Epidural local anesthetics: a novel treatment for fetal growth retardation?

BACKGROUND: Chronically compromised uterine perfusion may lead to placental insufficiency and subsequent intrauterine growth restriction (IUGR). Various therapeutic approaches (e.g. vasodilators, low-dose aspirin, intravenous glucose infusion, and hemodilution) are often of limited efficacy. Local anesthetics have been shown to improve placental blood flow in pre-eclamptic women. We hypothesized that epidural administration of local anesthetics might improve outcome in IUGR independent of the underlying cause. In preparation for a clinical trial to test this hypothesis, we performed a pilot study in 10 patients. METHODS: After approval of the study protocol, 10 pregnant women presenting with oligohydramnios and IUGR were included in the study. In addition to our standard protocol (magnesium, glucose, betamethasone), each patient received an epidural catheter (T10/T12) with continuous infusion of bupivacaine 0.175% at a rate of 5 ml/h. Uteroplacental circulation was monitored by Doppler sonography and the amount of amniotic fluid was estimated daily. RESULTS: Epidural insertion and infusion was performed without complications. Four patients continued to deteriorate rapidly, amniotic fluid volume did not change and uterine artery pulsatility index (PI) tended to increase. In the remaining 6 patients the clinical status stabilized, amniotic fluid volume tended to increase and uterine artery PI tended to decrease during treatment. This improvement was associated with a prolonged interval to cesarean section and increased infant birth weight. CONCLUSION: Our data suggest that, even if the underlying cause of IUGR is not pre-eclampsia, epidural local anesthetic administration might improve placental blood flow and be beneficial in a subgroup of patients. A clinical trial to test this hypothesis appears warranted.

Ectrodactyly-ectodermal dysplasia-clefting (EEC) syndrome presenting with a large nephrogenic cyst, severe oligohydramnios and hydrops fetalis: a case report and review of the literature.

OBJECTIVES: To report a case of EEC syndrome with a large nephrogenic cyst detected by prenatal ultrasonography. METHODS: Prenatal ultrasonographic detection, genetic counselling, termination of pregnancy, radiographic study, autopsy and ultrastructural study of scalp hair. The literature on EEC syndrome with genitourinary anomalies and prenatal diagnosis was also reviewed. RESULTS: A 6-cm cyst in the right side of abdominal cavity was detected in a fetus of 24 weeks' gestational age with severe oligohydramnios and hydrops fetalis. The autopsy revealed bilateral renal dysplasia with a large nephrogenic cyst at the right side and markedly hypoplastic urinary bladder and pulmonary hypoplasia. The fetus also had ectrodactyly and syndactyly of hands and feet and ectodermal dysplasia and left cleft lip and palate. Ultrastructure of hair from scanning electron microscopy revealed no obvious abnormality. CONCLUSION: This is a rare case of fetal malformation partly detected prenatally. In order to detect this syndrome, careful ultrasound search for acral anomalies should be performed in cases with renal malformation or obstructive uropathy.

To induce or not to induce labor: a macrosomic dilemma.

We assessed the effect of labor induction among parturients carrying macrosomic fetuses on the risk of a cesarean section (CS). The study population consisted of consecutive women with singleton fetuses weighing >/=4,000 g, delivered between 1988 and 1999. A comparison was made between parturients who delivered after labor induction and those who delivered without labor induction. The Mantel-Haenszel procedure was used to obtain the weighted odds ratios while controlling for confounding variables. During the study period, 4,755 women delivered macrosomic newborns in our institution. In 20% of the women (n = 951) labor was induced, while 80% of them (n = 3,804) delivered without labor induction. The women who delivered after labor induction were more likely to be nulliparous (18.0 vs. 10.0%; p < 0.001). In addition, these women had significantly higher rates of gestational diabetes (23.3 vs. 10.7%; p < 0.001), hypertensive disorders (10.1 vs. 5.3%; p < 0.001), hydramnios (17.4 vs. 9.9%; p < 0.001), and oligohydramnios (2.1 vs. 0.2%; p < 0.001). The CS rate was significantly higher among the patients who delivered after labor induction as compared with those in whom labor was not induced (17.8 vs. 11.9%; odds ratio 1.6, 95% confidence interval 1.3-1.9, p < 0.001). Stratified analysis using the Mantel-Haenszel technique was performed to control for confounders such as gestational diabetes, hypertensive disorders, previous CS, hydramnios, oligohydramnios, and nulliparity. None of these variables changed the significant association between induction of labor and CS. The induction of labor among women carrying macrosomic fetuses was found to be an independent risk factor for a CS.

