Ultrasound fetal biometry charts for a North American Caucasian population.

PURPOSE: This study was done to produce enhanced fetal biometry charts and graphs presenting percentile values as a function of fetal age. METHODS: The relationships between the ultrasound measurements of 10 fetal parameters and menstrual age were determined by a cross-sectional study. Data were obtained from 508 to 790 fetuses. Anatomic structures were scanned and measured 3 times during 1 routine sonographic examination. The study group consisted of 1,396 Caucasian women who had normal singleton fetuses with confirmation of menstrual dates by sonography before 14 weeks and for whom complete pregnancy outcome information was available. For each of the 10 parameters, percentile curves were derived for the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles. RESULTS: Ready-to-use fetal measurement charts and graphs are presented in a format giving the percentile values as a function of fetal age. There were no significant differences between male and female fetuses. CONCLUSIONS: These fetal biometry charts and graphs, obtained from a North American Caucasian population, enhance previously published data.

Antenatal invasive and noninvasive management of alloimmune thrombocytopenia.

The outcome analysis of 10 pregnancies at risk for neonatal alloimmune thrombocytopenia (NAIT) is presented. An experimental protocol of cordocentesis and maternal administration of intravenous immunoglobulin (IVIG) is compared to a control group of older untreated affected siblings. The outcome in pregnancies treated with IVIG shows improved fetal platelet count in 70% and no intraventricular hemorrhage. We conclude that maternal administration of IVIG appears to improve clinical outcome in fetuses at risk for NAIT.

Selective feticide in twin transfusion syndrome using ultrasound-guided insertion of thrombogenic coils.

Twin transfusion syndrome is a common complication of monozygotic twin pregnancies. Selective feticide is one of the many different aggressive and invasive therapies that has been suggested to improve an otherwise dismal perinatal outcome. The ideal method of selective feticide remains to be delineated for cases of twin transfusion syndrome that occur remote from term. We describe a case involving the use of intracardiac placement of thrombogenic coils to attempt selective termination.

Cordocentesis: overall pregnancy loss rate as important as procedure loss rate.

A 4-year retrospective review of cordocentesis at a single center with four operators identified 182 patients undergoing 214 cordocenteses. The major indications were chromosomal, fetal platelet and rhesus evaluation. The procedure was successful in 95%. A positive genetic diagnosis was present in 18% with 64% having trisomy 18, 21 or 13. The procedural pregnancy loss rate was 3.25, 1.25 and 2.75% for chromosomal and nonchromosomal indications and total population, respectively. The overall fetal loss rate (procedural, nonprocedural) in chromosomal risk population was 47%. This overall pregnancy loss risk should be included in patient counselling.

The sensitivity and specificity of subjective and a semi-quantitative technique of amniotic fluid volume assessment in predicting intrapartum morbidity.

The aim of this study was to evaluate the ability of two techniques of amniotic fluid volume assessment to predict intrapartum morbidity in a high-risk population. A total of 213 pregnant women at the Grace Maternity Hospital, Vancouver, Canada were examined ultrasonically and the amniotic fluid volume was assessed subjectively and using the amniotic fluid index. Both techniques showed high specificity and negative predictive values for all outcome measures, but had an associated poor sensitivity and positive predictive value. Both techniques were similar in their ability to identify situations involving intrapartum morbidity. It is concluded that amniotic fluid assessment is a weak predictor of intrapartum morbidity but may be useful in certain conditions such as when the pregnancy is post-dates.

Influence of maternal factors on cord and neonatal plasma micronutrient levels.

The influence of gestational length, maternal prenatal supplement and maternal levels on umbilical cord and neonatal plasma selenium, alpha-tocopherol, and retinol were studied and appropriate reference intervals for ongoing studies of gestational and perinatal micronutrient requirements were derived. We measured retinol, alpha-tocopherol (total and alpha-tocopherol:cholesterol ratio), selenium, and glutathione peroxidase in 160 umbilical cord samples and 58 paired maternal and neonatal samples collected on the third postpartum day. Selenium and glutathione peroxidase were also measured in 25 paired umbilical artery and vein samples. The strongest correlation with gestational age and birthweight was found for the cord blood variables, whereas levels in maternal blood were not related to either gestation or weight. Neonatal values were significantly lower than maternal for selenium (0.96 [0.25] compared with 1.56 [0.27] mumol/liter), retinol (0.54 [0.19] and 1.26 [0.45] mumol/liter), alpha-tocopherol (11.5 [3.63] and 32.4 [9.20] mumol/liter), and glutathione peroxidase (446 [174] and 873 [176] U/liter) but not for the ratio of alpha-tocopherol:cholesterol (5.0 compared with 6.0). Maternal use of tocopherol and retinol supplements did not significantly affect blood concentrations. Maternal plasma selenium levels at term were about 60% of nonpregnant adult females. Selenium concentration and glutathione peroxidase activity did not differ between paired umbilical cord arterial and venous samples. Selenium, retinol, and glutathione peroxidase differed between infants born before or after 37 weeks' gestation.

