Safety Aspects of Perinatal Ultrasound.

Ultrasound safety is of particular importance in fetal and neonatal scanning. Fetal tissues are vulnerable and often still developing, the scanning depth may be low, and potential biological effects have been insufficiently investigated. On the other hand, the clinical benefit may be considerable. The perinatal period is probably less vulnerable than the first and second trimesters of pregnancy, and ultrasound is often a safer alternative to other diagnostic imaging modalities. Here we present step-by-step procedures for obtaining clinically relevant images while maintaining ultrasound safety. We briefly discuss the current status of the field of ultrasound safety, with special attention to the safety of novel modalities, safety considerations when ultrasound is employed for research and education, and ultrasound of particularly vulnerable tissues, such as the neonatal lung. This CME is prepared by ECMUS, the safety committee of EFSUMB, with contributions from OB/GYN clinicians with a special interest in ultrasound safety.

Maternal and neonatal outcomes after induction of labor: a population-based study.

PURPOSE: To evaluate maternal and neonatal outcomes at and beyond term associated with induction of labor compared to spontaneous onset of labor stratified by week of gestational age. METHODS: In this retrospective cohort study, data form 402,960 singleton pregnancies from the Austria Perinatal Registry were used to estimate odds ratios of secondary cesarean delivery, operative vaginal delivery, epidural analgesia, fetal scalp blood testing, episiotomy, 3rd/4th-degree lacerations, retained placenta, 5-min APGAR <7, umbilical artery pH <7.1, and admission to neonatal intensive care unit. Multivariate logistic regression models based on deliveries with gestational age ≥37 + 0 were applied for adjustment for possible confounders. RESULTS: Induction of labor was associated with increased odds for cesarean delivery (adjusted OR; 99% confidence interval: 1.53; 1.45-1.60), operative vaginal delivery (1.21; 1.15-1.27), epidural analgesia (2.12; 2.03-2.22), fetal scalp blood testing (1.40; 1.28-1.52), retained placenta (1.32; 1.22-1.41), 5-min APGAR <7 (1.55; 1.27-1.89), umbilical artery pH <7.1 (1.26; 1.15-1.38), and admission to neonatal intensive care unit (1.41; 1.31-1.51). In a subgroup of induction of labor with the indication, "post-term pregnancy" induction was similarly associated with adverse outcomes. CONCLUSIONS: In Austria, induction of labor is associated with increased odds of adverse maternal and neonatal outcomes. However, due to residual confounding, currently, no recommendations for treatment can be derived.

2 year neurodevelopmental and intermediate perinatal outcomes in infants with very preterm fetal growth restriction (TRUFFLE): a randomised trial.

BACKGROUND: No consensus exists for the best way to monitor and when to trigger delivery in mothers of babies with fetal growth restriction. We aimed to assess whether changes in the fetal ductus venosus Doppler waveform (DV) could be used as indications for delivery instead of cardiotocography short-term variation (STV). METHODS: In this prospective, European multicentre, unblinded, randomised study, we included women with singleton fetuses at 26-32 weeks of gestation who had very preterm fetal growth restriction (ie, low abdominal circumference [<10th percentile] and a high umbilical artery Doppler pulsatility index [>95th percentile]). We randomly allocated women 1:1:1, with randomly sized blocks and stratified by participating centre and gestational age (<29 weeks vs ≥29 weeks), to three timing of delivery plans, which differed according to antenatal monitoring strategies: reduced cardiotocograph fetal heart rate STV (CTG STV), early DV changes (pulsatility index >95th percentile; DV p95), or late DV changes (A wave [the deflection within the venous waveform signifying atrial contraction] at or below baseline; DV no A). The primary outcome was survival without cerebral palsy or neurosensory impairment, or a Bayley III developmental score of less than 85, at 2 years of age. We assessed outcomes in surviving infants with known outcomes at 2 years. We did an intention to treat study for all participants for whom we had data. Safety outcomes were deaths in utero and neonatal deaths and were assessed in all randomly allocated women. This study is registered with ISRCTN, number 56204499. FINDINGS: Between Jan 1, 2005 and Oct 1, 2010, 503 of 542 eligible women were randomly allocated to monitoring groups (166 to CTG STV, 167 to DV p95, and 170 to DV no A). The median gestational age at delivery was 30·7 weeks (IQR 29·1-32·1) and mean birthweight was 1019 g (SD 322). The proportion of infants surviving without neuroimpairment did not differ between the CTG STV (111 [77%] of 144 infants with known outcome), DV p95 (119 [84%] of 142), and DV no A (133 [85%] of 157) groups (ptrend=0·09). 12 fetuses (2%) died in utero and 27 (6%) neonatal deaths occurred. Of survivors, more infants where women were randomly assigned to delivery according to late ductus changes (133 [95%] of 140, 95%, 95% CI 90-98) were free of neuroimpairment when compared with those randomly assigned to CTG (111 [85%] of 131, 95% CI 78-90; p=0.005), but this was accompanied by a non-significant increase in perinatal and infant mortality. INTERPRETATION: Although the difference in the proportion of infants surviving without neuroimpairment was non-significant at the primary endpoint, timing of delivery based on the study protocol using late changes in the DV waveform might produce an improvement in developmental outcomes at 2 years of age. FUNDING: ZonMw, The Netherlands and Dr Hans Ludwig Geisenhofer Foundation, Germany.

