Adverse outcome following selective termination of presenting twin vs non-presenting twin.

OBJECTIVE: Data are lacking on the impact on pregnancy outcome of the position of the abnormal fetus in a discordant twin pregnancy undergoing selective termination (ST). Tissue maceration post ST of the presenting twin may lead to early rupture of membranes, amnionitis and preterm labor. The aim of this study was to evaluate pregnancy complications and outcome following ST of the presenting vs non-presenting twin. METHODS: This was a multicenter retrospective cohort study of dichorionic diamniotic twin pregnancies that underwent ST due to a discordant fetal anomaly (structural or genetic) between 2007 and 2021. The study population was divided into two groups according to the position of the reduced twin (presenting or non-presenting) and outcomes were studied accordingly. The primary outcome was a composite of early complications following ST, including infection, preterm prelabor rupture of membranes and pregnancy loss. RESULTS: A total of 190 dichorionic twin pregnancies were included, of which 73 underwent ST of the presenting twin and 117 of the non-presenting twin. The groups did not differ in either baseline demographic characteristics or mean gestational age at the time of the procedure. ST of the presenting twin resulted in a significantly higher rate of early complications compared with the non-presenting twin (19.2% vs 7.7%; P = 0.018). Moreover, the rates of preterm delivery (75.3% vs 37.6%; P < 0.001) and neonatal intensive care unit admission (45.3% vs 17.1%; P < 0.001) were higher, and birth weight was lower (P < 0.001), in those pregnancies in which the presenting twin was reduced. CONCLUSIONS: ST of the presenting twin resulted in a higher rate of adverse pregnancy outcome compared with that of the non-presenting twin. These findings should be acknowledged during patient counseling and, if legislation permits, taken into consideration when planning ST. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Sliding sign in third-trimester sonographic evaluation of intra-abdominal adhesions in women undergoing repeat Cesarean section: a novel technique.

OBJECTIVE: Intra-abdominal adhesions are associated with an increased risk of complications during repeat Cesarean section (CS), such as bladder and bowel injury, hemorrhage, infection and hysterectomy. We present a simple sonographic marker, the 'sliding sign' of the uterus, for the prediction of intra-abdominal adhesions in the third trimester of pregnancy in women undergoing repeat CS. METHODS: This was a prospective observational study of pregnant women with a history of at least one Cesarean delivery evaluated by transabdominal ultrasound during the third trimester of an ongoing pregnancy. In order to diagnose intra-abdominal adhesions, we assessed a sonographic sign, the sliding of the uterus under the inner part of the fascia of the abdominal muscles during deep breathing. Women were considered to be at high risk for severe adhesions if uterine sliding was absent and at low risk in the presence of obvious or moderate uterine sliding. A comparison between sonographic findings and intra-abdominal adhesions observed during surgery was performed. RESULTS: Of the 63 patients with one or more previous CS examined, 59 completed the study and underwent CS at our institution. In 16 of the 19 cases assigned to the high-risk group for severe adhesions due to absence of sliding of the uterus, the suspicion was confirmed at surgery. The prediction of low risk for adhesions was confirmed in 35 out of 40 patients. The sensitivity and specificity of the sliding sign in predicting presence of intra-abdominal adhesions in women undergoing repeat CS were 76.2% and 92.1%, respectively. Inter- and intraobserver correlation using Cohen's kappa coefficient were 0.52 and 0.77, respectively. CONCLUSION: Our data show that a simple sonographic sign might be able to discriminate between high and low risk for intra-abdominal adhesions in patients with a history of Cesarean delivery. This technique may aid clinical decisions in patients undergoing repeat CS. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Nitrogen Dioxide pollution and hazardous household environment: what impacts more congenital malformations.

