Prenatal diagnosis of fetal growth restriction with polyhydramnios, etiology and impact on postnatal outcome.

To assess the spectrum of different etiologies, the intrauterine course, outcome and possible prognostic markers in prenatally detected fetal growth restriction (FGR) combined with polyhydramnios. Retrospective study of 153 cases with FGR combined with Polyhydramnios diagnosed by prenatal ultrasound over a period of 17 years. Charts were reviewed for ultrasound findings, prenatal and postnatal outcome. All cases were categorized into etiological groups and examined for differences. Five etiological groups were identified: chromosomal anomalies (n = 64, 41.8%), complex malformation syndromes (n = 37, 24.1%), isolated malformations (n = 24, 15.7%), musculoskeletal disorders (n = 14, 9.2%) and prenatal non-anomalous fetuses (n = 14, 9.2%). Subgroups showed significant disparities in initial diagnosis of combination of both pathologies, Ratio AFI/ gestational weeks and Doppler ultrasound examinations. Overall mortality rate was 64.7%. Fetuses prenatally assigned to be non-anomalous, showed further complications in 42.9% (n = 6). Fetuses prenatally diagnosed with FGR combined with polyhydramnios are affected by a high morbidity and mortality. Five etiologic groups can be differentiated, showing significant disparities in prenatal and postnatal outcome. Even without recognizable patterns prenatally, long-term-follow up is necessary, as neurodevelopmental or growth delay may occur.

Twin-twin transfusion syndrome and the definition of recipient polyhydramnios.

BACKGROUND: Controversy exists regarding the threshold of recipient twin polyhydramnios required to diagnose twin-twin transfusion syndrome at a gestational age of ≥20 weeks. One criterion set (Quintero staging) requires the amniotic fluid maximum vertical pocket for the recipient twin to measure ≥8 cm, whereas another (European) system uses a maximum vertical pocket for the recipient twin of ≥10 cm. OBJECTIVE: This study aimed to characterize the patients with twin-twin transfusion syndrome who were treated with laser surgery and would be excluded from laser surgery according to the European criteria. STUDY DESIGN: A total of 366 monochorionic diamniotic twins diagnosed with twin-twin transfusion syndrome from 20 to 26 weeks' gestation who underwent laser surgery at our center were studied. A maximum vertical pocket for the recipient twin of ≥8 cm was used to diagnose twin-twin transfusion syndrome. Patients were retrospectively divided into the following 2 groups: group A with a maximum vertical pocket for the recipient twin of ≥8 cm and <10 cm and group B with a maximum vertical pocket for the recipient twin of ≥10 cm. The association of each of the groups with the survivorship outcomes was tested. Bivariate associations between the patient characteristics and the 30-day donor twin and dual survivorship outcomes were evaluated. Tests used in the analysis were chi-square or Fisher exact tests as appropriate for categorical variables and Kruskal-Wallis tests for continuous variables. Multiple logistic regression models for each of the survivorship outcomes were then assessed. The results are reported as mean±standard deviation. RESULTS: Of the 366 studied patients, 53 (14.5%) had a maximum vertical pocket for the recipient twin of ≥8 and <10 cm (group A) and 313 (85.5%) had a maximum vertical pocket for the recipient twin of ≥10 cm (group B). Groups A and B did not differ in the Quintero stage. Notably, 60.4% (32 of 53) of group A patients were stage III or IV. When compared with group B, group A was diagnosed with twin-twin transfusion syndrome at an earlier gestational age (21.7±1.6 vs 22.3±1.6 weeks; P=.0037) and had a higher prevalence of donor growth restriction (81.1% [43 of 53] vs 65.5% [205 of 313]; P=.0260). Rates of at least 1 twin and dual twin survival between group A and B were similar (98.1% [52 of 53] vs 95.8% [300 of 313]; P=.7023, and 79.2% [42 of 53] vs 83.4% [261 of 313]; P=.4369, respectively). Logistic regression models adjusted for perioperative characteristics showed no difference in the outcomes between the groups (group B as reference) (donor twin survival odds ratio, 0.64; 95% confidence interval, 0.29-1.42; P=.2753; and dual survivor odds ratio, 0.90; 95% confidence interval, 0.42-1.91; P=.7757). CONCLUSION: Restriction of the definition of twin-twin transfusion syndrome to a maximum vertical pocket for the recipient of ≥10 cm beyond 20 weeks gestational age would potentially exclude 14.5% of patients from laser surgery, the majority of whom had advanced stage twin-twin transfusion syndrome. A unifying criterion of a maximum vertical pocket for the recipient of ≥8 cm regardless of gestational age would allow inclusion of these patients and access to surgical management.

