Umbilical arterial Doppler sonography for fetal surveillance in pregnancies complicated by pregestational diabetes mellitus.

Antepartum fetal surveillance constitutes an essential component of the standards of care in managing pregnancies complicated by pregestational diabetes mellitus. Fetal hyperglycemia is associated with increased oxidative metabolism, hypoxemia and increased brain and renal perfusion without any significant changes in fetoplacental perfusion. Human cordocentesis data show that fetal hypoxemia and acidemia are associated with changes in the umbilical arterial Doppler indices in maternal diabetes mellitus complicated by fetal growth restriction or pre-eclampsia. Consistent with this, observational studies suggest significant diagnostic efficacy of the Doppler method in diabetic pregnancies complicated by vasculopathy, and in the presence of fetal growth restriction or hypertension. However, the relationship between abnormal umbilical arterial Doppler indices and the quality of glycemic control remains unproved. Although there are no randomized trials specifically addressing this issue, existing evidence suggests that Doppler velocimetry of the umbilical artery may be beneficial for antepartum fetal surveillance in diabetic pregnancies complicated by vasculopathy, fetal growth restriction or hypertension.

Sonographically estimated fetal weight percentile as a predictor of preterm delivery.

OBJECTIVE: To evaluate the association between relative growth restriction and preterm birth. STUDY METHODS: Pregnant women referred for sonographic fetal weight assessments between 24 and 34 weeks of gestation were studied for gestational age at delivery. If a patient underwent more than one study, only the last one was considered. Patients with delivery induced iatrogenically or with abnormal growth patterns due to known pathology, such as maternal diabetes or fetal congenital anomaly, were excluded. A gestational age of 37 weeks or less was considered preterm and a gestational age of more than 37 weeks at delivery was considered term. Fetal weight estimation was obtained by Hadlock's formula based on biparietal diameter, femur length, and head and abdominal circumferences. The estimated fetal weight percentile was computed according to William's tables. Mean gestational age and incidence of preterm delivery for each fetal weight percentile between 1 and 100, at increments of 10, were calculated. The mean estimated fetal weight percentile, biparietal diameter, femur length, head circumferences and abdominal circumferences of preterm and term patients were compared. RESULTS: Among the 419 patients who met the inclusion criteria, duration of gestation was significantly shorter in fetuses with low estimated fetal weight percentile. The risk of preterm birth was 49% in fetuses of less than the 40th birth-weight percentile compared with a risk of 20% in fetuses of more than the 40th birth-weight percentile, representing a relative risk of 2.3. Individual fetal measurements indicate a head-sparing effect in the preterm group. CONCLUSION: Sonographically estimated fetal weight percentile measured between 24 and 34 weeks' gestation may be used as an additional and individually pertinent predictor of preterm birth.

Intra-amniotic pressure reduction in twin-twin transfusion syndrome.

OBJECTIVE: Our purpose was to measure intra-amniotic pressure before and after decompression amniocentesis in twin-twin transfusion syndrome. STUDY DESIGN: Intra-amniotic pressures were measured during decompression amniocentesis on 18 occasions in 5 pregnancies complicated by twin-twin transfusion syndrome. The intra-amniotic pressure was determined with a water manometer before and after removal of amniotic fluid. For comparison, intra-amniotic pressure was determined in 10 uncomplicated gestations. RESULTS: Initial intra-amniotic pressures in twin-twin transfusion gestations (mean, 17.2 +/- 5.2 cm H2O; range, 5.5 to 33.0 cm H2O) were higher than those of the uncomplicated gestations (mean, 8.4 +/- 3.3 cm H2O; range, 3.5 to 13.5 cm H2O; p < 0.002). Intra-amniotic pressures following therapeutic amniocentesis (mean, 10.9 +/- 5.1 cm H2O; range, 3.5 to 23.0 cm H2O) were not different from those of the uncomplicated gestations (p = 0.16). CONCLUSION: The intra-amniotic pressure in twin-twin transfusion gestations is higher than that of the uncomplicated gestation. Decompression amniocentesis reduces intra-amniotic pressure to that of the uncomplicated gestation.

Seronegativity to varicella-zoster virus in a tertiary care obstetric population.