Nitrogen Dioxide (NO2) is a product of fuel combustion originating mainly from industry and transportation. Studies suggest an association between NO2 and congenital malformations (CM). We investigated an independent effect of NO2 on CM by adjusting to individual factors and household environment in 1024 Bedouin-Arab pregnant women in southern Israel. This population is characterised by high rates of CMs, frequent consanguineous marriages, paternal smoking, temporary housing and usage of open fire for heat cooking. Information on household risk factors was collected during an interview. Ambient measurements of 24-h average NO2 and meteorological conditions were obtained from 13 local monitors. Median value of daily NO2 measured in the area was 6.78ppb. CM was diagnosed in 8.0% (82) of offspring. Maternal NO2 exposure during the 1st trimester >8.6ppb was significantly associated with minor CM (RR=2.68, p=0.029). Major CM were independently associated with maternal juvenile diabetes (RR=9.97, p-value=0.002) and heating by open fire (RR=2.00, p-value=0.049), but not NO2 exposure. We found that NO2 emissions had an independent impact only on minor malformations, whereas major malformations depended mostly on the household environment. Antepartum deaths were associated by maternal morbidity.

Polyhydramnios and adverse perinatal outcome - what is the actual cutoff?

OBJECTIVE: The purpose of this study was to evaluate the association between amniotic fluid index (AFI) and adverse perinatal outcome, and whether a critical cutoff can be defined. METHODS: A retrospective cohort study was conducted. Included were patients who were admitted to the ultrasound unit of the tertiary medical center between the years 1988 and 2010. Parturients were classified into five groups according to their AFI: <20 (n = 9974; comparison group), 20-23 (n = 2771), 24-27 (n = 1315), 28-31 (n = 494) and 32 + (n = 260). Pregnancy and the perinatal outcomes were compared between the groups. Statistical analysis included the chi-square tests for trends, and multivariable models to control for confounders (with AFI as a dummy variable). RESULTS: A significant linear association was found between AFI and adverse perinatal outcomes including hypertensive disorders, diabetes mellitus, preterm labor, macrosomia, placental abruption and low birth weight. Furthermore, using multivariable logistic regression models, controlling for confounders such as maternal and gestational age, hypertension, diabetes mellitus, etc., the significant association between all four subgroups of AFI > 20 and adverse perinatal outcomes remained. CONCLUSION: A significant linear association exists between AFI > 20 and perinatal complications such as perinatal mortality, low Apgar scores and preterm labor. Hence, the critical cutoff for polyhydramnios should be re-evaluated.

Prenatal diagnosis of isolated abnormal number of ribs.

OBJECTIVE: To determine the incidence of prenatal isolated abnormal number of ribs, using three-dimensional (3D) ultrasound. METHODS: This was a prospective study of low-risk women with singleton pregnancy and normal fetal anatomy scan. 3D examinations of the fetal ribs were carried out at the time of the routine anomaly scan at 14-16 or 20-24 weeks of gestation. A 3D volume of the spine was acquired with a mechanical sweep that lasted between 2 and 4 s per volume and was performed when the fetus had a minimally flexed head position. Fetal ribs were reviewed on the rendered image (maximal mode), both while the patient was in the clinic and again later. RESULTS: Three hundred and sixty-seven pregnant women were evaluated. Twenty-three (6.3%) fetuses were found to have an abnormal number of ribs. Fifteen (4.1%) had 11 ribs unilaterally, with the last (12(th)) rib missing. One patient (0.27%) had 13 ribs unilaterally (with a small extra rib after the last rib). Two (0.5%) patients had 13 ribs bilaterally with an extra rib after the 12(th) rib on each side and two (0.5%) patients had 13 ribs bilaterally with an extra cervical rib on each side. Three (0.8%) patients had an extra unilateral cervical rib. In all, 1.4% of patients had extra cervical ribs. CONCLUSIONS: The incidence of abnormal number of ribs in this normal population was 6.3%. When isolated, this finding is a normal variant.

Tightening McDonald cerclage suture under sonographic guidance.