Predictive Factors for Perinatal Outcomes of Infants Diagnosed With Micrognathia Antenatally.

INTRODUCTION: Advances in fetal imaging have allowed us to identify abnormalities previously not appreciated. With this study, we hope to identify factors predicting a difficult airway at birth and review the perinatal outcomes of these patients. METHODS: Sixteen patients with antenatally diagnosed micrognathia were reviewed from a tertiary care hospital database from 2011 to 2016. Jaw index (JI), amniotic fluid index (AFI), glossoptosis, gastric size, and oropharynx obliteration were assessed. The airway support required at birth, specialist team involvement, and outcomes were evaluated. RESULTS: Nine (56.3%) of 16 patients had JI <5th percentile, 3 (33.3%) of 9 had difficult intubation, 2 (22.2%) of 9 needed an emergency tracheostomy, and 1 (11.1%) of 9 died. Seven patients had polyhydramnios, 2 (28.6%) of 7 had difficult intubation, 2 (28.6%) of 7 required tracheostomy, and 1 (14.3%) of 7 died. Twelve patients had either JI <5th percentile or abnormal AFI, 5 (41.7%) of 12 had difficult intubation, 2 (16.7%) of 12 required tracheostomy, and 1 (8.33%) of 12 died. For the group without otolaryngology consultation, 8 (50%) of 16, 1 (12.5%) of 8 had difficult intubation and 1 (12.5%) of 8 died because airway was not secured after 45 minutes of resuscitation. CONCLUSION: Jaw index <5th percentile or abnormal AFI predicts a difficult airway. A multidisciplinary approach with otolaryngology involvement for airway intervention may be required at birth.

[Postnatal outcome from polyhydramnios without sonographic abnormalities]. / Issue postnatale en cas d'hydramnios sans anomalies morphologiques à l'échographie anténatale.

OBJECTIVES: To assess adverse outcome of polyhydramnios without morphological abnormalities and to determine the factors associated with an adverse outcome. METHODS: This is a retrospective observational cohort study conducted in a French tertiary care unit between 2008 and 2018 including all women with singleton pregnancy complicated by polyhydramnios. Presence of morphological abnormality was an exclusion criteria. The primary outcome was the rate of adverse outcome, defined by a composite criterion including death or postnatal discovery of malformation or chronic pathology. Maternal, obstetrical, paediatric and polyhydramnios characteristics were collected. RESULTS: Ninety-one women with polyhydramnios were included. The rate of adverse outcome was 24.2% (22/91). This rate was 20,3% in case of idiopathic polyhydramnios and 33,3% in case of maternal diabetes associated. The postnatal mortality rate was 5.5%. The rate of malformations not diagnosed in antenatal was 11%. Obesity (50% vs. 18,8%; P=0,004), early diagnosis (72,7% before 32 WG vs. 44,9%; P=0,02), and severity of polyhydramnios (22,7% vs. 4,3% in severe polyhydramnios; P=0,01) were associated significantly with an adverse outcome. In these cases, the incidence of preterm delivery was higher. CONCLUSION: Polyhydramnios must have second-line ultrasound, including isolated maternal diabetes. A systematic genetic assessment can be discussed.

