The implementation of a nationwide anomaly screening programme improves prenatal detection of major cardiac defects: an 11-year national population-based cohort study.

OBJECTIVE: To evaluate whether a nationwide prenatal anomaly screening programme improves detection rates of univentricular heart (UVH) and transposition of great arteries (TGA), and whether maternal risk factors for severe fetal heart disease affect prenatal detection. DESIGN: Population-based cohort study. SETTING: Nationwide data from Finnish registries 2004-14. POPULATION: A total of 642 456 parturients and 3449 terminated pregnancies due to severe fetal anomaly. METHODS: Prenatal detection rates were calculated in three time periods (prescreening, transition and screening phase). The effect of maternal risk factors (obesity, in vitro fertilisation, pregestational diabetes and smoking) was evaluated. MAIN OUTCOME MEASURES: Change in detection rates and impact of maternal risk factors on screening programme efficacy. RESULTS: In total, 483 cases of UVH and 184 of TGA were detected. The prenatal detection rate of UVH increased from 50.4% to 82.8% and of TGA from 12.3% to 41.0% (P < 0.0001). Maternal risk factors did not affect prenatal detection rate, but detection rate differed substantially by region. CONCLUSIONS: A nationwide screening programme improved overall UVH and TGA detection rates, but regional differences were observed. Obesity or other maternal risk factors did not affect the screening programme efficacy. The establishment of structured guidelines and recommendations is essential when implementing the screening programme. In addition, a prospective screening register is highly recommended to ensure high quality of screening. TWEETABLE ABSTRACT: Implementation of a nationwide prenatal anomaly screening improved detection rates of UVH and TGA.

Induction of labor by Foley catheter compared with spontaneous onset of labor after previous cesarean section: a cohort study.

OBJECTIVE: To evaluate the safety of induction of labor (IOL) with Foley catheter (FC) in women with a history of previous cesarean section (CS) and to assess risk factors for repeat CS and adverse maternal outcomes. STUDY DESIGN: Cohort study of 1559 women with a history of previous CS in Helsinki University Hospital, Finland between 2013 and 2014. RESULTS: Three hundred and sixty-one women (23.2%) underwent IOL by FC and 1198 (76.8%) had spontaneous onset of labor. The rate of repeat CS was higher in women undergoing IOL (38% vs 20.2%; P<0.001). The overall rate of uterine rupture was 0.3% in induced labor and 0.8% in spontaneous onset of labor (P=0.47). Adverse maternal outcomes were not significantly different. The intrapartum and postpartum infection rates were higher in women undergoing IOL compared with spontaneous onset of labor (6.1% vs 1.8%; P>0.001 and 5.3% vs 1.3%; P<0.001, respectively). CONCLUSION: FC appears safe and effective method for IOL in women with a history of previous CS.

Does obesity complicate regional anesthesia and result in longer decision to delivery time for emergency cesarean section?

BACKGROUND: Maternal obesity can cause problems with anesthesia and surgery which may be reflected in emergency cesarean sections (CS) as an increased decision-to-delivery interval (DDI). AIM: To study the association of elevated maternal BMI with DDI and the failure of regional anesthesia. METHODS: Eight hundred and forty-two consecutive emergency CSs during a period of 1 year in a tertiary hospital were studied retrospectively. DDIs were analyzed in Crash and < 30-min urgency categories (n = 528), while the time required to establish regional anesthesia and its success were analyzed for all emergency CS cases. RESULTS: The urgency distribution of the CSs was 11%, 52%, and 37% in Crash, < 30-min, and > 30-min urgency categories respectively. Increased BMI was associated with longer DDI time in the < 30-min urgency category (33(13-176) vs. 38(18-118) min; P < 0.05 for BMI < 30 and > 35 group respectively). Regional anesthesia failures (new regional anesthesia, conversion to general anesthesia, or complaint of pain during surgery) took place in 3.7%, 6.8%, and 8.5% in the BMI < 30, 30-35, and > 35 groups respectively (P = 0.021). Epidural top-up resulted in shorter DDI and time delay between arrival at the operating room and skin incision across all urgency and BMI groups than combined spinal epidural (CSE) anesthesia. CONCLUSION: Higher BMI was associated with longer DDI and more regional anesthesia failures. Epidural top-up was faster than CSE for establishing CS anesthesia.

