Sonographic imaging of fetal tympanic rings.

OBJECTIVE: To examine the feasibility of ultrasonographic imaging of fetal tympanic rings. METHODS: This was an observational cohort study of 80 healthy fetuses in low-risk pregnancies, divided into four gestational-age subgroups (12, 16, 23 and 32 weeks), each comprising 20 consecutive fetuses. Tympanic ring visualization was achieved by two-dimensional and three-dimensional (3D) sonography. A standard algorithm for tympanic ring examination was constructed using 3D multiplanar reconstruction. The volume acquisition plane was directed to the inferolateral aspect of the fetal temporal bone. Transvaginal scans were carried out in the 12-week and 16-week subgroups, and transabdominal scans in the 23-week and 32-week subgroups. Study parameters included the inferomedial inclination angle (IMIA) of the tympanic ring relative to the vertical skull axis, the anteromedial inclination angle (AMIA) of the tympanic ring relative to the anteroposterior skull axis and the longest (LTRD) and shortest (STRD) tympanic ring diameter, the latter measured perpendicular to the LTRD. The feasibility of tympanic ring demonstration was assessed in each gestational-age subgroup. RESULTS: Tympanic rings appeared as round-oval, thin, echogenic structures in a plane tangential to the inferolateral surface of the fetal skull below the inferior border of the squamous part of the temporal bone. Higher demonstration rates were achieved in the 16-week and 23-week subgroups (90% and 80%, respectively) than in the others. LTRD and STRD each showed a linear correlation with gestational age (r = 0.96 for both measurements; P < 0.01). Mean IMIA ranged from 41.0 to 60.4° and mean AMIA from 17.3 to 23.4° across the different gestational-age subgroups. The malleal manubrium was observed only in examinations in the second half of pregnancy, appearing as a bright echo within the upper area of the tympanic ring in 56% (9/16) and 82% (9/11) of cases with tympanic ring imaging appropriate for measurement of the study parameters in the 23-week and 32-week subgroups, respectively. CONCLUSION: This is the first report of sonographic imaging of fetal tympanic rings and shows that this is feasible in the second trimester. We discuss the possible implications of our findings for the prenatal diagnosis of congenital hearing loss.

Cervical varices complicated by thrombosis in pregnancy.

We present a case of a 36-year-old pregnant woman with varicose veins of the uterine cervix diagnosed during the second trimester. The cervical tissue was completely replaced with dilated venous plexus. Therapeutic decisions were further complicated by the presence of blood clots within the dilated vessels. Pregnancy proceeded uneventfully, no bleeding occurred and the patient underwent a planned Cesarean delivery. This is the first reported case in the medical literature where the rare phenomenon of cervical varices was accompanied by thrombosis.

Association between ultrasound-based assessment of fetal head station and clinically assessed cervical dilatation.

OBJECTIVES: To describe the association between ultrasound-based determination of fetal head station and clinical assessment of cervical dilatation during active labor. METHODS: From 427 women with singleton uncomplicated term pregnancies we obtained, during the active phase of labor, 907 pairs of measurements. Fetal head station and position were determined using the LaborPro system, based on position tracking and ultrasound imaging technology, and degree of cervical dilatation was determined by digital vaginal examination. The association between them was analyzed. RESULTS: The overall correlation between cervical dilatation and fetal head station was 0.64 (P < 0.001). Complete dilatation was observed in 78% of women with fetal head engagement, and in all women with a fetal head station of + 1.5 or more. CONCLUSIONS: There is good association between non-invasive ultrasound-based determination of fetal head station and clinically assessed cervical dilatation.

Complication of laparoscopic detorsion of adnexal mass.

Detorsion of an ischemic adnexal mass has recently been advocated for most cases of twisted adnexa. Usually, the affected ovary regains some or all of its vitality and function. However, when the ovary is completely necrotic, it may form an abscess if it contains tissue components that cannot be eliminated by the peritoneal immune system. We report a case of pelvic abscess formation in a detorsed ovary that previously contained an unsuspected dermoid cyst. We call for an extensive inspection of the detorsed ovary before ending the laparoscopic operation, and if it remains necrotic and is suspected of containing a dermoid cyst, it should be removed promptly.