Sonographic Markers in the Prediction of Fetal Complex Gastroschisis.

OBJECTIVE: To investigate the ultrasound (US) markers predictive of complex gastroschisis (CG), mortality, and morbidity in fetuses with gastroschisis. MATERIALS AND METHODS: This was a retrospective cohort study of 186 pregnancies with isolated fetal gastroschisis. Eight US markers were analyzed. The predictions and associations of US markers with CG, mortality, and morbidity were assessed. Combinations of US markers predictive of CG were investigated. RESULTS: Extra-abdominal bowel dilatation (EABD), intra-abdominal bowel dilatation (IABD), and polyhydramnios were predictive of CG. EABD between 25 and 28 weeks had a sensitivity of 64%, a specificity of 89%, a positive predictive value (PPV) of 56.2%, and negative predictive value (NPV) of 91.8%. The predictions of IABD were sensitivity = 26.7%, specificity = 96.7%, PPV = 61.5%, and NPV = 86.8%. The odds ratios for CG in the presence of 1 and 2 US markers, compared with the absence of a US marker, were 18.3 (95% CI, 3.83-87.64) and 73.3 (95% CI, 6.14-876), respectively. CONCLUSION: US markers predictive of CG were established. The combination of these markers increases the probability of CG.

Thoracoamniotic Shunting for Fetal Hydrothorax: Predictors of Intrauterine Course and Postnatal Outcome.

OBJECTIVE: To assess predictors for survival and complications among a relatively large cohort of fetuses with hydrothorax treated by thoracoamniotic shunting. METHODS: All cases with hydrothorax treated by thoracoamniotic shunting in a 10-year period (2002-2011) in two centers were retrospectively reviewed. RESULTS: A total of 78 fetuses with hydrothorax treated with thoracoamniotic shunting were included in the study. Mean gestational age at diagnosis was 25.6 weeks (12-34 weeks). Initial thoracoamniotic shunting was performed at a mean gestational age of 26.5 weeks (16-33 weeks). A mean of 2.53 shunts (1-7) were inserted per fetus. Of the 78 fetuses, 9 (11.5%) died in utero, 69 (88.5%) were born alive and 46 (59%) survived. Prognostic markers significantly associated with nonsurvival were polyhydramnios, hydrops placentae and mediastinal shift at initial scan, onset of hydrops after first shunt placement, rupture of membranes, a shunt-birth interval <4 weeks and low gestational age at birth. In our cohort, fetuses with trisomy 21 had a significantly better survival than euploid fetuses. CONCLUSIONS: Although associated with a significant rate of repeated interventions, thoracoamniotic shunting in fetuses with severe hydrothorax results in an overall survival rate of 59%. Fetuses with hydrothorax and trisomy 21 have a better survival when compared to euploid fetuses.

The risk of fetal death in nonanomalous pregnancies affected by polyhydramnios.

OBJECTIVE: The objective of the study was to evaluate the ongoing risk of intrauterine fetal demise (IUFD) in nonanomalous pregnancies affected by polyhydramnios. STUDY DESIGN: We analyzed a retrospective cohort of all singleton, nonanomalous births in California between 2005 and 2008 as recorded in a statewide birth certificate registry. We included all births between 24+0 and 41+6 weeks' gestational age, excluding multiple gestations, major congenital anomalies, and pregnancies affected by oligohydramnios. Polyhydramnios was identified by International Classification of Diseases, ninth revision, codes. χ(2) tests were used to compare the dichotomous outcomes, and multivariable logistic regression analyses were then performed to control for potential confounders. We analyzed the data for pregnancies affected and unaffected by polyhydramnios. The IUFD risk was expressed as a rate per 10,000. RESULTS: The risk of IUFD in pregnancies affected by polyhydramnios was greater at every gestational age compared with unaffected pregnancies. The IUFD risk in pregnancies affected by polyhydramnios was more than 7 times higher than unaffected pregnancies at 37 weeks at a rate of 18.0 (95% confidence interval [CI], 9.0-32.6) vs 2.4 (95% CI, 2.0-2.5) and was 11-fold higher by 40 weeks' gestational age at a rate of 66.3 (95% CI, 10.8-68.6) vs 6.0 (95% CI, 5.1-6.3) in unaffected pregnancies. When adjusted for multiple confounding variables, the presence of polyhydramnios remained associated with an increased odds of IUFD in nonanomalous singleton pregnancies, with an adjusted odds ratio of 5.5 (95% CI, 4.1-7.6). CONCLUSION: Ongoing risk of IUFD is greater in low-risk pregnancies affected by polyhydramnios at all gestational ages compared with unaffected pregnancies with the greatest increase in risk at term. Although further study is needed to explore the underlying etiology of polyhydramnios in these cases, the identification of polyhydramnios alone may warrant increased antenatal surveillance.