Is there significant improvement in neonatal outcome after treating pPROM mothers with amnio-infusion?

The aim of this study was to determine the effects of amnio-infusion treatment on fetal and neonatal mortality and neonatal pulmonary development in women with singleton pregnancies and premature rupture of the membranes occurring at a gestational age of <26 weeks and who had severe oligohydramnios. The treated group of 45 consenting women received serial amnio-infusion and was compared with the control group of 44 women who underwent waiting treatment. Our study confirmed a higher number of live births in the treated group, especially in cases with a gestational age at rupture (GAR) of <20 weeks. Furthermore, even if GAR is an important factor for predicting pulmonary hypoplasia, amnio-infusion treatment reduces the probability of pulmonary hypoplasia. In fact, over 20 weeks, amnio-infusion treatment significantly reduces the risk of pulmonary hypoplasia even if normal lung development cannot be guaranteed.

Preterm premature rupture of membranes, intrauterine infection, and oligohydramnios: risk factors for placental abruption.

OBJECTIVE: To examine whether preterm premature rupture of membranes (PROM), intrauterine infection, and oligohydramnios are risk factors for placental abruption. METHODS: Data for this retrospective cohort study were derived from the 1988 National Maternal and Infant Health Survey (N = 11,777). Association between abruption and these clinical risk factors was expressed as relative risk (RR) and 95% confidence interval (CI), with multivariate adjustment for potential confounders. RESULTS: The overall incidence of abruption was 0.87%. The risk of abruption was 3.58-fold higher (95% CI 1.74-7.39) among women with preterm PROM (2.29%) compared with women with intact membranes (0.86%). The rates of abruption among women with and without intrauterine infection were 4.81% and 0.83%, respectively (RR 9.71, 95% CI 3.23-29.17). However, oligohydramnios was not associated with abruption (1.46% compared with 0.87%; RR 2.09, 95% CI 0.92-5.31). Compared with women with intact membranes, the RR for abruption among preterm PROM and whose membranes were ruptured for 24-47 hours and 48 hours or more before delivery, respectively, were 2.37 (95% CI 0.99-9.09), and 9.87 (95% CI 3.57-27.82). When preterm PROM was accompanied by intrauterine infections, the RR for abruption was 9.03 (95% CI 2.80-29.15) compared with women with intact membranes and no infections. Similarly, preterm PROM accompanied by oligohydramnios conferred over a 7.17-fold risk (95% CI 1.35-38.10) for abruption compared with women with neither of these 2 conditions. CONCLUSION: Women presenting with preterm PROM are at increased risk of developing abruption, with the risk being higher either in the presence of intrauterine infections or oligohydramnios. Physicians managing patients with preterm PROM should be aware that these patients are at increased risk of developing abruption after 24 hours following preterm PROM.

Clinical evaluation of the risk of twin-to-twin transfusion syndrome using the relative power contribution of fetal heart rate fluctuations.

OBJECTIVES: In twin pregnancies, it has been suggested that fluctuations of the two fetal heart rates should be considered as two variates that affect each other. We therefore investigated whether the relative power contribution (RPC) of heart rate fluctuation between twins reflects the clinical severity of twin-to-twin transfusion syndrome. STUDY DESIGN: Sixty-three cases of twin pregnancy including 43 monochorionic twins and 20 dichorionic twins were studied. Thirteen monochorionic twins with polyhydramnios in one twin were regarded as twin-to-twin transfusion syndrome (TTTS). Of the 13 TTTS cases, 8 cases with polyhydramnios in one twin and oligohydramnios in the other were deemed to be a 'stuck' twin. The RPC of the very low frequency domain (VL; 0.0125-0.0625 Hz) of fetal heart rate fluctuation in the twin fetuses of monochorionic and dichorionic pregnancies was obtained within a week of delivery. The relationship between the value of the RPC and the outcome of these twins was examined. RESULTS: For both monochorionic and dichorionic twins the RPC of twin fetuses was significantly higher in TTTS twins than in twins without TTTS. In particular, in pregnancies that resulted in fetal death, early neonatal death, or hydrops of one of the twins, this twin had a higher RPC than the other twin. No significant difference was observed in the RPC value between twins of either monochorionic or dichorionic pregnancies that did not develop TTTS. Serial changes in RPC values were followed in 7 cases of TTTS. The RPC value rose rapidly just before delivery in three cases with resultant poor outcome. CONCLUSION: A rapid change in the RPC of twin fetuses measured using the VL frequency domain of fetal heart rate fluctuations may predict poor outcome in twin pregnancies.

