Plasma estetrol as an index of fetal well-being.

Estetrol (15alpha-hydroxyestriol or E4) is considered to be a specific product of fetal liver and has been suggested as a good indicator of fetal well-being. The concentration of unconjugated estetrol (E4) was measured by rapid and specific radioimmunoassay in 1 ml of maternal plasma. E4 levels prior to the 18th week of pregnancy were often undetectable (smaller than 50 pg/ml). The mean plasma E4 level at term of 1.2 ng/ml was 7-fold higher than that observed at 24 weeks of gestation, and no diurnal variations were found. E4 levels in fetal plasma at term were 12-fold higher than those in maternal plasma and no fetal arterial venous differences were found. Umbilical vein but not maternal plasma levels of patients undergoing vaginal delivery were higher than those undergoing cesarean section (P smaller than 0.05) suggesting increased adrenal output of E4 precursors during labor. In patients with severe Rh-isoimmune disease plasma E4 levels were not helpful in assessing fetal well-being. However, in patients with chronic hypertension or pre-eclampsia, subnormal plasma E4 concentrations always preceded intrauterine fetal death. Plasma E4 appears to be a good indicator of fetal well-being in patients with hypertensive disease of pregnancy.

Elevated beta-human chorionic gonadotropin and testosterone in cord serum of male infants of diabetic mothers.

Leydig cell hyperplasia is a common histological finding in male infants of diabetic mothers. The functional correlates of this histological finding were investigated by measuring beta hCG, testosterone, androstenedione, dihydrotestosterone, and progesterone in mixed cord serum of male and female infants of diabetic mothers (n = 40) and normal mothers (n = 40) at term. Male and female infants of diabetic mothers had significantly higher cord serum beta hCG levels than male and female controls. Male infants of diabetic mothers had significantly higher cord serum testosterone concentrations than male controls, female controls, and female infants of diabetic mothers. Cord serum testosterone concentrations were similar in female infants of diabetic mothers and female controls. In the male infants of diabetic mothers, there was a significant positive correlation between beta hCG and testosterone (r = 0.64; P less than 0.01). There was no significant correlation between beta hCG and testosterone in the male controls (r = -0.15; P = NS). There was no significant difference in cord serum dihydrotestosterone in any group tested. Cord serum progesterone was significantly higher in the males than in the females. Cord serum androstenedione was lower in the infants of diabetic mothers than in the controls. This study suggests that the Leydig cell hyperplasia found in male infants of diabetic mothers is due, in part, to elevated concentrations of hCG and is accompanied by elevated testosterone concentrations in the fetal compartment.

Antenatal sonographic diagnosis of fetal gastrointestinal malformations.

Fetal gastrointestinal abnormalities are readily detected by ultrasonography. The presentation, management, and outcome of 17 cases of fetal gastrointestinal and associated anomalies are presented. Antenatal knowledge of these abnormalities can potentially decrease neonatal morbidity and mortality because the appropriate preparations can be made in advance of delivery.

Intrapartum maternal fever and neonatal outcome.

OBJECTIVE: Much of fever during term labor may not be infectious but rather a consequence of the use of epidural analgesia. Therefore, we investigated the association of elevated maternal intrapartum temperature with neonatal outcome when the infant does not develop an infection. METHODS: We studied 1218 nulliparous women with singleton, term pregnancies in a vertex presentation and spontaneous labor. Women were excluded if their temperature was >99.5 degrees F at admission for delivery, if they were diabetic or had an active genital herpes infection or if their infant developed a neonatal infection, had a congenital infection, or had a major malformation. Maximum intrapartum temperature was categorized as: 101 degrees F. RESULTS: During labor, 123 women (10.1%) developed a fever >100.4 degrees F; 62 (5.1%) women had a maximum temperature of 100.5 degrees F to 101 degrees F and 61 (5.0%) women had a maximum temperature >101 degrees F. Of febrile women, 97.6% had received epidural analgesia for pain relief. Infants of women developing a fever >100.4 degrees F were more likely to have a 1-minute Apgar score <7 (22.8% for >100.4 degrees F vs 8.0% for afebrile) and to be hypotonic after delivery (4.8% for >100.4 degrees F vs.5% for afebrile). Compared with infants of afebrile women, infants whose mothers' maximum temperature was >101 degrees F were more likely to require bag and mask resuscitation (11.5% vs 3.0%) and to be given oxygen therapy in the nursery (8.2% vs 1.3%). We also found a higher rate of neonatal seizure with fever (3.3% vs.2%), but the number of infants with seizure was small (n = 4). All associations remained essentially the same after controlling for confounding in logistic regression analyses. CONCLUSIONS: Intrapartum maternal fever, particularly if >101 degrees F, was associated with a number of apparently transient adverse effects in the newborn. Larger studies are needed to investigate the association of intrapartum fever with neonatal seizures and to determine whether any lasting injury to the fetus may occur.

