Effects of shoulder dystocia training on the incidence of brachial plexus injury.

OBJECTIVE: We sought to determine whether implementation of shoulder dystocia training reduces the incidence of obstetric brachial plexus injury (OBPI). STUDY DESIGN: After implementing training for maternity staff, the incidence of OBPI was compared between pretraining and posttraining periods using both univariate and multivariate analyses in deliveries complicated by shoulder dystocia. RESULTS: The overall incidence of OBPI in vaginal deliveries decreased from 0.40% pretraining to 0.14% posttraining (P < .01). OBPI after shoulder dystocia dropped from 30% to 10.67% posttraining (P < .01). Maternal body mass index (P < .01) and neonatal weight (P = .02) decreased and head-to-body delivery interval increased in the posttraining period (P = .03). Only shoulder dystocia training remained associated with reduced OBPI (P = .02) after logistic regression analysis. OBPI remained less in the posttraining period (P = .01), even after excluding all neonates with birthweights >2 SD above the mean. CONCLUSION: Shoulder dystocia training was associated with a lower incidence of OBPI and the incidence of OBPI in births complicated by shoulder dystocia.

Changes in symphysis pubis width during labor.

We studied changes in the width of the symphysis pubis in 32 women examined serially by ultrasound during labor. Measurements were made at the superior border of the symphysis and at its narrowest breadth in the latent phase, the active phase, and the second stage of labor. There was a significant increase in the width of the symphysis between the first and second stages of labor at both measured levels. Widening was observed in 94% at the superior symphyseal breadth and in 59% at the narrowest. Of those cases in which the width of the symphysis increased, there was a large spectrum of change, ranging from 9 to 98% of the original width at the narrowest measurement site and from 2 to 139% at the superior breadth. There was a strong inverse correlation between maternal age and the degree of symphyseal widening in nulliparas, but not in multiparas. We conclude that labor is associated with a substantial widening of the symphysis pubis in most, but not all women.

Does hospitalization prevent preterm delivery in the patient with a short cervix?

This study considers whether admission to the hospital of a patient diagnosed with a short cervix delayed delivery, prevented preterm delivery, and/or decreased the rate of change in the cervical length (CL) on follow-up measurements. The design was a retrospective cohort study of women carrying singleton pregnancies with cervical lengths

Antenatal assessment of discordant umbilical arteries in singleton pregnancies.

AIM: To assess the relationship between discordant umbilical arterial size and resultant blood flow parameters and determine the impact of discordance on fetal outcome. METHODS: This is a descriptive, cross-sectional study of 200 patients with a singleton gestation, who underwent a fetal anatomy survey between 18 to 23 weeks of gestation, with documented umbilical cord morphological patterns and blood flow characteristics. Umbilical vessel diameters and Doppler parameters (umbilical vein blood flow volume, mean resistance index, and peak-systolic velocity) were analyzed for discordance. Discordances encountered were examined for their possible association with perinatal outcome. RESULTS: We had adequate ultrasound umbilical cord images, Doppler flow parameters, and all necessary demographic data for 154 patients. Umbilical artery discordance averaged 13.1% and was significantly correlated with both the expected and the true percent of difference in resistance index values (RI, P<0.001). In 12 patients (7.8%), a significant discordance of more than 29.5%, or 95th percentile, was observed between the two umbilical artery diameters. However, in these cases no associated adverse perinatal outcome or significant placental pathology was noted. There was no significant difference between patients discordant or concordant umbilical artery in terms of maternal, labor, and neonatal data. CONCLUSION: The magnitude of umbilical arteries' luminal discordance directly influences the corresponding blood flow parameters. In our sample of patients, the presence of discordant-in-size umbilical arteries was not associated with umbilical cord or placental abnormalities.

Does a "vanishing twin" affect first-trimester biochemistry in Down syndrome risk assessment?