The secretion of PAPP-A, ADAM12, and PP13 correlates with the size of the placenta for the first month of pregnancy.

OBJECTIVES: Pregnancy Associated Protein A (PAPP-A), A Disintegrin and Metalloproteinase 12 (ADAM12) and Placental Protein 13 (PP13) are secreted from the placental trophoblastic tissue and are involved in normal implantation and placental development. The aim of the study was to assess the connection between the secretion of these proteins and the growth of the gestational sac and the placenta. STUDY DESIGN: In an observational longitudinal study at Oulu University Hospital, women with naturally conceived pregnancies were followed-up weekly to pregnancy week 11. MAIN OUTCOME MEASURES: PAPP-A, ADAM12 and PP13 serum concentrations and their correlation with the volumes of the gestational sac and the placenta were assessed using three-dimensional ultrasonography. RESULTS: The study group consisted of 41 women. The PAPP-A, ADAM12 and PP13 serum concentrations increased continuously from pregnancy week 4 to week 11 and correlated closely with each other. The serum concentrations of PAPP-A, ADAM12 and PP13 also correlated with the volumes of the gestational sac and the placenta up to pregnancy week 8. CONCLUSIONS: The secretion of PAPP-A, ADAM12 and PP13 is closely related to the size of the placenta in the beginning of pregnancy. After 8 weeks of pregnancy, which is the time for luteoplacental shift, the correlation disappears, possibly reflecting the morphologic transformation in the placenta.

Timing of intravenous patient-controlled remifentanil bolus during early labour.

BACKGROUND: Remifentanil labour analgesia is superior to nitrous oxide but less potent than epidural analgesia. The short onset and offset times of effect suggest that the timing of the bolus in the contraction cycle could have importance. We hypothesised that administering a remifentanil bolus during contraction pause would improve analgesia in early labour. METHODS: With permission from the ethical committee and the National Authority of Medicines, 50 parturients with uncomplicated singleton pregnancies and informed consent participated in a double blind cross-over study. Intravenous doses of 0.4 µg/kg remifentanil with 1-min infusion times were used during two study periods lasting six to eight contractions. Remifentanil and saline syringes were attached to two patient-controlled devices, one of which administered the bolus immediately after a trigger and the other targeted to start 140 s before the next contraction. The parturients assessed contraction pain, pain relief, sedation and nausea. Oxygen saturation (SaO(2)) pulse and blood pressure were recorded. SaO(2)<95% was the indication for oxygen supplement. RESULTS: Forty-one parturients were included in the analyses. Because of the period effect, pain and pain relief scores were analysed separately for each of the study periods. The mean pain and pain relief scores were similar during the two different dosing regimens. Side effects, the need for supplemental oxygen, SaO(2) and haemodynamics were similar. In a subgroup with long and regular contractions, however, delayed boluses were associated with lower pain scores. CONCLUSIONS: Administering a remifentanil bolus during the uterine contraction pause does not improve pain relief.

A comparison of intrapartum automated fetal electrocardiography and conventional cardiotocography--a randomised controlled study.

OBJECTIVE: To examine whether intrapartum monitoring by means of automatic ST analysis (STAN) of fetal electrocardiography could reduce the rate of neonatal acidemia and the rate of operative intervention during labour, compared with monitoring by means of cardiotocography (CTG). DESIGN: Randomised controlled trial. SETTING: Labour ward in tertiary-level university hospital. SAMPLE: A total of 1483 women in active labour with singleton term fetus in cephalic presentation. METHODS: Women were randomly assigned to be monitored either by STAN or by CTG. Fetal blood sampling (FBS) was optional in both groups. MAIN OUTCOME MEASURES: Neonatal acidemia (umbilical artery pH <7.10), neonatal metabolic acidosis (umbilical artery pH <7.05 and base excess <-12 mmol/l) and operative interventions: caesarean section rate, vacuum outlet (VO) rate and FBS rate. RESULTS: There were no statistically significant differences between the STAN group and CTG group in the incidence of neonatal acidemia (5.8 versus 4.7%) or metabolic acidosis (1.7 versus 0.7%). The caesarean section rate (6.4 versus 4.7%) and the VO rate (9.5 versus 10.7%) were also similar in the STAN and CTG groups. The incidence of FBS was lower (P < 0.001) in the STAN group (7.0%) than in the CTG group (15.6%). CONCLUSIONS: Intrapartum fetal monitoring by means of automatic STAN did not improve the neonatal outcome or decrease the caesarean section rate. However, the need for FBS during labour was lower in the STAN group.

