Large fetal size in early pregnancy associated with macrosomia.

OBJECTIVE: To assess if fetal size at the time of ultrasound dating examination is associated with the risk of macrosomia and complications associated with macrosomia. METHODS: This was a retrospective cohort study of 19 377 singleton pregnancies dated in gestational weeks 16-20 during the period 1998-2004 at Danderyd Hospital, Stockholm, Sweden. Obstetric outcome was assessed through linkage to the Swedish Medical Birth Register. RESULTS: When fetuses were > or = 7 days larger than expected at dating, compared with the expected size according to last menstrual period, there was a 59% increase in the risk of birth weight > or = 4500 g and a 145% increase in the risk of birth weight > or = 5000 g (odds ratio (OR), 1.59; 95% CI, 1.12-2.24 and OR, 2.45; 95% CI, 1.22-4.90, respectively). For a birth weight of > or = 4000 g the risk estimate was 1.19 (95% CI, 0.96-1.47). CONCLUSION: Fetuses that are larger than expected in the second trimester have an increased risk of macrosomia. This emphasizes that fetal size in early pregnancy is not only a function of gestational duration, but also of fetal growth. However, only a limited proportion of all infants born macrosomic can be identified as such at the time of ultrasound dating.

Expected day of delivery from ultrasound dating versus last menstrual period--obstetric outcome when dates mismatch.

OBJECTIVE: To analyse the association between fetal size at time of dating ultrasound and risk for preterm delivery and small-for-gestational-age (SGA) birth and to evaluate if timing of ultrasound, that is before 14 weeks of gestation or after 16 weeks affects this association. DESIGN: Retrospective cohort study. SETTING: Ultrasound departments of Ultragyn, Stockholm, Sweden. POPULATION: A total of 28,776 singleton pregnancies dated between 1998 and 2004. METHODS: Obstetric outcome was assessed through linkage of the cohort to the Swedish Medical Birth Register. MAIN OUTCOME MEASURES: Risks of preterm delivery, low birthweight for gestational age, pre-eclampsia, asphyxia, respiratory distress, instrumental delivery, caesarean section, and postterm birth were calculated for the groups dated early and late. RESULTS: When the expected date of delivery was postponed after ultrasound dating by 7 days or more, there was an increased risk for preterm delivery and pre-eclampsia in the late dating group (OR 1.49, 95% CI 1.27-1.73 and OR 1.27, 95% CI 1.02-1.60, respectively) but not in the early dating group. In both dating groups, there was an increased risk for SGA birth (OR 1.77, 95% CI 1.13-2.78 and OR 2.09, 95% CI 1.59-2.73, respectively) There was no increased risk for any of the other diagnoses. CONCLUSION: Our study gives further support to the notion that intrauterine growth restriction may be present as early as the first trimester. Accordingly, our study also suggests that surveillance of pregnancies with postponed estimated date of delivery may provide means for increased detection of fetal growth restriction.

Miscarriage after a normal scan at 12-14 gestational weeks in women at low risk of carrying a fetus with chromosomal anomaly according to nuchal translucency screening.

OBJECTIVES: To estimate the risk of second-trimester miscarriage in women with low risk of carrying a fetus with chromosomal abnormality, according to nuchal translucency (NT) screening, and to determine whether NT thickness or other factors affect the risk. METHODS: The study population comprised 14 278 singleton pregnancies with a risk of Down syndrome < 1:250 at NT scan, and where no fetal karyotyping was performed < 25 weeks. Risk factors for miscarriage were investigated by logistic regression. RESULTS: The median risk of Down syndrome was 1 : 3138 (range 1 : 9651-1 : 251) and median NT was 1.7 (range 0.4-3.0) mm. The miscarriage rate was 0.5% (77/14 278; 95% CI 0.4-0.6). After having controlled for maternal age, we found the number of previous deliveries and miscarriages to independently predict miscarriage: odds ratio (OR) for each previous delivery 1.48, 95% CI 1.22-1.94, P < 0.0001; OR for each previous miscarriage 1.34, 95% CI 1.07-1.68, P = 0.01. Excluding women with any previous miscarriage and adjusting for parity, we found a U-shaped relationship between maternal age and miscarriage (P = 0.04). CONCLUSION: In singleton pregnancies with estimated risk of Down syndrome < 1:250 according to NT screening at 12-14 weeks, the spontaneous fetal loss rate before 25 weeks is likely to be around 0.5%. NT thickness up to 3 mm does not seem to affect the risk of miscarriage in such pregnancies. Instead, the risk seems to increase with number of previous miscarriages and deliveries, and possibly the risk is highest in the youngest and oldest women.

