Impact of fetal growth restriction on pregnancy outcome in women undergoing expectant management for preterm pre-eclampsia.

OBJECTIVES: To assess whether coexisting fetal growth restriction (FGR) influences pregnancy latency among women with preterm pre-eclampsia undergoing expectant management. Secondary outcomes assessed were indication for delivery, mode of delivery and rate of serious adverse maternal and perinatal outcomes. METHODS: We conducted a secondary analysis of the Pre-eclampsia Intervention (PIE) and the Pre-eclampsia Intervention 2 (PI2) trial data. These randomized controlled trials evaluated whether esomeprazole and metformin could prolong gestation of women diagnosed with pre-eclampsia between 26 and 32 weeks of gestation undergoing expectant management. Delivery indications were deteriorating maternal or fetal status, or reaching 34 weeks' gestation. FGR (defined by Delphi consensus) at the time of pre-eclampsia diagnosis was examined as a predictor of outcome. Only placebo data from PI2 were included, as the trial showed that metformin use was associated with prolonged gestation. All outcome data were collected prospectively from diagnosis of pre-eclampsia to 6 weeks after the expected due date. RESULTS: Of the 202 women included, 92 (45.5%) had FGR at the time of pre-eclampsia diagnosis. Median pregnancy latency was 6.8 days in the FGR group and 15.3 days in the control group (difference 8.5 days; adjusted 0.49-fold change (95% CI, 0.33-0.74); P < 0.001). FGR pregnancies were less likely to reach 34 weeks' gestation (12.0% vs 30.9%; adjusted relative risk (aRR), 0.44 (95% CI, 0.23-0.83)) and more likely to be delivered for suspected fetal compromise (64.1% vs 36.4%; aRR, 1.84 (95% CI, 1.36-2.47)). More women with FGR underwent a prelabor emergency Cesarean section (66.3% vs 43.6%; aRR, 1.56 (95% CI, 1.20-2.03)) and were less likely to have a successful induction of labor (4.3% vs 14.5%; aRR, 0.32 (95% CI, 0.10-1.00)), compared to those without FGR. The rate of maternal complications did not differ significantly between the two groups. FGR was associated with a higher rate of infant death (14.1% vs 4.5%; aRR, 3.26 (95% CI, 1.08-9.81)) and need for intubation and mechanical ventilation (15.2% vs 5.5%; aRR, 2.97 (95% CI, 1.11-7.90)). CONCLUSION: FGR is commonly present in women with early preterm pre-eclampsia and outcome is poorer. FGR is associated with shorter pregnancy latency, more emergency Cesarean deliveries, fewer successful inductions and increased rates of neonatal morbidity and mortality. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Trisomy 21 screening with αlpha software and the Fetal Medicine Foundation algorithm.

BACKGROUND: Screening for trisomy 21 provides pregnant women with accurate risk information. Different algorithms are used to screen for trisomy 21 in South Africa (SA). The Fetal Medicine Foundation (FMF) provides software to screen for trisomy 21 in the first trimester by ultrasound or a combination of ultrasound and biochemistry (combined screening), and requires regular and stringent quality control. With αlpha software, first trimester combined screening and screening with biochemistry alone in the first or second trimester are possible. The αlpha screening requires quality control of biochemical tests, but not of ultrasound measurements. Ideally, a screening test should have a high detection and a low screen positive rate. Despite the availability of these screening programmes, only a minority of infants with trisomy 21 are detected prenatally, raising questions about the effectiveness of screening. OBJECTIVES: To determine the screen positive and detection rates of prenatal screening for trisomy 21 in the SA private healthcare system. METHODS: Data from the three largest laboratories collected between 2010 and 2015 were linked with genetic tests to assess screen positive and detection rates. Biochemical screening alone with αlpha software (first or second trimester) and combined screening using either FMF or αlpha software were compared. RESULTS: One-third of an estimated 675 000 pregnancies in private practice in the 6-year study period underwent screening. There were 687 cases of trisomy 21 in 225 021 pregnancies, with only 239 (35%) diagnosed prenatally. The screen positive rates were 11.8% for first trimester biochemistry, 7.6% for second trimester biochemistry, 7.3% for first trimester FMF software ultrasound alone, 3.7% for combined first trimester screening with FMF software, and 3.5% for combined first trimester screening with αlpha software. The detection rates for a 5% false positive rate were 63% for first trimester biochemistry, 69% for second trimester biochemistry, 95% for combined first trimester screening with FMF software and 80% for combined first trimester screening with αlpha software. Detection and confirmation rates were highest with FMF software. CONCLUSION: Screening with FMF software has a similar screen positive rate and better detection rate than screening with αlpha software. The low prenatal detection rate of trisomy 21 is mainly due to a low prevalence of screening. More research is needed in the SA setting to explore why screening and confirmatory testing after high-risk results are not performed in many pregnancies.