Fetal skeletal dysplasias: sonographic indices associated with adverse outcomes.

OBJECTIVES: To assess the utility of biometric indices and amniotic fluid volume in identifying fetuses with lethal skeletal dysplasia. METHODS: A review of pregnancies with sonographic diagnosis of skeletal dysplasia between January 1997 and March 2012 from a single institution was conducted. Biometric indices and amniotic fluid volumes were reviewed from the initial targeted sonograms and all subsequent examinations. Outcomes were verified in all cases. Pregnancies that resulted in fetal or neonatal death were considered to have lethal dysplasia, and those with survival to hospital discharge were considered to have nonlethal dysplasia. RESULTS: Of 45 fetuses with suspected skeletal dysplasia, 27 (60%) survived to hospital discharge; 9 (20%) died in the immediate neonatal period; 2 (4%) resulted in stillbirth; and in 7 cases (16%), pregnancy termination was elected. Those with lethal dysplasia were more likely to have hydramnios on initial detection than those who survived to hospital discharge (83% versus 27%; P < .01). Pregnancies complicated by lethal skeletal dysplasia had a significantly lower femur length-to-abdominal circumference ratio and were more likely to have a ratio below 0.16 than those with neonatal survival (91% versus 11%; P < 0.01). The lowest femur length-to-abdominal circumference ratio and the proportion with a ratio below 0.16 at any point in gestation were significantly different between those with lethal and nonlethal dysplasia (P< .01). As fetal size increased with advancing gestation, the relationship of sonographic parameters (eg, femur length-to-abdominal circumference ratio) became more pronounced. There was no infant survival when hydramnios was encountered at any point during gestation in the setting of a femur length-to-abdominal circumference ratio below 0.16. CONCLUSIONS: In our series, a femur length-to-abdominal circumference ratio below 0.16 in conjunction with hydramnios effectively identified fetuses with lethal skeletal dysplasia.

Association and prediction of amniotic fluid measurements for adverse pregnancy outcome: systematic review and meta-analysis.