Correlation of subjective assessment of amniotic fluid with amniotic fluid index.

We assessed the correlation between abnormal amniotic fluid volumes as defined by the two techniques of (1) subjective evaluation and (2) the amniotic fluid index. Ultrasound evaluation of amniotic fluid volume was conducted on 420 pregnant women with known gestational age greater than twenty weeks but less than 42 weeks. Amniotic fluid was evaluated subjectively and placed into one of three categories: normal, oligohydramnios or polyhydramnios. After fetal biometry was performed, the amniotic fluid volume was assessed semi-quantitatively by the amniotic fluid index technique and assigned to similar categories. We analyzed the data with 2 x 2 contingency tables, using amniotic fluid index as the 'gold standard test'. Our study demonstrates that there was moderate agreement (kappa.5) between both amniotic fluid techniques in the identification of oligohydramnios. However, agreement between the techniques was poor for the identification of polyhydramnios (kappa.16).

Delayed delivery of second twin: report of four cases and review of the literature.

In four cases of delayed delivery of a twin pregnancy with survival of the second twin, the interval ranged at 41-143 days. Review of the literature and our cases supports the following approach: high ligation of the umbilical cord with an absorbable suture, cervical suture in the presence of cervical dilatation, and serial monitoring of fetal growth and maternal coagulation indices. Disseminated intravascular coagulation has not been reported in such cases.

A comparison of the effects of single- and split-dose methadone administration on the fetus: ultrasound evaluation.

A prospective study was conducted to evaluate the effects of oral methadone on fetal activity (body movements, breathing, longest inactive period) for drug-dependent pregnant women on methadone maintenance. Seven consenting drug-dependent pregnant women between 26 and 37 weeks gestation were enrolled in the study. Pairs of ultrasound observation studies were conducted, before and after single-dose methadone (SDM) treatment and split-dose methadone treatment. There were significant decreases in both body movements (p less than 0.001) and breathing episodes (p less than 0.01), and a significant increase in the longest period of inactivity (p less than 0.001) following SDM. A similar but not significant trend was noted before and after split-dose methadone. The results of the single-dose studies differed significantly from normal controls. However, the results of the split-dose studies were similar to controls. It is recommended that women on methadone maintenance should be offered a split-dose treatment protocol.

Substance Abuse in Pregnancy: Approach for family physicians.

Drug-dependent pregnancies are on the increase, are high risk, and require skilled medical attention. Unfortunately, because they fear the "system," many addicted women do not receive this medical care, putting both mother and baby at risk. We describe a case in which we tried to make the system more approachable. The family physician is essential for providing the continuity of care necessary to improve prenatal care, establish a support system, and facilitate family development.

Caring for Obstetric Patients Who are Substance Abusers: Developing a plan for treating the patient.

The risks of pregnancy, when combined with the risks of substance abuse, can terrify even the most competent unless the physician develops a rational and organized plan to treat the pregnant patient. If exposure to drugs is recognized early, a team of experienced health professionals can manage treatment appropriately and improve the outcome.

Sonographic measurement of the fetal femur: factors affecting accuracy.

Variations have been observed in the measurement of fetal femoral diaphysis length by ultrasound. This in vitro study examines the effect of depth, the angle of the bone relative to the axis of the sound beam, the machine, and the observer on the precision of measurement. Using analysis of variance techniques, it demonstrates that three of these factors (depth, angle, and machine) have significant effects. Depth-associated variations were less than one millimeter and are probably not of clinical importance. However, the variations due to changes in angle are highly significant (P = less than 0.001) and may be controlled by obtaining the measurement with the femur perpendicular to the sound beam. Errors due to variation between machines were also highly significant (P = less than 0.001). When determining serial growth patterns, the errors due to variations between machines can be controlled by using the same machine for each examination. The variation between machines is also an important factor to consider when choosing a curve for reference purposes.

Pathology of intragestational intervention in twin-to-twin transfusion syndrome.

Selective intervention in multiple pregnancy is being used to enhance the chances of survival of at least one conceptus when the risks for the combined conceptuses and mother are considered too great. These procedures have been applied to induced polyembryonic conceptions (selective continuance) and discordant dichorionic twins (selective birth). We report attempts at selective intervention in three monochorionic twin gestations affected by twin-to-twin transfusion syndrome. In all three cases, both fetuses seemed doomed and the mother was in significant distress. The selected survivor in the first case is doing well; both twins were stillborn in the second case; in the third case, the selected survivor died as a neonate but the other twin survived and is doing well. We suggest possible explanations for the clinical outcome of each case based on detailed pathologic examination of the delivered placentas and autopsy examination of the nonsurviving twins. The shared chorionic circulation is the source of both the clinical disorder and the potential complications of any attempt to alleviate the disorder. This situation is unique to monochorionic twins, and we discuss the implications of this for intrauterine therapy of twin-to-twin transfusion syndrome.