By how much does increased nuchal translucency increase the risk of adverse pregnancy outcome in chromosomally normal fetuses? A study of 16,260 fetuses derived from an unselected pregnant population.

OBJECTIVE: In this study we aimed to estimate the magnitude of a possible increase in risk of adverse outcome in fetuses with normal karyotype and increased nuchal translucency (NT), and to determine how well NT measurements can distinguish between fetuses with normal and adverse outcome. METHODS: We studied 16,260 consecutive fetuses with normal karyotype derived from an unselected pregnant population. The following cut-offs for increased risk of adverse outcome were chosen a priori: NT > or = 95th percentile, > or = 3 mm, > or = 3.5 mm, and > or = 4.5 mm. The positive and negative likelihood ratios (+LR, - LR) of the risk cut-offs with regard to fetal malformation, miscarriage, perinatal death, termination of pregnancy and total adverse outcome were calculated, and receiver-operating characteristics (ROC) curves were drawn. RESULTS: The total rate of adverse outcome was 2.7%. + LR and - LR of NT > or = 3.0 mm were: for lethal or severe malformation, + LR 15.0 (95% CI 7.0-28.6), - LR 0.89 (95% CI 0.81-0.95); for malformation of at least intermediate severity, + LR 8.1 (95% CI 4.3-14.0), - LR 0.95 (95% CI 0.92-0.97); for termination of pregnancy, + LR 41.6 (95% CI 17.1-86.6), - LR 0.67 (95% CI 0.41-0.85); for any adverse outcome, + LR 6.4 (95% CI 3.4-11), - LR 0.96 (95% CI 0.94-0.98). The odds for these adverse outcomes increased with increasing NT. NT > or = 3 mm did not significantly increase the risk of miscarriage or perinatal death. Areas under ROC curves for NT were small, with 95% CI below or only slightly above 0.5. CONCLUSION: Our likelihood ratios can be used to calculate the individual risk of unfavorable outcome, but NT screening cannot reliably distinguish between normal and adverse outcome in fetuses with normal karyotype.

Detection of malformations in chromosomally normal fetuses by routine ultrasound at 12 or 18 weeks of gestation-a randomised controlled trial in 39,572 pregnancies.

OBJECTIVE: To compare the antenatal detection rate of malformations in chromosomally normal fetuses between a strategy of offering one routine ultrasound examination at 12 gestational weeks (gws) and a strategy of offering one routine examination at 18 gws. DESIGN: Randomised controlled trial. SETTING: Multicentre trial including eight hospitals. POPULATION: A total of 39,572 unselected pregnant women. METHODS: Women were randomised either to one routine ultrasound scan at 12 (12-14) gws including nuchal translucency (NT) measurement or to one routine scan at 18 (15-22) gws. Anomaly screening was performed in both groups following a check-list. A repeat scan was offered in the 12-week scan group if the fetal anatomy could not be adequately seen at 12-14 gws or if NT was >or=3.5 mm in a fetus with normal or unknown chromosomes. MAIN OUTCOME MEASURES: Antenatal detection rate of malformed fetuses. RESULTS: The antenatal detection rate of fetuses with a major malformation was 38% (66/176) in the 12-week scan group and 47% (72/152) in the 18-week scan group (P= 0.06). The corresponding figures for detection at <22 gws were 30% (53/176) and 40% (61/152) (P= 0.07). In the 12-week scan group, 69% of fetuses with a lethal anomaly were detected at a scan at 12-14 gws. CONCLUSIONS: None of the two strategies for prenatal diagnosis is clearly superior to the other. The 12-week strategy has the advantage that most lethal malformations will be detected at <15 gws, enabling earlier pregnancy termination. The 18-week strategy seems to be associated with a slightly higher detection rate of major malformations, although the difference was not statistically significant.