BACKGROUND: Measurements of amniotic fluid volume are used for pregnancy surveillance despite a lack of evidence for their predictive ability. OBJECTIVE: To evaluate the association and predictive value of ultrasound measurements of amniotic fluid volume for adverse pregnancy outcome. SEARCH STRATEGY: Electronic databases (inception to October 2011), reference lists, hand searching of journals, contact with experts. SELECTION CRITERIA: Studies comparing measurements of amniotic fluid volume with adverse outcome, excluding pre-labour ruptured membranes or congenital/structural anomalies. DATA COLLECTION: Data on study characteristics, design, quality. Random effects meta-analysis to estimate summary odds ratios (prognostic association) and summary sensitivity, specificity and likelihood ratios (predictive ability). MAIN RESULTS: Forty-three studies (244,493 fetuses) were included demonstrating a strong association between oligohydramnios (varying definitions) and birthweight <10th centile (summary odds ratio [OR] 6.31, 95% confidence interval [95% CI] 4.15-9.58; high-risk population [author definition] n = 6 studies, 28,510 fetuses), and mortality (neonatal death any population summary OR 8.72, 95% CI 2.43-31.26; n = 6 studies, 55,735 fetuses; and perinatal mortality high-risk population summary OR 11.54, 95% CI 4.05-32.9; n = 2 studies, 27;891 fetuses). There was a strong association between polyhydramnios (maximum pool depth >8 cm or amniotic fluid index ≥25 cm) and birthweight >90th centile (OR 11.41, 95% CI 7.09-18.36; n = 1 study, 3960 fetuses). Despite strong associations, predictive accuracy for perinatal outcome was poor. AUTHOR'S CONCLUSION: Current evidence suggests that oligohydramnios is strongly associated with being small for gestational age and mortality, and polyhydramnios with birthweight >90th centile. Despite strong associations with poor outcome, they do not accurately predict outcome risk for individuals.

Maximal amniotic fluid index as a prognostic factor in pregnancies complicated by polyhydramnios.

OBJECTIVES: Polyhydramnios is present in approximately 2% of pregnancies and has been associated with a variety of adverse pregnancy outcomes. Our aim was to evaluate the association between the maximal amniotic fluid index (AFI) and the frequency of specific adverse outcomes. METHODS: This was a retrospective chart review of 524 singleton pregnancies diagnosed with polyhydramnios and delivered in a single tertiary referral center between 2003 and 2008. Polyhydramnios was defined as either AFI ≥ 25 cm or a maximum vertical pocket (MVP) ≥ 8 cm even in the presence of AFI < 25 cm. The cohort was stratified into four groups based on the maximal AFI noted during the pregnancy: < 25 cm but with MVP ≥ 8 cm; 25-29.9 cm; 30-34.9 cm; and ≥ 35 cm. Data were collected to determine the frequency of the following adverse pregnancy outcomes: prenatally diagnosed congenital anomalies, fetal aneuploidy, preterm delivery, Cesarean delivery, low birth weight, 5-min Apgar score < 7 and perinatal mortality. RESULTS: Higher AFI was associated with a statistically significant increase in the frequency of adverse pregnancy outcomes. The most severe form of polyhydramnios, as based on the maximal AFI (≥ 35 cm; n = 67), was associated with the highest rates of prenatally diagnosed congenital anomalies (79%), preterm delivery (46%), small-for-gestational-age neonate (16%), aneuploidy (13%) and perinatal mortality (27%). No significant association between degree of polyhydramnios and adverse outcome was demonstrated in cases of idiopathic polyhydramnios (n = 253). CONCLUSIONS: There is an association between the frequencies of a variety of adverse pregnancy outcomes and the severity of polyhydramnios as reflected by the maximal AFI.

Risk factors for intrapartum fetal death and trends over the years.

OBJECTIVE: To determine the time trends and risk factors for intrapartum fetal death (IPFD). STUDY DESIGN: A case-control study comparing pregnancies with and without IPFD between the years 1988 and 2008 was conducted. A multiple logistic regression model was used to determine the risk factors for IPFD. RESULTS: During the study period, 204,102 singleton births were analyzed; of these, 110 IPFD cases occurred. The following independent risk factors were identified: Bedouin ethnicity (OR = 1.85, 95% CI 1.22-2.8), malpresentations (OR = 2.76, 95% CI 1.71-4.47), gestational age (OR = 0.72, 95% CI 0.69-0.76), polyhydramnios (OR = 3.49, 95% CI 1.94-6.26), meconium-stained amniotic fluid (OR = 3.18, 95% CI 2.01-5.05), umbilical cord prolapse (OR = 6.64, 95% CI 2.79-15.78), placental abruption (OR = 3.24, 95% CI 1.73-6.04), uterine rupture (OR = 38.59, 95% CI 10.58-140.71) and congenital malformations (OR = 2.41, 95% CI 1.47-3.97). A gradual decline over the years in the rate of IPFD was noted in the Bedouin population. No significant association was noted in the prevalence of IPFD during the weekends as compared to the week days (OR = 0.85; 95% CI 0.54-1.32; P = 0.475). CONCLUSION: Independent risk factors for IPFD are preterm birth, malpresentation, polyhydramnios, meconium-stained amniotic fluid, umbilical cord prolapse, placental abruption, uterine rupture, congenital malformations and Bedouin ethnicity. Weekends do not pose additional risk for the occurrence of IPFD.