OBJECTIVE: The technical factors contributing to failure of cerclage are not fully understood. The aims of this study were to assess the possibility of tightening the McDonald cerclage under ultrasound guidance and to examine the width and shape of the cervical canal before and after tightening the suture. METHODS: A prospective study was performed. The sole indication for cerclage placement was clinical history of cervical insufficiency. Cervical length and canal width were measured by transvaginal ultrasound, at 12-14 weeks' gestation, with the patient's bladder empty, after which the cerclage was performed. Tightening of the suture was performed under sonographic guidance (transabdominal or transrectal) until the cervical canal disappeared from view. After tying the suture, cervical length and the canal width were assessed sonographically. RESULTS: Fifty-eight patients were enrolled in the study; 50 patients had singleton pregnancies and eight patients carried twins. The mean cervical length at the beginning of the procedure was 31 +/- 13 mm (median 30 mm, range 15-48 mm). The mean cervical canal width was 2.1 +/- 0.9 mm (median 2.0 mm, range 0.9-4.5 mm). The mean addition to the length of the cervical canal after the procedure was 11 +/- 0.8 mm (median 1.0, range 8-19 mm). No complications were noted during the procedures. An interesting sonographic finding was an hourglass shape of the cervical canal after the procedure in 16 patients. Of 58 patients, 47 delivered at term, 10 delivered preterm and one miscarried at 18 weeks. Nine of 10 patients with preterm delivery had an hourglass-shaped sonographic appearance of the cervical canal after the procedure. CONCLUSIONS: McDonald cerclage can be tightened under ultrasound guidance. The sonographic appearance of an hourglass shape of the cervical canal following suture tightening may be a risk factor for preterm delivery.

Early sonographic prenatal diagnosis of seizures.

Fetal seizures are an unusual phenomenon. When diagnosed by ultrasonography, they are frequently associated with malformations and carry a poor prognosis. We describe first trimester seizures in two siblings with arthrogryposis multiplex congenita. In both cases, convulsions appeared before other sonographic signs of the disease. Review of the literature revealed 11 other cases of fetal seizures diagnosed by ultrasound, all later in gestation. Fetal seizures may be the first manifestation of defective neural and motor development. Therefore, in pregnancies at high risk for neuromuscular disease, early sonographic evaluation of fetal motility, in addition to the anatomical survey, is advised.

Cervical length assessment in women with idiopathic polyhydramnios.

OBJECTIVE: The aims of the study were to determine cervical length among patients with polyhydramnios and to assess the relationship between the severity of polyhydramnios, cervical length and gestational age at delivery. PATIENTS AND METHODS: A prospective study was designed including 92 consecutive singleton pregnancies with polyhydramnios between 24 and 40 weeks' gestation. Cervical length was measured using transvaginal sonography. Polyhydramnios was defined when amniotic fluid index (AFI) was equal to or greater than 20 cm. A single sonologist performed all the examinations of the cervical length and the AFI. RESULTS: The median cervical length and AFI were 37.5 (range, 7-52) mm and 28.8 (range, 20-43) cm, respectively. A significant gradual shortening of the cervical length was observed with advancing gestational age (P=0.027). No significant association was found between AFI and cervical length (P=0.24). A cut-off of 15 mm (n=5) was associated with a significantly lower gestational age at delivery (30+/-2.6 weeks vs. 37.2+/-4.2 weeks, respectively, P<0.001). CONCLUSIONS: Women with polyhydramnios have a gradual shortening of cervical length with advancing gestational age. However, this finding is not related to the severity of polyhydramnios.

Differential diagnosis in fetuses with absent septum pellucidum.

