusion, we were able to identify the transfused fluid within the fetal abdomen in all cases.

The role of velamentous cord insertion in the etiology of twin-twin transfusion syndrome.

OBJECTIVE: To evaluate the prevalence of velamentous cord insertion in twin-twin transfusion using the hypothesis that such insertions may contribute to the etiology of the condition. METHODS: All cases of placentas referred for pathologic evaluation at the University of California at San Francisco from 1984-1992 were reviewed for the citation of diamniotic-monochorionic placentation, including the presence of velamentous cord insertions. Maternal and infant records were studied for findings consistent with twin-twin transfusion syndrome. RESULTS: Thirty-eight cases of monochorionic-diamniotic twins were identified, 11 of which showed twin-twin transfusion syndrome. The prevalence of velamentous cord insertion in the transfusion syndrome subset was 63.6%, compared with 18.5% in those without (significant difference at P < .01). Twin-twin transfusion syndrome pregnancies with velamentous insertions were delivered at a significantly earlier gestational age; they also had fewer surviving infants and were more likely to have been treated prenatally than transfusion syndrome pregnancies without velamentous insertion, although these latter two findings were not significantly different. CONCLUSIONS: Velamentous cord insertions are more common in twin-twin transfusion syndrome pregnancies and may contribute to the development of profound disparity in fluid volume because the membranously inserted cord can be easily compressed, reducing blood flow to one twin. Large-volume amniocentesis may reduce this compressive force on the cord insertion, thus explaining the success of this mode of intervention.

Sonographic identification of autosomal recessive polycystic kidney disease associated with increased maternal serum/amniotic fluid alpha-fetoprotein.

A patient with no family history of renal disease was referred for obstetric sonography because of elevated maternal serum and amniotic fluid alpha-fetoprotein (AFP), and was proved to be carrying a fetus with autosomal recessive polycystic kidney disease. Review of records of previous cases with a sonographic diagnosis of this disease revealed one other case with elevated and one case with normal amniotic fluid AFP. Sonographers should be aware of the potential diagnosis of this condition in patients with elevated AFP, even in gestations not known to be at risk. Because the sonographic diagnosis of this disease can be difficult in gestations known to be at risk, AFP determination may prove to be a useful diagnostic adjunct in these pregnancies as well.

Ultrasonography in the evaluation of nontraumatic abdominopelvic emergencies.

Ultrasonography can provide prompt diagnostic information in many non-traumatic abdominal and pelvic emergencies. The safety of of diagnostic ultrasonography enables its use in many emergency situations that relate to pregnancy. The ability to demonstrate normal fluid-filled organs with clarity makes ultrasonography valuable in the emergency assessment of the gallbladder and aorta. Similary, ultrasound is sensitive to the detection of pathologic collections of fluid that can be applied in the search for abscesses or hematomas. Finally, ultrasonography is independent of organ function. In this regard, it is a useful ancillary test when radiographic examinations of the biliary or urinary tracts fail because of poor contract excretion.

Severity of intestinal damage in gastroschisis: correlation with prenatal sonographic findings.

From 1982 to 1986, 26 abdominal wall defects were detected prenatally. Seventeen pregnancies culminated in live births with ultrasound correctly distinguishing between omphalocele and gastroschisis in all cases. In the 11 cases of gastroschisis diagnosed before birth, we attempted to correlate the clinical outcome with the size of the abdominal wall defect, sonographic appearance of the eviscerated bowel, and known time of exposure to amniotic fluid (gestational age at birth to gestational age at diagnosis). Neither the time of exposure to amniotic fluid (median duration of 14 weeks) nor the defect size could be correlated with eventual clinical outcome. The presence of small bowel dilatation and mural thickening on prenatal sonography (four patients) had a high correlation with severe intestinal damage and poor clinical outcome. The absence of these two sonographic findings (seven patients) was associated with mild intestinal changes and benign clinical course with no morbidity or mortality. We conclude that obstetric ultrasound cannot only accurately detect the presence and type of abdominal wall defect, but it also gives an indication of the severity of intestinal damage and subsequent clinical course in prenatally diagnosed cases of gastroschisis. Early delivery of the fetus with prenatally diagnosed gastroschisis should no longer be performed to limit exposure to amniotic fluid. Now that reliable sonographic criteria of severe intestinal damage have been defined, the decision to deliver early can be restricted to those fetuses with bowel dilatation and mural thickening.