Three-dimensional power Doppler in the evaluation of painful leiomyomas and focal uterine thickening in pregnancy.

OBJECTIVE: To determine the usefulness of 3-dimensional (3D) power Doppler ultrasound in distinguishing painful leiomyomas from focal myometrial contractions or nonpainful leiomyomas in pregnancy. METHODS: A 2D section of the area of interest in the uterine wall was first obtained in 29 patients to determine whether the pain originated from a myoma or a uterine contraction. Then, volume acquisition was activated and Doppler indices (vascularization index, flow index, and vascularization-flow index) were calculated for thickened and normal uterine wall. RESULTS: Of 15 patients found to have uterine myomas, 11 had multiple tumors and 4 had single tumors. In the remaining 14 patients the painful uterine thickening proved to be a focal contraction. Painful segments of uterine thickening were associated with lower Doppler indices. Painful myomas were found to have significantly lower indices than normal uterine wall (P=0.008, 0.03, and 0.01 for VI, FI, and VFI, respectively, vs. 0.001, 0.003, and 0.01). However, the differences in indices between nonpainful myomas and uterine wall on the one hand, and nonpainful myomas and focal uterine contractions on the other, were not statistically significant. CONCLUSION: Three-dimensional power Doppler ultrasound may be a sensitive and reliable tool for distinguishing painful uterine myomas from focal myometrial contractions and nonpainful myomas.

Effect of maternal immunization with oral poliovirus vaccine on neonatal immunity.

During the summer of 1988, an outbreak of poliomyelitis caused by poliovirus 1 occurred in Israel, during which a national mass immunization campaign with oral poliovirus was undertaken. This prospective study was undertaken to assess the effect of maternal oral poliovirus immunization during the third trimester of pregnancy on neonatal immunity against poliovirus. Cord blood specimens of 88 neonates, born 2 to 7 weeks after maternal immunization, were examined for antipoliovirus antibodies and compared with 100 samples obtained from neonates 7 months before the outbreak. Blood samples were also obtained from the 62 mothers of neonates who had been immunized 2 to 5 weeks before delivery. Sera were tested for neutralizing antibodies to the 3 poliovirus types using a microneutralization technique. The geometric mean titer to poliovirus type 1 was significantly higher in neonates whose mothers were immunized during pregnancy (87.1) than in the offspring of the nonvaccinated group (53.0), P < 0.05. Two to 3 weeks after immunization, geometric mean titers against all 3 poliovirus types were higher in maternal blood than in cord blood whereas 4 to 5 weeks after vaccination a significant difference was found for type 3 only. Although oral poliovirus immunization during pregnancy resulted in higher neonatal antibody titers to poliovirus type 1, the proportion of newborns with titers of < 1:8 to the 3 poliovirus types did not change significantly.

Sonographic demonstration of endometrial fluid collection following termination of pregnancy.

Intrauterine fluid collections were demonstrated by transvaginal ultrasound in 19 of 21 patients, 4-6 hours after first-trimester termination of pregnancy. Similar but lesser findings were seen 3 days later in some of the cases. Five days postoperatively, the endometrium appeared normal in all patients. Appreciation of the normal sonographic appearance of the uterine cavity following abortion is important for detecting pseudosac of ectopic pregnancy or the possibility of inappropriate curettage of an intrauterine pregnancy.

Pseudomonoamniotic twins with cord entanglement following genetic funipuncture.

Amniocentesis was performed twice on a twin gestation, and twice there was cell growth failure in one of the twins. Therefore, funipuncture was attempted at 24 weeks. The anatomical relationship and position of the fetuses, placental cord insertion, and membranous septum dictated needle entry into the cord of the lower left fetus through the sac of the upper right fetus and the septum. The procedure was uneventful and the pregnancy was carried to 39 weeks. However, the septum between the twins had been disrupted, creating a pseudomonoamniotic pregnancy. This was noticed only after delivery of the first fetus, when it was found that the two umbilical cords were entangled. We believe that, whenever possible, puncture of the membrane between twins should be avoided. Should puncture be necessary, the possibility of pseudomonoamniotic twins must be considered.

