A comparison between amniotic fluid index and the single deepest vertical pocket technique in predicting adverse outcome in prolonged pregnancy.

OBJECTIVE: to compare perinatal outcome in induced postterm pregnancies with normal amniotic volume and in patients with prolonged pregnancy undergone induction for oligohydramnios, evaluated by two different ultrasonographic methods. METHODS: amniotic fluid volume was measured, using Single Deepest Vertical Pocket (SDVP) and Amniotic Fluid Index (AFI), in 961 singleton uncomplicated prolonged pregnancies. In 109 of these patients, hospitalization was planned for induction of labor, during or after 42 weeks of gestation, for oligohydramnios, postterm pregnancy and other indications in 47, 51 and 11 cases, respectively. Perinatal outcome included: rate of caesarean section, fetal distress, non reassuring fetal heart tracing, presence of meconium, umbilical artery pH < 7.1, Apgar score at 5 minutes < 7, admission to neonatal intensive care unit (NICU). RESULTS: oligohydramnios was diagnosed in 4.89% of cases, when at least one of the two methods was used. A reduced AFI and SDVP value identified 4.47% and 3.75% of cases, respectively, even if without statistical difference. No statistical differences were reported in perinatal outcomes in postterm versus prolonged pregnancies with oligohydramnios, also in relation to the two different ultrasonographic methods. CONCLUSIONS: oligohydramnios is more frequently diagnosed using AFI than SDVP, consequently determining a higher rate of induction of labor. Moreover, perinatal outcome in prolonged induced pregnancies is not affected by oligohydramnios.

Succenturiate lobe of placenta with vessel anomaly: a case report of prenatal diagnosis and literature review.

We report the case of a 33-year-old woman with antenatal ultrasound diagnosis of succenturiate placental lobe at 33 weeks confirmed by B-flow rendering, describing the advantages of the application of color Doppler to diagnosis and management of placental anomalies. We searched studies about antenatal diagnosis of succenturiate placental lobe, including only cases in which color Doppler was used. This case underlines the importance of color Doppler in increasing the accuracy of diagnosis and achieving an improved differential diagnosis.

Cerebral blood flow autoregulation and congenital heart disease: possible causes of abnormal prenatal neurologic development.

OBJECTIVE: To determine whether the major congenital heart diseases (CHDs) can modify the cerebrovascular flow dynamics and the biometrical parameters in fetuses at third trimester of pregnancy. METHODS: We studied 60 fetuses with CHD. Data included prenatal versus postnatal cardiac diagnosis, cerebral and umbilical artery doppler, fetal biometrical parameters, fetal weight, and gestational age. The pulsatility index (PI) was used to determine blood flow velocities in the umbilical artery (UA) and middle cerebral artery (MCA), while the cerebro/placental ratio (CPR) was assessed as a measure of cerebral autoregulation. Fetuses with CHD were compared to normal controls and then analyzed after being divided into groups based on specific defects. RESULTS: Compared with control fetuses, those with CHD showed a decrease of resistance blood flow in the middle cerebral artery (1.76 vs 1.92 PI) especially considering the CPR (1.66 vs 2.03 PI) (p < 0.01). Furthermore, fetuses with CHD also had smaller head circumferences (30.6 cm vs 31.5 cm p < 0.01) and head/abdominal (HC/AC) ratio (1 vs 1.05 p < 0.01). When stratified for single cardiac diseases, fetuses with hypoplasic left heart syndrome showed a lower CPR and HC/AC ratio. CONCLUSIONS: Cerebrovascular resistance is significantly lower in fetuses with CHD, especially in cases of left side obstruction. The cerebro/placental hemodynamic changes are similar to that described in fetuses with placental insufficiency and may contribute to their abnormal neurologic development.

Ultrasonographic weight estimation in large for gestational age fetuses: a comparison of 17 sonographic formulas and four models algorithms.

OBJECTIVE: To evaluate the accuracy of different formulas and role of fetal parameters (cephalic, abdominal, femur) used for estimation fetal weight (EFW) in large for gestational age (LGA) fetus in diabetic and non-diabetic mothers. METHODS: Seventeen formulas were assessed individually and clustered in four algorithms (X, Y, Z, W) on the basis of fetal biometric parameters using the mean absolute % error, standard deviation (SD), prediction within +/-5%, +/-10%, +/-15% of error and introducing new variable hypotenuse test (HPT) that can sum up precision and accuracy of formulas employed. For predicting fetal macrosomia (BW > or = 4200 g) a receiver-operating characteristic curve was constructed. RESULTS: Warsof2 formula showed the lowest mean % error, SD and HPT (p < 0.01) with overall prediction +/-5, +/-10%, +/-15% of birth weight in 68, 94 and 98%. The formulas that were only based on abdominal measurement (Warsof2, Hadlock1, Campbell) showed the best ability to identify fetal macrosomia. The X algorithm confirming primary role of abdominal circumference for EFW in diabetic mothers. CONCLUSIONS: Accuracy of EFW in LGA fetuses is attributable to the biometric parameters used. Our findings show that the best formulas for EFW are those which only consider the abdominal measurements, especially in diabetic mothers. The new variable that we propose (HPT) confirms this result.

