Human cytomegalovirus (HCMV) DNAemia in the mother at amniocentesis as a risk factor for iatrogenic HCMV infection of the fetus.

To investigate whether invasive procedures performed in the presence of human cytomegalovirus (HCMV) DNA in maternal peripheral blood (HCMV DNAemia) represent a risk for iatrogenic transmission of HCMV infection to the fetus, 194 pregnant women undergoing prenatal diagnosis because of a primary HCMV infection and their 199 fetuses were investigated. Overall, 27 (37%) of 73 mothers of uninfected fetuses and 22 (37%) of 59 mothers of infected fetuses were HCMV DNAemia-positive at amniocentesis. Of the 8 mothers of the 8 fetuses with false-negative amniocentesis results, 4 were DNAemia-positive and 4 were DNAemia-negative at amniocentesis. Therefore, maternal HCMV DNAemia is not a significant risk factor for iatrogenic HCMV transmission to the fetus during amniocentesis.

Should we explain lower urinary tract symptoms to patients?

AIM: The aim of our study was to evaluate the understanding of lower urinary tract symptom (LUTS) terminology used by patients. MATERIALS AND METHODS: Women attending urodynamic clinics in United Kingdom, Australia, and Italy were asked to complete a questionnaire testing the women's understanding of stress urinary incontinence, urge urinary incontinence, frequency, urgency, nocturia, and hesitancy. Five possible explanations for the meaning of each symptom were given. RESULTS: A total of 138 consecutive women were prospectively recruited. The terms of daytime frequency, nocturia, urgency, urge urinary incontinence, stress urinary incontinence, and hesitancy were defined correctly, according to the International Continence Society terminology, only by 33% (45/138), 44% (61/138), 46% (64/138), 39% (54/138), 37% (51/138), and 41% (57/138) of women, respectively. Over 20% of women were unsure about the meaning of each symptom. We did not find any statistical difference between the three groups in determining the correct definition (P = 0.5). CONCLUSIONS: Our findings showed that most women do not know the correct meaning of LUTS terminology currently used by physicians.

Fetal serum beta2-microglobulin before and after bladder shunting: a 2-step approach to evaluate fetuses with lower urinary tract obstruction.

PURPOSE: The evaluation of renal function in fetuses with lower urinary tract obstruction by analysis of electrolytes and beta2-microglobulin in fetal urine has limitations. We measured fetal serum beta2-microglobulin before and after bladder shunting to evaluate renal function. MATERIALS AND METHODS: A total of 12 fetuses with lower urinary tract obstruction underwent vesicoamniotic shunting. In addition to the standard evaluation of urinary electrolytes and beta2-microglobulin, fetal renal status was assessed by pre-shunt and post-shunt fetal serum beta2-microglobulin. RESULTS: At 2 to 4 weeks after shunting 2 of the 12 fetuses had persistent oligohydramnios, demonstrated increased values of serum beta2-microglobulin and were confirmed to have renal dysplasia. In the remaining 10 fetuses there was reaccumulation of amniotic fluid for a minimum of 4 weeks after shunting. Serum beta2-microglobulin values increased after shunting in 4 fetuses, all of which developed renal failure, whereas serum beta2-microglobulin did not change or was decreased after shunting in 6, of which 4 had normal renal function at latest followup. CONCLUSIONS: Urinary electrolytes, urinary beta2-microglobulin and pre-shunt serum beta2-microglobulin, whether increased or normal, failed to be predictive of potential response to prenatal intervention. Serial samples of fetal blood may provide distinction between patients who do and do not respond to prenatal treatment of lower urinary tract obstruction.

Fetal pleural effusion.

Fetal pleural effusion, a nonspecific accumulation of fluid in the pleural space, is an uncommon anomaly which can be associated with aneuploidy and a range of other structural malformations or genetic syndromes. Spontaneous resolution is not rare and confers a good prognosis. Perinatal outcome is better for those fetuses without hydrops than those presenting with hydrops. A detailed review of the literature indicates that, for fetuses with persistent effusions, in utero intervention (repeated thoracocentesis, intrauterine shunting and pleurodesis) may improve the chances of survival.

Cervical phIGFBP-1 in the evaluation of the risk of preterm delivery.