Neural tube defect diagnosis and outcomes at a tertiary South African hospital with intensive case ascertainment.

BACKGROUND: Neural tube defects (NTDs) are an important category of birth defect, but surveillance remains inadequate in South Africa. OBJECTIVES: To assess the identification of NTDs at a tertiary hospital using a range of prenatal, perinatal and postnatal data sources, and to estimate the impact of prenatal diagnosis and birth prevalence for the referral area. METHODS: Cases of anencephaly, encephalocele and spina bifida (SB) in a 6-year period were retrospectively identified from 5 data sources covering prenatal, perinatal and postnatal care. These were cross-correlated to avoid duplicate entries and to determine the contribution of different data sources. Details of prenatal diagnosis and termination of pregnancy (TOP) were obtained for 10 years, and birth prevalence over 2 years. RESULTS: During a 6-year period 195 NTDs were identified at a Western Cape Province tertiary hospital. These included 59 (30%) cases of anencephaly, 28 (14%) of encephalocele and 108 (55%) of SB. The majority of NTDs (71%) were detected prenatally, although SB was less commonly diagnosed prenatally than cranial defects (56% v. 88%; p<0.001). Of SB cases ascertained pre- or postnatally, 57% of patients were born alive and 50% discharged alive, but 72% of survivors had not been diagnosed prenatally. Women receiving prenatal diagnosis of any type of NTD before 24 weeks' gestation were nearly always offered TOP, and the majority accepted termination after non-directive counselling. For SB, later prenatal diagnosis was associated with much lower termination rates because the option was less often offered (51% v. 100%; p<0.001), and perhaps less often accepted (57% v. 78%; p=0.06). The estimated NTD birth prevalence for the referral area was 0.76 - 0.80 per 1 000 live births, but perhaps up to 1.18 per 1 000 when considering under-referral of lethal cranial lesions from rural areas. CONCLUSIONS: A substantial number of NTDs can be ascertained from a tertiary hospital environment if multiple data sources are used, even though adding data from the Perinatal Problem Identification Program for outlying health facilities increases detection of lethal defects. Hospital-based surveillance can be considered, especially for SB. Prenatal diagnosis was fairly common and pregnancy termination was often offered and accepted if detected before 24 weeks' gestation. A regional prenatal ultrasound programme, predominantly based in primary care but with ready access to a tertiary centre, can be quite effective, although limited or delayed access to prenatal diagnosis must be addressed.

Neural tube defect diagnosis and outcomes at a tertiary South African hospital with intensive case ascertainment