Spectrophotometry of amniotic fluid: a simple and rapid method for distinguishing between gestational sacs in second-trimester amniocentesis of twin pregnancies.

OBJECTIVE: To evaluate the use of an alternative and simple spectrophotometric method that could replace the intraamniotic injection of dye in the second-trimester amniocentesis of twins. METHODS: Optical densities (OD) of amniotic fluid (AF) obtained at second-trimester genetic amniocentesis were measured at 360 nm. Comparison was made between 36 twin pregnancies and 60 singleton controls. RESULTS: The mean difference in OD between two samples taken from the same sac of singleton pregnancies was very small (mean 0.004, standard deviation [SD] 0.003). However, samples drawn from each of the twin pairs' amniotic sacs varied widely (raw mean 0.176, SD 0.223; median 0.096, range 0.011-0.943). The difference between the groups was highly significant statistically (P < .001). CONCLUSION: Our preliminary experience with spectrophotometry of AF in twin amniocentesis suggests that this simple test may be useful in ascertaining that the AF samples were obtained from each of the two gestational sacs.

Familial occurrence of mature ovarian teratomas.

It has been suggested that genetic predisposing factors play a role in the development of ovarian teratomas. Familial occurrence of these tumors would support this view. Reported herein are identical twins, both of whom had a right ovarian mature teratoma. In both cases the presenting symptoms were acute torsion. The diagnosis was confirmed at laparotomy and subsequent histopathologic examination. The origin of ovarian teratomas seems to be linked to the process of parthenogenesis. This process probably involves a germ cell after its first meiotic division.

Continuous ambulatory peritoneal dialysis as the primary approach in the management of severe renal insufficiency in pregnancy.

Pregnancy is an unusual event in patients with chronic renal failure undergoing dialysis. The outcome in these cases is usually poor. We report a pregnancy complicated by severe renal insufficiency that was managed successfully by continuous ambulatory peritoneal dialysis. Dialysis was initiated at 24 weeks' gestation. At 34 weeks, premature labor associated with peritonitis resulted in the spontaneous delivery of a healthy male infant weighing 2400 g. The use of continuous ambulatory peritoneal dialysis during pregnancy offers theoretical advantages compared with hemodialysis. Our case, added to the available limited experience with this new modality, suggests that it may be an appropriate approach in women developing renal disease for the first time during pregnancy.

Pemphigus vulgaris and pregnancy.

Pemphigus vulgaris (PV), an autoimmune bullous dermatosis, is rarely encountered in pregnancy. Two women with PV and their three pregnancies are described. Pregnancy outcome was generally good, although one of the neonates had characteristic PV skin lesions that resolved spontaneously. The pathophysiology, clinical manifestations, and special issues of PV pertaining to pregnancy are discussed. With our cases added, there are now 23 reports in the English literature on PV in pregnancy. From these data it seems that transient skin lesions may occasionally appear in the neonate regardless of the severity of maternal disease. Such lesions are due to passive transplacental transfer of PV antibodies and do not have long-lasting clinical implication. On the other hand, and contrary to past traditional thinking, PV may be associated with poor neonatal outcome including prematurity and fetal death. Such complications seem to be restricted to pregnancies with clinically severe PV.

Second trimester abortion by laminaria followed by vaginal misoprostol or intrauterine prostaglandin F2alpha: a randomized trial.