OBJECTIVE: To determine the seronegativity rate of varicella-zoster virus in a tertiary care obstetric population. METHODS: At their initial prenatal visit, all obstetric patients at Westchester County Medical Center have a varicella-zoster virus IgG antibody titer (Varicella Stat; Biowhittaker, Inc., Walkersville, MD) performed. A value of 0.99 or greater units is positive. Patients were divided into three groups: seronegative, seropositive, and those with no test results. Mean maternal age was compared among groups using the unpaired two-tailed Student t test, with P < .05 considered significant. RESULTS: From February 1, 1994, to May 30, 1996, 927 women had an initial prenatal visit. Ninety-nine patients were varicella-zoster virus antibody negative (seronegativity 11.6%, which is significantly higher than that reported in other studies); 755 were varicella-zoster virus antibody positive, and 73 had no results. The mean age of the seronegative patients was 27 years and of the seropositive patients 28 years, which was not significantly different. CONCLUSION: Varicella-zoster virus seronegativity is higher in our obstetric population than generally is reported in adults. This may reflect the number of immigrants from tropical countries attending metropolitan hospitals. Mathematic models evaluating the impact of varicella-zoster virus vaccination and decisions regarding screening and postpartum vaccination must be based on accurate epidemiologic data, particularly in view of the effect of varicella-zoster virus on pregnant women, their fetuses, and their neonates.

Intrauterine transmission of hepatitis A virus.

BACKGROUND: Hepatitis A is a common, self-limited disease transmitted by fecal-oral contamination. CASE: A 23-year-old woman, para 2-0-0-2, developed hepatitis A at 20 weeks' gestation. At 27 weeks, ultrasound revealed polyhydramnios and fetal ascites. Hepatitis A immunoglobulin M antibody in fetal blood obtained by funipuncture confirmed acute hepatitis A infection in the fetus. Polyhydramnios and ascites persisted until 35 weeks, when the fetus developed ultrasound signs of meconium peritonitis, and delivery was accomplished uneventfully. Meconium peritonitis was diagnosed in the neonatal period and treated surgically. CONCLUSION: To our knowledge, this is the first report of intrauterine transmission of hepatitis A. The disease presented with fetal ascites and was confirmed by positive fetal blood serology.

Advantages of larger volume, less frequent intrauterine red blood cell transfusions for maternal red cell alloimmunization.

Larger volume intravascular transfusions to manage severe maternal red cell alloimmunization in pregnancy may prolong the interval between procedures without increasing maternal, fetal, or neonatal complications. A retrospective cohort study compared the management and outcome of 19 patients with severe red cell alloimmunization managed at two facilities with different intravascular transfusion protocols. The volume of blood transfused, pre- and post-transfusion fetal hematocrit, and interval (days) between intravascular transfusions were compared. The respective maternal, fetal, and neonatal results were compared. The red blood cell volume transfused per procedure and the post- but not pre-transfusion fetal hematocrits were higher at New York Hospital than at Westchester County Medical Center. The interval between transfusions at New York Hospital (25.2 +/- 8.65 days) was longer than at Westchester County Medical Center (13.5 +/- 6.0 days, p < 0.0001). Although larger volume transfusion was occasionally associated with transient fetal bradycardia, all red blood cell transfusions were completed without complication. The adverse outcomes, complication rates, and neonatal outcomes were otherwise similar in both management protocols. It is possible to significantly increase the interval between intravascular transfusions with larger transfusion volumes for the management of severe maternal red cell alloimmunization without undue risk. The overall risk for the fetus and mother may be reduced by performing fewer transfusions and avoiding additional blood product exposures.

In utero surfactant administration to preterm human fetuses using endoscopy.