Clinical significance of amniotic fluid glucose concentration in polyhydramnios.

OBJECTIVE: To evaluate whether amniotic fluid glucose concentration can predict poor neonatal outcome in cases with polyhydramnios as an overall assessment. METHODS: In this retrospective study, we have reviewed 42 consecutive pregnant women with singleton gestations complicated with polyhydramnios who gave birth at one tertiary care center between January 2003 and September 2010. Perinatal clinical findings were reviewed, and the neonatal outcome, such as livebirth or stillbirth and early neonatal death, was compared. A p value less than 0.05 was considered to be significant. RESULTS: Thirteen of 42 neonates had a poor outcome, including stillbirth or early neonatal death. Multiple logistic regression analysis showed that amniotic fluid glucose (p = 0.042) was significant factor influencing poor neonatal prognosis [odds ratio 0.66; 95% confidence interval 0.44-0.98]. Receiver operating characteristics curve and sensitivity and specificity curve showed that the optimal cut-off value of amniotic fluid glucose concentration for predicting poor neonatal outcome was 17 mg/dl. CONCLUSIONS: Amniotic glucose concentration less than 17 mg/dl and the presence of congenital heart anomaly were better predictors for a poor postnatal outcome in cases with polyhydramnios.

Pre- and postnatal diagnosis and outcome of fetuses and neonates with esophageal atresia and tracheoesophageal fistula.

OBJECTIVES: Clinical symptoms and ultrasound signs during pregnancy could suggest the presence of esophageal atresia (EA). However, most often EA is diagnosed postnatally. The aim of our study is to evaluate the course and outcome for prenatally and postnatally diagnosed EA. In addition, we studied the outcome of isolated versus nonisolated EA. METHODS: In a retrospective data analysis, ultrasound characteristics, maternal and neonatal variables as well as clinical outcome were compared for fetuses/neonates with prenatal (n = 30) or postnatal (n = 49) diagnosis of EA. Clinical outcome in terms of morbidity and mortality of isolated EA was compared with that of EA complicated by chromosomal or structural anomalies. RESULTS: Prenatally diagnosed children were born 2 weeks earlier than postnatally diagnosed children (36.4 weeks vs 38.2 weeks; P = 0.02). The former had higher mortality rates (30 vs 12%; P = 0.05) and more associated anomalies (80 vs 59%; P = 0.04). In both subsets, there was a high morbidity rate in the survivors (not significant). Nonisolated EA was associated with greater occurrence of polyhydramnios (53 vs 27%; P = 0.04) and higher mortality rate (28 vs 0%; P = 0.002). CONCLUSIONS: Mortality was significantly higher in prenatally diagnosed infants and in infants with additional congenital anomalies. Isolated EA is associated with good outcome.

A review of idiopathic hydramnios and pregnancy outcomes.