Intra-amniotic injection, as well as intravaginal application of prostaglandins, have been used to terminate second trimester pregnancies. There is as yet no consensus as to the most efficient protocol of such late abortions. Our goal was to compare the efficacy of intra-amniotic injection of prostaglandin F2 alpha (PGF2alpha) and intravaginal application of misoprostol in terminating second trimester pregnancies after pretreatment with intracervical laminaria. Women with live fetuses and requesting second trimester abortions were randomized into two groups. Eighteen hours following the insertion of intracervical laminaria, women were treated with either intra-amniotic injection of 40 mg PGF2alpha, or 12 hourly doses (to a maximum of 4 doses) of 200 mcg misoprostol. Fifty women were randomly assigned to each group. Failure to abort within 24 h of initiation of treatment occurred in 6 patients (12%) in the misoprostol group and 14 (28%) of the PGF2alpha group (p = 0.04). Mean time of induction of pharmacologic treatment to abortion was 13.6 h in the misoprostol group and 10.7 h in the PGF2alpha group (p = 0.03). The mean number of analgesic injections given were 0.8 in the misoprostol group and 1.6 in the PGF2alpha group (p = 0.0001). Only the method of abortion was predictive of abortion success and not other variables such as patient age, gestational age, gravidity, or parity. Following intracervical laminaria, vaginal misoprostol has been found to be more effective and less painful, compared with intra-amniotic PGF2alpha, for the termination of second trimester pregnancies with live fetuses.

Neonatal sepsis after prolonged premature rupture of membranes.

The objective of this study was to prospectively evaluate the incidence of neonatal sepsis after prolonged premature rupture of membranes (PROM), to correlate sepsis with gestational age and with the duration of PROM, and to evaluate the necessity for prophylactic antibiotic therapy in neonates born after PROM. Of 12,182 infants, 135 (1.1%) were delivered after PROM with a latency period of > 24 hours. Neonatal sepsis occurred in 11 infants (8.1%), 10 of whom were premature. The only term, septic newborn was a small-for-gestational-age infant. A latency period > 72 hours was not associated with an increased incidence of sepsis. Maternal fever, neonatal signs of infection including leukopenia, leukocytosis, thrombocytopenia, and positive gastric aspirate cultures, were not good predictors of sepsis. Of premature infants with PROM, 15% had sepsis, and thus the administration of prophylactic antibiotic therapy in these cases may be warranted. However, it may be unnecessary to administer prophylactic antibiotics to term, appropriate-for-gestational-age infants born after PROM.

In utero vaccination.

It is estimated that 4 million children die each year of vaccine-preventable diseases and another 4 million are permanently disabled. Although vaccination is the most cost-effective health method, there is a discrepancy between our level of knowledge and practices applied. Vaccination of pregnant women provides the mother with antibodies that could be transferred across the placenta and provide the neonate with high antibody titers until active immunization is likely to be protective. The ability to provide such passive childhood immunization is beneficial and cost-effective, especially in developing countries where routine childhood immunization is not widely practiced. Further progress depends on the development of more efficient antigens, carrier proteins, and formulations of multiple-antigen vaccines. Further studies should determine the ideal timing for in utero vaccination to provide protective antibodies to the full-term infant and the premature infant. This ideally should be achieved without compromising the protective effect during the first months of life and without causing immune tolerance when given early in pregnancy. The future of in utero vaccination depends on continuing basic research, which should provide improved vaccines and clinical studies that demonstrate the safety and effectiveness of vaccination for both mothers and infants. Liability issues should be addressed and greater awareness of obstetricians, family physicians, and the general public should be achieved.

Perinatal outcome of idiopathic small for gestational age pregnancies at term: the effect of antenatal diagnosis.

OBJECTIVE: To evaluate the effect of antenatal detection of the idiopathic term small for gestational age (SGA) fetus upon perinatal outcome. METHODS: A 3-year retrospective review of all term pregnancies with no associated maternal disease, with birth weights at least 2 S.D.s below the mean for gestational age. Perinatal outcome measures were compared between pregnancies that were diagnosed as SGA antenatally, and those that were detected only after delivery. RESULTS: Of 158 term SGA pregnancies, 47 were diagnosed antenatally, and III were recognized as such only after delivery. The antenatally diagnosed group had a higher incidence of adverse neonatal outcome (P < 0.01), as well as higher incidences of inductions of labor and emergency Cesarean sections (68% vs. 12%, P < 0.001, and 23% vs. 10%, P < 0.03, respectively). Logistic regression analysis with adverse neonatal outcome as the dependent variable has shown it to be dependent only on gestational age at delivery (P < 0.004), and birth weight (P < 0.001), and not on antenatal diagnosis. CONCLUSIONS: Antenatal detection of SGA may be associated with an increased incidence of obstetric interventions, with no demonstrable positive effect upon the short-term neonatal outcome.