OBJECTIVE: The purpose of this study was to evaluate the impact of spontaneous reduction in multifetal pregnancy on first-trimester maternal serum biochemistry. STUDY DESIGN: We evaluated first-trimester pregnancy associated plasma protein-A (PAPP-A) and free beta-human chorionic gonadotropin levels in singleton euploid pregnancies. Biochemical values in pregnancies with evidence of spontaneous reduction were compared to other singleton pregnancies. Mann-Whitney U, Student t test, Fisher exact test, and logistic regression analysis were used for statistical comparison. RESULTS: There were 41 cases (0.9%) of spontaneous reduction. Though spontaneous reduction was not associated with different levels of either analyte, reduction within 4 weeks was associated with higher levels of both PAPP-A (1.79 vs 1.18; P = .002) and free beta-hCG (1.28 vs 0.96; P = .03) compared with other pregnancies. Spontaneous reduction was associated with a higher frequency of PAPP-A >95th %ile (17.1 vs 4.7%; P = .003) and free beta-hCG >95th %ile (17.1% vs 5.0%; P = .004). Logistic regression identified independent associations between spontaneous reduction and both high PAPP-A and high free beta-hCG. CONCLUSION: Recent spontaneous reduction is associated with higher values of PAPP-A and free beta-hCG. These differences have the potential to affect risk assessment for fetal aneuploidy.

Clinical use of first-trimester aneuploidy screening in a United States population can replicate data from clinical trials.

OBJECTIVE: The clinical application of first-trimester aneuploidy screening remains controversial in the United States. The aim of our study was to evaluate the performance of maternal age, fetal nuchal translucency measurements, pregnancy-associated plasma protein A, and free beta-human chorionic gonadotrophin used in aneuploidy screening in a single institution outside of a clinical trial. STUDY DESIGN: Four thousand eight hundred eighty three patients underwent first-trimester aneuploidy screening at 11 to 13 6/7 weeks of gestation (fetal crown-rump length 45 mm to 84 mm) at our institution between January 2003 and September 2004. Measurement of nuchal translucency was performed according to the Fetal Medicine Foundation standards and was included in the overall risk assessment performed by NTD Laboratories. Measurement of pregnancy-associated plasma protein A and free beta-human chorionic gonadotrophin on maternal dried whole blood samples was conducted by NTD Laboratories and was reported as gestational-specific multiples of the median adjusted for ethnicity. Risk adjustment for trisomy 21 and trisomy 18 was done with a standard algorithm using maternal age, serum biochemistry, and nuchal translucency. Only singleton gestations (N = 4615) were included in the analysis. RESULTS: The median maternal age was 33.0 years (interquartile range 31.0 to 36.0) and the median crown-rump length was 61.2 mm (interquartile range 55.7 to 67.2) at the time of screening. There were a total of 22 fetuses diagnosed with trisomy 21 and 8 with trisomy 18. The detection rates for trisomy 21 for a 5% false-positive rate and 1% false-positive rate were 90.9% (20 of 22) and 77.3% (17 of 22), respectively. Similarly, the detection rates for trisomy 18 at a 5% false-positive rate and a 1% false-positive rate were 100% (8 of 8) and 100% (8 of 8), respectively. CONCLUSION: Non-investigational use of first-trimester aneuploidy screening for trisomy 21 and trisomy 18 can replicate results from investigational trials.

Absence of a relationship between umbilical cord thickness and coiling patterns.

OBJECTIVE: The purpose of this study was to evaluate a relationship between the umbilical cord thickness and cord coiling patterns during the fetal sonographic anatomic survey in the second trimester of pregnancy. METHODS: This was a prospective study of 470 patients with singleton pregnancies who had a fetal anatomic survey with recorded umbilical coiling patterns between 18 and 23 weeks' gestation. The umbilical cord thickness was assessed as an umbilical diameter at the level of the fetal abdominal cord insertion and compared with the antenatal umbilical coiling index (aUCI), calculated as a reciprocal value of the distance between a pair of umbilical cord coils. RESULTS: Three hundred twenty-one patients had adequate sonographic umbilical cord images and maternal demographic, antenatal, and labor data to meet inclusion criteria. The mean aUCI was 0.41 with 10th and 90th percentiles of 0.21 and 0.60, respectively. A total of 10.6% (34/321) and 9.3% (30/321) of patients were categorized as having hypocoiled and hypercoiled umbilical cords, respectively. The mean cord diameter +/- SD was 9.48 +/- 0.97 mm (range 7.0-12.5 mm). There was no statistically significant correlation between aUCI and umbilical cord thickness (P = .1164). CONCLUSIONS: An aUCI, or umbilical coiling pattern, does not correlate with umbilical cord thickness. It appears that a lesser amount of the umbilical supportive tissue, mainly Wharton jelly, is not related to an increased umbilical cord coiling pattern.