UNLABELLED: Idiopathic hydramnios is defined as hydramnios that is not associated with congenital anomalies of the central nervous system or gastrointestinal tract, maternal diabetes, isoimmunizaton, fetal infection (CMV or toxoplasmosis), placental tumors, or multiple gestations. Hydramnios is diagnosed when the AFI is > or = 24 or > or = 25 (> or = 95 or > or = 97.5%), the single deepest pocket (SDP) as being > or = 8, or the examiner's subjective assessment of having an increased amount of amniotic fluid volume. The prevalence of hydramnios is 1%-2% with 50%-60% of those cases as being idiopathic. A PUBMED search from 1950 to 2007 and Science Citation search from 2001 to 2007 revealed only 3 studies that compared pregnancies with idiopathic hydramnios to pregnancies without hydramnios, and 4 studies that evaluated perinatal mortality with hydramnios after correcting for congenital anomalies. Idiopathic hydramnios was found in the larger studies to be linked to fetal macrosomia, an increase in the risk of adverse pregnancy outcomes, and a 2- to 5-fold increase in the risk of perinatal mortality. Tests that may be helpful in the antenatal evaluation of these at-risk pregnancies are: Doppler flow velocimetry of the middle cerebral artery, nonstress test, biophysical profile, and contraction stress test. Prospective studies are needed in this area that is understudied where risk of an adverse pregnancy outcome and perinatal mortality are increased. TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to state the prevalence of idiopathic hydramnios, recall the lack of data relating to outcome, explain that there is a 2- to 5-fold increase in the risk of perinatal mortality, and summarize the lack of consensus in monitoring pregnancies afflicted with idiopathic hydramnios.

The impact of hydramnios on pregnancy outcome in twin gestations.

OBJECTIVE: To compare pregnancy outcome in twin pregnancies with and without hydramnios. STUDY DESIGN: A database of women receiving outpatient preterm labor surveillance services was studied for the period 1988 to 2002. Included were women with twin gestations under 30 weeks' gestation at start of outpatient services. We compared pregnancy outcomes for twin gestations with hydramnios (n=201) to twin gestations that had normal amniotic fluid volume (n=13,111). RESULTS: Obstetrical and perinatal outcomes in twin pregnancies were adversely affected by the presence of hydramnios. Delivery was shifted to earlier gestations in women with hydramnios (32.8 vs 35.1 weeks, p<0.001), especially under 32 weeks (38.3 vs 12.7%). Perinatal loss was notable in women with hydramnios: stillbirths (12.7 vs 1.1%, p<0.001) and neonatal mortality (7.5 vs 1.1%, p<0.001). CONCLUSIONS: Hydramnios in twin gestations negatively impacts gestational age at delivery. The incidence of perinatal mortality is significantly increased in the presence of hydramnios.

Fetal and neonatal outcomes in twin oligohydramnios-polyhydramnios sequence including cerebral palsy.

OBJECTIVE: The purpose of this study was to review consecutive pregnancies complicated by twin oligohydramnios-polyhydramnios sequence (TOPS) and to clarify the probable factors influencing the perinatal outcomes. METHODS: Twenty-five pregnancies with a diagnosis of TOPS were treated with and without amniocentesis. A poor perinatal outcome was defined when either perinatal mortality or cerebral palsy was observed. RESULTS: The mean gestational age at the time of diagnosis and of delivery was 27.8 (range 21-34) and 30.7 (range 23-35) weeks, respectively. Tocolytic therapy and therapeutic amniocentesis were done in 16 (64%) and 13 (52%) cases. Hydrops fetalis was present in 10 cases. The survival rate was 72%, and cerebral palsy was diagnosed in 8 of 36 infants (22%). The poor prognostic factors were gestational age at delivery (<30 weeks) and presence of symptomatic preterm labor and hydrops fetalis. Therapeutic amniocentesis did not influence the perinatal outcome. CONCLUSIONS: In this observational study, the long-term as well as the short-term perinatal outcome of pregnancy with TOPS seems to be poor. In addition, therapeutic amniocentesis in TOPS does not appear to affect fetal and neonatal outcomes.

Hydramnios and small for gestational age: prevalence and clinical significance.