ITP in pregnancy: use of the bleeding time as an indicator for treatment.

ITP is a relatively common disorder seen in pregnancy. Current recommendations for management of patient with ITP recommend maintaining the platelet count above 50 x 10(9)/L and the bleeding time less than 20 min. It has been well documented that the bleeding time in ITP is disproportionately shortened in many patients relative to the platelet count. We present a prospective study of 24 ITP patients in whom the bleeding time was used as an indicator for therapeutic intervention in pregnancy. Indications for therapy with prednisone and/or intravenous gammaglobulin were the following: significant clinical hemorrhage due to thrombocytopenia; bleeding time of greater than 20 min at the baseline platelet count; for normalization of hemostasis prior to delivery or surgical procedure. Caesarean section was performed only in cases in which there were obstetrical indications for this mode of delivery or when the fetal platelet count (obtained by fetal scalp vein sample) was less than 50 x 10(9)/L. Of 24 patients with ITP, eight had significant thrombocytopenia (platelet count less than 50 x 10(9)/L) throughout pregnancy. Only two patients required prolonged prednisone therapy. Both suffered side effects of chronic prednisone administration. Four patients were treated with prednisone for a short course (10-14 days) at term to improve hemostasis for delivery. One patient was treated with intravenous gammaglobulin at term in an effort to prevent severe neonatal thrombocytopenia. Seven patients required caesarean section; the remaining 17 patients underwent vaginal delivery. Only one minor bleeding complication was seen - a small wound hematoma post caesarean section. In summary, using the bleeding time as an indicator for therapeutic intervention, treatment of ITP in pregnancy can be minimized. Thus, therapy related toxicity can be avoided.

Fetal transfusion syndrome: antenatal factors predicting outcome.

Fetal transfusion syndrome is a serious complication of monozygotic multiple pregnancy and is associated with a high perinatal mortality rate. Recent literature has outlined aggressive interventions that attempt to improve the outcome of these pregnancies. We identified 25 cases of fetal transfusion syndrome from 595 multiple pregnancies delivered between January 1983 and December 1987 at the Grace Hospital. Analysis of antenatal factors with respect to survival showed that gestational age at delivery, the presence of hydrops, and the use of decompression amniocentesis may help in predicting outcome. These factors may be useful in deciding on the appropriate therapeutic approach for a particular pregnancy.

[Psychological effect of ultrasound examination on patients, relatives and the technician]. / Der psychologische Einfluss der Ultraschalluntersuchung auf Patienten. Angehörige und Untersucher.

To study the psychological influence of ultrasound diagnosis the authors examined special disciplines of obstetric practice and research. Relevant conclusions were drawn in respect of their application to other disciplines of medicine.

Role of prenatal detection of cardiac tumours in the diagnosis of tuberous sclerosis--report of two cases.

Tuberous sclerosis is an autosomal dominant disease with variable expression. Little is known about the intrauterine course of the disease and the fetal age at which specific abnormalities may be detected. The role of prenatal detection of cardiac tumours in the diagnosis of two fetuses at 28 and 32 weeks' gestation based on fetal echocardiography is discussed. The prenatal and postnatal course of the disease is described.

Maternal mortality in British Columbia in 1971-86.

We reviewed the 56 maternal deaths in British Columbia in 1971-78 and 1979-86 identified through the provincial Ministry of Health and compared the findings with data for the two preceding 8-year periods. The maternal death rate, defined as the number of deaths directly or indirectly related to pregnancy or delivery per 100,000 live births, decreased from 42 in 1955-62 to 5 in 1979-86. In the same interval the number of direct obstetric deaths decreased from 100 to 10 and the number of indirect deaths from 29 to 8. The number of deaths due to abortion decreased from 32 to 1. There was no change in the number of deaths among North American Indians. There was also no change in the number of deaths due to hypertension, most of which were avoidable; these findings have stimulated intensive teaching efforts to increase recognition and improve management of the problem. Review of maternal deaths can help identify deficiencies in the quality of care and can direct measures aimed at further reducing the maternal death rate.

Endocrine response to selective embryocide in a gonadotropin-induced quintuplet pregnancy.

With the increase of medical induction of ovulation, the incidence of grand multiple pregnancy is becoming more frequent. We report the endocrine response of a quintuplet pregnancy that was reduced at 9 weeks' gestation to a twin pregnancy by selective embryocide and compared with quadruplet, triplet, and twin pregnancies. The human chorionic gonadotropin titer declined fourfold, but there were no clinically significant changes in the progesterone or estradiol levels. We conclude that, despite the drop in human chorionic gonadotropin, the placenta had attained adequate secretory maturation to prevent any significant decline in progesterone and estradiol levels, which demonstrates the efficacy of this procedure at this gestational age.