Nitric oxide inhalation therapy in very low-birthweight infants with hypoplastic lung due to oligohydramnios.

BACKGROUND: Although nitric oxide inhalation (iNO) therapy improves arterial oxygenation and reduces the rate of extracorporeal membrane oxygenation in term neonates, the efficacy of this therapy in premature infants is controversial. The objective of the present study was to determine whether iNO therapy improves the survival of very low-birthweight infants with pulmonary hypoplasia due to prolonged rupture of membrane. METHODS: A retrospective comparative study of very low-birthweight infants with pulmonary hypoplasia due to oligohydramnios who had or had not been treated with iNO therapy, was performed (iNO-treated group, eight infants; control group, 10 infants). A neonate was considered to have pulmonary hypoplasia due to oligohydramnios if the following conditions were satisfied: (i) artificial surfactant treatment did not improve the respiratory distress; (ii) prolonged rupture of membrane (PROM) continued for more than 5 days with oligohydramnios; and (iii) sufficient arterial oxygenation did not occur even after giving 100% oxygen, and more than 8 cm H(2)O of mean airway pressure was needed to maintain arterial oxygenation. RESULTS: Nitric oxide inhalation improved arterial oxygenation rapidly and consistently in all eight infants with pulmonary hypoplasia. All eight iNO-treated infants survived longer than 28 days, while five of the 10 control infants died within 24 h of birth (P < 0.05). Before starting iNO, seven of the eight treated infants had shown persistent pulmonary hypertension, which was confirmed by echocardiography. No iNO-treated infant had IVH greater than grade 1, while one control infant had grade 2 IVH. All six long-term survivors in the iNO-treated group are developing normally, while only two of the control infants are developing normally as of February 2002. CONCLUSIONS: The majority of the infants with pulmonary hypoplasia due to oligohydramnios had persistent pulmonary hypertension. iNO improved the arterial oxygenation and significantly improved the survival rate. A controlled study to determine whether iNO therapy improves the survival rate of preterm infants with pulmonary hypoplasia due to oligohydramnios is necessary.

Isolated oligohydramnios is not associated with adverse perinatal outcomes.

OBJECTIVE: To examine fetal growth and perinatal outcomes in pregnancies with isolated oligohydramnios. DESIGN: A cohort study. SETTING: Multiple clinics and hospitals. POPULATION: Low risk pregnant women. METHODS: We used data from the multicentre clinical trial of Routine Antenatal Diagnostic Imaging with UltraSound (RADIUS), in which 15,151 low risk pregnant women were randomly assigned to the ultrasound screening group or the control group. Women in the screening group underwent sonographic exams at 15-22 and 31-35 weeks of gestation. Both groups could have clinically indicated sonographic exams at any time. MAIN OUTCOME MEASURES: We used changes of fetal weight z-score to assess whether fetal growth was compromised from the diagnosis of oligohydramnios until delivery, using a repeated-measures regression. We used a combined perinatal index as an indicator of adverse perinatal outcome, which consisted of severe perinatal morbidity and mortality. RESULTS: Oligohydramnios (amniotic fluid index < or =5 cm) was diagnosed in 1.5% (113/7617) of women with ultrasound screening compared with 0.8% (57/7534) among the controls. Approximately half of the oligohydramnios cases in the screening group were isolated with no clearly associated factors (e.g. premature rupture of the fetal membranes, congenital anomalies, diabetes, hypertension, postdate and intrauterine growth restriction). Fetal weight centiles in isolated oligohydramnios cases did not change significantly from diagnosis until delivery. Pregnancies with isolated oligohydramnios had perinatal outcomes similar to pregnancies with a normal amniotic fluid index. CONCLUSION: Isolated oligohydramnios is not associated with impaired fetal growth or an increased risk of adverse perinatal outcomes.

An amniotic fluid index < or =5 cm within 7 days of delivery in the third trimester is not associated with decreasing umbilical arterial pH and base excess.

