Antenatal corticosteroid treatment in singleton, small-for-gestational-age infants born at 24-31 weeks' gestation: a population-based study.

OBJECTIVE: To assess the impact of antenatal corticosteroid therapy on mortality and severe morbidities in preterm, small-for-gestational-age (SGA) neonates compared with preterm non-SGA neonates. DESIGN: Population-based study. SETTING/POPULATION: Israel National Very Low Birth Weight infant database from 1995-2012. METHODS: Singleton infants of 24-31 weeks' gestation, without major malformations. Antenatal corticosteroids were considered either any treatment or no treatment. MAIN OUTCOME MEASURES: Univariate and multivariable logistic regression analyses were performed to assess the effect of antenatal corticosteroids on neonatal mortality and a composite adverse outcome of mortality or severe neonatal morbidity. RESULTS: Among the 10 887 study infants, 1771 were SGA. Of these, 70.4% of SGA and 66.7% of non-SGA neonates were exposed to antenatal corticosteroids. Among SGA neonates, antenatal corticosteroids were associated with decreased mortality (32.2 versus 19.3%, P < 0.0001) and composite adverse outcome (54.1 versus 43.4%, P < 0.0001), similar to the effect in non-SGA neonates (mortality 26.7 versus 12.2%, P < 0.0001; composite outcome 50.5 versus 34.6%, P < 0.0001). Multivariable logistic regression analyses demonstrated a 50% reduction in mortality risk among SGA and 57% reduction in non-SGA neonates exposed to corticosteroids [OR = 0.50, 95% confidence interval (95% CI) 0.39-0.64 and OR = 0.43, 95% CI 0.38-0.47, respectively], P-value for interaction = 0.08. Composite adverse outcome risk was significantly reduced in SGA (OR = 0.67, 95% CI 0.54-0.83) and non-SGA infants (OR = 0.57, 95% CI 0.52-0.63), P-value for interaction = 0.04. CONCLUSIONS: Antenatal corticosteroids significantly reduced mortality and severe morbidities among preterm SGA neonates, with slightly a less pronounced effect compared with non-SGA preterm infants. Antenatal corticosteroids should be given to fetuses suspected of intrauterine growth retardation, at risk for preterm delivery, in order to improve perinatal outcome. TWEETABLE ABSTRACT: Antenatal steroids reduced mortality and severe morbidities among singleton, preterm SGA neonates.

Starry sky pattern of fetal liver sonogram as first sign of twin-twin transfusion syndrome.

'Starry sky' liver is one of the most common sonographic patterns in diffuse liver disease. It is characterized by clearly identified portal venules due to diminished parenchymal echogenicity. In advanced cases of twin-to-twin transfusion syndrome (TTTS), volume overload is considered the key factor in the pathogenesis of cardiac dysfunction of the recipient twin. When right-sided failure occurs, the liver might show signs of edema and, as in acute hepatitis, the appearance of starry sky might develop. We present a case in which the sonographic appearance of starry sky liver, along with right-sided cardiac failure (tricuspid regurgitation), were the first signs of TTTS in monochorionic twins at 20 weeks. A short time later, at 21 weeks, other signs of overload and signs of worsening heart failure were noted, as the typical triphasic waves in the inferior vena cava were replaced by a biphasic flow profile. Twin 2 at that time had relative oligohydramnios. A few days later, relative polyhydramnios and edema of the placental domain of the recipient twin were also noted. To the best of our knowledge, this is the first case report describing this hepatic sonographic pattern as an early sonographic sign of TTTS.

The role of umbilical cord alpha fetoprotein as a screening tool for neonatal hyperbilirubinemia.

Our aim was to test whether alpha fetoprotein (AFP) might serve as a marker of hepatic immaturity sufficient to predict an increased risk for neonatal hyperbilirubinemia (NHB) in term babies. We checked umbilical cord AFP (UC AFP) levels in 174 healthy full-term infants (male/female ratio 1.26:1) at birth. Bilirubin levels were measured upon discharge from the nursery on day 3 of life (mean, 57 +/- 10 hours of life). Mean UC AFP was 60.2 +/- 45.9 mg/L. UC AFP levels were linearly correlated with subsequent bilirubin levels, and significantly higher bilirubin levels were found in neonates whose UC AFP levels were 100 mg/L or more. Although statistically significant correlation between UC AFP and subsequent NHB exists, UC AFP cannot currently be recommended for use in clinical practice because of its inability to serve as a screening tool for significant NHB in the individual newborn.

Cerebrovascular reactivity in normal pregnancy and preeclampsia.