Clinical impact of first and early second trimester fetal echocardiography on high risk pregnancies.

OBJECTIVE: To evaluate the clinical impact of fetal echocardiography before 16 weeks' gestation on the management of pregnancies with fetuses at risk of congenital heart disease. DESIGN AND SETTING: Observational study in a fetal medicine unit. PARTICIPANTS AND METHODS: 222 consecutive women with high risk pregnancies (230 fetuses) underwent transabdominal fetal echocardiography at a median gestation of 14(+1) weeks. For 10%, transvaginal scans were also performed. Criteria for normal scans were normal sequential segmental analysis, symmetrical four chamber view, normal semilunar valves, arterial outflow tracts, and ductal and aortic arches. Early scans were compared with mid-second trimester fetal echocardiography. Postmortem and postnatal data were added. Adverse pregnancy outcomes were diagnosis of a major cardiac or extracardiac abnormality, chromosomal defects, intrauterine death, or termination of pregnancy. RESULTS: There were 21 abnormal cardiac scans (9%): 14 major structural defects (eight isolated, six with chromosomal or extracardiac abnormalities) in pregnancies resulting in three live births, one intrauterine death, and 10 terminated pregnancies. Seven scans showed asymmetry between right and left sided structures (two isolated, five with chromosomal or extracardiac abnormalities); six of the seven pregnancies were terminated. The scans were normal in 199 cases (87%). Cardiac follow up of 184 of 199 babies (93%) confirmed situs and connections. One case each of pulmonary stenosis and ventricular septal defect requiring postnatal intervention were diagnosed at later scans. In 28 of 199 (14%) babies there was a non-cardiac adverse outcome. First examination was not diagnostic for 10 (4%). CONCLUSION: Early fetal echocardiography in high risk pregnancies was diagnostic in 96%. Abnormal cardiac scans (isolated in 48%, major structural defects in 67%) led to termination of pregnancy in 76%. Most cardiac scans were normal, allowing family reassurance. The high number of adverse outcomes with normal cardiac anatomy stresses the need for a multidisciplinary approach to early fetal echocardiography.

The effects of pre-emptive epidural sufentanil on human immune function.

BACKGROUND: Surgical stress and general anaesthesia suppress immune functions, including natural killer cell (NK) activity. This suppression could be attributed, at least in part, to the effect of opiates. METHODS: Twenty patients undergoing abdominal hysterectomy received epidural sufentanil (50 microg) either before (pre-emptive) or at the end (control group) of surgery. Post-operative pain relief was provided using sufentanil from a patient-controlled epidural analgesia (PCEA) system. Systemic immunity was assessed by determining leucocyte counts, NK cell counts and activity, lymphocyte response to mitogen stimulation, and secretion of pro-inflammatory cytokines. RESULTS: In the pre-emptive group there was a significant decrease in NK activity on the first and third post-operative day (P < 0.05) compared with baseline values and on the third postoperative day (P < 0.05) compared with the control group. The number of total leucocytes and neutrophiles increased in both groups post-operatively, but no differences were found in the levels of mononuclear lymphocyte populations or in their mitogen responses. Interleukin-6 (IL-6) concentration increased in both groups after the operation. In addition, at the end of the surgery the IL-6 level was greater in the control group than in the pre-emptive group. Interleukin-1 (IL-1) levels had decreased significantly at the end of surgery and 4 h later compared with baseline levels in the pre-emptive, but not in the control group. CONCLUSIONS: Pre-emptive epidural sufentanil during combined propofol and isoflurane anaesthesia had minor effects on the immune response after hysterectomy. The lower production of pro-inflammatory cytokines (IL-1, IL-6) in the pre-emptive group compared with the control group is beneficial, but its clinical importance remains to be determined.

Uteroplacental hemodynamics during early human pregnancy: a longitudinal study.