Conservative management of placenta previa-accreta by prophylactic uterine arteries ligation and uterine tamponade.

BACKGROUND: Placenta previa-accreta is associated with severe hemorrhage occurring while separating the placenta during cesarean delivery and hysterectomy is considered the treatment of choice. Conservative management has recently been proposed. CASE: A 26-year-old woman had pregnancy complicated by placenta previa with suspected accreta. During elective cesarean section a prophylactic double bilateral ligation of uterine arteries was performed before removal of the placenta; subsequently, the continuous small bleeding from the placental bed was stopped by tamponade with a balloon catheter filled with saline solution. The patient was discharged 5 days later. An ultrasonographic color Doppler follow-up demonstrated a renewed uterine vascularization. CONCLUSION: Double bilateral ligation of uterine arteries can be used as a prophylactic surgical treatment when a severe bleeding because of placenta previa-accreta is expected, in order to avoid hysterectomy.

Successful treatment of post-cesarean hemorrhage related to placenta praevia using an intrauterine balloon. Two case reports.

The authors report a positive experience in controlling severe postpartum hemorrhage after cesarean section performed for placenta praevia by using an inflated intrauterine balloon and avoiding any further invasive surgery.

Cardiac circumference measurement: possible screening tool in early pregnancy for anomalous cardiac development.

OBJECTIVE: In this study, cardiac circumference (CC), measured by transvaginal sonography, was analyzed to determine the growth during the early stage of pregnancy and its relationship to abdominal circumference and femur length (FL). METHODS: Biometric measurements, including CC, were obtained in 1,182 euploid fetuses at 9-16 weeks' gestation. The CC measurements were related to gestational age (GA), abdominal circumference, and FL. The corresponding 95% confidence intervals were calculated. RESULTS: A linear growth function was observed between CC (mm) and GA (days) (r2 = 0.601; p < 0.0001; y = 0.573 GA - 24.185). Similarly, a good correlation is described with a linear function between CC (mm) and abdominal circumference (mm) (r2 = 0.70; p < 0.0001; y = 0.343 AC + 3.696) and between CC (mm) and FL (mm) (r2 = 0.626; p < 0.0001; y = 1.335 FL + 14.444). The regression analysis that best correlates the dependent variable CC (mm) with the independent variables, GA (days), abdominal circumference (mm), and FL (mm), is: y = 0.137 GA + 0.235 AC + 0.199 FL - 3.303 (r2 = 0.708; p < 0.0001). CONCLUSION: Our results provide normative data of the growth of the CC in early pregnancy. The good correlation described between CC and abdominal circumference and FL suggests that cardiac measurements in early pregnancy alone, or related to other fetal biometric parameters, could be used as a screening tool to identify fetuses at risk for abnormal heart development.

Uterine prolapse in pregnancy.

We present a case of a patient developing uterine prolapse during pregnancy. The cervix reached the introitus at 10 weeks gestation and subsequently protruted progressively as the pregnancy advanced. The patient was conservatively treated with bed rest and the main maternal and fetal risks are avoided. At 4 months postpartum follow-up there was no evidence of uterine prolapse.

Evaluation of femur/foot and humerus/foot ratios by transvaginal sonography between 62 and 116 days of gestation.

OBJECTIVE: The objective was to construct nomograms of femur/foot length and humerus/foot length ratios in early pregnancy by transvaginal sonography. METHODS: In the period 1994-2000, 1,008 singleton pregnant patients were examined from 62 to 116 days of gestation using transvaginal high-resolution ultrasound technique. As a part of biometric survey femur, humerus and foot length were recorded and evaluated as ratio at each gestational age. The distribution of the residuals for the different ratios is also described. RESULTS: A significant correlation was demonstrated between femur and foot length (R2=0.984; p<0.0001) and between humerus and foot length (R2=0.983; p<0.0001). The femur/foot length and humerus foot/length ratios were approximately 1 throughout this period of gestation with a narrow range. CONCLUSION: The presented data obtained in early pregnancy by transvaginal scan offer normative measurements of femur/foot length and humerus foot/length ratios which may be useful in the prenatal diagnosis of congenital syndromes that include skeletal maldevelopment.

Early transvaginal fetal orbital measurements: a screening tool for aneuploidy?

