Successful digoxin therapy of fetal supraventricular tachycardia in a triplet pregnancy.

BACKGROUND: Fetal supraventricular tachycardia is a rare complication of pregnancy associated with cardiac failure, hydrops, and fetal death. If no underlying cardiac defects are present, medical management with digoxin has been successful. CASE: A young woman with a triplet pregnancy presented at 23 17 weeks' gestation for routine Doppler auscultation which suggested fetal supraventricular tachycardia, confirmed by M-mode echocardiography. She was treated with oral digoxin for the remainder of her pregnancy with subsequent conversion of the tachycardic triplet to normal sinus rhythm with occasional premature atrial beats. After delivery, the triplet previously demonstrating supraventricular tachycardia had a normal sinus rhythm. CONCLUSION: Digoxin might be used safely and successfully to treat fetal supraventricular tachycardia in multifetal pregnancies.

Validation of fetal telemedicine as a new obstetric imaging technique.

OBJECTIVE: Our purpose was to establish whether obstetric ultrasonography interpreted by a live video telemedicine link is comparable to interpretation by videotape review in a low-risk patient population. STUDY DESIGN: An Integrated Services Digital Network (ISDN 6) was established from three satellite offices to our central prenatal diagnostic center. Patients seen at these satellite offices had a complete fetal anatomic survey recorded onto videotape by a trained ultrasonographer. A live interactive video telemedicine link was then established to our center by the digital network, and a perinatologist directed the ultrasonographer through the anatomy survey. Subsequently a different perinatologist, blinded to the telemedicine interpretation, reviewed the videotaped examination. The reports from the videotaped and telemedicine scans were then compared on the basis of a score of 33 anatomic items. RESULTS: The first 200 patients seen at the satellite offices were included. Telemedicine and videotape interpretations provided similar scores in 84% of scans. In 17 of the 33 anatomic categories telemedicine provided significantly better scores than videotape, whereas in the remaining 16 anatomic categories the scores were equivalent. More videotape than telemedicine examinations required repeat ultrasonography because of suboptimal imaging (10% vs 3%, p = 0.003). CONCLUSIONS: The interpretation of obstetric ultrasonography with use of live video telemedicine is comparable to videotape review. Fetal telemedicine may prove to be a useful tool for providing ultrasonographic interpretation of fetal anatomy to a network of low-risk obstetric practices.

Oligohydramnios and the appropriately grown fetus.

The perinatal implications of oligohydramnios prior to 37 weeks of gestation, in the absence of intrauterine growth restriction (IUGR), rupture of membranes or fetal anomalies, are unknown. We compared the outcomes of 65 women with oligohydramnios (amniotic fluid index ([AFI] < or = 8 cm) by sonography to those of a control group matched by sonogram indication. Study patients were between 17 and 37 weeks of gestation, with appropriately grown fetuses on index sonogram and no other detected explanation for amniotic fluid abnormalities. Patients were managed expectantly with fetal testing and follow-up sonograms for fetal growth. Delivery was not recommended solely for oligohydramnios until 37 weeks of gestation. Patients with isolated oligohydramnios prior to 37 weeks of gestation, when compared to a control group with normal amniotic fluid volume, had a significantly higher incidence of premature delivery (odds ratio [OR] 3.23, 95% confidence interval [CI] 1.4-7.3) but did not appear to be at increased risk of IUGR, intrauterine death, or birth asphyxia.

Lumbar disk disease in pregnancy.

BACKGROUND: Lumbar disk herniation is rare in pregnancy. We report on three pregnant women with this disorder seen over 2 years. CASES: Three women were seen with progressive back pain, paresthesias, and urinary retention. In all three cases, magnetic resonance imaging confirmed the diagnosis. All failed conservative treatment and required surgery. All did well postoperatively, with improvement of symptoms and delivery at or near term. CONCLUSION: Lumbar disk herniation should be considered in pregnant women presenting with considerable back or leg pain. Magnetic resonance imaging is a useful diagnostic tool. Most patients can be treated conservatively, but those with incapacitating pain, progressive neurologic deficits, or bowel or bladder dysfunction may require surgical treatment.

Minimal hydronephrosis in the fetus: clinical significance and implications for management.