Epidural anesthesia in early compared with advanced labor.

OBJECTIVES: To examine whether continuous lumbar epidural analgesia administered in the early phase of labor leads to an increased incidence of instrumental vaginal deliveries. METHODS: In a retrospective analysis we have studied 563 consecutive term cephalic vaginal deliveries where an epidural was given for pain relief in labor. The type of delivery was compared in two groups. In Group 1 epidurals were given when the cervix was 3 cm or less dilated; in Group 2 when they were greater than 3 cm dilated. RESULTS: There was no difference in the incidence of instrumental deliveries in the two groups. Other variables including station of the fetal head, premature rupture of membranes, meconium, and administration of pitocin and pethidine did not effect these results. CONCLUSIONS: There is no justification in delaying epidural analgesia in labor when it is clinically indicated.

Complete abortion of early ectopic pregnancy.

Abortion of an early ectopic pregnancy is a rarely diagnosed event. Coincidental serial hormonal studies performed on a patient suffering from idiopathic secondary infertility enabled the authors to record plasma estradiol, progesterone and beta-human chorionic gonadotropin concentrations, which, combined with the physical findings, ultrasonography and laparoscopy, led to the diagnosis of a complete abortion of an early ectopic pregnancy. Apart from slight vaginal bleeding on day 44 of a prolonged cycle, the patient was asymptomatic throughout and the importance of plasma beta-human chorionic gonadotropin determination in such a situation is discussed.

Decreased fetal activity in complications of pregnancy.

Fetal activity expresses the fetal condition in utero. Absence of fetal movements may signify fetal distress. The reduction in fetal movements (FM) to 3 or less or their cessation for at least 12 h with audible heart beats was referred to by us as movement alarm signal (MAS). The rate of MAS in 662 complicated pregnancies was studied. There were 43 patients (6.5%) with MAS mainly in cases of fetal malformations and conditions associated with reduced uteroplacental blood flow. In 13 cases a nonintervention approach was undertaken and all the fetuses died in utero. The remaining 30 cases with MAS were delivered promptly, mainly by Cesarean section and live births resulted. Eight of these died neonatally. It is suggested that in cases of MAS the diagnosis of fetal distress should be verified by additional tests. Should fetal distress be confirmed, especially in cases of polyhydramnios, oligohydramnios and symmetrical growth retardation, every effort should be made to exclude fetal malformations before delivery is undertaken especially by Cesarean section.

Postdate antenatal testing.

OBJECTIVE: To test the effect on pregnancy outcome of a policy of very early commencement of postdate surveillance testing, and induction of labor at 42 weeks. METHODS: Retrospective analysis of 2776 consecutive cephalic deliveries at 38-42 weeks of gestation. Management of the postdate pregnancies included twice-weekly antenatal testing beginning at 40 completed weeks and elective induction of labor at 42 completed weeks. Pregnancy outcome parameters were compared between the groups delivered at 38-40 weeks and at 41-42 weeks. RESULTS: There were 2138 pregnancies delivered at 38-40 weeks and 638 at 41-42 weeks. The latter group had a statistically significant increase in the rate of cesarean section, mainly accounted for by an increased rate of fetal distress and failure to progress in labor. Similarly the rate of instrumental vaginal delivery, meconium in labor and macrosomia had a statistically significantly higher incidence in the postdate group. These differences in outcome were already apparent at 41 weeks of gestation. CONCLUSION: Despite early initiation of fetal surveillance, starting at 40 completed weeks, postdate pregnancies are associated with an increased rate of emergency cesarean section, macrosomia and meconium in labor.