BACKGROUND: To determine normal physiologic changes in the uteroplacental hemodynamics during early placental development in the first trimester of pregnancy. METHODS: Sixteen normal singleton pregnancies were included in this longitudinal study. Transvaginal Doppler ultrasonographic examinations of uterine, arcuate, radial and spiral arteries were performed at the 5th, 7th, 8th and 10th completed gestational weeks. Peak systolic velocity (PSV), time-averaged maximum velocity (TAMXV) and the pulsatility index (PI) were measured. RESULTS: Uterine artery PSV, TAMXV and PI remained unchanged from the 5th to the 8th week of gestation. From the 8th to the 10th week, PSV (p = 0.02) and TAMXV (p = 0.005) increased and PI decreased (p = 0.006). Changes in the arcuate arteries were similar to those in uterine arteries. No significant changes in PSV, TAMXV or PI of the radial artery were noticed. Spiral artery PSV (p = 0.02) and TAMXV (p = 0.02) increased from the 5th to the 7th week. Thereafter they remained unchanged. Spiral artery PI decreased from the 5th to the 10th week, (p = 0.004). Throughout the study period, the PSV, TAMXV and PI values were significantly higher in the uterine artery than in the arcuate artery, and in the arcuate artery compared with the radial artery. At the 5th gestational week, no differences in PSV and TAMXV were found between radial and spiral arteries. From the 7th gestational week onwards, PSV and TAMXV were significantly lower in the radial artery than in the spiral artery. However, the PI values in the radial artery were significantly higher compared with those in the spiral artery during the whole study period. CONCLUSIONS: Spiral artery impedance decreases and blood flow velocities increase as early as between the 5th and the 7th weeks of gestation. During that period, the uterine and arcuate artery hemodynamics remain unchanged. In the uterine and arcuate arteries, decreases in impedance and increases in absolute velocities are detected after the 8th week of gestation. This delay between the changes in the spiral and uterine arteries may represent the magnitude of the increase of placental volume and spiral arterial involvement which is needed to affect uterine hemodynamics.

First trimester uterine, placental and yolk sac haemodynamics in pre-eclampsia and preterm labour.

BACKGROUND: We hypothesized that impaired trophoblast invasion leads to umbilicoplacental blood flow disturbances that could be detected by Doppler ultrasonography during the first trimester of the pregnancy. METHODS: After successful fresh IVF or ICSI programme, 41 of 47 enrolled subjects were followed up every 1-2 weeks between weeks 6 and 11 of gestation. Ten patients who later developed pre-eclampsia and/or preterm labour formed the study group and the control group consisted of 31 uncomplicated IVF/ICSI pregnancies. Doppler parameters of uterine, spiral, intraplacental, chorionic, umbilical and yolk sac haemodynamics were assessed. RESULTS: At the week 8, the study group demonstrated higher (P < 0.05) maternal intraplacental resistance indices (RI) than the control group. A week later, yolk sac artery RI and umbilical artery mean velocity (V(mean)) in the study group were lower (P < 0.05) compared to the control group. In late first trimester, increased (P < 0.01) velocities and RI were observed in chorionic arteries of the study group. During early pregnancy, no difference in uterine and spiral artery haemodynamics and in umbilical artery pulsatility index (PI) values was observed between the groups. CONCLUSIONS: Uterine and spiral artery RI and umbilical artery PI are unable to detect placental vascular disturbances during early pregnancy. Elevated intraplacental RI indicates increased maternal intraplacental impedance as early as week 8 of gestation. Decreased yolk sac artery RI and umbilical artery V(mean) in the study group at week 9 of gestation were speculated to indicate hampered transition of blood supply from yolk sac to umbilical circulation, underlining the emphasized role of yolk sac function for the maintenance of pregnancy.

Intraobserver and interobserver variability of ovarian volume, gray-scale and color flow indices obtained using transvaginal three-dimensional power Doppler ultrasonography.