Primary fetal hydrothorax: natural history and management.

Primary fetal hydrothorax presents a wide spectrum of severity ranging from small, harmless effusions, to life-threatening thoracic compression. To define natural history and management, we reviewed 32 cases seen at two large perinatal centers from 1980 to 1987. Spontaneous resolution of the effusions was seen in three fetuses, all of whom survived. Three fetuses were electively terminated. The overall mortality was 53%. In the 24 untreated fetuses, sex and the presence of polyhydramnios did not influence mortality, but hydrops, gestational age less than 35 weeks at delivery, and bilateral effusions were associated with a poor prognosis. Five fetuses underwent in utero decompression. In four, thoracentesis was performed, with rapid reaccumulation of the effusion. All four died from pulmonary insufficiency. In the fifth fetus, a thoracoamniotic shunt permanently decompressed the effusion, with resolution of the hydrops, and delivery of a normal viable infant. We conclude that (1) primary fetal hydrothorax may resolve or progress to hydrops, necessitating close follow-up with ultrasound; (2) pulmonary hypoplasia as a result of undrained large pleural effusions may result in neonatal mortality; (3) the gestational age at both diagnosis and delivery, the development of hydrops, and bilaterality of effusions are important prognostic predictors; and (4) the fetus with large effusions and hydrops has a poor prognosis, and thoracic decompression with a thoracoamniotic shunt may prove life saving.

Management of the fetus with congenital hydronephrosis.

Twenty-six fetuses with dilated urinary tracts were studied with serial sonograms. Eight fetuses with unilateral hydronephrosis were followed without intervention; all are well after postnatal surgical correction. Three cases of bilateral hydronephrosis resolved spontaneously before birth. Eight fetuses with bilateral hydronephrosis had evidence of poor function: Three were not treated and died shortly after birth with small lungs and dysplastic kidneys; three others had diagnostic intervention that demonstrated irreversible disease and allowed termination of the pregnancy; two had obstruction successfully corrected in utero, but renal damage proved irreversible and precluded survival at birth. Seven fetuses with bilateral hydronephrosis and equivocal function underwent early decompression. Four were delivered early and corrected ex utero; 1 has renal failure and the other 3 are well. Three had obstruction relieved in utero by a catheter shunt placed percutaneously; 1 had multiple anomalies and died; the other 2 are well. Serial sonographic observation improves perinatal management of the fetus with a dilated urinary tract. The need for diagnostic or therapeutic intervention depends on the type and severity of obstruction and the time in gestation when it is discovered. Most fetuses do not require treatment before birth; a few may benefit from early decompression in or ex utero.

The missing link in the pathogenesis of gastroschisis.

Is gastroschisis embryologically distinct from omphalocele or simply a ruptured small omphalocele (hernia of the umbilical cord)? Serial sonographic imaging of a fetus with a small omphalocele at 27 weeks gestation has now provided the "missing link" in the pathogenesis of gastroschisis by documenting in utero rupture resulting in a gastroschisis.

Management of the fetus with an abdominal wall defect.