Our purpose was to assess the feasibility of the endoscopic delivery of surfactant directly to the fetus during active preterm labor. A gas-sterilized intraoperative fiberscope was introduced through the cervical canal into the amniotic cavity after spontaneous rupture of membranes during preterm labor in 3 patients. The flexible fiberscope was inserted under constant endoscopic visual control to avoid possible trauma to the fetus and the mother. Surfactant was injected into the mouths of 3 preterms fetuses through a catheter placed through the biopsy channel of the fiberscope. Fetal heart rate tracings as well as neonatal and maternal outcome are reported for each case. In utero surfactant placement was successful in each case. The fetal heart rate remained normal throughout the procedure. No maternal or neonatal complications/infections were detected. Our preliminary experience indicates that in utero endoscopic delivery of surfactant to a preterm human fetus is feasible. The usefulness of intrapartum endoscopy in the prophylactic administration of surfactant directly to the fetus, prior to the first breath, has to be assessed in a prospective controlled study.

Middle cerebral to umbilical artery Doppler ratio in post-date pregnancies.

OBJECTIVE: To determine which antepartum test is the best predictor of post-date-related adverse outcome among the amniotic fluid index (AFI), nonstress test (NST), biophysical profile, or middle cerebral artery to umbilical artery Doppler ratio. METHODS: Pregnant women of 41 or more weeks' gestation with singleton fetuses and vertex presentations underwent antepartum testing twice a week. Pulsed Doppler ultrasound was used to obtain the flow velocity waveforms from the umbilical and middle cerebral arteries. Adverse post-date-related outcome was defined as the occurrence of meconium aspiration syndrome, cesarean delivery for fetal distress, or fetal acidosis. The predictive values of an AFI equal to or less than 5 cm, a biophysical profile score equal to or greater than 6, a nonreactive NST, and a middle cerebral artery to umbilical artery ratio less than 1.05 in identifying adverse outcome were compared. RESULTS: Forty-nine women met the inclusion criteria; ten (20.4%) had an adverse outcome. A middle cerebral artery to umbilical artery ratio of less than 1.05 was found to be the best predictor of adverse outcome, with a sensitivity of 80%, specificity of 95%, positive predictive value of 80%, and negative predictive value of 95%. The other three diagnostic tests had sensitivities equal to or less than 40%. The middle cerebral artery to umbilical artery ratio was also a better discriminator of adverse outcome than either the umbilical artery systolic-diastolic (S/D) ratio or the middle cerebral artery S/D ratio. CONCLUSION: Although the sample size of our study was small, the results suggest that a middle cerebral artery to umbilical artery ratio of less than 1.05 is an accurate method of predicting post-date-related adverse outcome.

Response of fetal heart rate to scalp stimulation related to fetal acid-base status.

The correlation of the response of the fetal heart rate (FHR) to scalp stimulation and the acid-base status of the fetal scalp blood (FSB pH) was studied in 104 term fetuses during labor. The mean FHR was determined for the 5-minute period before the preparation for fetal scalp blood pH determination and 1 minute following FSB pH. The analysis was performed for three pH groups: (a) Normal (pH more than 7.25, = 73); (2) preacidotic (pH 7.20 to 7.25, = 16); and (3) acidotic (pH less than 7.20, = 15). The pH was confirmed at delivery by determination of umbilical cord blood acid-base status. Regression analysis of the number of fetuses responding by changing their heart rate against time was significant only for the nonacidotic fetuses. There was no significant difference in the number of subjects whose mean FHR increased, decreased, or remained unchanged between the three pH groups. Furthermore, there was no difference between the three pH groups in the number of fetuses who demonstrated significant mean heart rate changes (p less than 0.05) following the stimulation compared to those who did not. Further analysis between fetuses in the three pH groups who increased FHR 15 beats/min or more following stimulation did not discriminate between groups. We conclude that scalp stimulation results in a FHR response in all three pH categories. However, the net change in the mean heart rate following the stimulation may be negative or positive. The magnitude and the direction of this change in FHR is not significantly related to FSB pH.(ABSTRACT TRUNCATED AT 250 WORDS)

Monozygotic twins with trisomy 18: a report of discordant phenotype.

The predicted incidence of liveborn monozygotic trisomy 18 twins is one per million births. The first case of liveborn monozygotic trisomy 18 twins was reported in 1989 and we report a second case in which striking phenotypic discordance existed. The probability of monozygotic trisomy 18 twinning and the mechanisms for phenotypic discordance in trisomic twins is discussed.

Direct quantitation of skin elasticity in systemic sclerosis.