BACKGROUND: To evaluate the accuracy of the decidual phosphorylated isoform of insulin-like growth factor binding protein-1 in endocervical secretions to predict premature delivery in symptomatic and asymptomatic pregnant women. METHODS: The study included 332 pregnant women: 109 symptomatic patients (study group) and 223 asymptomatic women (control group). For all women, qualitative and quantitative assessment of the decidual phosphorylated isoform of insulin-like growth factor binding protein-1 in endocervical secretions was carried out, but the quantitative assay was finally performed in 282 of 332. Student's test, the chi2 test, and Fisher's exact test were used as appropriate. RESULTS: The phosphorylated insulin-like growth factor binding protein-1 qualitative test was positive in 35 of 301 women (11.6%) and 11 (31.4%) of them delivered before 37 weeks; in the remaining 266 women with a negative test, there were 11 (4.7%) premature deliveries (relative risk = 5.8; 95% CI = 3.3-10.3). The mean values of quantitative phosphorylated isoform of insulin-like growth factor binding protein-1 were 56.9 microg/l (95% CI = 40.7-73.1) in cases of a positive qualitative test and 6.1 microg/l (95% CI = 4.0-8.3; p = 0.0001) in women with a negative result. The sensitivity, specificity, positive predictive value, and negative predictive value for phosphorylated isoform of insulin-like growth factor binding protein-1 test in symptomatic patients were 69.2%, 90.5%, 50%, and 95.6% respectively, while in the asymptomatic patients they were 22.2%, 91.8%, 11.8%, and 96% respectively. CONCLUSIONS: The phosphorylated isoform of insulin-like growth factor binding protein-1 in cervical secretions is a potential specific marker for preterm delivery occurring before 37 weeks. This test may have an important role in the management of women presenting with symptoms suggestive of preterm labour.

C-reactive protein in hypertensive disorders in pregnancy.

Hypertension is the most frequent medical complication of pregnancy. A recent report demonstrates the flogistic pathogenesis of pregnancy-induced hypertension. Because C-reactive protein (CRP) is a marker of inflammation, it can be used in the differential diagnosis of hypertensive disorders of pregnancy. A total of 322 pregnant women at 24 to 32 weeks' gestation were enrolled. The control group (A) comprised 190 women. Sixty-three women had preeclampsia (PE, group B), 31 women presented transient hypertension (TH, group C), 19 had HELLP syndrome (HS, group D) and 19 had chronic hypertension (CH, group E). CRP serum concentrations were significantly higher in groups B, C, and D in comparison with the group A. In the whole population, systolic and diastolic pressure value inversely correlate with weight at delivery and weeks of gestation at delivery. CPR levels in patients with PE and HS inversely correlate with birth weight and gestational week at delivery. Normal plasma levels of CRP may be an important marker of differential diagnosis between TH and CH. In TH, PE, and HS, CRP levels were higher than in the control and CH groups, suggesting that inflammation may be the common pathogenetic cause of TH and PE. Finally CRP levels in preeclampsia are believed to correlate with preeclamptic process severity.

Ballantyne syndrome: a case report.

Ballantyne syndrome (also called mirror syndrome or triple edema) describes the unusual association of fetal and placental hydrops with maternal preeclampsia. This is a case report illustrating a 37-year-old patient who was referred to our clinics at 28 weeks of gestation (wg) because of fetal hydrothorax. On examination, the woman did not show signs of preeclampsia. The fetal ultrasound examination revealed bulky hydrothorax, generalized subcutaneous edema, placental edema, and polyhydramnios. It was not possible to find the cause of the fetal hydrops. At 29 weeks and 4 days of gestation, the fetal hydrothorax was removed by two pleuro-amniotic shunts, but at the moment of our intervention anasarca was already present. In the following 3 days, despite observing bed rest, the mother developed edema of hands and face, while blood pressure remained normal. At 30 wg the patient underwent cesarean section because fetal movements ceased and the fetal heart rate monitoring showed loss of variability and decelerations. Before dying, the neonate lived for 20 days in a state of deep hypotension.

Prenatal magnetic resonance imaging of rhombencephalosynapsis and associated brain anomalies: report of 3 cases.

Rhombencephalosynapsis (RES) is a rare congenital abnormality characterized by vermian agenesis and fusion of the cerebellar hemispheres. In the 3 cases reported here, prenatal magnetic resonance imaging clearly depicted cerebellar features characteristic of RES, allowing a definite diagnosis.

The introduction of QF-PCR in prenatal diagnosis of fetal aneuploidies: time for reconsideration.

Quantitative fluorescent polymerase chain reaction (QF-PCR) has recently entered the field of prenatal diagnosis to overcome the need to culture fetal cells, hence to allow rapid diagnosis of some selected chromosomal anomalies. We reviewed the studies on the accuracy of QF-PCR in detecting chromosomal anomalies at prenatal diagnosis. Overall, 22 504 samples have been analysed. The detection rate of aneuploidies of the selected chromosomes (13, 18 and 21, and X and Y) was 98.6% (95% confidence interval 97.8-99.3). QF-PCR might play a major role and be considered a valid alternative to the full karyotype. Being less expensive, and almost entirely automated, more women could undergo invasive prenatal diagnosis without significant increase in health expenditure. By using QF-PCR as a stand-alone test, the chances of non diagnosing the commonest, and the only chromosome anomalies which do increase in frequency with maternal age, are approximately one in 150 abnormal karyotypes, or one in 10-30 000 samples, based on the age distribution. These error rates might be deemed acceptable, although most structural chromosomal anomalies will be missed. At present, women are rarely informed about the full spectrum of the conditions which might be diagnosed via amniocentesis or chorionic villous sampling. Some of these anomalies might be acceptable, in view of their limited or uncertain clinical relevance, and decision analysis might, in the majority of cases, confine the full karyotype to selected women who have specific indications.