OBJECTIVE: To elucidate the characteristic morphological features that may help in the prenatal differential diagnosis of absent septum pellucidum as demonstrated by ultrasound. METHODS: Twenty-six fetuses were referred to the fetal neurology clinic due to mild to severe ventriculomegaly and a connection between the lateral ventricles. The following ultrasonographic features were evaluated: place and extent of the ventricular communication, non-cleavage of the hemispheres and deep gray nuclei, callosal anomalies, position of the choroid plexus, and other central nervous system and facial or body anomalies. A flowchart was created in order to facilitate the final diagnosis. RESULTS: The presence of non-cleavage and/or characteristic facial anomalies prompted the diagnosis of holoprosencephaly (HPE) in 14 fetuses, including two fetuses with the middle interhemispheric variant. Ten fetuses were diagnosed as having hydrocephalus based on the lack of the same features and the observation that the communication between the lateral ventricles was at the level of the third ventricle with almost normal anterior and posterior segments. In two fetuses the diagnosis of septo-optic dysplasia vs. isolated agenesis of the cavum septi pellucidi was contemplated. CONCLUSIONS: The use of the proposed flowchart enabled differentiation between hydrocephalus and HPE. The communication between the ventricles in hydrocephalic fetuses may be due to a disruption of the septum pellucidum or to a pathological enlargement of the foramen of Monro. Published by John Wiley & Sons, Ltd.

Obstetric risk factors for failure to progress in the first versus the second stage of labor.

OBJECTIVE: To compare obstetric risk factors for failure of labor to progress in the first versus the second stage. STUDY DESIGN: A comparison was performed of all singleton, vertex and term deliveries with an unscarred uterus, complicated with non-progressive labor during the first and the second stages. Deliveries occurred between the years 1988 and 1999 in a tertiary university medical center. RESULTS: Patients with non-progressive labor in the first stage (n = 1197) were significantly older, of higher birth order, and were more likely to have complications such as gestational diabetes, hypertensive disorders, premature rupture of membranes, meconium-stained amniotic fluid, hydramnios and oligohydramnios (p < 0.001 for all variables) as compared to patients with non-progressive labor in the second stage (n = 1545). In addition, pregnancies complicated with non-progressive labor in the first stage had a significantly higher rate of fetal macrosomia as compared to patients with non-progressive labor in the second stage (11.6% vs. 8.8%; p < 0.001). CONCLUSIONS: Higher rates of fetal macrosomia and high-risk pregnancies were noted among pregnancies complicated with non-progressive labor during the first vs. the second stage. The significant increase in Cesarean deliveries during the first stage of labor among high-risk pregnancies might reflect exaggerated concern of caregivers. This concern may influence an overall conservative attitude leading to the seemingly simpler mode of direct intervention by Cesarean delivery.

Uterine artery Doppler velocimetry in patients with idiopathic hydramnios.

OBJECTIVE: To evaluate the role of overdistended uterus on the uterine artery (UA) blood flow velocimetry by comparing UA Doppler in patients with idiopathic hydramnios to patients with normal amniotic fluid (AF) volume. METHODS: Pulsatility index (PI) of both UAs was determined prospectively between 26 and 41 weeks of gestation in 72 consecutive pregnant women with singleton pregnancies and idiopathic hydramnios and in 72 pregnant women with normal AF volume. Hydramnios was defined as an AF index (AFI) above 24 cm. A normal amount of AF was defined as an AFI of 6-24 cm. Patients with known fetal structural or chromosomal anomalies and those with diabetes mellitus were excluded. RESULTS: No significant differences were observed between the groups with regard to maternal age, gravidity, and gestational age at examination. Gestational age at delivery and accordingly birth weight were significantly lower in patients with hydramnios compared to those with a normal AFI (34.9 +/- 2.1 vs. 39.1 +/- 1.2, p < 0.001; 2,508 +/- 399 vs. 2,995 +/- 420, p < 0.001, respectively). No significant differences were noted between right UA PI (0.73 +/- 0.3 in the hydramnios group vs. 0.71 +/- 0.2 in the control group; p = 0.091) and left UA PI (0.91 +/- 0.3 in the hydramnios group vs. 0.84 +/- 0.3 in the control group; p = 0.131) of both groups. CONCLUSION: UA velocimetry in patients with idiopathic hydramnios was not significantly different from those with a normal AF volume.

Infertility treatment is an independent risk factor for cesarean section among nulliparous women aged 40 and above.

