Correlation between changes in liver stiffness and preeclampsia as shown by transient elastography.

OBJECTIVE: The aim of this study was to evaluate the use of Fibroscan as a measure of liver transient elastography in women with preeclampsia and compare the results with a group of normotensive controls. MATERIALS AND METHODS: In this prospective observational case-control study, women at 24-41 weeks gestation who were diagnosed with preeclampsia using standard criteria, between January 2012 and December 2013, were included. The Fibroscan test was performed by a hepatologist 1-7 days postpartum. A control group consisted of low-risk women with normal pregnancy outcomes. RESULTS: Fibroscan results for fibrosis were significantly higher in the 32 preeclamptic women compared to the 16 normotensive women (mean 4.57 kPa vs. 3.66 kPa respectively, P = 0.01). There was no difference in liver steatosis between women with preeclampsia and normotensive women (226 vs. 225 kPa, respectively, P = 0.442) Conclusions: Fibroscan results for fibrosis were significantly higher in postpartum preeclamptic women (although within the normal range). Further studies are required in order to evaluate the usefulness of Fibroscan as an additional test in the evaluation and management of preeclampsia.

A survey of attitudes of expectant first-time fathers and mothers toward epidural analgesia for labor.

OBJECTIVE: To evaluate the attitude of expectant fathers to the use of epidural analgesia during labor and to compare it to the attitude of their partner. METHODS: The study group consisted of consecutive expectant, first-time parents who presented at the delivery room of a major medical center over a 3-month period. Only those with a single, term fetus in cephalic presentation were included. Both partners were asked to complete a questionnaire on desire to receive epidural analgesia firstly on admission and again later during labor at first discussion of the use of epidural analgesia with medical staff. Findings were compared between partners, between the two time points and with the actual use of epidural analgesia in labor. The effect of various socio-demographic variables on this decision was analyzed. RESULTS: One hundred fifty couples completed the study. On admission, 64.1% of the expectant fathers and 78.6% of the expectant mothers expressed a preference for epidural analgesia (P=0.01). Later in labor, the corresponding rates were 77.9% and 87.4%. In total 95.3% of the women received epidural analgesia. There was no effect of age, level of education, salary, or attendance in a birth preparatory course on the decision to use epidural analgesia by either partner. CONCLUSION: The decision to use epidural analgesia differs between partners, changes during the course of labor and is unrelated to socio-demographic factors.

In-utero development of the fetal colon and rectum: sonographic evaluation.

OBJECTIVE: To construct a normal range for the internal diameter of the fetal descending colon and rectum during gestation. SUBJECTS AND METHODS: This was a prospective, cross-sectional study including 379 healthy pregnant women with normal singleton pregnancies at 19-40 weeks of gestation. Measurements of the fetal descending colon (maximum internal diameter) and the fetal rectum (at the level of the bladder, measuring the anteroposterior diameter), were performed by high-resolution transabdominal sonography. RESULTS: Adequate bowel measurements were obtained in all 379 fetuses. The diameter of the descending colon and rectum plotted as a function of gestational age had a sigmoid curve; the curve estimation was expressed by a cubic regression equation with R(2) of 0.848 and 0.831, respectively (P < 0.0001). The normal mean and the 95% prediction limits were defined. CONCLUSION: The present data provide a normal range of fetal bowel (descending colon and rectum) diameters from the early second trimester of pregnancy onwards. They may allow intrauterine assessment of the development of the fetal colon and may serve as reference values in the detection of anomalies of the fetal bowel.

Normal cardiac flow velocities at 14-16 weeks of gestation measured by transvaginal ultrasound.

OBJECTIVE: Doppler ultrasound has been used to study the flow velocities through the valves and arteries of the fetal heart. Using transvaginal sonography, we sought to determine normal values for flow velocities through the fetal heart valves at 14-16 weeks of gestation. METHODS: Eighty-seven normal fetuses were examined. The flow velocity waveforms were visualized using Doppler ultrasound with the sample volume calipers placed just distally to the four fetal valves. Peak E- and A-wave velocities were recorded for the tricuspid and mitral valves and peak systolic flow velocities were recorded for the ascending aorta and pulmonary arteries. Linear regression for comparison of flow velocities with gestational age was performed. RESULTS: There was no significant correlation between any of the velocities and gestational age. CONCLUSIONS: Flow velocities through the fetal cardiac valves remain unchanged at 14-16 weeks of gestation as measured by transvaginal Doppler sonography.