Routine ultrasound examination at 12 or 18 gestational weeks for prenatal detection of major congenital heart malformations? A randomised controlled trial comprising 36,299 fetuses.

OBJECTIVE: To compare the rate of prenatal diagnosis of heart malformations between two policies of screening for heart malformations. DESIGN: Randomised controlled trial. SETTING: Six university hospitals, two district general hospitals. SAMPLE: A total of 39 572 unselected pregnancies randomised to either policy. METHODS: The 12-week policy implied one routine scan at 12 weeks including measurement of nuchal translucency (NT), and the 18-week policy implied one routine scan at 18 weeks. Fetal anatomy was scrutinised using the same check-list in both groups, and in both groups, indications for fetal echocardiography were ultrasound findings of any fetal anomaly, including abnormal four-chamber view, or other risk factors for heart malformation. In the 12-week scan group, NT >or=3.5 mm was also an indication for fetal echocardiography. MAIN OUTCOME MEASURE: Prenatal diagnosis of major congenital heart malformation. RESULTS: In the 12-week scan group, 7 (11%) of 61 major heart malformations were prenatally diagnosed versus 9 (15%) of 60 in the 18-week scan group (P= 0.60). In four (6.6%) women in the 12-week scan group, the routine scan was the starting point for investigations resulting in a prenatal diagnosis versus in 9 (15%) women in the 18-week scan group (P=0.15). The diagnosis was made

Is measurement of nuchal translucency thickness a useful screening tool for heart defects? A study of 16,383 fetuses.

OBJECTIVE: To determine the performance of nuchal translucency thickness (NT) measurement as a screening method for congenital heart defects (CHD) among fetuses with normal karyotype. METHODS: An NT measurement was made in 16 383 consecutive euploid fetuses derived from an unselected pregnant population. The cut-offs for increased risk of heart defects, chosen a priori and tested prospectively, were: NT >or= 95th centile for crown-rump length, NT >or= 3 mm, and NT >or= 3.5 mm. The sensitivity and false-positive rate (FPR; 1 minus specificity) of the risk cut-offs and their positive and negative likelihood ratios (+LR and -LR) with regard to CHD were calculated. RESULTS: Among the 16 383 fetuses with an NT measurement there were 127 cases with a diagnosis of heart defect confirmed by cardiac investigations after birth or at autopsy. Of these, 55 defects were defined as major, of which 52 were isolated (no other defects or chromosomal aberrations), corresponding to a prevalence of major heart defects in chromosomally normal fetuses/newborns of 3.3/1000. The sensitivity, FPR, +LR and -LR for NT >or= 95th centile with regard to an isolated major heart defect were: 13.5%, 2.6%, 5.2 and 0.9, respectively. For NT >or= 3.0 mm these values were: 9.6%, 0.8%, 12.0 and 0.9, and for NT >or= 3.5 mm they were: 5.8%, 0.3%, 19.3 and 0.9. CONCLUSIONS: NT measurement is a poor screening method for isolated major CHD. A method with a much higher detection rate and with a reasonably low FPR is needed. However, increased NT indicates increased risk of fetal heart defect, and women carrying fetuses with increased NT should be offered fetal echocardiography in the second trimester.

Ultrasound dating at 12-14 weeks of gestation. A prospective cross-validation of established dating formulae in in-vitro fertilized pregnancies.