Isolated fetal ascites caused by bowel perforation due to colonic atresia.

An isolated fetal ascites is a rare ultrasonographic finding. It is commonly diagnosed in association with fetal genitourinary or gastrointestinal conditions, mainly bowel obstruction. We present the sonographic features and neonatal outcome of a fetus with a large bowel obstruction, perforation and subsequent development of meconium peritonitis, prenatally diagnosed as isolated fetal ascites. A colonic atresia should be also included in the differential diagnosis of isolated fetal ascites.

The umbilical cord thickness measured at 18-23 weeks of gestational age.

OBJECTIVE: To establish an umbilical cord thickness nomogram from anatomy ultrasound scans performed between 18 and 23 weeks of gestational age in singleton pregnancies, and compare it to two previously published nomograms. MATERIAL AND METHODS: In this retrospective cohort study of 1107 patients, a total of 650 singleton pregnancies were included. The umbilical cord diameter measurements were performed at the level of fetal abdominal wall insertion, and were correlated with gestational age (GA) and estimated fetal weight (EFW). Statistical analysis with non-parametric polynomial least squares regression analysis was performed. RESULTS: A statistically significant correlation between umbilical cord diameter and GA (P<0001, r=0.399, 95% CI 0.331 to 0.464), and EFW (P<0001, r=0.420, 95% CI 0.353-0.483) was observed. A nomogram of umbilical cord thickness according to GA (y), and EFW (y'), was generated from the following equations:y=-51.30+5.367*x-0.1165*x(2) and y'=6.917+0.007233*x, respectively. CONCLUSION: Our nomogram is in agreement with one of the previously published nomograms that also measured umbilical cord diameter at the level of the fetal abdominal umbilical cord insertion. Therefore, we recommend umbilical cord thickness to be measured in close proximity to the fetal abdominal wall, but no further than 0.5 cm away from the wall insertion.

Ultrasound evaluation of abnormal umbilical cord coiling in second trimester of gestation in association with adverse pregnancy outcome.

OBJECTIVE: The purpose of this study was to evaluate the antenatal umbilical cord coiling index obtained during the fetal anatomic survey in the second trimester as a predictor of adverse pregnancy outcome. STUDY DESIGN: Four hundred twenty-five consecutive women who had a fetal anatomic survey between 18 to 23 weeks of gestation were evaluated for umbilical cord coiling. The antenatal umbilical cord coiling index was calculated as a reciprocal value of the distance between a pair of coils (antenatal umbilical cord coiling index = 1/distance in cm) and was correlated with the following adverse pregnancy outcomes: (1) small for gestational age, (2) mode of delivery, (3) presence of meconium-stained amniotic fluid, (4) presence of nonreassuring fetal status in labor, and (5) Apgar scores at 1 and 5 minutes. RESULTS: A total of 294 patients had adequate ultrasound images and all antenatal and labor data to meet the study inclusion criteria. Abnormal coiling was associated significantly with small for gestational age neonates at birth (P = .043) and non-reassuring fetal status in labor (P = .007). Nine of 58 neonates (15.5%) with abnormal umbilical coiling were small for gestational age infants compared with 15 of 236 small for gestational age neonates (6.4%) who had normal cord coiling. A non-reassuring fetal status in labor was observed in 25.7% of fetuses (15/58 fetuses) with abnormal umbilical coiling compared with 11.0% of fetuses (26/236 fetuses) with normal cord coiling. In contrast, no statistical difference for Apgar scores at 1 and 5 minutes or higher prevalence of interventional deliveries and meconium-stained amniotic fluid in labor between the groups with normal and abnormal umbilical cord coiling was observed. CONCLUSION: Abnormal umbilical cord coiling that is detected at the fetal ultrasound anatomic survey in the second trimester is associated with a higher prevalence of small for gestational age neonates and non-reassuring fetal status in labor. This observation can be used potentially as a predictor of adverse antenatal or perinatal events in future studies.