Background. Neural tube defects (NTDs) are an important category of birth defect, but surveillance remains inadequate in South Africa.Objectives. To assess the identification of NTDs at a tertiary hospital using a range of prenatal, perinatal and postnatal data sources, and to estimate the impact of prenatal diagnosis and birth prevalence for the referral area.Methods. Cases of anencephaly, encephalocele and spina bifida (SB) in a 6-year period were retrospectively identified from 5 data sources covering prenatal, perinatal and postnatal care. These were cross-correlated to avoid duplicate entries and to determine the contribution of different data sources. Details of prenatal diagnosis and termination of pregnancy (TOP) were obtained for 10 years, and birth prevalence over 2 years.Results. During a 6-year period 195 NTDs were identified at a Western Cape Province tertiary hospital. These included 59 (30%) cases of anencephaly, 28 (14%) of encephalocele and 108 (55%) of SB. The majority of NTDs (71%) were detected prenatally, although SB was less commonly diagnosed prenatally than cranial defects (56% v. 88%; p<0.001). Of SB cases ascertained pre- or postnatally, 57% of patients were born alive and 50% discharged alive, but 72% of survivors had not been diagnosed prenatally. Women receiving prenatal diagnosis of any type of NTD before 24 weeks' gestation were nearly always offered TOP, and the majority accepted termination after non-directive counselling. For SB, later prenatal diagnosis was associated with much lower termination rates because the option was less often offered (51% v. 100%; p<0.001), and perhaps less often accepted (57% v. 78%; p=0.06). The estimated NTD birth prevalence for the referral area was 0.76 - 0.80 per 1 000 live births, but perhaps up to 1.18 per 1 000 when considering under-referral of lethal cranial lesions from rural areas.Conclusions. A substantial number of NTDs can be ascertained from a tertiary hospital environment if multiple data sources are used, even though adding data from the Perinatal Problem Identification Program for outlying health facilities increases detection of lethal defects. Hospital-based surveillance can be considered, especially for SB. Prenatal diagnosis was fairly common and pregnancy termination was often offered and accepted if detected before 24 weeks' gestation. A regional prenatal ultrasound programme, predominantly based in primary care but with ready access to a tertiary centre, can be quite effective, although limited or delayed access to prenatal diagnosis must be addressed

Effects of alcohol, cigarettes, methamphetamine and marijuana exposure during pregnancy on maternal serum alpha-fetoprotein levels at 20-24 weeks'gestation.

OBJECTIVE: To examine the effects of cigarette, marihuana and methamphetamine smoking and consumption of alcohol during pregnancy on maternal serum alpha-fetoprotein (MSAFP) levels at 20-24 weeks. STUDY DESIGN: In the Safe Passage Study (SPS) more than 12,000 pregnant women were prospectively followed up during pregnancy and until the infant was one year old to examine the effects of exposure to alcohol during pregnancy on stillbirth and sudden infant death syndrome. The present study is a cross-sectional secondary analysis of MSAFP analyses done at 20-24 weeks gestation in 1,679 SPS participants, recruited at the Bishop Lavis Community Health Centre, Cape Town, South Arica. RESULTS: Low or moderate alcohol consumption with or without smoking, nor methamphetamine or marihuana use affected mean MSAFP levels. High MSAFP levels were associated with high alcohol consumption, young age, low body mass index (BMI) (<18 kg/m2) or small mid upper arm circumference (MUAC) (<230mm). High MSAFP levels were associated with stillbirth, preterm birth, abruption and a birth weight z-score of less than -1. CONCLUSION: The study confirms the association between high MSAFP levels and adverse pregnancy outcomes but, although exposure to smoking or drinking is associated with adverse pregnancy outcomes including stillbirth, MSAFP levels were not affected by any of these exposures except for continued high consumption of alcohol. The observed association between higher MSAFP levels and maternal nutritional status (as demonstrated by the lower MUAC and BMI) could explain some of the correlations of poor socioeconomic conditions with higher stillbirth rates effect.

CON4EI: Evaluation of QSAR models for hazard identification and labelling of eye irritating chemicals.