Nuchal fold thickness at 14-16 weeks' gestation as measured by transvaginal sonography.

OBJECTIVE: To establish normal values of fetal nuchal fold thick-ness at 14-16 weeks of gestation by transvaginal sonography. METHODS: Transvaginal sonography was used to measure nuchal fold thickness in 182 normal pregnancies at 14-16 weeks of gestation. Nuchal fold thickness was measured as the distance from the outer skull bone to the outer skin surface in the transverse axial image in the suboccipital-bregmatic plane of the head. RESULTS: There was no significant association between nuchal fold thickness and gestational age (r = 0.084; P = 0.258). The mean (standard deviation) was 2.2 (0.5) mm and the 95th centile was 3.0 mm. CONCLUSIONS: The 95th centile of nuchal fold thickness measured by transvaginal sonography at 14-16 weeks is 3.0 mm.

Cerebral lateral ventricular atrial diameter of male and female fetuses at 20-24 weeks' gestation.

OBJECTIVE: To determine if the lateral ventricular atrial diameter differs between male and female fetuses at 20-24 weeks' gestation. DESIGN: Prospective study. METHODS: The transverse diameter of the ventricular atrium was measured from inner wall to inner wall for a total of 202 pregnant women with 105 male fetuses and 97 female fetuses. RESULTS: The mean diameter of the ventricular atrium for the 202 fetuses was 4.96 +/- 0.96 mm (range, 2.1-8.4 mm). The 105 males had a mean diameter of 4.95 +/- 0.98 mm and the 97 females a mean diameter of 4.97 +/- 0.94 mm. There was no statistical difference between the sexes. CONCLUSIONS: In our population, there was no difference between ventricular atrial diameter in male and female fetuses at 20-24 weeks' gestation.

Interindividual variability in sensitivity to warfarin--Nature or nurture?

BACKGROUND: Interindividual variability in responses to warfarin is attributed to dietary vitamin K, drug interactions, age, or genetic polymorphism in the cytochrome P4502C9 enzyme (CYP2C9) (allelic variants 2C9*2 and 2C9*3 ) linked with impaired metabolism of the potent enantiomere S-warfarin. PATIENTS AND METHODS: We quantified the relative effects of age and of simultaneously determined CYP2C9 genotype, plasma warfarin and vitamin K concentrations, and concurrent medications on warfarin maintenance doses in 156 patients at optimized stable anticoagulation. RESULTS: Allele frequencies for CYP2C9*1, CYP2C9*2, and CYP2C9*3 were 0.84, 0.10, and 0.06. Warfarin doses were 6.5 +/- 3.2, 5.2 +/- 2.4, and 3.3 +/- 2.0 mg/d in the 3 genotype groups (P < .0001). Warfarin doses decreased with age as follows: 7.7 +/- 3.7 versus 4.9 +/- 2.9 mg/d at < 50 years and >66 years (P < .001), mainly as a result of decreased plasma warfarin clearance (2.8 +/- 1.4 mL/min versus 1.9 +/- 0.8 mL/min; P < .001). Vitamin K (1.6 +/- 1.1 ng/mL) did not differ among the age or genotype groups. Patients >or=66 years old with the CYP2C9*3 allele required only 2.2 +/- 1.2 mg/d compared with 7.9 +/- 3.7 mg/d in those

Expanded Möbius syndrome.

A woman presented at 33 weeks gestation with reduced fetal movements and a nonreactive nonstress test. Fetal ultrasound examination revealed a peculiar unilateral arm tremor. At emergency cesarean section, performed for fetal indications, a 1,672-gm male infant was delivered requiring intubation for feeble respiratory effort. After delivery the neonate was transiently hypertonic and later hypotonic. Continuing ventilatory support at minimal settings was necessary. The work-up for aneuploidy, metabolic disorders, and infection was negative. The infant died after being removed from ventilatory support on day 22. Postmortem examination revealed extensive bilateral brain gliosis and mineralization without evidence of inflammation, partial absence of cranial nerve nuclei III-XI, and a total absence of cranial nerve roots VI-XI. Together these finding are compatible with a diagnosis of expanded Möbius syndrome.

Hospitalization for early bonding of the genetic mother after a surrogate pregnancy: report of two cases.