OBJECTIVE: To assess intraobserver and interobserver variability in ovarian volume and gray-scale and color flow index measurements using transvaginal, three-dimensional, power Doppler ultrasonography. METHODS: Eleven women (22 ovaries) were examined on day 8 of controlled ovarian hyperstimulation therapy, which was part of their in vitro fertilization treatment protocol. The patients were examined twice by the first observer and once by the second observer. The acquired volume datasets were analyzed using the VOCAL imaging program, enabling the assessment of ovarian volume, vascularization index (VI), flow index (FI), vascularization flow index (VFI) and mean grayness (MG). For these parameters the intraclass (intra-CC) and interclass (inter-CC) correlation coefficients, within-observer and between-observers repeatability coefficient (r) and limits of agreement were calculated. RESULTS: Both intraobserver and interobserver repeatability of ovarian volume measurements were considered very good with an intra-CC value of 1.00 and inter-CC value of 0.99, respectively. Also VI, FI, VFI and MG measurements were repeatable by a single observer, the intra-CC ranging from 0.82 to 0.91. The interobserver reproducibility was also good for VI, VFI and MG measurements (inter-CC values 0.73, 0.70 and 0.81, respectively), but for FI measurements the reproducibility was poor (inter-CC = 0.29, r = 7.87). CONCLUSIONS: In general, the intraobserver reproducibility was better than interobserver reproducibility for all parameters. The volume assessments were reproducible both by one observer and by two separate observers. The intraobserver and interobserver variabilities were acceptable for VI, VFI and MG, whereas for FI the interobserver reproducibility was poor. Our results suggest that measurement of gray-scale and color Doppler flow indices is reproducible thus allowing them to be used in clinical practice and research.

Ultrasonographic features following thermal balloon endometrial ablation therapy.

The aim of this study was to evaluate the ultrasonographic changes taking place in the uterus after thermal balloon endometrial ablation therapy. The ultrasonographic findings in the uterus after thermal balloon endometrial ablation in 13 patients were compared to those found in 13 patients treated with gestagen therapy. Examinations took place before initiation of the treatment, on the 1st postoperative day (thermal balloon ablation group only), and 1 and 6 months later. One month after thermal balloon endometrial ablation therapy, the ultrasonographic examination revealed a clear-limited hyperechogenic zone surrounding the uterine cavity which was filled with fluid in 6 out of 10 patients. The ultrasonographic findings may represent a burn-injury-induced obstruction in the cervical canal with subsequent collection of fluid in the uterine cavity and a zone of coagulation in the submucosal layers. At the final examination in the thermal balloon group, the mean endometrial thickness was lower than the pretreatment level. No changes were observed in the gestagen therapy group.

Pre-emptive effect of epidural sufentanil in abdominal hysterectomy.

BACKGROUND: Experimental studies suggest pre-emptive administration of analgesics is effective but clinical evidence is less convincing. METHODS: Forty-one patients undergoing abdominal hysterectomy were allocated randomly in a double-blind fashion to receive sufentanil 50 micrograms via a lumbar epidural catheter before or at the end of surgery. RESULTS: Sufentanil consumption from a patient-controlled epidural analgesia (PCEA) system and numerical pain scores at rest and during movement over the initial 72 h were similar in the two groups. When the study period was divided into five time intervals, sufentanil consumption in the pre-emptive group was significantly less than in the control group between 8 and 16 h after surgery (P = 0.04). Furthermore, the number of failed bolus attempts from the PCEA device was significantly lower and patient satisfaction was significantly better in the pre-emptive group during the 72 h of PCEA treatment (P < 0.05). In addition, the median decrease in ACTH and cortisol on the first postoperative morning relative to baseline values was greater in the pre-emptive group than in the control group (P < 0.05). In subjects who had a Pfannenstiel incision, touch and pain sensitivity in the wound area were less in the pre-emptive group over the first 4 postoperative days (P < 0.05). CONCLUSIONS: We conclude that pre-emptive analgesia with epidural sufentanil was associated with a short-term sufentanil-sparing effect, and could have reduced stress hormone responses and wound sensitization after abdominal hysterectomy.

Intraobserver and interobserver variability of transabdominal Doppler velocimetry measurements of the fetal ductus venosus between 10 and 14 weeks of gestation.