Assessment of ocular irritation is a regulatory requirement in safety evaluation of industrial and consumer products. Although a number of in vitro ocular irritation assays exist, none are capable of fully categorizing chemicals as stand-alone assays. Therefore, the CEFIC-LRI-AIMT6-VITO CON4EI (CONsortium for in vitro Eye Irritation testing strategy) project was developed to assess the reliability of eight in vitro test methods and computational models as well as establishing an optimal tiered-testing strategy. For three computational models (Toxtree, and Case Ultra EYE_DRAIZE and EYE_IRR) performance parameters were calculated. Coverage ranged from 15 to 58%. Coverage was 2 to 3.4 times higher for liquids than for solids. The lowest number of false positives (5%) was reached with EYE_IRR; this model however also gave a high number of false negatives (46%). The lowest number of false negatives (25%) was seen with Toxtree; for liquids Toxtree predicted the lowest number of false negatives (11%), for solids EYE_DRAIZE did (17%). It can be concluded that the training sets should be enlarged with high quality data. The tested models are not yet sufficiently powerful for stand-alone evaluations, but that they can surely become of value in an integrated weight-of-evidence approach in hazard assessment.

Decreased endothelial function and increased subclinical heart failure in women several years after pre-eclampsia.

OBJECTIVES: Pre-eclampsia (PE) is associated with both postpartum endothelial dysfunction and asymptomatic structural heart alterations consistent with heart failure Stage B (HF-B). In this study, we assessed the relationship between endothelial function, measured by flow-mediated dilation (FMD), and HF-B in women with a history of PE. METHODS: This was an observational study in which 67 formerly pre-eclamptic women (≥ 4 years postpartum) and 37 healthy parous controls were assessed ultrasonographically for cardiac function and geometry, as well as for endothelial function by means of brachial artery FMD. HF-B was diagnosed as left ventricular hypertrophy (left ventricular mass index (LVMi) > 95 g/m2 ), concentric remodeling (relative wall thickness > 0.42 and LVMi ≤ 95 g/m2 ), mild systolic dysfunction (left ventricular ejection fraction > 40% and < 55%) or asymptomatic valvular disease. Cardiovascular and metabolic syndrome variables were compared between women with history of PE and controls, as well as between those in the formerly pre-eclamptic group who had HF Stage A, HF-B or no HF. Logistic regression analysis was performed to assess the associations of FMD with PE, metabolic syndrome risk factors and obstetric parameters. RESULTS: The prevalence of HF-B amongst formerly pre-eclamptic women was three-fold higher than that observed for controls (25% vs 8%, P < 0.05), while FMD was lower in formerly pre-eclamptic women compared with controls (6.12% vs 8.22%, P < 0.01); history of PE remained associated independently with lower FMD after adjusting for metabolic syndrome risk factors and obstetric parameters (ß, -1.88; 95% CI, -3.59 to -0.18). However, HF-B did not relate to low FMD in formerly pre-eclamptic women. CONCLUSIONS: Years after pregnancy, formerly pre- eclamptic women have lower FMD and have HF-B more often compared with healthy parous controls. Nonetheless, HF-B was not related to reduced FMD. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Cardiac remodeling in normotensive pregnancy and in pregnancy complicated by hypertension: systematic review and meta-analysis.

OBJECTIVE: The aim of this systematic review and meta-analysis was to describe comprehensively the pattern of cardiac remodeling during normotensive human singleton pregnancy and to compare it with that of pregnancy complicated by hypertension. METHODS: We performed a meta-analysis of the current literature on cardiac remodeling during normotensive and complicated pregnancies. Literature was retrieved from PubMed (NCBI) and EMBASE (Ovid) databases. Included studies needed to report a reference measurement (matched non-pregnant control group, prepregnancy or postpartum) and measurements made during predetermined gestational-age intervals. Mean differences between reference and pregnancy data were calculated using the random-effects model described by DerSimonian and Laird. RESULTS: Forty-eight studies were included in the meta-analysis, with publication dates ranging from 1977 to 2016. During normotensive pregnancy, most geometric indices started to increase in the second trimester. Left ventricular mass (LVM) increased by 28.36 (95% CI, 19.73-37.00) g (24%), and relative wall thickness (RWT) increased by 0.03 (95% CI, 0.02-0.05) (10%) compared with those in the reference group. During hypertensive pregnancy, LVM and RWT increased more than during normotensive pregnancy (92 (95% CI, 75.46-108.54) g (95%) and 0.14 (95% CI, 0.09-0.19) (56%), respectively). CONCLUSIONS: During normotensive pregnancy, most cardiac geometric indices change from the second trimester onwards. Both LVM and RWT increase, by 20% and 10%, respectively, consistent with concentric rather than eccentric remodeling. Cardiac adaptation in hypertensive pregnancy deviates from that in healthy pregnancy by a greater change in LVM (95% increase from reference) and RWT (56% increase from reference). Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Psychosocial predictors of fetoplacental blood flow during pregnancy.