Fetal growth assessment and neonatal birth weight in fetuses with an isolated single umbilical artery.

OBJECTIVE: To evaluate interval fetal growth and compare the incidence of small-for-gestational age (SGA) newborns between fetuses with an isolated single umbilical artery and those with a 3-vessel umbilical cord. METHODS: A retrospective, case-controlled study in which 84 singleton pregnancies with an isolated single umbilical artery were compared with 3-vessel umbilical cord fetuses as the control group. RESULTS: There was no statistical difference between the groups in maternal demographic data, except for ethnicity and neonatal outcomes, respectively. The mean newborn birth weight was similar between the isolated single umbilical artery and the control groups, 3,268 +/- 596 g and 3,274 +/- 627 g, respectively. The prevalence of SGA newborns was 7.1% (6 of 84) in the isolated single umbilical artery group and 4.8% (4 of 84) in the control group. An ultrasound examination demonstrated fetal growth restriction in 50% of cases (3 of 6) in the isolated single umbilical artery group and in 25% of subjects (1 of 4) in the control group, respectively. CONCLUSION: Fetuses with an isolated single umbilical artery are at similar risk for SGA compared with fetuses with 3-vessel umbilical cords. It appears that antepartum serial ultrasound examination does not provide more information for interval fetal growth assessment in fetuses with an isolated single umbilical artery.

Human immunodeficiency virus, pregnancy, and Stevens-Johnson syndrome.

BACKGROUND: Stevens-Johnson syndrome and toxic epidermal necrolysis are life-threatening dermatologic disorders that are more common in the setting of a compromised immune system. We present the case of a pregnant patient with known human immunodeficiency virus (HIV) infection who presented with Stevens-Johnson syndrome after treatment with antibiotics for a urinary tract infection. CASE: A young woman at 33 4/7 weeks of gestation with known HIV infection presented to the emergency room with a chief complaint of rash, fever, blisters, and lower abdominal pain. Her symptoms were present for 2 days after ingestion of nitrofurantoin, prescribed for a urinary tract infection. She was diagnosed with preterm labor and possibly Stevens-Johnson syndrome. Due to active labor, HIV, and vaginal stenosis, a primary cesarean was performed. A skin biopsy performed at the time of admission confirmed the diagnosis of a drug-induced dermatosis (erythema multiforme), evidenced by subepidermal bullae, hemorrhage, and acantolated, dyskeratotic eosinophilic cells. CONCLUSION: Stevens-Johnson syndrome and toxic epidermal necrolysis represent a spectrum of disease that has been long associated with multiple drugs, recently including many antiretroviral medications. It also seems that the incidence of these conditions is increased in immunocompromised patients. We speculate that the combination of HIV and pregnancy in addition to antibiotic treatment, such as with nitrofurantoin, may induce Stevens-Johnson syndrome in patients with severely altered immune systems.

A sonographic assessment of different patterns of placenta previa "migration" in the third trimester of pregnancy.

OBJECTIVE: The purpose of this study was to compare the rates and patterns of placental "migration" with the mode of fetal and placental delivery and the incidence of peripartum complications. METHODS: This was a retrospective study of 163 cases of placenta previa diagnosed by transvaginal sonography at 28 weeks' gestation that were followed serially by sonography. The patients were stratified into 3 groups depending on the placenta-to-internal cervical os distance: (1) an overlap of 0.0 cm or greater over the cervical os, (2) 0.1 to 2.9 cm, and (3) 3.0 cm or greater. The mean rate of placental migration (millimeters per week) was obtained at 28 to 32 and 32 to 36 weeks' gestation. A pattern of placental migration was classified as one with acceleration or deceleration of the placental migration in the late third trimester based on a comparison between the migration rates at 28 to 32 and 32 to 36 weeks' gestation. RESULTS: At the time of delivery, 22, 29, and 112 patients were included in groups 1, 2, and 3, respectively. The rates of placental migration correlated with the final placental distance from the internal cervical os (0.1 to 4.1 mm/wk for groups 1 and 3, respectively). Significantly higher rates of interventional cesarean delivery (CD) (P=.0002), elective CD (P=.0254), manual placenta removal (P=.0419), and placenta accreta (P=.0039), but not CD for indications other than placenta previa (P=.0752), were associated with a placental distance of less than 2.0 cm away from the cervix and a deceleration pattern of placental migration. In contrast, vaginal delivery was significantly associated with a placental distance of 2.0 cm or greater away from the cervix and an acceleration pattern of placental migration (P=.0034). CONCLUSIONS: A final placental distance of less than 2.0 cm from the internal cervical os and a deceleration pattern of placental migration were significantly associated with an interventional CD and a higher rate of peripartum complications.