Prenatal ultrasound detection of bilateral focal polymicrogyria.

OBJECTIVES: Prenatal diagnosis by ultrasound of fetal polymicrogyria has been reported only once. METHODS: We describe an additional case of polymicrogyria in a fetus from a monozygotic twin pair, probably the consequence of twin-to-twin transfusion syndrome. RESULTS: On ultrasound, there were bilateral cortical hyperechogenic spots, and prenatal magnetic resonance imaging demonstrated the typical features of bilateral focal polymicrogyria. CONCLUSION: Polymicrogyria can be considered in the differential diagnosis of hyperechogenic brain lesions on fetal ultrasound. We also confirm the risk of brain damage in monochorionic twins pregnancies and the likely hypoxic-ischemic etiology of polymicrogyria.

Recent progress in the therapeutic management of pre-eclampsia.

Pre-eclampsia is a pregnancy-specific syndrome of unknown aetiology, observed in 3 - 5% of all pregnancies, associated with pathological vascular lesions in multiple organs, activation of the coagulation system, and maternal multisystemic and fetal complications. Clinically, pre-eclampsia is characterised by the onset of hypertension, proteinuria and oedema, usually beginning in the third trimester. Conventionally, antihypertensive agents are the main pharmacological treatment. Recently, some studies have shown that the treatment of pre-eclampsia with antithrombin concentrate corrects the hypercoagulability and improves the fetal status and the perinatal outcome. No clear evidence supports the use of heparin. A conservative treatment of moderate- to- severe pre-eclampsia, based on the administration of antithrombin concentrate, may allow a significant prolongation of pregnancy and a better neonatal outcome, as well as fewer maternal complications.

Efficacy of AT in pre-eclampsia: a case-control prospective trial.

Pre-eclampsia is an extremely severe condition. It is associated with vasospasm, activation of the coagulation system and abnormal haemostasis. In pre-eclamptic patients increased plasmatic concentrations of fibronectin, laminin, von Willebrand factor (VWF) and endothelin are observed. Experimental studies on rats have also shown that the doses of antithrombin III (AT) needed to mediate anti-inflammatory processes are much higher than those required to obtain the anti-coagulant effect. The study aimed to evaluate the clinical efficacy of treatment with high AT doses (HD) in comparison with standard doses (SD). The primary endpoint was the prolongation of pregnancy defined as time (in days) from enrollment to delivery and to assess the maternal bleeding at and after delivery. The secondary endpoint was to demonstrate a role for AT in controlling haemostasis at conventional doses, and the inflammatory state at higher doses. The biochemical parameters assessed were: AT activity (%), Fibronectin (Fn), Fibrinogen, D-dimer, Uricemia, Proteinuria 24h, Protein C Reactive (PCR), Granulocyte Elastase and Endothelin. This study included 23 pre-eclamptic women. Patients were randomly subdivided into two groups: 10 patients ("cases") were treated with high doses of AT (6 vials: 3000 units) once daily for 5 days, or until delivery, while 13 women ("controls") were treated with doses of AT sufficient to maintain at least 80% of the activity. High-dose therapy was associated with prolongation of pregnancy by 2.5 days more when compared with controls (p = 0.03; Mann-Whitney test). The incidence of clinical significant bleeding was lower in cases than in controls (mean 550 mL vs. 650 mL, respectively). Preventive- and conservative-type treatment of moderate-severe pre-eclampsia, based on the administration high doses of AT, allows a significant prolongation of pregnancy, and thus a better neonatal outcome, as well as less maternal intra- and post-operative bleeding. Fn, PCR and elastase levels (markers of inflammation) decrease in the HD group in comparison with SD group. In the HD group, the AT plasma levels were obviously higher both at the end of the treatment (p < 0.0001) and after delivery (p = 0.03), in comparison with SD group. The fibrinogen and D-dimer levels were above the reference interval in both groups. TPA and PAI 1 were found to be significantly raised in the course of pre-eclampsia. In conclusion, the bio-chemical findings support a role for AT in controlling the haemostasis at conventional doses, and the inflammatory state at higher doses.