BACKGROUND: Although a number of studies have found significant associations between maternal psychological distress, anxiety and changes in fetoplacental blood flow, findings remain inconsistent. A recent pilot study by our group highlighted some of these inconsistencies. In the current study, we expanded this pilot analysis to include psychological distress, anxiety and a range of antenatal variables, with the aim of identifying predictors of fetoplacental blood flow. METHODS: Healthy pregnant women (n=148) underwent Doppler flow studies on uterine, umbilical and fetal arteries; as well as assessments of distress, anxiety and other antenatal variables (e.g. perceived social support, resilience, nicotine and alcohol use) in each trimester. RESULTS: Stepwise regression analyses found that state anxiety was associated with lower mid-cerebral artery pulsatility index at trimester 3. LIMITATIONS: Subjects were recruited from selected midwife obstetric units in the same health district, so the generalizability of our results may be limited. While most subjects received Doppler assessment at trimesters 2 and 3, only approximately half of our sample was assessed at trimester 1. CONCLUSION: The finding that anxiety is associated with increased blood flow to the fetal brain during trimester 3 of pregnancy, coincide with previous work. The findings emphasize a growing appreciation of the potential importance of psychological well-being during pregnancy for infant development. However, as associations were small and variable, further research using multivariate models to determine the precise mechanisms underlying these associations would be warranted.

Congenital rubella with agenesis of the inferior cerebellar vermis and total anomalous pulmonary venous drainage.

Congenital rubella infection has been associated with a number of abnormalities including cardiac, central nervous system and placental complications. We present a case with multiple fetal abnormalities detected on prenatal ultrasound, and confirmed postnatally, that included a single umbilical artery, severe tricuspid regurgitation, micrognathia and agenesis of the inferior cerebellar vermis. Postnatal echocardiography additionally revealed unobstructed total anomalous pulmonary venous drainage (TAPVD) into the coronary sinus. Placental examination showed signs of placentitis, and polymerase chain reaction on neonatal serum was positive for rubella. Following a multidisciplinary team review, it was decided to provide only supportive care, and the infant died at 6 months of age owing to a respiratory tract infection. To our knowledge, TAPVD and agenesis of the inferior cerebellar vermis have not been reported previously in association with congenital rubella infection. This case illustrates how congenital infection may present in atypical ways and stresses the importance of considering congenital infection in the differential diagnosis of fetal anomalies when multiple features are present.

Analysis of phthalates in food products and packaging materials sold on the Belgian market.

Phthalates are organic lipophilic compounds that are principally used as plasticiser to increase the flexibility of plastic polymers. Other applications are a.o. the use of phthalates in printing inks and lacquers. Human exposure to phthalates mainly occurs via food ingestion and can induce adverse health effects. In this study, the presence of eight phthalate compounds--dimethyl phthalate (DMP), diethyl phthalate (DEP), diisobutyl phthalate (DiBP), di-n-butyl phthalate (DnBP), benzylbutyl phthalate (BBP), di(2-ethylhexyl) phthalate (DEHP), dicyclohexyl phthalate (DCHP) and di-n-octyl phthalate (DnOP)--was investigated in 400 food products, divided over eleven groups, and packages sold on the Belgian market. For this purpose, suitable extraction techniques were developed and validated for four different matrices, namely high-fat foods, low-fat food products, aqueous-based beverages and packaging materials. The instrumental analysis was performed by means of gas chromatography-low resolution-mass spectrometry with electron impact ionisation (GC-EI-MS). A wide variety of phthalate concentrations was observed in the different groups. DEHP was found in the highest concentration in almost every group. Moreover, DEHP was the most abundant phthalate compound, followed by DiBP, DnBP and BBP. This survey is part of the PHTAL project, which is the first project that discusses phthalate contamination on the Belgian food market.