OBJECTIVE: To investigate the clinical significance of combined obstetrical pathology of small for gestational age and hydramnios as a predictor of peripartum complications, intrapartum morbidity and poor neonatal outcome. METHODS: The study population consisted of 152 small for gestational age neonates with hydramnios out of 67,806 singleton deliveries during the study period (0.22%). We compared the 152 small for gestational age neonates with hydramnios (hydramnios/small for gestational age) to a sample of 1% of the appropriate for gestational age neonates with normal amniotic fluid (normal amniotic fluid/appropriate for gestational age) (582 cases). Analyses were conducted for the entire cohort as well as for the cohort in which all cases with congenital malformations were excluded. RESULTS: There was a significantly higher rate of congenital anomalies in the hydramnios/small for gestational age group compared with the normal amniotic fluid/appropriate for gestational age group (25% vs. 2.4%, p<0.001). There were significantly more previous perinatal deaths, infertility treatments and diabetes type B-R among the hydramnios/small for gestational age group. These findings remained significant after exclusion of the neonates with congenital malformations. The rates of labor dystocia, placental abruptio, abnormal presentations, prolapse of cord and cesarean sections were significantly higher in the hydramnios/ small for gestational age group compared with normal amniotic fluid/appropriate for gestational age group (5.9/2.4%, p<0.05; 5.9/0.7%, p<0.001; 14.5/3.2%, p<0.001; 2/0.2%, p<0.01; 24.3/8.2%,p<0.001; respectively). Rates of ante partum death and post partum death as well as low 1 and 5 minute Apgar scores were significantly higher in the hydramnios/small for gestational age group (9.9/0.3%; 14.5/0.3%; 12.8/2.1%; 11.7/0.6%, p<0.001, respectively). CONCLUSIONS: The combination of small for gestational age and hydramnios is a risk factor for peripartum complications and perinatal mortality even in the absence of congenital malformations.

[The polyhydramnios symptom: analysis of 56 cases]. / Das Symptom Polyhydramnion: Analyse von 56 Fällen.

Analysis of 56 CASES: 56 cases of polyhydramnios, which were diagnosed sonographically over a period of three years, were analysed retrospectively in this study. In 9334 births, the prevalence of this symptom was 0.6%. Malformations were the most common cause (26.7%) of polyhydramnios (p < 0.001). In comparison to our normal patient group gestational diabetes, twin pregnancies with elevated amniotic fluid of one twin, virus infections, fetal chromosome abnormalities were diagnosed at a significantly higher rate (p < 0.001). The perinatal mortality rate (28.5%) in comparison to our normal collective (1.6%) was also significantly higher. Because of the high mortality, polyhydramnios must be assessed precisely and treated if possible. Fetal karyotyping should be routinely performed in the second trimester.

Stuck twin syndrome: outcome in thirty-seven consecutive cases.

OBJECTIVE: Our purpose was to further evaluate the role of serial amniocentesis in pregnancies complicated by the "stuck twin" syndrome. STUDY DESIGN: A cohort of 37 consecutive cases of stuck twin syndrome was followed up from 1986 through 1992. Evaluations included gestational age at diagnosis and at delivery, mean number of amniocenteses, volume of amniotic fluid withdrawn, placentation, perinatal complications, fetal survival, and neonatal follow-up. RESULTS: Five pregnancies were terminated, five had no intervention, and 27 underwent serial amniocenteses. The mean number of amniocenteses was 3.4 (range 1 to 6), and mean total amniotic fluid volume withdrawn was 5.8 L (range 0.75 to 4.0). In the serial amniocentesis group mean gestational age was 23.1 weeks (range 16 to 30) at diagnosis and 31.5 weeks (range 20 to 38) at delivery. Eighty-two percent had monochorionic placentas, and 36% had marginal or velamentous cord insertions. Infant survival was 39 of 54 (74%) in the serial amniocentesis group compared with four of 10 (40%) in the nonintervention group (relative risk 0.46, 95% confidence interval 0.24 to 0.90). CONCLUSION: Serial amniocentesis was associated with a 54% reduction in fetal and neonatal death in cases of stuck twin syndrome.