A simple instrument, the "skin elastometer," was used to evaluate the elastic and plastic properties of volar forearm skin in 24 patients with systemic sclerosis and 24 healthy individuals matched for age, race and sex. Skin elastance in 17 patients with diffuse scleroderma was found to be significantly different from matched controls (p less than 0.001), and was associated with clinical skin scores independently determined by examination (r = 0.89, p less than 0.001). Seven patients with limited scleroderma (the CREST variant) had values for skin elastance which were intermediate between those of the patients with diffuse scleroderma and healthy persons. Plastic deformation of the stretched skin was similar in patients and controls. Quantitative measurement of skin elastance is a simple technique which may prove to be of value in the assessment of patients with systemic sclerosis.

Determination of the elastic properties of the cervix.

The elastance of the uterine cervix of nonpregnant women was measured by placing a 3- or 4-cm compliant balloon in the cervical canal and determining its pressure-volume characteristic while filling with up to 5 mL of sterile water at a rate of 12 mL/minute. The mean elastance for 247 patients who had previously suffered either one or more spontaneous midterm pregnancy losses, preterm birth, or three or more early spontaneous abortions was significantly lower than that of 42 controls who did not meet these criteria. Elastances were significantly lower in groups having a clinically observed patulous cervix or laceration, or a clinically diagnosed incompetent cervix, than in the normal cervix group. No significant difference was found between the follicular and luteal phases for 64 regularly cycling women. Values were significantly reduced in women showing a widened cervix on a hysterosalpingogram when compared with those with a normal-appearing cervix. When larger Hegar dilators were passed without resistance, the elastance was generally lower, although there was not always good correlation between the largest dilator passed and elastance.

Isolated angiitis of brain in pregnancy and puerperium.

Isolated angiitis of the brain in labor and puerperium is described. Persistent headaches in a preeclamptic patient in the postpartum period usually suggests either persistent preeclampsia or subarachnoid hemorrhage. Isolated vasculitis of the brain, which was diagnosed in the present case, should be considered as it responds to medical (pharmacologic) treatment.

Some effects of maternal pethidine administration on the newborn.

The effects of maternal pethidine administration (100 mg intramuscularly) were investigated in 150 infants at 1-2 h after birth, 95 infants whose mothers had not received pethidine served as a control group. Pethidine administration showed no effect on pH or PCO2 of cord blood and neonatal arterial blood at 1-2 h after birth if the time interval between pethidine administration and delivery was less than or equal to 1 h. However, when the interval was greater than 1 h: umbilical vein blood PCO2 was higher; neonatal arterial blood PCO2 was higher; neonatal baseline heart rate was higher, although long-term variability was similar; the percentage time spent crying was considerably reduced compared with the corresponding values in the control group. The long-term effects of pethidine are unknown but the adverse neonatal factors particularly if the time interval between administration of the drug and delivery is greater than 1 h should be kept in mind.

Tricolor photography for assessment of spermatozoa motility.

A rapid and accurate technique for assessment of spermatozoa motility has been developed. With the use of tricolor photography with sequential exposures in green, red, and blue light, spermatozoa were photographed in Makler chambers with a depth of 10 mu. Exposure in green light had a 1-second duration and was immediately followed by the red light from an electronic flash, and 0.05 second later by the blue light from a second flash. With this system, spermatozoa with motility would leave a green track, at the end of which they would appear first red and then blue. The colors and their intensity were chosen so that, when superimposed on nonmotile spermatozoa, the latter would appear white. By projection of the transparent film onto white paper, spermatozoa, motile and nonmotile, were easily counted and the percentage and motility was determined. Also, concentration could be calculated because the photograph represented a semen volume of 0.001 mu. Measurement of the green track and conversion to true length in micrometers gave the velocity in micrometers per second.

Obstetric and gynaecological presentations of hydatid disease.

Hydatid disease of the female pelvis is rare in gynaecological practice. In Libya, where the disease is endemic, 14 women with pelvic hydatid disease were encountered in one hospital department between 1971 and 1979. Five of these women were pregnant, a hospital prevalence of 1 in 20 000. The other nine women accounted for 0.3% of all gynaecological laparotomies in the same hospital. The clinical features, diagnosis and management of this rare condition are described.