Determinants of preterm delivery in low-risk pregnancies. The RADIUS Study Group.

From 14,948 low-risk singleton pregnancies, we calculated incidence, risk ratios, and attributable risks for characteristics associated with spontaneous and medically induced preterm delivery. There were 754 women who gave birth prior to 37 weeks of gestation (50.4/1000 deliveries). The greatest fraction of the incidence of prematurity among low-risk pregnancies was due to unknown factors associated with carrying a first live birth, regardless of preterm delivery mechanism (i.e., spontaneous labor, PROM, medical intervention), with population-attributable risk percents (PAR%) ranging from 16.0 to 30.5%. Other than nulliparity, male sex of the fetus accounted for the greatest fraction of spontaneous labor-induced prematurity incidence (PAR% = 13.6%), and maternal age greater than 30 years or a positive urine culture accounted for the greatest fraction of PROM-induced prematurity incidence (PAR% = 7.9 and 6.7, respectively). All other risk factors for either preterm labor or PROM accounted for less than 5% of the incidence. Three characteristics explained a large fraction of medically induced prematurity: women over 150 pounds at the onset of pregnancy (PAR% = 23.8), a > or = 2+ prenatal urine protein (PAR% = 18.7%), and cigarette smoking during the first trimester (PAR% = 8.6). Our results suggest known risk factors may explain only a small fraction of spontaneous preterm delivery incidence in low-risk pregnancies.

Is there a sea change ahead for obstetrics and gynecology?

A number of beneficial sociocultural reforms have occurred throughout our society, including a new work/family balance. This change, and a number of others, are challenging the dynamic balance within our specialty. We must advocate for appropriate social, political, and economic interventions that will realistically mesh with the health care needs of our nation, while preserving that which is best about the culture of American medicine.

Fetal respiratory movements: only part of the biophysical profile.

In a period of 1.5 years, approximately 1000 women with high-risk pregnancy received sonographic examinations in the authors' laboratory. Of these patients, five women with postterm pregnancy were found to have oligohydramnios and no other reassuring body or limb movements, despite the finding in each case of regular, sustained fetal respiratory movements. Four of the five neonates had evidence of fetal compromise at birth and the fifth had intrauterine growth retardation but good Apgar scores. The recurrence of the problem emphasizes the need to consider fetal respiration as only one part of the total biophysical profile.

Amniocentesis under continuous ultrasound guidance: a series of 232 cases.

Presented is an improved technique for ultrasonic guidance of amniocentesis using continuous visualization of the needle. This technique was evaluated in 232 of 235 consecutive taps. The needle was easily observed from beginning to end of the procedure without contaminating the sterile field or using biopsy transducers. With this technique, clear fluid was obtained by single-needle pass more often than previously reported in the literature. This technique may lower the already low but present risk from amniocentesis.

Routine ultrasound screening in low-risk pregnancies: imperatives for further study.

The benefits of screening ultrasonography in low-risk pregnancies are uncertain and require further investigation. As researchers organize future trials, however, they will need to define clearly the structure and content of the screening ultrasound examination and explicitly detail those outcomes considered important. Such studies must examine the effectiveness of screening sonography in comparison with and in the context of other available prenatal tests and screens. Until studies showing efficacy are available, screening ultrasound in low-risk pregnancies should be considered only when patients, guided by clinicians, consider the potential benefits to be of value.