Congenital fibrosarcoma as cause for fetal anemia: prenatal diagnosis and in utero treatment.

OBJECTIVES: To discuss diagnosis and management of a case of a rare fetal tumor complicated by fetal anemia due to intratumoral hemorrhage. CASE REPORT: We report on a 29-week-old fetus with a tumor in the posterior left shoulder region. The morphologic aspect of the tumor, lack of fetal movements and an increased middle cerebral artery (MCA) peak systolic velocity (PSV) were indicative of fetal anemia caused by intratumoral bleeding. Following intravascular blood transfusion the pregnancy was safely prolonged for 15 days, during which lung maturity was induced. After delivery the neonate underwent surgical excision. Histological examination revealed an infantile congenital fibrosarcoma. CONCLUSION: Anemia must be ruled out in cases with fetal tumors. MCA PSV is useful in diagnosis and surveillance in these fetuses.

An unusual cause of sepsis during pregnancy: recognizing infection with chlamydophila abortus.

BACKGROUND: Chlamydophila abortus (formerly Chlamydia psittaci serovar 1) is a rare but severe cause of gestational septicemia, with particular problems in diagnosis and clinical management. CASE: A 32-year-old woman in her fourth pregnancy (16th week of gestation) presented with progressive septicemia after extensive contact with abortive material from her goat flock. Treatment with levofloxacin could not prevent abortion. Multiorgan failure requiring catecholamines and artificial ventilation developed in the patient. After the agent was identified by polymerase chain reaction from acute-phase serum, macrolides were administered and yielded clinical improvement. The patient fully recovered. There were no sequelae in the subsequent 6 months. CONCLUSION: Cp abortus must be considered in gestational septicemia after contact with ruminants. Polymerase chain reaction from acute-phase serum is a quick and easy way to establish the diagnosis. Macrolide antibiotics are still the treatment of choice.

[Training, practice and the increasing dominance of legal aspects in ultrasound in obstetrics and gynecology in Austria]. / Ausbildung, Ausübung und zunehmende Verrechtlichung des Ultraschalls in Gynäkologie und Geburtshilfe in Osterreich.

During the past few years, the Austrian Supreme Court has hanged down two landmark rulings concerning the use of ultrasound in obstetrics and gynecology. After a woman had died of ovarian carcinoma, her family sued the doctor for not having diagnosed the carcinoma by transvaginal ultrasound she had performed 8 months before the tumor was diagnosed. The plaintiffs won the case at the supreme court level, this making Austria the first country with implicit court-ordered ovarian cancer screening. A wrongful life case concerning a baby that had been born with bone deformities was also decided in favor of the plaintiffs, declaring ultrasound in pregnancy to be an instrument intended to help women decide whether or not to have an abortion. The impact of these two cases on the teaching and clinical application of ultrasound in obstetrics and gynecology in Austria is discussed.

The number of abnormal plasma glucose values in the oral glucose tolerance test and the feto-maternal outcome of pregnancy.

OBJECTIVE: With respect to the feto-maternal outcome of pregnancy both appropriate screening and treatment of gestational diabetes mellitus (GDM) remain a matter of debate. Furthermore, the importance of only one abnormal glucose value at the glucose tolerance test (GTT) is still discussed, including the term "gestational impaired glucose tolerance" with normal fasting but an increased 2h postprandial glucose value. STUDY DESIGN: We have evaluated the feto-maternal outcome of pregnancy in 152 women with abnormal glucose values during the oral 100g GTT. The data were analysed with respect to the number of abnormal GTT values and compared to age- and body mass index (BMI)-matched control groups including 304 women with normal GTT values. RESULTS: A positive family history of diabetes was found in 24.4% of the GDM women and in 16.4% of the control group. In 45.9% of the women with abnormal GTT values glucose target levels could be obtained by dietary management, 54.1% required additional insulin therapy. Insulin therapy was administered in 32.8% of the women with one abnormal GTT value, in 65.0% of the women with two abnormal values and in 83.3% of the women with three abnormal values. Compared to the age- and BMI-matched control group the percentage of women with hypertension was increased in women with one, two and three abnormal GTT values. The percentage of LGA and macrosomic infants was significantly increased only in women with three abnormal GTT values. Women with one, two or three abnormal GTT values revealed an increased percentage of caesarean section compared to the control group. CONCLUSIONS: Our results show that women with three abnormal GTT values are at an overall increased risk with respect to the feto-maternal outcome of pregnancy. Compared to the control group also women with only one abnormal GTT value revealed an increased risk indicating a need for further control and therapy.