Placental pathology and pregnancy outcomes in donor and non-donor oocyte in vitro fertilization pregnancies.

OBJECTIVE: Intrinsically poor maternal adaptation to pregnancy and dysregulated processes have been postulated to occur as a consequence of an immune response to the feto-placental unit as "foreign" material. The aim of our study was to compare placental pathology and pregnancy outcomes of in vitro fertilization (IVF) pregnancies conceived by donor oocytes with those conceived by non-donor oocytes. STUDY DESIGN: We conducted a retrospective, case-control study on 91 placentas from IVF pregnancies (36 from donor oocytes and 55 from non-donor cycles). All placentas were examined by a single pathologist for signs indicative of an immune response, including chronic villitis, chronic deciduitis, increased perivillous fibrin, ischemic change/infarction, decidual vasculopathy, increased syncytial knots, intervillous thrombi, and retroplacental hematomas. RESULTS: Placentas from donor cycles were significantly more likely to demonstrate certain pathologic findings: chronic villitis (P<0.001), chronic deciduitis (P=0.034), increased perivillous fibrin (P=0.001), ischemic change/ infarction (P=0.001), and intervillous thrombi (P =0.008). There was no statistical significance with respect to decidual vasculopathy, increased syncytial knots, or retroplacental hematomas. CONCLUSION: Pathologic evidence of an immune-mediated process is much more pronounced in donor oocyte IVF pregnancies compared to non-donor cycles. Clinical implications of these findings have yet to be determined.

Assessment of umbilical cord coiling during the routine fetal sonographic anatomic survey in the second trimester.

OBJECTIVE: The purpose of this study was to evaluate the sonographic accuracy to determine the umbilical coiling index (UCI) during the routine fetal anatomic survey in the second trimester. METHODS: In 300 consecutive women with singleton pregnancies and absence of gross fetal anomalies who had a routine second-trimester fetal anatomic survey, a distance between 2 pairs of coils was measured from the longitudinal images of the umbilical cord, and the antenatal UCI (aUCI) was calculated. The aUCI was compared with true UCI results obtained after birth. RESULTS: Two hundred thirty-six patients had adequate sonographic umbilical cord images, and all required demographic, antenatal, and labor data collection to meet the inclusion criteria. A statistically significant correlation between aUCI and true UCI was found (P < .0001; r = 0.643). The mean aUCI was 0.402 (80% confidence interval, 0.382), and the true UCI at birth was 0.203 (80% confidence interval, 0.176). The sonographic evaluation showed 12.3% and 8.9% of hypocoiled and hypercoiled cords, whereas evaluation at birth found 10.6% and 8.1% hypocoiled and hypercoiled umbilical cords, respectively. The sensitivity values of sonography to predict hypocoiling and hypercoiling at birth were 78.9% and 25.4%, respectively. CONCLUSIONS: A sonographic evaluation of umbilical cord coiling in the second trimester correlates with the true UCI at birth, although the sensitivity in predicting coiling patterns as hypocoiled and hypercoiled cords is less accurate. A difference between the aUCI and matched UCI at birth could be explained by a sonographic error in the sampling of different umbilical cord segments with discordant coiling patterns or the possibility of a dynamically evolving UCI with advancing gestational age.

Failure of conservative management of placenta previa-percreta.