Feasibility of non-contrast-enhanced magnetic resonance angiography for imaging upper extremity vasculature prior to vascular access creation.

OBJECTIVES: Preoperative mapping of arterial and venous anatomy helps to prevent postoperative complications after vascular access creation. The use of gadolinium in contrast-enhanced (CE) magnetic resonance angiography (MRA) has been linked to nephrogenic systemic fibrosis in patients with end-stage renal disease (ESRD). The purpose of this study was to evaluate non-contrast-enhanced (NCE) MRA for assessment of upper extremity and central vasculature and to compare it with CE-MRA. METHODS: NCE and CE-MRA images were acquired in 10 healthy volunteers and 15 patients with ESRD. In each data set, two observers analysed 11 arterial and 16 venous segments with regard to image quality (0-4), presence of artefacts (0-2) and vessel-to-background ratio. RESULTS: More arterial segments were depicted using CE-MRA compared to NCE-MRA (99% vs. 96%, p = 0.001) with mean image quality of 3.80 vs. 2.68, (p < 0.001) and mean vessel-to-background ratio of 6.47 vs. 4.14 (p < 0.001). Ninety-one percent of the venous segments were portrayed using NCE-MRA vs. 80% using CE-MRA (p < 0.001). Mean image quality and vessel-to-background ratio were 2.41 vs. 2.21 (p = 0.140) and 5.13 vs. 3.88 (p < 0.001), respectively. CONCLUSIONS: Although arterial image quality and vessel-to-background ratios were lower, NCE-MRA is considered a feasible alternative to CE-MRA in patients with ESRD who need imaging of the upper extremity and central vasculature prior to dialysis access creation.

Effectiveness of prenatal screening for Down syndrome on the basis of maternal age in Cape Town.

OBJECTIVE: The prenatal screening programme for Down syndrome (DS) in the South African public health sector remains primarily based on advanced maternal age (AMA). We assessed the changes over time and effectiveness of this screening programme within a Cape Town health district. METHODS: Retrospective analysis of the Groote Schuur Hospital Cytogenetic Laboratory and Pregnancy Counselling Clinic databases and audit of maternal delivery records at a primary health care facility. RESULTS: The number of amniocenteses performed for AMA in consecutive 5-year periods reduced progressively from 786 in 1981 - 1985 to 360 in 2001 - 2005. Comparing prenatal with neonatal diagnoses of DS, the absolute number and the proportion diagnosed prenatally have remained relatively constant over time. The Pregnancy Counselling Database showed that, of 507 women receiving genetic counselling for AMA in 2008 - 2009, 158 (3.1.1%) accepted amniocentesis--uptake has reduced considerably since the early 1990s. The audit of women delivering at a primary care facility found that only 10 (16.4%) of 61 AMA women reached genetic counselling in tertiary care: reasons included late initiation of antenatal care and low referral rates from primary care. CONCLUSION: Prenatal screening and diagnosis for DS based on AMA is working ineffectively in the Cape Town health district assessed, and this appears to be representative of a broader trend in South Africa. Inclusion of fetal ultrasound in the process of prenatal screening for DS should be explored as a way forward.

Severe early onset pre-eclampsia: prognostic value of ultrasound and Doppler assessment.