Pregnancy complicated by the Kasabach-Merritt syndrome.

The Kasabach-Merritt syndrome is the association of cavernous hemangiomas and consumption coagulopathy marked by anemia, thrombocytopenia, and hypofibronigenemia. Exacerbation of the consumption coagulopathy has been described in the 2 previous reports of this syndrome when associated with pregnancy. The authors report a third patient whose delivery and postopartum course were marked by increased coagulation abnormalities and subsequent hemorrhage. This patient's 32-day hospital course and need for multiple blood transfusions, clotting factors, platelets, heparin, and finally epsilon-aminocaproic acid underscore the need for patients with this syndrome to deliver in a referral center hospital where replacement therapy and hematologic consultation are readily available.

Humeral shortening in second-trimester fetuses with Down syndrome.

Individuals with Down syndrome have abnormally short long bones. Sonography has previously revealed slightly shortened femurs and thickened nuchal folds in affected second-trimester fetuses. Humeral and femoral lengths and nuchal folds were evaluated in 400 normal second-trimester controls and in 24 consecutive Down syndrome fetuses (14-20 weeks) undergoing amniocentesis for advanced maternal age or low maternal serum alpha-fetoprotein (MSAFP). Using the 400 normal control fetuses undergoing amniocentesis, the relationship between humeral length and biparietal diameter (BPD) was: Expected humeral length = -7.9404 + 0.8492 x BPD. A ratio of measured-to-expected humeral length of less than 0.90 identified 12 of 24 fetuses (50%) with Down syndrome and 25 of 400 normals (6.25%). Twelve of the 24 Down syndrome fetuses had a nuchal fold measuring 6 mm or larger. Combining nuchal fold findings with these humeral length criteria identified 18 of 24 affected fetuses (75%) without appreciable change in specificity, yielding a positive predictive value of 4.6% for women with a risk of one in 250 (age 35) of having a Down syndrome fetus. For women with risks of one in 500 and one in 1000 of having an affected fetus based on maternal age, a shortened humerus or thickened nuchal fold yielded positive predictive values of 2.3 and 1.2%, respectively.

Stillbirth after nonstress testing.

The authors' experience with stillbirth within one week of a reactive nonstress test was reviewed to determine the reliability of this test in postdates patients and general high-risk patients. The corrected stillbirth rates were the same in both groups. Thirty-three percent of stillbirths in postdates patients occurred as early as 41.5 weeks' gestation. The cause of stillbirth in postdates patients was not clear even after careful autopsy. In the general high-risk group, 60% of stillbirths were due to an acute event with the remainder due to chronic fetal compromise that was not predicted by the nonstress test. Induction at 41.5 weeks' gestation or more comprehensive fetal surveillance than weekly nonstress testing are possible approaches to the management of postdates pregnancy, which need to be further studied.

Second trimester oligohydramnios, a predictor of poor fetal outcome.

Twelve cases of severe second trimester oligohydramnios are reported. The outcome of these pregnancies was uniformly poor, with no survivors in the present series. Four patients had therapeutic abortions, one woman had spontaneous labor at 22 weeks' gestation, and seven patients continued to viability. Of these, five patients had severe renal abnormalities incompatible with life. Two infants died at, or shortly after, birth from severe intrauterine growth retardation (IUGR), one of which had a triploid karyotype. Review of the literature shows a similar poor outcome for pregnancies with severe oligohydramnios in the second trimester.

Ultrasonographic determination of chorion type in twin gestation.

Reported are sonographic criteria for distinguishing the chorionic type of twin pregnancies prenatally. Thirty-four twin pregnancies were prospectively evaluated with correct assignment of chorionic type in 33 cases. The ability to determine the chorionic type of twin gestation facilitated the prenatal diagnosis and management in eight of the studied cases. Knowledge of the type of twinning antenatally is important in the management of twin pregnancies.

Prenatal diagnosis of neural tube defects. IV. Maternal serum alpha-fetoprotein screening.