Management of respiratory deterioration in a pregnant patient with severe kyphoscoliosis by non-invasive positive pressure ventilation.

The problem of kyphoscoliosis in combination with pregnancy is uncommon and published cases are rare. Until now, little and controversial information on the outcome, optimal management and course of pregnancy in patients with kyphoscoliosis has been available. The majority of maternal deaths seem to be attributed to cardiorespiratory failure, while obstetric complications account for relatively few complications. We present the case of a 34-year old pregnant woman with congenital kyphoscoliosis and a forced vital capacity (FVC) of about one liter. A further deterioration of lung function was expected. In fact, severe limitations in exercise capacity (bed rest), fatigue and hypersomnolence, as well as a severe increase in pulmonary hypertension occurred during the second and third trimester. Nasal intermittent positive pressure ventilation (NIP-PV) with bilevel positive airway pressure (BiPAP) was started in the 20th week of gestation and adapted throughout pregnancy. Nasal BiPAP was well-tolerated and corrected exercise tolerance, fatigue and nocturnal oxygen desaturations. At 32 weeks of gestation, the patient was admitted for an elective Caesarean section under combined spinal-epidural anaesthesia with ongoing NIPPV, and delivered a healthy baby. Home nocturnal ventilatory support was continued as nocturnal episodic desaturations were also assessed during the postpartum period. At time of discharge, the patient's exercise capacity and lung function were nearly equal to levels before pregnancy. We conclude that pregnancy in selected kyphoscoliotic patients with severe limitations in lung function is relatively safe for both the mother and the child when NIPPV is used for overcoming respiratory deterioration and for preventing further cardiorespiratory failure.

3D ultrasound imaging of the human corpus luteum.

The aim of this article was to present the extent to which the state-of-the art ultrasonographic imaging can be used to visualize the features of the human corpus luteum (CL). In the late 1970s, the first ultrasonographic images of human CLs were published. The advent of transvaginal, high-resolution transducers has greatly improved the quality of imaging as did the subsequent introduction of color Doppler and 3D ultrasonography. In the present technical note, the examples of the various technical and imaging modalities used to examine the human CLs are shown. CL is a short-lived structure with a highly variable morphological appearance and the 3D ultrasonographic technique is an ideal tool to perform standardized measurements on the CL. The introduction of new imaging techniques in clinical reproductive medicine can only be successful if operators are properly trained.

Spontaneous abortion and the prophylactic effect of folic acid supplementation in epileptic women undergoing antiepileptic therapy.

BACKGROUND: Antiepileptic drugs (AEDs) like phenytoin (PHE), carbamazepine (CBZ), barbiturates and valproic acid (VPA) interfere with folic acid absorption and metabolism, which in turn can be the cause of adverse pregnancy outcome. OBJECTIVE: To study the prophylactic effect of folic acid supplementation with regard to spontaneous abortion and preterm delivery (fetal demise after week 20 of gestational age) in pregnant women receiving AED therapy, as well as benefits of most common dosage and preconceptional commencement. METHODS: Prospective examination of 104 patients, registered in EURAP from 1999-2004 at a single center and a retrospective analysis of data from our epilepsy databank completed with medical records and patients interviews of the Department of Neurology of Innsbruck University Hospital from 1971 to 1999. RESULTS: 388 pregnancies in 244 patients were analyzed. Pregnancies with folic acid supplementation showed significant reduction of spontaneous abortion. With regard to monotherapies, in the group of women taking VPA, supplementation of folic acid had significant benefit. Other examined monotherapies (CBZ, PHE, and PB) known to interfere with folic acid showed no significant results. CONCLUSIONS: This study confirms the prophylactic effect of folic acid supplementation on spontaneous abortion. For AED therapy, folic acid supplementation should be part of the therapy of every pregnant epileptic woman, especially for those treated with VPA.

Chemotherapeutic treatment of a pregnant patient with ovarian dysgerminoma.

BACKGROUND: Diagnosis of malignant ovarian tumours during pregnancy is uncommon. This report presents a case of a pregnant woman with ovarian dysgerminoma. CASE REPORT: At 24 weeks gestation, a 33-year-old patient was diagnosed with unilateral ovarian dysgerminoma. Because the tumour was considered to be at an advanced stage (FIGO III), she received three cycles of paclitaxel and carboplatin. At 36 weeks gestation, she underwent a caesarean section, abdominal hysterectomy, bilateral salpingovarectomy, omentectomy, and lymphadenectomy. After surgery, she received three additional cycles of chemotherapy in an adjuvant setting. At birth, the infant was responsive to stimuli, and 20 months after delivery, the infant exhibited normal development. CONCLUSION: This case report illustrates the difficulties arising from diagnosis of malignancy during pregnancy. Although combined treatment with paclitaxel and carboplatin is not considered a first-line therapy for ovarian dysgerminoma, in this case report it elicited an excellent response, and there were no adverse effects on the foetus.