OBJECTIVES: To determine the accuracy of established ultrasound dating formulae when used at 12-14 weeks of gestation. METHODS: One-hundred and sixty-seven singleton pregnancies conceived after in-vitro fertilization (IVF) underwent a dating scan at 12-14 weeks of gestation. Gestational age at the dating scan was calculated by adding 14 days to the number of days between the date of oocyte retrieval and the date of the ultrasound scan. Gestational age according to oocyte retrieval was regarded as the true gestational age. True gestational age was compared to gestational age calculated on the basis of 21 dating formulae based on fetal crown-rump length (CRL) measurements and to three dating formulae based on fetal biparietal diameter (BPD) measurements. In a previous study the three BPD formulae tested here had been shown to be superior to four other BPD formulae when used at 12-14 weeks of gestation. The mean of the differences between estimated and true gestational age and their standard deviation (SD) were calculated for each formula. The SD of the differences was assumed to reflect random measurement error. Systematic measurement error was assumed to exist if zero lay outside the mean difference+/-2SE (SE: standard error of the mean). RESULTS: The three best CRL formulae were associated with mean (non-systematic) measurement errors of -0.0, -0.1 and -0.3 days, and the SD of the measurement errors of these formulae varied from 2.37 to 2.45. All but two of the remaining CRL formulae were associated with systematic over- or under-estimation of gestational age, and the SDs of their measurement error varied between 2.25 and 4.86 days. Dating formulae using BPD systematically underestimated gestational age by -0.4 to -0.7 days, and the SDs of their measurement errors varied from 1.86 to 2.09. CONCLUSIONS: We have identified three BPD formulae that are suitable for dating at 12-14 weeks of gestation. They are superior to all 21 CRL formulae tested here, because their random measurement errors were much smaller than those of the three best CRL formulae. The small systematic negative measurement errors associated with the BPD formulae are likely to be clinically unimportant.

Screening for Down syndrome based on maternal age or fetal nuchal translucency: a randomized controlled trial in 39,572 pregnancies.

OBJECTIVES: Nuchal translucency (NT) screening increases antenatal detection of Down syndrome (DS) compared to maternal age-based screening. We wanted to determine if a change in policy for prenatal diagnosis would result in fewer babies born with DS. METHODS: A total of 39,572 pregnant women were randomized to a scan at 12-14 gestational weeks including NT screening for DS (12-week group) or to a scan at 15-20 weeks with screening for DS based on maternal age (18-week group). Fetal karyotyping was offered if risk according to NT was > or = 1:250 in the 12-week group and if maternal age was > or = 35 years in the 18-week group. Both policies included the offer of karyotyping in cases of fetal anomaly detected at any scan during pregnancy or when there was a history of fetal chromosomal anomaly. The number of babies born with DS and the number of invasive tests for fetal karyotyping were compared. RESULTS: Ten babies with DS were born alive with the 12-week policy vs. 16 with the 18-week policy (P = 0.25). More fetuses with DS were spontaneously lost or terminated in the 12-week group (45/19,796) than in the 18-week group (27/19 776; P = 0.04). All women except one with an antenatal diagnosis of DS at < 22 weeks terminated the pregnancy. For each case of DS detected at < 22 weeks in a living fetus there were 16 invasive tests in the 12-week group vs. 89 in the 18-week group. NT screening detected 71% of cases of DS for a 3.5% test-positive rate whereas maternal age had the potential of detecting 58% for a test-positive rate of 18%. CONCLUSIONS: The number of newborns with DS differed less than expected between pregnancies that had been screened at 12-14 weeks' gestation by NT compared with those screened at 15-20 weeks by maternal age. One explanation could be that NT screening--because it is performed early in pregnancy--results in the detection and termination of many pregnancies with a fetus with DS that would have resulted in miscarriage without intervention, and also by many cases of DS being detected because of a fetal anomaly seen on an 18-week scan. The major advantage of the 12-week scan policy is that many fewer invasive tests for fetal karyotyping are needed per antenatally detected case of DS.

Ultrasound dating at 12-14 or 15-20 weeks of gestation? A prospective cross-validation of established dating formulae in a population of in-vitro fertilized pregnancies randomized to early or late dating scan.