OBJECTIVE: To determine if an amniotic fluid index (AFI) < or =5.0 cm within 7 days of delivery in the third trimester is associated with decreasing umbilical arterial pH and base excess. STUDY DESIGN: Cases for this retrospective cohort study were all pregnancies > or =26 weeks with intact membranes and an AFI < or =5.0 cm within 7 days of delivery between 11/99 and 7/02. Multiple gestations, aneuploid, and anomalous fetuses were excluded. Controls with an AFI >5.0 cm within 7 days of delivery were matched to each case within 1 week by gestational age. For a control group with a mean+/-SD umbilical arterial pH of 7.26+/-0.07 and alpha=0.05, a sample size of 100 would have a power of 99% to detect a difference with a study group whose mean was 7.20. Data were compared using paired Student's t-test, Mann-Whitney, Fisher's exact, chi(2) and risk ratios with 95% confidence intervals. RESULTS: In all, 131 neonates with an AFI < or =5.0 cm were matched to 131 controls with an AFI >5 cm. There was no difference in gestational age (37.6+/-3.0, 37.7+/-3.0 weeks) or birth weight (2897+/-810, 2762+/-788 g). There was no difference in umbilical artery pH (7.25+/-0.07, 7.26+/-0.07) or base excess (-3.32+/-2.59, -2.83+/-2.45 mmol/l), even in small for gestational age (SGA) infants in both groups. There was no difference in the number of SGA neonates, 5-minute Apgar <7, respiratory distress syndrome, necrotizing enterocolitis, or neurologic morbidity. Linear regression showed no correlation between AFI and either umbilical arterial pH (r=-0.00047, SE=0.001, p=0.63) or base excess (r=-0.029, SE=0.037, p=0.428). CONCLUSION: An AFI < or =5.0 cm measured within 7 days of delivery in the third trimester is not associated with decreasing umbilical arterial pH and base excess.

Renal tubular dysgenesis and neonatal hemochromatosis without pulmonary hypoplasia.

Renal tubular dysgenesis is a rare disorder of differentiation of the fetal kidney. The condition has previously been reported as a postmortem diagnosis in infants who have had oligohydramnios commencing after 20 weeks gestation and have died of renal or respiratory failure shortly after birth with a clinical description of Potter sequence. The absence of clinically significant pulmonary hypoplasia in our case serves to emphasize that renal tubular dysgenesis, fetal anuria and long-standing oligohydramnios can occur without pulmonary insufficiency. The coexistence of renal tubular dysgenesis with neonatal hemochromatosis has been previously described in four published cases. The link between these two rare conditions is clinically important if dialysis or liver transplantation is considered in infants with hepatic and renal failure. Antemortem diagnosis by renal biopsy in our case enabled parental counseling and avoided the inappropriate use of peritoneal dialysis.

[Fetal pulmonary artery blood flow valuation in pregnancies complicated by oligohydramnios]. / Ocena wybranych parametrów przeplywu w tetnicach plucnych plodów w ciazach powiklanych malowodziem.

OBJECTIVES: The objective of the study was to estimate selected Fetal Pulmonary Artery blood flow parameters in pregnancies complicated by oligohydramnios in relation to normal pregnancies. MATERIALS AND METHODS: A total of 52 patients between 26 and 39 weeks of pregnancy complicated by oligohydramnios due to: placental insufficiency, PROM or idiopathic etiology and 69 normal pregnancies were involved in the study. Ultrasound examination using color and pulse Doppler were made. Signal was obtained from distal part of right or left pulmonary artery at the level of four chamber view. The RI, PI and S/D ratio were estimated. RESULTS: Significant increase in PI was observed in the group with severe oligohydramnios (AFI < 2.0 cm) compared to normal pregnancies. No significant differences were selected in RI and S/D ratio between mentioned groups. CONCLUSIONS: The study showed deterioration in fetal pulmonary artery blood flow in pregnancies complicated by severe oligohydramnios.

De novo 4p-syndrome with oligohydramnios sequence.

4p-syndrome, or Wolf-Hirschhorn syndrome, is associated with a deletion of chromosome 4p16.3 and involves multiple malformations that result in delayed growth and development and also facial dysmorphism. We report a case of Wolf-Hirschhorn syndrome in a female infant with a 4p deletion, for which the breakpoint was detected at p14. This patient had bilateral renal hypoplasia resulting from the oligohydramnios sequence (Potter syndrome), including characteristic facial abnormalities, deformed limbs, and pulmonary hypoplasia. Patent ductus arteriosus, ascites, and bilateral renal hypoplasia were noted. The patient had frequent pulmonary infections and died when she was 39 days old.

Neonatal lenticulostriate vasculopathy: further characterisation.