BACKGROUND: In surrogate pregnancies the genetic parents have little opportunity for early bonding to their infant, either prenatally (in utero) or in the immediate postnatal period. The purpose of this article is to describe a new method for encouraging early parent-infant bonding after surrogate pregnancy by hospitalizing the genetic mother in the maternity ward immediately after the delivery. METHODS: Two genetic mothers were hospitalized in the maternity ward (rooming-in system) at the Rabin Medical Center in Israel immediately after delivery of their infants by surrogate arrangement. The first birth was a singleton pregnancy with vaginal delivery and the second, a twin pregnancy with delivery by cesarean section. The genetic parents were counseled by a social worker from the adoption agency, starting 3 months before the estimated date of delivery. The parents were referred to the hospital social worker before the delivery. To assess attachment, we observed the parents' behavior toward their children during two daily 15-minute periods of free, unstructured interaction. RESULTS: The parents showed good primary caregiving functions and established affective verbal and physical contact with the infants. They began to recognize the infants' needs and temperament, and exhibited an aura of self-confidence during their interactions. All expressed satisfaction with the method at discharge and reported on reduction of their fears about returning home with the infants. CONCLUSIONS: We believe that early hospitalization of the genetic mother in a surrogate delivery may be desirable to establish good and safe early mother-infant bonding, and that it should be considered for adoption as regular hospital policy. Further randomized studies with larger samples over the long term are warranted.

Immunodetection of living trophoblast.

BACKGROUND: Human chorionic gonadotropin, the pregnancy hormone, is synthesized by trophoblast cells which make up the placenta. OBJECTIVE: To determine whether antibody to hCG can be used to specifically detect living trophoblast in vitro by binding to the external membrane. METHODS: Trophoblast was isolated from fresh placentas of women undergoing termination of pregnancy in the first trimester and incubated with monoclonal antibody to hCG. Anti-mouse immunoglobulin G with a fluorescent marker was then added. RESULTS: Syncytiotrophoblast stained positive on the external surface of the cell, while controls of leukocytes, endometrial cells and hepatocytes were negative. CONCLUSION: The hCG monoclonal antibody may be used to specifically detect hCG on the surface of living trophoblast in vitro.

Antenatal diagnosis of vesicouterine fistula.

BACKGROUND: In pregnancy, vesicouterine fistulas usually are diagnosed postpartum after cesarean deliveries. CASE: An 18-year-old woman, gravida 3, para 2, with two prior cesarean deliveries had pain and apparent rupture of membranes at 23 weeks' gestation. At 26 weeks' gestation, she developed increasing suprapubic pain and irregular contractions. Ultrasonographic findings included a small uterine defect and possible ballooning of membranes into her bladder. Cytoscopy showed ballooning of amnion into the bladder dome. A viable 900-g female infant was delivered by classic cesarean, the fistulous tract was excised, and the rupture sites were repaired. CONCLUSION: Vesicouterine fistulas might be diagnosed antenatally. With continued contractions and associated uterine rupture, cesarean delivery can be done with excision of the fistulous tract and repair of the rupture sites.

Improving pregnancy outcome in twin gestations with one malformed fetus by postponing selective feticide in the third trimester.

OBJECTIVE: To examine the course of pregnancy and fetal outcome in patients with twin gestations in which one abnormal fetus underwent selective feticide in the third trimester of pregnancy. DESIGN: A study of 23 consecutive late selective feticide procedures. SETTING: Department of Obstetrics and Gynecology, Rabin Medical Center, Israel. PATIENT(S): Twenty-three patients with twin pregnancies with one malformed fetus. INTERVENTION(S): Selective feticide with intracardiac injection of KCl was performed at 28-33 weeks of gestation after the diagnosis of fetal genetic (56.5%) or structural (43.5%) malformations made in the second trimester (18-24 weeks). All procedures were performed at the patient's request and on approval of a committee for fetal termination late in pregnancy. Betamethasone treatment was initiated to enhance lung maturity 3 weeks before selective feticide. All patients were placed on complete bed rest until 35 weeks' gestation. MAIN OUTCOME MEASURE(S): Early and late complications related to the procedure; outcome of pregnancy and fetal survival. RESULT(S): All 23 twin pregnancies had an uneventful course after selective feticide performed at 28-33 weeks. All birth weights were > 2,000 g (mean +/- SD, 2,628 +/- 646 g), indicating an excellent chance of survival. CONCLUSION(S): Our results suggest that late selective feticide in twin gestations is safe and efficient and results in a favorable outcome for the surviving fetus. This procedure should be performed at 28-30 weeks after treatment for enhancement of lung maturity.