Eleven fetuses with omphalocele and two with gastroschisis were diagnosed by prenatal ultrasonographic examination. Intact omphalocele was accurately distinguished from gastroschisis by detection of a membranous sac covering the herniated viscera, by liver protruding from the abdomen, and by the frequent association of major structural anomalies. Gastroschisis was characterized by the absence of these findings and the presence of bowel loops floating freely in the amniotic fluid. Nine of eleven fetuses with omphaloceles had other major malformations and did not survive. Two small omphaloceles and two gastroschises were correctly diagnosed as isolated defects, free from associated anomalies. All four underwent maternal transport and were successfully managed with good outcome. Prenatal ultrasonography allows rational decisions about perinatal management by distinguishing between omphalocele and gastroschisis and by screening for associated anatomic defects. Karyotype analysis should be a part of the prenatal workup. Most isolated defects can be followed and delivered normally near term. Accurate prenatal diagnosis allows maternal transport and in a few cases may alter the timing or mode of delivery.

Prenatal diagnosis and natural history of the fetus with a congenital diaphragmatic hernia: initial clinical experience.

To study the accuracy of prenatal diagnosis and define the natural history of fetal congenital diaphragmatic hernia (CDH), we reviewed experience with CDH at The University of California, San Francisco (UCSF) over the last three years. All nine babies born in our institution (inborns) and six of 11 babies referred from other hospitals after birth (outborns) died, an overall mortality of 75%. All had pulmonary hypoplasia. Forty percent had associated malformations or chromosomal abnormalities, a higher incidence than generally reported. Prenatal sonograms were available in all nine inborn cases. CDH was correctly diagnosed prospectively in only five, but could be recognized retrospectively in all nine cases using the sonographic criteria developed from the study. Polyhydramnios was present in all nine cases; in seven cases sonography was performed because the woman was large-for-dates clinically. There were no false positive interpretations, and when necessary the diagnosis was confirmed by amniography. All nine cases of CDH detected in utero died. Seven deteriorated so rapidly that surgical repair could not even be attempted. Two who had optimal care (maternal transport, immediate resuscitation and operation) died after repair despite maximal intensive care including vasodilator therapy. Despite the theoretical advantages of maternal transport to pediatric surgical specialty centers, a majority of fetuses with a prenatal diagnosis of CDH will die because their lungs are inadequate to support extra-uterine life even at term.

Early experience with open fetal surgery for congenital hydronephrosis.

The fetus with severe bilateral hydronephrosis and associated oligohydramnios in the second trimester is doomed at birth by ongoing pulmonary and renal damage. Since decompression with percutaneously placed catheters anesthetic, surgical, and tocolytic techniques for open fetal anesthetic, surgical, and tocolytic techniques for open fetal urinary tract decompression in animals, and have now applied those techniques to a small group of five patients. One had bilateral ureterostomies and the subsequent four had marsupialization of the bladder. All pregnancies proceeded to cesarean delivery at 32 to 35 weeks' gestation. There was no long-term maternal morbidity, and two mothers have since experienced normal pregnancies. Three fetuses had return of normal amniotic fluid dynamics, and all three had adequate pulmonary function at birth, suggesting that fatal pulmonary hypoplasia associated with early severe oligohydramnios had been reversed. Two neonates died at birth with pulmonary hypoplasia. One had no amniotic fluid even after decompression, and the other had some amniotic fluid after decompression but a tiny chest cavity due to the long period of severe oligohydramnios before decompression. Of the three surviving infants, one had normal renal function when she died of unrelated causes at 9 months of age. One has normal renal function at 23 months and the third had failing renal function at 2 1/2 years and has grown and developed normally, but will require renal transplantation. We have now developed selection criteria that would exclude from treatment the two fetuses who died of pulmonary hypoplasia and the one who developed renal failure.(ABSTRACT TRUNCATED AT 250 WORDS)

Correction of congenital diaphragmatic hernia in utero, V. Initial clinical experience.