BACKGROUND: Lenticulostriate vasculopathy (LSV) is sometimes detected on routine brain ultrasonography in neonates, and is often associated with various perinatal and neonatal abnormalities. However, most reports on LSV are retrospective with no controls. OBJECTIVES: To compare the perinatal and neonatal clinical characteristics of neonates with LSV with matched controls and to summarise all published reports of LSV. DESIGN: A prospective study that summarises the clinical, laboratory, and neurosonographic data of neonates with LSV. METHODS: Of 1184 neonates admitted to the neonatal intensive care unit (NICU) during a three year period, 857 had a routine head ultrasound examination. Twenty one had LSV, and were compared with 42 matched controls with regard to gestational, perinatal, neonatal, laboratory, and neurosonographic characteristics. RESULTS: LSV was detected in 21 of the 857 (2.45%) neonates. It was bilateral in 10 of the 21 cases and located in the thalamus (n = 14) and basal ganglia (n = 7). Infants with LSV were not significantly different from matched controls in most tested variables. However, compared with the control group, the LSV group included significantly more multiple births and more disturbances in amniotic fluid volume, but less meconial amniotic fluid. In addition, the patients with LSV required fewer blood transfusions and less phototherapy. CONCLUSIONS: Except for more multiple births, neonates with LSV did not display more adverse findings than their matched controls.

Incidence of fetal malformations in pregnancies complicated by oligo- and polyhydramnios.

Oligo- and polyhydramnios could be observed in 1%-7% of all pregnancies and are associated with an increased risk of fetal anomalies. We evaluated the fetal outcomes of 840 pregnancies with oligo- and polyhydramnios on the basis of ultrasonographic findings (oligohydramnios: single deepest pocket <2 cm, polyhydramnios: single deepest pocket >8 cm) between 12 and 42 weeks of gestation. We observed 734 pregnancies (752 fetuses) with oligohydramnios and 106 pregnancies (108 fetuses) with polyhydramnios. Of the 752 fetuses with oligohydramnios, 81% survived and 19% died in utero. Among the 108 fetuses of pregnancies with polyhydramnios, 72% of the babies survived and 28% died in utero. In polyhydramnios, 48% (52 of 108) of the fetuses had severe malformations, which is significant compared to the rate of 11.8% (89 of 752) of fetal malformations in oligohydramnios ( P-value<0.001). Oligohydramnios is predominantly associated with malformations of the urinary tract, whereas polyhydramnios is associated with anomalies of the gastrointestinal tract. In conclusion, measurement of single deepest pocket is a valuable screening method to evaluate pregnancies showing the complications of oligo- and polyhydramnios. Pregnancies with severe polyhydramnios have a poorer outcome and fetuses have a significantly higher risk of congenital malformations compared to pregnancies with oligohydramnios.

Fetal hydrocolpos leading to Pierre Robin sequence: an unreported effect of oligohydramnios sequence.

The presence of distal atretic vagina causing accumulation of fluid and mucus secretions in the proximal vaginal cavity resulted in fetal hydrocolpos. Obstructive uropathy developed gradually because of direct compression of hydrocolpos on bilateral lower ureters, resulting in oligohydramnios from decreased urine formation. Oligohydramnios inhibited normal mandibular development with resulting cleft palate and glossoptosis (Pierre Robin Sequence). The development of sequence of events in this case indicates Pierre Robin Sequence as another effect of Oligohydramnios Sequence arising out of deformational forces acting on cranio-facial structures.

Amniotic fluid index in low-risk pregnancy as an admission test to the labor ward.

BACKGROUND: Oligohydramnios has been shown to be a predictor of intrapartal fetal distress. In a selected group of low-risk pregnancies, however, it has not yet been established that oligohydramnios contributes to intrapartal fetal distress. METHODS: Ultrasonically estimated four-quadrant amniotic fluid index as a test for admission to the labor ward was evaluated as a predictive factor for fetal distress during labor in a prospective "blind" study comprising 600 low-risk pregnancies. Oligohydramnios was defined as an amniotic fluid index < or = 50 mm. The parturients were divided into two groups according to the status of the fetal membranes. The amniotic fluid index results were correlated to fetal outcome: Apgar score at 1 and 5 min, pH of blood in umbilical artery and vein, operative delivery because of fetal distress, cesarean delivery because of fetal distress, and number of babies referred to the neonatal intensive care unit. RESULTS: Two-hundred and sixty-seven women had ruptured membranes. Among these a significant increase in operative delivery because of fetal distress was seen in cases of oligohydramnios compared with the normal amount of amniotic fluid (odds ratio 3.86, confidence interval = 1.25-11.9). No significant differences were seen regarding other variables of perinatal outcome. The group with intact membranes comprised 333 parturients. Among these, no significant differences in perinatal outcome could be seen in relationship to the amniotic fluid index, although a 50% increase in emergency operations for fetal distress was seen in women with oligohydramnios. A significant correlation might have been evident even in that group if a larger sample had been studied. CONCLUSION: The results indicate that measurement of the amniotic fluid index in low-risk pregnant women admitted for labor might identify parturients with an increased risk of intrapartal fetal distress.