OBJECTIVE: To determine whether nulliparous women > 40 years old with singleton pregnancies who conceived after infertility treatment are at an increased risk for cesarean section compared with older nulliparous patients who conceived spontaneously. STUDY DESIGN: All subjects in this study were nulliparous women > 40 years old with singleton gestations who were delivered of their infants between 1990 and 1998. The Mantel-Haenszel procedure was used to obtain the weighted odds ratios and to control for confounding variables. RESULTS: During the study period, 115 nulliparous women > 40 years old with singleton pregnancies were delivered of their infants in our institute. Of those, 80 pregnancies were spontaneous and 35 pregnancies occurred after infertility treatment. Women treated for infertility had a higher rate of low-birth-weight (< 2500 g) newborns (34.3% versus 10.1%; odds ratio, 4.7; 95% CI, 1.5 to 14.6; P = .002). No other statistically significant demographic and obstetric differences were found between the groups. There were no cases of perinatal death in the study population. Women treated for infertility had statistically significant higher rates of cesarean section compared with those who conceived spontaneously (71.4% versus 41.3%; odds ratio, 3.6; 95% CI, 1.4 to 9.2; P =.002). Stratified analysis (the Mantel-Haenszel technique) was used to control for possible confounders such as low birth weight, pathologic presentations, failed induction, nonprogressive labor, and nonreassuring fetal heart rate tracings. None of those variables explained the higher incidence of cesarean section in the group treated for infertility. CONCLUSION: A history of infertility treatment among nulliparous women > 40 years old with singleton pregnancies increases the risk for cesarean delivery independently of other known risk factors.

Risk factors associated with true knots of the umbilical cord.

OBJECTIVE: To determine obstetrical risk factors and pregnancy outcome of fetuses with true knot of the umbilical cord. METHODS: Study population included 69,139 singleton deliveries occurring between the years 1990-1997. Data were retrieved from the database of the Soroka University Medical Center. Fetuses with malformations were excluded. RESULTS: The incidence of true knots was 1.2% (841/69,139). In a multivariate analysis the following factors were found to be significantly associated with true knot of cord: grandmultiparity, chronic hypertension, hydramnios, patients who undergone genetic amniocentesis, male gender and cord problems (prolapse of cord and cord around the neck). The incidence of fetal distress and meconium stained amniotic fluid was significantly higher among patients with true knots of cord (7% versus 3.6%, P<0.001 and 22% versus 16%, respectively, P<0.0001). Moreover, there was a four-fold higher rate of antepartum fetal death among those fetuses (1.9% versus 0.5%, P<0.0001). In addition, fetuses with true knots of the umbilical cord were more often delivered by a cesarean section (130/841 versus 711/68,298, P<0.0001). The following obstetrical factors were found to be significantly correlated to true knots of the umbilical cord in a multiple logistic regression model: gestational diabetes, hydramnios, patients undergoing genetic amniocentesis, male fetuses. CONCLUSIONS: Patients with hydramnios, who underwent genetic amniocentesis and those carrying male fetuses are at an increased risk for having true knots of the umbilical cord. Thus, careful sonographic and Doppler examinations should be seriously performed in these patients for detection of the complication of the umbilical cord.

Comparison study between induced and spontaneous term and preterm births of small-for-gestational-age neonates.