OBJECTIVE: To assess whether simple biometric parameters such as orbital diameters measured in early pregnancy by transvaginal sonography can be used as screening tools for aneuploid fetuses. METHODS: The study group consisted of 2771 fetuses of pregnant women referred to our center for genetic amniocentesis and examined by transvaginal sonography between 11 and 16 weeks' gestation. Karyotypes were normal in 2717 fetuses, and 54 fetuses were aneuploid. Individual values for the aneuploid fetuses were compared with normative data obtained previously for single orbital measurements (interocular and binocular distance) versus gestational age and head measurements. RESULTS: The orbital diameters were within the normal range in the cases with trisomy 21, gonosomal aberrations, trisomy 18, and unbalanced anomalies. Three of the 4 fetuses with trisomy 13 had hypotelorism, confirmed later at autopsy in 2 cases and after delivery in 1 case. CONCLUSIONS: With regard to the small number of cases, our data suggest that ocular biometric parameters may be useful sonographic markers for trisomy 13, even if further evaluation is needed.

Mathematical models to predict long bone lengths by transvaginal scan at 11-16 weeks' gestation.

OBJECTIVE: To propose a new mathematical model to estimate the length of fetal long bones in early pregnancy that can be used in the routine clinical setting. METHODS: In a group of 400 singleton normal fetuses, referred for transvaginal ultrasound examination between 11 and 16 weeks' gestation prior to genetic amniocentesis, a regression analysis was performed to evaluate the relationship between femur length (FLl) (mm) and biparietal diameter (BPD) (mm) and gestational age (GA) (days), as well as between humerus length (HL) (mm) and BPD (mm) and GA (days). The confidence intervals (CIs) of the predicted values for different values of BPD and for different gestational periods and CIs for the regression coefficients are stated as the mean +/- SD of standardized residuals. The accuracy of our best models obtained were evaluated at each gestational week between 11 and 16 with a 10% error cut-off limit. RESULTS: The best relationships between FL and HL versus BPD and GA are: expected FL = -16.92108 + 0.4569402 BPD +0.171617 GA (R(2) = 0.86) and expected HL = -16.28531 + 0.4283019 BPD + 0.1696017 GA (R(2) = 0.88), respectively. When a cut-off limit of 10% in estimating fetal long bones was utilized, the mathematical models revealed a good accuracy particularly at 13-14 weeks' gestation, a period when transvaginal biometric and morphologic examination is advisable and the highest percentage of scans are performed. DISCUSSION: Our proposed two linear models had a very good ability to estimate FL and HL and, due to the simplicity of the calculations, would be particularly useful in the routine clinical setting.

Reference values of fetal orbital measurements by transvaginal scan in early pregnancy.

OBJECTIVE: To construct reference ranges of orbital diameters, measured in early pregnancy by transvaginal sonography. METHODS: The study group consisted of 2717 fetuses of pregnant women referred to our center and examined by transvaginal ultrasound between 11-16 week's gestation. Nomograms with confidence intervals (5th and 95th percentile) for each orbital measurement (orbital diameter, interocular and binocular distance) versus gestational age were produced. RESULTS: The orbital measurements increased in a linear fashion throughout early pregnancy with a good correlation with gestational age. CONCLUSION: Transvaginal sonography is able to visualize and measure orbital diameters with accuracy in early pregnancy; reference ranges were developed that can be used to evaluate normal orbital development and can be helpful in the detection of syndromes with orbital growth defects and other associated fetal anomalies.

Early transvaginal biometry of fetal orbits: a cross-sectional study.

OBJECTIVE: To construct nomograms of orbital diameters in early pregnancy by transvaginal sonography. DESIGN: A prospective cross-sectional study. METHODS: The study was performed on 923 consecutive normal singleton pregnancies from 10 to 16 weeks of gestation, using transvaginal high-resolution ultrasound technique. The interocular distance (IOD), binocular distance (BOD), as well as the orbital diameter (OD) at each gestational age (GA, days), were recorded. The distribution of the residuals for the different orbital measurements are also described. RESULTS: The increase in each of the ocular parameters studied could be accurately described by a linear model. The regression equation for orbital measurements as a function of GA was: for IOD, y = 0.153 GA (days) - 6.73 (r2 = 0.82); for BOD, y = 0.387 GA (days) - 16.85 (r2 = 0.80), and for OD, y = 0.132 GA (days) - 6.435 (r2 = 0.79). IOD and OD demonstrate a normal distribution of the residuals with uniform variance. CONCLUSION: The presented data obtained in early pregnancy by transvaginal scan offer normative measurements of the orbital diameter which may be useful in the prenatal diagnosis of congenital syndromes that include, among other manifestations, orbit maldevelopment and growth disturbances.