OBJECTIVES: To determine the accuracy of established ultrasound dating formulae when used at 12-14 and 15-20 gestational weeks. METHODS: A total of 363 singleton pregnancies conceived after in-vitro fertilization (IVF) and randomized to a dating scan at 12-14 or 15-20 gestational weeks were studied. 'True' gestational age was calculated on the basis of the day of oocyte retrieval and was compared to gestational age calculated on the basis of seven dating formulae including the fetal biparietal diameter (BPD) and three dating formulae including BPD and fetal femur length (FL). The mean of the differences between estimated and true gestational age (systematic measurement error) and their SD (random measurement error) were calculated for each formula. RESULTS: Three formulae showed systematic errors of less than -0.7 days at both early and late scanning. Two formulae overestimated gestational age at both early and late scanning by 5.7 and 3.1 vs. 2.3 and 2.8 days, respectively, while five formulae manifested very different systematic errors at early and late scanning. The formulae used for clinical management underestimated gestational age by a mean of 3 days when dating was performed at 12-14 weeks, and by a mean of 0.8 days when dating was done at 15-20 weeks. The random error was on average 1 day less when the scan was carried out early (2 vs. 3 days; P < 0.0005). Mean true gestational age at delivery in IVF pregnancies with spontaneous start of labor was 279 days (SD 12.9); excluding preterm deliveries it was 281 days (SD 8.1). CONCLUSIONS: Ultrasound dating formulae originally intended for use in the middle of the second trimester do not necessarily perform well when used for dating earlier in gestation. The systematic and random error of any dating formula must be assessed for the gestational age interval in which the formula is intended to be used.

Fetal loss rate after second trimester amniocentesis at different gestational age.

BACKGROUND: Recent studies have debated the safety of early amniocentesis, one of which reported a significant increase in spontaneous fetal losses following amniocentesis performed at 10-13 weeks of gestation. The aim of this study was to determine the fetal loss rate following amniocentesis performed at different stages in the second trimester. METHODS: One thousand six hundred and fifty-one consecutive amniocenteses undertaken in a low risk population between 13 weeks+0 days and 20 weeks+6 days were evaluated. In 87% of the women the reason for testing was maternal age (mean 37.1 years). Data concerning patients, procedure details and pregnancy outcome were recorded. RESULTS: Spontaneous abortion before 28 weeks of gestation occurred in 1.1%, one third of which were within two weeks and the remaining within seven weeks after the procedure. The fetal loss rate was higher when the amniocentesis was performed earlier in pregnancy, at 13 weeks+0 days exceeding 3%. Abnormal color of the amniotic fluid and leakage of amniotic fluid were strong predictors of fetal loss. Transplacental needle insertion did not increase the risk of pregnancy loss. CONCLUSION: Amniocentesis performed very early in the second trimester is followed by an increased fetal loss rate that cannot be explained solely by a higher risk of spontaneous abortion at this time of gestation.

Doppler echocardiographic assessment of fetal blood flow redistribution during maternal hyperoxygenation.

Sixteen normal human fetuses were studied at both 20-23 and 30-33 weeks of gestation to investigate whether hemodynamic changes in the heart and major fetal arteries occurred in response to maternal hyperoxygenation in normal pregnancy. Velocity waveforms from the mitral valve, aortic valve, middle cerebral artery, aortic isthmus and umbilical artery were recorded before and during maternal breathing of 100% oxygen. The cerebral artery pulsatility index (PI) increased with oxygen administration at the first examination (1.56 +/- 0.25, mean +/- 1 SD, to 1.72 +/- 0.28, p < 0.05). At the second examination this increase in cerebral artery PI was more consistent (1.89 +/- 0.43 to 2.22 +/- 0.43, p < 0.001) and there was also a decrease in the aortic isthmus PI (2.64 +/- 0.43 to 2.40 +/- 0.33, p < 0.01) during oxygen administration. The variables determined from the velocity waveforms of the umbilical artery, aortic and mitral valve did not show any changes with maternal hyperoxygenation. Maternal hyperoxygenation resulted in velocity waveform changes suggesting an increase of cerebral vascular resistance and a redistribution of blood flow from the brain to the vascular beds supplied by the descending aorta in the normal human fetus in the third trimester, but this response was less obvious at mid-gestation. The middle cerebral artery and the aortic isthmus seem to be suitable sites for verification of this response.

Serial antenatal monitoring compared with labor induction in post-term pregnancies.