OBJECTIVE: To compare perinatal and maternal outcome between induced and spontaneous small-for-gestational-age (SGA) neonates at term and preterm deliveries. STUDY DESIGN: A cross-sectional study was designed and two groups were identified at each gestational age: study group - SGA neonates born after induction of labor, comparison group - SGA neonates born after spontaneous onset of labor. SGA was decoded as birth weight below 10th percentile. The population consisted of 367 consecutive SGA singleton preterm neonates (24-36 weeks' gestation) and 3921 term SGA neonates (37-42 weeks' gestation) delivered between 1990 and 1997. Patients with antepartum death and congenital anomalies were excluded from this study. RESULTS: The prevalence of SGA neonates among preterm deliveries was significantly higher than among term deliveries (9.3 versus 6.1%, P<0.001). The rate of induction of labor among preterm SGA deliveries was significantly higher than term SGA deliveries (17.7 versus 13.4%, P=0.002). The rates hypertensive disorders, suspected IUGR, placental abruption, cesarean section, chorioamnionitis and endometritis were significantly higher among preterm SGA than in term SGA. A multiple logistic regression analysis demonstrated that suspected IUGR, severe PIH (but not mild PIH), chronic hypertension and placental abruption were independent risk factors for induction of labor among preterm SGA neonates. In addition to these factors, oligohydramnios was considered to be an independent risk factor only among term SGA. No significant differences were found in the mean birthweight and post-partum death rates between the induced and spontaneous preterm and term SGA. The incidence of Apgar score < 7 at 5 min was significantly lower only among induced term SGA. CONCLUSIONS: Induction of labor in preterm SGA neonates is performed mainly due to maternal severe hypertension disorders. The indications for induction of labor among term SGA include maternal hypertensive disorders (mild or severe) as well as neonatal status, represented mainly by oligohydramnios. In addition, induction of labor in preterm or term SGA neonates does not change neonatal outcome. Moreover, since no evidence of improved neonatal outcome was demonstrated in either indicated group, preterm or term, the question of timing and indications for induction of labor should be discussed.

Low molecular weight heparin reduces proteinuria and modulates glomerular TNF-alpha production in the early phase of adriamycin nephropathy.

BACKGROUND/AIM: Heparin has been shown to be renoprotective in a number of experimental nephropathies. The inflammatory component in the early phase of Adriamycin (ADR) induced nephropathy has been established. A microdose of low molecular weight heparin (Fragmin; F) has been noted to exert immunomodulatory effects independent of its anticoagulant activity. We assessed the effects of microdoses of F on daily proteinuria and glomerular production of tumor necrosis factor alpha (TNF-alpha) and prostaglandins 8 and 15 days after induction of ADR nephropathy. METHODS: Following intravenous injection of ADR (7 mg/kg) to Wistar rats weighing 200 +/- 20 g, F 20 microg/day/rat s.c. was administered for 8 and 15 days (groups F8 and F15). The respective control groups (C8 and C15) received normal saline subcutaneously. Proteinuria, serum albumin, and creatinine clearance were evaluated on days 8 and 15. The production of TNF-alpha and prostaglandins from glomerular supernatants was measured by radioimmunoassay on days 8 and 15. RESULTS: F significantly reduced proteinuria (mg/day) on day 8: 13.6 +/- 1.2 in F8 versus 40.3 +/- 2.7 in C8 (p = 0.008). The glomerular production of TNF-alpha (pi/ml) was significantly lower on day 8 in rats treated with F: 356 +/- 33 in F8 versus 764 +/- 81 in C8 (p = 0.006). A decrease in the prostaglandin E2/thromboxane B2 ratio was noted in the F group between 8 and 15 days (1.1 in F8 vs. 0.9 in F15, p = 0.005) which principally reflects an increase of thromboxane B2. The antiproteinuric effect of F shown after 8 days was no longer present after 15 days (354 +/- 91 mg/day in F15 vs. 499 +/- 69 mg/day in C15, p = 0.33). The same trend was seen for the glomerular production of TNF-alpha. Light microscopy and immunohistochemistry for interstitial and glomerular macrophages were negative. CONCLUSION: The lowering effect of microdoses of F on the proteinuria seen during the early phase of ADR nephropathy may be mediated by a decreased production of glomerular TNF-alpha, supporting the anti-inflammatory action of low molecular weight heparin.

Evidence for abnormal middle cerebral artery values in patients with idiopathic hydramnios.