Prenatal magnetic resonance imaging evaluation of ischemic brain lesions in the survivors of monochorionic twin pregnancies: report of 3 cases.

The death of 1 twin of monochorionic pairs is associated with a significant risk of brain hypoxic-ischemic damage in the survivor. Ultrasound may diagnose cerebral anomalies only a few weeks after the event. We report 3 cases of single survivors of monochorionic-twin pregnancies in which prenatal magnetic resonance imaging detected brain changes earlier and with better definition of the brain abnormalities than ultrasound.

Prenatal diagnosis of vein of Galen aneurysmal malformations.

Vein of Galen aneurysmal malformations are rarely seen intracranial malformations. They represent less than 1% of the cerebral arteriovenous malformations. Prenatal diagnosis of an arteriovenous fistula malformation may be achieved by real-time and Doppler sonography with color flow imaging, by identifying dilated veins and arteriovenous shunts with turbulent flow. In addition, an elevated cardiac output may be observed and correlated with the magnitude of the cerebral arteriovenous shunt. The high incidence of cardiomegaly in neonates with arteriovenous malformations also suggests that high-output cardiac failure is already present in a significant number of cases during the 3rd trimester, and, therefore, treatment in utero may need to be considered to improve the hemodynamic status. In our case, all the above cardiovascular features were present during prenatal ultrasonography. The information on outcome compiled from the literature suggests that when an arteriovenous malformation is large enough to be detected prenatally, as in our case, it is likely to lead to cardiac failure either during the antenatal period or soon after birth. In this paper, we present the management of a case of 3rd-trimester diagnosis of a vein of Galen aneurysm associated with cardiac decompensation.

Apparent diffusion coefficient determination in normal fetal brain: a prenatal MR imaging study.

BACKGROUND AND PURPOSE: Diffusion-weighted MR imaging studies of normal brain development have focused on premature babies who were free of focal lesions on conventional MR images. The condition of prematurity, however, is dissimilar to intrauterine life. We sought to establish normal values of fetal brain apparent diffusion coefficient (ADC) to highlight its abnormal changes in pathologic conditions and to obtain information about normal brain development. METHODS: We measured the ADC, in utero, by using an echo-planar three-axes diffusion-sensitized sequence (b factor, 0 and 600 s/mm(2)), in frontal and occipital white matter and basal ganglia gray matter of 15 fetuses. Their gestational ages ranged from 22 to 35 weeks, and the postnatal MR images or sonograms revealed normal brain. RESULTS: Mean ADC value was 1.96 +/- 0.1 micro m(2)/ms (SD) in frontal white matter, 1.95 +/- 0.1 micro m(2)/ms in occipital white matter, and 1.56 +/- 0.1 micro m(2)/ms in basal ganglia. A significant negative correlation between ADC and gestational age was found for basal ganglia, whereas only a trend was present for frontal white matter. CONCLUSION: Although moderately higher, the ADC determinations we obtained are consistent with those reported in the literature in postnatal studies performed in premature babies.

Ex vivo testing of a temperature- and pressure-controlled amnio-irrigator for fetoscopic surgery.

BACKGROUND: Currently, amnioinfusion fluids used in operative fetoscopy usually are preheated to body temperature. As the complexity of procedures increases, purposed designed devices should be designed that allow control of pressure and temperature during amnioinfusion or amnioexchange. In the current study, a prototype amnio-irrigator and fluid heater were evaluated. METHODS: The medical fluid heater heats fluid by conduction up to 37 degrees C. The maximum irrigation pressure and flow rates can be preset. Actual irrigation pressure (0 to 30 mm Hg) and flow rate (0 to 300 mL/min) can be read on the front panel. A series of ex vivo experiments were set up to determine the relationship between the flow rate (FR) and lumen of the instruments as well as the maximum flow rate (MFR) with and without the pressure control. Further, the relationship between FR and the irrigation pressure (IP) was determined. In an artificial pseudoamniotic sac the relationship between FR and change in temperature was measured, with and without the use of the medical fluid heater. RESULTS: When the IP was limited to 24 mm Hg, FR and pressure were correlated (r = 0.34; P <.001). The larger the functional lumen of the fetoscopic instrumentation, the higher the flow (r = 0.43; P <.001) and the lower the increase in IP (r = -0.47; P <.001). A quadratic relation between flow and temperature was observed both for preheated fluid as when using the fluid heater (r(2) = 0.71 and r(2) = 0.88; P <.001). However, at low flow rates, a thermal decrease of over 3 degrees C was observed when the fluid heater was not used. CONCLUSIONS: The current study quantifies an expected relationship between the diameter of the irrigation channel and achievable flow rates. It also shows that a medical fluid heater is needed when strict control of temperature would be desired.