PURPOSE: We further define the natural history and management of minimal fetal hydronephrosis. MATERIALS AND METHODS: Experience with minimal fetal hydronephrosis (renal pelvic diameter 4 to 10 mm. before 20 weeks of gestation and 5 to 10 mm. from 20 to 24 weeks) was reviewed for 18 months at New England Medical Center. RESULTS: The incidence of minimal fetal hydronephrosis was 2.2% in the 5,900 fetuses screened by ultrasound. In 63% of cases prenatal ultrasound was done more than once, and revealed that dilatation of the urinary tract was stable during gestation in 31 (25%), and became normal in 35 (29%) and worse in 11 (9%). A total of 63 patients (103 renal units) followed for up to 1 year underwent postnatal sonography. Those with abnormalities were screened with a voiding cystourethrogram and renal scan, including 40 with normal postnatal ultrasound and no changes on subsequent evaluation. Of the 23 patients with abnormal findings 4 had functionally significant ureteropelvic junction obstruction and 1 had severe vesicoureteral reflux. A retrospective analysis of the sonograms of patients with minimal fetal hydronephrosis and persistence or progression of hydronephrosis revealed calicectasis, progression of minimal fetal hydronephrosis in utero and/or abnormal renal echogenicity in each fetus. CONCLUSIONS: Our study shows that in a small but significant number of fetuses minimal fetal hydronephrosis will progress, whereas in most it will resolve.

The vanishing fetal ureterocele: a cause for concern?

The natural history of fetal ureteroceles is poorly understood. We report two cases of fetal ureterocele which add to our understanding of its natural history. In both cases, the fetal ureterocele 'resolved' later in gestation. The postnatal findings emphasize the importance of an aggressive newborn evaluation despite apparent resolution of the ureterocele on prenatal ultrasound examination.

The role of percutaneous umbilical blood sampling in the management of immune thrombocytopenic purpura.

On consultation, percutaneous umbilical blood sampling (PUBS) was offered to women with immune thrombocytopenic purpura (ITP) to determine the mode and site of delivery prior to labour. Between January 1989 and December 1993, 41 pregnant women underwent PUBS. All women had a history of ITP, a platelet count less than 90 K, (+) antiplatelet antibody, and/or thrombocytopenia diagnosed early in pregnancy. PUBS was performed at term except in one patient with preterm labour, who underwent PUBS at 31 weeks' gestation. Patients with fetal platelet counts greater than 50 K returned to their referring physician for delivery. Records were complete in 39 pregnancies. Fetal blood was successfully obtained in 37 of 39 cases (95 per cent). Fetal platelet counts correlated with neonatal platelet counts in 36 of 37 cases (97 per cent). The interval between PUBS and delivery ranged from 0 to 31 days. Six of 37 fetuses (16 per cent) had significant fetal thrombocytopenia (< 50 K). These six patients underwent Caesarean section. Vaginal delivery was recommended in all others. There were two procedure-related complications. There were no cases of intraventricular haemorrhage in any of the neonates. In conclusion, there is a high incidence of fetal thrombocytopenia in women with ITP. PUBS reliably detects fetal thrombocytopenia and is therefore useful in the perinatal planning of the mode and site of delivery.

Diagnostic ultrasound in pregnancy: an overview.

The safety of ultrasonography in pregnancy is well documented. In screening populations, with the exception of the RADIUS trial, ultrasound examination can diagnose in approximately 50% of major anomalies. The accuracy of anomaly detection improves with increasing operator experience and advances in equipment resolution of the fetal image. The effect of routine sonography on perinatal outcome in low-risk pregnancies has not been established. Therefore, the role of ultrasound in routine screening remains controversial. However, in high-risk populations the accuracy of ultrasound in diagnosing congenital anomalies is well over 90%. The prenatal detection of abnormalities often influences obstetrical management and optimizes care of the fetus and newborn. The ability of ultrasound examination to determine gestational age, detect multiple gestations, and assess fetal well-being by diagnosing growth and fluid abnormalities has changed the practice of obstetrics more than any other technology in recent years.

Fetal ultrasonography.

Since its introduction in the 1950s, ultrasonography in pregnancy has been helpful in determining gestational age, detecting multiple pregnancies, locating placentas, diagnosing fetal anomalies, evaluating fetal well-being, and guiding obstetricians with in utero treatment. We review current standards and controversies regarding the indications, safety, accuracy, and limitations of ultrasonography in pregnancy.