Review of our experience with 45 cases of prenatally diagnosed congenital diaphragmatic hernia (CDH) confirms that most fetuses (77%) will not survive despite optimal pre- and postnatal care. Polyhydramnios, associated anomalies, early diagnosis, and a large volume of herniated viscera (including liver) are associated with a particularly dismal prognosis. After extensive experimental work demonstrated the efficacy, feasibility, and safety of repair in utero, we attempted to salvage six highly selected fetuses with severe CDH by open fetal surgery. Five had liver incarcerated in the chest: three died at operation because attempts to reduce the liver compromised umbilical venous return. In one, a Goretex diaphragm was constructed around the liver, but the baby died after birth. The last two fetuses, one with incarcerated liver, were successfully repaired. Both demonstrated rapid growth of the lung in utero, had surprisingly good lung function after birth despite prematurity, had the abdominal patch removed at 2 weeks, and subsequently died of nonpulmonary problems (an unrelated nursery accident in one and intestinal complications in the other). The only maternal complication was amniotic fluid leak and preterm labor. All six women are well and four have had subsequent normal children. From this phase I experience, we conclude that fetal surgery appears safe for the mother and her reproductive potential, that fetal CDH repair is feasible in selected cases, and that the fetal lung responds quickly after decompression. However, fetal repair remains a formidable technical challenge.

Management of the fetus with congenital hydronephrosis II: Prognostic criteria and selection for treatment.

Selecting appropriate management for the fetus with bilateral congenital hydronephrosis depends on our ability to accurately assess the severity of existing renal damage and to predict the potential for recovery of renal and pulmonary function if the obstruction is relieved. We reviewed our experience with 20 fetuses with congenital bilateral hydronephrosis to determine the prognostic value of various criteria used to assess functional potential, including temporary catheter exteriorization to measure fetal urine output and composition. Based on autopsy, biopsy, or clinical outcome, ten fetuses were classified retrospectively as "poor function," and ten fetuses as "good function." The good function group could be distinguished from the poor function group by the following criteria: Amniotic fluid (AF) status at presentation (P less than .001), ultrasound appearance of the fetal kidneys (P less than .05), fetal urine sodium and chloride concentration and osmolarity (P less than .001), and hourly urine output (P less than .02), but not by fetal urine iothalamate excretion or potassium and creatinine concentrations (P greater than .05). Based on these results, we have identified prognostic criteria that accurately identify the fetus with "good function" from the fetus with "poor function." We also reviewed the clinical management of our last 12 unreported cases. Ten fetuses had undergone diagnostic catheter placement and in utero renal function testing. This led to placement of a therapeutic indwelling catheter-shunt in seven fetuses (three required multiple shunts) and a suprapubic vesicostomy in another. Catheter related complications, including three cases of chorioamnionitis, emphasize the need for better methods of in utero decompression in selected cases. Our ability to select appropriate management has improved markedly.

Fetal cystic adenomatoid malformation: prenatal diagnosis and natural history.

We studied the natural history and pathophysiology of congenital cystic adenomatoid malformation (CCAM) detected prenatally by ultrasound in twelve fetuses. Two types of fetal CCAM can be distinguished by gross anatomy, ultrasound findings, and prognosis. Microcystic lesions are usually associated with fetal hydrops and have a poor prognosis (five cases with one survivor). Antenatal diagnosis, maternal transport, and immediate thoracotomy after birth allowed the first reported survival of a newborn with a large microcystic CCAM. Macrocystic lesions are not usually associated with hydrops and have a favorable prognosis (five of seven survived). We conclude that fetuses with hydrops are at high risk for fetal or neonatal demise without intervention. Fetuses with CCAM but without hydrops have a good chance for survival with maternal transport, planned delivery, and immediate neonatal resuscitation and surgery.

Iliac venous aneurysm in a pregnant patient with a renal transplant. A case report.

A 10-cm-diameter iliac venous aneurysm presented as an adnexal mass in a pregnant patient with a renal transplant. She also had a femoral-saphenous arteriovenous shunt for facilitation of dialysis prior to the transplant. Diagnosis was made at laparotomy. The aneurysm was thought to have arisen because of elevation of iliac venous pressure due to the fistula, vascular relaxation and pressure of the uterus on the pelvic veins.