OBJECTIVE: To compare cerebrovascular reactivity in normotensive and preeclamptic pregnant women. METHODS: Transcranial Doppler ultrasound was used to measure peak, end-diastolic, and mean velocities in the middle cerebral arteries of 45 normotensive and 36 preeclamptic women in the third trimester. All measurements were done in the left lateral position at baseline, during 5% carbon dioxide (CO2) inhalation, and during an isometric hand-grip test. Blood pressure (BP), heart rate, oxygen (O2) saturation, and end-tidal partial pressure of carbon dioxide (pCO2) were recorded with each Doppler measurement. The mean pulsatility index (PI), resistance index (RI), and cerebral perfusion pressure at each time was compared using two-way repeated measures analysis of variance. Cerebrovascular reactivity, calculated as the percentage change in response to each maneuver, was also compared using analysis of covariance. A post hoc power analysis was performed to evaluate the primary measures of the study (middle cerebral artery PI and RI). Using alpha error of 5%, the statistical power to identify a difference in PI and RI in women with preeclampsia compared with normotensive women was 90% and 67%, respectively. The statistical power to identify a difference in PI and RI in response to the two maneuvers was 69% and 53%, respectively. Statistical significance was set at P <.05. RESULTS: Preeclamptic women had higher baseline cerebral perfusion pressure (90.4 compared with 61.9 mmHg, P <.05) and lower PI (0.64 compared with 0.76, P <.05) and RI (0.46 compared with 0.51, P <.05) than normotensive pregnant women. In normotensive patients, both 5% CO2 inhalation and isometric hand-grip test caused a significant decrease in PI (-9.5% and -6.1%, respectively) and RI (-6.5% and -4.2%, respectively). In contrast, in preeclamptic patients there was no change in any of the middle cerebral artery parameters in response to either maneuver. CONCLUSION: Normotensive pregnant women had normal middle cerebral artery responses to both 5% CO2 inhalation and isometric hand-grip test. Preeclamptic patients had elevated baseline cerebral perfusion pressure and reduced vasodilatory responses to both tests. These findings are consistent with a state of vasoconstriction in preeclamptic women that is unresponsive to stimuli that under normal circumstances result in vasodilation.

Cervical ripening.

Induction of labor is indicated when the benefits to either the mother or the fetus outweigh the benefits of continuing the pregnancy. The state of the cervix is clearly related to the success of labor induction and the duration of labor. In cases of unfavorable cervices, physicians usually use a ripening agent before inducing labor. Unfortunately, as reviewed in this article, the ideal ripening agent is not found yet. No method of cervical ripening has shown a consistent and significant reduction in CS rate. In fact, women with the most unfavorable cervices (Bishop score, < or = 2) still face high rates of induction failure and CS.

Autonomic imbalance in preeclampsia: evidence for increased sympathetic tone in response to the supine-pressor test.

OBJECTIVE: To examine whether an increase in sympathetic nervous tone contributes to the augmented response to cardiovascular reflex testing in preeclamptic women. METHODS: Maternal electrocardiograms were recorded from 11 nonpregnant women and 25 normotensive and 15 preeclamptic nulliparous women at term, during periods of quiet respiration in the left-lateral position and after shifting to the supine position. Power spectral analysis was applied to epochs of 512 consecutive beat-to-beat intervals to determine the contribution of sympathetic tone, parasympathetic tone, and respiratory sinus arrhythmia to heart rate variability. RESULTS: Both normotensive and preeclamptic pregnant women showed a significant decrease in respiratory sinus arrhythmia and an increase in sympathetic tone compared with nonpregnant women. In nonpregnant and in normotensive pregnant women, shifting from the left-lateral to the supine position did not cause any change in autonomic characteristics. In contrast, preeclamptic women demonstrated a marked increase in power within the very low-frequency range representing sympathetic tone, from 288 +/- 214 to 556 +/- 322 second2/Hz, in response to the same challenge (P < .05). CONCLUSION: Third-trimester pregnancy is characterized by sympathetic overactivity. When complicated by preeclampsia, sympathetic overreactivity to cardiovascular reflex testing is observed. Our data support the notion that the pathophysiologic phenomena that characterize preeclampsia are mediated not only by circulating or locally acting vasoactive substances, but also, at least in part, by an increase in sympathetic nervous tone.

In utero diagnosis of intrapericardial teratoma: a case for in utero open fetal surgery.

We present a case of intrapericardial teratoma diagnosed by ultrasound at 26 weeks of gestation presenting as a large tumour mass and rapid development of hydrops fetalis. The fetus died in utero one day before scheduled open fetal surgery.