OBJECTIVE: In view of the increased risk of obstetric and perinatal complications in post-term pregnancy, and the lack of consensus regarding clinical routines for fetal surveillance and labor induction, the aim of this prospective controlled study was to compare obstetric and perinatal outcome after serial monitoring until 43 weeks of gestation with that after labor induction at 42 gestational weeks. MATERIALS AND METHODS: A study group of 193 gravidae scheduled for serial monitoring until 43 weeks of gestation was compared with a control group of 205 gravidae admitted for induction of labor at 42 weeks. A third, high-risk, group comprised gravidae (from either of the foregoing groups) who had to be admitted for emergency induction of labor owing to increased fetal risk (i.e., the presence of oligohydramnios or a small-for-gestational-age fetus). RESULTS: The frequency of labor induction was significantly lower in the study group than among controls (p < 0.001), but the two groups did not differ in obstetric or perinatal outcome. As compared with these two low-risk groups, the high-risk group was characterized by significantly higher frequencies of instrumental delivery (p < 0.01), operative delivery for fetal distress (p < 0.001) and infants requiring neonatal intensive care (p < 0.001). CONCLUSION: As the wait-and-see policy with serial monitoring resulted in a lower rate of labor induction, but not in a lower rate of instrumental delivery or perinatal complication, medically the two routines would appear to be comparable. However, an individual approach with intensified fetal surveillance is to be recommended, as it is vital to identify post-term pregnancies where the fetus is at increased risk. The use of such new techniques as umbilical artery flow velocimetry would no doubt improve the management of high-risk post-term pregnancies.

Umbilical artery velocimetry may influence clinical interpretation of intrapartum cardiotocograms.

BACKGROUND: In a previous prospective randomised trial on pregnancies complicated by small-for-gestational-age fetuses fewer operative deliveries for fetal distress were found after antenatal surveillance with umbilical artery Doppler velocimetry (Doppler group) than after surveillance with cardiotocography (CTG group). Despite that, the neonatal outcome was similar in both groups. This raised the question whether the knowledge of the antenatal Doppler results had influenced the obstetric management of labor. METHODS: In this retrospective study 242 intrapartum cardiotocogram tracings, obtained from the above mentioned prospective trial, were re-interpreted by an expert without knowledge of the results in the original study. The re-interpretation was then compared to the original interpretation. RESULTS: The expert interpreted 18 intrapartum tracings in the Doppler group and 18 in the CTG group as abnormal, whereas the clinicians interpreted only 8 tracings as abnormal in the Doppler group and 18 tracings in the CTG group. CONCLUSIONS: The results of this retrospective study lend support to our hypothesis that the obstetricians in clinical practice are influenced by the knowledge of a normal umbilical Doppler velocimetry when interpreting an intrapartum CTG. This finding may partly explain why there were fewer emergency cesarean sections for fetal distress in the Doppler group than in the CTG group in the original prospective study.

Value of uterine artery Doppler in endometrial cancer.

Twenty-seven women with endometrial cancer were studied with Doppler ultrasound coupled with a vaginal probe. Pulsatility index of the flow velocity of the uterine artery was recorded and compared to that of a control group. The subjects and the controls did not differ in blood flow measurements. There was no correlation between severity of disease and flow velocimetry values. Eleven of the patients underwent brachytherapy prior to surgery. Administration of brachytherapy resulted in a decrease of the peripheral resistance. The results of this study indicate that Doppler velocimetry of the uterine artery is not a valuable tool in discriminating between malignant and benign endometrium.

Comparison of umbilical-artery velocimetry and cardiotocography for surveillance of small-for-gestational-age fetuses.

Intrauterine growth retardation is associated with an increased risk of fetal asphyxia as well as greater perinatal morbidity and mortality. Ultrasound fetometry enables detection of fetuses that are small for gestational age. Doppler velocimetry of the umbilical artery has good predictive ability for fetal distress, but it is not yet clear whether it could replace cardiotocography in antenatal surveillance of small-for-gestational-age fetuses. We have done a randomised comparison of the two methods. At four obstetric departments in Sweden, women with fetuses found to be small on ultrasound examination at 31 completed weeks of pregnancy or later were randomly assigned to antenatal surveillance with either doppler velocimetry (doppler; 214) or cardiotocography (CTG; 212). Pregnancies in the doppler group were managed according to a protocol based on blood-flow classes deriving from the semiquantitative evaluation of umbilical-artery velocity waveforms; unless the pregnancy was complicated by any other disorder, no antenatal cardiotocography was done. By comparison with the CTG group, the doppler group had fewer monitoring occasions (mean 4.1 [SD 3.1] vs 8.2 [6.2], p < 0.01), antenatal hospital admissions (68 [31.3%] vs 97 [45.8%], p < 0.01), inductions of labour (22 [10.3%] vs 46 [21.7%], p < 0.01), emergency caesarean sections for fetal distress (11 [5.1] vs 30 [14.2%], p < 0.01), and admissions to neonatal intensive care (76 [35.5%] vs 92 [43.4%], p = 0.10). The groups did not differ in gestational age at birth, birthweight, Apgar scores, or total number of caesarean deliveries. Umbilical-artery doppler velocimetry of small-for-gestational-age fetuses allows antenatal monitoring and obstetric interventions to be aimed more precisely than does cardiotocography.