The maternal serum alpha-fetoprotein (AFP) in 6161 women in routine pregnancy [2771 in a hospital obstetric clinic (group 1) and 3390 in private practices (group 2)] was studied. Group 1 studies enabled the delineation of the normal range of serum AFP, whereas group 2 represented a true screening experience. In group 2, 39 (2.5%) of 1566 women at 16 to 18 weeks' gestation had raised (2.5 times the median or more) serum AFP. Of these 39 women, 3 (7.8%) had neural tube defects (NTDs), 6 (15.4%) had multiple pregnancies, 1 (2.6%) had congenital nephrosis, 7 (17.9%) had spontaneous abortions, 7 (17.9%) had miscellaneous associated factors, and 15 (38.5%) had raised serum AFP for no obvious reason. Only 16 (1%) women had "unnecessary" amniocenteses. None of these aborted subsequently. Analysis of the combined data showed that NTDs were detectable in 87.5% of patients-all 6 with anencephaly and 1 of 2 with spina bifida (1 spina bifida lesion closed); multiple pregnancy was determined in 45% (18/40 cases), and spontaneous abortion ensued in 14.5%. In group 1 a raised serum AFP was associated with a host of complications in 77.3% of the women. Low AFP values had associated complications in 72.2% of cases. Maternal serum AFP screening represents another potentially important tool for early detection of high-risk pregnancy.

The diagnosis of puerperal ovarian vein thrombophlebitis by computed axial tomography scan.

The diagnosis of puerperal ovarian vein thrombophlebitis by computed axial tomography (CAT) scan is reported. The characteristic finding, ie, a soft tissue mass with a diameter of 2 cm and length of 14 cm, extending from the uterine cornua to the level of the renal vein, can be seen by CAT scan. The near total resolution of the mass on follow-up CAT scan confirmed successful treatment with antibiotics and heparin. Observation of these findings will allow future cases to be definitively diagnosed and treated without invasive procedures.

Sonographic evaluation of hydrops fetalis.

Sonographic criteria were developed to aid in determining the cause of hydrops fetalis in 26 consecutive cases diagnosed antenatally. This enabled us to predict whether the hydrops was due to anemia-related causes (isoimmunization, fetomaternal hemorrhage, alpha-thalassemia) or non-anemia-related causes. Fetuses without anemia as the cause of hydrops most often exhibited pleural effusions (87%) or marked edema (62.5%). A combination of pleural effusions and marked edema was evident in fetuses without anemia 56.3% of the time. Those with anemia as the cause of hydrops were significantly less likely to exhibit pleural effusions (20%), marked edema (10%), or pleural effusions and marked edema (10%). A thickened placenta occurred significantly more frequently (80 versus 37%) in anemia-associated hydrops. With the use of cordocentesis and intravascular in utero transfusion, the early recognition and treatment of hydrops fetalis due to anemia should lead to improved outcome in fetuses so affected.

Induction of labor with anencephalic fetus.

Elective induction of labor, followed by vaginal delivery, was carried out at 25 to 39 weeks' gestation in 14 consecutive patients (15 pregnancies) with an anencephalic fetus. Laminaria tents and prostaglandin drugs were used. The procedures produced no serious untoward effects and required only 3 hospital days.

Abnormal karyotype of fetuses with omphalocele: prediction based on omphalocele contents.

The majority of fetuses with omphalocele have other congenital abnormalities and, in many cases, an abnormal karyotype. We retrospectively studied 22 consecutive fetuses with sonographically diagnosed omphalocele and available karyotype to determine whether the contents of the omphalocele could predict the karyotype. Of these 22 fetuses, 18 had normal and four had abnormal karyotypes. Sixteen of the karyotypically normal fetuses had liver herniated into the omphalocele and two had only bowel present in the defect. All four of the fetuses with abnormal chromosomes had only bowel in the defect.

Fetal pyelectasis: a possible association with Down syndrome.

Two hundred ten consecutive fetuses were identified as having renal pyelectasis among 7400 patients scanned during 1 year. Seven of these 210 fetuses had Down syndrome. We reviewed images of the kidneys of 44 fetuses with Down syndrome collected over 5 years and found that 25% of these affected fetuses had pyelectasis. The incidence of Down syndrome was 3.3% when fetal pyelectasis was present.