OBJECTIVE: To assess the intraobserver repeatability and interobserver reproducibility of transabdominal Doppler ultrasound measurements of ductus venosus blood flow in fetuses between 10 and 14 weeks of gestation. DESIGN: A prospective study with the following end-points: coefficient of variation, intraclass correlation coefficients within and between observers, repeatability coefficient and Cohen's kappa coefficient. SUBJECTS AND METHODS: Doppler velocimetry indices (maximum peak systolic velocity during ventricular systole, end-diastolic velocity during atrial contraction, peak systolic velocity/end-diastolic velocity ratio and pulsatility index for veins) were successfully measured three times by the same trained observer in 67 fetuses. Of these, in 24 fetuses, the measurements were then repeated by a second trained observer. In addition, both observers classified qualitatively the blood flow as being normal or abnormal with regard to the presence or absence/reversal of flow during atrial contraction. RESULTS: The intraobserver repeatability of the pulsatility index for veins measurements was considered good with a coefficient of variation of 8.9% and an intraclass correlation coefficient value of 0.62. However, inconsistencies occurred in maximum peak systolic velocity, end-diastolic velocity and systolic/diastolic ratio measurements, which had coefficients of variation of 19%, 28.5%, and 25.4%, respectively. The corresponding intraclass correlation coefficient values were 0.70, 0.69 and 0.60. Interobserver reproducibility of these indices was unsatisfactory, the coefficient of variation varying between 11.5% and 47.2% and the intraclass correlation coefficient between 0.18 and 0.44. Agreement between the repeated observations with regard to interpretation of normal or abnormal blood flow varied from moderate (interobserver) to very good (intraobserver). CONCLUSIONS: There was considerable variability in all Doppler indices except for the intraobserver repeatability of the pulsatility index for veins measurement. This makes the implementation of the semiquantitative Doppler indices in a screening setting difficult. On the contrary, qualitative classification of the flow velocity waveforms seemed to be a reproducible method.

Limitations of using first-trimester nuchal translucency measurement in routine screening for major congenital heart defects.

OBJECTIVE: To evaluate the effectiveness of nuchal translucency (NT) measurement in screening for major congenital heart disease (CHD) in chromosomally normal fetuses. DESIGN: A population based cohort study of all women having fetal NT measurement at 10-14 weeks of gestation in an unselected population over a 3-year period. The outcome measure was the identification of major CHD in chromosomally normal pregnancies either antenatally or postnatally. RESULTS: Major defects of the heart and great arteries were identified in 26 out of 7339 pregnancies (prevalence 3.5 per 1000 pregnancies). Out of 26 cases, only four (sensitivity 15.4%, 95% CI 4-35) were in the group of 258 pregnancies (3.5%) with increased NT of > or = 2.5 mm. The prevalence of major CHD increased from 3.1 per 1000 for NT < 2.5 mm to 50 per 1000 for NT > or = 3.5 mm (likelihood ratio of 14.1, 95% CI 4.2-47.9). The positive and negative predictive values for NT > or = 2.5 mm were 1.6% and 99.7%, respectively. CONCLUSIONS: The prevalence of major CHD in this study was 3.5 per 1000, suggesting that ascertainment of CHD in our study population was thorough. Fetuses with NT measurements > or = 3.5 mm have a significantly increased risk of major CHD, and this identifies a subgroup of high-risk patients in whom early fetal echocardiography would be advocated. The low sensitivity of NT for major CHD in the general population, however, indicates that NT cannot be relied on as the sole or major screening tool for this condition as previously reported.

Congenital microvillous inclusion disease presenting as antenatal bowel obstruction.

Prenatal ultrasound has led to confidence in the antenatal diagnosis of intestinal obstruction allowing counseling and birth planning. We describe a male infant of a diabetic mother who had an antenatal diagnosis of distal bowel obstruction. This baby was subsequently found not to have bowel obstruction, but a congenital enteropathy - microvillous inclusion disease. The antenatal scans had demonstrated polyhydramnios as well as multiple fluid-filled dilated loops of bowel in the fetal abdomen. To our knowledge, similar prenatal ultrasound findings have not been previously described in this condition. The baby was delivered in a pediatric surgical center and postnatally there was no evidence of bowel obstruction either clinically or on abdominal X-ray. This baby initially fed well, but became collapsed and acidotic on his third day, having lost 26% of his birth weight due to excessive stool loss. The diagnosis of microvillous inclusion disease was made by electron microscopy of a small bowel biopsy. Congenital microvillous inclusion disease is a very rare inherited enteropathy with high mortality and morbidity. This condition, and other enteropathies, should be considered in cases in which antenatally diagnosed bowel obstruction is not confirmed after birth.