Elective cytogenetic amniocentesis in the third trimester for pregnancies with high risk factors.

The aim of the present study was to report the findings in 14 women with extremely high risk ('precious') pregnancies, 5 of whom had twins, who underwent elective third-trimester cytogenetic amniocentesis. There were no procedure-related complications, and all newborns weighed more than 2000 g and showed normal development. This practice is accepted under Israeli law and our institutional policy. This preliminary work does not attempt to answer the moral and ethical questions surrounding the use of third (versus second) trimester amniocentesis in either 'precious' or normal pregnancies. We do show, however, that the procedure is safe and may constitute a good alternative for patients who are unwilling to accept the risks of early fetal karyotyping.

Risk of repetition of a severe perineal laceration.

OBJECTIVE: To compare the outcome of subsequent delivery in women with a history of a third- or fourth-degree laceration with outcomes in women without such a history. METHODS: This retrospective study used a perinatal database and chart review from 1978 to 1995. Only women whose first delivery was at our institution at more than 36 weeks' gestation, vaginal singleton, vertex presentation, and birth weight greater than 2500 g, with a subsequent delivery were included. The women were grouped by presence or absence of a third- or fourth-degree (severe) perineal laceration in their first delivery. The subsequent delivery was analyzed for maternal age, weight, birth weight, gestational age, method of delivery, use of episiotomy, and occurrence of a severe laceration. Comparison of data was by Fisher exact and t tests. RESULTS: Four thousand fifteen women met our starting criteria. In their first delivery, the average birth weight, use of instrumentation, and episiotomy rate were significantly higher in those women sustaining a severe laceration. When compared with women without a history of severe perineal laceration, women with such a history were at more than twice the risk for another in their subsequent delivery. The women at highest risk (21.4%) were those sustaining a laceration in their first delivery who underwent instrumental vaginal delivery with episiotomy in their subsequent delivery. When episiotomy or instrumental delivery was performed in the second vaginal birth, 52 (11.6%) of 449 women with a history of a severe perineal laceration sustained another, compared with 98 (6.5%) of 1509 without such a history (P < .001, odds ratio 1.9, 95% confidence interval 1.3, 2.7). CONCLUSION: Women delivering their second baby, and in whom episiotomy or instrumentation is used, are at increased risk of severe perineal laceration compared with women delivery spontaneously.

Predictors of cesarean delivery after prelabor rupture of membranes at term.

OBJECTIVE: To identify the significant predictors of cesarean delivery after prelabor rupture of membranes (PROM) at term. METHODS: In a multicenter study involving 72 institutions in six countries, 5041 women were randomized to induction of labor with oxytocin or prostaglandins or to expectant management. We did univariate and multivariate logistic regression analyses to determine the statistically significant independent predictors of cesarean delivery (P < .05). RESULTS: The following variables were found to be significantly associated with cesarean delivery: delivery in Israel, versus Canada (odds ratio [OR] 0.34); delivery in Australia, versus Canada (OR 1.93); nulliparity (OR 2.81); labor lasting more than 12 hours, versus less than 6 hours (OR 2.78); labor lasting 6-12 hours, versus less than 6 hours (OR 1.66); previous cesarean delivery (OR 2.75); epidural anesthesia (OR 2.66); clinical chorioamnionitis (OR 2.42); internal fetal heart rate monitoring (OR 2.19); birth weight of at least 4000 g (OR 2.07); use of oxytocin (OR 1.97); maternal age of at least 35 years (OR 1.44); latent period of at least 12 hours (OR 1.41); and meconium staining (OR 1.41). CONCLUSION: Strong predictors of cesarean delivery after PROM at term were country of birth, nulliparity, long labor, previous cesarean delivery, and epidural anesthesia.

Neonatal atrial flutter following fetal exposure to vibroacoustic stimulation.

The use of vibroacoustic stimulation (VAS) has become a common modality for testing fetal well being. A case of neonatal atrial flutter, following fetal exposure to VAS is presented. It should be emphasized that although VAS is a common and reliable test for evaluating fetal status, complications may occur.