Preinductive cervical ripening with PgE2 gel in term pregnant women with ultrasonically diagnosed intra-uterine growth-retarded fetuses.

Intra-uterine growth retardation (IUGR), often combined with other pregnancy-related complications, constitutes a rather common indication for labor induction. The objective of this prospective study was to evaluate a strict intracervical application of 0.5 mg PgE2 in gel for cervical ripening and labor induction. Eighty term pregnant women with an ultrasonically diagnosed IUGR (less than -2 SD) and an unripe cervix were given PgE2-gel. The main indication for labor induction was IUGR, but 26 women had other complications. IUGR was verified at delivery in 50 women (study group), whereas 30 women (control group) gave birth to infants of normal birth weight (greater than -2 SD). The cervical ripening effect did not differ between the groups. In the study group, 19 nulliparous and 15 parous women out of 50 had a favorable cervix after 12 h and were delivered within 24 h of gel application. The corresponding result for the control group was 11 nulliparous and 8 parous women out of 30. Failed induction was registered in 2 and one woman respectively. On the other hand, the number of instrumental deliveries was greater in the study group, 11 caesarean sections (CS) and seven ventouses, compared with one CS and three ventouses in the control group (p less than 0.05). The frequency of operative deliveries for fetal distress (ODFD) was higher among the women with verified IUGR (14/50) than in the controls, where the corresponding figure was 3/30. No side effects were observed. We conclude that strict intracervical application of 0.5 mg PgE2 is a safe and effective method for cervical ripening and labor induction in women with IUGR.

Sonographic localization of an intramurally placed intratubal device--the P-block.

Hysteroscopical application of hydrogelic non-medicated occlusive devices, P-blocks, in the intramural part of the human fallopian tube has become an alternative to abdominal sterilization. The check-up procedure involved repeated hysteroscopies at certain intervals. These check-ups had to be confined to the early proliferative phase of the menstrual cycle in order to get maximum vision. In view of this and as the number of patients increased, practical and administrative problems arose. The need for other methods to check the P-blocks in situ after the first insertion and later became very urgent. Linear-array ultrasound and hysterosalpingography were tried, both methods failing to reveal the exact intramural position of the P-blocks. Finally, transabdominal scanning by use of modern sonographic equipment (phase array electronic sector system) made it possible to detect the exact position of the P-blocks. Furthermore, transvaginal examination appeared to have a very high sensitivity as well as specificity even in cases with sharply retroflected uteri. Our achievements in the field of sonographic examination of intratubal devices are presented.

Maternal perception of sound-provoked fetal movements as a measure of fetal well-being.

Maternal perception of sound-provoked fetal movements was studied on 613 occasions in 259 risk pregnancies. The response was compared with a non-stress (N-S) test performed immediately after the sound stimulation. A positive response to sound stimulation, recorded as a fetal movement by the mother, occurred on 534 occasions (87%) and was always accompanied by a normal N-S test; sensitivity 100%. An inconclusive (3%) or negative response to sound (10%) had a specificity of 89% and a predictive value for a pathological N-S test of 19%. There was a positive correlation between inconclusive or negative test results and fetal growth retardation (P less than 0.01), fetal hypoxia (P less than 0.05) and neonatal mortality (P less than 0.05). This rapid test may have a place as a simple first-line screening test.