OBJECTIVE: Assess the prognostic value of ultrasound and Doppler parameters in severe preterm pre-eclampsia. STUDY DESIGN: Prospective cohort study in Cape Town, South Africa, involving 113 women with severe pre-eclampsia between 24 and 34 weeks of gestation and managed expectantly when suitable. Serial ultrasound and multivessel Doppler assessments were performed 2 to 3 times weekly. Observations included fetal weight estimation, growth pattern, amniotic fluid volume, appearance of the heart and bowel, pulsatility index of the uterine, umbilical and middle cerebral arteries and ductus venosus. Perinatal outcome (death or neurological compromise, n=12) and major morbidity (n=62) were related to findings at recruitment and on the last assessment preceding delivery. RESULTS: In univariate analysis, fetal growth asymmetry and waveform analysis of all three fetal vessels significantly correlated with both end points. The initial fetal weight estimation with a cutoff weight of 1080 g had the highest sensitivity (83.3%) and negative predictive value (97.5%) for poor outcome (P<0.001) while the final ductus venosus pulsatility index had the highest specificity (92%) and positive predictive value (33%). The combination of a raised placentocerebral ratio and ductus venosus pulsatility index close to delivery had the highest (57.1%) positive predictive value. Logistic regression showed the best overall predictive model for poor outcome to be a combination of initial fetal weight estimation and final ductus venosus pulsatility index (overall accuracy 94.6%, RR 20.20 (7.36, 55.41)). The initial fetal weight estimation with a cutoff weight of 1283 g provided the best correct prediction of major morbidity (83.2% overall accuracy, sensitivity 79.0%, specificity 88.2%, positive and negative predictive values of 89.1 and 77.6% respectively). This was better than using the gestational age at recruitment or delivery, birth weight or any of the Doppler results. The prediction of morbidity was not improved by the addition of any other variable in logistic regression analysis. CONCLUSION: For the short-term outcome measures assessed in this study, the estimated fetal weight at the time of diagnosis is the most important prognostic factor in severe pre-eclampsia with some additional value of ductus venosus assessment.

A case of hydatid cyst associated with postpartum maternal death.

A young, apparently healthy woman from a rural area in South Africa presented in the third trimester of pregnancy with a symptomatic abdominal mass between the uterine fundus and liver. The etiology was established to be an echinococcus cyst of the liver and medical treatment was initiated. The fetal outcome was good but the mother died 3 days postpartum due to an unusual but devastating complication of the hydatid cyst.

Sonographic measurement of cervical length and fetal fibronectin testing in threatened preterm labor.

OBJECTIVE: In women presenting with threatened preterm labor, both fetal fibronectin and sonographic measurement of cervical length have been shown to distinguish between true and false labor. The aim of this study was to determine whether the combination of both tests provides a better prediction than the individual tests alone. METHODS: We examined 195 women with singleton pregnancies presenting at 24-36 (median 31) weeks of gestation with regular and painful uterine contractions, intact membranes and cervical dilatation of less than 3 cm. On admission to the hospital fetal fibronectin positivity in cervicovaginal secretions was determined and transvaginal sonographic measurement of cervical length was carried out. The results were not made available to the attending obstetrician. The primary outcome measure was delivery within 7 days of presentation. RESULTS: Delivery within 7 days occurred in 51.4% (18 of 35) of those with cervical length below 15 mm and 0.6% (1 of 160) of those with cervical length of 15 mm or more, in 21.2% (18 of 85) of the fibronectin positive group and in 0.9% (1 of 110) of the fibronectin negative group. There was a significant association between cervical length and the incidence of fibronectin positivity (r = -0.921, P = 0.003). Logistic regression analysis demonstrated that the only significant contributor to the prediction of delivery within 7 days was cervical length, with no significant contribution from fibronectin positivity, ethnic origin, maternal age, gestational age, body mass index, parity, previous history of preterm delivery, cigarette smoking, or use of tocolytics. CONCLUSIONS: In women with threatened preterm labor assessment of fetal fibronectin in cervicovaginal secretions does not improve the prediction of delivery within 7 days provided by the sonographic measurement of cervical length.

Effects of psychologic stress on fetal development and pregnancy outcome.