Thermal balloon endometrial ablation therapy induces a rise in uterine blood flow impedance: a randomized prospective color Doppler study.

OBJECTIVE: To evaluate the possible hemodynamic changes in uterine blood flow using transvaginal color Doppler ultrasonography after thermal balloon endometrial ablation therapy. STUDY DESIGN: Prospective randomized study. PATIENTS AND METHODS: Twenty-seven pre- and post-menopausal women with either menorrhagia or endometrial hyperplasia (no sign of atypia) were randomized to receive either thermal balloon ablation therapy (n = 13) or gestagen therapy (n = 14). In the gestagen therapy group, a 3-month period of medroxy-progesterone acetate (10 mg/day) was given to premenopausal women during cycle days 15-24 and it was given to postmenopausal women continuously. Thermal balloon endometrial ablation therapy was carried out on cycle days 3-8. All the color Doppler measurements were also carried out on cycle days 3-8. Flow waveforms were obtained from the main branch of the uterine arteries, from arcuate arteries and from a subendometrial spiral artery. Doppler flow parameters were used for subsequent statistical analysis. The measurements took place before the initiation of treatment, on the first postoperative day (thermal ablation group only), and 1 month and 6 months after initiation of the study. RESULTS: No within-group or between-group differences were detected until the time of the last measurement 6 months after initiation of the treatment. Between the two randomized groups, the pulsatility index (PI) was significantly higher in the thermal ablation group in all three arteries in comparison with the gestagen group, in which no change in the PI took place. In the thermal ablation group, a significant rise from the pretreatment level was observed in the PI in the uterine arteries and in the spiral artery 6 months after the therapy. CONCLUSION: Thermal balloon endometrial ablation therapy induces a rise in uterine blood flow impedance, but not until 6 months after the treatment. The rise in impedance may be due to fibrosis in the uterine cavity which thermal balloon therapy has been shown to produce.

Antenatal diagnosis of fetal intra-abdominal umbilical vein dilatation.

Dilatation of the intra-abdominal portion of the fetal umbilical vein is a rare abnormality. We describe here a new case diagnosed at 31 weeks of gestation and discuss the clinical features and management of this abnormality.

Effects of bleeding on uteroplacental, umbilicoplacental and yolk-sac hemodynamics in early pregnancy.

OBJECTIVE: To determine the influence of vaginal bleeding with or without a persisting subchorionic hematoma on uteroplacental, umbilicoplacental and yolk-sac hemodynamics in early pregnancy. DESIGN: Twenty-six consecutive patients with vaginal bleeding entered this longitudinal study 1-3 days after the beginning of vaginal bleeding and were re-examined every 1-2 weeks. In three cases vaginal bleeding occurred at the 5th completed gestational week, in 13 at the 7th week, in nine at the 8th week and in one case at the 10th week. A subchorionic hematoma was identified in one case at the 5th week, in nine cases at the 7th week, in nine cases at the 8th week, and in seven cases at the 10th week. Four pregnancies ended in miscarriage. Blood velocity waveforms of uterine, arcuate, radial, spiral, umbilical, chorionic and yolk-sac arteries were obtained by transvaginal pulsed Doppler ultrasound and peak systolic velocities, time-averaged maximum velocities and pulsatility indices were calculated. The results were compared with our earlier observations in normal pregnancy obtained with a similar study protocol. RESULTS: At the 7th week, radial artery pulsatility-index values (mean (SD)) were higher in pregnancies with vaginal bleeding (1.84 (0.59); P = 0.04) and in pregnancies with a subchorionic hematoma (1.96 (0.63); P = 0.03) than in normal pregnancies (1.40 (0.46)). The pulsatility-index values of uterine, arcuate, spiral, umbilical and chorionic arteries did not differ between the groups. Vaginal bleeding with or without a subchorionic hematoma at the 8th week did not affect any of the measured parameters. Persistence of the subchorionic hematoma until the 10th week did not affect uterine, arcuate, radial, spiral, umbilical or chorionic artery hemodynamics. Yolk-sac hemodynamic parameters did not differ between the groups. CONCLUSIONS: Vaginal bleeding with or without a subchorionic hematoma is associated with increased radial artery impedance at the 7th week of pregnancy. Persistence of the subchorionic hematoma does not affect utero- and umbilicoplacental circulation.