OBJECTIVE: Idiopathic hydramnios is an independent risk factor for perinatal morbidity and mortality, although the precise mechanism is unknown. Hydramnios may alter oxygen delivery to the human fetus. The middle cerebral artery (MCA) pulsatility index (PI) is a sensitive parameter for detection of blood flow redistribution or centralization. The aim of this study was to determine whether idiopathic hydramnios is associated with changes in the PI of the MCA and the umbilical artery (UA). DESIGN: The PI of the MCA and UA were determined prospectively in 113 consecutive pregnant women with singleton pregnancies and idiopathic hydramnios (study group) and in 113 matched control patients with normal amniotic fluid (AF) volume (control group). The control group was matched for maternal age, gravidity, parity and gestational age at examination. Hydramnios was defined as an AF index above 24 cm. Patients with fetal structural or chromosomal anomalies and with diabetes mellitus were excluded. A PI below the 5th centile for the MCA was considered abnormal. RESULTS: The rate of abnormal MCA PI was significantly higher in the study group than in the control group (30.9% (35/113) vs. 5.3% (6/113), respectively, OR 8.0; p < 0.0001; 95% CI 3.3-22.1). A significant inverse correlation was found between MCA PI and increasing AF index among patients with hydramnios (p = 0.008, r = 0.46). In contrast, there were no significant differences between the UA PI (0.93 (0.57-2.06) vs. 1.0 (0.49-1.48), (p = 0.20)) and MCA/UA (1.86 (0.77-2.01) vs. 2.15 (0.86-4.11), (p = 0.14)) in both groups. CONCLUSIONS: Our observations provide evidence of cerebral blood flow redistribution in fetuses with idiopathic hydramnios.

Fetal cerebral blood flow redistribution in late gestation: identification of compromise in small fetuses with normal umbilical artery Doppler.

OBJECTIVE: To evaluate the role of middle cerebral artery Doppler in small fetuses during the late third trimester. DESIGN: Prospective observational study of structurally normal fetuses with an estimated fetal weight < 5th percentile for gestation. Perinatal outcome was determined using a structured datasheet sent to each referring obstetrician. SUBJECTS: Structurally normal fetuses at 35 or more weeks of gestation referred during a 2-year period to the fetal growth clinic of a regional fetal medicine unit in North London. Fetuses with aneuploidy and/or major structural abnormalities were excluded. METHODS: Umbilical artery and middle cerebral artery (MCA) Doppler waveforms were recorded and considered abnormal if above 95th or below 5th percentiles, respectively. Amniotic fluid was considered reduced if the maximum vertical cord-free pool was < 2 cm. The placenta was considered mature if the Grannum grade was II or III. The head circumference (HC)/abdominal circumference (AC) ratio was considered abnormal if > 95th percentile for gestation. Fetal growth, amniotic fluid, biophysical profile score and umbilical artery Doppler were used to advise the referring obstetrician about fetal well-being and he/she independently decided both the timing and mode of delivery. RESULTS: Forty-seven fetuses fulfilled the entry criteria. Thirty-four (72%) demonstrated normal umbilical artery Doppler waveforms. Sixteen (34%) demonstrated middle cerebral artery redistribution, of which nine (56%) had normal umbilical artery Doppler waveforms. MCA blood flow redistribution was associated with an increased incidence of cesarean delivery and need for neonatal admission. Of all gray-scale parameters, an elevated HC/AC ratio has the strongest association with MCA blood flow redistribution (15/16 vs. 1/31; P < 0.01). CONCLUSIONS: MCA Doppler may be a useful tool to assess the health of small fetuses in the late third trimester. Redistribution may occur in the presence of normal umbilical artery Doppler and should be suspected when the HC/AC ratio is elevated.

Prenatal diagnosis of hypoparathyroidism retardation and dysmorphism (HRD) syndrome.

We used linkage analysis for prenatal diagnosis of the recently reported hypoparathyroidism, retardation, and dysmorphism (HRD) syndrome. Five cases from four families were evaluated. Three fetuses were carriers and were born healthy. Two fetuses were affected but the parents decided not to terminate the pregnancies. The diagnosis of HRD syndrome was confirmed in these newborns. This is the first report about prenatal diagnosis of HRD syndrome.