Data from animal studies show that maternal stress is associated with disturbances in pregnancy outcomes and offspring development and behavior, possibly as a result of permanent structural and functional changes termed "early-life programming." There is growing interest in whether similar relationships are present in humans. Here we review recent significant findings from the literature on the impact of prenatal psychologic stressors on pregnancy outcome and offspring development, with a particular focus on the developing brain. Relevant papers were searched using PubMed, and reference lists from obtained articles were checked. In humans, prenatal stress is associated with pregnancy complications, developmental, cognitive, and behavioral disorders, and possible onset of psychopathology in later life. In contrast to the available research done in animals, virtually nothing is known about the effects of prenatal stress on morphologic fetal brain development, and the mechanisms underlying subsequent associated behavioral changes.

Sonographic measurement of cervical length in threatened preterm labor in singleton pregnancies with intact membranes.

OBJECTIVES: To predict when delivery will occur, within 48 h and 7 days of presentation and before 35 weeks' gestation in women presenting with threatened preterm labor. METHODS: Sonographic measurement of cervical length was carried out in 510 women with singleton pregnancies presenting with threatened preterm labor and intact membranes at 24 to 33 + 6 weeks of gestation. The measurement was not taken into account in the subsequent management of the pregnancies. The outcome measures were delivery within 48 h and 7 days of presentation and delivery before 35 weeks. RESULTS: The median gestation at presentation was 30 + 1 (range, 24 to 33 + 6) weeks and the median cervical length was 25 (range, 1-51) mm. Delivery within 48 h of presentation occurred in 21 (4.1%) cases, delivery within 7 days occurred in 43 (8.4%) and delivery before 35 weeks occurred in 76 (14.9%). Logistic regression analysis demonstrated that the only significant independent predictor of delivery within 48 h was cervical length (odds ratio (OR), 0.73; 95% CI, 0.65-0.81) and for delivery within 7 days the independent predictors were cervical length (OR, 0.69; 95% CI, 0.63-0.76) and vaginal bleeding (OR, 19.42; 95% CI, 3.87-97.4). In the subgroup of women who did not deliver within 7 days of presentation, the incidence of delivery before 35 weeks was 7.1% (33 of 467) and the only significant independent predictor of such delivery was cervical length (OR, 0.92; 95% CI, 0.88-0.96, P < 0.0001). There was no significant independent contribution to any of the outcome measures from ethnic group, maternal age, gestational age, body mass index, parity, cigarette smoking or use of tocolytics. CONCLUSIONS: In women with threatened preterm labor sonographic measurement of cervical length helps to distinguish between true and false labor and to predict early preterm delivery.

Vitrectomy for epiretinal membranes: visual outcome and prognostic criteria.

The treatment of choice for epiretinal membranes (ERM) causing marked retinal distortion and substantial visual impairment remains vitreoretinal surgery. The purpose of this study was to evaluate the results of surgery performed in our department and to investigate the prognostic value of different factors such as preoperative best-corrected visual acuity (BCVA), pre-existing cystoid macular edema (CME), intra-operative peeling of the internal limiting membrane (ILM), age and duration of symptoms. Eighty-eight consecutive eyes of 88 patients were operated on for ERM from July 1998 to June 2000. Both idiopathic and secondary cases were included. In all cases the ERM was successfully removed from the fovea. Mean BCVA after surgery increased from Snellen 0.2 (hand motion (HM) - 0.6) to Snellen 0.5 (HM - 1.0) (p<0.0001). Our results confirm the efficacy of surgical removal of the ERM in improving the visual acuity. Although not statistically significant, mean postoperative BCVA was slightly better in the group without pre-existing CME (p>0.05) and in the group where peeling of the ILM was performed (p>0.05). The data suggest that early surgery is likely to decrease the risk of developing irreversible macular damage (p<0.05). Because accelerated nuclear sclerosis with visual impairment is a common phenomenon after vitrectomy, one might consider performing a phaco-emulsification at the same time, especially in the elderly.