We present a patient with a placenta previa in which we failed to manage conservatively with methotrexate and uterine embolization. The patient was diagnosed in the second trimester as having a possible placenta previa-increta,and underwent a repeat classical cesarean delivery at 32 weeks of gestation due to significant antepartum vaginal bleeding. Following abdominal closure,the uterine vessels were embolized with the Gel-Foam by interventional radiology. The placenta previa was left in-situ and patient was discharged home in stable condition in five days. The patient reported on the 44th postoperative day with heavy vaginal bleeding. A total abdominal hysterectomy was performed due to an unstable patient's hemodynamic condition in association with fluid resuscitation and multiple blood transfusions. The pathologic findings revealed a 675 g uterus with placenta previa-percreta with extension of chorionic villi to the serosal layer. Our case demonstrates a need for careful selection of patients with placenta previa and suspected accreta/increta/percreta that would be suitable candidates for conservative medical management. Patients who opt for conservative medical management should be informed about the possibility of catastrophic bleeding associated with a retained placenta, that would ultimately require blood transfusions and hysterectomy.

Association of amniotic fluid index with estimated fetal weight.

OBJECTIVE: The relationship between amniotic fluid volume and gestational age has been described previously. The association of body weight and urine output has been observed in human neonates. Our goal was to assess the correlation of the amniotic fluid index (AFI) with estimated fetal weight (EFW) in the third trimester. METHODS: We conducted a retrospective observational study on 426 pregnant women with singleton gestations who were referred to our unit for sonographic evaluation in the third trimester. The AFI, EFW, and EFW percentile corrected for gestational age were evaluated. The sonographic examinations were stratified into 3 gestational age categories: 28 through 33.9 weeks, 34 through 37.9 weeks, and 38 weeks and later. Maternal and fetal outcome variables were collected from medical records. Linear regression, Mann-Whitney U, and Kruskal-Wallis tests were used for statistical analysis. RESULTS: There was no significant relationship between the AFI and EFW in the entire group of patients (R = 0.08; P = .096). There was a significant relationship between the AFI and EFW after 38 weeks' gestation (R = 0.30; P = .003). In addition, in female fetuses the EFW percentile correlated with higher AFI values at all gestational ages (R = 0.31; P < .001); this, however, was not observed in male fetuses. CONCLUSIONS: There is no relationship between the AFI and EFW during the third trimester, although a positive relationship between the AFI and EFW was noted late in gestation. In pregnancies with female fetuses, the AFI was positively associated with EFW percentile before 38 weeks' gestation.

Atypical sonographic presentation of fetal unilateral inguinoscrotal hernia in a multiple gestation.

Ultrasonographic demonstration of bowel peristalsis within the fetal scrotum has been described as a pathognomonic sign of inguinoscrotal bowel herniation. We present the sonographic features and neonatal outcome of a fetus with a scrotal mass seen at 34 weeks of gestation in a twin pregnancy. This mass was diagnosed postnatally as a non-reducible inguinoscrotal hernia, in which bowel peristalsis had not been observed by real-time ultrasound in utero.

Fetal aneuploidy and umbilical cord thickness measured between 14 and 23 weeks' gestational age.

OBJECTIVE: To evaluate and compare umbilical cord thickness of aneuploid fetuses with umbilical cord diameter nomograms generated from euploid fetuses between 14 and 23 weeks' gestational age. METHODS: A retrospective study was conducted in which 56 fetuses and neonates had diagnoses of abnormal karyotypes, of which 46 fetuses had numerical chromosomal abnormalities. Among these cases, 26 subjects with adequate umbilical cord sonographic images were included in the study. The umbilical cord thickness was measured and plotted against the umbilical cord diameter nomogram that was generated from previously published data. RESULTS: From 26 evaluated fetuses and neonates, in 14 subjects (53.8%), the umbilical cord thickness was greater than the 95th percentile for gestational age. A thick umbilical cord was observed in 57.8% of fetuses with trisomy 21 and 50% of subjects with trisomy 18 and monosomy 45,XO. One fetus with trisomy 2 had umbilical cord thickness within the normal range. The largest number of aneuploid fetuses with thick umbilical cords (87.5%) was observed between 16 and 17 gestational weeks. CONCLUSION: Aneuploid fetuses have thicker umbilical cords than euploid fetuses. The umbilical cord thickness can be related to an increased amount of Wharton jelly. Because of the smaller number of thick umbilical cords in aneuploid subjects at later gestational ages, we speculate that abnormal cord thickness has a natural tendency toward its own resolution with the advancement of gestational age.